Case study on neonatal death reduction in China Composition of Country Teams Lingli Zhang, DDG of MCH Dept., NHFPC Rong Luo, Director of Policy Division, NCWCH Yan Wang, Researcher on Child Health, NCWCH Cao Ying, Safe the Children, China Program Sufang Guo, MCH Specialist, UNICEF China 1

[Country Profile] Epidemiology and Demography: Total population: 1.34 billion Women (15-49 years): 380 million (28.5%) Children <5 years: 76 million (5.7%) Live births: 16 million 2 Heilongjian g Jilin Liaonin g Hebei Guangdon g Hainan Shandon g Jiangsu Beijing Tianjin Shangh ai Fujian Zhejian g Hong Kong Macao Taiwa n provin ce Xinjiang Tibet Qinghai Sichuan Yunnan Gansu Inner Mongolia Shaanxi Ningxia Shanxi Chongqin g Hubei Hunan Guizho u Guangxi Jiangxi Henan Anhui Eastern Central Western Regions

Description of the bottleneck analysis process Key partners involved during the process Department of Maternal and Child Health, NHFPC National Center for Women and Children’s Health China CDC PKU UNTG on MCH, China 3

Description of the bottleneck analysis process As part of child survival strategy review in China National consultation UN partner consultation 4

Data Collection Methods Government Document review Open published literature review Key informer counseling: individual and group 5

Update on the Situation of Children and Women Focus areas/Outcomes of H&N program is based on the six WHO health system building blocks

Good progress has been made! MMR and U5MR trends, MMR U5MR Deaths per 1,000 live births 16 Target:22 Target:16

Age distribution of deaths among under-five children New-born account for 50% of U5MR 8 Source: Ministry of Health, China Health Statistical Yearbook, 2012

Causes of neonatal deaths, Source: UN Countdown report, 2012

In postnatal and infancy periods coverage of interventions is still low 10 Coverage of interventions across the continuum of care for maternal and child health, 2008 and 2011

As hospital delivery rate increased, newborn mortality rate reduced NMR (1/1000 LBs) HDR (%) Source: China Health Statistic Year Book, 2011

Access Physical access: National average:88%; Financial access: – Although health insurance coverage in general population reached 88% (2008) and 96% (2011), that figure was low among newborn – Hospital delivery subsidy for rural women. Cultural access: HDR is still less than 50% in specific areas due to direct and indirect cost such as transportation, accommodation and cultural/belief 12 Health Insurance coverage (%)

Service delivery (including quality of care) Although quality of care has been improving, – only 56% of county level health facilities could provide CEmONC – 31% of township level hospitals could provide BEmONC – 10% county and township level health facilities are not qualified to provide BEmONC but they are providing BEmONC (MOH/UNICEF HR and facility survey). UNICEF is planning to work with MOH to develop standardized materials for in-service and pre-service training. Involving more sectors in health promotion/C4D is urgently needed. 13

Health financing 14

OOP 15

Leadership and governance MCH Law and NPAs for women and children exist, guidelines for MCH are available. Policies to address in-equities in recent health sector reform – Basic PH (free MCH service) – Priority PH program (Hospital delivery subsidy, folic acid supplement for pregnant women, integrated of PMTCT of HIV/syphilis/HBV ). However, some of financial input is left for local government which makes the policy enforcement weak. Code for marketing of breast milk substitutes/ baby friendly hospitals/ policies to encourage early initiation of breast feeding and exclusive breast feeding exist, but it is very weak and lacks enforcement and monitoring. Coordination mechanism for MCH is available (NPA). 16

Medical products, vaccine and technology Essential equipment are available in most of local health facilities. Some important essential drugs are not available. ORS is in essential drug list, but not necessary low osmolality ORS and not available in many clinics. 17

Information Maternal and child mortality surveillance system and MCH annual report system are available. Consolidated HMIS on MCH is planning. 18

Situation of health workforce is improved, disparity exists Number of physician and nurses, per 1,000 population

Equity analysis Equity Analysis

Maternal mortality ratio,

22 Neonatal mortality rate, 1991–2011 Source: Ministry of Health, China Health Statistical Yearbook, 2012

Despite overall progress, China is reducing U5M in an inequitable way U5MR in provinces in China, 2011 Beijing Jiangsu Guangdong Tianjin Shanghai Jilin zhejiang Hunan Henan Shandong Fujian Guangxi Liaoning Chongqing Anhui Shanxi Hubei Hebei Jiangxi Heilongjiang Shaanxi Sichuan Guizhou Hainan Inner Mongolia Ningxia Gansu Qinghai Yunnan Tibet Xinjiang Highest U5MR is 8x more than lowest U5MR: ± 203,560 children can be saved yearly should the whole country have the lowest U5MR Source: MCMSS, 2011; extrapolation based on SOWC, target

In western provinces and rural areas antenatal care (5 visits) coverage is still low 24 资料来源： Qun Meng, Ling Xu, Yaoguang Zhang, Juncheng Qian, Min Cai, Ying Xin, Jun Gao, Ke Xu, J Ties Boerma, Sarah L Barber ， “2003—2011 年中 国医疗卫生服务的可及性及经济保护变化趋势分析：一项横断面研究 ” ，《柳叶 刀》， 2012 年 3 月 3 日，第 379 卷，第 9818 期，第 页

Description of the bottleneck analysis process Key partners involved during the process Department of Maternal and Child Health, Ministry of Health National Center for Women and Children’s Health China CDC PKU UNTG on MCH, China 25

Description of the bottleneck analysis process As part of child survival strategy review in China National consultation UN partner consultation 26

Data Collection Methods Government Document review Open published literature review Key informer counseling: individual and group 27

Bottleneck analysis 28

Newborn care in general PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Low health insurance coverage for newborn High OOP Advocate national policy makers on financing of newborn health to reach free service for newborn care Lack of costed newborn health packageConduct costing exercise and develop costed plan Limited budget for C4D on newborn health and lack of C4D plan for newborn care Budgeted C4D plan for newborn care Poor access in terms of physical, financial and cultural access in remote areas MWR, CCT, C4D Insufficient staff trained for newborn care (pediatricians, obstetricians, midwives, nurses) in county and lower level institution Recruitment of staff (pediatricians, obstetricians, midwives, nurses); Incentives for staff to stay in stations ; Staff training based on identified needs; Training need to combine with the practice; Standard training package for in-serve and pre-service Update evidence based standard training model for in-service and pre-service Few BFHs stick to BFH standard Low EIBF rate Need strong enforcement and M&E for BFH Quality of delivery and PNC care are poorTraining plan 29

Prevention and management of preterm birth PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Cost-effective interventions is not applied in poor China (such as kangaroo mother care) Limited capacity on staff Promotion of cost-effective intervention base on Chinese context Long and short term plan 30 PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Physical, financial and cultural barriers for accessing to health service Focusing on targeted areas and improving access to HD through MWR, CCT, Skilled care at birth

BEmONC PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS 31% of township level hospitals could provide BEmONC TOT and cascade training 10% county and township level health facilities are not qualified to provide BEmONC but they are providing BEmONC (MOH/UNICEF HR and facility survey). Pre-service training 31 PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS only 56% of county level health facilities could provide CEmONC Long term training, technical support Over-used caesarean in all levels of institutions Regulation and standard on rational caesarean Reform payment scheme from fee-for- service or DRG to per capita perspective Capacity building CEmONC

32 Caesarean Section rate is still high Caesarean section rate, 2003, 2008 and 2011 资料来源： Qun Meng, Ling Xu, Yaoguang Zhang, Juncheng Qian, Min Cai, Ying Xin, Jun Gao, Ke Xu, J Ties Boerma, Sarah L Barber ， “2003—2011 年中 国医疗卫生服务的可及性及经济保护变化趋势分析：一项横断面研究 ” ，《柳叶 刀》， 2012 年 3 月 3 日，第 379 卷，第 9818 期，第 页

Basic Newborn Care PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Low EIBFIntroduction first embrace Low EBFGovernment’s commitment on promotion BFHI Poor quality of PNCIncrease staffing In-service, out of service training 33

Neonatal Resuscitation PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Poor capacity in grass root level National policy: at least one staff received updated training on newborn resusitation Training of staffs from grass-root level Introduce HBB in specific relevant areas Lack of essential equipment in gross root health facilities Advocate and development of standard equipment package for MCH 34 PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Kangaroo Mother care is not widely usedTraining and C4D Kangaroo Mother Care

Per 1,000 LBs % of child death Number before the name of province: GDP rank in reverse order Blue: UNICEF project provinces Red number: Per capita GDP rank in reverse order Strategic directions

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