By Dr Caroline Phiri Chibawe Ag Director MCH MCDMCH The MNCH Roadmap By Dr Caroline Phiri Chibawe Ag Director MCH MCDMCH

What is this MNCH Roadmap? A strategic document identified that highlights the need to address the problems of high maternal, neonatal, infant and under-5 mortality rates in Zambia over the next 10 years. (The Cape Town developed Countdown to 2015 report 2008 identified Zambia as one of the 68 countries which are in need of accelerated actions to attain their set MDG targets. This report further suggested that it could take up to 10 years of focused implementation of known high impact interventions to produce desired MDG impacts)

Goal  Accelerated reduction of maternal, newborn and childhood morbidity and mortality to attain set targets by 2015. (Thereafter focus on attaining universal coverage goals from 2016 to 2019 and aim to attain universal coverage (80% and above – nationally and within each district)   (In practice this might translate into reaching high impact populations groups first (to reach MDG targets for 2015) and then stretching out to ensure equitable distribution of benefits in efforts to attain universal coverage (80% and above – nationally and within each district)  

Objectives in MNCH Strategic plan  To reduce maternal mortality from 591 to 162 per 100,000 live births To reduce neonatal mortality from 34 to 20 per 1,000 live births To reduce Under-5 mortality rate from 119 to 64 per 1000 live births (based on ZDHS 2007)

Specific Objective Provide skilled attendance during pregnancy, childbirth, and the postnatal period, at all levels of the health care delivery system Strengthen the capacities of individuals, families, communities, line Ministries, and the private sector to share responsibility and play their role in efforts to significantly improve MNCH outcomes for universal coverage to attain the set MDGs.

Situational Analysis

Maternal and newborn health situation in Zambia Maternal mortality ratio – 591/100,000 live births Neonatal mortality rate – 34/1000 live births Infant mortality Rate – 70/1000 live births Under five mortality rate – 119/1000 live births Fertility rate 6.8 HIV prevalence – 14 % Men – 12 % Women – 16 % [Slide title (please do not read): Maternal and newborn health situation in Zambia] @ The Zambia Demographic Health Survey was conducted in 2007 and the preliminary results have been released. These indicators are important for monitoring any interventions that will be implemented. The important indicators for MNCH are: Maternal mortality ratio has reduced from 729 in the 2001 DHS to 449 per 100,000 Neonatal mortality rate has reduced from 37 to 34 deaths per 1000 live births Infant mortality rate went from 95 to 70 deaths per 1000 live births Under five mortality rate dropped from 168 to 119 deaths per 1000 live births The prevalence of HIV in the general population is 14.3% and this is a reduction from the 2002 rate of 16.7%. HIV prevalence is higher among women at 16% than among men at 12%.

Comparison of MMR versus SBA

Issues around the high MMR and NMR in Zambia TBA to train or not to train Three delay model Inadequate equipment Indirect effect of HIV, malaria and TB.   reduced funding affected out reach services Reduced Human resources The high coverage of antenatal care with at least one visit to a health facility (of over 92% coverage) does not translate into high institutional deliveries and high skilled deliveries. Not more than 60% of pregnant women are able to attend the required minimum of 4 focused antenatal care (FANC) visits during a pregnancy (ZDHS 2007

Rural versus Urban disparities Long distances to health facilities & high cost of care Uneducated, poor and living in rural areas. Less likely to attend 4 FANC visits, rarely seek ANC services in 1st trimester ANC services tend to be poor quality with inadequate drugs, laboratory services more likely to be seen by an unskilled health worker and rarely by a physician.

Rural versus Urban disparities Poor, rural, uneducated and multigravida women tend to deliver at home by unskilled TBA or relatives. No access to FP, postnatal and new born care No outreach services for Immunisation and GMP Schools have few teachers, high illiteracy rate, poverty, (access to social welfare ??) Early age marriages leading Obstetric complications, malnutrition,

Key Strategies to be implemented The continuum of care approach recognizes five critical phases in the life cycle of women and children which are: Adolescence and pre-pregnancy pregnancy, childbirth and the postnatal period, newborn and childhood

Key Strategies to be implemented 2. Using a three dimensional approach in coming up with strategies and interventions; ensuring engagement and synergy between the health system, communities, other line ministries and the private sector 3. Strengthening partnerships with the donor community and the private sector for sustainable long-term predictable financing to achieve universal coverage. The selected high impact interventions have been defined and grouped according to phases of the life-cycles. For each intervention there are suggested strategies and activities to be undertaken (in an integrated manner, but all contributing to progress on one selected indicator / intervention): By the health system (ensuring internal linkages and synergy between different departments/units in the Ministriesy of Health and Ministry of Community Development, mother nad Child Health), At the community level, and Through multi-sectoral approaches.   Thus there are packages of interventions for each phase of the life-cycle, as well as packages of strategies and/or activities within each selected intervention.

Advocacy and Resource Mobilization Advocacy efforts will : Increasing the budget allocation for MNCH interventions from both internal and external resources Revision of laws, policies that hinder effective provision of maternal, newborn and childcare services Improving the production, employment, deployment and retention of a skilled health work force at all levels Institutionalize the Maternal Death Reviews and make maternal deaths to be made notifiable events

Adolescence and pre-pregnancy investment in Information – to prevent sexually transmitted diseases, HIV, and unwanted pregnancies Education Availability and easier access to contraceptive services and supplies. The underlying thinking is that a good outcome of pregnancy starts before conception.

Pregnancy The thrust in interventions is ensuring provision of skilled care during pregnancy. provide quality FANC promote birth plan helping the family prepare for good parenting.

Childbirth and the postnatal period Focus on skilled, professional care during childbirth providing access to professional skilled care before, during and after childbirth; Train Health workers to provide quality Emergency obstetric and newborn care Skilled and professional care should also be available to the mother during the postnatal period ? Maybe EmONC should be emphasised here

Newborn (neonatal): bridging the postnatal and postpartum gap, ensuring no interruption in the continuum of care, and establish mechanisms for communication and handover between maternal and child programmes mix of approaches, from the improved care of newborns within the home, through home visits by health workers, better uptake of services in case of problems and referral when needed. ?This is what the roadmap says, I thought it would be better to simplify this slide

Childhood “Integrated Management of Childhood Illness” (IMCI) The Expanded programme on Immunisation “Integrated Management of Childhood Illness” (IMCI) Management of the newborn, nutrition promotion, the strengthening of school health programmes, shifting focus from health centres alone to a continuum of care that implicates families and communities, health centres, and referral-level hospitals   Dr Kalesha can add or subtract

Health System Strengthening and Capacity Development Health system strengthening for MNCH will comprise of improving service delivery by strengthening: The health workforce, Adopting Results Based Management (RBM) approaches, The health management information system (HMIS), The logistics management of medical products, vaccines and technologies, Increased financing to comply with Abuja target of 15%, Improving the infrastructure for service delivery, and Strengthened planning, leadership and governance

Improve referral system through: appropriate transportation and improving linkages between community and referral facilities Communications equipment (e.g., radio calls and mobile phones). Community structures for handling MNCH emergencies Mothers’ waiting shelters

Community Mobilization Educating and sensitising communities on community-based MNCH interventions Mobilizing resources at the village level for MNCH including emergency referral as well as building and strengthening health facilities. Orienting the facility governing committees to the MNCH Strategic Plan to ensure effective implementation of the plan at the health facility and community levels Institutionalizing ‘village health days’

Behaviour Change Communication (BCC) Use of BCC approaches for quality MNCH including nutrition and adolescent sexual reproductive health. Target community-based initiatives Use of targeted mass campaigns

Fostering Partnerships and Accountability Effective implementation of this MNCH Strategic Plan will require stimulating and establishing strategic partnerships improve coordination and collaboration between communities, partners galvanizing political will and mobilizing resources for long-term sustainable MNCH interventions. Coordinate regular planning, implementation, monitoring and evaluation of MNCH interventions to assess progress towards attainment of the MDGs.

Monitoring and Evaluation Framweork One agreed indicator of maternal, newborn and child health interventions will be evaluated 33 operational targets developed Include nutrition, water and sanitation and systems strengthening Quantitative indicators Qualitative indicators obtained through periodic and commissioned studies. Sources of data will include both the routine and non-routine health information systems The indicators will be updated from time to time as need arises It will be better just to chose a few indicators and make a table for those

Operational targets Indicator Current status Target Unmet need for Contraceptives 27% 14% Modern Contraceptive rate for women of Reproductive age 33% 58% Teenage Pregnancy 28% 18% % of women accessing ANC in first Trimester 19% % of women accessing 4 or more ANC visits 60% 80% % of women on IPT 2 or more 66% % of women accessing PMTCT Proportion of women delivered by skilled HW 47% 75% Proportion of women accessing postnatal care within 2 days weeks 39% 55%

Operational targets Indicator Current status Target % of women initiating early and exclusive breastfeeding 63% 90% % of districts with 50% HF implementing kangaroo care % 80% % of children receiving correct treatment for fever 38% % Vitamin A supplementation 60% % of households women accessing improved drinking water 24% % of households accessing improved sanitation 42% % of districts conducting maternal death reviews 50% 100%

Implementation Arrangements Involvement of a multisector approach to increase access to health services MCDMCH and Ministry of Health Other Ministries such as Finance, Information, chiefs and traditional affairs, Local Government, Agriculture, Work and supply, Education, gender, DMMU Cooperating partners- NGO and private sectors Say a sentence or so for each Ministry’s involvement in bringing the MMR

Conclusion The strategies are packages of interventions for each phase of life cycle and at each level of intervention within each selected intervention. The interventions have been costed Implementation of the MNCH plan should not be done in silos but comprehensively.

For a healthy nation, invest in us now! A prosperous, middle income Zambia requires healthy mothers and healthy newborns. [Slide title (please do not read): For a healthy nation, invest in us now!] We know what to do to keep our 19,000 women and more than 120,000 newborns alive and healthy! We need to invest in health now so that high impact interventions can reach all of Zambia’s women and children.