Pakistan National Consultation for Newborn Action Plan 1

Pakistan not on track to achieve MDG 4 and 5 2 Pakistan 4th in world Ranking with 352,000 under 5 child deaths every year. U5MR* – 89 per 1,000 live births – MDG Target 45 IMR* – 74 per 1,000 live births - MDG Target 40 NMR* – 55 per 1,000 live births - MDG Target 25 75% of all deaths of children under one year happen during first 28 days of life * PDHS

194,000 new born deaths during 2010 in Pakistan Third highest number of newborn deaths globally Almost all new born deaths are due to preventable causes Cost effective interventions are not only available but demonstrated to be effective in reducing NMR in communities where they have been implemented effectively Most important Causes have been proven to be treatable even by community health workers having requisite skills High mortality rate among admitted newborn as per locally generated evidence

Estimated causes of neonatal mortality during 2010 year 2010 for 194,000 neonatal deaths Source: Khan A et al Newborn survival in Pakistan: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii72–iii87 Data source: Pakistan mortality estimates (Liu et al. 2012). Note: Severe infection includes sepsis, meningitis, pneumonia and tetanus.

New Born Care Bottleneck Analysis Process In Pakistan Process led by the Government All major stakeholders involved during the process including WHO, UNICEF, Save the Children, PPA, SOGP, USAID, AANN, UNFPA, & MCHIP Existing data sources were used- PDHS, MICS Six Provincial/Regional meetings were followed by National consultation Group work conducted for every recommended evidence based intervention 5

Provincial and National Consultations Baluchistan National Azad Jammu Kashmir Khyber Pukhtoonkhwa Punjab

Facility Level – Staff absenteeism & Frequent postings / transfers – Gender and skill imbalances – Urban -Rural disparities for availability of health professionals – Lack of clearly defined referral mechanisms – Inappropriate locations – Poor maintenance of Health Facilities – Insufficient funding and issues of supplies – Management issues including supervision & monitoring – Non availability of necessary newborn equipment (e.g. bag and mask) Newborn Health Challenges BOTTLENECKS APPLICABLE TO ALL NEWBORN INTERVENTIONS

Community Level – The most underserved pockets of population still not covered by Lady Health Workers (60 % coverage) – Insufficient availability of skilled birth attendants About 48% of the deliveries being conducted by TBAs, Community Midwifery program recently introduced. Currently 6000 CMWs trained but there are deployment issues – Low confidence in public health facilities – Socio-cultural diversity coupled with low literacy and lack of awareness resulting in inappropriate behaviors and practices related to newborn health Newborn Health Challenges BOTTLENECKS APPLICABLE TO ALL NEWBORN INTERVENTIONS

Newborn Care in general PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Lack of Accountability in Public Sector Non Regulated Private sector Lack of updated policy document and good governance at all recommended levels Poor quality at the level of implementation Lack of capacity to implement Health strategies Quality assurance mechanisms and monitoring of Public Sector Legislation for Private sector Regulation Policy document needs to be updated with scaling up of BEOC with all protocols, SOPs including essential service health package at all levels Quality of pre-service and in-service trainings with focus on skill mix and multi-tasking, Competency based periodic recertification of all health cadres Capacity building of Human Resource for implementing Health strategies 9

Prevention and management of preterm birth Focus on Antenatal corticosteroids PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Prevention and management of preterm birth mentioned in Health Sector Strategies but no specific actions like Policy guidelines, SOPs and Capacity building framework for use of corticosteroid Inadequate finances The intervention should be incorporated in all policy documents; specific policy guidelines and SOPs should be developed (national consensus) and roll out accordingly Allocation of Adequate resources 10

Skilled birth attendance Focus on the use of the Partograph PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Lack of availability of Protocols for Partograph Lack of competency for using Partographs Lack of proper supervision Poor quality of Service Delivery Development of Protocols Development of competency based training on Partograph Institution of supportive supervision National Standards for quality Service Delivery 11

BEOC Focus on assisted vaginal delivery PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Lack of updated policy document and good governance at all recommended levels Inappropriate allocation of funds for BEOC services Insufficient HR / Lack of skills Procedural delays for supplies Lack of accessibility, acceptability and affordability of BEOC services Women lack knowledge and decision power on the use of BEOC services, they don’t know their rights Policy document needs to be updated with scaling up of BEOC with standard protocols & SOPs Proper allocation of funds to MNCH and timely releases National NMCH HR policy / strategy. Timely procurement of required medical products and supplies chain management. Equitable availability of quality BEOC services Women empowerment through education and increasing awareness. 12

PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Lack SOPs at all levels. Lack of planning and appropriate allocation of funds to MNCH related services including blood transfusions HR and management issues including non availability of 24/7 CEOC services General lack of awareness especially of adolescent girls, pregnant women and young couples about benefits of timely utilization of CEOC There should be SOPs with accountability, rigorous regular monitoring and evaluation systems. Proper planning and fund allocation to MNCH at all levels Formulation and implementation of HR policy. Ensure quality 24/7 CEOC services at recommended centers. Proper mechanism to ensure increased public awareness, especially of Women and men’s involvement. 13 CEOC Focus on C-Section and blood transfusion

Basic Newborn Care Focus on cleanliness, cord care, warmth, feeding PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Policy documents and standard treatment guidelines present but not widely disseminated or known by stake holders Lack of availability of clear job description Lack of HR trained on new- born care Policy documents and standard treatment guidelines to be widely disseminated amongst all stakeholders Clear job descriptions for Health care providers. Trained healthcare force 14

Neonatal Resuscitation PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS No uniform policy for new born resuscitation No neonatal resuscitation services at rural areas No supervision or monitoring/no quality checks To develop and widely disseminate MNCH policies to ensure availability of uniform neonatal resuscitation services in the country Procurement of neonatal resuscitation equipment to be prioritized. Health care providers to be trained Monitoring and quality assurance mechanisms to be instituted 15

Kangaroo Mother Care focus on skin to skin, breastfeeding, feeding support for premature and small babies PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS No policy guidelines Sociocultural Barriers No system in place to deliver KMC at the facility level (treatment) and community level (for awareness raising and behavioural change) National Consensus building and adaptation of the international guidelines in the local context. Behaviour Change Communication Incorporation in the pre- service, in-service curricula, advocacy at all levels and Behaviour change communication 16

Treatment of severe infections Focus on using injectable antibiotics PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Lack of uniform standardised policy & protocols Not adequately trained Community level health care providers(CMWs, LHWs) for injecting antibiotics. Irregular availability of Antibiotics. Lack of referral mechanism, transport Lack of proper monitoring Adaptation of WHO “Management of sick new born in the community.” and Implementation of uniform protocols Adequate training of all facility and community level health care providers (especially LHW) Uniform availability of Antibiotics. Transport facility and adequate referral mechanism should be developed. Efficient Monitoring system 17

Inpatient care for small and sick newborns Focus on IV fluids/feeding support and safe oxygen PRIORITY BOTTLENECKSSTRATEGIES AND SOLUTIONS Lack of uniform standardised document Administrative, procurement and proper resource allocation issues. Lack of Infection prevention protocols at health facility level Out of pocket payments required by clients Quality issues and lack of proper monitoring / accountability mechanism Adaptation of WHO document, “Management of sick new born at the facility.” Proper management and allocation of adequate Resources. Health facility staff should be trained in infection prevention and protocols implemented Cost free provision of quality care for all newborns needing care Proper record keeping, monitoring / accountability mechanism in place 18

Conclusion Progress for New born Survival Pakistan has progressed since 2000 when newborn health was absent from national policies, priorities and programs to 2007 onwards when it has received increasing national focus Evidence generation, advocacy, networking, technical assistance and partnerships with international donors were the key ingredients of the change Favorable policies are present yet the implementation of these policies is facing problems due to post devolution problems, lack of integration across the continuum of care and insufficient financial allocations Almost all interventions mentioned in latest documents have been initiated in Pakistan but vigorous efforts are required for national level scale up of some interventions

Conclusion FUTURE for New born Survival Furthering advocacy to keep newborn agenda alive and getting adequate financial and human resources Converting Devolution into an opportunity Bringing in more local evidence Strengthening existing newborn care services – Developing and strengthening inter-sectoral linkages – Supporting Technical Working Groups – Facilitating Curriculum Revisions Supporting Best Practices Scale Up

Acknowledgments National Ministry of Health Services, Regulation and Coordination Provincial / Regional Governments WHO AANN(Advisory and Advocacy network for newborns) Save the Children USAID UNICEF PPA SOGP MCHIP 21

Let no family suffer the loss of a mother or a child due to preventable or treatable cause in Pakistan Thanks