1. Health systems for MNCH Dr Mickey Chopra, Chief of Health, New York

2. Outline Global progress Challenges Role of health systems Conclusion

3. Vaccination campaigns, as in Indonesia, cut childhood deaths. Child Mortality at Record Low; Further Drop Seen

4. Trends in Immunization Coverage: The Measles Story Vaccine coverage has increased Measles deaths have declined

5. Source: UNICEF Global Database, Nov 2008 Percentage 6-59 months old fully protected with 2 Vitamin A doses Trends in Global Coverage of Vitamin A

6. Source: UNICEF Global Databases, November 2008 Trends in ITN Use, 2000-2006

7. >150% increase from 2005-2007 Paediatric ART Coverage, 2005-2007 Source: UNICEF Stocktaking Report, 2008

8. BUT WE NEED TO ACCELERATE PROGRESS

9. Can We Reach MDG 4? Trends in Under 5 Deaths, 1960-2006

10. Source: UNICEF Global Database, Nov 2008 Progress towards MDG 4: Reduction in under-five mortality by two- thirds, 1990-2015 On track: U5MR is less than 40, or U5MR is 40 or more and the average annual rate of reduction (AARR) in the under-five mortality observed for 1990-2007 is 4.0 percent or more rate Insufficient progress: U5MR is 40 or more and AARR is between 1.0 per cent and 3.9 per cent No progress: U5MR is 40 or more and AARR is less than 1.0 per cent Data not available

11. MDG 5 – Maternal Mortality

12. MDG1: Undernutrition – South Asia Note: Data refers to the most recent year available during the period specified. Source: UNICEF, The State of the World's Children, 2009.

13. WE ARE OFF TRACK FOR MANY KEY INTERVENTIONS

14. Optimal Management of Diarrhea Approved in 2003 Recommend for all cases of acute diarrhea 1.Low osmolarity ORS 2.Oral zinc sulfate 20 mg daily for 14 days 3.Antibiotics for dysentery No country has as yet implemented this strategy at scale

15. Little Progress in Case Management % Percentage of children under five with suspected pneumonia taken to an appropriate health provider Percentage of children under five with fever receiving anti-malarials Percentage of children under five with diarrhea receiving ORT (ORS or RHF or increase fluids) with continued feeding

16. Impact of community-based interventions in Asia on neonatal mortality Bhutta et al (Lancet 2008) 31% reduction in neonatal mortality (range 23- 39%)

17. MULTITUDE OF NEW INTERVENTIONS

18. Maternal Series 2006 Repro- ductive Health Series 2006 Child develop ment series 2007 Newborn 2005 Child 2003 Over 190 single interventions listed Nutrition series 2008 Proliferating interventions and proliferating Lancet series..

19. Role of health systems Faced with plethora of interventions many of which cannot be delivered through campaigns alone. A more systems based approach becomes essential. First step is to identify critical set of interventions according to local epidemiology

20. PackageLives saved Antenatal care plus peri-conceptual folic acid supplementation or fortification Childbirth care including full obstetric package (pre-eclampsia treatment, intrapartum care etc) plus antenatal steroids for preterm labour and neonatal resuscitation Postnatal care and support for appropriate feeding, early careseeking for illness Care for sick newborns, Kangaroo Mother Care for preterm newborns 700 4,300 2,600 3,900 Neonatal lives saved total 11,500 PMTCT of HIV using dual therapy at 95% coverage Exclusive breastfeeding at 50%, exclusive replacement feeding at 40% and mixed feeding at 10% 37,200 Child lives saved TotaI 48,700 Prioritise interventions/packages

21. Potential to be on track for MDG 4 and turn around for MDG 5

22. Can highlight ‘quick wins’ In Ethiopia and Northern Nigeria, an increase of contraceptive prevalence rate by 20% would result in 16,000 lives saved, a 25% reduction in deaths. If the following outreach interventions are scaled up by 20% points in 2011: improvements in exclusive breastfeeding, vitamin A, malaria prevention, immunisations (measles, Hib, DPT3), and case management of childhood illness (diarrhea, pneumonia, malaria), it would result in 188,800 lives saved, which is a 23% reduction in child deaths.

23. Health Systems This then allows planners to become clearer about packages of care and how they might be delivered across the continuum of care

24. Intervention packages that reduce newborn deaths Skilled obstetric and immediate newborn care (hygiene, warmth, breastfeeding) & resuscitation Emergency obstetric care to manage complications such as obstructed labour and hemorrhage Antibiotics for preterm rupture of membranes # Corticosteroids for preterm labour # Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies including Kangaroo Mother Care Clinical care Counseling and preparation for newborn care and breastfeeding, emergency preparedness Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care Extra care of low birth weight babies Case management for pneumonia Family- community Clean delivery by traditional birth attendant (if no skilled attendant is available) Simple early newborn care Infancy Neonatal period Pre- pregnancy Pregnancy Birth Focused 4-visit antenatal package including tetanus immunisation, detection & management of syphilis, other infections, pre-eclampsia, etc Malaria intermittent presumptive therapy* Detection and treatment of bacteriuria # Outreach services Postnatal care to support healthy practices Early detection and referral of complications Folic acid # # For health systems with higher coverage and capacity

25. Health Systems Next step is to measure the population coverage for these critical packages of care along the continuum of care

26. Coverage Along the Continuum of Care Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008

28. Models of delivery of packages of care Existing descriptions –Acute, discrete episodes –Doctor-based –Nurse-based –Hospital-based –Community-based –Home-based –…–… = simplistic and outdated in the context of continuum of care

29. MNCH as Continuum of care Extensive experience in high-income countries: diabetes, asthma, - Patient-centred care –Chronic care models –Clinical teams Need for lessons learning from these experiences to low-income countries

30. Mapping the system to look for bottlenecks

31. Thank you