Highlights Progress Report 2010-2011 m ATERNAL n EWBORN c HILD AND a DOLESCENT h EALTH WHO Library Cataloguing-in-Publication Data Maternal, newborn, child and adolescent health: progress report 2010-2011: highlights. 1.Child welfare. 2.Child health services. 3.Adolescent health services. 4.Maternal welfare. 4.Infant welfare. 4.Program evaluation. 5.Program development. I.World Health Organization. ISBN 978 92 4 150360 0 (NLM classication: WA 310) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). 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Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in France Design by paprika-annecy.com Highlights Progress Report 2010-2011 m ATERNAL n EWBORN c HILD AND a DOLESCENT h EALTH Message from the WHO Assistant Director-General The new decade has been marked by important new initiatives that focus on the health of women and children and seek to accelerate progress towards achieving the Millennium Development Goals 4 and 5. In September 2010, the UN Secretary-General Dr Ban Ki-Moon presented the Global Strategy for Women’s and Children’s Health. The Global Strategy that was developed by a broad range of constituencies, seeks to save 16 million lives of women and children by 2015 in the 49 poorest countries. Efciency and effectiveness are key words in the Global Strategy. We must invest more, but also direct our investments rightly. WHO in collaboration with the Partnership for Maternal, Newborn and Child Health summarized and published in 2011 the essential low-cost interventions, commodities and guidelines for women and children across the continuum of care. If these are implemented at scale, the global community can dramatically increase access to life-saving interventions for women, children and adolescents living in the most vulnerable populations. Governments and the global community at large have responded overwhelmingly positively to the call for commitments and over 40 billion US$ will be made available for the implementation of the Global Strategy. Commitments range from governments pledging to increase domestic health expenditure and expand the health work force to partners increasing access to low-cost technologies and increasing nancial support. Commitments need to translate into action and action has to generate results. The Commission on Information and Accountability for Women’s and Children’s Health, established by our Director-General Dr Margaret Chan in January 2011, came out with ten compelling recommendations for tracking results and resources. Moreover, the Commission called for a mechanism of internal oversight and I am delighted that an independent Expert Review Group was appointed by the UN Secretary General in September 2011, after a transparent and open nomination process. The ERG will report on progress every year and hold stakeholders to account, in beneciary as well as donor countries. WHO is privileged to host the Secretariat of the ERG and to facilitate access to information through its website at http://www.who.int/woman_child_accountability/en/ It is now a time of unprecedented opportunity. Never before has the global community rallied so strongly and uniformly around the cause of reproductive, maternal, child and adolescent health. WHO is determined to play its role and facilitate that indeed, investments will lead to improved access and coverage of essential interventions. The Family, Women and Children’s Health Cluster is uniquely positioned to take on the charge. Its new structure permits us to act in a more coherent way and respond efciently to the requirements for building the continuum of care. This report highlights achievements of the Department of Maternal, Newborn, Child and Adolescent Health. It pays testimony to a range of tools and actions developed and supported by our extensive network of staff in headquarter, regional and country ofces. WHO cannot do it alone, but with so many committed stakeholders, I would like to convey the message that we can and will deliver on the promises made. Flavia Bustreo, Assistant Director-General, Family, Women's and Children’s Health Cluster 4 Message from the Director The Department of Maternal, Newborn, Child and Adolescent Health was established from the 2010 merger of the departments of Making Pregnancy Safer and Child and Adolescent Health and Development. The merger represents a consolidation of efforts and a conrmation of WHO’s commitment to investing in Millennium Development Goals 4 and 5 and ensures the application of the continuum of care from pregnancy through infanthood and childhood to adolescence. The Department provides evidence, norms and standards and supports the adoption of evidence-based policies and strategies in line with international standards of human rights, including the universal right of access to health care. It also builds capacity for high-quality, integrated health services for pregnant women, newborns, children and adolescents, and monitors and measures progress in implementation and impact. To do this, the Department works closely with other technical units at WHO's headquarters and in regional and country ofces and with partners. The process of research and development of policies, norms, standards and tools, implementation, monitoring and evaluation is not a linear one but a cyclical one. WHO has a unique mandate to play a leadership role in that process. This highlights report for 2010- 11 shows examples of key achievements in the period and demonstrates that the Department has continued to be highly productive and effective throughout its reorganisation. Ultimately, it is the action and outcomes at country level measure the success of the work of the Department. This report provides a good picture of the depth and diversity of our work, and can serve as an inspiration for renewed and strengthened action for the health of mothers, newborns, children and adolescents. Elizabeth Mason, Director, Department of Maternal, Newborn, Child and Adolescent Health Working along the continuum of care MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011 5 The UN Global Strategy for Women’s and Children’s Health In September 2010, the UN Secretary-General launched the Global Strategy for Women’s and Children’s Health as a nal push towards the attainment of Millennium Development Goals 4 and 5. The Strategy was developed with the involvement of many partners and stakeholders, and generated commit- ments in excess of US$ 40 billion. Measuring results is key to the success of the Global Strategy, and in 2011 the Commission on Information and Accountability for Women’s and Children’s Health, set up by the WHO Director-General, was charged with this task. Chaired by President Jakaya Mrisho Kikwete of the United Republic of Tanzania and Canadian Prime Minister Stephen Harper, the Commission made 10 recommendations for tracking resources and measuring results. These recommendations form the basis of a common global work plan on accountability that focuses on the 75 countries with the highest burden of maternal and child mortality. The work plan calls for the strengthening of vital registration of births and deaths, national health information systems, and quality-of-care assessments including maternal death surveillance and response. It recommends that countries conduct annual reviews of progress combined with advocacy. It also promotes national digital health strategies and transparent reporting on resources by both recipient and donor countries. An independent expert review group will report on progress in the implementation of the Commission’s recommendations. The Department is playing an important role in follow-up of the accountability work plan together with the other H4+ agencies (UNICEF, UNFPA, WHO, the World Bank and UNAIDS) and in partnership with development agencies, academic institutions and non-governmental organizations. It will lead the working group on quality-of-care and maternal deaths surveillance and response, and support countries in the design and implementation of a national action plan to augment accountability for results as well as resources. From global strategy to national reality Efforts to put the UN Global Strategy for Women’s and Children’s Health into action reached an important milestone in 2011. By the end of the year, all 49 of the lowest income countries that are the focus of the Global Strategy had made specic commitments to accelerating action towards the achievement of Millennium Development Goals 4 and 5. WHO together with its partners in the H4+ inter-agency mechanism facilitated the development of national commitments. Now WHO is working with its H4+ partners to support countries to turn these national commitments into action. In countries with existing plans for maternal, newborn and child health interventions, the H4+ agencies are supporting faster implementation and linkages with national health strategies and systems strengthening efforts, as well as with monitoring progress in maternal, newborn, child and adolescent health. In Burkina Faso, the Democratic Republic of the Congo, the Republic of Sierra Leone, the Republic of Zambia and the Republic of Zimbabwe the H4+ agencies have jointly supported the development of country plans with a specic focus on accelerating progress in maternal and newborn health under the umbrella of a grant from the Canadian International Development Agency. In addition, with support of France, the H4+ agencies work in nine francophone countries in West Africa and in Haiti to improve maternal and child health. This joint support will continue over the next ve years to further reinforce the national scale-up of integrated reproductive, maternal, newborn and child health interventions, and national health systems strengthening and monitoring. United Nations Secretary-General Ban Ki-moon Global Strategy for Women , s and Children , s Health 6 gLOBAL CONTEXT AND STRATEGIC DIRECTIONS MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2011 7 The UN Convention on the Rights of the Child: more relevant than ever The 20 th anniversary of the UN Convention on the Rights of the Child (CRC), in 2009 was an ideal opportunity to look at how the CRC can be used as a practical framework and tool for improving child and adolescent health. With that in mind, WHO, UNICEF, Save the Children International, and World Vision International organized a technical consultation in May 2010, bringing together a diverse group of experts in the elds of child and adolescent health, human rights and law, including representatives from UN agencies, international aid organizations, academic institutions, and independent experts. While the Convention had been extensively used to advocate for and raise awareness of children’s and adolescents’ health, it had not been systematically applied as a tool for strategic planning and programming. The consultation provided a unique platform to explore and discuss both opportunities and challenges in applying the Convention as an essential legal and normative framework, as well as a programmatic tool, for advancing child and adolescent health in countries. A number of recommendations adopted at the consultation are now being implemented, including providing assistance to the UN Committee on the Rights of the Child in the development of a General Comment on children’s right to health. The consultation also revealed that raising awareness of the CRC must go hand-in- hand with demonstrating its practical added value in planning and programming for child and adolescent health. Planning informed by evidence Having a national strategy and plan of action to increase access and coverage of effective interventions is a pre-requisite for countries to make steady progress towards the attainment of improved health outcomes of the population, including the targets of the health-related MDGS. The Department is providing guidance on strategy development that involves identication of high impact interventions to address the burden of disease according to context, and costing of the resulting action plan. To this effect, a new tool is now available to guide the national dialogue. The United Nations OneHealth Costing Tool developed by UN agencies can be used to ensure that national strategies and plans for maternal, newborn and child health are appropriately prioritized and realistically costed. The tool covers multiple public health areas (such as immunization, HIV and tuberculosis) as well as health system functions such as human resources and medicines, supplies and equipment. It thus has potential to consider the health sector’s absorptive capacity and simplify and harmonise national planning and costing processes under one unied platform. Experts in health systems and maternal and child health programmes from nine countries in the Western Pacic Region attended a training workshop on using the OneHealth tool. At the end of the workshop, participants were able to cost health- related interventions in different country contexts and generate basic costing projections for their maternal and child health programmes. They could also perform a strategic assessment of a health system’s performance and capacity for key maternal and child health interventions. Additionally they could use the tool to compare alternative scenarios for scale-up, examining the nancial implications and the expected reduction in disease burden. One key aspect of OneHealth is the Lives Saved Tool (LiST), which is used for estimating intervention impact of different intervention packages and coverage levels for countries. In the Region of the Americas, an intercountry training was held on LiST in the Republic of Peru. This brought together government ofcials and academics in the elds of health care planning, health economics and health care nancing from six countries, together with technical staff from WHO country ofces in the Republic of Honduras and Peru. The workshop resulted in each country developing a plan of action to scale-up LiST with the ministries of health and other institutions. In 2012, Honduras will host a Central American Sub-regional LiST Workshop for an additional seven countries. Meanwhile, the Republic of Haiti is considering LiST for the development of its new 10-year National Health Strategic Plan. m ATERNAL HEALTH 8 Reducing maternal mortality Millennium Development Goal 5, to improve maternal health, is one goal that seems unlikely to be achieved under the current state of affairs. At 2.3%, the annual rate of reduction in estimated maternal mortality ratios over the past two decades (1990- 2008) remains well below 5.5%, the rate required to reach MDG5 (Figure 1). Maternal deaths are mostly concentrated in the African and South-East Asia regions (Figure 2). These two regions contribute to more than three-quarters of all maternal deaths worldwide and the African Region continues to have the highest maternal mortality ratio. At 620 per 100000 live births, it is more than 44 times the average in more developed regions. In three WHO regions—Western Pacic, South-East Asia and Europe—the estimated maternal mortality ratio has fallen by 50% or more. Several factors may have contributed to the decline in estimated maternal mortality rates, ranging from health systems strengthening to increasing female literacy. Improved vital registration and notication of maternal deaths are urgently needed for better understanding of and response to improve maternal health. More than 60% of maternal deaths occur in the postpartum period. The risk of death is highest close to birth and then decreases over the subsequent days and weeks. Delays in recognizing and responding to life-threatening complications at home are also important non-medical reasons for maternal deaths. Globally, the proportion of births attended by skilled health personnel has increased (Figure 3) and many countries are actively encouraging women to give birth in health facilities. While the increasing in number of births in facilities is encouraging, it is equally important to ensure good quality of care there. Figure 1 Trends in Maternal Mortality Ratios 1990 - 2008* 0 100 200 300 400 500 600 700 800 900 1990 1995 2000 2005 2010 Africa Eastern Mediterranean South-East Asia Western Pacic Americas Europe World Under-ve Mortality Rate per 1000 live births * with extrapolation to 2010 Figure 2 Maternal Mortality Ratios by country - 2008 Figure 3 Trends in the proportion of births by skilled health personnel 1990-2008 0 10 20 30 40 50 60 70 80 90 100 Global Africa Americas Eastern Mediterranean Europe South-East Asia Weatern Pacic Percentage 1990 2008 >20 20 - 99 100 - 299 300 - 549 550 - 999 ≥1000 Not applicable Data not available MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011 9 Road Map for reduction of maternal mortality in Africa By the end of 2011, 44 countries in sub-Saharan Africa had developed national Road Maps for accelerating the attainment of the Millennium Development Goals 4 and 5. As part of the implementation process, countries review their progress towards set objectives and adjust their strategies to ensure that targets are achieved by 2015. The Road Map review process developed by WHO (AFRO and HQ), together with other H4+ partners, USAID and others, aims to measure what progress has been made, identify constraints and bottlenecks, and propose solutions for accelerated implementation. In 2011, teams of Road Map review facilitators from 15 countries underwent training, after which the review process was implemented in ve countries in the region. Both processes showed that the Road Maps are playing a strategic role in bringing together all stakeholders and highlighting maternal and neonatal survival. There is still work to be done to improve quality and use of information for identifying the gaps, setting priorities and allocating resources. Sub-national analysis needs to be strengthened to highlight gaps in equity, access and distribution of maternal and newborn services, especially to identify differences between rural and urban areas and to ensure that the interventions are reaching the women and children that need them most. The Road Map review process will continue to roll out in the remaining countries in 2012. It will feed into the national health sector review processes related to monitoring country commitments to the UN Global Strategy for Women’s and Children’s Health and monitoring of progress towards the Millennium Development Goals related to maternal and newborn health. Progress in reducing maternal mortality in the Americas: A lot but not enough to reach MDG's Countries of the Region of the Americas have made great efforts to reduce maternal mortality. There has been a 41% reduction in the maternal mortality rate since 1990, and there have also been considerable improvements in the surveillance and monitoring of maternal mortality, allowing more accurate identication of maternal deaths than in previous years. The majority of maternal deaths are due to avoidable causes and are more frequent among vulnerable groups: poor adolescents, rural residents, indigenous women and those of African descent. The gains made so far are insufcient if the region is to reach Millennium Development Goal 5 by 2015. The Plan of Action to Accelerate the Reduction of Maternal Mortality and Severe Maternal Morbidity was developed by the Latin-American Center for Perinatology/Women and Reproductive Health, a WHO Regional Ofce of the Americas technical centre responsible for maternal and perinatal health. The plan focuses on four strategic areas: prevention of unwanted pregnancies and resulting complications; universal access to affordable, high-quality maternity services within a coordinated health care system; increasing the number of skilled personnel in health facilities for preconception, antenatal, childbirth, and postpartum care; and strategic information for action and accountability. IMPLEMENTING NATIONAL STRATEGIES m ATERNAL HEALTH 10 A better system for maternal and neonatal health surveillance in the Eastern Mediterranean Region The vast majority of maternal and newborn deaths occur around the time of delivery or shortly thereafter, most of which could be avoided by simple preventable measures and referral to emergency services. Effective surveillance, analysis and reporting of maternal and newborn morbidity and mortality are crucial to guide improvements in service quality. In 2010, the Eastern Mediterranean Regional Ofce brought together experts from 10 Member States, the American University of Beirut, the US Centers for Disease Control and Prevention, the Aga Khan Foundation and the Royal College of Obstetricians and Gynaecologists to formulate national plans of action for strengthening maternal and neonatal health surveillance systems in the participating countries. The meeting also produced technical recommendations to support the implementation of these plans. The Regional Ofce also developed generic facility-based maternal and newborn health client record forms. These forms are due for eld testing in early 2012. They will then be presented to the member states for adaptation and adoption to improve national maternal and newborn health information systems. Maternal mortality and morbidity audit: 'Beyond the Numbers' in the European Region The average maternal mortality rate in the WHO European Region dropped from 44 per 100 000 live births in 1990 to 21 per 100 000 in 2008. However, every year many women still suffer pregnancy-related complications and a number of them die as a result. There are also large discrepancies both between and within countries. Even in countries where resources are limited, most maternal and perinatal complications and deaths can be averted with basic and effective low-cost interventions. WHO in the European Region shows how this can be accomplished, using tools such as Beyond the Numbers. The Beyond the Numbers tool was introduced in the European Region in 2004 and since then many countries have implemented it under the leadership of Ministries of Health. In June 2010, 90 representatives from 16 countries gathered in Charvak, the Republic of Uzbekistan to share experiences and lessons learned using the tool, in order to further improve the quality of care for mothers and babies in their countries. There were a number of important lessons learned. The principles and practices of WHO/Europe Effective Perinatal Care as well as national clinical guidelines on major obstetric complications must be implemented for successful introduction of the Beyond the Numbers tool. For appropriate implementation of Beyond the Numbers, the support of ministries of health, together with external support from experts, is crucial. Case reviews at the meeting also showed that many of the recommendations were related to organizational issues. STRENGHTENING THE SURVEILLANCE SYSTEM [...]... emerged These included provision of maternal, newborn, child and adolescent health services in remote areas and improving motivation and supervision of health workers Use of telecommunications to improve maternal, newborn, child and adolescent health services was another common priority, as was community-based provision of care and improving quality of care in first level health facilities National institutions... upporting integrated maternal, neonatal and child health services in Lao PDR W  orking in partnership to improve maternal and newborn health in African and Caribbean countries The Government of Lao People’s Democratic Republic has developed a Strategy and Planning Framework for the Integrated Package of Maternal Neonatal and Child Health Services 2009-2015 With Millennium Development Goals 4 and 5 in mind,... providing maternal and newborn care Community mobilization on maternal and newborn health issues was enhanced and referral systems improved In addition, national capacity in planning and management were strengthened Increased awareness of donors and other stakeholders on women’s and children’s health issues has allowed for more funding secured in most countries to accelerate progress towards health MDGs... supported by The Partnership for Maternal, Newborn and Child Health (PMNCH) Consensus was reached through a consultative process of more than a dozen multilateral, development and donor agencies, health care professional associations, national governments, NGOs and academic institutions Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health compiles existing... diarrhoea and fever; • Identify and refer children with severe malnutrition to a health facility; • Advise on home care for all sick children Caring for the healthy child s growth and development: The community health worker counsels families on practices that they can carry out at home and promotes: • Care-giving skills • Child development • Infant and young child feeding • Family’s response to a child s... 120 maternal and child health staff have learnt about the importance of the epidemiology in planning effective programmes related to maternal and child health; recommended interventions for the health of mother and child; and the principles of implementation such as increased coverage, ensuring quality and equity They also studied packages of interventions along the continuum of care, using targets and. .. improving leadership, governance and management capacity for programme implementation; strengthening efficiency and quality of health service provision; and mobilizing individuals, families and communities for maternal, newborn and child health The programme EC/ACP/ WHO Partnership on Health Millennium Development Goals provided support to the health sector in eight African and Caribbean countries (Republic... national standards to improve adolescent health service delivery and training A number of health centres are now implementing the standards and an assessment of the implementation process has already been done and showed areas for improvement WHO has been working with the Ministry of Health to develop a tool for ongoing implementation assessment for other actions to improve child and adolescent health. .. please contact: Child and Adolescent Health (CAH) Department of Family Health and Research ( FHR) World Health House, Indraprastha Estate Mahatma Gandhi Marg, New Delhi-110002, India www.searo.who.int As part of wider efforts to implement adolescent health programmes, the regional office in collaboration with UNFPA, the London School of Hygiene and Tropical Medicine and the Public Health Foundation... reviewing and writing, indicate where existing interventions should be scaled up, and can help guide healthcare professionals at all levels of care in which interventions should be provided to reduce maternal, newborn, and child deaths It can also guide advocacy to support national efforts to improve women’s and children’s health 12 A  n updated approach to prevention and treatment of pre-eclampsia and . Department of Maternal, Newborn, Child and Adolescent Health Working along the continuum of care MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS. Strategy for Women , s and Children , s Health 6 gLOBAL CONTEXT AND STRATEGIC DIRECTIONS MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT