Ending Preventable Maternal, Newborn and Child Mortality: Regional Technical Advisory Group

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2 Ending Preventable Maternal, Newborn and Child Mortality: Regional Technical Advisory Group Report and Recommendations of the Second Meeting of the South East Asia Regional Technical Advisory Group (SEAR TAG) New Delhi, India 8 9 November

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4 Content 1. Objectives of the meeting 2. Introduction 3. Recommendations 4. Proceedings of the meeting 5. Annexes Annex 1: Selected country updates Annex 2: WHO Resolution SEA/RC69/R3 Annex 3: TAG Recommendations (Dec 2015) Annex 4: List of Participants Annex 5: Programme

5 Objectives of the meeting The second meeting of the SEAR TAG was organized at the WHO Regional Office for South East Asia, New Delhi on 8 9 November 2016 with the following objectives: Review the progress in implementing recommendations from the previous meeting Review the situation of maternal and child mortality in the Region Discuss country specific high impact actions towards finishing the work of MDGs 4 and 5 in priority countries Plan for the next SEAR TAG meeting in

6 Introduction The Technical Advisory Group for Women s and Children s Health in the WHO South East Asia Region (SEAR TAG) was established in 2015 as a mechanism to guide national governments, implementing partners and other stakeholders on how best to accelerate implementation and monitor strategies to advance the unfinished agenda of MDGs 4 and 5 and achieve progress towards SDG targets. In its first meeting, held in December 2015, the SEAR TAG focused on addressing neonatal mortality and developed a set of recommendations for WHO, countries and partner agencies. The subsequent WHO Resolution SEA/RC69/R3 Ending preventable maternal, newborn and child mortality in the SEAR with focus on newborn mortality, adopted by the Regional Committee in September 2016 provided an important basis for discussions during the current meeting. Urgent action is required to meet the MDG target levels for reducing maternal and under five mortality by no later than For this, specific high impact approaches need to be agreed and promoted in the priority countries in the Region: Bangladesh, India, Indonesia, Myanmar, Nepal, and Timor Leste. Improving the healthy development, health, safety, and well being of adolescents is also recognized as a high priority for the region. The SEAR TAG meeting was accompanied by discussions among the H6 partners (UNFPA, UNICEF, UNAIDS, UN Women, WHO and the World Bank). The H6 Regional Working Group was created to institutionalize the regional interagency platform that would provide technical assistance, promote multisectoral action, and coordinate partner and donor support to countries for implementing the Global Strategy. This reflects the clear intent to respond to governments request for less fragmentation and better alignment of efforts as well as the importance of consistent regional recommendations across the spectrum of reproductive, maternal, newborn, child and adolescent health, and across UN agencies. Recommendations The meeting resulted in recommendations to reinforce national commitment to the UN Secretary General s Global Strategy for Women s, Children s and Adolescents Health ( Global Strategy ), develop a Regional monitoring framework for that strategy, define national technical priorities, address implementation gaps, strengthen health systems, and intensify the focus on adolescent health and development. Reinforce national commitment to the UN Secretary General s Global Strategy for Women s, Children s and Adolescents Health ( Global Strategy ) and undertake urgent action towards ending maternal, newborn and child mortality 1. WHO and other H6 partners will undertake advocacy on reducing maternal, newborn and child mortality targeting heads of states, ministers of health and parliamentarians. This includes high level missions to the priority countries to: 2

7 a. Strengthen national commitment to achieving mortality reduction levels of MDGs 4 and 5 by 2018, and to furthering progress towards Global Strategy and SDG3 targets. b. Ensure resource mobilization from domestic and external sources. 2. Support countries to set intermediate targets for 2018, 2020, and 2025 towards achieving the 2030 targets of the Global Strategy and SDG3, with an initial focus on reducing mortality. 3. Strengthen interagency partnership and improve coordination at regional and country level through the H6 and other mechanisms. 4. Undertake periodic joint H6 missions to high priority countries for follow up to review progress and ensure technical assistance. Develop and implement a regional monitoring framework for the Global Strategy 5. WHO and H6 partners will prepare a feasible monitoring framework to guide Member States on reporting progress on implementing the Global Strategy. Define technical priorities for maternal newborn and child health for the period 2016 to Continue to take forward the 2015 TAG recommendations on reducing newborn mortality, with a specific focus on scaling up recent interventions such as simplified antibiotic treatment of newborn sepsis where referral is not possible. 7. Strengthen key interventions for maternal and newborn health in high priority countries to ensure that the Region achieves the MDG level of maternal and newborn mortality reductions by 2018: a. Good quality intra partum care for mothers and new borns at health facilities b. Good quality facility based care for small and sick newborn and for mothers with complications, with efficient referral transport to facilities c. Home based postnatal care for mothers and new borns d. Prevention and management of adolescent pregnancies 8. Strengthen key interventions for child health in high priority countries to accelerate mortality reduction to ensure that the Region achieves the MDG level of child mortality by 2018: a. Strong IMNCI implementation at all three levels of care home/community, first level and referral level b. Campaigns for the control of diarrhoea and pneumonia, aimed at improving government ownership, public awareness and participation and availability of essential supplies c. Improved coverage of routine vaccines (e.g. measles, HiB) and introduction of new vaccines (PCV, Rotavirus) Address implementation gaps 9. WHO and H6 partners will collaborate with and support Member States to address implementation gaps in coverage, quality, data collection and community engagement: 3

8 a. Coverage gap: build national capacity for effective planning to achieve high and equitable coverage of the key intervention packages, targeting underserved populations to ensure that no one is left behind. b. Quality improvement: build national capacity for continuous quality improvement methods, focusing initially on maternal and newborn care. c. Data collection: strengthen the health information system, expand birth and death registration (including still) as well as coverage data to monitor progress, strengthen capacity to conduct Maternal, Perinatal Death Surveillance and Response and Child Death Reviews. d. Community engagement: expand activities for public awareness, engagement and demand generation. Strengthen health systems 10. Support high priority countries to identify health system bottlenecks and undertake actions to address these: a. Improve financing by increasing domestic investment for RMNCAH and leveraging newer opportunities including GFF, GF, GAVI, and ensure financial protection to minimize out of pocket expenses. 1. Strengthen the health workforce for RMNCAH i. Adequate numbers and mix of staff, with a focus on midwives ii. Strengthen pre service education iii. Strengthen in service continuous professional development iv. Strengthen capacity of programme managers for planning and implementation at national and subnational levels b. Strengthen the service delivery by addressing: i. Gaps in the health infrastructure including basic amenities of WASH and electricity ii. Logistic management of essential supplies and equipment iii. Definitions of minimum standards for functioning of birthing centres (case load, staffing, physical infrastructure etc.) iv. Rationalized and stronger BEmONC and CEmONC services c. Improve health information system by strengthening birth and death registration (including still) and coverage data to monitor progress. Intensify the focus on adolescent health and development 11. Adolescent Health and Development' will be the theme of the next SEAR TAG meeting. This recommendation is based on the recognition that Primary care and hospital services have few or no specific provisions for adolescents; has poor coverage and is generally of sub optimal quality Universal health coverage (UHC) does not specifically address adolescents Adolescent pregnancy is associated with higher neonatal mortality and maternal morbidity Numerous risk behaviours for non communicable diseases (NCDs) are initiated during adolescence, indicating that NCD programmes should include adolescents as specific risk group 4

9 There is a double burden of nutrition disorders, where under nutrition including anaemia is common in boys and girls and overweight/obesity is gradually increasing The innovative use of information technology and social media for life skills and empowerment looks promising School health programming is a good option and requires stronger collaboration between the ministries of health and education Proceedings of the meeting Overview Between 1990 and 2015, the global maternal mortality ratio (MMR) decreased by 44%. Countries in the Region made significant progress, with a 69% drop in MMR, from 525 per live in 1990 to 164 in It is important to note that the burden of maternal mortality and morbidity in the Region is dynamic, with uneven shifts in the magnitude, causes, and distribution over time (see Table 1). Table 1: Progress on MDGs 4 and 5 by country in the WHO South East Asia Region Maternal Mortality Ratio (MMR) MMR 2015 MDG 5 Target Under 5 Mortality Rate (U5MR) U5MR 2015 MDG 4 Target Bangladesh [Achieved] Bhutan [Achieved] [Achieved] Democratic People s * 14 Republic of Korea India Indonesia [Achieved] Maldives 68* 169 9* 31 [Achieved] [Achieved] Myanmar Nepal [Achieved] Sri Lanka 30* 19 10* 7 Thailand 20* 10 12* 12 [Achieved] Timor Leste [Achieved] [Achieved] South East Asia Region (69% decline since 1990) (64% decline since 1990) Global (44% decline since 1990) *Below SDG target, need to ensure equity across all population groups (52% decline since 1990) Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. During the SEAR TAG meeting, members reviewed the state of programmes and policies towards achieving at least the MDG levels of mortality reduction in the six priority countries: 5

10 Bangladesh, India, Indonesia, Myanmar, Nepal and Timor Leste. The discussions aimed to provide guidance in coherence with WHO to national governments, implementing partners and other stakeholders on how best to accelerate key implementation strategies, and monitor these and to move from the MDGs to the new SDG and Global Strategy agendas. Maternal Health Regional situation: Dr Elizabeth Mason stressed that the Region made the most progress in MMR reduction among all the WHO regions during the MDG era. In 2015 the Region had fewer maternal deaths than in 1990, with the number having plummeted to 61,000. This is an unprecedented feat in maternal survival in the history of Member countries of South East Asia However, a review of epidemiology and of policies shows that work remains to be done (see Annex). Lancet Maternal Health Series: Dr Wendy Graham presented the highlights of the The Lancet Series on maternal survival. This series expands on the current knowledge of maternal health, its epidemiology, successes, and failings, and comes at a crucial time in the sustainable development framework to The series focused on analysing services that support safe and healthy motherhood. It uses lessons from high income countries with low caesarean section rates, yet good outcomes, and universally applicable low cost effective services such as: o Team based care in maternity hospitals o Low risk units alongside full scope maternity hospitals o Free standing and home based midwifery Dr Graham concluded with a call to action setting out five key targets to be met in the context of the SDGs: 1. Prioritize good quality maternal health services that respond to local needs and meet emerging challenges 2. Promote equity through universal coverage of quality maternal health services 3. Increase resilience and strength of health systems 4. Guarantee sustainable financing for maternal and perinatal health 5. Improve the availability and use of local evidence to inform quality improvement processes She proposed that SEAR countries focus on improving the quality of antenatal care and intrapartum care, also how to link quality with continuous professional development of health workers, both in their pre service and in service training. She also indicated that there needs to be a greater focus on equity and also disaggregation of the data to better understand causality. Child health Regional situation: The progress in child survival has been another remarkable achievement of the Region. With a 64% decline in child mortality, from 118 per 1000 live in 1990 to 43 per 1000 live in 2015, the reduction considerably exceeds the global rate of decline of 52%. 6

11 Reducing child survival is now increasingly dependent on reducing neonatal mortality, and Dr Rajesh Mehta elaborated on the progress since the previous SEAR TAG meeting. Post neonatal child deaths are still largely due to pneumonia, diarrhoea and malaria, with under nutrition being as high as 60% in some South East Asian countries. This contributes significantly to mortality, and is an area that the SEAR TAG must consider prioritizing. (See Annex) IMNCI Convergence for Child Survival: Shifting epidemiology trends such as the double burden of malnutrition, the proportion of child deaths during the newborn period, environmental challenges to child health along with new technology and innovations like mhealth, ehealth, new vaccines, diagnostic and treatment innovations indicate a need to a make changes in IMNCI guidelines and implementation. A global strategic review of IMNCI carried out in 2016 reflected on the lessons from 20 years of implementation. With a view to provide state of the art care for all children, the review included a big picture of the best investments in child health. Thirty four unique data sources were used and four SEAR countries were included in the review: Bangladesh, India, Myanmar and Nepal. Renewed joint leadership by WHO and UNICEF is focusing on the following tasks: Planning for a new set of harmonized, flexible guidelines for child health, with a userfriendly online dissemination platform; Planning for a new global expert advisory group to standardize the systematic review of care recommendations; Rethinking of positioning of child health to restore leadership and financing, and achieve larger scale implementation in countries. Adolescent Health: Strategic Guidance A review of available documents and reports relating to WHO and other multilateral regional strategies provided direction for developing Strategic Guidance on Adolescent Health for countries in the South East Asia Region Dr Bruce Dick presented the noteworthy progress to date: adolescent health is now firmly and sustainably positioned in a number of countries, and many activities are being undertaken to address both the unfinished MDG agendas and the SDG challenges. Taking advantage of the growing attention to adolescent health, and building on existing successful partnerships and collaboration, the key components of the upcoming strategy (to be endorsed by H6 partners) include: A life course approach: triple dividend An ecological model A human rights based approach The prominence of quality, equity and accountability Prioritizing, setting targets and implementing the evidence based interventions beyond sexual and reproductive health (SRH) Adolescents as a positive force for change The strategy will focus primarily on the role of the health sector. There is an increasing awareness of the need to pay attention to a range of adolescent health issues that are often 7

12 inter related and frequently have common determinants. These include mental health problems (suicide, depression and anxiety, stress and substance use), violence (interpersonal and gender based), unintentional injuries (road traffic injuries and drowning), nutrition (both under nutrition/anaemia and over weight/obesity); common endemic infectious diseases and chronic conditions/non communicable diseases (NCDs). They also include a range of healthrelated behaviours and conditions that undermine adolescents health now and carry risks for the future (tobacco and alcohol use, unhealthy diet and lack of exercise). Moving the strategy from words to action will require an operational plan that defines responsibilities for countries and for regional and national partners. The plan will need to cover a spectrum of issues, from capacity strengthening to the sharing of programme support tools and information about effective strategies for taking evidence based interventions to scale, in ways that retain the quality that is required for effectiveness. The SEAR TAG recognizes that: Primary care has few or no specific provisions for adolescents in hospital services and is of poor coverage and quality Universal health coverage does not specifically address adolescents Adolescent pregnancy is associated with higher neonatal mortality and maternal morbidity Numerous risk behaviours for non communicable diseases (NCDs) are initiated during adolescence, indicating that NCD programmes should include adolescents as specific risk group There is a double burden of nutrition disorders, where under nutrition including anaemia is common in boys and girls and overweight/obesity is gradually increasing The innovative use of information technology and social media for life skills and empowerment looks promising School health programming is a good option and requires stronger collaboration between the ministries of health and education The strategic guidance will be further developed and will be the main focus of the next TAG meeting. 8

13 UN Secretary General s Global Strategy for Women s, Children s and Adolescents Health: New and underfocused areas and country implications Dr Vinod Paul described the Global Strategy in the context of the South East Asia Region. Looking further into implications for individual countries, Dr Paul highlighted that countries with high burdens require urgent action and commitment from the SEAR TAG and H6 partners (above Table 2a and 2b). Table 2a: WHO South East Asia Region: Estimates of maternal mortality ratio, number of deaths, lifetime risk, and coverage of critical interventions in high priority countries Maternal health indicators Maternal Mortality Ratio (per live ) Births in health facility (%) Caesarean section (CS) rates (%) Number of maternal deaths a Life time Risk of maternal death Bangladesh India Indonesia Myanmar Low Nepal Timor Leste a Numbers of maternal deaths have been rounded according to the following scheme: < 100 rounded to nearest 1; rounded to nearest10; rounded to nearest 100; and rounded to nearest 1000 Source: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 9

14 Table 2b: WHO South East Asia Region: Estimates of under five mortality rate and coverage of interventions in high priority countries Child health indicators Under Five Mortality Rate (per 1000 live ) Children under 5 with suspected ARI given Ab (%) Children under 5 with diarrhoea given ORT (%) Number of under five deaths (thousands) Bangladesh India Indonesia Myanmar Nepal Timor Leste Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation The Global Strategy is guided by approaches that are country led, universal, sustainable, human rights based, equity driven, gender responsive, evidence informed, partnership driven, peoplecentred, community owned and accountable. It draws its purpose and power from the SDGs. The three cardinal objectives of the Global Strategy, Survive, Thrive and Transform, portray the aspiration not only to end preventable mortality, but also to avert illnesses, ensure wellbeing, and usher in a productive and empowered future. In this way the Global Strategy goes beyond and is more aspirational than the MDGs. Renewed commitment, new approaches and invigorated investments will be needed. Since the interventions to save maternal and child lives are similar for all settings, it is the strength and resilience of the health system that determines the coverage, equity and quality of implementation. Each of the building blocks of the health system (infrastructure, human resources, service delivery, commodities, finances, and governance and information system) has to be in place to make an impact. Monitoring the Global Strategy and SDG 3: Regional and country implications Monitoring implementation of the Global Strategy and tracking progress towards its implementation requires a certain number of agreed indicators. After global technical reviews and an open consultative process, a total of 60 indicators were selected to monitor the implementation of the Global Strategy. These are published in the Unified Accountability Framework. A sub set of sixteen key indicators were selected to give a snapshot of progress towards the Global Strategy targets across maternal, newborn/child and adolescent health, and the cardinal objectives of survive, thrive and transform. 10

15 These indicators will be relevant for tracking Regional progress on the Global Strategy and for evidence informed advocacy and accountability for resources, results and rights. Equity (SDG ) was a cross cutting theme. Furthermore, this framework can be used to support national SDG and health monitoring, with countries adding contextual indicators as relevant. Regional intermediate targets aligned with the SDG targets and the Global Strategy need to be set early on, with special emphasis on data availability and regularity. The SEAR TAG agreed that WHO, together with the H6 and other partners, would review and update relevant Regional data. Table 3: Proposed Regional intermediate targets on mortality indicators SEAR Maternal Mortality Ratio (SDG 3.1.1) Set intermediate Under 5 Mortality 43 Regional targets to Rate (SDG 3.2.1) achieve MDGs 4 & 5 levels Neonatal Mortality Rate (SDG 3.2.2) Stillbirth Rate Adolescent Mortality Rate Source: Accountability in the 2015 Global Strategy for Women s, Children s and Adolescents Health BMJ 2015; 351 doi: Still: rates, risk factors, and acceleration towards 2030, Lawn et al, Lancet DOI: (15) Conclusion The 2030 targets for SDG 3 and the Global Strategy include and go beyond the unfinished agenda of maternal, newborn and child survival. They require a global maternal mortality ratio of 70 per 100,000 live or less, and all countries to achieve neonatal mortality rate of 12 per 1000 live or less and an under five mortality rate of 25 per 1000 live or less. Realizing the importance of accelerating reductions in neonatal mortality, where the least gain was made during the MDG era, the Regional Flagship Ending preventable maternal, newborn and child deaths with focus on neonatal deaths was developed to provide the focus and resources needed. The SEAR TAG meeting provided a significant opportunity for members and experts to meet with H6 partners and discuss priorities for the Region. With over 350 million adolescents in the Region, the meeting aptly put adolescent health and development back on the agenda. The next SEAR TAG meeting is planned to be held in Bhutan in July 2017, and will focus on the Regional strategic directions for adolescent health. 11

16 Annex 1 Selected country updates Bangladesh Women s Health Maternal mortality ratio Proportion of attended by skilled health personnel Antenatal care coverage (at least one visit) Contraceptive prevalence rate Unmet need for family planning/ Demand unsatisfied for family planning Children s Health Under 5 mortality rate Infant mortality rate Proportion of 1 yearold children immunized against measles Target Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B Achieve, by 2015, universal access to reproductive health Target 4.A Reduce by twothirds, between 1990 and 2015, the under five mortality rate MDG Progress from1990 to 2015 Significant progress with 69% reduction More than 60% increase in the last decade but coverage remains low Achieved MDG 4 with 74% Reduction in under 5 mortality Newborn interventions prioritized 44% of neonatal deaths due to preterm birth Immunization coverage increased equitably Target SDG SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per live SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive health care services and rights SDG 3.2: By 2030, reduce under 5 mortality to at least as low as 25 per live SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1000 live Stillbirth rate Global Strategy target: By 2030, reduce still to single digits Adolescents Health Adolescent birth rate Indicator 5.4 under Target 5.B Adolescent Mortality Rate More than 50% of girls are married by 18 years of age, thus adolescent pregnancy continues to be very high SDG 2.2: End all forms of malnutrition and address the nutritional needs of adolescent girls, pregnant and lactating women and children - Situation in per live 42% 64% 62% 12% 38 per 1000 live 31 per 1000 live 80% 25.4 per 1000 total 113 per 1000 girls aged years Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication, 2016; Bangladesh DHS

17 Bangladesh lessons learnt and key actions: (Observations by Shams El Arifeen) 1. Prioritized newborn interventions for common causes of neonatal deaths: o Infections Chlorhexidine for cord care and emergency management of newborn infections o Birth asphyxia resuscitation of new borns o Prematurity Units set up for special care of newborn and for newborn stabilization; Antenatal corticosteroids provided; Kangaroo Mother Care prominent 2. To achieve SDGs we need to: o Make every effort possible to achieve, and possibly exceed, the optimistic coverage targets for the interventions: i. Substantially increase facility deliveries ii. Focus on a few well functioning facilities for providing delivery services iii. Make smart choices on selection of strategies for newborn interventions iv. Multiple communication channels to reinforce behaviour change o Invest in improving the quality of services to ensure expected or higher levels of effectiveness 3. We need to now move beyond the neonatal period and address critical child health problems: i. Stagnating rates of ORS use for childhood diarrhoea ii. Uncontrolled use of antibiotics for treatment of pneumonia iii. Preventing childhood deaths due to drowning 13

18 India Women s Health Maternal mortality ratio Proportion of attended by skilled health personnel Antenatal care coverage (at least one) Contraceptive prevalence rate Unmet need for family planning/ Demand for family planning Children s Health Under 5 mortality rate Infant mortality rate Target Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B Achieve, by 2015, universal access to reproductive health Target 4.A Reduce by twothirds, between 1990 and 2015, the under five mortality rate MDG Progress since 1990 in 2015 Significant progress with 69 % reduction 56% increase in delivery with SBA but fewer than half (47%) of child occur in facilities More than 75% covered but still one in four women missed With 62 % reduction, missed MDG 4 Highest number of newborn deaths ( per year) 34% of newborn deaths are due to preterm birth Target SDG SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per live SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive health care services and rights SDG 3.2: By 2030, reduce under 5 mortality to at least as low as 25 per 1,000 live SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1,000 live Proportion of 1 year old children immunized against measles Stillbirth Rate Global Strategy target: By 2030, reduce still to single digits Adolescents Health Adolescent birth rate Adolescent Mortality Rate Indicator 5.4 under Target 5.B - 43% girls married by 18 years and among them one in three have begun childbearing by 19 years SDG 2.2: End all forms of malnutrition and address the nutritional needs of adolescent girls, pregnant and lactating women and children Situation in per live 67% 75% 55% 21% 48 per 1000 live 38 per 1000 live 74% 23 per 1000 total 28 per 1000 girls 15 19years Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication,

19 India lessons on approaches for reduction in maternal mortality provision of safe delivery: (Observations by Nozer Sheriar) 1. Continue the shift to institutional deliveries o Optimize safer utilization of existing facilities with basic mandatory standards of care and resources o Invest in human resource and others including accessible safe blood banks and storage facilities 2. Embark on the Mother/Baby Friendly hospital initiative o WASH as one of the core indicators of quality 3. Develop and provide facilities for grass roots access o Basic maternity care to be available close to women o Enlist services of public and private sector o Defined role, training and respect for skilled birth attendants 4. Time to create a cadre of dedicated qualified midwifes o Independent providers of basic maternity care o Expected to be more sensitive to women and less likely to medicalize childbirth 5. Provide Emergency Obstetric and Neonatal Care facilities o Recognize significant role in mortality reduction o Provision of adequate technical resources 6. Increase facilities providing critical obstetric care o Develop replicable models of advanced critical care facilities for obstetrics o Map available facilities to identify unserved area 7. Build a system of transport for maternity care o Emergency response vehicles using toll free number, o Government and private ambulances o Referral transport for pregnant women and new borns o Reimbursement or subsidization of transport cost if necessary 8. Communication to women regarding health messaging and entitlements o Use mobile sms and voice based messaging o Role for grass root workers such as ASHAs in messaging and advocacy 9. Dissemination and implementation of guidelines o Standardize guidelines and protocols related to maternal health & childbirth o Develop a national credible and robust system to create guidelines o Work to disseminate and implement in partnerships including professional organizations 10. Create an ongoing system of guideline dissemination and upgrades o Healthcare delivery Checklists o Adoption of the WHO Safe Childbirth Checklist at all levels of maternity care 15

20 Indonesia Women s Health Maternal mortality ratio Proportion of attended by skilled health personnel Antenatal care coverage (at least one visit) Contraceptive prevalence rate Unmet need for family planning/ Demand for family planning Children s Health Under 5 mortality rate Infant mortality rate Proportion of 1 year old children immunized against measles Target Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B Achieve, by 2015, universal access to reproductive health Target 4.A Reduce by twothirds, between 1990 and 2015, the under five mortality rate MDG Progress since 1990 in 2015 Nearly achieved MDG 5 with 72% reduction 25% increase in SBA with more than 60% facility delivery Nearly all women get one ANC visit but starts declining as more visits are needed Achieved MDG 4 with 68% reduction in U5MR Third highest annual neonatal death toll in the region 260 newborn die each day 44% of the newborn deaths are due to preterm birth Expanded immunization Target SDG SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per live SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive healthcare services and rights SDG 3.2: By 2030, reduce under 5 mortality to at least as low as 25 per 1000 live Stillbirth Rate Global Strategy Target: By 2030, reduce still to single digits Adolescents Health Adolescent birth rate Adolescent Mortality Rate Indicator 5.4 under Target 5.B - 4 out of every 10 girls married by 18years Situation in per live 83% 88% 62% 11% 27 per 1000 live SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1000 live 14 per 1000 live SDG 2.2: End all forms of malnutrition and address the nutritional needs of adolescent girls, pregnant and lactating women and children 84% 13 per 1000 total 47 per 1000 girls 15 19years Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication,

21 Indonesia lessons from Expanding Maternal and Newborn Survival (EMAS) Programme (Observations by Mohammad Baharuddin) The USAID supported EMAS programme is a five year cooperative agreement aimed at contributing to the reduction of maternal and newborn deaths in Indonesia. Within this focus, EMAS has several overarching objectives: Contributing to 25% national reduction in maternal and newborn mortality; Improving quality of emergency care in at least 150 hospitals; Improving life saving clinical interventions and effectiveness of referrals in at least 300 puskesmas Key findings from EMAS implementation include: At provincial, district, and facility levels EMAS appears to be contributing to positive changes in quality, organization, and management of MNH services. One of EMAS most important results has been turning a fragmented referral system into a functional network, and developing relationships, connection, and communication within that network. Evaluation findings related to achieving impact and sustainability at scale include: Data available from EMAS and from health services do not allow connections between the observed and reported changes in processes with changes in health worker or system performance, nor with maternal and newborn mortality. Because of this lack of certainty about performance and mortality, it will be crucial to determine the actual operational and clinical causes of continuing maternal and newborn deaths. There are important changes happening in Indonesia that could override efforts to increase the effectiveness of maternal and newborn services. 17

22 Myanmar Women s Health Maternal mortality ratio Proportion of attended by skilled health personnel Antenatal care coverage (at least one visit) Contraceptive prevalence rate Unmet need for family planning/ Demand for family planning Children s Health Under 5 mortality rate Infant mortality rate Proportion of 1 yearold children immunized against measles Target Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B Achieve, by 2015, universal access to reproductive health Target 4.A Reduce by two thirds, between 1990 and 2015, the under 5 mortality rate MDG Progress since 1990 in % reduction but burden remains high 40% increase in SBA but only 36% deliver in facilities More than half the women who get one visit do not get a second one With 55% reduction insufficient progress towards achieving MDG 4 Target SDG SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive healthcare services and rights SDG 3.2: By 2030, reduce under 5 mortality to at least as low as 25 per 1000 live SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1,000 live Stillbirth Rate Global Strategy Target: By 2030, reduce still to single digits Adolescents Health Adolescent birth rate Indicator 5.4 under Target 5.B Adolescent Mortality Rate - 72% adolescents began child bearing by 19 years SDG 2.2: End all forms of malnutrition and address the nutritional needs of adolescent girls, pregnant and lactating women and children Situation in per live 78% 83% 46% n/a 50 per 1000 live 40 per 1000 live 86% 20 per 1000 total 30 per 1000 girls years Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication,

23 Myanmar lessons learnt and accomplishments made: (Observations by Katherine Ba Thike) 1. Transition of MDR to MDSR started in November 2015 (UNFPA and WHO support) 2. Technical and training guidelines of Child Death Surveillance and Response (CDSR) with advocacy meetings, TOT and multiplier trainings for CDSR done for 2016 and Health workforce initiative on Midwifery ASEAN Regional Guideline for Minimum Requirements for Training and Accreditation of SBA endorsed by ASEAN, released June Hospital Equity Fund to support reduction MMR and under 5 mortality (NMR, IMR, U5MR) according to national targets of the programme But efforts still needed: o Advocacy for investment in RMNCAH at different levels o Focus on ending preventable maternal and neonatal mortality o Implement plans that have been developed Every Newborn Action Plan, Strategic Plan for Reproductive Health o Address health system issues to support above plans o For WHO to help RMH/MoH to focus on a few issues and do it well 19

24 Nepal Women s Health Maternal mortality ratio Proportion of attended by skilled health personnel Antenatal care coverage (at least one visit) Contraceptive prevalence rate Unmet need for family planning/ Demand for family planning Children s Health Under five mortality rate Infant mortality rate Proportion of 1 year old children immunized against measles Stillbirth Rate Target Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B Achieve, by 2015, universal access to reproductive health Target 4.A Reduce by two thirds, between 1990 and 2015, the under five mortality rate Adolescents Health Adolescent birth rate Indicator 5.4 under Target 5.B Adolescent Mortality Rate MDG Progress since 1990 in 2015 Just missed despite 71% reduction but number of deaths very high 69% increase but still only one third population catered to for institutional deliveries Only half the population covered with very high geographic/social inequities Achieved MDG 4 but 57% of under five deaths are due to newborn conditions 40% of the girls are married by 18 years and begin childbearing by 19 years Target SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive health care services and rights SDG 3.2: By 2030, reduce under 5 mortality to at least as low as 25 per 1000 live SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1000 live Global Strategy Target: By 2030, reduce still to single digits SDG 2.2: End all forms of malnutrition and address the nutritional needs of adolescent girls, pregnant and lactating women and children SDG Situation in per live 36% 58% 50% 28% 36 per 1000 live 29 per 1000 live 88% 18 per 1000 total 71 per 1000 girls 15 19years Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication,

25 Nepal lessons learnt but challenges remain: (Observations by D S Manandhar) a. Financial High out of pocket expenditure. The policy is for free newborn care but funding is inadequate; cost of capacity building /strengthening infrastructure and equipment is large b. Programmatic Inconsistent use of antenatal corticosteroids; inadequate coverage of Kangaroo Mother Care; quality care issues e.g. use of partograph, inadequate institutional readiness for new born resuscitation, skilled human resource constraint particularly for newborn care, unavailability of services 24/7 for 365 days for both mother and neonates including postnatal care, inconsistent use of national protocols/guidelines, newborn component is not well addressed in MNCH training, and monitoring /quality information issues Way forward: Focus on upgrading existing birthing centres to birthing and newborn care centres Scale up community mobilization initiatives Strengthening referral mechanisms for all children Partnerships with private sector in newborn and child health programme Local context specific planning and support by all partners Operational research Continuum of quality services to newborn and children 21

26 Timor Leste Women s Health Maternal mortality ratio Proportion of attended by skilled health personnel Antenatal care coverage (at least one visit) Contraceptive prevalence rate Unmet need for family planning/ Demand for family planning Children s Health Under 5 mortality rate Infant mortality rate Target Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B Achieve, by 2015, universal access to reproductive health Target 4.A Reduce by twothirds, between 1990 and 2015, the under 5mortality rate MDG Progress since 1990 Achieved MDG 5: Policy environment enabling but number of deaths remain high Very poor SBA coverage with only 22% institutional deliveries 3/4 th women get one ANC visit but the number declines steadily and only half get four visits Country has achieved MDG4 because baseline in 1990 was quite high 34% of neonatal deaths are attributed to complication of preterm birth Target SDG SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive healthcare services and rights SDG 3.2: By 2030, reduce under 5 mortality to at least as low as 25 per 1000 live SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1000 live Situation in per live 21% 84% 22% 32% 53 per 1000 live 45 per 1000 live Proportion of 1 year old children immunized against measles Stillbirth Rate Global Strategy Target: By 2030, reduce still to single digits Adolescent s Health Adolescent birth rate Indicator 5.4 under Target 5.B Few girls married by 18 (6%) but 20% of the adolescent girls have begun child bearing by 19 years SDG 2.2: End all forms of malnutrition and address the nutritional needs of adolescent girls, pregnant and lactating women and children 70% 17 per 1000 total 50 per 1000 girls years Adolescent Mortality Rate Source: Levels & Trends in Child mortality Report 2015: Estimates Developed by the UN Inter agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication,

27 Timor Leste: Lessons learnt and key actions taken: (Observations by Sujeewa Amarasena) Timor Leste started with very high maternal and child mortality, which many thought was impossible to tackle. But a high degree of political will, initiatives to strengthen the health system and evidence based interventions taken to scale, to reach every woman ever child, have led to dramatic reductions in maternal and child mortality, and ultimately helping them achieve MDGs 4 and 5. Since 2000 the Government has publicized its commitment to the MDGs 4 and 5, and demonstrated very positive improvements. Increased coverage of skilled care at birth and institutional deliveries Improved quality of care around childbirth, including resuscitation Strengthened management of preterm labour and preterm babies Improved essential newborn care, and early postnatal care at home Strengthened care of sick and small new borns in hospitals 23

28 Thailand Country has already achieved SDG targets Maternal mortality ratio at 20 is less than SDG Target (70 per live ) Neonatal mortality at 7 is lower than the expected 12 per 1000 live Under 5 mortality at 7 is already below 25 per 1000 live Lessons from Thailand s success: (Observations by Sawasdivorn Siraporn) 1. Successful centralized health care coverage plan must be made at the central level but implemented at the local level 2. Coordination of planning and utilization of human resources must consider both providing health services (demand) and training qualify health care personnel (supply) 3. Owing to conscious capacity building on health care financing, Thailand gradually moved from an out of pocket payment to a prepayment system 24

29 Annex 2 SEA/RC69/R3 ENDING PREVENTABLE MATERNAL, NEWBORN AND CHILD MORTALITY IN THE SOUTH EAST ASIA REGION IN LINE WITH THE SUSTAINABLE DEVELOPMENT GOALS (SDGS) AND GLOBAL STRATEGY ON WOMEN S, CHILDREN S AND ADOLESCENTS HEALTH The Regional Committee, Recalling its resolutions SEA/RC53/R9 on Maternal mortality, SEA/RC56/R9 on Health of the newborn1 and SEA/RC58/R2 on Skilled care at every birth, as well as the recent World Health Assembly resolution WHA69.2 on Committing to implementation of the Global Strategy for Women s, Children s and Adolescents Health. Newborn period is first 28 days of life after birth Recognizing the significant progress made towards achieving MDGs 4 and 5 in countries of the South East Asia Region with a regional decline in child mortality rate of 64% and a decline of 69% in the maternal mortality ratio, between 1990 and 2015, and the need to further build upon these achievements, Noting that these figures fall short of the MDG targets of a two thirds reduction in child mortality and a three fourths reduction in maternal mortality, and that neonatal mortality has declined less rapidly than child mortality, that there are significant disparities in achievements across and within countries, and that maternal, newborn and child mortality continue to remain high in some countries in the Region, Acknowledging that the UN Secretary General s Global Strategy on Women s, Children s and Adolescents Health ( ), and the Sustainable Development Goals provide new opportunities and have set new targets for countries on reducing maternal mortality and ending preventable, newborn and child deaths, Further acknowledging that Universal Health Coverage is the overarching umbrella for taking forward the SDG Goal 3 on health, and that the SDGs provide an excellent framework to accelerate efforts to narrow equity gaps in accessing quality care, ensure adequate health financing and sufficient numbers and appropriate skill mix and deployment of health workforce, Appreciating the Regional Flagship Priority on ending preventable maternal, newborn and child mortality with a focus on newborn deaths, and the partnership commitment as exemplified by the joint statement by H6 agencies (WHO, UNICEF, UNFPA, UNAIDS, UN WOMEN and World Bank) on ending preventable maternal, newborn and child mortality, Considering that this resolution supersedes the three previous resolutions on related subjects namely, SEA/RC53/R9, SEA/RC56/R9 and SEA/RC58/R2; 1. URGES Member States: a) To achieve universal access to and coverage of essential intervention packages for reproductive, maternal, newborn, child and adolescent health (RMNCAH) across the continuum of care, with focus on good quality care of mothers and newborns at the time of childbirth and, including mothers and newborns with risks and complications, b) To review and strengthen national health systems, as appropriate, to identify gaps and solutions in relation to the needs of RMNCAH, including by investing in midwifery skills and development of sustainable health financing mechanisms to reduce out of pocket expenses for safe child birth and care of mothers and newborns, c) To strengthen the quality and use of data for programme improvement in line with the indicators and disaggregation in the SDGs and Global Strategy including still and cause of death related to maternal, neonatal, child and adolescent health, and 25

30 d) To reinforce multisectoral and multi stakeholder partnerships and commitments to address underlying social determinants of women s, children s and adolescents health such as early marriage2, nutrition, education, poverty, water sanitation, and to promote early childhood development, 2. REQUESTS the Regional Director: a) To intensify technical collaboration with, and support to, Member States to update their national RMNCAH strategies and plans to address the coverage gaps for essential interventions for RMNCAH, with specific guidance on organizing, planning and setting up quality services for child birth and newborn care, b) To support Member States to strengthen the quality and use of data for programme improvement in line with the indicators and disaggregation in the SDGs and Global Strategy including still and cause of death related to maternal, neonatal, child and adolescent health, c) To support Member States, upon request, for developing national RMNCAH investment case3and encourage adequate national and international investments for ending preventable maternal, newborn and child mortality and improving health and wellbeing of women, children and adolescents, and d) To report progress on implementation of this resolution to the Regional Committee in 2018, 2022, 2026 and September

31 Annex 3 SEAR TAG Meeting December 2015 Overarching recommendations (1) WHO to secure the buy in to the recommendations from all the national governments through the Regional Committee deliberations on Women s, Children s and Adolescents Health, with a focus on reduction in newborn mortality in September (2) To facilitate dissemination, buy in and adoption of the recommendations in countries, countries should be encouraged to replicate the Regional TAG, through national processes, e.g. multi speciality National Task Force. Each country is encouraged to undertake a strategic consultation with the support of H4+ and partners in the country. Countries to create/strengthen National Task Force or similar mechanism and share progress at the next SEAR TAG meeting. (3) Countries to focus on expansion of good quality care for mothers and new borns around the time of childbirth (including late antenatal care) and first few days thereafter including facility based and homebased care of small and sick babies. Countries to prioritize this and operationalize plans e.g. within ENAP immediately and share progress at the next SEARTAG meeting. (4) WHO to inform the intervention packages that will be required for reducing the NMR to low levels of 12 per 1000 live or less (secondary and tertiary care and other interventions). (5) WHO, UNH4+ and partners to support high priority countries for development of investment cases, to engage with Global Finance Facility and mobilise domestic resources for RMNCAH. WHO, UNH4+ and partners to prepare a strategic approach and support country level dialogue for development of investment cases in 2 3 priority countries in 2016 (6) WHO with H4+ to create a SEAR web based repository of best practices in RMNCAH and increase opportunities for cross learning and share innovative experiences. WHO with UNH4+ to create SEAR repository and inform of progress. 27

32 Annex 4 List of Participants SEAR TAG Members 1. Vinod Paul: Chair 2. Nozer Sheriar (India) 3. Mohammad Baharuddin Hasanudin (Indonesia) 4. Katherine Ba Thike (Myanmar) 5. Dharma Saran Manandhar (Nepal) 6. Sujeewa Amarasena (Sri Lanka) 7. Siraporn Sawasdivorn (Thailand) 8. Wendy Graham (connected through skype) H6 Partners: 1. UNCEF ROSA: Sufang Guo 2. UNICEF EAPRO: Kyoko Shimamoto 3. UNFPA: Wame Baravilala 4. UN WOMEN: Ms Subhalakshmi Nandi 5. World Bank: Dr Sheena Chhabra Consultants: 1. Elizabeth Mason 2. Bruce Dick 3. Krishna Bose Secretariat (WHO Regional Offic3): 1. Pem Namgyal, Director, Family Health, Life Course and Gender 2. Neena Raina, Coordinator, Health Through Life Course 3. Rajesh Mehta, Medical Officer, Child and Adolescent Health 4. Neelamani Hewageegana, Maternal and Reproductive Health 5. Priya Karna, Junior Public Health Professional 28

33 Annex 5 Programme 1. Opening Session 2. Progress in implementation of TAG recommendations Report on implementation Perspective from H6 agencies 3. Maternal Health: Finishing the MDG5 work Maternal Health Lancet Series Regional situation Country specific Reflections: (Bangladesh, India, Indonesia, Myanmar, Nepal, TLS) Recommendations for regional and country level actions 4. Child Health: Finishing the MDG4 work Regional situation Child Health Strategic Review Country specific Reflections: (Bangladesh, India, Indonesia, Myanmar, Nepal, TLS) Recommendations for regional and country level actions 5. Regional strategic guidance on Adolescent Health Setting the stage for new regional priority 6. Global Strategy: New and under focused areas and country implications 7. Monitoring Global Strategy and SDG3: Regional and Country 8. Plan for the next TAG Meeting (2017) 9. Conclusion of the meeting 29

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