TORs for. Title: Consultant development of new RNCH policy and strategy. Start Date: February Reporting to: Health Specialist.

Transcription

1 TORs for Development of Reproductive Newborn and Child Health (RNCH) Policy Review and update RNCH strategy (with a special emphasize on newborn care) Title: Consultant development of new RNCH policy and strategy Location: Duration: Freetown 40 days Start Date: February 2011 Reporting to: Health Specialist Background The social economic and demographic realities in Sierra Leone present ideal environment for poor maternal and child survival. High poverty levels, illiteracy, high fertility levels, teenage child bearing and low uptake of family planning methods are closely intertwined, complex in nature and with the strongest determining power over maternal and newborn survival outcomes. The population of Sierra Leone is characterized by high household size and fertility, poverty, high levels of illiteracy and visible disparities between geographic regions and the rural and urban divide. The status of maternal and child survival closely mirror the social, economic and demographic disparities seen between regions and the rural urban divide. As of 2008 the estimated population for Sierra Leone was 5.5 million people with an average household population size of about 6 people. About 70% of the population were living below the poverty line in 2007 (PRSP 2007). Most of the poor population is found in the Northern parts of the country and, in rural areas. The poor living conditions in rural areas is depicted by only 1% of the rural population having access to electricity, 30% accessing improved water and only 6% accessing improved toilet facilities. The fairer living standards in urban areas are characterized by 33% access to 1

2 electricity, 80% access to improved water and 21% access to improved toilet facilities (SLDHS 2008). On average only about 55% of household in Sierra Leone own a radio. The country has high illiteracy levels among both women age (66%) and men age (48%). Only 13% of the women have primary school as the highest level of education attained compared with 14% of the men in same age Only 19% of women and slightly more men 32% had attained secondary school education. Only 3% of women and 5% of men have more than secondary school education; Health situation analysis Sierra Leone has recently documented improvements in child hood indicators buts nevertheless, they remain high. The under five mortality rate is 140 deaths per 1000 live births; Infant mortality is 89 deaths per 1000 live births while, Neonatal Mortality is 36 per 1000 live births and that accounts for about 40% of all infants deaths- basically 40% of all infant deaths take place during the 1st 28 days of live. The newborns die from largely from three preventable conditions namely: birth asyphyxia; neonatal infections; hypothermia and low birth weight (figure 1). Figure 1: Neonatal (NN) conditions account for about 25% of all cause specific deaths in children under five years of age (0-60 months) Proportionate attribution Measles, 5 Pertusis, 2 Malaria, 12 Others, 13 Maternal and child undernutrition contributes to 57% U5 deaths Pneumonia, 24 Diarrhea, Neonatal combined-25% 2. Pneumonia-24% 3. Diarrhea-18% 4. Malaria-12% 5. Malnutrition 60% NN-Others, 3 NN- Sepsis, 9 NN-Asphyxia, 5 NN-Prematurity, 6 NN-Tetanus, 2 Women in Sierra Leone have an average of 5.1 children- 3.8 in urban areas. 5.8 in rural areas; lowest 3.4 in Western region, 5.8 children in Northern region- other regions also have high fertility rates. The fertility levels also vary with mother s education and economic status. Women who have more than secondary education have an average of 3.1 children, while women with no education have almost twice as many children. Fertility increases as the wealth of the households 2

3 decreases. The poorest women have twice as many children as women who live in the wealthiest households- 6.3 versus 3.2 children per women. Teenage child bearing is high at 33% nationwide. It is highest in the Northern region (40%) and lowest in the Western region at 18%. Women with no education are much more likely (54%) to have begun childbearing than women with secondary or more education (17%). Use of family planning method is low with only 7% of married women age using modern method. Modern methods are used by 14% of married women in urban areas compared with 14% in rural areas. About 28% of married women have an unmet need for family planning. One in every five infants in Sierra Leone is born less than two years after a previous birth largely as a result of low uptake of family planning methods. These infants have very high infant mortality rates of 182 deaths per 1000 live births compared with 54 deaths per 1000 live births for infants born four years after the previous birth. Family planning use or lack of it has one of the strongest single most effect on child mortality. The high neonatal deaths are closely linked maternal mortality ratio which is also high at 857 maternal deaths for every live births. The two outcomes are influenced in a similar manage by same health systems bottlenecks and, social economics and cultural confounders. Similarly the high impact evidence based maternal and newborn interventions have similar delivery strategies. The high impact interventions during antenatal period are best delivered in four focused antenatal care visits that start by the forth month of pregnancy. About 87% of women receive at most two antenatal care checkups from a skilled provider. Eighty percent of women s most recent births were protected against neonatal tetanus. Only about 30% of the women commence antenatal care visit by their forth month of pregnancy hence only this proportion has a chance of making up to all the four recommended visits before delivery. The fewer than recommended skilled antenatal attendance translates into lost opportunities for enhancing maternal and newborn outcomes. Skilled attendance during delivery and skilled post natal care attendance during 1st 24 to 48 hours offers the best survival lifeline for both the mothers and newborns since most of the associated mortality takes place at this same period. However for Sierra Leone many women and newborn are excluded from the lifeline when only 25% of births occur in health facilities and in total about 42% of the deliveries are assisted by a skilled service provider. And, only 38% of mothers receive first post natal check-up less that 4 hours after delivery. The skill level of the service provider and the number of such providers has long been a recognized bottleneck in Sierra Leone s health care system that is in the process of recovering from long periods of neglect. The coverage with other important Reproductive Child Health interventions are also low. The fully immunization coverage for children age months is only 40%. Households with at least one insecticide treated net were 37% whereas pregnant women who slept under an ITN were 27%. The situation of malaria and use of insecticide treated nets is set to radically change with the recent implementation of universal LLITN coverage campaign in Sierra Leone. 3

4 However, the country will not be on track for MDG 4 targets come 2015 unless acceleration takes place for high impact interventions for the under five years old populations (Figure 2). Figure 2: Achieving MDG 4-Underfive mortality trendat current pace, the country will miss the target Acceleration needed- Where? Poor health among disadvantaged groups results not just from lack of material resources (food, housing, water, etc.) but also from such psychological factors as lack of empowerment. In Sierra Leone, about 85% of married women are employed compared to almost all men at 98%. The women earn less and are more likely to be unpaid. And, in most parts of Sierra Leone women have little power to make household decisions. Only one in ten women make decisions about their own health care on their own and by extension that of their children. The status of women in general and low coverage and use of high impact maternal health interventions strongly imply that meeting MDG 5 targets by 2015 will not be easy for the country. As shown in figure 3 below, going by current progress the country will actually miss the target. 4

5 Figure 3: Achieving MDG 5- at current rate of progress the country will miss the target by 2015 Current progression MDG target Institutional policy and strategy arrangements Sierra Leone has experienced gradual strengthening of the strategic planning and programming environment in the health sector since That is the year when the country started implementing the Reproductive Child Health Strategic Plan It is also the same year that a nationwide needs assessment for Emergency Obstetrics and Newborn Care 2008 (EmONC 2008) and the first Sierra Leone Demographic and Health Survey were conducted. To date, findings from the two surveys continue to guide implementation of health activities in the country. The Reproductive Health Strategy comes to an end in 2010 when the National Health Strategic Plan (NHSSP) is effectively taking off the ground. NHSSP provides a common framework that guides all interventions by all parties at all levels of the national health system in Sierra Leone. Reproductive Health and Child Health Policies that were drafted in 2008 still remain in draft form to date. These policies will therefore need to be revisited, reviewed, updated and finalized as one Reproductive Newborn and Child Health policy to reflect on a stronger newborn agenda. The updated policy will then be used as basis for the review of current Reproductive and Child Health strategy and development of a new Reproductive Newborn and Child Health Strategy. The NHSSP has been translated into a Basic Package of Essential Health Services (BPEHS) for Sierra Leone that took effect in March The BPEHS contain components, interventions and services by level of care. For maternal and newborn care the intervention areas include: antenatal care; delivery and peri-natal care; post natal care; family planning; care of the newborn and emergency obstetric care. 5

6 Free Health Care policy for Sierra Leone was launched in The policy focuses on an essential package of health care services delivered free of charge at the point of services targeting pregnant women, lactating mothers and children under age of 5 years. Approximately 230,000 pregnant women and nearly 1 million infants benefit from free health care services countrywide. The operational dynamics of high impact interventions for each of the cohorts targeted for free care need to be clearly articulated and implemented to scale hence the justification for the review and development of a new operational strategy for RNCH. The operational strategy will also need to be aligned to the anticipated Performance Based Financing (PBF). Progress made in the implementation of Free Health Care (FHC) We still have acute human resources shortages despite recent attempts at recruiting additional staff following launch of Free Health Care in the country in March The human resource is also mal-distributed with most of them being located in Western Area and in towns. The additional staff recruitment increased percentage of technical staff in public health facilities by 56%. The number of health facilities with only one staff reduced from 59% to 33%, in other word, 67% of health facilities has more than one technical staff an improvement from 41% before initiation of FHC. Most of the 51 public hospitals are providing Comprehensive Emergency Obstetric Newborn Care. On the other hand, the Peripheral Health Units (PHUs) are poorly prepared for the provision of Basic Emergency Obstetric and Newborn Care services. Only 26 out of the 65 earmarked BEmONC facilities are partially equipped to deliver BEmONC. There is therefore a major gap in provision of BEmONC services. Major challenges in service delivery relate to drugs shortages in many health facilities in the country. The Fully Immunization Coverage at the end of September 2010 was 57%. Only 19% of the fully immunized children were reached through outreach services. Outreach services have declined since the beginning of the FHC implementation partly as a result of high health facility case loads and breakdown of some cold chain equipment. During the period Jan-Sept 2010, ANC, PNC and delivery services uptake increased followed by a decrease. A total of women attended PNC 1st week in September, an estimated 60% coverage. However estimated 2nd week visit reduced to 41%. More normal deliveries were taking place hospitals and not in lower level facilities hence introducing some elements of referral inefficiency. About 38% of all deliveries in the country took place in PCMH in Freetown, 10% in Kenema and a further 10% in Makeni. During the same period, there was hardly any hospital assisted deliveries. In 2009, the country established an institutional framework for maternal death reviews, countrywide social mobilization is ongoing. Subsequently we are now having more information on maternal deaths- when they occur and where they occur. During the period Jan-Sept 2010, a total of 1527 maternal deaths were documented. Hospital deaths were 164, PHU deaths were 839 and Community deaths were

7 Guiding principles for developing new RNCH policy and strategy The operational strategy will need to be fully aligned to the national health strategy, basic package of essential health services, Free Health Care and anticipated Performance Based Financing. There must be no conflicts. Current community level actions are vertical and fragmented with weak monitoring, supervision and oversight. Much more efforts and harmonization is needed at the community level. RNCH policy and strategy will need greater alignment to community level actions. RNCH policy and strategy will need to come out with a clear analysis and articulation of conditions for implementing change and in a simplified manner. Clarify the goal and align to the health sector goal Clarify the objectives and align to the greater health sector objectives. Incorporate simple technical features in the strategies as applicable. Clarify the monitoring and evaluation framework. Incorporate visible benefits and results with clear focus on managing for results. Clarify the costs based on precise costing of selected interventions and their coverage. Get participation of directorate of planning and WHO. Clarify strategies, content and interventions based on evidence. The specific tasks are as follows: The overall assignment is to work with a RNCH technical working group to develop the policy and strategy and share with other stakeholders, disseminate and monitor implementation. The specific assignment includes: Conduct a stakeholders analysis, identify uncertainties and propose strategies for greater buy in from key stakeholders- MOHS, WHO, UNFPA, UNICEF, CF, CHASL, CARE, IRC, DFiD TA, ADB, MSF Belgium, Save the children UK, Medical school, Midwifery, District Councils, DHMTs, Health workers, CHWs, beneficiaries-mothers and newborns. Ensure and support MOHS leadership in the policy and strategy development process. Conduct a situation analysis and prepare a draft policy and strategy write-up framework. Achieve buy in from the stakeholders. 7

8 Conduct a critical review and analysis of existing RH and Child Health draft policies and identify issues for discussion and consensus among stakeholders. Make presentations to the stakeholders, obtain feedback and incorporate to the process. Develop initial draft of the RNCH policy. Conduct a critical review and analysis of existing RCH strategy and identify issues for discussion and consensus among stakeholders. Make presentations to the stakeholders, obtain feedback and incorporate to the process. In a participatory manner, identify High Impact Interventions for RNCH, conduct bottleneck identification, analysis, reduction and formulate operation strategies and actions. Review and update RCH strategy and develop a new RNCH operational strategy with a clear focus on newborn care. Develop M&E framework Conduct and document an analysis of financial, technical and managerial resources available and required for the implementation of the RNCH policy and strategy. Build a strategic implementation process: involve planners and managers in analysis of how to execute policy, identify networks of supporters, manage uncertainty, promote public awareness, institute mechanisms for consultations, monitoring and fine tuning on policy, strategy and actions. Hold series of feedback dissemination meetings followed by systematic fine tuning of the operational strategy. Commence the review process in Nov-Dec 2010 with the aim of finalization in January Location The consultant will be based in Freetown and will work from UNICEF SL CSD section using own computer equipment. The consultant will be expected to spend over 70% of the time with Government counterparts and stakeholders. Deliverables 1. RNCH policy by end of February Debriefing report by end of February RNCH strategy by end of March Final debriefing report by end March

9 Desired background and experience The assignment requires an authority in Reproductive Newborn and Child Health programming with no less than 15 years of relevant international experience and proven high quality delivery of similar assignments. The consultant must possess exceptionally good documentation skills. At least a Masters Degree in a field related to maternal and child health and international policy work experience desired. Familiarity with the Sierra Leone health sector and high level policy makers and stakeholders will be an added advantage. Conditions The consultant will be responsible for: Overall management of the assignment; Liaison with UNICEF supervisor, Directorate of Reproductive and Child Health department and other stakeholders and, Consultant fees to be paid to the consultant on satisfactory completion of assignment. 9