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A Decade of Change
for Newborn Survival
Changing the trajectory of our future
Dr Anthony K Mbonye
Ministry of Health
Overview of the supplement and Uganda analysis
Health Policy and Planning, Supplement 3, 2012
1. Overview of a decade of change supplement Dr Anthony Mbonye, Ministry of Health
2. Changes in newborn health outcomes and coverage indicatorsDr Olive Sentumbwe, World Heath Organization
3. Programmatic and policy changes over the past decadeDr Hanifah Sengendo, Saving Newborn Lives, Save the Children
4. Changing the trajectory for our futureDr Gelasius Mukasa, IBFAN; Newborn Steering Committee
Outline of presentations
Uganda Decade of Change and Future Implications Analysis Group
Allisyn Moran (Saving Newborn Lives Save the Children)
Anthony K Mbonye (Community Health Services Ministry of Health)
Christine Zirabamuzaale (Consultant)
Francine Kimanuka (UNICEF Uganda)
Gelasius K Mukasa (IBFAN)
Geofrey Bisoborwa (WHO Uganda)
Hanifah Naamala Sengendo (Save the Children Uganda)
Imelda Namagembe (AOGU)
Jamil Mugalu (Mulago Hospital)
Janex M Kabarangira (USAID)
Jessica Nsungwa-Sabiiti (Ministry of Health)
Joy E Lawn (Saving Newborn Lives Save the Children)
Kate Kerber (Saving Newborn Lives Save the Children)
Lillian Luwaga (Ministry of Health)
Margaret Nakakeeto (Child Health Advocacy International – Uganda)
Mary Kinney (Saving Newborn Lives Save the Children)
Miriam Mutabazi [Management Sciences for Health (MSH)]
Miriam Sentongo (Reproductive Health Division Ministry of Health)
Nathalie Gamache (Saving Newborn Lives Save the Children)
Olive Sentumbwe-Mugisa (WHO Uganda)
Patrick Aliganyira (Save the Children Uganda)
Peter Waiswa (MUSPH; Karolinska Institutet)
Robinah Kaitiritimba (Uganda National Health Consumers Organization)
Romano Byaruhanga (Nsambya Hospital; AOGU)
Sabrina Kitaka (Uganda Paediatric Association)
Sakina Kiggundu (Uganda Private Midwives Association)
Sarah Kiguli (Makerere University)
Newborn health champions:11 authors
on behalf of 30 person expert working groupRepresenting
government, heath professional
associations, local academia and
research institutions, UN, donor partners, and civil society
To conduct a multi-country evaluation of
progress in reducing neonatal mortality
from 2000 to 2010 examining changes
in context, coverage of care, health
financing, and health systems and
policy, in order to identify pathways to
scale and potential accelerators or
constraints.
Purpose of the analysis and supplement
In some countries, newborns face a more certain future than 10
years ago, yet in other countries very little has changed.
– Darmstadt et al, HPP editorial
Editorial – Gary Darmstadt, David Oot, Joy Lawn
1. Overview and quantitative analysis:- Neonatal mortality rates and causes
- Multi-country regression modelling to understand predictors of change
- Financial analyses
2. Benchmarking readiness for scale up of newborn care
3. Bangladesh
4. Nepal
5. Pakistan
6. Malawi
7. Uganda
Overview of the papers in the supplement
Country case studies with in-country expert teams
Over 150 contributors globally
39,000 newborn deaths in 2010
• High and stagnant total fertility rate
• Most women access antenatal care and bring their children for immunisations
• Institutional births are increasing: 39% in 2001 to 57% in 2010)
• Gap in access and quality of care between the richest and poorest families
• Human resource for health crisis: health worker density of 14.3 per 10,000 population (2005) compared to WHO benchmark of 23 per 10,000 population.
• History of regional civil unrest and IDP/refugees
Uganda at a glance
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117.
• Neonatal, under-five and 1-59 months mortality
change from 1990-2010 and comparison to other
countries in the region
• Changes in coverage levels from household
surveys at national and sub-national levels
• Changes in quality of care from health facility
assessments and HMIS data
• Changes in financial inputs from government and
official development assistance and comparison to
Countdown to 2015 countries
Quantitative data analyses conducted
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117.
• Changes in national socio-political and
economic context
• Progress in achieving 27 sentinal benchmarks
reflecting readiness to scale up newborn care
interventions
• Inclusion of newborn survival specifically and
in general in national health policies,
programmes, and research activities using a
policy and programme timeline
Policy and programme change analyses
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117.
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Note: The missing
benchmark relates to financial commitments and does not have data.
Progress towards Scale-up Readiness
Benchmarks for newborn care
A Decade of Change
for Newborn Survival
Changing the trajectory of our future
Dr Olive Sentumbwe
WHO
Quantitative data findings for the Uganda analysis
Health Policy and Planning, Supplement 3, 2012
National progress towards Millennium Development
Goal 4 for newborn and child survival from 1990
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117.
Data sources: Uganda Demographic Health Surveys. UN estimates of neonatal and under-five mortality (UNICEF et al. 2011) with a new analysis of mortality trends by age of
death. IHME estimates (Lozano et al. 2011). Note: Survey point estimates are centred two years prior to survey date. MDG 4 target from Countdown to 2015 decade report
reflecting a 2/3 reduction from 1990 U5MR.
99
58
26
0
20
40
60
80
100
120
140
160
180
200
1990 1995 2000 2005 2010 2015
Mo
rtality
per
1000 liv
e b
irth
s
Year
Under-five mortality rate (UN)
Under-five mortality rate (IHME)
Under-five mortality rate (DHS)
Neonatal mortality rate (UN)
Neonatal mortality rate (IHME)
Neonatal mortality rate (DHS)
MDG 4 target
Mortality for children aged 1-59 months reduced at nearly twice the
rate of newborn mortality (4.1% vs 2.2%)
Neonatal mortality trends from 1990
Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data sources:
Uganda Demographic and Health Surveys.. UN estimates (UNICEF et al. 2011a). IHME estimates (Lozano et al. 2011). Note: Survey point estimates are centred two years prior
to survey date.
Newborn mortality in Uganda is reducing at 2.2% per year, slightly
more than the regional average for Africa at 1.5%
Understanding neonatal mortality change, 2000-2010
144 countries, multiple regression modeling
Developed region3% reduction per year
Consistently rapid
neonatal mortality
reduction across countries
Strongest predictors of
NMR change
- Increased national
income
- Reduced fertility
Other regions(including Southern Asia)
3.2% reduction per year
Variable change in mortality
reduction across countries
Strongest predictors of
NMR change
- Reduced fertility
- Baseline level of
neonatal mortalitySub-Saharan Africa
1.5% reduction per year
Mortality reduction is slow and therefore difficult
to analyze what factors related to change.
Source: Lawn J,E. et al. 2012. Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning. 27(Suppl. 3): iii6-ii28.
Countries with increased contraceptive use have made more progress in reducing newborn deaths
Mortality reduction progress could not be attributed to changes in coverage due to limited coverage change and lack of coverage data.
Estimated causes of mortality in 2010
for 39,000 newborn deaths
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117.
Data source: Uganda-specific mortality estimates (Liu et al. 2012). Note: Severe infections include sepsis, meningitis, pneumonia and tetanus.
3 causes
account for 90%
of all newborn
deaths
Trends in coverage data for newborn-related interventions and packages
Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data sources:
Uganda Demographic and Health Surveys.
0% 20% 40% 60% 80% 100%
Exclusive breastfeeding (0-1 month)
Case management for pneumonia (0-6 months)
Postnatal care within 2 days (home births)
Breastfeeding initiated within 1 hour
Babies weighed at birth
Deliveries by caesarean section
Skilled birth attendance
Last birth protected against tetanus
Intermittent preventive treatment in pregnancy…
Antenatal care (4 or more visits)
Antenatal care (1 or more visits)
Contraceptive prevalence rate (any modern…
Percent coverage
UDHS 2001
UDHS 2006
UDHS 2011(preliminary)
Despite increases in coverage of some interventions many indicators
remain low, eg contraceptive use, PNC
17% point increase
Increases in coverage of skilled attendant at birth
12 11
18
56
39
27
3639
71
59
0
10
20
30
40
50
60
70
80
90
100
Bangladesh Nepal Pakistan Malawi Uganda
Co
vera
ge (
%)
Around the year 2000
Around the year 2010
Source: Lawn J,E. et al. 2012. A decade of change for newborn survival, policy and programmes (2000–2010): A multi-country evaluation of progress towards scale. Health Policy and Planning. 27(Suppl. 3).
Over half of women deliver with a skilled attendant in Uganda – an increase from 2000
Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data source:
Analysis of World Health Organization National Health Accounts (WHO 2011b). Note: all values in constant 2008 USD.
Total health expenditure by government, out-
of-pocket, and other private expenditure
Funding for health and MNCH has increased but
direct spending by families remains the bulk of health financing
Majority
is out-
of-
Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data source: (Pitt
et al. 2010) with special analysis done by C. PittNote: All values are in constant 2008 USD.
0
20
40
60
80
100
120
140
160
180
200
2003 2004 2005 2006 2007 2008
US
$ m
illi
on
s
Year
ODA for child health with no reference to
'newborn' (US$ millions)
ODA for MNCH with reference to 'newborn'
(US$ millions)
ODA for maternal and newborn health with
no reference to 'newborn' (US$ millions)
Changes in official development assistance for MNCH
Child health donor
projects with no
reference to newborn
terms in the search
fields
Maternal health
donor projects with
no reference to
newborn terms in the
search fields
MNCH donor projects
with reference to
newborn terms in the
search fields
A Decade of Change for
Newborn Survival
Changing the trajectory of our future
Dr Hanifah Naamala Sengendo
Saving Newborn Lives, Save the Children
Policy and Programme Change
Health Policy and Planning, Supplement 3, 2012
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Note: The missing
benchmark relates to financial commitments and does not have data.
0 3 6 9 12 15 18 21 24 27
2010
2005
2000
Number of benchmarks
Achieved Partially achieved Not achieved Missing
Progress towards Scale-up Readiness
Benchmarks for newborn care
Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Note: The missing
benchmark relates to financial commitments and does not have data.
Progress towards Scale-up Readiness
Benchmarks for newborn care
Formative
research
HBB, KMC,
VHT training
Timeline of progress
When was policy and programme change achieved?
Two pivotal milestones for newborn survival involving multiple champions,
partners and wide ownership
Advocacy, partnerships and convening
mechanisms
PakistanInformal advocacy by civil
society, academia, and donors
became formal in 2008 with
Advocacy and Advisory Network
for Newborns (AANN)
Bangladesh Informal partnerships led by MoH with collaboration
from high profile newborn health
champions
Uganda Formal convening mechanism through the
Newborn Steering Committee
within MoH Maternal & Child
Health cluster
How was policy and programme change achieved?
A Decade of Change for
Newborn Survival
Changing the trajectory of our future
Dr Gelasius Mukasa
Executive Director, IBFAN Uganda
Chairman, National Newborn Steering Committee
Current gaps and future plans for newborn health and survival
Health Policy and Planning, Supplement 3, 2012
• Neonatal mortality reduced by 20% in the past
decade, more than the regional average but not
enough to help meet MDG 4 for child survival
• Recent attention for newborn survival has lead to
rapid change in policies and programmes but
coverage increases arising from these changes have
yet to be seen
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of
Key messages from the Uganda analysis
• Local evidence and experience has been invaluable towards ensuring newborn health is prioritised across the health sector
• The Newborn Steering Committee has led in change and strengthened dialogue among the MNCH community – is it sustainable and what are the next steps?
Key messages from the Uganda analysis
Together we have the tools, funding and opportunity to transform
maternal, neonatal and child survival in Uganda– will we deliver?
• Link family planning programmes to maternal and newborn survival
• Integration with HIV/AIDS messages and programmes especially around PMTCT delivery
• Continued partnership with health professionals: AOGU, UPA, UPMA, etc
• Finding and developing multi- sectoral champions: education,
finance, planning, parliamentarians
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Outstanding gaps in programme integration
• Strategically include the private health sector as many people access the health services from it i.e. about 40% of health services in Uganda are offered by the private sector
• Business community not yet incorporated yet it can play a vital role, especially through corporate social responsibility
• Attention of social marketing groups / marketeers not yet drawn
Outstanding gaps in programme integration
• Methods for further increasing facility delivery and quality
of care at health facilities
• Capacity of VHTs to identify and refer sick newborns in
the context of iCCM
• Length and content of newborn care training package
• How to cover LSS, HBB, KMC, IMNCI, MPDR, etc
• H/Ws are very knowledgeable, however, their practical
skills are limited (seen from the pretests conducted).
There is urgent need to equip them with practical skills so
as to match their level of knowledge
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Outstanding gaps in evidence
Through an external evaluation, it was realized that:
The Steering Committee is operating at the central / national level
As a way forward:
1. Incorporate representatives from various districts onto the
central committee
2. Establish newborn district teams to enhance ownership at
district level and communication through district representatives
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Plans for the National Steering Committee
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DOWNLOAD AND USE THE SUPPLEMENTFull Report FREE ACCESS at Health Policy and Planning Website
http://heapol.oxfordjournals.org/content/27/suppl_3.toc?etoc
Summary Fact cards and additional information at the
Healthy Newborn Network:
http://www.healthynewbornnetwork.org/resource/decade-change-
newborn-survival-summary-cards
Additional materials, resources, powerpoints:
http://www.healthynewbornnetwork.org/page/decade-change-
newborn-survival
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