Division of Family and Reproductive Health 2008 in Brief habim
Impacting the lives of the most vulnerable in the WHO African Region
CONTENTS Page 3 5 6
Foreword Acknowledgements Abbreviations 1. FAMILY AND REPRODUCTIVE HEALTH 1.1 Introduction 1.2 Vision, mission and strategic orientations 1.3 Key achievements
7 8 9
2. CHILD AND ADOLESCENT HEALH 2.1 Key issues and challenges 2.2 Major achievements 2.3 Future perspectives
11 12 19
3. SEXUAL AND REPRODUCTIVE HEALTH 3.1 Key issues and challenges 3.2 Major achievements 3.3 Future perspectives
20 21 22
4. MAKING PREGNANCY SAFER 4.1 Key issues and challenges 4.2 Major achievements 4.3 Future perspectives
23 24 31
5. GENDER, WOMEN AND HEALTH 5.1 Key issues and challenges 5.2 Major achievements 5.3 Future perspectives
32 32 34
6. ENABLING FACTORS, CONSTRAINTS and LESSONS LEARNT 6.1 Enabling factors 6.2 Constraints 6.3 Lessons learnt
35 35 35
7. CONCLUSION
36
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FOREWORD High maternal, newborn and child morbidity and mortality in the WHO African Region continue to be a major concern to all stakeholders. The rate of decline of maternal mortality has been particularly slow, causing serious doubt about the attainment of Millennium Development Goal (MDG) 5. Currently we have proven effective interventions to address the above unacceptable morbidity and mortality rates. However, there are still challenges related to inadequate access to quality health care for children and women as well as inadequate sexual and reproductive health and rights, including gender-based violence. Women and children suffer disproportionately from the burdens of HIV/AIDS, malaria and tuberculosis; unchecked mother-to-child transmission of HIV infection; inappropriate feeding practices; increasing magnitude of child sexual abuse; increased vulnerability of adolescents to early sexual activity resulting in unwanted pregnancies and unsafe abortions; and high prevalence of harmful traditional practices such as female genital mutilation. Other determinants of health such as poverty, hunger discrimination and inequity prevalent in the Region combine forces to adversely affect the health of the most vulnerable individuals, families and communities. In addition, weak health systems in the Region continue to impact negatively on the maternal, newborn and child health indicators in most countries. Consequently, the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa (2008) urged countries to update their national health policies and plans according to the Primary Health Care approach in order to strengthen health systems and achieve the Millennium Development Goals, particularly child health and maternal health. The commitment of African Heads of State towards the achievement of the MDGs urged the Division of Family and Reproductive Health to enhance the critical role it plays in supporting countries to achieve their national maternal, newborn and child health (MNCH) objectives. Objective 4 of the Medium Term Strategic Plan 20082013 focuses on reducing morbidity and mortality during key stages of life which include pregnancy, childbirth, the neonatal period, childhood and adolescence; improving sexual and reproductive health; and promoting active and healthy ageing for all individuals. In 2008 the Division invested considerable resources in transforming two strategic documents into concrete policies and actions at country levels: the Road Map for Accelerating the Attainment of the MDGs Related to Maternal and Newborn Health in Africa and the Regional Child Survival Strategy. In a number of countries, important partnerships were built with key stakeholders to scale up implementation of interventions to increase access to care by mothers, newborns and children. The Road Map for Accelerating the Attainment of the MDGs was adopted in 2004, and the Child Survival Strategy was adopted by the Regional Committee for Africa at its fifty-sixth session. These two documents set the stage for reducing maternal, newborn and child morbidity and mortality in the Region. Increased collaboration with the African Union enabled the WHO Regional Office for Africa to take the Road Map and Child Survival Strategy to the highest level of commitment and established a continental agenda urging immediate action by all Heads of State. Also, the first regional meeting of national Child and Adolescent Health (CAH) and Making Pregnancy Safer (MPS) programme managers focused on sharing best practices
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and research results and how best they can be used at country level to strengthen reproductive health programmes and services. This report highlights the major achievements of the Division during the year 2008. It outlines the contributions made by the Division in collaboration with partners towards the attainment of the MDGs and assuring the highest standard of health for the people of Africa. The enabling factors, constraints and lessons learnt in the course of the year have been identified for consideration in future perspectives of the Division’s work. Thank you.
Dr Tigest Ketsela Director, Division of Family and Reproductive Health
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ACKNOWLEDGEMENTS The Division of Family and Reproductive Health would like to thank all those who contributed directly or indirectly to the completion of this report. The Division is grateful to Dr Luis G. Sambo, Regional Director, and Dr Paul Lusamba-Dikassa, Director of Programme Management, for their continuous support throughout the reporting period. The high quality of collaboration with Regional Advisers in the Divisions of Prevention and Control of Communicable Diseases; Prevention and Control of HIV/AIDS, Tuberculosis and Malaria; Prevention and Control of Noncommunicable Diseases; Health Systems and Services Development; and Administration and Finance has been invaluable. Colleagues from the Family and Community Health Cluster at WHO Headquarters, namely from the Departments of Reproductive Health Research, Making Pregnancy Safer, Child and Adolescent Health, and Gender and Women’s Health have worked closely with the Division to strengthen existing collaboration. The Departments of HIV/AIDS and Health Action in Crisis provided invaluable support to our work at country and regional levels. The Division acknowledges the support of the following partners: DFID, ECOWAS, ECSA, GAIN, GTZ, HKI, IBFAN, IPGRI, LINKAGES, PATH, SADCC and USAID. Collaboration with other UN agencies—FAO, UNAIDS, UNESCO, UNICEF, UNFPA, WFP and WORLD BANK—has been invaluable to all the four areas of work in the Division. The contributions of the Africa Bureau of the Global Bureau of the United States Agency for International Development and the Associates, namely Academy for Educational Development, AFRICA 2010, ADVANCE AFRICA, AWARE-RH, POLICY II and ACCESS, Ford Foundation and Melinda and Bill Gates Foundation as well as the Governments of Finland, France, Germany, Great Britain, Italy, Netherlands and Norway were crucial in achieving the results highlighted in this report. Many thanks go also to all the Regional Advisers of the Division of Family and Reproductive Health who have contributed immensely to enrich each area of work and programme. However, most of their work would not have been accomplished without the outstanding support staff. They all contributed to making the present document both a reference and an advocacy tool for raising awareness on the issues of family and reproductive health.
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ABBREVIATIONS AACHRD ARNS ETAT ADH AIDS ANC APADOC ARV CAH CPR CRC CSA DRH FFLH-Plus FGM GWH HIV HQ IBP IMCI IMPAC IPT MAC MDG MDA MNCH MPS MIP NCD NGO PMNCH PMTCT QII RHT RHR RPOA/FGM RFP SNL SFR UNGASS USAID WCC WMH
African Advisory Committee for Health Research and Development African Regional Nutrition Strategy Emergency Triage, Assessment and Treatment Adolescent Health Acquired Immunodeficiency Syndrome Antenatal care Alliance of Parents, Adolescents and the Community Antiretroviral Child and Adolescent Health Contraceptive Prevalence Rate Convention on the Rights of the Child Child Sexual Abuse Division of Family and Reproductive Health Female Functional Literacy and Health Promotion Female Genital Mutilation Gender, Women and Health Human Immunodeficiency Virus Headquarters Implementing Best Practices Integrated Management of Childhood Illness Integrated Management of Pregnancy and Childbirth Intermittent Preventive Treatment Malaria Action Coalition Millennium Development Goal Maternal Death Audit Maternal, Newborn and Child Health Making Pregnancy Safer Malaria in Pregnancy Noncommunicable Disease Nongovernmental Organization Partnerships in Maternal, Newborn and Child Health Prevention of Mother-to-Child Transmission (of HIV) Quality Improvement Initiative Reproductive Health Training Reproductive Health Research Regional Plan of Action to Accelerate the Elimination of Female Genital Mutilation Repositioning Family Planning Save Newborn Lives Social Aspects of Family and Reproductive Health United Nations General Assembly Special Session United States Agency for International Development WHO Collaborating Centre Women’s Health and Development
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1. Family and Reproductive Health 1.1 Introduction The underlying social, economic and cultural factors contributing to the high levels of maternal, newborn and child morbidity, mortality and malnutrition in the African Region are well known. Proven cost-effective interventions are known and available. However, reversing the downward trend has been a major problem for many years. The main issues related to this dramatic situation include inadequate translation of policies into action; weak health systems, especially the acute shortage of human resources; inadequate allocation of funds; and poor community participation in MNCH interventions, aggravated by malaria and HIV infections. In addition, poverty and high levels of illiteracy in many African countries contribute to the low status of women and poor health-seeking behaviour of communities which negatively affect women’s health. In view of this and other related issues, the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa (2008) urged countries to update their national health policies and plans according to the Primary Health Care approach in order to strengthen health systems and achieve the Millennium Development Goals, particularly child health and maternal health. Weak health systems in the Region continue to impact negatively on the maternal, newborn and child health indicators in most countries. In 2008, the Division of Family and Reproductive Health channelled work through four programmes, namely: Child and Adolescent Health (CAH); Gender, Women and Health (GWH); Making Pregnancy Safer (MPS); and Sexual and Reproductive Health (SHR). Through these areas of work, technical support to countries was strengthened with particular emphasis on efforts towards the attainment of the (MDGs) in the African Region. The main focus of the Division’s work was on reducing morbidity and mortality during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence; improving sexual and reproductive health; and promoting active and healthy ageing for all individuals.
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1.2 Vision, mission and strategic orientations DIVISION OF FAMILY AND REPRODUCTIVE HEALTH VISION
MISSION
Enjoyment by all people of the African Region of the best standard of family and reproductive health and development during all stages of the life course.
To support Member States to attain universal coverage of and access to costeffective interventions to reduce morbidity and mortality and promote the Family and Reproductive Health outcomes during the key stages of life including pregnancy, childbirth, neonatal period, childhood, adolescence and ageing.
STRATEGIC ORIENTATIONS •
• •
•
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Support countries to develop policies, strategies and programmes that enhance scaling up of essential health interventions to attain universal coverage and access. Support countries to strengthen health systems and improve quality of maternal, newborn and child health service delivery at facility and community levels. Support countries to strengthen community structures and resources to maximize family and community participation in maternal, newborn and child health interventions. Support countries to address key sociocultural health determinants that affect maternal, newborn and child health outcomes (e.g., harmful delivery practices, female genital mutilation, gender equity, food taboos for pregnant and lactating mothers and children, etc.).
1.3 Key achievements The significant achievements recorded in the reporting year demonstrate the commitment of Division staff, with the support of both internal and external partners. In spite of human resource constraints, the Division continued to make significant progress. The key achievements included: •
Revision of Integrated Management of Childhood Illness (IMCI) guidelines to include newborn care within the first week of life in five1 additional countries, bringing the cumulative total of countries with newborn care included in their IMCI algorithm to 21. Six countries expanded newborn interventions at district level.2 Tanzania and Uganda conducted situation analyses on newborn health and developed a newborn component for the MNCH Strategy. P
P
P
P
•
Seven regional facilitators and 27 national facilitators from nine countries were trained in using the new WHO Child Growth Assessment tool. Seven countries had national orientations and adopted the new growth standards
•
A total of 24 countries adopted policies on the use of low osmolarity oral rehydration salts and zinc in the management of childhood diarrhoea.
•
A total of 17 countries adopted policies for community health worker case management of pneumonia.
•
A training module on child health programme management was finalized and the first regional course was conducted with participants from 13 countries.
•
Partnerships for maternal, newborn and child health were enhanced through joint tracking of country progress in child survival.
•
Seven countries3 finalized or developed their adolescent health strategic plans, and five countries extended the implementation of adolescent and youth-friendly health services to district level.4 P
P
P
P
•
WHO in collaboration with partners, USAID and the Academy for Education Development, developed a repositioning FP advocacy toolkit. Botswana, Senegal, South Africa and Zambia updated their FP guidelines and manuals
•
The Regional Office in collaboration with HQ initiated a six-country pilot project on early detection of cervical cancer using visual inspection with acetic acid.
•
An additional six countries5 developed national Road Maps, bringing the total number to 42 countries, and 15 countries developed district plans for accelerated implementation of national Road Maps.
•
A total of 12 countries6 strengthened pre- and in-service training on emergency obstetric care. Nine countries7 developed PMTCT scaling up plans through the WHO/CIDA Partnership
TP
TP
TP
TP
TP
TP
1
Botswana, Lesotho, Namibia, Rwanda and South Africa. Ghana, Kenya, Malawi, Senegal, Uganda and Zâmbia. 3 Cameroon, Gabon, Ghana, Guinea, Madagascar, Mali and Togo. 4 Burkina Faso, Malawi, Mozambique, Senegal and Tanzania. P
P
2 P
P
P
P
P
P
Cape Verde, Chad, Equatorial Guinea, Sao Tome and Principe, South Africa and Tanzania.
5 P
P
Ethiopia, Gabon, Gambia, Guinea-Bissau, Malawi, Mozambique, Niger, Senegal, Tanzania, Uganda, Zambia and Zimbabwe. 7 Central African Republic, Democratic Republic of Congo, Ethiopia, Lesotho, Mozambique, Nigeria, Swaziland, Zambia and Zimbabwe. 6 P
P
P
P
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grant; 12 countries8 institutionalized MNH days and weeks for increased public awareness and political commitment. TP
•
TP
A total of 20 WHO Country Office programme managers were introduced to MPS and IMPAC tools and guidelines9 in order to improve the utilization of these tools at country level as a means of improving the availability of skilled attendants and quality of care. P
P
•
Maternal and Perinatal Deaths Review (MDR) methodology was introduced in four more countries, bringing to 27 the total number of countries on track for the institutionalization of MDRs
•
A regional consultation on haemorrhage during pregnancy, childbirth and the postpartum period was held in Luanda, Angola aimed at contributing to the reduction of maternal mortality due to haemorrhage in the African Region.
•
At its fifty-eighth session, the WHO Regional Committee for Africa adopted Resolution AFR/RC58/R1 on women’s health and proposed the establishment of a regional commission on women’s health.
•
The Regional Office, in collaboration with HQ, carried out a regional survey on gender issues.
•
A ten-year evaluation of implementation of accelerated FGM elimination action showed that all 12 countries had established national laws and institutions to fight against FGM.
Burkina Faso, Burundi, Eritrea, Ethiopia, Republic of Congo, Kenya, Madagascar, Mauritania, Niger, Nigeria, Tanzania, and Uganda.
P
8 P
P
Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice; Managing complications in pregnancy and childbirth: a guide for midwives and doctors; Managing newborn problems: a guide for doctors, nurses, and midwives; Standards; Beyond the numbers; Integrated health technology package; Midwifery educational material; Essential newborn care course; Midwifery tool kit; Needs assessment; Working with individuals, families and communities to improve maternal and newborn health.
9
P
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2. Child and Adolescent Health 2.1 Key issues and challenges The situation of most African children remains critical and is underpinned by serious poverty. Although the number of child deaths worldwide has been reduced to fewer than 10 million per year, Africa continues to bear the brunt of these deaths and now contributes 48% of global child deaths.10 Each year, about 4.6 million children under-five die of preventable and treatable conditions such as pneumonia, malaria, diarrhoea, measles, malnutrition, HIV, AIDS and neonatal conditions; 27% of all underfive deaths are among newborns. Seven years before 2015, data show that of the 46 countries in the World Health Organization (WHO) African Region, only five countries are indicated as being on track, 21 countries have insufficient progress and 20 are not making progress towards under-five mortality reduction targets.11 In countries where progress is lagging or where child mortality has increased, AIDS and conflict are likely to be major contributing factors. Infections are the main direct causes of child mortality. The WHO objective for 2008 was to support countries in the African Region to scale up implementation and measure the impact of strategies to reduce childhood morbidity and mortality, promote newborn health and child survival, and respond to the health needs and promote healthy development of adolescents. The strategic approaches for 20082009 include: advocacy for harmonization of child survival goals and agendas; strengthening health systems; empowering families and communities; operational partnerships; operations research; and mobilization of resources at international, regional and government levels for newborn, child and adolescent health. The key achievements realized during 2008 are summarized in this report.
10
World Health Organization, World health statistics, WHO, 2008. Progress for children: a world fit for children, Statistical review, United Nations Children’s Fund (UNICEF), Number 6, December 2007.
11
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Figure 1: Map of progress in under-five mortality trends towards Millennium Development Goal targets in the African Region
KEY FOR MDG 4 PROGRESS Target achieved or trend towards achievement Progress made but insufficient trend to reach the target
No progress made or decline
Algeria, Cape Verde, Eritrea, Mauritius, Seychelles Benin, Comoros, Côte d'Ivoire, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Lesotho, Madagascar, Malawi, Mauritania, Mozambique, Namibia, Niger, Nigeria, Senegal, Tanzania, Togo, Uganda, Zimbabwe Angola, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Republic of Congo, Democratic Republic of Congo, Equatorial Guinea, Gabon, Kenya, Liberia, Mali, Rwanda, Sao Tome and Principe, Sierra Leone, South Africa, Swaziland, Zambia
Sources: Countdown to 2015: tracking progress in maternal, newborn and child survival, the 2008 report; Progress for children: a world fit for children, Statistical review, number 6, December 2007, UNICEF.
2.2 Major achievements 2.2.1 Newborn health
Credit: WHO/PMNCH
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Health worker capacity for implementation of neonatal survival activities was strengthened in 11 countries.12 Cumulatively, a total of 31 countries have thus been supported to build capacity for neonatal survival activities in the last two years. Care of newborns was improved through inclusion of the first week of life in IMCI guidelines in five13 more countries, bringing the cumulative total of countries with newborns in their IMCI algorithm to 21. Six countries expanded newborn interventions at district level.14 Tanzania and Uganda conducted situation analyses on newborn health and developed a newborn component for the MNCH Strategy. Capacity-building (TOT) in community newborn care was conducted for countries in western, eastern and southern Africa. Of these, six countries trained community health workers.15 A pool of consultants was established to support newborn health care training at facility or community level in over one third of the countries in the Region.16
2.2.2 Infant and Young Child Feeding
Credit: MOH, Kenya
The prevalence of low birth weight ranges from 7% to 42% in sub-Saharan Africa. Exclusive breastfeeding rates are low, and complementary foods are inadequate and inappropriate in the Region. In response, the WHO Regional Office for Africa supported Member States through the provision of strategies, norms, standards and technical guidance to develop and implement national Infant and Young Child Feeding (IYCF) policies and plans. Key achievements in 2008 are described below. The Regional Office supported a regional workshop on the integrated approach to the management of severe acute malnutrition for selected countries (South Africa, Swaziland, Zambia and Zimbabwe). This workshop contributed to capacity-building for the integrated management of severe acute malnutrition in emergency and development contexts in the African Region. Gambia, Malawi,
12
Botswana, Eritrea, Gambia, Kenya, Lesotho, Liberia, Malawi, Namibia, Sierra Leone, South Africa and Swaziland. 13 Botswana, Lesotho, Namibia, Rwanda and South Africa. 14 Ghana, Kenya, Malawi, Senegal, Uganda and Zâmbia. 15 Ghana, Eritrea, Malawi, Nigeria, Uganda and Zambia. 16 Burkina Faso, Eritrea, Ghana, Kenya, Malawi, Mali, Niger, Nigeria, Senegal, Sierra Leone, Swaziland, Tanzania, Togo, Uganda, Zambia and Zimbabwe.
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Namibia and Nigeria were supported to organize national TOT to address malnutrition. National and provincial capacities were developed during an integrated IYCF counseling course. Five countries17 were supported to conduct national training of trainers in the integrated IYCF counseling course. More than 150 trainers, including tutors from pre-service health institutions, were trained to support and scale up IYCF counseling courses as well as mothers and caregivers. Currently over 32 countries have conducted national, provincial and district training for more than 6500 health workers. Seven regional facilitators and 27 national facilitators from nine countries18 were trained in child growth assessment, with particular emphasis on how to use the height/length board, weighing scale (UNISCALE), plotting of measurements, interpretation and counseling. Benin, Democratic Republic of Congo, Kenya, Malawi, Nigeria, Senegal and Uganda were supported to organize national orientation and adapt the new growth standards. Ghana, Nigeria, Tanzania and Zambia conducted national assessment of the level of implementation of the Global Strategy on IYCF with support from the Regional Office. Stakeholders meetings have been scheduled to take place in these countries in the coming year. The Regional Office provided technical support for field-testing the draft manual on implementing community activities in IYCF in Kisii District, Nyanza Province, Kenya. This manual is based on the experience from Haryana, India and provides clear guidance on designing and implementing a community intervention for improving IYCF within an existing health system.
2.2.3 Management of childhood illnesses Support for improving child health programme management was strengthened for 27 managers from 13 countries. Integrated Child Health Days were conducted in 12 countries.19 During maternal and child health days and weeks, several interventions are provided in a campaign mode. The interventions include immunization, vitamin A supplementation, de-worming, family planning, HIV testing and counseling, ITN distribution and re-treatment, chlorine and soap distribution, and care of sick children. These interventions and mini-campaigns complement routine services provided to women and children and increase coverage of key child survival interventions.
17
Gambia, Nigeria, Seychelles, Uganda and Zambia. Benin, Burkina Faso, Republic of Congo, Democratic Republic of Congo, Gabon, Mali, Níger, Senegal, Togo. 19 Burkina Faso, Cote d’Ivoire, Ghana, Kenya, Madagascar, Mali, Mozambique, Senegal, Sierra Leone, Togo, Zambia and Zimbabwe. 18
14
Credit: MOH, Kogi State, Nigeria
Credit: Malezi Bora, MOH, Kenya
Credit: Malezi Bora, MOH, Kenya
Support was provided to six countries for Global Fund proposal development aimed at MNH interventions, and three proposals have been approved. Support was provided to Burkina Faso, Malawi and Mozambique to develop their proposals to the Bill and Melinda Gates Foundation. Partnerships for MNCH were enhanced through joint tracking of country progress in child survival. In addition, joint regional child survival capacity-building activities and experience-sharing have enhanced collaboration between WHO and partners. 15
A total of 24 countries have adopted policies on the use of low osmolarity oral rehydration salts and zinc in management of childhood diarrhoea. A total of 17 countries have adopted policies for community health worker case management of pneumonia (Figure 2). Figure 2: Adoption of policies on the management of childhood diarrhoea and pneumonia in the African Region Policy and Implementation Status of CCM for Pneumonia, 2007 African Region
Status of Adoption of Low Osmolarity ORS and Zinc Policy, 2007 African Region
Permissive & Implemented Permissive & not Implemented Not permissive & Implemented
Adopted
Not permissive
Partial
No data or not AFRO
Not adopted No data or not AFRO
Source:Lancet, Vol 371, Nr 9620 Countdown to 2015, Bul WHO, May 2008, David R Marsh et al.
WHO Regional Office for Africa, 2007
WHO Regional Office for Africa, 2007
2.2.4 Policy and planning Support was provided for 13 countries20 to develop policies, strategies and plans for child survival. A total of 21 countries in the Region now have comprehensive strategies for scaling up child survival. 21 WHO has provided research support for IMCI research in Uganda and for newborn health research in Ghana. Kenya is being supported to pilot on-the job IMCI training in three districts. In collaboration with AFRICA 2010, activities are in progress to conduct oral rehydration salt assessments in Benin, Mali, Senegal, Uganda and Zambia.
20 20
Burkina Faso, Eritrea, Ethiopia, Gabon, Ghana, Kenya, Malawi, Mozambique, Rwanda, Senegal, Tanzania & Zimbabwe 21 Angola, Benin, Burkina Faso, Eritrea, Ethiopia, Gabon, Ghana, Kenya, Liberia, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, Zambia and Zimbabwe.
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Nigeria raises US$ 700 000 for implementation of integrated maternal, newborn and child survival strategy WHO and partners supported Nigeria to develop an integrated maternal, newborn and child survival strategy (IMNCHS) which would prevent 57% of newborn deaths, 70% of the million annual deaths among children under-five years of age and about 62% of pregnancy-related deaths. The additional annual investment needed for the plan is US$ 7.57 per person per annum. WHO and partners also supported the development of a roll out guide for the IMNCH strategy which details steps needed to ensure full implementation of the strategy at the different levels of health care. With the support of WHO and other partners, Nigeria raised US$ 700,000 from the global Partnership for Maternal, Newborn and Child Health. The grant, which will assist 12 states to roll out the implementation of the IMNCH strategy, is managed by WHO.
2.2.5 Monitoring and evaluating progress Ethiopia, Ghana and Zambia were supported to conduct IMCI health facility surveys. In addition, a field test of the rapid household survey tools for Maternal, Newborn, Child and Adolescent Health (MNCAH) was conducted in Tanzania. This tool measures the coverage and delivery channels of key evidence-based interventions along the continuum of care.
Assessment of Integrated Management of Newborn and Childhood Illness preservice training in Ethiopia, March 2008 WHO supported Ethiopia to evaluate the pre-service IMCI teaching in November 2007. TA total of 29 health professional training institutions that have started Integrated Management of Newborn and Childhood Illness (IMNCI) training were included in the survey. The survey included 34 academic programmes. Of the 34 programmes, 30 (88.2%) have integrated IMNCI in their curriculum. All academic programmes had at least one full-time staff for IMNCI classroom instruction (range 1–12), and 82% of the programmes use the mixed approach to teach pre-service IMNCI (staggered teaching of IMNCI concepts over a period of time with a concentrated consolidation period of IMNCI re-enforcement). IMNCI questions were included in written exams by all programmes, and similar questions were included in practical exams in 19 (55.9%) programmes. All students and instructors rated IMNCI concepts as very relevant or extremely relevant. IMCI pre-service training is well integrated in health professional training schools in Ethiopia.
2.2.6 Adolescent health In adolescent health, the focus was on supporting countries to adopt a systematic approach to strengthen health sector response to the specific needs of adolescents and young people. This approach included developing a multisectoral strategic plan,
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standards for adolescent and youth friendly health services (AYFHS), scaling up AYFHS implementation and evaluation of the programme.
In 2008, seven countries22 were supported to finalize or develop adolescent health strategic plans. Five countries extended the implementation of AYFHS at district level.23 The Democratic Republic of Congo and Togo developed standards for AYFH. Ethiopia received technical assistance to launch the implementation of the national adolescent health standards. To date, a total of 21 countries have developed strategic plans, and 7seven countries have developed national standards for AYFHS. 2.2.7 Working with partners Among the various joint activities with partners at global, regional and country levels, Tracking Progress in Maternal, Newborn and Child Health was done at a Global Child Survival Countdown conference where the 2008 Countdown to 2015 report was released. The report showed that some countries are making progress in child survival. Key contributing factors to this success include the decline in measles and malaria deaths. Conflict and HIV infection underlie the inadequate progress in countries making the least progress in child survival.
22 23
Cameroon, Gabon, Ghana, Guinea, Madagascar, Mali and Togo. Burkina Faso, Malawi, Mozambique, Senegal and Tanzania.
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Figure 3: Under-five mortality trends in the WHO African Region
LLIN – long-lasting insecticide-treated net ACT – artemisinin-based combination therapy
2.3 Future perspectives In 2009, WHO will strengthen advocacy, resource mobilization and partnerships to accelerate progress in newborn and child survival. WHO will also focus the limited available resources to support countries that have the highest burden of morbidity and mortality and are making the least progress in improving survival of newborns and children. Capacity will be built for inclusion of MNCH interventions in available funding opportunities, e.g. GFATM, GAVI etc. In addition, research and use of information generated through research for the improvement of service delivery will be supported.
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Key Issues and Challenges
3. Sexual and Reproductive Health 3.1 Key issues and challenges Reproductive ill-health continues to devastate the African continent. WHO estimates that poor reproductive health (RH) accounts for up to 18% of the global burden of disease and 32% of the total burden of disease for women of reproductive age. Currently the average contraceptive prevalence among married women in subSaharan Africa is very low, estimated at 13% and the total fertility rate (TFR) is 5.5 children per woman. The unmet need for family planning (FP) remains high, ranging from 16% in southern Africa to 28% in the eastern subregion (Figure 4). Hence the high lifetime risk of maternal death is estimated at 1 in 26 pregnancies. Sexual and reproductive health (SRH) programmes and interventions have been implemented in a vertical manner in most African countries and as a result have failed to produce the expected impact. The emergence of HIV and AIDS has increased the already heavy burden of sexual and reproductive health of women in Africa. Figure 4: Family planning methods and unmet family planning needs in subSaharan countries 80% 70% 60% 50%
30%
7% 8%
6%
Using modern methods
58%
20% 40%
16%
12%
Using traditional methods With unmet need for family planning
5%
5% 20% 10%
23%
28%
24%
23% 16%
0% Western
Eastern
Midde
Southern
Total subSaharan
Despite various global and national commitments for improved sexual and reproductive services, inequalities and problems still persist. Poor access to quality RH services, including FP, and inadequate utilization of evidence-based RH guidelines and tools are the main obstacles to the goal of universal access to sexual and reproductive health24 which is considered critical to the attainment of the MDGs.
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3.2 Major achievements In order to improve the technical quality of SRH services in the majority of countries in the Region, protocols or manuals will need to be updated with the incorporation of new developments and technologies. Botswana, Senegal, South Africa and Zambia were assisted by Regional Office consultants to upgrade their FP guidelines and manuals. The implementation of these activities is ongoing and will be completed by December 2009. The Strategic Partnerships Programme (SPP) is the actualization of the partnership between UNFPA and WHO, the two organizations working together for the attainment of healthy reproductive lives for all individuals. In July 2008, a regional SPP workshop was conducted for six SADC countries.25 This was followed by another workshop in Abuja, Nigeria for the ECOWAS countries of Gambia, Ghana, Liberia, Sierra Leone and Nigeria. In the two workshops, the 27 participants discussed the MDGs, including MDG 5b, and were oriented on SRH/FP performance; monitoring; and the evaluation of RH programmes including FP. As a result of the SPP training, countries were able to update the existing tools, policies and strategies developed at country level. Family planning is the first pillar of Safe Motherhood. The need for FP among married women in the Region is relatively high compared with other regions. It is on this basis that the Regional Office focused on increased advocacy for re-positioning FP. Furthermore, WHO in collaboration with partners, USAID and AED, developed a FP advocacy toolkit. In order to ensure effective use of the toolkit, programme managers and other stakeholders were trained in FP advocacy skills. In 2008, 32 individuals from eight ECOWAS countries26 participated in the training. In order to facilitate utilization of the FP advocacy toolkit in countries, the kit will be disseminated to all Country Offices, partner organizations, research institutions and centres of excellence in the Region. The FP toolkit needs to be adapted at country level. All the countries that participated in the training were encouraged to mobilize financial resources at country level for implementing the country-specific plans that were developed during the training. In order to strengthen adolescent-friendly health services in the Region, a regional workshop was held in February 2008 in Accra, Ghana. The aim of the workshop was to build skills for applying community-based interventions to improve the delivery of adolescent-friendly health services. There were 31 participants from ten countries.27 Cervical cancer is the leading cause of cancer mortality among women in Africa. More than 99% of cervical cancer cases are related to genital tract infection by the human papillomavirus (HPV). This frequent infection affects 660 million people worldwide. However, early detection of the condition can save many lives. The 25
Angola, Botswana, Lesotho, Mozambique, Zambia and Zimbabwe. Benin, Burkina Faso, Cote d’Ivoire, Guinea-Bissau, Liberia, Niger, Nigeria and Sierra Leone. 27 Benin, Burkina Faso, Central African Republic, Republic of Congo, Gabon, Kenya, Nigeria, Tanzania, Togo and Zimbabwe. 26
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Regional Office in collaboration with HQ initiated a pilot project on early detection of cervical cancer using visual inspection with acetic acid (VIA) in six countries: Madagascar, Malawi, Nigeria, Tanzania, Uganda and Zambia. In addition, there are plans to introduce vaccine for the prevention of HPV infection. This strategy will be part of a comprehensive approach to preventing cervical cancer. It will involve vaccination, screening and early treatment. It opens up new opportunities for strengthening reproductive health services and building interdisciplinary links. In order to make full use of this opportunity, 72 participants from 23 different countries; WHO staff (HQ, Regional Office, IST, Country Offices); and representatives from organizations such as PATH, UNFPA and JHPIEGO attended the WHO Ouagadougou regional consultation on cervical cancer prevention and control. One of the consultation recommendations is that countries should introduce VIA in their health system activities.
3.3 Future perspectives In order to contribute to the reduction of these challenges, the unit in 2009 will focus on three main areas: technical support to countries to strengthen capacities for planning, implementation and evaluation of RH services including FP; promotion of the utilization of evidence-based practices for the implementation of SRH/FP services; promotion of research and use of information generated through research for the improvement of SRH including FP programmes and service delivery. The development of a regional agenda for universal access to reproductive health services will be a priority.
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4. Making Pregnancy Safer 4.1 Key issues and challenges The levels of maternal and newborn mortality are still unacceptably high in the African Region, and the decline in maternal mortality between 1990 and 2005 in subSaharan Africa was only 0.1% per year while attainment of MDG 5 requires a decline of at least 5.5% per year.28 This calls for intensified efforts for scaling up priority interventions to improve access to and availability of skilled attendance. The percentage of births attended by skilled personnel is still very low; the average is 46.5%, ranging from 6% to 99%, with 21 countries having coverage below 50% and 37 countries below 80%. The main issues relating to this dramatic situation include inadequate translation of policies into action; weak health systems, especially the acute shortage of human resources; inadequate allocation of funds; and poor community participation in MNCH interventions, aggravated by malaria and HIV infections. In addition, poverty and high levels of illiteracy in many African countries contribute to the low status of women and the inadequate community health-seeking behaviour which negatively affect women’s health. There is urgent need to accelerate the scaling up of key interventions to increase our chances of attaining the MDGs related to MNCH. The most important challenges that need to be addressed are: (a) Increasing the capacity and availability of skilled personnel to meet national needs; (b) Increasing the availability of adequate financial resources at national and district levels for MNH and reducing the heavy dependence on project funds; (c) Improving the coordination and harmonization of approaches between programmes, levels and partners; (d) Ensuring the integration of programmes at regional and national levels, especially the integration of MIP, NUT, PMTCT and FP into MNCH services. In the African Region, the response to this situation is guided by the Road Map for Accelerating the Attainment of MDGs Related to Maternal and Newborn Health.29 The coordination of Road Map implementation is by the Making Pregnancy Safer Programme, including Malaria in Pregnancy (MIP) and Prevention of Mother-to-Child Transmission of HIV (PMTCT). In 2008, emphasis was put on supporting countries to increase the availability of skilled attendants; improve community participation; strengthen capacity in planning, management, monitoring and evaluating MPS programmes; and scaling up PMTCT of HIV.
Maternal mortality in 2005—Estimates developed by WHO, UNICEF, UNFPA and the World Bank, Geneva, World Health Organization 2007. 29 Developed by 16 partners in the Region and adopted in 2004 by the ministries of health in the Region, Resolution AFR/RC54/R9. 28
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4.2 Major achievements 4.2.1 Road Map development and implementation at country level The heavy burden of maternal and neonatal mortality borne by the African Region continues to be of major public health concern and needs to be addressed. In response, the Road Map for Accelerating the Attainment of the Millennium Development Goals Related to Maternal and Newborn Health in Africa was developed by partners in February 2004. Subsequently, the Road Map was adopted by ministers of health at the fifty-fourth session of the WHO Regional Committee for Africa (Resolution AFR/RC54/R9). The specific objectives of the Road Map are to provide skilled attendance during pregnancy, childbirth and the postnatal period at all levels of the health-care delivery system and to strengthen the capacity of individuals, families, and communities to improve maternal and newborn health (MNH). The Road Map represents a consensus among all partners on the way forward in the years ahead and offers an opportunity for harnessing resources from all partners. As a key intervention, special attention is paid to emergency obstetric care (EmOC) and essential newborn care (ENC) and to skilled attendance (skilled health workers, equipment, supplies and enabling environment) as a way of reverting the trends in maternal and newborn mortality. Since then, countries have been supported to develop their national Road Maps based on country priorities. A core group of 40 health experts from 14 countries30 were trained to support the development and implementation of Road Maps at country level. In 2008, six more countries31 developed national Road Maps, bringing the total number to 42 countries. Of these, 25 have been supported to implement their Road Maps, mainly by developing operational plans, building capacity of health professionals in EmOC, strengthening ENC and institutionalizing maternal death reviews (MDRs). However, the implementation of this national strategy was still very low and slow in most of the countries; one of the constraints identified was the inadequate translation of the strategy into operational plans, especially at district and service delivery levels. Consequently, in 2008, the Regional Office, in collaboration with UNFPA and UNICEF, trained 110 national experts from 17 countries32 to transform national Road Maps into district operational plans. Following the training workshop, 15 countries33 were supported in 2008 to develop district plans for accelerated implementation of national Road Maps.
Angola, Burkina Faso, Cape Verde, Ethiopia, Ghana, Guinea, Guinea-Bissau, Mauritania, Mozambique, Sao Tome and Principe, Senegal, Tanzania, Togo and Zambia. 31 Cape Verde, Chad, South Africa, Equatorial Guinea, Sao Tome and Principe, and Tanzania. 32 Burundi, Cameroon, Central African Republic, Republic of Congo, Ethiopia, Gabon, Gambia, Ghana, Kenya, Liberia, Malawi, Namibia, Nigeria, Rwanda, Sierra Leone, Uganda and Zambia. 33 Benin, Burkina Faso, Burundi, Cameroon, Côte d’Ivoire, Ethiopia, Ghana, Kenya, Malawi, Mali, Niger, Rwanda, Senegal, Uganda and Zambia. 30
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Figure 5: Road Map development and implementation status, December 2008
Algeria
Niger
Eritrea Chad
Burkina Faso Nigeria
Togo Liberia Côte Benin d’Ivoire Sao Tome & Principe
Cameroon Gabon
Ethiopia
RCA
Uganda Kenya
D.R Congo
Burundi Tanzania
Equatorial Guinea
Seychelles Comoros
Malawi
Angola
mb iq
Zimbabwe Botswana
Mo za
Namibia
ue
Zambia
Countries with Road Map
Rwanda
Mada gasc ar
Ghana
go
Bissau Guinea Sierra Leone
Mali
Con
Mauritania Senegal The Gambia Guinée Cap Vert
Mauritius
Swaziland
District implementation plans South Africa
Countries without Road Map
Lesotho
EMRO countries
Pre- and in-service training in EmOC was strengthened in 12 countries.34 PMTCT scaling up plans were developed in nine countries35 through the WHO/CIDA Partnership grant. Guidelines for integrated MNCH services delivery and a manual of recommendations for clinical practice for improved MNH care were developed in collaboration with SAGO and UNFPA. These recommendations are focused on the five most important causes of maternal mortality: complications during the first trimester of pregnancy, haemorrhage, hypertension disorders, sepsis and obstructed labour. They are meant as practical tools and job-aids on EmOC to be used at service delivery points. One chapter of the manual is dedicated to essential newborn care and resuscitation. Following the implementation of the above tools, three best practice interventions in MNH were documented: delegation of competence in major obstetric surgery— experiences of mid-level providers in Mozambique; Rwandan experience in scaling up MNH interventions; and building zero tolerance for maternal and infant deaths in Kogi State, Nigeria. Two of the best practices were shared during the Regional
Ethiopia, Gabon, Gambia, Guinea-Bissau, Malawi, Mozambique, Niger, Senegal, Tanzania, Uganda, Zambia and Zimbabwe. 35 Central African Republic, Democratic Republic of Congo, Ethiopia, Lesotho, Mozambique, Nigeria, Swaziland, Zambia and Zimbabwe. 34
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Committee session in Cameroon. A total of 12 countries36 were supported to institutionalize MNH days and weeks for increased public awareness and political commitment. Four additional countries were supported to develop advocacy tools and plans, bringing the total number to 12 countries.37 Support was provided to six countries for proposal development for the Global Fund out of which two were approved (Burundi and Côte d’Ivoire). As a way of improving supervision and monitoring of key interventions, experts from 12 countries38 were trained in the use of the integrated MNCH tools for monitoring and integrated supervision. This tool that can be used at all levels of the health-care delivery system, including district level, to monitor key MNCH indicators. It also provides a framework for integrated supervision which is expected to strengthen the capacity of health workers and improve quality of care. Currently, most countries in the Region have national strategies for reducing maternal and newborn mortality, including integrated maternal, newborn and child health strategies and integrated reproductive health strategies. The challenge now is to ensure that these national strategies are implemented at district level to ensure changes at the service delivery level and that the district plans are funded appropriately. Monitoring and evaluation systems need to be established or strengthened, and appropriate measures need to be taken to accelerate their implementation. 4.2.2 Capacity building to increase the availability of skilled attendants Skilled care for the mother and the newborn One of the Road Map’s specific objectives is to “provide skilled attendance at childbirth at all levels of the health-care delivery system”. Resolution AFR/RC54/R9 on the Road Map requested the Regional Director to support Member States to embark on an aggressive campaign to train mid-level health providers in obstetric care in order to increase coverage in the provision of maternal and newborn health. Credit: MOH Malawi
To respond to this need, a regional consultation on essential competencies for skilled attendants was held in March 2006 in Brazzaville. The consultation brought together experts and health professionals involved in midwifery and medical training and practice. Following this consultation, a consensus was reached on the essential 36Burkina Faso, Burundi, Republic of Congo, Eritrea, Ethiopia, Kenya, Madagascar, Mauritania, Niger, Nigeria, Tanzania and Uganda. 37 Burkina Faso, Cameroon, Ethiopia, Ghana, Mali, Mauritania, Niger, Nigeria, Senegal, Togo, Uganda and Zambia. 38
Benin, Burkina Faso, Republic of Congo, Eritrea, Kenya, Mali, Mozambique, Niger, Tanzania, Togo, Uganda and Zimbabwe.
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competencies for skilled attendants at various levels of health service delivery. During the reporting year, the list of essential competencies for skilled attendants guided the revision of midwifery curricula in Ethiopia, Malawi, Nigeria and Tanzania, and attempts at harmonization of midwifery training in West Africa in collaboration with WAHO and UNICEF. The same document was used to develop the generic skills mix matrix needed to ensure skilled care at the various levels of the health system (community, first level—primary health care [PHC] and referral levels). A core group of 20 regional trainers was trained in EmOC using the Integrated Management of Pregnancy and Childbirth (IMPAC) tools. This training was the precursor of the Skilled Care Initiative supported by the Regional Office and ACCESS. During 2008, three countries benefited from this joint support, and Ethiopia, Ghana and Tanzania strengthened their pre-service midwifery education through national training of tutors and strengthening the capacity of national training institutions. Nine other countries39 were supported in EmOC training. In addition, 20 WHO Country Office programme managers were introduced to WHO MPS/IMPAC tools and guidelines40 in order to improve the utilization of these tools at country level as a means of improving the availability of skilled attendants and quality care. The Eastern and Southern Africa Coalition against Malaria in Pregnancy (MIPESA) was supported to organize a learning session in Kigali, Rwanda for sharing best practices identified by countries through the implementation of the Roll Back Malaria Initiative. Two intercountry workshops for maternal and child health managers, ministry of health policy-makers and partners from 11 countries41 were conducted for capacitybuilding in strengthening integration of newborn health in maternal and child health services. The five intercountry capacity strengthening workshops have now covered 31 countries. Following these workshops, countries have adapted IMCI materials to include early newborn health (first seven days of life); many have revised their Road Maps to articulate the newborn component; and five countries have conducted situation analyses on newborn care. Capacity-building on essential newborn care for health workers caring for mothers and their newborns at birth and the first few weeks of life was introduced in Angola, Ghana, Nigeria and Sierra Leone. Such capacity-building has now been conducted in 11 countries of the Region. In collaboration with UNICEF, the Regional Office provided capacity-building in newborn care for 25 consultants from over a third of the countries in the Region. These consultants have supported training of trainers in home-based care of newborns in eastern, southern and western African countries; training of CHWs in six countries;42 and expanding ENC training. 39Gabon,
Gambia, Guinea-Bissau, Malawi, Niger, Senegal, Uganda, Zambia and Zimbabwe.
Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice; Managing complications in pregnancy and childbirth: a guide for midwives and doctors; Managing newborn problems: a guide for doctors, nurses, and midwives; Standards; Beyond the numbers; Integrated health technology package; Midwifery educational material; Essential newborn care course; Midwifery tool kit; Needs assessment; Working with individuals, families and communities to improve maternal and newborn health.
40
41 Botswana, 42
Eritrea, Gambia, Kenya, Lesotho, Liberia, Malawi, Namibia, Sierra Leone, South Africa and Swaziland. Ghana, Kenya, Malawi, Senegal, Uganda and Zâmbia.
27
Maternal and Perinatal Death Review (MDR) methodology was introduced in four more countries, bringing to 27 the total number of countries on track for the institutionalization of MDRs. The institutionalization of MDRs includes, among others, the development of relevant tools for data collection, training of health personnel or community individuals to build their capacity to apply one or more methodologies, compilation and analysis of data, translating results into action to address issues identified and evaluation. This process is now being used in some health facilities in some countries and the results have been used to justify changes in the organization of work at the health facility level in order to improve the quality of care. 4.2.3 PMTCT implementation and integration into MNCH programmes Prevention of mother-to-child transmission of HIV is a critical component in the implementation of three key strategic orientations in the WHO African Region, all endorsed by Member States of the Region: The Road Map for Accelerating the Attainment of MDGs Related to Maternal and Newborn Health; the Child Survival Strategy; and the HIV Prevention Strategy. PMTCT interventions are entry points for HIV-positive pregnant women and their families to access care, antiretroviral therapy and psychosocial support services. The provision of PMTCT services during antenatal, intrapartum, postpartum and postnatal care provides a platform for delivering integrated MNCH services, but this opportunity is generally under-utilized. Major achievements during 2008 in terms of PMTCT were in capacity-building at regional and national levels, support to partner initiatives for scaling up PMTCT, and development of guidance tools. In collaboration with partners, 15 countries43 adapted their national curricula and developed plans to roll out training. Experts from 11 countries44 had their capacity strengthened to accelerate scaling up of PMTCT and paediatric HIV care, support and treatment programmes. Joint technical missions with partners were conducted in seven countries45 to assess the status of implementation of PMTCT, identify gaps and make recommendations. This resulted in the UNITAID initiative which will provide US$ 20 million to accelerate PMTCT and paediatric AIDS interventions in seven countries46. This initiative includes the provision of HIV test kits and ARVs to HIV-positive pregnant women and mothers to accelerate the scaling up of PMTCT and paediatric HIV. In collaboration with UNICEF, support was provided to these countries for institutionalizing testing and counselling in PMTCT and use of more efficacious ARV regimens for treatment and prophylaxis in PMTCT, including care and support. Plans have been made to directly support these countries to update and adapt national treatment guidelines and policies to scale up this aspect of the programme and services. Under the technical leadership of WHO, during the last two years, several tools and guidelines were developed, namely: (i) Framework on integration of SRH/HIV/PMTCT/MIP/FP in MNCH services, in collaboration with UNFPA; (ii) 43Burkina
Faso, Republic of Congo, Cote d’Ivoire, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Swaziland, Tanzânia (including Zanzibar), Uganda and Zambia. 44 Burkina Faso, Cameroon, Central African Republic, Cote d’Ivoire, Democratic Republic of Congo, Kenya, Malawi, Nigeria, Senegal, Zambia and Zimbabwe. 45 Botswana, Burkina Faso, Cameroon, Lesotho, Nigeria, Swaziland and Zambia. 46 Burkina Faso, Cameroon, Cote d’Ivoire, Malawi, Rwanda, Tanzania and Zambia.
28
guidelines for management of children with HIV infection including HIV-exposed children for PMTCT; (iii) guidelines for testing and counselling of children with HIV infection; and (iv) the SADC Strategic Action Plan 2008-2010. 4.2.4 Advocacy for maternal and neonatal health Advocacy for putting maternal and neonatal health high on the political agenda for improved resource allocation for the implementation of the Road Map has been successfully executed in 12 countries47 through the celebration of maternal and newborn health days and women’s days. Madagascar was assisted to hold a presidential initiative forum for briefing 3000 women’s leaders on reproductive health and sensitize them on issues related to maternal and newborn health. Since 2005, the implementation of advocacy plans by countries using the REDUCE/ALIVE model to parliamentarians in different countries has led to policy change in favour of maternal health, such as the inclusion of maternal health in national development plans; adoption of laws decreeing maternal health services (caesarean section) free in Burkina Faso, Mali and Niger; decree for the utilization of debt relief funds to increase skilled attendance in rural areas; increased budget allocation to the health sector; and adoption of a reproductive health law in Togo. Seven countries48 were supported to organize national days on maternal and newborn health. Ministries of health in collaboration organized this activity with WHO, UNFPA, UNICEF and NGOs involved in maternal and child health at country level. In 2008, a regional consultation on haemorrhage during pregnancy, childbirth and postpartum period was held in Luanda, Angola. Haemorrhage is by far the leading cause of maternal deaths in sub-Saharan Africa, accounting for more than a third (35%) of the maternal mortality. The consultation was therefore aimed at contributing to the reduction of maternal mortality due to haemorrhage in the African Region. The meeting brought together 124 experts from 30 countries. Participants were from training institutions; national professional associations; ministries of health; and global associations such as FIGO, ICM and UN agencies (WHO, UNFPA UNICEF, World Bank). During this consultation, experts shared innovative approaches on preventing and managing postpartum haemorrhage such as the use of pharmacological agents, bimanual uterine compression and the brace suture technique. Further operational research is required before some of the techniques are widely promoted.
47 48
Angola, Benin, Burkina Faso, Cameroon, Chad, Comoros, Eritrea, Gabon, Mali, Mauritania and Uganda. Republic of Congo, Equatorial Guinea, Gabon, Kenya, Rwanda, Sao Tome and Principe, and Uganda.
29
Regional consultation on obstetric haemorrhage, Luanda, Angola, October 2008
Credit: WHO/AFRO
The meeting was chaired by the Minister of Heath of Angola, Dr José Van Dùnen (in the middle) and attended by 124 international and national experts in maternal health.
Dr Luis Gomes Sambo, WHO Regional Director for Africa, delivering his opening remarks at the meeting.
4.2.5 Operational research in MNCH In the African Region, research is generally under-funded and receives little attention from governments. However, its importance is increasing, and the number of countries using research to inform national policies and strategies is increasing. Three main research projects were conducted in 2008; these are discussed below. A situation analysis of obstetric fistula was conducted in the Gambia in collaboration with the MOH and UNFPA. The survey covered 5000 households in urban and rural areas of the country. The survey included all health facilities where delivery care is provided. The objectives were to identify the magnitude of fistula; evaluate quality of EmOC facilities; and assess community awareness of obstetric fistula and the associated, contributing sociocultural factors. Some of the main findings of the study include: Decision-making about whether a woman is to go to a health institution is taken by the woman in 20.1% of the cases (versus 42% for the husband and 16% for the woman’s mother-in-law). Only 1.7% to 20% of pregnant women know danger signs. The highest incidence of fistula (80%) is in rural areas. Fistula is a stigmatizing condition in all of the Gambia. Health facilities do not provide 24-hour services, and there is a shortage of human resources. All three delivery delays are associated with the occurrence of fistula: delay in the decision to seek care, delay in transportation and delay in receiving adequate care at the facility. Finally, there is the perception in the community and among traditional healers that married woman who die in childbirth go to heaven.
30
A community household survey was conducted in Tanzania. The main objectives were to measure coverage and delivery channels of key evidence-based interventions along the maternal, newborn, child and adolescent health continuum of care; and to explore various factors that might be attributed to maternal, neonatal, child and adolescent health from the community point of view. The preliminary report is now available. An evaluation of the integration of the Reproductive Health and Prevention of Mother-to-Child Transmission of HIV programmes was undertaken in Uganda. The integration of the two programmes started three years ago. The aim was to generate evidence in order to contribute to the development of a regional framework for integration. The objectives of the evaluation were to: -
-
Describe the step-by-step method taken in the implementation of the integrated approach and also identify the barriers, challenges and facilitating factors at all levels (central, district, facility and community) of the health system; Describe the re-organization or changes that were brought about in implementing the integrated approach at all levels, including partnership, coordination, management, monitoring, training and service delivery; Describe tools, guidelines and other documents used to enhance the integrated approach; Suggest ways to reinforce organizational linkages towards enhanced coordination, planning, implementation and system strengthening; Document lessons learnt (positive and negative) in the integrated approach; Identify what could be described as best practices in integration.
The draft report of the evaluation is being finalized.
4.3 Future perspectives In 2009, MPS will continue providing support to countries to implement national Road Maps as a strategy for accelerated reduction of maternal and newborn mortality. The main focus will be in the following areas: (a) Increasing the availability of skilled birth attendants through strengthening inservice and pre-service training; (b) Translation of national Road Maps into operational and budgeted district plans in the context of strengthening health systems and revitalizing Primary Health Care; (c) Strengthening district planning and management of MNH services; (d) Strengthening advocacy and partnership to mobilize resources at country level for the effective implementation of the Road Map; (e) Improving community participation; (f) Scaling up PMTCT interventions through development of national tools, capacity-building and strengthening the integration of PMTCT into MCH services; (g) Strengthening the newborn health component through training and development of integrated tools.
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5. Gender, Women and Health 5.1 Key issues and challenges Women and men experience different health risks, health-seeking behaviours, health outcomes and responses from health systems due to their social and biological differences. It is in this regard that the response of WHO to the Gender, Women and Health Programme for 2008 focused primarily on the provision of technical assistance to Member States in the development and adaptation of national women’s health policies, programmes and services in line with the Regional Women’s Health Strategy and the Women’s Health Profile Report.
5.2 Major achievements The role of women in the attainment of the MDGs has been recognized by the WHO Regional Committee for Africa. During the fifty-eighth session of the Regional Committee held in Yaounde, Cameroon in 2008, ministers of health adopted Resolution AFR/RC58/R1 on women’s health. This resolution was proposed because the status of women’s health, especially maternal health, continues to decline in most countries of the African Region despite the commitments of Member States and partners to provide better health for their populations. The Regional Committee requested the WHO Regional Director for Africa to pursue partnerships with relevant UN agencies and organizations to establish a commission to promote women’s health and to generate evidence on the role of improved women’s health in socioeconomic development. The establishment of the regional Commission on Women’s Health is in progress, and the first meeting of the Commission is planned to take place before the end of 2009. Gender is a social determinant of health. Women and men are innately different and have differing needs. Promoting equitable access to health care implies recognizing these differences and developing responses that address the varied needs of women and men throughout their lives. A regional survey on the involvement of gender issues in the work of the WHO Regional Office for Africa was carried out during the period under review. The survey analysed Country Cooperation Strategy documents in the Region, biennial workplans, selected Regional Office publications and selected speeches of the Regional Director. Some highlights of the findings include: • • • •
61% of Regional Office staff have a basic understanding of gender and health. Despite high levels of knowledge on gender and a strong recognition of its relevance, staff may not be able to translate this into applying gender analysis skills to their work. There is a reported lack of institutional support for the integration of gender. The areas that need most strengthening include: capacity-building with emphasis on skills in gender analysis and responsive actions; tools and
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•
• • •
resources on gender; generation of stronger evidence based on the role of gender in technical programmes; strengthening the network of gender focal points to provide technical support; and increasing budgetary resource allocation to gender. There is a sharp decrease in the percentage of programme focal points reporting “strong level of integration of gender” from the operational planning phase (37%) to the programme implementation process (6%) and the programme monitoring and evaluation phase (2%). Les than 10% the CCSs and country workplans reflected a strong level of gender integration; some reflected moderate levels of gender integration. There is a need for advocacy to promote the integration of gender into country workplans based on CCS to discuss the benefits. As far as publications are concerned, 4 out of 24 publications used sex disaggregated data and 11 out of 24 used gender analyses.
Figure 6: Level of knowledge of gender concepts by grade in the WHO Regional Office for Africa Level of knowledge (%) 100 80 No Knowledge 60
Some Knowledge Good Knowledge
40 20 0 D
P
G
Other
Staff category
D = Divisional head, P = Professional, G = General service
For the past ten years, Member States have implemented the Regional Action Plan to accelerate the elimination of female genital mutilation (FGM) on the continent for the period 1995-2015. An evaluation of this implementation was conducted in 12 countries.49The highlights of the report are presented below. TP
TP
According to the evaluation, all 12 countries have established national laws against FGM and national institutions to fight against the practice of FGM. Eritrea has put in place legislation officially banning the practice of FGM and its violation is punishable by law. Heads of State and First Ladies from Burkina Faso and Mali have clearly indicated their willingness to eliminate the practice of FGM. The report further shows that the involvement of women who have undergone FGM helps in data collection on P
49
Burkina Faso, Central African republic, Cha, Cote d’Ivoire, Eritrea, Ethiopia, Guinea, Liberia, Mali, Mauritania, Nigeria and Senegal. P
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the practice. The evaluation report was presented at the Global Research Forum on Health in Bamako, Mali in November 2008. There is a downward trend in the prevalence of the practice of FGM compared to 5 years ago (Table 1). Table 1: Major findings from the FGM evaluation
Population Participating Countries Burkina CAR Cote d’Ivoire Eritrea Ethiopia Guinea Liberia Mali Mauritania Nigeria Senegal Chad
Females
7.588.634 1.955.359 7.844.623 1.728.000 33.715.43 5.026.870 1.600.000 4.954.889 1.266.447 68.392.67 5.009.212 3.265.600
Males
7.676.10 1.939.77 7.522.04 1.372.20 33.957.6 4.883.44 1.700.00 4.856.02 1.241.71 69.890.5 4.346.12 3.014.40
Indicators Prevalence of FGM (%) 2002
2007
66 36 45 97 73 99 56 91 81 30 40 50,89
73 26 36 89 74 96 45 76 71 19 28 45
IMR per 1000
MMR per 100 000
Adoptio n of MGF
Year
169,2 106 89 48 97 91 117 229 77 105 61 102
5437,7 1355 543 898 871 980 578 582 686 704 401 1099
Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes
1999 2007 1998 1999 2004 1997 2005 1998 2004 1997 1997 1997
Nat’l FGM plan of action Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
5.3 Future perspectives In the coming biennium 2010-2011, the programme will assist countries to document best practices in eliminating FGM and fight against domestic violence. In addition, the ten-year evaluation report of the accelerated action plan on the elimination of FGM and the gender analysis report will be shared with Member States. The focus will be on establishing the regional Commission on Women’s Health for the African Region, scaling up resource mobilization to support countries and developing a regional strategy on ageing.
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6. Enabling Factors, Constraints and Lessons 6. Learnt
6.1 Enabling factors The Division was able to achieve the above results because of a number of enabling factors that facilitated the work of the units. These enabling factors included: • • • • •
Availability of technical expertise at country, subregional (IST) and regional levels for facilitated WHO support to countries; Commitments of national governments to improve maternal, newborn and child health; Collaboration with partners at different levels for facilitated progress in the Region; Interdivisional collaboration at both Regional Office and HQ levels for maximized efforts to support countries; Financial support from key traditional and new donors for critically addressing major funding gaps and thus ensuring uninterrupted support to countries.
6.2 Constraints Despite the achievements made, the Division faced various challenges in its provision of support to Member States and improvement of MNCH in the Region. These constraints included: • • • • •
Inadequate funding at country level to scale up effective MNCH interventions to the vulnerable who need them; Overall weak health systems, with human resource constraints at all levels; Limited access to services such as family planning and emergency obstetric care; Difficulty in the generation and collection of data for operational research, routine monitoring and evaluation; Difficulty in transforming research findings into policies and programmes at district and other implementation levels.
6.3 Lessons learnt In overcoming the challenges faced, there were some lessons learnt: • • •
Tracking of progress towards the Millennium Development Goals at global, regional and country levels facilitates advocacy and resource mobilization efforts for child survival. Effective collaboration with partners, especially at country level, improves quality of technical materials and financial support to countries. Integration of MNCH programmes into existing health services ensures sustainability. 35
7. Conclusion This brief Division report has addressed the major issues of each of the four units (CAH, MPS, SRH and GWH) in 2008. The report has also highlighted the key achievements and articulated the future perspectives. Important factors that contributed to the successes of the Division were mentioned; however, the Division has not been without challenges or constraints. These constraints were identified and some lessons learnt in addressing them were also documented. Achieving these successes with such limited resources gives hope that much more can be done with increased financial, material and human resources. The Division will continue to advocate to the relevant stakeholders to increase availability of resources at country level to reduce the unacceptably high morbidity and mortality of mothers, newborns and children in the African Region. We know what the problems are; we know what to do and how to address them because effective interventions are available. We know where the problems are; we also know how to talk about the problems. It is time to transform what we know into action and save the lives of mothers and children.
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