Family and Reproductive Health Cluster

2008-2009 Highlights

“towards improving the lives of the most vulnerable in the WHO African Region”

CONTENTS Foreword Acknowledgements Abbreviations

Page 4 5 6

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 HEALTH 2.1 Key issues and challenges 2.2 Major achievements 2.3 Future perspectives

11 12 16

3. SEXUAL AND REPRODUCTIVE HEALTH 3.1 Key issues and challenges 3.2 Major achievements 3.3 Future perspectives

17 17 19

4. MAKING PREGNANCY SAFER 4.1 Key issues and challenges 4.2 Major achievements 4.3 Future perspectives

20 21 30

5. GENDER, WOMEN AND HEALTH 5.1 Key issues and challenges 5.2 Major achievements 5.3 Future perspectives

31 31 33

6. ENABLING FACTORS, CONSTRAINTS AND LESSONS LEARNT 6.1 Enabling factors 6.2 Constraints 6.3 Lessons learnt

35 35 35

7. CONCLUSION

37

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List of figures 1.Map of progress in under-five mortality trends towards MDG targets in the African Region 2.Map of countries implementing IMCI, WHO African Region, December 2009 3.Road Map development and implementation status, December 2009 4.Percentage of women with HIV receiving ARV therapy for PMTCT, 2005 to 2008

11 13 22 27

List of tables 1.Knowledge and capacity for gender analysis in the WHO Regional Office for Africa 2.Trends in the practice of FGM, WHO African Region

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FOREWORD Maternal, newborn and child morbidity and mortality rates in the WHO African Region remain some of the highest in the world. The slow decline of maternal and child mortality rates in the Region causes concern about the attainment of Millennium Development Goals (MDGs) 4 and 5. The inability to implement the current available and effective interventions to scale means that morbidity and mortality rates remain unacceptably high. The challenges faced by maternal, newborn and child health (MNCH) in the Region are well known. They include inadequate access to quality health care for children and women; inappropriate feeding practices; inadequate sexual and reproductive health and rights including gender-based violence; sexually transmitted infections including HIV/AIDS; cervical cancer; harmful practices (such as female genital mutilation) and violence against women and children (including child sexual abuse); and increased early adolescent sexual activity resulting in unwanted pregnancies and unsafe abortions. Women and children bear the highest burden of HIV/AIDS, malaria and tuberculosis, including unchecked mother-to-child transmission of HIV infection. Other determinants of health such as poverty, hunger discrimination and inequity combine forces to adversely affect the health of the most vulnerable individuals, families and communities. Weak health systems in the Region have negative impacts on the maternal, newborn and child health indicators in most countries. To address this, 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 MDGs, particularly those relating to child health and maternal health. The fourth objective of the Medium Term Strategic Plan 2008-2013 focuses on reducing morbidity and mortality during the key stages of life (pregnancy, childbirth, neonatal period, childhood, adolescence); improving sexual and reproductive health; and promoting active and healthy ageing for all individuals. In 2008-2009 the Family and Reproductive Health Cluster supported countries to achieve their MNCH objectives by investing considerable resources in transforming two strategic documents into concrete policies and actions at country level. These were the Road Map for Accelerating the Attainment of the MDGs Related to Maternal and Newborn Health in Africa and the Regional Child Survival Strategy. Important partnerships were built with key stakeholders to scale up implementation of interventions to increase access to care by mothers, newborns and children in various countries. The Road Map was adopted in 2004, and the Child Survival Strategy in 2006. 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 Strategy to the highest level of commitment and established a continental agenda urging immediate action by all Heads of State. The first regional meeting of national Child and Adolescent Health and Making Pregnancy Safer programme managers focused on sharing best practices and research results for strengthening MNCH programmes and services at country level. This report highlights the major achievements of the Family and Reproductive Health Cluster during the biennium. It outlines the contributions made by the Cluster in collaboration with partners towards assuring the highest standard of health for the people of Africa and the attainment of the MDGs. The enabling factors, constraints and lessons learnt have been identified for consideration in future perspectives of Cluster work. Dr Tigest Ketsela Director, Family and Reproductive Health Cluster

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ACKNOWLEDGEMENTS The Family and Reproductive Health Cluster wishes to express our appreciation to all those who contributed directly or indirectly to the completion of this report. The Cluster is grateful to Dr Luis G. Sambo, Regional Director, and Dr Paul Lusamba-Dikassa, Director of Programme Management, for their guidance and continuous support throughout the reporting period. The high quality of collaboration with Regional Advisers in the Disease Prevention and Control Cluster; Prevention and Control of HIV/AIDS, Tuberculosis and Malaria; 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 Cluster to strengthen existing collaboration. The Departments of HIV/AIDS, Nutrition for Health and Development, and Health Action in Crisis provided invaluable support to our work at country and regional levels. The Cluster is grateful for the contributions and support from the following partners: Department for International Development (UK), Economic Community of Central African States, Economic Community of West African States, Gesellschaft für Technische Zusammenarbeit, Global Alliance for Improved Nutrition, Helen Keller International, International Baby Food Action Network, International Plant Genetic Resources Institute, LINKAGES, PATH, Southern African Development Community and United States Agency for International Development (USAID). Collaboration with other UN agencies is acknowledged—Food and Agricultural Organization; Joint United Nations Programme on HIV/AIDS; United Nations Children’s Fund; United Nations Educational, Scientific and Cultural Organization; United Nations Population Fund; World Bank; and World Food Programme. The contributions of the Africa Bureau of the Global Bureau of USAID and the associates, namely Academy for Educational Development, ADVANCE AFRICA, AFRICA 2010, AWARE-RH, POLICY II and ACCESS, Ford Foundation and the Bill and Melinda Gates Foundation as well as the governments of Canada, Finland, France, Germany, Great Britain, Italy, Netherlands and Norway have been crucial in achieving the results highlighted in this report. All the Regional Advisers of the Family and Reproductive Health Cluster deserve special thanks for their immense contributions towards each area of work and programme. However, most of their work would not have been accomplished without the outstanding support staff in the Cluster. 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 in the African Region.

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ABBREVIATIONS ADH AIDS AMDD ARV AU CAH CHW CIDA DHS EmONC EmOC ENC FIGO FP FRH FGM GWH HHA HIV HQ ICM IMAI IMCI IMPAC IST IYCF MDG MDR MNH MIP MNCH MPS NGO ORS ORT PMTCT RH RO SAM SPP SRH UN UNGASS USAID VIA WCO WHO

Adolescent Health Acquired Immunodeficiency Syndrome Averting Maternal Death and Disability Antiretroviral African Union Child and Adolescent Health Community Health Worker Canadian International Development Agency Demographic and Health Survey Emergency Obstetric and Newborn Care Emergency Obstetric Care Essential Newborn Care International Federation of Gynecology and Obstetrics Family Planning Family and Reproductive Health Cluster Female Genital Mutilation Gender, Women and Health Harmonization for Health in Africa Human Immunodeficiency Virus Headquarters International Confederation of Midwives Integrated Management of Adolescent and Adult Illness Integrated Management of Childhood Illness Integrated Management of Pregnancy and Childbirth Intercountry Support Team Infant and Young Child Feeding Millennium Development Goal Maternal Deaths Review Maternal and Newborn Health Malaria in Pregnancy Maternal, Newborn and Child Health Making Pregnancy Safer Nongovernmental Organization Oral Rehydration Salts Oral Rehydration Therapy Prevention of Mother-to-Child Transmission (of HIV) Reproductive Health Regional Office Service Availability Mapping Strategic Partnership Programme Sexual and Reproductive Health United Nations United Nations General Assembly Special Session United States Agency for International Development Visual Inspection with Acetic acid WHO Country Office World Health Organization

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1. Family and Reproductive Health 1.1 Introduction Maternal, newborn and child morbidity and mortality rates have not improved significantly over the past decade. In the World Health Organization (WHO) African Region, the current estimates of maternal mortality rate is 900 per 100 000 live births, the highest in the world, and the under-five mortality rate is 142 per 1000 live births. Presently the rate of decline in under-five mortality and maternal mortality is inadequate to reach Millennium Development Goals (MDGs) 4 and 5 by 2015. The average percentage of births attended by skilled personnel is 47%, ranging from 6% to 99%, with 17 countries having coverage below 50% and 37 countries below 80%. Currently, contraceptive prevalence among married women in sub-Saharan Africa is very low, estimated at 13%, and the total fertility rate is 5.5 children per woman. Although proven cost-effective interventions are known and available, reversing the trends has remained a major hurdle for many years in many countries in the Region. The key challenges to maternal, newborn and child health (MNCH) in the Region include inadequate transferral of policies into action; weak health systems, especially the acute shortage of human resources; inadequate allocation of funds; and inadequate community participation in MNCH interventions, aggravated by HIV, malaria and other infectious diseases. Poverty, high levels of illiteracy and inadequate health-seeking behaviour have contributed to the low socioeconomic status of women and have resulted in negative impacts on women’s health and development. To address the above challenges and accelerate efforts to achieve the MDGs by 2015, the WHO Regional Office for Africa put in place various initiatives. These include the Ouagadougou Declaration on Primary Health Care; Commission on Women’s Health in the African Region; Child Survival Strategy; Road Map for Accelerating the Reduction of Maternal and Newborn Mortality; and Repositioning Family Planning in the African Region. In 2008-2009, the Family and Reproductive Health Cluster comprised four programmes: Child and Adolescent Health (CAH); Gender, Women and Health (GWH); Making Pregnancy Safer (MPS); and Sexual and Reproductive Health (SRH). Technical support to countries focused on reducing morbidity and mortality during key stages of life, including pregnancy, childbirth, 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 FAMILY AND REPRODUCTIVE HEALTH CLUSTER VISION 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.

MISSION To support Member States to attain universal coverage of and access to cost-effective interventions to reduce morbidity and mortality and promote FRH outcomes during the key stages of life: pregnancy, childbirth, neonatal period, childhood, adolescence and ageing.



  

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STRATEGIC ORIENTATIONS 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 MNCH service delivery at facility and community levels. Support countries to strengthen community structures and resources to maximize family and community participation in MNCH interventions. Support countries to address key sociocultural health determinants that affect MNCH outcomes (e.g. harmful delivery practices, female genital mutilation, gender equity, food taboos for children and pregnant and lactating mothers).

1.3 Key achievements The significant achievements recorded in the 2008-2009 biennium are testimony to the commitment of the Cluster staff, and the support of both internal and external partners. In spite of human resource constraints, the Cluster continued to make considerable progress. The key achievements are listed below: a) A total of 21 countries expanded geographic coverage of IMCI implementation to 75% of districts; 27 countries adapted their IMCI guidelines to include HIV; and 28 countries included the first week of life. IMCI pre-service training is being implemented in 25 countries. b) A total of 13 regional facilitators and 64 national facilitators from 20 countries1 were trained in the new WHO child growth standards. Kenya, Nigeria and Zambia documented their best practices and experiences in scaling up infant feeding activities. c) A total of 24 countries adopted policies on the use of low osmolarity oral rehydration salts (ORS) and zinc in the management of childhood diarrhoea, and 17 countries adopted policies for community health worker case management of pneumonia. Six countries 2 were supported in the promotion of low osmolarity ORS for zinc treatment of acute diarrhoea. d) The capacity of child health programme managers from 18 countries3 was built in the new child health programme management course. e) Partnerships for MNCH were enhanced through joint tracking of country progress in child survival. f) Seven countries4 finalized or developed their adolescent health strategic plans, and five countries5 extended the implementation of adolescent and youth-friendly health services to district level. g) Following Strategic Partnership Programme (SPP) training, 12 countries6 were supported to revise their family planning (FP) guidelines, and eight countries7 updated their guidelines and manuals. h) The Regional Office in collaboration with HQ initiated a six-country8 pilot project on early detection of cervical cancer using visual inspection with acetic acid. i)

Seven more countries9 developed national Road Maps, bringing the total number to 42 countries. Of these, 27 have been supported to implement their Road Maps, mainly by developing operational plans; building capacity of health professionals in EmOC and ENC; and

Benin, Botswana, Burkina Faso, Republic of Congo; Democratic Republic of Congo, Ethiopia, Gabon, Ghana, Kenya, Malawi, Mali, Niger, Nigeria, Senegal, South Africa, Tanzania, Togo, Uganda, Zambia and Zimbabwe. 2 Botswana, Ethiopia, Kenya, Malawi, Swaziland and Tanzânia. 3 Botswana, Burkina Faso, Ethiopia, Ghana, Kenya, Lesotho, Liberia, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Sierra Leone, South Africa, Swaziland, Tanzânia, Uganda and Zâmbia. 4 Cameroon, Gabon, Ghana, Guinea, Madagascar, Mali and Togo. 5 Burkina Faso, Malawi, Mozambique, Senegal and Tanzania. 6 Angola, Botswana, Gambia, Ghana, Guinea, Lesotho, Liberia, Mozambique, Nigeria, Senegal, Sierra Leone and Zambia. 7 Benin, Cameroon, Cote d’Ivoire, Gabon, Guinea, Mauritania, Senegal and Tanzania. 8 Madagascar, Malawi, Nigeria, Tanzania, Uganda and Zambia. 9 Cape Verde, Chad, Equatorial Guinea, Mauritania, Sao Tome and Principe, South Africa and Tanzania. 1

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institutionalizing maternal death reviews (MDRs). j)

Three best practices in MNCH interventions were documented: delegation of competence in major obstetric surgery—experiences of mid-level providers in Mozambique; Rwandan experience in scaling up MNCH interventions; and building zero tolerance for maternal and infant deaths in Kogi State, Nigeria. Two of the best practices were shared during the Regional Committee session in Cameroon.

k) EmONC Needs Assessment and MNCH Service Availability Mapping were conducted in six countries10 and introduced in 15 others.11 The findings have been used to advocate for resource mobilization and develop strategies for addressing gaps. l)

In collaboration with partners, 17 countries12 in the Region were supported in development and implementation of the Accelerated PMTCT Comprehensive Plan through the WHO/CIDA Grant. An accelerated PMTCT plan has been implemented in 34 countries13 in the Region, contributing to improved uptake of PMTCT.

m) Advocacy for putting MNCH high on the political agenda for improved resource allocation to implement the Road Map has been successfully executed in 11 countries.14 n) Maternal and perinatal death review methodology was introduced in four more countries, bringing to 27 the total number of countries on track for the institutionalization of MDRs. o) 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. p) 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 which was formed in 2009. q) The Regional Office, in collaboration with HQ, carried out a regional survey on gender issues. r) A ten-year evaluation of implementation of accelerated FGM elimination action showed that 12 countries had established national laws and institutions to fight FGM.

10 Angola, 11

Ethiopia, Kenya, Mozambique, Randa and Sierra Leone. Benin, Botswana, Burkina Faso, Burundi, Chad, Republic of Congo, Cote d’Ivoire, Ghana, Kenya, Liberia, Madagascar, Niger, Nigeria, Sierra Leone and Zambia. 12 Angola, Central African Republic, Democratic Republic of Congo, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Nigeria, Rwanda, Senegal, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. 13 Angola, Benin, Bostwana, Burkina Faso, Burundi, Cameroon, Central African Republic, Republic of Congo, Cote d’Ivoire, Democratic Republic of Congo, Eritrea, Ethiopia, Ghana, Guinea-Bissau, Kenya, Lesotho, Liberia, Malawi, Mali, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Africa, Swaziland, Tanzania, Togo, Uganda, Zambia and Zimbabwe. 14 Angola, Benin, Burkina Faso, Cameroon, Chad, Comoros, Eritrea, Gabon, Mali, Mauritania and Uganda.

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2. Child and Adolescent Health 2.1 Key issues and challenges The WHO African Region continues to bear the brunt of child deaths globally. Despite the commitment of African Member States to the MDGs, the rate of decline in under-five mortality is still grossly insufficient to reach MDG 4 by 2015. Data indicate that the Region has made the least progress in improving child survival. Only five countries (Algeria, Cape Verde, Eritrea, Mauritius and Seychelles) in the Region are on track to meet the MDG 4 targets on child mortality reduction;15 a total of 25 countries are making insufficient progress while the remaining 16 are not making progress. Figure 1: Map of progress in under-five mortality trends towards MDG targets in the African Region KEY FOR MDG 4 PROGRESS COLOUR CODE Target achieved or trend towards achievement Progress has been made but insufficient trend to reach the target

No progress made or decline

COUNTRIES Algeria, Cape Verde, Eritrea, Mauritius, Seychelles Angola, Benin, Botswana, Comoros, Côte d'Ivoire, Democratic Republic of Congo, Ethiopia, Gambia, Ghana, Guinea, GuineaBissau, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, Senegal, Togo, Tanzania, Uganda Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Republic of Congo, Equatorial Guinea, Gabon, Kenya, Rwanda, Sierra Leone, Sao Tome and Principe, South Africa, Swaziland, Zambia, Zimbabwe

Sources: WHO, World health statistics, 2009; UNICEF, State of the world’s children, 2009.

The Inter-agency Group for Child Mortality Estimation estimates that in 2008, 8.8 million children died before their fifth birthday globally.16 These deaths were due mainly to preventable or treatable conditions, with under-nutrition contributing to over a third of the deaths. The African Region contributed 50% of the global child mortality, totaling 4.4 million child deaths in 2008. Huge gaps remain in scaling up coverage of effective child survival interventions in the Region. Accelerated efforts and increased resources are required to achieve MDG targets.

Countdown Coverage Writing Group on behalf of the Countdown to 2015 Core Group: Countdown to 2015 for maternal, newborn and child survival: the 2008 report on tracking coverage of interventions, The Lancet 2008:317:1247-58 16 Child Info: Monitoring the Situation of Women and Children, UNICEF, http://www.childinfo.org/mortality.html. Accessed 10 November 2009. 15

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The WHO Regional Office for Africa strategic approach for Child and Adolescent Health for 2008-2009 included advocacy for harmonization of child survival goals and agendas; strengthening health systems; empowering families and communities; partnerships; operations research; and mobilization of resources at international, regional and national levels for newborn, child and adolescent health. This biennial report summarizes the contributions of Child and Adolescent Health Programme in supporting countries to improve child and adolescent health. It also articulates the challenges and lessons learnt during the report period. 2.2 Major achievements 2.2.1 Development/update of national policies, strategies and plans for integrated newborn and child health The Regional Child Survival Strategy for the African Region was developed by WHO, UNICEF and the World Bank; it was adopted at the fifty-sixth session of the WHO Regional Committee for Africa in August 2006. The Strategy builds on IMCI and broadens the approach; it advocates for the implementation at scale of a key package of cost-effective child health interventions. During the report period, 22 countries were supported to develop and update national policies, strategies and plans; thus, 27 countries17 in the Region have been supported to develop, finalize or review child health policies and strategies. Mozambique, Nigeria and Tanzania have been supported to develop and cost their integrated Maternal, Newborn and Child Survival strategies and plans. Adoption of appropriate policies, strategies and plans facilitated implementation of effective child health interventions in countries. 2.2.2 Implementation of strategies for neonatal survival and health Realizing that the MDG on reduction of child mortality will not be achieved if neonatal mortality does not improve, partners have joined forces to implement neonatal survival strategies in the Region. From the last three years, 15 countries have been supported to implement neonatal survival activities. 18 During the reporting period, support was provided to seven countries to build capacity of health care providers in managing newborns.19 In the east and southern African subregion, Child and Adolescent Health (CAH) in collaboration with Making Pregnancy Safer (MPS) conducted a capacity-building course on essential newborn care (ENC) for Botswana, Lesotho and Namibia. The course built the capacity of a core group of key resource persons from health training institutions and Ministry of Health programmes. It is expected that the trained core group will facilitate the roll-out of training in their respective countries. Namibia trained 40 health professionals in ENC drawn from all 13 regions of the country. National partners in Namibia also expressed their willingness to support the roll-out of ENC training in the next biennium. Democratic Republic of Congo and Gabon were supported to train health workers in ENC. Equipment for newborn resuscitation and paediatric emergencies was provided to Burundi and the Democratic Republic of Congo.

Angola, Benin, Botswana, Burkina Faso, Cameroon, Central Africa Republic, Chad, Eritrea, Ethiopia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Senegal, South Africa, Tanzania, Togo, Uganda and Zambia. 18 Botswana, Eritrea, Gabon, Ghana, Lesotho, Madagascar, Malawi, Namibia, Nigeria, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. 19 Botswana, Gambia, Kenya, Namibia, Nigeria, Sierra Leone and Uganda. 17

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The ENC course is being translated into French for broader use on the continent. It is expected that with the intensified efforts in reducing newborn deaths, positive gains will be made in overall child mortality reduction. 2.2.3 Implementation of strategies for child survival and health Countries in the African Region continue to expand implementation of the Integrated Management of Childhood Illness strategy. As of December 2009, 22 countries had expanded geographic coverage of IMCI implementation to 75% of the districts; 27 countries adapted their IMCI guidelines to include HIV; and 28 countries have included the first week of life in IMCI guidelines. IMCI pre-service training is being implemented in 25 countries. The expansion of this strategy has contributed to improved capacity for child health-care in countries. Figure 2: Map of countries implementing IMCI, WHO African Region, December 2009

Legend: IMCI implementation in countries > 75 % districts implementing IMCI 25-75% districts implementing IMCI < 25% districts implementing IMCI Source: World Health Organization, Regional Office for Africa, Division of Family and Reproductive Health, December 2009

Since the introduction of the child health programme management course, the capacity of child health programme managers from 18 countries20 was developed to improve skills in the management of child health programmes. National programme management courses for child health were conducted in Ethiopia, Nigeria and Zambia. The roll-out of this training in countries is expected to improve the management of Child Health programmes in the African Region.

Botswana, Burkina Faso, Ethiopia, Ghana, Kenya, Lesotho, Liberia, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Sierra Leone, South Africa, Swaziland, Tanzania, Uganda and Zambia. 20

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Over the last two years (2008-2009), over 150 tutors of training institutions in Ethiopia, Gabon, Kenya, Malawi, Nigeria and Zambia built capacity in integrated infant and young child feeding (IYCF) counselling. Their knowledge and skills will ensure that their students also have the right skills to support mothers wherever they work. Capacity was built in 12 countries21 for the implementation and monitoring of the International Code of Marketing of Breast Milk Substitutes. Ghana, Nigeria and Zambia reviewed the implementation of their national IYCF strategy. Lesotho and Sierra Leone revised their IYCF policies. Kenya, Nigeria and Zambia documented their best practices and experiences in scaling up infant feeding activities. A total of 13 regional facilitators and 64 national facilitators from 20 countries 22 were trained in the new WHO child growth standards. Participants from 13 countries23 attended intercountry training courses held in Cameroon and Republic of Congo and a national course in Madagascar; 56 national facilitators were trained in the new WHO growth standards. 2.2.4 Improved family and community component of child survival WHO and UNICEF have continued to support countries to effectively promote key family and community practices. The two agencies developed and field-tested two sets of community health worker (CHW) training materials: one set for caring for the sick child in the community, and another set for caring for the newborn in the community. Home-based newborn care CHW training was field-tested in Kenya in February 2009. Intercountry training using the final version of these materials was done in October 2009 in Malawi for key resource persons from Malawi, Uganda, Zambia and Zimbabwe; the CHWs were all from Malawi. Eight countries24 were supported in community child health interventions. Six countries 25 were supported in the promotion of low osmolarity ORS for zinc treatment of acute diarrhoea. Implementation of integrated child survival packages was supported in six countries.26 Nigeria was supported to train community resource persons, using national community IMCI training materials developed by the Federal Ministry of Health, WHO and UNICEF; the WHO Regional Office for Africa did field-testing in 2005. In addition, community-based information system tools for community IMCI were reviewed and harmonized with the national health information system. 2.2.5 Adolescent health Six countries27 conducted situation analyses on adolescent health. Ten countries28 used their situation analyses to develop strategic plans for adolescent health. Thirteen countries29 developed standards for Angola, Botswana, Burundi, Comoros, Eritrea, Ethiopia, Kenya, Lesotho, Malawi, Rwanda, Uganda, and Zimbabwe. Benin, Botswana, Burkina Faso, Republic of Congo, Democratic Republic of Congo, Ethiopia, Gabon, Ghana, Kenya, Malawi, Mali, Niger, Nigeria, Senegal, South Africa, Tanzania, Togo, Uganda, Zambia and Zimbabwe. 23 Benin, Cameroon, Chad, Central African Republic, Republic of Congo, Cote d’Ivoire, Equatorial Guinea, Gabon, Madagascar, Mali, Niger, Sao Tome and Principe, and Togo. 24 Angola, Central African Republic, Democratic Republic of Congo, Eritrea, Ethiopia, Kenya, Mali and Nigeria. 25 Botswana, Ethiopia, Kenya, Malawi, Swaziland and Tanzania. 26 Gambia, Kenya, Nigeria, Senegal, Uganda and Zambia. 27 Cape Verde, Central African Republic, Chad, Cote d’Ivoire, Niger and Zambia. 28 Cameroon, Côte d’Ivoire, Gabon, Ghana, Guinea, Liberia, Madagascar, Sierra Leone, Tanzania and Zambia. 29 Burkina Faso, Democratic Republic of Congo, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Malawi, Mali, Senegal, South Africa, Tanzania and Togo. 21 22

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Adolescent and Youth Friendly Health Services. Within the 13 countries, five countries (Democratic Republic of Congo, Ethiopia, Malawi, Tanzania and Togo) developed training tools or implementation and monitoring tools for the standards. Six countries30 are providing adolescent and youth friendly services implementation at the district level. 2.2.6 Monitoring and evaluation During 2009, monitoring of child health interventions was supported through the Kenya Demographic and Health Survey and the Child Health Facility Surveys in Malawi and Zambia. In addition, an assessment of oral rehydration therapy (ORT) utilization was done by Africa 2010 Project in collaboration with UNICEF and WHO. Assessment of ORT utilization in five countries Africa 2010 Project facilitated an assessment of the utilization of ORT in five countries (Benin, Ethiopia, Mali, Senegal and Zambia) in collaboration with UNICEF and WHO. These assessments have been completed, and data analysis and report writing are in progress. The results of these assessments will inform childhood diarrhoea case management strategies in the Region. Kenya Demographic and Health Survey Kenya was supported to conduct the Kenya Demographic and Health Survey. Preliminary data from this survey show a decline in the levels of childhood deaths compared to rates observed in the 2003 and 1998 DHSs. The preliminary report corroborates the improvement in child survival with increases in child vaccination coverage and in ownership and use of mosquito bednets.31 Child Health Facility Survey, Malawi With technical support from WHO and other partners, Malawi conducted the Child Health Facility Survey. This was done through the Partnership for Maternal, Newborn and Child Health. The survey, conducted in all 18 districts of the country, assessed the quality of care provided to 899 children aged 2 months to 5 years in 110 health facilities implementing IMCI. National dissemination of results was done in August 2009. The survey showed that the management of sick children seen by providers trained in IMCI followed a systematic approach in most cases, and drugs were used rationally. However, skills acquired during training need to be sustained. Zambia Health Facility Survey Zambia conducted the IMCI Health Facility Survey in November 2008. Results of this survey were disseminated in 2009. The results showed an overall improvement in the management of sick children at health facilities as compared to the 2001 HFS. Of the health workers seen, 64% were trained in IMCI case management, and in more than half (54.3%) of the health facilities visited, at least 60% of the health workers were trained in IMCI. Only 22.3% of health facilities reported a supervisory visit that included case observation in the previous 6 months. The index of integrated assessment improved to 7.6 in the 2008 survey compared to 6.2 in 2001. There is need for improvement in the generally poor performing areas: symptomatic HIV assessment, checking for weight, nutrition assessment, doing rapid diagnostic tests before classification of a fever, Ghana, Malawi, Mozambique, Senegal, South Africa and Tanzania. Kenya National Bureau of Statistics, Kenya National AIDS Control Council, Kenya National AIDS/STD Control Programme, Kenya national Public Health Laboratory Services, Kenya Medical Research Institute, Kenya National Coordinating Agency for Population and Development and MEASURE DHS ICF Macro, Calverton, Maryland, United States of America: Kenya Demographic and Health Survey 2008-2009, September 2009. 30 31

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prescribing urgent referral and counselling of caretakers. Partnerships WHO, UNICEF and UNFPA are among the major partners in global, regional and national partnerships for MNCH. Technical support has been provided by these agencies to Burkina Faso, Malawi and Mozambique to strengthen rapid scaling up of MNCH interventions under a three-year grant that is funded by the Bill and Melinda Gates Foundation. The aim is to achieve a maximum reduction in maternal, newborn and child mortality within a three-year period; implement national Road Maps for reduction of maternal and newborn mortality; implement national strategic plans for accelerated child survival; and strengthen partner coordination. UNICEF, UNFPA and WHO are supporting national authorities to implement the grant. Countries developed national implementation plans and implementation is on-going. The three UN agencies continue to provide technical support for this effort at both country and subregional levels. In Nigeria, WHO and UNFPA facilitated the inclusion of the Integrated Maternal, Newborn and Child Health Strategy in the Strategic Health and Development Plans for all the 36 states and Federal Capital Territory. These State Strategic Health and Development Plans are being consolidated into one National Strategic Health and Development Plan and would form the basis for the compact which Nigeria will sign with the International Health Partnership Plus (IHP+) soon. This process will guarantee effective coordination and use of all government resources and aid inflow for MNCH. Furthermore, WHO, UNICEF and UNFPA under the aegis of the H4 Partnership developed a proposal to request a CIDA grant for US$ 20 million for accelerated reduction of maternal and newborn mortality in Nigeria. In the eastern and southern African subregion, technical support was provided, in collaboration with key partners, for the finalization of the African Union draft progress assessment tool for the Maputo Plan of Action on Sexual and Reproductive Health and Rights in Africa. There was participation in various missions including the workshop on “Working with individuals, families and communities to improve maternal and newborn health”. There was continued participation in the monthly meetings of the United Nations and Partners Regional Directors’ Team Health Cluster. The availability of high-level technical expertise in various agencies has facilitated timely and appropriate response to country requests for technical support in child health. There is, however, need to continue assisting countries to use their policies, strategies and plans to effectively increase coverage of child survival interventions. These strategic efforts need continued support in order to reduce child mortality in the Region. 2.3 Future perspectives WHO and partners need to continue supporting countries to improve child and adolescent health, focusing on: a) Advocacy for increased investment in health systems in order to effectively reduce newborn and child mortality in countries of the African Region; b) Support for resource mobilization to scale up effective newborn and child survival interventions; c) Support for monitoring achievements and challenges in child survival, including documentation of success stories in the Region.

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Key Issues and Challenges

3. Sexual and Reproductive Health

3.1 Key issues and challenges The 46 Member States of the WHO African Region are facing major sexual and reproductive ill-health accounting for a crucial part of the overall burden of diseases in the Region. Maternal and infant mortality and morbidity, unsafe abortion, sexually transmitted infections including HIV/AIDS, cervical cancer, harmful practices and violence against women and children, and sexual and reproductive health problems affecting young people are among the most pressing issues in sexual and reproductive health (SRH). Despite existing commitments and global efforts to improve women’s health and child health, many challenges still remain. The progress to alleviate the magnitude of reproductive health (RH) problems is slow. The root causes of poor progress in women, adolescent and child health lie in a range of factors comprising, among others, gender inequity in health service delivery; low access to education; and other socioeconomic determinants. Studies show that in 2005 in the sub-Saharan African Region, there were 900 maternal deaths per 100 000 live births. Very early, closely-spaced, late and frequent pregnancies are among the main determinants of maternal deaths. It is estimated that 32% of maternal deaths can be prevented if women who wish to stop or delay childbearing were able to use effective contraception. However, access to and use of contraceptives has not been widely successful. Unmet family planning (FP) needs average 27% in the 27 least developed countries of sub-Saharan Africa. Africa has the highest rate of unsafe abortion in the world. About 25% of unsafe abortions are among teenagers 15 to 19 years old. In addition, sub-Saharan Africa remains the Region most affected by HIV. The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding. Although significant progress has been made during the past five years, equitable access to antiretroviral (ARV) therapy, in particular for prevention of mother-to-child transmission of HIV (PMTCT) infection, in most countries is a tremendous challenge. Cervical cancer is the most common cancer among sub-Saharan African women; more than 99% of cervical cancer cases are related to genital tract infection by the human papillomavirus. Although 80% of deaths from cervical cancer can be prevented if detected early, 50% of cases are diagnosed at a later stage. One way to prevent cervical cancer is through screening and early treatment programmes. 3.2 Major achievements All countries in the Region are implementing their RH programmes based on the principles and recommendations stated in the WHO Global Reproductive Health Strategy. Eight countries32 revised RH policies and strategic plans to conform to the new MDG 5b target on universal access to RH, and the principles derived from the global reproductive health strategy adopted by WHO Member States. In order to improve the technical quality of SRH services, FP and sexually transmitted infection protocols or manuals in the majority of the countries in the Region were updated to incorporate new developments and technologies. Botswana, Senegal, South Africa and Zambia were supported to upgrade their FP guidelines and manuals.

32

Cote d’Ivoire, Kenya, Liberia, Malawi, Mauritania, Senegal, Sierra Leone, Zambia.

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The Strategic Partnerships Programme (SPP) is the actualization of collaboration between UNFPA and WHO, the two organizations working together for the attainment of healthy reproductive life for all individuals. In 2008 and 2009, three regional workshops on SPP were conducted and experts from 26 countries33 received orientation on the implementation framework of the global SRH strategy; nationallevel monitoring of the achievement of universal access to RH, including conceptual and practical considerations and related indicators; and revision and adaptation of RH/FP norms and technical guidelines. In addition, participants discussed MDGs, including the new target on access to reproductive health (target 5b) under MDG 5 stressing contraceptive prevalence, unmet need for family planning, adolescent birth rate and antenatal care coverage. As a result of the SPP training, countries were able to update existing tools, guidelines, policies and strategies developed at country level. A total of 12 countries34 were supported to revise their guidelines and eight countries 35 updated their guidelines. In accordance with Regional Committee Resolution AFR/RC54/R2, the Regional Office focused on increased advocacy for the repositioning of FP. In order to ensure effective use of the FP advocacy tool kit developed by the Regional Office and partners, four meetings were conducted during the biennium to build capacity of programme managers and other stakeholders in FP advocacy skills. Experts from 18 countries were oriented and financial support was provided to nine countries36 to implement advocacy activities to reposition FP. All the countries that participated in the training were encouraged to mobilize financial resources at country level for implementation of country-specific plans developed during the training. In order to facilitate utilization of the FP advocacy tool kit in countries, the kit was disseminated to all WHO country offices, partner organizations and research institutions including FP centres of excellence in the Region. In order to strengthen adolescent friendly health services in the Region, a regional consultation was held in February 2008 in Accra, Ghana. The aim of the workshop was to build skills to apply community-based interventions to improve the delivery of adolescent friendly health services. The workshop served 31 participants from ten countries.37 Cervical cancer is the leading cause of cancer mortality among women in Africa. However, early detection of the condition can save many lives. The 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.38 In October 2009, the final review of the project concluded that the “see and treat approach” has been effective in preventing cervical cancer. In 2008, the Regional Office held a regional consultation in Ouagadougou on cervical cancer prevention and control; 72 participants from 23 countries attended the meeting along with WHO staff (HQ, RO, IST, WCO) and representatives from PATH, UNFPA and Johns Hopkins Program for International Education in Gynecology and Obstetrics. One of the recommendations of the consultation was that countries should introduce VIA into their health system activities. Participants also discussed a comprehensive approach to preventing cervical cancer. This would involve vaccination, screening and early treatment, all of which open up new opportunities for strengthening reproductive health services and building interdisciplinary links. Experts

Angola, Botswana, Burkina Faso, Burundi, Central African Republic, Chad, Comoros, Republic of Congo, Democratic Republic of Congo, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Lesotho, Liberia, Madagascar, Mauritania, Mozambique, Nigeria, Senegal, Sierra Leone, Togo, Zambia and Zimbabwe. 34 Angola, Botswana, Gambia, Ghana, Guinea, Lesotho, Liberia, Mozambique, Nigeria, Senegal, Sierra Leone and Zambia. 35 Benin, Cameroon, Cote d’Ivoire, Gabon, Guinea, Mauritania, Senegal and Tanzania. 36 Benin, Burkina Faso, Cote d’Ivoire, Guinea-Bissau, Liberia, Niger, Nigeria, Sierra Leone and Zambia. 37 Benin, Burkina Faso, Central African Republic, Republic of Congo, Gabon, Kenya, Nigeria, Tanzania, Togo and Zimbabwe. 38 Nigeria, Madagascar, Malawi, Tanzania, Uganda and Zambia. 33

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from ten countries39 were trained in early detection and treatment of precancerous conditions and cervical cancer.

3.3 Future perspectives Many deaths and disabilities related to reproductive health can be prevented if well-known interventions are made more widely available and the target populations have access to quality health care. The tenyear reproductive health strategy for the African Region ended in 2007. In the context of growing poverty and globalization, a new regional RH agenda responding to current RH needs will be developed with a strong emphasis on Primary Health Care. In order to contribute to the reduction of challenges that the Region is facing, the SRH Unit will focus on the following during the 2010-2011 biennium: a) Technical support to countries to strengthen capacities for planning, implementation and evaluation of RH services; b) 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 programme and service delivery.

Angola, Central African Republic, Chad, Republic of Congo, Democratic Republic of Congo, Equatorial Guinea, Gabon, Guinea-Bissau, Mozambique, and Sao Tome and Principe. 39

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4. Making Pregnancy Safer 4.1 Key issues and challenges Maternal and newborn morbidity and mortality are still unacceptably high in the African Region; 99% of maternal deaths occur in developing countries and half of them in sub-Saharan Africa. In 2005, maternal mortality in sub-Saharan Africa was 900 deaths per 100 000 live births and the adult lifetime risk of maternal death was estimated at (1 in 26) while the developed regions had the smallest lifetime risk (1 in 7300). The decline in maternal mortality between 1990 and 2005 in sub-Saharan Africa was only 0.1% per year; however, attainment of MDG 5 requires a decline of at least 5.5% per year. 40 In the same time period, newborn mortality was estimated at 45 per 1000 live births. This calls for intensified efforts for scaling up priority interventions including action to improve access to and availability of skilled birth attendance which in sub-Saharan Africa remains low at 46.5%. Only 12% of the pregnant women requiring emergency obstetric care receive it.41 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 inadequate community health-seeking behaviour which negatively affect women’s health. As a result, pregnant women still face geographical, sociocultural and financial barriers to accessing quality health care for themselves and their children. There is urgent need to accelerate the scaling up of key interventions to increase Africa’s chances of attaining the MDGs related to MNCH. The most important challenges that need to be addressed are: (a) (b) (d) (e) (f) (g) (h)

Increasing the capacity and availability of skilled personnel at birth to meet national needs; Increasing the availability of and access to quality emergency obstetric care (EmOC) and essential newborn care (ENC); Ensuring universal access to RH services including FP; Increasing the availability of adequate financial resources at national and district levels for MNCH and reducing the heavy dependence on project funds; Ensuring the integration of programmes at regional and national levels, especially the integration of MIP, Nutrition, PMTCT and FP into MNCH services; Improving the coordination and harmonization of approaches between programmes, levels and partners; Monitoring progress towards the achievement of MDGs 4 and 5.

40

Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and World Bank. Geneva: World Health Organization, 2008. 41 WHO, UNFPA, UNICEF and AMDD. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization, 2009.

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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.42 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 and 2009, 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. 4.2 Major achievements 4.2.1 Road Map development and implementation at country level The heavy burden of maternal and newborn 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 post-partum and 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), to skilled attendance (skilled health workers, equipment, supplies and enabling environment) and to family planning as a way of reverting the trends in maternal and newborn mortality. Countries have been supported to develop their national Road Maps based on country priorities. A core group of 40 health experts from 14 countries43 were trained to support the development and implementation of Road Maps at country level. Seven more countries44 developed national Road Maps, bringing the total number to 42 countries. Of these, 27 have implemented their Road Maps, mainly by developing operational plans, building capacity of health professionals in EmOC and ENC, and institutionalizing maternal death reviews (MDRs). However, the implementation of the Road Map was still very low and slow in most 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 and 2009, the Regional Office, in collaboration with UNFPA and UNICEF, trained 110 national experts from 17 countries 45 to transform national Road Maps into district operational plans. Following the training workshop, some of these countries were given support during the biennium to develop district plans for accelerated implementation of national Road Maps bringing to 16 the total number of countries with district MNH plans.46 However, in most of these countries, only a few districts have developed operational plans for Developed by 16 partners in the Region and adopted in 2004 by the ministries of health in the Region, Resolution AFR/RC54/R9. Angola, Burkina Faso, Cape Verde, Ethiopia, Ghana, Guinea, Guinea-Bissau, Mauritania, Mozambique, Sao Tome and Principe, Senegal, Tanzania, Togo and Zambia. 44 Cape Verde, Chad, Equatorial Guinea, Mauritania, Sao Tome and Principe, South Africa and Tanzania. 45 Burundi, Cameroon, Central African Republic, Republic of Congo, Ethiopia, Gabon, Gambia, Ghana, Kenya, Liberia, Malawi, Namibia, Nigeria, Rwanda, Sierra Leone, Uganda and Zambia. 46 Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Kenya, Malawi, Mali, Niger, Rwanda, Senegal, Togo, Uganda and Zambia. 42 43

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accelerated implementation of MNH priority interventions. There is need to scale up district MNH planning. Figure 3: Road Map development and implementation status, December 2009

Algeria

Niger

Eritrea Chad

Nigeria

Gabon

Ethiopia

RCA

Uganda Kenya

R.D. Congo

Burundi Tanzania

Equatorial Guinea Angola

Zimbabwe Botswana

Countries without Road Map

Mo za

Namibia

Swaziland

Out of AFRO

Seychelles Comoros

Malawi Zambia

Countries with National Road Map Countries with District MNH Plans

Rwanda

South Africa

asca r

Sao Tome & Principe

Cameroon

e

Togo Liberia Côte Benin d’Ivoire

iqu

Ghana

Mada g

Burkina Faso

Con go

Bissau Guinea Sierra Leone

Mali

mb

Mauritania Senegal The Gambia Guinea Cap Verde

Mauritius

Lesotho

Capacity-building in costing of the MNH plans was provided to seven counties, three (Malawi, Mozambique and Tanzania) of which have already costed their MNH plans. Pre- and in-service training in EmOC was conducted in 24 countries.47 To guide countries on service delivery and ensure quality of emergency obstetric and newborn care, a manual, Recommendations for clinical practice of emergency obstetric and newborn care in Africa, was developed and launched in collaboration with SAGO and UNFPA. The recommendations focused on the five most important causes of maternal mortality: complications during the first trimester of pregnancy, haemorrhage, hypertension disorders, sepsis and obstructed labour. There are 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. The list of essential competencies for skilled birth attendants was provided to countries, and a framework for integrated MNCH services delivery towards achieving MDGs is being finalized. In addition, a training manual on antenatal care is under development and will be finalized and disseminated to countries in 2010. Following the implementation of the above mentioned 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 Committee meeting in Cameroon. Angola, Botswana, Burundi, Cote d’Ivoire, Ethiopia, Gabon, Gambia, Ghana, Guinea-Bissau, Kenya, Liberia, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, Zambia and Zimbabwe. 47

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As a way of improving supervision and monitoring of key interventions, experts from 12 countries48 were trained in the use of integrated MNCH tools for monitoring and integrated supervision. This tool 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. Service availability mapping (SAM), jointly developed by Health Metrics Network and MPS, provided countries with a key tool for gap analysis in the context of MNH planning and programme implementation at national and district levels; SAM also strengthened the capacity for geographical information. During the biennium, EmONC needs assessment and MNH SAM were conducted in six countries49 and introduced in 15 others.50 The findings have been used to advocate for resource mobilization and to develop strategies to address gaps. Currently, most countries in the Region have national policies and strategies for reducing maternal and newborn mortality, including integrated MNCH strategies and comprehensive RH 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 birth attendants 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 MNH.

Skilled care for the mother and the newborn

Benin, Burkina Faso, Republic of Congo, Eritrea, Kenya, Mali, Mozambique, Niger, Tanzania, Togo, Uganda and Zimbabwe. Angola, Ethiopia, Kenya, Mozambique, Sierra Leone and Rwanda. 50 Benin, Botswana, Burkina Faso, Burundi, Chad, Republic of Congo, Cote d’Ivoire, Ghana, Kenya, Liberia, Madagascar, Niger, Nigeria, Sierra Leone and Zambia. 48 49

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To respond to this need, a regional consultation on essential competencies for skilled birth 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 competencies for skilled birth attendants at various levels of health service delivery. During the biennium, the list of essential competencies for skilled birth attendants guided the revision of midwifery curricula in Ethiopia, Malawi, Nigeria and Tanzania; there were attempts at harmonization of midwifery training in West Africa in collaboration with the West African Health Organisation and UNICEF. The same list 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) and referral. A core group of 20 regional trainers was trained in basic EmOC using 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. 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 countries51 were supported in EmOC training. In addition, 20 WHO Country Office programme managers were introduced to WHO MPS/IMPAC tools and guidelines52 in order to improve the utilization of these tools at country level and improve the availability of skilled attendants and quality care. The Eastern and Southern Africa Coalition Against Malaria in Pregnancy 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 countries53 were conducted for capacity-building 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 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. 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 subSaharan Africa, accounting for more than a third (35%) of maternal mortality. The consultation was 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 various innovative approaches on preventing and managing postpartum haemorrhage including the use of pharmacological agents, bimanual uterine compression, intra-uterine condom tamponade and the brace suture technique. Further operational research is required before some of the techniques are widely promoted. Countries are expected to implement the recommendations and use the results to reduce maternal deaths due to postpartum haemorrhage. 51Gabon,

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. 52

53

Botswana, Eritrea, Gambia, Kenya, Lesotho, Liberia, Malawi, Namibia, Sierra Leone, South Africa and Swaziland.

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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.

Capacity-building on ENC for health workers caring for mothers and their newborns at birth and the first few weeks of life was introduced in seven countries.54 Such capacity-building has now been conducted in 15 countries in the Region,55 and 17 countries56 have trained at least three or four resource persons in ENC. Partners have expressed interest supporting some countries to roll out ENC training in 2010. National MNH policy-makers and programme managers in all these 17 countries have been oriented in strengthening integration of ENC services into MCH programmes. In collaboration with UNICEF, the WHO Regional Office provided capacity-building in newborn care for a pool of 25 consultants from over a third of the countries in the Region. These consultants have supported field-testing of materials; training of trainers in home-based newborn care; training of CHWs in home-based newborn care;57 and scaling up of ENC training. In collaboration with UNICEF, WHO developed a package on home-based newborn care for CHWs. This new guide has been introduced in Kenya, Malawi, Uganda, Zambia and Zimbabwe. Translation of the guide is ongoing, and it is expected to be available for use in francophone countries by the first quarter of 2010. The Regional Office participated in a technical working group for the development and review of training materials on neonatal and infant male circumcision. The package is now ready for finalization before use by the countries.

Angola, Botswana, Ghana, Lesotho, Namibia, Nigeria and Sierra Leone. Angola, Botswana, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Sao Tome and Principe, Sierra Leone, Tanzania, Uganda, Zambia and Zimbabwe. 56 Angola, Botswana, Eritrea, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Sierra Leone, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. 57 Ghana, Kenya, Malawi, Senegal, Uganda and Zambia. 54 55

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To monitor quality of services, Maternal and Perinatal Deaths Review (MDR) methodologies were introduced in six more countries,58 bringing to 29 the total number of countries supported to institutionalize their 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. 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, 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 pregnant women with HIV 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 underutilized. Major achievements during the biennium in terms of PMTCT were in scaling up PMTCT interventions through development of national plan and guidance tools; capacity-building at regional and national levels; strengthening the integration of PMTCT into MCH services; and strengthening monitoring, evaluation and reporting systems. In collaboration with partners, 17 countries59 in the Region were supported in the development and implementation of accelerated PMTCT comprehensive plans through the WHO/CIDA grant. Accelerated PMTCT comprehensive plans have been implemented in 34 countries60 in the African Region, contributing to improved uptake of PMTCT (Figure 4). As a result of the implementation of the WHO/CIDA grant in nine countries,61 a total of 7483 “infections averted” were reported from the implementing sites. During the last two years, under the technical leadership of WHO, 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) Guidelines for management of children with HIV infection including HIVexposed children for PMTCT; (iii) Guidelines for testing and counselling of children with HIV infection; and (iv) Revision of PMTCT guidelines and recommendations for infant feeding in the context of HIV. In addition, Ethiopia was supported to develop tools for the assessment of PMTCT interventions in routine MNCH services.

Botswana, Eritrea, Ghana, Lesotho, Swaziland and Zambia. Angola, Central African Republic, Democratic Republic of Congo, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Nigeria, Rwanda, Senegal, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. 58 59

60

Angola, Benin, Bostwana, Burkina Faso, Burundi, Cameroon, Central Africa Republic, Republic of Congo, Cote d’Ivoire, Democratic Republic of Congo, Eritrea, Ethiopia, Ghana, Guinea-Bissau, Kenya, Lesotho, Liberia, Malawi, Mali, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, Sierra-Leone, South Africa, Swaziland, Tanzania, Togo, Uganda, Zambia and Zimbabwe. 61 Central African Republic, Democratic Republic of Congo, Ethiopia, Lesotho, Mozambique, Nigeria, Swaziland, Zambia and Zimbabwe.

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Experts from 11 countries62 had their capacity strengthened to accelerate scaling up of PMTCT and paediatric HIV care, support and treatment programmes; 17 countries63 adapted their national curricula and developed national training plans. Figure 4: Percentage of women with HIV receiving ARV therapy for PMTCT, 2005 to 2008

45 34

Sub Saharan Africa

24 15

16

2008

11

West and Central Africa

2007

7

2006

4

2005

58 43

Eastern and Southern Africa

31 19

0

10

20

30

40

50

60

70

Source: Towards Universal Access: scaling up priority HIV/AIDS interventions in the health sector

Over 130 participants from 17 countries64 were trained in the IMAI/IMPAC integrated PMTCT course. This training strengthened capacity of health workers in the comprehensive management of pregnant women with HIV infection including use of antiretroviral therapy for mother and baby for PMTCT. A total of 18 participants from 11 countries65 were oriented in the PMTCT monitoring and evaluation guidelines as well as the requirements for reporting universal access indicators. CIDA supported nine countries66 with technical assistance in adapting national PMTCT monitoring and evaluation guidelines to meet WHO recommended standards. Joint Missions of the Inter-Agency Task Team were conducted in nine countries67 to assess the status of implementation of PMTCT. The Task Team also identified gaps, made recommendations and advocated to ministries of health and other partners for support of PMTCT towards achievement of UNGASS 2010 targets. In the Round 9 Global Fund applications, three countries (Benin, Côte d’Ivoire and South Africa) were supported to include PMTCT in the Global Fund proposal. Three countries (Botswana, Tanzania and Zambia) had their Global Fund proposals reviewed. 62

Burkina Faso, Cameroon, Central African Republic, Cote d’Ivoire, Democratic Republic of Congo, Kenya, Malawi, Nigeria, Senegal, Zambia and Zimbabwe. 63 Burkina Faso, Republic of Congo, Cameroon, Cote d’Ivoire, Democratic Republic of Congo, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Swaziland, Tanzânia, Uganda, Zambia and Zimbabwe. 64 Benin, Burkina Faso, Central African Republic, Chad, Democratic Republic of Congo, Ethiopia, Gabon, Kenya, Lesotho, Malawi, Nigeria, Swaziland, Tanzania, Togo, Uganda, Zambia and Zimbabwe. 65 Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. 66 Central African Republic, Democratic Republic of Congo, Ethiopia, Lesotho, Mozambique, Nigeria, Swaziland, Zambia and Zimbabwe. 67 Botswana, Burkina Faso, Cameroon, Ethiopia, Lesotho, Malawi, Nigeria, Swaziland and Zambia.

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Community engagement activities were undertaken in Nigeria to sensitize the community-based stakeholders to the importance of scaling up PMTCT services; in Swaziland, to improve awareness among young people on HIV prevention and available HIV services, including PMTCT; and in Zambia, to strengthen male involvement in PMTCT by increasing the number of men being tested with their pregnant spouses. 4.2.4 Advocacy for maternal and newborn health Advocacy for putting maternal and newborn health high on the political agenda for improved resource allocation to implement the Road Map has been successfully executed in 11 countries68 through the celebration of maternal and newborn health days and women’s days. Madagascar was supported 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 has led to policy change in favour of maternal health. Changes include the inclusion of maternal health in national development plans; adoption of laws making maternal health services (caesarean section) free in Burkina Faso, Mali and Niger; utilization of debt relief funds to increase skilled birth attendance in rural areas; increased budget allocation to the health sector; and adoption of a reproductive health law in Togo. Eight countries69 were supported to organize national days on maternal and newborn health; these national days were organized by ministries of health in collaboration with WHO, UNFPA, UNICEF and NGOs involved in maternal and child health at country level. A total of 12 countries70 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.71 Support was provided to six countries for proposal development to the Global Fund; proposals from two countries (Burundi and Côte d’Ivoire) were approved. MPS has been working on strengthening collaboration and partnership at regional and country level; improving cross-country collaboration; increasing information-sharing and advocating to improve maternal and newborn health through various initiatives. The third HHA Regional Directors meeting was held in December 2009 in Tunis with the aim of consolidating some of the gains from the HHA process and further strengthening decision-making around health policy, planning and budgeting through improved collaboration and dialogue between health and finance ministries of Health and Finance. Other initiatives include the H4 Initiative; Vision 2010; and the White Ribbon Alliance72 for Maternal and Newborn Health. Support was given by UN agencies through the H4 to countries to undertake a mapping of MNH interventions; joint country visits were conducted in Democratic Republic of Congo and Ethiopia. In collaboration with WHO, African Union (AU) launched the Campaign for Accelerated Reduction of Maternal Mortality at the fifty-ninth session of the WHO Regional Committee for Africa. National launchings are planned for Angola, Burkina Faso, Ethiopia, Namibia, Zambia and Zimbabwe. WHO Angola, Benin, Burkina Faso, Cameroon, Chad, Comoros, Eritrea, Gabon, Mali, Mauritania and Uganda. Republic of Congo, Comoros, Equatorial Guinea, Gabon, Kenya, Rwanda, Sao Tome and Principe, and Uganda. 70Burkina Faso, Burundi, Republic of Congo, Eritrea, Ethiopia, Kenya, Madagascar, Mauritania, Niger, Nigeria, Tanzania and Uganda. 71 Burkina Faso, Cameroon, Ethiopia, Ghana, Mali, Mauritania, Niger, Nigeria, Senegal, Togo, Uganda and Zambia. 72 WRA: The White Ribbon Alliance is an international coalition of organizations and individuals. It is a grassroots movement that builds alliances, strengthens capacity, influences policies, harnesses resources and inspires action to save the lives of women and newborns around the world. It was launched in 1999, and has members in 143 countries and National Alliances in 15 countries. 68 69

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technical support was provided to the AU to develop and finalize a progress assessment tool to assess implementation of the Maputo Plan of Action. Further support was provided to the AU to conduct the African Union continental conference on maternal, newborn and child mortality reviews in April 2008. 4.2.5 Improve community participation in MNCH Community participation is the key to timely access to obstetrical and newborn care. In line with this, WHO developed a framework for the development of a model integrated health promotion-based intervention to ensure community participation in WHO priority programmes. Using a global tool, a training workshop was held on the role of individuals, families and communities in improving maternal and newborn health. The workshop was held in Nairobi, Kenya in May 2009; the tool was later introduced in Malawi and Tanzania. The regional expert consultation on strengthening community participation for improving maternal and newborn health in the African Region was held in Entebbe, Uganda. Participants came from five countries in the African Region (Burkina Faso, Ethiopia, Malawi, Niger and Uganda) and included MNH and health promotion partners from UNICEF, USAID and NGOs (Save the Children and Uganda Christian University) attended the meeting. Recommendations for strengthening national capacities included strategies to: a) Establish a functional (multisectoral) national working technical group with clear terms of reference on strengthening community participation in MNH (should be linked to existing RH working groups); b) Orient members of the working group (learning from other experiences from countries); c) Advocate for implementation of the community component of the Road Map; d) Train the multiple players (individuals, families, communities) in MNH programmes; e) Identify goodwill ambassadors to spearhead advocacy for community participation in MNH. Burkina Faso, Malawi, Niger and Tanzania were supported to train health professionals in how to work with communities. There was enhanced community mobilization in Burkina Faso with the establishment of village health teams for EmONC; WHO provided support for training guidelines for the village health committee as well as guidance on the new role of traditional birth attendants. In Malawi, village health committees and local leaders were trained in data collection and maternal deaths reporting. In Niger, support was provided to community health insurance schemes. 4.2.6 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 Ministry of Health and UNFPA. The survey covered 5000 households in urban and rural areas of the country. The survey included all health facilities where delivery care was 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 are summarized. 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% by the husband and

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16% by 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. 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, newborn, 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: a) 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; b) 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; c) Describe tools, guidelines and other documents used to enhance the integrated approach; d) Suggest ways to reinforce organizational linkages towards enhanced coordination, planning, implementation and system strengthening; e) Document lessons learnt (positive and negative) in the integrated approach; f) Identify what could be described as best practices in integration. 4.3 Future perspectives In 2010 and 2011, 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 on: (a) Increasing the availability of skilled birth attendants through strengthening in-service and preservice training; (b) Transforming national Road Maps into operational and budgeted district plans in the context of strengthening health systems and revitalizing Primary Health Care; (c) Ensuring the availability of and universal access to quality emergency obstetric care (EmOC) and essential newborn care (ENC); (d) Strengthening advocacy and partnerships 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) Monitoring progress towards the achievement of MDGs 4 and 5.

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5. Gender, Women and Health 5.1 Key issues and challenges Gender inequity, poverty among women, weak economic capacity, and sexual and gender-based violence including female genital mutilation are major impediments to the improvement in women’s health in the African Region. To ensure that women and men have equal access to the necessary opportunities to achieve their full health potential and health equity, the health sector and the community need to recognize that women and men differ in terms of both sex and gender. Because of social and biological differences, women and men experience different health risks, health-seeking behaviour, health outcomes and responses from health systems. There are still misunderstandings about gender equality and women’s empowerment. Understanding gender is critical for human development to progress. Empowerment leads to the recognition of the productive and reproductive roles of women not only within the family but also within the society. The advancement of women cannot be an added dimension to other development activities but a process at the core of society that has an impact on all developmental actions. 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 various needs of women and men throughout their lives. The change in the age structure of the world’s population is considered one of the biggest challenges of the 21st century. There is a need for countries in the African Region to put in place programmes aimed at addressing this challenge.

5.2 Major achievements The role of women in the attainment of the MDGs has been recognized by the WHO Regional Committee for Africa. It is in this regard that the Committee, at its fifty-eighth session held in Cameroon in 2008 adopted Resolution AFR/RC58/R1 requesting the Regional Director to establish a Commission on Women’s Health “to generate evidence on the role of improved women’s health in socioeconomic development for improved advocacy and policy action”. In response, the Regional Director established a multidisciplinary commission of 18 members including a head of state as the chairperson, high-level political personalities, including parliamentarians, a representative of the African Union, and a group of experts with skills in sociology, economics, epidemiology, anthropology, research, obstetrics and gynaecology. The commission was to generate political, cultural and socioeconomic evidence for improved maternal health. The group of experts has deliberated on the development of the Commission’s report; organization of the report has been agreed upon and the collection of data is ongoing. Women’s Health Day in the African Region has been designated as 4 September each year. The theme for the first Women’s Health Day, celebrated in 2009, was “Women’s Health: The Key to Achieving the MDGs”. A regional survey on the inclusion 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

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documents in the Region, biennial workplans, various Regional Office publications and selected speeches of the Regional Director. The highlights of the findings are summarized below and in Table 1. The greater proportion of staff believes in the relevance of gender to their work, and most staff are aware of some institutional policies and strategies that have been adopted and are already engaged in applying gender concepts. However, there is need for institutional support to enable optimum integration of gender concepts in all work. Hence, capacity-building in gender competency for staff (all levels and categories) is needed to acquire the necessary knowledge. There is weak integration of gender issues into main health programmes. Table 1: Knowledge and capacity for gender analysis in the WHO Regional Office for Africa Issue raised 1. Percentage of staff who report awareness of at least one WHO gender policy or strategy Male Female Directors Professionals GSS 2. Percentage of staff who report good knowledge of gender concepts Male Female Directors Professionals GSS 3. Percentage of staff who report that gender is relevant to the work of the unit Male Female Directors Professionals GSS 4. Percentage of staff who report that gender is relevant to their own work Male Female Directors Professionals GSS 5. Percentage of staff who at least moderately apply gender concepts to their work Male Female Directors Professionals GSS 6. Percentage of staff who report at least some institutional support for gender integration in their work Male Female Directors Professionals GSS

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Findings N=71 74% 68% 78% 76% N=58 59% 57% 78% 64% 49% N=65 73% 57% 78% 79% 43% N=66 78% 78% 47% N=36 43% 28% 63% 43% 33% N=30 36% 23% 38% 35% 22%

Based on the outcome of the gender analysis, the Unit conducted an orientation seminar involving major programme managers on gender mainstreaming into health programmes in the Regional Office. In addition, the maternal and child health focal persons in the WHO country offices from 44 countries were oriented on gender issues and integration of gender into health programmes during the DRH annual review meetings in Burkina Faso and Zimbabwe. In order to strengthen national capacity to conduct gender analyses, national capacity-building workshops for CHWs were conducted in Ghana and Kenya. Since its adoption by the Regional Committee in 1997, the Plan of Action to accelerate elimination of FGM in the African Region was prepared, shared and implemented by all the countries practising FGM in the Region. In 2003, a five-year evaluation of implementation was conducted. This was followed by the midterm evaluation in 2008 involving 12 countries.73 The report of the midterm evaluation shows that all 12 countries have established national laws against the practice of FGM. In Burkina Faso, Eritrea and Mali, violation of laws banning the practice of FGM carries heavy fines or imprisonment. There is active involvement of Heads of State and First Ladies from Burkina Faso, Cameroon and Mali in advocating for elimination of FGM. The involvement of women who have undergone FGM helps in data collection, and the evaluation report proposes that these victims be fully deployed as agents for the elimination of FGM in Member States. The report highlights downward trends in the prevalence of the practice of FGM in most countries after two evaluations. The evaluation report was presented at the Global Research Forum on Health in Bamako, Mali in November 2008. Table 2: Trends in the practice of FGM, African Region Population Participating countries Burkina Faso Central African Republic Cote d’Ivoire Eritrea Ethiopia Guinea Liberia Mali Mauritania Nigeria Senegal Chad

Prevalence of FGM (%)

Females

Males

7.588.634 1.955.359 7.844.623 1.728.000 33.715.430 5.026.870 1.600.000 4.954.889 1.266.447 68.392.675 5.009.212 3.265.600

7.676.101 1.939.779 7.522.049 1.372.200 33.957.601 4.883.447 1.700.000 4.856.023 1.241.712 69.890.565 4.346.126 3.014.400

Evaluation year 2002 2007 66 73 36 26 45 36 97 89 73 74 99 96 56 45 91 76 81 71 30 19 40 28 50,89 45

5.3 Future perspectives In the coming biennium 2010-2011, the programme will continue to assist Member States to document best practices in eliminating FGM and intensify campaigns against gender and sexual based violence. 73

Burkina Faso, Central African Republic, Chad, Cote d’Ivoire, Eritrea, Ethiopia, Guinea, Liberia, Mali, Mauritania, Nigeria and Senegal.

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In addition, the reports of the midterm evaluation of the implementation of the action plan on the accelerated elimination of FGM and the Regional Office gender analysis will be shared with Member States and action taken on the recommendations. The focus will also be on producing the report of the Commission on Women’s Health; the report will be used for scaling up resource mobilization and advocacy for greater commitment by Member States. Member States will also be supported to develop programmes and strategies on healthy ageing.

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6. Enabling Factors, Constraints and Lessons 6. Learnt 6.1 Enabling factors In achieving the results described in the above sections, a number of enabling factors facilitated the work of the Cluster. These enabling factors included: a) Availability of technical expertise at country, subregional (Intercountry Support Teams) and regional levels to facilitate WHO support to countries; b) Establishment of a pool of consultants ready to provide technical support to countries on request; c) Commitments of national governments to improve maternal, newborn and child health; d) Collaboration with partners at different levels to facilitate progress in the Region; e) Interdivisional collaboration at both Regional Office and HQ levels for maximized efforts to support countries; f) Financial support from key traditional and new donors to address major funding gaps and thus ensure uninterrupted support to countries. 6.2 Constraints Despite the achievements made, the Cluster encountered some challenges and constraints in its efforts to provide support to Member States and improve MNCH in the Region. These constraints included: a) Inadequate funding at country level to scale up effective MNCH interventions to the vulnerable who need them; b) Overall weak health systems, with human resource constraints at all levels; c) Limited access to services such as family planning and emergency obstetric care; d) Difficulty in the generation and collection of data for operational research, routine monitoring and evaluation; limited use of sex disaggregated data; e) Difficulty in transforming research findings into policies and programmes at district and other implementation levels; f) Inability to sustain interventions which continue to depend essentially on external donor funding; g) Reduced donor support for family planning in the African Region; fragmentation of FP interventions by various stakeholders.

6.3 Lessons learnt Some important lessons have been learnt in the process of addressing the challenges faced in the biennium. Lessons learnt include:

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a) Tracking of progress towards the Millennium Development Goals at global, regional and country levels facilitates advocacy and resource mobilization efforts for maternal, newborn and child health. b) Effective collaboration with partners, especially at country level, improves quality of technical materials and increased financial resources available to implement planned activities in countries. c) Integration of MNCH programmes into existing health services ensures sustainability.

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7. Conclusion This report of the Family and Reproductive Health Cluster has reviewed the major issues of each of the four programmes (CAH, MPS, SRH and GWH) during the biennium. The report also highlighted the key achievements and articulated the future perspectives. Some of the salient factors that contributed to the Cluster’s success were mentioned; however, the FRH Cluster has not been without challenges or constraints. These constraints were identified, and the report also discussed some lessons learnt while addressing the various challenges. Because much success has been achieved with very limited resources, the future promises hope that much more can be accomplished as financial, material and human resources increase. The Cluster will continue to advocate to the relevant stakeholders to make more resources available at country level to reduce the unacceptably high morbidity and mortality of mothers, newborns and children in the African Region. The time to transform knowledge into concrete actions for the benefit of mothers and children is now because they cannot wait any longer. The problems are known, the required actions are known and the effective interventions are available. It is now time to put words into action.

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