Final 2nd TAG Meeting Report Designed-PK

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Ending Preventable Maternal, Newborn and

Child Mortality:

Regional Technical Advisory Group

Report and Recommendations of the Second Meeting of the South East Asia

Regional Technical Advisory Group (SEAR TAG)

New Delhi, India

8‐9 November 2016

SEA/CAH/131

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© World Health Organization 2017

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Content

1. Objectives of the meeting

2. Introduction

3. Recommendations

4. Proceedings of the meeting

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5. Annexes

Annex 1: Selected country updates

Annex 2: WHO Resolution SEA/RC69/R3

Annex 3: TAG Recommendations (Dec 2015)

Annex 4: List of Participants

Annex 5: Programme

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Objectives of the meeting The second meeting of the SEAR‐TAG was organized at the WHO Regional Office for South‐East

Asia, New Delhi on 8‐9 November 2016 with the following objectives:

Review the progress in implementing recommendations from the previous meeting

Review the situation of maternal and child mortality in the Region

Discuss country‐specific high impact actions towards finishing the work of MDGs 4 and 5 in

priority countries

Plan for the next SEAR‐TAG meeting in 2017

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Introduction

The Technical Advisory Group for Women’s and Children’s Health in the WHO South‐East Asia

Region (SEAR‐TAG) was established in 2015 as a mechanism to guide national governments,

implementing partners and other stakeholders on how best to accelerate implementation and

monitor strategies to advance the unfinished agenda of MDGs 4 and 5 and achieve progress

towards SDG targets.

In its first meeting, held in December 2015, the SEAR‐TAG focused on addressing neonatal

mortality and developed a set of recommendations for WHO, countries and partner agencies.

The subsequent WHO Resolution SEA/RC69/R3 ‘Ending preventable maternal, newborn and

child mortality in the SEAR with focus on newborn mortality’, adopted by the Regional

Committee in September 2016 provided an important basis for discussions during the current

meeting.

Urgent action is required to meet the MDG target levels for reducing maternal and under‐five

mortality by no later than 2018. For this, specific high impact approaches need to be agreed

and promoted in the priority countries in the Region: Bangladesh, India, Indonesia, Myanmar,

Nepal, and Timor Leste. Improving the healthy development, health, safety, and well‐being of

adolescents is also recognized as a high priority for the region.

The SEAR‐TAG meeting was accompanied by discussions among the H6 partners (UNFPA,

UNICEF, UNAIDS, UN Women, WHO and the World Bank). The H6 Regional Working Group was

created to institutionalize the regional interagency platform that would provide technical

assistance, promote multisectoral action, and coordinate partner and donor support to

countries for implementing the Global Strategy. This reflects the clear intent to respond to

governments’ request for less fragmentation and better alignment of efforts as well as the

importance of consistent regional recommendations across the spectrum of reproductive,

maternal, newborn, child and adolescent health, and across UN agencies.

Recommendations

The meeting resulted in recommendations to reinforce national commitment to the UN

Secretary‐General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (“Global

Strategy”), develop a Regional monitoring framework for that strategy, define national technical

priorities, address implementation gaps, strengthen health systems, and intensify the focus on

adolescent health and development.

Reinforce national commitment to the UN Secretary‐General’s Global Strategy for Women’s,

Children’s and Adolescents’ Health (“Global Strategy”) and undertake urgent action towards

ending maternal, newborn and child mortality

1. WHO and other H6 partners will undertake advocacy on reducing maternal, newborn and

child mortality targeting heads of states, ministers of health and parliamentarians. This

includes high level missions to the priority countries to:

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a. Strengthen national commitment to achieving mortality reduction levels of MDGs 4

and 5 by 2018, and to furthering progress towards Global Strategy and SDG3

targets.

b. Ensure resource mobilization from domestic and external sources.

2. Support countries to set intermediate targets for 2018, 2020, and 2025 towards achieving

the 2030 targets of the Global Strategy and SDG3, with an initial focus on reducing

mortality.

3. Strengthen interagency partnership and improve coordination at regional and country level

through the H6 and other mechanisms.

4. Undertake periodic joint H6 missions to high priority countries for follow‐up to review

progress and ensure technical assistance.

Develop and implement a regional monitoring framework for the Global Strategy

5. WHO and H6 partners will prepare a feasible monitoring framework to guide Member

States on reporting progress on implementing the Global Strategy.

Define technical priorities for maternal newborn and child health for the period 2016 to 2018.

6. Continue to take forward the 2015 TAG recommendations on reducing newborn mortality,

with a specific focus on scaling up recent interventions such as simplified antibiotic

treatment of newborn sepsis where referral is not possible.

7. Strengthen key interventions for maternal and newborn health in high priority countries to

ensure that the Region achieves the MDG level of maternal and newborn mortality

reductions by 2018:

a. Good quality intra‐partum care for mothers and new‐borns at health facilities

b. Good quality facility‐based care for small and sick newborn and for mothers with

complications, with efficient referral transport to facilities

c. Home‐based postnatal care for mothers and new‐borns

d. Prevention and management of adolescent pregnancies

8. Strengthen key interventions for child health in high priority countries to accelerate

mortality reduction to ensure that the Region achieves the MDG level of child mortality by

2018:

a. Strong IMNCI implementation at all three levels of care – home/community, first

level and referral level

b. Campaigns for the control of diarrhoea and pneumonia, aimed at improving

government ownership, public awareness and participation and availability of

essential supplies

c. Improved coverage of routine vaccines (e.g. measles, HiB) and introduction of new

vaccines (PCV, Rotavirus)

Address implementation gaps

9. WHO and H6 partners will collaborate with and support Member States to address

implementation gaps in coverage, quality, data collection and community engagement:

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a. Coverage gap: build national capacity for effective planning to achieve high and

equitable coverage of the key intervention packages, targeting underserved

populations to ensure that no one is left behind.

b. Quality improvement: build national capacity for continuous quality

improvement methods, focusing initially on maternal and newborn care.

c. Data collection: strengthen the health information system, expand birth and

death registration (including stillbirths) as well as coverage data to monitor

progress, strengthen capacity to conduct Maternal, Perinatal Death Surveillance

and Response and Child Death Reviews.

d. Community engagement: expand activities for public awareness, engagement

and demand generation.

Strengthen health systems

10. Support high priority countries to identify health system bottlenecks and undertake actions

to address these:

a. Improve financing by increasing domestic investment for RMNCAH and

leveraging newer opportunities including GFF, GF, GAVI, and ensure financial

protection to minimize out‐of‐pocket expenses.

1. Strengthen the health workforce for RMNCAH

i. Adequate numbers and mix of staff, with a focus on midwives

ii. Strengthen pre‐service education

iii. Strengthen in‐service continuous professional development

iv. Strengthen capacity of programme managers for planning and

implementation at national and subnational levels

b. Strengthen the service delivery by addressing:

i. Gaps in the health infrastructure including basic amenities of WASH

and electricity

ii. Logistic management of essential supplies and equipment

iii. Definitions of minimum standards for functioning of birthing centres

(case load, staffing, physical infrastructure etc.)

iv. Rationalized and stronger BEmONC and CEmONC services

c. Improve health information system by strengthening birth and death registration

(including stillbirths) and coverage data to monitor progress.

Intensify the focus on adolescent health and development

11. Adolescent Health and Development' will be the theme of the next SEAR‐TAG meeting. This

recommendation is based on the recognition that

Primary care and hospital services have few or no specific provisions for

adolescents; has poor coverage and is generally of sub‐optimal quality

Universal health coverage (UHC) does not specifically address adolescents

Adolescent pregnancy is associated with higher neonatal mortality and maternal

morbidity

Numerous risk behaviours for non‐communicable diseases (NCDs) are initiated

during adolescence, indicating that NCD programmes should include adolescents as

specific risk group

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There is a double burden of nutrition disorders, where under nutrition including

anaemia is common in boys and girls and overweight/obesity is gradually increasing

The innovative use of information technology and social media for life skills and

empowerment looks promising

School health programming is a good option and requires stronger collaboration

between the ministries of health and education

Proceedings of the meeting

Overview

Between 1990 and 2015, the global maternal mortality ratio (MMR) decreased by 44%.

Countries in the Region made significant progress, with a 69% drop in MMR, from 525 per

100 000 live births in 1990 to 164 in 2015. It is important to note that the burden of

maternal mortality and morbidity in the Region is dynamic, with uneven shifts in the

magnitude, causes, and distribution over time (see Table 1).

Table 1: Progress on MDGs 4 and 5 by country in the WHO South‐East Asia Region

Maternal Mortality Ratio (MMR)

Under‐5 Mortality Rate (U5MR)

MMR 2015

MDG 5 Target

U5MR 2015

MDG 4 Target

Bangladesh 176 142 38 48 [Achieved]

Bhutan 148 236 [Achieved]

33 45 [Achieved]

Democratic People’s Republic of Korea

82 19 25* 14

India 174 139 48 42

Indonesia 126 112 27 28 [Achieved]

Maldives 68* 169 [Achieved]

9* 31 [Achieved]

Myanmar 178 113 50 37

Nepal 258 225 36 47 [Achieved]

Sri Lanka 30* 19 10* 7

Thailand 20* 10 12* 12 [Achieved]

Timor Leste 215 270 [Achieved]

53 59 [Achieved]

South‐East Asia Region

164 131 (69% decline since

1990)

43 39 (64% decline since 1990)

Global 216 96 (44% decline since

1990)

43 30 (52% decline since 1990)

*Below SDG target, need to ensure equity across all population groups.

Source: Levels & Trends in Child mortality ‐ Report 2015: Estimates Developed by the UN Inter‐agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.

During the SEAR‐TAG meeting, members reviewed the state of programmes and policies

towards achieving at least the MDG levels of mortality reduction in the six priority countries:

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Bangladesh, India, Indonesia, Myanmar, Nepal and Timor Leste. The discussions aimed to

provide guidance in coherence with WHO to national governments, implementing partners and

other stakeholders on how best to accelerate key implementation strategies, and monitor these

and to move from the MDGs to the new SDG and Global Strategy agendas.

Maternal Health

Regional situation: Dr Elizabeth Mason stressed that the Region made the most progress in

MMR reduction among all the WHO regions during the MDG era. In 2015 the Region had 149

000 fewer maternal deaths than in 1990, with the number having plummeted to 61,000. This is

an unprecedented feat in maternal survival in the history of Member countries of South‐East

Asia However, a review of epidemiology and of policies shows that work remains to be done

(see Annex).

Lancet Maternal Health Series: Dr Wendy Graham presented the highlights of the ‘The Lancet

Series on maternal survival’. This series expands on the current knowledge of maternal health,

its epidemiology, successes, and failings, and comes at a crucial time in the sustainable

development framework to 2030. The series focused on analysing services that support safe

and healthy motherhood. It uses lessons from high‐income countries with low caesarean

section rates, yet good outcomes, and universally applicable low‐cost effective services such as:

o Team based care in maternity hospitals

o Low‐risk units alongside full scope maternity hospitals

o Free‐standing and home based midwifery

Dr Graham concluded with a call to action setting out five key targets to be met in the context

of the SDGs:

1. Prioritize good quality maternal health services that respond to local needs and meet

emerging challenges

2. Promote equity through universal coverage of quality maternal health services

3. Increase resilience and strength of health systems

4. Guarantee sustainable financing for maternal and perinatal health

5. Improve the availability and use of local evidence to inform quality improvement

processes

She proposed that SEAR countries focus on improving the quality of antenatal care and

intrapartum care, also how to link quality with continuous professional development of health

workers, both in their pre‐service and in‐service training. She also indicated that there needs to

be a greater focus on equity and also disaggregation of the data to better understand causality.

Child health

Regional situation: The progress in child survival has been another remarkable achievement of

the Region. With a 64% decline in child mortality, from 118 per 1000 live births in 1990 to 43

per 1000 live births in 2015, the reduction considerably exceeds the global rate of decline of

52%.

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Reducing child survival is now increasingly dependent on reducing neonatal mortality, and Dr

Rajesh Mehta elaborated on the progress since the previous SEAR‐TAG meeting. Post‐neonatal

child deaths are still largely due to pneumonia, diarrhoea and malaria, with under nutrition

being as high as 60% in some South‐East Asian countries. This contributes significantly to

mortality, and is an area that the SEAR‐TAG must consider prioritizing. (See Annex)

IMNCI ‐ Convergence for Child Survival: Shifting epidemiology trends such as the double

burden of malnutrition, the proportion of child deaths during the newborn period,

environmental challenges to child health along with new technology and innovations like

mHealth, eHealth, new vaccines, diagnostic and treatment innovations indicate a need to a

make changes in IMNCI guidelines and implementation.

A global strategic review of IMNCI carried out in 2016 reflected on the lessons from 20 years of

implementation. With a view to provide state of the art care for all children, the review

included a ‘big picture’ of the best investments in child health. Thirty‐four unique data sources

were used and four SEAR countries were included in the review: Bangladesh, India, Myanmar

and Nepal. Renewed joint leadership by WHO and UNICEF is focusing on the following tasks:

• Planning for a new set of harmonized, flexible guidelines for child health, with a user‐

friendly online dissemination platform;

• Planning for a new global expert advisory group to standardize the systematic review of

care recommendations;

• Rethinking of positioning of child health to restore leadership and financing, and

achieve larger‐scale implementation in countries.

Adolescent Health: Strategic Guidance

A review of available documents and reports relating to WHO and other multilateral regional

strategies provided direction for developing Strategic Guidance on Adolescent Health for

countries in the South‐East Asia Region 2017 – 2020. Dr Bruce Dick presented the noteworthy

progress to date: adolescent health is now firmly and sustainably positioned in a number of

countries, and many activities are being undertaken to address both the unfinished MDG

agendas and the SDG challenges.

Taking advantage of the growing attention to adolescent health, and building on existing

successful partnerships and collaboration, the key components of the upcoming strategy (to be

endorsed by H6 partners) include:

• A life course approach: “triple dividend”

• An ecological model

• A human rights‐based approach

• The prominence of quality, equity and accountability

• Prioritizing, setting targets and implementing the evidence‐based interventions beyond

sexual and reproductive health (SRH)

• Adolescents as a positive force for change

The strategy will focus primarily on the role of the health sector. There is an increasing

awareness of the need to pay attention to a range of adolescent health issues that are often

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inter‐related and frequently have common determinants. These include mental health

problems (suicide, depression and anxiety, stress and substance use), violence (interpersonal

and gender‐based), unintentional injuries (road traffic injuries and drowning), nutrition (both

under nutrition/anaemia and over‐weight/obesity); common endemic infectious diseases and

chronic conditions/non‐communicable diseases (NCDs). They also include a range of health‐

related behaviours and conditions that undermine adolescents’ health now and carry risks for

the future (tobacco and alcohol use, unhealthy diet and lack of exercise).

Moving the strategy from words to action will require an operational plan that defines

responsibilities for countries and for regional and national partners. The plan will need to cover

a spectrum of issues, from capacity strengthening to the sharing of programme support tools

and information about effective strategies for taking evidence‐based interventions to scale, in

ways that retain the quality that is required for effectiveness.

The SEAR‐TAG recognizes that:

Primary care has few or no specific provisions for adolescents in hospital services

and is of poor coverage and quality

Universal health coverage does not specifically address adolescents

Adolescent pregnancy is associated with higher neonatal mortality and maternal

morbidity

Numerous risk behaviours for non‐communicable diseases (NCDs) are initiated

during adolescence, indicating that NCD programmes should include adolescents as

specific risk group

There is a double burden of nutrition disorders, where under nutrition including

anaemia is common in boys and girls and overweight/obesity is gradually increasing

The innovative use of information technology and social media for life skills and

empowerment looks promising

School health programming is a good option and requires stronger collaboration

between the ministries of health and education

The strategic guidance will be further developed and will be the main focus of the next TAG

meeting.

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UN Secretary‐General’s Global Strategy for Women’s, Children’s and Adolescents’ Health: New and under‐focused areas and country implications

Dr Vinod Paul described the Global Strategy in the context of the South‐East Asia Region.

Looking further into implications for individual countries, Dr Paul highlighted that countries with

high burdens require urgent action and commitment from the SEAR‐TAG and H6 partners

(above Table 2a and 2b).

Table 2a: WHO South‐East Asia Region: Estimates of maternal mortality ratio, number of deaths,

lifetime risk, and coverage of critical interventions in high priority countries

Maternal health indicators

Maternal Mortality Ratio (per

100 000 live births)

Births in health facility (%)

Caesarean section (CS) rates (%)

Number of

maternal deathsa

Life time Risk of maternal death

Bangladesh 176 37 23 5 500 240

India 174 47 8 45 000 220

Indonesia 126 63 12 6 400 320

Myanmar 178 36 Low 1 700 260

Nepal 258 35 5 1 500 150

Timor‐Leste

215 22 2 94 82

a Numbers of maternal deaths have been rounded according to the following scheme: < 100 rounded to nearest 1; 100–999 rounded to

nearest10; 1000–9999 rounded to nearest 100; and ≥ 10 000 rounded to nearest 1000

Source: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.

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Table 2b: WHO South‐East Asia Region: Estimates of under‐five mortality rate and coverage of

interventions in high priority countries

Child health indicators

Under Five Mortality Rate (per 1000 live

births)

Children under 5 with suspected ARI given Ab (%)

Children under 5 with

diarrhoea given ORT (%)

Number of under‐five

deaths (thousands)

Bangladesh 38 71 84 119

India 48 83 54 1 201

Indonesia 27 39 47 147

Myanmar 50 34 66 46

Nepal 36 7 50 20

Timor‐Leste

53 45 78 3

Source: Levels & Trends in Child mortality ‐ Report 2015: Estimates Developed by the UN Inter‐agency Group for Child Mortality Estimation

The Global Strategy is guided by approaches that are country‐led, universal, sustainable, human

rights‐based, equity‐driven, gender‐responsive, evidence‐informed, partnership‐driven, people‐

centred, community‐owned and accountable. It draws its purpose and power from the SDGs.

The three cardinal objectives of the Global Strategy, Survive, Thrive and Transform, portray the

aspiration not only to end preventable mortality, but also to avert illnesses, ensure wellbeing,

and usher in a productive and empowered future. In this way the Global Strategy goes beyond

and is more aspirational than the MDGs.

Renewed commitment, new approaches and invigorated investments will be needed. Since the

interventions to save maternal and child lives are similar for all settings, it is the strength and

resilience of the health system that determines the coverage, equity and quality of

implementation. Each of the building blocks of the health system (infrastructure, human

resources, service delivery, commodities, finances, and governance and information system)

has to be in place to make an impact.

Monitoring the Global Strategy and SDG 3: Regional and

country implications

Monitoring implementation of the Global Strategy and tracking progress towards its

implementation requires a certain number of agreed indicators. After global technical reviews

and an open consultative process, a total of 60 indicators were selected to monitor the

implementation of the Global Strategy. These are published in the Unified Accountability

Framework. A sub‐set of sixteen key indicators were selected to give a snapshot of progress

towards the Global Strategy targets across maternal, newborn/child and adolescent health, and

the cardinal objectives of survive, thrive and transform.

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These indicators will be relevant for tracking Regional progress on the Global Strategy and for

evidence‐informed advocacy and accountability for resources, results and rights. Equity (SDG

17.18.1) was a cross‐cutting theme. Furthermore, this framework can be used to support

national SDG and health monitoring, with countries adding contextual indicators as relevant.

Regional intermediate targets aligned with the SDG targets and the Global Strategy need to be

set early on, with special emphasis on data availability and regularity. The SEAR‐TAG agreed

that WHO, together with the H6 and other partners, would review and update relevant

Regional data.

Table 3: Proposed Regional intermediate targets on mortality indicators

SEAR 2015 2018 2020 2025 2030

Maternal Mortality Ratio (SDG 3.1.1)

164 Set intermediate Regional targets to

achieve MDGs 4 & 5 levels

135 100 70

Under 5 Mortality Rate (SDG 3.2.1)

43 37 31 25

Neonatal Mortality Rate (SDG 3.2.2)

24 20 16 12

Stillbirth Rate 24 20 16 12

Adolescent Mortality Rate

‐ ‐ ‐ ‐

Source: Accountability in the 2015 Global Strategy for Women’s, Children’s and Adolescents’ Health BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4248; Stillbirths: rates, risk factors, and acceleration towards 2030, Lawn et al, Lancet DOI: http://dx.doi.org/10.1016/S0140‐6736(15)00837‐5

Conclusion

The 2030 targets for SDG 3 and the Global Strategy include and go beyond the unfinished

agenda of maternal, newborn and child survival. They require a global maternal mortality ratio

of 70 per 100,000 live births or less, and all countries to achieve neonatal mortality rate of 12

per 1000 live births or less and an under‐five mortality rate of 25 per 1000 live births or less.

Realizing the importance of accelerating reductions in neonatal mortality, where the least gain

was made during the MDG era, the Regional Flagship “Ending preventable maternal, newborn

and child deaths with focus on neonatal deaths” was developed to provide the focus and

resources needed.

The SEAR‐TAG meeting provided a significant opportunity for members and experts to meet

with H6 partners and discuss priorities for the Region. With over 350 million adolescents in the

Region, the meeting aptly put adolescent health and development back on the agenda. The

next SEAR‐TAG meeting is planned to be held in Bhutan in July 2017, and will focus on the

Regional strategic directions for adolescent health.

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Annex‐1

Selected country updates Bangladesh

MDG SDG

Target Progress from1990 to 2015

Target Situation in 2016

Women’s Health

Maternal mortality ratio

Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

Significant progress with 69% reduction

SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births

176 per 100 000 live births

Proportion of births attended by skilled health personnel

More than 60% increase in the last decade but coverage remains low

42%

Antenatal care coverage (at least one visit)

Target 5.B Achieve, by 2015, universal access to reproductive health

SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive health care services and rights

64%

Contraceptive prevalence rate

62%

Unmet need for family planning/ Demand unsatisfied for family planning

12%

Children’s Health

Under‐5 mortality rate

Target 4.A Reduce by two‐thirds, between 1990 and 2015, the under‐five mortality rate

Achieved MDG 4 with 74% Reduction in under‐5 mortality

SDG 3.2: By 2030, reduce under‐5 mortality to at least as low as 25 per 1 000 live births

38 per 1000 live births

Infant mortality rate

Newborn interventions prioritized 44% of neonatal deaths due to preterm birth

SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1000 live births


Proportion of 1 year‐old children immunized against measles

Immunization coverage increased equitably

‐

80%

Stillbirth rate ‐ Global Strategy target: By 2030, reduce stillbirths to single digits

25.4 per 1000 total births

Adolescents’ Health

Adolescent birth rate Indicator 5.4

under Target

5.B

More than 50% of girls are married by 18 years of age, thus adolescent pregnancy continues to be very high

SDG 2.2: End all forms of malnutrition and address the nutritional needs of adolescent girls, pregnant and lactating women and children

113 per 1000 girls aged 15‐19

years

Adolescent Mortality

Rate

- ‐ ‐

Source:‐ Levels & Trends in Child mortality ‐ Report 2015: Estimates Developed by the UN Inter‐agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication, 2016; Bangladesh DHS 2014

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Bangladesh‐ lessons learnt and key actions: (Observations by Shams El Arifeen)

1. Prioritized newborn interventions for common causes of neonatal deaths:

o Infections‐ Chlorhexidine for cord care and emergency management of newborn

infections

o Birth asphyxia‐ resuscitation of new‐borns

o Prematurity‐ Units set up for special care of newborn and for newborn stabilization;

Antenatal corticosteroids provided; Kangaroo Mother Care prominent

2. To achieve SDGs we need to:

o Make every effort possible to achieve, and possibly exceed, the “optimistic” coverage

targets for the interventions:

i. Substantially increase facility deliveries

ii. Focus on a few well‐functioning facilities for providing delivery services

iii. Make “smart” choices on selection of strategies for newborn interventions

iv. Multiple communication channels to reinforce behaviour change

o Invest in improving the quality of services to ensure expected or higher levels of

effectiveness

3. We need to now move beyond the neonatal period and address critical child health problems:

i. Stagnating rates of ORS use for childhood diarrhoea

ii. Uncontrolled use of antibiotics for treatment of pneumonia

iii. Preventing childhood deaths due to drowning

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India MDG SDG

Target Progress since 1990 in 2015


Women’s Health



Significant progress with 69 % reduction




56% increase in delivery with SBA but fewer than half (47%) of childbirths occur in facilities

67%

Antenatal care coverage (at least one)


More than 75% covered but still one in four women missed

SDG 3.7 and 5.6: By 2030, ensure universal access to sexual and reproductive health‐care services and rights

75%


55%

Unmet need for family planning/ Demand for family planning

21%

Children’s Health



With 62 % reduction, missed MDG 4

SDG 3.2: By 2030, reduce under‐5 mortality to at least as low as 25 per 1,000 live births



Highest number of newborn deaths (748 000 per year) 34% of newborn deaths are due to preterm birth

SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1,000 live births



‐

74%

Stillbirth Rate ‐ Global Strategy target: By 2030, reduce stillbirths to single digits

23 per 1000 total births


Adolescent birth rate

Indicator 5.4

under Target 5.B

43% girls married by 18 years and among them one in three have begun childbearing by 19 years


28 per 1000 girls

15‐19years

Adolescent

Mortality Rate

-

‐

Source:‐ Levels & Trends in Child mortality ‐ Report 2015: Estimates Developed by the UN Inter‐agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication, 2016.

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India‐lessons on approaches for reduction in maternal mortality provision of safe delivery:

(Observations by Nozer Sheriar) 1. Continue the shift to institutional deliveries

o Optimize safer utilization of existing facilities with basic mandatory standards of care and

resources

o Invest in human resource and others including accessible safe blood banks and storage facilities

2. Embark on the Mother/Baby Friendly hospital initiative

o WASH as one of the core indicators of quality

3. Develop and provide facilities for grass roots access

o Basic maternity care to be available close to women

o Enlist services of public and private sector

o Defined role, training and respect for skilled birth attendants

4. Time to create a cadre of dedicated qualified midwifes

o Independent providers of basic maternity care

o Expected to be more sensitive to women and less likely to medicalize childbirth

5. Provide Emergency Obstetric and Neonatal Care facilities

o Recognize significant role in mortality reduction

o Provision of adequate technical resources

6. Increase facilities providing critical obstetric care

o Develop replicable models of advanced critical care facilities for obstetrics

o Map available facilities to identify unserved area

7. Build a system of transport for maternity care

o Emergency response vehicles using toll free number,

o Government and private ambulances

o Referral transport for pregnant women and new‐borns

o Reimbursement or subsidization of transport cost if necessary

8. Communication to women regarding health messaging and entitlements

o Use mobile sms and voice based messaging

o Role for grass root workers such as ASHAs in messaging and advocacy

9. Dissemination and implementation of guidelines

o Standardize guidelines and protocols related to maternal health & childbirth

o Develop a national credible and robust system to create guidelines

o Work to disseminate and implement in partnerships including professional organizations

10. Create an ongoing system of guideline dissemination and upgrades

o Healthcare delivery Checklists

o Adoption of the WHO Safe Childbirth Checklist at all levels of maternity care

16

Indonesia MDG SDG



Women’s Health



Nearly achieved MDG 5 with 72% reduction




25% increase in SBA with more than 60% facility delivery

83%



Nearly all women get one ANC visit but starts declining as more visits are needed


88%


‐ 62%


‐

11%

Children’s Health



Achieved MDG 4 with 68% reduction in U5MR

SDG 3.2: By 2030, reduce under‐5 mortality to at least as low as 25 per 1000 live births



Third highest annual neonatal death toll in the region – 260 newborn die each day 44% of the newborn deaths are due to preterm birth

SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1000 live births 14 per 1000

live births


Expanded immunization

‐

84%

Stillbirth Rate ‐ Global Strategy Target: By 2030, reduce stillbirths to single digits




Indicator 5.4

under Target 5.B

4 out of every 10 girls married by 18years


47 per 1000 girls 15‐19years

Adolescent

Mortality Rate

-

‐


17

Indonesia‐ lessons from Expanding Maternal and Newborn Survival (EMAS) Programme

(Observations by Mohammad Baharuddin)

The USAID supported EMAS programme is a five year cooperative agreement aimed at

contributing to the reduction of maternal and newborn deaths in Indonesia. Within this focus,

EMAS has several overarching objectives:

‐ Contributing to 25% national reduction in maternal and newborn mortality;

‐ Improving quality of emergency care in at least 150 hospitals;

‐ Improving life‐saving clinical interventions and effectiveness of referrals in at least 300

puskesmas

Key findings from EMAS implementation include:

‐ At provincial, district, and facility levels EMAS appears to be contributing to positive

changes in quality, organization, and management of MNH services.

‐ One of EMAS’ most important results has been turning a fragmented referral system

into a functional network, and developing relationships, connection, and

communication within that network.

Evaluation findings related to achieving impact and sustainability at scale include:

‐ Data available from EMAS and from health services do not allow connections between

the observed and reported changes in processes with changes in health worker or

system performance, nor with maternal and newborn mortality.

‐ Because of this lack of certainty about performance and mortality, it will be crucial to

determine the actual operational and clinical causes of continuing maternal and

newborn deaths.

‐ There are important changes happening in Indonesia that could override efforts to increase the effectiveness of maternal and newborn services.

18

Myanmar MDG SDG



Women’s Health



61% reduction but burden remains high

SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births



40% increase in SBA but only 36% deliver in facilities

78%



More than half the women who get one visit do not get a second one


83%


46%


n/a

Children’s Health


Target 4.A Reduce by two‐thirds, between 1990 and 2015, the under‐5 mortality rate

With 55% reduction insufficient progress towards achieving MDG 4




‐ SDG 3.2: By 2030, reduce neonatal mortality to at least as low as 12 per 1,000 live births



‐ ‐

86%

Stillbirth Rate ‐ ‐ Global Strategy Target: By 2030, reduce stillbirths to single digits



Adolescent birth rate Indicator 5.4

under Target

5.B

72% adolescents began child bearing by 19 years


30 per 1000

girls 15‐19 years

Adolescent Mortality

Rate

- ‐

‐

Source: Levels & Trends in Child mortality ‐ Report 2015: Estimates Developed by the UN Inter‐agency Group for Child Mortality Estimation: Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: World Health Statistics, WHO Publication, 2016.

19

Myanmar‐ lessons learnt and accomplishments made: (Observations by Katherine Ba‐Thike)

1. Transition of MDR to MDSR ‐ started in November 2015 (UNFPA and WHO support)

2. Technical and training guidelines of Child Death Surveillance and Response (CDSR) with

advocacy meetings, TOT and multiplier trainings for CDSR done for 2016 and 2017

3. Health workforce initiative on Midwifery‐ ASEAN Regional Guideline for Minimum

Requirements for Training and Accreditation of SBA endorsed by ASEAN, released June 20144.

4. Hospital Equity Fund to support reduction MMR and under‐5 mortality (NMR, IMR, U5MR)

according to national targets of the programme

But efforts still needed:

o Advocacy for investment in RMNCAH at different levels

o Focus on ending preventable maternal and neonatal mortality

o Implement plans that have been developed – Every Newborn Action Plan, Strategic

Plan for Reproductive Health

o Address health system issues to support above plans

o For WHO – to help RMH/MoH to focus on a few issues and “do‐it‐well”

20

Nepal MDG SDG



Women’s Health



Just missed despite 71% reduction but number of deaths very high




69% increase but still only one third population catered to for institutional deliveries

36%



Only half the population covered with very high geographic/social inequities


58%


‐ 50%


‐ 28%

Children’s Health

Under‐five mortality rate


Achieved MDG 4 but 57% of under‐five deaths are due to newborn conditions







‐ 88%

Stillbirth Rate Global Strategy Target: By 2030, reduce stillbirths to single digits



Adolescent birth rate Indicator 5.4 under Target 5.B

40% of the girls are married by 18 years and begin childbearing by 19 years


71 per 1000 girls 15‐19years



21

Nepal‐ lessons learnt but challenges remain: (Observations by D S Manandhar)

a. Financial‐‐ High out of pocket expenditure. The policy is for free newborn care but funding is

inadequate; cost of capacity building /strengthening infrastructure and equipment is

large

b. Programmatic ‐ Inconsistent use of antenatal corticosteroids; inadequate coverage of

Kangaroo Mother Care; quality care issues e.g. use of partograph, inadequate institutional readiness for new born resuscitation, skilled human resource constraint particularly for newborn care, unavailability of services 24/7 for 365 days for both

mother and neonates including postnatal care, inconsistent use of national protocols/guidelines, newborn component is not well addressed in MNCH training,

and monitoring /quality information issues

Way forward:

• Focus on upgrading existing birthing centres to birthing and newborn care centres

• Scale up community mobilization initiatives

• Strengthening referral mechanisms for all children

• Partnerships with private sector in newborn and child health programme

• Local context‐specific planning and support by all partners

• Operational research

• Continuum of quality services to newborn and children

22

Timor Leste MDG SDG

Target Progress since 1990


Women’s Health



Achieved MDG 5: Policy environment enabling but number of deaths remain high


215 per 100 00

live births


Very poor SBA coverage with only 22% institutional deliveries

21%



3/4th women get one ANC visit but the number declines steadily and only half get four visits


84%


‐ 22%


‐

32%

Children’s Health


Target 4.A Reduce by two‐thirds, between 1990 and 2015, the under‐5mortality rate

Country has achieved MDG4 because baseline in 1990 was quite high




34% of neonatal deaths are attributed to complication of preterm birth




‐

70%

Stillbirth Rate ‐ Global Strategy Target: By 2030, reduce stillbirths to single digits


Adolescent’s Health


Indicator 5.4 under Target 5.B

Few girls married by 18 (6%) but 20% of the adolescent girls have begun child bearing by 19 years


50 per 1000 girls 15‐19 years


‐


23

Timor Leste: Lessons learnt and key actions taken: (Observations by Sujeewa Amarasena) Timor‐Leste started with very high maternal and child mortality, which many thought was

impossible to tackle. But a high degree of political will, initiatives to strengthen the health

system and evidence‐based interventions taken to scale, to reach every woman ever child, have

led to dramatic reductions in maternal and child mortality, and ultimately helping them achieve

MDGs 4 and 5.

Since 2000 the Government has publicized its commitment to the MDGs 4 and 5, and

demonstrated very positive improvements.

Increased coverage of skilled care at birth and institutional deliveries

Improved quality of care around childbirth, including resuscitation

Strengthened management of preterm labour and preterm babies

Improved essential newborn care, and early postnatal care at home

Strengthened care of sick and small new‐borns in hospitals

24

Thailand Country has already achieved SDG targets

Maternal mortality ratio at 20 is less than SDG Target (70 per 100 000 live births)

Neonatal mortality at 7 is lower than the expected 12 per 1000 live births

Under‐5 mortality at 7 is already below 25 per 1000 live births

Lessons from Thailand’s success: (Observations by Sawasdivorn Siraporn)

1. Successful centralized health care coverage plan must be made at the central level but

implemented at the local level

2. Coordination of planning and utilization of human resources must consider both providing

health services (demand) and training qualify health care personnel (supply)

3. Owing to conscious capacity building on health care financing, Thailand gradually moved

from an out of pocket payment to a prepayment system

25

Annex 2

SEA/RC69/R3

ENDING PREVENTABLE MATERNAL, NEWBORN AND CHILD MORTALITY IN THE SOUTH‐EAST ASIA

REGION IN LINE WITH THE SUSTAINABLE DEVELOPMENT GOALS (SDGS) AND GLOBAL STRATEGY ON WOMEN’S, CHILDREN’S AND ADOLESCENTS’ HEALTH

The Regional Committee, Recalling its resolutions SEA/RC53/R9 on Maternal mortality, SEA/RC56/R9 on Health of the

newborn1 and SEA/RC58/R2 on Skilled care at every birth, as well as the recent World Health Assembly resolution WHA69.2 on Committing to implementation of the Global Strategy for Women’s, Children’s and Adolescents’ Health. Newborn period is first 28 days of life after birth

Recognizing the significant progress made towards achieving MDGs 4 and 5 in countries of the South‐East Asia Region with a regional decline in child mortality rate of 64% and a decline of 69% in the maternal mortality ratio, between 1990 and 2015, and the need to further build upon these achievements,

Noting that these figures fall short of the MDG targets of a two thirds reduction in child mortality and a three fourths reduction in maternal mortality, and that neonatal mortality has declined less rapidly than child mortality, that there are significant disparities in achievements across and within countries, and that maternal, newborn and child mortality continue to remain high in some countries in the Region,

Acknowledging that the UN Secretary‐General’s Global Strategy on Women’s, Children’s and Adolescents’ Health (2016‐2030), and the Sustainable Development Goals provide new opportunities and have set new targets for countries on reducing maternal mortality and ending preventable, newborn and child deaths, Further acknowledging that Universal Health Coverage is the overarching umbrella for taking forward the SDG Goal 3 on health, and that the SDGs provide an excellent framework to accelerate efforts to narrow equity gaps in accessing quality care, ensure adequate health financing and sufficient numbers and appropriate skill‐mix and deployment of health workforce,

Appreciating the Regional Flagship Priority on ending preventable maternal, newborn and child mortality with a focus on newborn deaths, and the partnership commitment as exemplified by the joint statement by H6 agencies (WHO, UNICEF, UNFPA, UNAIDS, UN WOMEN and World Bank) on ending preventable maternal, newborn and child mortality,

Considering that this resolution supersedes the three previous resolutions on related subjects namely, SEA/RC53/R9, SEA/RC56/R9 and SEA/RC58/R2;

1. URGES Member States: a) To achieve universal access to and coverage of essential intervention packages for reproductive, maternal, newborn, child and adolescent health (RMNCAH) across the continuum of care, with focus on good quality care of mothers and newborns at the time of childbirth and, including mothers and newborns with risks and complications, b) To review and strengthen national health systems, as appropriate, to identify gaps and solutions in relation to the needs of RMNCAH, including by investing in midwifery skills and development of sustainable health financing mechanisms to reduce out‐of‐pocket expenses for safe child birth and care of mothers and newborns, c) To strengthen the quality and use of data for programme improvement in line with the indicators and disaggregation in the SDGs and Global Strategy including still births and cause of death related to maternal, neonatal, child and adolescent health, and

26

d) To reinforce multisectoral and multi‐stakeholder partnerships and commitments to address underlying social determinants of women’s, children’s and adolescents’ health such as early marriage2, nutrition, education, poverty, water‐sanitation, and to promote early childhood development, 2. REQUESTS the Regional Director: a) To intensify technical collaboration with, and support to, Member States to update their national RMNCAH strategies and plans to address the coverage gaps for essential interventions for RMNCAH, with specific guidance on organizing, planning and setting up quality services for child birth and newborn care, b) To support Member States to strengthen the quality and use of data for programme improvement in line with the indicators and disaggregation in the SDGs and Global Strategy including still births and cause of death related to maternal, neonatal, child and adolescent health, c) To support Member States, upon request, for developing national RMNCAH investment case3and encourage adequate national and international investments for ending preventable maternal, newborn and child mortality and improving health and wellbeing of women, children and adolescents, and d) To report progress on implementation of this resolution to the Regional Committee in 2018, 2022, 2026 and 2030.

9 September 2016

27

Annex 3

SEAR TAG Meeting December 2015‐ Overarching recommendations

(1) WHO to secure the buy‐in to the recommendations from all the national governments through the

Regional Committee deliberations on Women’s, Children’s and Adolescents Health, with a focus on

reduction in newborn mortality in September 2016.

(2) To facilitate dissemination, buy‐in and adoption of the recommendations in countries, countries

should be encouraged to replicate the Regional TAG, through national processes, e.g. multi‐speciality

National Task Force. Each country is encouraged to undertake a strategic consultation with the support of

H4+ and partners in the country.

‐ Countries to create/strengthen National Task Force or similar mechanism and share progress at the next

SEAR‐TAG meeting.

(3) Countries to focus on expansion of good quality care for mothers and new‐borns around the time of

childbirth (including late antenatal care) and first few days thereafter including facility‐based and home‐

based care of small and sick babies.

‐ Countries to prioritize this and operationalize plans e.g. within ENAP immediately and share progress at

the next SEARTAG meeting.

(4) WHO to inform the intervention packages that will be required for reducing the NMR to low levels of

12 per 1000 live births or less (secondary and tertiary care and other interventions).

(5) WHO, UNH4+ and partners to support high priority countries for development of investment cases, to

engage with Global Finance Facility and mobilise domestic resources for RMNCAH.

‐ WHO, UNH4+ and partners to prepare a strategic approach and support country level dialogue for

development of investment cases in 2‐3 priority countries in 2016

(6) WHO with H4+ to create a SEAR web‐based repository of best practices in RMNCAH and increase

opportunities for cross learning and share innovative experiences.

‐ WHO with UNH4+ to create SEAR repository and inform of progress.

28

Annex 4

List of Participants

SEAR‐TAG Members

1. Vinod Paul: Chair

2. Nozer Sheriar (India)

3. Mohammad Baharuddin Hasanudin (Indonesia)

4. Katherine Ba‐Thike (Myanmar)

5. Dharma Saran Manandhar (Nepal)

6. Sujeewa Amarasena (Sri Lanka)

7. Siraporn Sawasdivorn (Thailand)

8. Wendy Graham (connected through skype)

H6 Partners:

1. UNCEF ROSA: Sufang Guo

2. UNICEF EAPRO: Kyoko Shimamoto

3. UNFPA: Wame Baravilala

4. UN WOMEN: Ms Subhalakshmi Nandi

5. World Bank: Dr Sheena Chhabra

Consultants:

1. Elizabeth Mason

2. Bruce Dick

3. Krishna Bose

Secretariat (WHO Regional Offic3):

1. Pem Namgyal, Director, Family Health, Life Course and Gender

2. Neena Raina, Coordinator, Health Through Life Course

3. Rajesh Mehta, Medical Officer, Child and Adolescent Health

4. Neelamani Hewageegana, Maternal and Reproductive Health

5. Priya Karna, Junior Public Health Professional

29

Annex 5

Programme 1. Opening Session

2. Progress in implementation of TAG recommendations

Report on implementation

Perspective from H6 agencies 3. Maternal Health: Finishing the MDG5 work

Maternal Health ‐ Lancet Series

Regional situation

Country‐specific Reflections: (Bangladesh, India, Indonesia, Myanmar, Nepal, TLS)

Recommendations for regional and country level actions

4. Child Health: Finishing the MDG4 work

Regional situation

Child Health‐ Strategic Review

Country‐specific Reflections: (Bangladesh, India, Indonesia, Myanmar, Nepal, TLS)

Recommendations for regional and country level actions

5. Regional strategic guidance on Adolescent Health

Setting the stage for new regional priority

6. Global Strategy:

New and under‐focused areas and country implications

7. Monitoring Global Strategy and SDG3: Regional and Country

8. Plan for the next TAG Meeting (2017)

9. Conclusion of the meeting

Final 2nd TAG Meeting Report Designed-PK

Documents

Transcript of Final 2nd TAG Meeting Report Designed-PK