TOWARDS THE MDGs: UNICEFs engagement in fragile states

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TOWARDS THE MDGs UNICEFs engagement in fragile
states
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Summary

• UNICEF vision and strategy in MNCH
• Building on experiences in development and post
  emergency contexts
• Country Examples
• Ethiopia
• Angola
• Challenges Considerations
• The way forward

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UNICEF Vision For MNCH

• Scaling-up integrated packages at community
  level for national impact
• Measuring results and public accountability
• Contributing to the policy and evidence-base
• Strategic partnerships and leveraging
• Social mobilisation and advocacy

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Choices In Defining Approaches To CS
Most challenging countries
More advanced countries
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ACSD Pilot 2002-2005
Aim To reduce mortality among children
less than 5 years of age
Strategy Use results-based planning to increase
coverage with three packages of
high-impact interventions emphasizing
community-based delivery
Extent Selected districts in 11 countries in
West Central Africa Population 17
million
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ACSD Pilot Targets

• Attain stated coverage targets within 2 years in
  intervention districts
• EPI and ANC 80
• IMCI 50
• Pregnant women under-5s sleeping under
  ITNs 60
• Achieve reduction of at least 5/yr in under-5
  mortality rate (U5MR)
• 15 U5MR reduction after 3 years (2004)
• 25 U5MR reduction after 5 years (2007)

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ACSD Pilot Results

• Major gains in coverage
• Vaccination
• Vitamin A
• ITN use
• Antenatal care
• Few gains, and some losses, in coverage
• Case management of pneumonia, diarrhoea, malaria
• Infant feeding
• Modelled estimates of impact
• Reductions in U5M
• 20 in high impact districts
• 10 in expansion districts
• Attributed mainly to increases in ITN use

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ACSD Pilot Independent Evaluation

• STRENGTHS
• Built on existing intervention priorities and
  delivery mechanisms
• Community-based approach and community
  involvement
• Monitoring, evaluation and supervision
  strengthening
• Funding for materials and supplies
• Promotion of policy uptake of the ACSD approach
• Leverage of funding from partners
• Emphasis on building capacity

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ACSD Pilot Independent Evaluation

• WEAKNESSES
• Limited effectiveness of treatment through CHWs
• Lack of treatment for pneumonia
• Ineffective antimalarials
• Delivery strategy choices
• ITNs only for fully vaccinated children
• C-IMCI implementation with improved care-seeking
  without F-IMCI
• Low motivation and turnover of voluntary CHWs
• Sustainability of funding and stock-outs

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Highest lt5 MR Ranked Countries

• 1) Sierra Leone
• 2) Angola
• 3) Afghanistan
• 4) Niger
• 5) Liberia
• 6) Somalia
• 7) Mali
• 8) Chad
• 9) Equatorial Guinea
• 10) DRC

• 11) Rwanda
• 12) Guinea
• 13) Cote D Ivoire
• 14) Nigeria
• 15) CAR
• 16) Burkina Faso
• 17) Burundi
• 18) Zambia
• 19) Ethiopia
• 20) Swaziland

Source UNICEF SOWC 2007
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Ethiopia

• Priority MNCH Activities during 2000-2005
• Measles/VAS campaign
• Food aid / Emergency Nutrition / TFCs
• Malaria control
• Emergency WES

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Ethiopia Strategic Scale-Up
Campaign
Outreach
Institution
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Ethiopia Measles/Vitamin A Scale-Up
Campaign -VAS 23m 6m-15y -Measles
28.4m 6m-15y-Single dose
Outreach EOS -VAS 13.2m U5severy six
months -Measles missed opportunities U2s every
six months -Measles follow up 13.5m 6-59m
Institution -HEWs give VAS measles
-Pentavalent gt90 with 3rd dose
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Ethiopia WASH Scale-Up
Campaign -WASH hygienepromotion
-Construction/ rehabilitationwater supply
sanitation
Accel. WASH -National WASH Movement -Sanitation
Strategy -MOU Health, Educ. Water
WASH -Universal Access Plan by 2012 -UNICEF
WES cluster lead
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Ethiopia PMTCT, Paediatric AIDS

Through HEWs -ANC at village level/link
VCT -Rapid VCT expansion -Village level clean
delivery/newborn care -Active follow-up on
mother/child
-Only 28 of pregnant women attend ANC -64
of children whose mothers tested positive will
not access prophylactic ARVs -After delivery,
mother/child are lost for further follow up
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ANGOLA Accelerated Child Survival and
Development
Population 2007 18,685,639 GDP growth Africa
6 2007 GDP growth Angola 27 in 2007 2nd
largest oil producer in Africa major diamond
producer China pledged 20 billion to Africa
China has awarded 11billion to Angola to date
2007 to host Afrobasket 2008 to host World Summit
of Diamonds 2010 to host African Cup of Nations
(football) but ranks 162nd out of 173
countries Human Development Index
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ANGOLA Accelerated Child Survival and
Development
Life expectancy 42-43 years old Fertility rate
7 one of the highest in the world 900,000
births estimated 2007 population will double
in 22 years 56 lt 18 years of age highest
percentage of youth in the world Literacy rate
1996 54 2001 57 (44 women literate) only
¼ children will finish 6 years of primary
school 1.1 million over-age students
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ANGOLA Accelerated Child Survival and
Development
68 population live below the poverty
line Under 5 (U5) mortality rate 260/1000
2nd highest in the world Every hour 25 children
die in Angola Maternal mortality rate 1500/
100,000 live births 12,000 maternal deaths/ year
1 in 10 pregnant women will die due to
delivery complications 1 in 2 women is
protected against neonatal tetanus only 1 in 4
births is assisted by skilled staff
contraception is 6 worlds 3rd
lowest Malnutrition is alarmingly high
comparable to Afghanistan Southern Sudan 2/5
children underweight 1/8 severely
underweight 1/2 U5 stunted
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ANGOLA Accelerated Child Survival and
Development
50 children are sick in a 2 week period 25
Diarrhea (5 episodes/ year) 25 Malaria (main
killer) 10 Acute respiratory illness
In 2004, Angola reported 3.2 million cases of
malaria, two-thirds of which occurred in children
under 5 years of age.
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ANGOLA Accelerated Child Survival and
Development
Angolan distribution of U5 deaths by cause,
2000-03 Source MICS 2001
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ANGOLA Accelerated Child Survival and
Development
Under 5 Mortality vs. Millennium Development Goal
in Angola
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Accelerated Child Survival Development
PREVENTION
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Accelerated Child Survival Development
TREATMENT
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WATER, HYGIENE AND SANITATION INTERVENTIONS
Source Fewtrell and Colford, 2004
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Accelerated Child Survival Development
DELIVERY MODES
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ANGOLA Accelerated Child Survival and
Development

• HOW TO DO IT
• Universal coverage via
• The fixed networks of public health, NGO and
  church health services
• Routine outreach and mobile health services to
  care for vulnerable groups which have no access
  to health services
• Community and household based activities
• Improving community participation

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Angola Phased Implementation

• Phase I (2007-2009) 5 out of 18 provinces
  covering 32 of total population
• Provision of package to 5 provinces. Lessons
  learnt will be used to advocate and scale up to
  remaining provinces
• Phase II (2010-2011) Nation-wide
• Total reduction of lt5 mortality by more than 44
  and neonatal mortality by 37 . This will save
  over an estimated 55,500 children and 3,000
  mothers lives per year
• Phase III (2012-2013) Nation-wide with additional
  interventions
• Nationwide coverage of services. It is expected
  to save an estimated 105,000 children and 8,000
  mothers lives each year.

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Angola UNICEF Upstream Contribution

• Supported the operational plan of the WHO,
  UNICEF, MoH for Accelerated Child and Maternal
  mortality reduction strategy 2004-2008.
• Accelerated Child Survival and Development
  Investment Plan 2007-2009
• UNICEF, UNFPA, WHO, UNHCHR and others commitment
  to support MoH in revitalizing health services,
• A proposed model that can be used to leverage
  government and donor funding for a national
  roll-out.
• Conducted supply chain assessments
• Supported the National Forum 2007
• Children! The Absolute Priority (national
  commitments for children)

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Angola UNICEF Downstream Contributions

• Capacity building/ training of government in
• planning
• conducting house to house campaigns
• microplanning for outreach from health centers.
• strengthening fixed centers
• Assistance towards implementation through
• provision of supplies,
• funding,
• mapping of provincial capacity and gap analysis
• Technical advice, macro and micro-planning for
  campaigns and outreach
• Child Health Days ( first round of integrated
  approach- vit A, polio, programme communication,
  deworming)
• Measles Plus (Child health measles bednets)
• Expansion of cold chain

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Challenges Considerations with Going to Scale
in Fragile States

• Capacity
• Health systems
• Human resources
• Leveraging Resources
• Financial
• Supplies
• Partnerships
• Traditional (Government, UN agencies, NGOs)
• Non traditional (Non-state entities, Ministries
  of Finance, Private Sector)
• Going to scale
• Ensuring quality
• Monitoring Evaluation

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The Way Forward

• Agree on a national framework with all key
  stakeholders (Government, ODA, UN, INGOs, NGOs)
• Ensure a two track approach Upstream/Downstream
  
• Agree on a minimum package (for various phases,
  contexts and delivery modes)
• Jumpstart EPI (measles, polio, TT), Vit A,
  Deworming, LLINs, Health promotion
  (Breastfeeding, handwashing, etc)
• Pulse activities (e.g., Child Health Days) EPI
  (mobile/ acceleration activities), Vit A,
  Deworming, Health Promotion, LLIN
  (Distribution/Retreatment)
• Routine (Facility/Outreach/Community/Family)
  Coverage of large geographic areas with a minimum
  package

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The Way Forward

• Conduct in-country policy dialogue to integrate
  ACSI into key policy and strategic documents
  CAF (DRC), UNTP (Somalia), NHSS (Sudan, DRC)
• Cost the package of services and leverage
  resources
• Prioritise the implementation package (in a
  step-wise manner)
• Forge partnerships (implementation/ops research)
• Establish monitoring and evaluation framework
• Document and share best practices within and
  among fragile states, contribute to the evidence
  base
• Build staff capacities (recruitment/retooling)