Scale Experience from CSHGP's Expanded Impact Category_Waltensperger_5.1.12


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Scale Experience from CSHGP's Expanded Impact Category_Waltensperger_5.1.12

  1. 1. Expanded Impact Project Malawi Newborn Health Program USAID/CSHGP 2006-11 (CS-22 Cycle) Karen Z. Waltensperger, Save the Children Thanks to Evelyn Zimba, Joby George, Tanya Guenther
  2. 2. Newborn health in Malawi• 2000-5 Saving Newborn Lives (SNL)-1 funded by BMGF• Developed community-based newborn care package with MOH/RHU• Implemented by Save the Children (Mangochi) and partners (Project Hope, Ekwendeni CCAP Mission Hospital, Kamuzu College of Nursing)• Collaboration at national level to advance newborn health agenda in context of Safe Motherhood
  3. 3. Opportunities in late 2005• Strong partnership with MOH/RHU and partners• National-level WILL to incorporate newborn• Uncertainty about Malawi’s inclusion as an SNL- 2 country• Opportunity to submit application to USAID/CSHGP for CS-22 cycle Expanded Impact Project (EIP) - $2.5m + match
  4. 4. CSHGP EIP Category• $2.5 million• Extend and build on existing, successful programs• IMPACT AT SCALE - multi-district, sub- national, national level• Roles – Secretariat – Partner coordination – Convener
  5. 5. Approach• Support for Malawi’s Road Map for Accelerated Reduction of Maternal and Neonatal Mortality• Catalytic inputs to advance newborn health agenda in Malawi and achieve impact at scale • Technical leadership and support • Limited material assistance • Support for “mainstreamed” training • Assistance with partner coordination
  6. 6. Community Component• Sub-grant for Ekwendeni CCAP Mission Hospital to document Agogo Approach (Mzimba District)• Transfer lessons learnt from Institute for Child Health’s Mai Mwana randomized control trial in Mchinji District (funded by SNL-1)
  7. 7. Transition• CSHGP application submitted late 2005• Malawi SNL-2 core country (2006-11)• SNL country planning May 2006 (CBMNC package with PNC focus, KMC)• CS-22 cooperative agreement awarded in late June 2006 (Oct 2006-Sep 2011)• CS-22 DIP approved June 2007• CS and SNL work plans merged ($5 million program)
  8. 8. Points of departure• National-level indicators (from MICS, DHS)• Conundrum of baseline for Rapid CATCH— where?• Decided not to hold DIP Workshop• MOH/RHU Deputy Director participated in DIP Review in US
  9. 9. SNL-2 ―match‖ / cost share• Develop and pilot a Community-Based Maternal and Newborn Care (CBMNC) Package• Delivered by Health Surveillance Assistants (HSAs) in 3 districts)• MOH, UNICEF, WHO, other partners• UNICEF to fund district-level implementation in district pilot
  10. 10. Package contents• ANC (3 visits), birth planning, facility delivery, PPFP, KMC (facility, ambulatory, community)• Focus on 3 postnatal home visits during first week (days 1,2,8)• Costing study• Community mobilization component added (―core‖ groups using Community Action Cycle)
  11. 11. PNC home visits• 3 visits (days 1,3,8) + extra for small neonates• Check newborn vital signs– weight, temperature, respiration• Check for danger signs in mother and newborn• PPFP counseling--LAM• PMTCT
  12. 12. Early lessons• “Not about us”• “Our timeline isn’t necessarily their timeline”• “Sometimes lead, sometimes follow— mostly walk together”• Things happen
  13. 13. IMNC Package• MOH/RHU priority• Integrated Maternal & Newborn Care training package for workers in first-line facilities• ANC, BEmONC, EmMNOC, SBA, immediate & essential newborn care, PNC• KMC (facility, ambulatory, community)• To be accomplished before roll out of CBMNC package
  14. 14. Piloting the CBMNCPackage• National development workshop• 3 districts selected by MOH (1 per region)• 4 additional districts supported by MCHIP (JPHIEGO & Save the Children)• Community mobilization component added using ―core‖ groups and Community Action Cycle• Ad hoc CBMNC TWG formed by Safe Motherhood Sub-Committee (Sexual and Reproductive Health Technical Working Group)
  15. 15. Some results at national level • Districts where CBMNC currrently rolled out—17+/29 • Sites offering KMC—123+ • First-line facilities with IMNC services—194+ • HBB in 14 districts (target 20) 15
  16. 16. CBMNC baseline & endline• Timeline: Baseline data collection in November 2007 (Formative research, HH survey, HF survey) Training of >600 HSAs and HF staff in 22 facility catchment areas July 2008 to June 2011 Support activities (supervision, monitoring) ongoing Endline data collection in May/June 2011 (HH survey and HF survey)
  17. 17. Coverage of services 100 Missed opportunity given high facility 80 delivery rate and relatively long duration of stay at health facilities 60 40 20 0 ≥1 ANC visit ≥4 ANC Facility SBA* Baby PNC check PNC check (skilled)* visits (any)* delivery* w eighed at for NB in 2 for mom in 2 birth* days* days* Baseline (n=713) Endline (n=900)
  18. 18. Knowledge and practices 100 80 60 40 20 No data No data 0 Complete First bath Nothing to Immediate Immediate Immediate Knowledge Knowledge birth plan* ≥6 hours* cord drying* BF* STS 2+ NB DS 2+ PP DS Baseline (n=713) Endline (n=900)
  19. 19. Health services assessment• 22 health facilities and 110 HSAs interviewed• HSA findings highlight challenges to achieving coverage of CBMNC within existing system: • Only 47% resided within their catchment area • 54% spent 3 or less days in the community in last week • 27% spent 3 or more days at the health facility in last week • Only 66% had conducted ≥1 pregnancy home visit and only 51% ≥postnatal home visit in past 3 months • Task overload?: ~40 deliveries/year = 5x40 = 200 home visits per year (17 per month) + CCM + growth monitoring + vaccination support + watsan activities +….
  20. 20. Excerpt from Policy andProgram Timeline Annex 12A: Malawi Newborn Survival Policy and Program Timeline Pre-2000 2000-2002 2003-2004 2005-2006 2007-2008 2009-2010 National context - political, humanitarian, etc. • Budget support • Famine/food • Bingu wa Mutharika • SWAp 1 Health • Bingu wa from donors elected president insecurity Sector Mutharika re- • Massive flooding • Intro of subsidized elected ravaged parts of farm inputs (e.g. country fertilizer, seeds, • Famine/food insecticides) insecurity Newborn survival increasingly incorporated at national level in macro policies, strategies, and plans (health sector MNCH - not NEWBORN specific) • Safe • National •Essential Health • Developed “Road • Official launch • CBMNC package Motherhood Reproductive Package launched Map for Accelerated of Road Map endorsed by Initiative (1994) Health Policy (2002) funded through Reduction of with increased MOH/RHU for • Safe (2002) SWAp Maternal and funding (March scale up to all Motherhood • Govt of Malawi •Drafting of Essential Neonatal Mortality 2007) districts (2010) Task Force (est. commits to MDGs Newborn Care and Morbidity” • Official role of • Reproductive 1992) •Change in policy Package (May 2003) which then linked to TBAs shifted to Health Policy and • National for Nurse and • PMTCT introduced EHP promotion of Strategy revised Strategic Plan to Midwife (2003) • Revised National skilled • Policy for reduce maternal Technicians to • Motivation training Reproductive Health attendants at introduction of mortality (1995) provide BEmOC cadre - doubling of Strategy 2006-2010 delivery (March ARVs to pregnant • Reproductive • Restructuring of intake in training (newborn 2008) fully women regardless Health Unit HMIS started institution incorporated) implemented of CD4 count established (1997) (2001) • Free ARVs (2004) • New Roles for across Malawi by • Emergency • HSAs - •Transportation • Introduction of TBAs assessment January 2009 Human Resource government improvements Emergency Human completed (August • ANC routine Programme e.g. National policies, strategies, plans, and milestones salaried cadre of • Service Level Resource Programme 2006) HIV testing Recruitment of community Agreement (SLA) (2004) (2008) 4000 new HSAs health workers MOH subsidies • Community • Co-trim linked to health CHAM to provide IMCI (2007) prophylaxis as part facilities free services for •Adopted 5-year of PMTCT for mothers and plan for ACSD exposed infants newborns (2002) and cIMCI • Community including midwife nurse newborn (2007) program initiated by First Lady and Calista Muthalika Foundation (2010). First training of community midwifes (Feb 2011)
  21. 21. Excerpt from Scale upReadiness Benchmarks No. Benchmark Definition 2000 2005 2010 Year Ranking Ranking Ranking 1 National level NB health Formal assessment of NB health, child health, and safe No Yes Yes 2002 needs assessment/ motherhood programs and strategies conducted in Situational Analysis collaboration with MOH and other partners conducted 2 NB health Research studies conducted in collaboration with the No No Partial services/packages tested MOH and/or partners/research institutions to test NB and documented in local health services/packages in local settings settings 3 Evidence of NB health At least one national level meeting with key partners and No No No 2010 interventions/packages stakeholders (dissemination of research findings or disseminated at strategy) to discuss evidence of at least one priority NB provincial/district and health intervention (thermal care, BF, clean delivery, early national levels home PNC visits) 4 Technical National level technical working/advocacy groups with No No Yes 2007 working/advocacy group representation from key stakeholders, partners, donors, established and advocating and community members established and advocating for for NB health through NB health through consensus building OR existing consensus building OR working/advocacy groups integrated newborn health in existing working/ advocacy terms of reference groups integrated newborn health into terms of reference 5 Focal person for NB health Focal person to provide technical input on newborn No No Yes 2010 established in MOH on NB health programs established within the MOH health 6 National NB National policy and/or strategy on newborn health No Yes Yes 2005 policy/strategy strengthened and adopted by MOH strengthened and adopted by MOH 7 National NB National NB policy/strategy integrated into at least one No Partial Yes 2005 policy/strategy integrated existing national health program (child, maternal, into existing programs reproductive, IMCI, etc) 8 National essential drugs National essential drugs and supply list for newborn care Partial Partial Partial 2001 and supply list for newborn developed and endorsed by MOH care developed and endorsed by MOH 9 National behavior change National behavior change communication strategy for NB No Partial Partial communication strategy for health established OR national behavior change NB health established and communication strategy integrates newborn and endorsed endorsed by MOH by MOH. Key elements include: BCC messages, BCC materials, Modes of communication, community mobilization; At least 3 messages include: thermal care, early and exclusive breastfeeding, clean delivery, early PNC visits.
  22. 22. Health Policy and Planning articlefor upcoming newborn health supplement
  23. 23. Unintended results• Save the Children partner on 2 of 3 USAID newly launched bilateral projects Support for Service Delivery Integration (SSDI-Services and SSDI-Communication)• Technical lead for Child Health (includes newborn), Nutrition, Community Approaches on SSDI-Services• Supports implementation in 6 Southern districts• Lead for Community Mobilization on SSDI- Communication
  24. 24. Mwayi wa Moyo (“A Chance toLive”)• Integration key objective of Malawi’s HSSP (2011-2016)• CS-27 cycle (2011-2016)• Blantrye District• MOH (RHU, IMCI Unit, PHC Unit)• College of Medicine (OR partner)• Purposefully integrated community-package incorporating CBMNC+CCM+PPFP
  25. 25. Thank you!