Transcript Slide 1

Health systems for MNCH
Dr Mickey Chopra,
Chief of Health, New York
Outline
•
•
•
•
Global progress
Challenges
Role of health systems
Conclusion
Child Mortality at Record Low; Further Drop Seen
Vaccination campaigns, as in Indonesia, cut childhood deaths.
Trends in Immunization Coverage:
The Measles Story
Vaccine coverage has
increased
Measles deaths have
declined
100
800
80
U-5 deaths due to measles (thousands)
Measles (MCV) immunization coverage (percentage)
MDG target coverage 90%
60
40
20
0
1980
1985
1990
1995
2000
2005
East Asia & Pacific
600
South Asia
400
Africa
200
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
Trends in Global Coverage of Vitamin A
Percentage 6-59 months old fully protected with 2 Vitamin A doses
100
80
60
40
20
0
2001
2003
2005
Source: UNICEF Global Database, Nov 2008
2007
Sw
az
il
Cô and
te
'0
d' 0 Sie Ivo '06
r ra ire -'0
Le '00 7
on
e ' '06
0
DR 0 '0
C
Ke '01 5
ny
a ' - '07
Ni 0 0
g
Bu er '0 '03
Ug run 0 '0
an di
Bu da '00 6
'
rk
in 00-' '05
a
0
Ca Fas 1 '0
o
m
er '03 6
oo
Rw n ' '06
an 00 da
'0
'00 6
CA
Se R ' '05
0
n
0
Be egal - '0
ni
6
n ' '00
01 - '0
Gh -'02 6
an
M a '0 '06
Ta ala 3
nz
an wi '0 '06
ia
'99 0 - '0
Za
6
m - '07
b
Et ia -'08
hio '99
pi
a ' - '07
Gu
T 05
Sa
i
o nea o go - '0
To
7
m Biss '00
e/
a
Pr u '0 '06
in
cip 0 Ga e ' '06
m 00
bi
a ' - '06
00
- '0
6
Trends in ITN Use, 2000-2006
100
80
60
20
49
40
16
13 13 15
10 10
8
7
7
6
6
5
4
4 3 2
2 2
01132 1 3 1 1 0 2 1
Source: UNICEF Global Databases, November 2008
26 29
25
20 22
33
1 2 2
42
38 39
23
15
7
0
children <15 years reciving ART (thousands)
Paediatric ART Coverage, 2005-2007
250
200
150
>150% increase from
2005-2007
198,000
100
127,000
50
75,000
0
2005
C. & E. Europe and the Caucasus
Middle East and North Africa
South Asia
East Asia and Pacific
Latin America & Caribbean
West and Central Africa
Eastern and Southern Africa
2006
2007
Source: UNICEF Stocktaking Report, 2008
BUT WE NEED TO
ACCELERATE PROGRESS
Can We Reach MDG 4?
Trends in Under 5 Deaths, 1960-2006
25
Africa
Asia
Other
20
4.1
14%
3.6
18%
15
Millions
11%
2.7
1.8
10
14%
13%
1.4
13.5
0.5
10.9
8.3
7
5.1
4
56%
5
0.1
2.9
3.2
3.5
1960
1970
1980
4.1
4.6
5.2
2.2
2
0
1990
Year
2000
2006
2015 with
achievement of
MDGs
Progress towards MDG 4:
Reduction in under-five mortality by twothirds, 1990-2015
On track: U5MR is less than 40, or U5MR is
40 or more and the average annual rate of
reduction (AARR) in the under-five mortality
observed for 1990-2007 is 4.0 percent or more
rate
Insufficient progress: U5MR is 40 or
more and AARR is between 1.0 per cent
and 3.9 per cent
No progress: U5MR is 40 or more and
AARR is less than 1.0 per cent
Source: UNICEF Global Database, Nov 2008
Data not available
MDG 5 – Maternal Mortality
MDG1: Undernutrition – South Asia
Percent
50%
50
46
45
46
45%
45
43
40%
40
41
Africa
45
South
Asia
45
South Asia
41
41
39
39
35
38
35
38% 40 38%
45
33
31
30
30%
28%
30
29
26
25
23
20
18%
20%
15
10
9%
10%
5
0
Bangladesh
India
Nepal
South Asia
Afghanistan
0%
Underweight
Wasted
Pakistan
Maldives
Sri Lanka
Based on 2006 WHO reference population
Stunting
Based on NCHSWHO
reference population
Note: Data refers to the most recent year available during the period specified.
Source: UNICEF, The State of the World's Children, 2009.
WE ARE OFF TRACK FOR
MANY KEY INTERVENTIONS
Optimal Management of Diarrhea
• Approved in 2003
• Recommend for all cases of
acute diarrhea
1. Low osmolarity ORS
2. Oral zinc sulfate 20 mg
daily for 14 days
3. Antibiotics for dysentery
• No country has as yet
implemented this strategy at
scale
Little Progress in Case Management
2000
%
2006
50
45
40
35
30
25
20
15
10
5
0
Pneumonia
Malaria
Diarrhea
Percentage of children under five with suspected pneumonia taken to an appropriate health provider
Percentage of children under five with fever receiving anti-malarials
Percentage of children under five with diarrhea receiving ORT (ORS or RHF or increase fluids) with continued feeding
Impact of community-based
interventions in Asia on neonatal
mortality
Review:
Comparison:
Outcome:
Study
or sub-category
Baqui cc 2008
Baqui hc 2008
Bhutta 2008
Darmstadt 2005
Jokhio 2005
Manandhar 2004
Community interventions and perinatal, neonatal and maternal outcomes
01 Community intervention package vs control
01 Neonatal mortality
log[RR] (SE)
-0.1984 (0.1404)
-0.4620 (0.1166)
-0.3240 (0.1653)
-0.6539 (0.1872)
-0.3510 (0.1410)
-0.3425 (0.1441)
Total (95% CI)
Test for heterogeneity: Chi² = 4.53, df = 5 (P = 0.48), I² = 0%
Test for overall effect: Z = 6.41 (P < 0.00001)
RR (fixed)
95% CI
Weight
%
RR (fixed)
95% CI
17.62
25.55
12.71
9.91
17.47
16.73
0.82 [0.62, 1.08]
0.63 [0.50, 0.79]
0.72 [0.52, 1.00]
0.52 [0.36, 0.75]
0.70 [0.53, 0.93]
0.71 [0.54, 0.94]
100.00
0.69 [0.61, 0.77]
31% reduction in neonatal mortality (range 230.1 0.2
0.5 1
2
5 10
39%)
Favours intervention Favours control
Bhutta et al (Lancet 2008)
MULTITUDE OF NEW
INTERVENTIONS
Proliferating interventions and
proliferating Lancet series..
Over 190 single
interventions
listed
Child
2003
Newborn
2005
Maternal
Series
2006
Reproductive
Health
Series
2006
Child
develop
ment
series
2007
Nutrition
series
2008
Role of health systems
• Faced with plethora of interventions many
of which cannot be delivered through
campaigns alone. A more systems based
approach becomes essential.
• First step is to identify critical set of
interventions according to local
epidemiology
Prioritise interventions/packages
Package
Lives saved
Antenatal care plus peri-conceptual folic acid supplementation
or fortification
Childbirth care including full obstetric package (pre-eclampsia
treatment, intrapartum care etc) plus antenatal steroids for
preterm labour and neonatal resuscitation
Postnatal care and support for appropriate feeding, early
careseeking for illness
Care for sick newborns, Kangaroo Mother Care for preterm
newborns
PMTCT of HIV using dual therapy at 95% coverage
Exclusive breastfeeding at 50%, exclusive replacement
feeding at 40% and mixed feeding at 10%
700
4,300
2,600
3,900
Neonatal lives saved total
11,500
37,200
Child lives saved
TotaI 48,700
Potential to be on track for MDG
4 and turn around for MDG 5
Can highlight ‘quick wins’
• In Ethiopia and Northern Nigeria, an increase of
contraceptive prevalence rate by 20% would result in
16,000 lives saved, a 25% reduction in deaths.
• If the following outreach interventions are scaled up by
20% points in 2011: improvements in exclusive
breastfeeding, vitamin A, malaria prevention,
immunisations (measles, Hib, DPT3), and case
management of childhood illness (diarrhea, pneumonia,
malaria), it would result in 188,800 lives saved, which is
a 23% reduction in child deaths.
Health Systems
• This then allows planners to become
clearer about packages of care and how
they might be delivered across the
continuum of care
Intervention packages that reduce newborn deaths
Clinical
care
Skilled obstetric and immediate newborn care
(hygiene, warmth, breastfeeding) & resuscitation
Emergency obstetric care to manage
complications such as obstructed labour and
hemorrhage
Emergency newborn care for illness,
especially sepsis management and
care of very low birth weight babies
including Kangaroo Mother Care
Antibiotics for preterm rupture of membranes#
Corticosteroids for preterm labour#
Outreach
services
Folic
acid #
Focused 4-visit antenatal
package including
Postnatal care to support healthy
practices
• tetanus immunisation,
• detection & management of
syphilis, other infections,
• pre-eclampsia, etc
Early detection and referral of
complications
Malaria intermittent
presumptive therapy*
Familycommunity
Detection and treatment
of bacteriuria#
Counseling and preparation
for newborn care and
breastfeeding, emergency
preparedness
Clean delivery by
traditional birth
attendant (if no skilled
attendant is available)
Simple early
newborn care
Healthy home care including
breastfeeding promotion, hygienic
cord/skin care, thermal care, promoting
demand for quality care
Extra care of low birth weight babies
Case management for pneumonia
Pre- pregnancy
Pregnancy
# For health systems with higher coverage and capacity
Neonatal period
Birth
Infancy
Health Systems
• Next step is to measure the population
coverage for these critical packages of
care along the continuum of care
Coverage Along the Continuum of Care
Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008
Models of delivery of packages of
care
• Existing descriptions
–
–
–
–
–
–
–
Acute, discrete episodes
Doctor-based
Nurse-based
Hospital-based
Community-based
Home-based
…
= simplistic and outdated in the context of
continuum of care
MNCH as Continuum of care
• Extensive experience in high-income
countries: diabetes, asthma,
- Patient-centred care
– Chronic care models
– Clinical teams
Need for lessons learning from these
experiences to low-income countries
Mapping the system to look for
bottlenecks
The nature of clinical
ART: phases & levels
Patients not yet
needing ART
Gene
ra
cons l ward &
ultat
ion
Concerned well
CT
PM T
Periodic
follow-up
Low
expertise;
standardisable
When
needing ART
STD
Long-term follow-up
HIV
testing
Staging
+ deciding
on
eligibility
‘Easy’ patients
needing ART
ART initiation +
early follow-up
After
±3 months
TB
= monitoring
- adherence
- treatment failure
- side-effects
If
problems
‘Difficult’ patients
needing ART
Clinical
management:
- Opportunistic inf
- Pregnant women
- Non-naïeve patients
- ...
After
‘stabilisation’
After
‘stablisation’
Management of
‘difficult’
patients
After
stabilisation
If treatment
failure confirmed
Putting on
second line
ART + early
follow-up
Identification of HIV+
Selection of people needing ART
ART initiation + early
follow-up
Long-term ART follow-up
(+ second line ART)
High
expertise
Thank you