Transcript Progress of implementation of PMTCT programs

GIVS and UNICEF:
Strategic Priorities
For Immunization and Child Survival
Dr. Peter Salama,
Chief Child Survival and Immunization Unit
Health Section, Programme Division
UNICEF
GIM, March 28th 2006
Outline
•
•
•
•
•
•
UNICEF context
UNICEF and GIVS
Progress in 60 countries
Programme models
CS indicators- some examples
Next steps
New UNICEF Context
•
•
•
•
•
•
UN reform
Paris Principles
Child survival and MDG 4
New partnerships
GIVS and strategic frameworks
New Executive Director
Health and Nutrition Strategy:
Conceptual implementation framework
Policies,
plans &
budgets
Leveraging
policies, plans
and budgets
through enhanced
Knowledge &
evidence
Translating
policies, plans
and budgets into
large scale action
All MDGs
Impact
MDGs 1, 4, 5 & 6
MDG 4
Knowledge
& Evidence
Large scale
action
Learning by
doing, and doing
better by learning
Global Causes of Under 5 Mortality*
3%
6%
3%
10%
34%
Malnutrition
Contributes to
about 50% of
this mortality
22%
Neonatal
Diarrhoea
ARI
Malaria
HIV
Measles
Other
22%
*Source: Lancet Child Survival Series, (measles data revised). Total 10.8 million deaths per year
Global Causes of Under 5 Mortality By
Vaccine-Preventable Status*
10%
13%
Non-VPD
VPD
Potential VPD
77%
*Source: WHO/UNICEF
Total 10.8 million deaths per year
GIVS and UNICEF
• 1) Reaching the unreached
– Complete ADC agenda
– Large countries, marginalized pops, complex
emergencies
• 2) New vaccines
• 3) Linking child survival interventions
• 4) Global interdependence
– Forecasting, supply and procurement
– Financing
Priority Countries
Child Survival Countdown - 60 priority countries
Criteria:
Either total number of under-five deaths ≥ 50,000
Or under-five mortality rate ≥ 90 per thousand
Where we are….
We know:
● How many children are dying
● What they are dying of
● Which interventions can prevent most child deaths
Need to know:
● What are current coverage levels of interventions
● Is progress being made
● Where do we need to focus programs
Under 5 Mortality
Progress for
60 Countdown
priority countries in <5 MR
60
40
20
0
On track
Watch
High Alert
Immunization
Measles and DTP3
DPT3
100
Developing
World
76%
•
Major progress during the 1980s
•
Coverage stagnated since 1990
Target
90
80
70
Measles
60
50
40
30
Developing
World
74%
20
10
Measles
DPT3
0
1980
1985
1990
1995
2000
2005
Measles and DTP3
60 Countdown priority countries
• 10 countries with 90% or more coverage
• Most countries still below target and need intensified efforts
Measles
DPT3
60
60
44
40
20
10
0
>90%
CAR, Cote
d’Ivoire,
Liberia,
Nigeria,
PNG,
Somalia
40
40
20
CAR, Chad,
Cote
d’Ivoire,
Eq. Guinea,
Gabon,
Haiti,
Liberia,
Nigeria,
PNG,
Somalia
10
10
>90%
<50%
6
<50%
0
Prevention
Insecticide-treated Nets
Vitamin A Supplementation
Vitamin A Supplementation
• 3-fold increase in %
children fully protected
by two doses
Developing
World
61%
70
59
60
56
58
50
52
50
40
36
•
37
27
30
20
• Greatest gains in least
developed countries
61
16
10
% children receiving at least one dose
% children fully protected by two doses
0
1998
1999
2000
2001
2002
2003
2004
Among the 60 priority
countries, 26 have 70%
or more coverage with
at least one dose, and
7 have unacceptably
low coverage
ITNs
SubSaharan
Africa
3%
• Low rates of ITN use
• Major investments in
recent years
• Rapid increases expected
soon; 10-fold increase in
nets distributed in
Sub-Saharan Africa
(1999-2003)
Togo
Malawi
Gambia
44%
36%
15%
Tanzania
Mali
Zambia
Guinea-Bissau
Benin
10%
8%
7%
7%
7%
6%
Niger
Rwanda
Kenya
Guinea
Ghana
Côte d'Ivoire
Sierra Leone
Senegal
CAR
Burkina Faso
Angola
Nigeria
Eq. Guinea
Congo D.R.
Chad
Burundi
Uganda
Swaziland
Sudan
Somalia
Sub-Saharan Africa:
malaria endemic countries
5%
5%
4%
4%
4%
2%
2%
2%
2%
2%
1%
1%
1%
1%
1%
0%
0%
Abuja
target
2005
0%
0%
0%
20%
40%
60%
80%
Case Management
80%
(1 dose)
Pneumonia Case Management
• Pneumonia kills more children than any other illness,
accounting for 19% of all under five deaths
• Only 1 in 5 caregivers
know the ‘danger
signs’ of pneumonia –
cough and fast or
difficult breathing
• 54% of children with
pneumonia are taken
80%
to an
appropriate
(1 dose)
health care provider
Neonatal
causes
27%
Neonatal
pneumonia/sepsis
is estimated to
cause 26% of all
neonatal deaths.
Pneumonia
19%
Pneumonia Case Management
Roughly 20% of children with pneumonia received antibiotics
(based on limited data from the early 1990s)
100
● Current estimates
not available
80
75
● Questions on antibiotic
60
use for pneumonia
included in current round
of MICS and DHS
40
30
● Rapid progress is
80%
possible
(1 dose)
25
20
0
1985
Egypt
5
1990
1995
2000
Colombia
2005
Nutrition
Exclusive Breastfeeding
•
Significant progress has been made since 1990
•
Sub-Saharan Africa, in particular, has made significant
gains during the 1990s
Developing
World
36%
•
Rates continue to be low across the developing world
60%
50%
+41%
+9%
Eastern/
Southern
Africa
South Asia
+21%
40%
30%
+450%
20%
10%
0%
Developing
countries
Western/
Central
Africa
1990
2004
Exclusive Breastfeeding
Rapid progress is possible
Rapid progress
Higher rates achieved
Ghana
Rapid progress
Rates still low
Cameroon
Tanzania
100
100
100
80
80
80
60
53
40
60
60
41
40
31
23
20
4
7
1988
1993
29
40
32
24
20
20
7
12
0
0
1998
2003
1991
0
1992
1996
1999
Zambia
Madagascar
100
100
80
80
80
53
40
20
7
1992
1997
40
40
27
20
4
60
60
40
31
2004
Burkina Faso
100
60
1998
2003-04
19
20
19
10
3
6
0
1993-94
0
0
2000
2003-04
1992
1996
1999
2001-02
1998-99
2003
Exclusive Breastfeeding
60 Countdown priority countries
23 countries with unacceptably low rates
Newborn Health
80%
(1 dose)
Summary of Findings
●
Coverage levels remain too low for most indicators
●
Rapid progress is possible
●
Analysis needed of why rapid progress occurs in some
countries, and for some interventions, but not others
Summary of Findings
Coverage too low for most causes of child death
Intervention coverage
Cause of death
Malaria
3% ITN use
Pneumonia
Diarrhea
Antibiotics
20%
ORT
ORT/continued feeding
33%
Exclusive breastfeeding
Undernutrition
36%
Vitamin A supplementation (> 1 dose)
61%
Exclusive Breastfeeding
Skilled attendant at birth
Neonatal
59%
Measles vaccine
Measles
0%
20%
40%
60%
74%
80%
100%
Surveys for 2005-6
national household survey activity
2005-2006
MICS
DHS
Other surveys
GIVS Strategy 3
Integrating immunization, other
linked interventions and
surveillance in the health systems
context
UNICEF Approach:
● Using immunization to deliver evidence-based
packages of child survival interventions at country
level
Evidence-Based Selection will Lead to a Mix
of Interventions and Operational Strategies
Birth
Before
birth
Weeks
1-2
Approximate child age in months
2
4 6
9
Antimalarial intermittent
preventive treatment
Tetanus Toxoid
Nevirapine &
Preventive interventions
replacement feeding
Neonatal interventions*
Breastfeeding
antenatal steroids
Insecticide-treated
materials
Hib vaccine
Zinc
Complementary
feeding
Vitamin A
Measles vaccine
* Includes clean delivery with skilled attendant, temperature
management, antibiotics for premature rupture of membranes &
neonatal sepsis, steroids
15
21
27
33
39
45
51
57
SELECTION OF EVIDENCE BASED HIGH
IMPACT INTERVENTION PACKAGES
•
EPI+
•
•
•
•
•
•
Antenatal care+:
•
•
•
•
•
•
Strengthening routine EPI
Vitamin A supplementation
ITNs*
Cotrimoxazole prophylaxis*
IPTi*
Refocused ANC
Tetanus immunization
Intermittent presumptive treatment (IPT) against malaria
Vitamin A (post partum)
PMTCT*
IMCI +
•
•
•
•
Exclusive Breastfeeding
ORT
ITNs (pregnant and under 5 children)
Community management of Malaria and ARI
Systematic Scaling Up of Proven Interventions and
Appropriate, Situation-Specific Strategies that
Benefit Children and Women’s Health and Nutrition
Estimated Impact of ACSD on Under 5 Mortality Rate
in MALI High impact districts, Koulikoro-Mopti-Segou
30%
25%
Control Zones
ACSD Zones
ACSD-Control Zones
Under 5 Mortality Rate
20%
15%
10%
5%
0%
family/ community care
-5%
outreach
clinical care
Total Family & comm.
Outreach & Clinical care
Impact of ACSD package on DPT3 coverage in
selected districts of 3 West African Countries
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Mali HIP
2001 Baseline
2003 Survey
Benin HIP
Senegal HIP
ACSD and Malaria
Increases in Children sleeping under bednets in ACSD
expansion Districts in 4 West African Countries
60%
BENIN
GHANA
MALI
SENEGAL
50%
40%
30%
20%
10%
0%
CONTROL 2001
ACSD 2001
CONTROL 2003
ACSD 2003
ACSD 2004
Using immunization as a platform for delivery
of package of child survival interventions
• Help countries to tailor integrated packages of interventions
at immunization contacts with priority on outreach and
strategies for hard to reach
• Ensure selected additional interventions are included in the
multi-year plan
• Assist in effective implementation and monitoring of the joint
interventions
• Continue to learn and adapt packages and implementation
Why is T/S Prophylaxis Important for HIV-Infected Children in
Resource-Poor Settings?
CHAP Study: 43% Decrease Death with T/S
Proportion Alive
1.00
0.80
0.60
Cotrimoxazole
Placebo
0.40
0
.5
1
1.5
Years from randomisation
*Source: Chintu C et al. Lancet 2004;364:1865-71
2
Afghanistan;
under five child survival indicators as of 2004
U5MR 257 per 1000 live births- Ranked 4
100
90
80
70
60
50
86
66
61
48
40
30
20
31
28
10
0
ORT & Feeding
Vitamin A
ARI taken to care
DPT3 2000
Source: SOWC 2006
DPT3 2004
MCV 2004
DR Congo;
under five child survival indicators as of 2004
U5MR 205 per 1000 live births- Ranked 8
100
80
80
64
60
45
40
20
40
36
17
12
1
0
ORT & Feeding
Rec Anti-malarials
DPT3 2000
Vitamin A
Under Bednet
DPT3 2004
Source: SOWC 2006
ARI taken to care
Under ITN
MCV 2004
64
Rwanda;
under five child survival indicators as of 2004
U5MR 203 per 1000 live births- Ranked 10
100
90
86
89
80
60
40
20
16
20.3
12.6
6
5
0
ORT & Feeding
Rec Anti-malarials
DPT3 2000
Vitamin A
Under Bednet
DPT3 2004
Source: SOWC 2006
ARI taken to care
Under ITN
MCV 2004
84
Ethiopia;
under five child survival indicators as of 2004
U5MR 166 per 1000 live births
100
80
80
71
65
56
60
40
20
37.9
15.8
3
0
ORT & Feeding
Rec Anti-malarials
DPT3 2000
Vitamin A
Under Bednet
DPT3 2004
Source: SOWC 2006
ARI taken to care
Under ITN
MCV 2004
Nigeria;
under five child survival indicators as of 2004
U5MR 197 per 1000 live births- Ranked 13
100
80
60
40
28
27
33
35
34
20
24
6
25
1
0
ORT & Feeding
Rec Anti-malarials
DPT3 2000
Source: SOWC 2006
Vitamin A
Under Bednet
DPT3 2004
ARI taken to care
Under ITN
MCV 2004
ACSD Booster Initiative
Sub Saharan Africa
200
Current trend
160
Phase I
ACSD Booster
120
Phase II
<5 MR
80
Phase III
1000 LBs
MDG 4 target
40
0
1990
1993
1996
1999
2002
Year
2005
2008
2011
2014
Next Steps
• Formal independent evaluation ACSD
• Refine costing tool
• Mobilize partners: WHO, WB, AU, GAVI,
GFATM, CIDA, USAID, Norway, PMNCH
• Investment case
• Implementation plan
• Continue to support government scale-up
• Monitoring framework
• Lessons learned