WORKSHOP REPORT
Bontana Hotel, Nakuru
15-17 March 2010
ACRONYMS
ACT Artemisinin Combination Therapy
AOP Annual Operative Plan
AMREF African Medical Research Foundation
BCC Behaviour Change Communication
DCAH Division of Child and Adolescent Health
DFID Department for International Development
DHP Division of Health Promotion
EHS Essential Health Services DFID Technical Assistance Project
FCI Family Care International
FHI Family Health International
FTP File Transfer Protocol
GTZ German Technical Cooperation Agency
HENNET Health NGO Network
HII High Impact Interventions
HMIS Health Management Information System
IEC Information Education and Communication
IMR Infant Mortality Rate
IPT Intermittent Presumptive Treatment
JHPIEGO Johns Hopkins Program for International Education in Gynecology and Obstetrics
JICA Japan International Cooperation Agency
KDHS Kenya Demographic and Health Survey
KEMRI Kenya Medical Research Institute
LLITN Long Lasting Insecticide Treated Net
MCHIP Maternal and Child Health Integrated Program
MDG Millennium Development Goal
MgSO4 Magnesium Sulphate
MNH Maternal and Neonatal Health
MNCH Maternal Neonatal and Child Health
MOH Ministry of Health
MOPHS Ministry of Public Health and Sanitation
MTEF Medium Term Expenditure Framework
NASCOP National AIDS Control Program
NGO Non Government Organization
NMR Neonatal Mortality Rate
ORT Oral Rehydration Therapy
PATH Program for Appropriate Technology in Health
PMTCT Prevention of Mother to Child Transmission
PPH Post partum haemorrhage
PPP Public Private Partnership
SOPO Hand Washing Campaign
TT Tetanus Toxoid
U5MR Under Five Mortality Rate
UN United Nations
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
Background
With only six years left to the Millennium Development Goal (MDG) date, there has been reduction in infant and under five mortality. However, maternal and newborn health indicators in Kenya have generally stagnated or show very marginal improvement. The recently released KDHS revealed the following:
· Reduction in Infant Mortality from 77 to 52/1000
· Reduction in Under Five Mortality from 115 to 74/1000
· Newborn mortality rate has reduced from 33 to 31/1000
· Delivery by a health care professional has increased from 42 to 44%
· Delivery in a health facility increased from 40 to 43% but with some regions reporting only 17% delivery in a health facility
· FP contraceptive prevalence rate has increased from 39 to 46%
· Maternal mortality ratio has decreased from 414 to 410/ 100 000
· Breastfeeding coverage
These changes are still way below the National as well as the MDG targets. Kenya therefore like other sub Saharan Africa countries has to put in place strategies to accelerate the reduction in maternal, newborn and child morbidity and mortality. With NMR contributing over 60% of IMR, we know that if this is addressed, we will be able to attain MDG 4. However issues of the newborn cannot be addressed separately as they are intrinsically entwined with pregnancy, labour, delivery and postpartum care. Hence addressing maternity care automatically translates to improved newborn health.
Many stakeholders are expressing greater interest in investing in Maternal and Newborn health. Key policy documents have been developed including the National MNH Road Map which is almost finalized , the Child Survival and Development Strategy and the Infant and Young Child Feeding Strategy and the National MNH Road Map. These key policy documents clearly outline the broad strategies and priority actions necessary to accelerate the reduction in maternal and newborn morbidity and mortality. The priority interventions therefore need to be adapted by the districts and included in the Annual Operational Plans.
Justification for the Retreat:
The need for this workshop was muted out of the concerns emanating from the results of the KDHS 2008/9 and the AOP 4 (2008-2009) review which revealed little progress in attaining MDG 1 (nutrition), 4 & 5. At the same time it was clear that there was a need to integrate the maternal, neonatal and child Health (MNCH) - Cohort 1 &2 for better progress in MNCH in Kenya.
The main Objectives of the retreat were:
1. To bring together MNH stakeholders for updating on the status of MNH in Kenya and what different partners are doing to date
2. To identify key priority actions to be incorporated into the AOP6 for the purpose of accelerating the attainment of MDGs 4& 5
3. To obtain stakeholder buy in and resource mobilisation for implementation of identified priority actions
Expected Outcomes of the meeting were as follows:
1. The situation of maternal, newborn, child survival and nutrition Kenya is reviewed
2. The activities to expedite progress in acceleration of the implementation of the MNH Road map, Child Survival and Development Strategy and nutrition strategies are identified.
3. The actions and commitments to implement the identified activities and strategies are clearly spelled out with timeline.
The format of the meeting comprised targeted presentations in plenary followed by group discussions.
Participants
The workshop brought together stakeholders in Maternal, Newborn and Child health from policy, Implementation and Partners levels. They included: the Director of Public Health and Sanitation, Provincial heads, representatives from the development partners (DFID, GTZ, JICA, USAID), the UN agencies (WHO, UNICEF), NGOs (Save the Children, AMREF, HENNET, FHI, JHPIEGO, FCI, PATH, Capacity project, Clinton Foundation, MCHIP, World Vision, Micronutrient Initiative, PSI),heads and programme managers of technical divisions of the MOPHS (DRH, DCAH, HMIS, Nutrition, Health promotion, NASCOP, Community Strategy), EHS, The White Ribbon Alliance, Training Institutions (Moi Teaching and referral hospital, University of Nairobi, Aga Khan University hospital), CHAK, Catholic Health Commission, KEMRI Wellcomme, CIFF, and The Nairobi City Council Health services, among others. The complete list of participants is attached.
Figure 1: Section of participants to MNCH retreat
Session 1 and 2: Situation analysis
The first 2 sessions reviewed the global, regional and national situation analysis on MNCH and nutrition. These were presented by the following;
· Global and Regional Situational Analysis:
o Maternal Health: Dr. Joyce Lavussa WHO
o Neonatal and Child Health: Dr. Sanjiv Kumar UNICEF
· Situational Analysis Kenya:
o Maternal Health: Dr. Isaack Bashir
o Neonatal and Child Health: Dr. Annah Wamae
o Nutrition in Achieving MNC Survival Goals: Ms. Grace Gichohi
Key points from these presentations were that:
· Sub-Saharan countries are lagging behind other regions in progress towards MDG 1, 4 and 5 targets.
· Worldwide, 536 000 women loose their life during pregnancy and childbirth every year. The world map below indicates the magnitude of the maternal mortality ratio. Maternal mortality ratio is by far the highest in Sub-Saharan Africa, where 1 in 23 women faces life time risk of dying, when compared to 1 in 2300 in Europe"
· Children living in Africa have a much higher chance of dying before the age of five, and among those, it are the children of the poorest families who will suffer most. Of these 1 in 4 deaths occur during the neonatal period
l There is no sub-Saharan country among the 63 on track for attainment of MDG 1, with 54% of childhood mortality being associated with under nutrition.
Results of the 2008 Kenya Demographic and Health Survey (KDHS) indicate that:
· All maternal health indicators remain poor. Kenya is 14th in the list of the worst 20 countries that contribute the highest numbers of maternal deaths
· Child Survival has improved but is being pulled back by the high newborn deaths. (In 2008 DHS, neonatal mortality has increase to 60% of the IMR, up from 45% in 2003).
· Nutritional indicators have also largely remained unchanged over the last decade.
Available strategies were reviewed and outlined by;
· The Maternal and Newborn Health as outlined in the National Roadmap which is adapted from the African Union Road Map: Dr. Shiphrah Kuria, DRH
· The Child survival and Development Strategy: Dr. Annah Wamae DCAH
· The Nutrition and Infant and Young Child Feeding strategy: Ms. Grace Gichohi, DN
· The Community Strategy: Dr. James Mwitari, Division of Community Health Services.
Discussion following the presentations focused on the need to rally other players from different sectors e.g. Ministry of Education, Gender, Agriculture, Social services, Youth, Roads, Transport and Communication, Finance, Office of the president etc, since reduction of MNC morbidity and mortality goes beyond the health sector.
The operations research component and health financing issues need to be highlighted strongly in all the MNCH and nutrition strategies.
The use of local best practices that are cost effective in reducing maternal, newborn, and child morbidity and mortality needs to be scaled up.
Figure 2: A Group work session
Session 3: Group work
Participants in 5 groups identified the problems /bottlenecks slowing Kenya’s progress towards attaining the MNCH and nutrition targets.
The groups looked at: 1) commodities; 2) Monitoring of data flow/ HMIS, 3) Communication for behavior change, 4) Human resources, 5) Referral and quality assurance
Session 4: Highlights from Group Discussions
Group 1: Commodities for MNCH
· Challenges were identified as inadequate financial allocations and delays in disbursement of procurement funds, Inadequate capacity of human resources for logistics management, Unavailability of reporting tools and poor reporting , Push system is a challenge leading to mal-distribution of commodities , Delayed deliveries of commodities
· It was proposed that: concerned departments and divisions to advocate for adequate funding allocation in the MTEF process, Capacity strengthening be done at all levels on logistic management, and beaurocratic and legal delays be addressed
· There is need for divisions working in MNCH to engage with and participate in the commodities and supplies ICC
Group 2: Monitoring of data flow/ HMIS
· Key challenges included: incomplete data in 50 -70% of districts, multiplicity of reporting tools, low numbers of records officers/ skilled HMIS personnel, and low capacity for utilisation of data
· Suggested interventions included- Capacity building for data management, harmonisation of tools, prioritisation of key indicators and supportive supervision.
· It was proposed that the private sector and FBOs be encouraged to submit their data to the district, provincial and central level
Group 3: Communication for behaviour change
· Challenges include: poor articulation/ understanding of the community strategy, communication strategies not user friendly, low participation of communities in design , development and dissemination of messages, demand created when services are not yet available.
· To address this, capacity building for IEC/BCC, Strengthen linkages at all levels, and all partners need to work in synergy
· There is need to avoid demand creation without commensurate services being in place
Group 4: Human resources for MNCH
· Challenges noted include: HRH coverage and poor deployment of available staff; this is augmented by deficient competencies in MNCH, lack of harmonised guidelines, and inadequate facilitative supervision. Poor staff attitudes have also been noted to affect quality of service provision
· Short term measures to address these include: Onsite training / mentoring for higher level facilities (level 4 and above), Revitalise or strengthen rural health facilities for the lower level, rational and equitable distribution of available staff, and integrated MNCH facilitative supervision
· The government under the economic stimulus package is set to deploy 20 additional nurses per constituency. The USAID is also supporting contract hiring of health workers for hard to reach areas.
Group 5: Other health systems challenge s (Referrals, Q/A)
· Challenges included: lack of collaboration with other key ministries (transport, roads, security, etc); lack of community based referral systems, deficient communication and feedback mechanisms, deficient competencies in management of referral systems
· Suggested measures to address this included: Strengthening community referral systems, review GOK referral management system and strengthen linkages with other sectors
· With regard to quality of care there is no standardised quality improvement system or tools in place. Short term measures to address this include revitalisation of Quality Management committees, audits, and COPE (client-oriented, provider-efficient services).
Figure 3: Thank God its break time
Day 2:
Session 5: Learning from Global and Regional Good Practices
In this session, the good practices from global experience and some countries that have made a good progress in maternal, newborn and child survival were highlighted and discussed.
Accelerating Child Survival and Development- Malawi Mr. Humphreys Nsona, National IMCI/ACSD Coordinator, MOH Malawi
Malawi has been able to accelerate child survival and development (and overshoot their MDG targets) by investing in simple cost effective interventions. Malawi’s package of services emphasized community participation, selected outreach / facility based interventions, as well as individual oriented curative services. The country has an established community structure that supports a cadre of staff that is able to provide simple and safe basic promotive and curative care for the most important causes of child morbidity, such as acute malnutrition, malaria, pneumonia and diarrhoea to save lives in the interim, while referring more complicated cases of pneumonia, sepsis.
Operationalising of the Child Survival and Development Strategy Dr. Vincent Orinda, UNICEF
Evidence based High Impact Interventions (HII) to operationalise child survival and developments as outlined in the Lancet series were disseminated. These include both preventive and treatment as summarized below:
To operationalise this, the country needs to prioritise their interventions and to ensure that the government leads the process.
Overview of Best Practices in preventing maternal mortality – Dr. Nancy Kidula, WHO
Success stories to reduce maternal mortalities in various countries covering Skilled Birth Attendance, Family Planning, Transport, advocacy, multi-sectoral approach were also shared. These included simple, cost effective interventions such as: increased numbers and coverage of skilled birth attendants as in the case of Thailand, Sri Lanka and Malaysia; Increased advocacy for MNH by White Ribbon Alliance; and strengthening community initiatives as in Eritrea.
Reducing Maternal Mortality by Focusing in PPH Prevention - Dr. Marsden Solomon, KOGS
The KOGS also shared the concept paper for reducing maternal mortality by focusing on prevention of PPH. There following areas need to be strengthened
· Intensify Advocacy for prevention and reduction of complication rates of PPH