Maternal, Newborn, + Child Health

ISSUE

APPROACH

Women and children bear the brunt of global disease mortality and morbidity. CHAI works across program areas to reduce deaths and allow women and their children to live long, productive lives.

The Issue

Women and children bear a disproportionate amount of the disease burden in developing countries. Each year, nearly 7 million children in low-income countries die before their fifth birthday, and nearly 300,000 mothers die from childbirth-related complications. According to the World Health Organization (WHO), almost two-thirds of these deaths are the result of a small amount of largely preventable causes, including infectious diseases, malaria, pneumonia, diarrhea, sepsis, measles, and AIDS.

The Approach

CHAI believes that there are opportunities for well-timed and targeted interventions to dramatically reduce mortality and allow children and their mothers to live long, productive lives. In particular, CHAI works to address areas that contribute significantly to maternal, newborn, and child deaths, including maternal and neonatal health around birth, gaps in family planning access and services, nutrition among young children, and diarrhea in children under 5.

Essential Medicines for Diarrhea & Pneumonia

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Issue

Diarrhea is the second leading killer of children worldwide, responsible for nearly 600,000 deaths each year. Children with diarrhea can become fatally dehydrated and at risk for worsened malnutrition and weakened immune systems, which, in turn, increases the chance of death from other diseases.

However, the World Health Organization (WHO) recommends a combination of oral rehydration salts (or “ORS,” a formula that replaces fluids and essential salts lost to dehydration) and zinc (a micronutrient that reduces the duration and severity of diarrhea, and protects the child from future episodes of diarrhea) for the treatment of child diarrhea. Together, ORS and zinc can prevent over 90 percent of diarrhea-related deaths and cost less than US$0.50 per child, yet few children in need are receiving it. Globally, an estimated 32 percent of children with diarrhea receive ORS, but less than one percent receives the full recommended combined treatment of ORS and zinc. Instead, the vast majority of children continue to use suboptimal products like antibiotics and antidiarrheals, or receive nothing at all.

The root cause of this issue is clear: health providers and consumers are often unaware that the combination of ORS and zinc is the recommended treatment for child diarrhea, resulting in low demand. Suppliers have limited incentive to invest in distribution and promotion of these products. There is also often limited attention and funding for ORS and zinc uptake, and in some cases, unfavorable policies or regulatory conditions where zinc is still a prescription-only product.

Approach

To overcome these market traps and increase access to ORS and zinc, CHAI is working at both the global and national levels to scale up ORS and zinc use. At the global level, CHAI works closely with UNICEF and other partners to support scale up of diarrhea and pneumonia treatment in 10 high-burden countries, representing about 60 percent of global diarrheal deaths. Additionally, CHAI works in four countries—India, Kenya, Nigeria, and Uganda—to increase access to and use of ORS and zinc at the national level. In each country, CHAI partners with government and local stakeholders to execute a large-scale approach that breaks the market trap by simultaneously building demand for ORS and zinc and ensuring widespread availability in public and private facilities, particularly in rural areas. This comprehensive approach seeks to demonstrate that effective treatment can be scaled up through a holistic approach in high-burden countries.

In 2015, CHAI’s program expanded to incorporate pneumonia treatment in existing geographies and to reach new geographies (including Ethiopia and Nigeria) with combined diarrhea and pneumonia efforts. Pneumonia is the leading killer of children under 5, responsible for more than 900,000 deaths each year. The program includes increasing access to key pneumonia commodities, such as amoxicillin dispersible tablet, pulse oximetry, and oxygen treatment.

Change

CHAI-supported accomplishments have included:

  • As of Q1 2015, coverage of ORS has increased from an average of 33 percent at the start of the program in 2011/2012 to an average of 50 percent across focal geographies, while zinc coverage increased from an average of less than 3 percent to 20 percent.
  • Over 20 new high-quality, affordable and optimal ORS and zinc products (including 13 co-packaged products) have been introduced in local markets in Uganda, India, and Nigeria. The increased market competition has led to reductions in wholesale prices by 40-75 percent and will enable many more children to access the lifesaving treatment.
  • Last-mile distribution channels have been established to expand access of zinc/ORS beyond urban areas to remote villages in selected focus countries where the most children are dying from diarrhea. Over-the-counter status for zinc has been achieved in all four countries, allowing the product to be used widely in all retail outlets, thus increasing access points for patients.
  • Government-led national plans are in place, prioritizing treatment scale-up to reduce diarrheal deaths as a key national priority and driving coordination of efforts across partners.
  • Impact and lessons learned from CHAI’s programs have extended beyond its focal countries through global engagement as co-chair (with UNICEF) of the Diarrhea & Pneumonia Working Group.

Family Planning

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Issue

Voluntary access to contraception saves the lives of women and infants, improves their health outcomes, strengthens the financial well-being of families, and helps achieve national health and economic goals. By allowing women to safely delay, space, and limit pregnancies, family planning reduces the risk of death or injury to mothers and their babies and prevents unsafe abortions. It is one of the most cost-effective, high-impact health interventions available.

However, despite the efficacy of family planning, approximately 222 million women of reproductive age in developing countries had an unmet need for contraception in 2012. Barriers that can prevent women from accessing contraceptives of their choice include global level issues such as product price and availability; local issues such as inadequate funding, stockouts, and a lack of trained providers; and cultural and societal factors.

Approach

The most widely available contraceptives—short-acting methods such as condoms and pills—are also the least effective. Therefore, CHAI particularly focuses on increasing contraceptive choice to include long-acting reversible contraceptives (LARC) such as implants and IUDs, which are over 99 percent effective and can prevent pregnancy for up to 12 years.

CHAI assists governments to increase access to LARC by improving the efficiency and cost effectiveness of family planning supply chains and service delivery systems. This work includes national and subnational efforts to improve forecasting and supply chain management, develop evidence-based plans and targets, conduct gap analyses and better allocate resource to fill gaps, track and manage performance of LARC service delivery, coordinate partners to support national scale-up efforts, and develop and implement more cost-effective and government-led approaches to increasing LARC service delivery capacity. CHAI helps governments to ensure that, through more robust coordination and use of data, family planning products and program funding are directed to where they are most needed, ensuring that supplies, clinical skills, and demand align to enable equitable, quality provision of family planning services. CHAI also helps strengthen integration of postpartum family planning services into existing programs.

CHAI’s Family Planning country programs launched in 2013 with funding from the Bill & Melinda Gates Foundation (BMGF) for seven countries in Sub-Saharan Africa. Following rapid success in these countries, CHAI transitioned out of three of them and expanded the program to five additional countries. CHAI’s Family Planning program now includes Cameroon, Democratic Republic of Congo, Ethiopia, Indonesia, Kenya, Lao PDR, Nigeria, Tanzania, and Uganda. Together, these countries represent an estimated 134 million women of reproductive age.

Change

CHAI-supported accomplishments have included:

  • CHAI supported the governments of Cameroon, Kenya, Liberia, Malawi, Nigeria, Tanzania, and Zambia to double the number of women accessing implants, which translates to nearly 2.4 million additional women accessing contraceptive implants in CHAI-supported countries since the program launched in 2013. Average monthly consumption in the countries CHAI supported grew by 215 percent in two years. Other FP2020 countries without CHAI support have seen 97 percent growth in monthly consumption during the same period.
  • CHAI’s Family Planning program transitioned out of Zambia in 2015 after the MOH had the tools and capacity to manage and track investments in human resources for family planning, and will continue to provide remote support as needed. The MOH continues to track hundreds of LARC-trained health workers in CHAI’s absence to so that trainings are better coordinated.
  • Working with the Bill & Melinda Gates Foundation and other partners, CHAI helped secure a 50 percent price reduction in the price of contraceptive implants using a volume guarantee. By improving visibility into demand and solidifying donor commitments for purchases, this deal led to more than US$100 million in savings for donors and developing country governments in 2015 and will result in US$420 million in savings over six years.
  • In Nigeria, CHAI developed the National FP Dashboard for the Federal Ministry of Health (FMOH) to track consumption, stockouts, and training efforts for all family planning products nationwide. The FMOH and eight states are now actively using the tool to improve the efficiency of their resource allocation and manage the performance of those investments. Monthly consumption increased by 47 percent nationally over the course of 2015, reaching 33,611 implants per month in Q4 2015.
  • In Kenya, CHAI helped the government to design, pilot, and cost a new on-the-job training approach to update current implant service providers to insert Implanon NXT. The approach has been approved by the MOH for national use and is being modified for use in other countries, as well. Implants are now the second most popular method of contraceptive in Kenya, helping to drive a rapid rise in contraceptive use over the past several years.
  • In Cameroon, CHAI helped the government design a new electronic logistics management information system that will launch in late 2016. Monthly implant consumption in Cameroon is now ten times what is was when the program began in 2013. In Tanzania, CHAI worked to complete the first-ever country-wide mapping of all of the health workers in mainland Tanzania who have been trained in LARC. This information helped the MOH’s Training Coordinator to advise USAID where to invest additional training funds.
  • At the global level, CHAI is a member of the Coordinated Supply Planning group and has provided country-level insight and analytical capacity to help prevent or remedy implant stock outs in nine countries, reallocating or expediting shipment of over half a million implants in 2015.

Nutrition

Issue

In most parts of sub-Saharan Africa and South Asia, more than 40 percent of children are chronically malnourished. Persistent gaps in the quality and quantity of foods available for young children constrain healthy development, with a particularly detrimental impact on the brain and the immune system. Due to its prevalence and impact, chronic malnutrition is considered an underlying cause of nearly half of all childhood deaths around the world.

Approach

In collaboration with government partners and the private sector, CHAI is launching a new initiative to improve childhood nutrition with high-quality, nutrient-dense complementary foods. These foods are specially designed for children who are 6 months to 2 years old, a critical window for healthy growth and development. CHAI is facilitating the launch of state-of-the-art food processing facilities to produce complementary foods in partner countries at impeccable quality standards. Staple ingredients will be purchased from farming cooperatives, promoting local agricultural growth and economic development. Distribution systems will ensure that these foods reach the children who need them, even in remote areas, with subsidy structures in place for the poorest and most vulnerable households. By working through government health systems, the foods will be distributed with guidance on appropriate preparation and serving sizes, with emphasis on the importance of exclusive breastfeeding from birth to 6 months and continued breastfeeding through 2 years of age.

Change

CHAI is rolling out the nutrition initiative with two partner countries in 2016, with scale-up plans in place to work with additional countries over the ensuing years.

Maternal & Neonatal Health (MNH)

Issue

According to UN estimates, almost 1 million newborns never live past their first day of life, while another 1 million will die before the end of their first week of life. Further, an estimated 2.6 million annually are reportedly born stillborn. Though progress has been made globally to reduce the number deaths of children under 5 years of age, this success has mostly been limited to older children. Of the estimated 5.9 million children under 5 who died in 2015, 45 percent were neonates (a newborn less than four weeks old) and this proportion continues to grow. Estimates suggest that, if current trends hold, around half of the 69 million child deaths forecast between 2016 and 2030 will occur during the neonatal period.

In 2015, approximately 830 women died each day due to complications of pregnancy and child birth, according to the WHO. Each of these women left children, widowers, families, and communities behind. Maternal conditions contributed to 2.7 percent of deaths among women worldwide and 12 percent of deaths among women aged 15-44 years. Global progress against maternal mortality masks the limited achievements in Sub-Saharan Africa and disproportionate burden suffered by the region that accounts for nearly two-thirds of global maternal mortality.

The majority of maternal and neonatal deaths are caused by a handful of conditions from which death is largely preventable. Three maternal complications – hemorrhage, sepsis and eclampsia – account for half of all maternal deaths, and three causes of neonatal death — preterm birth complications, birth asphyxia, and neonatal infections — account for more than 80 percent of the total neonatal burden. Evidence from the UNFPA shows that while only 15 percent of pregnancies actually result in life-threatening complications, over 40 percent of all pregnancies have some form of complication that if mismanaged could become life-threatening. When these complications occur they are largely within a very narrow timeframe, lending themselves to focused and targeted interventions.

Approach

To dramatically reduce maternal and newborn mortality, CHAI believes that an integrated approach is required that addresses critical gaps, creates linkages through the entire health system–from the community level to the hospitals–and is sustainable. Effective, low-cost interventions exist to avert a majority of these preventable deaths, so it is essential to implement a continuum of care from the community level to tertiary hospitals to ensure early identification of complications, prompt and effective clinical management of delivery and complications, and timely and appropriate referral when necessary.

Planned in consultation with our government partners, CHAI has developed and implemented an integrated, strategic approach to dramatically reduce maternal and neonatal mortality. Consistent with WHO guidelines, the approach focuses on averting the preventable deaths that can occur in the 24-48 hour window around the birth process by implementing the interventions necessary to deliver the following, straightforward results:

• Potential complications are identified early to prevent them becoming life threatening;
• Simple interventions are applied immediately to stabilize and ensure survival; and
• Cases are referred quickly to the appropriate health system level for proper treatment

CHAI’s approach involves the creation of a comprehensive system, centered at the primary health center (PHC), which connects a pregnant woman to each level of the health system. It begins with the identification and tracking of all pregnant women in the catchment area and every pregnant woman coming into the PHC for an essential first antenatal care visit early in her pregnancy. It continues with each pregnant woman being seen periodically by healthcare workers and receiving appropriate screening tests conducted to diagnose specific complications and to identify pregnancies at risk. High-risk pregnancies are tracked closely and attended frequently by healthcare workers and clinical birth plans will be prepared which include ready transport to the nearest hospital in advance of or at onset of delivery. For the remainder of pregnancies, no matter where a birth occurs, a Skilled Birth Attendant (SBA) who has undergone an extensive Midwife Mentoring program, would act as a ‘first responder’ and be present at each birth to minimize complications from occurring, recognize warning signs early and to stabilize and, where possible, treat complications when they occur while waiting for emergency referral and transport to the health center or hospital.

This comprehensive system ensures that no birth is overlooked or undervalued. It means that birth attendants at all levels in the health system are empowered and equipped to stabilize and treat complications as they arise. It results in a majority of births successfully being delivered at the lowest levels of health systems, closest to where most pregnant women reside. It also ensures that a speedy and efficient referral system is in place linking the most isolated and mobile communities all the way through to a hospital sufficiently equipped to handle emergencies.

Change

CHAI supports Ministries of Health in our partner countries to drastically reduce maternal and neonatal deaths by scaling up the integrated MNH approach over an accelerated timeline.

The impact of CHAI’s MNH program can be most clearly seen in three states in Northern Nigeria. Nigeria accounts for the largest proportion of maternal deaths (19.1 percent), neonatal deaths (12.5 percent), and stillbirths (11.6 percent) worldwide. In 2014, working in partnership with the Nigerian Federal Government and the state governments of Kaduna, Kano, and Katsina, and funded by the Norwegian Ministry of Foreign Affairs, CHAI initiated the MNH program across a population of approximately 10 million people. Within six months of field-level intervention implementation, dramatic results were achieved to reduce maternal and newborn deaths across these three states.

An independent external evaluation in November 2016 verified that the following significant and sustained reductions were achieved within 12-18 months within the focus geographies:

• Maternal mortality: 37% reduction;
• Neonatal mortality: 43% reduction; and
• Stillbirth: 15% reduction.

The evaluation concluded that “the CHAI Maternal-Neonatal Health Program accomplished impressive, rapid and, to date, sustained reductions in newborn mortality, maternal mortality, stillbirth, perinatal mortality and a combination of stillbirth and newborn mortality equivalent to or beyond those observed in other efforts to improve neonatal and maternal survival.”

A separate, second independent external evaluation agreed with these findings, concluding that the program was “relevant at all levels”, that the stated reductions “most likely… understates the achievements of the programme” and “is considered to provide good value for money provided that the lessons gained are brought forward and used in future programmes.”

Continuing this level of sustained impact will not only lead to significant results across the three focus states in Nigeria, but can also serve as a model for other countries and partners with the comprehensive MNH approach now being rolled out in other countries where the need for an effective and efficient approach towards MNH is great. In Ethiopia for instance, CHAI responded to a Federal Ministry of Health request to scale the program up in 40 woredas (districts) in in 2017, covering an estimated population of 5 million people. Targeting woredas with some of the highest maternal and neonatal mortality burden in Ethiopia, the program aims to reduce maternal and neonatal mortality rates by 30% and 40% respectively. This builds on previous work, supported by the RMNCH Trust Fund, to roll out an institutionalized midwife mentoring program in 278 health centers located in 100 hard-to-reach districts across Ethiopia. Institutional delivery, antenatal care, and postnatal care increased throughout the course of 2015 by 42 percent, 61 percent, and 38 percent, respectively, in those sites supported by the mentoring program.

The sustainable systems established through CHAI’s MNH program ensures further lives are saved beyond the project implementation period. Continuing this level of sustained impact will not only lead to significant results, but can also serve as a model for other countries and partners looking to implement an effective, efficient and sustainable approach towards maternal and neonatal mortality reductions.