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Dr Nnenna Ihebuzor Director Community Health Services National Primary Health Care Development Agency Abuja, Nigeria Team Nigeria @ Global Newborn Health Conference Johannesburg, South Africa April 16th 2013
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Context
Women and children in Nigeria continue to lose their lives in large numbers
Although Nigeria has made some strides inAlthough Nigeria has made some strides in improving women and childrens health, progress has not been fast enough and Nigeria lags behind other countries in dramatically shifting outcomes, especially for newborns
The current shift in Nigerias response aspires to deliver significant, visible, and immediate results in the lives of Nigerias newborns, women and children
deliver significant, visible, and immediate impact and bend the curve for newborn survival by scaling up access to essential newborn care
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Nigerias Demographics
Map of Nigeria Showing the Six (6) Geo-Political Zones
Niger
Sokoto Katsina Zamfara Kebbi Kano Jigawa Yobe Borno
Chad
Bauchi Kaduna Niger Plateau Kwara Oyo Osun Ogun Lagos Ekiti Ondo Edo Enugu Anambra Ebonyi Delta Cross River ImoAbia Akwa Ibom Bayelsa Rivers Kogi Benue FCT, Abuja Nassarawa Adamawa Gombe
B e n in
am e
ro u
Taraba
Zone
Federation of 36 States Population: 167 million + Large under five population and high birth cohort Five main language groups, 250+ regional languages/dialects Infrastructure and logistics challenges: roads, unstable power, dense and rural populations, poor sanitation West Africas transport and migration hub bordering four countries
Atlantic Ocean
Countries with the highest numbers of newborn deaths are similar to those with high maternal deaths
Ranking for numbers of neonatal deaths 1 1 Ranking for numbers of maternal deaths
India
NIGERIA
3 4 5 6 7 8
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2.4 million neonatal deaths
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8 13 3 5 6 7
Pakistan
China
DR Congo
Ethiopia
Bangladesh
Indonesia
Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Updated June 2010
Afghanistan 9 number of newborn4deaths in Africa Nigeria has the highest Tanzania 10 17th in terms of rates 9 and ranks 5 254,000 deaths in 2010 (NMR of 40)
More mothers and babies die in Nigeria per year than in comparable countries
Ghana2 409 352 306 Uganda2 Sudan2
Nigeria1
545
40
31
29
36
1 MMR Data 2008 NDHS, NMR Data 2008 NDHS 2 MMR Data 2008 IHME, NMR Data 2005 WHO 6
SOURCE: National Demographic Health Survey, World Health Organization, Institute of Health Metrics and Evaluation
Maternal Mortality Ratios (deaths per 100,000 live births) Total Fertility Rate (children/woman) At least one ANC attendance (%)
The poorest Nigerian women have significantly less access to MNCH services than richer women
MCH service access by the poorest and richest women in Nigeria, 2003 91% 31% +196%
Multiple antenatal care (ANC) visits % of pregnant women 85% 13% +555%
+469%
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SOURCE: World Bank: Socio-economic Differences in Health, Nutrition, and Population within Developing Countries
Government Tier
Federal
State
Local Government
Deconcentration SMoH, SACA, SASCP Delegation NAFDAC, NPHCDA, NASCP Devolution LGAs for PHC Health is on the concurrent list
Some States and LGAs simply do not prioritize health and/or make adequate budgetary allocations resulting in inconsistent health services across states and local government areas
Generally, health services, uptake and indicators in southern States better than in northern States
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Workforce per 10,000 population 2005 2006 2007 3.0 3.54 3.70 10.0 8.95 9.10 6.8 6.36 6.39
Translates to 20 physicians, nurses and midwives per 10,000 population Much higher than for many SSA countries Closer to WHO benchmark of 25/10,000 population required to provide minimum MNCH services. But main constraint is maldistribution
Source: Health Workforce Profile, Nigeria, 2008
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SBA
13
14
14
15
35
30
25
20
20
15
10
2.33
0.4
Early neonatal Late Neonatal Post-neonatal (Day 0-6) (Day 7-28) (1 - 11 months)
JE Lawn based on global ENMR, NMR estimates by WHO, and IMR and U5M by UN child mortality group around the year 2008
Source: Saving Newborn Lives in Nigeria, 2011. Data from DHS 2008
Progress to MDG4
NDHS U5MR UN U5MR IHME U5MR NDHS NMR UN NMR
160 157
250
200
IHME NMR
150
138
100
50
40
0 1995 2000
Year
1990
2005
2010
2015
Child deaths (<5 years) are declining BUT still little progress for neonatal deaths... Now 29% of under five deaths, up from 24% (in 2008) 18
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Mapping of newborn deaths, newborn care delivery points and strategic state/LGA government and partner support
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At home 62%
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Prematurity Antenatal steroids in health facilities for preterm labour Scaling up KMC
Skilled delivery Expand access to facility deliveries (MSS and SURE-P) Improve training (inservice and preservice) on newborn care within MSS and SURE-P
Community care Family planning Engaging families through Closing the gap for unmet needs for contraception essential newborn care messages (early and exclusive breastfeeding, clean cord care and warmth) Educating families on newborn danger signs Improve and increase access to CBNC - through CHEWS 22 and VHWs
Intrapartum injury/Asphyxia
Prematurity
Antenatal steroids
prevention
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Antenatal and postnatal care Chlorhexidine for cord care in communities Early and exclusive breastfeeding Ambulatory KMC Identification and referral of sick newborns to health facilities
Linking community to facilities Community engagement for improved practices & care seeking Ward health committees Village health workers/ counselors Emergency Transport System
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In Nigeria as in most of Sub-Saharan Africa, the majority of neonatal deaths are at home Reducing delays is critical
Delay 2: Transport to care
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Lawn JE, Lee AC, et al IJGO 2009
Platforms and Options for Scaling Up Essential New Born Care in Nigeria
The objective of any maternal and newborn health (MNH) program expansion should be to increase ACCESS to and QUALITY of services being provided!
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The Midwives Service Scheme has delivered visible results within two years of implementation
789 584
-26%
11
-22%
41%
50% +22%
16%
+33%
1% 2009
2% 2011
+100%
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UCH FMCA FMC Gusau King Fahd WCH Sheikh Mohd Jidda GH Fagwalawa GH Kaura Namoda GH Danbatta GH Gezawa Anka GH MMSH Waziri Shehu Gidado Sir Mohd Sanusi GH Dawakin Tofa Shinkafi Tudun Wada GH Zurmi Tsafe GH Rano GH
Tertiary Hospitals
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The SURE-P MCH programme will build on the impact of MSS through supply and demand-side interventions along the continuum of care
Continuum of care Training Antenatal visit 1 Payment Conditions Demand Inputs Conditional Cash Transfer
Recruitment
Deploy-ment
Ident-ification
All cadres receive a one-week training Antenatal visit 4 Skilled attendant at birth Postnatal care Women who meet conditions are paid a set incentive value
Midwives and CHWs recruited from school or unemployment database, VHWs from communities
Midwives and CHWs deployed after enrolment, VHWs deployed after training
Women are encour-aged to meet programme conditions (i.e. to access MCH services at PHCs)
Family Planning
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These health workers will reach deeper into target communities with the help of the ward development committees
WDC Midwives PHC referral VHWs CHWs PHC Patient
Patient
Midwives
CHWs
VHWs
PHC referral
Hospital PHC
Midwives Patient
Patient
Midwives WDC
CHWs
VHWs
VHWs
CHWs
WDCs play important roles in this system: Ensure beneficiaries are aware of the programme and receive the benefits Monitor implementation within the community Hospitals key for providing services for complicated births SURE-P to provide health commodities to the PHCs and health workers in each community
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The supply-side intervention will dramatically scale up the number of health workers
Scale-up from 2011-15 Thousands of workers
2.0 0.8 0.6 2.0 9.4
Description
Midwives
12.0
48.0 12.0
MSS programme who provide a wide range of health services within their community, but to be trained on MNCH by SURE P.
3.0 0.9
14.1
trained on basic health care services and household practices Primary role is to stimulate demand for health services
2011
12
13
14
2015 Total
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Nigeria DHS 2008 Why Doesn't Skilled Birth Attendance Alone Lower Neonatal Mortality?
100
90
80
70
60 NNM SBA
50
40
30
20
10 North East North Central South South South West South East
0
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North West
The focus on human resources and demand stimulation comes from earlier lessons about what drives outcomes
Implications for SURE-P
access components
inefficiently, often lack basic equipment and supplies and are underutilized
demand-side intervention using PHCs that already exist appropriate given evidence that building new PHCs is unlikely to dramatically improve outcomes
SOURCE: McKinsey
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Opportunities )
Government
UNCC Nigeria as co chair Saving One Million Lives Initiative Child Survival Call to Action and African Leadership for Child Survival Road Map SURE-P MCH
State of the Worlds Mothers 2013 Donors Development agencies Private sector
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Thank you
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