Three Paths to Newborn Survival
Peru, Malawi and Nepal demonstrate rapid progress in reducing neonatal mortality.
Newborns make up nearly half of the children under five who die every year. That’s 2.9 million children dying within their first month of life, despite significant progress in under-five child mortality overall.
New research in The Lancet examines why newborns have been left out of progress in child survival and makes the case for integrating them into the post-2015 agenda.
As part of the series, one paper, led by a team of experts from UNICEF, examines bottlenecks in health systems in countries where maternal and neonatal mortality are highest and provides strategies for overcoming them. Three country case studies offer a road map to success. They are excerpted below.
Peru: Expanding coverage to the poorest populations
Closing the gap in equity has been the focus of Peru’s strategy, which emphasizes comprehensive health care programs targeting women and newborns in the country’s poorest communities, mostly in rural areas.
The proportion of SIS insured people in rural areas grew from 24.7% in 2004 to 73% in 2011.
In 2002 the Peruvian Government introduced the Comprehensive Health Insurance Scheme (SIS), which includes free access to basic health care for children younger than 5 years as well as for pregnant women while giving priority to vulnerable populations living in extreme poverty. The proportion of SIS insured people in rural areas progressed from 24·7% in 2004 to 73% in 2011. Efforts to reduce the equity gap were remarkable, with an increase in coverage of maternal and newborn health interventions among the poorest populations and those living in rural areas. Peru has integrated various social inclusion programmes such as conditional cash transfers (JUNTOS), emphasising their cross-cutting nature, and thus the need to ensure the participation of multiple public and private sectors in their implementation. Accordingly, health financing is focused on implementation of interventions related to public health problems identified through wide consultation processes, and it follows a results-based budgeting, which emphasises monitoring of progress in coverage and effect indicators related to reproductive, maternal, newborn, and child health.
Malawi: Generating high-level commitment
High-level attention allowed a small group of technical champions working with the Ministry of Health to ensure that specific newborn care interventions were included in national policies. A dramatic increase in the number of community-based health care providers (pictured above) was pivotal to expanding coverage.
The national Emergency Human Resource Program resulted in a 66% increase in health worker density.
Between 2000 and 2010, Malawi achieved substantial progress in incorporating newborn health into national policies, programmes, agendas, and implementation guidelines. A pivotal moment for policy change occurred in 2005 with the integration of newborn health into the national plan, Road Map for Accelerating Reduction of Maternal and Newborn Mortality and Morbidity in Malawi, which was linked to the sector-wide approach and cost implementation plan. High-level attention to newborn health enabled an effective small group of technical champions working with the Ministry of Health to ensure the inclusion of specific newborn care interventions, such as facility-based kangaroo mother care (KMC) and an integrated community-based package, into wider health policies, programmes, and preservice training. The newborn sub-working group of the Safe Motherhood Taskforce has met routinely since 2007 and has recently been formalised to strengthen the coordination across reproductive, maternal, newborn, and child health mechanisms.
Nepal: Providing incentives to use birth facilities
Strong coordination among researchers, government and the medical community, supported by a high-level political commitment to newborn health, drove Nepal's expansion of social insurance schemes to encourage use of birth facilities.
The maternal incentive scheme has successfully shifted behavior and increased skilled care at birth by 13%.
The Maternity Incentive Scheme (later called the Safe Delivery Incentive Programme) was initiated in 2005 and included fee exemptions at facilities in poorer districts only and incentive payments to women and health workers in other areas. The programme has been successful in shifting behaviour and increasing skilled care at birth (13% increase). The next major shift introduced incrementally since 2006, was a more general move towards free essential health care; starting from free emergency and inpatient care for specific disadvantaged populations in district hospitals and primary health-care centres in 2006 to free care to all at health posts and primary health-care centres in 2007, and at all district hospitals in 2009. In Nepal, the free delivery policy (called Aama Surakshya Karyakram) includes universal free delivery services, launched in 2009, and a continuation of the Safe Delivery Incentive Programme, providing cash payments to women who deliver in facilities and incentive payments for health workers who undertake home deliveries. Monitoring results 1 year after the Aama policy was launched show an increase in institutional deliveries (19% increase).