Case study on neonatal death reduction in China

Composition of Country Teams

Lingli Zhang, DDG of MCH Dept., NHFPCRong Luo, Director of Policy Division, NCWCHYan Wang, Researcher on Child Health, NCWCHCao Ying, Safe the Children, China Program Sufang Guo, MCH Specialist, UNICEF China

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[Country Profile]

Epidemiology and Demography: •Total population: 1.34 billion•Women (15-49 years): 380 million (28.5%)•Children <5 years: 76 million (5.7%)•Live births: 16 million

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Heilongjiang

Jilin

Liaoning

Hebei

Guangdong

Hainan

Shandong

Jiangsu

BeijingTianjin

Shanghai

Fujian

Zhejiang

Hong KongMacao

Taiwan province

Xinjiang

Tibet

Qinghai

Sichuan

Yunnan

Gansu Inner Mongolia

Shaanxi

Ningxia Shanxi

Chongqing

Hubei

HunanGuizhou

Guangxi

Jiangxi

Henan

Anhui

EasternCentralWestern

Regions

Description of the bottleneck analysis process Key partners involved during the process

• Department of Maternal and Child Health, NHFPC

• National Center for Women and Children’s Health

• China CDC• PKU• UNTG on MCH, China

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Description of the bottleneck analysis process

• As part of child survival strategy review in China• National consultation• UN partner consultation

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Data Collection Methods

• Government Document review• Open published literature review• Key informer counseling: individual and

group

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Update on the Situation of Children and Women

Focus areas/Outcomes of H&N program is based on the six WHO health system building blocks

Good progress has been made!MMR and U5MR trends, 2000-2012

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MMR U5MR

Deaths per 1,000 live births

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Target:22 Target:16

Age distribution of deaths among under-five childrenNew-born account for 50% of U5MR

8Source: Ministry of Health, China Health Statistical Yearbook, 2012

Causes of neonatal deaths, 2008

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Source: UN Countdown report, 2012

In postnatal and infancy periods coverage of interventions is still low

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Coverage of interventions across the continuum of care for maternal and child health, 2008 and 2011

As hospital delivery rate increased, newborn mortality rate reduced

NM

R (1/1000 LBs)

HD

R (%

)

Source: China Health Statistic Year Book, 2011

Access

• Physical access: National average:88%; • Financial access:

– Although health insurance coverage in general population reached 88% (2008) and 96% (2011), that figure was low among newborn

– Hospital delivery subsidy for rural women.

• Cultural access: HDR is still less than 50% in specific

areas due to direct and indirect cost such as transportation, accommodation and cultural/belief

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Health Insurance coverage (%)

2003

2008

2011

Service delivery (including quality of care)

• Although quality of care has been improving, – only 56% of county level health facilities could provide

CEmONC – 31% of township level hospitals could provide BEmONC – 10% county and township level health facilities are not

qualified to provide BEmONC but they are providing BEmONC (MOH/UNICEF HR and facility survey).

• UNICEF is planning to work with MOH to develop standardized materials for in-service and pre-service training.

• Involving more sectors in health promotion/C4D is urgently needed.

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Health financing

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• OOP

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Leadership and governance

• MCH Law and NPAs for women and children exist, guidelines for MCH are available.

• Policies to address in-equities in recent health sector reform– Basic PH (free MCH service)– Priority PH program (Hospital delivery subsidy, folic acid supplement for pregnant women,

integrated of PMTCT of HIV/syphilis/HBV ).However, some of financial input is left for local government which makes the policy enforcement

weak.

• Code for marketing of breast milk substitutes/ baby friendly hospitals/ policies to encourage early initiation of breast feeding and exclusive breast feeding exist, but it is very weak and lacks enforcement and monitoring.

• Coordination mechanism for MCH is available (NPA).

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Medical products, vaccine and technology

• Essential equipment are available in most of local health facilities.

• Some important essential drugs are not available. ORS is in essential drug list, but not necessary low osmolality ORS and not available in many clinics.

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Information

• Maternal and child mortality surveillance system and MCH annual report system are available. Consolidated HMIS on MCH is planning.

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Situation of health workforce is improved, disparity exists

Number of physician and nurses, per 1,000 population

Equity analysisEquity Analysis

Maternal mortality ratio, 2000-2012

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Neonatal mortality rate, 1991–2011

Source: Ministry of Health, China Health Statistical Yearbook, 2012

Despite overall progress,China is reducing U5M in an inequitable way

U5MR in provinces in China, 2011 Beijing

Jiangsu

Guangdong

Tianjin

Shanghai

Jilin

zhejiang

Hunan

Henan

Shandong

Fujian

Guangxi

Liaoning

Chongqing

Anhui

Shanxi

Hubei

Hebei

Jiangxi

Heilongjiang

Shaanxi

Sichuan

Guizhou

Hainan

Inner Mongolia

Ningxia

Gansu

Qinghai

Yunnan

Tibet

Xinjiang

Highest U5MR is 8x more than lowest U5MR:± 203,560 children can be saved yearly

should the whole country have the lowest U5MR

Source: MCMSS, 2011; extrapolation based on SOWC, 2012

2015 target

In western provinces and rural areasantenatal care (5 visits) coverage is still low

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资料来源： Qun Meng, Ling Xu, Yaoguang Zhang, Juncheng Qian, Min Cai, Ying Xin, Jun Gao, Ke Xu, J Ties Boerma, Sarah L Barber ， “ 2003—2011年中国医疗卫生服务的可及性及经济保护变化趋势分析：一项横断面研究”，《柳叶刀》， 2012 年 3 月 3 日，第 379 卷，第 9818 期，第 805-814 页

Description of the bottleneck analysis process Key partners involved during the process

• Department of Maternal and Child Health, Ministry of Health

• National Center for Women and Children’s Health

• China CDC• PKU• UNTG on MCH, China

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Description of the bottleneck analysis process

• As part of child survival strategy review in China• National consultation• UN partner consultation

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Data Collection Methods

• Government Document review• Open published literature review• Key informer counseling: individual and

group

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Bottleneck analysis

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Newborn care in generalPRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONSLow health insurance coverage for newbornHigh OOP

Advocate national policy makers on financing of newborn health to reach free service for newborn care

Lack of costed newborn health package

Conduct costing exercise and develop costed plan

Limited budget for C4D on newborn health and lack of C4D plan for newborn care

Budgeted C4D plan for newborn care

Poor access in terms of physical, financial and cultural access in remote areas

MWR, CCT, C4D

Insufficient staff trained for newborn care (pediatricians, obstetricians, midwives, nurses) in county and lower level institution

Recruitment of staff (pediatricians, obstetricians, midwives, nurses);Incentives for staff to stay in stations ;Staff training based on identified needs;Training need to combine with the practice;

Standard training package for in-serve and pre-service

Update evidence based standard training model for in-service and pre-service

Few BFHs stick to BFH standardLow EIBF rate

Need strong enforcement and M&E for BFH

Quality of delivery and PNC care are poor

Training plan 29

Prevention and management of preterm birth PRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS

Cost-effective interventions is not applied in poor China (such as kangaroo mother care)Limited capacity on staff

Promotion of cost-effective intervention base on Chinese context

Long and short term plan

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PRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS

Physical, financial and cultural barriers for accessing to health service

Focusing on targeted areas and improving access to HD through MWR, CCT,

Skilled care at birth

BEmONCPRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS31% of township level hospitals could provide BEmONC TOT and cascade training10% county and township level health facilities are not qualified to provide BEmONC but they are providing BEmONC (MOH/UNICEF HR and facility survey).

Pre-service training

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PRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS

only 56% of county level health facilities could provide CEmONC

Long term training, technical support

Over-used caesarean in all levels of institutions

Regulation and standard on rational caesareanReform payment scheme from fee-for-service or DRG to per capita perspective Capacity building

CEmONC

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Caesarean Section rate is still high

Caesarean section rate, 2003, 2008 and 2011

资料来源： Qun Meng, Ling Xu, Yaoguang Zhang, Juncheng Qian, Min Cai, Ying Xin, Jun Gao, Ke Xu, J Ties Boerma, Sarah L Barber ， “ 2003—2011年中国医疗卫生服务的可及性及经济保护变化趋势分析：一项横断面研究”，《柳叶刀》， 2012 年 3 月 3 日，第 379 卷，第 9818 期，第 805-814 页

Basic Newborn Care PRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS

Low EIBF Introduction first embrace

Low EBF Government’s commitment on promotionBFHI

Poor quality of PNC Increase staffingIn-service, out of service training

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Neonatal ResuscitationPRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS

Poor capacity in grass root level

• National policy: at least one staff received updated training on newborn resusitation

• Training of staffs from grass-root level• Introduce HBB in specific relevant

areasLack of essential equipment in gross root health facilities

Advocate and development of standard equipment package for MCH

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PRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS

Kangaroo Mother care is not widely used Training and C4D

Kangaroo Mother Care

Per 1,000 LBs % of child death

Number before the name of province: GDP rank in reverse orderBlue: UNICEF project provinces

Red number: Per capita GDP rank in reverse order

Strategic directions

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