1

Scaling Up MNCH Cambodia

The Partners’ Forum

Dar es Salaam, the United Republic of Tanzania

17-20 April 2007

2

Outline

• Background of the country MNCH profile• Context of the health sector• Exiting MNCH strategic plans: objectives, target,

implementation framework• Current MNCH interventions being implemented

in the country• Major constraints for MNCH in the country• Lessons learnt• Next step for scaling

3

1. Background of the country MNCH profile Key Socio-Demographic Data (1)(1)

Total Population: Total Population: 13.5 millions13.5 millions

Percentage rural: Percentage rural: 84%84%

Annual pop. growth rate: Annual pop. growth rate: 2.5%2.5%

Literacy rate (M Literacy rate (M vsvs F):F): 71%71% vsvs 42%42%

Access to safe water:Access to safe water: 29%29% vsvs 69%69%

(rural (rural vsvs urban)urban)

Access to safe Access to safe sanitasanita.:.: 9%9% vsvs 49%49%

(rural (rural vsvs urban)urban)

Chronic food shortage:Chronic food shortage: 30%30%

Pop. under poverty line:Pop. under poverty line: 36%36%

4

1. Background of the MNCH profile Selected Health Indicators (2)

3758Post neonatal mortality rate (per 1,000 live births)

2837Neonatal mortality rate (per 1,000 live births)

6595Infant mortality rate (per 1,000 live births)

83124Under-5 mortality rate (per 1,000 live births)

CDHS2005CDHS2000

5

1.Background of the MNCH profile Selected Health Indicators (3)

66.6%40%Children 12-23 months of age fully immunized

60%11%Exclusive breastfeeding

37%45%Percentage of children under five years with stunting

7%15%Percentage of children who are Wasting

36%45%Percentage of children who are underweight

0.6%2.8%HIV Sero-prevalence rate among 15-49 years

CDHS2005CDHS2000

6

1.Background of the MNCH profile Selected Health Indicators (4)

?32%Clean Delivery

54%30%Tetanus Toxoid (pregnant women)

29%41%

15%34%

Postpartum care (delivered outside facility)-TBA-Medical Professional

22%10%Delivery at health facility

44%32%Skilled birth attendance (TBA)

68%38%Antenatal care (ANC)

CDHS2005CDHS2000

7

Sources: UNICEF - The State of the World's Children 1997Sprechman et al.: Estimating maternal mortality in Cambodia, July 1996CDHS 2000, 2005

Maternal Mortality Rate

900

473 437 472

1990 1996 2000 2005

MM

R pe

r 100

,000

Liv

e Bi

rths

8

2. Context of Health SectorMinistry of Health

Cabinet of the Minister

DG for HealthDG for Admin

& Finance DG for Inspection

National Centers (MCH, TB, Malaria, HIV/AIDS)

National Hospitals (5)

Central Departments (8) Provincial Health Office (25)

Operational Districts Offices (76)

Health centers & Health Posts (960?)

Referral Hospitals

9

3. Existing MNCH Strategic Plans: Objectives, Target, Implementation Framework

• National Strategic Development Plan of was approved the council of the minister in by 2006

• Cambodian Child Survival Strategy• Cambodian Reproductive and Sexual

Health Strategy

10

4. Current MNCH Interventions being implemented in the country

• The maternal, newborn and child health is a priority action in the health strategic plan 2007-2010 for the Ministry of Health as well as in the national strategic development plan 2006-2010 that was approved by the council of the minister meeting on 27 January 2006.

11

12 key interventions for child health

70%44%32%4-32%Skilled Birth Attendance

95%0.2%62%5%Malaria Treatment

75%48%35%7%Antibiotic for pneumonia

85%58%74%15%Oral Rehydration Therapy (ORT)

<10%?181%?Vector control

80%4.2% (11-35%)9% (3-38%)7%Insecticide Treated Nets

80%54%30%2%Tetanus toxoid

92%77%55%1%Measles vaccine

85%35%31%2%Vitamin A

95%82%76%6%Complementary Feeding

80%60%11%13%Exclusive Breastfeeding

60%35%11%?Early initiation of Breastfeeding

Target 2010

CDHS2005

CDHS2000

Potentialchild mortality

reductionIntervention

12

Essential Service Package for RSH

• Birth Spacing• Comprehensive ANC• Labour and Delivery• Post-natal Care• Emergency Obstetric Care• Reduction of Unsafe abortion• STIs/HIV/AIDS/PMTCT• Violence against women, Infertility, Menopause and Old age,

Cancer of breast & reproductive tract• Reproductive Rights, Gender and Male involvement• Review and revise all midwifery training curricula to include all

reproductive health key elements.

National reproductive and sexual health strategy 2006-2010

13

5. Major Constraints for MNCH in the

Country: Health care services (1)

• Low utilization of cost-effective public health interventions (22%*)

• Poor quality of care in both public and private sectors

* CDHS 2005

14

5. Major Constraints for MNCH in the Country: Human resources development (2)

• Inadequate capacity: training and personnel management and leadership in M&E, and evidence-based, delegated decision making

• Poor attitudes and practices among service providers in communicating with consumers

• Mal-distribution of qualified staff, especially shortage of trained midwives

• Low salaries and lack of incentives to work in remote areas

* CDHS 2005

15

5. Major Constraints for MNCH in the Country: Financing (3)

• High prices, limited access to essential services among the poor, especially to referral hospitals

• Irregular and inadequate flow of funds to service delivery

• Limited coordination on external financing in the sector

16

7. Recoomemended Maternal and Child Health Interventions and next step

17

12 key interventions for child health

70%44%32%4-32%Skilled Birth Attendance

95%0.2%62%5%Malaria Treatment

75%48%35%7%Antibiotic for pneumonia

85%58%74%15%Oral Rehydration Therapy (ORT)

<10%?181%?Vector control

80%4.2% (11-35%)9% (3-38%)7%Insecticide Treated Nets

80%54%30%2%Tetanus toxoid

92%77%55%1%Measles vaccine

85%35%31%2%Vitamin A

95%82%76%6%Complementary Feeding

80%60%11%13%Exclusive Breastfeeding

60%35%11%?Early initiation of Breastfeeding

Target 2010

CDHS2005

CDHS2000

Potentialchild mortality

reductionIntervention

18

Challenges ahead

• We know the problems and the technical interventions, so how do we plan for implementation and scale-up?

• What are realistic targets for the short- and long-term?

• To get impact, how do we ensure quality and access to health services, esp. by the poor?

• What resources are needed to meet the MDGs? How can we spend wisely now?

19

• Three scenarios:

– Ambitious (optimal policies, maximum coverage targets, full intervention package)

– Middle (lower coverage targets, low-cost key interventions)

– Business as usual (no changes – will get nowhere)

• Time pressing and enormous things to do!

Challenges ahead

20

Recommended Interventions (1): System-Wide

– Strengthen the implementation of CPA Guidelines, including HR, supplies and equipment as well as development of clinical management guidelines for maternal and reproductive health, newborn care and child health.

– Commence implementation of Midwifery Review recommendations: pre and in-service training, midwife coverage, staff competency

– Scale up implementation of the 12 Child Survival Score Card interventions, with special attention to IMCI, Nutrition and training for Paediatric Care (including neo-natal) at Referral Hospitals. (Community, HC, RH. Funding needed for scale-up and training).

– Expand BCC activities for exclusive and complimentary feeding, increase the number of Baby Friendly Hospital and Communities and re-enforce Sub-decree of marketing on IYCF products.

– Expand of CBD and long term method to reduce unwanted pregnancy, and promotion of safe abortion through training, equipment and supplies (DfID supported implementation commencing)

21

Recommended Interventions (2): Disrtict with special needs

• Strengthen MCH continuum of care (ANC, delivery, new born care and post partum care) at community, and Health Center Level and RHs (CPA2 strengthening, with emphasis on improving quality of EOC and pediatric care), in districts where birth assisted by trained health personnel is low. (10 GAVI/HSS supported ODs. CPA strengthening still needs funding).

• Establish maternity waiting house with benefits (food, travel cost) at RH’s in remote districts.(UNFPA currently supporting Stung Treng.)

• Extend equity fund supported safe motherhood in districts where birth assisted by trained health personnel is low. (MoH/HSSP expansion of HEF planned)

• Prioritize remote facilities for PMG/Performance based incentives expansion (expected 2008-09)

22

Recommended Interventions (3): Funding/Implentation Gaps Identified

• CPA strengthening system-wide, as well as for EOC and pediatric care focus of the the 10 RH’s serving the GAVI/HSS supported districts for MCH Continuum of Care.

• IMCI, Nutrition and capacities strengthening for Paediatric Care.• Exclusive and complimentary feeding promotion; IYCF re-

enforcement.• Maternity Waiting Houses

23

Next Steps• Costing of priority interventions, commitment to fund and identification of

external support where necessary: JAPR process • Identification of priority ODs for CSS, MPA and CPA strengthening using

CDHS, HIS, and other appropriate data sources• Identification of HR, supplies and equipment gaps in health facilities for

MPA and CPA implementation through facilities checklists distributed with AOP Guidelines.

• In AOPs at all levels, increase planned expenditure on the 5 HS Priorities, including the interventions recommended here by 20%.

• Ensure quarterly monitoring and reporting of AOP implementation at all levels of the system, with special focus on RH’s and OD’s.

• Align interventions with existing MoH policy and projects, especially for those focused on districts with special needs (GAVI, GFATM, HSSP, Contracting, HEF, CSS Costing etc.)

• For more detail, you can read the priority for 2007-2008

24

Thank you for your attentionand for helping to make a difference........