the challenge & context of mdg 4 and 5 - world health ... challenge & context of mdg 4 and...

The challenge & context of MDG 4 and 5: how can health care professionals contribute?

Zulfiqar A. BhuttaHusein Lalji Dewraj Professor & Head

Division of Maternal & Child HealthThe Aga Khan University

Karachi, Pakistan

& Treasurer

International Pediatric Association

World Map: Land Area

SASI Group and M. Newman 2006

Maternal Mortality

Infant Deaths


War deaths

Absolute Poverty

Affordable drugs

Physician Density


Millennium Development Goal 5 is seriously off-track

0

50

100

150

200

250

300

350

400

450

1990 1995 2000 2005 2010 2015

Mat

erna

l dea

ths

per 1

00 0

00 li

ve b

irths

MDG 5 Target

MDG5: 75% reduction in maternal mortality ratio between 1990-2015

So is MDG 4 for child survival for many countries

Millennium Development Goal 4 can only be achieved if neonatal deaths are addressed - missing from current programmes

050

100

150

Glo

bal m

orta

lity

per 1

000

birt

hs

1960 1980 2000 2020Year

Under-5 mortality rate

Late neonatal mortality

Early neonatal mortality

Target for

MDG-4

Most of the newborn deaths are early

2006-07 PDHS, NIPS and Macro International

58% of all newborn deaths are in the first 72 hours of life

“The facts are always less than what really happened!”

Nadine Gordimer

Equity remains a challenge(Under 5 Mortality by Wealth Quntiles)

Year-1990

0 50 100 150 200 250

Lowest

second

third

fourth

highest

Year-2007

0 50 100 150 200

Lowest

second

third

fourth

highest

Where are the shortages of health service providers?

Source: The World Health Report 2006

MDGs: Worker density & service coverage

0 .5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Cov

erag

e (%

)

80

40

60

100

20

Skilled Birth Attendance

Measles Immunization

Health Worker Density (per 1,000)Source: JLI 2004.

17

MDGs: Worker density and mortality

0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5

Density (workers per 1,000, log)

Mor

talit

y (p

er 1

,000

, log

)

Maternal

Infant

Under-5

Source: Anand & Baernighausen- 2004 (JLI)

(Data from 117 countries)

Karachi

Dadu

Thatta

Badin Tharparkar

Mirpurkhas

Sanghar

Hyderabad

Nawabshah

Khairpur

NaushahroFeroz

Larkana

Shikarpur

Jacobabad

Ghotki

Sukkur

15

2

3

6

5

6

2

1

2

13

257

22

2

279

#Karachi 279Hyderabad 25Nawabshah 15Larkana 13Mirpurkhas 7Sukkur 6Khairpur 6N Feroze 5Sanghar 3Dadu 2Shikarpur 2Tharparkar 2Badin 2Ghotki 2Thatta 2Jacobabad 1

# of PediatricianSINDH

Number of Pediatrician by Districts (Sindh)

30 +20 to 3010 to 205-10< 5

80%

Referral HospitalTertiaryUniversity Hospital

SecondaryDistrict General HospitalSub-district Hospitals

PrimaryRural Health Center

Village Health Units

50-60%

35-40%

5-10%

Strategies for strengthening and expanding Health workforce

Existing workforce

New workforce

Task shifting/sharing

Skill mix

Continuous develop.

Scaling up

Multipurpose HW

Essential categories

Based on projected

needs, considering contexts like

equity, access, quality,

programme requirements

and others

Lady Health Workers Program

• Program established in 1994

• 163 million population– 34% Urban 56 Million– 66% Rural 107 Million

• 1 LHW: 1000 Population

• Medium Term (2008-11) 110,000– 30% Urban 16000 LHWs– 90 % Rural 95 000 LHWs

HealthCare

Professionals

Continuum of care across care providers

Family & Community

TBAs Semi-skilledBirth

Attendants

AncillaryHealthStaff

Poorly developed Intermediate Well developed

Health Systems

Task Sharing or Task Shifting

Trained TBAs and community health workers

Newborn care

Trained CHWsAncillary health workers

Infant & child care


Postnatal care

Promoting skilled care Trained TBAs & referral

Care during child birth

CHWs and Packages Trained TBAs & referral

Pregnancy care

Community support groups Poverty alleviation strategies

Pre-pregnancy care

Conditional cash transfers & social security networksContracting services

General & supportive care

Poorly developed health systems (mostly home births)


Trained community midwivesOutreach workers


Newborn care

Ancillary health workers


Infant & child care



Postnatal care

Trained skilled attendantsCommunity midwives



CHWs outreachOutpatient care


Pregnancy care

CHWs & trained birth attendants (community midwives)


Pre-pregnancy care

CCTs & voucher schemesNGO contracting



Partially functional health systems with some home births



Routine facility based care



Newborn care

IMCI trained workersAncillary health workers


Infant & child care

Routine facility based care



Postnatal care

Skilled & trained attendants in facilities

Trained skilled attendantsCommunity midwives



Skilled & trained attendants in facilities

CHWs outreachOutpatient care


Pregnancy care

General education & care

Promoting care through outpatient services

CHWs & trained birth attendants (community midwives)


Pre-pregnancy care

M & E Identify & target at-risk groups

CCTs & voucher schemesNGO contracting



Well developed health systems with facility births

Partially functional health systems with some home births


Task shifting

Conclusions• Maternal and Child survival remains a major challenge for

health care professionals globally and at current rates, many high burden countries will not be able to meet MDG4 and 5 targets.

• Shortage of human and health system resources to deliver essential MNCH services is a key barrier to action.

• Future strategies will need development of alternative cadres ifworkers in the short term to share delivery strategies. It is feasible to use CHWs working in close partnerships with communities to implement a range of promotive and preventive interventions at scale. However, these interventions work best when linked to functional first & second level facilities

the challenge & context of mdg 4 and 5 - world health ... challenge & context of mdg 4 and...

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