comprehensive needs assessment of newborn care in selected

Comprehensive newborn care assessment

Comprehensive needs assessment of newborn care in selected

countries Cross-country report

March 2013


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Comprehensive needs assessment of newborn care in selected

countries Cross-country report

Final report - March 2013

Consultant team: Melissa Diaz Els Duysburgh Vini Fardhdiani Birgit Kerstens Khamphong Phommachanh Katherine Villegas Reyes


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FOREWORD

Continued and accelerated reduction of preventable child deaths is our target in this region. But this target will not be achieved, if new born deaths are not addressed. There is solid evidence that targeted and cost-effective investments can reduce number of newborns who die from preventable causes. And this evidence shows that it is a myth that newborn care is more expensive. We know that a 25 to 60 % reduction in the neonatal mortality rate is possible if we can ensure healthy home care and postnatal practices are in place and if there is early detection and referral of complications. Emergency newborn care for sick babies (including extra care for pre-term and low birth-weight babies) can achieve a further 23-50% reduction in neonatal deaths. Emergency care does not necessarily mean having costly incubators as good quality emergency care is now possible with simple techniques like Kangaroo Mother Care. All three countries examined in this comprehensive newborn care assessment – Indonesia, Lao PDR, and the Philippines - have pledged to reduce preventable child deaths under the “A Promise Renewed” call for child survival. Their support for this comprehensive newborn care assessment is an expression of their dedication to translate this promise into action. In the analysis provided, policies, administrative infrastructure and implementation levels have been examined to expose gaps and enable the governments to more accurately focus their resources where they are needed. Inequities have been highlighted to help identify the most vulnerable populations. Quality-of-care issues have been described and data gaps revealed. The assessment examines all health system building blocks and provides a holistic picture of what is happening and what is not. The assessment also identifies each country’s strengths and opportunities. In each there are areas of best practice which can be scaled-up. Potential champions are identified and options to engage the private sector and civil society are explored. In this assessment, much useful information necessary to facilitate country-level planning and subsequent action has been condensed into a few pages. We hope that information will serve as a milepost on a journey towards a world in which all babies are able to survive and thrive.

Daniel Toole Regional Director UNICEF East Asia and Pacific Regional Office


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ACKNOWLEDGEMENTS

Our appreciation goes to National Ministries of Health and country focal points for their un-wavering support to the comprehensive newborn assessment. We are indebted to the following government partners for providing the desired leadership and convening partners around this very important issue:

Associate Professor Dr. Bounnack Saysanasongkham, Deputy Director, Department of Health Care, Lao PDR,

Dr. Kirana Pritasari, Director of Child health Directorate, MoH Indonesia

Dr. Juanita Basilio, Division Chief, Family Health Office, National Center for Disease Prevention and Control, DoH , the Philippines and

Dr. Anthony Calibo, Programme Manager for Newborn Care, Family Health Office, National Center for Disease Prevention and Control, DOH, the Philippines

This work would not have been possible without the active support, participation and logistical facilitation by the UNICEF country teams from Lao PDR, Indonesia and the Philippines. Dr.Viorica Berdaga, Susan Albone and Onevanh Phiahouaphanh from Lao PDR; Dr. Robin Nandy and Dr. Karina Widowati from Indonesia and Dr. Willibald Zeck and Dr. Mariella Castillo from the Philippines need special mention for their intensive support to compile relevant materials for desk review, engaging with ministries of health and partners for an inclusive process of consultation, arranging field visits and taking time to meticulously review the country reports. Dr. Kim Dickson, Senior MNH Advisor at UNICEF Head Quarters provided critical inputs at the stage of drafting the Terms of Reference and providing continuous inspiration to serve the cause of newborn health. HERA and the team of consultants engaged in the design, field work and report writing have been excellent collaborators and were flexible to the demands of ever changing situation and re-scheduling of in-country meetings. We are indebted to many partners and stakeholders who provided their valuable insights during the process and especially our colleagues from WHO, UNFPA and development partners including USAID, Aus AID and Luxgembourg Development who could participate in joint meetings and field visits. Ms. Kulanuch Rungnopkhunsri our Research Assistant deserves applause for efficiently supporting the contract related administrative processes and branding the report.

Basil Rodriques, Chief Young Child Survival and Development section & Dr. Nabila Zaka, Maternal and Child Health Specialist

UNICEF East Asia and the Pacific Regional Office


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TABLE OF CONTENTS

TABLE OF CONTENTS ....................................................................................................................................... IV

LIST OF FIGURES ............................................................................................................................................... V

LIST OF TABLES ................................................................................................................................................. V

LIST OF ABBREVIATIONS AND ACRONYMS ..................................................................................................... VII

EXECUTIVE SUMMARY .................................................................................................................................... IX

1 INTRODUCTION........................................................................................................................................ 1

2 COUNTRY PROFILES ................................................................................................................................. 3

2.1 GENERAL CONTEXT ...................................................................................................................................... 3 2.2 HEALTH SECTOR ......................................................................................................................................... 4 2.3 HEALTH STATUS OF NEWBORNS AND MOTHERS ................................................................................................. 5

2.3.1 Mortality data and trends ................................................................................................................. 5 2.3.2 Causes of maternal and neonatal mortality and morbidity .............................................................. 8 2.3.3 Health seeking behaviour and local practices ................................................................................... 9

3 POLICY CONTEXT FOR NEWBORN CARE ................................................................................................. 11

4 HEALTH SYSTEM CONTEXT FOR NEWBORN CARE ................................................................................... 13

4.1 HEALTH SERVICE DELIVERY .......................................................................................................................... 13 4.1.1 MNCH services provided before, during and after childbirth .......................................................... 13 4.1.2 Access to newborn services ............................................................................................................. 18 4.1.3 Referral system ................................................................................................................................ 19 4.1.4 Quality of essential newborn care ................................................................................................... 19 4.1.5 Emergency obstetric and newborn care .......................................................................................... 21

4.2 HUMAN RESOURCES FOR HEALTH ................................................................................................................. 23 4.3 HEALTH FINANCING ................................................................................................................................... 26 4.4 ESSENTIAL DRUGS AND COMMODITIES .......................................................................................................... 28 4.5 HEALTH INFORMATION SYSTEMS .................................................................................................................. 30 4.6 LEADERSHIP AND GOVERNANCE ................................................................................................................... 30

5 NEEDS ASSESSMENT .............................................................................................................................. 31

5.1 BENCHMARK ASSESSMENT .......................................................................................................................... 31 5.2 EQUITY ANALYSIS ...................................................................................................................................... 31 5.3 SWOT ANALYSIS ...................................................................................................................................... 38

6 FINDINGS AND RECOMMENDATIONS .................................................................................................... 44

6.1 MAIN FINDINGS ........................................................................................................................................ 44 6.2 RECOMMENDATIONS ................................................................................................................................. 44

ANNEXES .......................................................................................................................................................... 1

ANNEX 1: EQUITY INDICATORS ................................................................................................................................... 1 ANNEX 2: READINESS FOR SCALING UP NEWBORN CARE IN INDONESIA, LAO PDR AND THE PHILIPPINES .................................... 6 ANNEX 3: INTERNATIONAL RECOMMENDATIONS FOR ROUTINE NEWBORN CARE AND ESSENTIAL INTERVENTIONS......................... 9 ANNEX 4: REFERENCES ........................................................................................................................................... 10


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LIST OF FIGURES

FIGURE 1: TREND IN NEWBORN MORTALITY (PER 1,000 LIVE BIRTHS), INDONESIA, LAO PDR AND THE PHILIPPINES (1990-2015) .... 7 FIGURE 2: RECOMMENDED NEWBORN POSTPARTUM CARE VISITS ........................................................................................ 11 FIGURE 3: SIX BUILDING BLOCKS OF THE HEALTH SYSTEM .................................................................................................... 13 FIGURE 4: COVERAGE OF MNCH SERVICES ALONG THE CONTINUUM OF CARE, INDONESIA, LAO PDR AND THE PHILIPPINES (DATA

FROM 2007 TO 2012) ....................................................................................................................................... 15 FIGURE 5: COVERAGE OF MNCH SERVICES ALONG THE CONTINUUM OF CARE BY MOTHERS’ EDUCATION LEVEL, INDONESIA

(2007/10/12), LAO PDR (2011/12) AND THE PHILIPPINES (2008) ........................................................................ 16 FIGURE 6: COVERAGE OF MNCH SERVICES ALONG THE CONTINUUM OF CARE BY WEALTH QUINTILE, INDONESIA (2007/10), LAO PDR

(2011/12) AND THE PHILIPPINES (2008) ............................................................................................................. 16 FIGURE 7: COVERAGE OF MNCH SERVICES ALONG THE CONTINUUM OF CARE BY RESIDENCE, INDONESIA (2007/10/12), LAO PDR

(2011/12) AND THE PHILIPPINES (2008) ............................................................................................................. 17 FIGURE 8: QUALITY OF CARE INDICATORS BY EDUCATION LEVEL, INDONESIA (2007), LAO PDR (2011/12) AND THE PHILIPPINES

(2008), (%) .................................................................................................................................................... 21 FIGURE 9: NEONATAL MORTALITY BY WEALTH QUINTILE, INDONESIA (2007), LAO PDR (2011/12) AND THE PHILIPPINES (2008) . 32 FIGURE 10: NEONATAL AND UNDER-FIVE MORTALITY BY RESIDENCE, INDONESIA (2007), LAO PDR (2011/12) AND THE PHILIPPINES

(2008) ........................................................................................................................................................... 33 FIGURE 11: PERCENTAGE OF SKILLED BIRTH ATTENDANCE AND FACILITY-BASED DELIVERIES BY RESIDENCE, INDONESIA (2012) LAO PDR

(2011/12) AND THE PHILIPPINES (2008) ............................................................................................................. 34 FIGURE 12: PERCENTAGE OF DELIVERIES BY CAESAREAN SECTION BY WEALTH QUINTILE, INDONESIA (2007), LAO PDR (2011/12)

AND THE PHILIPPINES (2008) .............................................................................................................................. 35 FIGURE 13: PERCENTAGE OF EARLY INITIATION OF BREASTFEEDING BY RESIDENCE, INDONESIA (2007), LAO PDR (2011/12) AND THE

PHILIPPINES (2008) .......................................................................................................................................... 36 FIGURE 14: PERCENTAGE OF NEWBORN WEIGHT MEASURED AT BIRTH BY MOTHER'S EDUCATION, INDONESIA (2007), LAO PDR

(2011/12) AND THE PHILIPPINES (2008) ............................................................................................................. 36 FIGURE 15: PERCENTAGE OF BCG VACCINATION COVERAGE BY WEALTH QUINTILE, INDONESIA (2007), LAO PDR (2011/12) AND THE

PHILIPPINES (2008) .......................................................................................................................................... 37


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LIST OF TABLES

TABLE 1: COUNTRY POPULATION DATA (NUMBERS AND %), INDONESIA, LAO PDR AND THE PHILIPPINES (2010 OR LATER) ............. 3 TABLE 2: COUNTRY INCOME DATA (USD AND %), INDONESIA, LAO PDR AND THE PHILIPPINES (2010 OR LATER) .......................... 4 TABLE 3: EARLY CHILDHOOD MORTALITY (PER 1,000 LIVE BIRTHS), INDONESIA (2007/12), LAO PDR (2011/12) AND THE

PHILIPPINES (2008) ............................................................................................................................................ 6 TABLE 4: MATERNAL MORTALITY (PER 100,000 LIVE BIRTHS), INDONESIA (2007), LAO PDR (2011/12) AND THE PHILIPPINES

(2008) ............................................................................................................................................................. 8 TABLE 5: MAIN CAUSES OF NEONATAL MORTALITY, %, INDONESIA, LAO PDR AND THE PHILIPPINES (2010) ................................. 8 TABLE 6: COVERAGE OF SERVICES LINKED WITH THE QUALITY OF MATERNAL AND NEWBORN CARE, INDONESIA (2007), LAO PDR

(2011/12) AND THE PHILIPPINES (2008), (%) ...................................................................................................... 20 TABLE 7: EMERGENCY OBSTETRIC AND NEWBORN CARE, INDONESIA, 2011 ........................................................................... 22 TABLE 8: PERCENTAGE OF FACILITIES THAT PERFORMED EACH SIGNAL FUNCTION, BY TYPE OF FACILITY, LAO PDR, 2008 AND 2011 (%)

...................................................................................................................................................................... 23 TABLE 9: ESTIMATED NUMBER OF PHYSICIANS, MIDWIVES AND NURSES, INDONESIA, 2006 AND 2007 ....................................... 24 TABLE 10: AVAILABLE HEALTH STAFF, LAO PDR, 2011 ..................................................................................................... 24 TABLE 11: HEALTH WORKERS DISTRIBUTION, THE PHILIPPINES ............................................................................................ 24 TABLE 12: HEALTH FINANCING, INDONESIA, LAO PDR AND PHILIPPINES, 2010 ..................................................................... 26 TABLE 13: AVAILABILITY OF ESSENTIAL DRUGS AND BEMOC EQUIPMENT IN PHC CENTRES, INDONESIA, 2011 ............................ 28 TABLE 14: STOCK-OUT STATUS OF ESSENTIAL DRUGS AND COMMODITIES IN HOSPITALS AND HEALTH CENTRES, LAO PDR, 2011 ..... 29 TABLE 15: AVAILABILITY OF DRUGS FOR EMOC SERVICES BY HOSPITAL LEVEL, LAO PDR, 2011 (%) ........................................... 29 TABLE 16: AVAILABILITY OF EQUIPMENT AND SUPPLIES FOR EMOC SERVICES BY HOSPITAL LEVEL, LAO PDR, 2011 (%) ................. 29 TABLE 17: SWOT ANALYSIS OF NEWBORN HEALTH POLICIES .............................................................................................. 39 TABLE 18: SWOT ANALYSIS OF HEALTH SERVICE DELIVERY FOR NEWBORNS ........................................................................... 39 TABLE 19: SWOT ANALYSIS OF HUMAN RESOURCES FOR NEWBORNS ................................................................................... 40 TABLE 20: SWOT ANALYSIS OF HEALTH FINANCING FOR NEWBORNS .................................................................................... 40 TABLE 21: SWOT ANALYSIS OF ESSENTIAL DRUGS AND COMMODITIES FOR NEWBORNS ........................................................... 41 TABLE 22: SWOT ANALYSIS OF HEALTH INFORMATION SYSTEM FOR NEWBORNS .................................................................... 42 TABLE 23: SWOT ANALYSIS OF LEADERSHIP AND GOVERNANCE FOR NEWBORNS .................................................................... 42 TABLE 24: SWOT ANALYSIS OF NEWBORN CARE .............................................................................................................. 43 TABLE 25: EARLY CHILDHOOD MORTALITY, BY SOCIO-ECONOMIC AND DEMOGRAPHIC BACKGROUND, INDONESIA (2007/12)

1, LAO

PDR (2011/12) AND THE PHILIPPINES (2008), (%) ................................................................................................. 1 TABLE 26: COVERAGE OF MNCH SERVICES, BY SOCIO-ECONOMIC AND DEMOGRAPHIC BACKGROUND, INDONESIA (2007/10/12)

1,

LAO PDR (2011/12) AND THE PHILIPPINES (2008), (%) ........................................................................................... 2 TABLE 27: BENCHMARKING STATUS FOR AGENDA SETTING, SELECTED COUNTRIES ..................................................................... 6 TABLE 28: BENCHMARKING STATUS FOR POLICY FORMULATION, SELECTED COUNTRIES .............................................................. 7 TABLE 29: BENCHMARKING STATUS FOR POLICY IMPLEMENTATION, SELECTED COUNTRIES .......................................................... 8 TABLE 30: INTERNATIONAL RECOMMENDATIONS FOR ROUTINE NEWBORN POSTPARTUM CARE AND INTERVENTIONS (WHO 2006,

WHO 2009, WHO 2010B) ................................................................................................................................ 9


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LIST OF ABBREVIATIONS AND ACRONYMS

ANC Antenatal care

ARI Acute respiratory infections

AusAID Australian Agency for International Development

BCG Bacillus Calmette-Guérin (tuberculosis vaccine)

BEmOC Basic emergency obstetric care

BF Breastfeeding

CEmOC Comprehensive emergency obstetric care

CIA Central Intelligence Agency

CIDA Canadian International Development Agency

CS Caesarean section

CSO Civil society organisation

DHS Demographic and Health Survey

DoH Department of Health

DTP Diphtheria, tetanus, pertussis vaccination

EAPRO East Asian and Pacific Regional Office (UNICEF)

EMAS Expanding maternal and neonatal survival

EmOC Emergency obstetric care

FBD Facility based delivery

FHS Family Health Survey

FP Family planning

GDP Gross domestic product

GHO Global Health Observatory

GNI Gross national income

HMIS Health management information system

HR Human resources

IDHS Indonesia Demographic and Health Survey

IMCI Integrated management of childhood illnesses

LBW Low birth weight

LGU Local Government Unit (Philippines)

LSIS Lao Social Indicator Survey

MDG Millennium development goal

MMR Maternal mortality rate

MNCH Maternal newborn and child health

MNH Maternal and newborn health

MoH Ministry of health

MoRES Monitoring results for equity systems

NA Not applicable

n.a. Not available

NGO Non-governmental organisation

NHIS National health information system

NMR Neonatal mortality rate

PDHS Philippines demographic and Health Survey


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PHC Primary healthcare

PMR Perinatal mortality rate

PMTCT Prevention of mother-to-child transmission

Puskesmas Primary healthcare centre at sub-district level

Jamkesmas Jaminam Kesehatan Masyarakat - Health insurance for the poor from

national budget

Jampersal Jaminan Persalinan - Health insurance for maternity and newborn care

from national budget

PDR People's Democratic Republic (Lao PDR)

PPC Postpartum care

PPP Purchasing power parity

SBA Skilled birth attendants

SWOT Strengths, weaknesses, opportunities, threats (evaluation tool)

TBA Traditional birth attendant

U5MR Under-5 mortality rate

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

UNICEF EAPRO UNICEF East Asia and Pacific Regional Office

US United States

USAID United States Agency for International Development

USD US dollar

WHO World Health Organisation

WQ Wealth quintile


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EXECUTIVE SUMMARY

Worldwide neonatal mortality (deaths of infants less than 28 days of age) has declined from 33.2 deaths per 1,000 live births in 1990 to 23.9 per 1,000 live births in 2009 (Oestergaard et al. 2011). However this decline is slower than the under-five mortality decline for the same period (Liu et al. 2012). Between 1990 and 2009 neonatal mortality declined globally on average 1.7% per year while under-five mortality declined 2.1% per year (Oestergaard et al. 2011, You et al. 2010). As a result the proportion of child deaths due to neonatal mortality increased in all regions of the world from 38.2% globally (3.681 million) in 2000 to 40.3% (3.072 million) in 2010 (Liu et al. 2012). These findings urge the need for focus on newborn health as newborns are the age category lagging behind in improved child health outcomes. This assignment on behalf of and funded by UNICEF EAPRO (UNICEF East Asia and Pacific Regional Office) answers this need for focus on newborn health. Its main objective is to conduct a comprehensive, equity-focussed needs assessment for country-specific newborn care programming in three selected countries in the East Asian and Pacific region: Indonesia, Lao People's Democratic Republic and the Philippines. The findings of the three country assessments have been compared and summarised in this report which highlights overlapping issues and opportunities. The consultancy teams used the same stepwise approach in the three countries, whereby the situation analysis of newborn care was reflected upon at national level. The tools used for the newborn needs assessment are all described in the work plan of October 2012. Newborns’ health status The neonatal mortality rate (NMR) in Lao PDR (32 per 1,000 live births in 2011/12) is twice as high as in the Philippines (16 per 1,000 live births in 2008), with the NMR in Indonesia close to the latter (19 per 1,000 live births in 2012). Over the period 1990-2010, a significant decline in the under-five mortality rate (U5MR) of around 3.5% annually has been observed in the three countries (Lozano et al. 2011). In the East Asian and Pacific region the decrease of newborn mortality is lagging behind compared with the decline of under-five and infant mortality in the same period. As a result, newborn mortality gradually takes a larger proportion of the overall under-five mortality. All categories of early childhood show a clear tendency towards higher mortality rates for groups with deprived socio-economic and demographic characteristics. Higher mortality rates are found in the lowest wealth quintiles, among the less educated women and among rural residents. The main causes of neonatal deaths in the three selected assessment countries are preterm birth complications, intra-partum related events (e.g. birth asphyxia), and infections such as sepsis, tetanus, meningitis. Health seeking behaviour is influenced by local practices during pregnancy and after childbirth, especially in Indonesia and Lao PDR. Traditional birth attendants have still an important position in providing maternal and newborn care especially in rural areas. Policy context for newborn care Maternal and child health policy strategies exist in the three assessment countries and include specific newborn-related policy recommendations which are in line with international guidelines and standards. Measures to reduce inequities in access and coverage of maternal and neonatal care services have been addressed in the national policies. Although newborn policies are available, the implementation of these policies, primarily the responsibility of the decentralised administrative levels, remains challenging in the three countries.


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Health system context for newborn care Newborn health can only be delivered through a well-functioning health system. Looking at the six main health system building blocks, being (1) service delivery, (2) human resources, (3) essential medicine and technologies, (4) health financing, (5) health information systems, and (6) governance of the health sector, strengths and weaknesses in the system that directly or indirectly affect newborn care were identified. In Indonesia and the Philippines the private sector is increasingly important in the provision of healthcare although coordination and regulation of the private sector by the government is weak. The three countries have a decentralised health system with different roles and responsibilities regarding healthcare delivery at the different administrative levels (province, district, municipality). Newborn service provision covers all levels of care from primary healthcare provided at community level up to specialised care provided in referral health facilities. Along the continuum of care the coverage rates for selected maternal and newborn services show the same patterns for the three countries with clients going in (e.g. for antenatal care visits and BCG vaccination after birth) and out (e.g. initiation of breastfeeding) of the health system depending on the services provided. Coverage rates of Lao PDR are nevertheless considerably lower compared with the two other countries. Despite the availability of health facilities providing high quality of essential newborn care, overall the quality of newborn care was recognised as a major concern since not all maternal and newborn services are performed adequately in the assessed countries. Limited knowledge and skills on newborn care of all level health workers was identified as an important reason for this poor quality. In the context of quality of care we found that supervision and mentoring (quality control) of health staff was rather poorly implemented in the three countries. Access to care remains challenging in remote and difficult to reach areas. Strategies to overcome the gaps in geographic accessibility are implemented in the three countries and have led to improved access to care although gaps in accessibility remain. In Indonesia and the Philippines there are enough midwives, nurses and medical doctors available though the unequal distribution of these health providers disadvantages the difficult to reach areas. Staff retention in these areas was also identified to be challenging. Apart from the unequal distribution and retention problems, overall workforce shortage is another problem in Lao PDR. Equitable access to newborn care is an issue. Most newborn services and care coverage declines with lower mothers’ education and wealth level, is lower in rural areas compared to urban areas and can differ significantly between regions/provinces. National tax based health insurance schemes covering maternal and newborn care for all or for part of its population are in place in Indonesia and in the Philippines. In Lao PDR the government has recently agreed on the policy for free delivery and free healthcare for children under 5 years old. However an exact roll-out plan and the required budget are not yet available. Stock-outs of drugs and commodities needed for essential newborn care and emergency obstetric services were found to be common in the three assessed countries. There is a need to rationalise and improve drugs procurement and management. Similar challenges and problems regarding health information are present in the assessed countries. A national health information system collecting data on maternal and newborn health is in place, but management of the system seems to be challenging leading to incomplete and/or poor quality of the data. Additionally data from the private health sector is not (yet) included.


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Following the health sector decentralisation, roles and responsibilities of the different levels of the health sector administration remain unclear. Due to the distribution of responsibilities for different components of newborn health over multiple departments, and the weak interdepartmental coordination and collaboration, successful implementation of the MNCH strategies is challenging. Conclusions: main findings and recommendations The main findings related to newborn care in the three countries are: (1) insufficient progress has been made in reducing newborn mortality, (2) comprehensive newborn policies in line with international standards exist although the implementation of these policies is poor, (3) quality of newborn care is generally substandard, (4) limited access to skilled health providers mainly in rural and remote areas, (5) decentralisation of the health system brought opportunities and threats. An important opportunity is the possibility to tailor healthcare to the local context and needs, but a main threat is the often weak management encountered at provincial and district level, (6) fragmentation of newborn care across several MoH departments hampers prioritisation and efficient coordination and implementation of newborn care, (7) socio-economic and demographic inequities in maternal and newborn care are considerable, and (8) lack of regulation of and cooperation with the private sector in Indonesia and the Philippines. Based on the assessment findings main recommendations to improve newborn care and health include: (1) Improve governance and leadership to enhance implementation of newborn policies among

others through: (a) defining clear responsibilities and roles of authority for all departments and all administrative, (b) implementing measures to reduce the fragmentation in several departments and units, (c) improving management skills and capacity at provincial, district and municipality level by a system of learning from ‘model’ districts, (d) for Indonesia and the Philippines cooperating with and regulation of the private sector.

(2) Improve access to newborn care and services in remote and difficult to reach areas among others through: (a) facilitating staff retention, (b) using task shifting, (c) increasing number of health providers based at community level, (d) ensuring sufficient availability of ambulances and other transport means (e.g. boats in Indonesia and the Philippines) for referral, and (e) establishing maternity waiting homes.

(3) Increase the number of deliveries by skilled birth attendants and at health facilities among others through: all the recommendations mentioned under (2) and improving the availability of facilities providing good quality of EmOC.

(4) Improve quality of newborn care among others through: (a) a system of learning from ‘model’ health facilities/ centres of excellence, (b) strengthening supporting supervision/mentoring, (c) guaranteeing quality of pre- and in-service training on newborn care for all level health workers, (d) cooperation with professional associations, (e) establishing and/or strengthening neonatal and perinatal death audits, (f) upgrading knowledge of health workers on when and where to refer newborns, and improving procurement of drugs and commodities.

(5) Minimize socio-economic inequities in newborn health among others through: (a) ensuring in Lao PDR commitment of the government to guarantee availability of funds to roll out the free delivery and free under-five health services, (b) covering of transport costs for poor and for people living in remote areas by the health insurance in Indonesia and the Philippines, and (c) focussing on intervention reaching urban poor in Indonesia.

(6) Finally, increase demand for newborn care among others through: (a) continuous health promotion and (b) providing context-specific health education and information in case local beliefs and practices hampering access to newborn care.


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1 INTRODUCTION

The main objective of this assignment is to conduct a comprehensive, equity-focussed needs assessment for country-specific newborn care programming in three selected countries in the East Asian and Pacific region: Indonesia, Lao People's Democratic Republic and the Philippines. The findings of the three country assessments have been compared and summarised in this report which highlights overlapping issues and opportunities. This cross-country report reflects on the main findings, conclusions and recommendations of newborn care in the three countries assessed.

The three country studies, which were conducted at the end of 2012, contribute to the identification of gaps in newborn care programming at both policy and implementation level and help to assess family and community practices that influence maternal and newborn survival in Indonesia, Lao People's Democratic Republic (PDR) and the Philippines. The continuum of care approach and a strong focus on equity have been taken into account in the country assessments. Findings will contribute to develop country level strategies, country and regional work plans and partnerships for accelerating momentum towards reduction of neonatal mortality and morbidity. This cross-country report provides a comparative analysis of newborn care in the three study countries covered by the regional office of UNICEF in East Asia and the Pacific (EAPRO). The consultancy teams used the same stepwise approach in the three countries, whereby the situation analysis of newborn care was reflected upon at national level. The tools used for the newborn needs assessment are all described in the work plan of October 2012.

A newborn infant, or neonate, is a child under 28 days of age1 . Postpartum care covers all care and services offered to mothers and newborns up to 6-8 weeks after childbirth (WHO 2010b).

The country’s in-depth and comprehensive situation analysis included a critical review of maternal and newborn healthcare policies and programmes in the country and related documentation, as well as a country visit to get an understanding of the successes and challenges in programme implementation. During the country visits the findings of the situation analysis and the country’s readiness for scaling up newborn care were (further) explored through face-to-face interviews with key informants at different levels of the healthcare system, and with stakeholders from supporting organisations or agencies. In addition to meetings in the capital, a short field visit to health facilities was made in all three countries. With the information gathered a "strengths, weaknesses, opportunities, threats" (SWOT) analysis was conducted to evaluate the current newborn care situation. The Save the Children benchmarking tool was used for mapping the country's readiness for scaling up newborn care (Moran et al. 2012). During the whole assessment special attention was given to identify drivers for inequities in newborn health. The selected periods for the country visits (November-December 2012) were less opportune for the UNICEF country offices since these were eventful periods for the Ministry of Health officials, UNICEF staff and development partners. In Indonesia e.g. the H4+2 meeting planned during the country visit was cancelled due to conflicting agendas of its members, but ultimately individual meetings with most of the H4+ members were conducted during the visit. In the Philippines there were several overlapping meetings about mother and child health (e.g. guideline development meeting, programme implementation meeting) within the same timeframe of the country visit, which made

1 http://www.who.int/topics/infant_newborn/en/. 2 H4+ members in Indonesia are: UNFPA, UNICEF, WHO, UNAIDS and the World Bank.


2

contacting stakeholders and planning appointments challenging. But after all the agenda allowed to meet and interact with sufficient stakeholders and to collect relevant background documents for an evidence-based analysis. In none of the countries it was possible to carry out the planned workshop to discuss the preliminary findings and recommendations with key stakeholders, mainly due to time constraints and organisational issues. The findings of this report are based on publicly available data, which were not all from recent date. For the equity analysis, we used the recently published social indicator survey data of Lao PDR while for Indonesia and the Philippines we had to rely on older demographic and health survey data published in respectively 20073 and 2008. Furthermore, we noticed that, depending on the source, data could be different, although these differences were mostly not substantial.

3 When available data from the Demographic and Health Survey 2012 – Preliminary Report is used, otherwise

data from the Demographic and Health Survey 2007.


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COUNTRY PROFILES

General context

To better understand the similarities and differences between the three countries assessed with regards to newborn care, we briefly present their population characteristics (see table 1). While the Lao People's Democratic Republic is a landlocked mountainous country with a population of 6.4 million, the Republic of the Philippines comprises of 7,107 islands with an estimated population at 92.4 million and the Republic of Indonesia is the world’s largest archipelago and fourth most populous country, having about 248.6 million people unevenly scattered across one third of its 17,500 islands. In 2012 the annual population growth rate was lowest in Indonesia with 1.03%, followed by Lao PDR with 1.65%. In the Philippines the annual population growth was on average 1.9% for the period 2000-2010, being the slowest growth in the Philippines since 1960, reflecting a decreasing fertility rate.

Table 1: Country population data (numbers and %), Indonesia, Lao PDR and the Philippines (2010 or later)

Indonesia1 Lao PDR

2 Philippines

3

Estimated population 248.6 million 6.4 million 92.4 million Annual population growth rate Percentage living in rural areas

Annual urbanisation rate

1.03% (2012) 56%

1.7% (2010-2015)

1.65% (2012) 67%

4.9%

1.90% (2000-2010) 49%

2.3% (2012) Life expectancy 71.6 years 62.8 years 71.9 years Sources: 1 CIA, The World Factbook: Indonesia (www.cia.gov/library/publications/the-world-factbook/geos/id.html).

2 Lao Statistics Bureau (www.nsc.gov.la). CIA, The World Factbook: Lao PDR

(www.cia.gov/library/publications/the-world-factbook/geos/la.html). LSIS 2011/12. 3 WHO Country Health Information Profiles, The Philippines, 2011.

About 67% of the population in Lao PDR lives in rural areas though there has been a substantial movement from rural to urban areas across all provinces with an estimated urbanisation rate of 4.9%. The Philippines is also a rapidly urbanizing country, with an annual urbanization rate of 2.3% while still 49% of the population is living in rural areas. In Indonesia 44% of the population is living in urban areas with an estimated annual urbanization rate of 1.7% in the period 2010-2015. The Lao PDR population is made up of 49 officially recognised ethnic groups which can be categorised broadly in four ethno-linguistic groups (Lao-Tai, Mon-Khmer, Hmong-Mien and Chinese-Tibetan). The Filipino population is made up of 180 different ethnic groups with the three largest groups (Tagalog, Cebuano and the Ilocano) accounting for 50% of the population. In Indonesia the largest ethnic groups are the Javanese and Sundanese, together accounting for more than 50% of the population. Life expectancy at birth for the total population is the same in Indonesia (71.6 years) and the Philippines (71.9 years) but considerably lower in Lao PDR with 63 years of age. Indonesia, Lao PDR and the Philippines are lower-middle income countries with Indonesia and the Philippines having a more similar economic profile with their per capita gross national income (around 4,000 USD) and the proportion of their population living under the poverty line of 1 USD per day falling within the same range (see table 2).

http://www.cia.gov/library/publications/the-world-factbook/geos/id.html


4

Table 2: Country income data (USD and %), Indonesia, Lao PDR and the Philippines (2010 or later)

Indonesia Lao PDR Philippines Per capita gross national income (PPP int. USD

1)

Annual economic growth

4,200 USD

6.4% (2011)2

2,440 USD

8% (2011)3

3,980 USD

7.6% (2010)4

3.9% (2011)4

Population living on <1 USD a day 18.1% 33.9% (2008) 18.4% (2009) Sources: WHO Global Health Observatory (available from: apps.who.int/gho/data/#). Notes: 2010 data has been used, unless otherwise stated. 1 The gross national income (GNI) is converted to international dollars using purchasing power parity (PPP)

rates. An international dollar has the same purchasing power over GNI as a US dollar has in the United States. 2 data.worldbank.org/country/indonesia [accessed online].

3 Department of Economic Statistics, Lao Statistics Bureau, MPI. See also: www.nsc.gov.la. [accessed online].

4 www.cia.gov/library/publications/the-world-factbook/geos/la.html [accessed online].

In latest years economic growth in the three countries was high, ranging from 4 to 8%. In Lao PDR the firm economic growth is fully driven by foreign direct investments in natural resource extraction industries and hydro-electric power. Despite the firm economic growth in Lao PDR in the recent years the proportion of the population living under the poverty line of 1 USD per day was 33.9% (2008). In spite of natural and man-made disasters, and regardless of the global financial crisis, the Philippine economy has also experienced significant growth over the last decade, although recently slowing down to an estimated 3-4% annual growth rate. The Philippines managed to withstand the recession better than many other countries in the region due to minimal exposure to international security issues, lower dependence on export, and large and continuously growing remittance from the large group of Filipinos working overseas, which accounts for up to 10% of the country’s gross domestic product. In 1997 and 1998, Indonesia went through its worst economic crisis since its independence in 1945, causing a negative economic growth of 13%. Since 2000, the economy has been growing again and in 2011 the annual economic growth was estimated at 6.5%.

Health sector

As one of the major health sector reforms in the past 30 years, the Philippine healthcare system was devolved, as mandated by the Local Government Code of 1991 (Republic Act 7160). The devolution transferred legal authority from the central government to the Local Government Units (LGUs). Provincial governments are mandated to provide secondary hospital care, while city and municipal administrations are charged with providing primary care, including maternal and child care. The Department of Health (DoH) has the responsibility to provide national policy direction and develop national plans, technical standards and guidelines on health. LGUs are granted autonomy and responsibility for their own health services, but are to receive guidance from the DoH through the Centres for Health Development. In Indonesia the health sector was decentralised in 2001 shifting the responsibility for healthcare provision largely to the regional governments. However the decision to decentralize administrative authority directly to district level created confusion regarding the roles of the different levels of administration in health development, the provincial level in particular. The lack of management capacity and skills at provincial and district level following the fast pace of the decentralisation is another challenge. Districts are given full discretion in prioritising sectors for development, however in many situations, due to lack of management skills, health problems are not always prioritised and managed in the best way. The Ministry of Health (MoH) of Lao PDR remains the main health provider in the country, very much supported technically and financially by multilateral and bilateral development agencies and


5

international non-governmental organisations. The public health system in Lao PDR has three arms focussing on (1) healthcare; (2) prevention, promotion and disease control; and (3) health management and administration. The government of Lao PDR has gradually devolved administrative authority, which according to the Law on Health Care of 2005, lies now with the provincial and district health authorities that have the right for public health facilities to implement user fees and exemptions and to nominate legitimate service charges. In the Philippines health facilities include hospitals, rural health units (at municipality level) and barangay health stations (at community level). While most hospitals are privately-owned, around 40 percent of hospitals are public hospitals. Still, there are roughly equal numbers of public and private beds (Rosell-Bial 2008, WHO 2011a). The number of government hospitals nationwide increased from 623 in 2000 to 721 in 2009. Out of these 721 public hospitals, 70 are managed by the DoH while the remaining hospitals are managed by LGUs and other national government agencies. Although the private sector is much larger than the public sector in terms of human, financial and technological resources, it caters to only 30% of the population (WHO 2011a). At present more than half of the hospitals in Indonesia are private hospitals (private-for-profit and private-non-for-profit) (Ministry of Health, 2011) and an estimated 60% to 70% of health providers who are employed in the public health sector have second jobs in the private sector or operate a private practice after hours (Rokx et al. 2009). Despite the importance of the private sector, accreditation, regulation and monitoring of this sector by national and regional authorities is weak. This is also the case for the Philippines, where the DoH does not have a system for collecting data from the private sector. Compared to the public sector, the private sector in Lao PDR plays a less important (but growing) role in healthcare provision, although in urban areas provision of health services in private clinics is increasing. Low utilisation of healthcare services, shortage and unequal distribution of health staff as well as availability of staff with adequate skills and motivation remain critical issues for health service provision in the three countries.

Health status of newborns and mothers

This section describes the health status of mothers and their newborns by looking into the mortality and morbidity trends and related determinants. Main data sources used in this chapter are the 2007 and 2012 Demographic and Health Survey of Indonesia4, the recently published 2011/12 Lao Social Indicator Survey 2011/12 and the 2008 National Demographic Health Survey of the Philippines, complemented with the Countdown 2012 report (WHO and UNICEF 2012) and the systematic analysis on maternal and child mortality (Lozano 2011).

1.1.1 Mortality data and trends Tables 3 and 4 present the most recent data for child and maternal mortality indicators in Indonesia, Lao PDR and the Philippines, and the respective targets, which the countries are aiming to reach by 2015. Over the period 1990-2010, a significant decline in the under-five mortality rate (U5MR) of around 3.5% annually has been observed in the three countries (Lozano et al. 2011), resulting in a "current"5 mortality rate of 34 under-five deaths per 1,000 live births in the Philippines, 40 in Indonesia and 79 in Lao PDR. The constant downward trend holds a promise for the near future that one of the main indicators for MDG4, i.e. the reduction of the under-five mortality rate by two-thirds between 1990 and 2015, will be achieved in the three countries assessed (WHO and UNICEF 2012).

4 If available data from the Demographic and Health Survey 2012 – Preliminary Report are used. If data are not

available from this report data from the Demographic and Health Survey 2007 are used. 5 The comparison is based on the latest DHS data of each country, with 4 years difference between the

Philippines (2008) and Lao PDR (2011/12) and Indonesia (2012).


6

Table 3: Early childhood mortality (per 1,000 live births), Indonesia (2007/12), Lao PDR (2011/12) and the

Philippines (2008)

Mortality1

Indonesia Lao PDR The Philippines 2007/12 2015 target 2011/12 2015 target 2008 2015 target

1. Neonatal mortality rate

19°

142 32 24 16 10

2

2. Infant mortality rate

32°

23 68 45 25 19 3. Under-five mortality rate

40°

32 79 55 34 26.7

% of newborn deaths in total under-five deaths

48% 39% 47%

4. Perinatal mortality rate

24.8*

n.a. 28.5 n.a. 27.6 192

Early neonatal mortality rate

14.4*

203 14.4

Stillbirth rate

10.4*

8.5 13.2 Sources: Indonesia:

°

DHS 2012 and *DHS 2007. Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008.

Notes: 1 Definitions used: 1. Number of deaths during the first 28 completed days of life per 1,000 live births. 2.

Number of deaths between birth and exactly one year of age per 1,000 live births. 3. Number of deaths between birth and exactly five years of age per 1,000 live births. 4. Number of stillbirths and deaths in the first week of life per 1,000 live births (= sum of early neonatal mortality rate and stillbirth rate). 2 The MDG reports of Indonesia and the Philippines do not provide a target for neonatal mortality. However, in

both countries specific targets were set by the Ministry (or Department) of Health. In Indonesia, the Child Health Unit of the Ministry of Health mentions 14 newborn deaths per 1,000 live births as target for neonatal mortality by 2015 (Pritasari 2011), while in the Philippines a target of 10 newborn deaths per 1,000 live births was set as a target for 2016 (National Objectives of Health, 2011). Similarly a target was set in the Philippines for perinatal deaths. 3 Lozano et al. 2011.

Although under-five and infant mortality rates are "on track" towards achievement of the 2015 target, caution is needed for newborn mortality, since its decrease is lagging behind compared with the decrease of under-five and infant mortality for the same period. As a result, newborn mortality gradually takes a larger proportion of the overall under-five mortality. While the neonatal mortality rate (NMR) only covers the short period of the first 28 days of a newborn, it amounts to 39%-48% of the under-five mortality rate; a proportion that is observed worldwide6 . The neonatal mortality rate of Lao PDR (32 per 1,000 live births in 2011/12) is twice as high as in the Philippines (16 per 1,000 live births in 2008), with the NMR of Indonesia close to the latter (19 per 1,000 live births in 2012). Most recent data indicates that the three countries are likely to achieve the 2015 target for newborn mortality rate (see figure 1).

6 An updated systematic analysis of child mortality (Liu et al. 2012) shows that in 2010 40.3% of the 7.6 million

children who died in the first 5 years of their life, occurred in newborns. The burden of mortality of under-fives was the highest in Africa with 3.6 million deaths of children younger than five (47% of total number of under-five deaths) and in South East Asia where 2.1 million children died before the age of 5 years (28% of total number of under-fives).


7

Figure 1: Trend in newborn mortality (per 1,000 live births), Indonesia, Lao PDR and the Philippines (1990-2015)

Sources: 1991 data: WHO GHO (online) & UNICEF 2012. 2011 data: Lozano 2011. MDG targets: see country reports.

The maternal mortality ratio (MMR) is 357 maternal deaths per 100,000 live births in Lao PDR and is both high compared to other countries in the region7 and compared to the country´s MDG5 target of 260 per 100,000 live births by 2015. The annual rate of decline of the MMR in the period 1990-2011 was 2.4% in Indonesia, 2.5% in Lao PDR and 3.8% in the Philippines (Lozano et al. 2011). The 2012 Countdown report states that Lao PDR is on track to achieve the MDG5 target and that Indonesia and the Philippines, with lower maternal mortality ratios than Lao PDR, are making progress towards achievement of the MDG target (WHO and UNICEF 2012). Most recent Family Health Survey data in the Philippines (with a MMR of 221) does not confirm this downward trend in maternal mortality (FHS, 2011). However, this data is still disputed. Data on maternal mortality by socio-economic and demographic characteristics are not available. Maternal and neonatal mortality have root causes in gender inequality, low access to education (especially for girls), early marriage, adolescent pregnancy, low access to sexual and reproductive health services (including for adolescents) and other social determinants. The mother's health and nutritional status influences the chances of survival, growth, and long-term health of the child. Also fertility, family planning, and maternal age are important determinants (which are discussed in the country reports) for neonatal morbidity and mortality

7 For comparison reasons the 2010 data for the maternal mortality ratio was copied from the WHO's Global

Health Observatory. The MMR of 470 maternal deaths per 100,000 live births (and a range of 260-840) in Lao PDR contrasts with those in the neighbouring countries. The respective estimates (and ranges) are: Thailand: 48 [33-70]; Vietnam: 59 [27-130]; Myanmar: 200 [120-330]; and Cambodia: 250 [160-390]. The two other countries of the newborn care assessment also have lower maternal mortality ratios: Indonesia: 220 [130-350] and the Philippines: 99 [66-140].

29

17

14

38

27

24

22

12

10

0 5 10 15 20 25 30 35 40

1990

2011

MDG Target

1990

2011

MDG Target

1990

2011

MDG TargetIn

do

ne

sia

Lao

PD

RP

hili

pp

ine

s


8

Table 4: Maternal mortality (per 100,000 live births), Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008)

Mortality

Indonesia Lao PDR The Philippines 2007 2015 target 2011/12 2015 target 2008 2015 target

Maternal mortality ratio

1 228 102 357 260 (162)2 52.3

Sources: Indonesia: DHS 2007. Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008.

Notes: 1 Definition used: Number of women who die while pregnant or within 42 days of termination of pregnancy,

irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes, per 100,000 live births. 2 Data obtained from 2006 Family Planning Survey.

1.1.2 Causes of maternal and neonatal mortality and morbidity Regional data from the 2012 Countdown report shows that haemorrhage (32% of all maternal deaths), indirect causes (22%) and hypertension (17%) were the main causes of maternal deaths in South East Asia in the period 1997-20078. Together these causes account for 80% of maternal deaths. Easy access to good quality antenatal, emergency obstetric and postpartum care is crucial for the management of these complications. In 2010 preterm birth complications, intrapartum-related complications (e.g. birth asphyxia) and infections such as sepsis, tetanus or meningitis were globally the leading causes of neonatal deaths (Liu et al. 2012). Country data from the 2012 Countdown report shows that the main causes of neonatal death in the three countries under study are similar to those observed globally.

Table 5: Main causes of neonatal mortality, %, Indonesia, Lao PDR and the Philippines (2010)

Preterm birth complications

Intrapartum-related

complications

Infections (sepsis, tetanus,

meningitis)

Cumulative % of leading mortality

causes Globally 14.1 9.4 5.2 28.7 Indonesia 45 21 11 77 Lao PDR 44 26 15 85 The Philippines 19 12 6 37 Source: WHO and UNICEF (2012) Countdown to 2015 Maternal, Newborn & Child Survival, The 2012 Report. Table 5 shows that these causes together account for the majority of all newborn deaths in Indonesia and Lao PDR, while in the Philippines more than 60% of the newborn deaths are due to other causes. This divergence may partially be explained by differences in newborn mortality registration. Weight at birth is a good indication not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. It is generally known that individuals with low birth weights (LBW) have higher risk of dying during infancy and early childhood (Kuzawa and Eisenberg 2012). The DHS 2007 data of Indonesia indicates that 6.7% of the newborns had a birth weight of less than 2.5 kg and are as such classified as having LBW (Statistics Indonesia and Macro International 2008)9. In Lao PDR 14.8% of children (Ministry of

8 In Indonesia hypertensive disorder is according to the 2010 population census the main cause of maternal

mortality and also postpartum haemorrhage remains with 20% an important cause of maternal mortality. Based on data from accredited hospitals in the Philippines nationwide (USAID, 2004), the major causes of maternal deaths include haemorrhage (34%), hypertensive diseases (25%), and infection (10%). 9 Recent data indicates that Indonesia has one of the highest rates of preterm birth rates worldwide with a

preterm birth rate of 15.5% (data for 2010), meaning that 15.5% of all children were born before 37 weeks of gestation (Blencowe et al. 2012).


9

Health of Lao PDR and Lao Statistics Bureau 2012) are born at a low birth weight, or a weight of less than 2.5 kg. Various sources of information estimate the proportion of LBW in the Philippines between 11 and 47%; the PDHS 2008 reports a LBW of 20%. It is unclear whether LBW is caused by prematurity or by infants that are small for gestational age, as the gestational age is not reported and also often not known). Deaths from preterm birth complications can be reduced by more than three-quarters, even without the availability of neonatal intensive care but only by ensuring at primary healthcare level the availability of health professionals skilled in the care of premature babies and the improved supplies of life-saving commodities and equipment (March of Dimes et al. 2012). Preterm birth occurs for a variety of reasons. Despite the availability of studies on these reasons and prevention of preterm birth (March of Dimes et al 2012, Rours 2010, Sebayang et al. 2012, Sungkar et al. 2012) more research is needed to have a better understanding of this condition. Moreover, better reporting on preterm and stillbirths is also a precondition to improve the understanding. Neonatal tetanus is still present in Indonesia, with 147 cases reported for the whole of Indonesia of which 57% newborns died. In the Philippines, neonatal tetanus is not a common cause of death. The mortality rate due to neonatal tetanus is 0.08 per 1000 live births (Department of Health Republic of the Philippines et al. 2011b). Tetanus toxoid (TT) vaccinations are provided to women of childbearing age, so that they are immune against neonatal tetanus to any child born to her. Lao PDR has set the target of maternal and neonatal tetanus elimination by 2012 and following a successful pre-validation mission by WHO-UNICEF in January 2013 will request WHO and UNICEF to conduct the validation. Neonatal death audits have poorly been performed in Indonesia and not at all in Lao PDR or the Philippines. The regular audit of these deaths could provide important information towards a better understanding of the causes behind neonatal deaths.

1.1.3 Health seeking behaviour and local practices Health seeking behaviour is influenced by local practices during pregnancy and after childbirth, especially in Indonesia and Lao PDR. For example in some communities in Indonesia the mother and baby are not allowed to leave the home during the first 40 days after childbirth (Sondakh et al. 2011), while in certain communities in Lao PDR, women assisted during childbirth by their husbands, do not leave the hut until after a 5-day trial period (Lamxay et al. 2011). Other examples are the crucial role of the family for support and advice regarding maternal and newborn care, food habits and use of traditional medicines and herbs in connection with reproductive health (Krier 2011, Wulandari and Klinken Whelan 2011, Lamxay et al. 2011, de Boer et al. 2011). Another practice often mentioned in the Indonesian and Lao context is the use of hot beds and steam saunas after childbirth. Non-compliance of this "mother roasting" is believed to lead to maternal or neonatal death, lactation problems or diseases such as diarrhoea. Mother roasting is mainly done to ‘dry out’, cease expulsion of lochia, restore the uterus to its pre-pregnancy condition and to alleviate postpartum abdominal pain. It is also seen as an opportunity to rest, as it is being practiced for a period of two weeks on average. The roasting practice on hot charcoal embers includes the use of plants and herbs, which are believed to have beneficial antimicrobial, analgesic or anticoagulant properties (de Boer et al. 2011). Evidence of potential negative effects of this practice on the mother was not found. The impact of this practice on the health of the newborn, e.g. on acute respiratory infections (ARI) and pneumonia occurrence, is unclear. The literature reported an increase in ARI and pneumonia in children under-five living in homes where an open fire is used for cooking (Smith et al. 2011, Dhimal et al. 2010), but no research or literature could be found on the effect of short period exposure to indoor smoke on the occurrence of ARI and pneumonia among newborns.


10

Understanding the complexities of the above local practices, beliefs and myths is the first step to improving awareness of how to preserve maternal and newborn health and prevent complications. Despite the impact of these beliefs and practices on health seeking behaviour a study conducted in West Java province found that the main reasons among women for not using antenatal, delivery and postpartum services were economic and geographic barriers (Titaley et al. 2010).


11

POLICY CONTEXT FOR NEWBORN CARE

Focus on mothers and their infants has increased significantly with the Millennium Declaration and the related Millennium Development Goals in 2000 and resulted in national policies and strategies specifically addressing issues such as high under-five and maternal mortality. Building further on existing health policies and plans, Indonesia, Lao PDR and the Philippines have each recently prepared a strategy with a specific focus on maternal, newborn and child health, primarily to reach the Millennium Development Goal (MDG) targets for health, with special attention to MDG 4 (reduce child mortality) and 5 (improve maternal health):

In Indonesia the Health Strategic Plan 2010-2014 includes a chapter on Nutrition and Mother and Child Health, with the main objective being the quality improvement of maternal, child and reproductive health services;

In Lao PDR the Strategy and Planning Framework for the Integrated Package of Maternal, Neonatal and Child Health Services 2009-2015, mostly referred to as the Pink Book, aims to provide a "unified strategy and planning framework, to guide stakeholders in designing, implementing and evaluating maternal, neonatal, child health, immunisation and nutrition programmes under stronger government leadership"; and

In the Philippines the Administrative Order 2008-0029 on Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality provides the strategy for rapidly reducing maternal and neonatal deaths through a package of maternal, newborn, child health and nutrition services.

The above strategies incorporate the continuum of care for maternal, newborn and child health (starting with the non-pregnancy-related reproductive health issues, from antenatal care, childbirth delivery and newborn care to postnatal care and child healthcare) and include specific newborn-related policy recommendations in line with international guidelines and standards. According to WHO recommendations (WHO 2006, WHO 2009, WHO 2010b) three routine visits are to be scheduled for the newborn in the postpartum period: immediate after childbirth (first 24 hours), early visit (48 hours) and late visit (6 weeks). The selected countries have each modified these recommendations to their local context. In the Pink Book of Lao PDR an essential MNCH package has been defined which advocates for a first postnatal visit at 48-72 hours of life, a second postnatal visit at 7 days of life and an immunisation visit at 6 weeks of life. In the "Essential newborn care" pocket book in Indonesia three newborn visits are proposed: visit 1 scheduled at 6 to 48 hours postpartum, visit 2 at 3‐7 days postpartum and visit 3 at 8‐28 days postpartum. In the Philippines, two post-partum visits are recommended; the first follow-up visit within the first 2-3 days and the second visit on the 7th day (see figure 2).

Figure 2: Recommended newborn postpartum care visits

First week 4th week

6th week

1st day

2nd day

3rd day

4th day

5th day

6th day

7th day

...- 42 days

WHO recommended visits

Visit 1 Visit 2

Visit 3

Indonesia Visit 1 Visit 2 Visit 3

Lao PDR Visit 1 Visit 2 Visit 3

The Philippines Visit 2 Visit 2

Measures to reduce inequities in access and coverage of maternal and neonatal care services have been addressed in the national policies. In Indonesia, one of the objectives of the MoH Strategic Plan aims to reduce the disparity in health and nutritional status between regions and between socio-


12

economic level and gender by 2014 with 50% compared to 2009. The decentralisation reforms and the tax-based health insurance schemes covering maternal and newborn care for the whole population cover pro-poor support. The Decree on free maternal and services for under-five children in Lao PDR offers opportunities for improving access to maternal and newborn services, which are often hampered by financial barriers. Universal Health Care for all Filipinos is the main target of the Aquino Health Agenda. Apart from income and wealth, other socio-economic and demographic characteristics such as mother's education, place of residence (urban/rural), region and ethnic group, influence equity. The fact that the maternal, newborn and child strategies focus strongly on mothers involves a gender-sensitive approach. The formulation of the newborn policy requires further steps and actions for implementation. In the Philippines a Manual of Operations 2009 for the maternal, newborn, child health and nutrition strategy was prepared by the MNCHN Taskforce, and updated in 2011. In addition, a monitoring manual was developed in 2011 and a strategic plan is currently being developed. An annex of the Pink Book includes an implementation plan for the MNCH package in Lao PDR with expected results, outputs, responsibilities, and timeframe, but yet the strategy does not spell out specifically how the means of verification are to be monitored and evaluated and by whom. In Indonesia policies, strategies and guidelines on newborn health seem to be known among policy makers and senior health providers, but implementation of these policies, being the responsibility of the district level, remains challenging. To set, promote and monitor the agenda for newborn care and services each of the countries rely on existing convening mechanisms. The monthly meetings of the H4+ group in Indonesia serve for discussions on present and planned activities regarding maternal, newborn and child health. In Lao PDR the Technical Working Group on Maternal, Neonatal and Child Health and Nutrition holds regular meetings in order to discuss technical issues, share information, and/or monitor progress on MDGs 4 and 5 and other indicators with particular focus on MNCH and nutrition. In the Philippines the MNCHN Taskforce was established in 2009 and integrated into the Family Health Office in 2010. Although the Family Health Office has taken over responsibility, its mandate remains unclear nowadays. A focal person for newborn health has been appointed in the ministries of health of the three countries.


13

HEALTH SYSTEM CONTEXT FOR NEWBORN CARE

Quality newborn health can only be delivered through a well-functioning health system. By looking at the six building blocks of the health system from a broader perspective, one may reveal strengths and weaknesses in the system that directly or indirectly affect newborn care. This chapter identifies similarities and differences in relation to newborn health between the three study countries for each of these building blocks. These building blocks include governance of the health sector; essential medicine and technologies; human resources; health information systems; health financing, and service delivery (see figure 3) (WHO 2010a).

Figure 3: Six building blocks of the health system

Health service delivery

This section presents an assessment of access to and utilisation and quality of the maternal and newborn services and care provided at different healthcare levels in the three countries included in the study.

1.1.4 MNCH services provided before, during and after childbirth Figure 4 present recent coverage rates for selected services for mothers and newborns along the continuum of care. Based on the gaps in care and service delivery, priorities regarding the improvement of maternal, newborn and infant care can be identified. Figure 4 shows that in the three assessment countries clients go in (e.g. for antenatal care visits and BCG vaccination after birth) and out (e.g. initiation of breastfeeding) of the health system depending on the services provided. Same patterns are identified for the three countries with low coverage of institutional deliveries and breastfeeding (BF) practices and better coverage of antenatal care, BCG and DTP3 vaccination. Coverage rates of Lao PDR are nevertheless considerably lower compared with the two other countries. Striking is the very low coverage of skilled birth attendance in Lao PDR, where only 38% of the women have delivery assistance of a skilled health professional, compared to Indonesia (83%) and the Philippines (72%). The number of women giving childbirth in a health facility is nonetheless also rather low in Indonesia and the Philippines (respectively 63.2% and 55%). The generally higher coverage of most MNH services in Indonesia and the Philippines compared with Lao PDR may be largely explained by a better developed community-based service delivery


14

component. In Indonesia the village midwife programme10 launched by the government in 1989, had and has a positive impact on linking the communities with the formal health sector and on increasing the coverage of care for mothers and newborns. In the Philippines, villages have village health stations, generally staffed by a midwife, providing basic MNCH services. In addition, the availability of community health teams that are generally composed of a midwife, a community health worker11 and the traditional birth attendants12 is supposed to have a positive effect on the population's health (Department of Health 2011). Lao PDR health service data by place of residence (see table 26 annex 1) seems to suggest that healthcare services do not reach all communities, especially women and children in rural remote areas. This is related to the dispersed, rural population (72.5% of total population) of which up to 10% is living in rural areas without roads. These communities are largely dependent on outreach services for their healthcare and have no access to permanently available services. During the quarterly outreach visits of the health centre staff mother and infant services are provided13, but because of the limited frequency of these visits many newborns are only seen at a later age (not within the critical period of 48 hours, even not always within the postpartum period of 42 days) or even not at all. Village health volunteers can partially compensate for absence of qualified healthcare providers, but they do not have all required skills and expertise. Breastfeeding practices are found to be poor in all three countries with low coverage of early initiation of BF and exclusive BF during the first 6 months of the child’s life. This despite the availability of specific government decrees in Indonesia14 and the Philippines15 to enhance BF practise. Apparently intensive promotion and marketing related to formula milk is difficult to control and has a big impact on BF practises in the three countries assessed. Apart from this, during the country visits to Indonesia and Lao PDR it became evident that many health providers, including midwives, were not familiar themselves with BF practices and the benefits of exclusive breastfeeding. Efforts to improve BF practices therefore have to focus on increasing health providers’ knowledge on the benefit of exclusive breastfeeding and on how to control advertising and distribution of formula milk. Improving mothers’ skills and knowledge on BF and developing family and community support for BF are additional important elements to increase BF practice in those countries.

10

Between 1989 and 1996, under this programme an one-year midwifery training was provided (Dawson et al. 2011a). In 1996, when enough midwives were available, this training was replaced with the three-year diploma course for high school graduates, which is still the present available midwifery course. The trained village midwives were assigned to villages/communities to deliver their services. 11

Community health workers, in the Philippines also known as barangay health workers (BHW), are community health volunteers that received a 3-days initial training to perform their tasks in the community. 12

Traditional birth attendants are known as ‘hilots’ in the Philippines. 13

The integrated outreach package (also referred to as EPI+, because it adds on to the existing vaccination services) includes:

For children: weighing and measuring for nutrition status; vaccination; Vitamin A supplementation and deworming; health check-ups for sick children.

For mothers: antenatal care, counselling on PMTCT; post-partum examination; provision of iron folate to pregnant and postpartum women; postpartum Vitamin A supplementation; newborn assessment.

For women of reproductive age: tetanus vaccination; family planning; health education. 14

Regulation on Exclusive Breastfeeding (PP Nomor 33 Tahun 2012 about "Pemberian Air Susu Ibu Eksklusif") Published by the Government of Indonesia (GoI), signed by the president on 1 March 2012. 15

The Milk Code (1986)


15

Figure 4: Coverage of MNCH services along the continuum of care, Indonesia, Lao PDR and the Philippines (data from 2007 to 2012)

Sources: Indonesia: IDHS 2007, IDHS 2012 (Preliminary Report) Indonesia Health Profile 2010 (MoH 2011). Lao PDR: LSIS 2011/12. Philippines: PDHS 2008 and FHS 2011. Note: Skilled birth attendant (SBA) includes doctor, nurse, midwife, and auxiliary nurse/midwife.

Equitable access to MNCH services along the continuum of care is an issue as indicated in table 26 in annex 1 and in figure 5 to 7 below. Coverage of MNCH services shows significant inequities depending on mothers’ and newborns’ socio-economic and demographic background. For most MNCH services the coverage declines with lesser education and wealth level and is lower in rural areas compared to urban areas. This is however not the case for BF practices where disparity is not so apparent and/or even the opposite effect of socio-economic and demographic characteristics on the coverage is observed. The coverage of FP and vaccination services shows less disparity than the other services, even though the inequity in coverage of these services, when comparing lowest and highest education levels, still remains high (see figure 5). Figure 6 shows that coverage of services highly depends on economic status. This is especially obvious for the gap between the richest and poorest quintile regarding the coverage of skilled birth attendance and facility-based delivery in all three assessment countries. It is also important to consider the limited access to services among poor living in densely populated regions. Attention for the urban poor is certainly needed in Indonesia and the Philippines, two countries characterised with large fast-growing urban agglomerations. Figure 7 confirms that the place of residence has an impact on the service coverage, with a higher coverage of most MNCH services in urban areas. On the other hand, as seen in figure 4, clients go in and out of the system depending on the services provided, independent of their socio-economic status or their residence.

88

96

82 83

63

44

81

70

84 89

42

72 71

54

37 38

28

40 37

40 41

78

40

56

69

92

78 72

55 54

87

77

92

27

83

0

20

40

60

80

100

Co

vera

ge (

%)

Indonesia

Lao PDR

Philippines


HERA & ICRH / Cross-country report / March 2013 16

Figure 5: Coverage of MNCH services along the continuum of care by mothers’ education level, Indonesia (2007/10/12), Lao PDR (2011/12) and the Philippines (2008)

Sources: Indonesia: IDHS 2007, IDHS 2012 (Preliminary Report) and Indonesia Health Profile 2010 (MoH 2011). Lao PDR: LSIS 2011/12. Philippines: PDHS 2008 and FHS 2011.

Figure 6: Coverage of MNCH services along the continuum of care by wealth quintile, Indonesia (2007/10), Lao PDR (2011/12) and the Philippines (2008)

Sources: Indonesia: IDHS 2007 and Indonesia Health Profile 2010 (MoH 2011). Lao PDR: LSIS 2011/12. Philippines: PDHS 2008 and FHS 2011.



Figure 7: Coverage of MNCH services along the continuum of care by residence, Indonesia (2007/10/12), Lao PDR (2011/12) and the Philippines (2008)

Sources: Indonesia: IDHS 2007, IDHS 2012 (Preliminary Report) and Indonesia Health Profile 2010 (MoH 2011). Lao PDR: LSIS 2011/12. Philippines: PDHS 2008 and FHS 2011.



1.1.5 Access to newborn services Apart from the availability of newborn care services it is equally important to consider access to these services, in all its components (financial, geographic and socio-cultural accessibility and access to services in-time). Geographic access to newborn care is an issue for people leaving in remote and difficult to reach areas in Indonesia, Lao PDR and the Philippines. Strategies to overcome the gaps in geographic accessibility are implemented in the 3 countries. In Indonesia the deployment of village midwives aims to increase access to MNCH, Lao PDR seeks to reach the population in difficult to reach areas by regularly organised outreach clinics, and in the Philippines community health teams are established to improve access to care, including newborn care. Although these strategies have improved geographic access to care, gaps in accessibility remain (see figure 7 in chapter 4.1.1 above) with lower coverage of services in rural areas than in urban areas. In Lao PDR it remains moreover a challenge to reach the population living in rural areas without roads, and in Indonesia and the Philippines to serve remote, sparsely populated islands. Financial access Fees and healthcare-related costs to be paid by clients to access newborn care were identified as an important barrier in the three countries and are confirmed by the findings in figure 6 above. In a recent study in Lao PDR cost was identified by 60% of women as the most important factor influencing their choice of delivery site (Martinez et al. 2012). The planned introduction in Lao PDR of free care for children aged under five and free delivery is supposed to reduce the financial barriers for pregnant women, women giving childbirth, postpartum women (until 42 days after delivery) and children under 5 years of age seeking maternal and newborn care. However confusion around the implementation of this strategy may cause target groups not to access healthcare. In the Philippines and Indonesia health insurance schemes covering maternal and newborn care for respectively the poor and for all citizens are in place16. However in both countries administrative requirements are often complicated and unclear which hinders the implementation of these schemes and/or makes them prone to arbitrary. In addition, in the Philippines the numbers of facilities accredited by the health insurance programme are severely lagging behind, especially in rural areas causing the indigents not to receive health insurance benefits. Moreover, not all poor are yet enrolled in the insurance scheme. Enrolment numbers are increasing but still many of the eligible target group are not reached. The fact that transport costs are not covered by the insurance schemes in Indonesia and in the Philippines are a financial barrier to care for the poor and in remote areas (Febriani et al. 2011, UNFPA and CHSM Gadjah Mada University 2011). Access in-time In Indonesia PHC facilities are often only open until the early afternoon (from 8:00am till 14:00pm). The same is observed in the public hospitals where from 14:00 pm onwards most specialists are only available on call. This means that several services are not always easily accessible throughout the day. In Lao PDR problems about the unavailability of staff and limited opening hour of PHC facilities were not observed during the field visit neither reported by key informants. In the Philippines a health facility can only be classified as a BEmOC facility if a doctor is available 24 hours/7days. However because of the existence of BEmOC networks, where one doctor is responsible for provision the BEmOC services in a cluster of health facilities, a doctor is not always available at each facility and travelling between the facilities can take some time. The PDHS 2008 also states that a reason for people for not going to a health facility is the lack of health staff (National Statistics Office and ICF Macro 2009).

16

In Indonesia the main health insurance schemes regarding MNCH are called ‘Jampersal’ and ‘Jamkesmas’, in the Philippines it is known as ‘PhilHealth’.



Socio-cultural accessibility Local beliefs and practices affecting access to maternal and newborn health exist (Agus et al. 2012, Lamxay et al. 2011, Sondakh et al. 2011, Wulandari and Klinken Whelan 2011). It is always important to consider the existence of local practices and beliefs and its impact on access to care, especially in countries with such an ethnic diversity as the three assessed countries. Close cooperation of the formal health sector with local communities/indigenous people is therefore very important. Providing context-specific health education and information on the importance of newborn care, with respect for local beliefs and practices, is required.

1.1.6 Referral system A tiered referral system is in place in all three assessment countries: women and newborns in need of more specialised care are referred from community level to the primary healthcare facility based at sub-district/district level. If the case cannot be managed at the PHC facility it is further referred to the referral hospital at district level and if needed to the regional or central hospital providing specialized and high-tech care. We were not able to find evidence on the functionality of the referral system in the three assessment countries, but based on information gathered during the field visits, there seem to be weaknesses regarding the functionality of the system in all countries: (1) The referral system is often by-passed by the patients (mainly because of lack of trust but also

due to economic factors such as transport costs, hospital charges, medical and food expenses). (2) Transport needed for newborn and maternal referrals are paid by the health system in the three

assessed countries. However in Indonesia and the Philippines it was found that transportation means (ambulance, health facility boat) are often lacking in which case patients have to look and pay themselves for the referral. Moreover, cross boundary transportation by ambulance (e.g. from one municipality to another) may cause conflict about which municipality is responsible for carrying the costs of transportation, as was observed in the Philippines.

(3) Key informants mentioned that very sick newborns with very severe, hardly treatable or untreatable conditions are referred as newborns with conditions that need referral and can be easily treated at the referral facility are not or too late referred often causing avoidable newborn deaths. This indicates the urgent need to rationalise referrals which implies instructing health providers at primary healthcare level on newborn health conditions that need referral and learn them how to recognise and identify these conditions.

1.1.7 Quality of essential newborn care Despite the availability of facilities, providing high quality of essential newborn care, overall the quality of newborn care was recognised as a major concern since not all maternal and newborn services are performed adequately in the assessed countries. Poor quality of care was observed at all stages of the continuum of care and at all levels of care, including routine newborn care, the management and treatment of complications occurring in newborns and emergency newborn care. Knowledge as well as skills and practises on newborn care among health providers (nurses, midwives and doctors) were often found to be inadequate. In all three countries findings from the newborn assessment reveal gaps in the routine newborn care provided by health workers. In the Philippines an assessment of newborn care done within the first hour of life in 51 large hospitals in 2009 showed poor warmth management and breastfeeding practice as examination. Weighing and providing eye prophylaxis and Vit K and BCG and Hep B vaccinations were well preformed, although in sequences that did not allow the newborns to benefit from all of their mothers’ natural protection in the first hour of life, i.e. provision of warmth, blood transfusion from the placenta, protection from infection via skin-to-skin contact and completion of colostrum feeding (Sobel et al. 2011). When health workers during the field visits in Indonesia and Lao PDR were asked about which routine newborn care needed to be provided, they often not knew what care was needed or in which preferred order. This was definitely the case regarding warmth



management (delayed bathing and skin-to-skin contact) and breastfeeding practice which is in line with the findings in the Philippines. This is confirmed by the data in table 6 that indicates that early initiation of BF is poorly performed in the three assessed countries with 43.9% of the newborns receiving BF in the first hour of their life in Indonesia, 39.1% in Lao PDR and 53.5 % in the Philippines. Rooming-in, a breastfeeding-supporting condition, was observed to be also poorly performed in Indonesia but is based on the assessment results of the above mentioned study better performed in the Philippines (83% of the newborns were roomed-in at a median time of 2 hours and 35 minutes after delivery). Based on observations made during the field visit rooming-in seems to be performed well in Lao PDR. Knowledge on the benefits of breastfeeding and on how to initiate and support BF was often missing among health providers interviewed in Indonesia and Lao PDR. Poor knowledge definitely leads to poor practice. Table 6 has some data on the coverage of services linked with the quality of maternal and newborn care. Except for measuring newborn weight in Indonesia the services are rather poorly performed which is also visualised in figure 8. Although the adequate range for the caesarean section (CS) rate in a country remains a matter of debate studies indicate that the rate of CS should be between ± 5 % and ± 15% to reflect good access to and/or quality of care (Gibbons et al. 2010, WHO 2013b). The percentages of CSs in Indonesia (Statistics Indonesia and Macro International 2008)17 and the Philippines (National Statistics Office and ICF Macro 2009) are situated in this range, however table 26 in annex 1 shows a substantial difference in the number of CS performed depending on the place of residence, mother’s education level and wealth quintile (these differences are also observed for Lao PDR). Mothers living in rural areas, being not or less educated and belonging to the lowest wealth quintiles have CS percentages of less than 5 %. Percentages on CSs higher than 15% are found in the highest wealth quintile for Indonesia and for the Philippines and in the highest education level for Lao PDR and the Philippines; these percentages could reflect over-medicalisation which are often caused by gain-driven objectives due to privatisation (private-for-profit) of the health sector. Data on kangaroo mother care could not be obtained.

Table 6: Coverage of services linked with the quality of maternal and newborn care, Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008), (%)

Newborn services and care Indonesia

Lao PDR

Philippines

Women who received ANC care and were informed on danger signs of pregnancy

38.8 n.a 68.8

Women who received ANC care and had their blood sample taken

29.2 23.21

46.6

Deliveries by caesarean section 6.8 3.7 9.5 Newborn weight measured 81.7 42.5 72.5 Early initiation of breastfeeding (within 1 hour of birth)

43.9 39.1 53.5

Newborns who need (birth weight <2000g) and received kangaroo mother care

n.a. n.a. n.a.

Sources: Indonesia: IDHS 2007. Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008. Note: 1

For Lao PDR this data is the percentage of pregnant women who had their blood pressure measured, urine sample taken, and blood sample taken as part of antenatal care. A separate data for women who had only their blood sample taken during ANC care was not found for Lao PDR.

17

The Indonesia Health profile 2010 (MoH – Republic of Indonesia 2011) mentions a CS percentage of 15.3%.



Figure 8: Quality of care indicators by education level, Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008), (%)

Sources: Indonesia: IDHS 2007. Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008.

Important to report in the context of quality of care is supervision and mentoring (quality control) of health staff. We found that this aspect of healthcare provision was rather poorly implemented in the three countries where supervision and monitoring is supposed to be organised by the province/district health offices. However, at these levels, skills and capacity to set-up and manage a functioning supervision/quality control system are often lacking. The attitude of health providers towards their clients should also be considered in the assessment of quality of care. In Indonesia and the Philippines providers attitude was found to be a topic of concern. Some key informants interviewed in Indonesia expressed this concern, while in the Philippines a study found that several charity patients being treated in hospitals in Manila reported being shouted at, scolded, treated like a child, ignored, being made to wait, being passed up in favour of patients who could afford, and being handled roughly, i.e. without consideration for privacy or pain (Hataman et al.). As found in a study by Martinez on Lao PDR and observed during the field visit, health providers attitude seems not to be an issue in Lao PDR (Martinez et al. 2012). To conclude, quality of routine newborn care at primary healthcare level and referral facilities was generally identified to be a concern in all assessed countries. However quality of provided care varies and in all assessment countries we also observed good quality of newborn care.

1.1.8 Emergency obstetric and newborn care Although only few data could be obtained, the available data on the number/percentage of health facilities that conduct deliveries and perform emergency obstetric and newborn care services (EmOC) shows that availability of facilities providing these services is limited in the three assessed countries. In Indonesia, the primary healthcare (PHC) centre and hospital surveys conducted in 2011 mention that 18.6% of the PHC are basic emergency obstetric care (BEmOC) centres (see table 7) (Ministry of Health 2012a) and 16.2% of the government general hospitals are comprehensive emergency obstetric care (CEmOC) facilities (Ministry of Health 2012b). During the field visit, it was noticed that

0

20

40

60

80

100

Women informedon danger signs

Women who hadblood taken

Deliveries by CSNewbornsweighted

Early initiation ofBF

Indonesia

Lao PDR

Philippines



the classification as BEmOC or CEmOC health facility does not really mean that all seven and respectively nine signal functions18 are provided at these facilities. Data on private hospitals providing EmOC services were not found.

Table 7: Emergency obstetric and newborn care, Indonesia, 2011

Number of facilities

Basic EmOC Comprehensive EmOC

n n % n % Government Hospital 684

1 NA NA 109 16.2%

PHC centre (puskesmas) 8,981

2 1,667 18.6% NA NA

with beds 3,052 1,441 47.2% NA NA without beds 5,929 226 0.04% NA NA

Sources: Puskesmas and hospital health facility survey, MoH, 2011. Notes: 1

684 government general hospitals of the total of 689 government general hospitals were included in this survey. 2

8,981 PHC centres (puskesmas) of the total of 9,005 centres were included in the survey.

In the Philippines as of early 2013, there are 279 on at a total of 721 public hospitals (38.8%) providing CEmOC services19 (personal communication DoH 2013). No information could be obtained on the distribution of BEmOC and CEmOC facilities over the different regions. According to PhilHealth, the health insurance organisation, distribution of facilities applying for accreditation, including for BEmOC and CEmOC accreditation, is not monitored (personal communication, PhilHealth, 2012). Anecdotal evidence suggests that most of these facilities are situated in urbanized and easily accessible areas. A list of accredited facilities confirms that most accredited facilities are located in urbanized locations (see https://gis.philhealth.gov.ph/view_hosp1.php). Although, this list does not exclusively show the facilities accredited for the mother and child package.

Data on EmOC services in Lao PDR include data from:

the 2008 Skilled Birth Attendance assessment, which gives an overview of EmOC facilities per province and provides self-reported data on BEmOC and CEmOC signal function performed in the facility (Ministry of Health of Lao PDR and UNFPA 2008); and

the 2011 EmOC assessment which presents the percentage of facilities that performed each signal function in the last 3 months, by region, and type of facility (University of Health Sciences 2011).

This data shows that most of the assessed health facilities were not able to conduct all 7 or 9 signal functions needed to be classified as BEmOC or CEmOC facility (see table 8).

18

The nine signal functions are: (1) Administer parenteral antibiotics (2) Administer uterotonic (e.g. parenteral oxytocin) (3) Administer parenteral anticonvulsants for pre-eclampsia and eclampsia (e.g. magnesium sulphate) (4) Manual removal of placenta (5) Removal of retained products (e.g. manual vacuum aspiration, dilatation and curettage) (6) Perform assisted vaginal delivery (e.g. vacuum extraction) (7) Perform basic neonatal resuscitation (e.g. with bag and mask) (8) Perform surgery (e.g. caesarean section) (9) Perform blood transfusion BEmOC includes signal function 1 to 7 CEmOC includes signal function 1 to 9 19

No clear information on how many facilities providing BEmOC services could be obtained for the Philippines.

https://gis.philhealth.gov.ph/view_hosp1.php



Table 8: Percentage of facilities that performed each signal function, by type of facility, Lao PDR, 2008 and 2011 (%)

No. of facility Nine signal functions of EmOC services2 (in %

3)

sample/Existing1

(1) (2) (3) (4) (5) (6) (7) (8) (9)

2008 (SBA assessment) Central hospital

3 -/3

Provincial hospital 4/17 100 100 100 100 100 100 75 100 100 District hospital A 3/24 100 100 33 100 100 100 100 100 100 District hospital B 7/103 100 100 14 100 43 0 14 0 0 Health Centres 20/818 45 35 5 30 0 0 5 NA NA

2011 (EmOC assessment) Central hospital

3 -/3

Provincial hospital 12/17 100 100 50 75 100 58 92 92 100 District hospital A 18/24 100 100 39 72 89 50 89 77 44 District hospital B 21/103 100 95 95 67 76 5 71 5 0 Total 51 100 98 30 67 86 33 82 29 39 Source: Ministry of Health & UNFPA. 2008 (SBA assessment: text + annexes 4 and 7). University of Health Sciences. 2011. Notes: 1 Total numbers of existing public health facilities in Lao PDR, coming from other source (WHO - Western Pacific

Region. Western Pacific Region Health Databank, 2011 Revision: Lao People’s Democratic Republic): 20 general hospitals (including 4 teaching and referral hospitals and 16 district hospitals), 130 district first level referral hospitals and 862 health centres. 2

see signal functions and corresponding numbers footnote 19. 3 Percentage of facilities in the sample that performed the signal function.

4 The central hospitals were not included in the SBA assessment.

Table 8 (2011 EmOC assessment) shows that newborn resuscitation (signal function 7) is performed in 82% of the assessed health facilities. In Indonesia poor newborn resuscitation practice was observed. Several midwives interviewed during the field visit indicated they never performed newborn resuscitation. They told that they received newborn resuscitation training at midwifery school but never practised resuscitation during their training. This results in lack of skills and confidence to perform newborn resuscitation in the field. Absence of newborn resuscitation equipment was told and observed to be another reason why resuscitation was not performed.

Human resources for health

Human resources involved in maternal and newborn health differ by level of healthcare and range from village/community health volunteers over nurses and midwives to obstetrician/gynaecologists and paediatricians. Due to weak human resources information systems the exact number of healthcare personnel is uncertain in the three assessed countries. This also results in different data depending on the source consulted as shown for the data for Indonesia and the Philippines (see table 9 and 11). Table 9 presents MoH data from Indonesia, which does not include HR data from private hospitals and from hospitals belonging to other ministries or to the army/police. However it is estimated that between 60% and 70% of public service providers are also employed in the private sector (Rokx et al. 2009). This means that the majority of the HR working in the private sector is nonetheless counted for as they are also employed in the public sector. Data reported in the column ‘Indonesian Medical Council 2007’ includes the data of Indonesian Medical Council on the number of medical doctors and data from the nurses association.



Table 9: Estimated number of physicians, midwives and nurses, Indonesia, 2006 and 2007

Staff cadre

MoH 20061

Indonesia Medical Council 2007

2

n Per 10,000 population

n

Specialist 12,374 0.55 15,499 General practitioners 44,564 1.99 56,750 Midwife 78,158 3.54 80,000 Nurse 308,306 13.79 500,000

3

Total of professional health workers 443,402 19.87 652,249 Sources:

1 Rokx et al. 2008.

2 Hong et al. 2009.

Notes: 3

The Indonesian Nursing Association uses this number in their brochure.

Table 10 has data from Lao PDR. In the Philippines often healthcare workers who have ever worked in the healthcare system are still included in the data. Various sources provide different estimates (Dawson et al. 2011b). An overview of the various data on available staff for each of the cadres, are shown in table 11.

Table 10: Available health staff, Lao PDR, 2011

Staff cadre Available (2011)

n Per 10,000 population Obstetrics/gynaecology 12 0.05 Paediatrician 15 0.10 Anaesthesiologist 45 0.20 Medical doctors 425 1.80 General surgeons 55 0.20 Midwives 113 0.50 Nurses 1,129 4.70 Nurse anaesthetist 27 0.10 Lab technician 148 0.60 Total of health workers 1,969 8.25 Source: University of Health sciences 2011. (EmOC Assessment).

Table 11: Health workers distribution, the Philippines

Staff cadre Number per location

1

Total (n) Per 10,000 population Urban Rural

Medical doctor 90,370 10.3 Midwife

24% 76% 136,036 16,534

2

15.5 1.9

2

Registered Nurse 42% 58%

352,398 4,720

2

40 0.5

2

Hilot (TBA) 54,5572 6.2

2

CHW3

17% 83%

169,5001

200,000 1.3 million 195,928

2

19.31

2.3 147.8 22.3

2

Source: Dawson et al. 2011b (Republic of the Philippines Department of Health 2005, Republic of the Philippines 2009, Ronquillo et al. 2005, Senate of the Philippines 2007, WHO 2010). Note: 1

These statistics relate only to government-employed staff in 1997.

2 Health workers employed by local government unit in 2002.

3 CHW known as ‘Barangay health workers’ aren’t formally trained. They only received in-service training to be

able to conduct their tasks.



While there is no gold standard for the sufficiency of the health workforce, WHO estimates that countries with fewer than 23 healthcare professionals (counting only physicians, nurses and midwives) per 10,000 population will be unlikely to achieve adequate coverage rates for the key primary healthcare interventions prioritized by the Millennium Development Goals20. The total of 19.87 health professionals per 10,000 population found for Indonesia (2006 data) is below this WHO standard however as already mentioned above this number is believed to be an underreporting of the real HR for health situation in Indonesia. Reaching this quota of 23 healthcare professionals per 10,000 population seems to be no problem in the Philippines either. However the ratio of 8.25 healthcare professionals per 10,000 population reported in Lao PDR is far below the WHO gold standard. The largest groups of health workers in Indonesia and the Philippines are nurses and midwives. In both countries there is an annual oversupply of nurses and midwifes (Dawson et al. 2011a, Dawson et al. 2011b). Despite the sufficient numbers of nurses and midwifes, their unequal distribution in favour of the urban areas and retention problems, especially in rural areas, leads to staff shortages in some country regions (Dawson et al. 2011b, Makowiecka et al. 2008, IMMPACT 2007, WHO 2011a, WHO 2011b). In Lao PDR the largest group of health workers is nurses followed by medical doctors. Apart from the unequal distribution and retention problems also seen in Indonesia and the Philippines overall workforce shortage is a problem in Lao PDR. In order to address the above mentioned challenges initiatives were/are implemented in all three assessed countries. In Indonesia the government launched in 1989 the village midwife programme with the purpose to reduce maternal death by assigning a resident midwife to each village in the country (Makowiecka et al. 2008). In Lao PDR the national SBA Development Plan 2008-2012 was developed with the aim to establish a skilled workforce. This Plan includes: developing midwife cadres, producing the skilled SBA workforce, deploying, retaining and supervising the skilled SBA workforce, strengthen the working environment and the links between the health sector and community, including referral system for obstetric and neonatal emergencies (Ministry of Health of Lao PDR 2008). In the Philippines a comprehensive HRH Master Plan has been developed. This Master Plan (2005–2030) is a 25-year strategic plan set out in three phases. Phase One (2005–2010) focused on workforce planning (such as redistribution of health workers) and management of domestic deployment and international migration. Phase two (2011–2020) will address retention schemes, explore public-private partnerships to increase investment in health and generate information and management systems for HRH. Phase three (2021–2030) will include an analysis of monitoring and evaluation to ensure functioning systems and enable on-going planning. The HRH network was established in 2006 in order to develop and implement the Human Resources Plan and to mobilize support and funding (Ronquillo 2010, Dawson et al. 2011b, WHO 2011b). However, despite these present and past initiatives, HR challenges remain in all countries and need further focus. Traditional birth attendants (TBA) The position of the TBA is still very important in all assessed countries, especially in rural communities. The remaining importance and influence of the TBA in the community regarding maternal and newborn health and care is recognised in the three countries and TBAs are integrated in the overall MNCH care provided through the formal health sector. As such the TBA is considered and used as an extension of the formal healthcare system, serving as an advocate for women to get skilled birth attendance, providing social support and community mobilisation but they are not allowed to do deliveries.

20

Source: WHO, World Health Statistics, May 2009.



Medical, nursing and midwifery education In Indonesia training is provided through public and private institutions. It was found that accreditation, standardisation, regulation and monitoring of the training institutions is rather weak resulting in variable quality of medical, nursing and midwifery training. Special concern about the quality of training provided in private-for-profit schools was mentioned as these schools seem to focus more on the profit they can make than on the quality of training. A recently published comment in the Lancet on the maternal health situation in Indonesia mentioned that in government subsidies for midwives have spawned scores of substandard training institutions producing poorly trained midwives amidst numerous corruption charges. Licences for the academies are issued by the ministry of education, not the ministry of health. The comment further states that a licence can be easily bought and that there is no certification or inspection of the hundreds of new training institutions (Webster 2012). The limited possibility for internship in health facilities (for all cadres) during pre-service training was also identified as a factor hindering the provision of good quality pre-service training. In recent years, Lao PDR has invested a lot in improving pre-and in-service training on MNCH in cooperation with UNFPA. Regulation of midwifery and nursing training institutions and of the University of Health Sciences of Laos (the only medical school in Lao PDR), all public institutions, has been established.

Health financing

Total expenditure on health as a percentage of gross domestic product is 2.6% in Indonesia, 4.5% in Lao PDR and 3.6 % in the Philippines (see table 12). Private expenditure on health as a percentage of total health expenditure is significantly higher in Lao PDR (66.7%) and the Philippines (64.7%) compared with Indonesia (50.9%). Per capita total expenditure and government expenditure on health are higher in Indonesia and the Philippines compared with Lao PDR. However most striking is the difference in dependency on external resources (official development assistance) for health. While this dependency is negligible in Indonesia and the Philippines with for both countries less than 2% of the total expenditure on health coming from external resources, Lao PDR is still quite dependent on external resources with 15% of its total expenditure on health coming through these resources.

Table 12: Health financing, Indonesia, Lao PDR and Philippines, 2010

Indonesia Lao PDR Philippines

Total expenditure on health as a percentage of gross domestic product

2.6% 4.5% 3.6%

Government expenditure on health as % of total expenditure on health

49.1% 33.3% 35.3%

Expenditure on maternal and child health as % of total expenditure on health

1 n.a. n.a. n.a.

Private expenditure on health as % of total expenditure on health

50.9% 66.7% 64.7%

Out-of-pocket expenditure on health as % of private expenditure on health

75.13% 76.7% 83.6%

Per capita government expenditure on health (in PPP $)

55 USD 32 USD 50 USD

Per capita total expenditure on health (in PPP $) 112 USD 97 USD 142 USD External resources for health as a percentage of total expenditure on health

1.3% 15.1% 1.4%

Source: WHO, Global Health Observatory http://apps.who.int/gho/data/# accessed online January 2013. Note: 1 Not available since there are no national health subaccounts.

http://apps.who.int/gho/data/



National Health Insurance Indonesia and the Philippines have a tax based national health insurance covering maternal and newborn healthcare. In the Philippines non-paying health insurance beneficiaries are the poor, in Indonesia everyone is covered (Jamsos Indonesia 2012). In the Philippines the health insurance, better known as PhilHealth, was introduced in 1995. In Indonesia a first scheme covering the poor and near poor was launched in 2005 (known as jamkesmas) and since 2011 a scheme covering every Indonesian (called Jampersal) is in place (Jamsos Indonesia 2012). It is not yet clear whether the introduction of the health insurance schemes have increased the utilisation of MNH services as expected. The PhilHealth insurance program has not significantly increased the probability of delivery in a health facility and it seems that other factors are involved in deciding whether to deliver in a facility or at home. However, evidence suggests that the expansion of the PhilHealth insurance program was associated with increases in achievement of minimal standards for prenatal care among women in the Philippines (Backes Kozhimannil et al. 2009). In Indonesia the health insurance scheme was only introduced recently, nevertheless two studies conducted in 2011 mention that the introduction of health insurance increased the utilisation of services in many health facilities (Febriani et al. 2011, UNFPA and CHSM Gadjah Mada University 2011). Challenges with both insurance systems exist. In the Philippines problems with the identification of the poor are known (WHO 2011a) and meeting, as a health facility, the requirements for PhilHealth accreditation is difficult causing an uneven distribution of the accredited health facilities and a barrier to expanding coverage to the more rural areas (Huntington et al. 2012). In Indonesia the implementation of the insurance schemes seems to work quite well, although there are complaints about the difficult and complex administration of the schemes and about the fact that transport costs (which can be high in remote areas) are not covered. Another issue is that some health providers refuse to work for these schemes because they consider the reimbursement they receive from the government for their services provided as insufficient (Febriani et al. 2011, UNFPA and CHSM Gadjah Mada University 2011). It was also mentioned that the increased utilisation might have a (negative) effect on the quality of provided care and services because often health facilities are not equipped to manage this increased number of patients (Febriani et al. 2011, UNFPA and CHSM Gadjah Mada University 2011). In the Philippines as well as in Indonesia public and private facilities can provide health services covered by the health insurance. No national health insurance system exists in Lao PDR. However, 18.5% of its population is covered by one of the four current insurance schemes21. In Lao PDR, the Prime Ministerial Decree No. 52 in 1995 authorised the collection of official user fees at public health facilities but also provided for fee exemptions for the poor. In its eagerness to meet the MDGs 4 and 5, the Lao government has recently agreed on the policy for free delivery and free healthcare for children under 5 years old at public health facilities. However an exact roll-out plan for the free delivery and MNCH services and the required budget is not yet available. Conditional cash transfer In Indonesia and the Philippines a government managed conditional cash transfer programme to alleviate poverty has been implemented, in Indonesia since 2005 and in the Philippines since 2008. Both programmes provide conditional grants to extremely poor households to improve their health,

21

Lao PDR has currently four social health protection schemes providing coverage of health services to their target populations, including the State Authority for Social Security for civil servants (79% coverage), the Social Security Office (27% coverage), the Community-based Health Insurance (4.7% coverage), and Health Equity Funds (11% coverage) (WHO and Ministry of Health of Lao PDR 2012).



nutrition and education particularly of children aged 0-14 (Jamsos Indonesia 2012). The effect of the programme in the Philippines has resulted in an increase in school attendance (Son and Florentino, 2008).

Essential drugs and commodities

The Indonesian as well as the Lao Essential Drugs List do not include magnesium sulphate (MgSO4) in the formulary for the primary health centre level although this drug should be available in BEmOC facilities as the drugs is required for one of the seven BEmOC signal functions (treatment of pre-eclampsia/eclampsia) (Ministry of Health 2008). In addition to MgSO4 the Lao essential drugs list does not include injectable antibiotics at health centre level. All the other essential maternal and newborn drugs are listed to be available at referral as well as PHC level in Indonesia and Lao PDR (Ministry of Health 2008).

For none of the assessed countries exact data could be obtained on the stock and availability of essential maternal and newborn drugs at the health facilities. Although during the health facility visits and interviews with key informants problems of stock-out were mentioned as well as observed. In the Philippines, some community health stations had empty shelves. Drugs had to be bought outside prior to service provision. Poor drug procurement was mentioned in the three countries to be an important reason for stock-outs. In Indonesia and Lao PDR poor drug storage was also observed22. In Indonesia data from the 2011 health facility survey states that among the 8,981 surveyed health centres23 only 19.9% had more than 80% of the essential general drugs, needed to be available at the facility according to the essential drug list, in stock at the time of the survey. Only 17.8% of the PHC health centres providing BEmOC24 had more than 80% of the needed BEmOC commodities available at the time of the survey and almost one quarter of the PHC centres had less than 20% on the needed equipment available (see table 13) (Ministry of Health 2012a). For Lao PDR data from the EmOC assessment report (although limited sample size and not all provinces were included) are given in tables 14 to 16 (University of Health Sciences 2011). This data also reflects stock-out problems. In the Philippines a 2005 survey found only 15% median availability of a list of 34 essential generic medicines (Batangas 2005). A study in 2009 showed a slightly higher percentage of 27% median availability (Batangas and Juban 2009).

Table 13: Availability of essential drugs and BEmOC equipment in PHC centres, Indonesia, 2011

Percentage PHC centres with >=80% availability

Percentage PHC centres with 60-79% availability



Percentage PHC centres with <20% availability

Essential general drugs 19.9 65.9 13.0 0.7 0.5 BEmOC commodities 17.8 29.3 20.3 8.8 23.8 Source: HFS puskesmas 2011.

22

Oxytocin was not always found to be stored in a fridge. 23

Total number of PHC centres in Indonesia is 9,005 24

All PHC centres that provided BEmOC were included in the survey.



Table 14: Stock-out status of essential drugs and commodities in hospitals and health centres, Lao PDR, 2011

Essential drug1

Never had drug/commodity (%)

Stock-out last 12 months (%)

No stock-out last 12 months (%)

Oxytocin 0.0 6.0 94.0 Magnesium sulphate (MgSO4) 53.0 6.0 41.0 Analgesia 0.0 100.0 0.0 Parenteral antibiotic(s) 0.0 100.0 0.0 Ketamine 37.2 3.9 58.9 Atropine 17.7 1.9 80.4 Source: Copied from University of Health Sciences. 2011 (EmOC Assessment). Note: 1

Data on equipment & supplies and on infection prevention is not available and therefore not included in this table (see table 16 below).

Table 15: Availability of drugs for EmOC services by hospital level, Lao PDR, 2011 (%)

Drug/Commodity related to the signal functions and emergencies

Provincial hospitals

Type A district hospitals

Type B district hospitals

Total

(n=12) (n=18) (n=21)

Antibiotics 100.0 100.0 100.0 100.0

Anticonvulsants 100.0 100.0 85.7 94.1

Antihypertensives 83.3 61.1 42.8 58.8

Oxytocics & Prostaglandins 100.0 100.0 100.0 100.0

Drugs used in emergencies 100.0 100.0 90.4 96.0

Analgesics 100.0 100.0 100.0 100.0

Tocolytics 100.0 100.0 80.9 92.1

Steroids 100.0 88.8 80.9 88.2

IV fluids 100.0 100.0 100.0 100.0

Antimalarials 83.3 94.4 90.4 90.1

ARVs 75.0 16.6 9.5 51.8

Source: Copied from University of Health Sciences. 2011 (EmOC Assessment), Table 46.

Table 16: Availability of equipment and supplies for EmOC services by hospital level, Lao PDR, 2011 (%)

Equipment and supplies Provincial hospitals

(n=12)


(n=18)


(n=21) Total

Filled oxygen cylinder with cylinder carrier and key to open valve

91.7 77.8 38.1 64.7

Ultrasound 58.3 55.6 19.0 41.2 BP cuff 100.0 94.4 100.0 98.0 Stethoscope 100.0 94.4 100.0 98.0 Foetal stethoscope 91.7 94.4 85.7 96.1 Kidney basins 91.7 100.0 95.2 96.1 Sponge bowls 91.7 88.9 76.2 84.3 Clinical oral thermometer 100.0 100.0 95.2 98.0 Rectal thermometer for newborn 16.7 11.1 0.0 7.8 Low reading thermometer (32/35°C) 25.0 0.0 0.0 5.9 Scissors 100.0 100.0 90.5 96.1 Needles and Syringes (10-20cc) 100.0 72.2 71.4 78.4 Syringes (1ml, 2ml, 5ml, 10ml) 91.7 100.0 100.0 96.1 Needles (23-25 gauge) 91.7 66.7 76.2 76.5 Suture needles/suture materials 100.0 88.9 85.7 90.2 Catheter for IV line (16-18) 100.0 66.7 61.9 72.5 IV Infusion stand(s) 100.0 100.0 95.2 98.0



Equipment and supplies Provincial hospitals

(n=12)


(n=18)


(n=21) Total

Urinary catheters 100.0 94.4 85.7 92.2 Source: Copied from University of Health Sciences. 2011 (EmOC Assessment), Table 48.

Indonesia and the Philippines have large pharmaceutical markets. There are six government pharmaceutical factories in Lao PDR producing together 880 types of medical formulations. It is estimated that almost 50% of the local population’s demand for medicines in Lao PDR is met by local production.

Health information systems

Similar challenges and problems regarding health information are present in the assessed countries. National health information system(s) collecting data on maternal and newborn health are in place. However management of these systems seems to be challenging leading to incomplete and/or poor quality of the data. This is mainly due to decentralisation, resulting in a partial breakdown of health information systems, and to lack of capacity and skills at regional/provincial/district level to collect, analyse and interpret data. Poor data collection and management hinders planning, monitoring and evaluation of newborn health, care and services. Additionally health information data does not include data from the private sector. As a result, comprehensive data that covers the entire country is not available. Neonatal and perinatal death audits are poorly or not performed in the assessed countries.

Leadership and governance

A similar organisational structure and similar challenges regarding leadership and governance have been observed in Indonesia, Laos and the Philippines. In the three countries the Ministry of Health, as the central management authority, provides leadership, coordinates all technical departments, divisions and centres involved in MNCH, and advises the provincial and district health offices to implement the MNCH strategy. Due to the distribution of responsibility for different components of newborn health over multiple departments, and the weak interdepartmental coordination and collaboration, successful implementation of the MNCH strategies is challenging. Decentralisation of authorities and delegation of responsibilities to provincial and district levels enhances the opportunity to adapt healthcare delivery to the local context and needs, but also creates confusion regarding the roles of different levels of administration in health management, including planning and implementation. Management capacity and skills at provincial and district level are often limited and jeopardise the implementation of quality newborn care and services. Among others poor planning, budgeting, management of resources, supervision/mentoring/quality control and data management hinder the implementation of newborn care. Collaboration with and regulation of the private sector was found to be weak in the three countries and should be strengthened in order to guarantee standardized newborn care in all health facilities.



NEEDS ASSESSMENT

The needs assessment includes an analysis based on the benchmarks for newborn care readiness developed by Save the Children, an equity analysis and a strengths-weaknesses-opportunities-threats (SWOT) analysis, which together lead to the main findings and recommendations in the last chapter.

Benchmark assessment

The "Scale-up Readiness Benchmarks" developed by Save the Children was applied to assess and map the country's readiness for scaling up newborn care. Thirty-two benchmarks, categorised under agenda setting, policy formulation and policy implementation, were assessed. The results of the benchmarking assessment are shown in annex 2. Agenda setting In Indonesia and Lao PDR the basic requirements for agenda setting are fulfilled with a focal person for newborn care appointed within the Ministry of Health and with a convening mechanism being functional, but more dissemination of local evidence is needed to set agenda and priorities. The Philippines currently lack a well-functioning convening mechanism which hampers prioritisation and implementation. Policy formulation While all three countries have formulated a comprehensive strategy for newborn care, relevant policy issues or specific strategies have been omitted: e.g. in Indonesia and Lao PDR there is an urgent need for sensitisation and communication strategies for newborn healthcare and for setting health expenditure targets. Limitations in the Midwifery Act of the Philippines e.g. still obstruct the administration of injectable antibiotics for newborn infections and the performance of neonatal resuscitation by midwives. Policy implementation Care during the first week of life is integrated in the in-service training for facility-based cadres and in IMCI procedures in the three countries. In- and pre-service trainings to upgrade staff in newborn care skills are available and running, but maintaining and upgrading these skills by technical support and supervisions is lagging behind in Indonesia and may be at risk by lack of sufficient resource commitments, especially for home-based newborn care, in Lao PDR. In the Philippines there are no resource requirements available for scaling up home-based care as home-based care is not promoted. In Lao PDR and the Philippines clear "hands-on" protocols and guidelines on newborn care to assure the quality of standardized care for the sick newborns are missing as well. Ultimately a system for neonatal and perinatal death audits should be put in place in Lao PDR and the Philippines, while these audits should be performed more regularly in Indonesia and used as a tool to generate evidence-based conclusions regarding newborn services and care.

Equity analysis

Data for all categories of early childhood (from newborns to under-fives) shows a clear tendency towards higher mortality rates for groups with deprived socio-economic and demographic characteristics. Higher newborn mortality rates are found in the lowest wealth quintiles, among the less educated pregnant women and among rural residents. Figure 9 presents rates for neonatal mortality by wealth quintile: a baby born into a poor family is e.g. more likely to die during his/her first month of life than a baby from a rich family, with about twice as many newborns dying in the lowest wealth quintile compared to the highest wealth quintile in Lao PDR and in the Philippines and



one third more newborn deaths occurring among the babies from the lowest wealth quintile in Indonesia compared to the highest wealth quintile. Moreover, the neonatal mortality rate in the lowest wealth quintile in Lao PDR is twice as high as in the Philippines.

Figure 9: Neonatal mortality by wealth quintile, Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008)

Sources: Indonesia:

IDHS 2007. Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008.

Under-five mortality rates by wealth quintile show even larger discrepancies between the lowest and highest wealth quintiles (see table 25 annex 1), with almost four times more newborn deaths in the lowest wealth quintile compared to the highest wealth quintile in Lao PDR and in the Philippines and more than twice as many newborn deaths occurring in the lowest wealth quintile in Indonesia as compared to the highest wealth quintile. Across countries, the under-five mortality rates in the lowest and highest wealth quintiles in Lao PDR are twice as high as in the Philippines. The same pattern is observed for children from mothers without education or born in rural areas (see annex 1 for the data). Poverty, geography, ethnicity and educational level of the mother are therefore important determinants of health inequities and become even more significant when the child grows. Figure 10 shows a disproportion of neonatal and under-five mortality rates between urban and rural areas in Indonesia, Lao PDR and the Philippines and illustrates moreover that the gap becomes larger with the age of the child; i.e. the percentage point difference between urban and rural areas is larger for under-five mortality than for newborn mortality, in all three countries. The mortality rates per 1,000 live births are always the highest in Lao PDR, with both their NMR and U5MR being twice as high as in the Philippines. Socio-economic and demographic characteristics not only determine health status, but along the continuum of care, specifically for the stages directly related to delivery and postpartum, disparities in the coverage and utilisation of maternal and newborn services are determined by the same characteristics.

40

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Lao PDR Indonesia Philippines

NMR - Lowest wealth quintile NMR - Highest wealth quintile

Gap: 22Gap: 10

Gap: 10

NMR in the lowest wealth quintile is twice as high in Lao PDR compared to the Philippines

10 to 22 NMR gap between lowest and highest wealth quintile



Figure 10: Neonatal and under-five mortality by residence, Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008)


Delivery stage Having a health professional with midwifery skills present at childbirth is the most critical intervention for safe motherhood. Many obstetric complications could be prevented or managed if women would have access to skilled birth attendants, including a doctor, nurse or midwife, during childbirth. Regardless the national percentage of women delivering by a skilled health provider being much higher in Indonesia (83%) and the Philippines (62%) than in Lao PDR (38%), there is always a substantial gap in skilled attendance at delivery between women from urban and rural areas. This disparity by place of residence varies from 17 (in Indonesia) to 49 (in Laos) percentage points which calls for actions to ensure that all women, even in remote areas, can be attended by a skilled health provider at the time of delivery (see figure 11). When comparing the percentage of skilled birth attendance in rural areas in the three selected countries, we observe substantial differences, with Lao PDR having the lowest proportion of deliveries attended by a skilled heath professional. This contrasts with the observation of having almost no differences in skilled attendance at birth between urban areas across the three countries. The intention of the MoH of Lao PDR to upgrade the village health volunteers to village health workers may contribute to ensuring universal access to skilled care for childbirth. These village health workers could provide specific promotion, preventive, and curative services about maternal and child care, identify complications at an early stage, and facilitate early referral. The deployment of women' groups or community-support groups through trained community health workers often offers a cost-effective mechanism for reaching populations at risk or in remote areas (Bhutta 2008) and the linkage between the village health worker and the village health committee may need to be strengthened or officialised by embedding the village health worker into the committee. Although the precise mechanisms of effect and direction of effect through such interventions are unclear, there seems to be an effect - beyond maternal and newborn survival - on family awareness, domiciliary care practices (such as the use of clean delivery kits), breastfeeding practices, and care-seeking for newborn illnesses (Bhutta 2008, Rosato 2008).

2218

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NMR - Urban NMR - Rural U5MR - Urban U5MR - Rural

In Indonesia & the Philippines: 6-7 NMR gap between urban and rural against 18-22 U5MR gap

In Lao PDR: 17 NMRgap between urban and rural against 55

U5MR gap

NMR and U5MR in rural areas in Lao PDR twice as high as in the Philippines



Figure 11: Percentage of skilled birth attendance and facility-based deliveries by residence, Indonesia (2012) Lao PDR (2011/12) and the Philippines (2008)

Sources: Indonesia: IDHS 2012 – Preliminary Report. Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008.

The guiding principle that every delivery should be attended by a skilled health professional and be facility-based is supported by the three countries, but the proportion of facility-based deliveries is significantly lower at 44% in the Philippines and 63% in Indonesia than for skilled birth attendance. Large gaps (of 29 to 47 percentage points) are observed between facility-based deliveries in an urban and rural setting (see figure 11 above). Causes for this gap in access to facility-based deliveries are likely to be financial, geographical and cultural and due to health workers attitude. As for rural areas, the data shows that in Lao PDR the proportion of skilled attendant and facility-based deliveries are rather similar, data for Indonesia and Philippines indicates that in rural areas an important proportion of deliveries done by a skilled birth attendants takes place outside of health facilities. This can partly be explained by the effect of the village midwife programme in Indonesia and the community health teams in the Philippines which allows skilled birth attendants doing deliveries at home. This discrepancy of childbirth conditions by place of residence confirms that future strategies to improve maternal and newborn survival need to integrate both community-based strategies and facility-based care. More deliveries take place in facilities in urban areas in Indonesia (80%) and Lao PDR (74%) than in the Philippines (59%). The percentage of deliveries by Caesarean section can be used as a measure of access to life-saving services for mothers and newborns and for the prevention of severe obstetric morbidity (such as obstetric fistula). The percentage of deliveries by CS is considered having to be between ± 5% and ± 15% in a well-functioning health system, with percentages under 5% indicating lack of access to live-saving services as EmOC and percentages above 15% reflecting over-medicalization of the health sector, often driven by profit-making, which causes avoidable iatrogenic complications (Gibbons et al. 2012, WHO 2013b). Figure 12 suggests that the latter may be the case for women residing in urban areas in Indonesia (17% of deliveries by Caesarean section) and the Philippines (28%). The figure also clearly shows that the poorest women when faced with obstructed labour, eclampsia or other obstetric emergencies often do not receive the life-saving caesarean section (0.1 to 2%), in contrast to women in the wealthiest quintile. Financial barriers such as user fees, medicines and transportation costs partly explain the observation that poor women do not or cannot access EmOC

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Skilled birth attendance - Urban Skilled birth attendance - Rural

Facility -based delivery - Urban Facility-based delivery - Rural

44 percentage point gap for skilled birth attendance in rural areas between Indonesia and Lao PDR, while smaller differences in urban areas

Gap: 47Gap: 29

Gap: 33

29 to 47 percentage point gap between urban and rural facility-based deliveries



services, in addition to the limited availability of EmOC facilities in rural areas and geographical constraints, as the poor are more often living in remote areas.

Figure 12: Percentage of deliveries by caesarean section by wealth quintile, Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008)


The pro-poor measure of free delivery to be implemented Lao PDR is expected to be instrumental in improving access of pregnant women, not only for skilled birth attendance and - if needed - EmOC services or even Caesarean sections but also for newborn and child care services. In Indonesia better regulation and control of the private-for-profit sector is required in order to avoid medical over-consumption and its adverse side effects, also for newborns. Urban poor also need special attention. Immediate postpartum stage Early initiation of breastfeeding is beneficial to both infant and mother. For the mother it is beneficial, as it stimulates uterine contraction, and so limits blood loss. For the infant it is beneficial, as breast milk contains all elements necessary to enhance infant growth and to protect against infections. It is therefore recommended to start breastfeeding within one hour of birth. The gap between early breastfeeding in urban versus rural areas across the three countries is relatively small, ranging from 1% in the Philippines to 10% in Lao PDR, in the latter even in favour of the babies born in urban areas (see figure 13). The effect of awareness-raising activities and even cultural practices in Lao PDR may explain the residential differences. Only 32.4% infants in Indonesia are exclusively breastfed during the first 6 months of their life and initiatives to increase BF practice targeting the whole population are needed. The decree on exclusive BF, which was signed by the president of Indonesia in March 2012 is a step in the good direction. Additionally sensitisation of the general population as well as the health providers to initiate breastfeeding immediately after birth and to prolong with exclusive breastfeeding until six months after delivery should be intensified also in Lao PDR (now estimated at 40%) and especially in the Philippines (estimated at 34% in 2008), where the industry opposition to the Milk Code continues and where - if passed into law - the recent House Bill titled “an Act Promoting a Comprehensive Program on Breastfeeding Practices and regulating the Trade, Marketing and promotions of Certain

0 2 1

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13 to 27 percentage point gap between lowest and highest

wealth quintile

Gap: 13

Gap: 15

Gap: 27

Percentage of deliveries by C-section in the

highest quintile is twice as high in the Philippines

compared to Lao PDR



Foods for Infants and Children“ would narrow down the Milk Code to an artificial feeding restriction for the age group of 0 to 6 months instead of the current 0 to 36. Figure 13: Percentage of early initiation of breastfeeding by residence, Indonesia (2007), Lao PDR (2011/12)

and the Philippines (2008)

Sources: Indonesia: IDHS 2007. Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008. Note: Early initiation of breastfeeding is defined as start of breastfeeding within 1 hour after birth.

Postpartum care is important for both mother and child in order to treat complications arising from the delivery, but also to provide the mother with important information on how to care for herself and her child. Because the first 48 hours are most critical in terms of complications, there is an increased importance of checking the health status of mother and newborn within the two days after delivery. Data on postpartum care for the newborn within the first 48 hours segregated by mother's education could not be obtained for all three countries and therefore the percentage of newborns weighed immediately after birth is used as a proxy indicator. The majority of babies whose mothers received higher education have been weighed at birth, in contrast to babies whose mothers had no education, with gaps ranging from 55 to 78% percentage points in Indonesia and Lao PDR respectively (see figure 14).

Figure 14: Percentage of newborn weight measured at birth by mother's education, Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008)


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1 to 10 percentage point gap between urban and rural, with more early breastfeeding in urban areas than in rural aras in Lao PDR,

with inverse situation in Indonesia and the Philippines

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The discrepancy decreases when their mothers received primary education. Other socio-economic and demographic characteristics (e.g. residence, region, income) may also influence the proportion of newborns weighted at birth. Strengthening healthcare services (with special attention for quality of care) and incessantly stressing the relevance of antenatal, childbirth and postpartum care with special focus on vulnerable socio-economic and demographic disadvantage groups, are likely to improve the utilisation rates of the above services. The combination of facility-based and community interventions will be the most effective approach to reach this goal. Late newborn stage Immunisation plays an important role in reducing newborn and child mortality. According to UNICEF and WHO guidelines25, an infant should receive BCG, DPT-Hep-Hib, polio and measles vaccination before the age of one year. Although immunisation is mainly relevant for the older infant and child, BCG immunisation coverage is a useful proxy indicator for the care provided to the newborn as BCG vaccination should be administered at birth, according to the immunisation schedule in Lao PDR and the Philippines, and within the first month after birth in Indonesia. The overall BCG coverage rates in Indonesia (78%26), Lao PDR (79%) and the Philippines (94%) are high, but show a difference of 13 to 36 percentage points between the lowest and highest wealth quintile for the Philippines and Indonesia respectively, despite vaccination being provided for free in all three countries (see figure 15). This is possibly due to the fact that women of the lowest quintiles are more likely to deliver at home and so to miss the opportunity of BCG (and Hepatitis B) vaccination. After delivery in a health facility, these vaccines are routinely administered before discharge, provided that the vaccines are not out-of-stock.

Figure 15: Percentage of BCG vaccination coverage by wealth quintile, Indonesia (2007), Lao PDR (2011/12) and the Philippines (2008)


25

The WHO Immunisation profile is available online for each country: http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileresult.cfm?C=idn. 26

The preliminary DHS report shows a BCG coverage rate of 89.3% in 2012.

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Lowest wealth quintile Highest wealth quintile

33 % point gap

between poorest

and richest

Gap: 36 Gap: 13

Gap: 26

http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileresult.cfm?C=idn



Continuous information sharing about the importance of skilled antenatal care and birth attendance, preferably in a well-equipped health facility, and the importance of postpartum services being provided there, and making these services easier accessible and acceptable for vulnerable groups could help to increase the vaccination coverage and to narrow the disparity in coverage. The above equity analysis shows and confirms that newborn care and services are inequitably accessible depending on socio-economic and demographic background. The poor, who are commonly overrepresented in the rural and more remote areas, and who in general complete less education, are therefore not only vulnerable due to their limited resources but also due to a lower education level, and constraints related to the place or region of residence. Equity and the way to reduce inequities should be considered in all policies, strategies, initiatives and interventions regarding improving newborn health. In its 2009 maternal, newborn and child health strategy the government of Lao PDR states that all maternal, newborn and child health interventions must reach the poorest and most marginalised households, including groups being marginalised by geographical, social, political, economic, and ethnic and gender factors in order to reduce the prevailing inequities in the country. The strategic plan 2010-2014 of the Indonesian MoH clearly states to reduce disparity in health and nutritional status between regions and between socioeconomic level and gender by 2014 (Kementerian Kesehatan RI 2011). As resources are limited, the MNCHN Strategy of the Philippines specifically prioritizes the areas with poor maternal and newborn health performance, large populations with poor and less educated mothers, and that are geographically and disadvantaged, as these areas are at higher risk for adverse maternal and neonatal outcomes. Several initiatives, such as the free MNCH policy in Lao PDR, the implementation of conditional cash transfer and health insurance schemes in Indonesia and the Aquino Health Agenda in the Philippines, are likely to be instrumental in reducing existing inequities and increasing universal health coverage, especially for maternal and newborn care services. Targeted interventions to reach vulnerable (e.g. urban poor) and excluded groups in remote areas must be included in the national policies as well.

SWOT analysis

Based on the current status of the newborn policy and health system context in Indonesia, Lao PDR and the Philippines described in the two chapters above, the strengths, weaknesses, opportunities and threats of these policies and the health system related to newborn care are summarised. Despite the differences found when comparing Lao PDR with two other countries with a significant lower newborn and under-five mortality, higher coverage of MNCH services and less donor dependency, several similarities were identified as well. These are presented in the tables below, followed by country-specific observations. Newborn health policies In the three countries comprehensive newborns policies, linked to or being part of the national MNCH policies, were identified to be in line with international standards. Although newborn-related policies are available, the implementation of these policies was found to be challenging in the three settings. Fragmentation of the health sector was found to be an important reason for hampering the efficient implementation of these policies. The decentralised health sector makes context-specific adaptation of the newborn policies possible, but due to limited management skills and capacity at decentralised level (regions, provinces and districts) this opportunity is often missed. See table 17.



Table 17: SWOT analysis of newborn health policies

Strengths Weaknesses

Comprehensive newborn policies in line with international standards

Poor implementation of the newborn policies

Opportunities Threats

Decentralisation of the health sector makes it possible to adapt newborn policies to the local context and needs

Fragmented MoH structure may hamper continuum of care, prioritisation and efficient implementation of newborn care and transparency and accountability

Health system building blocks with focus on newborn 1. Service delivery The biggest challenge in service delivery is how to increase the coverage of (maternal and newborn) services along the continuum of care. Although newborn care is integrated in the MNCH services, routine newborn services and management of newborn complications are often not provided. Insufficient coverage is also due to difficulties in accessing care, with financial and geographical barriers being the most prominent. Large socio-economic and demographic disparity in utilisation of the MNCH services was found in all three countries. The availability of EmOC services is increasing in all assessed countries, but remains far from sufficient. A matter of consideration is the implementation of universal HIV screening of pregnant women. See table 18.

Table 18: SWOT analysis of health service delivery for newborns


Newborn care integrated in MNCH services

EmOC services are available

Insufficient coverage of EmOC services

Limited quality support of maternal and newborn services and care (supervision & mentoring)

Poor monitoring of and cooperation with the private health sector

Poor newborn referral system

Financial and geographic access to services

Socio-cultural and demographic disparity in coverage of services

Weak mid-level management (regional/provincial /district/municipality level) hampering the health service delivery


Regulate and cooperate with the private (for-profit and not-for-profit) sector in order to improve access to newborn services

More focus on maternal than on newborn care

Country specific findings Community organisation of services was found to be strong in Indonesia and the Philippines with the availability of village midwives and community health volunteers in Indonesia and the availability of community health teams in the Philippines. This component was found to be rather weak in Lao PDR where outreach clinics in the communities cannot sufficiently provide the services and care needed for newborns. Health insurance schemes introduced in Indonesia and the Philippines with the aim to improve access to newborn care with focus on the poor have challenges in both countries. In both counties it is also noticed that more is needed to decrease socio-economic disparity in coverage of newborn care than offering free care. A wider sensitisation and specifically targeted interventions, including improving distribution of services, are needed to reach the disadvantaged groups.



Socio-cultural barriers to newborn care were identified in all three countries. It is important to consider these barriers and adapt sensitisation and information regarding newborn care to locally acceptable beliefs and practices. 2. Human resources Upgrading the quality of pre-service training to improve the knowledge and skills of medical doctors, midwives and nurses to manage normal deliveries, to provide essential newborn care, to recognise neonatal complications and to make timely referrals could reduce neonatal morbidity and mortality. Unequal distribution of human resources for health and staff retention problems make service delivery challenging, especially in remote regions. See table 19.

Table 19: SWOT analysis of human resources for newborns


See county specific findings below Lack of knowledge and skills on newborn care, despite training

Unequal distribution of HR, especially in rural and remote regions


Further providing and upgrading quality of pre-service training for all cadres

Decentralisation may provide opportunities to addressed HR issues locally and human resource planning can be adapted to the local context and needs, e.g. use task shifting

Retention problems

Country specific findings In Indonesia and the Philippines enough midwives and nurses are annually trained and are available. This in contrast with the situation in Lao PDR where there is a staff shortage in all cadres. However also in Indonesia and the Philippines there is a shortage of nurses and midwives in remote regions due to unequal distribution of the staff and retention problems. In Indonesia there is a shortage of paediatricians and gynaecologists/obstetricians, while in the Philippines enough specialists are available, although as said, not equally distributed over all regions. In Indonesia and the Philippines the lack of adequate human resource planning was also recognised as weaknesses in HR management. 3. Health financing Health insurance schemes exist in all three countries. In Lao PDR health insurance coverage remains low with less than 20% of its target population covered while in the Philippines an increasing number of disadvantaged and vulnerable families are covered. Unfortunately, the indigents are often not sufficiently aware of the benefits of the programme, and might still not have access to healthcare services due to concerns about high out-of-pocket spending. In Indonesia maternal and newborn care is free for all Indonesians since January 2011, but the fact that transport costs are not covered by health insurance hinders access to services by the poor and in remote areas where transport costs can be high. See table 20.

Table 20: SWOT analysis of health financing for newborns


Health insurance schemes covering maternal and newborn care exist

Government expenditure on health is low


Inclusion of vulnerable groups in insurance program

Administrative requirements for health insurance difficult to achieve or not in place



Country specific findings In Indonesia and the Philippines a threat identified is the presence of administrative requirements that are difficult to reach or not in place, e.g. accreditation requirements for health facilities in the Philippines. In Indonesia the administration of health insurance is complex and health facilities are often not equipped to manage the increased number of patients caused by the introduction of the health insurance which might have an impact on the quality of provided care. In the Philippines health facility requirements for health insurance accreditation are difficult to achieve causing a slow increase in number of accredited facilities in rural areas. In the Philippines pay for performance schemes run by the government and by the health insurance are opportunities to improve the local government performance and the quality of provided care. In Lao PDR no mainstream government budget is available for full roll-out of policy of free delivery and free healthcare for children under five. 4. Essential drugs and commodities Improving the supply chain for essential medicine is an absolute priority issue when implementing measures to scale-up newborn care, and to avoid out-of-pocket spending in case drugs need to be bought outside the health facility. With an improved supply chain and available essential drugs, there is still a need for clear regulations regarding the administration of life-saving drugs by nurses, midwives and community health volunteers. Allowing these health professionals to administer these drugs might save lives, especially in those areas where no doctor or other health professional who is allowed to administer these drugs is available. See table 21.

Table 21: SWOT analysis of essential drugs and commodities for newborns


All drugs needed for maternal and newborn care are on the essential drugs list

Stock-outs of essential drugs and commodities are common, especially at primary healthcare level

Poor drug procurement Opportunities Threats

Authorise midwives/nurses/community health volunteers to administer life-saving drugs

See county specific findings

Country specific findings Limited knowledge on storage and use of drugs and commodities among health providers was identified in Indonesia and Lao PDR. The focus on high costs equipment and drugs even when essential commodities were not available, was identified as a threat in Indonesia and the Philippines. Traditional medicines are still very important in Indonesia and Lao PDR. 5. Health information system Many data is being collected from the community level up to the central level. Data management is a challenge, especially as there are so many different levels involved. At provincial and district level limited capacity and skills to collect, analyse and interpret data are a problem. The fact that definitions regarding health status or health service may not be uniformly interpreted results in low validity of data (see example of stillbirth and preterm birth). Another weakness is that data from the private sector are not included in the reporting. See table 22.



Table 22: SWOT analysis of health information system for newborns


Infrastructure to collect public sector data from community up to central level is in place

Neonatal and perinatal death audits are not or not regularly performed

At provincial and district level limited capacity and skills to collect, analyse and interpret data

No system to collect data from the private sector Opportunities Threats

Conduct/reinforce neonatal and perinatal death audits

Weak governance of the health information system

6. Leadership and governance A focal person who advocates for newborn care has been assigned at the Ministry of Health of each country assessed. However, translating policy into practice is a challenge. Roles of authority in addressing newborn care is being multiplied over different MoH departments/units/centres. See table 23.

Table 23: SWOT analysis of leadership and governance for newborns


Focal point assigned for newborn care Poor management capacity and skills at provincial and district/municipality level

Weak coordination due to fragmentation of MNCH strategy over multiple departments

Lack of stewardship (at central level) and clear roles of authority

Lack of collaboration with the private sector

Limited collaboration with professional associations


Focal point to take leadership on maternal and newborn care

Decentralisation with limited capacity and skills of mid-level management (provincial/district)

Country specific findings In Lao PDR a threat regarding leadership and governance is the insufficient government funding available to fully implement MNCH strategy and full roll-out of free delivery and free MNCH. In Indonesia high turn-over of management staff at provincial and district health offices is a treat to strong governance. Newborn care Quality of newborn care was recognised during this assessment as a major concern since not all maternal and newborn services are performed adequately in the assessed countries. Limited quality of newborn care was identified at primary healthcare level as well as referral level and for routine newborn care as well as for the management and treatment of newborn complications and emergency newborn care. Also socio-cultural and demographic disparity in quality of care exists with lesser quality of care found in the lower wealth quintiles, in rural areas and among less educated mothers. See table 24.



Table 24: SWOT analysis of newborn care


Newborn care is integrated meaning promotional, preventive and curative care are provided at the same consultation

Quality of newborn care (primary healthcare and referral care) is often limited

Socio-cultural and demographic inequity in quality of provided care

Lack of supervision and quality control system Opportunities Threats

Upgrade/organise supporting supervision/ mentoring

Upgrade quality of pre-service and in-service training

Loss of trust in health system because of poor quality of care causing decrease of utilisation of health services



FINDINGS AND RECOMMENDATIONS

Observations and findings on different aspects of newborn care are described in detail in the three comprehensive needs assessment reports. The main cross-country findings and recommendations are summarised in this chapter. When substantial differences were observed, it is indicated to which country they relate.

Main findings

The main findings related to newborn care in the three countries are:

1. Insufficient progress has been made in reducing newborn mortality. Newborn mortality has slowly been decreasing, but is still relatively high. There is still insufficient insight in the causes of mortality, as neonatal death audits are not or not regularly enough conducted.

2. Comprehensive newborn policies in line with international standards exist although the implementation of these policies is poor.

3. The quality of newborn care at primary healthcare and referral level is generally substandard. Monitoring of quality of newborn care and supervision are suboptimal.

4. Access to skilled health providers, mainly in rural and remote areas, remains limited, not only due to unequal distribution or lack of health staff and financial and geographic barriers but also because of local beliefs and practices.

5. Decentralisation of the health system brought opportunities and threats. An important

opportunity is the possibility to tailor healthcare to the local context and needs, but a

main threat is the often weak management encountered at provincial and district level.

6. Fragmentation of newborn care across several MoH departments hampers prioritisation and efficient coordination and implementation of newborn care.

7. Socio-economic and demographic inequities in maternal and newborn care are considerable despite the introduction of several initiatives and programmes addressing these inequities.

8. Lack of regulation of and cooperation with the private sector in Indonesia and the Philippines.

Recommendations

General recommendations 1. Improve governance and leadership to enhance implementation of newborn policies among

others through:

Defining clear responsibilities and roles of authority for all departments and all administrative levels (central/regional/provincial/district/municipality level) involved in newborn care.



Implementing measures to reduce the fragmentation in several departments and units at the provincial and district health offices to enhance efficiency and to increase transparency and accountability regarding newborn care.

Improving management skills and capacity in planning, budgeting, supply chain management and quality control/supervision at provincial and district/municipality level through a system of learning from a ‘model’ district. Identify provinces, districts/municipalities where newborn health is well managed. Link these to provinces, districts/municipalities where the quality of management is sub-standard so they can learn from the good examples they see. A system of mentorship where staff from the ‘model’ provinces, districts/ municipalities support the others should be established.

For Indonesia and the Philippines; cooperating with and regulation of the private sector in order to improve access to newborn care and to guaranty quality of newborn care. In order to achieve this in Indonesia the existing government regulation bodies should be made functional, in the Philippines a regulation system should be established.

2. Improve access to newborn care and services in difficult to reach/remote areas among others

through:

Facilitating staff retention, for example by selecting for training someone from the remote village to increase the changes that once trained the health worker/midwife will go back and stay in his/her remote village27. The Philippine Rural Health Team Placement Program could be an effective measure, as long as it is well managed and made sustainable.

Using task shifting (e.g. the community health volunteer administers injectable antibiotics for the newborn when no skilled health worker is available, the general practitioner conducts CSs) when skilled staff is not available. Task shifting should be context-specific and limited in place and time. The availability of good in-service training and a well organised and functioning clinical supervision is a precondition for task shifting.

Making community health workers, midwives, nurses available to provide home-based delivery and/or post-partum care.

For Indonesia and the Philippines; ensuring sufficient availability of ambulances and boats for referral and cover transport costs for people living in remote areas by the health insurance as transport cost can be very high in these areas.

Maternity waiting homes may be an option to increase access to newborn care but feasibility and acceptability of these homes need to be investigated before establishing them.

3. Increase the number of deliveries by skilled birth attendants and at health facilities among

others through all those recommendations mentioned under ‘recommendation 2’ and:

Improving the availability of facilities providing good quality of EmOC (for good quality of care see ‘recommendation 4’).

4. Improve quality of newborn care among others through:

Improving quality of newborn care by a system of learning from ‘model’ health facilities/ centres of excellence. Identify facilities that provide good quality of newborn care. Link these with health facilities where the quality of provided care is sub-standard so they can learn from the good examples they see. A system of mentorship where staff from the ‘model’ institutions/ centres of excellence support the others should be established.

Strengthening supporting supervision/mentoring for all health facilities and for all health workers.

27

This is already done in some areas in Indonesia. In this case it is recommended to conduct some research on the outcome of this strategy.



Guaranteeing quality of pre- and in-service training on newborn care for all level health workers.

Cooperating with professional associations, more specifically the associations of obstetricians/ gynaecologists and paediatricians. This may be needed to prepare clear guidelines and to implement the best possible newborn care. Identification of champions in newborn health and their involvement and advice in newborn health discussions and programming in should be considered.

Reinforcing neonatal death and perinatal death audits or putting these in place if they were not preformed yet.

Strengthening the referral system by health staff referring in time to health centre (for normal delivery) or to district hospital (if complications are expected).

Improving drugs and commodities procurement. For this, procurement management at health facility, district and province level needs to be upgraded.

5. Minimize socio-economic inequities in newborn health among others through:

In Lao PDR firm commitment of the government to ensure that funds are available to roll out the free delivery and free under-five health services is required.

In Indonesia and the Philippines the administration of the health insurance schemes should be made less complex and health insurance schemes should also cover transport costs for poor and for people living in remote areas.

In Indonesia interventions focussed on urban poor are needed (including improved data collection on urban poor and newborn care).

6. Increase demand for newborn care among others through:

Making continuously efforts for health promotion, especially regarding delivery and postpartum care to be provided to both mother and newborn.

Always taking into account local beliefs and practices affecting maternal and newborn health. Providing context-specific health education and information on the importance of newborn care is needed in case local beliefs and practices hampering access to care are identified.

Community health workers should serve to build trust and link the communities with the formal health sector. They should refer and inform about the need for routine antenatal and postpartum visits.

7. Operational research is recommended in areas where improvement is required and where

information is missing. This includes among others research on; institutional delivery coverage, birth preparedness, community transport schemes, initiation of and exclusive breastfeeding, causes and management of preterm births and low birth weight, health workers attitude, staff retention strategies, quality of newborn care, impact of mothers nutrition status on the newborn.

8. One of the benchmarks assessed relate to the dissemination of local evidence on newborn survival. The assessment team suggests to use the country reports and this synthesis report to further discuss the findings and recommendations within the existing convening mechanisms on newborn care. Involvement of champions identified during the country visits should be considered. Country plans with specific actions for newborns should be elaborated in line with the work in progress of the regional Action Plan.

In the annex (annex 3) is a list with recommended newborn care to be provided the first month of life. The list is based the WHO documents ‘Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice, 2006’ (WHO 2006), ‘WHO Recommended Interventions for Improving



Maternal and Newborn Health, 2009’ (WHO 2009) and ‘WHO Technical consultation on postpartum and postnatal care, 2010’ (WHO 2010b).


Annexes - Page | 1

ANNEXES

Annex 1: Equity indicators

Table 25: Early childhood mortality, by socio-economic and demographic background, Indonesia (2007/12)1,

Lao PDR (2011/12) and the Philippines (2008), (%)

Mortality / Background characteristic

Indonesia1

Lao PDR

Philippines

Neonatal mortality rate (per 1,000 live births)

Residence Urban 18 22 13 Rural 24 39 20

Mother's education2

No education 39 44 37

Primary 23 35 16 Secondary + 14 22 11

Wealth quintile Lowest 27 40 20 Second 25 47 19 Middle 19 43 15 Fourth 17 17 15

Highest 17 18 10 Total 19 (19) 36 16 Under-five mortality rate (per 1,000 live births)

Residence Urban 38 45 28 Rural 60 100 46

Mother's education1

No education 94 116 136

Primary 56 91 48 Secondary + 32 41 18

Wealth quintile Lowest 77 120 59 Second 56 109 38 Middle 44 85 32 Fourth 36 53 27

Highest 32 33 17 Total 44 (40) 89 34 Sources: Indonesia: IDHS 2007 and IDHS 2012 (Preliminary Report) Lao PDR: LSIS 2011/12. The Philippines: PDHS 2008. Notes: 1

If data is available in the IDHS 2012 – Preliminary Report, this data is given in brackets. 2

Only those education levels that are have comparable levels as reported on in the respective DHSs in the three countries are given in this table. ‘Primary’ is ‘Elementary’ in the PDHS and ‘Complete primary’ in the IDHS. ‘Secondary +’ is ‘Higher’ in the LSIS and ‘College’ in the PDHS.


Annexes - Page | 2

Table 26: Coverage of MNCH services, by socio-economic and demographic background, Indonesia (2007/10/12)

1, Lao PDR (2011/12) and the Philippines (2008), (%)

MNCH service/ Background characteristic

Indonesia1

Lao PDR

Philippines

Women receiving ANC (at least one visit) from a skilled provider3

Residence Urban 97.7 (98.2) 83.4 94.2 Rural 90.1 (93.3) 45.9 88.1

Mother's education2

No education 62.6 (64.0) 23.1 44.0

Primary 92.4 (94.0) 56.1 80.6 Secondary + 99.1 (98.6) 93.0 97.1

Wealth quintile Lowest 82.2 22.9 77.1 Second 92.1 42.1 91.4 Middle 95.5 62.0 95.9 Fourth 98.5 77.1 97.6

Highest 99.2 91.7 98.3 Total 93.3 (IDHS) (95.7) 54.2 91.1 Women who delivered by a skilled provider

3

Residence Urban 87.6 (91.8) 79.6 77.5 Rural 62.7 (74.6) 30.7 47.7

Mother's education2

No education 31.5 (31.8) 16.1 10.9



Highest 95.4 90.7 94.4 Total 73.0 (IDHS) (83.1) 41.5 62.2 Women who delivered in a health facility Residence

Urban 70.3 (80.0) 74.2 59.2 Rural 28.9 (46.7) 27.0 29.8

Mother's education2

No education 15.4 (21.1) 15.0 6.3



Highest 83.3 87.4 83.9 Total 46.1 (IDHS) (63.2) 37.5 44.2 Deliveries by caesarean section Residence

Urban 11.0 10.0 13.8 Rural 3.9 1.9 5.3

Mother's education2

No education 2.6 0.6 0.0

Primary 2.9 2.5 2.2


Annexes - Page | 3


Indonesia1

Lao PDR

Philippines

Secondary + 13.1 18.1 20.8 Wealth quintile

Lowest 1.8 0.1 1.3 Second 4.5 1.1 5.1 Middle 5.1 2.2 7.3 Fourth 7.3 5.7 15.5

Highest 16.8 13.1 27.7 Total 6.8 (IDHS) 3.7 9.5 Early initiation of breastfeeding (within 1 hour of birth) Residence

Urban 41.6 46.7 52.5 Rural 45.5 36.9 54.4

Mother's education2


Primary 44.8 37.8 55.2 Secondary + 40.2 56.6 48.3


Highest 40.0 49.1 50.3 Total 43.9 (IDHS) 39.1 53.5 Women who received postpartum care within 2 days Residence

Urban 69.1 69.5 78.3 Rural 70.6 30.9 75.6

Mother's education2


Primary 71.3 34.4 71.1 Secondary + 72.8 90.2 82.8


Highest 67.8 81.9 84.0 Total 70.3 (IDHS) 39.5 76.9 Children age 12-23 months who received BCG Residence

Urban 85.3 (93.7) 86.3 96.2 Rural 70.2 (85.1) 75.8 91.6

Mother's education2

No education 59.2 (52.0) 62.0 45.7



Highest 90.9 95.1 98.3 Total 77.9 (MoH)

85.4 (IDHS) (89.3) 78.3 93.9

Exclusive breastfeeding (< 6 months)


Annexes - Page | 4


Indonesia1

Lao PDR

Philippines

Residence Urban 25.2 38.2 n.a. Rural 29.3 41.0 n.a.

Mother's education2

No education n.a. 45.1 n.a.

Primary n.a. 35.0 n.a. Secondary + n.a. (45.6)

5 n.a.

Wealth quintile Lowest 34.7 46.6 n.a. Second 30.5 39.7 n.a. Middle 26.6 41.8 n.a. Fourth 19.9 36.8 n.a.

Highest 17.5 34.1 n.a. Total 61.3 (MoH)

4

32.4 (IDHS) (41.5) 40.4 34.0

Children age 12-23 months who received DTP3 Residence

Urban 67.9 (77.1) 67.7 88.2 Rural 55.9 (67.2) 51.7 82.9

Mother's education2

No education 28.7 (25.9) 33.4 35.8



Highest 86.3 81.4 94.0 Total 61.9 (MoH)

66.7 (IDHS) (72.0) 55.5 85.6

Percentage of demand satisfied among currently married women Residence

Urban 87.7 (87.4) 73.2 71.7 Rural 86.8 (88.3) 70.7 67.0

Mother's education2

No education 79.9 (83.0) 59.5 39.3



Highest 88.6 73.4 70.9 Total 87.2 (IDHS) (87.9) 71.4 69.4

Sources: Indonesia: IDHS 2007, IDHS 2012 (Preliminary Report) and Indonesia Health profile 2010 (MoH - Republic of Indonesia 2011) Lao PDR: LSIS 2011/12 Philippines: PDHS 2008 Notes: 1

If data is available in the IDHS 2012 – Preliminary Report, this data is given in brackets.


Annexes - Page | 5

2 Only those education levels that are have comparable levels as reported on in the respective DHSs in the

three countries are given in this table. ‘Primary’ is ‘Elementary’ in the PDHS and ‘Complete primary’ in the IDHS. ‘Secondary +’ is ‘Higher’ in the LSIS and ‘College’ in the PDHS. 2

Skilled provider includes doctor, nurse, midwife, and auxiliary nurse/midwife. 4

Total exclusive breastfeeding <6 months is reported to be 61.3 % in the Indonesia Health profile 2010. However when looking at the percentages of exclusive breastfeeding <6 months per sex, residence and wealth quintile, given in the same report, these percentages are a lot lower and more in line with the percentage 32.4% of total exclusive breastfeeding <6 months given in the DHS 2007. 5

Figures in parentheses are based on 25-49 un-weighted cases


Annexes - Page | 6

Annex 2: Readiness for scaling up newborn care in Indonesia, Lao PDR and the Philippines

The "Scale-up Readiness Benchmarks" developed by Save the Children was applied to assess and map the country's readiness for scaling up newborn care. The tool, consisting of a set of scale-up readiness benchmarks, is part of the "framework for action and analysis" which was developed in the context of the Saving Newborn Lives programme (Moran et al. 2012). This assessment tool consists of several benchmarks that measure the degree to which the country's health system and national programmes are ready to deliver interventions for newborn survival at scale, and is divided in three categories: (1) Agenda Setting, (2) Policy Formulation, and (3) Policy Implementation, having respectively 6, 13 and 13 benchmarks28. After analysis and discussion, each benchmark was marked ‘achieved’ (green), ‘partially achieved’ (orange) or ‘not achieved’ (red). These traffic light colours give a snapshot of the country's readiness to scale up newborn care programmes. The benchmark tool leaves room for interpretation and discussion since no guidelines on definitions (what exactly is meant with the benchmark?) and scope (is the benchmark referring to the situation at national or subnational level?) exist. The use of the benchmark tool is also limited as many stakeholders lack information on the issues brought forward in the tool and are thus unable to participate in a discussion on the achievements. To tackle this deficiency, clarifications on the reasoning behind the classification of the benchmarks as achieved, partially achieved or not achieved are included in the country reports.

Table 27: Benchmarking status for agenda setting, selected countries

Agenda Setting (6 benchmarks) Indonesia Lao PDR Philippines

National needs assessment for newborn conducted

Local evidence generated for newborn survival

Local evidence disseminated on newborn survival

Existence of a convening mechanism for newborn health issues

Focal person for newborn health in Ministry of Health

Key maternal and newborn indicators included in national surveys

28

In the terms of reference of this assignment the list of benchmarks was longer than the 27 benchmarks originally used in the Save the Children tool. This is mainly because some of the original indicators are split in two (e.g. on the audits system or the resource requirements).


Annexes - Page | 7

Table 28: Benchmarking status for policy formulation, selected countries

Policy Formulation (13 benchmarks) Indonesia Lao PDR Philippines

National newborn policy endorsed

Newborn policy integrated into other health policies or strategies

National behaviour change communication strategy

Essential drug list includes injectable antibiotics for primary level care

Midwives authorized to perform neonatal resuscitation

Community-based cadres authorized to administer injectable antibiotics for newborn infections

Primary level cadres authorized to administer injectable antibiotics for newborn infections

Community-based cadres authorized to perform neonatal resuscitation

Primary level cadres authorized to perform neonatal resuscitation

Key maternal and newborn indicators included in national health information systems

National targets to track newborn health established

Reproductive, maternal, newborn and child health expenditure per child under five and per woman aged 19–

49

Costed implementation plan for maternal, newborn and child health


Annexes - Page | 8

Table 29: Benchmarking status for policy implementation, selected countries

Policy Implementation (13 benchmarks) Indonesia Lao PDR Philippines

Cadre identified for home-based newborn care

In-service newborn care training materials for community-based cadres

In-service newborn care training materials for facility-based cadres

Pre-service newborn care education for community-based cadres

Pre-service newborn care education for facility-based cadres

Supervision system for maternal, newborn and child health established at primary health centre level

Protocol or standard for district hospital care of sick newborns in place

Integrated Management of Childhood Illness algorithm adapted to include the first week of life

Resource requirement for scaling up home-based newborn care available

Resource requirement for primary healthcare level available for newborns

Resource requirement for secondary level healthcare available for newborns

System for neonatal death audits exists

System for perinatal death audits exists

Note: Because no community-cadres exist in Lao PDR the benchmarks on in-service and pre-services newborn care training for community-based cadres have been left white because these are not applicable since community workers are currently not part of the public health system.


Annex 3: International recommendations for routine newborn care and essential interventions

Recommended WHO guidance for care in the postpartum period includes examination within one hour of delivery of the placenta, observation for at least 24 hours, and routine examinations at 2 days and 6 weeks. For women with identified additional needs, more frequent care is advocated. The components of care are summarised in table 27. Newborns can receive routine care at an appropriate level for them and if identified with complications or additional risk factors can be treated or referred to the next level of care. Where a healthy, term baby has been born in an uncomplicated delivery, most guidelines call for the dyad to stay under observation by a skilled attendant for 24 to 48 hours. If mother and baby are discharged from the facility sooner than 48 hours, a qualified professional or skilled attendant should assess them within 24 to 48 hours after discharge. Evidence base newborn postpartum interventions that tackle challenges and particular areas of risk for the newborn are also given in table 27.

Table 30: International recommendations for routine newborn postpartum care and interventions (WHO 2006, WHO 2009, WHO 2010b)

Routine care and interventions Interventions, if required Newborn care immediate after childbirth (first hour)

Immediate thermal care, in skin-to-skin contact with the mother

Check vital signs (breathing)

Assess need for urgent intervention

Examine for anomalies

Apply antimicrobial to eyes

Administer vitamin K

Dry newborn (do not remove vernix or bathe the baby)

Hygienic cord and skin care

Initiate breastfeeding

Neonatal resuscitation and ventilation for babies who do not breathe at birth (birth asphyxia management)

Refer if problems are present that cannot be managed at the healthcare level where the baby was born

Immediate (first 24 hours), early (48 hours) and late (6 weeks) newborn care (visit from/at home)

Weigh the baby – assess weight gain

Assess and support breastfeeding – alternative feeding methods

Assess newborn’s warmth

Assess for infection

Assess jaundice

Assess danger signs

General health education – baby care, hygiene

Awareness of danger signs

Immunize if due (BCG, hepatitis B, oral polio vaccine)

Bed-nets (in malaria endemic regions)

Rooming-in

Kangaroo mother care for preterm (premature) babies and babies weighing less than 2,000 grams

Extra support for feeding small and preterm babies

Management of newborns with jaundice

Prophylactic antiretroviral therapy for babies exposed to HIV

Presumptive antibiotic therapy for newborns at risk of bacterial infection

In preterm babies continuous positive airway pressure to manage babies with respiratory distress syndrome

Surfactant to prevent respiratory distress syndrome

Case management of neonatal sepsis, meningitis and pneumonia

Refer if problems are present that cannot be managed at the healthcare level where the baby was born


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impacts of a national health insurance program and franchise midwife clinics on achievement of prenatal and delivery care standards in the Philippines’ Health Policy, 92(1), 55–64.

Batangas, D.B. (2005) Medicine prices, availability, affordability and price components, World Health

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community-based perinatal care: results from a pilot study in rural Pakistan', Bulletin of the World Health Organization, 86(6), 452-9.

Blencowe, H., Cousens, S., Oestergaard, M. Z., Chou, D., Moller, A. B., Narwal, R., Adler, A., Vera

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community level: A profile of the Republic of the Philippines, Human Resources for Health Knowledge Hub and Burnet Institute, Sydney, Australia.

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comprehensive needs assessment of newborn care in selected

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