Preview: National committee donor toolkit A regional approach
UNICEF aims for equity in health in Central and Eastern Europe and the Commonwealth of Independent States
ABOUT THIS PREVIEW The UNICEF CEE/CIS Regional Office is breaking new ground to produce the first ever National committee donor toolkits with a regional focus. The toolkits will focus on three themes: Early Childhood Development, and Maternal and Child Health and Nutrition, and Most-at-Risk Adolescents, making the case for crossregional investment in cross-cutting issues. All three kits will be available in May 2011.
Introduction UNICEF CEE/CIS is launching a new cross-regional Health and Nutrition Strategy that aims for equity and quality in health services. The strategy focuses on the countries with the highest infant and child mortality rates in the region: Azerbaijan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan. The story of health in the CEE/CIS region is a story of fragile progress, disparities and a failure to adapt to harsh new realities. While many countries have made progress on key health indicators, including the Millennium Development Goal (MDG) targets, some countries and communities are being left behind. Meanwhile, the ‘cradle to grave’ health services that were once the norm in the region are deteriorating, while the remaining services struggle to cope with new health risks linked to growing social deprivation, including malnutrition and the spread of HIV and AIDS. Last year, the region was confronted with an outbreak of polio – a disease that was once eradicated in this part of the world. The outbreak highlighted serious weaknesses in routine immunization, showing what happens when you drop your guard on health services. The new UNICEF CEE/CIS Health and Nutrition strategy aims to restore some balance, and address the issues that prevent everyone having an equal chance of access to good quality health care. It will work ‘upstream’, influencing health policy and spending, and ‘downstream’, supporting and rolling out examples of best practice. It will take a cross-sectoral approach – recognising that health issues go
This Preview sets out the ‘headlines’ from the forthcoming kit on Maternal and Child Health and Nutrition. It provides a snapshot of our results in this area, and a glimpse into the lives of those we have reached. Our goal is to stimulate feedback from National committees as we prepare the full toolkits, and all comments are welcome.
beyond health services – and cover a group of countries. The strategy aims to help health systems protect and promote the rights of children and contribute to the achievement of all of the MDGs – not only those related to health. Background While the CEE/CIS Region is broadly on track to reach the health-related Millennium Development Goals (MDG1 on hunger, MDG4 on child mortality and MDG5 on maternal mortality) there are alarming health disparities between countries in the region and, within countries, between geographic areas and population groups. Countries in Central Asia and the Caucasus have child mortality rates that are far higher than the regional average. In many countries the under-five mortality rate (U5MR) is between 50 and 100 per cent higher in the poorest families than in the richest and there are similar disparities by gender, level of maternal education, location (whether urban or rural), ethnicity and mother tongue. Chronic malnutrition, exa-cerbated by poverty and rising food prices, is reflected in high rates of stunting. Progress on MDG6 – combating HIV/AIDS, Tuberculosis and other diseases – is simply inadequate. The region has the fastest growing
HIV epidemic worldwide, and many countries are seeing a resurgence of vaccine-preventable diseases including, most recently and alarmingly, the spectre of polio in a region once declared polio-free. New health concerns include mortality rates among children aged 5 to 18. Far too many are dying as a result of injuries, violence, substance abuse, traffic accidents and suicide. Then there are the threats posed by social deprivation, including impaired child development, child abandonment, maltreatment and institutionalization. Overall, limited access to health services – and the poor quality of those health services – is undermining child well-being and contributing to child poverty. What is going wrong? The CEE/CIS region is known as a region that has tackled health reform while reducing infant and child mortality. The problem is that the two processes have not been aligned. And, as the polio outbreak has shown, the progress made to date is fragile. A review of the impact of health system reforms in the region suggests that they have improved the sustainability of health systems, but this has not always translated into better services for mothers and children.
What is missing? • Equity. Health system reforms have, in some cases, even increased inequalities in maternal and child health and in health. • Quality of care. The reforms have not ensured good quality care in terms of safety, effectiveness and patient responsiveness, or in providing a continuum of care for children from conception through to adolescence. • Continuity and integration of care. The reforms have not forged strong enough links between families and health services, or between health, education and social services – links that are crucial for wider issues of health and well-being. • A public health approach. Health systems are failing to recognise or respond to the social factors, such as poverty and exclusion, which undermine the health of mothers and children. These four gaps need to be filled, to tackle the old and new threats to child health and well-being in the region. About the strategy UNICEF’s new health strategy aims to influence health policy at the highest level, while scaling up successful health initiatives in the five countries with the highest child mortality rates in the region: Azerbaijan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan. The aim is to create Mother and Child Friendly Health Systems to tackle the old and new threats to child health and well-being. These are systems that not only ensure the survival and health of mothers and their children, but also improve the quality of life, as well as child growth, development and protection. It means moving from a fragmented approach to specific
POLIO IN 2010 “Even if one non-immunized child is left in the village, it would be like a bomb for all the children in the village and the area, because everyone should be vaccinated without exception. We are all responsible for them.” Umeda Sadykova, Health and Nutrition Programme Assistant, UNICEF Tajikistan The polio outbreak that erupted in Central Asia in April 2010 was the first since 1998 and a major setback in a region that was declared polio-free in 2002. The outbreak exposed underlying weaknesses in health systems, which were consistently failing to meet the regional vaccination coverage target of 95 per cent. These weaknesses included various barriers that prevented people accessing immunization services, as well as low service quality, inadequate funding, vaccine shortages, cold chain failures, sub-standard training and supervision, weak district health management and the erosion of the primary health care work force. These problems, combined with poor public communication and a resulting fall in demand for immunization, let polio back in. The outbreak spread rapidly in the region but was concentrated in Tajikistan, which accounted for 70 per cent of the world’s polio cases at the peak of the epidemic. Most of those affected were children. The UNICEF Regional Office for CEE/CIS, and the Supply and Programme Divisions responded immediately in collaboration with World Health Organization and the Centers for Disease Control, supplying vaccines, communication and social mobilization and field monitoring to support 24 mass immunization campaigns in seven countries. UNICEF delivered more than 50 million doses of oral polio vaccine worth $8 million, and spent more than $1 million on mass communication materials and social mobilization at community level. The swift response by the affected countries contained the outbreak and has paved the way for stronger routine immunization. The last polio case was identified in the region in September 2010, but there is still a risk that the entire European Region could lose its polio-free status as a esult of the 2010 Central Asia outbreak.
health issues towards a comprehensive approach to health systems as a whole. Priority areas: Working closely with partners, UNICEF will provide policy advice, based on solid evidence, for the delivery of an equitable continuum of care. We will advocate for, and support, social mobilization to stimulate awareness of, and demand for, good quality mother and child health services.
We will build the capacity of institutions to: •Monitor equity in access to health services and in the planning of investments in more equitable health systems for women and children •Strengthen the delivery of health services, particularly at family and community level, and empower families and communities to ensure that they have access to early childhood development interventions •Strengthen public health approaches, with a particular focus on: health education and promo-
A vision for 2015
How the money would be spent:
The goal is to achieve the following vision by 2015: • The most vulnerable women and children have access to a good quality, evidence-based continuum of care that is contributing to the achievement of MDGs 4 and 5 in priority countries and population groups • A service delivery model is being scaled up to promote the continuity and integration of care, in its broadest sense, at family and community level, safeguarding and improving child-care practices and the protective environment that surrounds children and families • National and local institutions are able to manage effective health programmes for women and children, with a particular focus on the equity and quality of care • National institutions are able to communicate on public health priorities that relate to women and children and in crisis situations, and are ensuring the sustainability of immunization and nutrition programmes.
WHY THIS STRATEGY MATTERS TO NATIONAL COMMITTEES Despite the overall progress in the CEE/CIS region on MDGs 4 and 5, there are a number of countries (Azerbaijan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) that are lagging behind and are in danger of falling even further back, as the recent polio outbreak demonstrated. The 2010 polio outbreak in Central Asia, for example, has now jeopardised Europe’s polio-free status. TOTAL FUNDING REQUIRED UNICEF needs a total of $8.5 million (approx. Euro 6.2 million) to cover five priority countries for 2011 and 2012: Azerbaijan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan.
To share comments or find out more, please contact: Octavian Bivol, Regional Advisor on Health Systems and Policy Telephone: +41 22 909 5549 Email: obivol@unicef.org The UNICEF CEE/CIS website contains a wealth of information on health issues across the region, including human interest stories. Full URL: http://www.unicef.org/ceecis A photo essay captures the key moments of the 2010 polio outbreak and UNICEF’s response.
Full URL: http://www.unicef.org/ceecis/14433.html
• Strengthening national systems to monitor the equitable provision of the continuum of care for women and children ($500,000) • Building the capacity of health workers to deliver life-saving packages of interventions, based on sound evidence ($1.75 million) • Strengthening the capacity of institutions to improve the quality of maternal and child health services ($1.5 million) • Empowering families and communities, and communication on health issues ($1.5 million) • Strengthening health systems to provide effective public health interventions ($1.5 million) • Providing life-saving, cost effective health equipment for women and child ($1 million) • Evaluating and documenting the impact ($250,000) • Providing technical support ($500,000)
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tion; adequate and quality nutrition; Water, Sanitation and Hygiene (WASH); and to safeguard the progress already made in most CEE/ CIS countries in immunization and the prevention of vaccine preventable diseases. •Strengthen health quality management systems, with a particular focus on the sub-national level.
KEY STATISTICS The CEE/CIS region as a whole has more than halved under-five mortality (U5MR) in the last two decades, from 51 deaths per 1,000 live births in 1990 to 21 in 2009. This puts the region on track to reach MDG 4. The infant mortality rate (IMR) has also been more than halved – falling from 42 per 1,000 in 1990 to 19 in 2009. Regional progress on U5MR conceals disparities, with U5MR as high as 36 per 1,000 in Uzbekistan, 37 per 1,000 in Kyrgyzstan, and 64 per 1,000 in Tajikistan. The average maternal mortality rate (MMR) for the region is 34 per 100,000 live births, compared to an industrialized country average of 14 per 100,000. In Tajikistan, the MMR is as high as 170 per 100,000.