Maternal, Newborn, + Child Health

To overcome these market traps and increase access to ORS and zinc, CHAI is working at both the global and national levels to scale up ORS and zinc use. At the global level, CHAI works closely with UNICEF and other partners to support scale up of diarrhea and pneumonia treatment in 10 high-burden countries, representing about 60 percent of global diarrheal deaths. Additionally, CHAI works in four countries—India, Kenya, Nigeria, and Uganda—to increase access to and use of ORS and zinc at the national level. In each country, CHAI partners with government and local stakeholders to execute a large-scale approach that breaks the market trap by simultaneously building demand for ORS and zinc and ensuring widespread availability in public and private facilities, particularly in rural areas. This comprehensive approach seeks to demonstrate that effective treatment can be scaled up through a holistic approach in high-burden countries.

In 2015, CHAI’s program expanded to incorporate pneumonia treatment in existing geographies and to reach new geographies (including Ethiopia and Nigeria) with combined diarrhea and pneumonia efforts. Pneumonia is the leading killer of children under 5, responsible for more than 900,000 deaths each year. The program includes increasing access to key pneumonia commodities, such as amoxicillin dispersible tablet, pulse oximetry, and oxygen treatment.

CHAI-supported accomplishments have included:

• As of Q1 2015, coverage of ORS has increased from an average of 33 percent at the start of the program in 2011/2012 to an average of 50 percent across focal geographies, while zinc coverage increased from an average of less than 3 percent to 20 percent.
• Over 20 new high-quality, affordable and optimal ORS and zinc products (including 13 co-packaged products) have been introduced in local markets in Uganda, India, and Nigeria. The increased market competition has led to reductions in wholesale prices by 40-75 percent and will enable many more children to access the lifesaving treatment.
• Last-mile distribution channels have been established to expand access of zinc/ORS beyond urban areas to remote villages in selected focus countries where the most children are dying from diarrhea. Over-the-counter status for zinc has been achieved in all four countries, allowing the product to be used widely in all retail outlets, thus increasing access points for patients.
• Government-led national plans are in place, prioritizing treatment scale-up to reduce diarrheal deaths as a key national priority and driving coordination of efforts across partners.
• Impact and lessons learned from CHAI’s programs have extended beyond its focal countries through global engagement as co-chair (with UNICEF) of the Diarrhea & Pneumonia Working Group.

The most widely available contraceptives—short-acting methods such as condoms and pills—are also the least effective. Therefore, CHAI particularly focuses on increasing contraceptive choice to include long-acting reversible contraceptives (LARC) such as implants and IUDs, which are over 99 percent effective and can prevent pregnancy for up to 12 years.

CHAI assists governments to increase access to LARC by improving the efficiency and cost effectiveness of family planning supply chains and service delivery systems. This work includes national and subnational efforts to improve forecasting and supply chain management, develop evidence-based plans and targets, conduct gap analyses and better allocate resource to fill gaps, track and manage performance of LARC service delivery, coordinate partners to support national scale-up efforts, and develop and implement more cost-effective and government-led approaches to increasing LARC service delivery capacity. CHAI helps governments to ensure that, through more robust coordination and use of data, family planning products and program funding are directed to where they are most needed, ensuring that supplies, clinical skills, and demand align to enable equitable, quality provision of family planning services. CHAI also helps strengthen integration of postpartum family planning services into existing programs.

CHAI’s Family Planning country programs launched in 2013 with funding from the Bill & Melinda Gates Foundation (BMGF) for seven countries in Sub-Saharan Africa. Following rapid success in these countries, CHAI transitioned out of three of them and expanded the program to five additional countries. CHAI’s Family Planning program now includes Cameroon, Democratic Republic of Congo, Ethiopia, Indonesia, Kenya, Lao PDR, Nigeria, Tanzania, and Uganda. Together, these countries represent an estimated 134 million women of reproductive age.

CHAI-supported accomplishments have included:

• CHAI supported the governments of Cameroon, Kenya, Liberia, Malawi, Nigeria, Tanzania, and Zambia to double the number of women accessing implants, which translates to nearly 2.4 million additional women accessing contraceptive implants in CHAI-supported countries since the program launched in 2013. Average monthly consumption in the countries CHAI supported grew by 215 percent in two years. Other FP2020 countries without CHAI support have seen 97 percent growth in monthly consumption during the same period.
• CHAI’s Family Planning program transitioned out of Zambia in 2015 after the MOH had the tools and capacity to manage and track investments in human resources for family planning, and will continue to provide remote support as needed. The MOH continues to track hundreds of LARC-trained health workers in CHAI’s absence to so that trainings are better coordinated.
• Working with the Bill & Melinda Gates Foundation and other partners, CHAI helped secure a 50 percent price reduction in the price of contraceptive implants using a volume guarantee. By improving visibility into demand and solidifying donor commitments for purchases, this deal led to more than US$100 million in savings for donors and developing country governments in 2015 and will result in US$420 million in savings over six years.
• In Nigeria, CHAI developed the National FP Dashboard for the Federal Ministry of Health (FMOH) to track consumption, stockouts, and training efforts for all family planning products nationwide. The FMOH and eight states are now actively using the tool to improve the efficiency of their resource allocation and manage the performance of those investments. Monthly consumption increased by 47 percent nationally over the course of 2015, reaching 33,611 implants per month in Q4 2015.
• In Kenya, CHAI helped the government to design, pilot, and cost a new on-the-job training approach to update current implant service providers to insert Implanon NXT. The approach has been approved by the MOH for national use and is being modified for use in other countries, as well. Implants are now the second most popular method of contraceptive in Kenya, helping to drive a rapid rise in contraceptive use over the past several years.
• In Cameroon, CHAI helped the government design a new electronic logistics management information system that will launch in late 2016. Monthly implant consumption in Cameroon is now ten times what is was when the program began in 2013. In Tanzania, CHAI worked to complete the first-ever country-wide mapping of all of the health workers in mainland Tanzania who have been trained in LARC. This information helped the MOH’s Training Coordinator to advise USAID where to invest additional training funds.
• At the global level, CHAI is a member of the Coordinated Supply Planning group and has provided country-level insight and analytical capacity to help prevent or remedy implant stock outs in nine countries, reallocating or expediting shipment of over half a million implants in 2015.

In collaboration with government partners and the private sector, CHAI is launching a new initiative to improve childhood nutrition with high-quality, nutrient-dense complementary foods. These foods are specially designed for children who are 6 months to 2 years old, a critical window for healthy growth and development. CHAI is facilitating the launch of state-of-the-art food processing facilities to produce complementary foods in partner countries at impeccable quality standards. Staple ingredients will be purchased from farming cooperatives, promoting local agricultural growth and economic development. Distribution systems will ensure that these foods reach the children who need them, even in remote areas, with subsidy structures in place for the poorest and most vulnerable households. By working through government health systems, the foods will be distributed with guidance on appropriate preparation and serving sizes, with emphasis on the importance of exclusive breastfeeding from birth to 6 months and continued breastfeeding through 2 years of age.

CHAI is rolling out the nutrition initiative with two partner countries in 2016, with scale-up plans in place to work with additional countries over the ensuing years.

To dramatically reduce maternal and newborn mortality, CHAI believes that an integrated approach is required that addresses critical gaps, creates linkages through the entire health system–from the community level to the hospitals–and is sustainable. Effective, low-cost interventions exist to avert a majority of these preventable deaths, so it is essential to implement a continuum of care from the community level to tertiary hospitals to ensure early identification of complications, prompt and effective clinical management of delivery and complications, and timely and appropriate referral when necessary.

Planned in consultation with our government partners, CHAI has developed and implemented an integrated, strategic approach to dramatically reduce maternal and neonatal mortality. Consistent with WHO guidelines, the approach focuses on averting the preventable deaths that can occur in the 24-48 hour window around the birth process by implementing the interventions necessary to deliver the following, straightforward results:

• Potential complications are identified early to prevent them becoming life threatening;
• Simple interventions are applied immediately to stabilize and ensure survival; and
• Cases are referred quickly to the appropriate health system level for proper treatment

CHAI’s approach involves the creation of a comprehensive system, centered at the primary health center (PHC), which connects a pregnant woman to each level of the health system. It begins with the identification and tracking of all pregnant women in the catchment area and every pregnant woman coming into the PHC for an essential first antenatal care visit early in her pregnancy. It continues with each pregnant woman being seen periodically by healthcare workers and receiving appropriate screening tests conducted to diagnose specific complications and to identify pregnancies at risk. High-risk pregnancies are tracked closely and attended frequently by healthcare workers and clinical birth plans will be prepared which include ready transport to the nearest hospital in advance of or at onset of delivery. For the remainder of pregnancies, no matter where a birth occurs, a Skilled Birth Attendant (SBA) who has undergone an extensive Midwife Mentoring program, would act as a ‘first responder’ and be present at each birth to minimize complications from occurring, recognize warning signs early and to stabilize and, where possible, treat complications when they occur while waiting for emergency referral and transport to the health center or hospital.

This comprehensive system ensures that no birth is overlooked or undervalued. It means that birth attendants at all levels in the health system are empowered and equipped to stabilize and treat complications as they arise. It results in a majority of births successfully being delivered at the lowest levels of health systems, closest to where most pregnant women reside. It also ensures that a speedy and efficient referral system is in place linking the most isolated and mobile communities all the way through to a hospital sufficiently equipped to handle emergencies.

CHAI supports Ministries of Health in our partner countries to drastically reduce maternal and neonatal deaths by scaling up the integrated MNH approach over an accelerated timeline.

The impact of CHAI’s MNH program can be most clearly seen in three states in Northern Nigeria. Nigeria accounts for the largest proportion of maternal deaths (19.1 percent), neonatal deaths (12.5 percent), and stillbirths (11.6 percent) worldwide. In 2014, working in partnership with the Nigerian Federal Government and the state governments of Kaduna, Kano, and Katsina, and funded by the Norwegian Ministry of Foreign Affairs, CHAI initiated the MNH program across a population of approximately 10 million people. Within six months of field-level intervention implementation, dramatic results were achieved to reduce maternal and newborn deaths across these three states.

An independent external evaluation in November 2016 verified that the following significant and sustained reductions were achieved within 12-18 months within the focus geographies:

• Maternal mortality: 37% reduction;
• Neonatal mortality: 43% reduction; and
• Stillbirth: 15% reduction.

The evaluation concluded that “the CHAI Maternal-Neonatal Health Program accomplished impressive, rapid and, to date, sustained reductions in newborn mortality, maternal mortality, stillbirth, perinatal mortality and a combination of stillbirth and newborn mortality equivalent to or beyond those observed in other efforts to improve neonatal and maternal survival.”

A separate, second independent external evaluation agreed with these findings, concluding that the program was “relevant at all levels”, that the stated reductions “most likely… understates the achievements of the programme” and “is considered to provide good value for money provided that the lessons gained are brought forward and used in future programmes.”

Continuing this level of sustained impact will not only lead to significant results across the three focus states in Nigeria, but can also serve as a model for other countries and partners with the comprehensive MNH approach now being rolled out in other countries where the need for an effective and efficient approach towards MNH is great. In Ethiopia for instance, CHAI responded to a Federal Ministry of Health request to scale the program up in 40 woredas (districts) in in 2017, covering an estimated population of 5 million people. Targeting woredas with some of the highest maternal and neonatal mortality burden in Ethiopia, the program aims to reduce maternal and neonatal mortality rates by 30% and 40% respectively. This builds on previous work, supported by the RMNCH Trust Fund, to roll out an institutionalized midwife mentoring program in 278 health centers located in 100 hard-to-reach districts across Ethiopia. Institutional delivery, antenatal care, and postnatal care increased throughout the course of 2015 by 42 percent, 61 percent, and 38 percent, respectively, in those sites supported by the mentoring program.

The sustainable systems established through CHAI’s MNH program ensures further lives are saved beyond the project implementation period. Continuing this level of sustained impact will not only lead to significant results, but can also serve as a model for other countries and partners looking to implement an effective, efficient and sustainable approach towards maternal and neonatal mortality reductions.