1
Review and Mapping of Initiatives in
Maternal and Newborn Health in Zambia
20th November 2012
Meredith Budge
Consultant for Tribal strategies p/l
For The Zambia UK Health Workforce Alliance
October 22nd 2012
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Contents
Contents .............................................................................................................................................................. 2
Acronyms ............................................................................................................................................................. 4
Executive Summary ............................................................................................................................................. 6
1. Background .................................................................................................................................................. 7
2. Study objectives and methodology ............................................................................................................. 9
2.1 Objectives ............................................................................................................................................ 9
2.2 Methodology ....................................................................................................................................... 9
2.3 Limitations ........................................................................................................................................... 9
3. Study Findings ................................................................................................................................................ 10
3.1 Distribution of Maternal and Newborn Health Initiatives ................................................................ 10
3.2 Staffing of health facilities ................................................................................................................. 11
3.4 Monitoring & Evaluation (M&E) ........................................................................................................ 13
3.6 Community Practice .......................................................................................................................... 16
3.7 Innovation .......................................................................................................................................... 16
3.8 Integration ......................................................................................................................................... 16
3.9 Lessons Learnt ................................................................................................................................... 17
3.10 Future coverage ................................................................................................................................. 17
4 Discussion .................................................................................................................................................. 18
5 Conclusion ................................................................................................................................................. 20
Bibliography ....................................................................................................................................................... 21
Appendices ........................................................................................................................................................ 23
Appendix 1 ..................................................................................................................................................... 23
Appendix 2 ..................................................................................................................................................... 26
Note: this paper should be read or printed in colour to enable understanding of diagrams and figures.
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Figures
Figure 1: Trends in the maternal mortality ratio and births attended by skilled birth attendants in Zambia 7
Figure 2: PMCH (2011) Adapted from WHO (2005) Make every mother and child count. .............................. 7
Figure 3: Global leading causes of neonatal and child deaths .......................................................................... 8
Figure 4: Coverage vs no Coverage .................................................................................................................. 10
Figure 5: Map of health worker vacancies across Zambia (WHO, 2010). ....................................................... 11
Figure 6: Percentage of projects using best practice models in designing the projects ................................ 12
Figure 7: Sources of best practice .................................................................................................................... 12
Figure 8: Project Partners ................................................................................................................................. 12
Figure 9: M&E and Baseline and Endline Evaluations ..................................................................................... 13
Figure 10: Types of interventions; cumulative facility vs. community based ................................................ 14
Figure 11: Projects surveyed continuing beyond 2012 .................................................................................... 17
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Acronyms
ANC Antenatal Care
BCC Behaviour Change Communication
CBO Community Based Organisation
CDC Centre of Disease Control
CHA Community Health Assistant
CHAI Clinton Health Access Initiative
CHW Community Health Workers
CHV Community Health Volunteers
CIDA Canadian International Development Agency
CORDAID Catholic Organisation for Relief and Development Aid
DANIDA Danish International Development Agency
DFID Department for International Development
DHS Demographic and Health Survey
EmOC Emergency Obstetric Care
EU European Union
GRZ Government of the Republic of Zambia
HRHSP Human Resource for Health Strategic Plan
IEC Information, Education, Communication
INGO/NGO International Non-Governmental Organisation/Non-Government Organisation
MCDMCH Ministry of Community Development, Mother and Child Health
MDG Millennium Development Goals
M&E Monitoring & Evaluation
MMR Maternal Mortality Ratio
MNH Maternal and Newborn Health
MNCH Maternal, Newborn and Child Health
MOH Ministry of Health
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NMR Neonatal Mortality Ratio
NZAID New Zealand Agency for International Development
PEPFAR President's Emergency Plan For AIDS Relief
PMTCT Prevention of Mother to Child Transmission
PRA Participatory Rural Appraisal
RDT Rapid Diagnostic Test
SBA Skilled Birth Attendants
SIDA Swedish International Development Agency
SMAGs Safe Motherhood Action Groups
TBA Traditional Birth Attendant
THET Tropical Health Education Trust
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
ZAMFOHR Zambia Forum for Health Research
ZISSP Zambia Integrated Systems Strengthening Program
ZNAN Zambian National AIDS Network
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Executive Summary
The Ministries of Health and for Community Development, Mother and Child Health (MCDMCH) have
requested that a mapping of maternal and newborn health (MNH) initiatives be conducted to find out who is
doing what in Zambia. Using the continuum of care as the structure for maternal and child health
interventions, the survey tool was developed and made available to Community Based, Faith Based and Non-
Government Organisations to complete. Respondents were able to complete the survey online, via email,
over the telephone or on paper. The survey tool will remain active over the next two months for additional
organisations to contribute their information.
The surveyed projects show that health organisations are present in every district but that there is a
concentration of effort in high population areas and that health centres in more remote areas, particularly in
Western and North Western Province, are in need of more community health interventions. This follows a
similar pattern to health staff vacancies across Zambia. The survey results show that projects use a multitude
of best practice models and that the sector would benefit from a more coordinated and harmonised project
design and implementation. Sixty percent of groups actively engage communities in programs to promote
uptake of Antenatal Care (ANC) and promoted facility births. Seventy-nine percent of organisations partner
with the MOH and 38% partner with MCDMCH. Ninety-seven percent of projects have monitoring and
evaluation plans and 85% have conducted baseline surveys. A majority of projects applied an integrated
approach bringing health, traditional leadership, cultural change, nutrition, agriculture and income
generation activities together to improve health seeking behaviours in their communities.
Key stakeholder interview reflections suggest that while community mobilisation is important; health
services must be adequately staffed to provide the full continuum of care needed to save lives.
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Martenal mortality ratio (Zambia)
200
649
729
591
162
0
100
200
300
400
500
600
700
800
1992 1996 2001 2007 2015
Mat
erna
l dea
lths/
100
,000
live
birt
hs
Source: Zambia DHS data sets
Progress & trends towards reducing the Maternal Mortality Ratio [MMR] to attain the
MDG target of 162 by 2015 in Zambia
38%
40%
42%
44%
46%
48%
50%
52%
1992 1996 1999 2001 2007
Source: Zambia DHS data sets
Proportion of women (%) attended to by skilled health workers during birth in Zambia
1. Background
Zambia has the political will, the policies in place and the commitment to meet MDGs 4 and 5 but to date
progress has been slow, as figure 1 clearly shows.
This mapping project was requested by MCDMCH and the MOH to examine the key actors in Maternal and
Newborn Health and to find out what is working that could be scaled up to fast track progress towards the
Millennium Development Goals 4 and 5 in Zambia.
Figure 1: Trends in the maternal mortality ratio and births attended by skilled birth attendants in Zambia
The graphs in figure 1 make the important link between skilled birth attendance and safe delivery, in line
with overwhelming global evidence; however the causes of maternal deaths are complex therefore require a
complex and integrated response.
Global evidence (Gabrysch et al, 2011; Koblinsky et al, 2011; WHO, 2012) indicates that a full continuum of
care must be in place from community to health facilities in order to encourage women to seek out health
services. Health facilities must be adequately staffed by skilled birth attendants who can provide a quality of
service that builds community trust in the health system. The survey tool was therefore structured around
the full continuum of care, as summarised in figure 2.
Figure 2: PMCH (2011) Adapted from WHO (2005) Make every mother and child count.
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The chart in figure 3 below demonstrates that there is also a need for greater skills development in newborn
care to prevent asphyxia, sepsis and to manage preterm births. This is an essential and under-emphasised
component of the continuum of care (WHO, 2012).
Figure 3: Global leading causes of neonatal and child deaths
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2. Study objectives and methodology
2.1 Objectives
To collate all available secondary data on maternal and newborn health interventions in Zambia and
to map these out – “who is doing what and where”?
To compare what is being done in Zambia with global evidence regarding high impact interventions
recognised to decrease maternal and newborn mortality;
To map out the critical gaps with a view to focusing future interventions.
2.2 Methodology
Carrying out a desk review of documents and reports of maternal and newborn health interventions
in each district;
Conducting interviews with donors and major stakeholders;
Developing a database of maternal and newborn health interventions including government, NGO,
CBOs and private sector;
Mapping out maternal and newborn health interventions including government, NGO, CBOs and
private sector;
Showing gaps in implementation from both demand and supply;
Analysing the data presented against global evidence regarding what is and what is not effective in
reducing maternal and newborn mortality in Zambia;
Identifying gaps in current interventions in Zambia;
Providing recommendations about how gaps in the demand and supply side could be filled by
interventions supported by global evidence.
The survey tool was developed in consultation with an advisory group, the Ministry of Community
Development Mother and Child Health (MCDMCH) and the Ministry of Health (MoH), and designed to map
the range of health interventions being conducted by organisations in Zambia. Due to time constraints, the
survey was developed to enable online access using the Fluid Online Survey tool. A word version of the
survey was also emailed to as many contacts as possible to enable groups with poor internet access to
complete the survey. Four data assistants were recruited to phone organisations to encourage them to
complete the survey. Where necessary, the data assistants helped groups complete the survey over the
phone or in person. All the word versions were entered into the online survey by data entry officers. The
survey team used a “snowball approach” to contact as many organisations as possible. Participants were
encouraged to email the survey onto other organisations, or provide contact details to the survey team to
ring those groups with poor or no internet access. Four people used the phones for a combined total of 55
days and over 400 phone calls to complete 116 surveys. The database arising from this survey will be handed
over to MCDMCH.
2.3 Limitations
The greatest limitation is the possibility of missing information. While the survey team worked hard to
distribute the survey tool as widely as possible, the data collated may not represent all the groups which are
active in MNH in Zambia. The survey did attract responses from every district in Zambia, but it cannot be
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assumed that every group in every district is captured. Currently the number of organisations working in
MNH in Zambia is unknown. As such, the conclusions made in the following analysis may need further
qualification once MCDMCH gather further data.
3. Study Findings
3.1 Distribution of Maternal and Newborn Health Initiatives
As the map in Figure 4 indicates there is concern about the distribution of activities. Of the 1828 health
facilities across Zambia, only 1322 or 72% of primary health care facilities were supported, with additional
initiatives from partner organisations (Community Based, Faith Based, international and local NGOs). The
maps demonstrate that in Western and North Western Provinces and the more remote areas of most
districts have fewer initiatives. The red flags represent health facilities which the survey found did not have
supporting activities. This raises the question as to whether the spread of MNH initiatives is equitable and
strategically located. The actual interventions are far less concentrated than they appear in figure 4,
although they are often focused in similar areas.
Figure 4: Coverage vs no Coverage
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3.2 Staffing of health facilities
The map in figure 5 represents the level of vacancies or unfilled health worker positions in Zambia. The areas
in green have less than 25% vacancies but areas in yellow have between 25% and 50% unfilled positions,
orange areas have between 50% and 74% vacancies while the areas in red have 75% or more unfilled
positions (WHO, 2010). This shows a similar pattern to the concentration of partner organisation initiatives
which are more often focused in larger towns or within easier access.
Figure 5: Map of health worker vacancies across Zambia (WHO, 2010).
The Human Resources for Health Strategic Plan (HRHSP) 2011-2015 describes a major shortfall in health
workforce across Zambia. As a result, only Lusaka, the Copperbelt, Kabwe, Mazabuka and Livingstone have
reasonable staffing ratios. Many rural health centres are therefore run by unskilled staff.
3.3 Details of initiatives
Sixty seven percent of projects indicated the use of best practice models to design their project. A number of
projects drew upon USAID or K4Health resources or used MoH guidelines, manuals or tools to guide their
project design.
Vacancy rates
12
Figure 6: Percentage of projects using best
practice models in designing the projects
When respondents were asked about the
source of best practice, the sources were
multiple and scattered, as figure 7 depicts.
There is a need to examine why so many
different sources are being used; it
suggests that work may be needed to
harmonise effort to make sure consistent
and evidence based approaches are
applied across Zambia.
Figure 7: Sources of best practice
However, 79% of groups surveyed indicated partnerships with MOH and 21% with MCDMCH.
Figure 8: Project Partners
Bar chart of Partnerships
NGOs/CBOs
Number of survey respondents
INGOs
MCDMCH
MoH
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There was also a broad mix of funding sources. Whilst USAID funded 29% of organisations, and large
international donors such as DFID, the EU, SIDA, CIDA and AUSAID funding another 9% of organisations, 77%
were funded through a multitude of other sources. When broken down, 27% of these were funded through
smaller trust funds and small international agencies; another 18% of projects described their source as a
larger INGO such as Plan, Save the Children World Vision or ZISSP; 10% were funded through GRZ, MOH or
MCDMCH (whose funding comes from CIDA, DFID, EU and SIDA but this was not explicitly classified as such
by the organisations participating in the survey), 4% by JICA ;3% CDC and 3% PEPFAR; 2% each from UNICEF,
EU and ZNAN. The final 10% of organisations were funded through other organisations including B&M Gates
foundation; CORDAID; DANIDA; Irish Aid; NZAID. Four projects included their communities as the source of
their financial support and four others identified private partners. The mechanisms for coordinating this
complex multitude of funding sources was not examined in the survey; there may be more work to be done
in this area by the MCDMCH.
3.4 Monitoring & Evaluation (M&E)
Ninety-seven percent of projects had monitoring and evaluation plans, 47% of these were independently
evaluated and 85% had conducted baseline and endline evaluations to assess the effectiveness of their
projects.
Figure 9: M&E and Baseline and Endline Evaluations
M&E Plan in place Baseline and endline evaluation conducted
3.5 Types of interventions
The intervention list used for this survey follows the more detailed continuum of care as outlined in the
MNCH Roadmap (GRZ MOH, 2011). The large number of activities, across many of the interventions, shows
that the majority of projects have an understanding of the importance of a continuum of care from the
community to health services, from pre-pregnancy through to postnatal care. Figure 10 shows a strong
emphasis on promoting facility births with a Skilled Birth Attendant, early Antenatal Care (ANC), engagement
of traditional leaders, promoting birth planning, malaria prevention, knowledge of danger signs, and infant
and child nutrition. A large number of projects supported a broad range of community based interventions.
The activities that are less frequent are more often clinical interventions such as EmOC training, the use of
uterotonics, neonatal resuscitation, other essential newborn care interventions such as Kangaroo care.
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Distribution of uterotonics may grow in the future once the Misoprostol program is scaled up across health
facilities.
Figure 10: Types of interventions; cumulative facility vs. community based 1
1 The cumulative responses from 116 surveys.
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3.6 Community Practice
Sixty percent of projects applied community engagement processes in the implementation of their
programs. Many groups used drama or radio programming. The majority of projects engaged communities in
Participatory Rural Appraisal (PRA) and action planning which aimed to promote local awareness and
ownership of their health issues. Forty-four percent of health projects included some form of income
generation or savings and loans scheme that will hopefully see sustainable improvements in the
communities. Sixty-one percent engaged traditional leaders in their programs, aimed at promoting a shift in
cultural practices and a change in once accepted norms, such as early marriage and blaming obstructed
labour on infidelity. In addition 55% of projects responded yes when asked whether their projects included
raising gender awareness issues.
3.7 Innovation
Eighty-three percent of projects described their projects as having innovative features including:
Community action planning, including selecting their own indicators;
Working with traditional leaders; youth leaders; church leaders in challenging topics related to
reproductive health and adolescent sex education;
Campaigning to outlaw early marriage;
Community gardens and malnutrition feeding programs;
Task shifting and task sharing with volunteers and community health volunteers;
Working with communities to build mothers waiting shelters;
Introduction of patient registration and appointment books to reduce long patient queues and to
track missed appointments;
SMS cellular phone technology being used to provide low-cost appointment reminders, to improve
diagnostic testing systems, to reduce time between testing and treatment, and to trace and return
lost infants to mothers through facilities for care;
Scratch card voucher system, similar to a mobile phone scratch card, distributed for the supply of
health or food goods from local stores. This enables local suppliers to supply goods to selected
clients then claim their credit for the sale by sending the scratch number to the distribution agencies
via mobile phone.
Increasing the community’s voice to advocate for better services, through developing client
satisfaction surveys or forming community action groups to influence behaviour change.
3.8 Integration
The majority of the surveyed projects took an integrated approach, bringing health promotion, agriculture,
income generation and genuine community ownership and design to the projects. The majority of the
respondents used strategies to engage communities fully in the design and ownership of their program
initiatives. Seventy-five percent of smaller NGOs and CBOs listed INGOs as sources of both their funding and
integrated project design. INGOs are therefore supporting local efforts to promote better health outcomes,
bringing together international expertise with the local knowledge and strong community ownership of local
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NGOS and CBOs. These partnerships aim to see small NGOs, CBOs and Faith Based Organisations strengthen
their skills, governance practices and prepare them to become the implementers of choice into the future.
3.9 Lessons Learnt
Of the 90 respondents that answered the question about key strengths, over 50% of these identified
community participation as a major positive project design feature.
When asked what groups would do differently next time, the survey produced the following reflections:
Increase engagement of traditional leaders to drive cultural change more effectively;
Reach out to marginalized and poor communities to add a strong voice to their health needs;
Sponsor and train more midwifery students who can be bonded to rural areas;
Strengthen referral systems and availability of ambulances;
Train and empower members of the community with skills to identify problems, develop long and
short term plans for effective community problem solving;
Adopt a more integrated approach to MCH interventions;
Allocate more funds to M&E and develop a database;
Increase male involvement;
Seek to include people with disabilities in all future programming;
Take care in the handling of incentives for volunteers;
Invest more in community based transport solutions;
Support more girls to attain tertiary education.
3.10 Future coverage
Figure 11 shows how many of the surveyed groups will continue their projects beyond 2012. With only 48%
indicating that they would be continuing, the results raise questions about the sustainability of healthcare
interventions beyond the initial completion of the projects. However, 42% of all interventions included
income generating activities designed to support volunteers to continue their activities beyond the life of the
project.
Figure 11: Projects surveyed continuing beyond 2012
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4 Discussion
There is extensive international (WHO, 2011; WRASM, 2002) and Zambian research (Gill et al, 2011; Hamer
et al, 2011; Strasser et al, 2012) to prove that simple, cost effective interventions can save lives.2 It requires a
continuum of care from community level initiatives such as Safe Motherhood Action Groups (SMAGS) to
promote health seeking behaviours and prevent the first delay (the decision to go to a health facility). It then
requires birth planning and transport options to enable women to attend the health centre (the second
delay). Well-equipped and well-staffed health centres are then required to provide primary health care, and
finally good referral systems to hospitals are needed that can provide more complex care, including
comprehensive emergency obstetric and newborn care (to address the third and fourth delays).
However, the distribution data of current interventions suggests that more strategic planning of
interventions is needed across the country to address the delays in healthcare provision. Healthcare
interventions are unevenly spread with some of the most remote and rural areas of Zambia, particularly in
the northern and western provinces, in desperate need of health care programs and a trained workforce.
A study by Sabine Gabrysch in Zambia, found that distance impacted on the uptake of health services;
increasing the level of care available at the closest health centre was crudely associated with increases in
facility delivery. The final model revealed that “as distance to the closest health facility doubled, the odds of
facility delivery decreased by 29%” (Gabrysch, 2011 pp1). With some health posts as far as 90 km from their
designated health centre, the likelihood of a woman delivering at a fully equipped health facility is
substantially reduced. Therefore distance, access, poor road infrastructure and unskilled health workers still
remain an obstacle for many women and a challenge to decreasing rates of maternal mortality in Zambia.
Despite these obstacles, the survey revealed encouraging results on the levels of community engagement by
the projects. This is a significant component of the continuum of care and many of the projects described in
the survey have a focus on community empowerment and engaging traditional leaders. Safe Motherhood
Action Groups (SMAGs) and Community Health Workers (CHWs) are also able to increase demand for and
the uptake of health services3. Additionally, Zambia is seeing community volunteers mobilise communities,
increase male involvement, work with traditional leaders and shift dangerous cultural practices; all of which
is leading to improved health seeking behaviour for women and children. However, while these individuals
can be good at creating demand, as Dr Mwaba said, “you cannot build a quality and reliable health system
on volunteers”; a comprehensive health system needs trained professionals.
Community mobilisation can drive demand for health services, but as Richard Klausner (2011) observes, this
needs to be backed up with a quality services that the ‘customer’ can trust. Too often women report poor
quality service, even if a health worker is available. It has been found that only 30% of Zambian women gave
birth at a facility in 2011, and that distance and quality of care had major impact on their uptake of services.
The same research found that each step increase in quality of care led to 26% higher odds of a facility
delivery (Gabrysch et al, 2011). It is important to note that increasing the number of health facilities is not
enough; it is not the density of facilities that affect a country’s MMR, but the level of staffing and skills at
2 The Conference booklet includes links to much of this research and to the many good documents which summarise
international best practice. 3 Africare SMAGs increased facility deliveries from a baseline of 36% to 92% in the target communities; MAMaZ: 43% to
51% and the CSH Change Champions project describes two Chiefdoms with no maternal deaths in two years.
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those health facilities (Gabrysch et al, 2011). The MMR in Zambia is reducing but not at the pace needed to
meet MDG 5.
This survey seems to indicate that there is a need to fast track the availability, training and deployment of
skilled birth attendants to well-equipped health facilities. Here Zambia can learn from the success and
progress made by her neighbours. For example, Malawi has achieved higher availability of SBAs by offering
integrated or combined three-year nursing and midwifery courses, or a four-year nursing followed by one-
year midwifery courses, and a graduate programme (Fullerton and Leshabari, 2010). Additionally, Malawi
produces community health nurses (CHNs) who provide maternal and child health services, including district
PMTCT coordinating, in health centres and public and private hospitals, including conducting deliveries. In
general, midwifery education in Malawi seems efficient and cost-effective because upon graduation, all
midwives are nurses and all nurses are midwives and can be deployed in any general service area (Chibuye,
2012).
One problem facing Zambia, as with many other countries, is the continual updating of WHO guidelines
which change based on accumulating evidence4. While the new evidence is welcome, the downside is that
countries are expected to adapt to the changes in their guidelines before the previous guidelines have been
implemented to an appreciable extent (e.g. Nutrition guidelines, the use of TBAs and PMTCT). It is well
known that when guidelines are changed, they do not reach all the health workers promptly and so there is,
as elsewhere, likely to be a mixture of conflicting guidelines being implemented across Zambia. Malawi’s
experience seems to show that it is important for future programming to implement one set of guidelines to
scale and make any changes after an evaluation has been performed. One reason Malawi has progressed
further than Zambia is partly because Malawi remained focused on what it knew worked:
fast tracking the training and deployment of SBAs across the country;
promoting family planning;
promoting facility deliveries;
promoting exclusive breastfeeding and infant feeding best practice.
Zambia is making some serious efforts to learn from its regional neighbours and from its own experience
about ways to fast track skilled birth attendants and provide incentives to recruit deploy and retain staff in
rural and remote areas. Many initiatives are being implemented which are targeting training, retention and
deployment of skilled health workers in rural areas. The Ministry of Health is working with cooperating
partners to develop the HRHSP which provides a comprehensive outline of the state of play now and the
strategies needed to overcome the shortfall of staff and the National Training Operational Plan (NTOP) has
been completed to guide scale up the training of health workers. A new cadre of Community Health
Assistants (CHAs) are being selected by their communities and trained in primary health care for 12 months.
Donors are exploring ways to scale this up and place two CHAs at all health posts. CHAs will be an important
first point of primary health care, provide support to volunteers and increase referrals to higher level health
care facilities as required. In addition, the MoH and UN agencies, through CIDA H4+ are developing
additional programmes aiming to reduce mortality rates by 50% through the recruitment and training of
SBAs across five districts.
In addition to these efforts to address Zambia’s HR challenges, there are several initiatives in place to
remove some of the barriers to health seeking behaviours that could save lives. Communications Support for
4 Discussion with Dr Makuka 4/10/2012.Former Health Adviser to UN for Zambia.
20
Health (CSH) is bringing together international best practice and local Zambian formative research to
produce multimedia materials, tools and guidelines for Behaviour Change Communications (BCC) in health.
These materials are carefully field tested and adapted to meet the varied needs of different communities
and to address the many and varied cultural practices that impact on health in rural communities. Afya
Mzuri’s Dziwani Knowledge Management Centre is making sure that good quality Information, Education
and Communication (IEC) tools and BCC materials produced in Zambia in recent years are made available
more broadly across Zambia. In addition ZAMFOHR is providing a clearing house of all health research in
Zambia which is available online and a new National Technical Working Group has been established to
review and approve all new IEC and BCC materials to ensure they are effective and consistent with Zambia
health policy and international best practice.
These initiatives may be central in kindling acceleration towards achieving the MDG 4 and 5 in Zambia.
Concerted and coordinated effort from all partners will be necessary to get there.
Three key messages emerge from the survey findings:
1. The distribution of initiatives is uneven and seems to relate to the remoteness of the location not the
needs of the population.
2. Overall support to projects comes from a wide variety of funders, multiple players are involved and
projects use multiple good practice guidelines. This makes the large-scale adoption and scaling up of
MNH initiatives to achieve national impact difficult.
3. The focus of projects is more commonly on community awareness and increasing demand rather than
developing health services. The survey does not explain why this is the case or what the consequences
might be. It could be explained by greater survey participation from community led organisations than
clinical services. This could be a subject for further research.
5 Conclusion
This review paper was presented at a Maternal and Newborn Health Conference, hosted by the Zambia UK
Health Workforce Alliance at the Intercontinental Hotel, Lusaka on the 1st November 2012. The conference
aimed to consider priorities and actions to reduce maternal and newborn mortality and morbidity in Zambia;
further details of the conference can be found in Appendix 1. This paper was considered alongside a series
of presentations regarding current interventions in Maternal and Newborn Health in Zambia. The outcomes
and conclusions of the conference are given in Appendix 2.
The survey information and database will ultimately belong to the Ministry of Health and the Ministry of
Community Development, Mother and Child Health. This will assist them with their ongoing strategy and
coordination of maternal and newborn health interventions.
21
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2011-050102.15.
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23
Appendices
Appendix 1
Maternal and Newborn Health Conference Programme
Held at the Intercontinental Hotel, Lusaka on the 1st November 2012
Background:
The Zambia UK Health Work Force Alliance (ZUKHWA) is a network of 70 UK and Zambian organizations who
work together to promote and improve the coordination and impact of Zambia-UK joint work in health.
ZUKHWA’ s main objective is to support the Government of the Republic of Zambia (GRZ) through the
Ministries of Health and Community Development, Mother and Child Health to achieve its national health
strategy plan and global health goals. This current initiative is to support the Zambian government achieve
the Millennium Development Goals 4 and 5 around maternal and newborn health. ZUKHWA is hosting this
conference to bring together Zambian and international stakeholders, partners and NGOs to critically
evaluate what is happening today and what the next steps are in improving maternal and newborn mortality
and morbidity.
For further information about the Zambia UK Health Workforce Alliance, please visit www.zuhwa.com
Conference objectives:
To share local experiences and identify evidence-based interventions that will accelerate attainment of
improved maternal, child health services in Zambia
To present current activity in Maternal and Newborn health services in Zambia and consider this in relation
to international best practise.
To develop recommendations to rapidly improve maternal and newborn mortality and morbidity.
08:30 – 09.30 REGISTRATION
09:30 – 10.05 Chaired by Dr. Peter Mwaba Greetings and welcome Objectives and why we are here Keynote speech
Prof. Elwyn Chomba, PS (MCDMCH) Lord Crisp, Chair of Zambia UK Health Work Force Alliance (ZUKHWA) Dr Joseph Katema, Minister of Community Development, Mother and Child Health (MCDMCH)
10.05 – 10.25
Presentation of and strategy in the MNCP Roadmap.
Dr. Caroline Phiri, (MCDMCH)
10.25 – 10.55
Presentation of Review paper: Survey of Maternal and Newborn Health Initiatives in Zambia.
Meredith Budge, Consultant, Tribal Strategies
10.55 – 11.03 Ministry of Health Jenny-Meya Nyirenda (MoH)
24
11.03 – 11.10
Overview of the Community Health Workers Program. Midwives Association of Zambia (MAZ)
Mr David Mbewe, Vice President
11.10 – 11.20 Collect refreshments and return to tables promptly
11.20 – 11.45 Q&A chaired by Lord Crisp
11.45 – 12.20 Safe Motherhood Action Groups Presentation Panel Introductions and Update on the implementation of Safe Motherhood Action Groups in Zambia Safe Motherhood Action Groups (SMAGs) training in Mwinilunga district AFRICARE: Mobilizing communities to reduce maternal mortality Communications Support for Health “Mother’s Alive” Campaign Questions to Panel
Chaired by Dr. Elizabeth Chizema Monde Imasiku, Principle Nursing Officer (PMO) Mr Ernest Kakoma, (MoH), Solwezi
Elizabeth Simwawa Maggie Sinkamba
12.20 – 12.50
Access to Care and Community Interventions Church’s Health Association of Zambia (CHAZ) Community Leadership: PMTCT Programme to improve health outcomes of HIV exposed babies MAMAZ Mobilising Access to Maternal Health Services in Zambia: Interventions Medecins Sans Frontieres: “The Bicycle Ambulance” Riders for Health: Transport Reducing delays to accessing laboratory-based testing Questions to Panel
Chaired by Dr. Peggy Chibuye Dr. Dhally M. Menda, Director of Health Programmes Mr Abdul Razak Badru Hemmend Lukongs Ms. Constance Chibiliti
12.50 - 14.00 LUNCH (Visit Project and Poster Displays)
14.00 - 14.45
Maternal Health Care Interventions Saving Mothers, Giving Life Endeavour (Summary of 4 Abstracts) Emergency Obstetric and Newborn Care
Chaired by Dr. Sebastian Chinkoyo U.S. Government Agencies and Implementing Partners USG Representative Dr. Carla Chibwesha, CIDRZ
25
14.45 – 15.10
The Role of Intensive Mentorship in Emergency, Obstetric and Neonatal Care SAFE Obstetrics Society for Family Health: Use of Misoprostol for PPH prevention Questions to Panel Newborn Health Care Interventions Outline of Newborn Strategy Center for Infectious Disease in Zambia (CIDZR): Newborn Care Training in Developing Countries: The First Breath Clinic trial Zambia Center for Applied Health Research and Development (ZCHARD): ZAMCAT Trial and TBA Training Questions
Martha Ndhlovu, MCHIP Prof. John Kinnear Ms Jully Chilambwe Chaired by Dr Penelope Kalesha-Masumbu, Ministry of Health Dr. Albert Manasyan Dr. Godfrey Biemba
15:10 – 15.25 Collect refreshments and return to tables promptly
15.25 – 15.30 Introducing Discussion Groups, Lord Crisp
15.30 - 16.15
Discussions and Action Points 12 tables of participants will propose key priorities and action points to move forward
Chaired by Lord Crisp
16.15 – 17.00 Presentations of Recommendations by each table
Chaired by Lord Crisp Rapporteurs: Dr. David Percy (ZUKHWA) and Mercy Mbewe (Nurse and Midwife Educator)
17.00 – 17.30 Plenary discussion of recommendations Setting Priorities and Action to move forward
Chaired by Lord Crisp
17.30 – 17.45 Closing Remarks / Follow up: What next? Prof. Chomba, and Dr. Mwaba.
26
Appendix 2
Conference Outcomes and Issues from the Maternal and Newborn health
conference, Lusaka, 1st November 2012.
After a day of presentations and discussion regarding interventions in maternal and newborn health from
key stakeholders working in Zambia (see the conference programme in Appendix 1), the final session of the
conference asked the conference delegates through round table discussions to consider key priorities or
issues for ongoing discussion, between the Ministries, Cooperating and Implementing partners, to rapidly
accelerate the reduction of maternal and newborn mortality in Zambia.
The following is a summary of the outcomes of the discussions and the issues and priorities presented by
each table leader on behalf of his/her table during the plenary discussion. Issues for further consideration
are in bold and numbered in each relevant section.
Skilled Birth Attendants (SBA) and Traditional Birth Attendants (TBA)
The current health strategy in Zambia is to have a health system where all mothers and newborns should be
looked after by a Skilled Birth Attendant. However, it will take time to train and deploy Skilled Birth
Attendants. Conference delegates discussed whether, in the short term, Traditional Birth Attendants should
be trained in some of the relevant competences to make them safe practitioners.
Traditional Birth Attendants
It is estimated that Traditional Birth Attendants are engaged in the delivery of 23% [31% in rural areas and
5% in urban areas] of babies in Zambia; meaning that some babies are being delivered at home by TBAs, who
may not be able to recognize or manage potential complications. A further 25% of babies are delivered by a
family member and 5% of women are alone during delivery. Delegates discussed the fact that the
involvement of TBAs in deliveries will not change in the short term. It was recommended by a majority of
participants that, in the short term, TBAs should be trained to recognize danger signs in pre, intra and post-
partum care, to help them to refer mothers in a timely fashion to the next levels of care.
Further it was proposed by some delegates that in the short term, when an SBA is unavailable, TBAs should
be trained to have the competences to deal with some basic and emergency care of both mother and baby.
Some disagreed with this recommendation stating that TBAs should not be trained but more effort should
be made to increase skilled health workers.
Below are issues for further consideration as presented by table leaders related to TBAs;
1) Provide TBAs with training and mentoring to equip them with the competences to provide safe and
comprehensive care from family planning through to postnatal care, as well as basic lifesaving
skills. For example, being able to administer Misoprostol to manage post-partum hemorrhage and
equipping them with the competences to help babies breathe.
2) Develop a transition strategy for the redeployment of TBAs once SBAs are available.
Skilled Birth Attendants
27
Delegates noted that no country has turned around its MMR and NMR without skilled birth attendants.
Below are issues for further consideration as presented by table leaders related to SBAs;
3) They endorsed the current plans to increase the capacity of training institutions to increase the
output of nurse/midwives. It was suggested that the ministries and international donors continue
to work together to plan and resource a rapid increase in training capacity.
4) They encouraged the ministries to review the policy framework for staff establishment to ensure
the employment, deployment, retention, supervision and continued training of SBAs in all health
settings including 24 hour coverage of health facilities.
5) Encourage the ministries to review the curriculum to develop health professionals with the
required competences in maternal and newborn health, including lifesaving skills. Some delegates
suggested that graduates should be both a nurse and a midwife through shortened courses.
Increased involvement of Safe Motherhood Action Groups
Delegates noted that the government of Zambia responded to the challenge of providing a continuum of
care by supporting pilot programmes to establish Safe Motherhood Action Groups (SMAGs) at community
level. A framework has been established for the national scale-up of SMAGs, through a standardized training
package. During the conference evidence was presented on the effectiveness of SMAGs and it is anticipated
that when further evidence is available this will guide future SMAG interventions.
Below are the issues to be considered further as presented by each table leader in relation to SMAGs
6) Increase the number of SMAGs to cover all districts.
7) Expand the role of SMAGS to include antenatal, intra-natal and post-natal care and family planning.
8) Strengthen SMAGs competences so that they can further develop their community interventions.
Volunteers and Community Health Assistants
It was noted by delegates that Community Volunteers and Community Health Assistants are offering services
that address maternal and newborn care and they also noted that accountability of volunteers to the health
system is weak.
Below are the issues to be considered further as presented by table leaders related to Volunteers and
Community Health Assistants.
9) Developing a volunteer management and coordinating system needs to be considered, to include
equitable remuneration, supervision and accountability mechanisms.
10) Reconsider the term ‘Volunteer’ as it does not carry authority, and define accountability or
remuneration.
11) That Community Health Workers/Assistants should complement the role of nurse/ midwives and
there should be a degree of task sharing or task shifting.
12) They supported the training of Community Health Assistants and that they take on key roles
[especially with the introduction of an expanded curriculum] in reproductive, maternal and
newborn health.
Community involvement
28
The potential positive impact of community leaders on best practice in maternal and newborn health was
highlighted in discussion.
Below is the issue to be considered further as presented by table leaders related to community leaders
13) Engage with Chiefs, Traditional Leaders, Head Men and Church Leaders in all districts to encourage
them to be advocates for safe maternal and newborn health practices.
NGOs and Coordinated Leadership
The conference survey and other evidence confirmed that there are a large number of organizations (INGOs,
NGOs, FBOs etc.) working in maternal and newborn health in Zambia. There is currently no clear strategy,
coordination or rationalization of the many organizations involved. The survey showed that best practices
informing activities in MNH are numerous and diverse.
Table leaders’ issues for the Ministries to consider further are:
14) Ministries taking the lead in the coordination and geographical distribution of organizations
working in MNH through an MOU and rules of engagement which include the use of human and
financial resources.
15) Developing best practice guidelines which organizations should use to guide activities in MNH.
Strengthening access to care
It was noted that Zambians have difficulties in access to care in rural areas due to the distances to health
facilities and poor road infrastructure, particularly in the wet season.
Table leaders presented the following issue for further consideration:
16) The ministries should consider providing patient transport to each health facility and make
resources available to maintain them. These could be community managed (including bicycles,
motorbikes or boats) and delegates further recommended that the service should be free to
expectant mothers.
Emergency care
It was discussed that health posts were not fully developed in all districts and that health centers were not
always fully staffed and do not always have the equipment or infrastructure to provide emergency obstetric
and neonatal care [EmONC] nationwide.
Table leaders presented the following priorities for further consideration:
17) All mothers should be delivered where there are accessible EmONC services including basic
equipment, infrastructure and where there is access to emergency surgery by a trained health
worker.
18) Deliveries should be done in a health facility. Access to EmONC services should be available at
facility including referral system in place if it is not an EmONC site.
Finalization of the MNCP Roadmap
29
It was discussed that the MNCP Roadmap had not been fully adopted into policy and that its implementation
requires a consistent approach to monitoring and evaluation.
The issues that table leaders presented for further consideration are:
19) Zambia’s health management information system needs to be enhanced and to guide the
allocation of resources, including the use of standardized maternal and newborn indicators.
20) The Ministries should consider taking the lead in ensuring that organizations involved in maternal
and newborn health use a monitoring and evaluation framework that is aligned to that of the
Ministries.
Family planning
It was highlighted in discussions that birth spacing reduces MMR and NMR and that family planning coverage
across Zambia is only at 33%.
The following are issues for further consideration as presented by table leaders:
21) The ministries should consider rapidly accelerating family planning coverage using a range of
providers working to government strategy and standards.
22) The availability of injectable contraceptives should be increased, potentially using community
health assistants and workers as a method of administration. Delegates also highlighted that the
quality of this service could be ensured through the Health Professions Council of Zambia issuing
good practice guidelines.
