Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696592712016.pdf (Zimbabwe)
Performance of the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) Programme Dr M. Venge Acting Deputy Director Reproductive Health Ministry of Health and Child Care Vision and Mission of the RMNCAH programme Vision A Zimbabwe where pregnancy and childbirth do not pose a threat to the lives of mothers and newborns; where children are healthy and free of the preventable common childhood illnesses and are able to survive, grow and develop to their full potential thereby fulfilling their role in the socioeconomic development Mission To provide high quality comprehensive and integrated maternal, newborn and child health services by scaling up proven cost effective interventions at high population coverage through family and community, outreach and health facility level care 11/8/2022 2 Policy Environment/Operating Framework • RMNCAH activities are guided by strategic policy documents, policy pronouncements and strategies • The policy documents/pronounc ements are at all levels (international, regional, national and programme specific) Sustainable Development Goals (SDGs) National Development Strategy (NDS) 1 [2021-2025] National Health Strategy (NHS) 2021-2025 RMNCAH Strategy: 2017 – 2021 Zimbabwe MNH Strategy: 2017 – 2021 Zimbabwe National Family Planning Strategy: 2022- 2026 Adolescent Health and Youth Implementation Plan: 2021 – 2025 (under development) National Cervical Cancer Screening and treatment of pre-cancerous lesion guideline: 2021-2025 National Health Sector Monitoring Evaluation Policy Sustainable Development Goals related to RMNCAH 4 1 2 3 4 Reduce global maternal mortality to 70 per 100,000 live births by 2030.
Reduce neonatal mortality to at least 12 per 1000 live births by 2030 in every country .

Reduce Under Five Mortality Rate to at least 25 per 1000 live births by 2030 in every country.
Ensure universal access to sexual and reproduct ive health services (including for family planning) and rights 11/8/2022 RMNCAH Programme objectives • Increase the Modern Contraceptive Prevalence Rate (mCPR) from 67% in 2015 to 80% by 2025 • Reduce Adolescent Birth Rate from 108 births per 1,000 adolescent girls in 2019 to 93 per 1,000 by 2025 • Reduce Maternal Mortality Ratio from 462 in 2019 to 240 by 2025 • Reduce Neonatal Mortality Rate from 32 in 2019 to 20 deaths per 1,000 live births by 2025.
• Reduce the Under-five Mortality Rate from 65 in 2019 to 41 deaths per 1,000 live births by 2025 • Achieve by 2025 universal access to Reproductive Health RMNCAH Interventions currently being implemented Family Planning • Zimbabwe National Family Planning Council (ZNFPC) is the coordinating body for all FP activities • There are various players in the provision of FP services in the country (Government, parastatals, private sector including NGOs etc) • More focus being given to Long Acting Reservable Contraceptives (LARCs) eg IUCD and Implanon to improve the method mix • Trainings of health workers to provide LARCs ongoing • Rolling out of Sayana Press to all the provinces in the country Current Key Family Planning Issues 1.
Inequity: People in hard to reach areas including those with disabilities do not have adequate access to FP services 2.

Human Resources For Health: Shortage of staff trained in LARCs due to attrition 3.

Commodity security challenges: Shortage of FP commodities 4.
Poor quality of care: High coverage vs poor outcomes Cervical Cancer Screening and Management • Objective of the programme is to contribute to the reduction of the incidence, prevalence, morbidity and mortality due to cervical cancer and improve the quality of life of cervical cancer patients.
• There are various players in the provision of cacx prevention and control services (Government, parastatals, private sector including NGOs etc) • Every district & Mission hospital & some high volume clinics offering VIAC services • High screening rates - Treatment rates previously low have picked up significantly • Currently rolling out HPV DNA testing Current Key Issues on Cervical Cancer Screening and Management Inadequate support for screening and treatment of HIV negative women: Partners are supporting HIV positive women – screening and treatment now skewed towards HIV positive women Human Resources For Health: Shortage of staff trained in VIAC due to attrition- mostly affecting service sprovision for non partner supported clinics Poor quality of care: Delays in treatment of patients requiring LEEP (some patients waiting for longer periods).
LEEP devices not readily available Obstetric Fistula (OF) Repair Programme MoHCC is implementing a national programme to repair women with OF.
New OF camps opened up, there are 6 camps at the moment: 1.Chinhoyi P Hospital - Mashonaland West 2.Mashoko Mission Hospital- Masvingo 3.Morgenster Mission Hospital - Masvingo 4.Chidamoyo Mission Hospital - Mashonaland West 5.United Bulawayo Hospitals (UBH) - Bulawayo 6.Mutambara Mission Hospital - Manicaland Chinhoyi and UBH now offering OF repair service using local doctors Current Key Issues on OF 1.

Limited funding for OF camps.

UNFPA stopped supporting 2.


Limited number of local doctors who are able to officer service 3.

Limited number of Health Facilities offering the service (only 6 hospitals nationwide.

Most provinces do not offer service ) Maternal and New- born Health Current Key Issues in Maternal and Newborn Health Programming Adolescent Sexual and Reproductive Health (ASRH) • Programme goal is to reduce morbidity and mortality associated with sexual and reproductive activities among adolescents and young people.
• Currently implementing the WHO’s 9 standards in 358 health facilities- health facilities have been certified as Youth Friendly Centres • ASRH interventions are delivered based on the ASRH Strategy and service delivery guidelines.
Consultant has been hired to lead development of the 2021- 2025 ASRH Costed Implementation Plan • Pre-service teaching guide for nursing and midwifery schools being implemented • Training of health service on the 9 standards affected by the COVID 19 pandemic Current Key Issues in ASRH Programming Human Resources For Health challenges: Shortage of staff trained in ASRH due to attrition.

The few available have low staff morale and staff burnout Low/Poor access to RMNCAH services by the young people, why???
Equity issues - poor access to services by hard to reach young people and those disabled Research, Monitoring and Evaluation Activities conducted by the M&E Desk • Quarterly monitoring and supportive visits (integrated) • Production of the quarterly RMNCAH&N Scorecard • Production of quarterly, biannual and annual programme updates/reports • Biannual data verifications exercises • Beneficiary verification exercise • Programme review and planning meetings • RMNCH Studies Current Key Issues in M&E • Poor data quality - (HMIS and notification forms) • Poor submission of notification and reporting forms to HQ • Poorly age disaggregated data collection tools – T5 • Lack of consensus on denominators for selected indicators (eg ANC 4th visit) and target setting Performance of the RMNCAH Programme Based on routine/health facility data: 2017 - 2022 Family Planning • Declining mCPR vs rising unmet need for FP • 2021 targets were 68% for mCPR and 6.5% for unmet need • Staff attrition affected provision of LARCs • FP commodities- challenges with supply side t n e c r e P 80 70 60 50 40 30 20 10 0 65.8 66.8 67.2 69 67.8 9.9 9 8.6 10 10.7 2017 2018 2020 2021 2019 Year mCPR unment need New Acceptors of LARCs • New acceptors of LARCs (IUCD and implants) declined by 2% between the first half of 2021 and that of 2022, WHY??
• Indicator does not seem to have been affected by COVID 19 that much as it has been stagnant at 21% since the first half of 2019 ) % ( s r o t p e c c a w e N 21.5 21.0 20.5 20.0 19.5 19.0 18.5 18.0 17.5 17.0 21.3 21.1 20.7 18.6 Jan to Jun 2019 Jan to Jun 2020 Jan to Jun 2021 Jan to Jun 2022 Period Obstetric Fistula • Provision of OF services in 2020 and 2021 affected by the COVID 19 pandemic • Target cases for 2021 reduced due to the COVID 19 pandemic • Increase in the number of cases identified and admitted for surgery in 2022 – due to relaxation of COVID 19 restrictions s e s a c f o r e b m u N 300 250 200 150 100 50 0 250 250 200 131 250 243 192 214 180 147 151 (77%) 87(66%) 92 103(70%) 33 24(73%) 2019 2020 2021 2022 Year Target cases Identified Admitted Repaired ANC: Early bookings (< 16wks ) At least 4 ANC visits n o i t a t s e G s k e e w 6 1 < d e k o o b % 30 25 29 29 29 Target was 34% 28 27 97 89 86 100 95 90 85 80 75 70 ) % ( t i s i v + 4 C N A Target was 74% 74 74 2017 2018 2019 Year 2020 2021 Year 2017 2018 2019 2020 2021 69000 68000 67000 66000 65000 64000 63000 62000 61000 60000 59000 s g n i k o o b y l r a e f o r e b m u N ANC Bookings • There was a decline in ANC bookings in the first half of 2022 when compared to previous years • Total bookings declined by 2% and bookings below 16 weeks gestation by 4% between the first half of 2021 and that of 2022.
• What explains the decline?
234774 234485 234161 236000 235000 234000 233000 232000 231000 67690 229498 230000 65145 64284 62408 229000 228000 227000 226000 Jan to Jun 2019 Jan to Jun 2020 Jan to Jun 2021 Jan to Jun 2022 Period ANC below 16 Weeks Gestation Total ANC Bookings s g n i k o o b C N A f o r e b m u N Institutional deliveries C/Section Rate 95 90 85 80 75 70 65 ) % ( s e i r e v i l e d l a n o i t u t i t s n I 90 Target was 87% 88 86 84 87 10 9 Target was 11% 9 9 8 10.5 10 9.5 9 8.5 8 7.5 7 6.5 6 ) % ( e t a R n o i t c e S C / 2017 2018 2019 2020 2021 Year 2017 2018 2019 2020 2021 Year Deliveries 194000 192000 191286 • The number of deliveries in health facilities increased by 4% between the first half of 2021 and that of 2022 • Home deliveries fell by about 22% in the same period s e i r e v i l e d y t i l i c a f f o r e b m u N 190000 188000 186000 184000 182000 180000 178000 176000 191805 25000 20000 19833 19327 s e i r e v i l e d e m o h f o r e b m u N 15548 15094 15000 183995 181976 10000 5000 0 Jan to Jun 2019 Jan to Jun 2020 Jan to Jun 2021 Jan to Jun 2022 Period Facility deliveries Home deliveries PNC Coverage • PNC covered has been declining since 2019, ?
COVID 19 • 2021 target for coverage at day 3 was not met • Coverage decreasing as we move further from the day of delivery ) % ( e g a r e v o C C N P 85 80 75 70 65 60 55 50 Day 1 Day 3 Day 7 78 79 81 80 77 69 69 66 66 67 65 59 53 2017 2018 2019 2020 Year Target was 84% 55 50 2021 PNC Attendances • PNC attendance increased by about 2% at day 1, 9% at day 3, 13% at day 7 and by about 11% at 6 weeks, between the first half of 2021 and that of 2022 • Uptake and utilization of PNC services has not yet gone back to the pre- COVID 19 levels in 2019 Jan to Jun 2019 Jan to Jun 2020 Jan to Jun 2021 Jan to Jun 2022 e c n a d n e t t a C N P f o r e b m u N 180000 160000 140000 120000 100000 80000 60000 40000 20000 0 1 Day 3 Days 7 Days Jan to Jun 2019 Jan to Jun 2020 Jan to Jun 2021 Jan to Jun 2022 169615 161996 158332 160979 144575 119918 112902 122583 138521 107780 103703 117613 PNC timing 6 Weeks 141352 120923 122899 136314 Institutional Maternal Mortality Ratio (IMMR) • IMMR rising since 2019 • This reflects a struggling health delivery system • Pre and post COVID 19 challenges with the health system esp HRH issues 240 200 160 120 80 40 0 s e i r e v i l e d , 0 0 0 0 0 1 / s h t a e d l a n r e t a M 132 93 92 103 Target was 98 122 2017 2018 2019 2020 2021 Year Institutional and Community Maternal Mortality Ratio: Jan – June 2019 - 2022 • Institutional Maternal Mortality Ratio (IMMR) declined by 7% between the first half of 2021 and that of 2022 s e i r e v i l e d 0 0 0 0 0 1 / s h t a e D , 140 120 100 80 60 40 20 0 IMMR 115 107 103 92 Jan to Jun 2019 Jan to Jun 2020 Jan to Jun 2021 Jan to Jun 2022 Period Maternal mortality by province/organizational unit: January to June 2022 Province/unit Deliveries at health facility Deliverie s at home Maternal death at facility Maternal death at home Total materna l death IMMR (maternal deaths at HFs/100,000 deliveries) Bulawayo Province Chitungwiza City Harare Province Manicaland Province Mashonaland Central Province Mashonaland East Province Midlands Province Matabeleland
 North Province Matabeleland South Province Masvingo Province Mashonaland West Province Mpilo United Bulawayo Hospitals Chitungwiza Central Hospital Parirenyatwa Group of Hospitals Sally Mugabe Central Hospital Total 111/100,000 deliveries 56/100,000 deliveries 45/100,000 deliveries 52/100,000 deliveries 21/100,000 deliveries 56/100,000 deliveries 57/100,000 deliveries 98/100,000 deliveries 89/100,000 deliveries 458/100,000 deliveries 627/100,000 deliveries 303/100,000 deliveries 538/100,000 deliveries 195482 15094 210 36 246 107/100,000 deliveries Cause of maternal deaths 2021 (n=216) AIDS Defining Condition 3% Other 11% Unknown 8% Malaria 4% PIH 2% Cardiac disease 3% C/Section related 2% Puerperal sepsis 8% Eclampsia 18% PPH 28% APH 5% Ruptured uterus 4% Ectopic pregnancy 2% Post abortal sepsis 2% Facility Neonatal Mortality Rate, Perinatal Mortality Rate and Fresh Still Birth Rate • There was no improvement on mortality indicators for perinatal health • There is serious under reporting of perinatal deaths at all levels of care • Poor notification and auditing of perinatal deaths at all levels of care 35 30 25 20 15 10 5 0 e t a R 2017 2018 2019 2020 2021 Facility Neonatal Mortality Rate Perinatal Mortality Rate Fresh Still Birth Rate 23 29 5 22 28 5 20 29 6 21 30 7 22 29 6 Year Facility Perinatal Mortality Rate, Facility Early Neonatal Mortality Rate and Fresh Stillbirth Rate by province/organizational unit and by period: Jan – June 2019 - 2022 Province/unit Bulawayo Province Chitungwiza City Harare Province Manicaland Province Mashonaland Central Province Mashonaland East Province Midlands Province Matabeleland North Province Matabeleland South Province Masvingo Province Mashonaland West
 Province Mpilo United Bulawayo Hospitals Chitungwiza Central Hospital Parirenyatwa Group of Hospitals Sally Mugabe Central Hospital Total January - June 2021 Perinatal Mortality Rate 11/1000 births 5/1000 births 18/1000 births 26/1000 births Early Neonatal Mortality Rate 2/1000 livebirths 1/1000 livebirths 1/1000 livebirths 12/1000 livebirths Fresh Still Birth Rate Perinatal Mortality Rate January - June 2022 Early Neonatal Mortality Rate 5/1000 births 2/1000 births 11/1000 births 6/1000 births 19/1000 births 14/1000 births 9/1000 births 24/1000 births 3/1000 livebirths 1/1000 livebirths 1/1000 livebirths 11/1000 livebirths Fresh Still Birth Rate 7/1000 births 6/1000 births 4/1000 births 5/1000 births 24/1000 births 9/1000 livebirths 8/1000 births 25/1000 births 11/1000 livebirths 7/1000 births 22/1000 births 8/1000 livebirths 6/1000 births 20/1000 births 7/1000 livebirths 6/1000 births 26/1000 births 10/1000 livebirths 6/1000 births 27/1000 births 11/1000 livebirths 6/1000 births 18/1000 births 8/1000 livebirths 4/1000 births 19/1000 births 8/1000 livebirths 5/1000 births 20/1000 births 7/1000 livebirths 5/1000 births 21/1000 births 7/1000 livebirths 5/1000 births 23/1000 births 8/1000 livebirths 6/1000 births 23/1000 births 9/1000 livebirths 7/1000 births 26/1000 births 9/1000 livebirths 7/1000 births 26/1000 births 10/1000 livebirths 6/1000 births 63/1000 births 35/1000 livebirths 5/1000 births 59/1000 births 31/1000 livebirths 7/1000 births 54/1000 births 28/1000 livebirths 2/1000 births 55/1000 births 37/1000 livebirths 3/1000 births 91/1000 births 38/1000 livebirths 7/1000 births 111/1000 births 47/1000 livebirths 9/1000 births 103/1000 births 48/1000 livebirths 19/1000 births 71/1000 births 28/1000 livebirths 8/1000 births 117/1000 births 56/1000 livebirths 8/1000 births 93/1000 births 46/1000 livebirths 6/1000 births 301000 births 12/1000 livebirths 7/1000 births 30/1000 births 12/1000 livebirths 6/1000 births Cause of stillbirths in 2021 (n=279) Cause of
 Early Neonatal Deaths in 2021 (n=646) ) % ( t n e c r e p 35 30 25 20 15 10 5 0 33 31 20 16 Other 17% Neonatal Sepsis 1% Prematurity 42% Cause of stillbirth Birth Asphyxia 40% • Routine data shows that while performance of the programme was affected significantly by the COVID 19 pandemic in 2020, there were notable improvements in 2021 and 2022 • While some coverage indicators (ANC and delivery) picked up in 2021 and 2022, some did not perform well (ANC bookings and FP indicators) • Challenges with human resources for health (staff attrition, low morale and burnout) remains the major factor militating against better programme performance Findings from MICS Indicator MICS Target 2014 2019 2020 2025 • Programme generally preforming well according to MICS 2014 and 2019 • Except for Neonatal Mortality, all RMNCAH indicators performed well • However targets for 2020 could nit be met for most of the indicators except Institutional Deliveries and Skilled Attendance at Birth ANC Coverage 93.7% 93.3% 96% 95.1% ANC 4+ visits 70.1% 71.5% 90% 78% ANC 8+ contacts - 10.2% - 50.2% Adolescent Birth Rate 120 108 99 93 Institutional deliveries 79.6% 85.5% 85% 90.9% Skilled Attendance at birth 80% 86% 85% 91.4% C/Section rate 6% 8.8% 10% 15% PNC Coverage - Mother 77.3% 82.1% 85%* 87.1% PNC Coverage - newborn Neonatal Mortality Rate Maternal Mortality Ratio 85% 90.9% 95.2% 29 32 20 20 614 462 300 240 Declining trends in MMR 614 in 2014 to 462 (MICS 2019) 657 in 2008 to 217 (ZMPMS 2022) Corroborated by routine data until 2019 Challenges and Recommendations Challenges Mitigation/Recommendation Responsible HRH issues- shortage of staff, high turnover of trained staff, burnout, low morale and motivation impacted negatively on access and quality of care Poor quality of care at service delivery level • Revitalize the PCN training programme and train more staff • Recall retired nurses to assists with service • • • • • provision in hard hit health facilities Improve working conditions for
 health workers and operationalize sustainable staff retention schemes Establish Caring for the carer programs Improve HRH working conditions Strengthen IPC at service delivery level Implement quality focused RBF in health facilities PSC PSC PSC HR unit • PSC • Health managers • RH and Policy depths Thank you