(WP)CHD/ICP/CAH/2.2/001-A Report series number: RS/2006/GE/16(LAO) REPORT WHO/UNICEF WORKSHOP ON CHILD SURVIVAL. Convened by:

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1 (WP)CHD/ICP/CAH/2.2/001-A Report series number: RS/2006/GE/16(LAO) English only REPORT WHO/UNICEF WORKSHOP ON CHILD SURVIVAL Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Vientiane, Lao People's Democratic Republic 9 11 May 2006 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines November 2006

2 NOTE The views expressed in this report are those of the participants in the WHO/UNICEF Workshop on Child Survival and do not necessarily reflect the policies of the World Health Organization. This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the WHO/UNICEF Workshop on Child Survival, which was held in Vientiane, Lao People's Democratic Republic from 9 to 11 May 2006.

3 CONTENTS SUMMARY... i 1. INTRODUCTION Background Objectives Participants Meeting structure and organization PROCEEDINGS Opening session Session 1. Review of the child survival situation in the Region and introduction of the WHO/UNICEF Regional Child Survival Strategy Session 2. Review of country experiences and plans, identification of next steps to maximize child survival outcomes in collaboration with key stakeholders Session 3. Discussion and agreement upon a common monitoring framework for implementing national strategies on child survival Panel on advocacy and resource mobilization SUMMARY AND CONCLUSIONS Child survival strategy overview Policy/strategy development Stakeholders Country experiences Financing child survival Plan of action Monitoring progress Development partners Page ANNEXES: ANNEX 1 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS, REPRESENTATIVES/OBSERVERS AND SECRETARIAT ANNEX 2 - WORKSHOP AGENDA ANNEX 3 - CHOICE OF INDICATORS FOR REPORTING Key words Child health / Child survival

4 - i - SUMMARY Around 3000 children under five years of age die every day in the Western Pacific Region from common preventable and treatable conditions including diarrhoea, pneumonia, and perinatal events. Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam account for 75% of all deaths in the Region among children under five, accounting for as many as child deaths. A joint WHO/UNICEF Regional Child Survival Strategy was developed to outline a unified direction to accelerate and sustain action towards achieving the national targets for Millennium Development Goal 4, and reduce inequities in child survival, particularly in areas of greatest need. The strategy was endorsed by the fifty-sixth session of the Regional Committee for the Western Pacific in September It focuses on the implementation of an "Essential Package for Child Survival" composed of seven intervention areas and proposes 10 core child survival indicators for regular monitoring of progress. In order to intensify child survival actions in countries and areas of greatest need, WHO and UNICEF held a workshop to officially launch the strategy with government representatives from countries with the highest burden of childhood deaths, discuss implementation issues and plan for a common monitoring framework to track progress among all stakeholders. Three objectives guided the workshop: (1) to review the child survival situation in the Region and introduce the WHO/UNICEF Regional Child Survival Strategy to countries with a high burden of deaths among children under five years of age; (2) to discuss and agree upon a common monitoring framework for implementing national strategies that aim at taking to scale the "Essential Package for Child Survival" in line with the Regional Strategy; and (3) to review country experiences and plans, and identify next steps to maximize child survival outcomes in collaboration with key stakeholders including funding and development partners. The workshop was conducted from 9 to 11 May 2006 in Vientiane, Lao People's Democratic Republic. The more than 100 participants included: government representatives from various child health-related programmes representing the six priority countries, international experts, a large WHO/UNICEF secretariat, and representatives of partner agencies. To address the first objective, three presentations provided an overview of child survival in the Region, summarized the regional strategy and reviewed the implementation of key interventions in the six countries represented in the workshop. In addition, there was group work and plenary discussion on stakeholding in child survival. Country delegates and partners welcomed UNICEF s and WHO s effort to address child survival in the Region through an evidence-based coherent joint strategy which strongly emphasizes cost-effective interventions and equity. It was emphasized that countries experiencing early decreases in under-five mortality rates must now focus on reducing neonatal

5 - ii - mortality. This requires improved early initiation of exclusive breastfeeding, birth spacing, tetanus prevention, health and nutrition of pregnant women, and deliveries by skilled attendants. The six participating countries presented their experiences. The Lao People's Democratic Republic summarized the maternal and child health policy and strategy development. Viet Nam presented a strategy to improve newborn survival. China summarized the work on assessment of national maternal and child survival strategies. Papua New Guinea shared their efforts to coordinate child survival activities, and the Philippines presented child health care financing in the country. General presentations on financing child survival and applying equity to child survival included: a review of the challenges in financing child health, a brief introduction of the Biregional Health Care Financing Strategy, a presentation of possible financing tools for child survival interventions in Cambodia, and a case study on costing for maternal and child health (MCH) in China. The China financing exercise showed that the essential package of seven child survival interventions is affordable. Governments should reallocate and mobilize funds for the essential package, include it in insurance schemes (if applicable), and identify partners to support the efforts. The next steps were addressed through a presentation on a framework for developing national policies and strategies for child survival as well as group work and plenary on enhancing national child survival strategies. Countries announced their commitment to developing and implementing operational plans to increase coverage of the essential package of child survival interventions. Operational plans should include geographical concentration and phasing, geographical targeting, if applicable, a clear timeframe, human resource development plans, financing plans, methodology to elicit and address community-identified barriers to accessing care, monitoring and evaluation strategy, and accountability at all levels. Monitoring issues were introduced through presentations on data for decision-making and demand generation, monitoring and evaluating child survival, and key concerns on the health information system. Current problems such as the lack of clarity and use of common indicators and related definitions, parallel data collection system, reporting burden, ignorance of what other programmes are collecting, limited or no sharing of information and limited use of information for policy decision-making were highlighted. A draft framework for monitoring and evaluating implementation of national child survival strategies and activities was discussed in groups. Monitoring was seen to be crucial for the assessment of progress, identification of gaps, adjustment of programmes, and tracking of resources. The participants expressed a need to hold a joint UNICEF/WHO workshop on data for decision-making, where the focus would be on the operational level. The participants concluded that all six countries are carrying out many aspects of the essential package. However, quality and coverage vary. Socioeconomic and geographic disparities hinder reaching poor segments of society with basic services. Fees for services are common, while health insurance coverage is low. This further impedes poor persons from accessing care. Consequently, policy development, funding, programmes, and monitoring and evaluation will need to mainstream equity considerations. Countries will need to enhance the monitoring and evaluation system for child survival strategy implementation, within the national health information system framework. Operationalization of the monitoring and evaluation system will require institutionalization at all levels. Quality improvement cycles should involve all levels and be an integral part of operationalization.

6 - iii - Data collection strategies need to be less extractive and more useable at the community level where data are collected. When communities see data being used to influence change, they are more likely to contribute to data collection and participate in the change. As a last activity, participants and donors discussed how to enhance funding for child survival. WHO/UNICEF proposed holding a follow-up meeting in two years to examine progress made through the implementation of the child survival strategy and the impact on key indicators. The participants agreed.

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8 INTRODUCTION 1.1. Background Around 3000 children under fve years of age die every day in the Western Pacific Region from common preventable and treatable conditions including diarrhoea, pneumonia, and perinatal events. Many of these deaths are associated with undernutrition. Vaccine preventable diseases and injuries further contribute to this high number of childhood deaths. Child survival interventions to address these conditions are widely known and their cost-effectiveness have been proven. Most childhood deaths occur in low-income countries or poor communities in middle-income countries where many deaths are unrecorded. Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam account for 75% of all deaths in the Region among children under five, accounting for as many as child deaths. The Millennium Development Goal (MDG) 4 of the United Nations Millennium Declaration calls for a reduction by two thirds, between 1990 and 2015, of the under-five mortality rate. Analysis of the progress towards the goal in the Region shows mixed results, and the achievement of the goal proves challenging for many countries as long as mortality reduction continues to stagnate, preventable and treatable causes of childhood mortality persist and huge disparities in child survival exist. Also, further investments to take to scale evidence-based interventions should be the moral imperative of all stakeholders. Concerned about the situation, the WHO Regional Committee at its fifty-fourth session in 2003 urged Member States, in particular those with high child mortality, to place child health higher on their political, economic and health agendas, and to ensure the provision of health care to all children in need. Consequently, through an extensive consultative process, WHO together with UNICEF developed a joint WHO/UNICEF Regional Child Survival Strategy that outlines a unified direction to accelerate and sustain action towards achieving the national targets for MDG 4, and reduce inequities in child survival, particularly in areas of greatest need. The WHO Regional Committee endorsed the strategy at its fifty-sixth session in September The WHO/UNICEF Regional Child Survival Strategy focuses on the implementation of an "essential package for child survival" composed of seven intervention areas: (1) skilled attendance during pregnancy, delivery and the immediate postpartum; (2) care of the newborn; (3) breastfeeding and complementary feeding; (4) micronutrient supplementation; (5) immunization of children and mothers; (6) integrated management of sick children; and (7) use of insecticide-treated bednets (in malarious areas). At the heart of the strategy are 10 core child survival indicators for regular monitoring of progress towards universal coverage of the different intervention areas. As a way forward towards universal coverage of the essential package for child survival, coordination mechanisms are suggested to be set up, national strategic and action plans to be developed, monitoring and evaluation frameworks to be agreed upon, and advocacy and resource mobilization efforts stepped up. In order to intensify child survival actions in countries and areas of greatest need, WHO and UNICEF held this workshop to officially launch the strategy with government representatives from priority countries, discuss implementation issues and plan for a common monitoring framework to track progress among all stakeholders.

9 Objectives (1) To review the child survival situation in the Region and introduce the WHO/UNICEF Regional Child Survival Strategy to countries with a high burden of deaths among children under five years of age. (2) To discuss and agree upon a common monitoring framework for implementing national strategies that aim at taking to scale the "essential package for child survival" in line with the Regional Strategy. (3) To review country experiences and plans, and identify next steps to maximize child survival outcomes in collaboration with key stakeholders including funding and development partners Participants The workshop brought together more than 100 participants including: international experts; a large WHO/UNICEF secretariat from all levels of the two organizations (headquarters, regional and country offices); and representatives of partner agencies (see Annex 1). Participants included representatives from the six priority countries in the Western Pacific Region, namely Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam. Each country delegation consisted of managers of child health programmes, decision-makers and other experts. International experts covered different areas related to child survival including policy development, epidemiology, evidence-based interventions, monitoring and evaluation, and financing. Observers represented a variety of institutions including other United Nations agencies, funding agencies and nongovernmental organizations (NGOs) Meeting structure and organization The workshop was conducted from 9 to 11 May 2006 at the Don Chan Palace Hotel in Vientiane, Lao People's Democratic Republic. Dr Somchit Akkhavong was appointed as Chairperson; Professor Sann Chan Soeung and Dr Paulyn Rossell-Ubial as Vice-Chairpersons; and Mr Enoch Posanai, Dr Wang Bin and Dr Dinh Thi Phuong Hoa as Rapporteurs for days 1, 2 and 3, respectively. The three-day workshop agenda is presented in Annex PROCEEDINGS 2.1. Opening session This session included speeches by the Regional Director of the Western Pacific Region of the World Health Organization, the UNICEF representative in the Lao People's Democratic Republic, and the Minister of Health of the Lao People's Democratic Republic. Dr Shigeru Omi, WHO Regional Director, welcomed the participants by highlighting the fact that for the very first time, policy- and decision-makers as well as diverse

10 - 3 - child health-related programmes were represented in the same workshop. He encouraged everyone to take advantage of the opportunity of being together to discuss how to advance countries' efforts for improving the survival of children, including ways to mobilize more resources. He pointed out that children have no voice in advocating greater investments in child survival, and therefore it doesn't always get the attention that is warranted from moral, economic and health grounds. He noted though that WHO and UNICEF are seriously committed to coordinating efforts to support countries, as reflected in the variety of programmes represented in the meeting. As such, a new modus of operandi may be born to seriously, and with joint action, tackle child survival issues in the Region. He finally wished the participants fruitful discussions and thanked the Government of the Lao People's Democratic Republic for hosting the meeting. Ms Olivia Yambi, UNICEF representative to the Lao People's Democratic Republic, welcomed the participants to the meeting and noted that it represents a significant milestone in progress towards improving child survival in the Region. She thanked and congratulated WHO and UNICEF for developing the joint Regional Child Survival Strategy and highlighted the importance of United Nations organizations working together to contribute to higher results and better support implementation efforts in countries. She concluded by wishing for a successful workshop. His Excellency Dr Ponmek Dalaloy, Minister of Health of the Lao People's Democratic Republic, welcomed the participants to Vientiane. He indicated that he was pleased to host the meeting and to have so many partner agencies attending it. The Minister pointed out that improving child survival could be done, but making changes and ensuring that the evidencebased interventions are delivered to those who need them would be difficult. He also indicated that some steps can and must be done immediately, recognizing that countries should not start from scratch but instead combine the efforts of all the child health-related programmes and strategies to enhance the resource base and facilitate delivery of interventions. He concluded by expressing wishes for an active and productive workshop Session 1. Review of the child survival situation in the Region and introduction of the WHO/UNICEF Regional Child Survival Strategy Session 1 contained three presentations, group work and plenary discussion. The first presentation provided an overview of child survival in the Region, the second summarized the regional strategy, and the third reviewed the implementation of key interventions in the six countries with the highest burden of deaths among children under five Overview of child survival in the Region This presentation summarized the causes of deaths as well as distribution of deaths among children under five years old. It referred to the high percentage of deaths in the neonatal period, the importance of undernutrition and low birth weight as associated factors, and the fact that diarrhoea and pneumonia remain as very important causes of death. Important factors that underlie child deaths include inadequate care for women, high fertility, community and environment, inappropriate infant and young child feeding practices, lack of access to safe water and sanitation, and lack of access to basic social services. The presenter also highlighted the importance of equity and intranational disparities WHO/UNICEF Regional Child Survival Strategy This presentation started with a brief review of child survival in the Region, including the slow progress, persistence of causes of death disparities between and within countries, insufficient funding and fragmented approach. The presentation then introduced the strategy s

11 - 4 - goal, objectives and essential package for child survival, elaborating on each of the seven intervention areas and referring to the very low cost of the child survival commodities. Contributing actions for child survival were discussed, as well as the strategic approaches (improving leadership and governance, consolidating partnerships, improving efficiency and quality of service delivery, engaging and empowering families and communities, ensuring health care financing support for child survival). The grouping of the countries and characteristics of each group were also presented, as well as the way forward with "the three ones plus two" (one coordination mechanism, one national plan, one monitoring and evaluation process, advocacy and communication, and mobilization of resources Coverage of essential child survival interventions The last presentation in this session summarized the coverage of essential child survival interventions as reported in the recently compiled child survival country profiles of the six countries represented in the workshop. The presentation reviewed the expected number of deaths averted by implementing the essential package of interventions, stressed that information was collected in coordination with the Ministry of Health/Department of Health and summarized the data included in each profile. The current situation on implementation of each intervention in the six countries was presented using the 10 core indicators included in the Regional Strategy. It was concluded that countries are implementing many of these child survival interventions, but coverage is low, and that countries use different indicators for the same intervention, making data comparison and tracking progress towards implementation coverage difficult Group work and plenary: stakeholding in child survival This session ended with group work and plenary discussion on stakeholding in child survival. Participants were divided in six groups and asked to indicate the following: (1) reasons why partners should contribute to child survival activities; (2) a list of "missing" partners and the role they could play to bring child survival forward; and (3) what will be the individual contribution to improve child survival, indicating the type of institution each individual belongs to. During the plenary discussion, participants indicated the need to discuss how to concretely operationalize the child survival strategy at country level, without diluting delivery of desired programme-specific results. The importance of different stakeholders was discussed, including the usefulness of involving ministers of finance. Countries were urged to apply the child survival strategy by focusing on the seven essential sets of interventions and the core 10 indicators Session 2. Review of country experiences and plans, identification of next steps to maximize child survival outcomes in collaboration with key stakeholders This session included presentations by the six participating countries The Lao People s Democratic Republic The Lao People's Democratic Republic presented a summary of the maternal and child health policy and strategy development, starting with a summary of demographic and health services data including levels of maternal and child mortality. The presenter indicated that access to and quality of MCH services are poor, the capability of management is limited, and MCH staff lack communication skills. The content of the current policy was summarized in 11 points to address needs of women during pregnancy, delivery and postpartum care as well as needs of children under five. The policy covers the period and includes activities

12 - 5 - related to health services, health facilities, capacity-building, community outreach, and information, education and communication (IEC) Viet Nam Viet Nam's presentation referred to a strategy to improve newborn survival. The presenter reviewed the current situation of newborn health and the gaps in newborn health care, showing the stagnant level of neonatal mortality rate, low percentages of appropriate feeding practices, and prevalence of human immunodeficiency virus (HIV) among pregnant women. The disparity among regions and socioeconomic groups was stressed. The strategy to improve newborn survival builds on existing national aims and targets. It proposes working within the existing health care system to: ensure continuum of care, target unreached and vulnerable populations, improve facility-based clinical care and outreach through home visits and family-community care, strengthen the health system, provide in-service and pre-service training, mobilize more funds, monitor and evaluate, and collaborate with all stakeholders China The representative from China summarized the work on assessment of national maternal and child survival strategies with the aim of achieving MDG 4 and 5 in China. The review included epidemiological analysis on the trend of maternal and child mortality, and elaboration on the immediate, predisposing, and underlying factors. The Lancet model (child survival) and British Medical Journal model (maternal survival) had been used to analyse the essential package of interventions. The presenter indicated that counties and cities were classified according to a composite development index in six groups. The reviewers found that urban and rural under-five and maternal mortality have declined impressively, but important gaps remain between urban and rural areas. They also found that the majority of deaths occur in rural counties (types 2 and 3). The analysis also showed gender imbalances, inadequate services, cultural barriers, inadequate financing, and lack of human resources in poor rural areas. The assessment team recommended the delivery of an essential package of maternal and child care, differentiated by areas and levels to ensure universal access. This would require health system reform, capacity-building and financial solutions Cambodia Cambodia's presentation referred to the Cambodian child survival scorecard, a concept that was conceived during the preparation for the consultation on MDG 4 in Cambodia in The scorecard assesses progress, focusing on what the health sector can do, while seeking the allocation of available resources for interventions that are most likely to lead to child survival. The presenter indicated that a Cambodian child coming from the richest quintile has a good chance of receiving most child survival interventions, while 80% of Cambodia's children receive only a few of them. Only if the full package of interventions is delivered to most children will there be a reduction in mortality. The Ministry of Health has decided that the child survival scorecard will include interventions based on the Lancet Child Survival Series of 2003 and for which it is directly responsible. The scorecard will also include vector control to fight dengue fever because this disease accounts for 2% of hospital mortality of children under five. Current data seem to indicate that Cambodia is back on track for child survival, even though the progress across interventions is uneven. Cambodia will use the scorecard to focus on interventions with the highest impact on child survival and to report on progress every year, in a comprehensive way.

13 Papua New Guinea Papua New Guinea presented how they are coordinating child survival activities. Family Health Services of the Department of Health, which is responsible for technical issues in child health, is in charge of developing policies, standards and guidelines; developing training materials; securing funds; advocating for recognition of child survival as a priority; monitoring and surveillance; and providing technical support to provinces and districts. The Paediatric Society of Papua New Guinea provides links to clinical services, provides technical advice and collaborates in the different activities. Additional partners involved in child health include other branches of the government, the National AIDS Council, and the University of Papua New Guinea. Inter-Agencies Coordination Committee, Child Health Technical Advisory Committee and Reproductive Health Technical Advisory Committee are also important coordinating groups. The presenter also indicated the importance of various provincial agencies for improving child health. Examples of initiatives and achievements reached as a result of good coordination were provided. The presenter ended by summarizing the challenges that the partners face, such as difficulty with implementing the child health programme at provincial/district level, management and coordination, legislative reform, geographical barriers to effective delivery of services, surveillance and overall manpower issues The Philippines The representative from the Philippines summarized the information on child health care financing in the country, starting with demographic data, the current coverage of the interventions included in the essential package, and the significant disparities in coverage for poorer families, rural areas, families with low educational background and depressed urban areas. The average out-of-pocket expenditure per capita is equivalent to 26% of a poor Philippine family income. Children account for 50% 70% of patients visiting health centres, and 20% 34% of inpatients in public hospitals. The main constraints to universal coverage of child health interventions are the inadequate financing for public health interventions, stock shortages, and high out-of-pocket payments at hospital level. The presenter indicated that the documented assessment and analysis of health financing can be used for advocacy with policy- and decisionmakers, to be linked to the potential of using the health sector reform and the initiative called "Fourmula One" to advance child health in the Philippines. In response to the country presentations, participants requested clarifications of some points and congratulated all presenters, recognizing the work done so far for improving the survival of children in the six countries Financing child survival The presentation on financing child survival included a review of the challenges in financing child health, a brief introduction of the Bi-Regional Health Care Financing Strategy, and application of possible financing tools for child survival interventions in Cambodia. The following challenges in child health financing were mentioned: (1) determining how much should be spent on child health/survival; (2) assessing if the expenditures match the needs; and (3) mobilizing resources for child health/survival. Each point was expanded. The Bi-Regional Health Care Financing Strategy ( ) covers the common challenges in the two regions: low investment in health, extensive private/out-of-pocket payments, limited access to health services, limited coverage by health insurance, lack of social safety nets, and low efficiency in resource use. The strategies are: increase investment and public spending on health; achieve universal coverage and strengthen social safety nets; develop pre-payment schemes including social health insurance, such as Social Health Insurance in Asia and the Pacific; support the national and international health and development process; strengthen regulatory frameworks and

14 - 7 - functional interventions; improve evidence for health financing policy development and implementation; and strengthen monitoring and evaluation. The presenter listed interventions for which relatively good funding (including donor funding) is available and should remain properly funded in the medium term, interventions for which external support is low but can be easily identified in the medium term, and interventions for which funding is extremely limited. A case study report on costing for MCH in China was also presented. The presenter indicated that, since the 1970s, government health funding and social health contribution have been declining in terms of the proportion of total health expenditure in China. The Chinese Government is aware that MCH funds cannot match the overall need for MDG 4; it has made MCH a priority of health investment and has committed more funding in the future. The presentation provided the context of health care financing and MCH financing profile in China based in the costing for child survival included in the joint review on MCH strategy in China in Preliminary results include a total cost for the essential package (3.731 billion Yuan), which the Government can afford to pay with the additional revenue of 500 billion Yuan in 2004 and Financing options in China for child survival were also presented Applying equity to child survival The presentation on applying equity to child survival revealed that there was a need to worry about equity because of moral and practical reasons. The presenter summarized the types of inequity and, using Brazil as an example, discussed global and in-country gaps. The presenter then explained an exercise conducted to assess coverage by wealth, which used DHS surveys from nine countries. The study calculated the number of interventions received by each child aged one to four years and found that some children received many interventions while others received few or none. Coverage was clearly related to wealth and to mortality. An equity-oriented approach will include the identification of relevant indicators, aiming at universal coverage with all of these interventions, thinking ahead about equity, monitoring coverage, assessing equity and incorporating equity in routine data Framework for developing national policies and strategies for child survival The last activity included a presentation on a framework for developing national policies and strategies for child survival as well as group work and plenary on enhancing national child survival strategies. The presentation described a framework that summarizes some of the main steps and implications of developing national child survival strategies and operational plans, identifying crucial elements for successful operationalization. The process of strategy development was presented together with the enabling component of building ownership and ensuring coordination among partners. The three phases of the strategy development process situation analysis, development of a strategy and action plan, integrating strategy and action plan in sector development plans and macroeconomic policies were then described in detail. Finally, the presenter reviewed the strategy development process at local level Group work and plenary: enhancing national child survival strategies Participants were divided into six groups to discuss the current status of efforts to integrate the seven priority child survival intervention components in each country. They were requested to select a province with high mortality for analysing the extent of implementation of the seven intervention components, and the degree of integration in the implementation. They had to identify main problems and propose concrete steps to ensure integration and scaling up of the interventions.

15 - 8 - Cambodia began its presentation by describing the integration of programmes such as immunization, micronutrient supplementation, management of sick children, skilled attendance, newborn care and infant feeding. Barriers for integration were identified as well as possible solutions. Actions suggested by the group included: (1) develop operational and budgetary guidelines (including funding mechanisms) for the 12-visit preventive child survival encounters that form the integrated delivery sessions; (2) use the monthly Child Survival Management Committee and the technical working group for coordination of any national programmes related to child survival; (3) promote advocacy at the operational district/provincial level for integrated child survival strategy in order to influence from the bottom up the annual operational plans and participation in the review process of these plans. China presented the current status of integration efforts as framed in the national programme of action for women and children development in China ( ). All child survival intervention components are part of the programme, except insecticide treated bednets since malaria is not a problem in the country. The group's representative indicated that policies are almost fully integrated but not fully implemented. Problems and potential interventions were summarized. The latter include advocacy with senior policy-makers, incentive policy for having professionals at local level, funding mechanisms, and the link with national transportation development. The presenter of the Lao People's Democratic Republic summarized the current situation, indicating that the Ministry of Health has developed a new policy of initially integrating with other projects at the grassroots levels. The lack of human resources to meet the job or project needs, however, is a problem. Potential interventions include: organizing a meeting at the central and provincial levels with stakeholders in order to introduce the child survival package; creating national operational guidelines on integration of child survival strategy with maternal and child health; selecting districts with high infant mortality; introducing the child care package to provinces with the reproductive health project; and training staff. The presenter of the Philippines started by indicating the level of integration between programmes. In terms of regulation, the Philippines has a certification system of health centres for quality assurance that includes the child survival interventions. Among the main problems are: human resources with ceilings of cost personnel ratio, lack of midwives especially for newborn care, inadequate payment of benefits, and inadequate trainings and management. The Philippines is taking concrete steps to address the problems including capacity-building, improvement on delivery mechanisms, and alternative financing mechanisms. A framework for strategic planning was presented. The Papua New Guinea presenter summarized the national policy framework that includes the essential package of interventions. A Family Health Services Coordinator is responsible for all intervention areas. The group identified a variety of problems and proposed solutions including incentives for staff in rural areas, engagement of community groups and organizations, capacity-building, and seeking support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Viet Nam has all seven intervention components already implemented at different levels with some already integrated. The degree of integration is also variable according to the level (national, provincial, district, commune). Problems identified include low quality of care, disparity between regions in coverage, incoherent health management information and weak monitoring systems. The solutions proposed include prioritizing neonatal care, improving paediatric emergency and referral care, increasing coverage of all components in remote areas, and improving HMIS and monitoring/supervision activities. Actions to be taken include the dissemination and adaptation of the Regional Child Survival Strategy development and

16 - 9 - implementation of a national action plan to improve coverage and quality of care for child survival. The facilitator summarized the results of the countries' presentations as follows: (1) All six countries have shown increased and strong commitment to investing in the child survival priority interventions (China and Viet Nam have put special emphasis on newborn care). (2) All six countries have started a process for developing national action plans, in some cases within a long-term strategy (China and the Lao People's Democratic Republic). (3) All six countries face major problems in integrating current child survival interventions although efforts towards integration have been made at various levels of the health system. (4) All six countries witness important sometimes increasing inequities in mortality indicators and coverage of essential child survival interventions, and face major challenges in addressing poor areas and population groups. Major obstacles found by countries referred to financing, human resources, delivery strategies and management/stewardship. For financing, obstacles included lack of integration of child survival interventions in current health plans, resulting in insufficient funding, unavailability of free access to key child survival interventions at point of delivery for most of the poorest, health expenditure ceilings at both national and local level, and the fact that the poorest areas get less money from the central government. Suggested solutions are as follows: link with and integrate within national health system plans, expand coverage of health insurance and/or provide free access to key child survival interventions, increase proportion of funding (as a fixed percentage or conditional to implementation) for child survival integrated interventions at central and local level and put in place compensation mechanisms in resource allocation at central and local level (more money to poorest areas). In relation to human resources, major problems include deployment of key staff in poor areas, recruitment and training of a sufficient number of key health providers (midwives), poor motivation and lack of incentives to reach out. Potential solutions would be: incentives (monetary and others) for health providers to work in poorest areas, allowances for costs of outreach activities, national and local training plans for specific health providers. As for delivery strategies, major obstacles mentioned by countries are: lack of focus on outreach delivery strategies, lack of integrated delivery channels, and logistical problems in outreach (partially a funding problem). The proposed solutions include explicit plans (and indicators, such as local score cards) for outreach activities as part of usual business, integrated delivery of interventions by midwives (pre-postnatal care, breastfeeding, EPI, others). Waiting homes for delivery care is also an opportunity for integrated care and IEC. Finally, the obstacles identified in the area of management/stewardship include poor coordination, poor managerial capacity at various levels, no incentives to integration, poor awareness of child survival among key provincial health officials and policy makers, lack of supervision, lack of good data and use at local level, and lack of dissemination of updated guidelines. The potential solutions proposed are: coordinating mechanisms at central and local level, capacity-building for intermediate health managers, incentives to integration, periodic

17 benchmarking (scorecard) as advocacy tool for public health officers and policy-makers, demand generation strategies to influence decisions of local policy-makers, and supervision activities as part of terms of reference for public health officers Additionally, countries identified obstacles beyond the health sector, including welfare system (safety nets) insufficiency, lack of transport and commodities for public servants and lack of IEC on good (and dangerous) practices. Potential solutions for addressing these obstacles include the improvement and expansion insurance scheme coverage; conditional cash transfers and vouchers for key child survival interventions; and development of IEC tools, strategies, education and information within schools. The facilitator concluded his summary by indicating that some unaddressed areas might become major obstacles for implementation of child survival strategies, for example, quality of care (quality assessment, improvement mechanisms, child survival training materials) and legislation (maternity leave, birth registration). Participants agreed with the summary presented and highlighted the need to identify issues/activities that can be addressed in the short term, while some broader issues in the society need strategies for long-term implementation Session 3. Discussion and agreement upon a common monitoring framework for implementing national strategies on child survival This section included three presentations, group work and plenary discussion Data for decision-making The first presentation pointed out that health information systems are overloaded. Every programme, project and development partner tends to have a separate monitoring and evaluation plan. They have a focus on indicators but not on a system for generating them. There is insufficient data interpretation packaging and use for policy-making and management of child health programmes. The presenter summarized the emerging Health Metrics Network standards, available information from Global Health Atlas, WHO/UNICEF global child survival indicators, the World Health Statistics and their relevance for child survival. The opportunity for collaboration with the Health Metrics Network, which has identified five of the six child survival countries in the Region as their priority countries, was highlighted Monitoring and evaluating child survival The presentation on monitoring and evaluating child survival touched upon "countdown to 2015", a two-year cycle of rolling reviews to assess progress towards reducing child mortality and improving maternal health. During the first review in December 2005, countries were classified in three categories: on track, watch or high alert. Out of 60 countries, only seven were on track for achieving MDG 4. The presenter also summarized the global monitoring framework on child survival as developed for WHO Headquarters. The presenter indicated that many agencies are involved in monitoring and evaluation. While some measure impact on health status, and coverage of interventions, other important areas receive less interest.

18 Key concerns on the health information system The key concerns on the health information system include the parallel data collection systems, reporting burden, ignorance of what other programmes are collecting, limited or no sharing of information and limited use of information for policy- and decision-making. The presenter summarized the steps necessary for implementing the monitoring and evaluation component, the need to consider other indicators to measure political will and financial mechanisms. A regional monitoring framework for child survival has been drafted, and worksheets were provided for a quick assessment of the current situation Group work and plenary: monitoring progress Participants were divided in six country groups to discuss monitoring progress in child survival. Worksheets were provided by the facilitators. The results of the group work were submitted to the facilitators' team and summarized by them in three sections: purpose of monitoring, summary information on usefulness of indicators (mortality, health system, coverage) (see Annex 3) and problems/challenges. The purposes of monitoring identified by each country were as follows: (1) China: monitor implementation of MDG and National Plan of Action, identify constraints and problems, adjust plan of action, provide evidence for policy-making, mobilize funds. (2) Cambodia: keep track of progress measure impact, identify problems, guide future directions, set priorities, allocate resources, assess delivery strategies, review/set targets, carry out research and development, formulate policy, encourage accountability, improve programme coordination. (3) Philippines: improve accountability, advocacy, benchmarking for local decision-makers, track resources for child health (National Health Account). (4) Papua New Guinea: indication of progress/ monitor impact, planning and policy, resourcing/ deciding on commitment, looking for gaps, ensuring that the programme is on track. (5) Viet Nam: assess current stage of implementation, identify problems, adjust plans and strategies, provide evidence for decision-making, improve quality of child survival interventions, improve health system. (6) Lao People's Democratic Republic: assess progress by monitoring performance (monthly or quarterly), measure impact, identify problems, design programme (correct problems), implement. The facilitator summarized the work of all country groups, indicating that the assessment of progress, identification of gaps, and adjustment of programmes were considered crucially important. Also, tracking resources was seen important. It was also raised that indicators for skilled care attendance (in and out of hospital) and integrated management of sick child should be considered as monitoring indicators.

19 Data for demand generation The presentation on data for demand generation revealed how communities could use community-generated data to increase demand for child survival services. Involving the community in data collection generally lessens community resistance and increases the take-up of child survival interventions. Communities can become involved in mapping their villages, ranking and walking around to take a closer look. Discussing the effects of reduced demand with the villagers has also shown to help. As a result of the participatory process, some communities have noted an increased engagement in immunization and a reduction in the cases of serious disease. The Chairperson ended the session by indicating that a lot work still needed to be done and that the current status of monitoring and evaluation needed to be improved. 2.5 Panel on advocacy and resource mobilization A panel was conducted with the participation of representatives from the Japanese Government, JICA, AusAID, USAID, Save the Children, BASICS, Red Cross Lao People's Democratic Republic. The AusAID representative indicated her agency's support to child survival activities in the Region. As a demonstration of support, AusAID agreed to fund implementation of the Regional Child Survival Strategy during Panel members were asked three questions referring to a previous presentation on financing where the types of child survival interventions were identified as those with limited funding, those with relatively good funding, and those with low external support but for which support could be identified in the medium term. Panel members agreed that funds are usually allocated to activities that have an easy-to-identify product, preferably a commodity. Countries should therefore make an effort to identify products that will come out of the implementation of each intervention. The other types of projects or activities that get support are those that show results in the short term (usually within a three-year funding cycle). Countries should also consider that when requesting support. Panel members also suggested using a keyword/slogan to improve the visibility of some interventions. Next, panel members provided ideas on what would it take to get long-term support for the other types of activities. They were asked what it would take to break the "short-term mentality" of funding groups, something that is especially important if the expected result is reduction in mortality. Panel members suggested using other measurements available. They also suggested a multiyear investment framework with time markers that would help to track progress. In general, they all agreed that child survival and evidence-based interventions needed to be advocated to the different funding groups/agencies. The fact that some of the funding groups are increasingly supporting local-level initiatives was also raised. 3. SUMMARY AND CONCLUSIONS 3.1 Child survival strategy overview Country delegates and partners welcomed UNICEF s and WHO s effort to address child survival in the Region through an evidence-based coherent joint strategy which strongly emphasizes cost-effective interventions and equity.