REPORT WHO/UNICEF WORKSHOP TO REVIEW PROGRESS AND ACTIONS TO IMPROVE CHILD SURVIVAL. Convened by:

WPR/DHP/04/CHD(1)/2009 Report series number: RS/2009/GE/55(CHN) English only REPORT WHO/UNICEF WORKSHOP TO REVIEW PROGRESS AND ACTIONS TO IMPROVE CHILD SURVIVAL Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC and UNITED NATIONS CHILDREN'S FUND REGIONAL OFFICE FOR EAST ASIA AND THE PACIFIC Xi an, China 13 16 October 2009 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines April 2010

NOTE The views expressed in this report are those of the participants in the WHO/UNICEF Workshop to Review Progress and Actions to Improve 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 the governments of Member States in the Region and for those who participated in the WHO/UNICEF Workshop to Review Progress and Actions to Improve Child Survival, which was held in the People's Republic of China from 13 to 16 October 2009.

CONTENTS SUMMARY. i 1. INTRODUCTION...1 1.1 Background...1 1.2 Objectives...1 1.3 Participants and resource persons...1 1.4 Workshop venue and agenda... 2 2. PROCEEDINGS... 2 2.1 Methods...2 2.2 Summary of child health status...3 2.3 Programme inputs...17 2.4 Programme outputs...20 2.5 Successes, challenges and gaps in implementing child health programme...23 2.6 Impact assessment, costing and expenditure tracking...31 2.7 Country planning for the way forward...32 3. CONCLUSIONS...40 3.1 General conclusions...40 3.2 Next steps...42 ANNEXES: ANNEX 1 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS, RESOURCE PERSONS, REPRESENTATIVES/OBSERVERS AND SECRETARIAT ANNEX 2 - AGENDA ANNEX 3 - METHODS FOR ESTIMATING CHILD MORTALITY Page Keywords Child health / Child survival

SUMMARY The WHO/UNICEF Regional Child Survival Strategy was endorsed by the WHO Regional Committee for the Western Pacific in 2005 and launched in 2006 in countries with the highest burden of under-five mortality in the Region. To review progress in seven priority countries, a WHO/UNICEF Workshop to Review Progress and Actions to Improve Child Survival was held in Xi'an, China from 13 to 15 October 2009. The intention was to review achievements, best practices and challenges that remain in achieving Millennium Development Goal (MDG) 4, and to identify solutions for overcoming barriers. The workshop was jointly organized by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). The workshop had 95 attendees. Participants included representatives of child healthrelated programmes in Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines, and Viet Nam. The Secretariat included representatives of WHO and UNICEF Headquarters in Geneva and New York, the WHO Regional Office for the Western Pacific, the UNICEF East Asia and Pacific Regional Office and the Asia-Pacific Shared Services Centre, and staff from related country offices. A number of regional and international partner agencies were also in attendance. At the end of the workshop, the participants will have: (1) reviewed progress of the implementation of the WHO/UNICEF Regional Child Survival Strategy in priority countries; (2) shared experiences and lessons learnt including best practices and barriers in accelerating actions to improve child survival; and (3) identified key actions to scale up implementation, including ways of sustaining and expanding partnerships. Participants reviewed the status of child health globally, regionally and in the seven countries, and the status of child health programme inputs and outputs. In small groups, participants discussed strengths, weaknesses and possible solutions to problems in main technical areas, and priority activities needed to improve coverage of key interventions. Technical updates were given in child health technical areas, and on impact assessment, costing and expenditure tracking using LiST software. The workshop was conducted as plenary sessions, small group discussions and hands-on practice using LiST software. The following conclusions were agreed by the group: (1) The seven participating countries are making progress towards MDG 4 and are tracking intervention coverage of key interventions for child survival and health. While five countries are likely to achieve the MDG 4 targets if a high level of effort is sustained, two are less likely to do so unless programme efforts are further intensified. (2) Undernutrition is an important contributor to child mortality in the Region. A high proportion of children in the Region are stunted and underweight. The proportion of children who are wasted is generally low.

- ii - (3) Intervention coverage for key child indicators has shown improvements in several areas, with variations between countries. Immunization and vitamin A coverage have tended to show improvements. However, coverage of interventions to treat pneumonia and diarrhoea, of skilled attendance during pregnancy and delivery, and of infant and young child feeding has been slow to improve. (4) Newborn deaths constitute an increasing proportion of under-five deaths in all countries in the Region. There is a need for more attention to maternal and newborn care including integrated post-natal care for newborn infants and mothers. Better data on newborn care practices are needed in order to plan interventions. (5) Despite good overall progress in reducing mortality, inequities exist in all countries, with some subgroups at higher risk of death and less likely to receive child health and nutrition interventions. Strategies and resources for ensuring that programmes reach all groups are important, including use of new strategies for interventions that already have higher coverage. (6) All countries have made progress in improving programme inputs for maternal, newborn and child health and nutrition. These include development of costed strategies, mechanisms for coordinating maternal and child health, and adoption of key policies and guidelines. More data are needed on financial and training inputs at all levels. There is a need for a common mechanism for all countries to report programme inputs regularly using the regional monitoring framework (linked with regular reporting of intervention coverage and programme outputs). (7) Most countries are not tracking programme outputs for maternal, newborn and child health and nutrition. Outputs are activities conducted to improve coverage. Activity data are needed in a number of areas including human resources and training, health system supports, community engagement, and health promotion. There is a need for a common mechanism for all countries to report programme outputs regularly using the regional monitoring framework (linked with regular reporting of intervention coverage and programme inputs). (8) A number of programme strengths were identified including adoption and revision of key policies, use of international norms and standards, improved systems elements including drug and vaccine supply, better coordination between programmes, and improved pre- and in-service training coverage in several areas. (9) Programme gaps in several areas will need to be addressed in order to better deliver interventions to the population that needs them. Ensuring financial protection for women and children, better understanding of resource needs and expenditures, and improving resource mobilization need to be addressed. Strategies for targeting high-risk populations are needed. Human resource availability needs to be improved at lower levels, supported by viable systems for supervision and referral practices. More attention is needed at the community level to improve demand creation, including better support for communities and improved use of volunteers and community groups. (10) Most countries do not conduct follow-up after training or measure quality of services provided by health workers for newborns and children. More data collection efforts in these areas is needed and a better use of these data for planning. (11) In order to improve the quality of care provided to mothers, newborns and children, clear training strategies and training plans are needed for maternal, newborn and nutrition interventions, as well as Integrated Management of Childhood Illness (IMCI). Training strategies should include approaches to improve staff retention, monitor the quality of training, and improve follow-up after training. They also should be complemented by efforts to ensure

- iii - that health system requirements (medicines, equipment, supplies, supervision) are in place to support trained health workers in their work. Based on the conclusions and discussions in small and large groups, the following next steps are proposed: (1) Countries in the Region will continue to focus on the implementation of priority maternal, newborn and child health and nutrition interventions. (2) Programme managers and policy-makers will place increased emphasis on activities that have been identified as being particularly important for increasing intervention coverage, quality and equity. These include: better reaching high-risk populations, increased effort in the area of newborn health and nutrition, improved quality and reach of health promotion and behaviour change activities, and strengthened community-based partnerships and support. Strategies for improving resource mobilization for child health, financial protection for women and children and coordination of all activities will be strengthened. (3) Countries will continue to use data for tracking programme implementation. To this end, they will continue to periodically monitor intervention coverage over time. In addition, they will commit to improved monitoring of programme inputs and outputs, in order to follow the adequacy of programme implementation. They will use the regional monitoring framework as a guide for monitoring. (4) Partners in the Region including international organizations (WHO, UNICEF), bilateral donors and nongovernmental organizations will continue to provide support to country programmes in order to increase coverage and quality of priority interventions. They will commit to working with individual programmes in order to identify gaps, and to increase resource allocation in those areas that need more attention. (5) The WHO Regional Office for the Western Pacific will commit to establishing a mechanism for tracking country progress over time by regular monitoring of activities. This process will also be used to help make technical and financial resources available, based on country needs and priorities. Links between donors and country programmes will be facilitated to ensure that the technical quality of all activities is maintained. (6) Countries in the Region, and partners, will commit to regular regional meetings to further review progress, identify successes and gaps, and plan further action. These meetings should be convened every two to three years.

1. INTRODUCTION A WHO/UNICEF Workshop to Review Progress and Actions to Improve Child Survival was held in Xi'an, China from 13 to 15 October 2009. The workshop was planned to review progress with child health programming in seven countries in the Region. The intention was to review their achievements, best practices and challenges that remain in achieving Millennium Development Goal (MDG) 4, and to identify solutions for overcoming barriers. The workshop was jointly organized by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF). 1.1 Background The WHO/UNICEF Regional Child Survival Strategy was endorsed by the WHO Regional Committee for the Western Pacific in 2005. It was launched in 2006 in six countries with the highest burden of under-five mortality in the Region. The Strategy outlined a unified approach to achieving the national targets for MDG 4 and reducing inequities in child survival. In 2007, the WHO Regional Committee for the Western Pacific reviewed progress. During this review, Member States were urged to strengthen national commitment to child survival, prioritize the implementation of the Strategy, and regularly measure progress in these countries. To guide the monitoring of implementation efforts, WHO and UNICEF convened a Technical Consultation on Measuring Progress towards Child Survival in 2007. This review resulted in a regional consensus on indicators for measuring child survival over time, including impact indicators, coverage indicators for key child health interventions, and input and output indicators to measure how well programmes have been implemented on the ground. 1.2 Objectives At the end of the workshop, the participants will have: (1) reviewed progress of the implementation of the WHO/UNICEF Regional Child Survival Strategy in priority countries; (2) shared experiences and lessons learnt including best practices and barriers in accelerating actions to improve child survival; and (3) identified key actions to scale up implementation, including ways of sustaining and expanding partnerships. 1.3 Participants and resource persons Participants came from seven countries in the Region (Cambodia, China, Lao People's Democratic Republic, Mongolia, Papua New Guinea, Philippines and Viet Nam), WHO Headquarters (Child and Adolescent Health and Development [CAH] and Health Systems Financing [HSF]), WHO Regional Office for the Western Pacific (Division of Healthy Communities and Populations [DHP], Child and Adolescent Health [CHD]; Expanded Programme on Immunization [EPI], Health Systems Development [HSD], Making Pregnancy Safer [MPS] and Nutrition [NUT]), WHO country offices (Cambodia, China, Lao People's Democratic Republic, Mongolia, Papua New Guinea, Philippines and Viet Nam), UNICEF New York, UNICEF Asia Pacific Shared Services Centre, UNICEF country offices (Cambodia, China

- 2 - and Philippines), and a number of partners (Burnet Institute, Centre for International Child Health, Futures Institute, Global Fund to Fight AIDS, Tuberculosis and Malaria [GFATM], Helen Keller International, International Baby Food Action Network [IBFAN] Asia, Johns Hopkins Bloomberg School of Public Health, Korean International Cooperation Agency, Save the Children [UK] China Programme, and World Vision International). A list of participants is attached as Annex 1. 1.4 Workshop venue and agenda The workshop was held from 13 to 16 October 2009 in Xi an, China. The workshop agenda is attached as Annex 2. 2. PROCEEDINGS 2.1 Methods The workshop consisted of plenary sessions and small group discussions on key issues. The findings from group sessions were presented and discussed in plenary session. Conclusions from small group and plenary discussions were summarized and compiled on the final day. Plenary presentations included: Presentations in session 1: Global, regional and country summaries of progress toward MDG 4. Each country presented impact and coverage data, and data on programme inputs since 2006. Presentations in session 2: Updates on main technical areas: newborn care, nutrition, IMCI, immunizations and health systems. Presentations in session 3: Evidence-informed planning for child health. An overview of the LiST software was presented, including an introduction to impact assessment, and assessment of financing needs and current expenditures. Country groups used data from one priority country to carry out an assessment of impacts, financing needs and expenditures. Small groups worked on the following areas: Group session 1: Analysis of successes, challenges and gaps implementing child health programmes on the ground. Five small groups were established to discuss progress in the areas of newborn health, nutrition, IMCI, immunizations and health systems. Each group reviewed two key coverage indicators that have been slow to change. Main activity areas considered included: policy, planning and management, health financing, pre- and in-service training, health promotion and behaviour change, improving community support, improving health systems, and monitoring and evaluation. Group session 2: Planning the way forward. Country groups selected the four most important activities that needed to be done in each key technical area in order to move

- 3 - towards improved intervention coverage. Findings from the previous discussion on strengths, weaknesses and gaps were considered. 2.2 Summary of child health status 2.2.1 Mortality All countries in the Region have shown downward trends in mortality since 1990 (Figure 1). Five of the seven countries are projected, based on current declines, to reach their MDG targets (Table 1). In some cases, differences were noted between country-specific MDG targets and estimates of mortality, and global MDG targets and estimates of mortality made by the Interagency Group for Child Mortality Estimation (IGME). 1 Both sets of data are shown in Table 1. The IGME estimates trends from all available data sources by fitting a regression curve to the year of interest. The method used is summarized in Annex 3. Figure 1: Under-five child mortality in seven Western Pacific Region countries, 1990 2007 Source: Interagency Group for Child Mortality Estimation (IGME) Table 1: MDG targets, estimated under-five mortality rates and current trends in seven Western Pacific Region countries, October 2009 Country Most recent local data IGME data, 2007 Local MDG4 or under-five mortality target for 2015 (deaths per 1000 live births) Estimated under-five mortality (deaths per 1000 live births) Current trend on track or not on track to reach MDG4 target Global MDG4 or under-five mortality target for 2015 (deaths per 1000 live births) Estimated under-five mortality in 2007 (deaths per 1000 live births) Current trend on track or not on track to reach MDG4 target Cambodia 65 83 On track 40 91 Not on track China 32 (2010) 18 Achieved 15 22 On track 1 The Interagency Group for Child Mortality Estimation (IGME) consists of experts at the United Nations Children's Fund (UNICEF), WHO, World Bank, United Nations Population Division (UNPD) as well as members of the academic community.

- 4 - Lao PDR 54 98 On track 54 70 On track Mongolia 29 23 Achieved 29 43 On track Philippines 26 34 On track 21 28 On track Papua New Guinea 31 75 Not on track 31 65 Not on track Viet Nam 18 27 On track 18 15 On track Sources: Interagency Group for Mortality Estimation (IGME) and Child and Adolescent Health and Development (CAH), 2009; Cambodia: DHS (2005); China: MCH surveillance (2007); Lao People's Democratic Republic: MICS (2005); Mongolia: HMIS (2008); Philippines: DHS (2008); Papua New Guinea: DHS (2006); Viet Nam: MICS (2006). In general, neonatal mortality has been slower to change than total under-five mortality. In the Region, neonatal mortality now represents a significant proportion of all under-five mortality (ranging from 28% to 50%), and has been increasing over time. The proportion of under-five mortality that is due to newborn causes is lowest in Cambodia and Papua New Guinea and highest in China and Viet Nam (Figure 2). Figure 2: Proportion of under-five mortality due to deaths in the neonatal period in seven Western Pacific Region countries Source: Interagency Group for Mortality Estimation (IGME), Child Health Epidemiology Reference Group (CHERG) and Child and Adolescent Health and Development (CAH), 2009. Variations in mortality are noted in all countries by region or geographic area, maternal education, rural or urban residence, birth interval (shorter birth intervals have increased risks of under-five mortality) and wealth. Countries reported challenges reaching remote and rural populations, migratory populations (particularly in Mongolia where 67% of the population of soums are nomadic herders), and poor populations in both urban and rural areas. Equity remains a concern in all countries. In high-mortality countries where data are available by wealth quintile, the pattern of inequity is generally top inequity, with the wealthiest quintile doing better than all other economic groups. In the Philippines, mortality curves by quintile may be beginning to show more of a linear pattern, which is intermediate between top and bottom inequity. For the moment, most countries have a policy of universal coverage, but they are not targeting specific sub-groups.

- 5 - Summary: Mortality The seven priority countries in the Region are experiencing downward trends in underfive mortality. Five out of the seven countries are on track to achieve MDG 4 based on current global projections. Deaths in the neonatal period constitute 28% to 50% of all under-five mortality. In all countries in the Region, inequities exist between economic quintiles, geographic areas, maternal education and other factors. It will be increasingly important to develop strategies to reach the subpopulations in greatest need. 2.2.2 Nutritional status Nutrition remains a concern in all countries in the Region. The Asian Region is estimated to have higher rate of stunting (40%) than the African Region (36%). Similarly, the prevalence of underweight among children is estimated to be higher in Asia (27%) than in Africa (21%). Rates of low birth weight are also estimated to be higher in Asia, with 18% of all infants weighing less than 2500 grams at birth, compared to 14% in Africa. 2 While stunting and underweight have shown general downward trends over time, rates remain high, with the prevalence of stunting ranging from 14% in China to 44% in Papua New Guinea, and the prevalence of underweight ranging from 6% in Mongolia to 37% in the Lao People's Democratic Republic. Rates of wasting have generally been low (Figure 3). Overall, these patterns suggest that chronic undernutrition is more of a problem than acute undernutrition. Globally, undernutrition is estimated to contribute directly or indirectly to approximately 35% of under-five child mortality, and needs to remain a key focus of all child survival programmes. Figure 3: Rates of stunting, underweight and wasting in seven Western Pacific Region countries Sources: Cambodia: CAS (2008); China: NNHS (2002); Lao People's Democratic Republic: MICS (2006); Mongolia: MICS (2005); Philippines: NNS (2008); Papua New Guinea: NS (2005, preliminary data); Viet Nam: MICS (2006). 2 Tracking Progress on Child and Maternal Nutrition A Survival and Development Priority. UNICEF, 2009.

- 6 - It has been difficult to reduce rates of stunting. Infant feeding practices, particularly the quantity, quality, consistency and frequency of complementary foods, need to be improved. Continued efforts are also needed to improve rates of exclusive breastfeeding and early initiation of breastfeeding, which remain low in many countries and have proved difficult to change. Rates of stunting, underweight and wasting vary by region, geographic area, mother's education, wealth quintile, urban or rural residence and other factors. These differences will be important when planning strategies for reducing overall rates of undernutrition. Estimates of prevalence of low birth weight range from 3% in Mongolia to 20% in the Philippines (Figure 4). Most countries reported that rates of low birth weight have been stable over the last 10 15 years. In the Philippines, however, the prevalence of low birth weight increased from 13% in 2003 to 20% in 2008, according Demographic Health Surveys (DHS) carried out in those years. Survey-based estimates rely on written records (all infants weighing less than 2500 grams), if available, or mother s perception of whether her child was very small or smaller than average. Low birth weight is associated with increased risk of death as well as increased risk of stunting and wasting. Figure 4: Prevalence of low birth weight in seven Western Pacific Region countries Sources: Cambodia: CDHS (2005); Lao People's Democratic Republic: MICS (2006); Mongolia: HMIS (2008); Philippines: DHS (2008); Viet Nam: MICS (2006). Prevalence rates for anaemia in children 6 59 months are relatively high, ranging from 19% in China to 62% in Cambodia (Figure 5). Some countries reported a reduction in prevalence over time (Mongolia, Philippines), while others reported an increase in prevalence (Cambodia). No data on anaemia is available from the Lao People's Democratic Republic. Anaemia remains an important problem. Continued high rates suggest that intake of iron, folate, vitamin B12 or other nutrients may be low. Intestinal worms are also likely to play a role. Malaria is likely to contribute in areas where malaria is endemic. The contribution of haemoglobinopathies to anaemia in the Asian Region has not been well investigated.

- 7 - Figure 5: Anaemia in children 6 59 months in seven Western Pacific Region countries Sources: Cambodia: CDHS (2005); China: NNHS (2005); Mongolia: NNS (2004); Philippines: NNS (2008); Papua New Guinea: NS (2005, preliminary data); Viet Nam: MICS (2006) Up-to-date data on serum retinol status are not available in most countries. Vitamin D deficiency is an important problem only in Mongolia, where assessment and management of vitamin D status is part of IMCI, and where a programme to distribute vitamin D supplements and to increase exposure to light has been implemented. Summary: Nutrition Stunting and underweight remain important problems in the Region, and more needs to be done to address them. The prevalence of wasting has generally been low and has not changed much over time. Rates of low birth weight range from 3% in Mongolia to 20% in the Philippines. In the Philippines, the prevalence of low birth weight has increased over time. Undernutrition is a contributor to around 35% of under-five mortality globally. It is important to ensure that the contribution of nutrition to all-cause mortality is duly acknowledged by policy-makers when reviewing/presenting under-five mortality. Rates of anaemia remain high in young children in most countries in the Region. 2.2.3 Intervention coverage Intervention coverage was reviewed along the continuum of care for the mother and child. Key coverage indicators were those agreed at the regional Technical Consultation for Measuring Progress in Child Survival in 2007. Sources of data varied between countries, although large population-based surveys, including Multi-Indicator Cluster Survey (MICS), Demographic Health Survey (DHS) and other national nutrition or reproductive health surveys, were available in most. 2.2.3.1 Pregnancy Period Intervention Indicator Pregnancy Adequate antenatal care (ANC) Proportion of pregnant women who receive at least four ANC visits Tetanus toxoid to all pregnant women Proportion of newborn infants protected against tetanus at birth

- 8 - Coverage with four or more antenatal care (ANC) visits ranged from 27% in Cambodia to 99.5% in Mongolia. In most countries, the trend for four or more ANC visits is upwards. In two countries, Papua New Guinea and the Philippines, coverage has declined slightly over time. WHO currently recommends a minimum of four visits in order to ensure that key interventions are delivered and problems are identified and managed. Timing of the first ANC visit is important. Early visits (in the first trimester) are needed in order to ensure that women receive micronutrients, immunization against tetanus, and counselling as soon as possible in pregnancy. The median timing of the first ANC visit in the three countries with data available was: 4.2 months (Cambodia, DHS, 2005), 3.8 months (Philippines, DHS, 2008) and 3.6 months (Viet Nam, MICS, 2006), suggesting that first visits tend to occur after the first trimester. Data available from six countries show that the proportion of antenatal care being provided by a skilled provider is 100% in Mongolia, 91% in the Philippines, 86% in Viet Nam, 78% in Papua New Guinea, 70% in Cambodia, and 35% in the Lao People's Democratic Republic. As ANC coverage improves, it is important to review the quality of antenatal care provided, including assessment tasks conducted, management of problems, counselling (including birth and emergency preparedness) and provision of preventive measures such as tetanus toxoid (TT) vaccine and iron/folate. DHS surveys usually collect data on the quality of antenatal care, and in the longer term, these data will be useful for developing activities to improve quality. Country data for ANC visits and skilled birth attendance are summarized in Figure 6. Figure 6: Antenatal visits and skilled birth attendance in seven Western Pacific Region countries Sources: Cambodia: DHS (2005); China: MCH surveillance network (2008); Lao People's Demographic Republic: MICS (2006); Mongolia: HMIS (2008); Philippines: DHS (2008); Papua New Guinea: DHS (2006); Viet Nam: MICS (2006). Data on the proportion of neonates protected against tetanus at birth were available from five of the seven countries. In some of these countries, coverage has improved over time, with the latest reported coverage being 69% in Cambodia (2005), 56% in the Lao People's Democratic Republic (2006), 76% in the Philippines (2008), 70% in Papua New Guinea (2006) and 80% in

- 9 - Viet Nam (2006). Mongolia has eliminated neonatal tetanus and has stopped giving TT vaccine to pregnant mothers. These data suggest that strategies to improve the TT vaccination status of women have been effective, although a continued emphasis on vaccinating women during pregnancy is needed. All countries should collect data on this indicator routinely. Summary: Pregnancy Coverage with at least four ANC visits has been increasing and in Mongolia is above 90%. Available data suggest that the first ANC visit is usually after the first trimester. Antenatal care is provided by skilled providers in the majority of counties. Improving the quality of antenatal care, including assessment, management of problems, provision of preventive measures and counselling, is important. 2.2.3.2 Delivery and immediate post-delivery period Labour and delivery Period Intervention Indicator All deliveries assisted by a skilled birth attendant Identification and treatment of maternal emergencies Early initiation of breastfeeding Proportion of deliveries assisted by skilled birth attendants Caesarean section rate among rural pregnancies Proportion of infants less than 12 months who were breastfed within one hour of birth Trends in skilled attendance at birth have been upwards in most countries in the Region, although overall coverage remains relatively low in most (ranging from 20% in the Lao People's Democratic Republic to 99% in Mongolia) (Figure 6). In Mongolia and China, skilled attendance at birth is close to 100% due to the use of maternity waiting homes and near universal access. Improving skilled attendance at birth is an important proxy measure for improving the quality of delivery and immediate post-delivery care. "Skilled care" refers to the care provided to a woman and her newborn infant during pregnancy, childbirth and immediately after birth by an accredited and competent health care provider. A "skilled attendant" is an accredited health professional, such as a midwife, doctor or nurse, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborn infants. Data on the rural Caesarean section rate were available in the Philippines and Viet Nam. In these countries, the rates are low (5% and 7% respectively), but an upward trend was evident. The overall Caesarean section rate is 17% in Mongolia. The proportion of Caesarean sections among all deliveries in provincial hospitals in Papua New Guinea was 4% in 2008 (Annual Sector Review, 2008). Unfortunately, these data are not adequate to get a picture of trends over time. More data are needed from all countries in the Region. The proportion of rural deliveries conducted by Caesarean section is a measure of improved access to referral care and improved quality of care. Since rural populations typically have the most limited access to referral care, the rural Caesarean section rate is considered to be a good marker of how effectively programmes are reaching populations at highest risk. Improving the Caesarean section rate

- 10 - among the rural population implies that referral practices for women with medical emergencies, such as eclampsia or obstructed labour, are improving. Early initiation of breastfeeding has benefits for both the mother (reduced post-partum haemorrhage) and infant (protection against infection, hypoglycaemia and hypothermia), and is associated with improved attachment and breastfeeding behaviour in the longer term. Rates of early breastfeeding range from 30% in the Lao People's Democratic Republic to 81% in Mongolia, with improvements over time noted in Cambodia, Mongolia and the Philippines. Early initiation of breastfeeding has been relatively static in Viet Nam over time. Only a single data point for this measure is available from the Lao People's Democratic Republic. No data on early breastfeeding was available from China or Papua New Guinea. Country data for delivery and post-delivery care are summarized in Figures 6 and 7. Figure 7: Post-delivery practices in seven Western Pacific Region countries Sources: Cambodia: DHS (2005); Lao People's Democratic Republic: MICS (2006); Mongolia: HMIS (2008); Philippines: DHS (2008); Viet Nam: MICS (2006). Summary: Delivery and immediate post-delivery period Coverage with skilled delivery care remains low in four countries in the Region. In China and Mongolia, almost all deliveries are attended by skilled providers. Data on rural Caesarean section rates are available from only two countries. Early initiation of breastfeeding has generally shown improvements over time in three out of five countries where data are available. 2.2.3.3 Neonatal period Period Intervention Indicator Neonatal period Postnatal care visit Proportion of mothers and newborn infants who received postnatal care contact in the first three days of life

- 11 - No data on early postnatal care coverage was available from China, the Lao People's Democratic Republic, Papua New Guinea and Viet Nam. Postnatal care coverage was 64% in Cambodia, 65% in Mongolia, and 77% in the Philippines (in the Philippines, the indicator was defined as care contact received in the first two days of life). Early postnatal care visits have shown an upward trend in Cambodia and the Philippines but have been static in Mongolia. Since the majority of deliveries in many countries still take place in the home, getting early postnatal care remains a challenge. It is important that countries without data ensure that future population-based surveys collect data on this measure. The indicator for postnatal care visits measures postnatal care contacts received. Postnatal care may be received at health facilities or at home. A postnatal care contact at home requires that the home be visited by a trained provider of postnatal care. A postnatal care contact at a health facility may take place in two ways: (1) mothers who deliver at home visit health facilities with their infants within three days of delivery; and (2) mothers who deliver at health facilities receive a postnatal care contact before discharge (in many settings, mothers and babies are required to remain in health facilities for at least 24 hours after delivery, so that postnatal checks can be provided). The indicator does not measure the quality of postnatal care received. Therefore, it is not clear whether providers of postnatal care recognize and refer problems appropriately, or if they give high-quality counselling. Improving the provision of postnatal care is a key element of most programmes intending to reduce neonatal mortality. In order to reduce mortality, postnatal care should: (1) recognize sick newborn infants and refer them immediately to an appropriate provider; (2) promote appropriate preventive practices, such as early and exclusive breastfeeding and thermal care, and discourage inappropriate practices; and (3) take place early enough to detect problems when they occur. Country data for postnatal care visits are summarized in Figure 7. Summary: Neonatal period Data on postnatal care contacts in the first three days of life are available from only Cambodia, Mongolia and the Philippines. Coverage has shown improvements in Cambodia and the Philippines but has remained stable in Mongolia. Four countries had no data on early postnatal care contacts. These countries should collect data using population-based methods. 2.2.3.4 Children 1 59 months Period Intervention Indicator Infants and children Exclusive breastfeeding Proportion of infants less than six months of age exclusively breastfed Appropriate complementary feeding Proportion of infants 6 9 months receiving breast milk and appropriate complementary feeding Micronutrient supplementation Proportion of children 6 59 months who received a dose of vitamin A in the previous six months Immunizations against vaccinepreventable diseases Proportion of one-year-old children vaccinated against measles Prevention of malaria (in high-risk malaria areas) Proportion of children 0 59 months who slept under an insecticide-treated bednet the previous night

- 12 - Care-seeking for pneumonia Antibiotic treatment for suspected pneumonia Oral rehydration therapy (ORT) for diarrhoea Use of zinc for the treatment of diarrhoea Antimalarial treatment for malaria Proportion of children 0 59 months with suspected pneumonia in the past two weeks taken to appropriate provider Proportion of children 0 59 months with suspected pneumonia in the past two weeks who received appropriate antibiotics Proportion of children 0 59 months with diarrhoea in the past two weeks who received ORT Proportion of children 0 59 months with diarrhoea in the past two weeks who received an appropriate course of zinc supplements Proportion of children 0 59 months with fever in the past two weeks who received appropriate antimalarial drugs (1) Nutrition interventions Exclusive breastfeeding: Exclusive breastfeeding means that an infant is breastfed and given no other solids or liquids, including water, although drops of vitamins, minerals or medicines are allowed. The indicator should be interpreted as the proportion of infants currently being exclusively breastfed since it is based on a 24-hour recall of what has been given to the infant in the 24 hours prior to the survey. Rates of exclusive breastfeeding for the first six months of life have shown mixed findings, with coverage rates ranging from 17% in Viet Nam to 79% in Mongolia. The trend has been upwards in Cambodia and Mongolia. In the Lao People's Democratic Republic and the Philippines, rates have remained unchanged over time. In Viet Nam, rates fell between 2000 and 2006. No data on exclusive breastfeeding rates was available from China. Complementary feeding: Rates of appropriate complementary feeding and continued breastfeeding for infants 6 9 months of age range from 58% in the Philippines to 82% in Cambodia and Mongolia. No national data on complementary feeding was available from China. In all countries where this measure is available, trends have been upwards over time. This measure is a 24-hour dietary recall and asks whether children were given solid or semi-solid foods in addition to breast milk. It is recognized that this indicator has several limitations. It reflects only the prevalence of complementary feeding. It does not allow an assessment of: (1) the quality of food (energy density, macro or micronutrient composition, or consistency of food handling); (2) the quantity of food given; and (3) the frequency of feeding. A new set of complementary feeding indicators have been developed and are now available; countries in the Region were encouraged to review the new indicators and to consider adopting them for local use. Nutrition findings are summarized in Figure 8.

- 13 - Figure 8: Feeding practices in seven Western Pacific Region countries Sources: Cambodia: CAS (2008), DHS (2005); Lao People's Democratic Republic: MICS (2006); Mongolia: RHS (2008); Philippines: DHS (2008); Papua New Guinea: DHS (2006); Viet Nam: MICS (2006). (2) Preventive interventions Measles coverage: Measles coverage is relatively high in all countries except the Lao People's Democratic Republic, and has shown improvements over time (ranging from 33% in the Lao People's Democratic Republic to 87% in Viet Nam). Although population-based data have not been available from the Lao People's Democratic Republic since the 2006 MICS, measles coverage is now likely to be higher after supplemental measles vaccination campaigns in 2007, 2008 and 2009. Measles coverage is measured for children less than 12 months of age. Population-based estimates of coverage are used for evaluation. Routine health information data (administrative data) also include data on measles immunization coverage. Administrative data have the advantages of being available annually for planning and of being relevant to district and subdistrict levels. Disadvantages include variability in reporting, variability in the quality of data, and problems estimating the target population (denominator). Routine data also do not usually capture vaccines given by private providers. Vitamin A supplementation: The proportion of children 6 59 months who have received a vitamin A supplement in the previous six months has increased over time in Cambodia, Mongolia and Papua New Guinea. Coverage has declined or remained static in the Philippines and Viet Nam. Although population-based data have not been available from the Lao People's Democratic Republic since the 2006 MICS, coverage is now likely to be higher because vitamin A was distributed with supplemental vaccination activities in 2007, 2008 and 2009. No data is available from China. Bednet use for malaria: In countries with endemic malaria, data on the use of insecticidetreated bednets (ITNs) are available from the Lao People's Democratic Republic, the Philippines, Papua New Guinea and Viet Nam. In all countries, use of ITNs has shown improvements over time. In China and Mongolia, malaria is not a public health problem. Findings for preventive interventions are summarized in Figure 9.

- 14 - Figure 9: Preventive interventions in seven Western Pacific Region countries Sources: Cambodia: DHS (2005), CAS (2008); China: MCH surveillance network (2008); Lao People's Democratic Republic: MICS (2006); Mongolia: MICS (2005); Philippines: DHS (2008) and malaria survey (2008); Papua New Guinea: WHO/UNICEF joint report on immunization (2008) and NS (2005, preliminary data); Viet Nam: MICS (2006). (3) Treatment interventions Oral rehydration therapy (ORT) for diarrhoea: ORT coverage is generally low (ranging from 15% in Papua New Guinea in 2006 to 83% in Mongolia in 2008). In Cambodia, Papua New Guinea and the Philippines, ORT use rates have declined or remained static over time. More work is needed to improve this indicator. The current indicator is the proportion of children 0 59 months of age with diarrhoea in the previous two weeks who were treated with oral rehydration therapy, which includes oral rehydration salts (ORS) or recommended home fluids (RHF). An RHF may be a cereal-based mixture, soup or plain water (if nothing else is available). Homemade sugar-and-salt solution is not recommended in most settings due to the difficulty of measuring the amounts of sugar and salt correctly. No data on ORT coverage is available from China. Zinc for diarrhoea: The proportion of children under five years with diarrhoea who were treated with a course of zinc was 1.5% in the Philippines. None of the other six countries reported use of zinc for the treatment of diarrhoea. Zinc is still not widely available in the Region, even in countries that have a policy in place. In the future, population-based surveys will need to measure for this indicator. Current international recommendations, based on data from a number of settings, suggest that children with diarrhoea receiving elemental zinc in addition to ORS experience the following: a significantly faster recovery, about a 20% reduction in the duration of diarrhoea, a 30% reduction in stool volume, and a 20% reduced risk of acute episodes lasting at least seven days. Data also show that zinc supplementation can reduce the duration and severity of persistent diarrhoea and the risk of bloody diarrhoea after an episode of dysentery. A 20 mg dose of elemental zinc per day for 10 14 days has been shown to be effective and safe for children

- 15 - over six months. A 10 mg dose of zinc per day is recommended for infants less than six months of age. Zinc is recommended as an adjunct to fluids and continued feeding. 3, 4 Care-seeking for pneumonia: The proportion of children with suspected pneumonia taken to an appropriate provider has remained relatively low in all countries with the exception of Viet Nam (ranging from 32% in the Lao People's Democratic Republic to 83% in Viet Nam). In the Philippines and Papua New Guinea, coverage has shown slight declines over time. No data was available from China on this measure. More attention is needed in this area. Pneumonia remains an important contributor to under-five mortality in the Region (ranging from 8% to 19% of all under-five mortality). Population-based surveys define a child with suspected pneumonia as a child who is reported to have a cough, to be breathing faster than usual with short, quick breaths or to be having difficulty breathing, excluding children that have only a blocked nose. Appropriate provider is defined as any provider trained in standard case management of children with suspected pneumonia. In most settings, this group includes midwives, nurses, doctors and other staff trained in IMCI. In Cambodia and the Lao People's Democratic Republic, communitybased health workers in selected areas have been trained in a simplified version of IMCI, and are permitted to give antimicrobials. In this setting, these workers are also considered to be appropriate providers of case management for children with suspected pneumonia. Antibiotic treatment for suspected pneumonia: Only four countries had recent data on use of antibiotics for suspected pneumonia. Population-based surveys have often omitted this question. More data are needed over time in order to better understand trends in antibiotic use. Recent data were available from the Lao People's Democratic Republic (52% in 2006), Mongolia (71% in 2005), the Philippines (42% in 2008) and Viet Nam (55% in 2006). In general, coverage remains relatively low. Antimalarial treatment for fever: The indicator for this intervention has not been widely reported from countries with endemic malaria. It is a difficult measure to interpret when malaria is limited to a few areas with high transmission within a country. In this case, national summary statistics have little value. In order to make this measure useful, the rate of treatment for fever should only be reported for those areas with endemic malaria. Better methods for reporting this indicator are needed. This indicator needs to be reviewed in light of a recent recommendation to implement parasite-based diagnosis as a basis for giving malaria treatment. Findings for treatment interventions are summarized in Figure 10. 3 Bahl R et al. Effect of zinc supplementation on clinical course of acute diarrhoea Report of a Meeting, New Delhi, 7-8 May 2001. Journal of Health, Population and Nutrition, 2001, 19(4):338 346. 4 Bhutta ZA et al. Prevention of diarrhoea and pneumonia by zinc supplementation in children in developing countries: Pooled analysis of randomized controlled trials, Zinc Investigators Collaborative Group, Journal of Paediatrics, 1999, 135(6):689 697.

- 16 - Figure 10: Treatment interventions in seven Western Pacific Region countries Sources: Cambodia: DHS (2005); Lao People's Democratic Republic: MICS (2006); Mongolia: MICS (2005); Philippines: DHS (2008); Papua New Guinea: DHS (2006); Viet Nam: MICS (2006). Summary: Interventions for children 1 59 months Rates of exclusive breastfeeding for the first six months of life have been slow to change and coverage remains relatively low. Rates of complementary feeding for infants 6 9 months have shown improvements in several countries, although it is not certain that this measure is a good indicator of actual feeding practices. New indicators for complementary feeding should be reviewed and considered for collection in population-based surveys. Preventive interventions: Coverage with measles vaccine and insecticide-treated bednets for malaria is relatively high in most countries in the Region and has shown upward trends. Findings for vitamin A coverage are mixed, with four countries showing upward trends in coverage, and two showing downward trends or little change. Treatment interventions for pneumonia, diarrhoea and fever generally have lower coverage and have been slow to change. Few data are available for treatment of pneumonia with antibiotics, treatment of diarrhoea with zinc, or treatment of fever in malaria-endemic areas. Data gaps were noted in several areas. All countries should review coverage indicators and ensure that data are collected whenever population-based surveys are planned and conducted. Improving coverage will require attention to improving access to and availability of services. Each country needs a model that suits their circumstances (e.g. use of maternity waiting homes in Mongolia and mountain outreach in the Lao People's Democratic Republic).

- 17 - Activity area Policy Planning 2.3 Programme inputs Input indicators measure whether the resources needed to conduct programme activities have been applied. These might include financial, human or material resources. Countries reviewed the current status of inputs. Findings are summarized in Table 2 and Figure 11. Table 2: Child health programme inputs in seven Western Pacific Region countries, October 2009 Indicator Cambodia China Lao PDR Costed national plan for ensuring universal access to newborn and child survival interventions available Proportion of key technical policies and guidelines adopted and being used* CRC reporting mechanism established and working Mechanism for monitoring the International Code for Marketing of Breastmilk substitutes established and working Laws on vital registration adopted Proportion of medical, nursing or other health worker training schools giving pre-service IMCI training One coordination mechanism for MNCH Proportion of districts implementing IMCI Proportion of total health budget allocated to MNCH in the previous year Proportion of proposed child health budget received on time the previous year Mongolia Philippines Papua New Guinea Yes No Yes Yes Yes Yes No 4/6 67% 3/6 50% 5/6 83% 6/6 100% 6/6 100% 3/6 50% Viet Nam 5/6 83% Yes Yes Yes Yes Yes Yes Yes No No No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes 100% 16%MS 100% NS, 0% MS 100% 40% N/MWS 17% MS 100% CHW, 43% NS Yes Yes Yes Yes Yes Yes No 90% MS 90% 22% 73% 100% 72% 11% 30% NA 2% NA NA 4% NA 6% NA NA NA 100% 100% NA NA CHW-community health worker; CRC-Convention on the Rights of the Child; IMCI-integrated management of childhood illness; MNCH-maternal, newborn and child health; MWS-midwifery school; MS-medical school; NS-nursing school. * Key technical policies and guidelines cover: (1) zinc and low osmolarity ORS for case management of diarrhoea; (2) IMCI updated to include management of sick newborn infants (and children with HIV, where appropriate); (3) standards for newborn care, including newborn resuscitation and essential newborn care, reviewed and updated in the previous two years; (4) essential drugs list includes minimum package of IMCI drugs (including pre-referral); (5) community-based management of pneumonia; and (6) financial protection of infants and children.

- 18 - Figure 11: Key policies and guidelines adopted in seven Western Pacific Region countries, October 2009 IMCI-integrated management of childhood illness; EDL-essential drug list; CM-case management; MNC-maternal and newborn care 2.3.1 Summary of policy inputs Costed national plan for ensuring universal access to newborn and child survival interventions available. Five countries have costed national plans. The policy recommendation is that all countries should have a single national child health plan available and costed (to complement a National Health Plan). The plan is used to secure funding from government or nongovernmental sources. Plans are usually written for periods of five to 10 years. A costed national plan should include three components: (1) a strategic plan outlining interventions to be included and how they will be delivered; (2) an implementation plan outlining activities and tasks that will be done in the next year; and (3) a costing component based on all proposed activities and tasks. Without a single cohesive plan, it is unlikely that activities will be conducted systematically. A common problem is that some technical pieces are implemented as vertical programmes in areas where funding is available, while others are not implemented at all. Proportion of key technical policies and guidelines adopted and being used. Mongolia and the Philippines have all key policies in place, and Viet Nam and the Lao People's Democratic Republic have five out of six policies in place. Other countries have made some progress, but further work is needed. Six key technical policies and guidelines were considered for improving the technical quality of child health programmes: (1) Zinc and low osmolarity ORS for the management of diarrhoea (adopted in five countries: Cambodia, Lao People's Democratic Republic, Mongolia, Philippines and Viet Nam). (2) IMCI updated to include management of sick newborn infants and management of children with HIV in areas where HIV is a public health problem (adopted in seven countries). (3) Newborn care standards, including neonatal resuscitation and essential newborn care, reviewed and updated in the previous two years so that that they are consistent with current guidelines (adopted in four countries: Lao People's Democratic Republic, Mongolia, Philippines and Viet Nam).