Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition in South Africa

Objectives

The 2012–2016 Strategic Plan for Maternal, Newborn, Child and Women’s Health and Nutrition seeks to provide accessible, caring and high-quality health and nutrition services, reduce mortality and morbidity, improve nutritional status, and advance women’s reproductive health and gender equity.[1][2]Its overall goals are to reduce maternal, neonatal, infant and child mortality rates by at least 10% by 2016, ensure universal access to reproductive health services, empower women, and improve nutrition for mothers and children.[2]

• Reduce maternal mortality through better antenatal, intrapartum and post-natal care, stronger HIV testing and treatment pathways, prevention of mother-to-child transmission, and safer access to labour and emergency care.[3][4]
• Improve newborn survival through resuscitation, standardised care for small and ill newborns, Kangaroo Mother Care, early post-natal visits, and breastfeeding support.[5][6]
• Strengthen child health through immunisation, nutrition, growth monitoring, deworming, Integrated Management of Childhood Illness, hospital care and HIV diagnosis and treatment.[7][8][9]
• Expand women’s health services, including contraception, termination of pregnancy, adolescent-friendly reproductive health care, cervical screening, gender-based-violence prevention and comprehensive post-rape care.[10][11]
• Address inequity and social determinants of health, particularly poverty, water and sanitation, gender inequity, violence, access to basic services and the needs of underserved districts.[2][12][13]
• Build an integrated continuum of maternal, newborn, child and women’s health and nutrition services across community, primary health care, district hospital and regional hospital levels.[2][14]

Implementation

Implementation is centred on strengthening primary health care and the District Health System through coordinated, evidence-based and cost-effective service packages, with provincial health departments leading delivery across district, facility and community levels.[15][16][13]The approach combines community outreach, primary health care, hospital quality improvement, multisectoral action, workforce development, routine monitoring and mortality review.[2][17][18]

• Deliver community and household services through generalist community health workers in ward-based primary health care outreach teams, including home visits, mothers’ support groups, community campaigns, early childhood development support and social mobilisation.[19][14][20]
• Integrate maternal, newborn, child, women’s health and nutrition services with HIV services, recognising HIV’s contribution to maternal and child mortality and morbidity.[2]
• Strengthen access to labour and emergency care through obstetric ambulances, maternity waiting homes where appropriate, referral systems, blood availability for caesarean services, standard protocols, partogram use and improved anaesthesia skills.[21][4]
• Improve facility and hospital quality through district clinical specialist teams, clinical guidelines, skills training, accreditation systems, audit programmes and regular review of maternal, perinatal, neonatal and child deaths.[22][23][24]
• Expand preventive and child-health interventions through routine and campaign immunisation, vitamin A, mass deworming, breastfeeding support, growth monitoring, zinc availability and integrated childhood illness management.[7][25][20][26]
• Coordinate school health through the Integrated School Health Programme, jointly involving the Departments of Health and Basic Education, with progressive expansion towards coverage of all learners by 2016.[10]
• Engage national and provincial health departments, districts, municipalities, other government departments, academic institutions, professional bodies, civil-society and community-based organisations, private providers and development partners.[16][12][27]
• Align development-partner activities with the strategic plan and use a stakeholder forum to coordinate interventions.[27]
• Strengthen human resources by appointing district clinical specialist teams, defining workforce roles and staffing norms, reviewing pre-service curricula, and coordinating in-service training through Regional Training Centres.[17][28]
• Monitor implementation and outcomes at national, provincial, district, sub-district and facility levels through routine information systems, monthly and quarterly reports, annual indicator review, supportive supervision and mortality surveillance.[17][18]
• Institutionalise facility death reviews and address identified care deficiencies, with targets for all hospitals to review maternal, perinatal and child deaths by 2016.[24][18]
• Use targets to guide performance, including reducing the maternal mortality ratio from 310 to 270 per 100,000 live births by 2014, neonatal mortality from 14 to 12 per 1,000 live births by 2014, and under-five mortality to 40 per 1,000 live births by 2016.[15]
• Cost provincial and service-delivery plans to identify resource gaps, advocate for additional resources and support more rational allocation; no monetary budget, funding source or quantified funding gap is specified.[14][27][13]

Monitoring & Evaluation

The framework establishes a multi-level monitoring, evaluation and accountability system for maternal, newborn, child and women’s health and nutrition, linking national targets and routine service indicators with facility mortality reviews, supervisory mechanisms and periodic population surveys.[17][18][29]

• Monitor implementation and trends in key indicators at national, provincial, district, sub-district, facility and community levels, using routine health-information systems and annual review of available data.[17][18][29]
• Track mortality targets, including reducing the maternal mortality ratio from 310 to 270 per 100,000 live births, neonatal mortality from 14 to 12 per 1,000 live births, infant mortality from 40 to 36 per 1,000 live births, and under-five mortality from 56 to 50 per 1,000 live births by 2014.[15][29]
• Track further 2016 targets, including under-five mortality of 40 per 1,000 live births, infant mortality of 32 per 1,000, neonatal mortality of 11 per 1,000, antenatal-care attendance of 98%, attendance before 20 weeks’ gestation of 80%, skilled birth attendance of 90%, exclusive breastfeeding of 75%, and contraceptive prevalence of 75%.[15][29]
• Monitor prevention of mother-to-child transmission of HIV, with a target below 2% at six weeks and below 5% at 18 months by 2016.[4][29]
• Measure service coverage and quality through indicators for post-natal reviews, breastfeeding, immunisation, vitamin A supplementation, integrated management of childhood illness, HIV testing and treatment, school-health access, youth-friendly facility accreditation, emergency care, hospital case-fatality rates and maternity services.[5][7][20][26][30][23]
• Strengthen mortality surveillance by increasing the proportion of deaths reported through routine information systems from 50% at baseline to 75% in 2013 and 90% in 2016.[18]
• Institutionalise monthly maternal, perinatal, neonatal and child death reviews at health facilities, use confidential enquiries and audit programmes to identify avoidable factors, and address identified care deficiencies.[21][31][17][12][24][18]
• Use the Perinatal Problem Identification Programme, Child Problem Identification Programme, Saving Babies reports and relevant ministerial or confidential-enquiry committees to improve data quality, review deaths and support corrective action.[31][9][24][28][18]
• Require hospitals to review maternal and perinatal deaths and address deficiencies, reaching 80% of hospitals by 2013 and 100% by 2016; review child deaths in 60% of hospitals by 2013 and all hospitals by 2016.[18]
• Strengthen supervision through written standardised reports following monthly visits, with targets for at least one monthly supervisory visit to 85% of primary health-care facilities in 2013 and 100% in 2016.[30]
• Require monthly and quarterly reports for provincial and national programme managers, targeted at 90% coverage in 2013 and 100% in 2016, while training managers to analyse and use data.[24][18]
• Use vital registration, the District Health Information System, demographic and health surveys, population surveys and disease-specific surveillance to supplement routine reporting; indicators not routinely collected should be assessed through intermittent large-scale surveys, generally every three to five years.[32][18][29]
• Assign policy formulation, coordination, monitoring and evaluation responsibilities to National Department of Health maternal and child health structures, with provincial units supporting implementation and monitoring.[16]

Costing & Financing

The plan requires service-delivery and implementation plans for maternal, newborn, child and women’s health and nutrition to be costed, so that resource requirements can inform advocacy for additional funding and more rational allocation.[14][27]No monetary budget, expenditure allocation, financing source, quantified funding gap, costing methodology or economic assumption is provided in the supplied material.[2][14][27]

• Cost provincial and district plans to close gaps between current and expected service delivery, including the provision of all maternal, newborn, child and women’s health and nutrition services.[14][27]
• Complete costing of provision of all maternal, newborn, child and women’s health and nutrition services by 2012.[27]
• Use completed costing to advocate for additional financial resources, improve the rationality of resource allocation and identify measures to bridge any resource gap.[14][27][13]
• Recognise that full implementation requires additional financial and human resources, including staffing, training, equipment, essential medicines and supplies, hospital and critical-care beds, emergency transport, referral systems, outreach teams, obstetric ambulances and maternity waiting homes.[31][17][24][13]
• Prioritise integrated packages of proven cost-effective and low-cost interventions, although the source does not quantify their unit costs or overall affordability.[15]
• Align planning across provincial health services, districts, hospitals, pharmaceutical services and partners to support resource deployment, but the source does not specify financing responsibilities or contributions by institution.[17][12][27]