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I. Background
Ethiopia has achieved admirable results in reducing the under-five mortality rate (U5MR), from a very high level of 222 deaths per 1,000 live births in 1990 to 55 deaths per 1,000 live births in 2019 (Mini EDHS 2019), effectively reducing theU5MR by two thirds. Despite this success, the neonatal mortality rate (NMR) has remained at 30 deaths per 1,000 live births thus increasingly accounting for a
larger proportion of the under five deaths. There is also wide geographic variation in under-five mortality according to the EDHS 2016. Similarly, significant variation is also observed among different socio-economic groups within the same geographic areas. As part of the sustainable development goal 2030, the government has developed the Health Sector Transformation Plan-2 (HSTP-ii), 2021 – 2024, with explicit goals and targets that directly and indirectly contribute to the survival and development of newborns and children.
To achieve this, Major newborn and child health program packages are being implemented with integration to Nutrition, Expanded Program of Immunization, Maternal and Newborn health, Malaria Prevention and Control, Pediatric HIV Prevention, Care and Control, TB control program and WASH activities. A package of 39 high-impact and cost-effective newborn and child survival interventions are prioritized with coverage targets for 2024. The strategic objective for the coming five years is to ensure universal coverage of quality, high impact newborn and child heath interventions along with meaningful community empowerment to maximize demand generation and service utilization.
II. Neonatal and Child Health initiatives
Neonatal Health Packages
The neonatal period is one of the most crucial phases in the survival and development of a child. There are proven and cost effective newborn survival interventions, such as clear delivery practices, exclusive breastfeeding, early detection of danger signs, and effective and timely treatment of complications such as sepsis and birth asphyxia.
Community Based Newborn Care (CBNC)
Building on previous community based MNCH activities that have been implemented by HEWs as part of HEP and ICCM, and drawing evidence from local and global large scale experience, MOH launched the “Community Based Newborn Care” program in March 2013. The objective of CBNC implementation is to further strengthen the Primary Health Care Unit and the Health Extension Program in delivering quality MNCH services through efficient and effective linkages between health centers and health posts. The guiding principles of the initiative are government leadership and ownership, balance between preventive and curative care at the community level, continuum of care, health system support, partnership, quality, community participation, phased approach, and scale-up approach. It uses the four C’s in implementing the intervention package; 1) prenatal and postnatal Contact with the mother and newborn; 2) Case-identification of newborns with signs of possible severe bacterial infection; 3) Care, or treatment that is appropriate and initiated as early as possible; and 4) Completion of a full 7-day course of appropriate antibiotics whether the child needs referral or not.
The nine interventions under the CBNC package include:
- Early identification of pregnancy
- Provision of Focused Antenatal Care (ANC)
- Promotion of institutional delivery
- Safe and Clean delivery including provision of misoprostol in case of home deliveries or deliveries at the health post level
- Provision of immediate newborn care, including application of Chlorhexidine on cord
- Recognition of asphyxia, initial stimulation and resuscitation of neonates
- Prevention and management of hypothermia
- Management of pre-term and/or low birth weight neonates
- Initiation of treatment for neonatal sepsis/very severe conditions at community level followed by prompt referral to health facilities.
By the end 2012 EFY, 94% of health posts in the country have started providing CBNC packages.
Neonatal Care Corner
A package of interventions that are delivered at the delivery room by midwives and other health professionals targeting the three main causes of newborn mortality; prematurity, asphyxia and infection. In 2011, the Ministry of Health, with support from partner organizations, piloted the newborn care corner at 50 health centers and 50 hospitals throughout the country. By the end 2012EFY, the intervention was implemented in more than 2794 health centers
Neonatal Intensive Care Unit (NICU)
To further strengthen the health facilities in delivering quality MNCH services through efficient and effective linkages between health centers and health posts, facility-based packages of interventions are being rolled out by the Ministry of health. While working towards meeting international standards, facilities are providing the best possible care for newborns with the minimum set of equipment and supplies available. The implementation followed operational standards to classify NICUs into three levels, i.e. Level I (Basic) for district hospitals, Level II (Specialty) for regional hospitals and Level III (Sub Specialty) for tertiary hospitals.
Intervention packages at each level include:
- Level I (Basic): a hospital organized with personnel and equipment to perform neonatal resuscitation, evaluate and provide postnatal care for healthy newborn infants, stabilize and provide care for infants born at 35-37 weeks gestation who remain physiologically stable, and stabilize newborn infants born at less than 35 weeks gestational age or ill until they are transferred to a facility that can provide the appropriate level of neonatal care.
- Level II (Specialty): a hospital special care nursery organized with personnel and equipment to provide care to infants born at more than 32 weeks gestation and weighing more than 1500gm who have physiologic immaturity such as apnea of prematurity, inability to maintain body temperature, or inability to take oral feedings; or are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis; or are convalescing from intensive care.
- Level III (Subspecialty): a hospital NICU organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness. Level III is subdivided into 3 levels based on their capacity to provide advanced medical and surgical care.
Currently, there are 425 nurses from 90 hospitals that have been trained in neonatal intensive care level II. Facilities are also supported technically through provision of essential equipment to strengthen neonatal intensive care services.
III. Child Health Interventions
Integrated Management of Newborn Child Illnesses (IMNCI)
IMNCI is a globally promoted integrated package of preventive and curative child health services provided at the facility (HC and Hospital) level. Its objective is to reduce mortality and morbidity by combining improved management of common childhood illnesses with proper nutrition and immunization and to promote improved growth and development among children under five years of age to achieve the MDG 4 target. Ethiopia endorsed IMNCI in 1996 and started implementing it soon after.
At health facility level, each sick child is assessed for general danger signs, IMNCI main symptoms (cough, difficulty breathing, fever, diarrhea, ear problem), nutritional status, immunization status and other complaints. Each child’s condition is classified and treatment is provided based on the classification (following the ‘Assess, classify, and treat’ approach). The generic IMNCI was designed to manage sick children and young infants as health facilities by a front line health worker. It was later modified to include newborn and other common problems.
Some of the conditions managed under IMNCI include newborn sepsis, asphyxia, pneumonia, diarrhea, meningitis, malaria, measles, common skin conditions, ear infections, HIV/AIDS and anemia. By the end of 2012 EFY, 95% of the total 3,582 health centers throughout the country have started providing IMNCI.
Integrated Community Case Management (ICCM)
Launched in 2003 EFY, the HEP initially emphasized preventive and promotive activities, and was later expanded to include selected high impact curative interventions including treatment of under-5 children with diarrhea (using ORS), malaria (using ACT or chloroquine), and severe acute malnutrition (with Ready-to-Use therapeutic food) and referral to higher level for pneumonia cases. With emergence of local and international evidence supporting the feasibility of treating pneumonia by community health workers, in 2009 the Ministry of Health made a policy change supporting community-based treatment of childhood pneumonia and ICCM has been implemented throughout the country through the HEP platform. As of June 2020, ICCM coverage is estimated to be more than 98.5%.
Early Childhood Development (ECD) initiative
Despite the achievements in reducing under 5 children mortality, in Ethiopia majorly of children are at risk of sub-optimal development. Cognizant of that line ministries (MoH, MoE,MoWCY&MoLSA) revised the pre-existing “Early Childhood Care and Education Policy Framework”, with a commitment to ensure that every child has a better start in life and to grow in a protective and stimulating environment. Eventually,MoH developed the National Health Sector Strategic Plan for Early Childhood Development (2020/21 – 2024/25) to operationalized the policy framework.
The ECD strategic plan is on implementation under the child health program, aiming that all children grow and thrive in a secured, safe and nurturing environment. The implementation approach is integrating the overlooked/missed components of nurturing care interventions (Early stimulation & Responsive care giving) in RMNCH-N program packages across the continuum of care. And MoH is working with Regional Health Bureaus (RHBs) line ministries and its development partners to ensure the implementation of quality ECD interventions.