Mandip Jheeta, a Birmingham Graduate, writes about neonatal mortality and how the international health community could pull together to to tackle the issue. 

Every year, an estimated 4 million babies die in the neonatal period; the first 4 weeks of life. 99% of these deaths arise in low and middle-income countries. (1,2) The highest death rates are mainly in sub-Saharan Africa, which has 14 of the 18 countries with neonatal mortality rates (NMRs) above 45 per 1000 livebirths. Furthermore, data from 20 sub-Saharan African countries show consistently higher NMRs for those in the poorest quintile compared to the richest. (1)

Currently, coverage of interventions is low, progress in scaling up is slow, and inequity is high regarding neonatal survival in sub-Saharan Africa. (3) Health outcomes and health systems, particularly for maternal, neonatal and child health, are consistently inequitable: More and higher quality services are provided to the rich, who need them less than the poor who are unable to obtain them. (4,5,6,7) In the absence of policies for health systems to address the needs of the poorest, most disadvantaged and vulnerable populations, this trend is likely to continue. (4,6)

There is clearly a need to improve the current situation, but will it happen?

In low- and middle-income countries, preventing newborn deaths has often not been a focus of child survival or safe motherhood programmes. (1,2) Consequently, progress has lagged behind. Perhaps more significantly, the need for health policy or reform is widely observed to be a poor predictor of whether it will be implemented. (5,6,7,8) This is because health policy making is mainly observed to be a ‘messy’ process, which is influenced by political factors to varying degrees.

In recognition of this complex policy making environment and the need to improve neonatal survival and equity, this article aims to suggest ways to:

• Get policy makers interested in and strengthen political will for improving neonatal survival;
• Improve equity in neonatal survival strategies and the wider health system;
• Increase the capacity of policy makers to make significant improvements in neonatal survival, and increase the capacity to improve equity.

Raising interest

A degree of broad-scale and multisectoral collaboration in the sub-Saharan African region is likely to be necessary to effectively address the main causes of neonatal death, particularly poverty. Collaboration may have the potential to generate ‘political economies of scale’ of raising interest and influence on health policy. Such attention is essential for an area that has often been neglected by policy makers. (6,7,9)

The Lancet Neonatal Survival Series (1,3,9,10) addresses issues of neonatal survival, and represents the most thorough and useful evidence and support for policy formation. The series recognises varying contexts, and identifies 16 interventions with proven efficacy for improving neonatal outcomes in low- and middle-income countries. Considerable recommendations are also made for how to plan and build support for realistic neonatal programmes. For example, it highlights how early successes in averting neonatal deaths are possible, even with high mortality and weak health systems. (10)

One collaborative suggestion may be to formalise the recommendations of current evidence on neonatal survival, for example from the Lancet Neonatal Survival Series and elsewhere, into an integrated policy framework for the sub-Saharan African region. A framework promoting, informing and suggesting neonatal survival strategies may be feasible and appealing for policy makers and key stakeholders, rather than a ‘one-size fits all’ approach.

Other proposals for raising the interest and will to improve neonatal survival include adopting NMR as an indicator for Millenium Development Goal 4 (a commitment by the international community to reduce mortality in children younger than 5 years by two-thirds between 1990 and 2015, and encouraging countries to produce and publish plans of action to reach their neonatal targets. (9)

Promoting equity

Various strategies exist to promote equity in health systems:

• Establishing goals and policies for improved coverage in disadvantaged populations, rather than entire populations; (4)
• Modifying existing goals towards disadvantaged groups. (4) For example, in Tanzania ‘raising attended deliveries in the entire population’: from 50% in 2000 to 80% in 2010′, can be adjusted to ‘raising attended deliveries in the 48% of the population below the national poverty line’: from 37% in 1999 to 80% in 2010; (4)
• Using appropriate techniques where pro-poor policies have worked successfully in other countries, and encouraging collaboration and dissemination of experiences; (4,6,7)
• Implementing primary and preventative care strategies, which tend to be less regressive than higher care levels; (4,5,7) Contracting or encouraging services in the not-for-profit private sector (which are often very significant in sub-Saharan Africa) to develop pro-poor strategies or performance indicators, particularly those organisations that may be amenable to such objectives (e.g church health services, mission organisations, charitable NGOs); (4)
• Empowering poor clients to have a more central role in health system design and operation, to counterbalance the influence of the rich; (4,5,6)

Improving the political climate

Strategies also exist to improve the political climate towards promoting equitable neonatal survival policies:

• A greater dissemination of information on neonatal outcomes, inequalities and inequities. Such policy-relevant information may be a force for change at national, regional and community levels; (3,5,6,9)
• Making solutions and interventions broadly inclusive, but disproportionately benefiting the target or deprived group should help to build political support by not excluding other interest groups. (5,6) Effective interventions may, however, require specific targeting, and social and cultural tailoring; (7)
• The support of influential professional groups should be sought and cultivated in initiating significant policy changes; (5,7)
• Having a strong evidence base for interventions; (3,6,9)
• A phased management plan, of initial short-term gains, followed by strategies for medium term gains, and then long-term gains, to build momentum and progressively accumulate political consensus. (3,5,6,9)

Looking forward

Collaborative efforts in the sub-Saharan Africa region have the potential to increase the low coverage of current interventions, speed up the slow progress in scaling up care, and improve the high inequity with regard to neonatal survival. Consideration and understanding of the complex policy making environment is essential to reversing this trend, and should be a part of all health initiatives. Such understanding is necessary to successfully place neonatal survival on the policy agenda, and implement effective and sustainable neonatal survival strategies.

Mr Mandip Jheeta

Medicine MBChB 2002-08

University of Birmingham

Birmingham, UK

mandipjheeta@gmail.com

References

• (1) Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet. 2005 365(9462): 891-900
• (2) World Health Organisation. Chapter 5: Newborns: no longer going unnoticed; in World Health Organisation. The World Health Report 2005: Making every mother and child count. 2005. Geneva: World Health Organisation; 2000, 79-101
• (3) Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, Paul VK; Lancet Neonatal Survival Steering Team. Systematic scaling up of neonatal care in countries. Lancet. 2005 365(9464): 1087-98
• (4) Gwatkin DR, Bhuiya A, Victora CG. Making health systems more equitable. Lancet. 2004 364(9441): 1273-80
• (5) Cassels A. Health sector reform: key issues in less developed countries. J Int Dev. 1995 7(3): 329-47
• (6) Birdsall N, Hecht R. Swimming against the tide: strategies for improving equity in health (working paper). World Bank; 1995 [cited 2006 May 9] Available from http://www-wds.worldbank.org/servlet/WDS_IBank_Servlet?pcont=details&eid=000009265_3961019111234
• (7) Dmytraczenko T, Rao V, Ashford L. Health sector reform: how it affects reproductive health. Population Reference Bureau (PRB); 2003. [cited 2006 May 9]. Available from http://www.phrplus.org/Pubs/HealthSectorReformColor.pdf
• (8) Collins C, Green A, Hunter D. Health sector reform and the interpretation of policy context. Health Policy. 1999 47(1): 69-83
• (9) Martines J, Paul VK, Bhutta ZA, Koblinsky M, Soucat A, Walker N, Bahl R, Fogstad H, Costello A; Lancet Neonatal Survival Steering Team. Neonatal survival: a call for action. Lancet. 2005 365(9465): 1189-97
• (10) Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L; Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005 365(9463): 977-88

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