ENAP Metrics Overview V11dec2014

Improving and
using metrics for

action
ENAP Metrics Group meeting, Ferney Voltaire, 3-4th

December 2014
Professor Joy Lawn

London School of Hygiene & Tropical Medicine
& Dr Mathews Mathai, WHO
On behalf of ENAP Metrics Group
@joylawn
Every Newborn Series

5 papers
6 comments
55 authors from 18+ countries
60+ partner organisations
Main funders: Bill & Melinda Gates Foundation, USAID, Childrens Investment Fund Foundation
Every Newborn Action Plan
Based on the evidence from the Series

Co-led by UNICEF & WHO, Launch June 2014
Consultation >60 country governments
>80 organisations, >1000 individuals
World Health Assembly 2014 resolution
Now to action in many countries

Closely linked to post-2015 action
Eg A Promise Renewed
www.lancet.com/series/everynewborn
@joylawn
#EveryNewborn
ENDING
PREVENTABLE CHILD AND MATERNAL
DEATHS
3
@joylawn
#EveryNewborn
Ending preventable child deaths

A Promise Renewed target:
National U5MR of 20 or less
Every Newborn target:

National NMR of 10 or less
From 2.9 to 0.8 million neonatal deaths
About 29 countries will have to more than double their rates of progress
Source: Lancet Every Newborn series, paper 2
Sub national equity goals also to be set
#EveryNewborn
Also ending preventable stillbirths
2035
Every Newborn target
National stillbirth rate of 10 or less
From 2.6 to 1.1 million stillbirths
Aligned with NMR target but more ambitious change needed

Sub national equity goals also to be set
#EveryNewborn
AND ending preventable maternal deaths

Maternal mortality target included in Every Newborn Action Plan
Global average MMR of 70 per 100,000

With different targets for different countries
Lancet GH Sept 2013 : The Lancet Global Health 2013; 1:e176-e177 (DOI:10.1016/S2214-109X(13)70059-7)
#EveryNewborn
ACTING ON
THE ACTION PLAN
7
#EveryNewborn
When? For women, stillbirths, newborns, highest risk is at same time

Birth day
1.2 million intrapartum

stillbirths
>1 million neonatal deaths
~113,000 maternal deaths
75% neonatal
deaths
Birth is the time of greatest risk of death and disability

TRIPLE return on investment quadruple if count development outcomes
#EveryNewborn
Why? 3 million lives could be saved per year with universal

coverage
Source: The Lancet Every Newborn series, paper 3
2 of the 3 MILLION
LIVES SAVED PER YEAR
Running cost $1.15 per person
#EveryNewborn
What? Packages of integrated care for women & children
CARE AT BIRTH, TRIPLE RETURN

Highest impact, cost effective
Yet lowest coverage,

widest inequity and
weakest data
#EveryNewborn
Care at birth, and care of small and sick newborns

First opportunity is the QUALITY gap for facility births
Could save 2 million lives a year by closing this quality gap

Particular focus on health workers especially midwives
Every Mother Every Newborn quality initiative
Source: Lancet Every Newborn series
#EveryNewborn
#EveryNewborn
#EveryNewborn
#EveryNewborn
#EveryNewborn
5 things to do differently
Investment for
impact
Integrated
Plans
Governance, community
participation, partner
alignment
Integrated service
delivery, continuum of
care, coordination
Implementation &
Innovation
Address health system
bottlenecks, Every Mother
Every Newborn initiative
Indicators &
metrics
Intentional
leadership
development
Especially in countries
with highest burden
Targets in post 2015

Measurement of progress
and impact
AMBITIOUS
MEASUREMEN
T CHANGE IS
CRITICAL TO
EVERY STEP
#EveryNewborn
GLOBAL LEVEL
EVERY
20
35
20
30
202
5
NATIONAL LEVEL
NEWBORN ACTION PLAN MILESTONES
2035 Assessment of progress to national targets of <10 for newborn

deaths & stillbirths
Global NMR target of 7 per 1,000 lives births and SBR of 8 per 1,000 total births
2030 Review of progress to national mortality targets of <12 for
newborn deaths & stillbirths
Global NMR milestone of 9 per 1,000 lives births and SBR of 9 per 1,000 total
births
2025 Review of progress to national mortality targets
Global NMR milestone of 12 per 1,000 lives births and SBR of 11 per 1,000
total births
By 2020
ENAP milestone to ensure 10

core indicators and linked
metrics are defined
institutionalised in national
metrics platforms and widely
used for programmatic
change
2020 Review of progress to national mortality targets
202
0
20
17
Global NMR milestone of 15 per 1,000 lives births and SBR of 14 per
1,000 total births
Stillbirths
20
16
Key
Milestone
201
s in
1st5yr
Coverage goals assessment:

Universal coverage for all packages
Stillbirth
interventions
and strategies
of the Every
Newborn Action
Plan more
clearly
delineated.
Monitoring &
data
improvement
plan
Develop a plan for

tracking impact,
coverage and
quality, including
addressing
Minimum perinatal
dataset
EMEN
Coverage indicators for

Mother-baby friendly
package. Coverage
indicators for care of
small and sick newborns.
Outcome metrics developed

and to include stillbirths and
development outcomes.
Simple and standardised
measurement methods across
different health system
contexts. Improvement Every
of
Mother Every Newborn
Accountability
accuracy and quality of(EMEN)quality
key
of care initiative
Tracking linked
data.to
Package defined, encompassing high
Every Woman
quality and respectful care at birth,
Every Child and
notably workforce and commodities
other established
standards, plus maternal and perinatal
accountability
mortality surveillance and response
mechanisms.
(audit).
2025 coverage goals assessment:

[1] Care at birth: 95% of births receive quality
care.
[2] Care of small and sick newborns: >75%
KMC; >75% sepsis management;
Comprehensive neonatal intensive care:
(country specific targets).
[3] Community care: 90% coverage for
postnatal care; 50% at 6 months for exclusive
2020 coverage goals assessment:
breastfeeding.
[1] Care at birth: 90% of facility births receive
quality care.
[2] Care of small and sick newborns: >50%
KMC; >50% sepsis management;
Comprehensive neonatal intensive care:
(country specific targets).
[3] Community care: 20% increase
in postnatal
National
data
EMEN adaptation
care.
tracking
>50% of 75 Countdown countries
adapted/ adopted Mother-baby friendly

package. Standards, policies, training,
indicators updated for care at birth and
for small and sick newborns.
National RMNCH plans

sharpened
>50% of 75 Countdown
countries have sharpened and
costed RMNCH strategies to
address newborn health.
Essential commodities
countries have included all 4
newborn commodities of the 13
RMNCH commodities on EML
and designed systems to track
progress.
countries are collecting
and using data for
minimum perinatal
dataset metrics.
National finance
tracking
countries tracking and
reporting national
expenditures for
RMNCH, with specific
line item for care at
birth.
Community voice esp
women
countries with national
policy enabling
community voice e.g.
village committees,
local champions,
religious leaders,
All items in red text depend on improved metrics methods, tools, and
Core indicators selection during ENAP

development
Step 1: Developed matrix of the relevant indicators
According to ENAP Impact FW from impact (mortality) down to
inputs including financial such as ODA (>120 rows!)
Step 2: Graded each indicator as follows:

Direct relevance to ENAP 5 objectives and focus (from A to C)
Current availability of the data (from 1 to 3)
Step 3: Ranked indicators

By A to C, with A being closest match to ENAP focus.
By 1 to 3 where 1 is most currently available
Ambition to count what matters

Indicators prioritised by importance (category A)
Then develop an urgent programme of work to improve the input
data for those not currently available or only for a few countries.
eg HIV ART coverage data was lacking at the start of 3x5 but was quickly scaled up.
egFrom
Malaria
ITNtodata
wasstart
also
but
urgently
Ref: Every Newborn:
evidence to action
deliver a healthy
for thelacking
next generation.
Masonwas
et al foraddressed
the Lancet Every Newborn
Study Group. Lancet 2014.
#EveryNewborn
Every Newborn action plan core indicators

Text = WHO 100 indicators core list.
Text = WHO indicators additional list
Core Indicators
Additional Indicators
1. Maternal Mortality Ratio

2. Stillbirth Rate
3. Neonatal Mortality Rate
Impact
Intrapartum Stillbirth Rate

Low birth weight rate
Preterm birth rate
Small for gestational age
4. Skilled attendant at birth

Coverage:
5. Early postnatal care for mothers
Care for all
and babies
mothers &
6. Exclusive breast feeding to 6
newborns
months
7.
Antenatal corticosteroid use
Coverage:
8.
Newborn resuscitation
Complication
9.
Kangaroo mother care, feeding
s and extra
support
care
10. Treatment of neonatal sepsis
Neonatal morbidity rates , eg

infection
Disability after neonatal conditions
Immediate breastfeeding
Caesarean section rate
Chlorhexidine cord cleansing
Death registration, plus cause of

death
Ref: Every Newborn: From evidence to action to deliver a healthy start for the next generation. Mason et al for the Lancet Every Newborn Study Group. Lancet 2014.
ENAP
"MotherBaby" high quality care at
#EveryNewborn
service
birth
Counting
Birth registration

Core ENAP Indicators
Impact
Focus
on
Thursday
2. Stillbirth Rate

Preterm birth rate
infection
Coverage:
Care for all
mothers and
newborns

5. Early postnatal care for mothers and babies
6. Exclusive breast feeding to 6 months
7. Antenatal corticosteroid use

Coverage:
8. Newborn resuscitation
Complications and
9. Kangaroo mother care, feeding support
extra care
Shaded = not currently routinely tracked.
Counting
Birth registration
Death registration, cause of death
Bold = indicator requiring additional evaluation for consistent measurement
All indicators to be tracked so that
they can be broken down
assess equity,
e.g.at
urban/rural,
"MotherBaby"
hightoquality
care
birth regional, wealth quintile
ENAP service
delivery packages
Care of small and sick newborn
#EveryNewborn

Core ENAP Indicators

2. Stillbirth Rate
Impact

Preterm birth rate
infection
Coverage:
Care for all
ENAP
mothers and
Coverage
newborns

5. Early postnatal care for mothers and babies
6. Exclusive breast feeding to 6 months
task teams
7. Antenatal corticosteroid use

Coverage:
8. Newborn resuscitation
Complications and
9. Kangaroo mother care, feeding support
extra care
Shaded = not currently routinely tracked.
Counting
Birth registration
Death registration, cause of death
Bold = indicator requiring additional evaluation for consistent measurement
All indicators to be tracked so that
they can be broken down
assess equity,
e.g.at
urban/rural,
"MotherBaby"
hightoquality
care
birth regional, wealth quintile
ENAP service
delivery packages
Care of small and sick newborn
#EveryNewborn
ENAP treatment coverage

indicators Task Teams
Tasks
DEFINITON of the intervention
NUMERATOR as simple as possible and for now safer to avoid

compound versions
DENOMINATOR
Given issue of measuring at risk group eg babies (neonates
<2000 gms)
OUTPUTS
consider alternatives such as used by EPI eg per 100 live births
1. ACCURATE indicator based
2. POTENTIALLY MEASURABLE indicator
3. SHORT LIST OF QUALITY /PROCESS indicator
Some examples
Treatment completion rate
Drug commodity stock out
4 of the 5 interventions are primarily

implemented at facility level and are
challenging to collect through maternal recall
in surveys so facility focus for validation
Every newborn management including ENAP Metrics

Every Newborn
Steering Group
Every Newborn
Management
team
1. Country
work streams
Implementation
UNICEF & WHO
2. ENAP Metrics
group
WHO & LSHTM
3. Advocacy &
mobilisation
UNF/PMNCH &
Save the Children
Research
working group
(Cross cutting)
Light touch
secretariat at
UNICEF
ENAP Metrics
group:
CO
CHAIRS
COORDINATION
GROUP
(purpose to link to
existing metrics
work, and
institutionalise)
TASK TEAMS
(working on specific
metrics, linked with
existing initiatives)
WIDER INTEREST
GROUP
Very inclusive
INSTITUTIONAL
PARTNERS
to build capacity
especially Africa &
Asia
WHO: Matthews Mathai

LSHTM: Joy Lawn
UNICEF: Holly Newby plus
alternate
UNFPA: Sennen Hounton
SNL/NBITWG: Lara Vaz
CIFF: Suzanne Fournier
Gates: John Grove
USAID: Allisyn Moran
Task teams
Initial focus on the 4+1
specific newborn care
interventions
>100 people drawn from
wider metrics community
including Newborn indicators
technical working group
Aim to have 2-4 academic
institutional partners in high
burden countries linked to
EMEN pilot sites (Ghana, Tz,
Bangladesh, Kenya)
Improving, institutionalising & using ENAP metrics for action

ENAP Milestones by 2020
Count births and deaths in CVRS (women, newborns and stillbirths)
Minimum perinatal dataset & perinatal mortality audit being widely
used in countries
ENAP core indicators to be defined , incorporated in national metrics
platforms and widely used
ies 2020
r
t
n
cou ability
n
i
se count
u
d
n
ac
a
d
g
n
n
esti ement a
t
s
ri c
ov
Met e impr
r am
g
o
r
for p
June 2015 - May

2018
Testing indicators
Jan- May 2015 and tools in limited
number of countries
Refining and
Dec 2014 consulting on metrics
Meeting
plan
To
scope
& ENAP monitoring
World
World Health
Health
Assembly
Assembly
ENAP Metrics
FW
improvement
May/June 2014
plan
www.everynewborn.org
June 2018 - May

2020
Wide use in many
countries
CVRS, facility HMIS,
surveys
#EveryNewborn
Three tracks of work for ENAP metrics

1
Technical
mapping &
planning
of indicators,
tools & work in
progress
Improve
&
2
institutionalis
e
tools in
national data
collection
platforms &
global metrics
architecture,
accountability
3
Capacity
development
to improve &
use the data
for action
www.everynewborn.org
Initial focus testing 4 + 1 ENAP specific intervention

coverage
1.
2.
3.
4.
5.
KMC (coordinated with KMC acceleration gp and LSHTM with

SNL)
Resuscitation (USAID/MCS, SNL Bangladesh, WHO, HBB,
UNCoLSC, etc)
Antenatal Corticosteroids (WHO and UNCoLSC TRT etc)
Sepsis case mx (WHO, UNCoLSC etc)
CHX cord cleansing (UNCoLSC, SNL etc)
.Coverage/ content maternal & newborn care
(with
NBITWG & ICM)
.Impact indicators including disability (LSHTM & WHO)

Birth and perinatal death certificates, coverage &
.Priority research agenda for HMIS, surveys, and
quality
related tools, work in progress and gaps (LSHTM &
WHO)
Develop and test Minimum Perinatal Dataset
Perinatal Mortality audit tool, to link to maternal
death surveillance and response, led by WHO
Household surveys modules and Verbal autopsy
tools (eg birth/pregnancy history, improved birthweight and GA
assessment)
Standard data collection in facility HMIS and

facility assessments (eg SPA,SARA)
Improving
User friendly
formats, and
intentional
links to tools
birthweight
GA assessment
accountability and parent voices (eg partnerships
with E4A and WRA)
Testing linked to EMEN work (~4 countries)
Southern institutions & INDEPTH as centres of
excellence
Integrated l oversight especially with maternal
#EveryNewborn
Data Action messages

1
Ensure post 2015 targets
Neonatal and maternal targets likely in SDGs

Stillbirth counting needs major push! And more
data
Improve and use the data
Some metrics ready for wider scale use now

Many need strategic plan for technical advances
and linked tools
Intentional capacity development
to improve, use and further improve the data
We have the potential to transform

survival and health for EVERY newborn EVERY mother
including for the worlds poorest families
Acting on the plan depends on better data

@joylawn
#EveryNewborn

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Improving and

using metrics for

ENAP Metrics Group meeting, Ferney Voltaire, 3-4th

Professor Joy Lawn

Every Newborn Series

Every Newborn Action Plan

Based on the evidence from the Series

Now to action in many countries

Ending preventable child deaths

Every Newborn target:

From 2.9 to 0.8 million neonatal deaths

Also ending preventable stillbirths

From 2.6 to 1.1 million stillbirths

Aligned with NMR target but more ambitious change needed

AND ending preventable maternal deaths

Global average MMR of 70 per 100,000

When? For women, stillbirths, newborns, highest risk is at same time

1.2 million intrapartum

Birth is the time of greatest risk of death and disability

Why? 3 million lives could be saved per year with universal

Source: The Lancet Every Newborn series, paper 3

Running cost $1.15 per person

What? Packages of integrated care for women & children

CARE AT BIRTH, TRIPLE RETURN

Yet lowest coverage,

Care at birth, and care of small and sick newborns

Could save 2 million lives a year by closing this quality gap

Source: Lancet Every Newborn series

Targets in post 2015

2035 Assessment of progress to national targets of <10 for newborn

2025 Review of progress to national mortality targets

ENAP milestone to ensure 10

Coverage goals assessment:

Develop a plan for

Coverage indicators for

Outcome metrics developed

2025 coverage goals assessment:

adapted/ adopted Mother-baby friendly

National RMNCH plans

Core indicators selection during ENAP

Step 2: Graded each indicator as follows:

Step 3: Ranked indicators

Ambition to count what matters

Every Newborn action plan core indicators

1. Maternal Mortality Ratio

Intrapartum Stillbirth Rate

4. Skilled attendant at birth

Neonatal morbidity rates , eg

Chlorhexidine cord cleansing

Death registration, plus cause of

Every Newborn action plan core indicators

1. Maternal Mortality Ratio

Low birth weight rate

Intrapartum Stillbirth Rate

4. Skilled attendant at birth

7. Antenatal corticosteroid use

Care of small and sick newborn

Every Newborn action plan core indicators

1. Maternal Mortality Ratio

Low birth weight rate

Intrapartum Stillbirth Rate

4. Skilled attendant at birth