Sexual, reproductive, maternal, newborn, child and adolescent health: policy survey, 2018-2019: summary report
Publication date: 2020
SEXUAL, REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH POLICY SURVEY, 2018–2019: summary report Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018-2019: summary report ISBN 978-92-4-000409-2 (electronic version) ISBN 978-92-4-000410-8 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design, layout and proofreading: Green Ink, United Kingdom (greenink.co.uk) https://creativecommons.org/licenses/by-nc-sa/3.0/igo https://creativecommons.org/licenses/by-nc-sa/3.0/igo/ http://apps.who.int/iris/ http://apps.who.int/bookorders http://www.who.int/about/licensing http://greenink.co.uk SEXUAL, REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH POLICY SURVEY, 2018–2019: summary report Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 4 The World Health Organization’s 2018– 2019 survey finds that a great majority of countries worldwide have policies on sexual and reproductive health, maternal health and the health of infants, children and adolescents. On average, countries have policies addressing 13 of the 16 key policies that the survey covered. Introduction Under the Sustainable Development Goals (SDGs) and the United Nations Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), all Member States of the World Health Organization (WHO) have committed to improving the health of women, children and adolescents by accelerating the coverage and improving the quality of health services. Achieving these goals requires adopting and implementing strong, evidence- informed and equity-focused policies spanning the continuum of care for sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH). To track country progress in adopting WHO recommendations, the WHO Department of Maternal, Newborn, Child and Adolescent Health and Ageing (MCA) and the Department of Sexual and Reproductive Health and Research (SRH) conducted the global SRMNCAH policy survey in 2018–2019. This survey is the fifth such survey on maternal, newborn, child and adolescent health since 2009–2010, and it is the first to include sexual and reproductive health and to align with the SDGs and the Global Strategy for Women’s, Children’s and Adolescents’ Health. The key objective of the survey was to track countries’ progress in adopting WHO recommendations through national health legislation, policies, strategies and guidelines. The survey is part of WHO’s efforts to inspire greater global and national policy dialogue, to stimulate the development of country plans for investment in SRMNCAH and to mobilize accountability for accelerated progress towards the goals and targets of the Global Strategy. By undertaking these activities, WHO seeks to provide useful information to governments, partners and communities on the challenging path to implementing the Global Strategy. © WHO/Patrick Brown Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 5 Table 1. Response rate of WHO Member States to the 2018–2019 global SRMNCAH policy survey WHO Region Number of Member States Number responding to the survey Response rate (%) African Region 47 42 89 Eastern Mediterranean Region 21 15 71 European Region 53 39 74 Region of the Americas 35 29 83 South-East Asia Region 11 11 100 Western Pacific Region 27 14 52 Global 194 150 77 Methods WHO’s MCA and SRH departments developed the survey questionnaire with input from a Policy Reference Group established for the purpose, other SRMNCAH experts, regional WHO SRMNCAH advisors, the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA). In the process, the departments reviewed 30 other sources of information and streamlined the questionnaire to minimize duplication. The SRMNCAH policy survey questionnaire, consisting of several modules (cross-cutting, maternal and newborn health, child health, adolescent health, reproductive health and gender-based violence), was programmed into an online platform. This survey was developed to be administered in a modular approach, to allow specific respondents to complete the module(s) in their area(s) of expertise. The survey and all training materials were made available in all six United Nations languages (Arabic, Chinese, English, French, Russian and Spanish) and in Portuguese. In each country the WHO country officer or another assigned country focal point was responsible for coordinating with the ministry of health and/or other United Nations agencies to complete the survey. � Response rate. The global SRMNCAH policy survey was distributed to all 194 WHO Member States. Of these, 150 completed the survey, for a response rate of 77%. Regionally, response rates ranged from 52% in the Western Pacific Region to 100% in the South-East Asia Region (Table 1). 16 national policy areas covered in the 2018–2019 SRMNCAH policy survey � Family planning/contraception � Diagnosis, treatment and counselling for sexually transmitted infections (STIs) � Comprehensive national cervical cancer prevention � Antenatal care (ANC) � Childbirth � Postnatal care for mothers and newborns � Management of low birth weight and preterm newborns � Child health and development of children � Early childhood development � Integrated management of childhood illness � Management of childhood pneumonia � Management of childhood diarrhoea � Management of malaria with appropriate recommendations for children (in malaria- endemic countries) � Management of acute malnutrition in children � Policies/guidelines specifically addressing people ages 10–19 � Multisectoral plans of action and policies/ guidelines for the health system response to violence against women. Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 6 � Scope and further publication. The findings of this short report and the full version, published separately as Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health Policy Survey: Global Report 2018–2019, reflect the responses of the 150 Member States that completed the survey. Additional publications will be prepared that will cover in depth questions related to specific health service areas. Regional reports will also be made available and may include data from the five non-Member States that responded to the survey. Further, all legislation-related responses will be reported separately, as the relevant data are undergoing a critical validation process. Publications and further information will be available at: https:// www.who.int/data/maternal-newborn-child- adolescent/national-policies? Overview The Member States’ responses to the survey show that, globally, countries have policies on an average of 13 of the 16 key areas (83%). While most countries have at least 75% of the key policies, 16 of the 150 countries fall below the 50% mark (Fig. 1). Availability of policies in all 16 key areas varies by region. At one end of the scale, 95% of responding countries in the South-East Asia Region have national policies on all 16 areas. At the other end of the scale, 69% of responding countries in the Western Pacific Region have national policies on all 16 areas. More than 90% of countries have policies or guidelines on sexual and reproductive health, antenatal care (ANC), childbirth, postnatal care for mother and child, and child health and development. Only in the categories of adolescent health and violence against women do fewer than 90% of countries have policies/guidelines (Fig. 2). Figure 1. National availability of policies in 16 key SRMNCAH areas The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Data Source: Maternal, Newbon, Child, and Adolescent Health Policy Survey, 2018 Map Production: Department of Maternal, Newborn, Child, and Adolescent Health World Health Organization © WHO 2018. All rights reserved. N 50%-75% 75%-99% 100% Data not available Not applicable Proportion of key policies available 25%-50% https://www.who.int/data/maternal-newborn-child-adolescent/national-policies? https://www.who.int/data/maternal-newborn-child-adolescent/national-policies? https://www.who.int/data/maternal-newborn-child-adolescent/national-policies? Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 7 Sexual and reproductive health � Existence of national policies. National policies/guidelines on reproductive health care are almost universal: 94% of countries report that they have national policies or guidelines for reproductive health (RH). � Policy topics. RH policies/guidelines vary in their inclusion of specific topics. Almost all countries (93%) include family planning/contraception in national RH policies. Fewer include topics related to preconception care (71%) and menopause (55%). � Contraceptives. Globally, national essential medicines lists typically include contraceptive pills (83%), intrauterine devices (81%), injectables (78%), male condoms (74%), emergency contraceptives pills (67%) and implants (67%). Less often included are female condoms (50%) and vaginal rings (26%). Only 14% of countries include all eight of these contraceptives on their essential medicines lists. � Sexually transmitted infections (STIs). Nearly 9 of every 10 countries (88%) have a national policy or guideline on STI diagnosis, treatment and counselling. Three quarters of countries (75%) have national policies/guidelines on STIs that recommend integration of HIV and STI testing. Most national STI policies/guidelines (70%) include a target for reduction of congenital syphilis, and about half (52%) have a target for reduction of Neisseria gonorrhoeae infection. � Cervical cancer. Four of every five countries (80%) have national policies/guidelines on comprehensive cervical cancer prevention and control. About three quarters of these policies address diagnosis (77%), screening for precancerous lesions (77%), treatment of precancerous lesions (76%) and treatment of cervical cancer (73%). Policies in three of every five countries (60%) have provisions for a human papillomavirus vaccination (HPV) programme. Antenatal care � Existence of national policies. Almost all countries report having national policies/ guidelines on ANC (96%). More countries have policies/guidelines on ANC than on any other SRMNCAH category (Fig. 2). � Number and timing of ANC visits. Policies in just over half of countries (52%) recommend at least four ANC contacts, while 39% of countries call for at least eight ANC contacts during a normal pregnancy, as WHO currently recommends. Europe (56%) and the African Region (48%) are the regions where country policies are most likely to recommend eight visits or more. � ANC interventions. For pregnant women, national ANC policies/guidelines generally specify provision of iron and folic acid (93%), nutrition (90%), screening for STIs (91%), prevention and treatment of syphilis (89%), Figure 2. Percentage of countries with policies/guidelines in various SRMNCAH areas 0% 20% 40% 60% 80% 100% Violence against women Adolescent health Child health and development Postnatal care Childbirth Antenatal care Sexual and reproductive health Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 8 prevention and treatment of HIV (87%), birth preparedness and complications readiness (89%) and immunization (87%). Also, nearly four of every five countries (79%) recommend ultrasound examination before 24 weeks’ gestation. Childbirth � Existence of national policies. Nine of every 10 countries (91%) have national policies/ guidelines on childbirth. � Delivery care. A large majority of countries (87%) have national policies/guidelines on women’s right to skilled care at childbirth. The most common components of policies on delivery care include prevention and treatment of postpartum haemorrhage (87%) and the use of magnesium sulfate to prevent and treat eclampsia (86%). Fewer countries include guidance on the presence of a companion of choice during labour and delivery (59%) or a recommendation to allow the woman to choose the birthing position (46%). � Death notification and review. Roughly four of every five countries (81%) have national policies/ guidelines/laws requiring all maternal deaths to be notified to a central authority within 24 hours, and 84% of countries require review of all maternal deaths. It is less common to require review of stillbirths (43% of countries) or neonatal deaths (0–28 days) (67%). � Essential medicines. The great majority of countries include on their national essential medicines lists magnesium sulfate (91%), misoprostol tablets (90%), oxytocin (89%), gentamycin injection (88%), chlorohexidine (87%) and metronidazole injection (87%). On average, countries include 81% of 18 medicines and equipment items indicated for use during pregnancy, childbirth and postpartum care in their national essential medicines lists and commodities lists. Postnatal care for mothers and newborns � Postnatal care. More than 9 of every 10 countries (92%) have national policies/guidelines on postnatal care, and nearly all of these recommend assessment of both mother and newborn. � Low birth weight and preterm newborns. A large majority of countries (85%) have a national policy/guideline on the management of low birth weight and preterm newborns. Also, most national policies/guidelines recommend feeding breast milk to low birth weight and preterm newborns (81%) and kangaroo mother care or skin-to-skin contact for clinically stable newborns weighing 2000 g or less at birth (71%). � Sick newborns. More than four of every five countries (83%) have national standards for the management of newborn infants with severe illness, with 77% of countries specifying the availability of special newborn care units (SNCUs) and 77% specifying newborn intensive care units (NICUs). Globally, 54% of countries have a national policy/guideline for the treatment of sick newborns with possible serious bacterial infection at primary health care facilities when referral is not possible. Child health � Existence of national policies. Globally, 93% of countries have a national policy/guideline on child health and development of children. Policies in 55% of countries cover children ages 0–9 years, while 37% cover ages 0–5 years only. Policies covering children ages 0–9 are most common in the South-East Asia Region (73%) and the European Region (72%) and least common in the Eastern Mediterranean Region (20%). � Pneumonia. Four of every five countries (80%) have national policies/guidelines on the management of childhood pneumonia, a leading cause of death in children aged under 5 years. The national policies/guidelines of 30% of countries specify that pneumonia with chest indrawing should be treated at primary-level Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 9 facilities, while 41% specify treatment at referral facilities. As for treatment, 65% of countries recommend amoxicillin as the first-line treatment for pneumonia with chest indrawing, while 59% recommend amoxicillin for pneumonia with only fast breathing. � Diarrhoea. Some 81% of countries have national policies/guidelines on the management of diarrhoea in children. Nearly three quarters of countries (73%) recommend treatment of diarrhoea with oral rehydration salts, zinc or fluids. � Malaria. More than four of every five countries (82%) in regions with malaria1 have national policies/guidelines on the management of malaria in children. Four of every five countries have national policies/guidelines that recommend parasitological confirmation of malaria before treatment. While 46% of countries specify confirmation by rapid diagnostic test, 28% specify confirmation by microscopy. � Malnutrition. Three quarters of countries (75%) have national policies/guidelines on 1 Countries in the European Region and some countries in the Region of the Americas are excluded because they are free of malaria. management of acute malnutrition in children. All countries in the Eastern Mediterranean Region and the South-East Asia Region have these policies. � Overweight or obesity. About three of every five countries (59%) have national policies/ guidelines for routine assessment of children for overweight or obesity. In the Region of the Americas, 83% of countries have such a policy or guideline, but in the other regions less than 60% have such policies or guidelines. � Early childhood development. Globally, more than three quarters of countries (77%) have national policies/guidelines on early childhood development. The proportion is highest in Europe (87% of countries), the Region of the Americas (83%) and South-East Asia (82%) but lower in the African Region (69%), the Eastern Mediterranean Region (60%) and the Western Pacific Region (57%). � Integrated management of childhood illness (IMCI). Some 70% percent of countries have national policies/guidelines on IMCI. Nearly all low-income countries (97%) and lower-middle- income countries (92%) have policies/guidelines on IMCI. © WHO/Olivier Asselin Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 10 Adolescent health � Existence of national policies. Globally, 85% of countries have national policies/guidelines that specifically address adolescent health issues, but availability ranges from 93% of countries in the Region of the Americas to 60% of countries in the Eastern Mediterranean Region. Some 62% of countries have a national standard for the delivery of health services to adolescents. However, only 44% of countries clearly define in their policies/guidelines a comprehensive package of services and monitoring of implementation. � School health. Almost two thirds of countries (64%) have national standards for health- promoting schools, and over half (52%) monitor implementation of these standards. There is wide variation across regions, ranging from 23% of countries in the European Region to 82% in the South-East Asia Region. � Adolescent health programme. Nearly two thirds of countries (64%) have national adolescent health programmes, and 52% of countries have at least one person designated to work full-time for the programme. Only 34% of countries have regular government budget allocations to support the programme. Just 29% of countries have both full-time staff and government budgets. � Competencies. Just over half of countries (53%) have national policies/guidelines specifying the competencies of health workers in adolescent health. Fewer than half of countries (47%) have a continuous professional education system for primary health workers to receive adolescent- specific training. About one third (32%) include adolescent health in pre-service training for health workers. The South-East Asia Region has notably higher percentages in all these categories than other regions. Violence against women � Existence of national multisectoral plans and health sector response. Globally, 73% of countries have national multisectoral plans of action on violence against women. A higher percentage (79%) have national guidelines or protocols addressing the health sector’s response to violence against women/gender- based violence. The availability of health sector guidelines/protocols ranges from 91% of countries in the South-East Asia Region to 57% of countries in the Western Pacific Region. � Topics included in national protocols. The most widely included topics in national protocols on violence against women are HIV post- exposure prophylaxis (PEP), STI prophylaxis for survivors of sexual assault and psychological support/first-line support (71% of countries in each category). About two thirds or more of countries explicitly allow for emergency contraception after sexual assault (69%) and call for sexual assault services to be available around the clock (65%). � Training. Two thirds of countries (66%) report having national training programmes to strength the capacity of health-care providers to respond to violence against women. Cross-cutting issues � Coordination of planning. Nearly four of every five countries (79%) report having national coordination bodies that look at SRMNCAH or its components. A national policy to ensure the engagement of civil society organizations in national planning of SRMNCAH programmes is available in 55% of countries. � Participation of stakeholders in programme reviews. Globally, 83% of countries have policies calling for the participation of stakeholders in reviews of SRMNCAH programmes. The most common stakeholders who participate are the ministry of health (83%), other government bodies (77%) and H6 partnership organizations2 (73%). Civil society, academia, professional associations and other implementing partners participate in reviews of SRMNCAH programmes in approximately two thirds of countries. Stakeholders who participate less frequently in 2 The H6 partners are UNAIDS, UNFPA, UNICEF, UN Women, WHO and the World Bank Group. The H6 partnership provides technical support to advance the Every Woman Every Child Global Strategy. Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 11 Figure 3. Service areas addressed by national policies/guidelines to improve quality of care in SRMNCAH 0% 20% 40% 60% 80% 100% 57% 73% 65% 69% 75% 77% 77% Proportion of countries with all service areas included Average proportion of service areas included Adolescent health Sexual and reproductive health Child health Newborn health Maternal health reviews of national SRMNCAH programmes are adolescents/young people (43%), the private sector (44%) and donors (46%). � Quality of care. Three quarters of countries report having national policies on quality of care that address maternal health (77%), newborn health (77%) and child health (75%) (Fig. 3). Just over half of countries (57%) have policies that address all five service areas (RMNCA). Service areas that are least often included in national policies/guidelines to improve quality of care are sexual and reproductive health services (69%) and adolescent health services (65%). Only half of countries (51%) have a national steering committee or technical working group on quality of SRMNCAH care. Limitations of the survey A number of limitations should be taken into account when interpreting the findings of the 2018–2019 global SRMNCAH policy survey. First, the survey asked about national policies only; it does not include subnational-level policies that may address these issues. Second, the survey represents countries’ self-reported responses. Countries were asked to upload source documents. This was not required, however, and, where source documents were provided, the survey database was not checked against the source document. A source document validation exercise is under way, and the results will be made available. Finally, not all country teams had the opportunity to validate the reported data after the survey was submitted. The survey results will be presented at regional and country levels, which may result in some changes to the database. Such changes will be reflected in the MCA Department’s data portal, where the survey dataset will also be available for further analysis: see https://www. who.int/data/maternal-newborn-child-adolescent/ national-policies. Conclusions The 2018–2019 global policy survey constitutes the most comprehensive examination of SRMNCAH policies, with information from 150 WHO Member States. Overall, most of the 16 key policies are found in over 80% of countries (Fig. 4). However, the correlation between policy availability and the coverage of key interventions is difficult to assess, partly due to lack of data on coverage trends. Data on the coverage of health interventions were available for only half of the responding countries. Separate analysis of these data did not reveal any clear relationship between the availability of SRMNCAH policies and levels of intervention coverage. Moving forward, it is important that each country identifies gaps between policy and implementation, assesses the reasons for these gaps and addresses them. Having the appropriate laws, policies and guidelines in place is critical, but only through their implementation will the health of women and children improve. https://www.who.int/data/maternal-newborn-child-adolescent/national-policies https://www.who.int/data/maternal-newborn-child-adolescent/national-policies https://www.who.int/data/maternal-newborn-child-adolescent/national-policies Sexual, reproductive, maternal, newborn, child and adolescent health policy survey, 2018–2019: summary report 12 Figure 4. Percentage of countries with each of 16 key SRMNCAH policies, globally and by WHO region 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Na tio na l p ol icy /g ui de lin e on fa m ily p la nn in g/ co nt ra ce pt io n Na tio na l p ol icy /g ui de lin e ex ist s o n se xu al ly tr an sm itt ed in fe ct io ns (S TI s) d ia gn os es , t re at m en t a nd co un se lli ng Co m pr eh en siv e na tio na l c er vi ca l c an ce r pr ev en tio n an d co nt ro l p ol icy /g ui de lin e ex ist s Na tio na l p ol icy /g ui de lin e o n an te na ta l c ar e Na tio na l p ol icy /g ui de lin e o n ch ild bi rth Na tio na l p ol icy /g ui de lin e on p os tn at al ca re fo r m ot he rs a nd n ew bo rn s Na tio na l p ol icy /g ui de lin e ex ist s o n m an ag em en t o f lo w b irt h w ei gh t a nd p re te rm n ew bo rn s Na tio na l p ol icy /g ui de lin e on ch ild h ea lth a nd d ev el op m en t o f c hi ld re n Na tio na l p ol icy /g ui de lin e o n ea rly ch ild ho od d ev el op m en t ( EC D) Na tio na l p ol icy /g ui de lin e on th e in te gr at ed m an ag em en t o f c hi ld ho od il ln es s ( IM CI ) Na tio na l p ol icy /g ui de lin e on th e m an ag em en t o f c hi ld ho od p ne um on ia Na tio na l p ol icy /g ui de lin e on th e m an ag em en t o f c hi ld ho od d ia rrh oe a Na tio na l p ol icy /g ui de lin e on th e m an ag em en t o f m al ar ia w ith a pp ro pr ia te re co m m en da tio ns fo r c hi ld re n* Na tio na l p ol icy /g ui de lin e on th e m an ag em en t o f a cu te m al nu tri tio n in ch ild re n Na tio na l p ol icy /g ui de lin e th at sp ec i� ca lly a dd re ss es a do le sc en t ( 10 –1 9 ye ar s) h ea lth is su es Na tio na l m ul ti- se ct or al p la n of a ct io n fo r v io le nc e ag ai ns t w om en African The Americas Eastern Mediterranean European South-East Asia Western Pacific WHO Regions: * Excludes countries in the European Region and Region of the Americas where malaria is not endemic. 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