1. Expanded Impact Project
Malawi Newborn
Health Program
USAID/CSHGP
2006-11 (CS-22 Cycle)
Karen Z. Waltensperger,
Save the Children
Thanks to Evelyn Zimba, Joby George,
Tanya Guenther

2. Newborn health in Malawi
• 2000-5 Saving Newborn Lives (SNL)-1 funded by BMGF
• Developed community-based newborn care package
with MOH/RHU
• Implemented by Save the Children (Mangochi) and
partners (Project Hope, Ekwendeni CCAP Mission
Hospital, Kamuzu College of Nursing)
• Collaboration at national level to advance newborn
health agenda in context of Safe Motherhood

3. Opportunities in late 2005
• Strong partnership with MOH/RHU and partners
• National-level WILL to incorporate newborn
• Uncertainty about Malawi’s inclusion as an SNL-
2 country
• Opportunity to submit application to
USAID/CSHGP for CS-22 cycle Expanded
Impact Project (EIP) - $2.5m + match

4. CSHGP EIP Category
• $2.5 million
• Extend and build on existing, successful
programs
• IMPACT AT SCALE - multi-district, sub-
national, national level
• Roles
– Secretariat
– Partner coordination
– Convener

5. Approach
• Support for Malawi’s Road Map for Accelerated
Reduction of Maternal and Neonatal Mortality
• Catalytic inputs to advance newborn health
agenda in Malawi and achieve impact at scale
• Technical leadership and support
• Limited material assistance
• Support for “mainstreamed” training
• Assistance with partner coordination

6. Community Component
• Sub-grant for Ekwendeni CCAP Mission Hospital
to document Agogo Approach (Mzimba District)
• Transfer lessons learnt from Institute for Child
Health’s Mai Mwana randomized control trial in
Mchinji District (funded by SNL-1)

7. Transition
• CSHGP application submitted late 2005
• Malawi SNL-2 core country (2006-11)
• SNL country planning May 2006 (CBMNC
package with PNC focus, KMC)
• CS-22 cooperative agreement awarded in late
June 2006 (Oct 2006-Sep 2011)
• CS-22 DIP approved June 2007
• CS and SNL work plans merged ($5 million
program)

8. Points of departure
• National-level indicators (from MICS, DHS)
• Conundrum of baseline for Rapid CATCH—
where?
• Decided not to hold DIP Workshop
• MOH/RHU Deputy Director participated in DIP
Review in US

9. SNL-2 ―match‖ / cost share
• Develop and pilot a Community-Based Maternal
and Newborn Care (CBMNC) Package
• Delivered by Health Surveillance Assistants
(HSAs) in 3 districts)
• MOH, UNICEF, WHO, other partners
• UNICEF to fund district-level implementation in
district pilot

10. Package contents
• ANC (3 visits), birth planning, facility delivery,
PPFP, KMC (facility, ambulatory, community)
• Focus on 3 postnatal home visits during first
week (days 1,2,8)
• Costing study
• Community mobilization component added
(―core‖ groups using Community Action Cycle)

11. PNC home visits
• 3 visits (days 1,3,8) + extra for small
neonates
• Check newborn vital signs– weight,
temperature, respiration
• Check for danger signs in mother and
newborn
• PPFP counseling--LAM
• PMTCT

12. Early lessons
• “Not about us”
• “Our timeline isn’t necessarily their
timeline”
• “Sometimes lead, sometimes follow—
mostly walk together”
• Things happen

13. IMNC Package
• MOH/RHU priority
• Integrated Maternal & Newborn Care training
package for workers in first-line facilities
• ANC, BEmONC, EmMNOC, SBA, immediate &
essential newborn care, PNC
• KMC (facility, ambulatory, community)
• To be accomplished before roll out of CBMNC
package

14. Piloting the CBMNC
Package
• National development workshop
• 3 districts selected by MOH (1 per region)
• 4 additional districts supported by MCHIP
(JPHIEGO & Save the Children)
• Community mobilization component added using
―core‖ groups and Community Action Cycle
• Ad hoc CBMNC TWG formed by Safe
Motherhood Sub-Committee (Sexual and
Reproductive Health Technical Working Group)

15. Some results at national level
• Districts where CBMNC currrently
rolled out—17+/29
• Sites offering KMC—123+
• First-line facilities with IMNC
services—194+
• HBB in 14 districts (target 20)
15

16. CBMNC baseline & endline
• Timeline:
Baseline data collection in November 2007
(Formative research, HH survey, HF survey)
Training of >600 HSAs and HF staff in 22
facility catchment areas July 2008 to June
2011
Support activities (supervision, monitoring)
ongoing
Endline data collection in May/June 2011
(HH survey and HF survey)

17. Coverage of services
100
Missed opportunity
given high facility
80 delivery rate and
relatively long duration
of stay at health facilities
60
40
20
0
≥1 ANC visit ≥4 ANC Facility SBA* Baby PNC check PNC check
(skilled)* visits (any)* delivery* w eighed at for NB in 2 for mom in 2
birth* days* days*
Baseline (n=713) Endline (n=900)

18. Knowledge and practices
100
80
60
40
20
No data
No data
0
Complete First bath Nothing to Immediate Immediate Immediate Knowledge Knowledge
birth plan* ≥6 hours* cord drying* BF* STS 2+ NB DS 2+ PP DS
Baseline (n=713) Endline (n=900)

19. Health services assessment
• 22 health facilities and 110 HSAs interviewed
• HSA findings highlight challenges to achieving
coverage of CBMNC within existing system:
• Only 47% resided within their catchment area
• 54% spent 3 or less days in the community in last week
• 27% spent 3 or more days at the health facility in last week
• Only 66% had conducted ≥1 pregnancy home visit and only
51% ≥postnatal home visit in past 3 months
• Task overload?: ~40 deliveries/year = 5x40 = 200 home visits
per year (17 per month) + CCM + growth monitoring +
vaccination support + watsan activities +….

20. Excerpt from Policy and
Program Timeline
Annex 12A: Malawi Newborn Survival Policy and Program Timeline
Pre-2000 2000-2002 2003-2004 2005-2006 2007-2008 2009-2010
National context - political, humanitarian, etc.
• Budget support • Famine/food
• Bingu wa Mutharika • SWAp 1 Health • Bingu wa
from donors
elected president insecurity
Sector Mutharika re-
• Massive flooding • Intro of subsidized elected
ravaged parts of farm inputs (e.g.
country fertilizer, seeds,
• Famine/food insecticides)
insecurity
Newborn survival increasingly incorporated at national level in macro policies, strategies, and plans (health sector MNCH - not
NEWBORN specific)
• Safe • National •Essential Health • Developed “Road • Official launch • CBMNC package
Motherhood Reproductive Package launched Map for Accelerated of Road Map endorsed by
Initiative (1994) Health Policy (2002) funded through Reduction of with increased MOH/RHU for
• Safe (2002) SWAp Maternal and funding (March scale up to all
Motherhood • Gov't of Malawi •Drafting of Essential Neonatal Mortality 2007) districts (2010)
Task Force (est. commits to MDGs Newborn Care and Morbidity” • Official role of • Reproductive
1992) •Change in policy Package (May 2003) which then linked to TBAs shifted to Health Policy and
• National for Nurse and • PMTCT introduced EHP promotion of Strategy revised
Strategic Plan to Midwife (2003) • Revised National skilled • Policy for
reduce maternal Technicians to • Motivation training Reproductive Health attendants at introduction of
mortality (1995) provide BEmOC cadre - doubling of Strategy 2006-2010 delivery (March ARVs to pregnant
• Reproductive • Restructuring of intake in training (newborn 2008) fully women regardless
Health Unit HMIS started institution incorporated) implemented of CD4 count
established (1997) (2001) • Free ARVs (2004) • New Roles for across Malawi by • Emergency
• HSAs - •Transportation • Introduction of TBAs assessment January 2009 Human Resource
government improvements Emergency Human completed (August • ANC routine Programme e.g.
National policies, strategies, plans, and milestones
salaried cadre of • Service Level Resource Programme 2006) HIV testing Recruitment of
community Agreement (SLA) (2004) (2008) 4000 new HSAs
health workers MOH subsidies • Community • Co-trim
linked to health CHAM to provide IMCI (2007) prophylaxis as part
facilities free services for •Adopted 5-year of PMTCT for
mothers and plan for ACSD exposed infants
newborns (2002) and cIMCI • Community
including midwife nurse
newborn (2007) program initiated
by First Lady and
Calista Muthalika
Foundation (2010).
First training of
community
midwifes (Feb
2011)

21. Excerpt from Scale up
Readiness Benchmarks
No. Benchmark Definition 2000 2005 2010 Year
Ranking Ranking Ranking
1 National level NB health Formal assessment of NB health, child health, and safe No Yes Yes 2002
needs assessment/ motherhood programs and strategies conducted in
Situational Analysis collaboration with MOH and other partners
conducted
2 NB health Research studies conducted in collaboration with the No No Partial
services/packages tested MOH and/or partners/research institutions to test NB
and documented in local health services/packages in local settings
settings
3 Evidence of NB health At least one national level meeting with key partners and No No No 2010
interventions/packages stakeholders (dissemination of research findings or
disseminated at strategy) to discuss evidence of at least one priority NB
provincial/district and health intervention (thermal care, BF, clean delivery, early
national levels home PNC visits)
4 Technical National level technical working/advocacy groups with No No Yes 2007
working/advocacy group representation from key stakeholders, partners, donors,
established and advocating and community members established and advocating for
for NB health through NB health through consensus building OR existing
consensus building OR working/advocacy groups integrated newborn health in
existing working/ advocacy terms of reference
groups integrated newborn
health into terms of
reference
5 Focal person for NB health Focal person to provide technical input on newborn No No Yes 2010
established in MOH on NB health programs established within the MOH
health
6 National NB National policy and/or strategy on newborn health No Yes Yes 2005
policy/strategy strengthened and adopted by MOH
strengthened and adopted
by MOH
7 National NB National NB policy/strategy integrated into at least one No Partial Yes 2005
policy/strategy integrated existing national health program (child, maternal,
into existing programs reproductive, IMCI, etc)
8 National essential drugs National essential drugs and supply list for newborn care Partial Partial Partial 2001
and supply list for newborn developed and endorsed by MOH
care developed and
endorsed by MOH
9 National behavior change National behavior change communication strategy for NB No Partial Partial
communication strategy for health established OR national behavior change
NB health established and communication strategy integrates newborn and endorsed
endorsed by MOH by MOH. Key elements include: BCC messages, BCC
materials, Modes of communication, community
mobilization; At least 3 messages include: thermal care,
early and exclusive breastfeeding, clean delivery, early
PNC visits.

22. Health Policy and Planning article
for upcoming newborn health supplement

23. Unintended results
• Save the Children partner on 2 of 3 USAID
newly launched bilateral projects Support for
Service Delivery Integration (SSDI-Services and
SSDI-Communication)
• Technical lead for Child Health (includes
newborn), Nutrition, Community Approaches on
SSDI-Services
• Supports implementation in 6 Southern districts
• Lead for Community Mobilization on SSDI-
Communication

24. Mwayi wa Moyo (“A Chance to
Live”)
• Integration key objective of Malawi’s HSSP
(2011-2016)
• CS-27 cycle (2011-2016)
• Blantrye District
• MOH (RHU, IMCI Unit, PHC Unit)
• College of Medicine (OR partner)
• Purposefully integrated community-package
incorporating CBMNC+CCM+PPFP

25. Thank you!