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Mapping Maternal Health Advocacy a CASE STUDY of ZAMBIA TABLE of CONTENTS

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Mapping Maternal Health Advocacy a CASE STUDY of ZAMBIA TABLE of CONTENTS 2012 Basil Safi, Courtesy of Photoshare Mapping Maternal Health Advocacy A CASE STUDY OF ZAMBIA TABLE OF CONTENTS I. INTRODUCTION 3 II. MATERNAL HEALTH IN ZAMBIA 4 III. THE MATERNAL HEALTH POLICY ENVIRONMENT 5 IV. MATERNAL HEALTH ADVOCACY STAKEHOLDERS 6 V. ADVOCACY GOALS, MESSAGES, AND DISSEMINATION STRATEGIES 9 VI. OPPORTUNITIES, CHALLENGES, AND PRIORITIES 11 VII. THE PRIVATE SECTOR AND MATERNAL HEALTH 12 VIII. CONCLUSION AND RECOMMENDATIONS 14 IX. BIBLIOGRAPHY 15 List of Boxes BOX 1: FAMILY CARE INTERNATIONAL’S (FCI’s) MATERNAL HEALTH ADVOCACY MAPPING 3 BOX 2: KEY GUIDELINES, CURRICULA, AND FRAMEWORKS FOR MATERNAL HEALTH 5 BOX 3: A MISSED OPPORTUNITY 12 List of Tables TABLE 1: KEY MATERNAL HEALTH INDICATORS FOR ZAMBIA 4 TABLE 2: ZAMBIA’s NATIONAL, REGIONAL, AND INTERNATIONAL COMMITMENTS 7 TABLE 3: MAP OF MATERNAL HEALTH ADVOCACY STAKEHOLDERS 8 TABLE 4: MESSAGES AND TARGETS FOR MATERNAL HEALTH ADVOCACY 10 TABLE 5: KEY PRIVATE-SECTOR STAKEHOLDERS 13 © Family Care International, 2013. Edited by Beth Anne Pratt, Global Health Insights. This briefing paper is a summary of a full report Mapping Maternal Health Advocacy: A Case Study of Zambia, based on research by Beth Anne Pratt. This initiative was supported by a grant from Merck, through its Merck for Mothers Program. I. INTRODUCTION © 2006 Jarrett Cassaniti, Courtesy of Photoshare In 2000, the adoption of the Millennium Development Goals (MDGs) marked the beginning of a renewed global commitment to improving the social and economic well-being of the world’s population [1]. Of the eight goals, MDG 5 (Improve Maternal Health) is directly relevant to maternal health; a number of other MDGs, including those focusing on education (Goal 2), gender equality (Goal 3), child mortality (Goal 4), and HIV/ AIDS (Goal 6), also have an impact on maternal health and well-being. In 2010, a review of countries’ progress towards the MDGs revealed that many countries were falling short of achieving their targets [2]. A number of global and regional efforts now exist to help accelerate progress towards maternal health and the MDGs; these include the United Nations (UN) Secretary-General’s Global Strategy for Women’s and Children’s Health, Countdown to 2015, the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) [3], and the 2001 Abuja Declaration on health-sector funding. Advocacy can play a critical role in mobilising commitment and support for maternal health. At the global and regional levels, advocacy efforts have encouraged governments to sign commitments and set targets for maternal health. At the national level, civil society organisations (CSOs) utilise advocacy to hold governments and other stakeholders accountable to these commitments, and generate public demand for better maternal health services. This report (Box 1) maps the current advocacy environment for maternal health in Zambia. It outlines sys- tems of maternal health governance, identifies stakeholders working in maternal health advocacy, and analyses opportunities and challenges for maternal health advocacy organisations. It identifies the potential of engaging the Zambia private sector on maternal health issues, and concludes with a set of recommendations for strength- ening maternal health advocacy efforts in the country. Although civil society organisations have not yet mo- bilised around maternal health issues in Zambia, there is a robust policy framework in place, and the country has signed a number of commitments to improve delivery, uptake, and outcomes of maternal health services. There are numerous opportunities for engagement, both with advocates and with the private sector, on maternal health in the country. Data for this report were collected at the national level using a multidimensional qualitative model based on key informant interviews and a literature review. Respondents were identified via purposive sampling and included representatives from UN and government agencies, bi- and multi-lateral organisations, international and national non-governmental organisations (NGOs), health professional associations, advocacy coalitions, and private-sector organisations. Data were analysed using a thematic approach. BOX 1: FAMILY CARE INTERNATIONAL’S (FCI’s) MATERNAL HEALTH ADVOCACY MAPPING Family Care International (FCI) completed a comprehensive mapping activity in Zambia in 2013 to gather information on the maternal health policy environment. The study assessed the organisations, partnerships, and networks currently and potentially engaged in maternal health advocacy, as well as the advocacy goals, strategies, resources, and core messages being used. The study also sought to understand the role the private sector currently and potentially has in maternal health in Zambia, and to identify points of engagement with potential private-sector partners. A Case Study of Zambia 3 II. MATERNAL HEALTH IN ZAMBIA Zambia has been making good progress in meeting a number of its health-related MDGs. National measles and diphtheria, pertussis (whooping cough) and tetanus immunisation coverage is higher than regional averages, reaching 91% and 82% of children under five [4]. Zambia’s HIV/AIDS prevalence is estimated to be 13.5%, down from 17.5% in 2008, and HIV/AIDS specific mortality has declined from 630 per 100,000 people in 2000, to 341 per 100,000 in 2009 [4]. Zambia has one of the highest rates of antiretroviral therapy (ART) coverage in Sub- Saharan Africa, with 72% of people with advanced HIV/AIDS having access to ART [4].a Zambia is one of only 11 countries in Africa with evidence of a greater than 50% decrease in malaria incidence cases between 2000 and 2011, and the country has seen a 30% decrease in under-five all-cause child mortality rates since 2000 [4]. Indicators for maternal health, however, have lagged far behind (Table 1). In 2002, Zambia’s maternal mortal- ity ratio was 720 per 100,000 live births. By 2010, the country had managed to reduce this number to 440 per 100,000, but the rate is still far off both the country’s MDG target of 162, and the more ambitious target of 159 set by the National Health Strategic Plan 2011–2015 (NHSP) [4–6]. Skilled birth attendants are present at only 46.5% of all births [4]. The average fertility rate is 6.2 children per woman [6]. Many other maternal health indi- cators have failed to decline steadily since the mid-1990s, and vary greatly across provinces [7]. Leading causes of maternal death include haemorrhage, sepsis, obstructed labour, hypertensive conditions, abortion, malaria, and HIV [8]. Table 1: Key Maternal Health Indicators for Zambia and Sub-Saharan Africa Indicators Zambia Sub-Saharan Africa Maternal mortality ratio (per 100,000 live births) 440 480 Population growth rate (%) 2.7* 2.4 Antenatal care coverage (%) at least 1 visit 94 74 Antenatal care coverage (%) at least 4 visits 60 43 Births attended by skilled health personnel (%) 46.5 48 Nursing and midwifery personnel density (per 10,000 population) 7.1 9 Births by Caesarian section (%) 3 4 Post-natal care visit within two days of childbirth (%) 39 37 Total fertility rate (number of children per woman) 6.3 4.8 Pregnant women with HIV receiving antiretroviral b medicines for PMTCT (%) 75 50 Unmet need for family planning (%) 27 25 Contraceptive prevalence (%) 41 24 Sources: All statistics from World Health Organization. 2012. World Health Statistics 2012. Geneva: WHO, except * Government of Zambia. 2012. 2010 Census of Population and Housing: Summary of Findings. Lusaka: Central Statistics Office. a The regional average is only 49% [4]. b Preventing mother-to-child transmission of HIV 4 Mapping Maternal Health Advocacy Zambia’s progress has been impeded by number of supply- and demand-side barriers to accessing maternal health services. Barriers include the human resource crisis (e.g. lack of midwives, high level of staff turnover), lack of emergency obstetric services, low levels of contraceptive usage, cultural attitudes towards pregnancy, labour, and delivery, and high levels of malaria and anaemia [4]. Once evidence began to show that Zambia’s MDG 5 performance was lagging, and that its targets would not be met by 2015, the Ministry of Health (MoH) began to redirect its attention towards maternal health. Following elections in 2011, a new ministry was created – the Ministry of Community Development and Mother and Child Health (MCDMCH) – to help guide implementation of programmes and direct service delivery closer to communities. MDG 5 is now prioritised as a performance indicator on the Sixth National Development Plan 2011–2015 (SNDP). The country has been host to a number of large, donor-funded initiatives to address barriers to service delivery and utilisation, and to reduce high levels of maternal mortality. These initiatives include Mobilising Access to Maternal Health Services in Zambia (MAMaZ) and Scaling Up Family Planning (SUFP) (both funded by DFIDc); as well as Saving Mothers, Giving Life (SMGL). MAMaZ ended in March 2013. The other two projects are ongoing. III. THE MATERNAL HEALTH POLICY ENVIRONMENT The health policy environment in Zambia is supportive of maternal health. Existing health governance structures are currently being strengthened and formalised. Strategic plans, policies, road maps, guidelines, and curricula are either already in place, in the process of being finalised, or in planning stages (See Box 2). Maternal health is one of the key areas in which health governance is being actively reviewed, expanded, and improved. Zambia is a signatory to many international
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