INFORME ESPECIAL SPECIAL REPORT
Alianzas para mejorar la salud de los recién nacidos en América Latina y el Caribe
Molly K. Miller-PetrieI; Goldy MaziaII; Magdalena SerpaII; Bertha PooleyIII; Margaret MarshallIV; Carlos MeléndezV; Marisol VicuñaVI
IPATH/United States Agency for International Development, Bureau of Global Health, Maternal and Child Health Integrated Program (MCHIP)/Latin American and Caribbean Neonatal Alliance, London, United Kingdom. Send correspondence to: Molly K. Miller-Petrie, email@example.com
IIPATH/United States Agency for International Development, Bureau of Global Health, Maternal and Child Health Integrated Program (MCHIP)/Latin American and Caribbean Neonatal Alliance, Washington, District of Columbia, United States of America
IIILatin American and Caribbean Neonatal Alliance, La Paz, Bolivia
IVUnited States Agency for International Development, Washington, District of Columbia, United States of America
VMinistry of Health, San Salvador, El Salvador
VIThe Collective for Neonatal Health, Lima, Peru
The regional Latin American and Caribbean (LAC) Neonatal Alliance and national neonatal alliances in Bolivia, El Salvador, and Peru were studied through in-depth interviews and a review of publications. Findings were analyzed to distill successful strategies, structures, and tools for improving neonatal health by working through alliances that can be replicated at the regional or national level.
The studies found the following factors were the most critical for successful outcomes from alliance work: inclusion of the Ministry of Health as a leader or primary stakeholder; a committed, diverse, technically expert, and horizontal membership; the presence of champions for neonatal health at the national level; development of a shared work plan based on feasible objectives; the use of shared financing mechanisms; the use of informal and dynamic organizational structures; and a commitment to scientific evidence-based programming. The relationship between the regional and national alliances was found to be mutually beneficial.
Key words: Infant, newborn; organization and administration; Bolivia; El Salvador; Peru; Latin America; Caribbean region.
Se estudiaron la Alianza de Salud Neonatal para América Latina y el Caribe a escala regional, y las alianzas nacionales de salud neonatal de Bolivia, El Salvador y Perú, mediante entrevistas exhaustivas y un análisis de las publicaciones. Se analizaron los resultados para extraer las estrategias, las estructuras y las herramientas eficaces para mejorar la salud neonatal trabajando mediante alianzas que puedan repetirse a escala regional o nacional.
Los estudios descubrieron que los factores más decisivos para obtener resultados exitosos del trabajo mediante alianzas fueron los siguientes: la inclusión de los ministerios de salud como líderes o interesados directos principales; una afiliación comprometida, diversa, técnicamente experta y horizontal; la presencia de promotores de la salud neonatal a escala nacional; la formulación de un plan de trabajo compartido basado en objetivos factibles; la utilización de mecanismos de financiamiento compartido; el uso de estructuras organizativas informales y dinámicas; y un compromiso con la programación científica basada en datos probatorios. Se observó que la relación entre las alianzas regionales y nacionales resultaba mutuamente beneficiosa.
Palabras clave: Recién nacido; organización y administración; Bolivia; El Salvador; Perú; América Latina; región del Caribe.
Although significant progress has been made worldwide in the last 10 years in reducing mortality in children under 5 years old, newborn mortality rates have declined at a significantly slower pace, and most countries are not expected to meet their targeted commitments for the fourth Millennium Development Goal (MDG 4) (1) of reducing child mortality (2). This disparity is particularly important given that newborn deaths account for 41% of all under-5 deaths worldwide (3). A greater focus on newborn health could thus contribute to significant reductions in child mortality and increased progress toward MDG 4 (4).
According to 2010 United Nations estimates, the Latin American and Caribbean (LAC) region has a newborn mortality rate (NMR) of 10/1 000 live births, ranging from 3 (in Cuba) to 25 (in Haiti) (5), and a maternal mortality ratio (MMR) of 80/1 000 000 live births, ranging from 25 (in Chile) to 350 (in Haiti) (6), with great variation both within and between countries. Other challenges in maternal and child health faced by the region include high levels of inequality; increasing deaths due to complications of preterm births; and indigenous, rural, and other vulnerable populations that have the greatest risk for maternal and neonatal mortality.
Fortunately, the majority of direct causes of neonatal death are both known and preventable, and evidence-based strategies exist to address them. The challenge for policymakers and program implementers is how to effectively fund and scale up these interventions as part of coordinated neonatal health plans. A general barrier to effective health programming is the plurality of actors working on the same issues but in relative isolation. There is often a lack of communication between ministries of health (MoHs), nonprofits, professionals, and other stakeholders, who share common neonatal health goals but do not coordinate their efforts. This can lead to duplication of efforts, the creation of parallel programs and strategies, lack of information sharing, and inconsistent or unsustainable projects enacted on a smaller scale.
These challenges can be addressed by strong alliances that promote communication, trust, and cooperation to support efforts led by MoHs. Working in alliances provides opportunities to combine resources, utilize diverse strengths, increase information sharing, and incorporate inclusive views into national policy setting, as well as achieve the standardization of indicators and improve data availability in neonatal health, a current research gap.
MATERIALS AND METHODS
Four case studies were conducted-three country studies (in Bolivia, El Salvador, and Peru) on national neonatal health alliances in the LAC region and one regional study on the LAC Neonatal Alliance. The goal of these studies was to construct an overview of the formation processes, internal structures, and successes and challenges faced by these alliances to distill commonalities between these experiences and recommended best practices for adaptation and replication at the national or regional level.
For the country studies in El Salvador and Peru, the research team carried out in-person, in-depth interviews with the alliance members; attended internal meetings; visited key program implementation sites; and reviewed publications, communications, bulletins, regulations, and other key documents shared by the alliances. For the country study in Bolivia, a comprehensive analysis had already been completed (7), so the results of that study were used, along with additional interviews and documentation obtained by email. For the regional study on the LAC Neonatal Alliance, extensive interviews were conducted with past and current members, including one representative each from the United States Agency for International Development (USAID); Save the Children; the USAID Maternal and Child Health Integrated Program (MCHIP) and PATH; the United Nations Population Fund (UNFPA); and the United Nations Children's Fund (UNICEF); as well as two representatives from University Research Co, LLC (URC); two former Save the Children employees; and one former Pan American Health Organization (PAHO) employee. A review of internal and published documents was also conducted.
Preliminary results were shared with the LAC Neonatal Alliance membership and the national alliances as well as with other regional neonatal stakeholders at the LAC Regional Technical Meeting on Priority Interventions for Newborn Health held in San Salvador, El Salvador, June 23 - 25, 2013. The results were also used to create an interactive toolkit (8) on USAID's Knowledge for Health website1 in both Spanish and English to support other countries in establishing their own national alliances.
RESULTS AND DISCUSSION
Overall, between 2005 and 2012, neonatal mortality in the LAC region dropped from 17 to 13, with significant reductions in Bolivia, El Salvador, and Peru (9) (Table 1). El Salvador, in particular, achieved a significant reduction in neonatal mortality (from 9 deaths per 1 000 live births in 2008 (10) to 5.2 per 1 000 in 2012 (11).
The LAC Neonatal Alliance works to support the formation of national-level alliances to create country-specific neonatal health policies and plans. This process is mandated in PAHO's Regional Strategy and Plan of Action for Neonatal Health, which calls for member countries to "support the reduction of maternal and neonatal mortality as a priority within health programs by expanding, strengthening, or sustaining the implementation of the Strategy and Regional Plan of Action and consider the Plan of Action when formulating national plans, among other actions to support improved neonatal and maternal health" (12).
Many countries in the region have formed a variant of a national-level neonatal alliance, including Bolivia, El Salvador, and Peru, the three countries covered in this report. The national neonatal alliances in those countries include the Bolivian Safe Birth and Motherhood Committee, the Neonatal Alliance of El Salvador, and the Neonatal Health Collective of Peru. Details on the successes and challenges reported by these three alliances are described below, and structures and processes common to all of them are identified and analyzed.
Though their specific activities may differ, the three above-mentioned national alliances share similar areas of focus, which can be partly attributed to their interaction with the LAC Neonatal Alliance, whose work reflects the four areas of focus outlined in PAHO's Regional Strategy and Plan of Action for Neonatal Health: 1) create a favorable environment; 2) strengthen health systems and improve access to health services for the mother, newborn, and child; 3) promote community-based interventions; and 4) develop and strengthen surveillance, monitoring, and evaluation systems to assess progress.
As part of the qualitative review reported here, each alliance identified their most significant successes and challenges and the strategies that helped them to achieve and address them respectively. These findings are provided below.
Bolivia. The Bolivian Safe Birth and Motherhood Committee ("the Committee") is the only alliance covered in this study that addresses both maternal and newborn health. In addition, as the longest running alliance included in the study, it has experienced and adapted to the greatest range of political changes and has thus reported many lessons learned.
The success of the Committee has been attributed to creative thinking and the dedication of its members. The majority of the successes cited by members have involved three major activities: communicating and advocating for the political priority of newborn health to government officials, stakeholders, and civil society; communicating and advocating for technical evidence-based interventions to address newborn mortality that have been approved and incorporated into the National Safe Birth and Motherhood plan for 2009 - 2015; and monitoring and evaluating both the current situation and the impact of programs to better design newborn health programs. These three activities have had a significant impact on newborn health in Bolivia.
Significant challenges described by Committee members include a changing public policy environment; maintaining a horizontal and nonhierarchical format; sustaining departmental-level committees; incorporating civil society; addressing disparities in monitoring and evaluation standards and lack of a disaggregated, regional-level data analysis to guide newborn policies at the local level; and balancing maternal and neonatal health priorities. The Committee continues to use creative solutions to address these challenges.
Members provided the following commentary on the successes of the Committee:
• "The success of the Committee over the years has been based on the ability of the members to work together-without losing institutional autonomy-under common goals and clear roles and responsibilities."
• "Values, which include respect, transparency, equity, shared leadership, and trust among the partners, have given the Committee technical, social, and financial sustainability, which has allowed for more efficient interventions, strengthened political and community support, and greater accountability and ownership among the members."
• "An alliance implies a systematic and continuous process, which allows for and responds and adapts to political and social changes in the framework of mutual agreements."
• "It is imperative to create a power balance between the state/international organizations/civil society in favor of a shared vision in order to maintain good coordination. Good communication channels are essential."
• "It is important to maintain the reputation of the alliance as a solid partner and a technical reference for maternal and newborn health. The alliance is a platform to share experiences and update members on evidence-based interventions for maternal and newborn health, which allows for scale-up of successful interventions."
El Salvador. Of the three national alliances covered in this study, the Neonatal Alliance of El Salvador ("the Alliance") is the one most closely modeled on the LAC Neonatal Alliance. The Alliance developed the MoH Plan for the Reduction of Maternal, Perinatal, and Neonatal Mortality 2011 - 2014 (13), which follows the same format as PAHO's Regional Strategy and Plan of Action for Neonatal Health and forms the basis of the Alliance's shared work plan. The organization is active in program implementation and consistently engaged in projects on the ground as well as in advocacy and monitoring and evaluation projects. The success of the Alliance is also reflected in the MoH's replication of the Alliance's structure in other health areas such as reproductive health.
The Alliance's main activities include publishing clinical guidelines, community action plans, and promotional and scientific materials for priority interventions, along with the national plan; research and data collection on the status of neonatal health in El Salvador; and implantation of projects countrywide. Projects have included 1) the creation of three human milk banks and the promotion of breastfeeding; 2) conducting Helping Babies Breathe (HBB)2 trainings; 3) creating three Kangaroo Mother Care (KMC)3 centers in hospitals; 4) developing birth-defect awareness campaigns and curriculum; and 5) creating and distributing newborn care kits to families.
Members identified the primary challenges as financial limitations and the lack of a formal means to collect funds; obstacles to communicating with high-level officials within the MoH and government to maintain political prioritization of newborn health; and gaps in the availability of neonatal health data at the national level.
Members offered the following advice to newly formed alliances:
• "Begin by conducting a situational analysis so that the major factors contributing to neonatal mortality are known and can be addressed; continue to maintain knowledge of the reality on the ground."
• "Include a diversity of members with strong technical capacities-members can then each play to their strengths and provide multiple perspectives, including clinical, public health, governmental, and scientific."
• "Find a strong coordinator and a secretary to provide a backbone to the alliance and create flexible working groups for specific tasks."
• "Utilize creative thinking with limited funding, and keep an institutional memory."
• "Focus on the three main causes of neonatal deaths-complications from prematurity, asphyxia, and infection-and on low-cost high-impact interventions."
Peru. The Neonatal Health Collective of Peru ("the Collective") is the most informal and fluid of the alliances covered in this study. Its membership comprises a high level of technical expertise and commands respect from the MoH in technical matters, functioning much like an advisory body and affecting policies and norms at the national level. It has made significant contributions to neonatal norms in Peru, achieved the inclusion of neonatal indicators in national information systems, and enacted work at the local level through member organizations, including training sessions in HBB and other priority interventions and conducting research on community- and home-based interventions.
The Collective's main successes include the publication of national technical norms for health (no. 74, "Articulated interventions to diminish neonatal deaths at the primary care, family, and community level" and no. 78, "The establishment of a national subsystem for epidemiological monitoring of perinatal and neonatal health") (14, 15). While helping to implement these norms remains a challenge for the Collective, the initiation of monitoring for neonatal indicators has led to the successful publication of detailed epidemiological bulletins providing disaggregated neonatal data on a monthly basis. The Collective also participates in a number of other alliances within the health sector, reaching out to additional partners and identifying other channels for incorporating neonatal health objectives into other agendas.
Members of the Collective cited implementation of the technical norms as one of the alliance's main challenges, along with 1) affecting health at the regional level; 2) the lack of funding; 3) high turnover rates and bureaucratic issues within the MoH; 4) conflict between certain members within the alliance; and 5) occasional lapses in activity between meetings due to the alliance's informal structure.
Members made the following recommendations:
• "Identify committed and passionate neonatal advocates for membership. Members are the greatest assets. Define common objectives and identify shared areas of interest. Look for ways to cooperate, not to differentiate."
• "Include professional associations and technical colleges in your membership to have the greatest impact. Impact on students will impact a future generation of health care providers."
• "Reach out to other alliances to collaborate."
• "Focus on sharing technical data with members. Increase combined knowledge."
• "Focus on neonatal care as a part of the continuum of care, from pre-conception to postnatal care."
• "Focus on the most vulnerable areas and try to form regional-level alliances in those areas."
The LAC Neonatal Alliance ("LAC Alliance") was formed in 2005 as an interagency working group for World Health Day. The LAC Alliance includes members from UN agencies, USAID, nonprofits, regional professional organizations, and MoHs. The LAC Alliance has published a number of policy and technical documents providing guidance for neonatal health, including the interagency consensus Reducing Neonatal Mortality and Morbidity in Latin America and the Caribbean (16), and the PAHO publication and accompanying resolution on PAHO's Regional Strategy and Plan of Action for Neonatal Health (12). The LAC Alliance also promotes evidence-based interventions for newborn health, especially those targeting the three primary causes of newborn deaths, including HBB for newborn asphyxia, KMC for premature and low-birth-weight babies, and the management of neonatal sepsis, among others. The LAC Alliance disseminates information and updates at global and regional meetings and through brochures and advocacy for inclusion of priority interventions in regional guidelines, and provides direct technical assistance when needed. An overview of HBB and KMC training sessions conducted by the LAC Alliance is provided in Table 2.
The LAC Alliance maintains its presence primarily through hosting regional technical meetings, which have taken place in 2006, 2007, 2009, 2011, and 2013. LAC Alliance members also participate actively in other neonatal forums regionally and globally, and use these opportunities to promote LAC Alliance policies as well as recruit new members and advocate for national-level alliances. This high-profile activity has fostered an increased level of political priority for newborn health both regionally and at the national level, paving the road for resolutions and policies that focus on the newborn as well as promoting alliance work (4).
Members of the LAC Alliance emphasized the importance of the incorporation of regional professional organizations. As advisors in their technical areas, these organizations bring diverse expertise to the membership and provide the organization with the opportunity to affect the continuum of maternal and neonatal health regionally through the work of nurses, pediatricians, gynecologists, and midwives exposed to LAC Alliance advocacy. LAC Alliance members speak and provide technical workshops at the annual meetings of these organizations and invite them to play central roles in LAC Alliance activities.
LAC Alliance members also participate in other regional and global alliances, bringing the newborn and LAC agenda to the forefront of global initiatives, including the LAC chapter of the UN Commission on Information and Accountability for Women's and Children's Health (WHO/PAHO), the UN Commission on Life-Saving Commodities for Women's and Children's Health, and the Every Newborn Action Plan (ENAP) (WHO).
Commonalities in alliance formation and structure
Though the three national alliances covered in the study were initiated in different ways, several similarities can be identified in their histories. First, in each case a core group of passionate leaders in newborn health came together from diverse organizations and began to discuss the idea of interagency cooperation. These conversations were sparked in part by advocacy efforts undertaken by the LAC Alliance and participation in LAC Alliance events. In the case of Bolivia, this advocacy helped to facilitate the incorporation of newborn health into an existing maternal health alliance. In some cases, members of the LAC Alliance were able to support national-level actors directly through their respective agency's national counterparts. For example, in El Salvador, USAID played a key role in bringing together national stakeholders and facilitated engagement with the MoH.
Second, all three alliances focused on engaging the MoH early on, and in all three cases the MoH continues to play a key role. Members highlighted the advantages of maintaining strong MoH ties, including the ability to participate in the development of national policies and norms, and increased sustainability of alliance output as a result of coordinated efforts, among others. In Bolivia and El Salvador, the MoH participates in the Alliance as an active member, and in El Salvador an MoH representative currently chairs the group. In Peru, the Collective serves as an informal advisory body to the MoH and includes the MoH in its core membership. One challenge for all three alliances has been how to engage with higher-level national authorities to sustainably prioritize and finance newborn health.
Third, each alliance allowed its structures to evolve organically. The three alliances were formed by presidential decree (Bolivia); a memorandum of understanding (El Salvador); and informally (Peru), and their initial memberships included stakeholders engaged in newborn health and in the dialogues initiated by the LAC Alliance and other entities. Each of the three alliances also focused on ensuring a diverse membership, including government, UN organizations, aid organizations, nonprofits, professional organizations, and civil society. Alliance members noted that the diversity of membership allowed each organization to take on a leadership role in their area of expertise, increasing the regional and technical reach of the LAC Alliance as a whole.
The three alliances share a similar structure with varying levels of formality. In Bolivia, the Committee's structure and rules have changed over the 16 years since it was founded. However, formal internal rules exist governing structure, membership, representation, and decision-making. The Committee meets regularly once per month as well as once per year to design a shared and communally budgeted work plan In addition, Departmental Committees function cooperatively with and autonomously from the central committee. In El Salvador, the Alliance also maintains formal internal rules governing membership. The Alliance meets once per month and maintains a shared and communally budgeted work plan that is reviewed each meeting. In the case of Peru, there are no formal guidelines governing membership of or participation in the Collective. Members may call a meeting as events arise, and share a communally budgeted work plan. It is interesting to note that the regional LAC Alliance and many of the national alliances began informally and functioned successfully as informal alliances before opting to formalize to varying degrees. In this case, formal institutionalization has not been necessary to achieve an impact.
LAC Alliance members highlighted keys to success that included shared ownership of the mission and objectives; strong technical skills of members; participation of MoHs, UN agencies, and professional organizations; consistency in meetings and communications; the use of regional collaborative processes generating buy-in for action plans and policies; and the incorporation of neonatal health into other cross-cutting themes. The LAC Alliance has served as a mechanism to place neonatal health on national agendas and to utilize this momentum in implementing national-level policies.
Major challenges faced by the LAC Alliance include 1) integrating maternal health programming with neonatal health programming while maintaining the focus on the newborn; 2) logistical barriers-primarily a lack of funding and difficulties coordinating meetings between a geographically and linguistically diverse membership; and 3) the time commitment that participation requires, particularly in coordinating LAC Alliance activities in addition to full-time professional positions. Another significant challenge is determining how to best support national-level alliances, an issue addressed in this study.
The alliances described above cited several strategies that proved successful. The authors conclude from these experiences that in the LAC region, the model of working on neonatal health through a regional alliance mutually supported at the national level by national alliances using similar but diverse formats has been an effective means of generating political priority; conducting advocacy; promoting and scaling up evidence-based, high-impact interventions; and increasing collaboration, buy-in, and momentum among stakeholders in neonatal health. Though a variety of challenges exist to maintaining and improving upon these strategies, other regions and countries could benefit from adapting or replicating many of these approaches in diverse health areas. Since the writing of this report, additional alliances have been formed in the English-speaking Caribbean, Haiti, and Paraguay.
Acknowledgments. The authors thank the past and present membership of the LAC Neonatal Alliance, the Bolivian Safe Birth and Motherhood Committee, the Neonatal Alliance of El Salvador, and the Neonatal Health Collective of Peru, for their collaboration on this project. The authors also thank the team from PATH/ United States Agency for International Development, Bureau of Global Health, Maternal and Child Health Integrated Program (MCHIP), for their support of the project.
Conflicts of interest. None.
1. Pan American Health Organization. Neonatal health in the context of maternal, newborn, and child health to fulfill the Millennium Development Goals of United Nations. Washington: PAHO; 2006. (CD47.R19).
2. United Nations Children's Fund. Children and the Millennium Development Goals: progress towards a world fit for children. New York: UNICEF; 2007.
3. The Partnership for Maternal, Newborn, and Child Health. Child mortality: Millennium Development Goal (MDG) 4 [Internet]. Geneva: World Health Organization PMNCH; c2011. Available from: http://www.who.int/pmnch/media/press_material/fs/fs_mdg4_ childmortality/en Accessed on 13 November 2013.
4. Shiffman J. Issue attention in global health: the case of newborn survival. Lancet. 2010; 375(9730):2045 - 9.
5. United Nations Children's Fund. Levels and trends in child mortality. Report 2012. Esti mates developed by the UN Inter-agency Group for Child Mortality Estimation. New York: UNICEF; 2012.
6. World Health Organization. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA, and The World Bank estimates. Geneva: WHO; 2012.
7. Socios para el Desarrollo; Prudencio C, Pooley B, Escobar A, Lara Palma R. Memoria de la Mesa Nacional por una Maternidad y Nacimientos Seguros. La Paz: PROSALUD; 2011.
8. Miller-Petrie M. Neonatal Alliance Toolkit / La Alianza Neonatal para América Latina y el Caribe: herramienta guía. Washington: United States Agency for International Development Maternal and Child Health Integrated Program; 2014.
9. World Health Organization Global Health Observatory Data Repository. Child mortality levels: probability of dying per 1 000 live births: data by country [Internet]. Geneva: WHO; 2014. Available from: http://apps.who.int/gho/data/node.main.ChildMort-2?lang=en Accessed 23 May 2014.
10. Asociación Demográfica Salvadoreña. Encuesta nacional de salud familiar. San Salvador: ADS; 2008.
11. Ministerio de Salud (SV). Informe de labores 2012 - 2013. San Salvador: MS; 2013.
12. Pan American Health Organization. Regional strategy and plan of action for neonatal health within the continuum of maternal, newborn, and child care. Resolution CD48.R4. 48th Directing Council of PAHO, 60th Session of the Regional Committee of WHO for the Americas; 2008 Sep 28 - Oct 3; Washington, USA. Washington: PAHO; 2008.
13. Ministerio de Salud (SV). Plan estratégico nacional para la reducción de la mortalidad materna perinatal y neonatal, 2011 - 2014. San Salvador: MS; 2011.
14. Ministerio de Salud (PE). Norma Técnica de Salud que establece el conjunto de intervenciones articuladas para la reducción de la mortalidad neonatal en el primer nivel de atención. Lima: MS; 2008.
15. Ministerio de Salud (PE). Norma Técnica de Salud que establece el Subsistema Nacional de Vigilancia. Epidemiológica Perinatal y Neonatal. Lima: MS; 2009.
16. Interagency Working Group for the Reduction of Maternal and Neonatal Mortality. Reducing neonatal mortality and morbidity in Latin America and the Caribbean: an interagency strategic consensus. Antigua, Guatemala: PAHO/WHO, UNICEF, USAID, ACCESS, BASICS, CORE, and SNL/Save the Children USA; 2007.
Manuscript received on 21 January 2014
Revised version accepted for publication on 26 May 2014
1 https://www.k4health.org/toolkits/neonatal-alliances (English) and https://www.k4health.org/toolkits/alianzas-neonatales (Spanish).