Prioritizing MNCH Services in the Covid-19 Pandemic and Beyond

Executive Summary

During the fall of 2021, the CSIS Global Health Policy Center and Save the Children convened a series of roundtable discussions focused on accelerating progress toward meeting global goals related to maternal, newborn, and child health (MNCH) in the context of the pandemic. While Covid-19 has not directly caused a significant increase in child mortality in most countries, the pandemic has negatively affected access to maternal, neonatal, and child health services worldwide. From the diversion of health resources toward outbreak response to the social and economic disruptions provoked by lockdowns and curfews, the pandemic’s impacts on the health of mothers and children have been significant. The World Bank estimates there were more than 250,000 more infant deaths in lower- and lower-middle-income countries in 2020 than would have otherwise been expected.

Over the course of three meetings with representatives of bilateral assistance agencies, multilateral institutions, public-private partnerships, nongovernmental organizations, and research institutions with expertise in the areas of immunizations, maternal and child health, health systems strengthening, and primary health care, several priorities were highlighted. As the global community looks ahead to the 10th anniversary of the 2012 Child Survival Call to Action and its goal of reducing child mortality to 20 or fewer child deaths per 1,000 live births in every country by 2035, now is an opportune time to take stock of the ways in which the United States, one of the convening governments, along with India and Ethiopia, and in collaboration with the United Nations Children’s Fund (UNICEF), can reinforce its support for MNCH in the time of coronavirus. Ensuring access to adequate protection and ongoing training of health workers dedicated to MNCH services; providing programs with the flexibility to pivot and adapt in times of crisis; making better use of existing data to monitor for service quality and equity; and prioritizing continuity of MNCH services within pandemic and health emergency response can help ensure women, adolescents, and children have the support they need to live healthy lives now and in the future.

The 2012 Child Survival Call to Action

In 2012, governments, multilateral institutions, and nongovernmental partners launched the Child Survival Call to Action, an effort to ignite a sustained global effort to end preventable child deaths. In signing on to “A Promise Renewed,” governments and civil society organizations committed to working in partnership to strengthen financing, planning, and delivery of services for children living in the most disadvantaged settings. Through the Global Roadmap, efforts were focused on a subset of 24 countries representing the highest percentage of deaths to children under the age of five, with an emphasis on high-impact interventions, integrated approaches to service delivery, and country ownership.

Prior to the pandemic, Sustainable Development Goal (SDG) 3 focused attention on ending preventable deaths of newborns and children under five years of age, while the Global Financing Facility was launched in 2015 to offer financial and technical assistance to 30 lower- and lower-middle-income countries in preparing national plans to ensure affordable and quality healthcare for women, adolescents, and children. The updated Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016–2030) envisions “a world in which every woman, child and adolescent in every setting realizes their rights to physical and mental health and well-being, has social and economic opportunities, and is able to participate fully in shaping sustainable and prosperous societies.”

There had been some good progress on improving immunization coverage and reducing child mortality, but in recent years momentum had stalled. New vaccines had been introduced in a number of lower- and lower-middle-income countries between 2010 and 2018, and Gavi’s new five-year strategy (2021–2025), approved in 2019, was focused on reaching “zero-dose” children with lifesaving interventions. Nevertheless, coverage of the diphtheria-tetanus-pertussis (DTP) vaccine had plateaued after 2015. And while UNICEF reported positive trends in reducing the mortality of children under five and ensuring children living with HIV were on antiretroviral therapy, its 2019 annual report noted that progress was slow and that reaching ambitious global targets was unlikely.

Impacts of Covid-19 on MNCH Services

Since the World Health Organization (WHO) declared the Covid-19 outbreak to be a global pandemic in March of 2020, access to routine health services for mothers, adolescents, and children has been a challenge. The diversion of health workers, including doctors, midwives, nurses, and community health workers, along with health resources, to outbreak response has meant fewer available appointments and a reduced number of hospital beds, whether for mothers delivering babies or for children requiring hospitalization. With limited Covid-19 diagnostic capacities, many countries have been unable to test pregnant women when they have presented at health facilities with Covid-19 symptoms.

Since 2020, women’s access to antenatal services has been down in lower- and lower-middle-income countries in sub-Saharan Africa, Asia, and Latin America, with fewer well-child visits and fewer deliveries with skilled attendants at a health facility. The WHO and UNICEF estimates of national immunization coverage (WUENIC) data from 2021 also show that immunization services have dropped over the past two years, with DTP coverage decreasing 3 percentage points since 2019, essentially reversing a decade of progress. Access to the measles vaccine, given around age one and again at age five, and to the HPV vaccine, administered to adolescents, also dropped in 2020. Since these vaccine doses also serve as indicators for a child or adolescent’s access to the health system, we can infer that the infants, children, and adolescents who miss these critical vaccine doses are also missing other health services. The WHO estimates that the number of deaths from malaria was higher in 2020 than the previous year, with at least two-thirds of those deaths due to disruptions from Covid-19; 80 percent of those deaths were among children under the age of five. The closure of educational facilities over much of the first year of the pandemic also limited children’s access to the supplemental meals and other health services they would normally access there, while adolescent girls out of school have faced greater vulnerability to sexual violence, sexually transmitted infections, and unplanned pregnancies.

Despite the considerable challenges to MNCH posed by the pandemic, some adaptations and innovations made during Covid-19 have opened new opportunities for strengthening families’ access to health services and should be maintained in the longer term. Programs that provided health facilities with the flexibility to pivot services reported greater success in shifting to digital health platforms for monitoring and case management; moving to telehealth, mobile outreach, or home-visit appointments for postnatal care; engaging civil society organizations and community members in the distribution of medications and health information; and disseminating training modules to help health workers adapt to the changes than those that did not. And some countries have been able to use the delivery of Covid-19 vaccines as a way of connecting with mothers and fathers to link them and their children to other health interventions, such as routine immunizations or preventive care. The emphasis on scaling up access to oxygen for Covid-19 patients may have important implications for securing sustainable supplies of oxygen for maternal and neonatal care as well.

Sustaining and Improving the Delivery of MNCH Services in Health Emergencies

In looking ahead to the 10th anniversary of the Child Survival Call to Action, the global community can consider lessons from the Covid-19 pandemic in redoubling efforts to close gaps and meet the ambitious SDG target of ending preventable child and maternal deaths. As the United States envisions its bilateral and multilateral support for MNCH beyond the pandemic, it can support efforts that recognize the importance of prioritizing continuity of MNCH as essential services and integrate key MNCH indicators into emergency preparedness and response plans. And it can prioritize activities that:

  • Situate the provision of MNCH services within community-based, primary healthcare programs. The delivery of services at the local level by members of the community who have the trust and confidence of their neighbors has proven to be critical in responding to outbreaks of infectious disease and crises such as Covid-19. A strong primary healthcare system supports disease surveillance and the delivery of vaccines, while at the same time ensuring communities can continue to access preventive services such as antenatal care and be linked to hospitals for surgeries or advanced services if the need arises. Doctors, nurses, midwives, community health workers, and other care providers must be protected, compensated, trained, and empowered to advocate for continuity of MNCH services, including during health emergencies.
  • Ensure access to a diverse array of tools to facilitate MNCH service delivery and sustain health workforce training. During the pandemic, as a means of promoting social distancing and preventing disease transmission, many mentoring and health monitoring programs that previously relied on in-person contact have shifted to telehealth or the delivery of services via telephone. To help care providers adopt these new approaches, some countries, such as Bangladesh, also developed e-modules and e-platforms to provide health workers with virtual training, including in local languages. Digital health technologies offer numerous opportunities to improve patient access to health services during periods of social distancing, as well as when patients are in remote settings; however, scaling up the use of digital tools will require health sector collaboration with communications and tech companies to increase access to internet services, software maintenance, and data plans. Yet it is also important to maintain investments in traditional methods of service provision and data collection so that uptake of digital tools does not further widen access gaps between communities that already have access to wireless or internet communications and those that do not. It will also be important to address gender-based barriers to accessing technology and ensure that all health workers have the tools, training, and technologies needed to continue providing routine health services to mothers and children during crises.
  • Allow programs the flexibility to adapt in the event of crisis. Building flexibility into program agreements and ensuring implementers have the necessary authority to quickly oversee a shift to telehealth or direct community outreach during periods of quarantine and social distancing can help ensure continuity of MNCH services during challenging periods. At the same time, health systems that have prioritized support and protection for healthcare workers, such as creating surge teams that can step in to provide care if a group of colleagues becomes infected with SARS-CoV-2, have been better able to sustain services for pregnant women, adolescent girls, infants, and children.
  • Integrate MNCH care with other healthcare services. It is important to both incorporate plans for continuity of essential MNCH services into pandemic preparedness efforts and identify a comprehensive package of related services, such as sexual and reproductive health, nutrition, and mental health and psychosocial support (particularly for women and girls, as well as health workers), along with water and sanitation and hygiene (WASH) services, that should be included. At the same time, it is important to outline plans for sustaining and improving the collection, cross-referencing, and utilization of data to measure and monitor access to services and quality of MNCH care at national and subnational levels.

In commemorating the 10th anniversary of the 2012 Child Survival Call to Action and its goal of reducing child mortality to 20 or fewer child deaths per 1,000 live births in every country by 2035, the United States and others in the global community can take concrete steps to sustain and reinforce support for MNCH in times of crisis. These include ensuring there are guidelines in place to maintain continuity of MNCH services during health emergencies; protecting health workers delivering MNCH services; allowing implementers the necessary program flexibilities to pivot or adapt in crisis; and making better use of data to ensure affordable, quality care. Taking these important steps can help women, adolescents, and children access the support they need to weather the current pandemic and confront future health challenges as well.

Katherine E. Bliss is senior fellow and director of immunizations and health systems resilience with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C. Smita Baruah is head of government relations with Save the Children, U.S.

The authors are grateful to the participants at the fall 2021 policy roundtables for sharing their experiences, insights, and recommendations. We also thank Michael Rendelman and Mackenzie Burke for their support and Uma Govindswamy and Maclane Speer for their research assistance.

This publication is made possible through the generous support of the Bill & Melinda Gates Foundation.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2022 by the Center for Strategic and International Studies. All rights reserved.

Katherine E. Bliss
Senior Fellow and Director, Immunizations and Health Systems Resilience, Global Health Policy Center

Smita Baruah

Head of Government Relations, Save the Children, U.S.