RESULTADOS DE LA ENCUESTA REALIZADA A LOS DOCENTES

Goals

Goals in RMNH are closely aligned with MDGs Four and Five, specifically the following targets:

• Achieve universal access to reproductive health services, including family planning

• Reduce maternal mortality by 75 percent • Reduce neonatal mortality by two-thirds58 The main objectives of this plan fall into three catego- ries- reproductive, maternal, and neonatal health: Reproductive Health

• Increased access to and quality of contraceptive services that offer permanent and reversible methods for both men and women.

• Reduced barriers to contraceptive access espe- cially common in rural areas and among indig- enous women, adolescents and youth.

Maternal Health

• Increased access to emergency obstetric care, especially in rural and marginalized urban areas.

• Increased access for poor, rural women to skilled labor and delivery personnel.

Neonatal Health

• Increased access to childbirth care provided by qualified and competent personnel, especially in rural and marginalized urban areas.

• Reduced neonatal mortality by improving ob- stetric care and implementing actions to im- prove the quality of immediate care provided to the newborn, especially in communities re- moved from large metropolitan areas.

Target Population

The target populations for RMNH interventions are “women of reproductive age (15-45 years) and new-

borns. Proposed actions will be directed mainly to the poorest populations, indigenous women and commu- nities, adolescents and young adults, mainly concen- trated in rural areas.”59

Overlaps with other health areas in both the proposed impacts and target populations provide natural op- portunities for integrated delivery of care. This popu- lation has striking parallels with the nutrition and immunization target groups in particular. Immediate and exclusive breastfeeding, for example, serves the goals of both RMNH and Nutrition. Campaigns target- ing women of reproductive age could easily integrate messages on taking prenatal vitamins, recognizing signs of pre-eclampsia and getting tetanus immuni- zations into healthy-pregnancy campaigns. There is also some overlap with populations targeted by the vector-borne disease interventions, as prenatal clinic visits are a prime opportunity for malaria education and distribution of bed nets. Integrating services and messages where they naturally overlap, increases ef- ficiency and educational message repetition and po- tential impact.

Service Delivery Channels

RMNH interventions are delivered primarily in three settings: homes, community clinics, and hospitals. During pregnancy, birth and newborn care, there are multiple instances in which women are likely to seek care from a public health facility. This relatively in- tensive period of contact with health professionals not only provides a significant opportunity to attend to health issues related to pregnancy and birth, but also to address nutrition, immunizations and vector- borne disease. While caution should be exercised to avoid overloading the health professional and the consumer with too much information, mothers’ inter- actions with health professionals can greatly expand the target population’s awareness of health risks and services available to improve health outcomes. Media campaigns and educational materials on birth pre- paredness and healthy-newborn care directed at this target population offer further opportunities to in- clude messages on vaccination, nutrition and vector- borne disease prevention.

Pregnancy and the first 28 weeks of life provide a critical window to save lives. Because many of the nutrition and immunization interventions are intri- cately linked to the health of mothers, newborns and eventually young children, it is efficient to organize the Initiative around a maternal and neonatal health framework. In endemic areas for vector-borne disease, the Initiative can expand to include activities such as developing VBD infrastructure, educational campaigns and treatment particularly for pregnant mothers. Key Interventions

Packages within the RMNH area include interventions that will address maternal mortality, neonatal mortal- ity and reproductive health:

• Tested interventions to reduce postpartum hemorrhage, eclampsia, and septic abortion – the primary causes of maternal mortality have been outlined.

• Interventions that will address asphyxia, infec- tions, hypothermia, and sepsis are proposed to address neonatal mortality.

• Finally, as ensuring availability of family planning counseling and education, availability of a variety of contraception choices, access to vasectomy, and post-abortion counseling are outlined.

Despite ample evidence that effective low-cost inter- ventions significantly reduce maternal and neonatal mortality, unacceptably high mortality rates persist. Deficiencies in service and resource provision have failed to make interventions fully accessible to the entire population. As noted in Section Two, capacity building at multiple levels is fundamental to achieving better coverage of RMNH activities.60 _{Capacity building} of skilled birth attendants, including traditional mid- wives (who are often preferred by indigenous wom- en), working in both community clinics and attending home births will be the primary means to achieving more equitable RMNH coverage in this area. There is significant evidence that confirms that building

capacity of traditional midwives is a way to signifi- cantly decrease maternal mortality.61 _{According to} the RMNH Master Plan, training for traditional birth attendants in particular should include essential new- born package care and low birth rate baby package.62 Implementation of the recommended interventions will vary substantially in approach depending on whether delivered in a hospital setting, community facility or in the home. As is true throughout the four health areas, more work could be done to include the perspective of the target population and those work- ing in targeted geographic areas in order to develop effective implementation strategies that address the true reality of the health challenges within target populations. The Immunization Master plan provides an overview for using qualitative research to better understand the target population. A similar approach is also needed in RMNH.

Conclusion

While the challenges are significant, attending to preg- nancy, birth and newborns provides an opportunity to improve the entire continuum of care, from the home to the emergency room, and all levels in between. Because of the comprehensive nature of maternal health needs, improving quality and access in this area will likely have a ripple affect in other health areas.

3.4 Vector-Borne Diseases: Malaria and

Dengue

Vector-Borne Disease control strategies for Malaria and Dengue differ from one another. Although mos- quitoes are vectors for both diseases, the mosquito vectors are different. Unlike malaria, there are no medications for treating dengue virus. The strategy for eliminating malaria from Mesoamerica is first to elim- inate disease transmission in low-risk, endemic areas, reducing mosquito vectors and human reservoirs of disease in endemic areas to residual pockets. Inten- sive abatement activities will focus on the remaining areas, eventually eliminating the disease. Surveillance and maintenance activities will continue for several

years to detect and control any resurgence of disease and to prevent reinfestation. Malaria elimination de- pends on high-functioning surveillance and informa- tion systems to identify, track, and analyze high-risk neighborhoods.

Dengue programs emphasize disease control rather than elimination. Focusing on peri-urban and urban areas, especially those with poor sanitation and infra- structure, this program also relies heavily on surveil- lance and information systems to identify, track and control outbreaks, concentrating on controlling high risk areas to prevent the spread of dengue vectors. Early laboratory diagnosis of severe dengue cases is critical to reducing disease mortality.

Malaria

Goals

The long-term goal is to eliminate malaria transmis- sion from the region by 2020.

Target Populations

Persistent, low levels of malaria are found mainly in low-income, rural zones with limited disease surveil- lance. These dispersed rural areas tend to be heavily populated by indigenous groups and migrants, target groups for these interventions. Because human risk factors for disease are unknown, mapping techniques are the primary tool for identifying target areas for control.

Service Delivery Channels

As an environmental health issue, malaria control ef- forts can involve a range of programs in both the pub- lic and private sector. The breadth of service delivery channels presents opportunities for intensifying both environmental control and educational activities. Sur- veillance, data collection and analysis are government functions. Clinical management of malaria is also a public function provided through the primary health care system. Environmental management, such as in- secticide spraying, may be conducted by public and/or private operators. Private sector advertising agencies

can be engaged to develop mass media communica- tions reinforcing social norms for malaria prevention. Non-governmental organizations (NGOs) as well as local clinics can conduct educational activities to sup- port mosquito-free environments at the community level.

Key Interventions

Malaria control activities fall into four major categories:

• Surveillance – building capacity for risk stratifi- cation, data management and analysis;

• Case Management – rapid, improved laboratory diagnosis and treatment; expansion of regional laboratories for case confirmation;

• Environmental Management – increased abate- ment activity in high/medium risk areas, case homes and neighbors;

• Community Involvement – community clean- up of breeding sites, domestic prevention activities.

Dengue

Goal

The goal is to decrease dengue transmission 50 per- cent below current levels by 2015 and maintain hem- orrhagic fever lethality below 1 percent.

Target Population

The target group includes inhabitants of urban ar- eas with high dengue transmission, especially settle- ments on the fringes of these areas lacking sanitary infrastructure and conducive to high vector mosquito densities.

Service Delivery Channels

Dengue education and prevention can also involve programs across the public and private sector. As with malaria prevention, environmental education can be included in a number of programs, including prenatal and postnatal care, community outreach programs,

and behavior-change communication campaigns. Environmental management, in the form of insecti- cide spraying, can be reinforced by dissemination of educational materials supporting behaviors that pre- vent the spread of disease. NGOs can lead community clean-up of mosquito breeding sites at the local level. Key Interventions

As vector densities in urban areas grow, dengue out- breaks have become more frequent. Stronger surveil- lance systems will enable programs to spot high con- centrations of mosquitoes and control their spread. Timely laboratory-based disease diagnosis will also improve case management and survival from severe illness.

Dengue-control activities follow along the same lines as those for Malaria:

• Surveillance – building capacity for risk stratifi- cation, data management and analysis

• Case Management – rapid, improved laboratory diagnosis of suspected cases; expansion of re- gional laboratories for case confirmation • Environmental Management – increased abate-

ment activity in high/medium risk areas, and in the homes of identified dengue cases and neighbors

• Community Involvement – community clean-up of breeding sites, domestic prevention activities The charts below summarize known opportunities for joint service delivery between vector-borne diseases (both malaria and dengue) and other health areas of the Initiative.

Health Focus Area W omen of Reproductive Age Pregnant Women Neonates 0 to 28 weeks old Children <2 to 5 years old Other Health System Level Immunization

Vaccination and infant IPT + Vitamin A (for anemia and malaria)

Distribution of insecti

-

cide-treated bed nets as part of immunizations campaigns

Integrated training of CHWs and other health professionals Integrated health com

-

munication and educa

-

tion campaigns

Community Outreach Primary Healthcare

Health Focus Area W omen of Reproductive Age Pregnant Women Neonates 0 to 28 weeks old Children <2 to 5 years old Other Health System Level RMNH

Domestic hygiene promo

-

tion, home screen instal

-

lation, ‘patio limpio’ Malaria prevention and education as part of prenatal care visits Distribution of insecticide-treated nets at prenatal visits IPT Malaria treat

-

ment as part of prenatal visits Detection and treatment of ma

-

laria and dengue at prenatal visits Vaccination and infant IPT + Vitamin A (for anemia and malaria) Malaria prevention education as part of postnatal care Distribution of insec

-

ticide-treated nets at postnatal visits Laboratory diagnosis of febrile illness and treatment at postna

-

tal visits

Distribution of insecti

-

cide-treated bed nets as part of immunizations campaigns Laboratory diagnosis of febrile illness and treat

-

ment at postnatal visits

Integrated training of CHWs and other health professionals Integrated health com

-

munication and educa

-

tion campaigns

Community Outreach Primary Healthcare (Clinical)

4 Conclusion

The Mesoamerican Health Initiative is driven by the belief that health inequity is not inevitable. Vulner- able, disenfranchised and poor persons should not be subject to obstructed access to health care, inferior quality of care, or worse health. This report proposes integration as a strategy for achieving regional and national health equity and offers suggestions for in- tegrated approaches to delivering innovative, cost-ef- fective and culturally appropriate health interventions to people most in need in Mesoamerica.

The framework presented in this report integrates the multiple vertical and horizontal components of the