Final Report of The Third Meeting of The Who Strategic and Technical Advisory Group of Experts For Mncah Nutrition

Report of the Third Meeting of
the WHO Strategic and Technical

Advisory Group of Experts
for Maternal, Newborn, Child and
Adolescent Health and Nutrition
27–29 APRIL 2021

Abbreviations and acronyms 3
Executive summary 4
Background 6
Opening session and report 6
Workstream 1: Mitigating the impact of COVID-19 9

on maternal, newborn, child and adolescent
health services
Background 9
Discussion 10
STAGE recommendations 11
Workstream 2: Evidence and guidelines for impact 14

Kangaroo Mother Care: next steps 14
Discussion 15
Workstream 3: Knowledge translation: private 17

sector engagement
Background 17
Discussion 17
Workstream 4: Maternal, newborn, child and 19

Contents
adolescent health throughout the life-course:

redesign of maternal and child health
Background 19
Discussion 21
Closure and next steps 24
Annex 1. Meeting agenda 25
Annex 2. Report on STAGE recommendations 28

from November 2020
Report of the Third Meeting of the WHO Strategic and Technical Advisory Group of Experts • 27-29 April 2021
Abbreviations and acronyms

HMIS health management information systems
HPS health-promoting schools
KMC kangaroo mother care
MCA Mother and Child Health
MNCAHN maternal, newborn, child and adolescent health and nutrition
MNCH maternal, newborn and child health
PSE private sector engagement
SDG Sustainable Development Goals
STAGE Strategic and Technical Advisory Group of Experts
UN United Nations
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
3
Executive summary
The World Health Organization (WHO) convened the third meeting of the Strategic
and Technical Advisory Group of Experts (STAGE) on a virtual platform on 27–29 April
2021. The meeting included 28 STAGE members who were joined by staff at WHO
headquarters and regional offices and 62 participants from partner organizations as
observers.
After the opening remarks by the Deputy Director The recommendations were finalized during the
General, the Director, Maternal, Newborn, Child closed session of STAGE members held after each
and Adolescent Health and Ageing (MCA), meeting day.
summarized the actions undertaken along with At the closing session, Dr Anshu Banerjee, Director,
activities that are ongoing in WHO that address MCA, and Dr Francesco Branca, Director, Nutrition
the recommendations of STAGE at its meeting in and Food Safety made remarks, and Professor
November 2020. Homer thanked all members and partners for their
participation. She reiterated that STAGE members
Professor Caroline Homer, Chair of STAGE, would finalize the recommendations on the basis
described the way in which the meeting had been of all the inputs received during the meeting. She
planned, which consisted of the formation of four commented on the planned prioritization process
workstreams, three of which were continuations for soliciting input from the global community, from
from the working groups in November 2020. The STAGE members and from WHO, which would be
additional workstream, Evidence and guidelines for considered as topics for future STAGE meetings.
impact, was created to review means for bridging
the gaps between evidence, guidelines and impact. The main recommendations of STAGE are
The workstreams and topics were thus: summarized below. The full recommendations are
given in the relevant sections.
• Mitigating the impact of COVID-19 on maternal,
newborn, child and adolescent health and Mitigating the impact of COVID 19 on
nutrition (MNCAHN) services, MNCAHN service provision and use
• Evidence and guidelines for impact: kangaroo
mother care, • WHO and partners are to support Member
• Knowledge translation: private sector States to develop, a timely and coordinated
engagement (PSE) and response to health emergencies and crises with
• MNCAHN throughout the life-course: redesign better coordination and communication among
of maternal and child health. national and sub-national emergency response
Three to four members of STAGE participated in structures, health systems, and programmes
each workstream, which met three or four times for the life-course, nutrition, and diseases to
during February and March 2021 to discuss ensure that the response addresses both the
draft recommendations. These were presented direct, and the indirect impact of COVID-19 on
during the STAGE sessions, which were open populations at risk. Coordination is expected
to STAGE members, partners and observers. to start at WHO between the emergency
response structures and other programmes.
4
• WHO and partners, particularly donors, are to harmonized way to maximize impact. The
have a sustained commitment to strengthen working group will prepare a global position
health management information systems paper on KMC and guidance for KMC and for
(HMIS) and surveillance in countries to integrating KMC with other key newborn care
ensure reporting of granular, sensitive data, interventions in routine health systems.
including on the work of private providers and
nongovernmental entities. Knowledge translation: Private sector
• WHO is to continue to work with partners to engagement
identify, document and share experiences
and lessons from countries that are meeting • WHO is to identify the key provisions and
national policy objectives to reduce SARS- strategies for PSE specifically to achieve equity,
CoV-2 infections while also maintaining with better outcomes for women, children and
essential MNCAHN services. WHO is to adolescents as part of high-quality universal
continue to work with partners engaged with health coverage. STAGE requested a short
adolescents to identify any vulnerability that report on the approach taken to advance
might have been exacerbated by COVID-19. MNCAHN within the broader WHO PSE
STAGE requests WHO to further strengthen strategy.
self-care in MNCAHN and ensure its integration
into the “Maternal–Child Health Redesign” life- MNCAHN throughout the life-course:
course approach. Redesign of maternal and child health
• WHO at its three levels (headquarters and
• STAGE endorsed the document “Investing
regional and country offices) is to support
in our future: A comprehensive agenda for
MNCAHN technical working groups in
the health and well-being of children and
ministries of health in collaborating with
adolescents” and fully supported the agenda
partners to optimize research and minimize
described by WHO, UNICEF and partners.
duplication of work in countries. At global
• While strengthening existing child and
level, WHO to collate and synthesize studies
adolescent health programmes to improve
of critical interventions for anticipating needs
survival, WHO is to establish “well-child” and
and maintaining essential MNCAHN services
adolescent services by increasing the number
during shocks.
of scheduled contacts between caregivers,
• WHO is to establish a working group composed
children and adolescents with health services,
of experts in digital health and MNCAHN to
including in schools, and finding new platforms
identify what contribution WHO can make to
for the delivery of interventions for health
country programmes to assess how digital
and well-being with guidance and tools for
health tools can effectively improve MNCAHN
programme implementation.
outcomes.
• WHO, with UNESCO, is to lead a global coalition
of national governments, United Nations (UN)
Evidence and guidelines for impact: agencies and donors to improve school health
kangaroo mother care and nutrition and make every school a ‘Health
• STAGE should convene working groups on Promoting School’
priorities that are likely to have an impact, by • WHO is to include maternal health and
addressing difficult problems, interventions for wellbeing as part of the life-course approach in
which evidence is available or likely to become the maternal health review and further develop
available and problems that would benefit from the networks of care as an innovative model of
bringing stakeholders together. integrated service delivery.
• STAGE should create a working group on • WHO and UNICEF are to present the agenda to
kangaroo mother care (KMC) to facilitate several governments and partners and discuss
consensus and acceptance of strategies so its implications for policy and programming.
that governments and partners can act in a
5
Background
The WHO departments of Maternal, Newborn, Child and Adolescent Health and Age-
ing (MCA), Nutrition and Food Safety and Sexual and Reproductive Health convened
the STAGE for its third meeting on a virtual platform on 27–29 April 2021. During the
3 days, 28 of the 31 STAGE members were joined by staff at WHO headquarters and
regional offices and 62 participants from partners organization as observers.
After the previous meeting, in November 2020, All 28 STAGE members who attended the meeting
extensive consultations between the WHO confirmed that they had no new conflict of interest
secretariat and STAGE led to the formation of four since the previous meeting. Earlier conflicts were
workstreams, three of which were continuations, assessed by the WHO secretariat, and none was
with fluid STAGE and WHO secretariat membership relevant for the current meeting.
according to the topics. An additional workstream,
on “evidence and guidelines for impact” was Opening session and report
created to find ways of bridging gaps between
evidence and guidelines and impact. This group Dr. Zsuzsanna Jakab, Deputy Director-General,
discussed the process and endorsed the value of WHO, opened the meeting. She described the
working groups, as recommended in the STAGE impact of the various waves of the COVID-19
operational handbook. pandemic on essential services, especially on those
for mothers and children, and school closures,
The agenda items (Annex 1) for the meeting which have affected the physical and mental health
were chosen either because of the importance of children and adolescents. It is to be hoped that
of the topic (e.g. COVID-19) or because they lessons learnt from the pandemic will improve the
were areas identified by WHO teams as priorities response to future crises and make health and
for discussion by STAGE (e.g. redesign of child the other systems more resilient. She welcomed
health) within its terms of reference. A topic is the broad expertise of STAGE members and the
considered either directly by STAGE or through useful recommendations provided at the previous
a working group according to the level or depth meeting for improving coordination within and
of information available. Most of the workstreams beyond WHO and translation of WHO’s normative
met during February and March 2021 to discuss products into efficient, effective programmes in
detailed evidence or information provided by countries. WHO will continue to provide updates
WHO on the topic. The discussions addressed on progress on those recommendations. She
technical areas; STAGE focal points provided looked forward to STAGE inputs on the redesign of
inputs, and then made recommendations to be maternal and child health programmes, in the short
presented for further discussion with the larger and long term, as WHO strives to reach the triple
STAGE group. A document on the topic and the billion targets.
draft recommendations were sent to all STAGE
members two weeks before the meeting and were Professor Caroline Homer, STAGE Chair, thanked
presented during the open session for remarks Dr Jakab for her remarks and echoed the welcome
by STAGE members, representatives of WHO to STAGE members and partners in virtual space,
regional offices, UN partners and participants. thanking especially those who were attending the
The recommendations were finalized on the basis meeting at unsociable hours, although she noted
of comments and discussion during the closed that the format reduced emissions due to travel.
sessions at the end of each day. She explained that STAGE had worked differently
6
for this April 2021 meeting, focusing on issues The third recommendation was for mitigating the
identified by WHO as requiring strategic guidance: effect of COVID-19 on MNCAHN services and
mitigation of the impacts of COVID-19 on MNCAHN learning lessons for the future. A WHO project
service provision and use, guidance on KMC, PSE coordinated by the MCA department consists of
and redesign of maternal and child health. She collating lessons learnt from 19 countries and also
invited the Director of MCA, Dr Anshu Banerjee, from previous events that disrupted health systems.
to describe WHO’s work in following up the The results will be discussed with countries and
recommendations made by STAGE at its previous partners. The recommendation included the impact
meeting. of COVID-19 on the health workforce, and WHO
will soon publish “Standardized measurement and
Dr Banerjee noted that full implementation of the reporting of impacts of COVID-19 on health and
STAGE recommendations would take a few years. care workers”.
As WHO has been able to mainstream some of the
STAGE recommendations, they are complementary Several recommendations were made on strategies
to work already under way. He said that progress for knowledge translation to improve use of WHO
would be reported regularly, and a written report guidelines and for monitoring gaps. The Quality,
will be attached to the STAGE report (Annex 2). Norms and Standards department at WHO was
He recalled that the recommendations fell into investigating several issues that influence both the
two broad themes: the impact of the COVID-19 uptake and monitoring of use of WHO guidelines
pandemic on MNCAHN services and knowledge in countries. To improve uptake, an MNCAHN
translation for better implementation of WHO operational handbook will be prepared within the
guidelines. frameworks for universal health coverage and
primary health care based on human-centred
The first recommendation was for a global design methods; they will be complementary to
mechanism for measuring the disruption caused existing tools and make use of digital opportunities.
by the COVID-19 pandemic and its socio-economic The Sexual and Reproductive Health and Research
impact on MNCAHN, so that the lessons learnt can department has launched the WHO SMART
be applied for any future shocks, in coordination guideline on antenatal care to increase the
with the WHO emergency response. The STAGE availability and impact of WHO recommendations,
recommendations were communicated to the and the approach will be extended to intrapartum
secretariat of the Global Preparedness Monitoring care, postnatal care and a new health emergencies
Board, and a number were incorporated into the mobile application. The latter is being developed
COVID-19 Strategic Response Preparedness and with many organizations working in humanitarian
Response Plan 2021. settings, which are investigating adaptation and
integration of clinical pathways for neonatal and
The second recommendation addressed real-time child health, including nutrition. MNCAH guidelines
measurement of public health with strengthened are also disseminated in countries through the
national HMIS data, which was discussed with the “quality of care network” for international and
WHO emergency response department and the national learning, which is to be extended.
Global Preparedness Monitoring Board secretariat,
which have the same goals. WHO’s mortality In order to monitor use of guidelines, WHO is
database now includes weekly and monthly data reviewing evidence of their uptake, and operational
on mortality (by cause) from 30 countries and is research has been undertaken to improve
expected to include more countries. To support implementation of the guideline on antenatal care.
countries in analysis and use of HMIS data for
examining changes in health service use, WHO The fourth recommendation is for institutionalizing
has published “Analysing and using routine data a programme of support in training health-care
to monitor the effects of COVID-19 on essential workers. WHO is designing a framework for global
health services: Practical guide for national and competence linked with undergraduate curricula. In
subnational decision-makers” in January 2021. collaboration with the WHO Academy, applications
are being developed for a midwifery training toolkit
7
and for distance training in integrated management In response to a question on WHO’s work on
of neonatal and childhood illness, which will be inequity, Dr Banerjee recalled that this was the
in modular format for incorporation into national focus of World Health Day in 2021. Work is under
curricula according to country needs. The final way to monitor inequity in reproductive and
recommendations related to regional and national MNCAH service delivery, and the intention is to
technical advisory groups, and Dr Banerjee noted develop a toolkit to support programme managers
that such groups have been formed in the South in ensuring that all population groups are included.
East Asia and African regions.
He said that, although work on some of the

recommendations complemented current work,
they also encouraged in-house collaboration.
8
Workstream 1: Mitigating the impact This could result in a balance between crisis-related
of COVID-19 on MNCAHN services actions and maintenance of essential services.
Background Case studies in four countries explored the

correlation between targeted macroeconomic
Ms Anayda Portela, MCA, presented the lessons policies and continued coverage of maternal,
learnt in maintaining the provision of MNCAHN newborn and child health (MNCH) services during
services during the COVID-19 pandemic on the COVID-19. Nationally aggregated numerical counts
basis of the experience of 19 countries, a systematic of monthly use of health facilities for a few key
scoping review of the literature on measures indicators in 2020 (January–December) were
taken to maintain service provision and use during similar to those reported in 2019, suggesting
crises/health service disruptions and case studies minimal changes in use patterns. It is speculated
on macroeconomic policies during the pandemic. that cash transfers, the main economic intervention
used in the four countries, may have eased
Although policies and guidance were quickly the economic burden on households and thus
developed at national level, some countries find minimized disruption of health care use; however,
it difficult to disseminate them sub-nationally, other competing or contributing factors were not
resulting in lack of harmonization of principles and fully considered
standardized action. Policies and guidance relating
specifically to adolescents was found to be lacking. A scoping review of the literature of measures
taken to maintain the provision and use of
Countries identified key indicators from the health essential MNCAH health services during past
information system and used this to identify gaps crisis/ disruptions is still being analysed. The
and actions to be taken. However, this was reported methods and preliminary findings were presented.
as a challenge, as decisions had to be taken with In contrast to the information presented from
poor-quality data, insufficient disaggregation and experiences of 19 countries, the published literature
lack of data from some sources (like community- addressed mainly activities led by international
based services and the private sector). Although non-governmental organizations. The problems
many partner agencies are keen to undertake and the interventions used to maintain services
relevant studies and surveys, a key lesson for future varied from those for abrupt events to longer-term,
shocks was that high-quality health information more complex emergencies and income level. Low-
systems are necessary for obtaining real-time data. income countries often manage a crisis with few
resources, weak systems and international input,
The actions reported by countries to be the most whereas, in high-income countries, governments
important for maintaining MNCAHN services lead crisis responses. The literature on responses
were: digital health interventions for interaction to the COVID-19 pandemic refers mainly to
with service users; online training; strengthened adaptations by individual clinics and facilities in
infection, prevention and control; measures to high-income countries, with limited evaluation.
motivate and care for health-care providers, Telemedicine is also mentioned frequently in
including their mental health; and regular use of this literature, showing the opportunities but also
data for decision-making. limitations, including access and potential loss of
quality as compared with face-to-face contact.
Countries had learnt that the indirect harms of
a shock such as COVID-19 could be limited by
broadening contributions to decisions beyond
traditional incident management teams to include
components and partners of health programmes
and systems. A whole-of-government approach,
intersectoral action and strong subnational
links were considered more effective for crisis
management, with a specific plan for maintaining
essential MNCAH services.
9
Discussion Professor Mariam Claeson, on behalf of STAGE

focal points presented the draft recommendations,
Representatives of the UN Population Fund which was followed by a discussion by STAGE
(UNFPA), the UN Children’s Fund (UNICEF) and members and regional WHO staff and partners.
the World Bank described their experiences Themes highlighted in the discussion were issues
in supporting countries to maintain essential of coordination, data systems, equity in service
MNCAHN services during the COVID-19 pandemic. provision, use of digital tools, the impact of shifts to
learn for the future, support to the health workforce
Dr Anneka Knutsson, UNFPA, emphasized the and protection of rights.
importance of WHO’s normative role. She noted the
importance of real-time measurement to confirm Partnerships outside the health sector are essential,
or adjust estimates of the impacts of COVID-19 as the social dynamics and economic implications
on MNCAH, to understand decision-making with of COVID-19 require inter-sectoral collaboration
scarce data and to support capacity to analyse and and engagement with the whole society. The
use data for decision-making. She also noted the recommendation emphasizes One WHO; however,
importance of work with adolescents and young One UN indicates better coordination between
people, highlighting UNFPA resources and the role WHO and other UN agencies. Solidarity among
of peer support. She concurred with the emphasis countries appears to be suboptimal, and a Health
on care for the health workforce, which should Council, similar to the UN Security Council, might be
include gender-transformative approaches, as 70% a mechanism for better coordination of responses
of the workforce are women but they are unequally to crises.
represented among decision-makers.
The accuracy, completeness and sources of health
Dr Luwei Pearson, UNICEF, described how data information data should be considered. Data from
can be used to predict the magnitude of shocks the private sector are not usually reported in HMIS
and to improve response. She highlighted school and, similarly, there is very little data on COVID-19
disruptions and asked the group to consider the and MNCAHN intervention coverage. Coordination
lasting effects of these changes. with non-State actors to provide or triangulate
data could provide a more complete picture.
Dr Muhammad Ali Pate, World Bank and the The limitations of completeness, accuracy and
Global Financing Facility, agreed that a whole-of- timeliness of data were present before COVID-19,
government approach is essential for an effective however the pandemic has exacerbated or revealed
response to the pandemic. He said that threats to gaps. Short-term investments will not address the
essential services include continuing disruptions underlying issues. Sustained work and investment
as second and third waves of COVID-19 hit are required to build data systems for specific
countries, the fact that vaccination will further contexts that provide synthesized information
strain compromised health systems and that it is for decision-making. Researchers are partially
estimated that more than 150 million people will contributors for poor data, as they often build
fall into extreme poverty by the end of 2021, giving parallel data collection systems rather than use
them even fewer resources available to access existing routine monitoring data. STAGE expressed
care. Furthermore, slowed economic growth its support to WHO in efforts to improve routine
and high debt will limit governments’ spending MNCAHN data. Furthermore, academics and non-
on social sectors, risking lower per capita public State actors, especially those in countries with sub-
health expenditure. With these pressures, it will be optimal systems, could support strengthening of
important to protect spending on essential services national data systems, automation of data analysis
and accelerate efficiency reforms and innovation in and use of data in the long term, although this will
service delivery and financing. He emphasized the require resources. Other aspects include mistrust
crucial role of the health workforce, planning for of data and that entities do not always wish data to
their protection (both physical and mental health) be transparent. In some countries, coordination of
with adequate equipment and training and rational research by national institutes rather than ministries
deployment of front-line health workers. of health could reduce duplication of effort.
10
Some major shifts in practice will continue, even if Recommendation for integration of MNCAHN
they are not positive, and WHO and partners could into emergency response structures
influence the “new normal” to ensure that the good
is kept and the bad is minimized. For example, there STAGE strongly reaffirms its recommendation
have been increases in remote care using digital
of November 2020 for enhanced coordination
technology, shifts to the private sector health service
between emergency response and MNCAHN
and losses of the health workforce. The impact of
these trends on MNCAHN outcomes should be programmes in the response to external shocks
monitored and positive innovations, such as digital in the light of lessons learnt from the COVID-19
learning, extended, for example to pre-service pandemic and the evolving situation.
education. In any recovery or future resilience, the
protection, inclusion, appreciation and training of STAGE urges WHO and partners to support
health workers are important. Mitigating harm is Member States in developing coordinated
especially important in communities that are more responses to emergencies and health
difficult to reach, including refugees, pastoralists crises through better coordination and
and people living in urban slums and humanitarian communication among emergency response
contexts. Better coordination and learning among
structures, health systems and programmes for
agencies with respect to guidance for these groups
the life-course, nutrition and specific diseases
as well as for adolescents and young people and
people with disabilities is necessary. at national and subnational levels, to ensure a
timely, coordinated response that addresses
Gender and social norms can shift during a both the direct and the indirect impact of
shock, and there maybe opportunities revealed COVID-19 on populations at risk. Integration of
through the pandemic for gender transformation. MNCAHN would facilitate closer monitoring of
The Ebola virus disease outbreak showed that the (direct and indirect) impact of COVID-19 on
community trust in the health system is important, women, newborns, children and adolescents;
as lack of trust has cost many lives; nevertheless, more effective responses to the needs of
in some contexts, the importance of community these populations; and help protect essential
engagement has again been overlooked. In some MNCAHN services to minimize the impacts on
contexts, human rights (in childbirth and newborn
MNCAHN.
care) have been eroded, and it will be important
to understand how such changes affect long-
term trust in the health system. The COVID Law STAGE further recommends that WHO
Lab is a resource in which countries can examine strengthen integration of life-course-,
legal instruments that were developed during the nutrition- and disease- specific programmes
pandemic, some of which were positive for health. in WHO emergency response structures in
headquarters and at regional and country
STAGE recommendations offices to expedite uptake of the above
recommendation and to enhance its own
The meeting took place during a surge in the coordinated support and guidance to countries
COVID-19 pandemic. STAGE members made to ensure a more proactive response to the
recommendations for current and anticipated
direct and indirect impacts of COVID-19 on the
direct and indirect effects as countries undergo
repeated waves of infections and further erosion health and well-being of women, newborns,
of resilience, especially in vulnerable communities. children and adolescents. Such integration is
The comments received during the meeting and timely for the pandemic and would be relevant
during the closed session led STAGE to make the for future, similar shocks.
following recommendations.
11
Recommendation to strengthen use of data STAGE recommends that WHO, at its three
for decision-making and health information levels (headquarters and regional and country
systems for MNCAHN offices), support MNCAHN technical working
groups under the leadership of ministries
STAGE recommends that WHO and partners, of health in Member States in working with
particularly donors, make a sustained partners to optimize research and minimize
commitment to strengthening HMIS and duplication at country level. Many studies are
national surveillance systems to ensure that under way, and the many more are planned
they are granular and sensitive to shifts in in each country, region and globally to
MNCAHN indicators, health status and the understand, measure and evaluate the impact
needs of different populations. Specific of the COVID-19 pandemic on MNCAHN and
mechanisms are required to include the work its services and the measures used to mitigate
of private providers and nongovernmental disruption to those services. Implementing
entities. Furthermore, systems should be partners are also urged to work with national
strengthened to capture and integrate gender- technical working groups and bodies
disaggregated and other indicators of various responsible for research to review and develop
forms of inequity. It is important that data are a portfolio of research to address priorities,
publicly available to enable comparisons and identify gaps, enhance understanding of key
support accountability. WHO has a critical mitigation activities, shifts in the delivery of
normative role in establishing indicators and MNCAHN health care, equity and gender-
definitions and supporting Member States in transformation opportunities.
using MNCAHN data for decision-making. To
succeed, Member States will require coherent, STAGE recommends that WHO lead, in
non-duplicated support from partners under partnership with relevant stakeholders, to
government leadership. facilitate a support a portal for information
which could be vetted for quality with a six-
Recommendation to support countries to monthly update of relevant studies to enhance
optimize learning and invest in future resilience understanding of effective interventions
in order to anticipate needs and maintain
STAGE recommends that WHO continue to essential MNCAHN services during future
work with partners to identify, document and shocks. This would contribute to a critical
share experiences and lessons from countries review of improved practices beyond the
that have been able to reduce SARS-CoV-2 pandemic and help in preparation for future
infection while maintaining essential MNCAHN health shocks. The results should also reflect
service provision. This could include examples optimal ways for ensuring the identification of
of governance mechanisms that encourage high-quality information for decision-makers
enhanced coordination among emergency on actions and understanding the status
response structures, health systems and and trends in essential services during crisis
life-course-, nutrition- and disease-specific response.
programmes and with implementing partners,
including those in other sectors, the private STAGE requests WHO to further strengthen
sector, professional associations, civil society self-care in MNCAHN and ensure its integration
and academia. Documentation from fragile into the “Maternal–Child Health Redesign” life-
or conflict-affected countries and those that course approach being designed by WHO and
effectively reach vulnerable groups would be partners.
particularly informative. Mechanisms to share
information and enable discussion need to be
determined.
12
STAGE requests WHO to establish a working STAGE recommends that WHO continue to work
group composed of experts in digital with partners engaged with adolescents to
health and MNCAHN to identify the unique identify any vulnerability that was amplified during
contribution of WHO to support country COVID-19, such as mental health, mistreatment
and early marriage, and support countries in
programmes in assessing how digital tools
ensuring that their essential MNCAHN services
can effectively contribute to better MNCAHN
include the particular needs of adolescents and
outcomes, including interactions and people- innovative ways of reaching this age group when
centred care, with consideration of populations they are isolated during pandemics, such as
outside the digital health infrastructure. This teleconsultations. This work would draw on good
recommendation is a response to the rapid practices that could be scaled up in partnership with
proliferation of digital health tools, which could other agencies (UNICEF, UNFPA, Global Financing
increase self-care and family care practices Facility, Partnership for Maternal, Newborn and
and bring services closer to women, children, Child Health and others). The response to this
adolescents and families. The work would recommendation could inform the Maternal–
bring together the many people developing Child Health Redesign life-course approach being
such tools and the many documented lessons undertaken by WHO and partners.
learnt, including advantages, limitations and
concerns.
13
Workstream 2. Evidence and are required to determine the potential impact

guidelines for impact of starting KMC as soon as possible after birth.
Three studies coordinated by WHO but with wide
A new workstream was formed to explore how participation were conducted to respond to those
evidence is used for guidelines and impact. Using questions.
KMC as an example, Professor Betty Kirkwood on
behalf of the workstream made a recommendation Implementation research on facility-based KMC
on STAGE processes to further develop the was conducted in Ethiopia and India to determine
operational procedures indicated in the STAGE how to overcome barriers to achieve > 80% KMC
handbook. coverage in districts. The study showed that
KMC (defined as 8 h of skin-to-skin contact and
Recommendation exclusive breastfeeding) increased coverage to
53–82%. Areas for improvement were identified as
STAGE should convene working groups on more accurate weighing of newborns, providing a
priorities (a) that are likely to have a large impact dedicated environment for KMC, respect, care and
by addressing difficult problems (b) for which facilities for mothers and ensuring staff that KMC is
evidence of effective interventions is available or the standard of care.
is likely to become available and (c) that would
benefit from convening stakeholders to chart a A randomized controlled trial on community-
way forward under the leadership of STAGE. Topics initiated KMC was conducted in India to determine
for consideration can be proposed by STAGE the safety and efficacy of community-initiated KMC
members, WHO and other stakeholders, including on neonatal survival of stable infants weighing >
country programme managers, UN agencies and 1500 g born at home. In the intervention group,
bilateral development or donor agencies. The KMC was initiated at home as soon as possible
proposed topics should be assessed by STAGE after birth, while a control group practised
members according to defined criteria, which will routine newborn care. The study showed a 30%
be set in the coming months. All working groups (confidence interval, 4 ; 49) lower rate of neonatal
convened by STAGE should have clearly specified mortality in the intervention group.
time frames and outputs, which could include
advice on gaps in evidence and/or guidelines and A randomized controlled trial was conducted
building consensus on implementation strategies in Ghana, India, Malawi, Nigeria and the United
among stakeholders. Republic of Tanzania to determine the safety
and efficacy of KMC initiated as soon as possible
Kangaroo mother care: next steps after birth for infants weighing 1000–1800 g. The
difference between the two arms was the time of
Dr Rajiv Bahl, MCA, presented the background on KMC initiation, as the control group received KMC
maximizing the impact of KMC on newborn survival after the infant had become stable. The study
to illustrate movement from evidence to impact. team established a newborn intensive care unit in
He highlighted the evidence available in 2015, the which mothers could provide the necessary care
gaps in knowledge and the findings from three for their infants and a mother–newborn intensive
studies to address those gaps. care unit in which the mother’s bed and chair
were in the newborn intensive care unit, modelled
In 2015, despite the existence of guidelines, on Scandinavian experience and testing of its
global coverage of KMC was estimated to be applicability in low-resource contexts.
less than 5%. The first challenge was to increase
its coverage. Secondly, the evidence was limited
to KMC initiated in hospitals, and it is not clear
whether community KMC improves neonatal
survival. Thirdly, KMC is usually started 3–10 days
after birth, after stabilization, by which time about
two thirds of low-birth-weight babies would have
died before KMC was initiated. Therefore, studies
14
The potential impact of implementation extrapolated STAGE members, regional colleagues and partners.
from the new evidence was illustrated. The The team was congratulated on a well-thought-
current impact, assuming 5% coverage with a 40% through research agenda and translation of
reduction in mortality in stable infants weighing the agenda into research. While the work had
< 2000 g, is 10 000 deaths prevented annually. taken years, now, advocacy is necessary for
Increasing coverage in facilities to 60% would implementation at scale. This, however, has cost
prevent 150 000 deaths, which would increase to implications, especially for a space for mothers in
250 000 lives saved if community-initiated KMC, newborn intensive care units and training of health
with 80% coverage in stable infants weighing workers; donor agencies should be included in the
< 2500 g, is added. Addition of the anticipated working group to provide resources for KMC in
effect of immediate KMC of a 20% reduction in countries. The proposed 6–12-month working group
should have wide stakeholder representation, in
mortality would result in approximately 400 000
addition to donors, national representation and the
newborns saved per year.
presence of parents’ groups.
The implications are as follows. KMC could be
Cultural acceptance and determining how to
considered for scale up in facilities that provide
change behaviour at all levels of the system would
newborn care and should be extended to all low-
be an important next step. It was noted that KMC
birthweight babies (< 2500 g), although this would
is often acceptable to mothers, regardless of
require a strategy for postnatal wards. Furthermore,
their religion, urban or rural residence or region.
a paradigm shift for preterm and low-birthweight
Therefore, women should be empowered and their
babies could be considered of no separation and
well-being ensured during KMC, as well as wider
the presence of mothers in newborn intensive care
acceptance by fathers, families, communities and
units. Lastly, community-initiated KMC could cover
care providers and associated support. Investment
infants born at home or infants born in a facility and
in education and tailored messaging for health-
discharged without initiation of KMC.
care providers, programme managers, policy-
makers, professional associations and politicians
New WHO guidelines are being drawn up; however,
will be important for implementation and updated
the challenge is to integrate KMC into routine
decision-making.
newborn care in facilities and the community.
Barriers to how STAGE, partners and the global
It should be emphasized that KMC is an effective
community can catalyse such integration are that
intervention for all newborns, regardless of the
parts of the KMC community consider skin-to-
country’s economic level; it is the standard of
skin contact 24 h a day as the only option, and
care and not a second-best choice for low- and
some health care providers and families believe
middle-income countries. Stressing that KMC is
that incubators are superior to KMC. The current
effective beyond early development, throughout
service delivery system and infrastructure should
the life-course and the associated benefits of
be changed to set up maternal–newborn intensive
breastfeeding are key elements for increasing
care units.
acceptance. A tailored approach should be used in
each context to lower the barriers to implementing
Professor Kirkwood presented the draft
high-quality KMC. It is important to learn from
recommendations on behalf of the group, which
places and people for whom it has worked but also
were discussed by STAGE members and partners.
to acknowledge the poor uptake since 2015, and a
new impetus is required.
Discussion
Professor Homer commented that this evidence- Many discussants stressed the importance of
based intervention is yet to be implemented incorporating KMC into routine newborn care
successfully at scale, and she sugegsted that and into health systems but also acknowledged
STAGE members, with their broad expertise, could opportunity costs and other causes of mortality,
meet this challenge. Observations, barriers and which will not be solved by KMC alone. Avoidance
solutions were offered in the discussion among of a vertical approach, even in language, was
15
emphasized as well as maintaining flexibility in local The working group should be charged with
interpretations of KMC for adaptation by countries producing the following three outputs within 6–12
and facilities. One mechanism for sustaining months:
advocacy and learning beyond the STAGE group • a global position paper on KMC, summarizing
would be use of learning networks as platforms the evidence and outlining strategies on
for sharing and documenting lessons learnt during implementing KMC as part of ongoing maternal
implementation. and newborn programmes;
WHO has the responsibility to make a difference, • implementation guidance for different levels
and commitment by WHO and partners is central. of health care and services adaptable by
The support and leadership of STAGE would be countries; and
valuable as the work develops to build momentum • guidance to integrate KMC with other key
for KMC as essential for newborn survival within a newborn care interventions within routine
wider health system strategy. health systems at scale, while using a continued
learning process to address knowledge gaps
STAGE recommendations
The members of the working group should
STAGE should convene a working group on KMC comprise WHO (as secretariat), selected STAGE
to reach consensus on implementation strategies, members, other scientists and key stakeholders,
so that all governments and partners act in a such as country programme managers and
harmonized way to maximize impact. representatives, UN agencies, the World Bank, the
Global Financing Facility; bilateral development
KMC was chosen as the first priority topic for the agencies in Australia, Canada, Japan, Norway, the
following reasons: USA and other countries; foundations such as the
a. high potential impact on newborn survival and Bill & Melinda Gates Foundation, the Children’s
development, new evidence suggesting that Investment Fund Foundation and the Wellcome
almost 400 000 newborn deaths could be Trust; and professional bodies, nongovernmental
prevented each year; organizations and women and parent organizations.
b. substantial challenges in achieving high
effective coverage; and
c. building consensus among all stakeholders on
approaches for implementation is critical for
maximal impact.
16
Workstream 3. Knowledge The work of the MCA department is now included

translation: private sector in broader WHO work on PSE for universal
engagement health coverage. Current work addresses PSE
to deliver high-quality maternal and newborn
Background services, which will include a situational analysis in
Bangladesh (in collaboration with the US Agency
Dr Blerta Maliqi, MCA, presented the rationale for for International Development in a project led by
using PSE as an example of knowledge translation. Institute for Healthcare Improvement and Save
The private sector delivers more and more services the Children), Ghana and Nigeria and the role of
in low- and middle-income countries. In some the private sector during the COVID-19 pandemic
WHO regions, such as the Eastern Mediterranean, (starting in May 2021). WHO should clarify its PSE
over 70% of first contacts with health care are in strategy with regard to the MNCAH agenda. The
the private sector. WHO’s role is to enable Member aim should be to contribute to the development of
States to ensure that evidence-based guidance and health systems that can deliver care for all women
recommendations are used by all health system and children, no matter where or how they access
providers, irrespective of their sector. In order for services. The agenda is broader than WHO MNCH,
WHO guidance to reach every user of services and partners such as the Global Financing Facility
and make an impact, national health systems must and the US Agency for International Development
address service delivery in both the public and the MOMENTUM Private Healthcare Delivery are
private sector. already addressing various aspects of PSE for
MNCH. STAGE should advise WHO on the inclusion
PSE is a new priority for WHO, requested by and improvement of MNCAH outcomes in its PSE
Member States to accelerate achievement of high- agenda.
quality, equitable universal health coverage. The
challenge has become evident during the response Discussion
to the COVID-19 pandemic. Dr Maliqi said that her
presentation was not about how WHO engages Participants commented on the role of accrediting
with the private sector but focused on WHO’s agencies or national therapeutic regulators;
guidance to Member States on the governance of clarification of how WHO and governments will
private sector service delivery. engage with the private sector; use of economic
and funding models, especially insurance
In 2020, WHO developed a strategy for Member models, in private health care; the reasons for
States to use in strengthening governance of their disengagement of the private sector in some
engagement with the private health service sector. countries, including incentives for providers of
The strategy calls for a focus on governance of continuing medical education and for better quality
both private and public health sectors to ensure of care, which could be influenced by professional
quality and financial protection for patients, bodies; definition and indicators of the quality of
irrespective of where they seek care. The advisory MNCH services; the role of the MCA department
group selected six aspects of governance for the (e.g. guiding ministries of health in engaging with
strategy – build understanding, foster relations, the private sector). Areas of concern or that require
enable stakeholders, align structures, nurture trust attention included policies to ensure better data-
and deliver the strategy – each with a specific goal sharing by the private sector, engagement of the
and scope of action. One issue raised by countries private sector at a high policy level and areas of
about engagement with the private sector in mistrust that should be resolved. Many participants
improving the quality of MNCAH care was their called for better regulation, especially of the
lack of accountability in use of ministry of health quality and equity of care provided by the private
or WHO guidance, limited data- and information- sector. They noted, however, that the distinction
sharing and minimal regulations and governance between public and private providers could be
oversight. blurred in countries in which providers could work
in both sectors. WHO could learn from experiences
and best practices of PSE during the COVID-19
pandemic in both MNCAH and direct surveillance
and management of COVID-19 patients.
17
Participants commented that a broader group of STAGE recommendations

experts and stakeholders should be engaged in
the discussions, including for instance experts in The draft recommendation was presented by Mike
health economics and financing, health insurance, English on behalf of the STAGE focal points. The
professional organizations and associations, comments received during the meeting and during
national governments, civil society and patient the closed session led STAGE to make the following
groups. They agreed that PSE is important for recommendations.
WHO, and the department would benefit from
further exploration of the issue. STAGE members STAGE suggests that WHO identify the specific
requested clarification of collaboration in WHO’s provisions or strategies for PSE that are necessary
broader work on PSE and the possible contribution for or will help to achieve equity in improved
of a STAGE working group. MNCAHN outcomes for all women, children and
adolescents as part of high-quality universal health
coverage.
STAGE suggests that it receive feedback on the

approach taken to advance MNCAHN as part of the
broader WHO PSE strategy in the form of a short
report on: the priorities for achieving MNCAHN
goals, the scope of work on MNCHAN, progress
in any work conducted and how MNCHAN is
represented in WHO PSE-related working groups.
18
Workstream 4: Maternal, newborn, regions. The interventions will require leadership,

child and adolescent health and governance, financial and human resources and
nutrition throughout the life-course: means for integrating them in a health system that
redesign of maternal and child health has so far focused on the management of illness.
Background The steps to be taken in 2021 will include

integration of the well-child and adolescent care
Dr Wilson Were, MCA, described the extensive work programme into national programmes; individual
accomplished with various WHO departments, UN packages adapted to countries and co-design of
partners and experts, which builds on the Global programmatic guidance and tools with several
Strategy for Women’s, Children’s and Adolescents’ countries. STAGE guidance will be crucial in
Health, Ending Preventable Maternal Mortality and directing these steps.
the Every Newborn Action Plan. The work reflects
the change in focus from ending preventable Dr Valentina Baltag, MCA, said that although the
deaths to “thrive and transform” as part of the idea of “health-promoting schools” (HPS) was
reframing of the global agenda for children and introduced in 1995 by WHO, the United Nations
adolescents to health and well-being. He described Educational, Scientific and Cultural Organization
global contributions to the framework over the past (UNESCO) and UNICEF, few countries have
2 years (“Investing in our future: A comprehensive implemented the approach to scale, with little
agenda for health and well-being of children and attention to support systems and a focus on single
adolescents”), which included reviews of trends in outcomes, such as nutrition, de-worming or mental
mortality, morbidity and nutrition. He asked STAGE health. Health was generally considered to be
to endorse the framework and recommendations external to the core business of education, and
for its implementation. schools were used as platforms to deliver rather
than to strengthen their capacity as institutions to
The goal of the paradigm shift is to ensure that improve health and well-being. Teachers’ training
every child and adolescent from 0 to19 years is is an important component of the programme,
healthy and is being raised in a safe environment, although performance measures are often not
is prepared physically, mentally, socially and addressed. In view of the length of time children
emotionally and can contribute to the social and spend in schools (8000–10 000 hours, up to
economic well-being of society. The aim is to build 14–15 years of age), building resilience and
on gains at each stage of development and to connectedness and nurturing relationships are
tailor programmes to the needs determined by the important.
unique combinations of risks and protective factors
to which children are exposed. Six domains were The COVID-19 pandemic highlighted the fact that
identified as critical for the health and well-being school is much more than an institution for ensuring
of children – good health; adequate nutrition; literacy and numeracy, as the mental and physical
responsive relationships and connectedness; a health of children, including nutrition services, are
secure, safe, clean environment; opportunities for all being disrupted.
learning and education; and personal autonomy
and resilience. The interventions in those domains, Global standards and indicators and implementation
such as vaccination, will be universal for every guidance for HPS have been developed by expert
child. Services for sick child and those with groups. The eight global standards are intended
disabilities will also be emphasized. He showed to function as a system, governed by national
a matrix of interventions, from preconception to policy and resources, to promote strategic shifts
19 years, which will be presented to countries for and greater accountability. The implementation
selecting and prioritizing programmes. Many of guidance is to be published with the WHO guideline
the interventions will include other sectors, such on school health services. Guidance from STAGE
as education, agriculture, water and sanitation, is sought on how WHO can improve its reach to
and will account for mortality and morbidity the education sector and ministries of education to
and changing epidemiology in countries and ensure that promoting health is part of education;
19
how WHO and partners can better support and adolescents’ mental health, psychosocial
countries in building such systems; how leadership well-being, noncommunicable diseases, injury
can be encouraged in teacher education; how prevention and chronic care, with a focus on
the education system can contribute to the health communities to improve access to financing,
and well-being of children; and the options for increase quality, strengthen data systems and
increasing resources. introduce use of digital solutions. They will continue
to work with WHO to ensure that child health and
Dr Allisyn Moran, MCA, summarized a review on well-being are part of primary health care, including
maternal and perinatal health (in collaboration through multisectoral community platforms.
with UNFPA and UNICEF) based on a framework
for “obstetric transition” (among levels of baseline Dr Anneka Knutsson, UNFPA, addressed the
maternal mortality), and an overview of work on well-being and rights of young people, including
networks of care. The review was the basis for access to sexual and reproductive health services.
guidance and recommendations on different UNFPA provides opportunities to young people
models of care for optimal outcomes in countries both within and outside schools. She commented
at different stages of the obstetric transition, that the review on maternal health was opportune
which are expected to be implemented in up to for maternal and perinatal programmes, including
20 countries in 2021. Studies of six countries are lessons learnt during the pandemic. The review
being analysed. Networks of care comprise care will be used to strengthen support to countries,
from primary to tertiary level and community care. especially for midwifery, and to highlight the
The review explains how the networks function, importance of improving the quality of routine and
links between front-line workers and higher-level emergency obstetric care.
facilities and how to strengthen the links while
ensuring sufficient skilled staff with adequate Dr Christopher Castle, UNESCO, said that the HPS
supplies and equipment. initiative was a good example of the link between
education and health and looked forward to working
Although the focus remains on reducing mortality, with WHO on the new standards. UNESCO will
the team would like to extend it to include the ensure that the standards are promoted and taken
health and well-being of mothers, thus linking it up by countries and will continue to lead research
with child and adolescent well-being. Guidance and advocacy. UNESCO and WHO are working
from STAGE is sought on packaging services at with a few countries (Botswana, Egypt, Ethiopia,
different levels of care in different contexts for Kenya and Paraguay) that have already adopted
child and adolescent well-being, use of networks the scheme. Globally, UNESCO will make the case
of care to optimize and build resilient health for integration to the education sector, arguing that
systems (being tested in Cameroon and Nepal) and achieving health and nutrition goals will also lead to
how interventions should be designed for the well- positive education outcomes. The focus is on safe,
being of mothers and newborns. inclusive, health-promoting learning environments,
especially for noncommunicable diseases. He
looked forward to the recommendation of STAGE.
Reflection from UN partners
UN partners commented that the plans for Following the presentations and reflections from
redesigning maternal and child health are well UN partners, the draft recommendations were
aligned with their priorities and strategic objectives. presented by George Patton, on behalf of the
STAGE focal points. STAGE members, regional
Dr Aboubacar Kampo, UNICEF, recalled that their colleagues and partners presented their views,
focus is on primary health care, in a zero-dose mainly on HPS, with some comments on child
community approach in which the emphasis is not health redesign and the maternal health reviews.
only on health but also on education, nutrition,
water and sanitation. They try to reach the
communities most severely deprived of all such
services. Attention is being extended to children’s
20
Discussion countries require practical tools and guidance to

tackle these rates first. A representative of the
Child health redesign Region of the Americas said that political arguments
are necessary to translate the framework into
STAGE members endorsed the strategy, which national policy effectively and efficiently. In the
is based on universal principles and is relevant Eastern Mediterranean Region, the emergency
to low-, middle- and high-income countries, with and humanitarian context is important and should
sufficient focus on vulnerable communities. While be considered in implementation plans. Continued
progression from “survive” to “thrive” is important, advocacy and accountability for women and
a balance must be maintained to ensure that children’s health are required in this Region and
mortality in countries where the rate is high is elsewhere.
addressed equitably.
Health-promoting schools
The universal principles should be adapted to
national needs and priorities. Some suggestions for STAGE members commented that the HPS concept
adaptation were to encourage countries to ensure should be linked to the COVID-19 pandemic, to
that plans for maternal, child and adolescent health change the strategy from a binary decision on
are based on or incorporate the principles and keeping schools open or closed to keeping schools
strategies in a way that is relevant to their context; safe, with guidance on testing, ventilation, social
to develop a generic curriculum for maternal, child distancing so that children can remain in school.
and adolescent health programmes to be used Health and education departments usually give
in nursing and health-care worker training; to separate guidance about school closure and rarely
develop a universal curriculum on the Sustainable jointly. Joint working groups (or a mechanism for
Development Goals (SDGs) for use in schools in intersectoral work) between ministries of health,
different detail at different ages; and to connect education and social protection should be created.
organizations for people-centred care. People, or If a school closes, there should be provision to
at least families, should have ownership of their continue the services.
data, with child records from conception to meet
the SDGs. The reasons that HPS was not adopted when it
was introduced 25 years ago should be found to
Participants also stressed that the child health ensure that the same mistakes are not repeated
redesign framework and implementation guides in teacher training and in integration of health. Dr
should include gender considerations and that Baltag said that a thorough review had been made
gender be reflected throughout the strategy. An of barriers and enablers in countries. In 1995, an
intersectional approach could be used to ensure underlying assumption was that health and well-
that it reaches children living in poverty, with a being are not the responsibility of the education
disability or other inequities. sector, and this attitude must change for HPS to be
successful.
Regional colleagues expressed support for the
framework and called for greater focus on and The issue of non-state and private school systems
consultation with regions and countries in its was raised, including those considered to be
implementation. In the European Region, a greater informal or complementary, which are often not
focus on clinical care is necessary, and they regulated by ministries of education yet account
are preparing a pocketbook for primary care of for large numbers of learners in some contexts.
children and adolescents. The approach should be The interconnectedness of school health and
comprehensive, with more competent providers, maternal health for mothers who leave school
health information systems, health financing and because of pregnancy, parenting and/or marriage
pre-service training. Work on HPS had begun in was noted. For topics in HPS that comprise
the European Region several years previously, reproductive rights and choices, gender and even
with networks of “school for health”, which could vaccines, WHO, UNFPA and UNICEF should work
provide lessons for other regions. In the African together and with religious organizations, which
Region, maternal and child mortality rates remain are major providers of or have a considerable
high and thus survival is still the primary issue; direct influence on schools.
21
Other sectors, such as agriculture and environment, level. This approach could align evidence-based
should also be included; in some countries, packages for countries, strengthen midwifery,
gardening programmes have been introduced in improve access to and the quality of emergency
schools. Introducing the global vision at local level obstetric and newborn care. Reference was made
may be difficult in view of existing fragmentation of to the report on the state of world midwifery and
vertical programme. Country dialogue is essential the importance of this workforce in taking forward
for changing school, maternal and child health the concept of maternal well-being.
programmes. As systems may not be ready to
adopt all the proposed changes, incremental gains STAGE recommendations
might be sought.
STAGE members used the discussion to finalize
Although schools should not be overburdened, their recommendation.
changing social behaviour is as important as
literacy and numeracy; gender and a focus on STAGE endorses the document “Investing in our
poverty, disability, gender and other inequities future: A comprehensive agenda for the health
should also be introduced. Research has identified and well-being of children and adolescents”, and
skills-based health education, comprehensive fully supports the agenda of WHO, UNICEF and
sexuality education and safe, inclusive learning partners to promote the good health and well-being
environments as priorities for preventing of women, children and adolescents. The agenda
noncommunicable diseases. builds on state-of-the-art evidence and responds
to the “survive, thrive and transform” objective of
Concern was raised that the definition of “health” the Global Strategy for Women’s, Children’s and
is too narrow and that teachers would require Adolescents’ Health for attainment of the SDGs. It
experience or medical expertise to teach health as is an appropriate response and a major strategic
now defined. It was suggested that the definition shift to address the growing demographic and
of health include jobs, social security, personal epidemiological transition and to invest in the
security, housing, human capital and governance. human capital of current and future generations to
In all countries, there are more teachers than health build stable, prosperous societies.
workers, and it might be useful to redefine health
more broadly and foster collaboration between STAGE recommends that, while strengthening
the two sectors to advance health and nutrition existing child and adolescent health programmes
throughout the life-cycle and achieve the SDG to address survival, there are compelling reasons
agenda. to establish well-child and adolescent services
beyond the antenatal and postnatal period to
Teachers who are responsible for including health vaccination and school entry check-ups. This
and well-being in the curriculum often have limited will require more scheduled contacts between
knowledge and experience in teaching health caregivers, children and adolescents with services,
promotion. Queries were raised about accreditation including in schools, and new platforms for delivery
standards for HPS and whether teachers’ unions or of health and well-being interventions. The purpose
professional organizations have provided input to of these services is to monitor health, growth,
the model. development and well-being, provide anticipatory
guidance on developmental transitions and age-
Maternal health review specific needs and ensure timely interventions to
address apparent difficulties or additional needs.
Maternal health should be provided with evidence- This will require investment to ensure available,
based practices adapted to countries’ context and accessible, adequate health and other providers
needs. Systems should be flexible and adaptable. to improve service coverage and realize the
Countries need practical tools for use in their programme goals, particularly in fragile and low-
context and setting. Care in childbirth emergencies resource settings.
should be included, with rapid response and
resuscitation (stabilization) available at community
22
STAGE recommends that WHO and UNICEF extend STAGE recommends that WHO expand the
evidence-based packages of interventions and maternal health review to include maternal health
indicators throughout the life-course to provide and well-being as part of the life-course approach.
contacts with multiple services and platforms, with This should specify the activities to be conducted
guidance and tools for implementation of this broad in each of the six domains of the health and well-
agenda. STAGE would welcome the opportunity to being of women, from preconception to those
review progress in this regard at its next meeting, already articulated for child and adolescent health
in November 2021. and well-being.
STAGE advises the WHO Director-General that STAGE encourages WHO to develop the concept
making school health and access to school health of networks of care further, as it is an innovative,
and specific nutrition services an Organizational integrated model for service delivery throughout
priority. This would be a major step towards the life-course, building on the findings of the
achieving the target of “1 billion lives made maternal health review. A functional network of care
healthier” by 2023. Schools are an exceptionally uses the existing system to strengthen linkages
large, cost-effective system for promoting student and collaboration for coordinated continuity of
well-being. STAGE recommends that the Director- high-quality care and service delivery for MNCAHN
General, with UNESCO, lead a global coalition and well-being, ultimately optimizing linkages for
of national governments, UN agencies and efficient, resilient health systems.
donors to improve school health and nutrition
and make every school an HPS. This will require STAGE recommends that WHO and UNICEF
more investment, creation of leadership cadres engage with several governments and partners to
for health promotion in the education system, present the agenda and discuss the implications of
strengthening and disseminating the evidence current programming and next steps on the basis
base and creating a framework for accountability of the multisectoral discussions under way in many
so that health and well-being become measures countries on nurturing care and adolescent health
of the performance of national education systems and well-being.
and core considerations in education.
23
Closure and next steps health practitioners. HPS is important, as, over time,
the nutrition component of school policies has been
Professor Homer thanked all the participants weakened, and there are no clear standards. His
and said that she would present the STAGE department is also preparing standards for school
recommendations to the Director-General on 30 food and has published a document on public food
April. She invited Dr Anshu Banerjee, Director, procurement. As 43 million meals are delivered to
MCA, and Dr Francesco Branca, Director, Nutrition children in schools, there is enormous potential for
and Food Safety to make remarks. (Dr Ian Askew influence. Some governments are taking a lead;
sent his apologies.) for example, the German Government is creating
a school food coalition with Brazil, Finland and
Dr Banerjee noted the wide spectrum of topics Sri Lanka. An integrated service delivery model
chosen for the meeting, some of which, like KMC, should not just be preached but also practised.
were ready for implementation and scaling-up Maternal nutrition is an area of concern, as nutrition
and required guidance on implementation with services cannot be provided to pregnant women.
partners, while others, like HPS, are at an earlier Alternative means must be found, integrated into
stage and their operationalization requires more communities.
reflection. STAGE guidance is important at both
strategic and operational levels. He noted the Professor Homer thanked the STAGE members,
comments of regional colleagues on redesigning partners, WHO technical leads and the STAGE
maternal and child health with regard to consulting secretariat (who have been working both online
countries on areas relevant to them. He said that and offline since November 2020). She said that
reducing child mortality should still be stressed in the next step should be to prioritize a few key
countries with high rates, whereas a move to the issues, guided by the multidisciplinary expertise
“thrive and transform” agenda was important in of STAGE and inputs from the broader group
countries in which child mortality rates are falling. of partners and stakeholders. She said she
Country ownership is essential, and he referred to would form a group for that purpose, with the
comments from STAGE members about designing WHO secretariat. She would continue work to
appropriate national plans with countries. The break down silos of implementation policy and
COVID-19 pandemic, and especially the second programming by involving countries and regions in
wave in many countries, underscores the need STAGE discussions. She wished everyone well in
to learn lessons from 2020 to build back better. these difficult times, especially those in countries
He looked forward to continued guidance from hit badly by second and third waves of COVID-19
STAGE to WHO in translating its guidance into and closed the meeting.
implementable country programmes. While all the
STAGE recommendations will not be implemented
within 1 or 2 years, the journey would be taken
together among the three levels of WHO.
Dr Branca thanked the group for their comments.

He was pleased that STAGE had endorsed the
framework “investing in our future”, the call for
new platforms to improve nutrition. He noted
that fortification of food at home has been used
widely as an alternative to supplementation. New
ways should be found to address adolescent
obesity, through alternative channels such as
social media, and his team is preparing guidelines
on the management of obesity in children and
adolescents. A delivery platform that is suitable for
adolescents is the key, as what they want and care
about and their views of health differ from those of
24
Annex 1: STAGE Agenda
Meeting of the Strategic and Technical Advisory Group of
Experts (STAGE) on Maternal, Newborn, Child, and Adolescent
Health and Nutrition (MNCAHN)
27 to 29 April 2021
Agenda for Virtual meeting
25
26
STAGE Website: https://www.who.int/groups/strategic-and-technical-advisory-group-of-ex-
perts-for-maternal-newborn-child-and-adolescent-health-and-nutrition
27
Annex 2: Feedback report

from STAGE November 2020
Recommendations
Directors Progress report, April 2021
The STAGE recommendations have long term trajectories that stimulate internal and external alignment.
This is the first report of progress to recommendations and feedback to STAGE made at the April 2021
STAGE Meeting. A feedback report will be provided to STAGE at every meeting. Recommendations in full
are in the November 2020 report.
Recommendation Progress
COVID Impact and Mitigation • WHO has shared these STAGE recommendations with various
entities such as the Global Preparedness Monitoring Board; and the
Mechanism to coordinate: WHO WHO COVID-19 Strategic Preparedness and Response Plan 2021.
leads the development process • The secretariat of the Global Preparedness Monitoring Board has
of a recognized and inclusive expressed interest in this recommendation - especially capturing
coordination mechanism at the real-time quality data during crises. The STAGE recommendation
global level (that gets triggered will be highlighted to the upcoming meeting of the Monitoring
during external shocks, and Framework Working Group.
coordinated with the emergency • Some of the STAGE recommendations are incorporated as part of
response mechanisms at WHO) to lessons learned or as recommendations in the COVID-19 Strategic
capture the disruption and impact Response Preparedness and Response Plan. Operational plan is
on MNCAHN and socioeconomic yet to be finalized, where we expect further incorporation of the
outcomes (global standards on recommendations from STAGE.
definitions and indicators) along • Some internal discussion started within WHO for better coordination
with guidance and information on between Emergency response and Health system responses during
continuation of essential health crises.
services and information on • To monitor the continuity of essential health services (EHS), MCA,
mitigation and modelling Nutrition and Food Safety and Sexual and Reproductive Health and
Research advised on the RMNCAH content that was included in
various tools such as the EHS pulse survey on service disruption
and mitigation strategies and suite of health service capacity
assessments.
• MCA team conducted training on LiST for regions, countries and
partners; a review of all modelling assessing impact of COVID-19 on
RMNCAH is to be published soon.
28
Measurement in real time: • A Guide on how to analyse and use routine data to monitor effects of
WHO to work with countries to COVID-19 on EHS published in January 2021.
strengthen real-time national • The COVID-19 Mitigation project also uses data from RHIS in the 19
RHIS to enable collection and countries and have mapped indicators that can be monitored, and
analysis of quality data in a timely this will be published
manner—requires increased • There is renewed interest and momentum to strengthen and use
investment; development of SOPs RHIS data. WHO is seeking additional resources to work and support
for pre-identified list of indicators this effort.
• WHO’s Division of Data, Analytics, and Delivery for Impact (DDI)
has set up a mortality data portal with information collected weekly/
monthly from countries—currently 30 countries are providing weekly
data on Covid and other deaths by age and sex. Other countries are
expected to provide similar data into this portal.
• The Global Preparedness Monitoring Board (is interested in
strengthening the real time data collection processes in countries
during crises that extends beyond the direct health consequences of
a crisis. WHO’s effort as it evolves, will be synergistic to the work of
the Global Preparedness Monitoring Board (as it develops indicators
for a monitoring framework to assess preparedness, response, and
recovery.
• Recommendations have been shared with the RHIS working group of
the Health Data Collaborative and internally with DDI group working
on RHIS.
Mitigate and learn for the future: • The WHO project to maintain essential MNCAH services during
WHO to work with global partners COVID-19 will publish findings on lessons learned and actions
to strengthen investments on taken by 19 countries, and findings of systematic scoping review of
documenting lessons learned actions taken and lessons learned from past service disruptions and
(both in short and long term) COVID-19.
and developing methods for • The Health Workforce Department, WHO will soon publish the
implementation and operational Standardized measurement and reporting of impact of COVID-19 on
research including rapid health and care workers.
evaluation to enable countries to • An interim guidance was published in December 2020 –Health
assess the impact of mitigation Workforce Policy and Management in the context of the COVID-19
measures and to identify pandemic Response
sustainable measures beyond the
pandemic to improve MNCAHN
outcomes and address health
system resilience, with special
attention to the health workforce
Knowledge Translation There has been a dialogue with all regional offices in relation to this
recommendation and of note, the AFRO Regional Director has recently
WHO to support national and established a RTAG and are in early consultation regarding national
regional technical advisory TAGS.
groups (TAGS) and sub-national
committees. In terms of the landscape of TAGS (or similar structures that exist already):
• SEARO has an established Technical Advisory Group (TAG) since
2015.
• WPRO has an Independent Review Group for early essential
newborn care with technical experts to review progress and provide
technical support on implementation.
• EURO established a TAG on Schooling during the time of COVID-19.
• PAHO has a TAG on newborn health
• There are various national committees for different topics across the
regions but only a few national TAGs for MNCAHN.
29
Strategies to improve guideline Knowledge Translation is an area of ongoing work for WHO and the
uptake: MCA, Sexual and Reproductive Health and Research and Nutrition and
Produce limited number of Food Safety departments. Some of the STAGE recommendations will
consolidated comprehensive be addressed within ongoing work and have already triggered further
guidelines bringing together discussions within WHO and will stimulate new alignment and activities.
all recommendations, which
are regularly updated as new • The departments have started discussions on further consolidating
evidence becomes available. guidelines beyond the existing compilations and developing an
operational handbook in a modular form that addresses MNCAHN
Develop a comprehensive programme implementation as part of Univeral Health Care and
operational handbook. Primary Health Care. Principles behind this work include to build on
and be complementary to existing resources, use human centered
design methods to identify scope, purpose and use and consider
Support national MOH websites digital technologies for presentation, distribution and use.
to house locally endorsed WHO • On 18 February 2021, WHO launched its vision for SMART guidelines
guidelines and released its first SMART guideline on antenatal care, which aims
to accelerate the availability and impact of WHO recommendations
within digital systems at the country level. This approach is being
promoted by the Science Division (the department of Quality Norms
and Standards and the department of Digital Health and Innovation),
which will enable adoption across WHO.
• In terms of updating guidelines so products remain up to date, in
addition to established processes, the living guideline approach has
been used by Sexual and Reproductive Health and Research and
has been valuable especially for areas that have rapid evolution of
Support National MNCAHN evidence. Under the guidance of Department of Quality Norms and
quality improvement programs Standards, this approach is being used increasingly across WHO,
especially in the context of COVID-19.
• The Network for Improving Quality of Care for Maternal, Newborn
and Child Health is one of the mechanisms that WHO is using to
support countries to build sustainable systems able to scale up
quality of care (QoC) for MNCH and other programmes. The network
is assisting countries to implement their national QoC strategies and
plans, and has a very strong learning agenda.
• During 2020, in response to country needs and demands, the
Network supported over 34 webinars organized four series on
delivering QoC during COVID-19 pandemic that were attended by
over 8000 participants from 93 countries.
• The Network implementation guidance was adapted by all WHO
programmes as part of the “Quality health services: A planning
guide” and is leading the work on community engagement for
QoC, with the guidance on “Integrating stakeholder and community
engagement in quality of care initiatives for maternal, newborn and
child health”, both released in quarter four of 2020.
• WHO will continue to assist countries to introduce, implement and
monitor the implementation of QoC Standards for MNCH, including
the newly launched standards for the small and sick newborn.
30
Use of multi-media outputs in Relevant work in the realm of multi-media in multiple-languages include:
multiple languages • Work is ongoing with the WHO Academy to support knowledge
translation with associated changes in practice. The WHO Academy
is supporting the development of training modules including distance
Integrated Management of Neonatal and Childhood Illness, Mental
Health in Primary Care and an Interprofessional Midwifery education
toolkit for maternal, newborn, sexual, reproductive and perinatal
mental health.
• WHO is developing a new health in emergencies mobile application
– Em Care. Adapting and integrating clinical pathways for neonatal
and child health including nutrition is the pathfinder for Em Care
and a prototype should be available by the end of 2021; it will later
expand to other populations and areas of health care across the life-
course.
WHO to take a lead on the • WHO follows rigorous procedures on guideline development, so
coordination of guidelines rather than arbitrating other guidelines at a global level, it is more
between other agencies that efficient and effective to develop WHO recommendations. There
produce health guidelines, are multiple examples where other UN agencies have contributed to
including international development of these guidelines and are acknowledged accordingly.
professional bodies, international • WHO continues to act as a convener of stakeholders, thereby
NGOs and other UN agencies. contributing to alignment of guideline updates and their contextual
interpretation. This alignment could be supported by TAGs, as also
recommended by STAGE in November 2020.
HCW worker training support There are ongoing initiatives that relate to this recommendation
to increase teaching of WHO and there has been further engagement with the Health Workforce
guidelines; Pediatric nurse Department.
training • The UHC Compendium is a database of health services and
intersectoral interventions designed to assist countries in making
progress towards universal health coverage. Within the universal
health coverage framework, the Health Work Force Department is
developing a Global Competency and Outcomes Framework. This
will link competencies with undergraduate educational curricula
for health workers within 12-48 months programmes that lead to
diplomas or degrees.
• For in-service or life-long learning the WHO Academy will develop
a series of on-line courses that can be adapted and used by
government education institutes, national professional associations,
NGOs, UN and other partners to provide credit for continued
professional development (see under “strategies to improve
guideline uptake” for initial modules). This will use the learning-
transfer evaluation model (measuring behavioral change) plus the
use of learning outcomes through which to assess achievement of
competency. This modular approach supports national ownership
of curricula for specialized post-graduate courses as countries can
utilize them according to their needs and timeframes from updates.
31
Monitor guideline implementation Quality Assurance of Norms and Standard Department (QNS) is
and report lesson learned from supporting WHO departments to improve the process of developing
operational research and designing guidelines so they are locally adaptable, user-friendly and
increasingly incorporate user feedback.
• In 2020, WHO developed a monitoring and evaluation framework
to better understand and improve the uptake and use of WHO
guidelines and other normative and standard setting products, at the
country level. The intention is to pilot this framework with countries
and departments, including MCA.
• A review of literature “Improving WHO’s Understanding of WHO
Guideline Uptake and Use in Member States” by QNS and University
of Ottawa/Bruyere Research Institute study, will to be published in
the last quarter 2021. It will contribute to what is known about the
uptake and use of WHO’s normative and standard setting products
by policy makers, managers and health professionals at practice
level in low- and middle-income countries. The review covers a broad
scope of recommendations and includes: breastfeeding, anaemia,
pre-eclampsia and eclampsia. The findings and recommendations
from this initial review intends to inform the WHO about the existing
evidence, that could potentially be used to guide and further
strengthen the framework for Monitoring, Evaluation, and Learning
on the uptake and use of WHO guidelines in low- and middle-income
countries.
Existing experiences within the departments will continue to support
future work in this realm including most recently Implementing antenatal
care recommendations in South Africa.
Another related activity is the Global Reproductive, Maternal, Newborn,
Child and Adolescent Health Policy Survey (2018-19) which tracks
adoption of specific WHO SRMNCAHN recommendations into country
policy. This work is imminently to be complemented with a searchable
publicly available repository on the WHO website to enable access to
country guidelines, policies and laws. This will be an excellent resource
for countries that are yet to incorporate policy changes in line with WHO
recommendations, as they may benefit from approaches employed
elsewhere.
32

Final Report of The Third Meeting of The Who Strategic and Technical Advisory Group of Experts For Mncah Nutrition

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Report of the Third Meeting of

the WHO Strategic and Technical

27–29 APRIL 2021

Opening session and report 6

Workstream 1: Mitigating the impact of COVID-19 9

Workstream 2: Evidence and guidelines for impact 14

Workstream 3: Knowledge translation: private 17

Workstream 4: Maternal, newborn, child and 19

adolescent health throughout the life-course:

Closure and next steps 24

Annex 1. Meeting agenda 25

Annex 2. Report on STAGE recommendations 28

Abbreviations and acronyms

HPS health-promoting schools

KMC kangaroo mother care

MCA Mother and Child Health

MNCAHN maternal, newborn, child and adolescent health and nutrition

MNCH maternal, newborn and child health

PSE private sector engagement

SDG Sustainable Development Goals

STAGE Strategic and Technical Advisory Group of Experts

UNESCO United Nations Educational, Scientific and Cultural Organization

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

He said that, although work on some of the

Background Case studies in four countries explored the

Discussion Professor Mariam Claeson, on behalf of STAGE

Workstream 2. Evidence and are required to determine the potential impact

Workstream 3. Knowledge The work of the MCA department is now included

Participants commented that a broader group of STAGE recommendations

STAGE suggests that it receive feedback on the

Workstream 4: Maternal, newborn, regions. The interventions will require leadership,

Background The steps to be taken in 2021 will include

Discussion countries require practical tools and guidance to

Dr Branca thanked the group for their comments.

Annex 2: Feedback report

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