Maternal and Newborn Health Thematic Fund Annual Report 2020

Publication date: 2021

THE MATERNAL AND NEWBORN HEALTH THEMATIC FUND Saving lives and mitigating the impact of COVID-19 on mothers and newborns ANNUAL REPORT 2020 4 Cover photo: © UNFPA Sudan, Sufi an Abdul-Mouty, 2020. Winner of the 2021 MHTF photo contest. Women and girls from White Nile State in Sudan have to travel dozens of kilometers to reach health facilities to give birth. The region is responding to the needs of hundreds of thousands of refugees, an extra challenge for an already fragile health system. Sarah travelled 50 kilometers from her village on a tuktuk, a three-wheeled motorized vehicle, to give birth at Kosti Maternity Hospital. Its maternity ward was rehabilitated and expanded as part of the national EmONC response plan. DELIVERING.A.WORLD.WHERE EVERY.PREGNANCY.IS.WANTED, EVERY.CHILDBIRTH.IS.SAFE, AND.EVERY.YOUNG.PERSON’S POTENTIAL.IS.FULFILLED THE MATERNAL AND NEWBORN HEALTH THEMATIC FUND Saving lives and mitigating the impact of COVID-19 on mothers and newborns ANNUAL REPORT 2020 2 CONTENTS Acronyms. .3 Acknowledgements.4 Foreword. .5 Executive.Summary.6 PART I KEY.RESULTS.9 1.1. Midwifery.10 1.2. Emergency.Obstetric.and.Newborn.Care. .13 1.3. Maternal.and.Perinatal.Death.Surveillance.and.Response. .19 1.4. Obstetric.Fistula. .22 1.5.COVID-19.Response. .26 1.6. Sexual.and.Reproductive.Health.and.Rights.Integration. .28 PART II OPTIMIZING.EQUITY.IN.ACCESS,.QUALITY.OF.CARE.AND.ACCOUNTABILITY:. A.COMPREHENSIVE.APPROACH.33 Country.Examples.of.Implementation.in.Service.Delivery. .34 PART III MHTF.RESOURCE.MANAGEMENT.37 3.1. Background.37 3.2. Contributions.37 3.3. Operating.Budget. .38 3.4. Expenses. .39 3.5. Categories.of.Expenditure.40 PART IV LESSONS.LEARNED.AND.WAY.FORWARD. .43 Challenges. .43 Lessons.Learned.44 Way.Forward. .45 ANNEX 1: CAMPAIGN.TO.END.FISTULA.PARTNERS. .47 ANNEX 2: DETAILED.BUDGET.ALLOCATIONS. .48 ANNEX 3: LIST.OF.COUNTRIES.SUPPORTED.BY.MHTF.PHASE.III. .52 ANNUAL REPORT 2020 3 We look forward to building on these productive and valued collaborations. ACRONYMS EmONC Emergency obstetric and newborn care FIGO International Federation of Gynecology and Obstetrics GIS Geographic information system H6 UNAIDS, UNFPA, UNICEF, UN Women, World Bank Group and the WHO ICM International Confederation of Midwives Jhpiego Johns Hopkins University Program for International Education in Gynecology and Obstetrics MHTF Maternal and Newborn Health Thematic Fund MPDSR Maternal and perinatal death surveillance and response NGO Non-governmental organization PPE Personal protective equipment SDG Sustainable Development Goal SRHR Sexual and reproductive health and rights UN Women United Nations Entity for Gender Equality and the Empowerment of Women UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization 4 ACKNOWLEDGEMENTS The United Nations Population Fund (UNFPA) wishes to extend its sincere appreciation to all its close partners and stakeholders in countries and regions, national governments, donor agencies, implementing partner organizations, United Nations sister entities, civil society organizations, and development and private sector institutions. Their support has enabled the Maternal and Newborn Health Thematic Fund (MHTF) to contribute to achieving the 2030 Agenda for Sustainable Development. We acknowledge with gratitude the generous support of multiple UN Member State donors. In particular, we would like to thank the governments of Germany, Luxembourg, Poland, Portugal and Sweden. With their support, the MHTF was able to focus support on 32 high-priority countries to improve equitable access to quality sexual, reproductive, maternal and newborn health services. Yielding a significant return on investment, this wide-reaching support produces a multiplier effect, extending impacts beyond these core countries to over 100 nations in total that benefit indirectly from MHTF-supported interventions. This saves and transforms the lives of women, girls, newborns and families across borders. We also thank our private sector partners, especially Johnson & Johnson, Takeda and Friends of UNFPA, for their generous support. Our sincere appreciation extends to UN colleagues around the globe who join UNFPA in a strong partnership through the H6 (UNFPA, the World Health Organization [WHO], the Joint United Nations Programme on HIV/AIDS [UNAIDS], the United Nations Children’s Fund [UNICEF], the United Nations Entity for Gender Equality and the Empowerment of Women [UN Women] and the World Bank Group) and initiatives like Ending Preventable Maternal Mortality and Every Newborn Action Plan. We are grateful for their collaboration and coordination in advancing global sexual, reproductive, maternal, newborn and adolescent health. In continued partnership, we will build synergies, support national governments, and demonstrate our leadership, commitment and strong partnership for the future. Our thanks also go to our UNFPA colleagues, whose continuous efforts at the country, regional and global levels help support and strengthen the delivery and quality of integrated maternal and newborn health programmes grounded in sexual and reproductive health and rights (SRHR). Finally, our academic and advocacy partners play significant roles as champions and technical experts, and we greatly appreciate their many valued contributions. These partners include the International Confederation of Midwives (ICM), the International Federation of Gynecology and Obstetrics (FIGO), the International Society of Obstetric Fistula Surgeons, Operation Fistula, Columbia University’s Averting Maternal Death and Disability Program, the Maternity Foundation, the Liverpool School of Tropical Medicine, the London School of Hygiene and Tropical Medicine, Laerdal Global Health, the Johns Hopkins Program for International Education in Gynecology and Obstetrics (Jhpiego) and the Woodrow Wilson Center. A list of our Campaign to End Fistula partners is included in Annex 1; we gratefully acknowledge their contributions. ANNUAL REPORT 2020 5 FOREWORD In 2020, the COVID-19 pandemic overwhelmed health systems across the globe and severely impacted the global health workforce. The pandemic threatens to derail progress in advancing sustainable development, jeopardizing the health, rights and well-being of women and newborns, particularly in low- and middle-income countries. Within this challenging environment, the UNFPA Maternal and Newborn Health Thematic Fund continued to rise to the challenge, with a strong focus on promoting equity in access, universal health coverage, and improving accountability and quality of care. It supported 32 high-priority countries to ensure that past gains in integrated sexual, reproductive, maternal and newborn health and rights are safeguarded and that pandemic recovery measures prioritize these essential services. In 2020, the MHTF supported the education and training of more than 34,000 midwives, strengthened networks of emergency obstetric and newborn care facilities, and bolstered maternal and perinatal death surveillance to improve quality of care. The Fund also supported nearly 8,000 fistula repair surgeries and provided psychosocial and mental health services to help fistula survivors overcome the social stigma associated with the condition, regain their dignity and reintegrate into their communities. These are some of the achievements, which show that efforts to save and improve the lives of women and newborns can be effective even during a global health crisis. They also highlight the need for such efforts to be comprehensive and rights-based, so that the most vulnerable in society can continue to access the quality services they need. UNFPA appreciates the collaborative efforts of all its partners in promoting the rights, health and choices of women and girls, including governments, United Nations partner agencies, civil society organizations, academic institutions, development agencies and private sector partners. With donor support and commitment, the MHTF continues to advance its mission to build inclusive, high-quality health systems capable of both responding to the ongoing pandemic and ensuring that every woman and newborn receives the care they need and deserve. We can end preventable maternal and newborn deaths in our lifetime. We know what needs to be done to promote the health, rights and well-being of mothers and newborns so that no one is left behind. Working together, I am confident that we will deliver a world where every pregnancy is wanted, every childbirth is safe, and every young person’s potential is fulfilled. Dr. Natalia Kanem Executive Director, United Nations Population Fund (UNFPA) 6 EXECUTIVE SUMMARY Since 2008, the MHTF has served as UNFPA’s flagship programme on maternal and newborn health. In Phase III of the MHTF Business Plan (2018-2022), the fund focuses on a people-centred, rights-based, life course approach to delivering integrated, comprehensive sexual and reproductive health services to mothers and newborns. This approach is based on realizing equitable access to SRHR information and services, quality care and human rights-based accountability. The MHTF in 2020 supported 32 countries with among the highest rates of maternal and newborn mortality and morbidity across five regions (the Arab States, West and Central Africa, East and Southern Africa, Asia and the Pacific, and Latin America and the Caribbean). The fund continued to focus on building capacities to provide maternal and newborn health care; improve the quality of care through quality midwifery services, emergency obstetric and newborn care (EmONC) and maternal and perinatal death surveillance and response (MPDSR); and prevent and treat obstetric fistula to ensure the most marginalized women and girls realize their human right to a healthy life. Upon the declaration of the COVID-19 pandemic by the WHO on 11 March 2020, MHTF-supported countries quickly adapted their programmes. MHTF partners took opportunities to adapt and sustain critical support for maternal and newborn health services. As the pandemic exposed and deepened gender, socioeconomic and geographical disparities, negatively impacting equity in care access and quality, and accountability for sexual, reproductive, maternal and newborn health care, the MHTF set new priorities for interventions that aligned with an integrated response. These included the protection of staff in health facilities providing maternal and newborn health services; improvement of hygiene to minimize viral transmission; and continuity of SRHR-integrated maternal and newborn health services. Remarkable progress despite challenges testifies to the adaptive capacities built through MHTF support. Health-care systems across countries faced setbacks, however, with activities paused due to lockdowns and the reallocation of funds to support the COVID-19 response. Strained health facilities and the limited mobility of patients and providers were among the factors hindering efforts to achieve universal access to health care. In 2020, the MHTF supported the pre-service and in- service education and training of over 31,500 midwives and the further higher education of over 2,900 midwives who graduated from bachelor’s, master’s or doctoral degree programmes. More than 500 midwifery schools have been accredited across MHTF-supported countries, aligning with WHO and ICM standards. Nineteen countries have mainstreamed midwifery in their national human resources for health policies or have existing stand-alone midwifery policies. While resources were shifted to support country responses to the pandemic, the MHTF’s global midwifery workplan was nearly fully implemented. A study supported in 2020 showed that 2.2 million lives could be saved per year over the next 15 years if midwifery coverage in line with international standards increases by 25 per cent. The start of a new decade, while presenting challenges, also offered opportunities. The inaugural advisory board to the MHTF established in 2020 provides new continuity and perspectives on the catalytic impact and direction of the fund. In 2020, the MHTF saw diverse and unique collaborations, including with the ICM, the WHO, Jhpiego, Johnson & Johnson and Takeda. Advocacy for MHTF-supported initiatives to improve sexual, reproductive, maternal and newborn health care reached global and national audiences. The commemoration of the International Year of the Nurse and Midwife and the International Day to End Fistula featured remote discussion panels and webinars that called for greater awareness, regulation, innovation and investment. The MHTF supported progress towards establishing equitably distributed networks of EmONC health facilities to improve health-care access and quality while measuring key determinants of access to and quality of care. In 2020, nine countries established and strengthened a functional 24/7 EmONC facility network with enough trained midwives. The MHTF backed the training of more than 11,800 midwifery students in pre- service education centres assisted by UNFPA. Countries developed mentorship programmes targeting gaps in skills and knowledge among health-care providers and applied maternal and perinatal death assessments to improve quality of care. Twenty MHTF-supported countries have a national monitoring tool for MPDSR; over 10,400 maternal deaths have been reviewed. ANNUAL REPORT 2020 7 EXECUTIVE SUMMARY Given a lack of government support for MPDSR in some cases, the MHTF and its partners aided in devising country-level workplans to implement programmes and identify solutions. Ten years remain for eradicating fistula and UNFPA continues to lead the Campaign to End Fistula by 2030. Fistula is treatable with a surgical procedure, and significant progress in administering surgeries has occurred over the years. While elimination of fistula is within reach, it requires intensified efforts. Nearly 8,000 fistula surgeries were performed in 2020 through MHTF support. More than 1,200 fistula survivors benefitted from a social reintegration programme providing psychosocial and mental health services. The UN General Assembly adopted a resolution on increasing investment in ending fistula, calling for bold political leadership and partnerships. By the end of 2020, 21 countries had national strategic plans to end fistula within a decade. The MHTF’s catalytic nature allows the fund to spearhead innovative solutions to sexual, reproductive, maternal and newborn health-care needs. Midwifery education in 2020 saw a transition to remote or offline educational resources, while private partnerships, such as with Johnson & Johnson and Takeda, created new opportunities to scale up fistula surgeries and midwifery services in countries with limited capacities, including Benin, Guinea, Kenya and Nigeria. Critical maternity care was provided in refugee camps and other emergency contexts. Countries have taken COVID-19 protective measures while sustaining family planning and contraception, postnatal care, comprehensive abortion care and cervical cancer screenings. In 2020, the MHTF aided effective, evidence-based programmes with life-saving and sustainable impacts. Taking an integrated sexual, reproductive, maternal and newborn health-care approach, the MHTF improves fragile health systems and alleviates maternal and perinatal deaths and disabilities. While the full measured impacts of the pandemic are not yet known, strengthening midwifery, EmONC networks, MPDSR programmes and the path to fistula eradication continue to be crucial to building resilient health systems. To meet critical needs across currently supported and additional countries, the MHTF wholly relies on increased funding support from existing donors and private partners. 8 PART I ©UNFPA.Haiti,.Samuel. Laméry.Pierre,.2020. Photo.submitted. to.the.2021.MHTF. photo.contest. "Building on state-of-the-art evidence and lessons from past years, the MHTF in 2020 continued to apply a holistic, person-centred and integrated health system approach." ANNUAL REPORT 2020 9 PART I KEY RESULTS 1 WHO, UNFPA, UNICEF, Mailman School of Public Health and Averting Maternal Death and Disability (2009), Monitoring Emergency Obstetric Care: A Handbook. 2 UNFPA (2021), Obstetric Fistula and Other Forms of Female Genital Fistula. The MHTF is integral to UNFPA’s comprehensive, holistic strategy to achieve universal access to SRHR, including among adolescents. Since 2014, the MHTF has been central to the UNFPA Strategic Plan. Building on state-of-the-art evidence and lessons from past years, the MHTF in 2020 continued to apply a holistic, person-centred and integrated health system approach. Strategic interventions took place in its four areas – midwifery, EmONC, MPDSR, and obstetric fistula and other morbidities. Recognizing that the context in which the MHTF operates is changing, a new narrative positions the fund’s role as central to an evolving emphasis on quality of care; universal health coverage; SRHR integration and complementarity with other programmes, such as adolescent sexual and reproductive health; the elimination of harmful practices; gender equality; morbidities and disability; human rights; humanitarian responses; family planning and supplies; and broader women’s health issues, including cervical cancer, anaemia, malaria and mental health. In 2020, the MHTF established an advisory board under Phase III of the MHTF Business Plan. Composed of MHTF donors and stakeholders, the board provides opportunities for strategic discussions, information exchange, guidance and consultation. During a first meeting in December 2020, board representatives reviewed MHTF strategic priorities and the scope of operations, assessed progress on Phase III and the impact of COVID-19, and advised on resource mobilization and advocacy opportunities and strategies for 2021 and 2022. Moving forward, the advisory board will meet on a yearly and ad hoc basis. In 2020, the MHTF increased global programme advocacy and visibility. An international stakeholder forum convened global maternal and newborn health stakeholders and current and potential future donors to share MHTF results and impacts. The objective was to increase awareness of how the MHTF improves the lives of mothers, newborns, families and communities, and how the fund is aligned with the UNFPA Strategic Plan 2018-2021. The forum raised interest among members and donors of the global public health and development community in partnering with MHTF-supported initiatives. In 2020, parallel efforts widely disseminated MHTF products and lessons learned to the global public health community to generate interest and increase visibility. In 2020, the MHTF was instrumental in shaping and influencing the global maternal and newborn health and public health landscape. As co-lead of the Ending Preventable Maternal Mortality initiative, the MHTF serves as an intermediary between the global maternal and newborn health communities. The fund co-finances and co-leads the current revision of Monitoring Emergency Obstetric Care: A Handbook, the reference guide on EmONC development since 2009.1 As the leader of the global Campaign to End Fistula, and with support from the MHTF and campaign partners, UNFPA led the updating of new and much needed global guidance on clinical management and programme development for obstetric fistula and other female genital fistula.2 The MHTF is also engaged in global maternal and newborn health initiatives such as the H6, the Global Action Plan for Healthy Lives and Well-being for All, UHC 2030, the MNCH Quality of Care Network, the Every Newborn Action Plan coalition and universal health coverage initiatives of the European Parliamentarian Forum. The COVID-19 pandemic was without doubt the most impactful crisis of 2020. It has posed considerable challenges to countries in maintaining high-quality, essential maternal and newborn health services. The MHTF’s timely, tailored and catalytic support helped countries maintain progress on sexual, reproductive, maternal and newborn health goals. Taking a human rights-based, people-centred and gender-focused approach, the 2020 MHTF programme continued to implement initiatives in four areas: midwifery, EmONC, MPDSR, and obstetric fistula and other morbidities. The following sections outline key results in each. https://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/ https://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/ https://www.unfpa.org/publications/obstetric-fistula-other-forms-female-genital-fistula 10 1.1 MIDWIFERY Midwives work with women and provide essential care, support and advice during pregnancy, labour and the post- partum period. Care includes preventative measures, the promotion of normal birth, the detection of complications for both the mother and newborn, referral to medical care or other appropriate assistance when needed, and the provision of emergency measures. By helping to build a competent, well-trained and well-supported midwifery workforce around the globe, the MHTF has given midwifery substantial momentum. Increasingly, results are seen in legislation and regulation. By the end of 2020, over 70 per cent of MHTF-supported countries had a human resources for health policy that included midwifery. With the entire health workforce, including midwives, severely impacted by COVID-19, programme priorities shifted to coordination of a global sexual, reproductive, maternal and newborn health-care response; maintaining the continuity of maternity services; and protecting the health workforce, particularly midwives. With personal protective equipment (PPE) shortages, the shutdown of midwifery schools, lockdowns and the disruption of maternity services, the MHTF rolled out COVID-19 technical guidance, and developed remote models of midwifery service delivery and online learning to sustain midwifery education and continuing professional development. Despite the challenges, the MHTF implemented more than 95 per cent of its global midwifery workplan in 2020. A large number of COVID-19 related activities were added throughout the year (see further details in Section 1.5). The declaration of 2020 as the International Year of the Nurse and the Midwife by the World Health Assembly made it a significant moment for midwifery. As the lead UN agency for advocacy on midwifery, UNFPA used the opportunity to draw global attention to the role of midwives in ending preventable maternal and newborn mortality and morbidity. It helped raise global and national visibility around the importance of investing in midwifery by strategically organizing a series of events for the International Year. 3 Women in Global Health (2020), “International Year of the Nurse and Midwife.” 4 Women in Global Health (2020), “Digital Content for the Launch of YONM.org.” 5 The International Confed (2020), “100 Outstanding Women Nurse and Midwives: Social Media Toolkit.” 6 Wilson Center (2020), “The Importance of Midwives in Achieving Universal Health Coverage.” 7 Wilson Center (2020), “Indigenous Midwives.” 8 Wilson Center (2020), “Impact of Midwives: A New Study Published in the Lancet Global Health.” 9 Sarah Matthews (2020), “Maori Midwives on the Power of Indigenous Birthing Practices.” The International Day of the Midwife was celebrated by countries and regions on 5 May, mostly through remote discussions and panels. UNFPA introduced a detailed advocacy resource toolkit, the UNFPA Executive Director gave a statement, and two high- level panels with midwifery leaders and technical experts were organized with the ICM, the WHO, Jhpiego and others. UNFPA and the ICM issued a joint call for actions by governments, decision makers, donors and health institutions, highlighting the adverse impacts of COVID-19 on midwives, women and newborns, and urging their protection. On World Health Day, a statement on midwives was released. Collaboration with Women in Global Health, the ICM, the WHO and the International Council of Nurses established a digital library of stories and experiences of more than 100 outstanding nurses3 and midwives. These feature on a new website with a promotional toolkit4 and digital media kit.5 In keeping with the spirit of the International Year of the Nurse and the Midwife, UNFPA held, in partnership with the Wilson Centre’s Advancing Dialogue on Maternal Health Series, several global advocacy events on the importance of midwives in achieving universal health coverage.6 These events included a private roundtable of global partners on creating an enabling environment for midwives, a panel focused on the contributions and challenges of indigenous midwives,7 and the launch of a study8 on the impact of midwives. In collaboration with the ICM, a podcast on the role midwives play in promoting maternal and newborn health and saving lives at birth was produced. The first episode featured indigenous midwives.9 In 2020, a major global highlight was the development of the State of the World’s Midwifery Report 2021. A midwifery mapping exercise was completed with the ICM, and the MHTF, the ICM and the WHO issued a new midwifery study, Potential Impact of Midwives in Preventing and Reducing Maternal and Neonatal Mortality and Stillbirths: A Lives Saved Tool Modelling Study. This important study, published in Lancet Global Health in December 2020, was part of a series of publications leading up to the https://yonm.org/ https://docs.google.com/document/d/1NxUV4LREd6TIuCWtr1j-6B6s0dnviJXa5sI-TeQ1ySs/edit https://spark.adobe.com/page/3L9Obj2RhKrdJ/ https://www.youtube.com/watch?app=desktop&v=G4dLwE2S2Q0&ab_channel=WoodrowWilsonCenter https://www.wilsoncenter.org/event/indigenous-midwives/ https://www.wilsoncenter.org/event/impact-midwives-new-study-published-lancet-global-health https://www.newsecuritybeat.org/2020/12/maori-midwives-power-indigenous-birthing-practices/ ANNUAL REPORT 2020 11 PART I State of the World’s Midwifery.10 The study provides new estimates on the potential impacts of midwives in reducing maternal and neonatal mortality and stillbirths. It shows that even a 25 per cent increase in the coverage of interventions by midwives meeting global standards can save 2.2 million lives per year by 2035. This study is particularly timely given diminished access to sexual and reproductive health services due to COVID-19. An infographic highlighting key findings was developed by the MHTF with support from Johnson & Johnson. In 2020, the MHTF remained committed to improving the quality of midwifery pre- and in-service education and training, mainly by strengthening regulation and national associations and encouraging and scaling up innovative approaches. The MHTF contributed to the WHO Midwifery Education Toolkit: Essential Childbirth Care Course, and with the closure of most midwifery schools globally due to the pandemic, it assisted remote models of education and training. By the end of 2020, 10 Andrea Nove et al. (2020), Potential Impact of Midwives in Preventing and Reducing Maternal and Neonatal Mortality And Stillbirths: A Lives Saved Tool Modelling Study. 502 midwifery schools had been accredited and were following a curriculum aligned with ICM standards. Overall, in 2020, the MHTF supported the pre-service education of about 18,000 midwives and provided continuous professional development (in-service training) to over 13,500 midwives, bringing the total number of educated and trained midwives to 31,500. These trainings, depending on the country and skills gaps, covered mentorship, fistula identification and management, EmONC, the Minimum Initial Service Package, respectful maternity care, haemorrhage, post- abortion care, cervical cancer screening and MPDSR trainings, among other areas. Despite the raging pandemic, 2,900 midwives graduated from higher education midwifery programmes with a bachelor’s, master’s or doctoral degree. About 1,000 midwifery tutors benefited from MHTF-assisted training in clinical and teaching skills, bringing the total number of tutors trained to date to over 13,000. Since it began ©UNFPA Democratic Republic of the Congo, Junior Mayindu, 2020. Photo submitted to the 2021 MHTF photo contest. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30397-1/fulltext https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30397-1/fulltext 12 in 2008, the MHTF has helped educate and train 181,500 midwives capable of delivering 31.8 million safe births annually. The MHTF supported more than 300 midwifery schools with training models, computers, books and equipment in 2020, bringing the total number assisted to around 750 schools since programme inception. Almost 3,000 midwives and educators benefited from Laerdal Global Health Helping Mothers Survive and Helping Babies Breath programmes in 12 countries. The MHTF continued to support national midwifery associations; more than 68 per cent of midwifery associations now have a current strategic plan and are deeply engaged in advocacy, mentorship, midwifery workforce planning, continuous professional development and other leadership promotion activities. In 90 per cent of MHTF- assisted countries, mentoring is a main activity of the midwifery association. Eight countries developed an annual report on the national mentorship programme for 2020, and by the end of the year, over 70 per cent of MHTF-supported countries had a policy on health human resources that included midwifery. A number of countries successfully deployed new midwifery graduates within a year of graduation, despite the pandemic. Burkina Faso, Chad, Ethiopia, Guinea, Guinea-Bissau, Lao People’s Democratic Republic, Liberia and Madagascar reported deploying a total of over 2,200 new midwifery graduates. To further scale up quality midwifery education, UNFPA obtained a grant from Johnson & Johnson for 2020 through 2023. An initial midwifery education needs assessment was completed in 2020 in collaboration with the ICM. Its insights will inform the planning of subsequent interventions. The following country examples highlight some achievements in the midwifery programme. In Liberia, MHTF support played a major role as UNFPA assisted government efforts to combat COVID-19, including through case management, infection prevention, surveillance and logistical supplies to facilitate contact tracing. A total of 120 cases of COVID-19 among pregnant women were managed at a temporary maternity unit. In Ghana, the MHTF backed leadership capacity building among midwives to help enhance national leadership, ownership and accountability for midwifery programmes along with improved service quality. The involvement of Madagascar’s Ministry of Health as a "midwifery recruiter" helped in advocating the accreditation of midwifery training schools according to ICM and WHO standards to the Ministry of Higher Education. In Uganda, the role of midwives in saving lives while risking their own during the pandemic was highlighted during celebrations of the International Day of the Midwife under the leadership of the Ministry of Health and the Nurses and Midwifery Association of Uganda. A 20-minute documentary was screened to ETHIOPIA: LEARNING AND PROFESSIONAL DEVELOPMENT IMPROVE QUALITY OF CARE UNFPA in Ethiopia plays a key role in strengthening the Ethiopian Midwives Association. It supported a 2019 study finding that the country has only 16,925 midwives, leaving the ratio of midwives to the population below the global standard. Only 7,000 midwives were registered members of the Ethiopian Midwives Association, which has faced membership management challenges. UNFPA subsequently helped the association improve its membership management system to achieve greater operational efficiency and better support continuing professional development. The system registers new members, renews membership, identifies active members and provides online services regardless of geographic barriers. The association now expects the system will reach all 16,925 midwives who eventually will register and take advantage of online courses. The system also feeds into the National Integrated Human Resource Information System and regulatory bodies in the Ministry of Health as well as regional health bureaus that check the compliance of midwives with professional development requirements as part of mandatory licensing. Such advances stand to further influence government and development partners to invest in midwifery and reproductive health. Source: UNFPA Ethiopia. ANNUAL REPORT 2020 13 PART I commemorate the International Year of the Midwife, an effort supported by the MHTF, the Embassy of Sweden and the Ministry of Health. 1.2 EMERGENCY OBSTETRIC AND NEWBORN CARE Too many women and newborns lack timely access to quality health care and life-saving interventions when facing an obstetric or newborn emergency. This can result in death, further morbidities or disability. To achieve Sustainable Development Goal (SDG) targets 3.1 and OPENING THE PHONE LINES FOR THOUSANDS OF WOMEN IN NEPAL DURING COVID-19 Prasansha Budha Lama is in the first batch of 14 professional midwives in Nepal. When COVID-19 shut services down in March 2020, she and her colleagues set up an emergency hotline for pregnant women and girls who could not get help. “All the health facilities were closed except for emergency services,” Prasansha says. “There was no transport at the time. Pregnant women were so scared because they did not know where to go in case of an emergency. They were out of options.” At first, Prasansha and her fellow midwives shared their phone numbers so that women could call them for advice when needed. Soon, with support from the Midwifery Society of Nepal, they set up a national, toll-free hotline providing tele-health sessions. “We wanted to make sure the Government was responsible for pregnant women,” Prasansha explains. “Pregnant women could not wait, so we developed the support system they needed.” The midwives not only provided advice, transport and referrals but also developed tailored remote services to help women cope with anxiety, serving 2,900 women. Initial support from the Midwifery Society and then from UNFPA and other UN agencies helped Prasansha and her colleagues expand outreach. UNFPA covered the cost of midwives involved in the hotline and mobile phone charges. Prasansha and her friends knew that most pregnant women had limited knowledge about childbirth and pregnancy. So they also started a programme called Childbirth Education for Young People in Nepal in association with the Midwifery Society, Rural Community Health Care Nepal, the Nepal Society of Obstetricians and Gynaecologists, and Amakomaya. Young people under 25 years old were enrolled and provided with education on pregnancy, the physiology of pregnancy, and care before, during and after pregnancy. “We empower them by talking about the danger signs during pregnancy and after childbirth,” Prasansha says. “We also talk about respectful maternity care and gentle birth methods, and what special preparations are needed to avoid and manage complications.” The programme successfully completed training of the first batch of young people, with plans to enroll a second batch. Prasansha and her colleagues are an inspiring example of making use of professional expertise and personal initiative to help others during the pandemic. “Instead of blaming the Government, other people or other organizations, we can start contributing ourselves,” she comments. MHTF funding was instrumental in addressing immediate needs and keeping sexual and reproductive health services going during the pandemic. It also helps ensure the Government can develop a professional cadre of midwives per global standards. UNFPA continues to promote midwifery education and training, advocate for stronger workforce policies and regulatory frameworks, and help integrate midwives into the formal health- care system. Source: UNFPA Nepal. 14 3.2i, every pregnant woman should have the opportunity to access high-quality care from skilled health-care providers during pregnancy, childbirth and in the weeks after childbirth. In 2020, the MHTF continued to support governments in developing national health facility networks providing quality 24/7 EmONC services. As the main highlight of 2020, the MHTF published an implementation manual to support countries in setting up national health facility networks to provide EmONC. The manual was developed based on experiences and lessons learned from several countries in sub-Saharan Africa.11 It responds to the limited progress made in providing access to functioning EmONC facilities in countries with a high burden of maternal mortality. The MHTF takes an approach to EmONC facility development that seeks to improve care access and quality by focusing resources on a limited number of facilities while ensuring coverage of the population within two hours of travel time (and one hour in some countries). Targeting public health authorities and stakeholders concerned by limited progress on EmONC, the manual describes concrete steps towards implementation of the EmONC framework developed in 2009.12 It makes use of recent developments in geographic modelling, including geographic information system (GIS) technology, for optimizing physical access to health facilities. The manual proposes new programmatic approaches to strengthen the routine management, monitoring and use of maternal, newborn and reproductive health data and indicators, linked with health management information 11 Benin, Burundi, Guinea, Haiti, Madagascar, Senegal and Togo. 12 WHO, UNFPA, UNICEF, Mailman School of Public Health and Averting Maternal Death and Disability (2009), Monitoring Emergency Obstetric Care: A Handbook. systems. It draws on implementation research to improve the quality of care in referral maternity facilities. In 2020, the MHTF EmONC network approach was implemented in nine countries. It is expected that more countries will follow in 2021. In collaboration with the Bill & Melinda Gates Foundation, the MHTF is co-financing and providing technical support to the revision of the 2009 EmONC framework. This major undertaking is urgently needed since newborn health along the continuum of care was not fully reflected and due to the need to take stock of 10 years of EmONC implementation experience. The updated version will consider recent evidence and reflect innovative approaches to EmONC facility network development and strengthening in MHTF-supported countries. In the revision process, four work streams were established: on signal functions, level of care, quality of care, and EmONC indicators and lessons learned. Since 2017, the MHTF has partnered with the University of Geneva to develop population coverage indicators and, specifically, an indicator measuring the proportion of the population able to access an EmONC health facility within two hours of travel time. This new indicator takes advantage of the increased use of GIS and the availability of free geographical modelling tools and quality geographical data. Inclusion of these indicators has proven informative for health system planning and strengthening. The indicator has been applied in 10 countries and is currently being considered by the Ending Preventable Maternal Mortality initiative ©UNFPA Haiti, Samuel Laméry Pierre, 2020. Photo submitted to the 2021 MHTF photo contest. https://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/ https://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/ https://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/ ANNUAL REPORT 2020 15 PART I as a global indicator. UNFPA will include population coverage indicators in the framework of its upcoming Strategic Plan. Complementing global efforts, the MHTF will generate tools to allow indicator measurement at the country level. In 2020, MHTF teams at UNFPA headquarters and the UNFPA West and Central Africa Regional Office organized a global webinar on EmONC monitoring at the country level. People from 11 countries (Benin, Burkina Faso, Burundi, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Guinea, Madagascar, Niger, Senegal and Togo) actively participated in the webinar. Since six countries had initiated national EmONC facility network development, the webinar offered further support to ensure that monitoring processes would remain on track despite the pandemic. The MHTF since 2017 has supported nine countries in sub-Saharan Africa in redesigning their health-care delivery system for maternal and newborn health and establishing national networks of EmONC health facilities. Through work with ministries of health and stakeholders at the subnational level, some countries have identified the number of EmONC facilities as below the international recommendation of five facilities per 500,000 people. Despite reduced numbers, countries achieved good population coverage. Figure 1.1 shows access to and coverage by functioning EmONC facilities in MHTF-supported countries in 2020 (hashed countries indicate ongoing work on the EmONC national network). This represents the current baseline of population access to facilities, usually showing low coverage, indicated by many areas coloured in red. The figure illustrates baseline coverage for EmONC facility networks. Figure 1.1 Coverage of the population by functional EmONC maternity units Côte.d'Ivoire * * . 16 Figure 1.2 displays designated national EmONC networks, or coverage of the population by EmONC health-care facilities that are not functional but are planned by health ministries. Compared to Figure 1.1, Figure 1.2 features potential population coverage targets that could be reached if planned EmONC facilities are upgraded to functioning EmONC facilities. The MHTF strives to support health ministry efforts to make the increased coverage in Figure 1.2 a reality in the near future, ensuring that a substantial proportion of the population has access to functioning EmONC health-care facilities in the next three to five years. Table 1.1 summarizes the MHTF’s support to ministries of health in designing the most effective and robust EmONC facility networks. Among the countries listed, most national EmONC networks have coverage below the recommended international standard of five facilities per 500,000 inhabitants. In Chad and Madagascar, the population is widely spread across the country and road conditions are so challenging that population coverage is particularly low. In these two countries, increasing the number of facilities would not necessarily improve population coverage but could jeopardize the overall goal of turning designated EmONC facilities into functional ones. Establishing national EmONC networks offers the opportunity to address key components of the maternal and newborn health programme, including the role of EmONC and particularly basic EmONC health facilities in a given health system. The process uncovers the number of skilled health personnel required and whether services are being provided 24/7 according to the obstetric and neonatal workload. With MHTF support, several countries have established national standards that articulate the number of midwives required in an EmONC facility network. Table 1.2 lists the number of Figure 1.2 Coverage of the population by designated EmONC maternity units Côte.d'Ivoire ** ** ** . . ANNUAL REPORT 2020 17 PART I midwives required in designated facilities based on established national norms. In most countries, less than half of designated EmONC health facilities have no gaps in midwives. The Government of Togo established its first standard for the number of midwives required in EmONC health facilities in 2015, when it had a deficit of 65 midwives in such facilities. Only 42 per cent of the facilities (46) had no deficit. In 2018, Togo increased its standard to a minimum of three midwives per EmONC facility instead of two and reduced its planned EmONC health facilities from 109 to 73 facilities. Two years later, applying this new standard, the deficit in midwives declined to 13 midwives and 84 per cent of EmONC facilities (61) had no gap in midwives. This success story highlights the importance of measuring the deployment of midwives at the facility level by using a dedicated, national indicator. Regular analyses and reviews subsequently inform human resources decisions and management. Togo also illustrates the importance of keeping the process flexible and allowing in-depth discussions around a realistic national standard that can be adopted for a given time period. Table 1.1 Designated EmONC network and population coverage within a two-hour travel time by designated and functioning EmONC health facilities in nine African countries Number of EmONC health facilities (5 per 500,000 people) Number of EmONC health facilities designated by the Ministry of Health Population covered by designated EmONC health facilities within a two-hour travel time Population covered by functioning EmONC health facilities within a two-hour travel time Benin 107 112 99 95% Burundi 113 112 68 22% Chad 158 109 61 34% Côte d’Ivoire 231 207 95 27% Guinea 118 105 81 35% Senegal 157 142 92 68% Sudan 396 167 90 74% Togo 67 73 96 91% Table 1.2 Tracking the Deficit in Midwives in EmONC facilities Minimum number of midwives Maximum number of deliveries per midwife per month Deficit in midwives in EmONC facilities (number) Proportion of EmONC facilities with no deficit in midwives (percentage) Benin (2018) 4 30 122 49 Chad (2018) 3 30 64 - Côte d’Ivoire (2019) 5 30 223 54 Guinea (2018) 3 30 170 49 Madagascar (2019) 3 30 220 42 Senegal (2020) 3 30 82 29 Sudan (2018) 3 30 367 35 Togo (2015) 2 30 65 42 Togo (2018) 3 30 13 84 18 The MHTF assisted several other EmONC-related country initiatives in 2020. Ghana conducted a national EmONC assessment to define equity, quality and accountability gaps, and UNFPA, the World Bank, the United States Agency for International Development, Jhpiego and the University of Geneva are advocating for national adoption of the EmONC network approach to optimize government resources. In the Democratic Republic of the Congo, the MHTF supported pre-service education of anaesthetists and nurse anaesthetists and in-service training in comprehensive EmONC facilities. Anaesthetists from four provinces, together with operating room nurses, were also trained in managing obstetric fistula cases. In Ethiopia, after a 2016 EmONC assessment revealed a lack of knowledge and skills as a significant factor in poor-quality care in rural health centres, UNFPA collaborated with the Ethiopian Midwives Association to implement catchment-based mentorship programmes in several regions of the country. Engaging key stakeholders 13 WHO (2019), “Maternal Mortality.” from the start of such programmes improves their likelihood of success and sustainability. A startling 99 per cent of all maternal and newborn deaths occur in low- and middle-income countries. While most health-care solutions to prevent or manage complications leading to deaths are known, it is important to identify and address barriers that limit access to quality health services to minimize mortality and morbidity.13 Access to EmONC services is particularly critical since most deaths are due to direct obstetric complications. Interventions to address gaps in access, availability and the delivery of good quality care by skilled health-care providers, including 24/7 EmONC services, are challenging, especially in ensuring these are cost-efficient and sustainable. The MHTF’s EmONC network strengthening process offers a proven solution for improving programme management, particularly for EmONC at scale. In the coming years, the MHTF will continue to expand its support and build on a wealth of experience to assist decision-makers in developing networks of referral facilities to provide quality care. ©UNFPA Lao People's Democratic Republic, Phetmany Viyadeth, 2020. Photo submitted to the 2021 MHTF photo contest. https://www.who.int/en/news-room/fact-sheets/detail/maternal-mortality ANNUAL REPORT 2020 19 PART I MPDSR VERBAL AND SOCIAL AUTOPSIES SAVE LIVES IN BANGLADESH Bangladesh is among the MHTF-supported countries reporting on maternal and perinatal deaths in communities, using verbal autopsies to determine medical and social causes. Following a maternal or neonatal death notification, health supervisors perform a verbal autopsy within 7 to 15 days by interviewing the family of the deceased person. Results give unique insights into awareness, the need for care in a given community, cultural norms and beliefs, and local and traditional practices. The autopsy also identifies the “three delays'' that may lead to the death of a mother or newborn. Findings are analysed and presented to quality improvement committees at the district and subdistrict levels. The committees use the findings for evidence-based planning to avert preventable deaths in the future. Findings also provide an opportunity to explore in-depth the causes of deaths with links to health-care facilities. Bangladesh has also introduced social autopsies for an immediate community response after a death. A trained facilitator such as a government health supervisor leads community groups through a structured, standardized analysis of the physical, environmental, cultural and social factors contributing to a maternal or neonatal death. The process increases self-realization, builds knowledge, enhances future accountability and boosts local empowerment. It can improve community behaviours and attitudes towards seeking quality care at health facilities, thus fostering demand for quality services. Based on Bangladesh’s national MPDSR guideline, social and verbal autopsies are supposed to be conducted in the same community within four weeks after a death. In this way, the social autopsy builds on the verbal autopsy findings, creating a new opportunity for community engagement and active participation. Source: UNFPA Bangladesh. 1.3 MATERNAL AND PERINATAL DEATH SURVEILLANCE AND RESPONSE MPDSR is vital for improving the quality of maternal and newborn care. It identifies causes of death in pregnancy, childbirth and the post-partum period, and implements solutions in communities or health facilities to prevent future deaths. It is embedded in a global approach to improving the quality of health care in facilities and communities and pre-empting maternal and perinatal deaths. MPDSR provides a critical link between information and improvements in life-saving interventions along the sexual, reproductive, maternal and newborn health continuum. It is designed to count maternal, fetal and newborn deaths; analyse medical and non-medical causes; and examine preventive measures for improvements in care. Uptake and sustainability, however, pose major challenges, especially in already weak health systems. The MHTF is the only global programme that monitors different MPDSR programme components in a large number of countries. In 2020, the MHTF made further efforts to engage in MPDSR initiatives at the global and regional levels and to implement MPDSR in countries. The MPDSR Global Technical Working Group concluded an active year as UNFPA's MHTF, the WHO, UNICEF and other organizations generated and validated a 2020-2022 workplan to back country-level implementation. It comprises four workstreams: implementation and sustainability, capacity building and mentorship, monitoring and reporting, and dissemination. The MHTF actively contributed to capacity building and mentorship, and with the Centers for Disease Control and Prevention co-led the group on monitoring and reporting, which analysed 37 MPDSR annual reports. The review confirmed the need for more quality control since many reports had incomplete data sets and gaps in notification and review processes. Many reports referred to “counts” rather than “ratios” and “rates”. One recommendation was to follow SMART (specific, measurable, achievable, relevant and timely) criteria more rigorously to elaborate recommendations in MPDSR reports. The analysis was presented to the global MPDSR working group, which suggested developing a guidance note to help countries improve the quality of reports. The MHTF led consultations around maternal death notification processes and reviewed coverage rate indicators within the MPDSR Global Technical Working Group. This confirmed great interest in establishing an indicator for monitoring national MPDSR programme implementation. 20 LESSONS LEARNED FROM SENEGAL’S MPDSR PROGRAMME ASSESSMENT AND EVALUATION. In 2020, the MHTF supported Senegal’s Ministry of Health in assessing its MPDSR programme. An evaluation focused on a quality control analysis of the MPDSR programme was led by an MPDSR committee. It considered a 2019 analysis of 101 maternal deaths in 16 facilities across two regions. About 80 per cent of the deaths were attributable to a direct cause, with eclampsia and post-partum haemorrhage as leading causes. Ten per cent were attributable to indirect causes and 10 per cent had no discernible causes. The evaluation concluded that 90 per cent of all maternal death audit reports generated by the MPDSR committee were accurate, confirming that maternal death reviews are reliable. But the translation of audit reports into MPDSR reporting tools was not satisfactory because the cause of maternal death was not reported on 60 per cent of the forms. Learning from the Senegal experience, the MHTF will encourage other countries to assess their MPDSR programmes. Source: UNFPA Senegal. In collaboration with the WHO and the Centers for Disease Control and Prevention, the maternal death notification coverage rate indicator was generated and its comparative advantages analysed. UNFPA has included it in the upcoming framework for its Strategic Plan. In 2020, the COVID-19 pandemic led to a stronger MHTF effort to analyse programme implementation in countries with a high burden of maternal mortality. MPDSR Phase III key indicators revealed that COVID-19 had no significant impact. Surprisingly, the proportion of maternal deaths being notified and reviewed slightly increased in 2020 (see Figure 1.3). To maintain MPDSR training in countries during the pandemic, a virtual in-service training package was developed by the WHO, UNFPA, UNICEF and Jhpiego. Facilitators used it to conduct virtual workshops wherever face-to-face training was not possible. This approach was piloted in Eritrea, Ghana, Kenya, Liberia, Malawi and Zimbabwe. The package will be finalized in 2021 along with one for pre-service MPDSR training developed jointly with the WHO, UNFPA, UNICEF, Jhpiego and the Liverpool School of Tropical Medicine. UNFPA’s Eastern and South Africa Regional Office conducted a series of virtual capacity-building webinars on MPDSR in collaboration with the regional offices of the WHO and UNICEF. More than 684 participants attended from national ministries of health, district health offices, non-governmental organizations (NGOs), academia, regional bodies and others. The first webinar addressed the sustainability of quality MPDSR systems and how cause of death classifications could be reported more accurately during the pandemic. The second webinar focused on perinatal deaths and the specific role of MPDSR during the pandemic. The third webinar emphasized community MPDSR mechanisms; UNFPA shared the experience from Bangladesh and elaborated on the integration of COVID-19-related maternal deaths in investigations of causes of death. MPDSR programmes rest on four pillars defined by the WHO: national guidelines and tools, mandatory maternal death notification, functioning national committees and a strategic plan with a budget. The MHTF team analysed 29 countries in 2020, finding that compared to 2018, the number with all four pillars in place had doubled (Figure Figure 1.3 Uptake of MPDSR pillars 20 15 10 5 0 4 pillars 3 4 10 10 16 12 5 8 6 11 1 1 3 pillars 2 pillars 1 pillar 2016 2018 2020 ANNUAL REPORT 2020 21 PART I 1.3). In countries that fall short, the missing pillars are often a budgeted strategic plan and functioning review committees. The analysis revealed that more efforts are needed to improve programme management and implementation. As shown in Figure 1.4, average maternal death notification and review coverage rates for 28 high- burden countries are still low with 29 per cent of expected maternal deaths notified and only 16 per cent reviewed. The low values underscore that important efforts are needed to implement MPDSR at scale and reach a target of 100 per cent of expected maternal deaths notified and reviewed. In 2020, the MHTF made a number of advances on MPDSR in individual countries. In Uganda, MPDSR continues to be a national priority for leaders in the Ministry of Health. Based on gaps identified during maternal and perinatal death reviews, the MHTF supported the refurbishment of a neonatal unit at a referral hospital and optimized its functionality. Following the intervention, a notable decline was observed from 111 neonatal deaths to 67 neonatal deaths in two months. UNFPA also supported the Government in identifying certain facilities referred to as “death hotspots” in the Kampala metropolitan area and addressing quality care gaps. Joint technical visits to referral hospitals strengthened comprehensive EmONC services. In Ghana, 776 maternal deaths were notified, of which 652 were audited. As with other public health indicators, COVID-19 had a significant impact on MPDSR. Amid growing needs, UNFPA’s country office continued to advocate for establishing an intersectoral committee for MPDSR. From the maternal death review in Niger, 958 maternal deaths were reported from health facilities, of which 264 were reviewed and audited. Anaemia was identified as one of the main causes of death, leading to steps to boost the availability of blood bags and increase blood collection. Ferrous salt was distributed to pregnant women during prenatal consultations and vital medicines (oxytocin and misoprostol) were provided to health- care facilities. Blood transfusion centres were equipped with 4,000 blood bags, and collection campaigns are underway in four regions with the support of the Association of Traditional Chiefs. In Nigeria, the MHTF provided technical and financial support for strengthening the subnational institutionalization of MPDSR. The Lagos State Ministry of Health conducted quarterly supervisory visits to monitor facility-level MPDSR technical committee meetings in 23 general hospitals. These visits ensured that meetings followed national guidelines, planned actions and reported consistently to the state platform. Health facilities that were unable to report were provided with technical assistance to improve planning and implementation of action plans. UNFPA also supported Figure 1.4 Evolution of the mean maternal death notification and review coverage rates for 28 countries from 2015 to 2020 (percentage) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2015 2016 2017 2018 2019 2020 Average notification coverage rate Average review coverage rate 9 17 13 26 13 26 11 22 14 27 16 29 22 MPDSR steering and subtechnical committees in virtual coordination meetings, ensuring a seamless transition from paper-based to electronic monitoring platforms. More than 400 staff were trained on using the MPDSR National Obstetric Quality Assurance e-platform and entering data through mobile devices. The e-platform automatically notifies each maternal and neonatal death from the community or health centre level and feeds data into the health management database. Such data will be used to generate real-time reports. In its support for MPDSR, the MHTF stresses tactful discussion of sensitive topics with governments and stakeholders. There has been limited commitment to the issue, however, alongside a lack of individuals willing to act as champions, limited coordination of stakeholders and marginal support from donors. The lack of funding has always been a major challenge. An increase to support national and subnational programming could substantially improve the quality of care in maternity units and maternal and neonatal programme management. The MHTF together with sister UN agencies and partners will increase technical support and guidance on programme implementation and data management at the country level with better-defined targets, programme assessment, improvements to maternal death reviews, response tracking and integration with a qualitative approach package. Furthermore, the MHTF will continue to make efforts to improve stakeholder coordination at the country and regional levels. 1.4 OBSTETRIC FISTULA Eradicating obstetric fistula is central to the MHTF’s work and fundamental to realizing the vision of the International Conference on Population and Development Programme of Action and the SDGs. In 2020, a 10-year countdown began to ending obstetric fistula by 2030, as called for by UN Member States in the 2018 General Assembly resolution on fistula.14 While countries are making progress in reducing maternal and newborn mortality and morbidity, the injustice of fistula persists. Worldwide, 14 A/RES/73/147 (2018). 15 The Campaign to End Fistula aims to eradicate fistula globally, leaving no one behind. It is active in over 55 countries, brings together over 100 partners worldwide and focuses on four key strategies: prevention, treatment, social reintegration and advocacy. 16 A/75/264 (2020). 17 A/RES/75/159 (2020). approximately 500,000 women and girls suffer from fistula, with new cases occurring annually. Although this is still a significant number, the elimination of fistula by 2030 is within reach if efforts are intensified, resources increased and partnerships enhanced. This process must prioritize and scale up programmes tackling the root causes of fistula, including by improving women’s and girls’ reproductive health through fistula prevention and treatment, upholding human rights, and advancing empowerment, educational and economic opportunities. This direction is especially pertinent as crises such as COVID-19 threaten to erode gains made in reproductive and maternal and newborn health. In 2020, the MHTF continued its support of the UNFPA-led global Campaign to End Fistula, catalysing interventions to prevent and respond to fistula amid the pandemic.15 The disruption of health services exacerbated gender-based, socioeconomic and intersectional inequalities, and deepened structural and systemic barriers already faced by women and girls at risk of or living with fistula. The MHTF supported high-level engagements around fistula prevention and response through innovative approaches and advocacy platforms, such as the International Day to End Obstetric Fistula and the International Day of the Midwife. These efforts aimed to increase awareness, foster national and governmental commitment and action, and provide financial support to improve maternal and newborn health outcomes, including fistula prevention and response. Support from the MHTF complemented prevention, treatment, and social reintegration and advocacy interventions implemented by partners in the global Campaign to End Fistula. In 2020, the MHTF supported development of two high- level advocacy tools, the UN Secretary-General’s Report on Intensifying Efforts to End Fistula within a Decade16 and the United Nations General Assembly resolution on intensification of efforts to end obstetric fistula.17 The Secretary-General’s report was developed by UNFPA and detailed progress on efforts to end fistula worldwide from 2018 to 2020. The report recognized an overall decrease in the global prevalence of fistula, with 500,000 women and girls now living with the condition, and recommended significantly increased investments, bold political leadership and strategic partnerships to http://www.endfistula.org/publications/un-resolution-fistula-2018 http://www.endfistula.org/publications/un-report-obstetric-fistula-2020 http://www.endfistula.org/publications/un-resolution-fistula-2020 ANNUAL REPORT 2020 23 PART I strengthen health systems and maintain gains made, while ensuring that gender equality remains a key focus within and beyond health and social protection systems. Building on the recommendations of the report, the resolution on fistula was developed by the United Nations with technical support from UNFPA. The resolution, adopted by Member States in December 2020, called for urgent efforts and significantly increased investment to improve sexual and reproductive, maternal, newborn and child health. It outlines key recommendations and actions including a call to fistula-affected countries to develop and implement comprehensive national strategies and action plans to end fistula by 2030. The resolution serves as a powerful tool for high-level engagement to foster commitments to improve maternal health and end fistula at the global, regional and country levels. Government ownership and leadership are crucial to tackling fistula. By the end of 2020, 66 per cent of MHTF-supported countries (21) had national strategies to end fistula in place; 95 per cent had costed operational plans to end fistula, indicating increased political commitment.18 Government-led national fistula task teams were active in 72 per cent of MHTF-assisted countries, strengthening coordination and monitoring and providing technical and operational guidance for the national response. In 2020, UNFPA supported nearly 8,000 women and girls in MHTF-assisted countries in accessing fistula surgeries, helping to restore quality of life for survivors. To date, UNFPA has directly aided over 121,000 fistula surgeries, with thousands more assisted by Campaign to End Fistula partners around the globe. Unmet need for treatment of fistula, however, remains high in many countries. Many women and girls with fistula are still unable to access needed services, prolonging their suffering. About 87 per cent of MHTF-supported countries reported routine, continuously available fistula treatment services in strategically selected hospitals. In 2020, over 6,000 health workers, including surgeons, anaesthetists, midwives and nurses, were trained on preventing fistula, and managing and caring for the condition. This helped to build sustainable and quality fistula repair capacity, facilitating the transition from repair campaigns to integrated and routine care. Measures to strengthen 18 Bangladesh, Burkina Faso, Benin, Congo, Côte d’Ivoire, Chad, Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Guinee Bissau, Kenya, Madagascar, Mauritania, Mozambique, Nigeria, Senegal, Somalia, Togo and Uganda. 19 Campaign to End Fistula partners that were directly involved included Direct Relief, the Fistula Foundation and the International Society of Obstetric Fistula Surgeons. the capacities of 1,475 health facilities sought to reduce maternal mortality and morbidity and improve fistula prevention and quality care through the provision of fistula repair kits, medical supplies and equipment. Scaling up national capacities to provide access to comprehensive emergency obstetric care; treating fistula cases; and addressing underlying health, socioeconomic, cultural and human rights determinants are fundamental to eliminating fistula. Unfortunately, fistula surgeries had to be widely suspended or slowed down in 2020 as they were deemed non-emergency procedures, along with a myriad of other surgical and medical procedures. The suspension of surgery reduced the risk of COVID-19 infection during the pandemic. In 2020, UNFPA and Campaign to End Fistula partners produced a much needed update of new guidance on the clinical management of obstetric fistula and other forms of female genital fistula (e.g., iatrogenic fistula).19 The guidance, a culmination of nearly 15 years of work collecting evidence and best practices from national, regional and global initiatives and from efforts to end obstetric fistula with campaign partners, will serve as the authoritative, gold-standard guide to eliminating obstetric fistula. The guidance is based on the latest evidence, strategies, tools and resources on programming, policies, prevention, treatment and social reintegration. The manual emphasizes quality of care as a significant factor in improving maternal and newborn health outcomes and will serve as a guiding light on the path to achieving health, gender equality and human rights for all. The new guidance was launched and disseminated in 2021. Advocacy is key to increasing awareness, strengthening partnerships, and fostering commitment, leadership and ownership, at the national and subnational levels, to end fistula. In 2020, advocacy engagements were intensified to highlight the criticality of available, accessible and continuous maternal health services to prevent fistula during the pandemic. The commemoration of the International Day to End Obstetric Fistula on May 23 at the global, regional and country levels offered scope for wide-reaching advocacy around the theme “End gender inequalities! End health inequities! End fistula now!” Using electronic and social media, countries and regions engaged with high-level 24 political figures, national fistula task teams, fistula survivors, midwives, fistula surgeons, and beneficiaries of maternal and newborn health services and communities through virtual platforms and social media to discuss and highlight fistula in the broader context of maternal health. Advocacy highlighted fistula as a public health concern and a human rights violation. A social media pack and an information circular with key messages were created and disseminated widely to UNFPA-supported countries and Campaign to End Fistula partners to facilitate effective engagements for the day. Powerful stories in the media showing the human face of fistula; influential champions and fistula advocates speaking out; and enhanced collaboration and coordination with partners all helped to ensure that fistula is not forgotten. A blog co-authored by fistula survivor Kevin Nalubwama and the Campaign to End Fistula emphasized the importance of “leaving no one behind” by not forgetting fistula survivors, especially during the pandemic.20 A paper co-authored by the MHTF, UNFPA and the Campaign to End Fistula and published in the International Journal of Obstetrics and Gynaecology highlighted that the failure to eliminate fistula jeopardizes attainment of several SDGs. It stressed that fistula elimination requires protecting the human rights of women and girls while addressing social determinants that affect their ability to “survive, thrive and transform”.21 Robust, quality data are essential to track efforts to end fistula. Though challenges remain, the MHTF recorded progress in improving data availability in 2020. By the end of the year, 63 per cent of MHTF-assisted countries (17) had integrated fistula-related indicators into their national health information management systems, making annual data available for tracking national decision-making and programming on fistula. The MHTF strengthened national capacities for fistula data in Bangladesh through the development of fistula data monitoring tools; Côte d’Ivoire through the design of a web-based fistula data collection platform; Mozambique through a real-time data monitoring system, Info Fistula; and Uganda through the development of national fistula management documentation and reporting tools. 20 Erin Anastasi and Kevin Nalubwama (2020), “Obstetric Fistula at the Time of COVID-19: Let’s not Forget those ‘Most Left Behind'!" 21 Erin Anastasi, Bridget Asiamah and Geeta Lal (2020), “Leaving No One Behind: Is the Achievement of the Sustainable Development Goals Possible Without Securing the Dignity, Rights, and Well-Being of Those Who Are ‘Invisible’?” A holistic approach to the psychosocial and socioeconomic needs of fistula survivors ensures full recovery and healing yet requires increased financing. The MHTF and the Campaign to End Fistula promote evidence-based social rehabilitation and reintegration programmes for fistula survivors, and advocate that all countries affected by fistula track an indicator on access to reintegration services for all women and girls in need. By the end of 2020, 78 per cent of MHTF- assisted countries (25) reported having mechanisms to follow up with survivors after treatment. Mozambique and Uganda evaluated social reintegration packages for fistula survivors, building evidence to inform quality future programmes. Providing social, educational and economic opportunities is key to helping fistula survivors to rebuild their lives and livelihoods, and reclaim their dignity and agency after treatment. In 2020, in-person capacity building on income generation skills as part of social reintegration and rehabilitation for fistula survivors, such as training on vocational skills, decreased significantly due to COVID-19 prevention protocols. Approximately 1,290 fistula survivors received a form of social reintegration, including psychosocial and mental health support as well as awareness on COVID-19, during pre-, peri- and post-operative stages. Social reintegration interventions included telephone follow-up with survivors (Bangladesh, Burundi and Mauritania); face mask production for COVID-19 prevention and handicraft- making (Bangladesh); dressmaking, textile-making and trading (Congo, Burkina Faso and Mauritania); microfinance (Burkina Faso and Nigeria); education on SRHR and fistula (Mozambique); and integration in women’s groups (Nigeria). An initiative funded by the United Nations Federal Credit Union Foundation continued to support women and girls with fistula, including those deemed incurable in southern and northern Nigeria, in partnership with a local NGO, Fistula Foundation Nigeria. The MHTF and the Campaign to End Fistula provided technical guidance, helping to strengthen referral linkages between communities and health facilities. In 2020, UNFPA in West and Central Africa developed an obstetric fistula investment case as an important resource for advocacy and resource mobilization. The region has seen increased political commitment including high-level engagements by first ladies on maternal http://www.srhm.org/news/obstetric-fistula-at-the-time-of-covid-19-lets-not-forget-those-most-left-behind/ https://doi.org/10.1002/ijgo.13031 https://doi.org/10.1002/ijgo.13031 ANNUAL REPORT 2020 25 PART I BANGLADESH: BEAUTY’S JOURNEY TO DIGNITY THROUGH HOLISTIC FISTULA CARE, A RIGHT FOR ALL FISTULA SURVIVORS Beauty, 34, married 12 years ago in a village of Rangpur district of Bangladesh. A year later, she had her first childbirth at home with a traditional birth attendant; the outcome was a stillbirth. Beauty got pregnant again. When she was due, she suffered obstructed labour for over 48 hours under the care of a traditional birth attendant. She was rushed to a hospital where she had another stillbirth and learned she had fistula. Beauty was later abandoned by her husband and became frustrated, lost hope and felt suicidal. Fortunately, a health-care provider who visited her village informed her of available fistula treatment. She was successfully treated at the LAMB hospital in Rangpur with support from UNFPA in Bangladesh. Beauty struggled economically before and after her surgery. Through a UNFPA and LAMB Hospital initiative, she and 11 other fistula survivors in 2020 learned tailoring skills to produce three-layered cloth face masks as part of a social reintegration programme. Following guidelines provided by the country’s Directorate General of Health Services, the survivors produced and sold over 2,000 masks for COVID-19 prevention. Empowered with the ability to earn her own money and ensure her own survival, Beauty now lives with dignity and gives back to her community through her vocational skills. The Government of Bangladesh has a national fistula strategy in place and aims to end the condition by 2030, partnering with UNFPA, the MHTF and the Campaign to End Fistula. In 2020, the Directorate General of Health Services declared that two upazilas or subdistricts in the Panchagarh district were fistula-free and published an annual report on fistula for the first time in Bangladesh. Source: UNFPA Bangladesh. health, the rights of women and girls, and ending fistula, child marriage and female genital mutilation. A regional strategy to end fistula in the region was finalized by UNFPA and its partners. As part of a wider regional strategy to improve maternal health in Asia and the Pacific, four MHTF-assisted countries, Bangladesh, Lao People’s Democratic Republic, Nepal and Timor-Leste, implemented roadmaps to reduce maternal mortality and morbidity, including fistula. National achievements included training more than 350 fistula survivors in Bangladesh to produce three- layer cloth masks for COVID-19 protection as part of rehabilitation and reintegration support. A total of 87 fistula patients were referred and supported to undergo fistula repair surgery at a UNFPA partner hospital. With MHTF support, the Ghana Health Service conducted 58 obstetric fistula repairs in 2020, of which 30 per cent were newly identified cases. UNFPA supported fistula repair centres and mothers in maternity units with fistula repair equipment, COVID-19 PPE and dignity kits. In the Democratic Republic of the Congo, the MHTF assisted efforts to enhance community awareness and sensitization on obstetric fistula. Hospital transport was provided to women suffering from the condition. The Kindu General Referral Hospital performed more than 30 repair surgeries and is now a centre of excellence offering quality obstetric fistula treatment. The hospital was supported with obstetric fistula repair kits, medicines and other supplies. In Ethiopia, UNFPA’s continuous advocacy brought obstetric fistula to the attention of policymakers. Obstetric fistula has been included in the public health emergency management system with corresponding training materials for effective service integration. Obstetric fistula has also been defined as an essential SRHR service exempt from out-of-pocket payment. In Niger, specialist outreach strengthened the skills of 15 surgeons in obstetric fistula repair and led to operations for 80 fistula survivors. In addition, 27 paramedics (10 surgical assistants, 10 anaesthetists and 7 nurses) benefited from capacity building in pre-, peri- and post-operative care. Ten surface technicians 26 built capacities for infection prevention. In the Blue Nile State of Sudan, UNFPA supported the Ministry of Health by bringing two fistula surgeons on board to address a gap in treatment, resulting in 23 fistula operations. In Zambia's Luapula province, field visits assessed the post- operative outcomes of fistula repair surgeries and fistula survivors’ vulnerability and access to social services. Out of 47 survivors, 33 were found vulnerable and included in a social cash transfer programme. In Nigeria, in partnership with Johnson & Johnson, 267 fistula repair kits were distributed to 11 fistula treatment centres to support the surgical and post-operative care of 5,340 fistula patients. The kits increased access to free, quality fistula repair for poor and underserved patients. 1.5 COVID-19 RESPONSE The COVID-19 pandemic has placed enormous pressure on health systems in the 32 MHTF-supported countries, especially those already struggling to provide universal access to quality, comprehensive services. The pandemic has threatened to reverse recent gains in SRHR- integrated maternal and newborn health care. In 2020, most MHTF countries were impacted by breakdowns in supply chains; lockdowns; limited access to health facilities, medical supplies and health-care workers; and a huge surge in demand for PPE. The pandemic also adversely affected the social determinants of health, in some cases with devastating socioeconomic and psychosocial impacts on women, children, families and communities. As the COVID-19 pandemic harmed maternal and newborn health directly and indirectly, it created new vulnerabilities for women and their health, and further exacerbated longstanding social and gender disparities. Primary effects: Pregnant women and mothers are not at higher risk for COVID-19 infection than people who are not pregnant, but pregnant people with symptomatic COVID-19 may experience more adverse outcomes compared to non-pregnant people.22 Secondary effects: Beyond temporary measures, many health-care facilities closed their doors entirely during the pandemic. This left many pregnant women without access to timely, SRHR-integrated maternal and newborn health care, especially during the onset of the pandemic. The pandemic has also substantially 22 Bethany Kotlar et al. (2021), The Impact of the COVID-19 Pandemic on Maternal and Perinatal Health: A Scoping Review. 23 Gabriele Saccone et al. (2020), Psychological Impact of Coronavirus Disease 2019 in Pregnant Women. impacted maternal mental health. There is evidence that feelings of anxiety and depression are associated with maternal fear of the vertical transmission of the virus to their infants, limited accessibility to antenatal care resources and lack of social support.23 As UNFPA country offices and governments pivoted strategies and reprogrammed funds for critical COVID-19 responses, measurement of some indicators had to be postponed to 2021. Limited access to data resulted mainly from nationwide lockdowns. Despite data collection gaps and even with challenged capacities, MHTF-supported UNFPA country offices demonstrated remarkable commitment to tracking key health and social protection outcomes among at-risk and vulnerable populations. In 2020, the MHTF addressed both the primary and secondary effects of the pandemic across its four pillars. It supported UNFPA country offices and governments in modifying workplans by prioritizing three key interventions: protecting staff in maternity units, improving hygiene in maternity units to reduce COVID-19 transmission, and maintaining SRHR-integrated maternal and newborn health services. Midwifery: The COVID-19 pandemic had a significant impact on maternal and newborn health care, the midwifery workforce, and the health and well-being of women and newborns worldwide. UNFPA strengthened the capacity of midwifery and nursing schools in MHTF-assisted countries by providing PPE, hygiene and disinfection products and information regarding COVID-19. The MHTF also did widespread global advocacy to address the issues being faced by midwives (protection, stigma, and deployment to other non- midwifery related COVID 19 activities). In an effort to integrate the COVID-19 response with activities around the International Day of the Midwife and International Year of the Nurse and the Midwife, a series of global events were organized to raise awareness on the impact of the pandemic on the midwives and pregnant women. Some key initiatives undertaken by MHTF to support midwives are highlighted below: z Given demand for remote training materials for midwives, the MHTF launched two new global partnerships. One with the Liverpool School of Tropical Medicine developed and updated five midwifery e-modules on post-partum haemorrhage, https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-021-01070-6 https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-021-01070-6 https://doi.org/10.1016/j.ajog.2020.05.003 https://doi.org/10.1016/j.ajog.2020.05.003 ANNUAL REPORT 2020 27 PART I preeclampsia/eclampsia, sepsis, comprehensive abortion care, and prolonged and obstructed labour. A second partnership, with the Maternity Foundation, translated 13 modules of the Safe Delivery App into Arabic. Additional needs emerged for technical guidance to deliver alternate models including for remote service provision and the protection of health workers. The MHTF supported a number of steps. z The MHTF collaborated with UNFPA’s Asia and the Pacific Regional Office and the Burnet Institute to develop comprehensive technical guidance to ensure the continuity of essential maternity services and protection of the health workforce.24 z In collaboration with global partners, including the ICM, the MHTF developed advocacy materials to ensure the continuation of midwife-led care and the protection of midwives as part of the essential health workforce.25 z The MHTF highlighted the impact of COVID-19 on pregnancy26 and the role of UNFPA in maintaining service delivery during the pandemic27 through publications, partner panel discussions and interviews. z A thirteenth module on COVID-19 was added to the Safe Delivery App. z A series of global UNFPA-led webinars made participants aware of the challenges posed by COVID-19, disseminated technical guidance, and addressed SRHR staff mental health and emotional challenges due to COVID-19. z UNFPA and the ICM launched a new joint global research study with support from Johnson & Johnson featuring the impact of COVID-19 on midwives. z A joint UNFPA-ICM midwifery publication, “A Moment for Midwives: Celebrating our Global Midwife Community Amidst the COVID-19 Pandemic”, was developed to conclude 2020 as the International Year of the Nurse and the Midwife and launched in early 2021.28 24 UNFPA (2020), “COVID-19 Technical Brief for Maternity Services.” 25 UNFPA (2020), “Global Call to Action: Protecting Midwives to Sustain Care for Women, Newborns and their Families in the COVID-19 Pandemic.” 26 Motherhood Collective Impact Programme (2020), “Positive Pregnancy Experience in the COVID Era – What Will Be the New Normal?” 27 Sarah Bar-Zeev et al. (2020), “UNFPA Supporting Midwives at the Heart of the COVID-19 Response.” 28 ICM (2020), “A Moment for Midwives: Celebrating our Global Midwife Community Amidst the COVID-19 Pandemic.” 29 Barbara Chmielewska et al. (2021), Effects of the COVID-19 Pandemic on Maternal and Perinatal Outcomes: A Systematic Review and Meta-Analysis. EmONC: COVID-19 has had profound impacts on underresourced health systems. High dropout rates among front-line health workers due to long lockdowns and illness weakened fragile health systems even further, resulting in increased maternal and newborn morbidity and mortality. Using its available funding, UNFPA supported the local procurement and delivery of essential supplies and PPE for health workers; ensured access to sexual, reproductive and maternal health care and services responding to gender-based violence; and supported communication and community engagement on protective measures. Burkina Faso faced the closure of health facilities due to COVID-19 and attacks by unidentified armed men. To compensate for the impact on maternal and newborn health-care service delivery and EmONC, village birth attendants were offered skills enhancement and delivery kits. With MHTF support, EmONC facilities undertook a monitoring exercise to improve the quality of sexual and reproductive health services. Data on PPE availability for regional teams were analysed in a national report. MPDSR: Emerging evidence indicates that the pandemic has harmed pregnant women and babies. Stillbirth and pre-term birth rates have increased; similar trends are being observed for maternal deaths. Some studies have found an increase in maternal stress and ruptured ectopic pregnancies compared with before the pandemic.29 Reductions in health-care-seeking behaviour and maternity services have been suggested as possible causes. Robust estimates of the indirect maternal health effects of the pandemic were not available in 2020, however. The pandemic yielded both positive and negative impacts on MPDSR. At the global level, it provoked strengthened efforts to analyse MPDSR efforts in countries with high maternal mortality rates. UNFPA regional offices organized webinars to support countries but nationwide lockdowns, disruption of health-care services, fear of attending health-care facilities and in-country travel restrictions made recording and reviewing maternal and newborn deaths difficult. As some countries are carefully lifting nationwide lockdowns, UNFPA is making efforts to revitalize MPDSR programmes and undertake https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447209/ https://www.unfpa.org/resources/covid-19-technical-brief-maternity-services https://www.unfpa.org/resources/global-call-action-protecting-midwives-sustain-care-women-newborns-and-their-families https://motherhoodcollectiveimpact.org/positive-pregnancy-experience-in-the-covid-era-what-will-be-the-new-normal/ https://dx.doi.org/10.1016%2Fj.wombi.2020.08.005 https://a-moment-for-midwives.internationalmidwives.org/ https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00079-6/fulltext https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00079-6/fulltext 28 retrospective analyses of maternal and newborn deaths during lockdowns. Obstetric fistula: Service disruptions, travel restrictions and reluctance by pregnant women and girls to use services due to the fear of getting COVID-19 likely increased the risk of obstetric fistula and potentially maternal and newborn mortality and morbidity as well. In 2020, fistula repairs were widely halted or slowed down as they were deemed non-urgent and unsafe. This is expected to heighten the backlog of fistula cases. UNFPA took steps to mitigate gaps in care. In Uganda, for example, it supported the transportation of health workers and pregnant women to health facilities amid travel restrictions. This ensured access to critical reproductive health services, especially antenatal care and institutional delivery. Obtaining real-time data on fistula during COVID-19 remains a challenge; such data hardly exist in low-income settings. The full impact of the pandemic may, therefore, only be realized at a later stage, when more robust data become available. At that point, new strategies will be required to address the backlog of fistula cases while ensuring timely, quality and safe fistula surgery and redoubling prevention efforts. 1.6 SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS INTEGRATION ENSURING ACCESS TO QUALITY MATERNAL AND NEWBORN HEALTH CARE DURING COVID-19: THE UNFPA-TAKEDA PARTNERSHIP UNFPA’s COVID-19 strategy aims to maintain the continuity of maternal and newborn health services. To leverage strategic COVID-19 interventions and national EmONC facility networks, the Takeda Pharmaceutical Company supported the MHTF in responding to COVID-19 in Benin, Guinea and Togo, providing US$4.6 million for 12 months. The aim was to reach at least 350,000 women and newborns (including 12,700 women facing life-threatening complications) with life-saving maternal and newborn health services. The programme was designed by the MHTF in close collaboration with the health ministries of the respective countries and UNFPA’s country offices and regional office for West and Central Africa. In Togo, all 73 designated EmONC health facilities were provided with PPE, COVID-19 infection prevention and control training, and improved hygiene standards. Ten EmONC health facilities in one region received specific support in maintaining and improving the quality of services through the deployment of midwives, the procurement of life-saving commodities, the provision of remote prenatal and postnatal consultations, and the strengthening of referral transport for obstetric and newborn complications. In Benin, 49 health facilities were supported with PPE and COVID-19 prevention measures and referral transport. Supply chain networks were strengthened using drones to transfer life-saving medicines and blood supplies. In Guinea, 10 EmONC health facilities were provided with PPE, improving facility and mobile antenatal and postnatal care services, and community reproductive health services. In the first three months of the Takeda partnership, the MHTF supplied PPE (including 182,956 masks) and disinfection products to 132 targeted EmONC health facilities. Simultaneously, protocols and standards for COVID-19 risk mitigation were developed. Training on infection prevention and control supported 56 recruited midwives, and training on MPDSR bolstered skills among 46 health-care providers. Furthermore, 25 logisticians were equipped with drones and trained on last-mile supply chain management. UNFPA mobilized health ministries, public and private partners, media and communities to ensure the continuity of quality maternal and newborn health-care services. A monitoring system tracking the provision of services and the number of women and newborns benefiting from the partnership with Takeda found that after three months of implementation, the number of targeted EmONC health facilities providing services 24/7 increased from 11 per cent to 23 per cent in Guinea and from 40 per cent to 50 per cent in Togo. Preliminary results indicate that obstetric activity was maintained and even increased compared to the same period in 2019, as highlighted in Figure 1.5. ANNUAL REPORT 2020 29 PART I Better organized EmONC facility networks and quarterly monitoring increased Takeda’s interest in building resilient capacities amid the pandemic. The outcomes of the partnership demonstrated the catalytic impact of supporting EmONC facilities through adaptive and innovative approaches. The maintenance and even increase in obstetric services despite powerful downward pressures on resources make a compelling case for actions and investments like Takeda’s that can generate both immediate and lasting impacts. The contribution of the MHTF to the integration of the broader SRHR agenda is fully aligned with the overall principles of UNFPA’s work on SRHR. This is grounded in human rights principles and standards, including the right to sexual and reproductive health and well-being as part of the human right to health. Good sexual and reproductive health is a state of complete physical, mental and social well-being in all matters related to sexuality and reproduction. Everyone has a right to make informed decisions about their sexual and reproductive health, the capability to reproduce, and the freedom to decide if, when and how often to do so.30 UNFPA adheres 30 UNFPA (2019), Sexual and Reproductive Health and Rights: An Essential Element of Universal Health Coverage. to a life course approach, which recognizes the evolving nature of health-related needs and preferences, requiring tailored care for individuals when they need it throughout their lives, from birth through adolescence and various stages of reproductive life and old age. During 2020, linkages among the four MHTF pillars and with other elements of SRHR continued to be strengthened. The four pillars offer a unique opportunity for providing integrated services, enabling the MHTF to connect different components and take a comprehensive Figure 1.5 Number of births in 132 supported EmONC health facilities in Benin, Guinea and Togo 8000 7000 6000 5000 4000 3000 2000 1000 0 August September October November December 2019 2020 5.697 5.739 7.067 6.594 5.816 4.369 4.792 5.802 5.365 5.198 https://www.unfpa.org/sites/default/files/pub-pdf/UF_SupplementAndUniversalAccess_30-online.pdf https://www.unfpa.org/sites/default/files/pub-pdf/UF_SupplementAndUniversalAccess_30-online.pdf 30 approach on a path towards universal health coverage that includes SRHR. As part of its focus on midwifery and EmONC, and aligned with SDG targets 3.1 and 3.2, UNFPA seeks to strengthen health-care facilities and the health workforce and improve access to life-saving services for women and children, including the prevention of unsafe abortion and post-abortion care services. In partnership with the Liverpool School of Tropical Medicine, UNFPA commenced development of a mentorship toolkit for sexual, reproductive, maternal and newborn health- care providers. It offers guidance and resources to train mentors as well as guidelines, tools and resources for building the skills of mentees. Contents include suggested training equipment, case studies, role plays, clinical simulations, values clarification and attitude transformation exercises. The examples and activities are focused on delivery of maternal and newborn care, including EmONC. The toolkit supports high-impact mentorship and support to peers to strengthen capacities to deliver high-quality, integrated services for individuals across the life course. The development of networks of functioning EmONC facilities in a number of countries to improve access to high-quality health care as described earlier is one concrete example of how the interventions contribute to the integration of SRHR. A multi-step process begins with a situation analysis and an assessment of the ability of the health-care system to deliver EmONC services along with gaps and needs to realize fully functional facilities. In 2020, UNFPA revised EmONC assessment modules in collaboration with Columbia University’s Averting Maternal Death and Disability Program, seeking to capture data across the spectrum of integrated sexual and reproductive health services, and to strengthen questions and language on contraception and family planning services and comprehensive abortion care, including medical abortion. The 12 modules cover human resources; essential drugs, equipment and supplies; EmONC signal functions and other essential services; provider knowledge and competency and other topics. The updated tools and new module will be piloted through an EmONC assessment in Rwanda in 2021. The work testifies to UNFPA’s commitment to integrating services and demonstrates the power of EmONC as a platform for this. In East and Southern Africa, UNFPA applies a regional approach to promoting the integration of services as critical for advancing SRHR. It coordinates regional activities on policy, advocacy and strengthening health systems across multiple entities, partners and stakeholders. New activities and projects are integrated within this broader framework to work towards shared regional and country goals and ensure the greatest and most sustainable impact. In Zambia, UNFPA has trained health-care providers on SRHR across health- care facilities in the Central and Western provinces. Integrating an adolescent and youth focus into these trainings supports high-quality, respectful care for young people. SRHR stakeholder engagement meetings involving a range of health-care services and community leaders from the catchment areas provided an opportunity to build awareness of integrated approaches. In Mozambique, UNFPA is engaging communities and integrating information on a range of SRHR services in sensitization activities such as community debates and radio programmes. It is developing additional SRHR modules for youth mentorship training programmes as part of a commitment to leaving no one behind and improving access to services for young people. In the Democratic Republic of the Congo, the national cervical cancer strategy was implemented in functioning EmONC facilities using a streamlined screen-and-treat approach; UNFPA assisted with its programme management. A campaign for cervical cancer sensitization and screening and training for adequate treatment in Maniema Province benefited more than 700 women and girls. Two cryotherapy machines were ordered through UNFPA Procurement Services for delivery in 2021. Health personnel will be trained to use the machines for screening and treatment of early cervical cancer lesions. ANNUAL REPORT 2020 31 PART I ©UNFPA.Democratic. Republic.of.the.Congo,. Junior.Mayindu,.2020. Photo.submitted.to.the. 2021.MHTF.photo.contest. 32 PART II ©UNFPA.Bangladesh,. Fahima.Tajrin,.2020. Photo.submitted.to.the. 2021.MHTF.photo.contest. by.Alka.Jahan. "In 2020, the MHTF demonstrated impressive results across three important cross-cutting core principles: equity in access, quality of care and accountability." ANNUAL REPORT 2020 33 PART II OPTIMIZING EQUITY IN ACCESS, QUALITY OF CARE AND ACCOUNTABILITY: A COMPREHENSIVE APPROACH 31 WHO, “Quality of Care.” 32 WHO, “Health System Governance.” As UNFPA’s flagship programme, the MHTF is unique in the UN system in its focus on strategic interventions to strengthen health systems and improve equitable access to quality SRHR-integrated maternal and newborn health services. In 2020, the MHTF demonstrated impressive results across three important cross-cutting core principles: equity in access, quality of care and accountability. It made major efforts to ensure the continuation of SRHR- integrated maternal and newborn health services as the COVID-19 pandemic exacerbated existing disparities across all 32 MHTF-supported countries and exposed gaps in access to and demand for essential quality maternal and newborn health services. Equity in access implies that access to health care should be within reach of all, regardless of race, gender, ethnicity, disability, ability to pay, culture, geographic location, religion, political belief or socioeconomic condition. Yet striking disparities in health still exist within and between populations. Inequities in access to care persist and tend to affect the most vulnerable people, such as the poorest or those with the most complex health-care needs. Women and girls have been disproportionately affected by the COVID-19 pandemic and its consequences given gaps in essential services and complex intersections among the determinants of health. Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes, in a respectful manner. It is informed by evidence-based professional knowledge and is critical for achieving universal health coverage, which is core to the MHTF’s work.31 Quality of care implies that services must be delivered in a safe, effective, timely, efficient, integrated, equitable and people- centred manner, based on care standards and treatment guidelines, and taking into account people’s experiences and perceptions of care, including affordability and acceptability. With the COVID-19 pandemic, it has become increasingly difficult for governments to effectively deliver quality health care to all mothers and newborns while protecting the well-being of the health- care workforce. Several governments have turned to the MHTF for support. Accountability considers rights-holders’ views and demands in planning and implementation of sexual, reproductive, maternal and newborn health programmes. Accountability in health systems is complex, covering multiple relationships. Health system users, health ministries, social health insurance agencies, public and private providers, legislatures, finance ministries and regulatory agencies are all interconnected in networks of control, oversight, cooperation and reporting.32 Review processes, enabling legislation and regulatory bodies each contribute to accountability, and underpin continuous quality of care, equity in access and overall responsibility for sexual, reproductive, maternal and newborn health. The COVID-19 pandemic has once more highlighted the importance of accountability in fragile health settings and public health emergencies. In 2020, the MHTF worked to strengthen governance and coordination mechanisms; generate, share and enable the use of health-related data; and empower health system stakeholders and beneficiaries. For example, in Mauritania, advocacy sought to accelerate the establishment of a regulatory midwifery body. Catalytic by nature, the MHTF has supported interventions that integrate these three principles so that high-burden countries quicken action and scale up evidence-based innovations for improving maternal and newborn health and well-being. The following country examples show how the MHTF integrates support across the three areas. 34 COUNTRY EXAMPLES OF IMPLEMENTATION IN SERVICE DELIVERY Equity in access In the Republic of Congo, the pandemic has been an opportunity for the MHTF to help address the needs of specific underserved populations (deaf, blind, disabled, persons with albinism, etc.) by providing tailored tools to raise awareness of maternal and newborn health and COVID-19. UNFPA launched "Yo! Moms" in Côte d'Ivoire, a digital application built around SMS communication services and automatic voicemail in French and local languages. It links health workers, pregnant women and women of reproductive age to share real-time information on COVID-19-related maternal and newborn health issues. Information is collected and fed into databases to adapt messages to the needs of women in the language they use. In Bangladesh, UNFPA supported the Government in deploying midwives to community and referral facilities to ensure uninterrupted maternal health care. In Ghana, assistance to youth-led programmes helped in using social media and other digital platforms to reach vulnerable populations such as poor rural-to- urban migrants, people with disabilities and juveniles in correctional facilities. Midwives were recruited to provide consultations and carry out mobile clinics in Haiti, helping to extend sexual and reproductive health services to more than 10,000 working women in industrial zones. With MHTF support, a designated obstetric fistula treatment centre in Nepal conducted 27 free surgeries on marginalized and disadvantaged women. After 193 participants attended awareness sessions, a two-day screening camp identified 70 cases of uterovaginal prolapse that were referred for treatment. In Nigeria, a rural Maternity Waiting Home was established to improve access to and use of emergency obstetric care services for women in underserved communities. All pregnant women, including pregnant fistula survivors, were encouraged to stay at the maternity waiting home, while supervised and supported by community midwives. The home provided services including antenatal and postnatal care, family planning, immunization, newborn care and health promotion. The procurement of 31 mini- ambulances helped serve hard-to-reach areas. In 2020, MHTF-assisted countries continued to explore innovative approaches to training midwives. In Côte d’Ivoire, midwifery students used a solar- powered digitized platform making education more accessible without requiring Internet access. Users tap into a smartphone to access course content offline, including text, images, video and practical virtual mannequin simulations. Bangladesh developed an app that facilitates health emergency transportation. In Nepal, a helpline staffed by midwives was launched with the “Mothers Love” app to aid in tracking pregnant and postnatal women. Within five months, a total of 2,656 calls to the helpline had requested information, counselling and referral services related to maternal and newborn health. Quality of care In Niger, MHTF assistance led to 61 midwives mentoring 511 inexperienced health-care workers on managing obstetric and neonatal complications, providing modern family planning methods and offering respectful quality care. Mentorship covered topics like infection prevention and control, organization of services, filling and maintenance of partograms, data collection and reporting tools. In Malawi, the National Midwifery Association mentored 83 midwifery leaders in 28 districts on leadership and respectful maternity care in the context of COVID-19. As a result, midwifery leaders at a decentralized level could better advocate for financial resources from the national level. In Bangladesh, assisted vaginal delivery training workshops for district SRHR officers and government medical officers substantially enhanced capacities to conduct safe deliveries. Mentorship and on-the-job training built skills in 19 newly established district-level cervical cancer screening centres. In Chad, handwashing devices provided to camps hosting refugees and internally displaced persons assisted in preventing or slowing the spread of COVID-19 among vulnerable populations. Training midwives on infection prevention and control and the provision of PPE sustained quality maternal health services. In the Democratic Republic of the Congo, training materials and mannequins for skill labs bolstered capacities in three midwifery schools, which were accredited based on curricula harmonized with international ICM and WHO standards. In Haiti, the MHTF furnished 48 EmONC maternity hospitals with PPE; these account for more than half the national EmONC network. Protocols for early detection of COVID-19 were disseminated, and 20 EmONC maternity hospitals established dedicated triage spaces. More than ANNUAL REPORT 2020 35 PART II 3,000 health professionals benefited from PPE supplies, including 1,000 involved in social work. The Ministry of Public Health and Population was supported in developing an orientation guide for adapting maternity services. In Nigeria, the Ogun State School of Midwifery in Abeokuta upgraded the quality of midwifery education by adhering to national accreditation requirements. UNFPA supported the establishment of a clinical skills laboratory and procured a high-speed Internet server and website domain, multi-user desktop computers and laptops with accessories, electronic demonstration teaching materials, e-books and electronic simulators, and demonstration models. It provided funds to renovate dilapidated school infrastructure and revise the training curriculum. Books, equipment, and teaching and learning aids also strengthened the capacity of midwifery schools in Kenya, Malawi and Timor-Leste. The MHTF, UNFPA and the Campaign to End Fistula contributed to the expansion of a competent health workforce by training 6,267 health workers, including fistula surgeons, midwives, nurses, anaesthetists and doctors, on the prevention of and response to obstetric fistula, and infection prevention and control. Training took place in Bangladesh, Burkina Faso, Burundi, the Democratic Republic of the Congo, Haiti, Guinea- Bissau, Mozambique and Nigeria. The provision of fistula repair kits, medical supplies and other equipment enhanced quality care in 1,475 health facilities. Accountability In Bangladesh, UNFPA built MPDSR capacities among health-care providers in six districts; 262 maternal deaths underwent a verbal autopsy; an MPDSR progress report was developed and a fistula data record tool was generated. In Burkina Faso, the International Day to End Obstetric Fistula was commemorated to strengthen national political commitment and mobilize regional authorities and civil society organizations in the fight to eliminate and reduce cases of obstetric fistula. In Mauritania, advocacy aimed at reinforcing commitment to strengthening national EmONC networks led to upgrading 16 health centres to the EmONC level and providing on-site training for 133 providers on EmONC best practices. 33 UN Women, “SDG 3: Ensure healthy lives and promote well-being for all at all ages.” In the Democratic Republic of the Congo, the midwifery association successfully introduced a parliamentary bill on midwifery with several important components, such as a midwifery act, and standards related to the midwifery scope of practice, licensing, examination process, school accreditation and staff retention. Respectful maternity care training improved skills for 30 midwives in Zambia, 52 in Guinea-Bissau, and 667 in Nigeria. The training heightened awareness of the rights of women during childbirth and positively influenced perceptions of respectful care, which contributes to reducing preventable maternal mortality and morbidity and meeting the SDG targets for maternal health.33 In Uganda, UNFPA continued to support scaled-up use of GIS to monitor the geographic distribution of the midwifery workforce and training for midwives on its use. In 2020, 3,049 midwives and 6,299 nurses enrolled in the GIS programme, bringing the total to 5,005 midwives and 10,602 nurses currently enrolled. UNFPA supported Côte d’Ivoire in a similar endeavour, helping to enhance its existing database to monitor and increase midwife registration and track geographical distribution. Through MHTF support, Malawi, Sudan and Zambia initiated new strategies to end fistula. A number of countries (Burkina Faso, Burundi, Chad, Liberia, Madagascar, Mauritania, Niger, Nigeria, Sudan and Uganda) reported that the MHTF played a significant role in increasing the capacity to mobilize resources to prevent maternal mortality and morbidity, including fistula. High-level advocacy by UNFPA in Burundi with First Lady Angéline Ndayishimiye Ndayubaha sparked significant commitment from Her Excellency and resulted in the mobilization of substantial funding from the private sector to support the integrated care of women with obstetric fistula. https://www.unwomen.org/en/news/in-focus/women-and-the-sdgs/sdg-3-good-health-well-being 36 PART III ©UNFPA.Ghana,.George. Koranteng,.2020.Photo. submitted.to.the.2021. MHTF.photo.contest.by. Doris.Aglobitse. "MHTF-supported country offices were able to raise substantial additional funding for maternal and newborn health programming at the national level." ANNUAL REPORT 2020 37 Table 3.1 MHTF resource allocation criteria and weighting MHTF resource allocation criteria and weighting Weight, percentage Maternal and newborn mortality reduction 20 Skilled birth attendant availability 20 EmONC availability 20 Expenditure rate 20 Maternal and newborn health programme monitoring (the extent to which information is available at various levels in the country) 20 Total 100 MHTF RESOURCE MANAGEMENT 3.1 BACKGROUND In 2020, the MHTF further strengthened its catalytic impact by leveraging additional resources and building capacity at the country and regional levels. MHTF- supported country offices were able to raise substantial additional funding for maternal and newborn health programming at the national level. The MHTF comprises two multi-donor funding streams: the Thematic Fund for Maternal and Newborn Health and the Thematic Fund for Obstetric Fistula. In line with most multilateral organizations, UNFPA increasingly sees donors earmarking resources for a specific purpose or region. MHTF funds are allocated to countries based on specific criteria to ensure that resources reach where they are most needed and work in harmony with other UNFPA funding streams and the Strategic Plan. Table 3.1 shows the criteria and weighting that the MHTF used in 2020 to calculate the needs of programme countries and allocate resources accordingly. For each category, each of the 32 MHTF-supported countries receives a score. Cumulatively, these form the basis for determining the annual resource envelope from the MHTF. To mitigate the impact of sudden changes in allocations, a cap limits budget reductions to 10 per cent a year. In 2020, the MHTF continued to prioritize high-burden countries in accordance with its programme agreement. Support for strategic, evidence-based activities took place in 32 countries and five regional offices (Asia and the Pacific, Arab States, East and Southern Africa, Latin America and the Caribbean, and West and Central Africa). The MHTF’s two funds have been programmatically integrated since 2009. The majority of the funding for the Campaign to End Fistula is provided directly from the Thematic Fund for Maternal and Newborn Health, since this eases coordination and programme management. See Annex 2 for approved allocations, expenditures and financial implementation rates. 3.2 CONTRIBUTIONS As shown in Table 3.2, in 2020, approximately US$18.1 million went to the Thematic Fund for Maternal and Newborn Health and US$0.5 million to the Thematic Fund for Obstetric Fistula, about US$4.5 million more than in 2019 when both funds received US$13.1 million. PART III 38 3.3 OPERATING BUDGET The 2020 operating budget for the Thematic Fund for Maternal and Newborn Health and the Thematic Fund for Obstetric Fistula encompassed the end-of-year balance for 2019 plus income received during the first three quarters of 2020. Income received during the fourth quarter is typically carried over to the following year since it normally cannot be programmed and expended within such a short time frame. In accordance with International Public Sector Accounting Standards, transactions are only recorded as expenses when services or goods have been carried out or handed over to an implementing partner. As Table 3.3 shows, the Thematic Fund for Maternal and Newborn Health and the Thematic Fund for Obstetric Fistula received US$426,416 in the fourth quarter of 2019 to be used in 2020. An additional US$4,832,438 was carried over from the regular programme budget from 2019 to 2020. Further, donors contributed US$14,896,176 during the first three quarters of 2020. This brought the total operating budget for the Thematic Fund for Maternal and Newborn Health to US$20,155,031 in 2020 (Figure 3.1). Table 3.2 Donor contributions to the Thematic Fund for Maternal and Newborn Health and the Thematic Fund for Obstetric Fistula in 2020 (US$) Donors Maternal and Newborn Health Fund Fistula Fund Total collected revenue Friends of UNFPA 14,659 3,861 18,520 Germany 2,366,849 2,366,849 Luxembourg 1,965,066 436,681 2,401,747 Poland 39,708 39,708 Portugal 56,883 Sweden 8,839,503 8,839,503 Takeda Pharmaceutical 4,750,023 Interest and adjustments 84,976 9,668 94,644 Total 18,077,958 489,918 18,567,875 * Collected revenue comprises actual amounts transferred from donors to UNFPA in 2020. In addition, the two funds received contributions for 2020 in the fourth quarter of 2019 as shown in Table 3.3. Table 3.3 Fourth quarter 2019 donor contributions to the Thematic Fund for Maternal and Newborn Health and the Thematic Fund for Obstetric Fistula (US$) Donors Maternal and Newborn Health Fund Fistula Fund Total collected revenue Friends of UNFPA 35,919 16,380 Germany 111,111 111,111 Laerdal Global Health 4,665 Poland 51,387 51,387 Sweden 93,197 Interest and adjustments 119,797 10,340 130,136 Total 364 689 61 727 426 416 ANNUAL REPORT 2020 39 PART III 2+8+22+2+25+41+y 3.4 EXPENSES In 2020, expenditures on maternal and newborn health through the Thematic Fund for Maternal and Newborn Health totalled US$12 million (US$11,989,889), compared to US$10.9 million in 2019, US$12.1 million in 2018, US$13.3 million in 2017, US$13.6 million in 2016, US$13.4 million in 2015 and US$16.8 million in 2014. In 2020, spending by country and regional programmes accounted for 75 per cent of expenditures, whereas global activities accounted for 25 per cent. Included in the global activities are disbursements of US$670,274 to international implementing partners. When accounting for the fact that international implementing partners use resources for country and regional operations, the distribution was 80 per cent for countries and regions and 20 per cent for global activities. Of total expenditures, 13 per cent, or US$1.5 million, was disbursed via NGOs; 23 per cent, or US$2.7 million, was disbursed via a government partner; and 64 per cent, or US$7.5 million, was disbursed via UNFPA directly. Among the regions, West and Central Africa accounted for most expenses for maternal health at 41 per cent (US$4,908,465) of the total. Headquarters expenses constituted 25 per cent (US$3,011,160). East and Southern Africa accounted for 22 per cent (US$2,631,807), Asia and the Pacific for 8 per cent (US$927,888), the Arab States for 2 per cent (US$254,845), and Latin America and the Caribbean for 2 per cent (US$255,724). See Figure 3.2. In 2020, expenditures on maternal and newborn health of US$12 million represented a financial implementation rate of 59 per cent against the total operational budget of US$20.1 million. The amount transferred to 32 country offices, four regional offices and headquarters units was US$15.3 million. Arab States Asia and the Pacific East and Southern Africa Latin America and the Caribbean Global/headquarters West and Central Africa 2% 8% 22% 25% 41% 2% Figure 3.1 Budget for the Thematic Fund for Maternal and Newborn Health and the Thematic Fund for Obstetric Fistula 2014-2020 (millions of US$) Figure 3.2 Shares of expenditures for maternal and newborn health by region and globally in 2019 30 25 20 15 10 5 0 2014 24.5 2015 18.3 2016 16.7 2017 7.7 2018 12.5 2019 15.3 2020 20.2 40 Staff and other personnel costs $3,348,056 Supplies, commodities, materials $1,355,977 Equipment, vehicles and furniture including depreciation $332,337 Contractual services $2,373,485 Travel $727,573 Transfers and grants to counterparts $19,004 General operating and other direct costs $3,025,414 Indirect support costs $808,042 28+11+3+20+6+25+7+y3%28%11%6%25% 7% 20% Figure 3.3 MHTF expenditures by category in 2020 3.5 CATEGORIES OF EXPENDITURE As highlighted in Figure 3.6, the total allocation to country, regional and global programmes in 2020 was US$15.3 million. Corresponding expenses reached US$12 million. Figure 3.3 details expenditure categories. ©UNFPA Guinea. ANNUAL REPORT 2020 41 42 PART IV ©UNFPA.Haiti,.Samuel. Laméry.Pierre,.2020. Photo.submitted. to.the.2021.MHTF. photo.contest. "Effectively assessing and responding to the challenges caused by the pandemic remains crucial to building resilient capacities for health systems to progress." ANNUAL REPORT 2020 43 LESSONS LEARNED AND WAY FORWARD 34 UNFPA (2021), “Impact of COVID-19 on Family Planning: What We Know One Year into the Pandemic.” CHALLENGES Since the inception of the UNFPA Strategic Plan 2018- 2021, the MHTF has been core to organizational goals and paths to achieve the SDGs. The MHTF remains UNFPA’s catalytic flagship programme for SRHR- integrated maternal and newborn health, accelerating progress towards achieving the 2030 Agenda for Sustainable Development and UNFPA’s transformative result to end preventable maternal mortality. In 2021 and beyond, the MHTF will build on its integrated approach to sexual, reproductive, maternal and newborn health within the scope of universal health coverage and improved quality of care. Effectively assessing and responding to the challenges caused by the pandemic remains crucial to building resilient capacities for health systems to progress. COVID-19 lockdowns have been associated with increased unintended pregnancies. While women continued to give birth, it is anticipated that lockdowns have disrupted family planning services. A study by UNFPA and Avenir Health showed that the pandemic disrupted contraceptive services for 12 million women, resulting in an estimated 1.4 million unintended pregnancies across 115 low- and middle-income countries.34 The COVID-19 pandemic has further strained already weak and fragile health systems, health workers and midwives in particular during the emergency response. It served as a stress test for SRHR-integrated maternal and newborn health services across all 32 MHTF-assisted countries. Even in countries with more robust health systems, new challenges emerged from the need to meet sudden surges in demand, maintain universal access and manage population-specific challenges. In dealing with the crisis, sexual, reproductive, maternal and newborn health services, which should have been considered essential, were often marginalized. In many MHTF- supported countries, not all health workers, such as midwives, received PPE. Maternity units were repurposed for general medical care, and midwives were removed from providing maternity services to work in public health or general medical areas. UNFPA’s efforts to address pandemic realities took precedence over other planned initiatives due to supply chain and health system disruptions, lockdowns, the limited mobility of providers and seekers of maternal health care, fear and stigma, closure of midwifery schools, and, above all, a lack of understanding of the impacts of the pandemic on maternal and newborn health. Alternative systems of service delivery, such as for remote antenatal and postnatal care and for education and training, had to be quickly developed and disseminated while recognizing that some places have inadequate digital access. Lockdowns stirred the shift to the virtual world. The demand for online learning for pre-service and in-service midwifery education, including e-modules and e-facilitation, skyrocketed. New partnerships with the Maternity Foundation and the Liverpool School of Hygiene and Tropical Medicine supported remote education and the acquisition of virtual education resources. Yet ongoing challenges from the poor quality of midwifery care continued to exist. These included overall weak health infrastructure and policies, limited investment in the quality of midwifery education and training, the lack of deployment and retention policies, weak midwifery associations, inadequate interprofessional collaboration, weak capacities of midwives in EmONC management and insufficient leadership within the midwifery workforce. Resource shortages have become an increasing concern for the MHTF, especially as COVID-19 impacts implementation across areas of work, despite tremendous and growing needs. Greater awareness of COVID-19-related challenges is imperative, requiring advocacy for resources and action. Funding for the MHTF goes beyond investing in public health. Equitable access to SRHR-integrated maternal and newborn health PART IV https://www.unfpa.org/sites/default/files/resource-pdf/COVID_Impact_FP_V5.pdf 44 services strengthens overall health systems, moving them closer to universal health coverage by extending sexual and reproductive rights and choices to all women and girls. These efforts have assumed even greater importance since the onset of the pandemic. The MHTF will continue to forge new partnerships across the global maternal and newborn health community to address increasing needs. As governments in the Global North experience unprecedented budget deficits and governments supported by the MHTF lack access to financial resources, however, the pandemic constitutes a profound threat to livelihoods and well-being. How donors respond to the COVID-19 pandemic and its aftermath over the next few years will shape the future of development cooperation and its ability to save lives on the ground. It is hoped that support to the MHTF will increase given dire needs. LESSONS LEARNED Midwifery continues to be affected by shortages of well-educated midwifery education faculty and a dearth of high-quality education to adequately prepare midwives for the workforce. The MHTF will maintain its efforts to improve midwifery pre-service education with comprehensive competency-based curricula. A new project finalized with Johnson & Johnson will address these gaps. Strong evidence-based advocacy for enhanced investments in a functional health system is required to provide an enabling practice environment for midwives, along with effective regulatory mechanisms. The 2021 State of the World’s Midwifery Report explores advocacy efforts. The MHTF will continue to maintain global partner and donor commitment and is making efforts to foster this at global convenings (e.g., the ICM, the FIGO Congress and a dialogue series with the Wilson Center). An integrated sexual, reproductive, maternal, newborn and adolescent health approach is needed to holistically address preventable maternal and newborn deaths. Leadership in midwifery associations needs to be strengthened and young midwifery leaders promoted. With UNFPA sufficiently positioned and recognized as a global midwifery leader, it is committed to scaling up midwifery staff capacities, midwifery-led models of care, the capacity of country and regional midwife advisers to advocate for increased quality midwifery care and other promising initiatives. EmONC networks and health systems need resilience to function in pandemics and sustain essential services including for SRHR. They must be able to provide quality assurance and maintain monitoring as crucial to the reduction of maternal and newborn mortality and morbidities such as fistula. Strengthened health systems can enhance and promote services for SRHR-integrated maternal and newborn health services. MPDSR remains critical for improving the quality of maternal and neonatal health care, as demonstrated throughout 2020. MPDSR is also instrumental in informing advocacy, policymaking, planning, service delivery and accountability for ending preventable maternal and neonatal mortality. While MPDSR is an excellent tool to address the underlying causes of maternal and newborn death, the COVID-19 pandemic and associated national lockdowns posed a variety of obstacles that aggravated others existing even before the pandemic. The latter include a culture of blame, fear of retribution, a lack of skilled staff, stand-alone management and inadequate funds. As the pandemic continues, the MHTF will remain focused on countries’ abilities to improve MPDSR programme management and implementation at scale, within SRHR-integrated maternal and newborn health programmes. The fund will continue to utilize MPDSR as a tool for improving the quality of care across midwifery, EmONC networks and fistula prevention efforts. MPDSR will further contribute to quality improvements in health-care facilities as well as monitoring and reporting at the subnational and national levels. Fistula’s decline in prevalence indicates significant progress being made towards eradication by 2030. Yet despite the efforts of the United Nations and a large cadre of partners, formidable challenges remain to sustain the gains made. Actions and investments need to be significant and accelerated. Financial and human resources, technical expertise and quality data to inform programmes will be key to take crucial additional steps towards eradication. Fistula prevention (including midwifery-led care and timely, quality EmONC), treatment and social reintegration programmes and policies should address both supply and demand side barriers for successful delivery. Ending fistula by 2030 also requires a vertical approach (such as UNFPA’s continued and strategic leadership of the global Campaign to End Fistula) and a horizontal one (such as integrating fistula into broader programmes on gender, human rights, disabilities, quality of care and SRHR, including adolescent sexual and reproductive health). Technical and financial support from the international ANNUAL REPORT 2020 45 PART IV community remain key for affected countries to eliminate obstetric fistula by 2030. SRHR integration efforts in 2020 affirmed the value of a holistic approach to improving health outcomes for women and girls. This approach takes into account the full ecosystem and multiple levels of socioecological systems, including advocacy and policy, organizational and health systems, and the community, interpersonal, and individual levels. Activities and movement at each level influence the others. Favourable policies, laws and regulations, for instance, are only meaningful if they are enacted, enforced and understood. Expanding the range of sexual, reproductive, maternal, newborn, child and adolescent health services available to women will only have an impact if they are aware of and able to access these. Similarly, without targeted health-care provider training, women will not be able to fully exercise their SRHR and make their own empowered choices. Social norms, gendered social expectations and stigma affect women’s and girls’ abilities to make decisions on their SRHR even if other elements of an enabling environment are present. WAY FORWARD Catalytic in nature, the MHTF will continue to make major strides towards reducing maternal and newborn mortality and morbidity by leveraging government and other resources at the country, regional and global levels. UNFPA in 2021 will develop its new global Strategic Plan maintaining the core role of the MHTF, which will continue to function as a flagship for SRHR-integrated maternal and newborn health, and for accelerating progress towards achieving the 2030 Agenda and UNFPA’s transformative result of ending preventable maternal and newborn mortality. An MHTF evaluation is planned for 2021. It will lay the groundwork for strategic ways towards the end of MHTF Phase III and beyond. The MHTF Advisory Board established in 2020 now serves as a platform for information exchange, guidance and consultation. Its role will be further strengthened as the MHTF’s initiatives continue to grow. Throughout the COVID-19 pandemic, UNFPA was at the forefront of galvanizing action to support front- line health workers. It will continue to ensure that maternity services are prioritized in every emergency while health workers are kept safe and midwives are not diverted from their core work. Alternative service delivery models for remote antenatal and postnatal care developed during the pandemic show potential for continued use beyond the pandemic. These new models are currently being evaluated by UNFPA in Asia and the Pacific together with the Burnet Institute. Innovative and technology-driven approaches are in high demand and are increasingly feasible even in low-resource settings. UNFPA has already taken steps towards updating existing e-modules and developing new ones for competency-based curricula. It is also developing and adopting learning and educational videos demonstrating key competencies and actions during obstetric emergencies. As the COVID-19 pandemic continues, the MHTF will prioritize SRHR-integrated maternal and newborn health, and implement cutting-edge, technology-based interventions to support women and their newborns. The fund will strengthen country capacities to implement and manage strong midwifery, EmONC, MPDSR and fistula programmes. Acknowledging that the health of women and newborns represents a critical window for life-saving interventions, and prevention and health promotion, with effects throughout the life course, the MHTF will continue to develop its successful initiatives and take further steps to harness global efforts to advance universal health coverage. Partnerships and synergies with the UNFPA Supplies Programme (contraceptives and maternal health medicines), the UNFPA-UNICEF Joint Programme on Female Genital Mutilation and Joint Programme on Child Marriage, UNFPA’s Comprehensive Sexuality Education Programme, UHC 2030, the Global Action Plan for Healthy Lives and Wellbeing For All, the global H6 Partnership, Ending Preventable Maternal Mortality, the Every Newborn Action Plan, the International Parliamentarian Union, the Human Rights Council, the European Parliamentary Forum for Sexual and Reproductive Rights, the private sector, civil society, and midwifery and Campaign to End Fistula partners will remain crucial for policy advocacy, scalability, sustainability and impact. These and new strategic partnerships will be further scaled up to invoke political will and action, including through the catalytic leveraging of national and other global resources for sustainable sexual, reproductive, maternal, newborn and adolescent health initiatives. 46 ANNEXES 47ANNUAL REPORT 2020 ANNEXES ANNEX 1: CAMPAIGN TO END FISTULA PARTNERS 1. Aden Hospital, Yemen 2 African Medical & Research Foundation 3. American College of Nurse-Midwives 4. Babbar Ruga Fistula Hospital 5. Bangladesh Medical Association 6. Bill & Melinda Gates Institute for Population and Reproductive Health 7. Bugando Medical Centre, United Republic of Tanzania 8. CARE 9. Centers for Disease Control and Prevention 10. Centre Mère-Enfant, Chad 11. Centre National de Référence en Fistule Obstétricale, Niger 12. Centre National de Santé de la Reproduction et du Traitement des Fistules, Chad 13. Columbia University's Averting Maternal Death and Disability Program 14. Comprehensive Community Based Rehabilitation in Tanzania 15. CURE International Hospital of Kabul, Afghanistan 16. Direct Relief International 17. Dr. Abbo's National Fistula and Urogynaecology Center, Sudan 18. East Central and Southern Africa Association of Obstetrical and Gynaecological Societies 19. EngenderHealth 20. Equilibres & Populations 21. Eritrea Women's Project 22. Family Care International 23. Fistula e.V. 24. Fistula Foundation 25. Fistula Foundation Nigeria 26. Freedom from Fistula Foundation 27. Friends of UNFPA 28. Focus Fistula, Mozambique 29. Geneva Foundation for Medical Education and Research 30. Girls' Globe 31. Governess Films 32. Gynocare Fistula Center, Kenya 33. Hamlin Fistula, Ethiopia 34. Healing Hands of Joy 35. Health and Development International 36. Health Poverty Action, Sierra Leone 37. Hope Again Fistula Support Organization, Uganda 38. HOPE Foundation for Women & Children of Bangladesh 39. Human Rights Watch 40. Institut de Formation et de Recherche en Urologie et Santé de la Famille, Senegal 41. International Confederation of Midwives 42. International Continence Society 43. International Federation of Gynecology and Obstetrics 44. International Forum of Research Donors 45. International Medical Response 46. International Nepal Fellowship 47. International Planned Parenthood Federation 48. International Society of Obstetric Fistula Surgeons 49. International Urogynecology Association 50. International Women’s Health Coalition 51. Islamic Development Bank 52. Johnson & Johnson 53. Johns Hopkins Bloomberg School of Public Health 54. Kupona Foundation 55. Lake Tanganyika Floating Health Clinic 56. Ligue d'Initiative et de Recherche Active Pour la Santé et l'Education de la Femme, Cameroon 57. London School of Hygiene and Tropical Medicine 58. Maputo Central Hospital, Mozambique 59. Médecins du Monde 60. Médecins Sans Frontieres 61. Mercy Ships 62. Moi University, Kenya 63. Monze Hospital, Zambia 64. Mulago Hospital and School, Uganda 65. National Obstetric Fistula Centre of Abakiliki, Nigeria 66. Obstetrical and Gynaecological Society of Bangladesh 67. One by One 68. OperationFISTULA 69. Pakistan National Forum on Women’s Health 70. Pan African Urological Surgeons Association 71. Population Media Center 72. Psychology Beyond Borders 73. Regional Prevention of Maternal Mortality Network 74. Royal College Of Obstetricians & Gynaecologists 75. Sana'a Hospital, Yemen 76. Selian Fistula Project 77. Société Africaine des Gynécologues-Obstétriciens 78. Société Internationale d’Urologie 79. Solidarité Femmes Africaines 80. The Association for the Rehabilitation and Re-Orientation of Women for Development, Uganda 81. Uganda Childbirth Injury Fund 82. United Nations Federal Credit Union Foundation 83. United Nations Population Fund 84. United States Agency for International Development 85. University of Aberdeen 86. University Teaching Hospital of Yaounde, Cameroon 87. Virgin Unite 88. West African College of Surgeons 89. White Ribbon Alliance 90. Women and Health Alliance International 91. Women's Health Organization International 92. Women's Hope International 93. Women's Missionary Society of the African Methodist Episcopal Church 94. World Health Organization 95. World Vision 96. Worldwide Fistula Fund 97. Zonta International 48 ANNEX 2: DETAILED BUDGET ALLOCATIONS Approved allocations, expenditures and financial implementation rates for both the Thematic Fund for Maternal and Newborn Health and Thematic Fund for Obstetric Fistula appear below. 2019 Maternal and Newborn Health Fund and Fistula Fund 2020 Maternal and Newborn Health Fund and Fistula Fund Regional office/country office/ global technical support 2019 Allocation ceiling, US$ 2019 Funds transferred, US$ 2019 Expenses, US$ 2020 Allocation Ceiling, US$ 2020 Funds transferred, US$ 2020 Expenses, US$ Utilization rate, percentage Change in expenses 2020 vs. 2019 US$ Arab States Regional Office 107,000 74,900 62,431 107,000 - - 0 (62,431) Somalia, Mogadishu 308,760 308,759 282,999 - - - 0 (282,999) Sudan, Khartoum 481,500 338,058 245,248 481,500 344,670 254,845 74 9,597 Total 897,260 721,717 590,678 588,500 344,670 254,845 74 (335,832) Asia and the Pacific Bangladesh, Dhaka 214,000 149,800 147,128 214,000 171,200 168,319 98 21,192 Lao People's Democratic Republic, Vientiane 328,058 328,115 327,594 327,955 300,349 298,855 100 (28,739) Nepal, Kathmandu 246,100 203,297 186,982 246,100 246,100 214,277 87 27,295 Regional Office 107,000 107,000 100,556 107,000 53,500 31,688 59 (68,868) Timor, Leste 327,848 224,700 174,049 388,789 321,820 214,749 67 40,700 Total 1,223,006 1,012,912 936,307 1,283,844 1,092,969 927,888 85 (8,419) East and Southern Africa Burundi, Bujumbura 428,000 428,000 400,098 428,000 399,067 395,387 99 (4,711) Democratic Repbulic of the Congo, Kinshasa 327,924 328,267 335,421 327,924 327,925 336,609 103 1,188 Ethiopia, Addis Ababa 453,424 604,500 325,234 453,425 665,635 348,683 52 23,449 Kenya, Nairobi 321,000 224,700 149,996 321,000 278,200 253,656 91 103,660 Madagascar, Antananarivo 424,279 424,278 402,979 424,279 361,194 351,327 97 (51,653) Malawi, Lilongwe 171,682 85,865 77,496 171,682 137,345 117,754 86 40,258 Mozambique, Maputo 321,000 196,577 191,949 307,019 182,849 124,445 68 (67,503) Regional Office 171,200 171,200 104,498 170,537 96,381 95,827 99 (8,671) Rwanda, Kigali 332,608 332,609 148,015 247,008 160,556 153,457 96 5,442 Uganda, Kampala 310,623 310,300 295,070 310,300 273,482 244,752 89 (50,318) Zambia, Lusaka 321,000 270,710 264,612 246,100 230,568 209,911 91 (54,702) Total 3,582,740 3,377,006 2,695,368 3,407,273 3,113,202 2,631,807 85 (63,561) Latin America and the Caribbean Haiti, Port-au-Prince 324,198 162,099 158,648 323,675 161,995 151,839 94 (6,809) Regional Office 107,000 107,000 106,819 107,000 107,001 103,885 97 (2,934) Total 431,198 269,099 265,467 430,675 268,996 255,724 95 (9,743) Office of the Executive Director Non-core Funds Management Unit 142,297 142,297 128,385 132,987 132,987 124,534 94 (3,851) Technical Division Sexual and Reproductive Health Branch 2,243,842 2,243,842 2,243,842 2,888,488 2,888,488 2,886,626 100 642,784 49ANNUAL REPORT 2020 ANNEXES 2019 Maternal and Newborn Health Fund and Fistula Fund 2020 Maternal and Newborn Health Fund and Fistula Fund Regional office/country office/ global technical support 2019 Allocation ceiling, US$ 2019 Funds transferred, US$ 2019 Expenses, US$ 2020 Allocation Ceiling, US$ 2020 Funds transferred, US$ 2020 Expenses, US$ Utilization rate, percentage Change in expenses 2020 vs. 2019 US$ Arab States Regional Office 107,000 74,900 62,431 107,000 - - 0 (62,431) Somalia, Mogadishu 308,760 308,759 282,999 - - - 0 (282,999) Sudan, Khartoum 481,500 338,058 245,248 481,500 344,670 254,845 74 9,597 Total 897,260 721,717 590,678 588,500 344,670 254,845 74 (335,832) Asia and the Pacific Bangladesh, Dhaka 214,000 149,800 147,128 214,000 171,200 168,319 98 21,192 Lao People's Democratic Republic, Vientiane 328,058 328,115 327,594 327,955 300,349 298,855 100 (28,739) Nepal, Kathmandu 246,100 203,297 186,982 246,100 246,100 214,277 87 27,295 Regional Office 107,000 107,000 100,556 107,000 53,500 31,688 59 (68,868) Timor, Leste 327,848 224,700 174,049 388,789 321,820 214,749 67 40,700 Total 1,223,006 1,012,912 936,307 1,283,844 1,092,969 927,888 85 (8,419) East and Southern Africa Burundi, Bujumbura 428,000 428,000 400,098 428,000 399,067 395,387 99 (4,711) Democratic Repbulic of the Congo, Kinshasa 327,924 328,267 335,421 327,924 327,925 336,609 103 1,188 Ethiopia, Addis Ababa 453,424 604,500 325,234 453,425 665,635 348,683 52 23,449 Kenya, Nairobi 321,000 224,700 149,996 321,000 278,200 253,656 91 103,660 Madagascar, Antananarivo 424,279 424,278 402,979 424,279 361,194 351,327 97 (51,653) Malawi, Lilongwe 171,682 85,865 77,496 171,682 137,345 117,754 86 40,258 Mozambique, Maputo 321,000 196,577 191,949 307,019 182,849 124,445 68 (67,503) Regional Office 171,200 171,200 104,498 170,537 96,381 95,827 99 (8,671) Rwanda, Kigali 332,608 332,609 148,015 247,008 160,556 153,457 96 5,442 Uganda, Kampala 310,623 310,300 295,070 310,300 273,482 244,752 89 (50,318) Zambia, Lusaka 321,000 270,710 264,612 246,100 230,568 209,911 91 (54,702) Total 3,582,740 3,377,006 2,695,368 3,407,273 3,113,202 2,631,807 85 (63,561) Latin America and the Caribbean Haiti, Port-au-Prince 324,198 162,099 158,648 323,675 161,995 151,839 94 (6,809) Regional Office 107,000 107,000 106,819 107,000 107,001 103,885 97 (2,934) Total 431,198 269,099 265,467 430,675 268,996 255,724 95 (9,743) Office of the Executive Director Non-core Funds Management Unit 142,297 142,297 128,385 132,987 132,987 124,534 94 (3,851) Technical Division Sexual and Reproductive Health Branch 2,243,842 2,243,842 2,243,842 2,888,488 2,888,488 2,886,626 100 642,784 50 2019 Maternal and Newborn Health Fund and Fistula Fund 2020 Maternal and Newborn Health Fund and Fistula Fund Regional office/country office/ global technical support 2019 Allocation ceiling, US$ 2019 Funds transferred, US$ 2019 Expenses, US$ 2020 Allocation Ceiling, US$ 2020 Funds transferred, US$ 2020 Expenses, US$ Utilization rate, percentage Change in expenses 2020 vs. 2019 US$ Western and Central Africa Benin, Cotonou 482,305 337,613 305,392 2,012,172 1,444,258 816,287 57 510,895 Burkina Faso, Ouagadougou 453,424 448,076 456,163 453,425 427,457 318,903 75 (137,260) Chad, N'Djamena 260,316 260,316 327,124 260,316 169,206 177,701 105 (149,423) Congo, Brazzaville 374,500 374,500 328,028 374,500 374,500 313,996 84 (14,032) Côte d'Ivoire, Abidjan 443,710 413,306 376,282 347,480 347,481 219,450 63 (156,832) Ghana, Accra 231,569 231,570 234,578 221,939 223,790 235,112 105 534 Guinea, Conakry 326,061 326,062 328,862 1,683,891 1,178,781 548,028 46 219,166 Guinea-Bissau, Bissau 162,099 111,597 66,451 162,099 161,834 165,919 103 99,468 Liberia, Monrovia 208,412 145,868 91,277 189,604 166,514 126,209 76 34,932 Mauritania, Nouakchott 231,569 162,099 157,374 231,569 185,259 137,514 74 (19,860) Niger, Niamey 540,330 540,330 450,369 540,330 470,779 446,445 95 (3,924) Nigeria, Abuja 303,880 278,346 260,882 303,880 303,024 302,396 100 41,514 Regional Office 171,200 119,840 112,596 128,400 128,400 113,093 88 497 Senegal, Dakar 293,189 293,300 194,081 288,909 231,895 202,488 87 8,407 Sierra Leone, Freetown 434,127 155,053 63,506 - - (78) 0 (63,584) Togo, Lome 428,000 428,042 293,056 1,958,100 1,667,060 785,002 47 491,946 Total 5,344,691 4,625,918 4,046,021 9,156,614 7,480,238 4,908,465 66 862,445 GRAND TOTAL 13,865,033 12,392,790 10,906,067 17,888,380 15,321,550 11,989,889 78 1,083,822 51ANNUAL REPORT 2020 ANNEXES 2019 Maternal and Newborn Health Fund and Fistula Fund 2020 Maternal and Newborn Health Fund and Fistula Fund Regional office/country office/ global technical support 2019 Allocation ceiling, US$ 2019 Funds transferred, US$ 2019 Expenses, US$ 2020 Allocation Ceiling, US$ 2020 Funds transferred, US$ 2020 Expenses, US$ Utilization rate, percentage Change in expenses 2020 vs. 2019 US$ Western and Central Africa Benin, Cotonou 482,305 337,613 305,392 2,012,172 1,444,258 816,287 57 510,895 Burkina Faso, Ouagadougou 453,424 448,076 456,163 453,425 427,457 318,903 75 (137,260) Chad, N'Djamena 260,316 260,316 327,124 260,316 169,206 177,701 105 (149,423) Congo, Brazzaville 374,500 374,500 328,028 374,500 374,500 313,996 84 (14,032) Côte d'Ivoire, Abidjan 443,710 413,306 376,282 347,480 347,481 219,450 63 (156,832) Ghana, Accra 231,569 231,570 234,578 221,939 223,790 235,112 105 534 Guinea, Conakry 326,061 326,062 328,862 1,683,891 1,178,781 548,028 46 219,166 Guinea-Bissau, Bissau 162,099 111,597 66,451 162,099 161,834 165,919 103 99,468 Liberia, Monrovia 208,412 145,868 91,277 189,604 166,514 126,209 76 34,932 Mauritania, Nouakchott 231,569 162,099 157,374 231,569 185,259 137,514 74 (19,860) Niger, Niamey 540,330 540,330 450,369 540,330 470,779 446,445 95 (3,924) Nigeria, Abuja 303,880 278,346 260,882 303,880 303,024 302,396 100 41,514 Regional Office 171,200 119,840 112,596 128,400 128,400 113,093 88 497 Senegal, Dakar 293,189 293,300 194,081 288,909 231,895 202,488 87 8,407 Sierra Leone, Freetown 434,127 155,053 63,506 - - (78) 0 (63,584) Togo, Lome 428,000 428,042 293,056 1,958,100 1,667,060 785,002 47 491,946 Total 5,344,691 4,625,918 4,046,021 9,156,614 7,480,238 4,908,465 66 862,445 GRAND TOTAL 13,865,033 12,392,790 10,906,067 17,888,380 15,321,550 11,989,889 78 1,083,822 52 13 ANNEX 3: LIST OF COUNTRIES SUPPORTED BY MHTF PHASE III 1. Bangladesh 2. Benin 3. Burkina Faso 4. Burundi 5. Chad 6. Congo 7. Côte d’Ivoire 8. Democratic Republic of the Congo 9. Ethiopia 10. Ghana 11. Guinea 12. Guinea-Bissau 13. Haiti 14. Kenya 15. Lao People’s Democratic Republic 16. Liberia 17. Madagascar 18. Malawi 19. Mauritania 20. Mozambique 21. Nepal 22. Niger 23. Nigeria 24. Rwanda 25. Senegal 26. Sierra Leone 27. Somalia 28. Sudan 29. Timor-Leste 30. Togo 31. Uganda 32. Zambia 53ANNUAL REPORT 2020 ANNEXES 21 1 15 29 17 20 18 4 24 32 8 6 23 3016 26 12 7 2 10 3 11 25 19 22 5 28 9 14 31 27 The designations employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of UNFPA concerning the legal status of any country, territory, city or area or of its authorities or the delimitation of its frontiers or boundaries. 54 3 ANNEX ANNUAL REPORT 2020 United Nations Population Fund 605.Third.Avenue New.York,.NY.10158 September.2021 UNFPA ensuring rights and choices for all. Acronyms Acknowledgements Foreword Executive summary part I KEY RESULTS 1.1 Midwifery 1.2 Emergency Obstetric and Newborn Care 1.3 Maternal and Perinatal Death Surveillance and Response 1.4 Obstetric Fistula 1.5 COVID-19 Response 1.6 Sexual and Reproductive Health and Rights Integration part II Optimizing Equity in Access, Quality of Care and Accountability: A Comprehensive Approach Country Examples of Implementation in Service Delivery part III MHTF Resource Management 3.1 Background 3.2 Contributions 3.3 Operating Budget 3.4 Expenses 3.5 Categories of Expenditure part IV Lessons Learned and Way Forward Challenges Lessons Learned Way Forward Annex 1: Campaign to end fistula partners Annex 2: Detailed budget allocations Annex 3: List of Countries Supported by MHTF Phase III

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