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Title: Health Information System
Description: Brief history on health system information
Description: Brief history on health system information
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Innovative Approaches to Maternal and
Newborn Health
Compendium of Case Studies
August 2013
Maternal, Newborn and Child Health
Working Paper
UNICEF Health Section, Program Division
unite for children
Innovative Approaches to Maternal and Newborn Health
Compendium of Case Studies
©United Nations Children’s Fund (UNICEF), New York, 2013
This compilation is based on internal field reports and other data
...
Statements in these case studies do not imply or constitute official opinions or policy
positions of either the United Nations or UNICEF
...
Contributors
Afghanistan: Nasreen Khan (UNICEF Afghanistan), Malalai Naziri (UNICEF Afghanistan), Nuzhat Rafique
(UNICEF Regional Office South Asia); Bangladesh: Riad Mahmud (UNICEF Bangladesh), Nuzhat Rafique
(UNICEF Regional Office South Asia); Cambodia: Malalay Ahmadzai (UNICEF Cambodia), Dr
...
Dickson (UNICEF NYHQ), Rene Ekpini (UNICEF NYHQ), Ariel Higgins-Steele (UNICEF NYHQ/Concern
Worldwide U
...
), Nuzhat Rafique (UNICEF ROSA), Aline Simen Kapeu (UNICEF NYHQ), Kristen Wenz
(UNICEF NYHQ), Nabila Zaka (UNICEF EAPRO)
For further information please contact:
Maternal and Newborn Health Unit
Health Section, Programme Division
United Nations Children’s Fund
3 United Nations Plaza, New York, NY 10017, USA
Telephone: +1-212-326-7000
iii
Contents
1
...
1
Purpose of compendium
...
2
Methods
...
2
Structure of compendium
...
Case studies: Innovative approaches to maternal and newborn health
...
6
BANGLADESH: Maternal and Perinatal Death Review for evidence-based prevention
...
12
CAMBODIA: Community care of mothers and newborns
...
20
CHINA: Ensuring every newborn’s financial access to health services
...
24
ETHIOPIA: Introduction of magnesium sulphate to manage pre-eclampsia and eclampsia
...
30
MONGOLIA: Evidence-based approaches to improving newborn care
...
36
PAKISTAN: Chief Minister’s Initiative for the Attainment and Realization of the MDGs
...
44
RWANDA: SMS alert system to monitor pregnancy and reduce maternal and child deaths
...
52
TIMOR-LESTE: Involving communities in addressing maternal health inequalities
...
Implications for public health programming
...
Conclusion
...
Introduction
The Millennium Development Goal targets to reduce child mortality (MDG 4) and maternal mortality
(MDG 5) have seen some gains around the world
...
1 Overall, improvements in maternal mortality have been less impressive than
those in child mortality
...
3 per cent or 3
...
3 Improving
maternal and newborn health is therefore still a critical priority, though important inroads have been
made in improved access and quality of care through local and global initiatives
...
Major
global initiatives continue to push towards ambitious, yet achievable goals of ending preventable deaths
for mothers and children, including in the crucial first 28 days of life
...
Part of this initiative is H4+, a joint
effort by the United Nations and related agencies and programmes: UNAIDS (the Joint United Nations
Programme on HIV/AIDS), United Nations Population Fund (UNFPA), UNICEF (United Nations Children’s
Fund), UN Women, the World Health Organization (WHO) and the World Bank
...
In 2012, the Governments of Ethiopia, India and the United States together with UNICEF convened
countries under ‘A Promise Renewed,’ a call to action around three main goals: to mobilize political
leadership to end preventable child deaths, to achieve consensus on a global road map highlighting
innovative and proven strategies to accelerate reductions in child mortality, and to drive sustained
collective action and mutual accountability
...
But these interventions still do not have the necessary reach and quality, especially in
resource-constrained settings
...
The global momentum for the reduction of maternal and neonatal deaths provides a strategic
opportunity for H4+ agencies and partners to pursue its goal of equitable development for all children
...
UNICEF’s maternal and newborn health
programming prioritizes working with various stakeholders and partners in countries to implement and
1
Lanzo R et al
...
The Lancet
...
2
Bhutta ZA et al
...
The
Lancet
...
3
Liu L et al
...
The Lancet
...
1
scale-up innovative strategies to expand facility- and community-based care, especially among
marginalized and deprived groups
...
These experiences must be shared broadly among maternal
and newborn health groups to encourage evidence-based programming and cross-country learning
...
Purpose of compendium
The aim of this compendium is to provide a resource for innovative approaches that have shown
promising results for improved health outcomes
...
Target audiences
This compendium is intended for individuals and agencies working in maternal and newborn health
globally
...
Methods
Case studies for innovative strategies and approaches to maternal and newborn health supported by
UNICEF were collected from UNICEF Country Offices, in collaboration with Regional Offices, from July
through October 2012
...
The template included open-ended narrative
sections followed by closed responses, to capture specific information
...
Key dimensions of maternal and newborn health programming
Several frameworks were used to describe and categorize each case study in an effort to systematically
document innovative approaches to delivering maternal and newborn health interventions
...
These have been characterized in the Tanahashi model as supply (or access), demand
(or use), quality and aspects of the enabling environment as part of health system coverage
...
5
Continuum of care
Indicates at which points along the continuum of care an innovative approach intervenes
...
Health service coverage and its evaluation
...
1978; 56: 295–303
...
The Comparative Cost Effectiveness of an Equity-Focused Approach to Child Survival, Health,
and Nutrition: A Modelling Approach
...
2012 http://press
...
com/childequity2
...
In the past, maternal, newborn and child health (MNCH) policy and
programmes tended to address the mother and child separately, resulting in gaps in care which
especially affect newborn babies
...
Interventions, both preventive and curative, should prioritize the
most critical time (birth and the first few days of life) and the place where care is most needed
(at home or close to home) with strong links to facility-based care
...
It is important in
describing whether an approach is being piloted or scaled up, either sub-nationally or nationally
...
See table 1 on the following page for an overview of case studies
included in this compendium
...
Section 2: Contains the actual country case studies; each case study includes the background, strategy,
implementation considerations, lessons learned, next steps and potential application, as well as a short
description of why it is considered innovative
...
Section 4: Concludes the compendium
...
Key characteristics of UNICEF maternal and newborn health case studies
Key issues/bottlenecks to
Country
Innovation
address
Health systems
areas
Continuum of
care
Pregnancy
Childbirth
Post-natal: mother &
newborn
Scale
Maternity waiting homes
Supply
Demand
Enabling environment
Maternal and perinatal death reviews
Supply
Enabling environment
Quality
Childbirth
Scaling up
subnationally
Demand
Pregnancy
Sustaining activities
Low rate of skilled delivery
Integrated community care for mothers and
newborns with targeted home visits during
pregnancy and post-partum periods and referral
to facility
Supply
Demand
Enabling environment
Pregnancy
Childbirth
Post-natal: mother &
newborn
China
Low rate of skilled delivery
Standard subsidies for normal and operative
hospital delivery
Enabling environment
Supply
Demand
Quality
Childbirth
Scaled up nationally
China
Financial barriers to accessing health
services for newborns in rural areas
Enabling environment
Supply
Demand
Post-natal: newborn
Scaling up nationally
China
Low rate of skilled delivery in remote
areas
Maternity waiting room and subsidies to mothers
Supply
Demand
Enabling environment
Childbirth
Scaling up subnationally; replicating
in other locations
Ethiopia
Low quality of maternal care,
especially the management of preeclampsia and eclampsia
Introduction of magnesium sulfate in public and
private hospitals leading to task shifting of drug
provision to nurses and midwives
Enabling environment
Supply
Quality
Pregnancy
Childbirth
Scaling up nationally
India
High newborn mortality rate after
hospital discharge
SMS system for tracking newborns after hospital
discharge and timely home visits by community
health workers
Supply
Quality
Postnatal: newborn
Scaling up within a
state
Afghanistan
Poor geographic access for pregnant
women living in remote areas
Bangladesh
Low quality of care associated with
inconsistent understanding of the
causes of deaths
Cambodia
Late uptake of ANC
Cambodia
ANC behaviour change communication campaign
to encourage early uptake
Evidence-driven assessment and advocacy to
inform policy makers and new policy
development to ensure insurance for newborns
Scaling up
subnationally
Scaling up
subnationally
4
Country
Key issues/bottlenecks to
address
Mongolia
Lack of BEmONC services including
insufficient human resources and
stock-out of commodities
Nepal
Low access to skilled birth attendants
and basic emergency obstetric and
newborn care (BEmONC) services
Pakistan
High maternal and neonatal mortality
and morbidity in flood-affected areas
Philippines
High maternal and neonatal mortality
rates
Rwanda
Slow progress in reduction of
maternal deaths
Sierra Leone
TimorLeste
Shortage of health personnel
providing emergency obstetric and
newborn care (EmONC) services in
underserved rural areas
Inequities in utilization of maternal
health services
Innovation
Integration of newborn care within maternal
health services and supplies (midwifery kits)
Upgrade of primary health facilities to birthing
centres in remote areas through a comprehensive
approach including creating an enabling
environment, facilitating access to care and
increasing demand for services
Upgrading BEmONC services by implementing a
comprehensive package: 24/7 service delivery,
incentives, performance-based financing, eHealth
monitoring and communication for development
6
(C4D)
Health systems
areas
Continuum of
care
Enabling environment
Supply
Quality
Childbirth
Postnatal: mother &
newborn
Supply
Demand
Enabling environment
Quality
Pregnancy/antenatal
Childbirth
Scale
Gradual national
scale-up following
policy adoption
Scaling up
subnationally
Suppy
Demand
Childbirth
Scaling up
subnationally
Supply
Demand
Quality
Childbirth
Postnatal: mother &
newborn
Scaling up
subnationally
Rapid SMS-MCH using mobile phones for
monitoring throughout pregnancy and postpartum and strengthen referral systems
Supply
Quality
Pregnancy
Childbirth
Postnatal
Scaling up nationally
Training of health workers using mannequins
Supply
Quality
Childbirth
Scaling up
subnationally
C4D model for community action / community
empowerment
Demand
Pregnancy
Childbirth
Scaling up
subnationally
Implementation of quality Essential Intrapartum
and Newborn Care (strategy to strengthen the
health system)
6
Communication for development (C4D) is an approach promoted by UNICEF that uses a two-way process for sharing ideas and knowledge using a range of communication
tools and approaches that empower individuals and communities to take actions to improve their lives
...
Case studies: Innovative approaches to maternal and newborn
health
AFGHANISTAN: Maternity Waiting Homes: Reducing geographic access barriers
Background
Decision-making on health care is seen to be
influenced by perceptions of accessibility
...
A more recent UNICEF study found that
distance similarly impacted health care knowledge
among women, as well as decisions to seek care
...
Why is this innovative?
Maternity Waiting Homes are an equity-based
strategy implemented for the first time in
Afghanistan to increase access to maternal
and newborn services among women from
remote areas
...
Maternity Waiting Homes increase
institutional deliveries and consequently
decrease maternal mortality caused by the
delay in reaching obstetric care
...
Of families trying to obtain care, three quarters
identified distance, availability of transport, and cost of transport and services as the most significant
obstacles to access
...
Cost was also a constraint, since many families had to buy blood and
medications
...
Deaths could
be averted if complications were prevented through optimization of general health status and if
complications that occurred were treated to reduce their severity
...
Maternity waiting homes (MWHs) were introduced as a key strategy to bridge the geographic gap in
obstetric care for people living in rural areas
...
Implementation
Six MWHs were built by UNICEF and the Ministry of Public Health in rural areas of Afghanistan in six
locations – Kandahar, Badakhshan, Laghman, Kunar Herat, and Bamyan – and they began functioning in
2009
...
Each
6
MWH can accommodate 10 women with their newborns at any given time
...
The MWHs do not have any specific catchment population
...
Operational guidelines for MWHs cover objectives, service provision, overall management and
oversight, community mobilization and referral support, and financial and technical reporting, thus
encouraging financial sustainability of MWHs
...
Administration and supervision of the
MWH operations are managed by a committee
...
Results
MWHs were constructed and operationalized Figure 1
...
)
to skilled and quality emergency obstetric
care during pregnancy, birth and post-partum period
...
For the fetal outcomes, 93 per cent were live births, 6 per cent still births and 1 per cent
neonatal deaths
...
Most of the clients were facility referrals and the numbers of community referrals are likely to increase
with the increase in female community health workers in the region
...
In terms of where MWH clients resided, 87 per cent of all clients belonged to Kandahar province and a
small fraction belonged to other south region provinces (Helmand 6 per cent, Uruzgan 5 per cent and
Zabul 2 per cent)
...
The number of women using the MWH in Kandahar is an indication that this approach is accepted by the
community and the facility is considered a credible provider of health services to women with high-risk
pregnancies
...
Women admitted in MWH are receiving new knowledge about health and nutrition issues
...
Clients are becoming repeat clients: families who used a
MWH once are coming for the next pregnancy, indicating
satisfaction with the services
...
MWHs provide good learning environment for newly
graduated midwives
...
Based on my experience with my first daughter-in-law, I encouraged
Gul Bakht to deliver at health facility because this is her first child
...
When we reached the hospital,
the staff referred us to the MWH and it is really like home
...
”
Next steps
Future scale-up of MWHs in focus districts in underserved areas, including Diakundai, Badghis,
Ghor, Kandahar and Hilamnd provinces
...
Advocacy is being planned to mainstream MWH into hospital management contracts
...
CHWs will be made more aware of
these facilities in their communities
...
Potential application
MWHs play a role in promoting facility-based deliveries and reducing maternal mortality
...
Acknowledgements: Nasreen Khan (UNICEF Afghanistan), Malalai Naziri (UNICEF Afghanistan), Nuzhat Rafique (UNICEF
Regional Office South Asia)
8
BANGLADESH: Maternal and Perinatal Death Review for evidence-based prevention
Background
Bangladesh has experienced a steady decline in maternal,
neonatal, infant and under-five mortality in recent decades;
however, the rate of decline is insufficient to achieve MDG 4 and
5 targets set for Bangladesh
...
The
Maternal and Perinatal Death Review (MPDR) is a mechanism to
understand medical or social causes of death and to put in place
preventive measures to avoid future maternal and neonatal
deaths
...
Why is this innovative?
Bangladesh newly introduced the
Maternal and Perinatal Death
Review to improve the quality of
services provided to women in
order to reduce maternal and
neonatal deaths
...
Strategy
UNICEF and two directorates of the Government of Bangladesh – the Directorate General of Health
Services and the Directorate General of Family Planning – initiated the MPDR with the Centre for Injury
Prevention and Research
...
After approval of the directorates, this
system and tools were first implemented in one district, Thakurgaon, in 2010
...
8 million people
...
Data collection
instruments developed include the notification of maternal and neonatal deaths and still births at both
facility and community levels, verbal autopsy in community deaths and facility death reviews
...
Over 5,700 health and family planning staff at the field
level were trained to perform death notifications of maternal and neonatal deaths and still births at
community and facility levels, perform verbal autopsies and social autopsies, and organize quarterly
review meetings at the subdistrict (upazila) and district level to analyse findings and plan remedial
actions
...
The process is also monitored and evaluated through two-way feedback
from communities to the providers as well as to the policy makers
...
Both directorates were represented during the formation of these committees to agree on
roles and responsibilities during implementation
...
The MPDR Technical Committee is composed of technical experts,
professionals and programme experts of the two directorates and provides technical inputs when
necessary
...
Field-level health
staff record maternal, neonatal deaths and still births at the community level, and nurses in health
facilities do so using death notification slips
...
All data are analysed and reviewed at periodic review meetings at upazila and district MPDR review
meetings
...
Follow-up actions are planned through participatory
discussions during the review
...
A central purpose of the MPDR is to continue to
integrate data into government planning and decision-making
...
It was followed by the training of the health care providers
and field staff under the two directorates, on the MPDR mechanism and associated tools
...
Deaths notified: A total of 306 maternal deaths, 3,371 neonatal deaths and 3,056 still births were
reported in 2011 in four districts (see figure 2)
...
The analysis of verbal autopsies and facility death reviews revealed
critical details for programme managers, making it possible to identify actions to improve care
...
Community death notification in four districts (Jan–Dec 2011)
Population
Maternal deaths
Neonatal deaths Still births
2,089,366
100
1,321
1,214
1,604,028
110
865
829
689,021
36
314
280
1,400,000
60
871
733
5,782,415
306
3,371
3,056
Verbal and social autopsies from the MPDR mechanism prompted the district committee to investigate
the Kashipur union based on deaths reported there
...
This is a remote area with illiteracy
and poverty rates higher than the national average
...
Local health authorities took action, deploying members of the Community of Skilled Birth Attendants to
work in this health facility and provide needed logistical support, besides launching awareness activities
...
Coverage with ANC, safe delivery and PNC including
newborn care increased, as did referrals to the health facility
...
An analysis of
maternal referrals showed that the community referred at least a few potentially serious cases
immediately to the district hospital
...
In a majority of the deaths, decisions were taken to go to facilities or for treatment within two
hours (41 per cent), and within six hours of the appearance of danger signs or complications (75 per
cent)
...
One woman’s story: Thakurgaon District Hospital examined the
facility death review findings of the 12 maternal deaths that occurred
in 2010
...
Trained doctors also
reviewed death cases using the Agreed Standard Procedure checklist
...
Health
authorities then established a blood bank, storing blood bags and establishing a network of volunteerdonors to meet future emergencies
...
She was saved by a blood transfusion, provisions for which had not existed
before
...
A cornerstone to effective implementation is ownership from
the community level up to the national level, which inspires action-oriented responses to challenges
identified through data on maternal and newborn deaths
...
Death mapping and the resultant findings created an awareness and enthusiasm among
local managers to plan and implement follow-up actions
...
Results have since been visible and
appreciated at the national level
...
All government, civil society and United Nations stakeholders will
also be consulted before updating the model
...
Scale-up of the MPDR is being discussed in sub-committees that are now working on updating the
National Maternal Health Strategy and standard operating procedures
...
But the MPDR needs to be adapted to the country context and its policies
...
Acknowledgements: Riad Mahmud (UNICEF Bangladesh), Nuzhat Rafique (UNICEF Regional Office South Asia)
Further reading: Centre for Injury Prevention and Research, Bangladesh (www
...
org)
11
CAMBODIA: Communication for Behavioural Impact to promote early antenatal care
Background
In 2005, Cambodia’s maternal mortality was estimated at
472 deaths per 100,000 live births and there was no
recorded reduction in maternal deaths since 2000
...
Only 22 per cent of all births were taking
place in health facilities, either at health centres or referral
hospitals; the other 78 per cent were home births
...
These are
all directed to specific behavioural
outcomes to improve ANC seeking,
especially among women living in
remote areas
...
6 per cent of women attended their first ANC visit within the first month of having missed
their period
...
The media component was national in scope, while interpersonal communication, social
mobilization and outdoor promotion focused on the seven ‘good BCC practice’ provinces
...
The BCC campaign was developed
using the Communication for Behavioural Impact (COMBI) approach
...
In order to achieve desired behavioural changes, the COMBI plan for ANC employed a blend of five
communications strategies including administrative and community mobilization, public relations and
advertising, personal selling, interpersonal communications, and point-of-service promotion
...
In these provinces, the National Center for Health
Promotion and the Provincial Health Promotion Units trained health centre staff and thousands of
Village Health Support Group volunteers called Maternal Child Health Missionary to promote ANC
...
12
The national advertising consisted of eight 3-week flights8 during the course of a one-year period
through various channels including television, radio, newspapers, and magazines
...
At the health centre level, midwives were retrained in providers’ rights and clients’ rights
...
e
...
This kit included a cloth bag with the campaign logo and branding in which there was a bar of
soap along with a booklet on pregnancy
...
They were a visual reminder to women passing by that this is where
they could come in for their ANC visit within one month of having missed their
period
...
Additionally, in midwife examination rooms, the same three posters were
displayed as a reminder to the midwife and the woman
...
Within the
first 12 month of the ANC campaign, 36 per cent of potentially pregnant women came in for their first
ANC visit within the first eight weeks, in the seven provinces
...
Data collected from 2008 to
2011 shows that these trends are sustained and that the number of pregnant women receiving two
tetanus toxoid vaccinations increased significantly, almost doubling in four of the seven provinces
...
The proportion of women delivering with
the support of traditional birth attendants decreased from 55 per cent in 2005 to 28 per cent in 2010
...
Noting the positive result of the ANC campaign, the Ministry of Health encouraged the National
Maternal and Child Health Centre and UNICEF to expand the campaign to other provinces
...
8
A flight is defined as that period of time during which the advertisements take off or are run (three weeks), followed by a
pause of several weeks (about 2-6 weeks), and then followed by another flight of another three weeks, another pause, and so
on
...
9
Cambodia Demographic and Health Surveys, 2005 and 2010
...
In addition, it was recommended that
sustained coordination among various Ministry of Health departments was essential for successful
implementation of the campaign activities
...
In addition, the media component
is also continuing to ensure that gains are sustained
...
Potential application
With appropriate adaptations to local contexts, in the channels used and the message, this targeted
approach to behavioural change can be used to increase demand for a number of essential maternal
and newborn health interventions
...
10 Cambodia was not on track for meeting
its 2010 MDG target set at 243 deaths per 100,000 live births
...
11
Why is this innovative?
For the first time, Cambodia
implemented a community-based
integrated maternal and newborn
initiative in low-performing districts,
using established CHWs to increase
the proportion of institutional
deliveries
...
Despite decreases in child mortality in Cambodia, the decline
in neonatal mortality had been slower than in post-neonatal
mortality (24 per cent and 36 per cent between 2000 and
2005, respectively)
...
And while Cambodia was on track for meeting its MDG targets for
infant and under-five mortality, future progress depended on neonatal mortality reduction
...
Only 22 per
cent of all births were taking place in health facilities; the other 78 per cent were home births
...
The widespread tradition for delivering at
home with a traditional birth attendant was posing serious risks to maternal and newborn health
...
Another traditional practice
after delivery translated as ‘roasting’12 restricts a mother’s ability to leave her house and seek health
services for a routine postpartum or newborn check-up
...
ANC, care during delivery, and PNC provided at health centres was of poor quality due
to the limited knowledge and skills of midwives and a shortage of drugs and supplies
...
Simple, low-cost interventions in newborn care received little attention in Cambodia and were either
not available or accessible to many Cambodian families
...
Japan International Cooperation Agency, Maternal and Child Health Study, 2006
...
Women stay on a mat bed over coals for three
to seven days and are not permitted to leave the bed
...
This was causing harmful delays in seeking immediate or emergency health
care
...
Strategy
In light of Cambodia’s high maternal and neonatal mortality, the Ministry of Health, with support from
UNICEF Cambodia, piloted the ‘Community Care of Mothers and Newborns’ (CCMN) package
...
13
CCMN promotes an integrated approach to the mother and newborn
...
The main objectives of this pilot
package were to assess:
Relevance, quality and effectiveness of training, monitoring and supervision;
Feasibility of the pilot implementation by volunteers and acceptability of volunteers’ work by
health centre staff and families;
Effectiveness of the pilot on family and community practices, including the uptake of ANC,
delivery and PNC at health facilities, and on referrals when signs of danger are seen in
pregnancies;
Feasibility and sustainability for replication and expansion
...
Implementation
During the home visits, trained community volunteers provide health education, advise families on care
during pregnancy and post-partum periods, refer to health facilities for ANC, delivery and PNC services,
assist pregnant women prepare a birth plan, advise and check for danger signs for both mothers and
newborns ─ referring them to a health clinic if necessary ─ and promote and support breastfeeding
practices
...
To ensure the continuity of
care, the CCMN package was implemented in areas where previous training, equipment and supervision
investments had already been made in the health system
...
The advantage of this cascade training model is that
it does not require an outlay of significant resources (i
...
, human, material and financial)
...
16
specifically, the programme does not have to hire and support a separate team to do the training, but
uses existing staff as trainers
...
g
...
The
process empowers health staff at all levels to plan and conduct trainings
...
The ANC portion of the training took four days,
with a one-month gap to ensure the community volunteers got exposure to field work, followed by
three days of PNC training
...
The community volunteers were provided with a register to facilitate adequate monitoring of their
activities including documenting the number of pregnant and post-partum women visited and referred
...
CCMN was piloted in two
provinces, Kampong Thom which is semi-rural and Stung Treng which is very rural and has a large
number of ethnic minority groups
...
Relevance: The pilot was shown to be in line with Cambodia’s health policies and plans
...
Priority was given to the health centres with
weaker coverage indicators to improve those that had lower performance, and staff from these health
centres were trained on integrated post-partum care
...
Implementation guidelines were followed for the
selection of the trainers and community volunteers; communities were involved in the selection of
community volunteers
...
12 per
woman
...
Other than referral
slips and registers, which needed to be
periodically replenished, supply was largely a
non-recurrent cost, i
...
, of procurement of
thermometers, timers and weighing scales for
community volunteers
...
Since the programme relies on existing
health workers and community volunteers, it
has no additional costs and can piggyback on
existing training and supervision mechanisms
...
Delivery practices in intervention and
non-intervention areas (2010)
Intervention
Non-intervention
70%
61%
45%
Institutional delivery
51%
Skilled birth attendance
17
Quality and effectiveness: Four hundred and
fifty women (300 in intervention villages and
150 in non-intervention villages) who had
delivered in the previous four months were
selected to participate in the quantitative
assessment, which focused on assessing their
knowledge and care-seeking behaviours
...
Across all knowledge-related
indicators such as knowledge of care for a
pregnant woman, birth preparedness, danger
signs and newborn care, there were
considerable differences, most of which were
statistically significant, with higher levels of
knowledge between intervention and nonintervention responses
...
Postnatal practices in intervention
and non-intervention areas (2010)
99%
98%
97%
95%
100%
89%
82%
90%
80%
65%
70%
60%
50%
50%
40%
30%
20%
10%
0%
Intervention
Non-intervention
Women in intervention areas were far more likely to cite midwives and community volunteers as
providers of ANC, at 72 per cent and 52 per cent respectively
...
Community volunteers were
cited as providers of ANC services possibly due to their presence in outreach ANC sessions as well as
their pregnancy visits
...
CCMN aims to vastly increase the proportion of deliveries taking place in institutions
...
The most marked differences were seen in postnatal practices of skin-to-skin contact and immediate
breastfeeding
...
Timely home visits by community volunteers, particularly in the post-partum period, are a critical part of
the CCMN strategy
...
Increasing the frequency of PNC visits by having
community volunteers in the villages is the most significant accomplishment of the CCMN
...
The timing of these visits was crucial
...
For those women who could recall the date of
the postnatal visits, half in intervention villages received a postnatal visit on the first day after delivery,
18
as compared to 24 per cent of women in non-intervention areas
...
These findings indicate that mothers are not being visited by community volunteers in the critical 24
hours after birth
...
Lessons learned
UNICEF and provincial health officers closely oversaw the training and implementation of CCMN in two
pilot provinces
...
Next steps
UNICEF’s future role with regard to scale-up would be technical assistance to the Ministry of Health in
developing a scale-up plan, and ensuring that vulnerable communities are prioritized for the CCMN
interventions
...
The assessment report indicated considerable increases in desirable health and nutrition practices, as
well as in service coverage
...
There are strong associations between the processes meant
to promote effective interventions (reported home visits and advice) and the reported practice of
desirable health behaviours and service use
...
By end of 2011, the pilot was scaled up in
36 per cent of the villages in 17 selected operational districts in Cambodia
...
While it requires commitment and technical and supply investments, it
is relatively low-cost and can demonstrate considerable improvement in outcomes related to maternal
and newborn health knowledge, attitudes and practices
...
Thus, UNICEF also
supported improvement of quality of care at the health centre levels, integrated outreach, emergency
referral systems and strengthening of the supervision and on the job coaching for health staff
...
Historically, China’s focus on primary
health care during the 1960s and 1970s contributed to lower
child mortality rates than countries with similar economic
development
...
Less
than half of women were giving birth in facilities at this time
with many home births occurring in rural areas
...
Why is this innovative?
China implemented the Safe
Motherhood Initiative and
expanded it beyond the health
system to reduce inequities in the
access to quality care
...
Strategy
Building on recent policies to improve maternal and newborn health, in 1999, UNICEF, in cooperation
with the Ministry of Health and the National Working Committee for Children and Women, launched a
safe motherhood initiative
...
The approach employed three core strategies:
Expanding the concept of safe motherhood beyond the health system by addressing three key,
related factors: demand creation, community mobilization, and the affordability and quality of
obstetric services;
Establishing incentives not only to promote hospital delivery at the community level, but also to
urge local health authorities to increase their commitment;
Increasing transparency and programme evaluation to ensure proper use of funds and assist
health managers to objectively assess achievements and constraints
...
Besides the strengthening of infrastructure, staff
training and supervision in township and low-level hospitals, the approach also establishes referral
channels to tertiary hospitals with the capacity to deal with comprehensive emergency obstetric and
newborn care (CEmONC)
...
The initial pilot was implemented in 40 counties with
low socio-economic characteristics
...
The scheme, which provided standard subsidies for normal and operative hospital delivery,
trained Maternal and Child Health (MCH) workers on life-saving skills and mobilized communities to
promote hospital delivery, was progressively expanded to 428 counties in 2002; 1,000 counties in 2005;
and 1,200 counties in 2007, always focusing on those with the most maternal deaths and rural poverty
...
9 billion renminbi (approximately
305 million USD) for such subsidies in all central and western rural counties; since 2009, women in all
20
2,297 rural counties in China are eligible for subsidized hospital delivery, as one element of China’s
health system reforms
...
In combination with separate initiatives to provide social
insurance for all and medical financial assistance for the poor, China’s hospital delivery rate increased
from 73 per cent in 2000 to 96 per cent in 2009
...
14
Most compelling, a statistically significant and causal association between the scheme’s support for
hospital delivery and reduced maternal mortality has been found
...
Lessons learned
Working closely with government, UNICEF supported the initial policy development, piloting and
evaluation, helping to increase the practicability, success and sustainability of the scheme
...
In doing so, local funding and support extended beyond the health
sector to the entire local government, and contributed to national health care reform initiatives
...
Many evidence-based, high impact interventions are not fully funded by the Government of
the People’s Republic of China
...
Potential application
Other countries can learn from China's substantial progress in reducing maternal and neonatal
mortality
...
16
China and other countries must ensure that family, community and hospital linkages are strengthened
technically, administratively, and financially for the most vulnerable
...
China's facility-based birth strategy and neonatal
mortality: a population-based epidemiological study
...
2011 Oct 22;378(9801):1493-500
...
Socioeconomic inequalities in hospital births in China between 1988 and 2008
...
2011;89:432-441
...
An impact evaluation of the safe motherhood program in China
...
16
Feng XL, Guo S, Hipgrave D, Zhu J, Zhang L, Song L, et al
...
The Lancet
...
21
CHINA: Ensuring every newborn’s financial access to health services
Background
China has made substantial progress on MDG 4 and MDG 5
targets, putting the country on track to meet both goals
...
In
terms of children under-five dying, more than half are less
than 28 days old (out of 18 of these deaths, 11 are in the
newborn period)
...
Due to low coverage of
newborns in the scheme, China
conducted evidence-driven
assessment and strong advocacy
initiatives to support policy revisions
and new policy development to
ensure that newborns were insured
...
The newborn mortality rate is
more than double for rural areas as compared to urban
areas
...
5 per cent of these deaths occurred at home (either the birth took place at home or mother had
returned from the facility) or en route to or from health facilities
...
17
The New Cooperative Medical Scheme (NCMS), a kind of social health insurance scheme covering rural
populations, was initiated in 2008 in China
...
A review of all newborn deaths in a study of four counties in poor, rural areas revealed that 92
...
The strategy for ‘ensuring every newborn’s
financial access to health services’ was adopted to address this barrier to access for infant children
...
Implementation
After discussions, UNICEF China and the Ministry of Health jointly conducted a study and survey to
gather evidence
...
They conducted a review of national and
provincial policy on NCMS and carried out a survey to understand NCMS coverage among newborns and
assess the cost projections for the central government to cover NCMS for newborns
...
For example,
since revenue collection is once a year, infants born after the data of revenue collection can join NCMS
only the following year
...
17
Unpublished results conducted by UNICEF and China’s National Center for Women and Children
...
UNICEF presented the evidence on gaps associated in
coverage for newborns to the Ministry of Health
...
At present, the government has partly
accepted UNICEF’s suggestion by issuing a formal document to all provinces and requesting all provinces
enrol newborns into NCMS automatically if the newborn’s mother was enrolled in NCMS
...
Now all local governments implement the NCMS according to the Ministry of Health’s
request
...
By being able to indicate how a mother’s insurance
coverage was not automatically connected to the insurance of newborns, and that this was associated
with negative health outcomes, an important gap was identified
...
Currently, China’s Ministry of Health is discussing with the Ministry of
Finance the funding to support the automatic enrolment of all newborns
...
Acknowledgements: Robert Scherpbier (UNICEF China), David Hipgrave (UNICEF China), Sufang Guo (UNICEF China), China
Health Development Research Center, National Center for Women and Children’s Health, Nabila Zaka (UNICEF East Asia and
Pacific Regional Office)
23
CHINA: Introducing and sustaining Maternity Waiting Homes
Background
Progress in reducing maternal mortality in China has been
impressive, with the MMR dropping from 95 deaths per
100,000 live births in 1990 to 37 in 2010
...
UNICEF and the Ningxia Hui Autonomous Region started a
maternal and newborn health initiative with the purpose of
improving
facility-based
deliveries
...
The total population in Ningxia is
5,800,000, of which 33 per cent are the Hui ethnic minority
whose socio-economic conditions tend to be lower than
other population groups in this area
...
The
approach effectively pairs community
mobilization strategies and the
provision of financial incentives to
mothers
...
The four project counties – Xiji, Haiyuan, Jingyuan and Yuanzhou – are situated in the southern
area of Ningxia, where maternal and child health indicators were worse than the national average even
by the standards of rural areas
...
The area is drought prone and
mountainous, and local communities have limited access to essential maternal and newborn services
including obstetric care
...
8 per cent,
which was 32
...
In the four counties, 18 townships chosen for the pilot covered a total population of 1
...
Unlike in other MWH initiatives in which spaces are constructed, this approach uses existing rooms in
the hospital, refurbishing these rooms into a maternity waiting room to avoid construction time and
expenses
...
Pregnant women living in remote villages with a travel time of more than one
hour by the quickest transport from the village to the townships were eligible to be admitted to the
waiting rooms
...
86 to help
defray the cost of using the maternity waiting rooms;
Providing free maternity waiting services including regular physician check-ups for pregnant
women when admitted;
24
Mobilizing village doctors and township MNCH workers to conduct interpersonal health
communication to promote the waiting rooms and encourage use among pregnant women
...
The Ningxia Health Bureau and four county
bureaus identified the townships, based on the
jointly developed criteria, and assisted in the
management of the waiting rooms
...
A woman from a village of Baiya township staying in a
maternity waiting room after delivery
According to a preliminary analysis, the MWH-based initiatives have contributed to the improved access
to and uptake of maternal and newborn health services since waiting rooms were initiated
...
6 per cent in 2006 to 86
...
9 per cent, much higher than in
townships without a waiting room (32
...
The yearly increase in township hospitals with waiting
rooms reached 25
...
9 per cent),
indicating that facility-based deliveries increased faster in townships implementing waiting room
initiatives than in townships without piloting waiting room interventions
...
Ms
...
Her first baby was delivered at
home due to the high transportation costs
...
Her experience, in her own words, reflected positive impressions of the waiting
room initiative: “When I got pregnant, the village doctor came to my family and encouraged me to give
birth in the hospital
...
It proved
to be true when I stayed there
...
After my baby was delivered, the hospital even gave me a suit of baby clothes as
a gift
...
”
Lessons learned
A maternity waiting room approach should be an integrated strategy, which not only includes the
physical improvements to the existing hospital rooms and provision of living necessities, but is successful
when also including promotion of waiting room use within communities and transport subsidy and living
allowance for pregnant women to help defray the cost of using the waiting rooms
...
Capacitybuilding of health providers at hospitals and the availability of essential medical supplies are essential
and should be addressed in this approach
...
The Ministry of Health values the approach and sees the potential of
applying it in hard to reach areas
...
The waiting room approach could influence the uptake of
institutional delivery and reduce maternal mortality in these areas
...
The maternity waiting
room approach of refurbishing existing rooms in health facilities means it is comparatively lower cost
and can be set up more quickly with local ownership and adequate supply-side conditions
...
Acknowledgements: Robert Scherpbier (UNICEF China), Sufang Guo (UNICEF China), Nabila Zaka (UNICEF East Asia and Pacific
Regional Office)
26
ETHIOPIA: Introduction of magnesium sulphate to manage pre-eclampsia and
eclampsia
Background
Ethiopia has a high burden of maternal and neonatal mortality
...
Rapid
mortality reduction depends on the ability of the health system
to provide quality care to mothers and neonates experiencing
serious complications during pregnancy, labour and the
immediate post-partum period
...
One of these proven high-impact interventions is the use of
the safe and effective anticonvulsant agent, magnesium
sulphate, for the management of severe pre-eclampsia and
eclampsia
...
This initiative
requires both involvement of
public and private hospitals and
shifting the duty of providing drugs
to nurses and midwives
...
Reasons included the unavailability of anticonvulsant agents and the
inadequate number of trained human resources to administer and monitor drug administration in most
facilities
...
Among the 72 health facilities missing only one signal function (out of a
total 751 health facilities providing delivery service), about half were missing parenteral administration
of anticonvulsants
...
Reasons for the delay in introducing this essential intervention included the perceived risk of serious
complications (i
...
, drug side effects from this treatment), lack of highly trained human resources to
manage complications if they arose, and unavailability of the drug and general resistance to change to a
‘new’ management in favour of established treatment modalities
...
Strategy
The Federal Ministry of Health, in collaboration with the Ethiopian Society of Obstetricians and
Gynaecologists with technical and financial support from UNICEF, implemented a one-year project to
introduce this essential intervention into the national health system
...
e
...
Supportive supervision and mentoring seeks to ensure the
quality of this intervention provided in the hospitals
...
Results
The project has successfully introduced the administration of magnesium sulphate for the management
of severe pre-eclampsia and eclampsia in all public and most private hospitals providing maternal and
newborn health services in the following way:
An initial consignment of magnesium sulphate was delivered to these facilities through UNICEF
support, and the management was initiated nationally in 113 public and 40 private facilities
...
Eighty-four per cent of the trainees were non-specialist doctors, health officers,
midwives and nurses, which emphasized the importance of task-shifting of the management of
the drug in order to scale-up care to the national health service delivery system
...
A clinical audit of outcome was collected from all facilities with emphasis on serious
complications related to the intervention, including respiratory complications
...
MgSO4 has been procured through government funding since 2010
...
Task-shifting for magnesium sulphate
provision is possible with appropriate support and oversight
...
The national scale-up of this essential intervention is occurring by expanding the provision of
magnesium sulphate at 3,200 health centers across the country, through training of midwives and
nurses and providing necessary supply through an enhanced partnership between the Ministry of
Health, UNICEF and the Ethiopian Society of Obstetricians and Gynaecologists
...
The project has successfully initiated this important, globally recognized,
low-cost and highly effective intervention for the management of this serious pregnancy complication
...
Acknowledgements: Luwei Pearson (UNICEF Ethiopia), Asheber Gaym (UNICEF Ethiopia), Janet Kayita (UNICEF East and South
Africa Regional Office)
29
INDIA: Tracking newborns treated in Special Newborn Care Units
Background
In the state of Madhya Pradesh, it was found that there
Why is this innovative?
was a high rate of infant death among preterm/infants
A novel information and
small for gestational age after discharge from the health
facility
...
Admissions showed at least 10 per cent of those
SMS system is being used in the state of
discharged after successful completion of treatment died
Madhya Pradesh to strengthen PNC
in their community before reaching one year of age
...
3 to 3
...
Four years of data from
year of life
...
7 per cent died after
discharge
...
18 Between early
2008 and 2011, the SNCU units treated nearly 80,000 newborns in Madhya Pradesh
...
Strategy
For the follow-up, a system was devised which involved six community visits in the first month of an
infant’s life by trained CHWs called Accredited Social Health Activists (ASHAs), and five facility visits
...
Implementation
Starting in 2010, the follow-up system was initiated in the pilot districts of Guna and Shivpuri using a
customized software and automated SMS system for tracking newborns after discharge and to facilitate
timely community and facility follow-up
...
After their discharge automated, periodic alerts were sent to the ASHA and family members for
follow-up care and support
...
In each district, a data entry operator was responsible for entering patient information into the database
using a computer with Internet connectivity
...
Upon admission, the operator recorded necessary
information including the mobile numbers of the family members or other persons in close contact with
the family
...
Once the operator entered discharge information for a patient in the system, dates of follow-up
18
Scheduled castes and scheduled tribes are two groups of historically-disadvantaged people recognised in the Constitution of
India
30
were generated automatically and provided to the family along with a follow-up card
...
Once the infant was discharged, the system automatically sent an SMS alert to the ASHA informing her
that the patient was returning to the village
...
On the day of follow-up, a reminder was sent to both the family and the responsible ASHA
...
In each case, a family was contacted 11 times through SMS from the day of discharge through the first
one year of life while the ASHA was reached 12 times
...
The cost of
sending a total of 23 SMS messages in the first year of life for each child amounted to only 1 rupee
(approximately 0
...
The data operator was provided a salary of 7,000 rupees (approximately 127
USD) per month and was also involved in regular data analysis at the SNCU
...
UNICEF was involved in generating evidence related to the need for
infant follow-up, conceptualizing the follow-up mechanism, developing the software and case record
sheets for data recording and tracking, training of data entry operators, and monitoring the system and
impact analysis
...
A total of 5,998 newborns were discharged during this period from units in Guna and Shivpuri
between 2010 and 2011
...
A
similar increase was seen for multiple visits with 48 per cent of newborns receiving three community
health visits in 2010, which increased to 67 per cent in 2011
...
The SMS system allowed the tracking of approximately 1,200 newborns
...
Among infants successfully
discharged from an SNCU, mortality reduced from 9
...
The use of low-cost SMS technology has proved effective in ensuring follow-up of these newborns
contributing to improved survival in a large remote district of Madhya Pradesh
...
Lessons learned
To maximize gains of facility-based newborn care, an effective follow-up system is strongly
needed for all newborns after discharge, with well-defined protocols for follow-up, with both
community and facility linkages
...
Customized software with periodic alerts based on admission and
31
discharge information can be developed to effectively use this information for targeted
population groups
...
Improvement in survival rates at one year of age compared to a cohort two years prior indicates
strong potential for continued use and replication in other areas where SNCUs exist
...
All the SNCUs have software for data recording and tracking installed in the system
and operators have been trained
...
Monitoring of follow-up is being made possible online using web-based software developed by UNICEF
for SNCU data management and tracking
...
To fully optimize the effectiveness of
newborn care units and improve survival rates of newborns even after discharge, a tracking system with
community follow-up is needed especially in regions where health workers are trained in skills for
community-based newborn care
...
High mobile
connectivity is a precondition, which may not be possible in all rural areas
...
Customized software storing data for each infant is necessary, as is a dedicated operator to
input data and maintain records
...
Having the
customized software for storing information on infants discharged from SNCUs is still very useful even
without SMS functionality to track patients
...
Acknowledgements: Gagan Gupta (UNICEF India), Jayashree Chandra (State Government of Madhya Pradesh), Tania Goldner
(UNICEF India), Henri Van Den Hombergh (UNICEF India), Rahul Bhadoria (Divisional Coordinator Gwalior), Nuzhat Rafique
(UNICEF Regional Office for South Asia)
32
MONGOLIA: Evidence-based approaches to improving newborn care
Background
Mongolia has been reducing maternal and child mortality rates
and making notable progress towards MDGs 4 and 5
...
It also found lack of information on the
current availability and quality of basic emergency obstetric
and newborn care (BEmONC)
...
Why is this innovative?
Using evidence-based strategies to
identify gaps in service provision,
Mongolia was able to make
targeted revisions to its national
maternal and newborn health
strategic plan
...
In 2008, UNICEF checked existing policy and service gaps against high-impact MNCH interventions, using
the Marginal Budgeting for Bottleneck analysis
...
Key bottlenecks of the health system were identified, including poor quality of
available primary health care services (especially for remote and disadvantaged communities), limited
skills among health practitioners, shortages of essential materials and poor implementation of health
communications activities
...
An assessment of EmONC needs completed in 2010 found additional service delivery gaps
...
County hospitals in particular lacked essential supplies such as blood pressure measurement apparatus
and antibiotics and obstetric forceps were available at only 25 per cent of them
...
Half of those interviewed felt it was not possible
to communicate with doctors freely and 76 per cent indicating not expressing themselves freely
...
Strategy
Based on findings from several assessments, UNICEF first advocated for revision of the maternal
mortality reduction strategy and a new plan to improve maternal and newborn health
...
The strategy included a monitoring and evaluation framework incorporating
indicators for essential obstetric care and supplies
...
A draft
memorandum of understanding
was developed between Ministry
of Health and the Employers
Federation and Chamber of
Commerce
...
Midwifery kits which
contained essential newborn items
and baby warmers were procured
and distributed
...
Work aids for health workers were distributed and IEC materials on
newborn care for parents were developed and distributed
...
Some MWHs were also established with a newborn corner for post-delivery care of newborns
to stabilize them before going to remote herding areas
...
There is improved awareness among government, health care providers,
private sector and NGOs on newborn needs, particularly on EmONC
...
Improved collaboration with UNFPA, WHO and other international
and national organizations has resulted in improved division of labour and coordination of EmONC
capacity-building in the country
...
Lessons learned
Motivation and support for team work among maternal and child health workers must be encouraged
...
In areas where there is inadequate capacity of the local
management team, this capacity must be built locally to improve EmONC systematically
...
To scale-up these improvements, a role model facility with full EmONC capacities would be
useful
...
The WHO
needs to conduct a training-of-trainers on diagnosis, reporting of newborn cases and death
audit
...
A C4D strategy will be developed and implemented for the empowerment
of parents
...
Acknowledgements: Surenchimeg Vanchinkhuu (UNICEF Mongolia), Aira Toivgoo (Well Spring), Dr Buyanjargal (Ministry of
Health, Mongolia), Khishigee Seded (National Maternal and Child Health, former Vice President of Mongolian Federation of
Obstetricians and Gynaecologists), WHO, UNFPA, Nabila Zaka (UNICEF East Asia and Pacific Regional Office)
35
NEPAL: Establishing and sustaining birthing centres closer to communities
Background
Although Nepal’s health system has experienced nearly 10
years of severe disruption caused by armed conflict, the
country managed to almost halve its MMR from 539 deaths
per 100,000 live births for 1989─1995 to 281 deaths per
100,000 live births for 1999─2005
...
Most maternal deaths were a
direct consequence of under-utilization of appropriate health
services and low quality of care, especially in rural areas
...
Why is this innovative?
Nepal initiated a nationwide upgrade
of health facilities into birthing
centres to address inequities in
access to delivery services among the
most deprived women
...
In 2005, 19 per cent of deliveries were conducted by SBAs
...
The Government of Nepal identified skilled birth attendance as the key strategy for
reducing maternal mortality
...
These facilities were not
widely used by the poorer groups who tend to go to lower level facilities
...
Strategy
The Government of Nepal determined that health facilities would be upgraded nationwide into birthing
centres to fulfil criteria set by the Family Health Division (FHD)
...
Strategies included creating an enabling
environment through micro-planning workshops at the district and health facility level using an
appreciative inquiry approach20, increasing access to quality BEmONC, increasing access to skilled
attendants at birth, and creating community awareness to increase demand for quality emergency
obstetric services, especially among the poor and vulnerable
...
One health facility – whether a Primary Health Care
Centre, Health Post or Sub-Health Post – is available in each village committee, staffed by one auxiliary
nurse midwife, assistant health worker and village health worker
...
Appreciative Inquiry is a method for studying and changing social systems (groups, organizations, communities) that
advocates collective inquiry into the best of what is in order to imagine what could be, followed by collective design of a desired
future state that is compelling and thus, does not require the use of incentives, coercion or persuasion for planned change to
occur
...
In Kessler, E
...
) The Encyclopedia of Management Theory
...
)
20
36
and maternal health
...
This process helped in understanding the quality of the services at
the time, the infrastructure, and human resources needed for better planning and budgeting
...
Interactive workshops included a review and planning of the birthing centre where needs
assessment findings and the maternal and neonatal health situation of the district was discussed
in detail
...
It created awareness among the community and helped participants to
understand the importance of investing in mothers and children
...
Birthing centres manage normal labour;
BEmONC sites manage both normal labour and some complications seen during pregnancy,
delivery and post-partum
...
The birthing centres criteria developed by FHD
requires at least three SBAs, three rooms (delivery, antenatal and postnatal rooms) and
equipment
...
Infection prevention: To ensure and strengthen proper infection prevention practices, an
important component in the quality of care, whole site infection prevention training was
conducted for all birthing centres
...
Technical support was provided to develop district level trainers for whole site infection
prevention training at newly established birthing centres and for supervision and monitoring of
infection prevention in these sites
...
The SBA training helped to develop competencies to provide quality ANC and
PNC, and manage normal deliveries and some complications during delivery
...
While health workers waited to be trained as SBAs, they received the
maternal and newborn health update package training as a short-term strategy to capacitate
them with knowledge and skills for the correct management of normal labour and timely
referral of complicated cases to CEmONC centres
...
The watch
group’s main role is to identify pregnant women in their ward, counsel and encourage them to
attend ANC and PNC clinics, help them understand the importance of maternal nutrition and
institutional delivery with SBAs, and ensure the woman has received a tetanus toxoid injection,
38
iron and deworming during pregnancy
...
Transport: The Aama programme – the Government of Nepal’s free delivery programme –
provides transport incentives to women who come for institutional delivery
...
The fund becomes
useful especially when the family of the pregnant woman has difficulties finding money for the
emergency
...
UNICEF supported the FHD to implement the community-based prevention of post-partum
haemorrhage using misoprostol in home births along with a birth preparedness package
...
This intervention has increased awareness among the family and communities on birth
preparedness and complication readiness
...
Results
In 2008, there were only 16 health facilities in 5 UNICEF districts providing BEmONC services according
to national standards
...
Access to delivery
sites in these 11 districts has increased significantly from less than 10 per cent to 36 per cent
...
The majority of the delivery sites in 11 districts (95 per cent) have at least one
trained SBA
...
Mobilization of female community health volunteers to increase awareness among the family and
community on the importance of ANC, institutional delivery and PNC services, birth preparedness and
complication readiness has proved to be very effective in encouraging the women to utilize services in a
timely way
...
Institutional deliveries in some of the areas have
increased dramatically from 7 per cent to 45 per cent
...
A recent fund utilization report showed that more women from the most disadvantaged group had used
the fund compared to higher economic groups
...
Lessons learned and potential application
This comprehensive approach adopted by districts with UNICEF support has proven to be effective in
making delivery sites functional full-time throughout the year
...
The involvement of local stakeholders during the development of the local action
plans and later in implementing the plans has shown to be more sustainable compared to the centrally
39
directed plans
...
Focusing on reaching the unreached population by establishing service sites in the most remote and
disadvantaged areas has improved access to services even to the most deprived communities
...
This approach has developed the capacity of personnel and created an enabling environment to
provide quality services which has resulted in the increased trust of the community in the service
providers and the services they provide
...
The partnership between decentralized health authorities and community
committees is well recognized and appreciated by the FHD and partners
...
Acknowledgements: Asha Pun (UNICEF Nepal), Hendrikus Raaijmakers (FHD, Department of Health Services, Ministry of Health
and Population), Senendra Upreti (FHD, Department of Health Services, Ministry of Health and Population), Nuzhat Rafique
(UNICEF Regional Office for South Asia)
40
PAKISTAN: Chief Minister’s Initiative for the Attainment and Realization of the MDGs
Background
In 2010, severe floods affected millions of people in Pakistan,
with approximately 4
...
Punjab’s total fertility rate is reported at 4
...
Both infant and under-five mortality rates have declined
since 1990; however, the rate of decline over the last 15 years
has been considerably slower than in other countries in the
region and neonatal mortality rate has remained relatively
stagnant
...
In all the flood-affected districts, development indicators
including MNCH were worse than the national average
...
Strategy
Punjab province health authorities, with financial and technical support from UNICEF and UNFPA,
started providing 24/7 EmONC services at selected basic health units and rural health centres in the
flood-affected districts, ensuring primary health care services with a focus on MNCH services
...
The programme was designed as a support and extension of the existing district health system so that it
could be integrated into the district system
...
Implementation
Several innovative components were developed and implemented including financial flexibility, robust
monitoring and evaluation (that included altogether new e-monitoring, mechanism of accountability
and rewards), pay-for-performance, reporting of results, and raising community involvement and
awareness through mobile phone text messaging service
...
The incentive kicks in when a night delivery occurred, splitting
the incentive by percentage among staff present, from medical officer to driver and security guard
...
SMS system for monitoring and reporting
incentive was provided to the
health
facility
based
on
performance evaluation
...
Real-time
monitoring
and
reporting: An innovative electronic
or e-monitoring system was devised
and is being piloted as part of the
CHARM program
...
Health
workers – specifically ‘Lady Health
Visitors’ – report directly to the
central database in the province
using an SMS-based reporting
mechanism
...
All health workers were trained to
submit the reports using a defined template
...
Referral report: Every health worker who refers a case from any of these facilities submits the
report by SMS using the referral template
...
Their movement is monitored by satellite
...
After an infant is
delivered, a report is sent by the health
worker and a congratulatory message is
generated from the central database
and sent to the parents and family
members asking them for feedback on
the services provided at the health
facility
...
Comparison of baseline, provincial average
and CHARM average for essential interventions
Baseline (Nov
...
2012)
CHARM average
(Aug
...
SMS messages continue through immunization of the child
...
Health facilities used to function for six hours a day before additional human resources were provided,
which led to the operational timing of the health facilities increasing fourfold
...
The CHARM programme has shown promising results compared to the baseline data of the same health
facilities before the intervention, as well as compared to the current data of other non-intervention
health facilities
...
Special attention is being paid to the provision of postnatal and family planning services, which had not
been as strong as facility-based care during and immediately after childbirth
...
Next steps
Observing these results, the Government of the Punjab has decided to extend similar services to 13
additional districts and sustain them in seven existing districts through its own resources in the coming
years
...
Potential application
Post-emergency response can be a good time to introduce new interventions in maternal and child
health that help the affected regions in terms of both immediate recovery and long-term development
...
Acknowledgements: Tahir Manzoor (UNICEF Pakistan), Nuzhat Rafique (UNICEF Regional Office for South Asia)
43
PHILIPPINES: Essential intrapartum and newborn care protocol
Background
In the Philippines, 40,000 newborns die each year from
causes that are mostly preventable such as complications of
prematurity (41 per cent), severe infection (16 per cent) and
birth asphyxia (15 per cent)
...
Only if measures are
instituted to reduce newborn mortality more rapidly can we
hope to achieve MDG 4 by 2015
...
Results from a recent national health
survey revealed maternal mortality in the country has in fact
increased from 162 per 100,000 live births in 2006 to 221
per 100,000 live births in 2010
...
Why is this innovative?
This approach was initiated as a quality
improvement initiative in referral
hospitals in contrast with the existing
approach of starting capacity-building in
primary facilities
...
A study was conducted in 2009 in 51 of the largest hospitals in 9 regions in the Philippines using an
assessment tool developed by the WHO to assess birthing practices
...
In these hospitals, practices prevented Philippine newborns from benefiting from their
mothers’ natural protection in the first hour of life, compromising the newborn’s chance for
maintenance of warmth, needed for its survival
...
Supported by the WHO and the Government of
Philippines’ Joint Programme on Maternal and Neonatal Health, the project is referred to as the ‘ScaleUp Essential Intrapartum and Newborn Care Project’ or ‘Unang Yakap 4&5’
...
EINC practices are evidence-based standards recommended for adoption in
hospitals with maternal and newborn care services and birthing facilities, both in the government and
private sectors
...
The recommended EINC practices for newborn care are a series of time-bound interventions: immediate
21
Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L,
Mathers C, for the Child Health Epidemiology Reference Group of WHO and UNICEF (CHERG)
...
The Lancet
...
22
Family Health Survey, Philippines National Statistics Office, 2011
...
Implementation
Since 2010, selected Department of Health hospitals have trained in and adopted the EINC set of
practices as part of a programme of the Department of Health funded by the Joint Programme on
Maternal and Neonatal Health and WHO
...
WHO took the lead in the assessment of the newborn care
practices in selected health facilities in the country
...
The EINC strategy uses a health systems strengthening approach with various components:
A clinical practice guideline on newborn care component that used GRADE (Grades of
Recommendation, Assessment, Development, and Evaluation) methodology;
Policy support for the newborn clinical practice guideline through the issuance of a Department
of Health national policy and incorporation with existing policies for Mother-Baby Friendly
Hospital Initiative criteria and the MNCH and nutrition policy;
Health financing incentivization of the new practices through reforms in the maternal and
newborn care packages of the national health insurance system;
Incorporation of EINC protocols in pre-service and in-service curricula starting with medical,
nursing and midwifery academic societies and incorporation in professional licensure
examinations;
Creation of a social marketing handle (‘The First Embrace’ or ‘Unang Yakap’) and campaign
initially targeted to change health worker behaviour and institutionalize the change in pilot
hospitals;
Use of social media for the dissemination of and sustenance of trained centres and personnel;
Creation of centres of excellence through technical assistance for the hospital
...
Since
October of 2010, in each of these hospitals, the scale-up process has entailed:
A baseline situational analysis including delivery assessments, time-motion studies in delivery
areas and newborn intensive care units, baseline neonatal morbidity and mortality data;
Training workshops for all hospital staff;
Monitoring and evaluation or facilitated supervision phase consisting of weekly meetings with
the hospital’s EINC Working Group over a typical six-month period with repeat assessments
...
This led to the
creation of training teams within the pilot hospitals themselves
...
The process was replicated by the USAID-funded SHIELD project in
Mindanao where they used the Quality Improvement Collaborative process to create service delivery
networks between rural health units and provincial hospitals
...
More hospitals and health professionals are aware of the protocol
and are providing EINC care
...
Breastfeeding within the first hour, pre- and post-training
across the 11 project sites, this scalePercentage (%)
Median time to
up process has been effective in Health facility
initiation (min
...
There was as
PrePostPrePostmuch as a 75 per cent reduction in
training
training
training
training
newborn intensive care unit
27
100
21
13
admissions, lower mortality and PGH
sepsis case, and lower fatality rates, Tondo Medical
90
90
50
61
and an increase in exclusive Cotabato Regional 90
100
43
28
breastfeeding rates on the seventh
Jose Reyes
36
60
27
61
and twenty-eighth day follow-up
20
40
61
46
visits
...
Babies who breastfed according to recommended practices were almost twice as likely to
exclusively breastfeed at 28 days
...
In addition, improvements were also seen in maternal
care and infection control practices, and in reduced workloads and expenses
...
An example of improved outcomes was the administration of intramuscular oxytocin
...
Simple cost-saving calculations by hospitals have revealed substantial savings averaging almost 500
Philippine pesos per vaginal delivery (approximately 12 USD)
...
Based on experiences to date, constraints to the
rapid national scale-up include the need for a critical mass of trainers and innovative means of training
large numbers of health workers, with an opportunity for a refresher or review, perhaps through the use
of the Internet and computer-based technology
...
46
Next steps
Scale-up to reach a wider number of facilities, mostly primary, is ongoing
...
Trainings of health workers will be done under the Joint Program on Maternal and Newborn
Health
...
Aside from primary facilities, the Joint Program will
expand to creating service delivery networks for seamless delivery of quality care
...
The social marketing handle
is catchy and the national government has assumed ownership of the brand
...
At the national and subnational management levels, compliance is to be
monitored through the incorporation of the EINC indicators in the national programme monitoring tool
and in the checklist for accreditation
...
With positive results such as reduced
number of admissions to neonatal intensive care units and decreased neonatal sepsis rates, it would be
worthwhile for other countries to learn from this experience and to explore opportunities to implement
such interventions adapted to their local context
...
47
RWANDA: SMS alert system to monitor pregnancy and reduce maternal and child
deaths
Background
Rwanda is among the sub-Saharan African countries
where the largest total percentage decline of maternal
mortality (51 per cent reduction) occurred between
1990 and 2008
...
Rwanda
has recently developed a comprehensive information
technology strategy plan that includes eHealth (the
combined use of electronic communication and
information technology in the health sector) and
mHealth as important components
...
The system includes
registration, effective monitoring and
appropriate care of pregnant women
throughout pregnancy up to delivery and
through the post-partum period
...
Established in 1995, the Rwanda community health
programme aims to increase the uptake of essential
maternal and child clinical services through the
education of pregnant women, the promotion of
healthy behaviour and follow-up and linkages to services
...
Working as volunteers elected by community members,
CHW responsibilities are divided into ‘binomes’ (a male-female CHW pair) providing basic care, and a
CHW in charge of maternal health
...
For CHWs in charge of maternal health – the focus of this case study – specific responsibilities in the
community consist of identifying pregnant women, making regular follow-ups during and after
pregnancy and ensuring deliveries occur in health facilities with an SBA
...
Developed by UNICEF and the
Rwanda Ministry of Health, the RapidSMS platform supports the documentation of pregnancies in the
community, increases contact with health facilities through ANC, and increases institutional delivery and
hence by proxy, professional care at birth
...
Clinical records of maternal care and
deliveries are centralized by RapidSMS in a database
...
The percentage of assisted
deliveries in health facilities in Musanze was estimated at 48
...
24 The district includes 13 health centres and one district hospital and has 18
23
Hogan MC, Foreman KJ et al
...
The Lancet
...
24
National Institute of Statistics of Rwanda (NISR), MoH, Statistical Yearbook 2010 Edition
...
Additionally, the district counted 1,296 CHWs,
including 432 CHWs specifically tasked with maternal and newborn health
...
A community health representative working at the district hospital
level manages the supervisors or CHWs from the facilities
...
RapidSMS, an open source SMS application platform, was developed to track the pregnancy life cycle,
enabling instant reporting of a pregnancy-related event and timely notification for emergencies by
alerting health facilities, hospital and ambulances
...
The SIM card provided by the mobile operator, MTN Rwanda, had reverse
billing to the Rwandan Ministry of Health, which allowed end-users to send SMS messages without
charge
...
Feedback was
analysed, documented and used to improve system functionalities
...
The final version was installed in a central server and linked
to a public IP address
...
The interface presents an
overview of the system’s outputs including individual and aggregated reports, statistics, and system
administration, log of reminders and activity of CHWs
...
A user working in a health facility at the district level will be
assigned an account, granting him or her permission to view and possibly modify data only from his or
her health facility’s catchment area
...
For each registered pregnancy, the system will send automated
reminders of upcoming ANC visits and due date of delivery to the CHW’s phone to follow-up with the
individual
...
This SMS includes the danger sign reported, the name of the
village and the telephone number of the health worker who sent the original message
...
The system incorporates features enabling continuous technical monitoring to recognize and record, in
an error log, inconsistencies such as wrong SMS formatting or mistakes in logic, indicating that the
message’s sender may have been having difficulties with reporting
...
The error log contributes to facilitate management of CHWs by supervisors who can
use these logs to provide feedback to CHWs
...
National trainers were encouraged to take part in the development of training
material
...
The third and
last stage of training involved a two-day training of 432 CHWs by the 24 supervisors and data managers
...
Training
materials were translated into the local language (Kinyarwanda)
...
Training was followed by intensive
follow-up supervision, and refresher training and feedback sessions to ensure effective capacity transfer
...
Results
Between May 2010 and April 2011,
35,734
SMS
reports
were
submitted to the system, including
11,502 pregnancy registrations (81
per cent of the 14,200 estimated
annual pregnancies in the district)
...
SMS
reminders were sent out to the
CHW’s phone in relation to each
registered pregnancy
...
The percentage of
deliveries varied between 72 and
Figure 8
...
92 per cent in health facilities and
2009-May 2011)
between 8 and 28 per cent at
home
...
Error rate (the
number of SMS sent with formatting errors) dropped from 54 per cent in the first four months to 8 per
cent by the end of April 2011
...
The most common danger sign
reported was antepartum and post-partum hemorrhage, accounting for 30 per cent of emergency cases
...
Usage patterns and challenges encountered by end users
were collated and used to make adjustments to the overall system (e
...
, SMS form, system’s application,
etc
...
Furthermore, clear delineation of administrative boundaries with defined roles and responsibilities for
CHWs facilitated monitoring and quality assurance
...
In Rwanda, CHWs are organized in cooperatives
in each sector of the district, and their income is mostly based on performance
...
Among other support
it provided to the pilot, the Ministry of Health engaged the private sector in a public-private partnership
to substantially lower the recurrent cost of SMS
...
05 USD) to 3 Rwandan francs (0
...
This cost reduction was
crucial to its expansion and sustainability
...
The CHWs were advised to recharge their
telephones at the closest health centre
...
CHWs in the present project perceive greater trust and
respect in their communities as a result of being empowered to request an ambulance in case of
emergencies
...
Next steps
The early results of this initiative prompted the Rwanda Ministry of Health to develop a national scaleup plan
...
Potential application
RapidSMS-MCH demonstrates that mobile phone technology offers an opportunity to overcome barriers
that limit access to quality maternal and newborn health
...
Acknowledgements: Friday Nwaigwe (UNICEF Rwanda), Janet Kayita (UNICEF East and Southern Africa Regional Office)
Further reading: Fidele F, et al
...
Pan African Medical Journal
...
panafrican-medjournal
...
51
SIERRA LEONE: Capacity development of human resources for maternal and newborn
health
Background
Sierra Leone faces a situation of high poverty,
illiteracy and fertility levels, high teenage
childbearing rates and a low uptake of family
planning
...
These factors combine to
produce the highest MMR in the world, estimated at
860 per 100,000 live births
...
The under-five mortality rate is
140 deaths per 1,000 live births; infant mortality is
89 deaths per 1,000 live births and neonatal
mortality is 36 per 1,000 live births
...
26
Why is this innovative?
This ‘skills and drills’ approach to training of
health workers is innovative because it uses
simple technology incorporating the use of
mannequins to train them in skills and
knowledge, in environments where that is not
otherwise possible due to low patient case
loads
...
The incorporation of a
monitoring and evaluation mechanism for the
capacity-building activity has shown that it is
possible to achieve high level results: a
reduction in case fatalities, increased
recognition of complications and a reduction
in still births
...
However, many Sierra Leonean women and newborns are excluded from this lifeline
because only 50 per cent of births occur in health facilities and about 62 per cent of deliveries are
assisted by a skilled service provider
...
28 The skill level of service providers and the number of such
providers have long been a recognized bottleneck in Sierra Leone’s health care system that is in the
process of recovering from long periods of neglect
...
As of
2010, the public health sector had about 24 public health specialists, 29 medical specialists, 115 medical
officers, 132 community health officers, 1,017 nurses and 825 maternal child health aides
...
However,
acute human resource shortages remain, particularly high in rural areas
...
Child Epidemiology Reference Group, SMART Survey, Sierra Leone, 2010
...
28
Sierra Leone Demographic and Health Survey 2008
...
26
52
Strategy
The goal of the ‘Make It Happen’ project is to improve knowledge and skills of health workers, leading to
a better quality of clinical practice through competency-based training
...
The
programme delivered a competency-based training package adapted to the country context which was
sustained by the training of in-country trainers and through supportive supervision and mentorship
within the workplace
...
Implementation
A critical first step in the development of this training programme was to assess the baseline status of all
target health facilities providing EmONC
...
Assessments were undertaken for
maternal and neonatal health and in particular SBAs, EmONC, numbers and cadres of staff, recordkeeping practices and whether or not there were any ongoing quality improvement activities
...
The approach was based on a ‘skills and
drills’ package delivered over a 3-4 day
period depending on the cadre of health
workers involved
...
Mannequins were used to teach the
skills and for drilling instead of the
traditional approach of relying on live
patients
...
Pre-service training of nurses with mannequins
In the traditional training model, the available patients may not represent the range of conditions
needing treatment; meaning that not all skills may be demonstrated in facility-based training
...
It includes modules on
communication, triage and referral, resuscitation of the mother and newborn, shock and the
unconscious patient, severe pre-eclampsia and eclampsia, haemorrhage, obstructed labour, sepsis,
assisted delivery, other common obstetric emergencies, complications of abortion and early newborn
30
Training package developed by the Liverpool School of Tropical Medicine in collaboration with the Royal College of
Obstetricians and Gynaecologists and the Department of Making Pregnancy Safer at WHO Geneva in 2006
...
The training package includes a section on surgical skills and on normal delivery, i
...
, skilled birth
attendance
...
Both the manual and course content were designed with the awareness of very real barriers to
accessing care that women in resource-poor countries face, as well as the realization that many health
care providers trying to provide skilled attendance at birth and essential (or emergency) obstetric care
for women with complications work in difficult circumstances with limited equipment and medical
commodities
...
Results
Training of health workers: A total of 837 health workers were trained over the period 2009─2012
...
Participating facilities: The 837 health workers were drawn from a total of 93 health facilities made up
of 21 hospitals (CEmONC centres) and 72 CHCs (BEmONC centres)
...
Change in knowledge and skills: A representative sample of 381 (46 per cent) of the total number of
health workers trained showed a statistically significant improvement (pre-test and post-test) in both
knowledge (mean of 46─65 per cent) and skills scores (mean of 31─70 per cent)
...
Pre-test and post-test scores for knowledge and skills (n=381)
Mean pre-test score (%)
Mean post-test score (%)
p-value
Knowledge
46
...
6
0
...
4
69
...
001
From key informant interviews and focus group discussions with training beneficiaries it has been
established that the improved skills and knowledge led to improvement in clinical practice, including
increased use of manual vacuum aspiration, the partograph, use of vacuum extraction and kangaroo
mother care
...
31 In 2008, only one hospital and none of the CHCs
provided all signal functions
...
32
Deliveries: Data from participating facilities show that in the period 2009─2012, there was a rapid
increase in the number of deliveries at health facility (overall 63 per cent increase), mainly in CEmONC
facilities
...
The large number of women using facilitybased delivery services therefore benefited from better services as a result of the improved skills and
knowledge of the personnel
...
LSTM Making It Happen Programme
...
Quarterly On the Job Training Report
...
The training approach therefore had greater effect in BEmONC facilities than in CEmONC
facilities
...
6 per cent in
CEmONC and 15 per cent in BEmONC health facilities
...
Client satisfaction: Feedback from programme beneficiaries indicated that programme interventions
were reaching intended beneficiaries and with the desired positive effects
...
Overall, the women
interviewed indicated that staff attitude among health workers had improved, but there were a few
reports of negative staff attitude as well
...
Even then, some complications can be missed so that it
is difficult for trainees to achieve comprehensive skills in relation to most important
complications
...
The approach to training can be adapted to suit different health professional cadres
...
Involvement of institutional tutors in the in-service training has made it easier to adopt the
approach in the pre-service training programmes as well
...
It is good practice to obtain direct feedback from beneficiaries, more so when the information is
used to improve delivery of interventions
...
Roll-out of in-service competency-based training
will be taking place for the next set of 65 CHCs over the next two years and with follow-up and refresher
training in previously covered facilities
...
Potential application
The project launched in October 2009 with the objective to cover 65 health facilities in three districts in
three years
...
Acknowledgements: Kennedy Ongwae (UNICEF Sierra Leone), Yaron Wolman (UNICEF Sierra Leone), Mariame Sylla (UNICEF
West and Central Africa Regional Office)
55
TIMOR-LESTE: Involving communities in addressing maternal health inequalities
Background
Timor-Leste is a young nation with one of the highest
rates of maternal mortality in the world: 557 per
100,000 live births
...
The proportion of women accessing institutions for
delivery is about 12 times higher in the richest quintile
as compared to the poorest quintile
...
The figure of
concentration curves of maternal health indicators
visually depicts the inequalities between the richer and
poorer populations for utilization of various maternal
health services
...
Institutional delivery is
most unequal between the poorest and richest
quintiles
...
This
strategy is participatory and allows the
identification of hard to reach and
deprived women, and the development of
community action plans (with strategies
such as facilitating transport, financial
incentives, micro-credits) to increase
equitable access and use of maternal and
newborn health services by women in the
community
...
Concentration Curves for Maternal Health in Timor Leste
(DHS 2009-2010)
Institutional delivery
100
90
80
70
60
50
40
30
20
10
0
Line of Equality
Knowledge of danger signs
Antenatal Care
Iron supplementation
TT Injection
Post Natal Care
0
20
40
60
80
100
Cumulative % population, ranked from poorest - richest
Delivery by SBA
Strategy
The innovative approach discussed here is primarily aimed at developing a model for community action
to reduce the inequities in maternal health care in a defined administrative unit
...
56
Documenting the lessons learned for refining the model and scaling up its application in the
future
...
A
critical aspect is the model for community action focused on addressing inequalities in maternal health
...
34
The model was implemented with community representatives including pregnant women and key
influencers to collaboratively explore the reasons for the inequities in the utilization of institutions for
delivery among women from the richest to the poorest quintiles
...
The project was implemented by the Ministry of Health and UNICEF in partnership with NGOs and
UNFPA
...
UNFPA provided support by providing maternity packages to pregnant women accessing health facilities
for delivery services
...
The first phase of the project helped in refining the fivestep model
...
The causality analysis revealed underlying reasons for
poor utilization of health facilities among women, such as feeling shy around male providers,
unavailability of money or/and transport, doubts about the quality and availability of services at
facilities, inability to predict the timing of the onset of labour, and not getting permission from the
husband
...
The end result of the exercise was the identification of 26 mothers most likely to need support
to access health facilities for delivery services
...
In May 2012, the implementation of the project was expanded to one
subdistrict (Hatolia) in Ermera district
...
Some examples of solutions in the community action plan include public commitments from
health volunteers and local leaders to help mothers requiring support, community members
volunteering to provide transport to health facility, and mother support groups (micro-credit groups)
providing social and financial support to mothers in need
...
57
Outcomes: This model of addressing inequities successfully exploited the community’s desire for
change, propelled communities into action and encouraged local solutions and mutual support, thus
leading to greater ownership of the process
...
The percentage of women accessing institutions for delivery increased from 11 per cent before
intervention (8 out of 70 deliveries) to about 86 per cent (6 out of 7 deliveries in the 3-month period
following implementation of the intervention, taking into account small sample size)
...
Preliminary reports show a significant jump in deliveries at the
community health facility in Hatolia subdistrict in the months after the intervention
...
Lessons learned
The process and findings were documented in the form of a case study and were presented formally to
the senior management of UNICEF and to the decision makers in the Ministry of Health of the
Government of Timor-Leste
...
Next steps
While the study focused on the demand-side issues for addressing inequities, the findings also suggest
important areas for action on the supply side, for the consideration of all stakeholders
...
An important element for sustainability of the programme is ensuring that the capacity and ownership
of the Ministry of Health is encouraged during the process of scaling up
...
Potential application
The analysis of equity in utilization of health services is incomplete without an understanding of the
causes of these inequities
...
The five-step model also provides some important
lessons in engaging with communities to address inequities
...
If implemented successfully on a large scale, this approach could help in
targeting people in the poorest quintile for service delivery and dramatically reduce health inequities
...
Implications for public health programming
These case studies present a range of interventions across the continuum of care and they address
different health system issues
...
The compendium allows us to highlight some strategic
points that should be considered when implementing an innovative solution, strategy or intervention in
maternal and newborn health based on the lessons that emerged from the case studies
...
In China, for example, an
evidence-driven assessment and advocacy was useful in informing policy makers in the development
and promotion of a policy that ensured insurance for newborns
...
This
increases their chances of sustainability and scaling up, if proven effective
...
The government should also lead the implementation of a financial scheme to reduce barriers to
utilization or improve the quality of care
...
Performance-based incentives including cash or in-kind payments to national or subnational
government managers, staff at health facilities, providers or consumers after pre-defined health
results have been achieved
...
The improvement of BEmONC services in Pakistan was done by introducing several initiatives to
improve both supply and demand: to improve supply, 24/7 service delivery, performance-based
financing systems, and eHealth monitoring were introduced; and to improve demand, incentives
were targeted to mothers and C4D approaches used for communities
...
The different
case studies on the integration of health services highlighted the importance of the following:
Government commitment to securing financial resources;
Strengthening linkages and referral systems between health facilities and communities through
measures such as targeted home visits during pregnancy and referrals to facilities for deliveries,
as well as home visits during the post-partum period and referrals for complications;
Task-shifting, by investing in the training of frontline workers to upgrade their skills and
capacities in maternal and newborn care;
Providing supplies including drug and medical devices to avoid stock-outs;
Providing incentives to health care workers in remote areas, who often experience a high
workload
...
Countries should consider mobilizing technical and financial resources by developing or
strengthening collaboration with the private sector
...
As seen in the Rwanda case study, publicprivate partnerships can lower the recurrent costs of SMS
...
For instance, almost all the innovative approaches in Sierra Leone,
Nepal, Afghanistan and Pakistan targeted mothers and newborns in rural or hard to reach areas, who
were in need of maternal and newborn health services, thus reducing inequities in access and increasing
maternal and newborn survival
...
Approaches moving to national scale include
the SMS system for CHWs in Rwanda, the policies on magnesium sulphate in Ethiopia and improving
facility-based delivery in China
...
Broker, strengthen and cultivate partnerships
These case studies provide concrete examples of the longstanding collaborations among H4+ agencies
...
Several
case studies describe how WHO, UNFPA and UNICEF have worked together to test and implement
innovative approaches that support national policies to reduce maternal and newborn mortality and
morbidity
...
60
4
...
Evidence-based strategies,
government ownership and political will, comprehensive and integrated equity-based approaches, and
supportive partnerships are shown to be effective and accelerate progress towards achieving MDGs 4
and 5
...
This compendium serves as a resource for
information on interesting approaches that are showing results
...
61
Title: Health Information System
Description: Brief history on health system information
Description: Brief history on health system information