Accelerating Efforts to Reduce Maternal Death and Disability: The Power of Partnership Symposium on Maternal Health in Developing Countries - What should be done to meet the Millennium Development Goals? - 11 & 12 June 2003 JICA Institute for International Cooperation Organized by: Ministry of Foreign Affairs (MOFA) & UNICEF In cooperation with: Japan International Cooperation Agency (JICA) Supported by: UNFPA, International Medical Center of Japan (IMCJ), Japanese Organization for International Cooperation in Family Planning (JOICFP) This Presentation... 1. Emergency Obstetric Care services are critical in programming for reduction of maternal death and disability 2. Establishing services that will save a woman's life need focus on quality technology, excellence in management and respect for human rights 3. Partnership of Government, technical and donor agencies is an imperative to address the massive hallenge of strengthening systems for ensuring life saving services for women. The situation... close to 4 million births per year - MMR estimated range 320 to 400 per 100,000 live births - Less than 50% women avail even a single ante-natal care check - More than 90% births take place in the home, mostly in unhygienic conditions - A family member, neighbour or relative is the birth attendant for roughly 60% births - Close to 30% births are conducted by traditional birth attendants (TBAs) with about 15% attributable to those who have been "Trained". - Awareness of the danger signs of obstetric complications is extremely low, particularly among the decision makers (mother-in-law and husband) - met need for EmOC is improving but still low Lessons Learned... ● there is no single service intervention or "magic bullet" ● the use of services is influenced by the women's status and self esteem ● All pregnant women are at risk of developing life threatening complications ● traditional interventions can neither predict nor prevent complications ● once a woman develops obstetric complications she needs prompt access to quality Emergency Obstetric Care (EmOC) ● systemic lethargies effect maternal health services the most Advance safe motherhood through human rights... "preventing maternal death and illness is an issue of social justice & women's human rights... redefining maternal mortality from a health disadvantage to a social injustice social injustice provides the legal and political basis for governments to ensure maternal health care for all women --care that will save their lives" Prof. Rebecca Cook 10 yrs of the SMI Srilanka 1997 there is a critical gap between women and the services that they have a right to... EmOC in Bangladesh... ● Focus started in 1993 ● various initiatives supported by different DPs ● adopted as key strategy for reducing maternal mortality in Health and Population Sector Programme (1998-2003) ● commitment to establishing functional EmOC facilities re-affirmed in Maternal Health strategy HEALTH AND POPULATION SECTOR PROGRAMME BANGLADESH National Maternal Health Strategy NATIONAL CONSENSUS WORKSHOP 18 SEPTEMBER 2001 Ministry of Health & Family Welfare Government of the Piople's Republic of Bangladesh National Maternal Health Strategy ・Outlines the essential services that will be established to meet the needs of women during pregnancy, child birth and the puerperium A family member, neighbour or relative is the birth attendant for management plan for establishing the services ・Provides a guideline for quality assurance, management, communication and social cmobilisation ・Gives an idea of financial investment needed to put the plan in place ・Provides direction and basis for the preparation of annual operational plans Principles and Priorities I. Focus on Emergency Obstetric Care for reducing maternal mortality II. Provision of Essential Obstetric Care/ Basic maternity care services for promotion of "Good Practices", early detection and appropriate referral of complications III. Promoting Women's Access to Resources IV. Quality of Services Aims and objectives The aim is to strengthen the provision of essential (including emergency) obstetrical care and improve utilization of services. Objectives are to achieve by 2010 are.. ● increase utilisation of services - Met need of EOC increased to 70% from 27% - ANC (3 visits) increased to 60% from 33% - Skilled Attendance at birth increased to 50% from 13% - PNC increased to 30% from 2% - CPR increased to 65% from 53.8% with larger proportion of clinical (particularly long-term) methods ● Reduce unsafe abortion practices ● Accreditation of facilities as woman friendly with provision of services for women subject to violence ● Improve nutritional status of women and adolescent girls Framework for action ●Factors Affecting Utilisation & Outcome Economic Status Educational Status Women's Status Illness Characteristics Distance Transport Roads Cost Quality of Care ●Phases of Delay Phase 1 Decide to Seek Care Phase 2 Reach Medical Facility Phase 3 Receive Adequate Treatment ●Priorities for Action Community Education campaign, IPC Decentralise EmOC First aid at community level Upgrade EmOC services training, drugs, equipment, monitoring Levels of existing health care facilities and expected obstetric services --HPSP Health care facility Level and number Obstetric care provider Expected services Medical College Hospital District (13) Specialist, MO, Nursing staff EsOC & CEmOC District Hospital District (59) Specialist, MO, Nursing staff EsOC & CEmOC Maternal Child Welfare Centre (MCWC) District (52), Thana (24), Union (11) MO, FWV, dai nurse, FWV, FWV EsOC & CEmOC, ANC, delivery, ANC, delivery Thana Health Complex (THC) Thana (400) Medical Officer, Nursing staff, FWV EsOC & CEmOC Health & Family Welfare Centre Union (4,770) FWV, MA ANC, delivery The questions? ● What is the coverage and extent of EmOC services? Minimum acceptable level-- for every 500,000 population: - 1 Comprehensive EmOC facility - 4 Basic EmOC facilities ● Who and how many are availing the services? Global assumption that 15% pregnancies develop life threatening complication Met need is the proportion of expected women with complications who seek services In 1994 there were an estimated 540,000 in 1999 there were an estimated 380,000 Met need of EOC... Caesarean Section as a proportion of all births... Woman's Right to Life and Health Accelerating efforts to reduce maternal deaths and disability in Bangladesh A collaborative initiative of the Government of Bangladesh, UNICEF and AMDD Project of the Mailman School of Public Health, Columbia University Supported by the Bill and Melinda Gates Foundation Values - Non-Discrimination and Social justice - Dignity, Respect and Self Determination - Right to Life and Survival - Participation and Voice - Accountability for Women - Care and Compassion - Interdependence Excellence in management Quality technology Respect for human rights Technology ● Provide quality 24 hour quality Emergency Obstetric Care services ● take action and measure progress Management ● Build and sustain accountability in health facility ● develop a shared vision ● develop internal and external systems for working ● commit adequate resources ● establish structures and processes for participatory decision-making ● continuous learning of new competencies and skills ● building leadership and management Rights ● Champion women's rights in your facility ● mobilise men, family and community accountability for saving women's lives ● support innovators and risk takers ● invest in people to cultivate a transformation ● build partnerships to reduce maternal deaths Objectives of the WRLH initiative... ● To contribute to an improvement in the availability and use of Emergency Obstetric Care -- life saving services! ● To focus on the deeper quality issues -- standard practices, provider behaviour and attitude, infection prevention ● To promote action in family and community Interventions in all district hospitals (59) and one upazila health complex per district (64) -- National programme Life saving services ● Provide quality 24 hour quality Emergency Obstetric Care services - technically competent personnel - efficient managers - necessary equipment, drugs and supplies - readiness of the facility - accountability - the will to act! ● Measure and review progress -- process indicators - record-keeping formats - staff orientation - compilation of status - periodic discussion, review and action Key Interventions of the WRLH Initiative ● Needs Assessment ● Human resource development for ensuring quality functioning of facilities ● Ensuring necessary logistic support ● MIS and Monitoring -- Information for facility based intervention and project management ● Hospital Microplanning ● Clinical Quality Assurance ● Communication for behaviour change and development ● Coalition building, networking and local level innovation Doing things differently... ●Factors Affecting Utilisation & Outcome Economic Status Educational Status Women's Status Illness Characteristics Distance Transport Roads Cost Quality of Care ●Phases of Delay Phase 1 Decide to Seek Care Phase 2 Reach Medical Facility Phase 3 Receive Adequate Treatment ●Innovation Woman's right to a healthy life and happy mind! Community Support systems Woman Friendly Hospital Initiative Woman Friendly Hospital Initiative ●Quality of Care ●Mother-Baby Package Services ●Management of Violence Against Women ●Gender Equity From a vicious cycle .... to a virtuous ring of support Abuse → Hospital → Physical Treatment → Home → ↓ DEATH ↓ Hospital → Documentation → LegalProcess → Community Awareness → Safe Healed Survivor Hospital → SocialWelfare → Psychologist → Local NGO → Safe Healed Survivor Community support systems... In Birampur of Dinajpur, groups have been mobilised with support of local government to address the delays through: ● popularising birth planning - care and practices during pregnancy - preparation for safe delivery - recognition of danger signs - emergency preparedness ● transportation and funds for women with obstetric emergencies ● community blood bank Woman's right to life... Are we making a difference? How has coverage changed since the baseline? Type of facility No EmOC - Base, 2002 Basic EmOC - Base, 2002 Comp EmOC - Base, 2002 District Hospital (59) 8, 4 9, 9 42, 46 UH Complex (64) 33, 32 28, 23 3, 19 Total (123) 41, 26 37, 32 45, 65 How does the performance in 2002 compare with needs assessment? Births complications treated C-section (in 97 facilities providing Basic or Comprehensive EmOC) How does the status of process indicators compare? The 123 facilities are located in 64 districts with an estimated annual births of 2,709,000 Indicator Base 2002 Proportion of births taking place in facilities providing EmOC (97) 1.29 1.91 Met Need* 4.12 9.22 Proportion of C-section deliveries 0.25 0.38 * 1% increase in met need = 4,100 complications treated! The numbers... # Births in facility Baseline: 34,907 2002: 51,848 # Women with comp. Baseline: 16,753 2002: 37,460 # C-Sections Baseline: 6,680 2002: 10,188 # Mat. Deaths Baseline: 483 2002: 759 Case fatality rate Baseline: 2.9 2002: 2.0 Trend in coverage of functioning facilities... Year: 1994 Basic EmOC - Number: 90 - ratio: 1:1,200,000 Comp. EmOC - Number: 30 - ratio: 1:3,700,000 Year: 1999 Basic EmOC - Number: 151 - ratio: 1:830,000 Comp. EmOC - Number: 68 - ratio: 1:1,800,000 Year: 2003 Basic EmOC - Number: NA - ratio: NA Comp. EmOC - Number: 127 - ratio: 1:1,000,000 What is contributing to making a difference? ● strong commitment of the Government -- policy, strategy, national programme ● regular review by senior officials of the DGHS … monitoring, monitoring, monitoring ● attention to detail (equipment, posting, reporting, hospital action planning) ● demonstration of change attracting more donor support -- GoJ ● investing in people --workshops in personal transformation, self-esteem, hospital microplanning and team building, gender sensitisation ● Overcoming procedural barriers (procurement, distribution, installation, orientation, end-use) EOC FIELD OPERATIONS GIS/MIS/DATABASE MANAGEMENT UNIT HEALTH AND NUTRITION SECTION UNICEF, BANGLADESH COUNTRY OFFICE GoJ support in strengthening EmOC Government of Japan is a special friend... ● Support in many social sector development programmes with appreciable role of JICA and NGOs ● Rapid response to emergency appeals ● strong participation in polio eradication initiative - 1996-2004, 4.8 Billion Yen for vaccines, cold chain equipment, social mobilisation and monitoring - also, participation of experts and volunteers Flood Emergency 1998-- GoB-GoJ-UNICEF partnership ● UNICEF support GoB Emergency assistance appeal and mobilised USD 3.0 Million for programming in health sector ● USD 1.2 Million allocated to drugs & equipment for Emergency Obstetrical Care ( both local and offshore procurement) - Operation Theatre Equipment for 22 Comprehensive EmOC sites providing life saving services to nearly 7 million people - Other hospital supplies for 179 sites - 850 drug kits to 179 facilities Steps to ensure proper end-use ● Allocations are made based on - functioning status - needs assessment - information on case load ● Funds have been allocated in Operational Plan to cover distribution costs ● Central Medical Store is visited on a regular basis ● Installation of OT equipment is done by local agent of supplier who also trains personnel on use and maintenance ● Monitoring visits to facilities and use of checklist to check status of distribution/collection and shelf life of drugs GoJ support - JICA supported NGO in Chowgacha, Jessore, supported the Upazilla Health Complex by providing critical life-saving equipment. - Japan Government has supported the construction and upgrading of the Maternal and Child Health Training Institute and is supporting the achievement of Woman Friendly Hospital status in this facility. Further GoJ support to EmOC ● In 2000, MOHFW further proposed Support to Strengthening of Emergency Obstetric Care Services in Bangladesh ● GoJ approved the proposal for grant aid in May 2001 and survey team visited Bangladesh July- August which led to commitment to equip Comprehensive and Basic EmOC sites ● In phase I, 27 CEmOC facilities and 64 BEmOC facilities have been equipped by Feb 2003.In phase II, 20 CEmOC facilities and 128 BEmOC facilities will be equipped.. UNICEF assistance in executing GOJ grants ● Finalisation of specification and supply lists ● procurement- local and offshore ● information generation and needs assesment ● tracking procurement, distribution and end use of supplies ● monitoring visits and status updates from EmOC Field Officers ● periodic review of status ● developing capacity human resources, ● ensuring readiness of facilities Importance of Japan Grant Aid ● Provided drugs and equipment to cover requirements during a critical period of HPSP ● Provides important technical assistance to human resource development in maternal health through MCHTI ● Will provide essential support in preparing facilities for providing EmOC which will complement support being provided with funding from Columbia University and UNICEF ● GoJ assistance is a major contribution to the MOHFW effort to ensure provision of life saving services for the women of Bangladesh A genuine partnership has evolved for the cause of women in Bangladesh... ...we need to learn from this to accelerate and expand efforts