Expanding PNC home visits in Bangladesh: the MaMoni experience

Imteaz Mannan MaMoni Integrated Safe Motherhood, Newborn Care, Family Planning Project

The Graph that launched a thousand ships

Postnatal Care in Habiganj 2011

Source: DGFP MIS data, Habiganj

WHO/UNICEF Joint Statement 2009 Home visits for the newborn child: A strategy to improve child survival

"Studies have shown that home-based newborn care interventions can prevent 30 60% of newborn deaths in high mortality settings under controlled conditions. Therefore, WHO and UNICEF now recommend home visits in the babys first week of life to improve newborn survival."

Chronology of Home Based Postnatal Care in Bangladesh

Projahnmo CB-PNC OR/SNL

03

04

05

06

07

08

09

NNHS approved

10

11

12

SNL BRAC CARE BPHC

SMPP
ACCESS ISMNC

SMPP-2

MaMoni

BRAC MANASHI UNICEF MNCS

Joint UN MNH BRAC HP/MNCH UNICEF/BRAC MNCH DFID Char Livelihoods Project

Postnatal Care in Bangladesh

NNHS 2009 defines and provides clinical guidelines for PNC

Transition from policy to action taking longer than expected

HPNSDP 2011-16 prioritizes MNH and PNC PNC traditionally recorded at MIS as care within 42 days Trained vs. medically trained provider

MaMoni ISMNC-FP Project One of the models of USAIDs GHIs upazila health system strengthening MOH&FW key service provider Partner NGOs - supportive and facilitative role An integrated package District wide approach Integration and linkage of Non health sectors community, LG with MOH health care providers

Habiganj Public Service Delivery System

1.8 mill pop 8 sub-district, 3 in haor 6 municipalities 29.6% staff vacancy

27% SP vacancy

5% pop in tea garden 3% pop in urban slums

The WHY" and the WHAT PNC Prescribed by MaMoni

To prevent mortality and morbidity of mother and newborn, ensure growth and development * PNC begins at ANC, if mothers are not identified and counseled, PNC may not happen Why?

Activity

Maternal

Newborn positioning/attachment, EBF, danger signs, delayed bathing, thermal management BCG, EPI

Counseling and LAM, PPFP, danger Support signs, nutrition Referral for PP Vit-A, PP-IFA, routine services Check for complication

Nipples/breastfeeding, Infection, LBW, hypothermia sepsis, other problems Same +S2S Contact,

Mgmt/Referral Identify appropriate of complications center, notify service provider Program Mgmt Misoprostol use validation

Birth registration (MOLGRD)

The Who", The When, The Where"

WHO

HA FWA/CHW FWV CHCP

Visit encouraged but not counted as care Volunteers TBAs/Village Doctors

WHEN

0-2 days 4-7 14 days

Home, satellite clinics Community Clinic UH&FWC Secondary Facilities

Home

Tea Garden

WHERE

Outreach Clinics

Clinic

MOH&FW STRUCTURE District & Below

Civil Surgeon, Deputy CS, MO District District Hospital (100 beded) UH&FPO, RMO, MA, EPI Technician, HI

Deputy Director of Family Planning

MCWC

Upazilla

Upazilla Health Complex (31 beded)

UFPO MO(MCH), SFWV

Few MCWC

Union

Health Sub Centre MO, MA, AHI, Pharmacist Community Clinic (For 6000 people)

UH&FWC FWV, SACMO, FPI

Ward/Out reach

EPI Centre Health Assistant

Satellite Clinic FWV, FWA

Househol d

HA

FWA

The How MaMoni Strategy to Expand PNC Activities Training (FWA, HA, FWV, SACMO) Volunteers /300 pop. Community groups /900 pop. or /village Satellite clinic strengthening - history Community -planning involving FWA, HA, volunteers to update MIS data
Habiganj

TBA orientation (delivery notification) PNC register revision FWA - 48h, 7d Supportive Supervision (JSV) Facility strengthening for delivery, PNC Referral chain setup, transport

PNC Coverage Jul 2011-Mar 2012

Source: DGFP MIS

Wait a Minute! Isnt it Supposed to be a percentage?

too low?
showing no trend?

Issues MIS & Reporting

No single report
Facility delivery often double counted HAs report not processed No record of continuum of care of ARH-FP-MNCH, some mothers not recorded at all

No single denominator
Live births vs. BCG: The 22-50 issue Identification system different for H&FP, not updated Delivery notification a challenge

Issues Service Delivery at Home

Less time: Move away from domiciliary services, promoting one-stop services (Community Clinics)
PNC/OPD confusion

More people: HH-CHW ratio doubled since last HR planning, even triple in some areas
1 FWA/6,000 population in 1995

More work: 18 items in the JD including promoting VAW, homestead gardening, etc.

MaMoni approach to solve these problems

Community microplanning (396/mnth) Birth notification by TBA, link to FWV/A UP registration GR support in one upazila Poil study
Single MIS for ANC/Delivery/PNC Validation of data (BCG/Live birth)

Take Away Message

Operationalizing policy takes time and patience

Need some transition activities before it can be scaled up

For high mortality districts, home based PNC is needed, lessons from Habiganj should be considered

"Childrens lives should be counted in years and decades, not in minutes, hours and days

Thank You