Improving Clinical Management of Newborns at Hospitals to Reduce Neonatal Deaths
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1 Improving Clinical Management of Newborns at Hospitals to Reduce Neonatal Deaths Bridging the Research-Policy Divide Australian National University (ANU) Canberra BUN Sreng Department of Communicable Disease Control (CDC)
2 2 Content Background Problem tree and my focus Solutions Stakeholders Policy improvement plan (PIP) Impacts of these actions (2-5 years)
3 3 Research: Household Survey on Maternal, Newborn, and Child Health Objectives To identify coverage of interventions on maternal, newborn, and child health Antenatal care (ANC) Delivery and immediate post-natal interventions Neonatal interventions Interventions for infants and children (Nutrition, Immunization, management of suspected pneumonia and diarrhea) To provide recommendations to increase the coverage
4 4 Rationale Hospitals provide Complementary Package of Services High maternal and under-five mortality in Cambodia 1 Maternal mortality ratio 1 206/100,000 live births Under-five mortality 1 54/1,000 live births Neonatal Mortality (0-28 days) 27/1,000 live births (50% of all under-5 deaths) Sources: 1 Cambodia Demographic and Health Survey 2010
5 5 Causes of neonatal deaths (0-28 days) Source: Svay Rieng Child Verbal Autopsy Study
6 6 Socio-Economic Loss Effects Neonatal deaths Utilization of Facilities Problem Poor clinical management of newborns in hospitals Causes Not well trained health staff No policy or guidelines Shortage of equipments and drugs Lack of other support services Poor medical/nursing curriculum Inadequate supply and poor maintenance
7 7 Problem Poor clinical management of newborns in hospitals Causes Not well trained health staff No policy or guidelines Shortage of equipments and drugs Lack of other support services Poor medical/nursing curriculum Inadequate supply and poor maintenance Solutions 1. Trained them 2. Revise medical/nursing curriculum Improve supplies and maintenance Develop guideline on newborn care Strengthen other supporting services
8 8 Current Models to strengthen health system Capacity Building Traditional +/-) Coaching & Mentoring Capacity Building Traditional Coaching & Mentoring + Health Equity Fund (HEF) (URC/USAID) Capacity Building + Performanc e-based incentive (indicators) (+/-) Health Equity Fund (JPIG) Improve Quality of Care in Hospital Setting
9 9 Evidence-Based Essential Newborn Care Antenatal Care Labor and Delivery Care Postnatal Care Tetanus toxoid Proper nutrition (iron, folate, iodine supplements, balanced protein and energy consumption Treat maternal infections Breastfeeding counseling Clean delivery Newborn resuscitation Hypothermia Hypoglycemia Exclusive breastfeeding Eye care Infections Birth spacing
10 10 My Policy Objective To make better services for sick newborns in the hospitals and that will have the following outcome Improve clinical management Increasing utilization of health service by care-takers of the sick newborns and Reduction of newborn mortality
11 Stakeholders Task Force for Maternal an Child Health (MCH): Mobilize resources National Centre for Maternal and Child Health (MCH) National Reproductive Health Programme (NRHP) National Immunization Programme (NIP) National Nutrition Programme (NNP) National Programme for Acute Respiratory Infections-Diarrhea and Cholera Control (ARI/DDC) National Programme for Prevention Mother-to-Child Transmission (PMTCT) National Pediatric Hospital (NPH) National Centre for Health Promotion (NCHP) Department of Communicable Disease Control (CDC) Department of Planning and Health Information (PHI) Department of Budget and Finance (DBF) Department of Human Resource Development (HRD) and educational institutions (UHS/Nursing Schools) Department of Hospital Services (HS) Health Development Partners: WHO, JPIG (AFD, AusAID, UNICEF, BTC, UNFPA, WB), JICA, USAID, GIZ, and MEDiCAM Provincial/Municipal Health Departments (+ Operational Health District Offices) and Health Facilities (Provincial Hospitals, Referral Hospitals, Health Centres/Health Posts) Village Health Support Groups (VHSG) Care-Takers and Community 11
12 12 SWOT Analysis Strengths (S) Some staff trained in management of sick newborns Supply of Medicines and Equipments Pediatric Ward Financing support Opportunities (O) Policy of RGC and MoH Policy of Partners Weaknesses (W) Not all staff trained Staff turnover insufficient supplies Not all Health Facilities able to have functioning Newborn Care Unit Few HF with HEF and PBCI Threats (T) Phasing out phase (partners) Expansion of Private Sector Trust of community with public facilities
13 13 Analysis of stakeholders in term of P, L, U No Stakeholders Power Legitimac y Urgency Types Symbols 1 Secretary of State Definitive SS 2 TF for MCH: CDC, PHI, HS, HRD, NCMCH, NCHP Dependent TechTF DBF Dominant FinTF Development Partners (Bilateral, UN, Banks) Dangerous P IO/NGO Demanding NGO 3 PHO, ODO Dormant PHDO/ODO 4 PH, RH, HC/HP, VHSG Dependent Prov 5 Newborn/Care-Takers Demanding Clients 6 Local Authorities Dangerous Local
14 14 POWER Local Authorities, PHDO, ODO DBF Development Partners Secretary of State Deputy DG (TFMCH) Hospitals & HC/HP Newborns/ Care-Takers (community) CDC, NCMHCH, NPH, NCHP, PHI, HS, HRD VHSG LEGITIMACY URGENCY
15 15 Alignment-Interest-Influence Matrix (AIIM) High Other Dept SS CDC/ MCH P IO Clients Alignment PHD/ OD HF DBF LA Low Low Interest High
16 16 Policy on newborn care adopted by Secretary of State/Minister of Health Policy on Newborn Care To get input from Task Force for Maternal and Child Health (TFMCH) To discuss with government and partners on the drafted quality improvement plan Brief the Deputy-Director General for Health and Secretary of State (MCH/CDC) Consult with PCB and department colleagues on quality improvement plan (drafted) P A T H W A Y O F C H A N G E Task Forces 4 for Health System Strengthening Risks Limited Workforce & Commitment Limited Equipments & Supplies Limited Financing Health Infrastructure (newborn care unit in hospitals)
17 17 Policy to Improve clinical management in Hospitals Goal: Adoption of policy to improve management of sick newborns in hospitals Objective 1: To assess the quality of pediatric care Objective 2: To use the findings to develop quality improvement plan (QIP) Objective 3: To review the pre-service training curriculum of the University of Health Sciences (UHS) and Nursing Schools (UHS/Nursing Schools) Objective 4: To develop the training curriculum and guideline for newborn care (pediatric ward)
18 18 Objective 1: To assess the quality of pediatric care (CDC, NMCHC, WHO, UNICEF) No Activities WHO WHEN Output 1 Discuss with WHO about assessment of pediatric care (advocate for funding) 2 Assign a CDC staff to develop workplan Desk review of all relevant documents Develop a conceptual paper CDC October, 2012 Provided budget CDC Oct, 2012 Drafted workplan 3 Brief DDG-TFMCH about workplan CDC Nov 2012 Agreed workplan 4 Work with WHO, UNICEF and URC, HS and key pediatricians to review the WHO assessment tool 5 Share the drafted assessment tool to all members of the TFMCH for reviewing 6 Organize a final consultation of the tool in the monthly TFMCH meeting 7 Organize a 4-days training for supervisors and surveyors (include 1-day field test and 1-day feedback) CDC Nov-Dec, 2012 & Jan 2013 Drafted assessment tool CDC Feb, 2013 Received feedback CDC March, 2013 Finalized assessment tool CDC March 2013 Trained supervisors and surveyors 8 Field data collection CDC April 2013 Data collected and edited 8 Data entry, management and analysis workshop CDC May 2013 Drafted report
19 19 Objective 2: To use the findings of the assessment to develop quality improvement plan (QIP) No Activities WHO WHEN Output 1 Develop a supervisory checklist for site visits CDC, WHO, NMCHC, CPA, UNICEF, URC May, 2013 Drafted checklist 2 Send to all members of TFMCH to get feedback CDC, WHO, NMCHC, CPA, UNICEF, URC May, 2013 Drafted workplan 3 Organize a final consultation on drafted checklist CDC, WHO, NMCHC, CPA, UNICEF, URC May, 2013 Agreed workplan 4 Organize a dissemination and quality improvement plan workshop Disseminate findings Improvement plan Present checklist CDC, WHO, NMCHC, CPA, UNICEF, URC Nov-Dec, 2012 & Jan 2013 Drafted assessment tool 5 Conduct quarterly visits to assessed hospitals CDC, WHO, NMCHC, CPA, UNICEF, URC Feb, 2013 Received feedback
20 20 Objective 3: To review the pre-service training curriculum of the University of Health Sciences (UHS) and Nursing Schools to review the curriculum (UHS/Nursing Schools) No Activities WHO WHEN Output 1 Assign a CDC staff to lead review 2 Collect curriculum of UHS/Nursing Schools and site visits 3 Create a team (NPH, AHC, CDC, NMCHC, WHO, UNICEF) 4 Review curriculum (desk review) by assigned team 5 Consultative meeting with relevant stakeholders 6 Dissemination of revised curriculum PCB Oct, 2012 Assigned staff PCB Nov 2012 Agreed workplan PCB Nov 2012 Formulated team PCB Nov-Dec, 2012 Revisited curriculum CDC, NMCHC, CPA, UHS/Nursing Schools CPA, UHS/Nursing Schools Jan-Feb, 2012 March, 2012 Revised curriculum Disseminated curriculum among faculty staff
21 21 Objective 4: To strengthen the capacity of selected hospitals to provide care for sick newborn (quality) No Activities WHO WHEN Output 1 Work with CDC staff to draft workplan (desk review and site visit) Prepare a conceptual paper 2 Brief DDG-TFMCH about workplan 3 Work with WHO to discuss on workplan (+fund) PCB Oct, 2012 Drafted workplan PCB Nov 2012 Agreed workplan PCB Nov 2012 Revised workplan 4 Brief DDG TFMCH PCB Nov, 2012 Revisited workplan
22 22 Objective 4: To develop the training curriculum and guideline for newborn care (pediatric ward) No Activities WHO WHEN Output 1 Discuss with NCMCH on progress of guideline development CDC Oct, 2012 Reviewed guideline 2 Finalize curriculum and guideline NMCHC? `Finalized guideline
23 23 Expected impact Short and medium terms: Skill and knowledge of health staff Technical and financial supports Harmonized, linked, coordination between pediatric ward and other supporting services (SOP) Strengthened partnership between Ministry of Health and partners Increased utilization of health facilities (annual contact of newborn) Long-term: Reduction of newborn death
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