World Health Organization 2007

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2 (Inside cover page of Review Report) World Health Organization Colombo Sri Lanka December 2007 Printed by World Health Organization 2007 The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization (WHO), United Nations Population Fund (UNFPA), or United Nations Children s Emergency Fund (UNICEF) concerning the legal status of any country, territory, city or area of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the WHO, UNFPA, UNICEF or Ministry of Health in preference to other of a similar nature that are not mentioned. All reasonable precautions have been taken by WHO, UNFPA, and UNICEF to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the WHO, UNFPA, or UNICEF be liable for damages arising from its use. The WHO, UNFPA, and UNICEF do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use All rights reserved. Requests for permission to reproduce or translate this publication not for sale or commercial use but for noncommercial distribution should be addressed to: The Secretary, Ministry of Healthcare & Nutrition, 385, Ven. Baddegama Wimalawanse Thero Mawatte, Colombo 10, Sri Lanka The principles and policies of each UN agency are governed by the relevant decisions of each agency s governing body and each

3 agency implements the interventions described in this document in accordance with these principles and policies, and within the scope of its mandate. Table of Contents List of figures & Annexes 6 Abbreviations.. 7 ExecutiveSummary 11 CHAPTER I BACKGROUND Health development & trends Maternal & Newborn Health Maternal Health Newborn Health Fertility and Family Planning Health System for MNH Health system infrastructure Central Level Provincial Level MNH Service delivery Financing for MNH Context and Rationale of the MNH Review Objectives of the review General objective Specific Objectives of the review 330 1

4 1.5.3 Expected outcome of the review 330 CHAPTER METHODOLOGY 2.1 Conceptual Framework of the Review Health System Structure and Functions MNH Services & Interventions Cross Cutting Areas Methods used for data collection Desk Review: Stakeholder Workshop Key Informant Interviews Focus Group Discussions Visits to institutions and field visits Visit to Hospitals and Clinics Visit to Provincial and District Offices Presentation of findings 37 CHAPTER ORGANISATION FOR MNH SERVICES 3.1 Organization for MNH services at National Level Stewardship of MNH Services at provincial level MNH service delivery at provincial and district levels 430 2

5 CHAPTER Maternal Health 452 MATERNAL AND NEW BORN CARE Preconception needs Antenatal Care Intrapartum (Natal) Care Provision of Essential and Emergency (Basic and Comprehensive) Obstetric Care Care of the critically ill patient: Caesarean Section Rates Postnatal Care of the Mother and Baby Factors contributing to maternal deaths and causes of maternal deaths Maternal Death Reviews Neonatal care Care of the low risk newborn Care of the high risk newborn Care of Preterm Babies Neonatal screening for Hypothyroidism Care of the newborn in the field Perinatal Death Reviews 67 CHAPTER 5 HUMAN RESOURCES FOR MNH Over view Planning of human resources for health 741 3

6 5.3 Selection, recruitment and placement Pre-placement education and training Pre-service education of MNH personnel Field personnel Public Health Midwives Curriculum Quality of training Supervising Public Health Midwives Public Health Nurses Medical Officers of Health Medical Officer Maternal and Child Health Medical Officer Public Health (posted in Medical institutions -Base hospital and above) Specialist in Community Medicine Institutional services Institutional midwives Midwifery qualified nurses District Medical Officers and Medical Officers in divisional hospitals and peripheral units Specialists in Obstetrics & Gynaecology and Paediatrics In-service training Private sector training Supervision and support 841 4

7 5.9 Career development, performance and motivation 841 CHAPTER 6 CROSS-CUTTING ISSUES Behaviour Change Communication (BCC and gender in relation to MNH Policy Planning and Resource Allocation Health Education Methods Awareness among mothers Capacity Building Role of Health Education Officers (HEOs) Importance of gender, language and sub-cultural dimensions in planning BCC/HE strategies and communication Male Participation and gender issues Supervision and Monitoring of MNH Programmes Management Information System Financing of MNH services Central level Provincial level Planning and Budgeting for MNH Family Health Bureau Health Education Bureau Budget for Maintenance Expenditure 95 5

8 Alternative Financing Coordination and Partnerships for MNH Coordination between Centre, Province and District Coordination with development partners Partnership with NGO and other sectors Linkages with other programmes Family planning Nutrition STI/AIDS control programme H8alth Education Bureau Communicable and Non-communicable diseases Psychological illness related to pregnancy Linkages with other sectors Local government (Colombo Municipal Council) Private sector Plantation (Estate) sector Operational Research and utilization of evidence based policies and strategies 1063 References 105 Acknowledgement 106 6

9 Annexes

10 List of Figures Figure 1. Trends in maternal mortality ratio Figure 2. Causes of maternal mortality Figure 3. Differentials in maternal mortality ratios in health regions Figure 4. Maternal mortality ratio and trained assistance at delivery 241 Figure 5. Home deliveries & untrained deliveries by health region Figure 6. Trends in caesarean section rates in government hospitals 25 Figure 7. Trends in infant and neonatal mortality rates Figure 8. Trends in contraceptive use List of Annexes Annex 1 Organisation Chart Ministry of Healthcare & Nutrition 108 Organisation Chart for health services under Provincial councils 109 Annex 2 Organisation frame work for the review 110 Organizational Framework for implementation of Review 111 List of Review Coordinating Committee members 112 Expert Review Team members 113 Conceptual Framework of the Review 114 Approach to Strategic MNH Programme Review - A Flow Diagram 115 Annex 3 List of background documents used for desk review 116 Annex 4 a Stakeholder Workshop List of Participants & groupings 118 Annex 4 b Levels of key informants interviewed 121 Annex 4 c Field sites visited 122 Annex 4 d Map of Sri Lanka showing sites visited 124 Annex 5a Current distribution of approved & available cadre for MNH service providers by district for the tear Annex 5 b Current criteria for selection, elements of basic training of different categories of MNH service providers & scheme of promotion 126 8

11 List of Abbreviations AHB AIDS ANC ARFH BCC BEmOC BFHI BH BMI CBR CD & MH CD CEmOC CMC CS CWC D DDG ET&R DDGMS DDGP DDGPHS DGHS DH DHS DIC DMO DPDHS DS EmOC ENT Annual Health Bulletin Acquired Immuno Deficiency Syndrome Antenatal care Annual Report on Family Health Behaviour Change Communication Basic Emergency Obstetric Care Baby Friendly Hospital Initiatives Base Hospital Body Mass Index Crude Birth rate Central Dispensary & Maternity Home Central Dispensary Comprehensive Emergency Obstetric Care Colombo Municipal council Caesarean Section Child Welfare Clinic Director Deputy Director General Education, Training & Research Deputy Director General Medical Services Deputy Director General Planning Deputy Director General Public Health Services Director General of Health services District Hospital Demographic Health Survey Disseminated Intravascular Coagulation District Medical Officer Deputy Provincial Director of Health Services Divisional Secretary or District secretary (GA) Emergency Obstetric Care Ear, Nose & Throat 9

12 FGD FHB FHW FP GBV GDP GOSL HDU HE HEB HEO HIV HQ HRH ICD ICU IDPs IEC IMR INGO KII LB LBW MC MCH MCH.FP/MNH MDG MHIS MIS Focus Group Discussion Family Health Bureau Family Health Worker Family Planning Gender Based violence Gross Domestic Product Government of Sri Lanka High Dependency Unit Health Education Health Education Bureau Health Education Officers Human Immuno-Deficiency Virus Head Quarters Human Resource for Health International Classification of Diseases Intensive Care Unit Internally Displaced Persons Information, Education & Communication Infant Mortality Rate International Non-Governmental Organisation Key Informant Interview Live Births Low Birth weight Municipal Council Maternal & Child Health Maternal & Child Health. Family Planning/ Maternal & Newborn Health Millennium Development Goals Management Health Information System Management Information System 10

13 11

14 MMR MNH MO MO/MCH MoH MOH MRI MS NCCP NCD NGO NHA NIHS NNMR NO NSACP NSC OPD PDHS PHDT PHI PHM PHNS PHO PIH PNC PPH PSDG PU QoC Maternal Mortality Ratio Maternal & Newborn Health Medical officer Medical Officer/ Maternal & Child Health Ministry of Health Medical Officer of Health Medical Research Institute Medical Superintendent National Cancer Control Programme Non- Communicable Diseases Non-Governmental Organisation National Health Accounts National Institute of Health Sciences Neonatal Mortality Rate Nursing Officer National STI/AIDS Control Programme National Steering Committee Out Patient Department Provincial Director of Health Services Plantation Human Development Trust Public Health Inspector Public Health Midwife Public Health Nursing Sister Paediatric House Officer Pregnancy Induced Hypertension Postnatal care Post Partum Haemorrhage Province Specific Development Grant Peripheral Unit Quality of Care 12

15 13

16 RDHS RE RH RH RNC RSPHNO SBA SPHM STD STD/AIDS: STI TH ToR UN UNDP UNFPA UNICEF USD VDRL WB WHO WR WWC Regional Director of Health Services Regional Epidemiologist Reproductive Health Rural Hospital Regionalised Neonatal Care Regional Supervising Public Health Nursing Officer Skilled Birth Attendant Supervising Public Health Midwife Sexually Transmitted Diseases Sexually Transmitted Disease/Acquired Immuno- Deficiency Syndrome Sexually Transmitted Infections Teaching Hospital Terms of Reference United Nations United Nations Development Programme United Nations Population Fund United Nations Children s Fund United States Dollars Venereal Diseases Research Laboratory (Test) World Bank World Health organisation WHO Representative Well Women Clinic 14

17 Executive Summary Sri Lanka has made remarkable progress in the last few decades in lowering infant, child and maternal mortality. This is attributed to a number of factors that have had a mutually beneficial effect which included, high political commitment to health, provision of free health care, a well-developed health infrastructure, free education, subsidized food schemes and other socio economic welfare measures. However, wide disparities in mortality rates exist between geographic regions as well as population groups. The Infant Mortality Rate (IMR) and Neonatal Mortality Rate (NNMR) have been stagnant over the past decade and many of the maternal deaths are preventable. There is also concern regarding inequitable distribution of services as well as deficiencies in quality of care. Competing interests for health resources as well as increasing costs in health care add to constraints faced by the Ministry of Health (MoH). In this context the Ministry of Health decided to commission an external review of the Maternal and Neonatal Health (MNH) services. The objectives of the review was to examine the MNH components of the current national Maternal and Child Health (MCH) Programme and to identify achievements, gaps and challenges faced by the programme, make recommendations and give direction to help with the development of a new strategic plan for the period and beyond. Methodology of the review In order to achieve the objectives of the review, a conceptual framework was developed taking into account the existing MNH policies and strategies, the demographic and epidemiological profile of the country, and the organisational structure for MNH service provision. The components of work were grouped into three inter-related themes for ease of data collection. The review team utilized a range of methodologies to collect information that included; an in-depth desk review of programme documents; a stakeholder workshop; key informant interviews, focus group discussions and field visits. 15

18 Summary of review findings At the national level, the Family Health Bureau (FHB) is the central organization of the Ministry of Health responsible for planning, coordinating, monitoring and evaluation of maternal and child health services and the family planning programme within the country. The bureau has a system of technical units, each led by a Consultant Community Physician. However, the FHB needs more support from the central ministry in order to carry out its assigned functions in a competent manner and to strengthen and support its interactions with the provinces/districts. Much has been achieved in maternal health, but the quality of care, both at institutional level and in the field, needs improvement. Pre-conception needs which are coming into focus, has to be addressed preferably through existing programmes such as school health and adolescent / youth health programmes. Antenatal care though having a broad coverage needs to be rationalised to avoid duplication of services as well as to improve some quality aspects of the services. In particular, improvements in intrapartum care need special focus on many service issues, which would improve the outcome of labour and impact on the health of the mother and the neonate. Coverage and quality of services for postpartum care were also addressed during the review process. Newborn care in the country s health system needs much improvement. Unlike for maternal health that has a national focal point in the FHB, there is none with regard to neonatal services. This review provides an opportunity for systematic planning of island wide high quality services for the newborn. A system for monitoring the quality of care of MNH services does not exist at present though it is a vital need. Within the district/province the fragmentation of managerial functions and authority between teaching hospitals and the provincial health services has resulted in difficulties in coordination of service provision and monitoring MNH care. It is also found that the coordination between the directorates within the MoH could be further strengthened to achieve MNH goals. Inadequate capacity for planning and budgeting at central as well as provincial and district levels has hampered the formulation of systematic and rationalised budgets. This impedes obtaining adequate and timely allocations for programmes resulting in bottlenecks in service delivery. 16

19 The MNH programme still uses the traditional approaches to health education. Knowledge and skills for Behaviour Change Communication was low among providers. Principles and concept knowledge were found to be significantly low among the recipients of services. Gender sensitivity too was low among all categories of MNH providers and recipients as well as in programme approaches. Although regular supportive supervision is essential to maintain motivation and quality of the service, the supervision process is weak. A large amount of data is gathered through the Management Information System, but the bulk remains underutilised at all levels. Many of the issues concerning human resources for MNH are of a generic nature, except those specific subject areas for MNH skills development. Therefore, issues of planning and management of HRH need all-round improvement. One of the basic requirements needed to achieve the intended MNH outcomes would be a comprehensive Human Resources Development effort that will build the capacity and strengthen the structures, functions, linkages and the monitoring and evaluation processes. Key recommendations A National Steering Committee (NSC) for family health should be established under the chairmanship of either the Secretary or Additional Secretary Ministry of Health to provide policy level support needed by the FHB to enable it to function as a centre of excellence. A National strategic plan for MNH should be formulated and approved by the NSC on the basis of which specific provincial and district plans could be developed. An Economic Evaluation Section to be set up within the Planning Unit of the MoH. The Family Health Bureau should be reorganised to strengthen its function as the centre of excellence for the national MCH.FP/MNH programmes. The Bureau should serve as a pool of technical resource, acting as the hub to bring together all other relevant specialities for further development of MCH.FP/MNH services in the country. New technical units should be created in the FHB for neonatal care and nutrition each under a Consultant Community Physician. 17

20 Responsibilities and authority for MNH service provision at different levels and particularly the shared responsibilities between the centre, province and the district should be clarified. The Provincial Director of Health Services and his team should play a strong advocacy role to accord a high place for MNH in the provincial agenda. FHB jointly with the provinces and districts should design MNH interventions that take into account the specific characteristics of the districts and special population groups within the national strategic plan. Develop programmes to address preconception needs and concerns among young people so as to improve MNH outcomes. Mechanisms should be established to create a conducive environment where antenatal mothers and their families would accept shared care with confidence. This would also reduce the duplication of services. The country should adopt an evidence based focused antenatal care strategy. For each province / district there should be comprehensive needs based plan for coverage and quality of BEmOC and CEmOC services. The implementation of this plan to full capacity should be seen as a priority of the highest order. The roles and responsibilities of the members of the team (medical, nursing and midwifery staff) providing intrapartum care should be reviewed and updated. A comprehensive set of national standards for obstetric care should be developed and disseminated together with in-service training for routine use. A system of surveillance of the quality of care of MNH services should be developed. A national study is needed to assess in detail the pattern of Caesarean Sections (CS) performed, including indications for the procedure and the outcome for mother and baby. Develop 18

21 mechanisms for institutions to routinely monitor/audit CS rates, their indications and outcomes. Every woman who has delivered (irrespective of the duration of pregnancy) should have a complete postnatal assessment at 6 weeks in an institution or a MOH clinic. Special postnatal clinics for women who have had complications during pregnancy and delivery should be established at institutional level. Nationally agreed upon evidence based protocols should be used for management of neonates Well designed neonatal intensive care units be organized at provincial level and newborn care nurseries be available in all specialist hospitals under the supervision of a neonatologist Routine neonatal screening for congenital hypothyroidism should be introduced nationally without delay. Nutrition should be made an integral component of the MCH.FP/MNH programme. The maternal mortality review process should have a no blame no shame approach. The institutional and field investigations should be conducted as at present to collect all necessary information. This should be followed by a confidential inquiry by a team of experts to ascertain the causes / factors leading to death and to identify clear points for action. Persons / institutions responsible for each of the actions recommended should be clearly identified and a mechanism developed to ensure that the follow up actions have been implemented. Establish the infrastructure necessary for reporting of perinatal mortality statistic (rate) to be a part of the national vital statistics system. The HRH division of DDG (P) should be strengthened to function as the national focal point for HRH planning and management with similar strengthening of the HRH planning process at the provinces. Review existing norms for creation of cadre and the approval process as a priority. Projections of the different categories and cadre revisions should be undertaken at least once in 5 years. 19

22 Curricula of the different categories of MNH providers be reviewed, and training reoriented towards competencies necessary to fulfil functions. Gender sensitisation to be included in the curricula / training of all categories of health personnel. Plan for the transition to a behaviour change communication model for MNH and to undertake an integrated planning process jointly between the HEB and FHB. The entire system of supervision should be re-examined and appropriate adjustments made in the training of supervisors as well as the logistics, particularly their mobility, to strengthen the supportive supervision at the different levels. The MIS should be reviewed and rationalised through identification of selected data and indicators for each level so as to provide for a more focused approach to effective planning monitoring and evaluation at each level. 20

23 Chapter I Background 1.1 Health Development and Trends For a low income country, Sri Lanka s achievements in the social sector have been exemplary for the region. The country has achieved a relatively high standard of health and social development in comparison with countries of similar economic development. In the year 2002, Sri Lanka's Human Development Index was 0.74, life expectancy at birth 72.5 years and the literacy rate more than 90 percent. The country s Gender Development Index of 0.74 is well above the average for developing countries (UNDP, 2006). The GDP in 2005 was around 6.2% and the per capita income about 1203 USD (Central Bank of Sri Lanka 2005). These good social indicators are in spite of 23% of the population living below the standard poverty line of one USD a day. About 30% of the estate population and 25% of those in the rural sector, fall below this level (UNDP, 2006) *. The country is experiencing a demographic and epidemiological transition. Non-communicable diseases such as cardiovascular disease, cerebro-vascular illnesses, diabetes and cancer are presently showing an increase, while problems of communicable diseases and malnutrition still persist. Sri Lanka is classified as a low prevalence country for HIV/AIDS with a cumulative total of 712 HIV infections reported at the end of 2006 (National STD/AIDS control programme). Over the past five to six decades key vital statistics have shown a significant reduction. The Crude Birth Rate (CBR) has declined from 39.7 per 1000 population in 1950 to 18.9 per 1000 in The Crude Death Rate declined from 21.5 per 1000 population in 1946 to 5.9 per 1000 in the year 2003 (AHB, 2003). * the figure quoted does not include the Northern and Eastern provinces 21

24 1.2 Maternal & Newborn Health Sri Lanka s success in reducing infant, child and maternal mortality is attributed to a number of factors having a mutually beneficial effect. High political commitment to health, a comprehensive MCH package - delivered through a well trained primary health care worker at community level, backed by a strong institutional network spread throughout the country and a health service free of charge at the point of delivery are key factors that contributed to the reduction in mortality. Equality of access to education for a majority of women resulting in high female literacy and educational attainment, as well as a high degree of motivation of mothers to seek services offered, together with a range of food subsidy schemes and other social welfare measures have contributed synergistically to the success of the health programmes Maternal Health Maternal mortality showed a steady decline during the last few decades reaching a low level of 38 per 100,000 live births in 2004 (ARFH ). Figures 1 and 4 show the trend in decline of maternal mortality as reported in the statistics of the Registrar General Department. Postpartum haemorrhage, pregnancy induced hypertension, heart disease complicating pregnancy and septic abortions were leading causes of maternal deaths in 2004 (Figure 2). It is noted that deaths due to puerperal sepsis, an important cause of maternal death in the 1940's, still accounted for 8 of the 157 deaths (5.1%) in 2003 and 6 of the 145 deaths (4.1%) in In 2003, a further 19 deaths (12%) were due to septic abortions while in deaths (11.7%) were from the same cause (Annual Report on Family Health, 2004). 22

25 Figure 1. Trends in maternal mortality ratio Per live births 3,000 2,500 2,000 1,500 1, Malaria Epidemic Source: Registrar General Department Control of malaria Development of maternal care services Extension of trained maternal care services and improved accessibility Greater utilisation of maternal care facilities Introduction of antibiotics year Figure 2. Causes of maternal mortality Expansion of EmOC facilities Greater availability of skilled health manpower Greater utilisation of skilled services Improved quality of services Improved management Percentage Years Haemorrhage Heart disease complicating pregnancy Liver disease complicating pregnancy Pospartum septicaemia Eclampsia & PIH Septic abortion AF/emboloism P/embolism Source: Annual Report on Family Health FHB/MoH2000, , However, there are wide differentials in maternal mortality ratios between districts/health regions and population sub groups, 23

26 ranging from 81 to 22 per 100,000 live births. (Figure 3 shows the district variations but not the variation in population sub-groups). Figure 3. Differentials in maternal mortality between health regions MMR per 100,000 live births Source: Annual Report on Family Health FHB/MoH Batticoloa Kalmunai Nuwara Eliya Vavuniya Killinochchi Mullaitivu Hambantota Ratnapura Puttalam Matale Matara Polonnaruwa SRI LANKA Colombo Kurunegala Galle Kandy Moneragala Jaffna Badulla Gampaha Trincomalee Kalutara Anuradhapura Kegalle Iron deficiency anaemia and malnutrition are common problems among pregnant women (MRI 2001). In a survey carried out by the MRI in 2001, the prevalence of anaemia among pregnant women was found to be 30% (MRI, 2001). Maternal weight gain in pregnancy is low, the average weight gain being around 8-10 Kg. The MCH statistics for the year 2004 shows that at the booking visit 27.1% of mothers had a BMI less than 18.5, while in 12.3% the BMI exceeded 25 (ARFH, ). The low haemoglobin levels and inadequate weight gain during pregnancy contributes to the high incidence of low birth weight. Approximately 98 % of women receive antenatal care in the field clinics (MOH) or in institutions. In contrast to antenatal care, coverage of postpartum care is only 78%. Trained assistance at delivery has had a dramatic impact on maternal mortality (Figure 4). Ninety six percent of births occur in hospitals 2-3% receive trained assistance by the PHM in the home, while the rest (1-2%) are attended by persons said to have experience in conducting 24

27 home deliveries (ARFH ). The latter practice is confined mainly to areas affected by the conflict such as the Northern and Eastern provinces and in some remote areas having travel constraints and where services of PHMs are not readily available (Figure 5). Figure 4. Maternal mortality ratio and trained assistance at delivery MMR per 100,000 live births rcentage deliveries with trained assistance Pe Years 0.00 MMR per 100,000 live births % deliveries with skilled assistance Source: The Maternal Mortality Decline- The Sri Lankan Experience UNICEF

28 Figure 5. Home deliveries and untrained deliveries by health region NUMBER Batticaloa Trincomalee Kalmunai Jaffna Badulla Anuradhapura Moneragala Ratnapura Nuwara Eliya Kurunegala Mullaitivu Kandy Puttalam Ampara Kilinochchi Matale Matara Kegalle Galle Gampaha Polonnaruwa Vavuniya Hambantota Kalutara Colombo CMC NIHS RDHS REGIONS Home Deliveries Untrained Deliveries Source: Annual Report on Family Health FHB/MoH, , There is an increasing trend in the caesarean section rate especially in some urban areas and in the private health sector (Figure 6) Figure 6. Trends in Caesarean section rates in government hospitals Percentage of LSCS Years LSCS rates Linear (LSCS rates) Source: Annual Health Bulletin (Tables 36/ 37)

29 1.2.2 Newborn Health The Infant Mortality Rate (IMR) has declined from 50/ 1000 live births in 1970 to 11.2 per 1000 in 2003 (Figure 7). Neonatal deaths which contribute to over 75% - 80% of infant deaths have remained stagnant for the past 10 years, with marked inter-district variation (AHB, 2003). The leading causes of death among newborns as reported in perinatal mortality reviews are disorders related to short gestation period and (unspecified) low birth weight (28.3%), infections in the perinatal period (15.6%), respiratory conditions of foetus and new born (13.8%),intrauterine hypoxia and birth asphyxia (5.9%) (ARFH,2005). The EPI programme in Sri Lanka has been very successful whereby almost total elimination of Neonatal Tetanus has been achieved by the tetanus toxoid component of EPI, reduction in congenital rubella syndrome through the Rubella immunisation programme, and elimination of military TB and TB meningitis in infants due to BCG immunisation given soon after birth which has a coverage of nearly 100%. Figure 7 Trends in infant and neonatal mortality rates Rate per 1000 live births Infant Mortality Rate Year Neonatal Mortality Rate Source: Registrar General Department 27

30 Low birth weight (less than 2500 grams) is still relatively high in Sri Lanka, although the proportion has shown a steady decline over the past few years. The incidence of low birth weight among infants born in government hospitals has declined from 22.8 percent in 1990 to 16.9 percent in Marked inter-district variation in low birth weight is noted (AHB, 2003) Fertility and Family Planning Fertility has declined steadily since The Total Fertility Rate has declined from 5.1 in 1993 to 1.9 in Contraceptive prevalence is 70.0%, of which 49.5% are modern contraceptive methods, 26.4% being modern temporary methods, and 23.1% permanent methods. The prevalence of natural/traditional methods is 20.5%.(DHS 2000) (Figure 8). The unmet need in contraception is estimated to be 11.4% (unpublished data from FHB based on DHS 2000) Figure 8. Trends in Contraceptive use Contraceptive Prevalence Modern Methods Traditional Methods Source: Demographic Health Survey

31 1.3 Health System for MNH Health system infrastructure Central Level The maternal and child health services in Sri Lanka have a long history. The first organised effort towards providing care and attention to child bearing women was made in 1879 with the establishment of the De Soysa Lying-in-Home now known as De Soysa Hospital for Women. The need for developing the preventive and promotive services was recognised by the government as early as In mid 1920 s, steps were taken to introduce a Health Unit System which could provide a comprehensive health care service (institutional and domiciliary) to mothers and children. The first Health Unit was established in 1926 at Kalutara, and this system was thereafter gradually extended to cover the country. By 1950, 91 Health Units were established and by 2003 there were 280 units (AHB 2003). The above system provided domiciliary as well as clinic based services during pregnancy, trained assistance at delivery and domiciliary services for the post natal mother and the infant. Family Planning was introduced to Sri Lanka in 1953 by the Family Planning Association: a Non Governmental Organization (NGO). The work done by the association was given Government recognition in 1954 in the form of a financial grant. In 1965, the Government accepted family planning as national policy, and family planning services were integrated with the already well developed Maternal and Child Health services provided through the Ministry of Health. Considering its national importance, a separate division was established in 1968 within the ministry, to implement the programme through out the country. This was initially named, the Maternal and Child Health Bureau and was later redesignated, the Family Health Bureau. At the central level the Family Health Bureau (FHB) of the Ministry of Health is the focal point for the national Maternal and Child Health and Family planning Programmes (MCH.FP) and is responsible for planning, coordinating, monitoring and evaluating these programmes. The Bureau also provides the necessary direction and technical guidance for effective implementation, and 29

32 also implements projects funded by international agencies to support and strengthen service delivery. The Bureau works in close collaboration with relevant units of the Ministry of Health and related Government institutions and Non-Governmental Organizations. The FHB reports to the Director General of Health Services through the Deputy Director General of Public Health Services Provincial Level Since 1989, the country s administration has been decentralised with devolution of administrative powers to nine Provincial Councils. Each province has a Provincial Director of Health Services (PDHS) who is responsible for provision of health care within the province and is supported by Regional Directors of Health Services (RDHS) who are in charge of each of the Health Districts (26) within the provinces. The RDHS is supported by a Medical Officer/ Maternal and Child Health (MOMCH), Regional Epidemiologist (RE) Regional Supervising Public Health Nursing Officer (RSPHNO), 2 or 3 Health Education Officers (HEO) and other technical staff. Each Health District is further sub-divided into Health Units/ Divisions (7-18) with each division being managed by a Medical Officer of Health (MOH) supported by a team of public health personnel comprising one to two Public Health Nursing Sisters (PHNS), 3 to 5 Public Health Inspectors (PHI), one or two Supervising Public Health Midwives (SPHM) and Public Health Midwives (PHMs). Each PHNS assisted by a SPHM supervises about 10 PHMs. Organisation chart of the Ministry of Health and the organisation chart for health services under the provincial councils are given in Annex MNH Service delivery MCH.FP/MNH services are provided through a well-developed health infrastructure that has grown steadily over the past few decades. The network of medical institutions and health units provide institutional and field based MNH services for women, children and their families. The PHM is the front line health worker providing domiciliary care to mothers and children within the community. She has a well demarcated geographic area with a population ranging from 2000 to She maintains an eligible couple s register which includes all married women15-49 years (legal or customary) and women 30

33 with children less than 5 years. This enables the midwife to provide a continuum of care commencing even before pregnancy. Through systematic home visits the PHM provides domiciliary MCH.FP/MNH services, gives advice to adolescents and identifies/refers clients to Well Woman Clinics (WWC). The PHM is a member of the team providing services at field and institutional clinics and links the domiciliary services to clinic/institutional care. The institutional framework has been revised and classified on the basis of size and the range of facilities / services in each institution namely: Primary care units - include all central dispensaries and maternity homes, central and branch dispensaries and visiting stations, Divisional hospitals - cover the present rural hospitals, peripheral units and some district hospitals, District Base Hospitals there are two categories of District Base Hospitals viz. A and B that are expected to provide basic specialist services (general medicine, surgery, paediatrics, obstetrics & gynaecology) and have the requisite facilities. It is planned that these hospitals will have Special Care Baby Units (SCBU). District General Hospitals - one per district, providing basic specialist services as well as some specialities such as ENT, ophthalmology etc... It is planned that these units will have a neonatal intensive care unit and the services of a neonatologist. Tertiary Hospitals - includes the Provincial and Teaching Hospitals Although norms and standards have been identified for each of these levels, most institutions are not functioning optimally due to shortcomings in physical infrastructure, human resources and management. Divisional hospitals with non specialist medical officers provide selected Basic Emergency Obstetric Care (BEmOC) and all higherlevel institutions with obstetricians provide Comprehensive Emergency Obstetric Care (CEmOC). District Base hospitals and above have facilities for blood grouping and cross matching and laboratory facilities including VDRL testing. 31

34 Safe blood transfusion services are available through central, regional and institution based blood banking services. Blood and blood products are routinely screened for HIV, syphilis, hepatitis B, hepatitis C and malaria Financing for MNH In 2005, the total expenditure for health was 4.2% of GDP, an increase from 3.8% in Government health expenditure has been rising as a percentage of GDP from 1.6 in 2000 to 2.3 in 2006, with an estimated figure of 2.4 in This trend is promising and in keeping with the recommendations of the WHO Commission on Macroeconomics and Health, which advocates that in developing countries the ratio of health expenditure to GDP increases at least by 1% in 2007 and 2% by In Sri Lanka, the total cost of health care is distributed between the pubic and private sectors, with 46.3% being attributed to the public sector. Per capita total health expenditure was USD 49 in 2005, an increase from USD 32 in 2000 (National Health Accounts, 2005). In 2005 curative healthcare was given the bulk (82.7%) of the central government health allocation with preventive care receiving only 5.8%. When total health expenditure is considered (inclusive of provincial expenditure) allocation for preventive / public health services in 2002 was 9%. In the 2008 central government estimates, the proportions have been intentionally increased, with preventive care being allocated 9.2% of government health expenditure, reducing the percentage curative care to 79.7%. This greater emphasis on preventive care is a noteworthy feature. It is recommended that the percentage for preventive care be further increased to 20% (NHA, 2005). The bulk of the government allocation is spent on recurrent expenditure. In 2005, 77.1% of the national budget and 87.1% of the provincial budget was spent on recurrent expenditure. The major items under recurrent expenditure were salaries and wages, overtime payments and medical supplies. The MNH budget cannot be separately identified, as MNH services are delivered at curative as well as preventive health facilities and are funded by both Central and Provincial budgets. In the years 2002 and 2003 direct and indirect obstetric causes was the sixth leading cause of hospitalization in government institutions and also accounted for 4.7% of discharges. Disease based National Health Accounts (NHA) statistics suggest that the largest allocation on a per capita basis is for maternal conditions 32

35 (approximately Rs. 475/=). The same study also points out that when standardized by age, the per capita expenditure on the age group 0-4 is relatively high in relation to other age groups. The volume of foreign aid appears to vary significantly from year to year: for example in 2002, it was 10.7% of total health expenditure while in 2003 it was only 4.5%. The Tsunami of 2004 resulted in a high inflow of foreign aid but by 2007 this is petering out. The four main sources of international aid for MNH activities are UNICEF, UNFPA, WHO and WB. However the contribution from foreign aid for preventive health services was not reviewed in detail. 1.4 Context and Rationale of the MNH Review Although Sri Lanka has achieved much in terms of MCH and is on track to achieving MDG goals 4 and 5, (child mortality and maternal health) disparities between geographic regions as well as population groups exist. There has been stagnation of IMR and NNMR over the past decade while many maternal deaths are identified as preventable. Concerns are also expressed regarding inequitable distribution and over-utilization / duplication of services, as well as deficiencies in quality of care. With increasing costs in health care delivery the government faces many constraints to maintain a high quality service free at the point of delivery. It is also a challenge to sustain past gains and further improve the MNH services in the face of competing demands for resources. It is felt that if MNH does not receive due priority, there is a danger of continuing stagnation of IMR and NNMR and even a reversal of these two indicators as well as the MMR. It is in this context that the Ministry of Health decided to commission an external review of the MNH services. 1.5 Objectives of the review General objective The general objective of the review is to examine the MNH components of the current national MCH Programme and to identify achievements, gaps and challenges faced by the programme, make recommendations and give directions to help with the development of a new strategic plan for the period and beyond. 33

36 1.5.2 Specific Objectives of the review Specific Objectives are to review and identify the achievements, gaps, and challenges in the current national MNH programme and give recommendations regarding: I. Organizational structure and implementation strategies of MNH care and service delivery; II. Linkages of MNH services with other Reproductive Health (RH) services; III. Management Information System (MIS); IV. MNH programme reviews and audits; V. MNH service accessibility and availability especially for vulnerable and risk groups; VI. Behaviour Change Communication component of MNH; VII. Overall Quality of Care (QoC) by examining available standards, guidelines and checklists Expected outcome of the review It is expected that the international experts in collaboration with national consultants will review and provide an independent assessment of the situation and make recommendations that will be useful for programme planners / managers to develop/formulate a new strategic plan for the period and beyond. 34

37 Chapter 2 Methodology 2.1 Conceptual Framework of the Review In order to achieve strategic outputs from the review and address interrelated issues a conceptual framework was developed. This took into account the existing MNH policies and strategies, the demographic and epidemiological profile of Sri Lanka and organizational structure for MNH services within the context and rationale of the review. The components of work were grouped into three strategic themes. The members of the review team were grouped into three groups, each group dealing with a specific thematic area. It was recognized that the themes would be complementary to each other in formulating recommendations: I. Health System Structure and functions II. MNH services and interventions III. Cross-cutting issues Health System Structure and Functions Review of health planning, budgeting in the context of decentralization of MNH services with particular emphasis on planning, management, coordination and partnerships between centre and province as well as within the province was undertaken. Adequacy of health infrastructure for providing BEmOC, CEmOC, newborn and critical care were reviewed. Human resource issues as well as financing which have strong implications for MNH service delivery were given emphasis MNH Services & Interventions Review of antenatal care, natal care, postnatal care, new born care, family planning, post abortion care, continuum of care, quality of care and linkage with other RH services were considered. Emphasis was given to a review of the content, adequacy and quality of these services, in keeping with prevailing WHO and other guidelines on evidence based best practices. 35

38 2.1.3 Cross Cutting Areas The cross cutting areas which have implications on MNH include BCC, Management Information System (MIS), reviews and audits, operational research and alternative approaches for health systems, appropriate technologies for MNH, maternal nutrition, gender issues, role of the community, social issues etc. which impact on MNH services delivery as well as MNH outcome were also reviewed and improvements suggested. The organisational frame work for the review, conceptual frame work and the flow diagram of the approach to strategic MNH programme review are given in Annex Methods used for data collection Each thematic group utilized the following methodologies I. In- depth desk review of programme documents II. Stakeholder workshop III. Key informant interviews (KII) at various levels IV. Focus group discussions (FGD) V. Field visits Desk Review: A desk review was carried out on relevant documents such as the Health Master Plan, poverty assessment, Medium Term Plan on Family Health, published surveys such as DHS, reports / minutes of maternal and perinatal mortality reviews and Annual Reports on Family Health. An analysis of stakeholder views reflecting the perspectives of a large cross section of stakeholders including INGO, NGOs, civil society, academics, researchers and the private sector on current MNH issues, which was prepared as a background document for the review was studied in detail. A List of background documents used for desk review is given in Annex 3. The information obtained from the desk review was utilized for identifying major strengths and weaknesses in the current MNH 36

39 Programme. These were addressed in the themes of the conceptual frame work of the review Stakeholder Workshop A stakeholder workshop was conducted as a means of obtaining stakeholder inputs from across the health system. The stakeholders who attended this workshop included participants from policy as well as operational levels from the centre, province, district and division. The private sector, representatives of Colleges and professional organisations, and representatives from UN Agencies also participated. Around one hundred participants from all parts of the country attended the workshop. The list of participants is given in Annex 4a. The stakeholders were divided into eight sub-groups. Issues to be discussed in the sub-groups were developed as semi structured questionnaires, which facilitated and guided the discussion. The issues included; MNH services and interventions, health system, human resource and cross cutting areas which have implications on MNH services such as decentralization and devolution, BCC, gender, supervision, reviews and MIS. The groups deliberated on existing strengths and weaknesses and possible areas for improvement as perceived by MNH service providers from policy to community level.. The issues which did not come out clearly from the stakeholder workshop were discussed individually with several key informants. (The reports of the proceedings of the stakeholder workshop are filed on record at FHB for reference if necessary.) Key Informant Interviews Key Informant Interviews (KII) were conducted with officials at policy level to cover broad areas on issues such as stagnation of IMR and NNMR, accountability, sustainability, raising the profile of MNH programme and resource allocation. KII at programme and operational levels covered the issues of access/ equity in difficult geographical areas, equity in human, financial and infrastructure, quality of care, supervision, monitoring and adequacy of supplies and equipment. 37