A Book of Case Studies Women's Right to Life and Health

Transcription

1 United Nations Chidren s Fund Regiona Office for South Asia A Book of Case Studies Women's Right to Life and Heath For every chid Heath, Education, Equaity, Protection ADVANCE HUMANITY

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3 A Book of Case Studies Women's Right to Life and Heath

4 This Working Paper is primariy intended for use by UNICEF staff and partners as an aid to good programming. Working Papers are not necessariy edited to the fu pubications standards of the agency. The United Nations Chidren s Fund (UNICEF) Regiona Office for South Asia, 2004 For further information, pease contact: Heath and Nutrition Section UNICEF Regiona Office for South Asia P.O. Box 5815, Lekhnath Marg Kathmandu, Nepa E-mai: rosa@unicef.org Cover Photo: UNICEF/HQ /Ami Vitae Design, Layout and Printing: Format Printing Press, Kathmandu, Nepa

5 Contents Introduction to Women's Right to Life and Heath 1 Managing Change Investing in Peope 7 Initiating Competency-based Training 19 Case Studies 31 Afghanistan 33 Bangadesh 37 Bhutan 45 India 49 Nepa 55 Pakistan 67 Sri Lanka 91 Annex 112

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7 Introduction to Women's Right to Life and Heath The Women's Right to Life and Heath Initiative (WRLH) was deveoped within the context of South Asia, based on goba evidence, principes and guideines for reducing materna death. Representatives from governments, donor agencies and technica partners worked together with UNICEF to design and impement a materna mortaity reduction strategy to increase the avaiabiity and utiisation of emergency obstetric care (EmOC). The strengthening of EmOC services targeted seect districts of seven countries Afghanistan, Bangadesh, Bhutan, India, Nepa, Pakistan and Sri Lanka. Between December 1999 and December 2003 the projected aocated and utiised amost $11 miion in its efforts to reduce materna deaths and demonstrate substantia improvement in the indicators for avaiabiity and utiisation of EmOC. Amidst traditiona cutures of entrenched patriarchy and ow status of women and girs, eary marriage, teenage pregnancies, ack of forma education, unskied home deiveries and a dearth of obstetric Situation in South Asia 30 per cent of the word's materna deaths 155,000 women every year: ~1 woman every 3 minutes Mae chid preference eads to repeated pregnancies 15 per cent of materna deaths in some areas reated to vioence Over 70 per cent of pregnant women are anaemic Increasing HIV/AIDS in young married women care services have prevaied. Couped with the widespread rura-urban disparity and the inequitabe distribution of services, women and girs in rura areas are at even greater risk of dying from compications of pregnancy and chidbirth. The design This South Asian profie refects the urgency not ony for addressing materna mortaity and morbidity but using principes that are based on socia deveopment. With the focus on women, creating access to obstetric care services from a rightsbased perspective provides the miieu for change. Imbuing rights-based thinking and action that buids effective management and accountabe governance, eadership and teamwork has made a generous contribution to quaity outcomes, consoidating gains for the poorest and most marginaised women, that wi assist in sustaining resuts and their contribution to reduced inequity. In December 1999 and January 2000, two regiona stakehoder meetings Governments, Coumbia University, technica experts and UNICEF were hed to deveop a regiona vision, mission and goa and guiding principes and strategies to be contextuaised and impemented at the country eve. The design envisioned the convergence of management, technoogy and human rights vaues as the means of operation for the core ife saving strategy emergency obstetric care which woud in turn strengthen the capacity of hospitas to provide improved services to their communities. UNICEF South Asia deveoped a five-step process to ensure these resuts: Step 1: A vision, mission and goa a ca to action to put women's right to ife and deveopment and their autonomy and participation at the fore. 1

8 Step 2: A vaues framework that creates the thinking and motivation for a rights approach. Goa: A sustained reduction in materna mortaity and reated disabiity. Step 3: The strategies for change that articuate what is to be done that refect the diversity and depth of the efforts required to save women's ives and incorporate the three key project components human rights, management, and technoogy. Step 4: A 'systems' approach to service deivery describes how to ink with the existing hospita systems to strengthen services and open possibiities for working at scae. Step 5: Measuring progress and driving change by using the standard UN process indicators for the avaiabiity and use of obstetric services and a quaity assessment. The vision, mission and goa Vision: The sef-determination and dignity of a women are universay vaued, and this vaue is refected in each woman's reaisation of her right to a safe, ife-enhancing pregnancy and birth. Mission: To nurture a transformation of individuas, societies and systems that resuts in a reduction of materna mortaity as the right of every woman and enhances her status, dignity and sefdetermination. The human rights framework gave impetus to the vaues and principes that woud unpin the work ethics and modaities in mobiising action at a eves nationa/sub-nationa, district/hospita, community, and househod for emergency obstetric care. Side with vaues TMR and EmOC Receiving appropriate timey emergency obstetric care is dependent on many factors. The Three Deays Mode, which anayses the diverse issues and barriers that affect prompt utiisation of ife saving care, guided project design. The strategies were inked directy to the critica junctures that increase the ikeihood of materna death the deay in deciding to seek care, the deay in reaching a medica faciity and the deay in receiving appropriate care at the faciity. They incuded direct investments with technica support and guidance, advocacy, and the importance of promoting and forging partnerships at a eves and between different stakehoders. Areas of action in management, technoogy and human rights: Management Technoogy Human Rights Strengthen capacity of individuas and groups to fufi responsibiities Provide 24-hour quaity EmOC services Buid accountabiity at a eves for saving women's ives Acknowedgement of past achievements and success factors Shared vision Equipment Drugs suppies Competency-based EmOC training Support poicy change Champion women's right to ife saving care Mobiise broader accountabiity Team work Standards and protoco Acknowedge risk-taking champions Resut-based actions Reguar reviews Infection prevention Quaity improvement Support innovations in hospitas and community Panning based on best practices Data coection reporting EmOC indicators Invest in peope for transformation Buid partnerships 2

9 Linked strategies with the three deays Factors affecting utiisation and outcome Deays Strategies Socia, cutura & economic factors 1 st Deay: Deciding to seek care Preparedness of men and women Increased knowedge Urgency for action Buid partnerships & accountabiity for saving ives Accessibiity of faciities 2 nd Deay: Identifying and reaching the heath faciity Schemes: bood, money, transport Champion human rights-based action Referra systems - Support risk-taking champions - Invest in human resource deveopment Quaity of care 3 rd Deay: Receiving adequate and appropriate treatment Quaity 24-hour EmOC services Champion human rights-based action Accountabiity of whoe faciity - Link to ANC, PNC, nutrition, HIV/AIDS & VAW - Support innovations and change Poitica commitment & poitica wi Overarching deay: Nationa eve poicies & financia & human resources Strengthen eadership & accountabiity Faciitating change from the regiona perspective In eary 2000, countries competed a needs assessment, creating a baseine and the evidence required for the project designs. Findings and designs were presented and discussed in a regiona workshop with governments, AMDD and UNICEF and by mid-year the work pans were underway. Whie countries were hiring staff and preparing to aunch activities, the regiona office for South Asia (ROSA) was preparing a project document as a concise guide to the WRLH initiative. An advocacy package was deveoped and disseminated, and a micro panning process was outined to assist countries with systematic impementation. Deveopment of processes for managing change Leadership and commitment for saving women's ives and supporting the medica/technica core of programming was supported through a series of human deveopment workshops, which contributed to the accountabiity of district and hospita managers and staff. Hospita and community faciitation for emergency obstetric care were designed and introduced and at the country eve they were further refined and adjusted to fit the particuar context. The capacity of country-eve faciitators was buit through technica workshops and on-site coaching over two-years, to strengthen competency and skis in workshop and interview design. Processes that acknowedged the domains of hospita and community, and cuminated in their convergence, ed to a reationship of mutua respect and acceptance between the medica and ay communities at the district eve. Manuas were produced for hospita and community stakehoder faciitation. Technica support Technica support was provided in response to specific gaps in capacity in country-eve programmes, for exampe: 3

10 An assessment process for obstetric suppies was deveoped with UNICEF's Procurement and Suppy Division (PSD), country offices and ROSA. Initiay, there were unforeseen deays in procurement, as country teams, with the exception of Bangadesh, were unfamiiar with the obstetric suppy ists and the specifications of instruments, equipment, and consumabe suppies as we as procurement options. PSD worked cosey with the WRLH staff and suppy personne to prepare a room-to-room Obstetric Suppy Assessment process that woud simpify the assessment at faciity eve, the understanding between programme and suppy staff and faciitate both the procurement at country eve and suppy from PSD. Competency-Based Training (CBT) for EmOC was introduced through AMDD's technica partner John Hopkins Program for Internationa Education in Gynecoogy and Obstetrics (JHPIEGO) in response to concerns raised by the countries. Athough Bangadesh had aready begun a oneyear EmOC course for doctors, training was a new undertaking for the other countries and they were finding the training of service providers a chaenge. Pacement in refresher courses for inservice providers was proving extremey difficut and programme managers were finding that current goba standards, protoco and procedures in basic and comprehensive obstetric care were unfamiiar to many trainers and service providers. An opportunity to attend the CBT training course deveoped by JHPIEGO in Indonesia convinced Governments, AMDD and UNICEF that this woud be a worthwhie investment for South Asia. A regiona review of a draft EmOC of the curricuum for obstetricians, anaesthetists and midwives was foowed by an initia training of trainers in Dhaka, Bangadesh of country teams obstetricians, anaesthetists and midwives from Afghanistan, Bangadesh, Bhutan, India, Nepa and Pakistan, and subsequenty in-country training sites were estabished. Based on the protoco guidebook Managing Compications in Pregnancy and Chidbirth, the curricua for CBT for EmOC for both trainers and participants were deveoped by AMDD and JHPIEGO as the standard toos for training. Monitoring and quaity improvement Tracking progress using the semi-annua monitoring forms was introduced in December This aowed for the systematic documentation of the process of bringing hospitas to functiona EmOC eve. The introduction of the UN process indicators for obstetric care amount and geographica distribution of comprehensive and basic EmOC faciities, proportion of women using faciities for deivery and obstetric compications, the percentage of Caesarean sections and the case fataity rate demanded improvement in the recording and reporting processes in faciities and encouraged more reguar reviews of progress. Now incorporated into the Heath Management Information Systems in severa countries, these data provide strong evidence for decision-makers. A project areas coected hospita eve data every six months and reviewed functionaity based basic and comprehensive signa functions. Toos deveoped by EngenderHeath for infection prevention and quaity improvement in EmOC were distributed and utiised, and AMDD's Criterionbased Audit was incorporated into quaity management processes in some faciities. Reguar reviews of improvements and gaps in technoogy, management and rights-based perspectives heped address bottenecks, consoidate progress and acceerate impementation. This aso aowed for reguar cinica monitoring and mentoring and the acknowedgement and appreciation of accompishments by peers and partners. A quaity assessment, which aowed for more quaitative data coection at different eves 4

11 nationa, poicy, district, hospita, community and househod was prepared by UNICEF/South Asia with country teams and carried out in Bhutan, India, Nepa and Pakistan. Annua review meetings Annua review meetings brought programming teams Government and UNICEF together to share successes and chaenges, estabish important areas of earning, as we as identify areas of priority and action for the coming year. Country teams were inspired by each other's resuts and found great soace in the fact that other countries were facing simiar constraints and issues. The reviews were aso used for sharing innovations and factors of success, for discussing chaenges and ways to address bottenecks, and for introducing and disseminating toos. Site visits and country eve meetings Nationa workshops and conferences provided opportunities for faciitating broader change in countries and reguar site visits enabed discussion on topics of interest and identification of specific areas for action. Experiences from the fied were coected and documented. 5

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13 Managing Change Investing in Peope Introduction The knowedge and evidence on how to prevent materna death exists and the medica technoogy is readiy avaiabe, yet women and their newborns continue to die from compications of pregnancy and chidbirth without ever receiving care. Medica and technica skis must be appied with urgency and competency in an obstetric emergency and skis training with the guarantee of medica suppies are the priority interventions for emergency obstetric care (EmOC). During the design phase of the Women's Right to Life and Heath (WRLH) Initiative, governments, with Coumbia University and UNICEF, unanimousy agreed that a shared commitment to making emergency obstetric services avaiabe required responsibe management teamwork at district/ hospita eve. For UNICEF, human rights principes underpin a deveopment processes. Operating a human rights-based approach to programming for the avaiabiity and utiisation of emergency obstetric care shoud imbue non-discrimination, participation, respect, accountabiity and hod the right to ife and deveopment at the core of responsibe change. To reinforce these principes, interdependence and compassion were incuded to underscore management processes and reinforce ife saving efforts. Issues The issues around managing change in EmOC in periphera faciities Hierarchy is sti deepy entrenched in South Asia and the government hospita is a microcosm of this construct. The ingering of traditiona top-down administration couped with rigid patriarchy has fostered an environment of imited sharing of information and minima participation in decisionmaking, particuary by women and ower cadres of staff. The ack of understanding about why decisions have been taken and why tasks and responsibiities are to be carried out in a particuar way has ed to a genera frustrated acceptance of the status quo. These perceptions and attitudes have contributed to an environment of ow morae and motivation and a genera ack of innovation and ownership. Issues common to hospitas Issues that commony arise in meeting the chaenge of 24-hour EmOC services incude: Staffing: Staff are usuay inadequate to cover services around the cock and athough posts have been aocated, staffs have not been depoyed, may not be wiing to go to periphera posts or have not been repaced due to frequent unexpected transfers. 7

14 The need for human resource deveopment: Reguar updating and upgrading of cinica skis has been negected. Simiary, there has been imited effort to assure that outdated and broken equipment is repaired, proper equipment instaed and consumabe suppies required for improved performance made avaiabe. Consequenty, service providers have been 'making do' with what they know and what they have, which has resuted in a genera ack of competent care. Improvement in infrastructure: Inadequate conditions such as poor water and eectricity suppy, ack of pubic toiets and waiting/sheter areas for famiy members, eaking roofs, impractica and underutiised space. Teamwork: Staff acks confidence in deaing with emergencies and fear punishment if a patient dies. As a resut they are ess ikey to take responsibiity for a difficut or emergency case, so referra, even when it means certain death, is not uncommon. There is itte confidence that coeagues wi support ife saving risk taking. Care and respect: Many heath faciities are generay unkempt and ack rigorous infection prevention procedures. In maternity sections, considerations for comfort and privacy during abour and deivery are sorey missing. The common issues for the community the hospita serves Timeiness and quaity of treatment; ceaniness; privacy; and information about procedures, the costs invoved and the choices avaiabe are a issues that draw women to utiise services. Women are not prepared for a compication during pregnancy and chidbirth. They don't know what can happen; the signs that mean they are experiencing a ife threatening compication; where they need to go, how they wi get there; or how much it wi cost. They haven't panned on where to get bood if required, or put some money aside 'just in case'. Women do not know what the hospita is ike and what wi happen to them once they get there. They fear they wi not be abe to afford the treatment and/or the additiona costs of tests and procedures and medicines and suppies ordered by the medica staff. When famiies are poor, the decision to seek care as opposed to 'waiting it out' or trying oca, ow-cost aternatives is a difficut one; this decision is further infuenced by the vaue paced on the woman's ife. Intervention Tacking the issues and taking appropriate action Hospitas are socia iving systems that form an integra part of the heath system. As they are dependent on the performance of peope managers, cinicians, technicians, administrators, guards, ceaners, store-keepers etc to function, they definitey possess the potentia to create and drive appropriate change. To address the management of EmOC services, 'investing in peope and buiding socia capita' was identified as a core strategy for achieving the avaiabiity and utiisation of obstetric services that save, protect and enhance the ives of women. The first thing was to make EmOC a priority by acknowedging the urgency required to save the ives of women and newborns. If the priority was to refect in action then stakehoders at every eve had to be invoved and motivated to make the change from the status quo to a state of ife-saving readiness. Ceary, processes were required to manage that change and achieve the expected resuts the avaiabiity and utiisation of 24-hour emergency obstetric care services at periphera hospitas. 8

15 Improvements Improved management of ife-saving EmOC Faciitating participation in managing change Firsty, government and UNICEF programme staff participated in a week-ong regiona orientation workshop to prepare them as mentors and faciitators for EmOC in their countries. They in turn, conducted advocacy meetings at nationa, sub-nationa and district eves to sensitise and prepare eaders, managers and programmers. The meetings were designed to increase understanding of why women die, what is required to avert avoidabe deaths and disabiities, and how it is possibe to bring about change by working together towards the common goa of materna mortaity reduction. Preparing faciitators and buiding capacity in the region Foowing this, each country seected a group of faciitators government, NGO, and UNICEF to attend preparatory workshops that provided an orientation to the hospita panning and review cyce, and, by going through the process themseves, assisted them to internaise the eve of thinking and participation required. They were then mentored through a process of faciitation to enabe them to guide hospita managers and staff through a simiar process in hospitas. A panning and review process using appreciative inquiry in hospitas Training of faciitators government, NGOs and UNICEF in managing change using appreciative inquiry was new, exciting, and aready a major shift from the norm of administrative management. The faciitators' workshops were conducted in-country and abroad (Nepa, India and Bangadesh) and incuded pre-workshop interviews, faciitation during the workshop, on-going coaching and reguar reviews. Faciitators then provided orientations for hospita and district eaders, and schedued pre-workshop interviews and whoe site workshops at a number of hospita sites in seected districts in each country. Uniquey, the process brought together a hospita staff. For many, this was the first time they had ever been in a workshop or had sat and conversed with more senior staff. The process, which began by sharing and drawing on each person's best experiences, opened doors of communication to discover the human heart of the hospita as a socia iving system. Together staff envisioned the hospita they wanted to work in and expored ways to create that environment an achievabe and desirabe future around the priority of saving women's ives. Together, they decided what needed to happen, formed thematic teams, mapped out annua work pans, and prepared monthy action pans. The teams hed reguar meetings and hospitas decided on review schedues to assess progress towards desired resuts. Annua assessment, review and panning are aso a requirement. As far as possibe, a hospita staff was invoved in management for EmOC. Sef-assessment interviews were used to identify gaps in knowedge, attitudes and practices at every eve of hospita function and a shared vision for the hospita was prepared based on the agreed upon best practices. Teamwork team-based panning, action and reguar reviews for EmOC were incorporated into the annua hospita process. Annua work pans with measurabe resuts were drawn up by hospita teams. Checkists for room-by-room set-up were used for procurement and suppy and for micro-eve 24-hour readiness. Community stakehoders were invited into the process to provide support to the site reorganisation and to address specific issues at the district and hospita eve. 9

16 The whoe site process requires two workshops in the first year, foowed by the annua review. If the staff interviews are incuded in 'day one' then, the first workshop is conducted over five-days. Four to six months ater, a second workshop is conducted for three days; and then the annua panning workshop for three days is hed at the end of the year for a tota of 11 days. If interviews are conducted separatey from the first workshop, an additiona seven working days is required to conduct the interviews; review the stories; and prepare the report. In some instances, the second and third workshops were shortened to two days. After competion of the first year, the hospita conducts an annua assessment, review and panning exercise using the same process hospita faciitators wi ead their annua review workshop to revisit the shared vision for the hospita, identify priority resuts for the coming year, and pan team breakthroughs. For hospita transformation to occur it is essentia that staff performance and effectiveness are enhanced, that management respond to the interests and needs of the staff, and that a more decentraised network of eadership is deveoped. Coaching by interna and externa faciitators provides an additiona input to strengthen staff capacity for creating continuous change. It assists them with the confidence to make necessary improvements in interna processes and systems and for buiding on knowedge and actions that ead to new eves of impact. Hospita Action Pan (HAP) as a micro panning process in Bangadesh UNICEF, Bangadesh had taken on 123 hospitas, many of them at Upazia Heath Compex (UHC) eve, so athough they pioted whoe-site management in 18 faciities, they aso deveoped a five-step micro panning process caed Hospita Action Pan (HAP). HAP was designed to reach more faciities in a shorter time, whie paying attention to team buiding and the detais of 24- hour EmOC readiness. In contrast to using appreciative inquiry HAP uses sef-assessment to improve individua performance and capacity for emergency response. It was conducted in 71 faciities and reviewed in 29 by the end of HAP was deveoped as a participatory process focused on advocacy and action for management of 24-hour services with specific objectives to: Overcome deays in estabishing EmOC services by focusing on each step necessary to achieve functioning faciity status. Organise and buid the EmOC team for effective management and performance of quaity EmOC services Organise and set up the faciity room by room with equipment, instruments, drugs, inen and other suppies. Create readiness in each room to respond to obstetric emergencies around the cock Strengthen the record-keeping, reporting and review functions Improve basic functions such as ceaniness, infection prevention practices and ensuring privacy for patients. HAP requires the formation of an EmOC team guard, ceaner, nurse, doctor, ab technicians. The aim of the team is to improve coective action through panning, defined roes and responsibiities of team members, and periodic review meetings. In HAP the investment is in the oca EmOC team, which is a substantia number of staff at UHC eve. It takes four days to compete the five-step process, incuding assessment of one's knowedge and skis; room-to-room readiness and site-set up for emergency action; preparation of a pan of action; aocation of responsibiities; and monthy team reviews. As pans are competed, new ones are formuated and tasks undertaken that wi continue to drive quaity improvement and ensure maintenance of hospita systems that support EmOC. 10

17 Quaity Care through productivity in Sri Lanka In Sri Lanka, a management process was deveoped to improve quaity care to increase utiisation of obstetric services. The process caed Quaity Heath Care through Productivity features customer focused organisation, performance exceence and tota quaity management with specific objectives to reorganise the hospita based on the 5S systems theory, improve efficiency using productivity concepts such as work improvement teams, suggestion schemes and Kaizan techniques (sma, gradua improvements that ead to overa positive change), and improved quaity of care through tota quaity management. The 5S system (in Japanese, seiri, seiton, seiso, seiketsu, shitsuke) incudes: Cearing systematicay removing a unwanted items Orderiness pacing wanted items/services in order with appropriate storage containers, abeing, and coour coding The strategies incude human resource invovement, human resource deveopment, mistake proofing, quaity of work ife, and organisation of the hospita systems. The activities invove meetings and diaogue with a staff to create awareness about the importance of quaity management and to buid their understanding on the use of the 5S system to enhance productivity and efficiency. Work Improvement Teams are then formed (one for each unit with 12 persons per team) and responsibiities aocated for the appication of 5S. The team eader is responsibe for recording and reporting on the monthy progress. Productivity indicators are prepared and reguary monitored by the management team. Leadership pays an important roe and at each shift a manager is designated for each unit. Materna and infant death reviews are conducted reguary to track quaity of care and a reward scheme is estabished to acknowedge the best run wards, most productive teams etc. Ceaning infection prevention practices, ceaniness and neatness of externa environment, creating a peasant, considerate and comfortabe pace for women and babies Resuts What are the resuts of these investments? Standardisation estabish and prepare standards and guideines and monitor them reguary Sef-discipine and training frequent awareness buiding, in-service refresher training The process begins with an assessment and anaysis of the hospita services i.e. infection rates, materna and neo-nata death reviews, and pubic image. The probems are then identified and documented in reports (situationa, performance etc), photographs, customer surveys (incuding etters from the pubic), and staff satisfaction surveys. Leading to measurabe resuts for EmOC services and for women For Bangadesh, the resuts of the whoe site management using AI and the HAP have not been separated. Overa, anaysis of functionaity and performance in 123 hospitas across the country reveas a 38 per cent in births in faciities, 125 per cent increase in the compications treated and a 50 per cent increase in the number of C-sections. Met need has doubed since baseine In the project sites of India, Pakistan and Nepa met need have increased substantiay. 11

18 Tabe: Met need in project sites: WRLH project site December 2001 December 2003 Remarks Bangadesh faciities nation-wide Bhutan faciities nation-wide India State of Rajasthan districts Nepa districts 12 faciities Pakistan Sindh Province districts 27 faciities Measurabe change based on work pans In Bhutan, the teams at Bajo hospita achieved 100 per cent of their tasks in the six months foowing the whoe site workshop. By the end of the third quarter it was a itte ess, at 33 per cent but the staff remained confident that they woud compete a the panned outcomes by the end of the year. rate of 2002 (1.75 per 100 surgeries) is haf that of Of the 14 materna deaths in 2002 none were cassified as avoidabe, compared with five of the 17 deaths in In hospitas, managing change is eading to shifts in staff attitudes "I have observed changes in the physica environment and in the attitude of staff, particuary in the way the staff come forward. They may have done things to improve quaity before but now they are doing more than required, more than the responsibiities in their job descriptions." An obstetrician/gynaecoogist with the Ministry of Heath in Bhutan In Sindh Province, Pakistan, the number of breakthrough tasks identified by staff during the workshops ranges between 10 and 17. Of the six faciities where whoe site appreciative management was introduced, two have achieved a breakthroughs and four have achieved 80 per cent of their panned breakthroughs. A faciities have staff wiing to be trained as EmOC services providers, incuding operation theatre technicians training, and four have aready competed their training. "Before these workshops I coudn't have imagined the stories that the staff woud come out with. I didn't reaise what they have to do and the importance of these EmOC services." Assistant Programme Officer with the Heath Department, Bhutan The Whoe-site Hospita Faciitation has been introduced to more than 30 faciities in the region. The Hospita Action Panning has been used in 65 faciities in Bangadesh and the 5 step process has now been successfuy introduced in severa Sri Lankan hospitas. Staff find the 5-step process pragmatic for hospita managers. The three key eements that have infuenced the change are: 1. Improved hospita eadership 2. Increasing accountabiity of hospita staff in fufiing their duties In Sri Lanka, quaity changes in Caste Street hospita using the 5 Step process have ed to a 30 per cent increase in the number of women using the hospita, couped with a substantia decrease in avoidabe materna deaths. Post LSCS infection 3. Community stakehoder invovement In India, overa changes in the way peope are working together have been observed. For exampe, the mindset of the hospita staff 12

19 demonstrating the power structures and behavioura norms are beginning to change: them more and tak to them in a manner which is more respectfu than before. A staff are invoved in panning, not just senior management, and staff are articuating their desired outcomes. Peope are performing better as individuas and taking action. By working in teams with specific roes and responsibiities, they are beginning to share accountabiity and the fruits of their individua and group efforts. As individuas, staff members are coming up with ideas and innovations to improve the quaity of care and comfort of patients and reatives. The attitudes of and conversations among hospita staff are aso beginning to change: Team members and peers are more confident working together. Senior staff are more appreciative of the contributions made by junior staff. Staff are more open, sharing their ideas, achievements and concerns; they take part in meetings together. Staff are more understanding of how patients fee and are taking time to expain and tak to "It has motivated and inspired workers to find the most efficient and effective ways to serve the faciity. It has aso heped me to ead and bring new changes. At first I was worried that it woud be difficut for me to ead the whoe team and manage it but I found that the process created a common foundation that I and the other members coud buid on it made many committed and wiing to initiate the change that was required for the faciity to function better". Dr. Sushma Panday of Jhaawar Hospita in India Participatory management In India, the project support staff note that a more decentraised, participatory management system that prioritises the provision of emergency obstetric care services is operationa throughout the hospitas. Responsibiities have been deegated to teams, thereby increasing everyone's participation and their accountabiity for particuar roes and responsibiities. In India, sma funds were aocated to teams to compete activities panned and prioritised for investment by the members. This has increased the autonomy of and innovation by the hospita staff. The process was seen as a means of sustaining practices of best hospita management in Pakistan. Effectiveness was identified in the opportunity for staff to anayse the strengths and weakness in their hospita and to design more adequate structures, working procedures and staff aocation to enabe the achievement of desired objectives. Interna cooperation, coordination and faciitation of the roes of administration have been strengthened. Quartery reports show increased interaction between administration and medica staff, greater teamwork and commitment to achieving breakthrough tasks. Supervisor reports show evidence of behaviour change among staff a wiingness to improve the quaity of their performance and more transparent distribution of tasks. Emergency Response Teams (ERTs) have been formed and meet each month to review the eve of emergency response readiness of each hospita. Physica environment and innovations In the 76 faciities where management processes were introduced in Bangadesh, improvements to meet the requirement of obstetric emergencies initiay focused on room to room readiness in maternity and OT. These areas were systematicay set-up and are maintained for 24-hour obstetrics and emergencies. Emergency drugs are now incorporated into the medica suppies register. 13

20 In severa cases separate obstetric units were estabished and consutants are providing their services beyond norma working hours and duty rosters for emergencies and surgery are maintained. Athough not a hospitas have a bood bank, 24-hour bood transfusion services supported by bood donor camps and donor ists are a priority. Uniforms were provided to ceaning staff and in some faciities, infection prevention practices are improving, athough simiar to other countries infection prevention practices require continuous, ong-term investment. In Bhutan, reorganising and setting-up a woman friendy environment that is aways ready for an emergency, has been the priority and data on obstetric services are showing a positive increase in utiisation. Paro Hospita is a 55-bed hospita in a busy district of Bhutan, and was one of two sites seected for the whoe site management process. The EmOC Team has rearranged the beds to aow for more privacy and the Maternity Team is providing a maternity unit orientation to women at 34 weeks gestation. They have sign-posted the hospita to direct women to the emergency and maternity areas and are assisting women to prepare their birth pans during routine antenata visits, so they know the danger signs and know what to do and where to go in an obstetric emergency. Simiary, in Pakistan they rearranged their faciities to provide 24-hour emergency care, incuding surgery, aboratory and bood bank services. They aso improved signboards, reception areas and operating theatres. In India, some of the innovations brought about by the more judicia use of funds for minor activities has incuded stretchers, housekeeping troeys, a centra oxygen system, and site renovations incuding waiting areas for reatives. These are simpe, yet commendabe achievements. A faciities have mobiised community and private sector funding for hospita improvements, and three hospitas have introduced Patient Wefare Committees to support donations in kind and cash, incuding bood donation and severa hospitas have buit sheters for reatives, and estabished midwifery and EmOC training faciities, incuding quarters for trainees. For Sri Lanka, the exampe of change is based on the resuts from the past two years that have ed to reorganised and refurbished hospitas. These changes incude: A centra unserviceabe items store. Damaged items are no onger in rooms scattered throughout the faciity The estabishment of a centra sterie suppies room has made a tremendous difference to staff efficiency as previousy each unit was responsibe for steriising their own items on-site. The estabishment of a centra inen suppy unit that was benchmarked on hote inen services. Supermarket troeys are used to distribute cean inen to each bed. A waste disposa system that provides separate bins are coour coded for a types of waste and a coour code chart is on the wa above each waste disposa area. A patient identification system that codes by coour means that during the busy ante-nata care cinics first visit mothers are separated from women in their ast month of pregnancy, A new cinic booking system and separate user-friendy checkists for emergency cases, admission and discharge make it easy for a staff to make sure they cover every item for every woman. The use of data reevant to quaity of care, monitoring of improvements and annua reporting of progress. Suppy systems In Paro hospita, Bhutan, the Maternity team has increased the number of deivery packs, updated their neonata resuscitation procedures and is 14

21 maintaining a continuous suppy of consumabe suppies. The bood bank team have procured the equipment required incuding transfusion sets, and coection suppies, negotiated with MoH to provide a trained ab technician to manage the bank and initiated a bood donor system. Together, they mobiised an emergency bood donor network, which now had 50 potentia donors tested and registered. In Nepa, the Medica Superintendent of Saptari Zona Hospita, Dr A Mishra, made the commitment that "No woman woud die due to ack of medicine", and in Dang District Hospita staff have worked on improving services through estabishment of a Centra Steriisation Unit. Interna resource mobiisation has aso resuted in the suppy of much needed hospita equipment. Using data for quaity improvement Improved record keeping and reporting from a faciities with EOC boards that dispay updated emergency care data is being maintained in Bangadesh faciities, and scientific seminars and new hospita ibraries are enhancing knowedge, and the use of data. In India, the management process has brought consensus for action so that many things, which shoud have but were not happening before in district hospitas in Rajasthan and Maharashtra are actuay happening now. Cinica teams are conducting reguar anaysis of the hospita data and decision making is based on the resuts. In some maternity units this is done weeky, and in Rajasthan new processes were put in pace to ensure timey avaiabiity of bood resuting in a substantia increase in the use of bood in maternity sections. This is eading to a sharp decrease in materna death due to haemorrhage. In district hospitas in Nepa, improved recording systems have been set up with the use of the partograph for monitoring progress of abour. Weeky Continuing Medica Education (CME) sessions have begun as we as adherence to standards through impementation of the Cinica Protocos for Reproductive Heath. One of the doctors at Caste Street hospita stated enthusiasticay, "The best thing is that these changes are based on what our cients want". Patient privacy has improved with the use of screens and curtains and the repositioning of beds. Heath education to patients and attendants has been strengthened more consistent and improved in quaity. Community stakehoder invovement The staff said, "We have encountered chaenges as we try to do what is best for women. We want to improve quaity; we need to address infection prevention. We need to invove the community stakehoders more and we need to have more support from resource persons to assist us with foow-up and guidance". In Bhutan, there have been resuts in strengthening community awareness and referra systems and in buiding a bood donor network. Members of the Women Vounteers Association are maintaining a register of pregnant women; arranging counseing sessions in the community by doctors and nurses; and mobiising bood donors and emergency transport for pregnant women at any time of the day or night. In India, the invovement of community stakehoders was identified as a priority in both the estabishment of the EmOC faciity and its utiisation. Stakehoder invovement in the hospita management process heped to bring commitment and support from the Rajasthan Medica Reief Society by: Raising the issue of the injustice of materna death -- as a priority issue to be addressed at the district and community eve. Budgetary support for making improvements in the hospitas came readiy. For exampe, provision of a separate eectrica feeder, waterhuts, patforms, air-conditioner, taking 15

22 responsibiity of maintenance of a particuar ward, etc. Community stakehoders accepted a vita roe in supporting bood donation and buiding bood donor networks. The hospita staff and stakehoders view avaiabiity of EmOC services as the right of a women in the district of Dang. The community stakehoders have mobiised interna resources with the District Counci aocating Rs 2,00,000 for the estabishment of a Bood Bank. In Nepa, whie hospita staff have accepted the roe of stakehoders, stakehoders view the hospita as "Our Hospita". A revoving fund for EmOC has been set up through community contributions amounting to Rs 45,000 whie UNICEF has contributed Rs 1,00,000 to community stakehoders activities/contributions. Other contributions in support of the hospita aso incude: Support for construction of a dispensary counter & tickets counter (S Parajui) Repair of a hospita eectrica wiring (BP Academy) Hospita wa painting (cost contributed by CDO, NRCS) Hospita sanitation campaign to dispose hospita waste (Hospita Support Groups) Cabinet for toys- HUCODEC Six dust bins (Prem Thapa ASI) Functiona ambuance service through 50 per cent discount for EmOC patients (Pathivara Taxi Samiti) Bood donor cub The Kapivastu workshop in Nepa, focused on incusion of women from the marginaised and minority groups, as stakehoders in the heath system. The presence of the so caed ow-caste iiterate women, participating in the same forum with highy paced oca government officias was initiay considered unacceptabe. However the high degree of participation of these viage women, encouraged dissenters to accept them eventuay. In Bangadesh, support mechanisms have been put in pace for poor patients that incude a drug bank and income generation activities to increase socia wefare funds. Increased poitica commitment is encouraged with the support of the district deveopment coordination committees (DDCC), which hod reguar meetings with an EOC agenda and oca members of pariament have been invoved in furthering the deveopment of services. Confict Resoution Dang district, Nepa, despite a very turbuent history in recent years due to poitica instabiity, continues to make steady progress foowing the first AI workshop. The AI workshop heped resove confict between two high eve oca government officias, through acknowedgement and appreciation, rather than anaysis of probems and their soution. Resoution of this confict has heped deveopment programmes in the district move ahead. Lessons Learnt What have we earned from these experiences? The importance of eadership in hospita management When hospita managers are not wiing to invest in management change it is extremey difficut to move forward. On the other hand, when the hospita eadership is committed to making quaity changes in the hospita remarkabe progress is possibe. The hospita director at Caste Street is convinced by the efficiency and cost effectiveness of the process. "We have made a these changes with the resources we aready had avaiabe. We didn't require extra funds because by having more 16

23 effective systems in pace we were abe to save money from previousy routine functions of the hospita." Committed eadership and continuous encouragement by hospita managers are key to maintaining the change processes and the enthusiasm of staff. Investment in eadership is an important requisite. Reguar foow-up and tracking of change by senior staff and on-site coaching by staff members seected and trained as faciitators/managers is important to identify both the chaenges and issues that arise and new tasks for furthering change. The vaue added by participation The participatory process nurtures eadership quaities of providers and the community aike. It makes interdependence more apparent and stimuates oca responsibiity and action for saving women's ives. Hospita management processes for assessment, panning, action and review are essentia but they are not sufficient to guarantee 24-hour quaity EmOC services. Processes have been backed up by the increased provision of competent EmOC providers, and essentia suppies and equipment, investment in persona deveopment, cinica support and intensive monitoring. "The key changes that I have observed over the past two years are the improved ceaniness, the eve of teamwork and the improved attitudes of the staff" senior staff manager, Caste Street Hospita, Sri Lanka The benefits of different management modes Different management toos have different benefits, however, participation in decision making, teamwork and reguar review processes are common processes that have demonstrated positive resuts. Sri Lanka found the 5 step process simper and easier to manage. The process is a cear and easy to foow bue-print for change. The Hospita Action Pan process requires imited resources, and ess person time as it invoves representatives from a cadres of staff in one EmOC team. It does not require the investment of skied faciitators. Whoe site management using appreciative inquiry requires a more substantia investment. For scaing up of this process competent faciitators are required. Programming requires the training of trainers and the buy-in of dedicated peope to train others and foow through on ensuring the competence of faciitators. On the other hand, it has ed to substantive changes in staff attitudes and eves of individua and coective accountabiity. It has aso ed to a variety of innovations in the workpace and fundraising activities to support oca improvements and priorities. In concusion, it is important to note that management is inextricaby inked to quaity improvement. Accepted standards are therefore vita to ensuring the quaity eves of EmOC, genera patient care and management are achieved and maintained. Reaching acceptabe eves of quaity takes time but with the use of benchmarks, and consistent, reguar use of criterion-based audits in technoogy, management and human rights, it is possibe to strongy infuence and hasten the changes required. Efforts to refine and streamine the processes need to be sustained to aow for strategic programming and scaing-up. Sustainabiity factors wi be reviewed in the onger-term. 17

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25 Initiating Competency-based Training Introduction Over the past decade there has been a growing body of evidence that points to the need for goba standards of maternity care founded on evidencebased practices. Such standards are required to ensure skied attendance at deivery and emergency obstetric care that is vita to goba efforts that address the persistent burden of materna death and disabiity. Two factors common to most countries for the stagnation in materna mortaity reduction are " faiure to focus on effective interventions and inadequate poitica commitment and resources". 1 In 1999, the Women's Right to Life and Heath Initiative, a partnership between the Coumbia University Averting Materna Death and Disabiity (AMDD) programme and UNICEF in South Asia, made resources avaiabe in the region for emergency obstetric care (EmOC) programming, the most effective intervention for saving the ives of women with ife threatening compications of pregnancy and chidbirth. The needs assessments conducted in eary 2000, by the countries invoved in the programme, drew attention to the dearth of skied providers at the periphery, and as impementation began, the urgency for an EmOC training strategy became apparent. heath system, to ensure infrastructure deveopment; avaiabiity of equipment, suppies and drugs; information and monitoring systems; and most importanty, to ensure sufficient skied human resources. Without them women's ives cannot be saved. Issues Insufficient skied staff at the periphery Eighty per cent of materna deaths resut from direct obstetric compications of pregnancy and chidbirth. These compications cannot be predicted and most cannot be prevented 2. Thus the avaiabiity and use of quaity emergency obstetric care services is essentia to reduce materna mortaity in South Asia. To ensure the avaiabiity of these services 24-hours a day, 7- days a week, sufficient numbers of competent staff obstetricians, anaesthetists, midwives and OT nurses and ab technicians are required. In addition, these providers are needed in the periphery, at district hospitas and primary heath care centres, so that women experiencing obstetric compications can access appropriate ife-saving care 'in time'. However, most South Asian countries currenty ack a sufficient number of skied staff to meet this need. 3 Estabishing and/or expanding avaiabiity of EmOC services - at seected faciities or nation-wide - requires effective management throughout the Apart from Bangadesh, where the Nationa Safe Motherhood Programme aready had a one-year EmOC training programme operationa, none of 1 Graham, W. and J. Be. Monitoring and Evauating Attendance at Deivery: trias and tribuations, paper presentation, Technica Consutation "Ensure Skied Attendance at Deivery", Word Heath Organisation, Geneva: Apri 2000, p UNICEF, Regiona Office for South Asia. A Human Rights-Based Approach to Materna Mortaity Reduction in the Context of South Asia - A review of the iterature, UNICEF ROSA, Kathmandu: 2003, p. ** 3 Ibid, p. ** 19