A Holistic Community Model for Maternal and Neonatal Health in Honduras. Catholic Relief Services

Transcription

1 1 A Holistic Community Model for Maternal and Neonatal Health in Honduras USAID/BASICS PRODIM Honduran Red Cross Plan International Save the Children Christian Children s Fund Catholic Relief Services World Vision Aldea Global PAG AMIHDE

2 2 Table of Contents I. Justification II. Background III. Description of the Strategy a. Purpose b. Goals c. Specific objectives d. Partners e. Geographic areas f. Beneficiary population g. Implementation period IV. Basic Principles of the Strategy a. Technical areas b. Conceptual framework c. Conceptual framework components and their interactions d. Administrative organization V. Field Implementation a. Capacity strengthening of the Rural Health Centers (CESARs) b. Defining and establishing Service Distribution Points (SDPs) c. Establishing and strengthening community health committees d. Coordination among community health volunteers VI. Next Steps ANNEXES Annex 1: Mapping Annex 3: Available training materials Annex 4: Proposed indicators

3 3 I. Justification In developing countries where access to reproductive health services is limited, many women and newborns die from pregnancy, childbirth, and postpartum related complications. In fact, 536,000 mothers and 4 million newborns die annually from causes that are mostly preventable. 1. Many of these deaths take place in rural communities, especially those with barriers to health services access (geographic, cultural, etc.). Between 75% and 80% of maternal deaths result from 4 main causes: postpartum hemorrhage, complications from unsafe abortion, sepsis, and pregnancy induced hypertension. 2 The principal causes of neonatal mortality are infections (36% including sepsis, pneumonia, diarrhea, and tetanus), complications of prematurity (27%), and birth asphyxia (23%). 1 Recent studies have shown that most maternal (60%) and neonatal deaths (75%) take place within the first week after delivery, usually within the first 2 3 days. Half of the deaths take place within the first 24 hours. 1,3 Therefore, a decrease with greater impact on maternal and neonatal mortality may be accomplished by means of appropriate care during the antenatal period and the delivery, and by carrying out detailed assessments during the stay at the health facilities if the delivery was institutional (with emphasis on the first 6 hours after birth), assessment and counseling on essential preventive care for the mother and the newborn before discharge or before the person who attends the home delivery leaves, and during early postnatal visits. The first assessment visit should take place within hours after delivery, ideally by a qualified provider or at least by a well trained community worker, followed by subsequent assessments at the end of the first, second, and fourth weeks, where possible. Postnatal assessments should include counseling on preventive healthy behavior, identification of danger signs, and appropriate care seeking in case of complications. For all the interventions above mentioned, community mobilization strategies and links between community and health services activities, aimed at promoting healthy behavior, particularly in maternal and neonatal health, are of the utmost importance. Honduras is one of the countries with the highest maternal (108 per 100,000 live births) and perinatal mortality rate (stillborns plus newborns 25 per 1,000 live births and 33 per 1,000 live births in rural areas) in the Latin American and Caribbean region. 4 1 The Lancet Neonatal Survival Series, March, The Lancet Maternal Health Series, October, World Health Organization. (1994) Mother-Baby Package: An Approach to Implement Safe Motherhood. 3 Li, X.F. et al. (1996). The Post-Partum period: The Key to Maternal Mortality. International Journal of Gynecology and Obstetrics, Volume 54, pp DHS National Epidemiological and Family Health Survey. Secretary of Health and MACRO International Inc.

4 4 Home delivery is a frequent practice in the country, where 30% of women in the rural area give birth with traditional birth attendants (TBA), some of whom have very few delivery care skills. 4 Some departments in the country show particularly high home delivery percentages: La Paz 53%, Intibucá 54%, and Francisco Morazán 40%. This translates in high neonatal mortality rates for the above mentioned departments, with 34/1,000 live births in La Paz, and 23/1,000 live births in Intibuca and Francisco Morazán. Moreover, the Ministry of Health guidelines for postnatal care emphasize the provision of care to the mother within the first 10 days after delivery, but the period with highest mortality rate, the first hours, should be prioritized. The situation is even more complex in departments like Intibucá and La Paz where 40% of mothers and newborns do not receive any postnatal care. 4 In order to improve basic health indicators for maternal and child health in the country, the Ministry of Health is implementing the Strategy for the Accelerated Reduction of Maternal and Child Mortality (RAMNI, by its Spanish acronym) during the 2008 to 2015 period. The national strategy for Essential Obstetric and Newborn Care (EONC) is being implemented for this purpose. Included among its lines of action is increasing demand and access to EONC services by means of community action development. 5 The community strategy shown here responds to national efforts aimed at improving maternal and neonatal health in Honduras. II. Background Since 2007, as an element of the implementation of the Latin America and the Caribbean Regional Strategy for Newborn Health, a small group of non governmental organizations (NGOs) with technical support from BASICS has taken part in the Initiative for Improved Quality in Prevention and Management Services for Neonatal Sepsis (focusing on the community level in Honduras) together with 2 additional countries in the region (El Salvador and the Dominican Republic at the facility level). Based on the positive results of the neonatal sepsis intervention, other NGOs were added during the initiative s second year (for a total of 9 organizations). This has resulted in a rapid geographic expansion, increasing the number of communities in priority areas with difficult access to health services, in the poorest Honduran municipalities, according to the UNDP s most recent report on human development. In the same way, other elements of essential newborn care elements were also added. The original partners were Christian Children s Fund (CCF), Save the Children, Catholic Relief Services (CRS), and PRODIM (Programs for the Development of Women and 5 Estrategia Nacional de Cuidados Obstétricos y Neonatales Esenciales (CONE). Secretaria de Estado en el Despacho de Salud. Honduras, Julio de [National Strategy for Essential Obstetric and Newborn Care (EONC). Government Secretariat in the Health Office. Honduras, July 2007.]

5 5 Children). The Honduran Red Cross, World Vision, Plan International, Proyecto Aldea Global and AMIHDE joined the initiative in the second year. Each partner brings great programmatic experience and diverse implementation methodologies in the maternal and newborn health area at the community level in their work in the various regions of Honduras. The current partners work in 9 departments and 71 municipalities in some of the most disadvantaged and inaccessible areas of the country (see table 1). The intervention has shown that a standard newborn health module may be incorporated into any health program, regardless of the strategy used for its implementation. This module includes community mobilization aspects aimed at protecting maternal and neonatal health, promoting preventive healthy behaviors, postnatal visits in the first 72 hours after birth (the period with the highest neonatal mortality rate), early identification of danger signs in the mother and child, and adequate referral to health services, through the continuum of care during the antenatal, delivery, and postpartum/postnatal period. Recent feedback from the group suggests that establishing the network or technical alliance of NGOs aimed specifically at improving maternal and neonatal health has enhanced collaboration and information sharing, and has produced results in a rapid and cost effective manner. For instance, one of the partners added work with TBAs to the activities in its focus areas; for this purpose, training and supervision tools and methods were adapted from another NGO participating in the initiative. The importance of a coordinating entity, as BASICS was during this experience, was highlighted. The approach shown in this document represents a strategy proposed for improving maternal and newborn health at the community level and for strengthening the continuum of care during the antenatal, delivery, and postnatal/postpartum periods, as well as links with health services within the framework of the RAMNI strategy. Based on field initiative strategies developed and tested by the partners, the group proposes a comprehensive maternal and neonatal community health model taking into account the lessons learned. Using spatial analysis to identify potential geographic and programmatic coordination, the participating partners would work in a standardized manner at the municipal level in order to execute this strategy and to meet the described goals (electronic annex). III. Description of the Strategy a. Goal Strengthening maternal and neonatal health community services within the framework of the National Strategy for the Accelerated Reduction of Maternal and Child Mortality (RAMNI), thus contributing to the achievement of the Millennium Development Goals #4 and #5.

6 6 b. General objectives 1. Standardizing quality maternal and neonatal health services at the community level. 2. Increasing demand and access to essential facility based obstetric and neonatal services (EONC). c. Specific objectives 1) Offering a standardized maternal and neonatal care strategy at community level. 2) Strengthening knowledge and skills of the different categories of community health providers. 3) Strengthening community organization for the protection of the health of the mother and the newborn. 4) Developing a maternal and neonatal health surveillance system at the community level. 5) Contributing to establishing policies and standards to improve community services. 6) Contributing to strengthening the quality of maternal and newborn health services at the local level (CESAR). 7) Strengthening links between communities and health services. d. Participating partners Christian Children s Fund Plan Internacional Catholic Relief Services Honduran Red Cross Aldea Global PAG PRODIM Save the Children World Vision AMIDHE f. Beneficiary population Pregnant women and newborns in the municipalities and communities where the strategy will be implemented. The activities will cover 9 departments and 71 municipalities with a population of 777,553 beneficiaries, including 194,388 women of childbearing age and 3,355 pregnancies expected per year. Detailed distribution is shown in table 1. Location, number and type of beneficiary of the intervention in essential maternal and neonatal community care in Honduras Department Municipality Women of Childbearing Age Expected Pregnancies Total Population

7 7 Table 1. Geographic areas and beneficiary population for the proposed activities Source: Statistics Department, Honduran Ministry of Health Dr. Georgina Díaz (Interpersonal communication, May 2009) g. Proposed implementation period October 2010 to September 2014 IV. Basic Principles of the Strategy

8 8 The fundamental principles of the strategy are based on: 1) Improving coordination among NGOs, the Ministry of Health, and the communities at the municipal level in order to cover the continuum of care of the mother and newborn dyad. 2) Strengthening the technical capacity of health workers in the most peripheral centers (CESAR), as well as that of the community volunteers, in order to promote healthy behaviors and appropriately manage pregnant women, promote institutional delivery, attend uncomplicated deliveries in cases with difficult access to health services, identify and refer neonatal and obstetric emergencies, and strengthen the early postpartum period coverage. In particular, for the CESARs staff, it will also involve strengthening technical capacities aimed at providing initial stabilizing treatments. 3) Strengthening referral and counter referral systems. 4) Increasing community participation and responsibility in aspects of maternal and neonatal health. 5) Unifying indicators and data collection in harmony with the strategies of the Ministry of Health. a. Conceptual framework components This strategy will focus on coordination between NGO partners and government entities at the municipal level in order to define programmatic strategic areas and common techniques for monitoring and evaluation activities, and for promoting a standardized maternal and newborn health community service structure, in harmony with the RAMNI national strategy. The NGO partners working in the same geographic regions will identify the way each entity is going to contribute to the different model elements using the comparative advantage of their capacities and strategies in the implementation of specific components of the program (for instance, Save the Children implements the AIN C strategy, while CCF has focused on capacity building of TBAs). The NGOs will coordinate these efforts with the health services in each region in order to improve the quality of maternal and neonatal care (particularly at the most peripheral level CESAR), as well as access to services, to create alliances with community health and emergency committees and to supervise community health workers. The NGOs will also coordinate with the Mayor s offices to ensure that all strategy elements to be used are part of the municipal strategic plans and can be assessed and discussed at open council meetings and round tables, according to the consultation mechanism adopted by each Mayor s office for the discussion of general issues in the municipality. Based on a review of the NGO programs, there are several community health care components that, if linked to form a model, can create a complete and proven maternal and neonatal community health system in Honduras. It is essential to consider the

9 9 elements of technical capacity and coordination between the involved players for each component. Coordination between each element is shown in Figure 1. Coordination at the Community Level Community Service Distribution Point - SDP (Community Fund; USC; etc.) X Committee X X Maternal Health Worker j. ) i.e. TBA Child Health Worker (i.e. monitor). Auxilliary Nurse/ Promoter NGOs Health Center Figure 1. Maternal and neonatal care components at the community level Rural Health Center (CESAR) The rural health center serves as a distribution point for basic preventive and curative health services in the most remote areas and ensures that RAMNI components (the individual family and community strategy, AIN C, IMCI, Health Communications, and Breastfeeding) are carried out at the community level. With a well trained staff able to provide quality services, with sufficient medicines and supplies, with strong community links by means of regular supervision of community workers (TBAs, monitors, counselors, etc.), and in coordination with the community committees, the CESARs are considered to be the principal strengthening points for mother and newborn primary care activities in the communities they serve. Community Service Distribution Points In communities with low access to CESARs, some NGOs have established service distribution points (SDPs) for the provision of preventive and curative health services

10 10 (Figure 2). Most of these units are managed by a group of volunteers trained to provide specific services and to cover the unit on a rotating basis so that it remains open 24 hours a day, 7 days a week. For example, PRODIM uses the Communal Medication Fund strategy in which medicines are sold at community pharmacies at a cost that is much lower than the market price. Moreover, community workers (counselors) have been trained to recognize danger signs in pregnant an postpartum women, and in newborns, in order to provide first line medicines and health education. Likewise, World Vision and CCF have established Community Health Units (CHUs) in which community workers are also trained to recognize and treat childhood diseases. In the existing SDP models, these manage emergency funds, serve as a referral mechanism and coordinate with the health centers, provide health education, collect information, coordinate with community workers and NGOs, and provide services such as the first dose of antibiotics and appropriate referral when sepsis is suspected in a newborn. These SDPs, as well as the health centers, are focal points for the implementation of national health policies at the community level. Community workers such as the AIN C monitors should work through these centers in order to coordinate service provision. Finally, SDPs can be managed by community health committees in order to ensure that the needs of the community are covered and standards are complied with. An SDP may serve several communities, facilitating access and promoting links between the communities and formal services, and sharing results in turn. Coordinating Mechanisms: Service Distribution Point (SDP) Components Health Committees : Community Workers Ministry of Health Funds Leaders Community Leaders NGOs Medications It serves some distant communities with obstacles to access Education Emergency Transportation Data collection Service Provision: Delivery, ENC, 1 st dose Referral Coordination with MOH and NGOs Figure 2. Service Distribution Point (SDP) Components

11 11 Community Health Volunteers Community health volunteers (CHVs), both those who work in maternal and newborn health (TBAs) and those who focus on child health issues, including the newborn, (monitors, counselors, and guide mothers), contribute greatly to community health care. Their technical capacity for identification of medical complications and emergencies, throughout the continuum of care (antenatal period to child health), within the MOH policy framework, is a strong component in several NGO programs. CCF, PRODIM, the Red Cross, World Vision, and CRS work with TBAs. The Red Cross, World Vision, and Save the Children work with the AIN C strategy (with its essential newborn care module) through monitors. Table 2 shows a list of different CHV categories, according to the strategy each partner NGO works with. CHVs should closely coordinate with SDPs and/or peripheral health centers for supportive supervision and guidelines, and they should be members and even leaders in the community health committees. Coordination among the various CHVs constitutes a critical aspect of this strategy for ensuring the continuum of care for mothers and newborns. This point is discussed in further detail later. Volunteer Function Department Standard Traditional Maternal and Individual, Family, Birth Attendant neonatal health and Community; Communications Monitor Table 2. Community health volunteer categories by participating NGO Community Health Committees Newborn and child health AIN C, IMCI, Communications Guide Mother Newborn and child health IMCI, Communications Counselor Child health IMCI, Communications Network of Maternal and child Individual, Family, Leaders health and Community NGO CRS, CCF, PRODIM, World Vision, Red Cross Save the Children, World Vision, Red Cross CCF PRODIM Red Cross Community health committees are a very important component in the community maternal and neonatal health strategy. There is generally one of these committees in each community, composed of community leaders and volunteer health workers, which provides credibility to its activities. Figure 3 explains the interaction of the actors who

12 12 participate in the committees. Committees may potentially serve as a coordinating mechanism for other community health components, as a guiding entity for community standards, and may also provide management supervision to the SDPs. In addition, committees operating within NGO programs have strong links with health services and take part in monthly coordination meetings, identify and provide follow up to pregnant women, and obtain and administer funds for referral and emergency transportation programs (for instance, loans may be made to families who require emergency transportation, other committees may buy hammocks and other supplies needed for mother and newborn transportation to health services in communities with difficult access to roads and means of transport). Distribution Points and Health Committees Committee Functions SDP Functions SDP management Coordination between the community, health centers, NGOs, and community workers Decision making on community health Defining and implementing community health standards One committee for each community Community workers Data collection Network of leadershealth education Fund management MOH NGOs Emergency fund management Referral and links with health centers Community health worker coordination Coordination with NGOs Service Provision: delivery, 1 st dose of antibiotic in areas with barriers to health service access Figure 3. Interaction between community health committees and SDPs V. Field Implementation Implementation of the strategy will include strengthening of the technical capabilities of each component into a standardized module for maternal and neonatal health and will formalization of the coordination among the various components in order to unify their application. Supportive supervision, and monitoring and evaluation components should be also added. Strengthening the capacity of peripheral health services Strengthening the capacity of peripheral health centers is a key factor in improving community maternal and neonatal health. Some NGOs currently provide support to peripheral health services in the public sector and this offers clear opportunities for

13 13 working at these levels and strengthening the technical capacity of the personnel, strengthening supervision and procedures, and establishing direct links with communities through periodic coordination meetings with health committees. Using materials standardized by the group and approved by the MOH, the NGOs may strengthen the skills of the CESARs auxilliary nurses to handle obstetric and neonatal emergencies, as well as promote healthy behavior in maternal and newborn health. Community volunteer supervision and extension activities such as health promotion are critical components in the strengthening of links between health services and the community. NGOs are able to work with the most peripheral health services in order to establish routine supervision guidelines and extension activities, collect data, and identify resources such as vehicles and gasoline. Moreover, providing guidelines and technical tools, in harmony with the EONC and specifically for this level of care, will also strengthen the capacity of the CESARs auxilliary nurses to effectively supervise volunteer workers and bring health interventions to communities in the most vulnerable areas. Some peripheral health services are already working closely at monthly meetings with the health committees from adjacent communities. Establishing a culture of coordination led by the peripheral health services strengthens relationships between facility staff and community members and stimulates community members to use health center services more. In addition, these meetings provide an opportunity to create capacity among committee members, allowing them to share information and data collection methods, and bring technical capacity in the areas of surveillance, first aid, and emergency transportat for mothers and newborns. Finally, this relationship facilitates the collection of community health data. Defining and establishing SDPs Several of the partner NGOs currently use different maternal and neonatal service distribution point models. The best practices for these models may be consolidated in one holistic unit serving as a focal point for community service distribution in areas with barriers to access to formal health services. Inputs from the community and the MOH are critical for defining these units. Key points to be defined include: 1. Function and activities (referral, health education, basic medications, coordination among NGOs, peripheral health services, community health volunteers, community health committees, emergency funds, data collection) 2. Components and roles (community health committees, community health workers) 3. Administrative structure (organization and fund management) 4. Technical supervision roles and procedures (NGOs, peripheral health facilities staff) 5. Acquisition and maintenance of equipment and supplies with appropriate sizes and concentrations for the newborn 6. Establishing technical guidelines and standards 7. Establishing standards and procedures for coordinating mechanisms

14 14 8. Monitoring and evaluation Once the functions and components have been identified, it will be possible to establish a training plan focused on administration of the SDPs, including financial and supply management, coordination, and technical aspects such as health education and data collection, for putting new SDPs into operation or for strengthening the existing ones. The formation of a committee of community health leaders and workers is an SDP administrative structure that should be considered based on the successful experience of some models. Most of the community health committees are composed of providers such as TBAs and local leaders, which ensures the community s trust. The committee would be responsible for determining activities, supervising volunteers who provide services, managing funds, and coordinating with the formal health sector and NGOs. Establishing and strengthening committees Establishing and strengthening the capacity of the community health committees to coordinate activities such as identification of pregnant women, promotion of healthy behavior for mothers and newborns, and data collection through an SDP or peripheral health services are critical for creating service demand, spreading health messages, and strengthening links between the community and the service distribution points. The first steps are to define the appropriate committee role and function within the specific context of each community. Member identification and selection is another critical activity. Once committees have been established, a work plan may be developed, defining activities and using it as a basis for developing a training plan focused on strengthening the specific abilities needed to implement the work plan. Training subjects will include fund management, surveillance, social mobilization, health education activities, social audit, and local community development. Coordination among community health workers One of the most important elements in this strategy is the strengthening and formalization of coordination among the various community volunteers working in maternal and neonatal health in order to cover the continuum of care, thus clearly defining their functions in relation to the others, and focusing this coordination on standardized training programs. Coordination is especially important among the volunteers who work in maternal and neonatal health and those who work in neonatal and child health, in order to strengthen the continuum of care. Figure 4 outlines the different tasks carried out by community volunteers in order to protect the health of mothers and newborns, from the antenatal to postpartum care.

15 15 However, there are not any volunteers trained to carry out all the related functions. Thus, newborn health will benefit from formalized coordination between volunteers who work in maternal health and those who work in child health. Community Worker Functions P r e v e n t i o n C u r a t i v e Mother Newborn Mother Newborn Antenatal Delivery Postnatal Identification; Birth plan; Danger signs; Four visits; ENC education; Vitamins and micronutrients Identification of Danger signs and referral; Transport; Medications Clean delivery; Danger signs; active management Third stage (pilot) Essential care (temperature, breastfeeding 1 st hour, cord, etc.) Danger signs; Referral; Medication First aid resuscitation (?); Danger signs; Referral Basic care; Danger signs /referral; Education Early postpartum coverage (2 nd day, 1 st week), ENC including infection prevention identification danger signs Referral Medication Danger signs, 1 st dose antibiotic Referral Figure 4. Tasks of the various community health volunteers in the continuum of care For instance, in the municipality of Curaren, CCF trained TBAs and AIN C monitors trained by Save the Children work in a coordinated manner. However, this coordination is a manifestation of the strong links between the communities and the CESAMO (Medical Dental Health Center), which is operated by CCF, in addition to the existence of community health committees and the coordination between the two NGOs. Both the monitors and TBAs report that they coordinate their work through their participation in the committees and meetings organized by the CESAMO. In some cases, the two categories of community health workers carry out antenatal and postnatal visits together, since they are both trained to identify and deal with danger signs in mothers and newborns. Nevertheless, this level of coordination is not consistent throughout all programs and geographic areas. In some cases, the same provider is a TBA and a monitor, and has the ability to respond to the needs of the mother and the newborn in the continuum of care from the antenatal to postpartum period.

16 16 Some providers take on both roles voluntarily but many feel that the responsibility and time commitment are too much. Therefore, in cases in which different providers are trained in different roles, a formal and defined coordination would improve the outcome, particularly ensuring that each one's functions are clearly defined in order to cover the continuum of care for the mother and newborn. All partners are involved in training the various community volunteer levels and, facilitated by the BASICS' newborn health initiative, they have exchanged materials and methodologies in an effort to strengthen existing curricula and create a standardized training package in maternal and neonatal health for each category of community volunteer. This is one of the implementation strategies, for which a workshop to standardize training materials has already been carried out with BASICS' technical assistance. By developing a unified vision of the role of each category of volunteers, with specific training programs, relationships with the formal health system, and within the community health system, a clear coordination mechanism will be established. Figure 5 identifies potential areas of overlap that may be strengthened in order to coordinate activities among the various categories of community health volunteer. Community Worker Profiles Maternal and neonatal health worker Newborn health worker Areas of Coordination Identifying danger signs and providing first aid for mother and newborn during antenatal, delivery and postnatal periods; appropriate referral Keeping records of pregnant women Providing clean and safe delivery in areas with barriers to access to health services Promoting facility deliveries Education of the mother on essential care for herself and the newborn Identifying pregnant women Antenatal and postnatal home visits Recognizing danger signs for mother and newborn Education on basic care for mother and newborn Identifying danger signs for the newborn Referral Postnatal visits (24-72 hours and one week) after delivery for assessment of the mother and newborn Medication, 1st dose antibiotic and referral Keep records on the child s health Education of the mother on ENC Weight Figure 5. Potential areas of coordination among the various community health volunteers D. Administration

17 17 The implementation of this strategy will require intensive coordination among NGOs from the central offices in Tegucigalpa in order to carry out a harmonious implementation of the strategy at the municipal level. Based on contributions from the partner NGOs involved in the BASICS Regional Newborn Sepsis Initiative, the presence of a coordinator not affiliated with any NGO has been critically important for successful collaboration among partners. The functions of that coordinator include grouping and organizing participants, facilitating an environment where implementation methodologies and lessons learned are shared, providing uniform technical assistance throughout all programs, as well as collecting, summarizing, and reporting neonatal health indicators from each partner s activities. In BASICS absence (when the project concludes in September 2009) it will be necessary to identify an entity to handle the coordination and technical and operational aspects of this strategy. The same NGOs that take part in the initiative could be technically and administratively organized so as to respond to the needs of a joint effort, and the strategy would become a pilot experience for the development and sustainability of an organization of NGOs. Moreover, it could serve for the compilation of lessons learned, as a database to analyze products and outcomes, and for collecting NGO mappings. However, enormous technical and administrative capacity is currently needed in order to provide adequate coordination support. Specific capacities include technical expertise in maternal and child health, in management of funds, contracts, and supplies, administration of knowledge, and data collection and reporting. E. Next Steps 1. Presentation of the strategy to the MOH and stakeholders for their consideration, discussion, and approval 2. Development of an organizational and administrative plan for the strategy 3. Development of a detailed implementation plan with its corresponding budget 4. Definition of the roles of each component of the strategy (based on MOH standards) o CESAR staff o Service distribution points o Community emergency committees o Community health volunteers: AIN C monitors, TBAs, medication fund counselors, guide mothers, etc. 4. Use of program mapping from partner NGOs by geographic location and components, in order to facilitate the identification of potential coordination points. For instance, the map may be useful for NGOs to identify whether other entities with complementary

18 expertise are operating in the same geographic areas and whether there is the potential for several NGOs to work together to implement the full strategy. 5. Development of a unified training plan in maternal and neonatal health, for the different staff categories (CESAR auxiliary nurses and various community health volunteer groups): o Standardizing available training materials (see annex 2). During the BASICS intervention, a workshop was carried out in which the above mentioned materials were reviewed and discussed and areas of possible harmonization and adaptation were identified in order to obtain a standardized module for each category of provider. These materials should be harmonized with those developed for the MOH s EONC strategy. o Training of trainers o Training of service providers from the various categories 6. Development of a supportive supervision plan to evaluate and maintain the knowledge and skills of the community health workers and CESAR staff (tools suggested in Annex 2) 7. Development of a strategy monitoring and evaluation plan. A list of potential indicators reviewed and approved by the participating NGOs is attached (Annex 3) 18

19 19 Annex 1. Available and suggested training and supervision materials Antenatal care Labor / delivery Traditional birth attendants Other community workers (monitors, counselors, etc.) Health service providers from CESAR/CESAMO/Maternal and child clinic BASICS Partners/NGOs BASICS Partners/NGOs BASICS* Partners/NGOs Training flipchart and facilitator s manual CCF Maternal and neonatal counseling flipchart Community health worker facilitator s guide Maternal and neonatal counseling flipchart Community health worker facilitator s guide NGO data collection tools, supervision checklists Training flipchart and facilitator s manual CCF NGO data collection tools, supervision checklists Maternal and neonatal counseling flipchart Community health worker facilitator s guide Learning and supervision checklists Maternal and neonatal counseling flipchart Community health worker facilitator s guide Learning and supervision checklists AIN C counseling cards and monitors manuals NGO data collection tools, supervision checklists BASICS/POPPHI tools: Reference manual, facilitator and participant guides technical presentations, learning and supervision checklists BASICS/POPPHI tools: Reference manual, facilitator and participant guides, technical presentations, learning and supervision checklists National maternal and neonatal care standards, 2005 EONC supervision checklists Clinical manual EONC Guidelines for basic care of the healthy newborn Clinical practice guidelines for care of newborns with sepsis, asphyxia, and born prematurely National maternal and neonatal care standards, 2005 EONC supervision checklists Postnatal / postpartum care Maternal and neonatal counseling flipchart Community health worker facilitator s guide Training flipchart and facilitator s manual CCF NGO data collection tools, supervision checklists Maternal and neonatal counseling flipchart Community health worker facilitator s guide Learning and supervision AIN C counseling cards and monitors manuals NGO data collection tools, supervision checklists BASICS/POPPHI tools: Reference manual, facilitator and participant guides, technical presentations, learning and supervision Clinical manual EONC Guidelines for basic care of the healthy newborn Clinical practice guidelines for care of newborns with sepsis, asphyxia, and prematurity National maternal and

20 20 checklists checklists neonatal care standards, 2005 EONC supervision checklists Crosscutting areas Community Community Emergency Plan Emergency Plan Manual CCF Manual CCF Committee Manual and guideline for the Communal Medication Fund's health counselor Pregnant Women s Club Manual CCF Manual for implementing a work strategy with individuals, families and communities BASICS tools for peripheral health services are being finalized and will be available on the website ( after September 2009.

21 21 Annex 2. Proposed indicators Indicators Definition Source Who collects Frequency Note General Neonatal mortality rate (# of infant deaths from birth to 28 days of age in the year/ # of births in the year) x 1,000 DHS / specific local Community workers, TBA, health providers Early neonatal mortality rate (# of infant deaths from birth to 7 days of age in the year/ # of births in the year) x 1,000 DHS (requires large sample) Community workers, TBA, health providers Stillborn rate (# of pregnancies longer than seven month that ended in fetal death in the year/ # of births in the year) x 1,000 DHS/ selected local Community workers, TBA, health providers Ideally disaggregate into fresh or macerated stillborns % of interviewed community workers who report having been supervised at least once within the last 6 months (# of interviewed community workers who report having been supervised at least once within the last 6 months / # of interviewed workers) x 100 Local survey NGOs Supervision includes 2 or more of the following items: report checking, observation of work, provision of comments, compliments, provision of updates, discussion of problems # of people trained in neonatal health (technical training) by category of trainee Trained staff using materials developed and / or approved by PAHO/WHO or any other qualified technical assistance agency Capacity and statistics building training NGOs

22 22 Antenatal care indicators Definition Source Who collects Frequency Note (# of interviewed mothers who report % of women who received four or more having received antenatal care four or check ups by qualified providers (doctor, DHS more times from qualified providers nurse, trained assistant) during their last during their last pregnancy / # of pregnancy interviewed mothers within a specific Data from visits period) x 100 % of women who during their last pregnancy received four or more check ups by a TBA / community volunteer (# of mothers who report receiving antenatal care from a TBA/health volunteer four or more times during their last pregnancy / # of interviewed mothers within a specific period) x 100 DHS Data from visits % of women who received at least two tetanus toxoid injections during their last pregnancy. (# of interviewed mothers who report having at least two TT dosages written down on their health card during their last pregnancy/ # of interviewed women) x 100 DHS Administrative coverage data % of mothers who recognize at least two danger signs during pregnancy (# of interviewed mothers who are able to mention at least two danger signs during pregnancy/ # of interviewed mothers within a specific period) x 100 DHS Labor and delivery % of women whose last delivery, was attended by qualified staff (doctor, nurse, trained assistant) (# of interviewed mothers whose last delivery was attended by qualified staff/ # of interviewed mothers within a specific period) x 100 DHS Qualified staff is defined by WHO as a health provider who has at least the knowledge and minimum skills to attend a normal delivery and provide firstline obstetric emergency care. Trained TBAs are not

23 23 included. % of women whose last delivery was attended by a trained TBA (# of interviewed mothers whose last delivery was attended by a trained TBA/ # of interviewed mothers within a specific period) x 100 DHS TBAs % of mothers whose newborn's umbilical cord was cut with a clean or new instrument or for whom a new and clean delivery kit was used for delivery at home % of mothers whose newborn did not receive any application of something harmful to the cord (# of mothers attended at home who report that their newborn s umbilical cord was cut by a clean or new instrument + # of mothers who report the use of a clean delivery kit / # of women with deliveries at home interviewed within a specific period) x 100 (# of mothers whose newborn did not receive any application of something harmful to the cord /# of interviewed mothers within a specific period) x 100. Nothing harmful means leaving the cord clean and dry or applying only alcohol or an antiseptic. DHS DHS Trained TBAs % of women who had a low birth weight delivery according the mother s estimate of < 2500 g (% of women who had a low birth weight delivery /# of interviewed women with a live delivery) x 100 DHS % of mothers whose newborn was not bathed within the first 6 hours after delivery (# of mothers whose newborn was not bathed within the first 6 hours after delivery /# of interviewed mothers within a specific period) x 100 DHS Postnatal care

24 24 % of mothers who did not give anything but breast milk within the first 3 days after delivery (prelacteal feeding) (# of interviewed mothers who report not having given anything but breast milk within the first 3 days after delivery/ # of interviewed mothers) x 100 DHS % of women who receive postpartum care within 2 days after delivery from qualified staff (# of women who receive postpartum care within 2 days after delivery from qualified staff/# of interviewed women within a specific period) x 100; DHS Disaggregate into home and facility deliveries % of babies who receive a postnatal checkup within 2 days after birth from qualified staff (# of babies who receive a postnatal check up within 2 days after birth from qualified staff/# of babies included in the interview within a specific period) x 100 DHS % of babies who receive a postnatal checkup within 2 days after birth from a community volunteer (# of babies born at home who received postnatal care within 2 days after delivery /# of babies born at home included in the interview within a specific period) x 100 DHS % of children from the last delivery who were breast fed within the first hour after birth # of mothers who breast fed their last newborn within the first hour after birth/ # of interviewed women within a specific period) x 100 DHS % of mothers who recognize at least two danger signs for the newborn (# of interviewed mothers who mention at least two danger signs for the newborn / # of interviewed mothers) x 100 DHS % of babies with danger signs who receive the first dose of antibiotic before the referral (# of babies with danger signs who received a first dose of antibiotic before the referral/ # of babies referred within the period) DHS

25 25 CESAR health services % of interviewed health workers who report having been educated/trained in neonatal health or in danger signs within the last twelve months (# of interviewed health workers who report having been educated/trained in neonatal health or in danger signs within the last twelve months/# of health workers) Institutional data NGOs % of interviewed health workers who report having been educated/trained in maternal health or in danger signs within the last twelve months (# of interviewed health workers who report having been educated/trained in maternal health or in danger signs within the last twelve months/# of interviewed health workers) x 100 Institutional data NGOs % of health clinics that keep updated records of sick newborns younger than one month of age (i.e.. age or date of birth, diagnosis, treatment, referral) (# of health clinics that keep updated records of sick newborns younger than one month of age /# of interviewed health clinics) x 100 Institutional data NGOs % of interviewed maternal and child health workers who report having been supervised at least once within the last 6 months (# of interviewed maternal and child health workers who report having been supervised at least once within the last 6 months /# of interviewed health workers) x 100 Institutional data NGOs 6 months Supervision includes two or more items related to the following: reviewed files or reports, observed work, feedback, acknowledgement of work, provided updates, problems discussed