World Health Organization 2007

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

agency implements the interventions described in this document in accordance with these principles and policies, and within the scope of its mandate. Table of Contents List of figures & Annexes 6 Abbreviations.. 7 ExecutiveSummary 11 CHAPTER I BACKGROUND 17 1.1 Health development & trends 217 1.2 Maternal & Newborn Health 218 1.2.1 Maternal Health 18 1.2.2 Newborn Health 263 1.2.3 Fertility and Family Planning 274 1.3 Health System for MNH 285 1.3.1 Health system infrastructure 285 1.3.1.1 Central Level 285 1.3.1.2 Provincial Level 296 1.3.1.3 MNH Service delivery 296 1.3.2 Financing for MNH 318 1.4 Context and Rationale of the MNH Review 29 1.5 Objectives of the review 29 1.5.1 General objective 29 1.5.2 Specific Objectives of the review 330 1

1.5.3 Expected outcome of the review 330 CHAPTER 2 341 METHODOLOGY 2.1 Conceptual Framework of the Review 341 2.1.1 Health System Structure and Functions 341 2.1.2 MNH Services & Interventions 341 2.1.3 Cross Cutting Areas 352 2.2 Methods used for data collection 352 2.2.1 Desk Review: 352 2.2.2 Stakeholder Workshop 363 2.2.3 Key Informant Interviews 363 2.2.4 Focus Group Discussions 374 2.2.5 Visits to institutions and field visits 374 2.2.5.1 Visit to Hospitals and Clinics 37 2.2.5.2 Visit to Provincial and District Offices 37 2.3 Presentation of findings 37 CHAPTER 3 396 ORGANISATION FOR MNH SERVICES 3.1 Organization for MNH services at National Level 396 3.2 Stewardship of MNH Services at provincial level 39 3.3 MNH service delivery at provincial and district levels 430 2

CHAPTER 4 452 4.1 Maternal Health 452 MATERNAL AND NEW BORN CARE 4.1.1 Preconception needs 45 4.1.2 Antenatal Care 46 4.1.3 Intrapartum (Natal) Care 496 4.1.4 Provision of Essential and Emergency (Basic and Comprehensive) Obstetric Care 531 4.1.5 Care of the critically ill patient: 563 4.1.6 Caesarean Section Rates 574 4.1.7 Postnatal Care of the Mother and Baby 585 4.1.8 Factors contributing to maternal deaths and causes of maternal deaths 618 4.1.9 Maternal Death Reviews 618 4.2 Neonatal care 631 4.2.1 Care of the low risk newborn 61 4.2.2 Care of the high risk newborn 63 4.2.3 Care of Preterm Babies 64 4.2.4 Neonatal screening for Hypothyroidism 66 4.2.5 Care of the newborn in the field 66 4.2.6 Perinatal Death Reviews 67 CHAPTER 5 HUMAN RESOURCES FOR MNH 69 5.1 Over view 69 5.2 Planning of human resources for health 741 3

5.3 Selection, recruitment and placement 752 5.4 Pre-placement education and training 752 5.5 Pre-service education of MNH personnel 763 5.5.1 Field personnel 73 5.5.1.1 Public Health Midwives 73 5.5.1.1.1 Curriculum 73 5.5.1.1.2 Quality of training 73 5.5.1.2 Supervising Public Health Midwives 75 5.5.1.3 Public Health Nurses 75 5.5.1.4 Medical Officers of Health 785 5.5.1.5 Medical Officer Maternal and Child Health 796 5.5.1.6 Medical Officer Public Health (posted in Medical institutions -Base hospital and above) 807 5.5.1.7 Specialist in Community Medicine 807 5.5.2 Institutional services 807 5.5.2.1 Institutional midwives 807 5.5.2.2 Midwifery qualified nurses 818 5.5.2.3 District Medical Officers and Medical Officers in divisional hospitals and peripheral units 818 5.5.2.4 Specialists in Obstetrics & Gynaecology and Paediatrics 79 5.6 In-service training 79 5.7 Private sector training 830 5.8 Supervision and support 841 4

5.9 Career development, performance and motivation 841 CHAPTER 6 CROSS-CUTTING ISSUES 85 6.1 Behaviour Change Communication (BCC and gender in relation to MNH 852 6.1.1 Policy Planning and Resource Allocation 852 6.1.2 Health Education Methods 863 6.1.3 Awareness among mothers 863 6.1.4 Capacity Building 874 6.1.5 Role of Health Education Officers (HEOs) 885 6.1.6 Importance of gender, language and sub-cultural dimensions in planning BCC/HE strategies and communication 896 6.1.7 Male Participation and gender issues 896 6.2 Supervision and Monitoring of MNH Programmes 907 6.2.1 Management Information System 909 6.3 Financing of MNH services 92 6.3.1 Central level 930 6.3.2 Provincial level 930 6.3.3 Planning and Budgeting for MNH 941 6.3.3.1 Family Health Bureau 941 6.3.3.2 Health Education Bureau 94 6.3.3.3 Budget for Maintenance Expenditure 95 5

6.3.3.4 Alternative Financing 952 6.4 Coordination and Partnerships for MNH 963 6.4.1 Coordination between Centre, Province and District 963 6.4.2 Coordination with development partners 974 6.4.3 Partnership with NGO and other sectors 97 6.5 Linkages with other programmes 985 6.5.1 Family planning 985 6.5.2 Nutrition 99 6.5.3 STI/AIDS control programme 97 6.5.4 H8alth Education Bureau 1018 6.5.5 Communicable and Non-communicable diseases 99 6.5.6 Psychological illness related to pregnancy 1030 6.6 Linkages with other sectors 1030 6.6.1 Local government (Colombo Municipal Council) 1030 6.6.2 Private sector 1041 6.6.3 Plantation (Estate) sector 1052 6.7 Operational Research and utilization of evidence based policies and strategies 1063 References 105 Acknowledgement 106 6

Annexes... 107 7

List of Figures Figure 1. Trends in maternal mortality ratio 1930-1996 19 Figure 2. Causes of maternal mortality 1999-2004 19 Figure 3. Differentials in maternal mortality ratios in health regions - 2004 230 Figure 4. Maternal mortality ratio and trained assistance at delivery 241 Figure 5. Home deliveries & untrained deliveries by health region 2003 252 Figure 6. Trends in caesarean section rates in government hospitals 25 Figure 7. Trends in infant and neonatal mortality rates1945-2003 263 Figure 8. Trends in contraceptive use 1975-2000 274 List of Annexes Annex 1 Organisation Chart Ministry of Healthcare & Nutrition 108 Organisation Chart for health services under Provincial councils 109 Annex 2 Organisation frame work for the review 110 Organizational Framework for implementation of Review 111 List of Review Coordinating Committee members 112 Expert Review Team members 113 Conceptual Framework of the Review 114 Approach to Strategic MNH Programme Review - A Flow Diagram 115 Annex 3 List of background documents used for desk review 116 Annex 4 a Stakeholder Workshop List of Participants & groupings 118 Annex 4 b Levels of key informants interviewed 121 Annex 4 c Field sites visited 122 Annex 4 d Map of Sri Lanka showing sites visited 124 Annex 5a Current distribution of approved & available cadre for MNH service providers by district for the tear 2007 125 Annex 5 b Current criteria for selection, elements of basic training of different categories of MNH service providers & scheme of promotion 126 8

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

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

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

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

Executive Summary Sri Lanka has made remarkable progress in the last few decades in lowering infant, child and maternal mortality. This is attributed to a number of factors that have had a mutually beneficial effect which included, high political commitment to health, provision of free health care, a well-developed health infrastructure, free education, subsidized food schemes and other socio economic welfare measures. However, wide disparities in mortality rates exist between geographic regions as well as population groups. The Infant Mortality Rate (IMR) and Neonatal Mortality Rate (NNMR) have been stagnant over the past decade and many of the maternal deaths are preventable. There is also concern regarding inequitable distribution of services as well as deficiencies in quality of care. Competing interests for health resources as well as increasing costs in health care add to constraints faced by the Ministry of Health (MoH). In this context the Ministry of Health decided to commission an external review of the Maternal and Neonatal Health (MNH) services. The objectives of the review was to examine the MNH components of the current national Maternal and Child Health (MCH) Programme and to identify achievements, gaps and challenges faced by the programme, make recommendations and give direction to help with the development of a new strategic plan for the period 2008-2012 and beyond. Methodology of the review In order to achieve the objectives of the review, a conceptual framework was developed taking into account the existing MNH policies and strategies, the demographic and epidemiological profile of the country, and the organisational structure for MNH service provision. The components of work were grouped into three inter-related themes for ease of data collection. The review team utilized a range of methodologies to collect information that included; an in-depth desk review of programme documents; a stakeholder workshop; key informant interviews, focus group discussions and field visits. 15

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

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

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

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

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

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

1.2 Maternal & Newborn Health Sri Lanka s success in reducing infant, child and maternal mortality is attributed to a number of factors having a mutually beneficial effect. High political commitment to health, a comprehensive MCH package - delivered through a well trained primary health care worker at community level, backed by a strong institutional network spread throughout the country and a health service free of charge at the point of delivery are key factors that contributed to the reduction in mortality. Equality of access to education for a majority of women resulting in high female literacy and educational attainment, as well as a high degree of motivation of mothers to seek services offered, together with a range of food subsidy schemes and other social welfare measures have contributed synergistically to the success of the health programmes. 1.2.1 Maternal Health Maternal mortality showed a steady decline during the last few decades reaching a low level of 38 per 100,000 live births in 2004 (ARFH 2004-2005). Figures 1 and 4 show the trend in decline of maternal mortality as reported in the statistics of the Registrar General Department. Postpartum haemorrhage, pregnancy induced hypertension, heart disease complicating pregnancy and septic abortions were leading causes of maternal deaths in 2004 (Figure 2). It is noted that deaths due to puerperal sepsis, an important cause of maternal death in the 1940's, still accounted for 8 of the 157 deaths (5.1%) in 2003 and 6 of the 145 deaths (4.1%) in 2004. In 2003, a further 19 deaths (12%) were due to septic abortions while in 2004 17 deaths (11.7%) were from the same cause (Annual Report on Family Health, 2004). 22

Figure 1. Trends in maternal mortality ratio 1930-1996 Per 100 000 live births 3,000 2,500 2,000 1,500 1,000 500 0 Malaria Epidemic Source: Registrar General Department Control of malaria Development of maternal care services Extension of trained maternal care services and improved accessibility Greater utilisation of maternal care facilities Introduction of antibiotics 1930 1934 1938 1942 1946 1950 1954 1958 1962 1966 year Figure 2. Causes of maternal mortality 1999-2004 Expansion of EmOC facilities Greater availability of skilled health manpower Greater utilisation of skilled services Improved quality of services Improved management 1970 1974 1978 1982 1986 1990 1994 30 25 20 Percentage 15 10 5 0 1999 2000 2001 2002 2003 2004 Years Haemorrhage Heart disease complicating pregnancy Liver disease complicating pregnancy Pospartum septicaemia Eclampsia & PIH Septic abortion AF/emboloism P/embolism Source: Annual Report on Family Health FHB/MoH2000, 2002-2003, 2004-2005 However, there are wide differentials in maternal mortality ratios between districts/health regions and population sub groups, 23

ranging from 81 to 22 per 100,000 live births. (Figure 3 shows the district variations but not the variation in population sub-groups). Figure 3. Differentials in maternal mortality between health regions- 2004 90 80 MMR per 100,000 live births 70 60 50 40 30 20 10 0 Source: Annual Report on Family Health FHB/MoH 2004-2005 Batticoloa Kalmunai Nuwara Eliya Vavuniya Killinochchi Mullaitivu Hambantota Ratnapura Puttalam Matale Matara Polonnaruwa SRI LANKA Colombo Kurunegala Galle Kandy Moneragala Jaffna Badulla Gampaha Trincomalee Kalutara Anuradhapura Kegalle Iron deficiency anaemia and malnutrition are common problems among pregnant women (MRI 2001). In a survey carried out by the MRI in 2001, the prevalence of anaemia among pregnant women was found to be 30% (MRI, 2001). Maternal weight gain in pregnancy is low, the average weight gain being around 8-10 Kg. The MCH statistics for the year 2004 shows that at the booking visit 27.1% of mothers had a BMI less than 18.5, while in 12.3% the BMI exceeded 25 (ARFH, 2004-5). The low haemoglobin levels and inadequate weight gain during pregnancy contributes to the high incidence of low birth weight. Approximately 98 % of women receive antenatal care in the field clinics (MOH) or in institutions. In contrast to antenatal care, coverage of postpartum care is only 78%. Trained assistance at delivery has had a dramatic impact on maternal mortality (Figure 4). Ninety six percent of births occur in hospitals 2-3% receive trained assistance by the PHM in the home, while the rest (1-2%) are attended by persons said to have experience in conducting 24

home deliveries (ARFH 2002-2005). The latter practice is confined mainly to areas affected by the conflict such as the Northern and Eastern provinces and in some remote areas having travel constraints and where services of PHMs are not readily available (Figure 5). Figure 4. Maternal mortality ratio and trained assistance at delivery 1945-1995 MMR per 100,000 live births 1800.0 1600.0 1400.0 1200.0 1000.0 800.0 600.0 400.0 200.0 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 rcentage deliveries with trained assistance Pe 0.0 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Years 0.00 MMR per 100,000 live births % deliveries with skilled assistance Source: The Maternal Mortality Decline- The Sri Lankan Experience UNICEF 2003 25

Figure 5. Home deliveries and untrained deliveries by health region 2003 600 500 400 NUMBER 300 200 10 0 0 Batticaloa Trincomalee Kalmunai Jaffna Badulla Anuradhapura Moneragala Ratnapura Nuwara Eliya Kurunegala Mullaitivu Kandy Puttalam Ampara Kilinochchi Matale Matara Kegalle Galle Gampaha Polonnaruwa Vavuniya Hambantota Kalutara Colombo CMC NIHS RDHS REGIONS Home Deliveries Untrained Deliveries Source: Annual Report on Family Health FHB/MoH, 2002-2003, There is an increasing trend in the caesarean section rate especially in some urban areas and in the private health sector (Figure 6) Figure 6. Trends in Caesarean section rates in government hospitals 1995-2003 25 20 Percentage of LSCS 15 10 5 0 1998 1999 2000 2001 2002 2003 Years LSCS rates Linear (LSCS rates) Source: Annual Health Bulletin (Tables 36/ 37) 1998 2003 26

1.2.2 Newborn Health The Infant Mortality Rate (IMR) has declined from 50/ 1000 live births in 1970 to 11.2 per 1000 in 2003 (Figure 7). Neonatal deaths which contribute to over 75% - 80% of infant deaths have remained stagnant for the past 10 years, with marked inter-district variation (AHB, 2003). The leading causes of death among newborns as reported in perinatal mortality reviews are disorders related to short gestation period and (unspecified) low birth weight (28.3%), infections in the perinatal period (15.6%), respiratory conditions of foetus and new born (13.8%),intrauterine hypoxia and birth asphyxia (5.9%) (ARFH,2005). The EPI programme in Sri Lanka has been very successful whereby almost total elimination of Neonatal Tetanus has been achieved by the tetanus toxoid component of EPI, reduction in congenital rubella syndrome through the Rubella immunisation programme, and elimination of military TB and TB meningitis in infants due to BCG immunisation given soon after birth which has a coverage of nearly 100%. Figure 7 Trends in infant and neonatal mortality rates 1945-2003 160 140 Rate per 1000 live births 120 100 80 60 40 20 0 45 50 55 60 65 70 Infant Mortality Rate 75 80 Year 85 90 95 Neonatal Mortality Rate 2000 2003 Source: Registrar General Department 27

Low birth weight (less than 2500 grams) is still relatively high in Sri Lanka, although the proportion has shown a steady decline over the past few years. The incidence of low birth weight among infants born in government hospitals has declined from 22.8 percent in 1990 to 16.9 percent in 2003. Marked inter-district variation in low birth weight is noted (AHB, 2003). 1.2.3 Fertility and Family Planning Fertility has declined steadily since 1950. The Total Fertility Rate has declined from 5.1 in 1993 to 1.9 in 1995-2000. Contraceptive prevalence is 70.0%, of which 49.5% are modern contraceptive methods, 26.4% being modern temporary methods, and 23.1% permanent methods. The prevalence of natural/traditional methods is 20.5%.(DHS 2000) (Figure 8). The unmet need in contraception is estimated to be 11.4% (unpublished data from FHB based on DHS 2000) Figure 8. Trends in Contraceptive use 1975-2000 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 1975 1982 1987 1993 2000 Contraceptive Prevalence Modern Methods Traditional Methods Source: Demographic Health Survey 2000 28

1.3 Health System for MNH 1.3.1 Health system infrastructure 1.3.1.1 Central Level The maternal and child health services in Sri Lanka have a long history. The first organised effort towards providing care and attention to child bearing women was made in 1879 with the establishment of the De Soysa Lying-in-Home now known as De Soysa Hospital for Women. The need for developing the preventive and promotive services was recognised by the government as early as 1920. In mid 1920 s, steps were taken to introduce a Health Unit System which could provide a comprehensive health care service (institutional and domiciliary) to mothers and children. The first Health Unit was established in 1926 at Kalutara, and this system was thereafter gradually extended to cover the country. By 1950, 91 Health Units were established and by 2003 there were 280 units (AHB 2003). The above system provided domiciliary as well as clinic based services during pregnancy, trained assistance at delivery and domiciliary services for the post natal mother and the infant. Family Planning was introduced to Sri Lanka in 1953 by the Family Planning Association: a Non Governmental Organization (NGO). The work done by the association was given Government recognition in 1954 in the form of a financial grant. In 1965, the Government accepted family planning as national policy, and family planning services were integrated with the already well developed Maternal and Child Health services provided through the Ministry of Health. Considering its national importance, a separate division was established in 1968 within the ministry, to implement the programme through out the country. This was initially named, the Maternal and Child Health Bureau and was later redesignated, the Family Health Bureau. At the central level the Family Health Bureau (FHB) of the Ministry of Health is the focal point for the national Maternal and Child Health and Family planning Programmes (MCH.FP) and is responsible for planning, coordinating, monitoring and evaluating these programmes. The Bureau also provides the necessary direction and technical guidance for effective implementation, and 29

also implements projects funded by international agencies to support and strengthen service delivery. The Bureau works in close collaboration with relevant units of the Ministry of Health and related Government institutions and Non-Governmental Organizations. The FHB reports to the Director General of Health Services through the Deputy Director General of Public Health Services. 1.3.1.2 Provincial Level Since 1989, the country s administration has been decentralised with devolution of administrative powers to nine Provincial Councils. Each province has a Provincial Director of Health Services (PDHS) who is responsible for provision of health care within the province and is supported by Regional Directors of Health Services (RDHS) who are in charge of each of the Health Districts (26) within the provinces. The RDHS is supported by a Medical Officer/ Maternal and Child Health (MOMCH), Regional Epidemiologist (RE) Regional Supervising Public Health Nursing Officer (RSPHNO), 2 or 3 Health Education Officers (HEO) and other technical staff. Each Health District is further sub-divided into Health Units/ Divisions (7-18) with each division being managed by a Medical Officer of Health (MOH) supported by a team of public health personnel comprising one to two Public Health Nursing Sisters (PHNS), 3 to 5 Public Health Inspectors (PHI), one or two Supervising Public Health Midwives (SPHM) and 20-25 Public Health Midwives (PHMs). Each PHNS assisted by a SPHM supervises about 10 PHMs. Organisation chart of the Ministry of Health and the organisation chart for health services under the provincial councils are given in Annex 1 1.3.1.3 MNH Service delivery MCH.FP/MNH services are provided through a well-developed health infrastructure that has grown steadily over the past few decades. The network of medical institutions and health units provide institutional and field based MNH services for women, children and their families. The PHM is the front line health worker providing domiciliary care to mothers and children within the community. She has a well demarcated geographic area with a population ranging from 2000 to 4000. She maintains an eligible couple s register which includes all married women15-49 years (legal or customary) and women 30

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

Safe blood transfusion services are available through central, regional and institution based blood banking services. Blood and blood products are routinely screened for HIV, syphilis, hepatitis B, hepatitis C and malaria. 1.3.2 Financing for MNH In 2005, the total expenditure for health was 4.2% of GDP, an increase from 3.8% in 2000. Government health expenditure has been rising as a percentage of GDP from 1.6 in 2000 to 2.3 in 2006, with an estimated figure of 2.4 in 2008. This trend is promising and in keeping with the recommendations of the WHO Commission on Macroeconomics and Health, which advocates that in developing countries the ratio of health expenditure to GDP increases at least by 1% in 2007 and 2% by 2015. In Sri Lanka, the total cost of health care is distributed between the pubic and private sectors, with 46.3% being attributed to the public sector. Per capita total health expenditure was USD 49 in 2005, an increase from USD 32 in 2000 (National Health Accounts, 2005). In 2005 curative healthcare was given the bulk (82.7%) of the central government health allocation with preventive care receiving only 5.8%. When total health expenditure is considered (inclusive of provincial expenditure) allocation for preventive / public health services in 2002 was 9%. In the 2008 central government estimates, the proportions have been intentionally increased, with preventive care being allocated 9.2% of government health expenditure, reducing the percentage curative care to 79.7%. This greater emphasis on preventive care is a noteworthy feature. It is recommended that the percentage for preventive care be further increased to 20% (NHA, 2005). The bulk of the government allocation is spent on recurrent expenditure. In 2005, 77.1% of the national budget and 87.1% of the provincial budget was spent on recurrent expenditure. The major items under recurrent expenditure were salaries and wages, overtime payments and medical supplies. The MNH budget cannot be separately identified, as MNH services are delivered at curative as well as preventive health facilities and are funded by both Central and Provincial budgets. In the years 2002 and 2003 direct and indirect obstetric causes was the sixth leading cause of hospitalization in government institutions and also accounted for 4.7% of discharges. Disease based National Health Accounts (NHA) statistics suggest that the largest allocation on a per capita basis is for maternal conditions 32

(approximately Rs. 475/=). The same study also points out that when standardized by age, the per capita expenditure on the age group 0-4 is relatively high in relation to other age groups. The volume of foreign aid appears to vary significantly from year to year: for example in 2002, it was 10.7% of total health expenditure while in 2003 it was only 4.5%. The Tsunami of 2004 resulted in a high inflow of foreign aid but by 2007 this is petering out. The four main sources of international aid for MNH activities are UNICEF, UNFPA, WHO and WB. However the contribution from foreign aid for preventive health services was not reviewed in detail. 1.4 Context and Rationale of the MNH Review Although Sri Lanka has achieved much in terms of MCH and is on track to achieving MDG goals 4 and 5, (child mortality and maternal health) disparities between geographic regions as well as population groups exist. There has been stagnation of IMR and NNMR over the past decade while many maternal deaths are identified as preventable. Concerns are also expressed regarding inequitable distribution and over-utilization / duplication of services, as well as deficiencies in quality of care. With increasing costs in health care delivery the government faces many constraints to maintain a high quality service free at the point of delivery. It is also a challenge to sustain past gains and further improve the MNH services in the face of competing demands for resources. It is felt that if MNH does not receive due priority, there is a danger of continuing stagnation of IMR and NNMR and even a reversal of these two indicators as well as the MMR. It is in this context that the Ministry of Health decided to commission an external review of the MNH services. 1.5 Objectives of the review 1.5.1 General objective The general objective of the review is to examine the MNH components of the current national MCH Programme and to identify achievements, gaps and challenges faced by the programme, make recommendations and give directions to help with the development of a new strategic plan for the period 2008-2012 and beyond. 33

1.5.2 Specific Objectives of the review Specific Objectives are to review and identify the achievements, gaps, and challenges in the current national MNH programme and give recommendations regarding: I. Organizational structure and implementation strategies of MNH care and service delivery; II. Linkages of MNH services with other Reproductive Health (RH) services; III. Management Information System (MIS); IV. MNH programme reviews and audits; V. MNH service accessibility and availability especially for vulnerable and risk groups; VI. Behaviour Change Communication component of MNH; VII. Overall Quality of Care (QoC) by examining available standards, guidelines and checklists. 1.5.3 Expected outcome of the review It is expected that the international experts in collaboration with national consultants will review and provide an independent assessment of the situation and make recommendations that will be useful for programme planners / managers to develop/formulate a new strategic plan for the period 2008 2012 and beyond. 34

Chapter 2 Methodology 2.1 Conceptual Framework of the Review In order to achieve strategic outputs from the review and address interrelated issues a conceptual framework was developed. This took into account the existing MNH policies and strategies, the demographic and epidemiological profile of Sri Lanka and organizational structure for MNH services within the context and rationale of the review. The components of work were grouped into three strategic themes. The members of the review team were grouped into three groups, each group dealing with a specific thematic area. It was recognized that the themes would be complementary to each other in formulating recommendations: I. Health System Structure and functions II. MNH services and interventions III. Cross-cutting issues 2.1.1 Health System Structure and Functions Review of health planning, budgeting in the context of decentralization of MNH services with particular emphasis on planning, management, coordination and partnerships between centre and province as well as within the province was undertaken. Adequacy of health infrastructure for providing BEmOC, CEmOC, newborn and critical care were reviewed. Human resource issues as well as financing which have strong implications for MNH service delivery were given emphasis. 2.1.2 MNH Services & Interventions Review of antenatal care, natal care, postnatal care, new born care, family planning, post abortion care, continuum of care, quality of care and linkage with other RH services were considered. Emphasis was given to a review of the content, adequacy and quality of these services, in keeping with prevailing WHO and other guidelines on evidence based best practices. 35

2.1.3 Cross Cutting Areas The cross cutting areas which have implications on MNH include BCC, Management Information System (MIS), reviews and audits, operational research and alternative approaches for health systems, appropriate technologies for MNH, maternal nutrition, gender issues, role of the community, social issues etc. which impact on MNH services delivery as well as MNH outcome were also reviewed and improvements suggested. The organisational frame work for the review, conceptual frame work and the flow diagram of the approach to strategic MNH programme review are given in Annex 2. 2.2 Methods used for data collection Each thematic group utilized the following methodologies I. In- depth desk review of programme documents II. Stakeholder workshop III. Key informant interviews (KII) at various levels IV. Focus group discussions (FGD) V. Field visits 2.2.1 Desk Review: A desk review was carried out on relevant documents such as the Health Master Plan, poverty assessment, Medium Term Plan on Family Health, published surveys such as DHS, reports / minutes of maternal and perinatal mortality reviews and Annual Reports on Family Health. An analysis of stakeholder views reflecting the perspectives of a large cross section of stakeholders including INGO, NGOs, civil society, academics, researchers and the private sector on current MNH issues, which was prepared as a background document for the review was studied in detail. A List of background documents used for desk review is given in Annex 3. The information obtained from the desk review was utilized for identifying major strengths and weaknesses in the current MNH 36

Programme. These were addressed in the themes of the conceptual frame work of the review. 2.2.2 Stakeholder Workshop A stakeholder workshop was conducted as a means of obtaining stakeholder inputs from across the health system. The stakeholders who attended this workshop included participants from policy as well as operational levels from the centre, province, district and division. The private sector, representatives of Colleges and professional organisations, and representatives from UN Agencies also participated. Around one hundred participants from all parts of the country attended the workshop. The list of participants is given in Annex 4a. The stakeholders were divided into eight sub-groups. Issues to be discussed in the sub-groups were developed as semi structured questionnaires, which facilitated and guided the discussion. The issues included; MNH services and interventions, health system, human resource and cross cutting areas which have implications on MNH services such as decentralization and devolution, BCC, gender, supervision, reviews and MIS. The groups deliberated on existing strengths and weaknesses and possible areas for improvement as perceived by MNH service providers from policy to community level.. The issues which did not come out clearly from the stakeholder workshop were discussed individually with several key informants. (The reports of the proceedings of the stakeholder workshop are filed on record at FHB for reference if necessary.) 2.2.3 Key Informant Interviews Key Informant Interviews (KII) were conducted with officials at policy level to cover broad areas on issues such as stagnation of IMR and NNMR, accountability, sustainability, raising the profile of MNH programme and resource allocation. KII at programme and operational levels covered the issues of access/ equity in difficult geographical areas, equity in human, financial and infrastructure, quality of care, supervision, monitoring and adequacy of supplies and equipment. 37

KII with community level health providers and recipients explored the issues of work load, reporting of data, knowledge and use of national guidelines, standards & ministry circulars, continuity & quality of care, and behaviour change communication issues.. Open ended questionnaires developed by the review team members were used for the interviews. The levels of Key Informants interviewed is given Annex 4b. 2.2.4 Focus Group Discussions 2.2.4.1 MNH Providers Focus group discussions were held with several categories of MNH service providers: PHM, MO, Obstetricians and recipients of services. The focus group discussions with PHMs were carried out to assess their knowledge of MNH, their attitudes and practices, and to assess their current workload in the context of issues such as women s health, mental health, NCD HIV/AIDS etc. Focus group discussions with Medical Officers of Health were conducted to gather information about the general health conditions in their respective MOH catchment areas, and practices regarding MNH, particularly maternal care, referral and supervision. 2.2.4.2 Focus Group Discussions with recipients of care The recipients of care were met in the clinics as well as in their homes. Focus Group discussion with mothers were done to assess their understanding of health education messages given by midwives, knowledge about pregnancy, postpartum care and family planning and their level of satisfaction with the services. 2.2.5 Visits to institutions and field Field visit were made to districts and institutions based on a list prepared by the Coordinating Committee. The areas selected represented districts with high, average and low performance indicators for MNH, conflict districts as well as plantation districts. The high mortality districts were Nuwara Eliya and Batticaloa, lowest MMR districts were Colombo and Matara while Polonnaruwa represented an average district. Batticaloa 38

represented a conflict district and Nuwara Eliya also represented the plantation sector. The institutions selected covered a range of facilities. Visits were made to five provinces and 8 of the 26 districts. The visit sites are given in Annex 4c and a map of sites visited in Annex 4d.. Visits were made to MoH, FHB, Provincial Ministries of Health, Provincial Directors of Health Services, Regional Directors of Health Services, Medical Officers of Health, Colombo Municipality, various grades of hospitals, field clinics and households including slums in the city of Colombo. The review covered all sectorsurban, rural and estate. Public Health Midwives were visited in their offices, MOH clinics and during domiciliary visits in the field. Care practices were observed in varied settings. 2.2.5.1 Visit to Hospitals and Clinics A facility assessment Questionnaire was used to assess adequacy of physical facilities and selected aspects of quality of care in 13 hospitals. 2.2.5.2 Visit to Provincial and District Offices The interviews with provincial and district health officials included topics such as: decision making at local level, role and support from FHB, supervision of MNH programme from the provincial level to the district and from centre to province and districts. Inquiry was made into issues arising out of devolution such as channels of communication, supervision, coordination and financing of the MNH services. Constraints in providing MNH care and suggestions for improvement were discussed, Findings from all these methodologies were discussed and led to formulation of recommendations. 2.3 Presentation of findings The findings of the review and the recommendations are presented in separate chapters as listed below: Chapter 3 - Chapter 4 - Chapter 5 - Chapter 6 - Organisation for MNH services Services for MNH Human resources for MNH Cross-cutting issues 39

Organisation for MNH services Chapter 3 3.1 Organization for MNH services at National Level At the National level, the Family Health Bureau is the central organization of the Ministry of Health responsible for planning, coordination, monitoring and evaluation of maternal and child health and family planning programmes within the country. The Health Master Plan has described 5 strategic objectives that are also applicable to MNH services and form the basis for formulation of a medium term plan for the FHB. The FHB is now working on a draft MCH policy and a strategic framework that would be followed up by the development of a medium term plan. In MCH.FP/MNH the Bureau provides necessary guidance and direction for effective implementation of programmes at the provinces and also implements special projects funded by international agencies. The Family Health Bureau works in close collaboration with the Epidemiological Unit, Health Education Bureau, National Cancer Control Programme (NCCP), National STD/AIDS Control Programme (NSACP), and with other directorates / units within the Ministry of Health such as nutrition, estate health, youth and elderly, MRI and other related Government and Non Governmental Organizations and International Organizations such as WHO, UNICEF and UNFPA. The Bureau also undertakes in-service training in family health and provides reproductive health services at its clinic centre. It is also responsible for procurement and distribution of contraceptives and some of the essential equipment and supplies needed for family planning and maternal and child health activities. The Bureau has a number of technical units such as; maternal and new born care; child care; school health; women s health and gender; family planning; logistics and supplies and research and evaluation. The Research and Evaluation Unit monitors MCH/FP programme implementation and is responsible for processing and analysis of MCH/FP data collected through the Management Health Information System (MHIS) and conducts relevant health systems research. Each unit responsible for a given subject area is under a Consultant Community Physician. However, these units are constrained by not having adequate staff to support their 40

activities. Although nutrition has a considerable impact on the health of the mother and the newborn, the FHB does not as yet have a separate unit under a Consultant Community Physician to deal with this subject. Organisationally, the FHB reports to the Deputy Director- General, Public Health Services. However, since the curative sector provides a large component of the MNH services at institutional level especially the secondary and tertiary hospitals, there is a need for better coordination between the FHB and the Deputy Director- General, Medical Services. Currently a separate budget line is available for the FHB in respect of capital and recurrent expenditure. However, no provision is made in the budget line for MCH.FP/MNH programme activities. The Bureau has to at times depend on donor funds that are often unpredictable. Recommendations National level (MoH) A national steering committee (NSC) for family health to be established under the chairmanship of either the Secretary or Additional Secretary Ministry of Health to provide policy level support needed by the FHB to enable it to function as a centre of excellence. The Committee should include DGHS, DDG (PHS), DDG (MS) representatives from the Colleges, with the Director MCH as member- secretary. A National strategic plan for MNH should be formulated and approved by the NSC on the basis of which specific provincial and district plans could be developed. Within the above plan, an essential package of evidenced based MNH interventions be developed and coasted to enable the provincial administration to allocate funds from their provincial budgets. A policy framework, planning process and an incentive structure be developed and approved by the NSC, to enable central, provincial, district and divisional levels to fulfil their responsibilities in delivering MNH interventions. It is recommended that a separate budget line be provided to the FHB for MCH programmes. 41

Recommendations - Family Health Bureau The Family Health Bureau should be reorganised to strengthen their function as the centre of excellence for national MCH.FP/MNH programmes. The Bureau should serve as a pool of technical resource acting as the hub to bring together all relevant specialities for further development of MCH.FP/MNH in the country. Continuing professional development opportunities should be provided for the FHB staff to update their technical competencies needed to fulfil designated functions especially Health Planning, Budgeting and Management FHB should play a stewardship role to suggest policy options to the Ministry of Health. The Bureau should provide technical guidance in planning, training, supportive supervision and coordination of MNH programme activities in the provinces and districts. The FHB should be accountable to the Ministry of Health for national MCH.FP/MNH programmes based on defined performance indicators. The capacity of the FHB should be increased through the provision of adequate staff competent to undertake planning, budgeting, monitoring, evaluation, policy analysis and operational research. FHB jointly with the provinces and districts should plan to design MNH interventions that take into account the specific characteristics of the districts and special population groups. In view of the importance of nutrition and new born care the FHB should establish separate units for these subjects each under a Consultant Community Physician. 42

3.2 Stewardship of MNH Services at provincial level The stewardship role for multi-sectoral, accountable and locally oriented provision of MCH.FP/MNH services, is not evident at ground level. This raises the need for strong advocacy for MCH.FP/MNH at provincial and district levels. The absence of powerful central mechanism to influence the provinces and districts to invest in MCH.FP/MNH is also seen as a major handicap for service delivery at the local level. Prior to 1989, the management of Maternal and Newborn Health services has been a central function handled by the FHB. Thereafter there was a shift with the devolving of this subject to the provinces through the establishment of Provincial Councils by 13th Amendment to the Constitution. The list 1(provincial council list) and list 111(Concurrent list) of the 9th schedule of the 13th amendment to the Constitution spells out among others the powers and functions delegated to provincial councils for the Health sector. Those that are relevant to MNH services is included in list 1 namely establishment and maintenance of public hospitals, maternity homes and dispensaries (other than teaching hospitals and hospitals established for special purposes) and the public health services that include maternity and child care. MNH thus is a fully devolved subject that includes planning and implementation of services in the province within national policy guidelines. Recommendations The powers vested to Provinces under list 1 should be further strengthened through enactment of statutes that would enable them to establish systems for implementation of programmes relevant to the province within national policy guidelines. Provincial Director of Health Services and his team have to play a strong advocacy role to bring MNH high up in the provincial agenda. Some provinces have been successful in this due to the strong stewardship shown by the provincial administration. This calls for orientation of provincial and regional directors to be able to play a more effective stewardship and negotiating role. 43

3.3 MNH service delivery at provincial and district levels The Teaching hospitals in the provinces are tertiary care institutions where most of the deliveries in a district occur, but having very little coordination with the provincial/district administration. There is fragmentation of managerial functions and continuity of care, due to the difference in authority and management structures between the Teaching hospitals including the provincial and district base hospitals that have been taken over by the MoH recently and the rest of the provincial health services. While there is good rapport between the provincial directors and directors of teaching hospitals and the larger hospital taken over by the MoH in some districts, in others it is drastically low causing some concern in MNH service provision, monitoring and follow up. The maternal death reviews have in a way helped to bring the two groups together to tackle issues of common interest. However, the role of PDHS, RDHS, FHB/ MO/MCH in bridging this gap is not well defined. The District MNH services that come under the Regional Director of Health Services are managed by MO.MCH who is the contact point for the FHB. However the lack of a designated person at Provincial level to coordinate district activities and also to liaise with the centre is found to be a major drawback. Another issue is the appointment of medical officers to these positions who are junior and without much experience to perform the required functions. Capacity constraints often cause serious bottlenecks in service delivery and can threaten the entire decentralization process. To correct this situation considerable effort needs to be directed at building institutional capacity at both the central and local levels. Recommendations It is recommended that an organisational structure be established with a Consultant Community Physician as the focal point to support the PDHS in all MCH.FP/MNH services in the Province. The focal point should act as the coordinator/ link for preventive and curative services on behalf of the PDHS. The required cadre positions need to be created. 44

Closer cooperation between Provincial and District levels be developed to share information and streamline training and services. One such mechanism is to have regular monthly reviews of MCH.FP/MNH activities among PDHS, RDHS, Hospital Directors and relevant staff. The Consultant Community Physician/ MO/MCH should play a lead role in organising this activity/process. The Provincial / District planning cells for health under the PDHS /RDHS be strengthened and the MOs planning will serve as member-secretary of these cells. In the preparation of MNH plans, these cells should obtain the services of all key personnel from both preventive and curative sectors involved in MCH.FP/MNH care in the province/district. Assistance and funds should be provided to improve institutional capacity for team training and on the job training on managerial and technical functions. Special attention has to be drawn to developing planning and management skills of officers at provincial/district levels to perform devolved MNH functions. These include priority setting, forecasting, planning, budgeting, monitoring and evaluation of programmes. Involve the provincial and district accountants in the planning process and strengthen communication between financial and technical personnel at all levels for improved financial planning, expenditure management and disbursements. Review the distribution of institutions and specialist facilities within a district taking into account local issues such as terrain, transport etc to optimise equity in accessibility and availability. An essential equipment list should be agreed upon nationally for specialised care in MNH to prevent the introduction of equipment that is inappropriate or cannot be serviced and maintained. An in house biomedical technician should be available in all specialist hospitals for preventive maintenance and repair of equipment. 45

Chapter 4 Maternal and New Born Care 4.1 Maternal Health Sri Lanka s achievements in maternal mortality reduction have been one of the spectacular aspects of its success story in human development which has been well documented. The mainstay of the Sri Lankan health care system for maternal and newborn health is the Public Health Midwife (PHM) who ensures a continuum of care from the pre-conception stage through antenatal to the postpartum period and beyond. Secondly, Sri Lanka has excellent coverage of facility based intrapartum care with over 95% of women delivering in an institutional setting. Currently 80% of women deliver in an institution with Comprehensive Emergency Obstetrics Care. (CEmOC). However, the quality of the services is a concern. More recently the reduction in the maternal mortality ratio has slowed down considerably and there are areas / population groups in the country where maternal mortality is still comparatively high. Programmatic and other issues related to quality of care is a concern and needs to be examined carefully and addressed. 4.1.1 Preconception needs Consanguineous marriage, teenage pregnancy and poor nutritional status in pre pregnant women are fairly common in some districts and need long term intervention. Assessment for chronic medical disorders such as heart disease, diabetes and hypertension in pre pregnant women is needed. With increasing survival of persons having conditions such as Thalassaemia which is widely prevalent in some districts, developing pre-conception counselling services are indicated. Special programmes aimed at young people to address pre-conception needs and issues and promotion of responsible and healthy parenthood seem to be required. The relatively high coverage with rubella immunization needs to be sustained and further increased, while the importance of the use of folic acid before conception highlighted and strengthened. Education about possible exposure to occupational hazards and environmental toxins and instituting preventive measures are gaining in importance. 46

Recommendation FHB should develop a programme to address pre-conception needs and concerns among young people so as to improve reproductive health outcomes. 4.1.2 Antenatal Care Data indicate that around 98% of women who are pregnant in the community are identified by the PHM, with over 80% of these women being identified before 12 weeks of pregnancy. Following early registration by the PHM, antenatal care is provided by a team of health personnel both in the field and at institutions. The PHM provides antenatal care at home and also in the clinic setting. She is able to carry out most of the essential components of routine antenatal care viz: history taking and risk assessment, measurement of height and weight, urine check for protein and glucose, abdominal palpation and check of foetal heart rate. The PHM was trained and permitted to check Blood Pressure (BP), but subsequently this practice was discontinued due to poor quality in the assessment of BP. In this context it is relevant to state that the BP is routinely checked in the antenatal clinics which are well patronised by pregnant mothers, thus making domiciliary BP checking a duplication of services. The PHM provides a very valuable service in educating the mother of danger signs during pregnancy, the onset of labour, choice of place for delivery and danger signs during the postpartum period. However she is not equipped during her basic training or thereafter to prepare the mother/couple for the birthing process. The mother is educated on the importance of breastfeeding and all aspects of care of the infant viz: immunisation, regular weighing and adequate nutrition as well as the early recognition of illness. In addition she provides educational material to the mother that is well designed and illustrated and contains up-to-date information. In recent times she has been trained to provide Early Childhood Care and Development which has equipped her to involve the family in the care of the pregnant woman and the newborn child in a more holistic fashion. The PHM and the PHNS assist in the primary care antenatal clinics (ANC). Such clinics are usually conducted and supervised by the MOH/DMO/MOIC and at which basic antenatal investigations are 47

also provided. Specialist ANCs are conducted under the supervision of a consultant obstetrician and more advanced investigations including ultrasonography are available at these clinics. The model of ANC visits currently used is the traditional multi - visit model, i.e.: once a month in the first 28 weeks, fortnightly during 28-36 weeks and weekly thereafter. Some of the ANC records examined during the review showed that only some components of the ANC package had been recorded. Field visit information suggests that pregnant women are simultaneously accessing services at multiple settings (i.e. field clinic, hospital clinic and some even through visits to an obstetrician in the private sector). Routine tests that are currently recommended at a booking visit for a pregnant woman include: - Screening for anaemia or determination of haemoglobin concentration - Test for syphilis (VDRL) - Test for urine protein and glucose - Determination of Blood Group and Rhesus factor. From site visits made to facilities, FGD and KII, it is clear that current laboratory services for MNH are inadequate in the government sector. Some women chose to have their laboratory tests especially VDRL and haemoglobin concentration carried out in the private sector. It was not possible to assess the quality of such investigations. Testing urine for glucose and protein was generally possible in the clinic but often a Benedict s test is done for sugar instead of the more accurate and simple dipstick method. Anaemia is detected by inspection of conjunctiva and/ or colour matching using the WHO recommended haemoglobin colour scale and sometimes the HemoCue analyser. In the specialist care settings other methods of estimation are used. Tetanus Toxoid is given to all mothers at the end of 12 weeks of gestation at the clinic according the new schedule. The Tetanus Toxoid coverage as assessed at the time of delivery is almost 100% contributing to almost total elimination of neonatal tetanus as mentioned in section 1.2.2. All pregnant mothers are routinely given iron-folate (UNICEF donated or Ferrous Sulphate and folic acid tablets separately) and 48

calcium lactate together with anthelminthic treatment at 12 weeks. It appears that the compliance for taking the Iron-folate is not adequate. A very large number of low risk antenatal mothers book at tertiary hospital clinics. Different reasons were seen to operate in the different districts visited. The common reasons noted were the desire of the public to obtain the highest possible level of care in view of the country s current low Total Fertility Rate (1.91) and the lack of a formal referral system. Direct access available to a consultant obstetrician facilitated by the current scheme of private practice for doctors serving in the government sector, is also a strong motivating factor for this health seeking behaviour. It is reported that there is a high incidence (17% in 2003) of low birth weight. Current information on the proportion of LBW due to intrauterine growth restriction is not known. The management of this problem during pregnancy would benefit by ultrasound monitoring. The review noted that there is a duplication of effort in the provision of ANC. The capacity of the government system to provide an antenatal care package of high quality is lacking and must be improved. There is a need to stream line the provision of ANC and bring it into line with current international best practice. Recommendations Mechanisms should be established to create a conducive environment through provision of facilities together with public and staff education where antenatal mothers and their families would accept shared care with confidence. This would also reduce duplication of services. It is recommended that the country adopts an evidence based focused antenatal care strategy with a minimum of 4 visits for low risk mothers. All women are seen by an MO for a full booking visit to include at a minimum full general examination including cardiac auscultation, full obstetric examination, 49

Haemoglobin measurement by Haemoglobin Colour Scale or HemoCue method, VDRL one stop test on site, Blood grouping and RH. test urine for protein, glucose and cells using a dipstick method. The current practice of providing iron folate, calcium, anthelminthics and prophylactic antimalarials (in endemic areas) be more systematically implemented and strengthened with appropriate logistics and education. The antenatal care of all women with risk conditions / complications should be under the supervision of a consultant obstetrician. The services should plan towards providing an ultrasound scan at the time of booking and at 18-24 weeks. The basic scan at booking may be achieved through training, certification and revalidation in basic ultrasound scanning for MOs with at least 6 months obstetric experience and mechanisms for referral to specialist care where indicated. Considering the importance of medical conditions as a cause of maternal death, it is recommended that a joint clinic by a physician and an obstetrician be held at least once a month, in institutions where specialist facilities are available. Considering the importance of hypertensive disorders in pregnancy as a cause of severe maternal morbidity and mortality, providers of antenatal care at all levels should be trained and provided with appropriate facilities and guidelines for the management of eclampsia including the use of parenteral magnesium sulphate. 4.1.3 Intrapartum (Natal) Care Over 95% of deliveries currently take place in a hospital. This high rate of institutional delivery with skilled birth attendants (SBA) is one of the key successes in the Sri Lankan MNH model. However, there is an urgent need to update the care given during the intrapartum period so that it is in line with current scientific evidence. It should be noted that antepartum and postpartum haemorrhage accounts for 22% of maternal deaths and 4.1% is 50

due to puerperal sepsis (FHB, 2004-05). The latter highlights the importance of infection control in the birthing process. Hospitals with a varying range of facilities conduct deliveries. There has been a shift in childbirth from non specialist institutions to institutions where services of a consultant obstetrician are available (52.6% in 1990 to 82.6% in 2003). During the same period, childbirth decreased from 40.4% to 14.7% in institutions that had only a medical officer. In institutions where there are no medical officers the births have reduced from 6.9% to 2.7% during this period. This change persists even when changes in availability of beds at the different levels are taken into account (calculated from data in table 36/37 in AHBs, 1990-2003). Visits by the review team identified some smaller facilities with less than 20 deliveries per year. It is likely that such facilities are unable to provide good quality of care and in addition, such underutilization is not financially sustainable. This creates the need to rationalise the use of such smaller facilities that currently perform only a few deliveries. It is suggested that unless a facility can at least provide BEmOC, it should not accept women for delivery. Currently many grades of staff in a facility attend a delivery. This includes a midwife, a nurse with or without midwifery training, an MO and/or an obstetrician. With regard to provision of intrapartum care (SBA), the role and function of each cadre of staff for an uncomplicated delivery should be examined. In some of the institutions visited, it was noted that practices not shown to confer any benefit such as shaving, provision of enema or other means to empty the bowels before delivery, withholding all fluids and light food during labour, confining the woman to her bed during labour, delivering in lithotomy position and the routine use of an episiotomy for all primiparous women, continue to be used. Beneficial practices such as allowing female companionship, providing adequate pain relief, light foods and fluids during labour and delivering in a position of choice were not observed. In most facilities standards for care, guidelines or protocols were not available on the delivery ward. Where standards and protocols were present these were generally designed locally by a few individual MOs and/or obstetricians. National guidelines for common obstetric problems are available. These need to be updated in line with current international evidence based practice. The number of guidelines and protocols needs to be expanded to cover the full range of obstetric practice and widely disseminated. Dissemination should be accompanied by in-service training to 51

update staff. At the moment there is no systematic scheme for inservice training of institutional staff. Most health care providers consulted during the review mentioned in-service training as one of the key areas that was needed to help motivate staff as well as update skills and knowledge. The use of the partogram is the key to quality intrapartum care. In addition the active management of the third stage of labour is crucial for the prevention of postpartum haemorrhage and retained placenta. The above procedures are practiced sub optimally. Even during six months of obstetric training the opportunities available for supervised hands on practice in the removal of retained placenta could be low. The use of models for training could be considered as an alternative. Women friendly practices such as appropriate measures to ensure privacy, allowing a companion during labour and delivery, keeping the woman informed about the progress of labour and providing adequate pain relief will help to improve the quality of intrapartum care. In the event of a woman having a delivery at home due to inability to reach a facility in time near optimum care should still be provided. This is hampered by the lack of recent experience in intrapartum care among PHMs. In service training should ensure skills needed to deal with such situations are adequate. This could be achieved through the use of simulated home situations during training. Recommendations In order to streamline and update intrapartum care it is recommended that: Place of delivery Only normal deliveries should take place in facilities able to provide BEmOC i.e. institutions where medical officers are present and have a functioning 24/7 referral system to a CEmOC providing facility Staff and training 52

The roles of the members of the team consisting of medical, nursing and midwifery staff currently providing intrapartum care should be reviewed and updated. A midwifery qualified nurse be the key member of the team to conduct a normal uncomplicated delivery in an institution. Components of BEmOC which could be provided by a midwifery qualified nurse should be identified. Active training for all levels of staff providing intrapartum care, in the correct use of the partogram and ensure it s continued use with supervision and follow-up. All in-service training programmes to introduce new technology and upgrading of skills should be team based, (medical, nursing and midwifery staff) Management of labour Ensure that women friendly intrapartum care is provided, including adequate analgesia during labour and delivery and companionship during labour and delivery. Review method of active management of the third stage of labour to determine practices appropriate for each level of intrapartum care. The use of medications such as syntocinon, ergometrine and misoprostol as appropriate for prevention and treatment of PPH needs to be evaluated considering the different settings in which labour is managed. In the above context consider training all members of the team providing intranatal care on the rationale and the methodology in the active management of the third stage and it s complications. Following delivery every mother should be monitored using a standard observation chart which must form part of the labour record and should be continued in the postnatal ward. Expand range of national standards for obstetric care and disseminate widely coupled with in-service training for routine use. 53

Intrapartum care be based on national guidelines and protocols developed and revised regularly in keeping with sound scientific evidence so as to address current intrapartum causes of mortality and morbidity with special reference to progress of labour and infection control. Establish mechanisms for clinical governance depending on resources available At institutional level the team providing intrapartum care should meet regularly to adopt protocols / guidelines and conduct audits so that these protocols may be implemented effectively. Quality assurance in intrapartum care be established through regular in-house formal audits of the use of the partogram, infection prevention and client satisfaction. Miscellaneous In areas where deliveries by unskilled attendants are significantly high, reasons for this practice be evaluated and corrective action taken. The respective local authorities should develop a rational basis for individual institutions to transfer emergency cases and define the receiving institutions. Specific guidelines on the process of transfer regarding emergency care should be developed. Facilities for communication during transfer to be established. Ensure improvement in the quality of documentation during transfers Consider accreditation of hospitals (a star system) that have attained women friendly status. Obstetric MIS to be implemented with introduction of Obstetric Bed Head Ticket, transfer form etc. 4.1.4 Provision of Essential and Emergency (Basic and Comprehensive) Obstetric Care 54

Areas in the health system consistently identified in maternal death reviews as well as during the current review (stake holder meetings, KII and field trips) as needing increased capacity and strengthening, included the following: - Capacity of divisional hospitals (medical officers present but no specialist services) to provide fully functioning BEmOC services (all 6 signal functions) - Capacity of institutions with specialist facilities to provide 24/7 CEmOC services (all 8 functions). - In particular, the signal functions of assisted vaginal delivery (vacuum extraction) and 24/7 availability of CS (i.e. functioning theatre with staff who can adequately perform CS and anaesthesia) - Availability of 24/7 blood transfusion services - Adequate referral system with good communication between referring and receiving centres. - Coverage of BEmOC and CEmOC in line with minimum UN standards (of 1 CEmOC and 4 BEmOC facilities per 500 000 population, taking into account terrain and access) is still to be achieved in some districts. Currently some districts / provinces have a plan to upgrade the capacity of hospitals to become fully functioning CEmOC facilities. Such effort should be based on clearly identified population based need taking into account the expected number of births as well as the terrain (and accessibility) of the area. Field visits show that, although there is no lack in the number of facilities (i.e. structure) there is often lack of capacity of these facilities to meet the 6 signal functions required for a functioning BEmOC facility and the 8 signal functions for a designated CEmOC facility. Provision of EmOC 24/7 is also not always assured and this appeared to be mainly a problem of staff capacity and availability. In general the upgrading of facilities to functioning BEmOC and CEmOC will require some extra equipment and supplies and improved training of staff to deliver EmOC. For BEmOC and CEmOC facilities an agreement is needed as to what constitutes the minimum numbers of staff and level of training for such a facility to be able to provide 24/7 BEmOC and CEmOC. 55

In the past 1-2 years the Sri Lanka College of Obstetricians and Gynaecologists have provided EmOC training in some districts which have been very positively received. Scaling up of such activities is recommended with a suitable monitoring and evaluation framework in place to assess effect of such inputs. It is clear from field visits, FGD and KII that all levels of staff welcome such in service training and is preferable if arranged at district level i.e. on site. All maternity cases have a potential for needing operative intervention. In the facilities that are defined to have comprehensive obstetric care the conditions to provide safe surgery should be fulfilled. 24 hour theatre cover is not available due to many logistic and organizational problems. Staffing deficiencies in anaesthesia, nursing cover and other supporting services were observed to hamper this essential requirement. Haemorrhage is the leading cause of maternal death. The need for blood replacement could be very urgent. While the physical facilities for blood transfusion in many hospitals are in place, gaps in terms of access and delays are a serious problem for quality intrapartum care. The medical staff providing this service should be competent in the total management of transfusions and this is lacking. Recommendations For each district there should be a clear cost estimated plan to identify which facilities should be upgraded to function as BEmOC and those to function as CEmOC. Plans must be based on estimates of population needs i.e. expected number of pregnancies and births as well as accessibility and road- infra structure (terrain). Where needs based plans for coverage with BEmOC and CEmOC for the district are available, implementation to full capacity should be seen as a priority of the highest order. In-service training in delivery of EmOC to be scaled up with a suitable monitoring and evaluation framework in place. All staff in BEmOC and CEmOC facilities to receive such training at least once a year. 56

MOs working in delivery wards of BEmOC and CEmOC facilities should have at a minimum 6 months of training in Obstetrics and Gynaecology. Staff complement should be such that 24/7 services can be provided. Availability of a dedicated functioning theatre providing a 24 hour service should be available preferably attached to the delivery room. Anaesthetic, nursing and other services should be available for this facility. An evaluation of the location of regional blood transfusion centres and distribution centres in each province/ district, be conducted in relation to institutions providing intrapartum care, taking road access into consideration so that blood and blood products could be made available at short notice. This should be treated as a matter of urgency. Whenever there is inadequate cover by designated medical officers for transfusion services in any institution, medical staff already working within the facility should receive sufficient training to provide emergency cover for blood transfusions. 4.1.5 Care of the critically ill patient: At present only a few institutions providing full CEmOC services have high dependency units (HDU) or dedicated ICU beds. A clear referral pathway to a tertiary centre with the above facilities is also lacking. Recommendation The need and availability for ICU / high dependency units with trained staff and other facilities must be evaluated and mapped out for each district and referral pathways for patients requiring such care must be clearly defined. Each obstetric unit to identify at least 2 4 dedicated beds with adequate resources for care of the critically ill mother. 57

4.1.6 Caesarean Section Rates There is growing concern about the increase in Caesarean Section (CS) rates. In the government institutions the CS rates have increased from 13.3% in 1998 to 20.0% in 2003. If the private health sector is also included this rate would most likely be much higher. There is a need to examine the CS rates with regard to population coverage as a whole, as well as by district, and make a comparison between the government and the private sector. In addition there is a need to examine the indication for carrying out CS and the resulting morbidity in both the government and private sectors. It is most likely that in tertiary centres the CS rate can be expected to be higher than in other institutions where there is specialist care, as these centres would receive a relatively higher number of high risk patients. In a private hospital visited, it was mentioned that CS rates could be as high as 50-70%. However this statement needs to be examined more closely. There is a general impression that the CS rate has increased because women demand it and some obstetricians oblige. It is likely that women are unaware of the increased risks associated with CS. In addition the chance of a normal vaginal delivery after a CS seems low and once a section always a section is still practiced by some. CS are also performed because there is lack of 24 hour/ 7 day coverage by a consultant obstetrician and or an anaesthetist especially on weekends. This leads to potential obstetric problems being cleared during the week when specialist staff coverage is adequate. It is also likely that social and cultural factors play a part i.e. being born on the right calendar day and at an auspicious time is considered important by some. It is believed that with improved quality of care during delivery, especially with improved pain relief, women will be able to make a more positive and pro-active choice to opt for a vaginal delivery. Increased woman friendliness of the delivery environment including privacy, companionship in labour, continuity of care etc. will enable women to accept a vaginal delivery more readily as a gratifying normal event. Recommendations 58

A national study is needed to assess in detail the pattern of Caesarean Sections (CS) performed, including indications and outcome for mother and baby. Develop mechanisms for institutions to monitor CS rates, indications and outcomes. The environment and the experience of the birthing process should be improved to include a more woman friendly environment, adequate pain relief, companionship during labour and continuity of care that would encourage women to opt for a vaginal delivery. Further to the above improvements in intrapartum care, the experience of a vaginal delivery should be actively promoted as a positive choice, through education and improved communication. Women who request for CS should be able to make an informed choice after being advised about the indications for CS and the possible risks of mortality and morbidity for both mother and baby following CS. 4.1.7 Postnatal Care of the Mother and Baby There is an excellent system for provision of Postnatal Care (PNC) in Sri Lanka. Currently all women delivering in a facility and their babies are observed in the delivery room for 2 hours and in the postnatal ward for 24 hours before discharge from hospital. From direct observations, focus group discussions and key informant interviews it seems clear that women and new born babies are adequately examined before discharge and that all information and education (on lactation, danger signs in the postpartum period, care of the baby and FP) is given. Subsequently, the PHM provides postnatal care at home. This includes 2 home visits in the first 10 days after a normal delivery, a further visit around 28 30 days and a visit at the end of 6 weeks. Postnatal care is given by the PHM at home but the coverage is not as high as in antenatal care. One reason for this is that a woman who has delivered may move out of her own PHM area to 59

her parent s home and/or may be lost to follow-up. Currently there is a system in place where a PHM is informed that a new mother and her baby have arrived in her catchment area however, often there are many delays. This process needs to be revised and strengthened. The PHM currently relies on a variety of sources of information to tell her that a woman in her area has delivered and has been discharged home. This includes: - A form from the hospital - Direct information from relatives - Information from another PHM e.g. moves to be with her parents. - The PHM s own records of expected date of delivery Despite this system approximately 20% of mothers may be missed and will not receive timely PNC and/or the optimal number of visits. There is thus a need to re- evaluate the way in which a PHM is notified of a delivery. Another factor contributing to low coverage of PNC by the PHM is her workload. Given her current target population it may not be possible to conduct all postnatal visits (2 in first 10 days, a visit around 28 30 days and an additional visit at the end of 6 weeks) in a timely manner. The current target population for a PHM is 3000 to 5000 population but in some areas of the country due to a shortage of PHM this may have increased to 10 000 or more. Information pertaining to an institutional delivery and recommendations on future management reaches the PHM via the back page of the Pregnancy Record (H 512A ). This record although available with the mother when she enters an institution for delivery is not systematically used at present. For any delivery other than a normal delivery i.e. for CS, assisted delivery or any complication, a separate diagnosis card is currently used. It was noted during field visits that most hospitals and MOH clinics do not generally conduct postnatal clinics. For women who have had complications during labour and/or delivery the introduction of a special clinic would be beneficial. Recommendations 60

Postpartum care at the institutions where delivery occurs should be based on nationally accepted guidelines. All postpartum mothers should be discharged following an examination based on a standard protocol that should be implemented nationally. It is recommended that a single system of reporting at discharge from hospital be used and that the H512A form be adapted as necessary to include all relevant information pertaining to delivery. While the PHM should continue to be the key provider of postnatal care at home, action should be taken to improve quality of care through focused training and the use of guide lines / checklists by the PHM. The system by which the PHM is notified that a woman has delivered and is discharged home should be reviewed, strengthened and monitored. The PHM should have access to a full summary of the delivery (complicated or otherwise) at the time of the first domiciliary postnatal visit. In view of the fact that mothers discharged home on the 3-4th day following LSCS have to be cared for by the PHM, it is recommended that the PHM be provided with adequate knowledge and skills and guide lines to competently take care of these mothers. Every woman who has delivered (irrespective of the duration of pregnancy) should have a complete postnatal assessment at 6 weeks in an institution or a MOH clinic, facilitated by the PHM. This assessment should include the status of general health, as well as gynaecological health, lactation management, nutrition and family planning counselling / services. Special postnatal clinics for women who have had complications during pregnancy and delivery (including assisted delivery and CS) should be established at institutional level. 61

4.1.8 Factors contributing to maternal deaths and causes of maternal deaths In the last few years the three commonest causes of maternal deaths have been identified as PPH, PIH and heart disease. In 2004, 11.4% of maternal deaths were due to abortion and a further 4.1% due to puerperal sepsis (FHB,2004-5). Perusal of the minutes of the maternal death review meetings for 2004 and 2005 highlighted that, in some cases the correct attribution of (medical) cause of death can be difficult and may be technically incorrect. In addition there appears to be confusion in the correct attribution between contributory and underlying causes of death. Sometimes the underlying causes may remain unidentified. In the peripheral institutions most of the maternal deaths are due to preventable causes, while in the in the larger institutions in addition to deaths due to preventable causes rarer conditions such as DIC. are observed (FGD/KII with Consultant Obstetricians) From discussions in the field and with key informants it became apparent that there is a move to make the proceedings of maternal death reviews fully confidential and to make sure that information revealed can not be used for legal purposes. It is likely that until this new policy is fully enforced there may be some misclassification of deaths from direct obstetric causes to indirect causes. In general logistic and infra-structure factors contributing to maternal deaths are more clearly and precisely identified at maternal death reviews. 4.1.9 Maternal Death Reviews Maternal deaths are notifiable in Sri Lanka. There is a comprehensive system in place to report maternal deaths. Information is collected actively both at the field level by the PHM and at the hospital level by the curative staff. All deaths are reported to the Family Health Bureau. In addition there is a comprehensive system of death registration which is the responsibility of the Registrar General. In the latter system there is no provision to indicate whether a woman of reproductive age was pregnant or not on the death declaration form or death certificate. It is planned that this information will be included in a future revised death declaration form and death certificate. 62

The national maternal death surveillance system is considered very reliable and includes deaths occurring both in the hospital and community. Estate areas and even conflict areas seem to be well covered. An institutional level inquiry and a field investigation is held within a week of the event coordinated by the MOMCH. District reviews are conducted on a quarterly basis followed by an annual district review coordinated by the FHB. A national review is held annually. Both preventive and curative sectors participate at these reviews. Minutes of mortality reviews are maintained with clear action points documented. All minutes are collated by the FHB and a summary published in the Annual Report on Family Health. The last 3 annual reports noted that there is a need to improve the quality of maternal care and the need for timely correction of deficiencies highlighted at institutional and district level. It is important that the review results are published disseminated and recommendations acted upon and the Sri Lanka College of Obstetricians and Gynaecologists be a partner in this process. Recommendations The capacity of the FHB to coordinate the national maternal mortality review should be strengthened. The maternal mortality review process should have a no blame no shame approach. The institutional and field investigations should be conducted as at present to collect all necessary information. This should be followed by a confidential inquiry by a team of experts to ascertain the causes / factors leading to death and to identify clear points for action. District and national reviews should be based on a compilation of the confidential inquiries. The district reviews should be held quarterly and the national review annually as at present, to discuss points of action recommended from the review. Following these reviews, persons / institutions responsible for each of the actions recommended should be clearly identified and a mechanism to ensure that each follow up action has been implemented. 63

There is a need to strengthen the technical knowledge of the review teams to accurately assign cause of death. The cause of maternal death is currently categorized according to ICD 10. A new simplified classification of cause of maternal death is being designed (WHO) and could be applied in Sri Lanka after dissemination and training. It is recommended that the proposed national steering committee on family health (section 3.1) should also discuss the findings of the maternal death reviews and monitor closely the implementation of the recommendations. A national report outlining the process and the findings of the maternal death reviews, be compiled, published and disseminated on an yearly basis. The process by which this is developed and the output would act as a gold standard for the region. Recommendations from the annual report should form the basis for identification of specific measurable needs for MNH services and feed directly into the proposed district and provincial annual cost estimated work plans. Recommendations from a national level maternal death review system should lead to revision and modification of standards of practice and consideration should be given to the introduction of criteria (standards) based audits to evaluate what hinders full implementation of such standards. Once the capacity for national mortality review is fully established then inquiry into severe maternal morbidity ( nearmiss inquiry) can also be introduced. 4.2 Neonatal care 4.2.1 Care of the low risk newborn infant It was noted that newborn care in the country needs much improvement. This review provides an opportunity for planning a high quality newborn care service that would ensure accessibility to quality services in all parts of the country. A system for 64

surveillance on the quality of care of the newborn does not exist at present though it is a vital need that must be addressed. In an ideal situation all infants must be assessed immediately after birth to determine whether they are crying or breathing well. The training and equipment for basic newborn resuscitation with bag and mask is essential for all deliveries. Suction and a source of oxygen should also be available if needed. It was noted that evidence based WHO guidelines for training on Essential Newborn Care (ENC) and life support has commenced. After successful resuscitation, if required, all those involved in managing the newborn infants should follow the principles of essential newborn care such as; drying and clamping the cord, skin-to-skin care, early initiation of breast feeding, and administration of vitamin K to prevent haemorrhagic disease. After placing identification bands, weighing the infant and performing a simple clinical examination, the infant should stay with the mother unless there are very good indications to separate them. A protocol for managing healthy infants in the first hours of life should be standardised and used nationally. Both medical and nursing staff must be trained in care of the healthy newborn. Exclusive breast feeding for 6 months should be supported and lactation management centres should be established in the larger hospitals. It is mandatory that upgrading the Baby Friendly Hospital Initiative (BHFI) should be a continuous process with external monitoring for its effective implementation in all hospitals having MNH services. Most of these practices were not universally observed in the institutions visited. Growth should be monitored for all infants in keeping with national guidelines to identify those with failure to thrive; immunised according to the national schedule; and observed for danger signs of illness. Currently this is carried out well by the public health team with the key person being the PHM. Recommendations Guidelines for essential newborn care should be disseminated and followed by all health care personnel responsible for neonatal care. It is recommended that a national system for surveillance on the quality of care of the newborn be established with the 65

creation of a separate newborn care unit within the FHB with its own dedicated staff. Skills and equipment for basic resuscitation as well as guidelines for immediate care of low risk infants must be available at all sites where mothers are delivered. The training programme on Essential Newborn Care (ENC) & life support based on the WHO training module be systematically extended to all institutions as a priority. Prophylactic vitamin K should be given to all newborn infants. Lactation management centres / Mother Baby Centres should continue to be established in the larger hospitals and also serve the district as a referral centre. Exclusive breastfeeding for 6 months (180 days) should continue to be promoted. The Baby Friendly Hospital Initiative (BHFI) should be independently monitored at institutional level to ensure its effective implementation and a system of accreditation of institutions be developed. In keeping with the recommendations of the Innocenti Declaration, a national coordinator for breastfeeding management be appointed and supported by a multi disciplinary team of experts. Monitoring the implementation of the Sri Lanka code for the promotion, protection and support of breastfeeding and marketing of designated products, should be further strengthened. 4.2.2 Care of the high risk newborn Services for high risk new born infants were found to be limited both in geographic distribution and quality. These infants should ideally be delivered in a hospital where specialist services and equipment for advanced resuscitation and life support are available. It is thus important to identify low birth weight babies, those with respiratory distress, congenital abnormalities, and signs of illness as early as possible. 66

A nursery for very small and ill infants was not available in all larger hospitals (base hospitals and above). The nursery should have adequate medical and nursing staff to provide round-theclock care for these infants. The pattern of staffing in the nursery, its design, facilities and equipment should meet national standards. Evidence based protocols for diagnosing and managing problems in the newborn were not seen in practice in institutions. Supplies and equipment necessary for infection prevention (proper hand washing facilities such as elbow operated taps for wash basins, liquid soap, and hand spray) were found to be lacking and must be available. Correct hand washing practices were poor. Rooming-in of mothers, uses of expressed breast milk and skin-toskin care are essential parts of modern newborn care. Many of these basic principles of caring for high risk infants are not being universally met at present. If high risk infants are born in smaller hospitals, they should be safely transferred to a hospital where the necessary skills and equipment is available for their management. A co-ordinated and well organized system for transport that can provide safe transfer of high risk babies including facilities for cardio-respiratory support is needed. Specialist hospitals should impart the required training for staff at smaller hospitals in the routine care of well infants and the emergency management of ill infants. A system of continuous evidence-based education must be instituted in all health facilities caring for newborn babies in order to improve and maintain the care of all high risk infants. A list of essential equipment will prevent the introduction of items that are inappropriate or cannot be serviced and maintained. Malfunctioning of equipment and instruments and subsequent long delays in repairing same was very commonly observed. Particularly in busy nurseries this results in compromising optimal care of critically ill neonates. It is essential that services of a bio medical technician is made available to the neonatal care units for preventive maintenance and repair of costly equipment. Recommendations All women expected to give birth to a high risk infant should be delivered in a hospital where specialist care is available. (Inutero transfer ) 67

Nationally agreed upon evidence based management protocols should be used for resuscitation and care for high risk (very small or ill) infants. Appropriately designed, equipped and staffed newborn care nurseries be available in all specialist hospitals. Skin-to-skin care should be widely used in the care of low birth weight infants. A system of continuous evidence-based education on Essential Newborn Care (ENC) must be instituted in all health facilities caring for newborn babies Consultants looking after newborn intensive care units in the larger hospitals need advanced neonatal training of at least 3-6 months. A national website with neonatal care guidelines and protocols should be created and updated from time to time with the help of experts and professional bodies. 4.2.3 Care of Preterm Babies It is evident from the available data that more than 50% of neonatal deaths occur in small preterm babies mostly below 1500 grams. If a substantial decrease in neonatal mortality is to be achieved, it is imperative that while providing Basic Essential Newborn Care a well organized neonatal intensive care services are put in place in tertiary care centres. The infrastructure to achieve this objective may be built up gradually over a period of 1-2 years. Training of personnel, procurement of equipment and designing of intensive care units needs to be done by a group of experts carefully chosen for this purpose. It is advisable that well designed regionalized neonatal care (RNC) services may be put in place which will be able to deliver quality primary, secondary and tertiary components of newborn care. Every province may be incorporated as a nodal point in this RNC with one well developed neonatal intensive care unit catering for the tiny sick preterm babies requiring cardio-respiratory support. It is imperative that this unit be staffed with trained health care personnel, provide high quality ventilator support with good back 68

up laboratory services and have a continuous supply of lifesaving drugs including surfactant and indomethacin. It will also be pertinent to have wide discussions among the neonatologists, paediatricians and representatives of national professional bodies to develop a national guideline to set the limit of salvageable preterm babies. In the process of upgrading preterm care and proving ventilator support to sick newborns, it must be ensured that babies receiving intensive care should have an effective and good quality follow up service to identify any handicap. Early recognition of any neurodevelopment deficit in these babies would help in effective management and a favourable outcome. There is a need to ensure that all hospitals with neonatal services establish mother-baby centres in which mothers and babies after special care can be provided with rooming-in facilities to enable them to look after their babies with confidence prior to discharge home. Guidelines for such a centre Is developed and is available. Recommendations To effect a substantial decrease in neonatal mortality, well designed neonatal intensive care units equipped with trained personnel, reliable round the clock laboratory facilities, appropriate equipment and life saving drugs must to be organized at provincial level. A national guideline needs to be developed to set the limit of salvageable preterm babies. Regular well organized follow up clinics managed by trained personnel for the care of high risk newborn babies with access to multidisciplinary services be established in relation to the nodal points in RNC Mother-baby centres should be established in all hospitals that provide neonatal services. All units that provide special care to neonates should have regular in-house audits regarding adherence to guide lines, infection control, and other quality assurance procedures. 69

4.2.4 Neonatal screening for Hypothyroidism Congenital hypothyroidism is a treatable condition when detected early. The incidence of the disorder is stated to be 1in 3000-4000 live births in the western world. However, in most developing countries the incidence is around 1in 1500 live births. Taking into account the total number of births in Sri Lanka at around 350000/year, it is expected that 230-250 hypothyroid babies would be born every year. These babies, if not diagnosed and treated soon after birth, become severely mentally retarded. The diagnosis of this disorder is simple, cost effective and can be organized without much difficulty. In this context it may be mentioned that Sri Lanka has a national programme for the prevention of Iodine deficiency disorders. Recommendation Routine neonatal screening for congenital hypothyroidism should be introduced nationally without delay. 4.2.5 Care of the newborn in the field In the past (late 1970s) the PHN was responsible for the care of the newborn in the home setting for the first 10 days. With the shortage of PHNS this responsibility has now fallen on the PHM. In this context the PHM has not been provided with adequate knowledge and skills in the care of the newborn and most certainly not that of the low-birth weight infant. Of special concern are the babies discharged from hospital following special care such as those who have been critically ill, pre term or growth compromised (IUGR). Recommendation It is recommended that PHMs be trained in the care of newborns, particularly those who have been critically ill, are preterm or growth compromised, so as to ensure they have the 70

necessary knowledge and skills to support mothers in the care of these babies. 4.2.6 Perinatal Death Reviews It is not clear whether all stillbirths and early perinatal deaths are recorded in the institutions. A generally agreed upon definition of a stillbirth is required. viz. all infants born dead after 28 weeks gestation or with a birth weight of 500 g or more. The latter is preferable where accurate gestational dating may be a problem. As most low risk women and their newborn infants are discharged from hospital after 24 hours, some cases of early neonatal death (death of a live born infant in the first 7 days of life) occurring at home may be missed. Without clear definitions some very small infants who die soon after birth may be recorded as stillbirths. It may be likely that the data on perinatal deaths and its classification may not be accurate. There is evidence that there may be some under reporting of infant deaths in conflict areas (Fonseka, 1999). At present, the vital statistics system does not report a perinatal mortality statistic. This is because still births are registered only in proclaimed areas i.e. an area where the deaths are registered by a medically qualified registrar. However, still births and early neonatal deaths (death of a live born infant in the first 7 days of life) are reported by the PHM through the field reporting system, as well as through the indoor morbidity and mortality return of all government medical institutions. At present perinatal death reviews, are referred to as perinatal death conferences which takes away from the importance as well as the official nature of this activity. It was observed that the institutional administration does not accord it the same degree of importance given to maternal death reviews. This results in the perinatal death review being carried out in an ad hoc manner. Often the field staff (MOH) do not attend the review meetings. The current perinatal mortality review should be improved and eventually expanded to include a morbidity audit. The form that is currently used to report perinatal death is cumbersome and is often incompletely filled when taken up for discussion. The discussions and inquiry into lapses is restricted by fears of likely litigation and often leads to non identification of underlying correctable service factors. 71

Recommendations The current system for collection of data (both RG and MIS) on perinatal, late neonatal and infant deaths needs to be discussed, evaluated and strengthened. Establish the infrastructure necessary for reporting of a perinatal mortality statistic (rate) as part of the national vital statistics system. The nomenclature of perinatal death conference be changed to perinatal death audit and be given the same level of importance as the maternal mortality review. The forms used in perinatal death audits need to be standardised and simplified. Good examples for this available internationally could be modified to meet local requirements. Regular systematic reviews of the causes of, and avoidable factors associated with perinatal deaths should be instituted in all regions. The use of accepted definitions for classifying perinatal deaths is needed. The audits should lead to identified actions towards further reduction in perinatal mortality. 72

Chapter 5 Human Resources for MNH 5.1 Over view Many of the issues concerning human resources for MNH are of a generic nature, except those specific subject areas for MNH skills development. Therefore, issues of planning and management of HRH need all round improvement. One of the basic requirements to achieve the intended MNH outcomes would be a comprehensive Human Resources Development effort that will build the capacity and strengthen the structures, functions, linkages and the monitoring and evaluation processes. Deputy Director General (Planning) is responsible for the overall needs assessment and planning of human resources for the country. This function is undertaken in consultation with the national level specialized units and the provinces. However the provinces have the authority to propose cadre changes within the Province but these require the concurrence of the Management Services Division in the Treasury and the Finance Commission. When the Provincial Council seeks new cadre creation, the latter two institutions seek the views of the DDG (P) of the MoH prior to making the decisions. The DDG (P) also maintains the HRH database for the country. An electronic data base which incorporates much of the information needed for HRH planning and management is being organized but is as yet incomplete. The HRH division of DDG (P) currently has very few trained staff who can handle this important function and clearly it needs considerable strengthening if it is to serve as the national focal point for this purpose. The Provincial Councils too are extremely weak in the human resources function and this is an area requiring urgent strengthening. There is concern that the areas and the population under each PHM in many divisions have grown to be too large and is a limiting factor to the further improvement of the MNH services. It would be useful to undertake an analysis of the current functions of the different public health personnel in MCH.FP/MNH. The DDG responsible for Education, Training and Research (DDGET&R) is in overall charge of all pre-service and continuing education. This Unit is also weak; the Deputy Director General 73

position is vacant at the moment and has very few full time permanent staff members to undertake the heavy load of work. FHB has the overall responsibility for supporting the provinces, districts and other institutions in ensuring the technical quality of the MNH program. The current level of engagement of the FHB in MNH HRH planning and management is limited. The technical expertise for HRH planning and management within the FHB is inadequate. It would help to improve the MNH services significantly if the MoH and the FHB assume a greater role in the planning of the human resources as this could improve the numbers, distribution and the overall quality of the health personnel utilized for MNH. Therefore it is important to note that the FHB should have the authority to influence HR planning for MNH at central and provincial levels and adequate funds to enable them to carry out supervisory functions. Annex 6a gives the distribution, both approved and available cadre for MNH service providers by district for the year 2007. The FHB is best suited to review the current roles and responsibilities and the most appropriate mix of MNH staff and suggest modifications. As a case in point the FHB could examine the desirability of utilizing midwifery trained nurses in the delivery rooms in the larger institutions, allowing the movement of the PHM to field duties. Similarly, it could examine the current procedures for the selection of the MOMCH who is the key link between FHB and the field services and is the key person undertaking technical supervision in the districts. One of the overarching issues is the concern regarding the level, the regularity and the quality of supervision in the system. This ranges from the infrequency of the centre providing regular technical supervision and support, to absence of a functioning system of supervision in the field at all levels. Even when there is such supervision, it is observed to be of little value, not being of a problem-solving, educative nature. This has adverse effects on the quality of care. Further more opportunities for practical improvement of the skills of health personnel are lost. The absence of a career development scheme and performancerelated incentives were expressed as two of the most important factors that limit the recruitment and retention of staff of good quality into the MNH program. The career development prospects are limited within the MNH programme itself, and this is evident at all levels. Related to this is the low level of motivation and morale among many of the staff. Even if these were to be considered a 74

generic issue in the health services, the other significant factor is the discrepancy in the recognition and the rewards available between the curative and public health sectors. Often there is a large gap in the remuneration of the staff in these two sectors, and added to the natural attraction of health personnel to work in the more visible curative sector, MNH staffing faces some serious problems. This is true of all categories but is particularly so for the medical graduates and public health nursing staff, as evidenced by the high turnover of crucial staff such as MOMCH and MOH and the limited numbers of nurses wanting to enter public health. The solution to the current problems requires both immediate and medium term measures. While the immediate measures will have to be managerial in nature, to overcome the immediate problems and issues, the medium term measures will need to also address education, training and re-training, continuing professional development and longer term issues related to utilization and performance. They will also have to re-examine the policies and plans that will help to achieve the MCH.FP/MNH human resources goals. 5.2 Planning of human resources for health Recommendations The HRH division of DDG (P) should be strengthened to function as the national focal point for HRH planning and management. Similarly it is necessary to strengthen the HRH planning process at the provinces. The current job descriptions of PHM, PHNS, SPHM, MOH, MOMCH should be reviewed to match and reflect the work that is required of them. A well planned functional analysis of the key MNH health personnel would help to answer these planning issues. Review existing norms for creation of cadre and the approval process as a priority and fill the cadre positions in the areas with wide shortages urgently. Projections of the different categories and cadre revisions should be undertaken at least once in 5 years. 75

Develop an updated HRH database of MNH personnel at the centre, with links to the FHB and to the provinces 5.3 Selection, recruitment and placement Recommendations MOMCH who is the pivotal person at the district level should be selected based on explicit recruitment criteria which includes an interview, and wherever possible, out of those with at least a MSc in Community Medicine. Each province should have a fully qualified Consultant Community Physician under the Provincial Director, who could support and coordinate the MNH work in the area. The midwifery trained nurses should only be posted in the maternity wards and labour rooms and provision for their career advancement as ward sisters should be put in place. 5.4 Pre-placement education and training Recommendations Pre placement training should be mandatory for all who join as MOH. The training should be reviewed and revised to include management skills, and skills in antenatal care, postnatal care, newborn care, FP and BCC should be strengthened. Review all MNH training for its quality and include the national standards and protocols related to MNH. Curricula of the different categories should be reviewed. The knowledge and skills needed to deliver the new tasks such as neonatal care, management of third stage of labour, 76

Adolescent Sexual and Reproductive Health (ASRH), Gender Based Violence (GBV), etc. should be included. A critical review of curriculum for topics that do not add value to the training should be undertaken. The quality of training in midwifery and the field training of the PHM should be assessed regularly. 5.5 Pre-service education of MNH personnel 5.5.1 Field personnel 5.5.1.1 Public Health Midwives 5.5.1.1.1 Curriculum Issues/Findings The pre-service training curriculum does not include many of the tasks currently undertaken by the PHM. The addition of new programmes under the FHB (such as Well Woman s Clinics, Adolescent Reproductive Health, and Women s health) includes tasks to be carried out by PHMs, with recording and reporting of the services provided. The PHM also has a role to play in the control of communicable diseases, mental health and noncommunicable diseases. This role needs to be studied and clearly identified, considering her existing workload. Based on the stakeholder consultations, interviews with trainers and previous assessments, the major curricular areas that need strengthening under MNH are; preconception needs / care, newborn care, management of the third stage of labour, family planning communication skills and counselling. 5.5.1.1.2 Quality of training Issues/Findings The link between Part 1 training (in a school of nursing) and field based Part 2 training (at NIHS and regional training centres) is weak. The quality of midwifery training in Part 1 is not known. It is uncertain whether the training in midwifery and FP in all training sites is based on national standards and guidelines. The quality of Part 2 field training can be improved. Checklists have been prepared by NIHS for monitoring acquisition of skills and 77

knowledge. While teaching aids are available in most schools, the appropriate use of these are not known. Monitoring the quality of the training in Regional Training Centres and the technical supervision by the NIHS is also a concern. The skills of trainers in competency based training, particularly in the field training component needs improvement. The main field trainers are senior PHMs, many of whom have had no training in competency based training methods. Recommendations A comprehensive assessment of the quality of training in midwifery and the field training should be undertaken. The curriculum should be reviewed and the areas identified in section 5.4. and the knowledge and skills needed to deliver the new tasks in areas such as Adolescent Sexual and Reproductive Health, Gender Based Violence, Essential Newborn Care etc. should be included. A critical review of the curriculum for topics that do not add value to the training should be undertaken and such topics be deleted and new topics based on evidence be included. Based on the assessment, the linkages between the two components of training should be strengthened. The clinical training skills of trainers in midwifery should be upgraded. The competence of the field trainers should be developed to impart to trainees skills and attitudes necessary for providing domiciliary care and field based services. Assess the capacity and capability of the nurses' training schools for MNH training with a view to strengthening them. PHMs with the requisite entry qualifications and attitudes should be permitted to proceed to nurses training and have opportunities to be midwifery qualified nurses on an annual fixed quota. 78

5.5.1.2 Supervising Public Health Midwives Issues/Findings The current training for the post of SPHM is deficient and lacks competencies necessary for training, monitoring and supervision Recommendation Review and revise the current selection criteria, and provide training to equip the SPHM for improved monitoring and supervision. 5.5.1.3 Public Health Nurses Issues/Findings There is no regular intake of nurses selected for PHNS training. The training being limited to the NIHS has led to severe shortages of this key supervisory category. The quality of current training is not known. There is a lack of skills in supervision of the PHMs, especially on problem-oriented support, neonatal care, nutrition, communication etc. Recommendations Institute a process of regular intake for training and explore the possibility of using regional training centres for training of PHNS. Review the appropriateness of the current training for the tasks the PHNS is required to perform in the field and strengthen the training program accordingly. 5.5.1.4 Medical Officers of Health Issues/ findings Those who have had NIHS training feel that the training is adequate. However, not all have received NIHS based training before taking up duties. They do not like to go to the NIHS once 79

they take up duties in their respective stations for many reasons. Discussions revealed the need to strengthen their clinical skills in ANC, newborn care, conducting of WWC, planning and management and BCC. No career development prospects have been clearly identified and motivation levels are low. Recommendations Pre-placement training should be mandatory for all who join as MOH. A comprehensive review of training should be carried out to strengthen areas of weakness identified, including the above. 5.5.1.5 Medical Officer Maternal and Child Health Issues/ findings No structured training, either pre service or in service, is available for this key category. Selection criteria are not clear and need to be made explicit. No career development prospects have been clearly stated. Motivation levels are low Recommendations Develop clear selection criteria. Design a pre-placement training programme that includes obstetric and newborn care, family planning, skills in monitoring and supervision including ensuring adherence to national standards, quality assurance, coordination of curative and preventive services for MNH in his/her area including maternal and perinatal death investigations etc. Regular in service training programmes to update technical skills for MNH should be instituted. Career advancement pathways within the MCH sector should be identified for those who have shown an aptitude for this work. 80

5.5.1.6 Medical Officer Public Health (posted in Medical institutions -Base hospital and above) Issues/findings This is a relatively new posting/appointment. No special training has been provided. Current holders interviewed were unaware of their job functions. Recommendation This position needs to be reviewed regarding its usefulness for strengthening public health services. 5.5.1.7 Specialist in Community Medicine Issues/findings The specialist training programme in Community Medicine needs a comprehensive review to strengthen practical competencies in management problems and in coping with MCH.FP/MNH issues. Recommendation Review and revise the curriculum and training activities for specialists in Community Medicine 5.5.2 Institutional services 5.5.2.1 Institutional midwives Issues/Findings The findings given in section 5.5.1.1 for PHM training also applies to the training of the institutional midwives. There is no special training provided to the institutional midwife to manage intrapartum 81

care without supervision, which is needed in the smaller institutions where deliveries take place. Recommendations A pre-placement course should be developed for those midwives posted in small institutions to enable them to provide basic midwifery services, including newborn care until such time that midwifery qualified nurses are posted to these stations. Midwives with the requisite entry qualifications should be permitted to proceed to nurse training on a fixed annual quota and have opportunities to be appointed as midwifery qualified nurses. 5.5.2.2 Midwifery qualified nurses There is a need to determine whether the midwifery qualified nurse should be the key member of the team providing intra and postpartum care for low risk pregnancies/ deliveries. If this decision is made the training of the nurses must be further streamlined, although the current training seems to be adequate and their performance is reported to be satisfactory. Recommendation Review midwifery qualified nurses training with regard to quality, ensuring national standards and guidelines for midwifery as well as care of the newborn. 5.5.2.3 District Medical Officers and Medical Officers in divisional hospitals and peripheral units Issues / findings No special training in obstetrics, FP and newborn care prior to appointment as DMO/MO. Some may not have had postings in Obstetrics & Gynaecology and or Paediatrics during their internship or later. 82

Recommendation Training in obstetrics, newborn care and family planning should be made mandatory for doctors taking up these positions. In addition, the training should include other clinical skills such as management of medical and surgical emergencies. 5.5.2.4 Specialists in Obstetrics & Gynaecology and Paediatrics Issues/findings Specialists in Obstetrics &Gynaecology and Paediatrics do not receive an orientation to national MCH programmes, health trends and the health infrastructure in the country or in the use of national standards and guidelines. They receive inadequate training in the team concept in provision of care, leadership and management. Recommendation Include an interdisciplinary module with inputs from public health and community medicine. Annex 6b summarizes the current situation with regard to the criteria for selection and the elements of the basic training that is being provided to the different categories of MNH related health personnel. It also highlights the currently available promotional prospects for these different categories. 5.6 In-service training Issues/findings Current ad hoc nature of in-service training was the main observation and concern. Even the FHB does not have a consolidated training plan yet. Each unit has its own separate plan and these are not synchronized. Donor funded programmes exert pressure at the centre as well as at the RDHS levels, and distorts both the services as well as the needed training. Training is not coordinated at the central level. Different units conduct their own 83

training programmes with little or no coordination with each other. Most Units including the FHB undertake training of master trainers / trainers. There is little or no monitoring of the quality of training by these trainers at district level and below. The master trainer system does not appear to work properly. Monitoring and evaluation of the quality of training is rare. Recommendations Review of in-service training in MNH, including the role of the FHB in training, management and coordination. A national training plan for various categories should be developed by FHB in consultation with NIHS and the provinces. The role of NIHS in the national continuing education and training plan should be defined in consultation with the other central units. Training skills for trainers and the master trainers at central, provincial and district levels should be regularly updated. Assess the capacity and capability of the in-service training institutions. 5.7 Private sector training Limited information is available with regard to the types and quality of training related to MNH in the private sector. Diverse institutions appear to be conducting training activities at present. There is no central quality control mechanism in place. The Ministry of Health has adopted a Private Health Institutions Bill which vests the Ministry with powers to regulate the quality of the services in the private sector, and this may provide an entry point to also assess the quality of the private sector training activities. Recommendations Curriculum of the private sector training for different categories should be approved by the Ceylon Medical Council (CMC) Examinations should be conducted jointly by private sector and govt appointed examiners. 84

The recently approved Private Medical Institutions Authority should monitor the quality of training in the private sector. 5.8 Supervision and support Recommendation The entire system of supervision should be re-examined and appropriate adjustments made in the training of supervisors as well as the logistics, particularly their mobility, to strengthen the supportive supervision at the different levels. 5.9 Career development, performance and motivation Recommendations The career development opportunities for all health personnel providing MNH services should be examined in the context of overall HRH management Ensure that the public health staff receives at least the equivalent emoluments as their counterparts in curative medicine. In order to raise the level of motivation, arrangements should be made to provide some basic avenues for MNH staff to improve their technical expertise and opportunities for career advancement Chapter 6 85

Cross-cutting Issues 6.1 Behaviour Change Communication (BCC) and gender in relation to MNH This is an important area in MNH that affects both providers and clients of MNH services. The existing status of BCC, in terms of BCC policy, methods used for health education, awareness and knowledge levels of service recipients, and the weaknesses in the current Health Education (HE) system have been reviewed. The role of health education officers as well as the importance of gender, language and socio cultural dimension in planning BCC / HE strategies and communication materials have been reviewed. 6.1.1 Policy Planning and Resource Allocation In the past when FHB launched the Family Health Action Programme (which included MCH), Health Education for MCH.FP/MNH was planned jointly by the Health Education Bureau (HEB) and the FHB. With passage of time deviations began to emerge. Now ad hoc requests are made to the HEB to produce IEC materials for MCH.FP/MNH. Currently there is no national HE strategy for MCH.FP/MNH. With the preparation of a new draft MCH Policy, BCC and community mobilization could be included as two important strategies for implementation at all levels to achieve targets of MCH.FP/MNH. HEB has no budget line for implementation of health education activities and for production of communication materials. These activities are implemented through donor funds. Recommendations Include behaviour change communication as a strategy in the new MCH policy. Develop a national BCC strategy for MNH jointly between FHB and HEB. Develop local BCC plans for MNH based on the national BCC strategy (province, district, division, PHM area) 86

Establish a budget line with seed funding for experimental BCC initiatives and production of prototype BCC materials in support of MNH initiatives. 6.1.2 Health Education Methods Traditional health education approaches characterized by top down an d one way communication methods that deliver prescriptive messages are used widely. The message given to all mothers is the same and does not change according to their needs and circumstances. The Triple A approach (assessment-analysis- action) is not used in planning and delivering health education. Under the triple A approach the communicator is required to (1) assess the knowledge, attitude, skills, behaviours, of the audience (mothers, husbands etc), and (2) analyze this information for deciding what type of knowledge, skills, and motivational messages should be delivered and which communication methods should be used (3) in taking appropriate action i.e. delivery of health education interventions and/or community mobilization actions. A positive aspect however is that PHMs take prompt action when they detect a risk factor in a mother. 6.1.3 Awareness among mothers Knowledge of mothers on ANC and PNC are very high. However principle and concept knowledge is significantly low, most likely due to the traditional health education methods used. As it is difficult to assess main MNH behaviours through the current Review methodology, a simple practice such as taking of iron tablets was selected as a proxy to assess behaviours of mothers. FGD done in the Colombo, Galle, Matara, Nuwara Eliya, Trincomalee, Polonnaruwa and Batticoloa districts showed that nearly one third of mothers take iron tablets incorrectly, indicating weakness of the one-way communication method even regarding a simple behaviour. The behaviours that are crucial to further enhance MNH are the ones that are comparatively complex, as most of them are influenced by social, cultural and economic factors in addition to 87

medical factors e.g. unmet need in family planning. Targeting of health education to specific needs/ circumstances/problems of mothers and their families are crucial to change the complex behaviours. However, the present health education methods do not allow for this flexibility. Recommendations Change the existing health education model to a behaviour change communication (BCC) model. The main characteristics of the proposed BCC approach are(1) developing health education messages appropriate and relevant to particular audience groups (mothers, fathers and families) through an assessment, and analysis of their risks, needs, and circumstances, (i.e. evidence based) and (2) deliver these messages and required skills for changing health behaviour using interactive communication methods. Strengthen the Health Education Bureau in undertaking the process of developing it s institutional capacity to make the transition from HE to BCC. Plan for transition to a behaviour change communication model for MNH and to undertake an integrated planning process for MNH jointly between the HEB and FHB. 6.1.4 Capacity Building Changing from the current traditional top down delivery of generalized blanket messages to all mothers to a more interactive evidence based targeted behaviour change communication approach requires capacity and skill building of PHMs and other relevant staff. Recommendations Short term 88

Train PHMs through a resource pool at district and divisional levels under the technical guidance of the HEB and the leadership of Provincial and Regional Directors of Health Services. Medium term Strengthen the NIHS curriculum on Health Promotion for training of PHMs by adding required content and reviewing training methods. Develop skills of new PHMs to plan and implement simple behaviour change communication approaches at village level. The needs of the Health Education Faculty in NIHS be reviewed and strengthened to train new PHMs on BCC including Triple A methodology. 6.1.5 Role of Health Education Officers (HEOs) Currently HEOs participate directl y in health education activities such as giving health education talks. However their main responsibility should be in capacity building, technical guidance and supervision, planning behaviour change communication, coordinating research and documentation. Recommendation HEOs to coordinate and plan training programmes for PHMs and other caregivers on BCC, and application of Triple A methods, under the guidance of the PDHSs and RDHSs with technical assistance from the HEB and FHB. This process is already underway on an experimental basis under the technical assistance of HEB and with the cooperation of some Provincial Directors of Health. Policy guidelines suggested in the Policy section would strengthen and formalize this initiative. 89

6.1.6 Importance of gender, language and sub-cultural dimensions in planning BCC/HE strategies and communication materials. To date, gender has not been considered as an important factor in planning BCC/IEC. This has to be remedied. The importance of producing IEC materials in the Tamil language is well understood. However, a dearth of competent staff at the HEB has hampered production of quality Tamil language IEC materials. In producing IEC material different approaches have to be taken to meet sub-culture, and /or life style requirements such as for estates, conflict affected areas and internally displaced persons. Recommendations Arrange for gender audit of all communication materials on MNH at the development stage of such communication materials. Enhance the capacity of the HEB in developing communication materials in the Tamil language. Implement BCC/Triple A approaches especially in areas that have heterogeneous populations as well as in areas that have particular sub-cultural traits. Plan separate communication materials for specific geographic areas and disadvantaged groups, e.g. estates, conflict affected areas etc. 6.1.7 Male Participation and gender issues Males in general appear to be ignored by the MNH system with a few exceptions, where responsibility is given to males to play a constructive role as equal partners and support their wives during pregnancy and in the parenting process. Lack of space, inability to provide complete privacy during examination and heavy workload on clinic days were cited as reasons why husbands have not been brought into the programme. However, it was observed that some 90

institutions conduct fortnightly classes for husbands of pregnant women. It was stated by some women that there is a gradual change occurring among husbands towards helping women, (for example with household chores), which has to be nurtured and popularized as a norm. A module on gender and gender-based violence has been included in the pre-service training curriculum of the PHM. The FHB has commenced in-service training of health care providers in gender issues related reproductive health in some districts. The women s health and gender unit of the FHB has been identified as the focal point for this activity. However, the midwives are not yet very comfortable talking about GBV, and family disputes during their domiciliary visits. Recommendations The initiatives to involve husbands in caring for their pregnant wives and in parenting currently implemented through the Early Childhood Care & Development (ECCD) programme should be strengthened and extended to institutional settings with a focus on MNH. Gender sensitisation should be included in the curricula / training of all categories of health personnel. 6.2 Supervision and Monitoring of MNH Programmes Regular supportive supervision is necessary to maintain the motivation of staff and the quality of service. The only category of staff who are supervised to some extent are the public health midwives. However, the quality as well as regularity of this activity is inadequate. Quality of care is often not included in supervision. This is partly due to the fact that supervision largely revolves round routinely collected information where mainly coverage is emphasised. At all levels the word supervision has come to be associated with a top down fault finding procedure. The MOH and MO.MCH are not adequately supervised by the province/district authorities and the FHB. There is no system for recognition of good work. Some of the 91

constraints to supervision identified during the review are: inadequate transport (vehicles and fuel), a lack of supervisory schedules and checklists as well skills in supervision among all levels of supervisory staff. Although there is a mechanism for identification of deficient skills and their rectification within the system this does not seem to function. Monitoring of MNH services/programmes is done using health reports and formats from institutions and field health services. However, reporting of neonatal events needs to be reviewed and revised. All data on Reproductive Health are sent to the FHB for analysis and inclusion in the annual report. A large quantity of data are forwarded to the FHB, with only a minimum amount of data being analysed and used at district and provincial levels. The Annual Health Bulletin as well as the Annual Reports on Family Health from the FHB should be more timely. Recommendations The supervision process should be strengthened. Current indicators which are mainly coverage indicators should be reviewed and modified to include quality of care indicators as well. Pre-service and regular in-service training should be instituted for supervisory staff at all levels to improve their supervisory skills. Standards and checklists for assessment of specific skills both in field staff as well as institutional staff (particularly for those working independently in small institutions) should be developed and procedures for use set up. It is recommended that performance appraisal be introduced and carried out, within a defined interval of time. Negotiated goals to be achieved should be recorded for re appraisal at next meeting. Standards of excellence should be developed and a certificate / letter awarded to midwives (health workers) to motivate persons to deliver high quality services. The latest available Annual Health Bulletin is for 2003 The Annual Report on Family Health is for 2004-2005 92

6.2.1 Management Information System Currently a large volume of data is collected and reported to the centre through a system of registers and returns. Although these registers and returns have been developed to serve as tools for self evaluation and supervision, their actual use for these purposes is very lo w. Information generated for programme management is underutilised at divisional, district and provincial levels. The overall quality of data is difficult to assess and could be improved. The system has no indicators of quality. Since the data processing is done at the central level feed back is not often timely. Recommendations The MIS should be reviewed and the large volume of information that is generated at present should be rationalised with timely feed back to all levels for more effective programme planning evaluation and management for MNH. Indicators for neonatal health should be reviewed to ensure the availability of information essential for programme management and quality assurance. The FHB should receive and concentrate on selected data so as to be able to analyse outcome indicators, quality of care and a few key process indicators at the national level. This should include data generated from both curative and preventive sectors and fed into the national planning, monitoring and evaluation process for MNH. Indicators and data necessary at the level of the province/district should be identified. These should mainly be process indicators with a few key output and quality of care indicators. The information should be analysed and fed into the district/ provincial planning, monitoring and evaluation process. In reorganisation of the MIS, the FHB should work towards an electronic data transfer, analysis and reporting system that would improve utilization of data for planning purposes. 93

6.3 Financing of MNH services 6.3.1 Central level Most of the funds for recurrent MNH expenditure are from the government budget. Capital expenditure for MNH comes from the government budget as well as from donor funding. At present the share of budget for the preventive sector is around 10% of the national budget. The budget for MNH services per se is not estimated separately because MNH services are delivered at all levels of hospitals and at community level. There is underutilization of approved capital funds and foreign aid. National budgeting procedures are changing and are now moving towards a performance based budgeting system. The capacity of the MOH planning unit is limited and hampering the formulation of systematic and rationalized annual budgets. This impedes obtaining adequate allocation for health, including MNH. Recommendations It is recommended that an Economic Evaluation Section be set up within the Planning Unit of the MoH. Appropriate mechanisms be instituted for simplifying release and reporting of donor funds for improving utilization. Absorption capacity should be developed in collaboration with donors. 6.3.2 Provincial level The source of funds for health including MNH comes from block grants, criteria based grants, matching grants and Province Specific Development Grants (PSDG). The secretariat of the Finance Commission is grossly understaffed and the capacity of planning officers involved in the health sector at provincial level is limited. Recommendations 94

It is recommended that capacity be increased by introducing new cadre and providing training in planning and budgeting for MNH services at Institutional, District and Provincial level. Reorient the role of accountant from that of a mere auditing officer to that of a Financial/Resource Manager. 6.3.3 Planning and Budgeting for MNH 6.3.3.1 Family Health Bureau Currently planning and budgeting activities in the Family Health Bureau (FHB) are carried out using the unit as the entity. There are eight technical units in the FHB. Budgeting occurs in two ways: with regard to local recurrent funding the unit determines its expenditure on a line item basis, inflating the expenditure in the case of items such as fuel and stationary to reflect likely changes in price and increased funding needs. However, it is not carried out in a systematic activity based manner. In the case of capital requests systematic budgeting is done, as in the case of foreign aid. In the latter instance however the amount of money involved is sometimes known and the budget is tailored to that sum rather than reflecting needs. Recommendations Capacity of the accountants as well as technical staff at FHB and at district level should be upgraded with regard to preparation of budgets. FHB should prepare an annual activity plan and budget for all planned activities simultaneously, whether funded locally or through foreign aid. 6.3.3.2 Health Education Bureau Sim ilar to the FHB, the HEB too, should prepare annual activity plans and budget for these planned activities in their entirety, so that the budget, as at present should not be merely limited to salaries and day to day running expenditure. This would allow for 95

initiating of innovative health education programmes determined according to national needs and priorities rather than merely have health education programmes that are mainly donor driven. 6.3.3.3 Budget for Maintenance Expenditure Currently maintenance expenditure is often merely inflated by some ad hoc percentage in the course of line item budgeting. No efforts are taken to estimate maintenance expenditure in line with the value of equipment and buildings. Systematic calculation of the depreciation value of each item of capital equipment/buildings (assuming life spans for each individual item) and then summing these values would provide a more realistic estimate for maintenance expenditure. As a capital is purchased or donated this item should be listed in an inventory and the depreciation rate and value determined so that the maintenance budget grows parallel to the institutions ownership of capital. Currently maintenance budgets are insufficient for this purpose and result in long delays in the repair of machinery leading to poor service provision. Recommendation Maintain systematic inventories of capital equipment, vehicles and buildings, with a designated person supervising this activity who will be responsible for the determination of depreciation rates and inclusion of depreciation values for any additions to capital stock to the maintenance estimates in the budget for the following year. 6.3.3.4 Alternative Financing Alternative financing by the public, such as by companies, NGOs and altruistic individuals often provide goods and equipment and maintain hospital buildings. They also support the publishing of health educational material. While such interactions should be encouraged it is of crucial importance that such opportunities are handled ethically, with no room left for the advertising of products in the course of such beneficiary acts. The names of companies could be listed but any visuals or trademarks must be handled in an ethical manner. 96

Recommendation Financing from sources other than the Government should be encouraged. Funds should be obtained for planned activities in a systematic manner and should be monitored and regulated to avoid ethical problems 6.4 Coordination and Partnerships for MNH 6.4.1 Coordination between Centre, Province and District The demarcation of responsibilities at different levels i.e. centre and the province, province and district, is still unclear - for e.g. there is no official equivalent to the MO.MCH at the provincial level and the MO.MCH who is technically responsible to the FHB is administratively under the RDHS. Monitoring and evaluation at the provincia l level is weak and linkages to the centre on the one hand and the district on the other needs to be further strengthened. It is also recognised that the coordination between the relevant directorates including the epidemiological unit, biomedical division and the medical supplies division could be further strengthened to support the province and the district more efficiently. District level networks are found to offer valuable opportunities for creative, innovative and locally-responsive initiatives for the MNH programme, since PHMs usually have good links with local government officials and NGO workers. Links between district health and local government institutions such as municipalities and urban councils remain weak. Recommendations Clarify responsibilities and authority for MNH service provision at different levels and particularly the shared responsibilities between the centre, province and the district. 97

Formal linking mechanisms may need to be established to secure sustainable multi-organizational and multi-sectoral initiatives at national and district level, 6.4.2 Coordination with development partners UNICEF, WHO, UNFPA and World Bank are the main development partners that support the MNH programme. Their contributions to the MNH programme budget are significant. There is a welcome move for developing comprehensive plans at district level under the World Bank, Health Sector Development Project (HSDP), which will help the district authorities as well as partners to identify possible contributions. The MNH inputs in these plans will depend on the priority given by the district and the commitment of the RDHS, MO.MCH and the MO Planning. The district planning process could be facilitated by the FHB through advocacy and guidance on priority areas. While many of these donors retain their priority areas for support, there should be better joint planning both at central and provincial / district levels to make their support more meaningful. The programmes undertaken using funds from the development partners need more co-ordination between all concerned. A common central monitoring system for donor funded programmes would facilitate better coordination with donors and the FHB as well as the provinces and districts. Recommendation Develop mechanisms for joint planning and monitoring of donor funded programmes 6.4.3 Partnership with NGO and other sectors Opportunities exist for partnership with NGOs and other locally appropriate groups/persons, but this is weak due to shortage of necessary skills, interest and a framework for such collaboration, at the provincial and district levels. 98

Decentralization was intended to be accompanied by formal consolidation of communication networks between the government sector and other organizations, to facilitate and enrich health related activities. However, true partnerships have not yet developed in terms of joint goals and objectives, planning, resource sharing, service delivery or co-ordination. Formal coordination mechanisms between the Ministry of Health and across other government ministries are also limited. These limitations have also affected the MNH programme. Recommendation Develop a framework for collaboration with NGOs at provincial and district levels so that NGO activities contribute to MNH outcomes Develop co-ordination mechanism/s between the Ministry of Health and across other government ministries and NGOs 6.5 Linkages with other programmes 6.5.1 Family planning From its inception, family planning services of the country were presented to the community through the PHM as part of the MCH package with emphasis on improving mother and infant health. This contributed much to the acceptance of family planning and the programme is fully integrated within MCH/MNH services. The PHMs remain the first point of contact with couples and their names are entered into an eligible couples register. Thereafter they become service recipients. This may happen immediately after marriage and occasionally even before marriage. In the areas visited the knowledge about contraceptives among women was generally good but was not necessarily linked to practice. Male involvement in family planning was found to be low. The full method mix (cafeteria approach) which is part of the national programme was not available, limiting the choice of contraceptive methods. It was further observed that follow-up of current acceptors of modern temporary methods was poor, often leading to abrupt discontinuation and a subsequent unplanned pregnancy. Accessibility to permanent family planning methods 99

(sterilisation) was limited. There is clearly a need for family planning services to be presented in a more strategic manner, coupled with proper education for behaviour change. Since unmet need in family planning together with high discontinuation rates can result in unwanted pregnancy leading to induced abortion, the family planning services need to be streamlined so as to enable all methods of family planning to be made easily accessible. In this context it should be noted that abortion is a major cause of maternal mortality and morbidity. Recommendations All methods of family planning should be made available in keeping with the cafeteria approach of the national programme. Special attention should be paid to quality of services and increasing access to permanent methods. More attention be paid to implementing strategies to identify those couples with unmet family planning needs and appropriate services provided. Operational research should be conducted to identify reasons for unmet need and circumstances that lead women to seek abortion. Improve strategies for follow-up of current acceptors of modern temporary methods with a view to reducing discontinuation Training for providers of family planning to be undertaken based on the WHO guidelines adapted to suit Sri Lankan needs. In view of the deaths due to abortion, post abortion care and counselling needs to be strengthened based on the recommendations provided in the WHO guidelines. 6.5.2 Nutrition The nutritional status of women is found to be low. Anaemia is prevalent in spite of receiving iron supplementation and de- Low birth weight among infants is around 16.9 % (AHB, worming. 2003) which is still very high. At present the subject of nutrition within the Ministry of Health is fragmented among a number 100

directorates, institutions and units. A well co-ordinated programme for nutrition of women infants and children is of the highest priority. Recommendation It is recommended that nutrition be made an integral component of the MCH.FP/MNH programme. 6.5.3 STI/AIDS control programme As Sri Lanka is a country with a low prevalence of HIV infection emphasis is given to the first prong of the UNICEF/WHO strategy for prevention of parent to child transmission of HIV. Community based health promotion programmes will support prevention of HIV among young men and women. Voluntary counselling and testing is to be promoted and positive women counselled to prevent unwanted pregnancies. Positive antenatal mothers are offered comprehensive package which includes anti- retrovirals, safe delivery and safe feeding interventions. The National STD/AIDS Control Programme (NSACP) provides both preventive and curative services through the centre and its reference laboratory situated in Colombo together with a network of 30 full time and 14 branch clinics distributed island wide. A specialist Venereologist or a medical officer trained in STD/AIDS is in charge of each clinic. The main objectives of the national programme are to interrupt transmission of STD/ HIV and provide care and support for those infected and affected. The interventions identified to provide optimal Maternal & Newborn care are antenatal screening for syphilis, prevention of parent to child transmission of HIV, behaviour change communication and counselling. In addition syndromic management of STI is being promoted at primary health care institutions and in locations where STD services are sparse. Incidence of infectious syphilis is low and the rate reported for the year 2004 was 0.67 per 100,000 population. Almost 98% of antenatal mothers have been screened for syphilis, yet, only 68.2% of tests are carried out in the government laboratories. In order to eliminate congenital syphilis steps should be taken to strengthen services to achieve 100% coverage through the government sector. In 2003, the VDRL positivity rate was 2.2% (AHB 2003) which includes biological false positives. Specific treponemal tests are carried out in STD clinics to confirm syphilis and the mothers are treated according to the stage of syphilis. 101

Recommendations There is a need to Increase the coverage of antenatal VDRL screening in the government sector through joint efforts by the NSACP and FHB. Reporting of antenatal VDRL testing from all MOH areas to be enhanced and monitoring and evaluation improved through identified indicators PPTCT activities to be Integrated into the Maternal and Newborn care package offered to all antenatal mothers ( at all stages : curricula, training, services) PPTCT care package offered to all antenatal mothers should be addressed at all stages of training with curricula changes. MO/STD should actively support the PHC staff to eliminate congenital syphilis and paediatric HIV infection in addition represent the NSACP at MCH performance reviews in provinces / districts. The Director NSACP and FHB should co-chair a steering committee for Sexual Reproductive Health and HIV/AIDS 6.5.4 Health Education Heal th promotion is an integral component of the MCH.FP/MNH package. This requires close collaboration between the FHB and the HEB. At provincial and district level the HEOs should work in closer collaboration with the MO.MCH and MOHs and their field staff. It is noted that health education / communication materials are produced centrally and sometimes the messages have scant relevance to local socio- cultural and behavioural patterns. In this context the HEB/FHB should involve the provincial / district service providers in presenting the message in a locally appropriate manner to suit provincial / district needs. A detailed analysis and recommendation on BCC is presented in section 6.1 Recommendations It is recommended that the existing health education model be changed to a Behaviour Change Communication model. 102

Health education messages be appropriate to the needs and the socio-cultural differences of provinces / districts. 6.5.5 Communicable and Non-communicable diseases Sri Lanka is undergoing an epidemiological transition. The Epidemiology unit of the Ministry of Health monitors the occurrence of the communicable diseases and implements the Expande d Programme of Immunisation (EPI) in the country in close collaboration with FHB. The success of the programme related to MNH is shown in the near elimination of neonatal tetanus, military TB, TB meningitis and control of congenital rubella syndrome While communicable diseases still continue to be of concern, non communicable diseases like diabetes, cancer and cardiovascular diseases are on the increase. Heart disease complicating pregnancy was seen to be the second commonest cause of maternal death in 2004 (ARFH, 2004-5). Out of a total of 145 maternal deaths, 25 were due to heart diseases. Of these 16 were due to valvular conditions which should have been detected pre pregnancy or at the booking visit and appropriate management strategies taken. Prevalence of diabetes is increasing. Early detection of diabetes in pregnancy and management of the diabetic mother and newborn with follow-up thereafter, is an area that needs coordination between the obstetrician, physician and neonatologist / paediatrician. Recommendation An integrated holistic package of care to deal with increasing trends in non communicable diseases in women of the reproductive age group and specifically during pregnancy and the puperium needs to be developed and implemented. Sustain the EPI programme in relation to MNH 103

6.5.6 Psychological illness related to pregnancy Psychological illness in the pregnant and postpartum mother is an area that the current MNH services are ill equipped to address. The extent of the problem is also not known. Recommendation A study needs to be carried out to document the extent of the problem and develop appropriate strategies in collaboration with the mental health programme of the MoH. 6.6 Linkages with other sectors 6.6.1 Local government (Colombo Municipal Council) The Municipality health services are headed by a Chief Medical Officer and assisted by 4 deputies, one position being the deputy Chief Medical Officer, Maternal and Child Health. Services delivered through six MOH areas, 13 Child Welfare Clinics (CWC) as well as 7 maternity homes that provide antenatal, postnatal, FP and WWC and child health services. About 30 % of the public health budget is spent on MCH and covers a population of about 690,000. CMC depends on the MoH/FHB for recording and reporting formats and FP supplies. However, links with other units such as the HEB is poor. MCH clinics provide antenatal, postnatal, FP, WWC and child health services. Maternity homes have provision for deliveries and are managed by a MO.MCH, nurses and midwives. Each of the maternity homes has a laboratory that carries out haemoglobin estimation, blood grouping and urine for albumin, sugar and microscopy. Pregnant mothers are seen at the antenatal clinics by prior appointment and the coverage is around 80%. About 8-10% of the deliveries in the area take place in maternity homes while the rest take place in two large government teaching hospitals that provide maternity care, situated within the CMC limits. Referral system as well as access to tertiary care facilities is good. 104

There is acute shortage of human resources. Although the specified cadre is 122 PHMs currently there are only 87 in position. Twenty one midwives are posted in the seven maternity homes. The cadre for nurses is 53, however only 30 are in place, 4 are PHNS and of the other 26, 20 are midwifery trained. Only 5 out of the 12 MO.MCH have had exposure to obstetrics and gynaecology during internship or later. Maintaining of seven maternity homes is not cost effective and there are plans to reduce the number. The population per PHM is large and quality of care is lacking. Supervision is weak. Opportunities for training of staff is not provided compared to that in the MoH. There is no technical support, training or guidelines provided by the MoH. Recommendations Consider PHM providing care only in the low income settlements, the rationale being: (a) the well to do hardly use the CMC clinics (b) PHM can provide quality domiciliary care to the poor (c) convenience to the community of receiving quality care closer to home To ensure provision of good quality domiciliary and clinic services the supervisory cadres should be increased. It is recommended that the MO.MCHs who are in charge of maternity homes should have experience or in-service training in delivery and newborn care. The CMC should explore possibilities of providing specialist services even on a part time basis. Closer links with FHB to be established. 6.6.2 Private sector The private sector plays a significant role in MNH service delivery. Almost 50% of the spending in health are out of pocket expenses of the consumer. The Government has overall responsibility to ensure that patients are protected and receive quality care. In this context the MoH has a Director in charge of private medical institutions and the government has also brought in a Private Medical Institutions Act for regulation of services in the private 105

sector. Consideration also needs to be given as to how best partnerships between state and private sectors are encouraged to deliver quality services and contribute to the national MNH goals. Recommendations It is recommended that the Act be implemented without delay and utilized for accreditation of facilities. A suitable reporting system be developed so that data from the private sector forms a part of the national health statistics. Develop and test out models for public - private partnership in MNH. 6.6.3 Plantation (Estate) sector It is one of the under served sectors of the country due to its historical origins, often remote location, difficult terrain, and sociocultural behaviour patterns. MNH related morbidity and mortality of the sector are higher than in the other sectors. The accessibility, availability and quality of service is found to be wanting compared to the rest of the country. A feature of the sector is that the labour force is more than 50% females being involved in different processes in the tea and rubber industry. Historically the health services in the estate sector were provided by the plantation companies with in-patient curative care being provided through linkages with the government medical institutions within the district. Following the Land Reform Law in 1971/1975, the estates came under the control of government. Special organisational structures were set up for the management of estates with their own social development divisions that had the responsibility for supervising provision of health care. Currently the Plantation Human Development Trust (PHDT) which has seven regional offices, oversees implementation of health services in the estates, with funding for services provided directly by the companies. Health programmes funded by UN agencies are channelled through the PHDT. At present there is a process whereby estate health services are being integrated with government health services in the districts. A new directorate was created in the MoH in June 1998, to implement the government policy. Estate medical institutions are being gradually taken over by the provincial councils and managed 106

as government medical institutions. Field health services provided by estate midwives, (a category where there is a severe shortage) are also being gradually integrated with the MOH services in the district. There have been significant improvements in the utilisation of trained cadres for maternal care during the past two decades. The proportion of mothers delivering in a medical institution has increased from 60% in 1985 to 98% in 2003. This has led to a significant reduction in maternal mortality in this sector, however, maternal mortality still continues to be higher than in other sectors. In spite of the recent initiatives accessibility and utilisation of services remain below the national level due to difficulties in terrain, transport and socio-cultural behaviour patterns. It is hoped that integration of the health services with that of the rest of the country will further improve the quality and access to MCH.FP/MNH care. Recommendations Quality and capacity of human resource and facilities needs to be improved to be on par with the rest of the country. The absorption and utilization of staff who have been working in the estate sector for a long time be integrated in such a way that optimises partnership between the estate health services and the government health system. 6.7 Operational Research and utilization of evidence based policies and strategies: The contribution of operational research and the evaluation and utilisation of research findings towards improvement of MNH services/programmes seems to be weak. There are several important issues that need operational research; for example: The question of what an optimum population for a PHM should be if she were to carry out extended functions. 107

Cost effectiveness and acceptance of evidence based models for improved focused antenatal care should be tested and tried in the Sri Lankan context and used if found suitable. Use of appropriate technologies in newborn care; factors contributing to low birth weight; and cause and prevention of anaemia in pregnancy; are some other areas in which operational research could be undertaken for improving MNH service provision. Evidence based standards, guidelines and protocols for aspects of MNH care which are available internationally could be adopted and tested regarding suitability for use in Sri Lanka. The process of adaptation and validation for Sri Lanka and the lessons learnt should be documented and disseminated. Recommendations Identification and regular review of MNH priorities for operational research and facilitating necessary research should be a function of the FHB and DDG/ETR Utilization of results and models in updating MNH policies and strategies. 108

References 1. Annual Health Bulletin 1998 Ministry of Health Sri Lanka 2. Annual Health Bulletin 1999 Department of Health Services, Sri Lanka 3. Annual Health Bulletin 2000 Department of Health Services, Sri Lanka 4. Annual Health Bulletin 2001Department of Health Services, Sri Lanka 5. Annual Health Bulletin 2002Department of Health Services, Sri Lanka 6. Annual Health Bulletin 2003 Department of Health Services, Sri Lanka 7. Annual Report on Family Health Sri Lanka, 2000, Evaluation Unit, Family Health Bureau, Colombo 8. Annual Report on Family Health Sri Lanka, 2002 2003 Family Health Bureau, Ministry of Health, Sri Lanka 9. Annual Report on Family Health Sri Lanka, 2004 2005 Family Health Bureau, Ministry of Health, Sri Lanka. 10. Assessment of Anaemia & status in Sri Lanka, A survey Report, 2001, MRI Ministry of Health 11. Fonseka WAAP. A study on the quality and coverage of death certification in a district of SL. MD thesis. 1996, PGIM Colombo. 12. Medium Term Plan on Family Health, 2007-2011 Family Health Bureau, Ministry of Healthcare & Nutrition, Sri Lanka 13. Maternal Mortality decline, The Sri Lankan Experience, UNICEF, 2003 14. National Health Accounts Web site: http://www.who.int/nha/country/lka.xls 15. Sri Lanka Demographic Health Survey 2000 Department of Census & Statistics 16. Sri Lanka Human Development Index UNDP, 2006 109

Acknowledgements The review team wishes to acknowledge the support received from the national, provincial and district health staff, participants at the stake holders meeting and focus group discussions, key informants, all health care personnel who provided information in the institutions and field sites visited and specially the health care recipients who contributed to the data gathering process. The readiness with which they entered into frank and open discussions with the review team enriched the data gathering process and is much appreciated. The team wishes to thank the Hon. Minister of Healthcare & Nutrition, staff of the Ministry and the Family Health Bureau for the ready cooperation extended. We thank the Review Coordinating Committee and its Coordinator for the preparatory work that was carried out and for providing the team with all necessary assistance and documentation. The technical, financial and logistic support provided by the WHO is acknowledged. The UNFPA and UNICEF provided technical and financial support. This is appreciated. A special 'thank you' to Ms. Marina Jayasinghe for secretarial assistance and Dilip Hensman of the IT section of the WHO, Colombo is extended. 110

ANNEXES 111

Annex 1 112

Annex 1 Contd. 113

Annex 2 Organizational framework for the review The Coordinating Committee The review process was initiated by the GOSL by appointing a Review Coordinating Committee comprising of local persons with experience and sufficient expertise, to coordinate the review process, facilitate and serve as resource persons if necessary to address any queries or problems that may arise in the course of the review The coordinating committee comprised of members from the MoH at policy and operational levels, provincial health ministries, professional colleges, university academics, and UN partners. This coordinating committee met regularly to formulate the review proposal and the ToRs of the team leader and the team. In addition, the committee in consultation with the GOSL selected and obtained approval for the members of the review team members. The review was supported by the UN partners viz. UNICEF, UNFPA and WHO. The overall organizational framework for implementation of review is given in chart 1 Composition of Review Team The review team comprised local and international experts in the filed of Maternal and Newborn Health (MNH) with expertise in the following areas: Strategic programme planning, health systems and policy development, Financial management, of health services, Behaviour change communication (BCC) Gender Obstetrics Nursing and midwifery Neonatology, Quality of Care, Management Information System (MIS) Maternal and perinatal deaths audit and review 114

Chart 1 Annex 2 Contd. Organizational Framework for Implementation of Review Review Coordinating Committee Composed of representatives of Government at policy and programme level Professional societies and colleges Community physicians Representative from academic institutions Representatives from UN partners External Review Team National & International Composed of representatives of Experts on MNH, Gyn/Obs, Neonatologists Health System, HRH, Health Economists BCC, Gender Health Policy Planning Nursing Midwifery Team Leader Responsible to WHO Representative and Coordinating Committee Sub Teams Health System MNH Services and Intervention Cross Cutting areas 115

Lists of names of the members of the Review Co-ordinating Committee, national and international experts are given below; LIST OF REVIEW CORDINATING COMMITTEE (RCC) MEMBER DESIGNATION Annex 2 Contd. MoH Members de Silva Dula Dr. DDG(PHS) II de Silva Terrence Dr. DDG (MS) Mahipala P.G Dr. DDG(PHS) I de Silva Dharma Ms. D/Nursing, Medical Services Provincial MoH Members Indrasiri Upali H.R. Dr. PDHS / WP FHB Members Karunaratne Vineetha. Dr. D/ MCH Programme Manager, MCH/FP de Silva Chithramalee Dr. CCP/ FHB Attygalle Deepika. Dr. CCP/ FHB Programme Officer Fernandopulle Sudarshini. Dr. CCP /FHB Moonesinghe Loshan. Dr. CCP /FHB Godakandage S.P. Dr. MO /FHB Jayasundera Chamanthi. Dr. MO /FHB Academical Institutions Fernando Dulitha Prof. Prof.Community Medicine/ Dean, Faculty of Medicine Professional College Members de Silva Srilal Dr. Vice President SLCP Jayawardena Pushpa Prof. President SLCCP Senanayake Lakshman Dr. President SLCOG UN Organisations UNICEF Aberra Berkely Dr. UNICEF, Programme Officer (left) Sapumal Danapala Dr. Asst. Programme officer UNICEF (left) Monjur Hossain Dr. UNICEF, Programme Officer Yakandawala Harrischandra Dr. Asst. Programme Officer, UNICEF UNFPA Galwaduge Chandani Dr. NPO/UNFPA WHO Borra Agustino Dr. WHO Rep. Sarweshwar Puri Dr. TO/ WHO Jayatileke Anoma Dr. NPO /WHO, Coordinator Hakamies Nina Ms. JPO / WHO Manikarajah Sarojini Dr. Consultant Coordinator of the committee 116

EXPERT REVIEW TEAM Annex 2 cont. International Dr. Suniti Acharya (Team leader) Prof. Atanu Kumar Jana, Dr. Nynke Van Den Broek, Prof. David Lawrence Woods Dr Saramma Thomas Mathai, Prof. Kanittha Volrathongchai Ex WR, Regional Advisor, MCH, WHO SEARO (Retired) Neonatologist, Christian Medical College & Hospital, Vellore, Tamil Nadu, Obstetrician & Gynaecologist, Liverpool School of Tropical Medicine, UK Neonatologist, University of Cape Town, and Groote Schuur Hospital, South Africa Regional Advisor, RH Services UNFPA Nursing & Midwifery, Khon Kaen University, Thailand Local Prof. Lalani Rajapakse, Professor in Community Medicine, Faculty of Medicine Colombo Prof. Harsha Seneviratne, Professor in Obstetrics & Gynaecology, Faculty of Medicine Colombo Dr Palitha Abeyakoone Regional Advisor, WHO SEARO (Retired) Advisor MoH Dr. U. Susantha de Silva, Ex DDG P, WR WHO (Retired) Dr. N.W, Vidyasagara, Regional Advisor, MCH, WHO, SEARO (Retired) Dr. Maxie Fernandopulle, Consultant Paediatrician (Retired) Dr. M.D.P Goonaratne, Consultant Obstetrician and Gynaecologist (Retired) Dr. Amala de Silva, Economist Dr Sepali Kottegoda, Sociologist Dr Lakshman Wickremasinghe, BCC Expert, Ms Vishaka Thillekeratne Nutrition Expert 117

Annex 2 Contd. CONCEPTUAL FRAMEWORK OF THE REVEW CONTEXT & RATIONALE Theme I Health System Structure and Functions Infrastructure Decentralization /devolution Financing Public / Private Service Provision Organizational capability Human resource Supervision & Referral Theme II MNH Services and Interventions Antenatal care Intra natal care Postpartum New born Basic & Critical care Linkage to RHFP/PAC/STI Services to Disadvantaged groups Quality of Care Theme III Cross Cutting Areas MIS/Monitoring/evaluation Reviews and audits BCC Gender including the role of males & family members Partnership and coordination Operational Research RECOMMENDATIONS 118

Annex 2 Contd. 119

Annex 3 List of background documents used for desk review 1) A profile of women seeking abortion 2) Action Plan- Sri Lanka's Population & reproductive health policy 2000-2010 3) Annual Health Bulletin 2002 4) Annual Health Bulletin 2003- Dept of Health services in Sri Lanka 5) Annual Report on Family Health in Sri Lanka 2000-6) Annual Report on Family Health in Sri Lanka 2002-2003 7) Annual Report on Family Health in Sri Lanka 2004-2005 8) British Medical bulletin Series of expert reviews Pregnancy Reducing Maternal death & disability. Pages 85-98 9) Building and other guidelines for Neonatal intensive care Units 10) Circulars file 11) Curriculum PHM Training Part II 12) Estimates of induced abortion in urban & rural Sri Lanka 13) Guidelines for Organization & Management of labour rooms 14) Health Master Plan in Sri Lanka - 2007-2016 15) Health Master Plan in Sri Lanka - Master plan brochure Nov. 2003 16) Instruction Guidelines for use of MCH Forms 17) Investing in Maternal Health Learning from Malaysia & Sri Lanka 18) Macroeconomics & Health Initiatives Sri Lanka 19) Manual of Management for District Hospitals, Peripheral Units & Rural Hospitals 20) Manual of Management for Provincial Directors 21) Manual of Management for Teaching Hospitals & Base Hospitals 22) Manual on Management of Divisional Health Services based on PHC 23) Maternal and Perinatal death review / audit reports and minutes 2003-2004 24) Maternal Deaths in Sri Lanka- Review of estimates & causes 1996 25) Maternal Mortality Decline- the Sri Lankan Experience UNICEF 26) Maternal Mortality reduction in Sri Lanka WHO 2003 27) Medium Term plan of Family Health 2007-2011 28) Millennium Development Goals in Sri Lanka 29) MIS forms file 120

30) Mother Baby Unit- Central Engineering and Consultancy bureau March 2006 31) National Plan of Action for the children of Sri Lanka 2008-2012 32) Needs assessment study- Women's right to life and health projects in Sri Lanka - Opportunities & challenges 33) Perinatal & Neonatal Mortality- Some aspects of Maternal & Child health in SL 1986 34) Population & Reproductive Health Policy 1998 35) Poverty Transition & Health- A Rapid health system analysis - March 2002-36) Review of National Response to Sexually transmitted infections and HIV/AIDS in Sri Lanka 37) Safe Motherhood Programme in Sri Lanka 38) Sri Lanka Demographics Health survey 2000 39) Sri Lanka Demographics Health survey Northern & Eastern Provinces 2001 40) Sri Lanka Health Atlas- WHO 2003 41) Sri Lanka Poverty Assessment Engendering Growth with Equity: 42) Technical guide on management of emergency obstetrics at peripheral hospitals 43) WHO Country Cooperation Strategy 2006-2011 CD's 1. Health Master Plan 2007-2016 MoH 2. Annual Health Bulletin 2003- MoH 3. Sri Lanka Health Atlas - WHO 4. National Guide lines MoH 121

Stakeholder Workshop List of Participants and Grouping Annex 4 a Group : Health Systems Group Participant Designation Subgroup A Dr. N. Jayathilake Addl.Secretary MS MoH Health System Dr Sanath de Silva PDHS SP Dr. H. Edirimanne RDHS Galle Dr. N. Thalagala CCP (CH II) FHB Dr. S.C. Warusavithana MOMCH Matara Dr. Haritha Aluthge MOH Deraniyagala Dr. Mrs. S. Ganesan Paediatrician Batticaloa Dr. A. Shanthi PDHS CP Sub Group B Dr. K. Nanthakumaran PDHS EP Dr. K. Eeshara MO(Pl.) MoH Dr. (Mrs.) U.K.D. Piyaseeli D/NIHS Human Dr. Chandrani Jayasekera DD/T NIHS Dr. A.W. Rajapakse MOH Kadugannawa TC, CP Resources Ms. N.A.R. Nettasinghe Tutor MNH NTS Dr. NIlani Fernando MOMCH (Kandy) Dr. Jayarajah J. Lilani MOMCH Vavuniya Dr. M.A. Badra Chandanie CCP/MO Galle Dr. A.M. Jahfar MOH - Akkaraipattu Mr. P.K.S.P. PHM Ratnapura Sub Group C Dr. Amitha Sumanasekera Asst. Provincial Secy. Uva Finance Dr. Shelton Chandrasiri PDHS Uva Province Dr. M. Thevarajan PDHS - EP Dr. S. Smarage DDG (Pl.) MoH Dr. V.T.S.K. Siriwardene RDHS - Moneragala Dr. I. S. Jayasinghe RDHS - Ampara Dr. Chithramalee de Silva FHB CCP(M&E) Dr. R.P.S.Rajapakse MOMCH - Hambantota Dr. S. Dhanapala CCP- CP Group: Cross cutting areas Sub Group A Dr. U.A. Mendis DGHS - MoH Decentralisation Dr. V. Jeganathan Consultant NE Recovery Dr. H.R.U. Indrasiri PDHS - WP & Devolution Dr. A. Ketheswaran RDHS - Jaffna Dr. W. A.K. Wijesinghe RDHS - Kegalle 122

Dr. Shanthi Gunawardene D/Nutrition Coordination MoH Dr. Jaseel Elahi MO/MCH - Kalmunai Dr. L.R. Liyanage MOMCH Colombo Dr. Jagath Elvitigala CCP (Planning) - Kegalle Dr. P.K.C.L. Jayasinghe D/Hospital - Ampara Dr. A.M.S.W. Bandara D/Hospital - Anuradhapura Dr. J.M. Jayathilake MOMCH - Polonnaruwa Dr. H.M. Fernando Consultant PHDT Sub Group B Dr. Dula de Silva DDG (PHS) II MoH Reviews, audits, Dr. A. Bandara Obstetrician- Nuwara Eliya Dr. C.S.T. Nanayakkara Neonatologist - CSHW MIS. Monitoring Dr. R. Rajamanthri D/Hospitals Col. NTH Dr. Geethika Amarasinghe MOMCH - Kurunegala & supervision Dr. C.M. Jayalath MOH - Kalutara Ms. Naleema Marikkar RSPHNO - Kegalle Ms. M.M.A.J. Ariyalatha Sp.Gr.Obs/PBU Sister Mr. H.B.M.S.M. Herath PHNS - Badulla Ms. Manel Gamlathge SPHM - Kalutara Ms. K.M.W.K. Senevirathne PHM - Matale Sub Group C Dr. Sarath Amunugama D/HEB - MoH BCC & Special Dr. Uma D/E & UH - MoH Dr. S. Wijemanne VOG / FHB groups Dr. N. Mapitigama CCP / FHB Dr. D.M.C.K. Dissanayake MOMCH - Matale Dr. G.S.K. Garusinghe MOH - Hataraliyadda Mr. K.S. Jayatissa HEO - Badulla Mr. Chula Metananda HEO - Galle Ms. M.J. Gnanaseelan SPHM - Vavuniya Ms. H.H. Chandralatha SPHM Kurunegala Ms. G.L.M.A.H. Perera RSPHN Kurunegala Group: Health Services & Intervention Sub Group A MNH services Sub Group B Dr. Kapila Kannangara Dr. G. Gnanagunalan Dr. Deepika Attygalle Dr. U.R. Sirimanne Ms. D.M. Kusum Ms. S.A. Chitra Ms. L.G. Banduwathie Dr. C. Wickremasinghe Ms. Theramirthathevie PDHS Sabaragamuwa RDHS Trincomalee CCP / FHB MOH Kurunegala PHNS Kurunegala SPHM Ratnapura PHM Galle Neonatologist, Kandy N/O Trincomalee 123

Ms. K.N.M. Mudannayake Ms. H.M.R. Senaratne Mrs. S. Anandamoorthy Dr. G.K.C. Guruge UN PARTICIPANTS PBU Obs. Nuwara Eliya NO Paediatric Ward PHM - Vavuniya SLCP Representative Dr. Harrischandra Yakandawala Dr. Chandani Galwaduge Dr. Anoma Jayathilake Ms. Nina Hakamies UNICEF UNFPA WHO WHO 124

Annex 4b LEVELS OF KEY INFORMANTS INTERVIEWED Po licy Level i Central & Provincial Ministry of Health Treasury Budget Unit Finance Commission Minister of Health Secy. Health Addl. Secy. Health (MS) DGHS Provincial Minister of Health Provincial Secy. Healt Policy Level ii DDGPH S DDGMS DDGP Colour Code Operational Lev el D/MCH Provincial DHS C/Epidemiologist RDHS Central Provincial, District & Division Treasury Others MOMCH MOH Director TH Director DGH MS BH DMO / MO / IC Service Delivery Level Supervisory Staff - PHNO Obstetricians Paediatricians Medical Officers Matron, Sister NO, MW Community Level PHM Client Others UN Agencies Professional Colleges 125

Field Sites Visited Annex 4 c Colombo Ministry of Healthcare & Nutrition: Hon Minister of Healthcare & Nutrition Secretary, Ministry of Healthcare & Nutrition Addl. Secretary, Ministry of Healthcare & Nutrition DGHS, DDGPHS, DDGMS, DDGP FHB CSHW CMC PDHS/ WP RDHS / Colombo MOH Padukka Durdens Private Hospital Galle Provincial Health Minister (SP) Provincial Secretary of Health Services (SP) PDHS /SP TH Mahamodhara Matara RDHS / Matara MOH Akuressa BH Kamburupitiya Trincomalee RDHS / Trincomalee DGH Trincomalee BH Kantalai Pollonaruwa RDHS / Trincomalee DGH Pollonaruwa MOH Lankapura MOH Welikanda Batticaloa RDHS / Batticaloa TH Batticaloa MOH Valaichchenai BH Valaichchenai 126

IDP Camps & resettled village Nuwareliya RDHS / Nuwareliya DGH Nuwareliya DH Rikiligaskada DH Maskeliya MOH Maskeliya Estate Hospital High Forest ( Govt) Estate Hospital Labookalle 127

128

Annex 5a Current Distribution of Approved & Available Cadre for MNH Service Providers by Districts for Year 2007 RDHS **MOH ap MOH AMOH - ap AMOH PHNS ap PHNS SPHM-ap SPHM PHM-ap PHM PPA-ap PPA 1.Anuradhapura 19 19 19 5 21 4 22 19 286 263 2 2. Badulla 15 14 11 17 15 8 18 18 235 234 12 3. Batticaloa 9 11 12 1 13 11 11 10 174 126 15 4. Ampara 5 7 7 1 8 6 11 6 113 92 4 5. Kalmunai 12 13 14 2 13 5 13 4 128 109 9 6. Colombo 12 12 22 22 43 33 20 2 362 319 11 7. Colombo M.C*. 0 0 0 0 0 4 4 147 87 0 8. Galle 16 16 13 10 17 7 18 0 323 300 12 9. Jaffna 11 0 12 0 11 1 18 6 194 95 4 10. Kilinochchi 4 2 3 0 3 1 3 1 48 25 2 11, Kalutara 10 9 10 12 24 22 19 3 260 268 8 12. N.I.H.S.* 2 2 2 8 16 10 3 0 80 81 1 13. Kandy 21 24 26 15 27 20 22 20 448 433 25 14. Kegalle 10 11 11 10 11 9 15 9 301 267 12 15. Kurunegala 18 23 28 24 33 32 29 22 399 429 24 16. Matara 14 15 13 11 14 5 13 0 258 278 17 17. Matale 10 11 13 5 11 8 14 14 159 149 9 18. Polonnaruwa 8 6 7 9 7 5 7 5 125 101 4 19. Puttalam 9 9 12 11 12 7 8 4 181 166 10 20. Ratnapura 15 16 20 13 16 9 21 10 329 316 9 21. Vavuniya 4 3 4 4 5 2 4 0 43 30 2 22. Mannar 4 2 4 0 5 0 4 0 50 13 4 23. Monaragala 10 9 8 9 10 4 10 7 168 162 8 24. Gampaha 14 14 24 28 45 30 18 0 475 413 14 25. Nuwara Eliya 7 8 8 6 7 5 7 7 256 198 8 26. Trincomalee 11 9 9 2 12 2 12 1 130 76 3 27. Hambantota 10 10 10 7 10 5 10 1 216 211 7 28. Mullaitivu 2 3 5 0 3 0 6 9 52 15 2 TOTAL 280 278 327 232 412 251 360 182 5940 5256 238 Source: FHB, ** AHB 2003 * Not separate RDHS divisions ap= approved cadre 129

Category of MNH service provider PHM Institutional midwife Annex 5b Current Criteria for Selection & Elements of Basic Training of Different Categories of MNH Service Providers & Scheme of Promotion Entry qualification A level (reduced to O level temporarily for North and East) Duration of training 18 months Main subjects covered Part 1: 12 months: Midwifery, nursing skills---- in Nursing schools Part 2: 6 months: Supervised field practice in home visiting in designated field areas attached to RTCs/NIHS Link between Part 1 and 2 same same Same (No extra preplacement training in midwifery) SPHMs PHM with 12-15 yrs of experience PHNO Nurses with -5 years of experience Midwifery qualified nurses Nurses with 6 months of experience Additional 3 months 18 months Supervision / management 6 months in post-basic midwifery in Nursing schools 12 months in public health in NIHS Supervi sory respons ibility Promotional ladder None SPHMs after 12-15 years of service. Few with requisite basic education can proceed to training in nursing same Supervise s 10-12 PHMs, compiles three monthly HMIS Supervise s PHMs in a MOH area (10-20 PHMs) 6 months Midwifery Supervise s midwives posted in institution s Same as above None RSPHNO / Matrons Ward sister (but not necessarily in midwifery) 130

Category of MNH service provider Entry qualificati on Duration of training Main subjects covered Supervisory responsibility Promoti onal ladder MOH MBBS 8 weeks in NIHS Public Health Management PHNS, SPHMs, PHMs Variable MOMCH MBBS No special training RDHS MO PH (posted in Medical institutions Base hospital and above) MBBS with Masters in Administrat ion or Community Medicine MSc, MD in community medicine None National programmes of MCH/FP Technical supervision of PHNS, SPHMs and PHMs & Medical institutions in MCH Supervises the district health services and staff Variable Variable None Not clear Variable Specialists (Obs., &Gyn., Paediatrics) Specialist in Community Medicine MS MD Specialist training (MS) Board certification & 1 year foreign training Specialist training MSc-1 year MD-3 months Part 1-1year & 9 months ; Part 2; 1year foreign - Clinical staff in wards - Variable 131

PDHS Masters in Administr ation or Communi ty Medicine training - Part 3 No special training - Supervises all the health institutions under the province 132