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District Planning Tool for Maternal and Newborn Health Strategy Implementation A practical tool for strengthening Health Management System District Planning Tool for Maternal and Newborn Health Strategy Implementation A practical tool for strengthening Health Management System WHO Library Cataloguing-in-Publication Data District planning tool for maternal and newborn health strategy implementation. 1.Community health services - organization and administration. 2.Maternal mortality 3.Infant mortality. 4.Maternal health services - organization and administration. 5.Perinatal care. 6.Health planning guidelines. 7.National health programs - organization and administration. 8.Developing countries. I.World Health Organization. ISBN 978 92 4 150097 5 (NLM classification: WA 310) © World Health Organization 2011 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorderw@who.int) Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). 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 concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization 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 World Health Organization be liable for damages arising from its use. Printed in Geneva v Table of Contents 1. 2. Introduction 1 1.1 The need for Maternal and Newborn Health (MNH) planning tool 1 1.2 Purpose of this district planning tool 3 Section I: Context: Why do mothers and babies die? And what can be done about it? 4 2.1 Prevalence of maternal mortality (MMR) 4 2.2 Causes of maternal deaths and disabilities 4 2.3 Perinatal deaths 5 2.4 Social and economic determinants of MNH 5 2.5. Failure of districts to provide required care for women and babies 6 2.6. What can be done to reduce maternal and newborn deaths and disabilities? Strategic MNH actions 3. 6 2.7. National Public Health Planning Framework 11 Section II: District planning framework for MNH 12 3.1 District planning process for MNH 12 3.1.1 Who should get involved? ‘Participatory approach’ 12 3.2.1 How to lead district planning process: Establish a core team 12 3.2 Key steps for MNH planning process 13 3.2.1 Step 1: MNH situation analysis 13 3.2.2 Step 2: Analyse causes of identified MNH problems 16 3.2.3 Step 3: Select priority problems 17 3.2.4 Step 4: Setting goals 17 3.2.5 Step 5: Develop strategies and set objectives 18 3.2.6 Step 6: Select activities to strengthen MNH services 19 3.2.7 Step 7: Resource needs estimate for MNH activities 20 3.2.8 Step 8: MNH action plan 21 3.2.9 Step 9: Monitoring and evaluation plan 22 3.2.10 Step 10: MNH plan approval and Advocacy 26 4. Conclusion 28 References 29 Annex A 1. Workshop Preparation 31 1.1. Introduction 31 1.2. Objectives 31 1.3. Expected result 31 1.4. Target audience 31 1.5. Orientation approach 31 District Planning Tool for Maternal and Newborn Health Strategy Implementation vi 1.6. Facilitation techniques 31 1.7. Instructional materials, supplies, venue, timetable 33 1.8. Roles & responsibilities 34 2. District planning process for mnh: from planning to action 35 Step 1: MNH situation analysis 36 Step 2: Analyse causes of identified problems 38 Step 3: Select priority problems 39 Step 4: Set goals 40 Step 5: Develop strategies and set objectives 41 Step 6: Plan activities 43 Step 7: Resource needs estimate for mnh activities 44 Step 8: Define mnh action plan 46 Step 9: Develop a monitoring plan 47 Step 10: MNH plan approval and advocacy 49 Annex B B-1: Summary of DPT - MNH steps 51 B-2: Situation analysis: proposed generic questionnaire for data collection at district level 52 B-3: SWOT analysis framework 54 B-4: Example of costing checklist 55 B-5. Shortlist of indicators for global monitoring of Reproductive Health 56 Glossary 57 Tables Table 1. Major causes of maternal deaths and key interventions to effectively prevent or treat them 7 Table 2. Major causes of neonatal deaths and key interventions to effectively prevent or treat them 7 Table 3. Major causes of stillbirths and key interventions to effectively prevent them 8 Table 4. Concepts of monitoring and evaluation 23 Boxes Box 1: Definition of a skilled birth attendant 8 Box 2. The concept of continuum of care 9 Box 3. Self-care provision for MNH 9 Box 4. Sri Lanka’s Success in Reducing Maternal Mortality 10 Box 5. Key components of MNH situation analysis 15 Box 6. Problem tree: Technique for cause analysis of health problems 16 Box 7. Tree diagram (MNH quality of care) 16 vii Box 8. Examples of District MNH goals 18 Box 9. ‘SMART’: Required criteria for a clearly stated objective 18 Box 10. Examples of district objectives for MNH 19 Box 11. Example: Monitoring skilled attendance at birth indicator 25 Box 12. Example. Shortlist of indicators for district monitoring of Reproductive Health 25 Box 13. Example of district plan outline for MNH 27 Figures Figure 1. Causes of maternal deaths world-wide 4 Figure 2. Example of Gantt chart 21 Figure 3. Conceptual framework of healthcare system: Implementation levels 24 Acronyms AIDS Acquired immune deficiency syndrome ANC Antenatal care CBR Crude birth-rate CPG Core Planning Group DP District planning FIGO International Federation of Gynecologists and Obstetricians GPG General Planning Group HC Health centre HIV Human immunodeficiency virus HMIS Health Management Information Systems HRH Human resources for health ICM International Confederation of Midwives IMCI Integrated Management of Childhood Illnesses MDGs Millennium Development Goals M&E Monitoring and Evaluation MIP Malaria in Pregnancy MMR Maternal mortality ratio MNH Maternal and newborn health MOH Ministry of Health NGO Non-governmental organization PMTCT Prevention of Mother – to – Child Transmission of HIV PRSP Poverty Reduction Strategy Paper STIs Sexually transmitted infections SWAp Sector Wide Approach SWOT Strengths, Weaknesses, Opportunities and Threats TB Tuberculosis TBA Traditional birth attendant TT Tetanus toxoid WHO World Health Organization District Planning Tool for Maternal and Newborn Health Strategy Implementation viii Acknowledgement This tool is based on country experiences and has been prepared to support World Health Organization (WHO) staff assisting countries in district level planning for Maternal and Newborn Health strategy implementation. The World Health Organization expresses appreciation to the Kenya Ministry of Health and Sanitation and The Tanzania Ministry of Health and Social Welfare for their valuable feedback from field-testing of the initial tool. Thanks are due to the many people who provided comments during the writing and reviewing of this document in the World Health Organization, particularly colleagues from the Department of Making Pregnancy Safer (MPS) and focal persons at regional and country levels. Maurice Bucagu, MPS, coordinated development and writing of this document. 1 1. Introduction 1.1 The need for district planning tool: MNH plan to make things happen No issue is more central to global well - being than maternal and perinatal health. Yet every day, 1,600 women and over 5,000 newborn (0 – 28 days) die due to complications, arising from pregnancy, childbirth and postnatal period, which could have been prevented. It is in this context that in 2000, the international community agreed on a vision for the world future which was translated into eight Millennium Development Goals (MDGs) to be achieved by 20151. Effective knowledge and tools exist to help reduce maternal and newborn suffering and death. And experience has shown that available interventions are affordable and can be effectively delivered even in the poorest countries. However, to be able to make a difference, they must reach all the mothers and their babies where and when they need them2. To date, in the context of MDG framework, most of the countries with high burden of maternal and newborn mortality and morbidity have developed national strategies / roadmaps towards reduction of maternal and newborn mortality and morbidity. Their specific objectives are to provide skilled care during pregnancy, childbirth, and postnatal period, at all levels of the health care delivery system and to strengthen capacity of Individuals, Families, and Communities to improve MNH. However, as reported in the 2008 Countdown report ‘…very few countries are making progress reaching women and children with clinical care services, such as skilled care at delivery…postnatal care is an especially important gap in the first week of life when mothers and newborns are at the highest risk’3. Most of the countries are currently implementing proposed strategies, but concerns are raised about the slowness of the process as well as the weak translation of proposed strategies / Road Maps objectives and targets into concrete actions at all levels, to be able to effectively reach all beneficiaries. Countries that have successfully managed to make pregnancy safer have the following three things in common: Firstly, policy–makers and health care managers were informed. They were aware that they had a problem, knew that it could be tackled and decided to act upon that information. Secondly, they chose an adequate strategy that proved to be the right one: not just promotion of antenatal care, but also skilled care at and after childbirth for all mothers and their newborns, by skilled midwives, nurse or doctors, backed up by hospital care. Thirdly, they made sure that access to required services – financial as well as geographical – is guaranteed for the entire population. Where information is lacking and commitment is hesitant, where strategies other than quality facility childbirth care are chosen or where universal access is not achieved, positive results are delayed. MNH services will be more likely utilized by women in need if they meet the following essential requirements: MNH services are essential during pregnancy, childbirth and postnatal period. Women will be more likely to use MNH services if these are accessible, affordable, culturally acceptable and of high quality. The most dangerous period for mothers and newborns is around the time of birth. Yet the timing of childbirth is unpredictable and happens at all times of day and night. So, MNH services, to effectively assist childbirth, need to be available 24 hours a day and 7 days a week. Even when services are available, some women may not be able to use them. In fact, District Planning Tool for Maternal and Newborn Health Strategy Implementation 2 some women, due to cultural barriers, do not seek assistance outside their home, because birth is seen as ‘life event’ to be dealt with inside the family. Available evidence suggests that adolescent pregnant women and those with unwanted pregnancies are less likely to use MNH services and to have poor maternal and newborn outcomes. Estimates suggest that 40% of all under – five deaths are neonatal deaths, of which many are preventable. Care services for the newborn have been often neglected. More specific attention needs to be given to essential and life saving health care for newborns at district level. MNH services may be used as entry point for other essential health services for the mother and her baby, such as: Prevention of neonatal tetanus; Prevention of mother – to – child transmission of HIV/AIDS; Distribution of bed nets to fight against Malaria etc. The country context may also affect provision and use of MNH services: Health sector reforms have been introduced in many countries (e.g. Sector Wider Approach ‘SWAp’ in African countries such as Malawi, Congo, Rwanda and Zambia etc) to improve efficient use of available resources for health, to increase availability and access to health services, including those for maternal and newborn survival. It is important for health planners and managers to be aware of how key MNH issues can be addressed and integrated into on – going or future reforms in their countries. They should also be able to inform those responsible for health sector reform of bottlenecks relating to access, provision and use of quality MNH services. Decentralization. While in many countries, national Ministries of Health make national health policies and coordinate provision of maternal and newborn health services, decentralization requires districts to make planning decisions and to implement MNH activities. As a result, districts now have more responsibility for setting their own priorities and managing their own budgets. Districts are therefore expected to be more accountable to their local populations for the quality of health services provided. Need for integration. Countries with high burden of maternal and newborn mortality and morbidity face competing demands for health services and have limited resources. To some extent, more can certainly be achieved by integrating MNH plans with those from other key health programs, such as HIV/AIDS (Prevention of Mother -To - Child Transmission of HIV), Malaria (Malaria in Pregnancy), nutrition, child health etc. A further reason for integrating services is that the number of health personnel available in many countries is currently limited, particularly in rural areas. For management effectiveness in this situation, available staff is required to work in an integrated way. And this integration needs to be adequately planned for and implemented at all levels (service provision, supervision, M&E etc). Intersectoral collaboration: To achieve required improvement for all, in maternal and newborn health outcomes, there is need for the health sector to collaborate and coordinate with stakeholders from other sectors (e.g. education, water and sanitation, gender, transport & communication as well as civil society organizations etc) that also have a role to play in MNH at district level. Empirical evidence has also shown that less than one third of African countries with the highest burden of maternal and newborn mortality and morbidity have district planning process in place. So, for all the above mentioned reasons, there is great need for MNH planning tool that would provide managers and planners, both at national and district levels, with practical tips for analysis, planning and effective implementation of evidence – based MNH essential interventions. 3 1.2 Purpose of this district planning tool for MNH Goal: The aim of this tool is to provide national and district health managers / planners with practical resources for planning and implementation of MNH health services towards making pregnancy safer. It is intended to be short and practical for anyone who is responsible for MNH programme management and all stakeholders at district level. Specific objectives: Users of this tool should be able to: Describe different steps for MNH planning process; Apply appropriate methodology for MNH situation analysis; Apply appropriate techniques for data collection, analysis and use for MNH plan development; Develop action plan for proposed MNH interventions; Develop M&E plan for MNH services at district level. Expected results: This planning tool should provide necessary tips and skills for health managers / planners to develop plans for effective implementation of national MNH strategy. Additionally, skills acquired should help to use efficiently and effectively available resources and to strengthen management capacity both at national and district levels. Content: This planning tool (PT - MNH) has 2 sections: Section I provides technical overview on prevalence and causes of maternal and newborn deaths and disabilities; and highlights strategic directions for improving maternal and newborn health. Section II describes the key 10 steps required for the proposed district planning framework for MNH. Throughout the document, the reader is directed to other available resources, including WHO tools and guides, which provide more detailed information on various issues addressed.