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National Maternal New born and Child health Programme

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Title: National Maternal New born and Child health Programme


1
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National maternal newborn child health punjab
3
  • MDG 5. Reduce by three quarters, between 1990
    and 2015, the maternal mortality ratio
  • MATERNAL HEALTH INDICATORS
  • 1) MMR
  • 2) SBA
  • 3) CPR
  • 4) TFR
  • 5) ANTENATAL COVERAGE

4
Indicators Definitions 1990-91 2001-02 2006-07 2007-08 2008-09 MTDF Target 2009-10 MDG Target 2015
Maternal Mortality Ratio No. of mothers dying due to complications of pregnancy and delivery per 100,000 live births 533 350 276 na na 300 140
Proportion of births attended by skilled birth attendants Proportion of deliveries attended by skilled health personnel (MOs, midwives, LHVs) 18 40 37 40 41 60 gt90
Contraceptive prevalence rate Proportion of eligible couples for family planning programmes using one of the contraceptive 12 28 29.6 30.2 30.8 51 55
5
Indicators Definitions 1990-91 2001-02 2006-07 2007-08 2008-09 MTDF Target 2009-10 MDG Target 2015
Total Fertility Rate Average number of children a woman delivered during her reproductive age 5.4 na 4.1 3.85 3.75 2.7 2.1
Proportion of women 15-49 years who had given birth during last 3 years Proportion of women (15-49) who delivered during the last 3 years and received at least one antenatal care during their pregnancy period from either public/private care providers 15 35 53 56 58 70 100
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Goal of the program
To reduce maternal and child deaths and
illnesses by improving their health status
particularly of the poor and the marginalized.
8
Objectives
Sr. No Indicators Base Line (PDHS survey 2006-07) Current Status (MICS 2011) MDG Target 2015
1 Under Five Mortality Rate 97/1000Lb 104 45
2 Newborn Mortality Rate 58/1000Lb Figure not available 25
3 Infant Mortality Rate 81/1000Lb 77 40
4 Maternal Mortality Ratio 227/100000Lb Figure not available 140
5 of deliveries attended by skilled birth attendants at home/ Health Facilities 38 59 gt90
6 Contraceptive Prevalence Rate 33 35 55
9
DETERMINANTS OF MATERNAL SURVIVAL IN PAKISTAN
  • GENERAL (SOCIOECONOMIC AND CULTURAL FACTORS)
  • A) Poor hygiene and sanitary conditions
  • B) Unsafe drinking water
  • C) Poverty
  • D) Low literacy (Female)
  • E) Low level of Health awareness
  • F) Urban Vs Rural disparity regarding
    development and provision of resources
  • G) Poor nutritional status of mother

10
DETERMINANTS OF MATERNAL SURVIVAL IN PAKISTAN
(Contd)
  • H) Mothers age and parity
  • I) Interval between births
  • J) Level of women empowerment
  • L) Natural disasters

11
MATERNAL HeaLth Challenges BOTTLENECKS
APPLICABLE TO ALL MATERNAL HEALTH INTERVENTIONS
  • Facility Level
  • Staff absenteeism Frequent postings / transfers
  • Gender and skill imbalances
  • Urban -Rural disparities for availability of
    health professionals
  • Lack of clearly defined referral mechanisms
  • Inappropriate locations
  • Poor maintenance of Health Facilities
  • Insufficient funding and issues of supplies
  • Management issues including supervision
    monitoring
  • Non availability of necessary equipment,
    medicines and supplies

12
MATERNAL Health Challenges BOTTLENECKS
APPLICABLE TO ALL MATERNAL HEALTH INTERVENTIONS
  • Community Level
  • The most underserved pockets of population still
    not covered by Lady Health Workers (60
    coverage)
  • Insufficient availability of skilled birth
    attendants
  • About 48 of the deliveries being conducted by
    TBAs,
  • Community Midwifery program recently introduced.
    Currently 6000 CMWs trained but there are
    deployment issues
  • Low confidence in public health facilities
  • Socio-cultural diversity coupled with low
    literacy and lack of awareness resulting in
    inappropriate behaviors and practices related to
    maternal health

13
EFFECTS ON VARIOUS OUTPUTS DUE TO DETERMINANTS
AND BOTTLENECKS
  • A) LOW SBA RATE
  • B) LOW LEVEL OF ANTENATAL COVERAGE
  • C) T.T IMMUNIZATION COVERAGE FOR PREGNANTS IS
    LOW
  • D) LOW CPR AND HIGH TFR
  • E) HIGH PREVELENCE OF ANEMIA
  • F) LOW REFERRAL RATES OF COMPLICATED CASES
    DURING ANTENATAL AND AT THE TIME OF DELIVERY
  • G) LOW PROPORTIONATE OF ASSISTED VAGINAL
    DELIVERY AND C-SECTION VS NORMAL DELIVERY IN
    HEALTH FACILITIES
  • H) HIGH INCIDENCE OF SEPTIC ABORTIONS

14
ESSENTIAL ELEMENTS OF MATERNAL CARE.
  • Care Before Pregnancy
  • HTSP
  • Family Planning
  • Improved Nutrition
  • Care During Pregnancy
  • Maternal immunization for tetanus toxoid
  • Nutritional support (including iron and folate
    supplementation)
  • Birth planning including transportation
  • Counseling on breast feeding
  • Recognition of danger signs and treatment or
    referral as needed
  • Where appropriate
  • - Presumptive malaria treatment
  • - Syphilis screening and treatment
  • - Voluntary counseling and testing for HIV

15
  • Care During Childbirth
  • Skilled birth attendance at delivery
  • Clean delivery hand-washing, clean space,
    clean cord care
  • Recognition of danger signs (for mother) and
    treatment or referral as needed

16
  • Continued Routine Visits with a Trained Health
    Care Provider
  • Early postnatal visit
  • Recognition of danger signs (e.g., fever) for
    mother with treatment or referral as needed
  • Post partum family planning

17
TEN STEPS FOR MAINSTREAMING MATERNAL HEALTH IN
THE SYSTEM
  • WHO has made these recommendations for making
    maternal health a viable program area at the
    country level
  • 1. Specify specific goals for reduction in
    maternal mortality rates.
  • 2. Write and adopt a national policy supporting a
    countrywide maternal health strategy.
  • 3. Conduct advocacy among multiple partners at
    the highest levels to mobilize resources.
  • 4. Adopt a country strategy providing options for
    programs in districts with different health
    infrastructures and mortality situations

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TEN STEPS ----Contd
  • 5. Mainstream maternal health through
    coordination between maternal and child survival
    and other health areas, as well as cooperation
    with other sectors.
  • 6. Develop partnerships among governments, NGOs,
    professional bodies, academia, and developmental
    partners at regional and country levels.
  • 7. Establish universal registration of births and
    deaths. Reach consensus on key indicators for
    maternal health. (Use these data for supportive
    supervision within the health system.)
  • 8. Include key indicators within national surveys
    and national health management information
    systems.
  • 9. Strengthen maternal care capacity through
    systematic training, skills development, and
    logistics.
  • 10.Conduct operations research to establish an
    evidence base for innovative programs

19
Financial Status
Year PC-1 Allocation PC-1 Allocation Releases Releases Releases  
Year Original Revised GOP DFID TOTAL TOTAL Expenditure
2006-07 21.871   - - - -
2007-08 1341.461   92.75 - 92.75 71.852
2008-09 2454.234   127.2 628.708 755.908 425.089
2009-10 1534.538   99.676 350.416 450.092 347.624
2010-11 1413.047   205.962 - 205.962 500.939
2011-12 1323.469   424.824 169.591 594.415 496.502
Total 8088.621   950.412 1148.715 2099.127 1842.006
2012-13 - 1457.186 571.227 829.072 1400.299 233.631
20
Note
  • 1- The released amounts has been mentioned in
    the year when these were released from the
    Finance Department Govt. of the Punjab.
  • The end of 2011-12 26 fund (Rs. 2099.127 M) were
    released against total allocation of Rs.
    8088.621 M.
  • The Govt. of Pakistan decided to continue funding
    till June 2015 _at_ funds released in 2010-11.
    Revised / New PC-I (2012-15) having total cost
    3558.180 Million is under the process of approval
    at CDWP.
  • DFID share Rs. 642.026 Million per year (One Year
    allocation up to 2014 is already available in
    program for the year 2011-12 released 2012-13)
    GOP (PSDP) share Rs. 544.034 million per year up
    to 2015.
  • 356 Million of DFID, 136.017 Million of GOP under
    the process of release from Finance Department
    Punjab

21
INTRODUCTION OF A CADRE OF CMWS TO INCREASE
SKILLED BIRTH ATTENDANTS (sbA) RATE
22
Community midwives
Target 6346 Total Recruited 5717
Passed Out 4367 Deployed CMWs 3947
23
Provincial CMWs Performance (Jan - Jun 2013)
24
CIVIL WORKS 1) COMMUNITY MIDWIFERY
SCHOOLS / HOSTELS 2) RENOVATION WORKS IN DHQ
HOSPITALS 3) RENOVATION WORKS AT THQ HOSPITALS
25
Status of Civil Work and Renovation Works in DHQs, THQs, under National MNCH Program, Punjab Status of Civil Work and Renovation Works in DHQs, THQs, under National MNCH Program, Punjab Status of Civil Work and Renovation Works in DHQs, THQs, under National MNCH Program, Punjab Status of Civil Work and Renovation Works in DHQs, THQs, under National MNCH Program, Punjab Status of Civil Work and Renovation Works in DHQs, THQs, under National MNCH Program, Punjab Status of Civil Work and Renovation Works in DHQs, THQs, under National MNCH Program, Punjab
CMW School CMW School CMW School CMW School CMW School CMW School
Sr Target Approved Completed In Progress Still Not
1 34 33 27 5 1
Note 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13. Note 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13. Note 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13. Note 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13. Note 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13. Note 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13.

DHQs Hospital DHQs Hospital DHQs Hospital DHQs Hospital DHQs Hospital DHQs Hospital
Sr Target Approved Completed In Progress Still Not
1 34 33 26 4 3
Note 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13. Note 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13. Note 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13. Note 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13. Note 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13. Note 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13.


THQs Hospital THQs Hospital THQs Hospital THQs Hospital THQs Hospital THQs Hospital
Sr Target Approved Completed In Progress Still Not
1 76 63 46 4 13
Note 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13. Note 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13. Note 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13. Note 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13. Note 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13. Note 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13.
26
PICTURES OF RENOVATION WORKS
THQ Hospital, Haroonabad
DHQ Hospital Bahawalnagar
THQ Hospital Mankera
THQ Hospital Shahpur
27
PICTURES OF CMW SCHOOLS
CMW SCHOOL ATTOCK
CMW SCHOOL BAHAWALNAGAR
CMW SCHOOL JHELUM
28
TRAININGS
29
Training Details
Type of Training Duration Staff Target Progress
IMNCI 11/07 Days Doctors, LHV, Disp. , Nurse /Staff Nurse , MT/HT/FMT 7464 1647
IMNCI (TOT) 05 Days Doctors/Consultant /Pediatrician /Gynecologists etc 7464 174
EmONC 12 Days WMO, Gyneo, LHV, 6698 515
Basic EmONC 06 Days Nurse /Staff Nurse 6698 515
ENC 04 Days Doctors, CMW Tutor Principal, LHV, Nurse, CMWs 1200 468
MIS Software 02 Days PHSs, SOs, COs   138
MNCH MIS Tool 02 Days CMWs, LHSs, LHVs   5109
CMW Tutor TOT 01 Month CMW Tutor   99
Revised CMWs Curriculum 04 Days CMW tutors, Clinical Instructors, Gynecologist, WMO,   114
30
Provision of 24/7 comprehensive and basic emonc
services
31
STANDARDS FOR BASIC AND COMPREHENSIVE EMOC FOR A
FACILITY TO MEET THESE STANDARDS, ALL SIX OR
EIGHT FUNCTIONS MUST BE PERFORMED REGULARLY AND
ASSESSED EVERY THREE TO SIX MONTHS. BASIC EMOC
FUNCTIONS PERFORMED IN A HEALTH CENTRE WITHOUT
THE NEED FOR AN OPERATING THEATRE IV/IM
ANTIBIOTICS IV/IM OXYTOXICS IV/IM
ANTICONVULSANTS MANUAL REMOVAL OF PLACENTA
ASSISTED VAGINAL DELIVERY REMOVAL OF RETAINED
PRODUCTS
32
COMPREHENSIVE EMOC FUNCTIONS REQUIRES AN
OPERATING THEATRE AND IS USUALLY PERFORMED IN
TEHSIL/DISTRICT HOSPITALS ALL SIX BASIC EMOC
FUNCTIONS PLUS CESAREAN SECTION BLOOD
TRANSFUSION
33
01 comprehensive 500,000 population 4
basic 500,000 as per standard
required comprehensive 190 basic 760 cur
rent situation comprehensive 127 basic 41
9 gaps comprehensive 63 basic 341
  • As per WHO, UNICEF UNFPA standards
    Comprehensive Basic EmONC services are required
    as follows

34
Progress on output level indicators (Output 1)
  • 24/7 Comprehensive Emergency Obstetric and
    Neonatal Care (CEmONC) Services

Target Progress Comments
All DHQ Hospitals to provide comprehensive EmONC services . All 89 THQ hospitals to provide comprehensive EmONC services. All DHQ Hospitals are providing Comprehensive EmONC services. All THQ Hospital are providing Comprehensive Basic EmONC services except the following. Attock (Hazro) Bahawalpur (Khairpur) Bhakkar (Kallor Kot, Mankera Darya Khan) Sialkot (Pasror) Khushab (Nosherah, Nur Pur Thal) Jhang (Shorkot, Ahmad Pur Sial) Lahore (Shahdra) Mianwali (Esa Khail, Kala Bagh Piplan) Multan (Jalal Pur Pir wala) Pakpattan (Arif wala) Rawalpindi (Murree) Most of the THQ Hospitals have no Anesthetist and Blood Transfusion Units. Some THQs are providing Comprehensive EmONC services without Gynecologist, BTOs and Anesthetist with local adjustments / alternates.
35
Progress on output level indicators (Output
1)
24/7 Basic Obstetric and Neonatal Care (BEmONC)
Services
Target Progress Comments
291 RHCs of Punjab All RHCs are providing 24/7 Basic EmONC services.
36
Procurement of logistics
37
Progress on output level indicators (Output 3)
  • Procurement of IT Equipment for
  • 1. MCH Cell 36
  • 2. Nursing Schools 26
  • Procurement of Furniture for
  • 1. MCH Cell 36
  • 2. Hostel / Classroom Furniture 26
  • Procurement of Transports
  • 1. Toyota Van 52
  • 2. Jimny Jeep 36
  • Procurement of Medical Equipment.
  • 1. CTG Machines 52
  • 2. CMWs Kits 3000
  • Procurement of Teaching Aids for School of
    Nursing.
  • 1. Midwifery Training Material 30 Sets
  • Procurement of Medicine for 11 Districts.
  • Procurement of Safe Delivery Kits for 36
    Districts.
  • Procurement of Printing Material
  • 1. IMNCI Books 2. EmONC Books
  • 3. CMW Tools 4. CMW Manual

38
Problems and issues
39
PROBLEMS/ ISSUES 1) RELATED TO PROGRAM
  • 2) CHALLENGES FACED BY THE CMWS
  • Insufficient training, CMW Tutor issue
  • Procedural Issues in Deployment and
    Certification
  • Inadequate skill sets and referrals
  • Financial issues
  • Mobility and security problems
  • Acceptance by the communities
  • Lack of Coordination with the other service
    providers
  • De-motivation

40
3) Problems related to establishment of basic and
comprehensive emonc centers 1) accessibility
issues 2) human resource related issues
(availability/ training) 4) Problems related to
human resource 1) difficult to retain on low pay
package as compared to counterparts 2) demand
for permanent job
41
Solutions
42
  • RECOMMENDATIONS
  • In light of all the problems described above, the
    following remedial measures are suggested
  • 1. Community integration for better uptake
  • 2. Improve Skill-set
  • 3. Clearer Job Descriptions and Coordination
  • Health Facility Linkages
  • 5. Alternate financial viability models
  • 6. Revisit the CMW Strategy

43
  • WAY FORWARD
  • CONTINUATION IN THE TRAINING PROGRAM OF CMW--- TO
    INCREASE COVERAGE UPTO 5000 AS WELL AS URBAN
    SLUMS AND INCREASING THE OVERALL POOL OF SBAs
  • INCREASING THE NUMBER OF BASIC EMOC AND
    COMPREHENSIVE EMOC CENTRES (RHS Model), THEIR
    EVEN DISTRIBUTION, UTILIZATION RATES IN DEALING
    COMPLICATIONS AND STRENGTHENING THEIR REFERRAL
    LINKAGES
  • PREPARATION OF TRAINED HUMAN RESOURCE IN
    PROVIDING MCH SERVICES.
  • PROMOTING THE CONCEPT OF TASK SHARING
  • INCENTIVE BASED PACKAGES
  • STRONG POLITICAL COMMITMENT AND INTERSECTORAL
    COORDINATION

44
  • WAY FORWARD (Contd)
  • 7) MOBILE RURAL AMBULANCE SERVICES
  • 8) MIS SYSTEM WITH PROPER ANALYSIS AND FEEDBACK
  • 9) INTRODUCING HEALTH FACILITY BASED MATERNAL
    DEATH AUDIT AND ITS REVIEW, STRENGTHENING VERBAL
    AUTOPSY
  • 10) PROVISION OF SERVICES IN INTEGRATED FORM

45
WAY FORWARD Contd------ 11) SUPPORTING EVIDENCE
BASED, COST EFFECTIVE AND HIGH IMPACT
INTERVENTIONS e.g. Assuring availability of
antibiotics, Oxytocics, IV fluids and
Oxygen Infection prevention Use of Misoprostol
and Magnesium sulphate
46
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