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Flash CS Bangladesh.Indd Country Case Study B A N G L A D E S H T R A I N S HEALTH WORKERS TO REDUCE MATERNAL MORTALITY GHWA Task Force on Scaling Up Education and Training for Health Workers SUMMARY BACKGROUND INFORMATION Medical doctors and nurses in Bangladesh are Plans to employ and retain the emergency concentrated in urban secondary and tertiary obstetric care providers were embedded in hospitals, while 70% of the population lives the EmOC initiative, which included a bonding in rural areas. This situation has created a period at designated facilities after training. major challenge for the national health system, However, by the end of 2007, the government particularly for reducing the high maternal had reached only 60% of its training target, and mortality rate, with fewer than 20% of births funding for the initiative had decreased. Without being attended by a skilled birth attendant. To increased investment and training capacity, it address this issue, the Prime Minister signed would be difficult to sufficiently staff all services. the Declaration of Safe Motherhood in 1997. A In addition, the attrition rate, both within and number of national programmes and strategies, after the bond period, was about 35%. Major such as the Health and Population Sector challenges were faced in attracting medical Programme (1998-2003), the Health Nutrition and officers, particularly females, to work in remote Population Sector Programme, and the National rural areas, where working conditions are poor Strategy for Maternal Health of 2001, further and there is no clear path for career advancement supported this declaration. after training. The government created two nationwide At the community health worker level, family human resource development plans: (1) to train welfare assistants and female health assistants emergency obstetric care (EmOC) teams to work are being trained in a six-month, competency- in district and subdistrict hospitals (medical based course for community-based skilled birth officers and nurses), and (2) to train 17,000 attendants, and are then certified and registered skilled birth attendants to work at the community by the Bangladesh Nursing Council. level by 2015. The Directorate General of Health Services manages the two complementary Skilled birth attendants are being trained by initiatives. However, due to limited government an array of partners through projects that have budgets, education and training activities require to be institutionalized into relevant training significant technical and financial support from a institutions. At the same time, Nursing Institutes large number of international partners. continue to produce direct-entry nurse-midwives, who have limited roles in midwifery services. The training approach evolved throughout the Efforts are needed to link these initiatives to EmOC initiative. Medical officers were initially the national health strategy with the goal of sent to Nepal for training, while capacity was improving the education, training and placement built in Bangladesh. After developing nationally of these cadres of workers. accepted curricula, Bangladesh medical college hospitals took over the training of emergency To strengthen management capacity, a joint plan care providers. Midway through the initiative, a was developed in 2007 between the Government shorter, 17-week, competency-based course was of Bangladesh and WHO to conduct training introduced to train emergency care providers courses for programme managers at all levels of in teams; and an orientation programme was the health system, as well as provide quarterly launched for facility managers, with an overriding monitoring and supervision visits to service objective to institutionalise competency-based providers of maternal and newborn health. training. 2 SUMMARY BACKGROUND INFORMATION For many years, Bangladesh’s public health to reduce the maternal mortality rate by 75% by system struggled to provide skilled birth 2015, complying with the MDGs, and to ensure attendants to assist with normal deliveries and access to reproductive health services to all. to have the capacity to refer complicated cases to hospital for often life-saving emergency obstetric Data from surveys indicated high levels of care (EmOC). From 1993 to 1997 the importance mortality and morbidity, and low coverage of EmOC gained support from professional of services. In 1993 there was only one bodies, women’s rights activists, development comprehensive EmOC centre for every 3.4 million partners and key policy makers. During this people, with centres mainly located in urban, period the UNFPA, UNICEF, WHO, the European district hospitals and staffed with medical Union and other development partners supported consultants in obstetrics, gynaecology and government projects to establish EmOC services. anaesthetics. In subdistrict hospitals, medical On May 28, 1997, the Prime Minister signed the officers and nurses delivered specialised care, Declaration of Safe Motherhood highlighting the but were not generally trained or experienced in need to focus on reducing maternal mortality and EmOC. More than 82% of pregnant women gave violence against women and calling for action birth without a skilled birth attendant present. In and commitment of resources to address the 2000 the maternal mortality ratio was estimated issues. In 2000, the government committed itself at 320 per 100,000 live births, representing more to the Millennium Development Goals (MDGs) than 30 deaths among pregnant women every to reduce maternal and child mortality, and has day. reiterated this commitment through various policy, strategy and planning documents. Due to the very high burden of maternal death and inadequate service provision, the The period following 1998 marked the beginning government launched the Women’s Right to of more concerted scaling up of efforts, with Life and Health Initiative (WRLH) in 2000, with a plan designed for establishing EmOC within the aim of reducing maternal mortality through the Health and Population Sector Programme the provision of comprehensive EmOC in the (1998-2003) and Health, Nutrition and Population country’s district and subdistrict hospitals. Sector Programme, the sector-wide approach The four-year initiative was implemented by adopted by the government to improve the the Directorate General of Health Services in overall health situation of the country. collaboration with UNICEF and the Averting Maternal Death and Disability Programme at Three major milestones were: 1) the formulation Columbia University. and approval in 2001 of the National Strategy for Maternal Health in Bangladesh, which aims to Major areas of activity within the WRLH included strengthen the provision of essential (including renovation of facilities, in-service training emergency) obstetric care and improve the of medical officers, nurses and laboratory utilisation of services; 2) the Interim Poverty technicians, supply of necessary equipment and Reduction Strategy of December 2002, which logistics, including strengthening of the health reaffirmed the obligation to reduce maternal management information system, improvement of mortality; and 3) the 2004 Poverty Reduction emergency readiness and quality of care. Human Strategy Paper, which expresses a particular goal resources development was one of the initiative’s 3 major activities. Training activities were designed aimed at expanding the skilled birth attendance to develop EmOC competencies among medical programme through six-month competency- SCALING UP E m OC SERVICES officers, nurses and laboratory technicians, as based training on basic midwifery for community well as strengthen management capacity. health workers in order to improve access to skilled care at community level, and strengthen In 2003 the government began piloting a training referral to EmOC for women with complications. programme for community-based skilled birth attendants in six districts, with technical support This country case looks in more detail at from WHO and Obstetrical and Gynaecological Bangladesh’s experience in scaling up EmOC Society of Bangladesh. Later on, UNFPA provided services and skilled birth attendants. financial support for scaling up of the training. It TRAINING OF TEAMS IN E m OC 4 SCALING UP E m OC SERVICES The 1998 Health and Population Sector their own training departments accountable. Programme contained objectives for increasing UNICEF maintained close connections with EmOC coverage (one comprehensive and all levels of the Ministry and medical college four basic EmOC facilities for every 500,000 hospitals in the implementation of the project. population) and utilisation of EmOC services The involvement of key stakeholders, particularly (met need increased from 5% to 70%). The WRLH the Directors of the medical college hospitals, EmOC initiative launched in July 2000 aimed to helped to promote understanding of EmOC strengthen the capacity of 59 district hospitals training activities and needs, as well as systems and 120 of the country’s 400 subdistrict hospitals of accountability. Although this system involved to deliver EmOC. Human resources development some administrative complexities, training of activities aimed to supply at least two medical managers improved. officers (one each in obstetrics and anaesthesia) and four nurses to each designated subdistrict Per trainee costs were approximately $1550 for hospital, and an additional five nurses at district one year for medical officers, $1020 for the 17- hospitals, all with improved skills for
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