Project Brief USAID’s MaMoni HSS Project

Improving Quality and Coverage of Maternal Health Services: How Strategic Support to UHFWCs Improved Quality and Increased Facility Delivery

Introduction To strengthen Maternal and Newborn Care around the summarizes the project’s learning and successes in time of birth, the fourth Health, Population, and Nutrition strengthening union level facilities for provision of quality Sector Program (2017-2022) of the Government of antenatal, delivery, and postpartum care. In MaMoni (GoB) includes a priority focus on HSS program areas, these efforts have led to: implementation of the Maternal Health Strategy and  Increases in utilization of antenatal care Standard Operating Procedures, as well as the national  Increases in deliveries with a skilled birth quality improvement (QI) strategic framework. The sector attendant program also recognizes the strategic opportunity for  Increases in public sector facility deliveries union health and family welfare centers (UHFWCs) to  Improvements in public sector service delivery reach poor and vulnerable populations along with the preparedness need to strengthen these facilities. There are 4,461  Improvements in the quality of care for ANC, UHFWCs across the country but 41 percent are not providing normal delivery services. labor and delivery, and PNC  Reductions in inequity for the most underserved USAID’s MaMoni Health Systems Strengthening (HSS) to access quality care project contributed to the strategies and approaches  A declining trend in the number of maternal prioritized in the sector program, particularly deaths reported through routine information strengthening maternal care at the union level. This brief systems

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MaMoni HSS Program Approach On the supply side, MaMoni HSS worked to support improved availability and quality of antenatal care The GoB and MaMoni HSS partnership focused on services, strengthened and equipped UHFWC’s to health systems strengthening efforts at both national provide round-the-clock delivery and essential newborn and district level to improve maternal and newborn care, strengthened referral systems, and improved health outcomes. At the district level, high intensity readiness of level facilities to manage support was provided by the project to district managers complications. in four districts – , JhalokatiJhalokati, Noakhali, and Lakhsmipur – which were prioritized because of their populations of rural and underserved communities The project placed a major emphasis on strengthening a as well as disproportionately poor health indicators when large number of strategically located UHFWCs to provide compared to national averages. In these areas, the goal a package of maternal and newborn care services on a was to reduce maternal and neonatal mortality by 24/7 basis. While the location and number of the improving the accessibility and quality of ANC and UHFWCs provided a strategic foundation for this effort, delivery services for the rural poor. On the demand side, the challenges to quality service delivery were many. the program strengthened outreach and care seeking Below is a summary of how district leadership, with through community action groups, mobile messaging, support from MaMoni HSS, responded to these and registration of pregnancies through community challenges to ensure the availability and accessibility of microplanning meetings, activities that were facilitated a quality integrated MNH/FP service package. by community volunteers, health assistants, and family

welfare assistants.

Photo Photo by: Akash,GMB MaMoni HSS

The Durgapur Union Health and Family Welfare Center in .

Union Health and Family Welfare Centers in Bangladesh

. UHFWCs are designed to offer a package of maternal, newborn, child health, nutrition, and family planning services to a catchment population of 25,000-30,000.

. There are 4,461 union level facilities in Bangladesh, 3,590 should be prepared to offer normal delivery services, though only 3,131 are actually equipped to do so. Of these, the majority (85%) require substantial investment in

infrastructure, staffing, and equipment to become fully functional for 24/7 delivery care. . Each UHFWC is staffed with a family welfare visitor (FWV) or paramedic, a sub-assistant community medical officer

(SACMO), an Aya (housekeeper) and a security guard. In a few facilities, there are additional positions of a doctor and a pharmacist available.

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MaMoni HSS inputs for UHFWC committees; and periodic internal and external assessment of quality of care against set standards. strengthening included: 6. Strengthened Local Government Engagement 1. Strengthened Health Management and MaMoni HSS also addressed the local government’s Leadership limited ownership of health services by deliberately To address low levels of leadership engagement and engaging and enhancing the role of the Union Parishad empowerment, targeted trainings for leadership and in planning, budgeting, and problem solving for health management were provided to health managers. The services. MaMoni HSS provided training and follow up project also facilitated decentralized planning to identify support to build the capacity of local government prioritized interventions and geographic areas for special institutions to actively contribute to MNCH-FP-N services. attention. Also vital registration systems (VRS) were strengthened

2. Improved Facility Readiness through improved coordination between the MOHFW and The condition of physical infrastructure of a majority of the Ministry of Local Government, Rural Development these facilities was poor and required moderate to major and Cooperatives (MOLGRDC). investments for repair and renovations. Many of the 7. Information Systems essential equipment were either missing or non- Incomplete data hampered the facility and districts’ functional, and staff residences required refurbishment. ability to use data for decision-making. To address this, With inputs from facility leadership, local government, MaMoni HSS worked with other stakeholders to review and the MaMoni HSS program, over 100 UHFWCs were and revise the registers and records at various levels to upgraded to provide an integrated package of maternal capture data on key indicators. MaMoni HSS also joined and newborn health services including 24/7 delivery a multi-partner initiative to support the MOHFW to design service. This started with strategic identification by and introduce an electronic health information system, district management on which facilities needed to be which developed digitalized tools for frontline health prioritized for improvements. The upgrades included workers of MOHFW, primary-level facility workers, and infrastructure repairs, updated equipment and supplies, their supervisors. At the district level, district managers and improved infection prevention and waste worked with MaMoni HSS to simplify information management systems. It also included support to management systems, track pregnant women and facilities and the relevant commodity stores for logistics deliveries, and strengthen follow up systems. and supply management to improve availability of essential MNH commodities. 8. Referrals to Higher Level Facilities The focus on strengthening the peripheral UHFWCs was 3. Human Resources complemented with efforts to strengthen weak referral To address the limited availability and vacancies of systems and referral facilities. This included referrals health providers in the facilities, a priority was placed on from the community to the UHFWC and to higher level ensuring that competent staff were residing in UHFWC’s facilities as needed for high risk cases. This included the to be available to provide 24/7 care. This was done introduction of initial management of severe pre- through advocacy with health managers and local eclampsia and eclampsia at UHFWCs where a loading government to deploy FWV’s in hard to reach areas, to dose of magnesium sulphate is administered by a staff district and upazila level facilities with an trained FWV while the patient and family members are obstetrician/anesthesiologist pair, and by providing counseled to seek higher level referral care. It also temporary gap management through project-supported included the establishment of an emergency transport staff. network with local transport providers. 4. Capacity Building for Integrated Service Package At the national level, the GoB and MaMoni HSS worked 9. Community Engagement to update and strengthen national guidelines for an MaMoni HSS increased demand for services through a integrated service package of MNH care. At the district number of social and behavior change communication level, the project reinforced the provision of high quality initiatives. This included the engagement of a cadre of services as per the national protocols with a focus on unpaid Community Volunteers (CVs) that led monthly integration of a comprehensive package of MNCH-FP-N community action group meetings to coordinate, services as applicable to each level. New best-practice implement, and follow up on community action plans interventions and services were added to the existing and to disseminate health information; organize platforms. community meetings; engage local leaders including religious leaders; organize interactive community video 5. Quality improvement initiatives shows; and use local communication channels such as Quality improvement measures focused on the use of cable TV networks. These volunteers also coordinated standardized clinical protocols, such as the active with MOHFW health workers during community management of third stage of labor and partograph; microplanning meetings to identify pregnant women and improving communication and counseling to clients and births, handle emergency referrals, and track maternal families; supportive supervision; ensuring availability of and neonatal deaths in their respective catchment medicines and supplies; quality improvement areas.

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Results supported districts are receiving ANC at higher rates than ever before, coverage of any ANC received by an As a result of GoB stewardship and MaMoni HSS efforts expectant mother increased from 51% to 82% from to strengthen the services at all levels of care, significant 2014 to 2016.2 There has also been significant positive improvements were recorded in program areas improvement in the number of women attending four or for indicators of service utilization, service delivery more ANC visits in MaMoni HSS supported districts, up preparedness, and service delivery quality. These from 18% to 43% (Figure 1). Refer to Figure 1 for more changes were captured through routine management results. information systems (MIS) data, MaMoni HSS program MIS, and MaMoni HSS administered household surveys, Facility preparedness to provide services has also shown health facility readiness assessments and quality of care significant improvements; as evidenced through program assessments. sentinel survey data for key diagnostic tests. In 2016, only 75% of surveyed facilities in program districts were Improvements in Antenatal Care Coverage and equipped to provide urine protein tests, but by 2017, Quality 100% of surveyed facilities were prepared to do so. The provision of antenatal care is foundational to Similarly, 92% of surveyed facilities in 2016 were able to reducing maternal mortality. As outlined in the WHO provide hemoglobin tests but by 2017, 100% of those Recommendations on antenatal care for a positive same facilities could provide the tests.3 pregnancy experience, “ANC reduces maternal and perinatal morbidity and mortality both directly, through Indicators for quality of ANC have also increased in detection and treatment of pregnancy-related MaMoni HSS supported areas, with quality of care complications, and indirectly, through the identification assessment showing improvements in the use of key of women and girls at increased risk of developing diagnostic tests and preventive interventions. For complications during labor and delivery, thus ensuring example, the percentage of women in Habiganj for whom 1 referral to an appropriate level of care.” urine albumin tests were conducted increased from 85% to 91% in just one year from 2016 to 2017 (Figure 2). Through the strengthened capacity of UHFWCs to provide And the percentage of women who received all required quality antenatal care, pregnant women in MaMoni HSS counseling in surveyed facilities during ANC increased by 39% from 2016 to 2017, from 13% to 52% (Figure 3).

Figure 1. Percent coverage of women attending four or more ANC visits from a trained provider in MaMoni HSS program districts

46 49 45 44 42 43 3740 40 37 32 3134 31 26 22 25 21 18 14 12 7

Habiganj Jhalokati Lakshmipur Noakhali MaMoni HSS National Districts Total

Baseline Year 2014 Year 2015 Year 2016 BDHS 2014 BMMS 2016

Data source: MaMoni HSS Household Surveys

1 World Health Organization, WHO Recommendations on antenatal care for a positive pregnancy experience, World Health 2 Data source: MaMoni HSS Household Surveys Organization 2016: 3 Data Source: MaMoni HSS Sentinel Surveys for Quality of Care http://www.who.int/reproductivehealth/publications/maternal_pe rinatal_health/anc-positive-pregnancy-experience/en/

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Figure 2. Percentage of women that received key ANC services in Habiganj District, a MaMoni HSS supported district 94 92 91 91 86 85 85 85 69

46 32 18

BP measured Urine sugar test Urine albumin test Hemoglobin test Referred for High Referred for Pre- conducted conducted conducted Blood pressure Eclampsia Year 2016 Year 2017

Data source: eMIS, Habiganj District

Figure 3 (left). Percentage of clients observed 86 during ANC that received counseling on the importance of all of the following: . Balanced diet during pregnancy 56 52 Four antenatal care visits 38 . 28 31 . Postpartum family planning 17 13 Danger signs during pregnancy 7 . 1 . Importance of institutional delivery Habiganj Jhalokati Lakshmipur Noakhali Total . Early initiation of breastfeeding . Exclusive breastfeeding Round 1 Round 2 . Iron folic acid Data source: MaMoni HSS quality of care assessments

Improvements in Coverage of Institutional District-level changes can also be compared with Deliveries in Public Sector Facility Deliveries divisional trends to understand changes in a Following MaMoni HSS efforts to strengthen care at comparable geographic area. The rate of increase in strategic UHFWCs, there has been a steady increase in facility deliveries is higher in all MaMoni HSS districts the number of UHFWC’s that are providing 24/7 MNH than it is in their respective divisions. For example, services and the number of deliveries taking place at program household surveys show that Noakhali these facilities. experienced a 24% increase in facility deliveries from 2014-2016, while a comparison of Chattogram The survey data collected by the program shows that in divisional data from 2014 BDHS and the 2016 BMMS the four MaMoni HSS supported districts – some of shows an estimated 7% increase. A summary of the most rural and underserved in the country - facility changes in specific MaMoni HSS districts as well as deliveries increased by 19% over three years of the their divisional-level comparisons is outlined in program, from 25% in 2014 to 44% in 2017. In a Figure 4. similar time period (from 2014 to 2016), the change in facility deliveries nation-wide was roughly 10%.4

4 To understand national and divisional trends, data points on BMMS 2016: Data collected from Aug 2016-February 2017, facility delivery from the BDHS 2014 and the BMMS 2016 are recall period of 3 years compared here. However, the percent changes derived from BDHS 2014: Data collected from June 2014-November 2014, these data points can be considered as general approximations, recall period of 3 years since the two national surveys have different methodologies MaMoni HSS 2014 Baseline Household Survey: Data collected and are not directly comparable. Additionally, the recall periods in 2014, recall period of 6 months between the national surveys and the MaMoni HSS household MaMoni HSS 2016 Household Survey: Data collected in 2016, surveys is different (see below) and these differences must be recall period of 6 months taken into consideration when comparing the data points.

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Figure 4. Trend of deliveries in 24/7 UH&FWCs in four MaMoni HSS district 25000 94 100 100 90 76 20000 80 70

15000 54 60 9919 41 50 10000 40 30 5000 11 20 10 1,050 4,678 8,117 12,191 15,500 19,838 0 0 2013 2014 2015 2016 2017 2018

Projected Number of Deliveries Number of delivery in 24/7 UH&FWCs No. of 24/7 UH&FWC

Figure 5. The percentage point increase in facility deliveries is higher in all MaMoni HSS supported districts when compared with total increases in their respective divisions GEOGRAPHIC AREA 2014 2016 BDHS BMMS 2016 POINT INCREASE BASELINE 2014 BETWEEN 2014-2016 National 37 47 10 Division (all districts) 23 36 13 Habiganj (MaMoni District in Sylhet) 18 34 16 Barishal Division (all districts) 30 34 4 JhalokatiJhalokati (MaMoni District in Barishal) 39 51 12 Chattogram Division (all districts) 35 42 7 Lakhsmipur (MaMoni District in Chattogram) 26 39 13 Noakhali (MaMoni District in Chattogram) 19 43 24

Increase in deliveries in the public sector: A key from 2014 to 2017 while private sector deliveries takeaway from the BMMS 2016 is that the country’s increased by 6%, and in Noakhali district public sector 24% increase in facility deliveries since 2010 is deliveries increased by 14% while private sector primarily in the private sector - which experienced an deliveries increased by 12%. 18% increase in service utilization, while the public sector saw only a 4% increase in the same period. In UHFWC’s are increasingly handling an increasing MaMoni HSS supported districts the story is different - proportion of public sector deliveries in program areas- the increase in facility deliveries is attributable to both from 12% of public sector deliveries in 2014 to 40% of growth in private sector and public sector deliveries, public sector deliveries in 2017. In Noakhali district with public facility deliveries increasing from 11% in this change has been the most drastic – in 2014, 2014 to 18% in 2017. In two MaMoni HSS districts, UHFWC’s were responsible for only 5% of deliveries. In the growth in public sector facility deliveries has been 2017, UHFWC’s were responsible for 60% of public even higher than in the private sector: in Habiganj sector deliveries. district the public sector deliveries increased by 9%

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Figure 6. National demographic data shows that between 2011 and 2014, public sector contributions towards the increase in facility deliveries has been minimal

0.3 Public sector = Public sector = 13% 0 12% 1.9 11.7 2 13

15.1 22 62.2 BDHS 71.0 BDHS 2011 2014

Home Private sector NGO sector Home Private sector NGO sector

Public sector FWV Public sector FWV

Data Sources: BDHS 2011, BDHS 2014

Figure 7. In MaMoni HSS districts, public sector deliveries, especially those taking place at UHFWCs, are on the rise Public Public sector = 18% sector = 1 11% 7 1 10

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56 25 69 2017 2014

Home Private sector Home Private sector NGO sector Public (Others) NGO sector Public (Others) Public (UH&FWC) Public (UH&FWC)

Data Source: MaMoni HSS Household Survey

Improvements in Quality of Care Service utilization data from Habiganj from 2017-2018 With targeted efforts to strengthen and equip the shows notable improvements in just one year in the UHFWCs for 24/7 services with competent providers, frequency of diagnostic tests provided during delivery, equipment, and commodities, and to strengthen referrals for complicated cases, and active referrals for higher level care, important changes were management of third stage of labor (AMTSL). also observed with respect to the quality of care.

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Figure 8. Percentage of women receiving key services for detection and treatment of complications

100 94 92 91 91 93 94 90 86 85 85 85 80 69 70 60 50 46 40 32 30 18 20 10 0 BP measured Urine sugar Urine albumin Hemoglobin Referred for Referred for AMTSL test test test High BP Pre-eclampsia provided

Year 2016 Year 2017

Figure 9. Percentage of newborns received 7.1% chlorhexidine application soon after birth by place of birth 70 61 60 53 50 45

40 36 34 28 30 27 22 21 20 17 11 12 11 13 8 7 7 10 3 1 0 2 2 1 1 0 In facility In home In facility In home In facility In home In facility In home delivery delivery delivery delivery delivery delivery delivery delivery Habiganj Jhalokati Lakshmipur Noakhali Year 2015 Year 2016 Year 2017

Strengthened Referrals With MaMoni HSS support, the Obstetrics and The project strengthened care at the community and Gynecological Society of Bangladesh (OGSB) worked union level, as well as referrals from lower to higher with union level providers to introduce pre-referral level facilities when complications were detected. management for SPE/E, where a loading dose of Service utilization data shows increases in the number injectable MgSO4 is administered by trained FWVs at of referrals from union level facilities to higher level UHFWCs, and the patients and their family members facilities in program areas. For example, in Noakhali, are counseled for referral care at higher level facilities. referrals nearly doubled in the course of a single year, from 846 to 1690 total referrals, while in Jhalokati the changes have been more modest, from 242 to 304 in the same time period.

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MIS data shows progressive increases in the initial Changes in Maternal Deaths management and referral of PE/E at UHFWC’s, an In program areas, MaMoni HSS tracked maternal intervention that has been introduced in 23 of mortality – including deaths in the home and in the Habiganj, Noakhali, Lakshmipur, and facilities - as reported through community volunteers JhalokatiJhalokati. From 2016 to 2018, the number of and frontline health workers; these deaths were also patients with SPE/E that received a pre-referral loading verified by MaMoni HSS staff. Outcomes of this dose of injectable MgSO4 at UHFWCs increased from 3 tracking through the project are positive, with a to 119. declining trend of reported maternal deaths (Figure 10).

Figure 10. Trends in number of maternal deaths reported through MaMoni HSS reporting system 2013-2017. 94 100 94 91 90 84 80 71 70 60 57 53 50 44 38 40 39 40 35 2628 30 23 24 34 19 20 14 6 10 0 Year 2013 Year 2014 Year 2015 Year 2016 Year 2017

Habiganj Jhalokathi Lakshmipur Noakhali

Discussion release of the BMMS 2016 results and associated Impressive increases in facility deliveries in recommendations. In addition to the increase in facility Bangladesh in the last decade have not led to a deliveries, one of the notable successes is the growth corresponding reduction in maternal mortality, which of public sector deliveries in program areas compared has remained stagnant from 194 deaths per 100,000 to other facilities. Public sector facilities are more in 2010 to 196 in 2016, as per the results of the affordable than private sector facilities, more recently released BMMS 2016. consistently staffed, and are accountable for the quality of services that are delivered. The strategic The successful approach of strategically strengthening focus on strengthening peripheral UHFWC facilities for UHFWCs experienced by the districts supported by 24/7 MNH care and strengthening referral MaMoni HSS is valuable for other districts to draw mechanisms offers an unprecedented level of access from to improve maternal health services following the to MNH services for poor, rural populations.

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Delivery room of one of the UH&FWCs in Noakhali

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FWV is checking a pregnant mother in UH&FWC

Waiting room of one of the UH&FWCs in Noakhali

Way Forward Looking ahead, it is important to note that while the GoB and the MaMoni HSS project were successful in demonstrating the benefits of UHFWCs as 24/7 facilities, these changes can only be sustained and extended for nationwide benefit with continued commitment and support from the Government of Bangladesh. This includes the dedication of resources at the national, district, and local government level for on-going management of facility readiness, health care staffing, commodity supply, and quality improvement. These priorities are part of the Health, Population, and Nutrition Sector Program 2017-2022, and will need concerted focus and resources from the GoB and partners to realize change for the mothers and newborns of Bangladesh. In lockstep for sustainable health systems strengthening through the sector plan will be the USAID’s MaMoni Maternal and Newborn Care Strengthening Project (MNCSP), a five-year program that follows MaMoni HSS and will be led by Save the Children starting from 2018. MaMoni MNCSP will work closely with the GoB for sustainable initiatives that strengthen district level capacity, improve the quality of MNC services and governance for quality of care, improve accessibility to and demand for MNC services, and strengthen GoB’s capacity to deliver quality MNC services at scale.

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About MaMoni Health Systems Strengthening (MaMoni HSS) Project

The MaMoni Health Systems Strengthening (HSS) is a 5-year project of USAID under the global Maternal and Child Health Contact Us ______Integrated Program (MCHIP). The focus of this project is strengthening the systems and standards for maternal, newborn MaMoni Health Systems Strengthening and child health, family planning and nutrition (MNCH/FP/N) that (MaMoni HSS) Project will result in declines in maternal, newborn and child mortality in Save the Children

Bangladesh. The project supports the Ministry of Health and Family Save the Children Hs No CWN (A) 35, Welfare (MOH&FW) to introduce and leverage support for scale-up Road 43, Gulshan 2, 1212, of evidence-based practices already acknowledged in Bangladesh. Bangladesh Email: MaMoni HSS is primed by Jhpiego in partnership with Save the [email protected] Children (SC), John Snow, Inc. (JSI), and Johns Hopkins University Web: http://www.mamoni.info (JHU)/Institute of International Programs (IIP), with national partners, icddr,b, Dnet, and Bangabandhu Sheikh Mujib Medical University (BSMMU) and six local non-government organizations. The project covers 40 upazilas in six districts and serves around 12.2 million people. The six focus districts are Habiganj, Lakshmipur, Jhalokati, Noakhali, Pirojpur and Bhola.

Authors

Saraswati Khalsa, Nazmul Kabir, Shumona Shafinaz, Joby George, Iftekhar Rashid

Acknowledgments

This work would not have been possible without the technical leadership of members of the Ministry of Health and Family Welfare, especially the Directorate General of Family Planning for their tireless efforts to improve maternal health care services.

Layout by: Kabirul Abedin Disclaimer: This brief is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents are the sole responsibility of USAID’s MaMoni HSS Project and do not necessarily reflect the views of USAID or the United States Government. 12

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