Functionality of Ceonc Sites in Two Districts and Selected Birthing Centres in Three Districts August 2016 This report has been funded by UKaid from the UK Government’s Department for International Development (DFID); however the views expressed do not necessarily reflect the UK government’s official. ACKNOWLEDGEMENTS Assistance of Sarah Hepworth, Dr Anne Austen, and Greg Whiteside in review and editing of this report are acknowledged. The EHCS team and DHO team Ramechhap, Dolakha and Sindhupalchowk hard efforts to implement the activities and monitor the out puts is also acknowledged. It would not have been possible to accomplish all these works without support and guidance from FHD and NHSSP leadership and advisors. 2 Table of Contents 1. Introduction ............................................................................................................................................... 6 1.1 Background ........................................................................................................................................ 6 1.2 Introduction to the districts and status of health services after the April/May 2015 earthquake ... 8 1.3 Approach to rehabilitation of health services and QoC of CEONC and BC services in 3 districts ... 11 2. Key Activities to Establish CEONC and BC Services and Quality Improvement Inputs ........................... 11 2.1 Coordination at central level for immediate response and planning for transition and recovery . 12 2.2 District level planning for “Coordinated District Plan for Transition and Recovery” ...................... 13 2.3 Establishment of CEONC services in Dolakha and Ramechhap ....................................................... 13 2.4 Quality improvement process at CEONC sites ................................................................................ 15 2.5 Quality improvement process at Str BCs and BCs ........................................................................... 16 2.5.1 CEONC site staff capacity enhancement and clinical mentors’ development ............................... 17 2.5.2 Skill enhancement of MNH staff using SBA FEP tool ...................................................................... 17 2.5.3 Whole-site Infection Prevention (IP) orientation and demonstration ........................................... 18 2.5.4 Facility Quality Improvement Process using self-assessment tools and action planning .............. 19 2.5.5 Supplies of critical equipment to health facilities .......................................................................... 20 2.5.6 Off-site staff training on FP and safe abortion ............................................................................... 21 2.6 Human resource support to fill gaps during the early part of the fiscal year ................................. 22 3. Progress in Service Availability and Quality of Care ................................................................................ 22 3.1 Service availability and expansion of services ................................................................................. 22 3.2 Service readiness, functionality and quality of care in three CEONC sites ...................................... 25 3.3 Baseline situation on QoC and signal functions for BCs and Str. BCs in three focal districts .......... 28 3.4 Progress on service readiness, quality of care and signal functions at 18 Str. BCs ......................... 32 3.5 Baseline and progress of MNH staff (SBA) capacity in core areas .................................................. 35 3.6 Service utilisation ............................................................................................................................ 39 4. Challenges, Lessons learnt and Recommendations ................................................................................ 43 4.1 Challenges ........................................................................................................................................ 43 4.2 Lessons learnt and recommendations ............................................................................................ 43 Annex 1: Coordinated Plan to Support Transition and Recovery of Health Services…………………………….44 Annex 2: Coordinated District Transition and Recovery Plan of Three Districts……………………………………46 Annex 3: No. of VDCs, health facilities, BCs and Str. BCs in Three Districts…………………………………………..99 Annex 4: Quality of Care Toolkit including Self Assessment Questionnaire…………..……………………………106 Annex 5: Action Plans of the Three CEONC Sites with Progress on Implementation…………………………..10825 Annex 6: QI Self-assessment Tool for BC Level…………………………………………………………………………………..130 Annex 7: Comparison of MNCH Major Indicators in 14 Affected Districts……………………………………….…139 3 Acronyms and Abbreviations Active management of the third stage of labour AMTSL Acute respiratory infection ARI Advanced Skilled Birth Attendants ASBA Antenatal care ANC Auxiliary Nurse Midwives ANM Basic Emergency Obstetric and Neonatal Care BEONC Birthing centre BC Caesarean Section C-Section Comprehensive centres of excellence CCE Comprehensive Emergency Obstetric and Neonatal CEONC Contraceptive prevalence rate CPR District Development Committee DDC District health offices DHO Earth Quake EQ Essential health care services EHCS Extended Programme of Immunisation EPI Family Health Division FHD Family planning FP Female Community Health Volunteer FCHV Follow-up Enhancement Programme FEP Health facilities HF Health facility operation management committee HFOMC Health facility QIP Health for Life H4L Health Management Information System HMIS Health Post HP Infection prevention IP Internally displaced people IDP Intrauterine contraceptive device IUCD Logistics Management Division LMD Married Women of Reproductive Age MWRA Maternal and New born Health MNH Maternal new born and child health MNCH MDGP, MDGP Medical abortion MA Memorandum of understanding MOU Ministry of Health MOH National Association of Medical Sciences NAMS National Health Training Centre NHTC National Public Health Laboratory NPHL Nepal Health Sector Strategy NHSS Nepal Health Sector Support Programme NHSSP Newborn resuscitation NBR 4 NHSS implementation plan NHSS-IP Nick Simon Institute NSI Operating theatre OT Oral Rehydration Salts ORS Out Patient Department. OPD Primary Healthcare Outreach PHCRD Post disaster needs assessment PDNA Postpartum haemorrhage PPH Prevention of mother to child transmission PMTCT Primary Health Care Center PHCC Public Health Nurse PHN Quality improvement process QIP Removal of retained product of conception MVA Reproductive health RH Save the Children International SCI Skilled Birth Attendant SBA Staff Nurses SN Strategic BCs Str BC United Nation Children Fund UNICEF United Nation Fund population UNFPA village development committee VDC Voluntary Service Overseas VSO 5 1. INTRODUCTION This report presents details of activities and outputs/outcomes accomplished for the transition and recovery of health services delivery focusing on Comprehensive Emergency Obstetric and Neonatal (CEONC) and birthing centre (BC) services in three earthquake affected districts (Dolakha, Ramechhap and Sindhupalchowk). The Nepal Health Sector Support Programme (NHSSP) has been supporting the Family Health Division (FHD) and the district health offices (DHO) of these districts to rehabilitate health services delivery. This report covers all the key interventions implemented to establish and strengthen CEONC and BC services in three focused districts. The report covers: baseline data on quality domains and signal functions in three CEONC sites, 29 Strategic BCs (Str BCs), and 34 BCs baseline information on Skilled Birth Attendant (SBA) capacity for 65 SBAs in BCs (excluding CEONC sites) progress in service delivery is reported only for the three CEONC sites, 18 Str BCs and for the 15 SBAs where follow up was competed before July 2016. For simplicity, all the Primary Health Care Centres (PHCCs) providing delivery care services are reported as a birthing centre (BC) as most of them were not providing Basic Emergency Obstetric and Neonatal Care (BEONC) level services in July 2015. 1.1 Background The April/May 2015 earthquakes and their many aftershocks caused considerable damage to hundreds of facilities across Nepal. Three district hospitals were completely damaged and six were partially damaged. The majority of BEONC/BCs in the earthquake affected districts suffered structural damage. 31% of health facilities with BCs were severely damaged and 39% were partially damaged. As a result, essential health care services (EHCSs) in earthquake affected districts became partly or fully unavailable at precisely the point when the health needs of the population were greatest. Moreover, the quality of services was also hampered. Restoring and sustaining the functionality of EHCS across the fourteen most earthquake affected districts is crucial, including restoring and improving maternal and newborn health (MNH) services. During the transition and recovery programme (which began in July 2015) NHSSP has supported FHD in assessment, planning, implementation and monitoring of service expansion and quality improvements for both CEONC and BEONC/BC levels. Provision of services close to communities for childbirth is considered an effective strategy to improve access to institutional deliveries, especially for the poor and marginalised. The Ministry of Health (MoH) has committed to providing CEONC services in all district level hospitals under