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 Bangladesh (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 September 2018 1 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 upazila level facilities to manage support was provided by the project to district managers complications. in four districts – Habiganj, 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 Noakhali district. 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. 2 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