Integrated facility/ community PMTCT (Maternal, New born and Child Health)

An Integrated facility –Community Intervention forImproving Maternal, Newbornand Child Health (MNCH)Services in Tanzania

Program Goal

•To link Pregnant and Postpartum Women as well astheir infants to the continuum of comprehensiveMNCH services through and integrated Facility -Community Approach. The community componentaims at promoting health seeking behavioursamong pregnant women, postpartum mothers andcommunity members while strengthening linkagesand improve rapport between facilities andcommunities, so as increase demand and utilisationof MNCH services especially Postpartum care (PPC)services inclusive of follow up of HIV +ve mothersand exposed infants and PPFP

Rationale

•Improve maternal health: 60% of maternal deaths occur duringfirst week postpartum, yet only 31% of women who deliver athome are seen within the first week after delivery

•Improve neonatal and infant health: 75% of neonatal deathsoccur during first week

•Prevent unintended pregnancies: Total fertility rate: 5.4;Contraceptive Prevalence rate is 27% for modern methods

•Ensure ongoing care of HIV+ mother and her exposed infant: by2011 only 64% of HIV infected pregnant women and 56% exposedbabies receive ARV for PMTCT

Intervention

Community

Raising awareness inthe community onthe importance ofantenatal, delivery,and postpartumvisits & key MNCHbehaviours formothers and infantswith support fromCHW

Ensuring ALLwomen are testedfor HIV postnatallyand all HIV+ womenand their exposedinfants are linked toa continuum of care

Facility

Implementation of the Facility & Community Linkage

There was three aspects :

1. Facility:

•Supported Development of the PPC guideline and LRP which also includesPPFP and HIV / PMTCT

•Supported training of National Facilitators on PPC

•Supported training of the facility providers on PPC

HIV testing for postpartum mothers and follow up of HIV + mothers andexposed infant as well as Post partum Family Planning (PPFP) was the point ofintegration.

2. Community:

•Supported Development of the integrated MNCH Guideline and LRP whichis in Swahili

•Supported training of National Facilitators

•Supported training of the CHWs

3. Innovation:

•Development of Mobile phone protocols for ANC and PPC for facilityproviders and CHWs

•Providers at the facility use mobile phone to report and generate thereport as well as for linking the clients to the community for continuumof care and follow up by the CHWs

To strengthen technical capacity or providers routine supportivesupervision conducted on a quarterly basis

Implementation of the Facility & Community Linkage (2)

Iringa

Morogoro

Lindi

Mtwara

Coverage Nov 2010-Feb2014:

•22 districts

•in 4 regions

Program active in 62facilities, of which:

•16 Hospitals

•35 Health Centers,

•11 Dispensaries

Regional coverage of the facility component of the PPC program

Program started in 2009 withGuidelines Development

2014

2012

2010

12 facilities

14 facilities

25 facilities

37 facilities

62 facilities

MOROGORO

IRINGA

LINDI

MTWARA

PHASED APPROACH METHOD OF IMPLEMENTATION

Achievements

1. PPC Materials developed in collaboration with the MoHSW:

•National Post Partum Care Guidelines

•Learning resources package: including Facilitators Guide,Participants guide, PowerPoint slides, pre and mid courseknowledge assessments, M&E tools

•Performance tools of PPC Standards Based Management atfacility level

2. Training of health care providers in PPC:

•Training of trainers in PPC for trainers in Morogoro and Iringa

•Training of providers in PPC in all 4 regions (Morogoro, Iringa,Lindi and Mtwara)

Trainings – PPC Facility Component

People trained

TOT Postpartum Care Facility Based Training

Post partum Care Facility Based Training

229

Service Delivery Achievements

•Increase in proportion of postpartum visits overall

•Increase in proportion of 3rd and 4th visits

•More women are receiving the message that they should comeback for PPC check-ups due to improved counselling

•More women are counselled on PPFP

•Women not tested during ANC or L&D have the option of testingat PPC

•HIV+ clients are reminded to follow up care at CTC for boththemselves and their new born

PPC visits by visit type 1st, 2nd, 3rd, 4th visit

HIV Specific Indicators

FY 2010

(Nov 2010-Sept 2011)

FY 2011

(Oct 2011-Sept 2012)

FY 2012

(Oct 2012-Sept 2013)

FY 2013(Oct 2013-Feb 2014)

TOTAL

Women tested forHIV at PPC

268

572

1,198

1,156

3,194

Women identifiedHIV+ after testing atPPC

(8%)

(4%)

(5%)

(2%)

129(4%)

HIV infected womenreceiving PPCservices

597

776

1,529

710

3,612

Integrated cMNCH Component

Integrated Community MNCH approach

•Development of standardized CHW program to promotecMNCH including PMTCT and PPFP in the community by homevisits

•Focuses on 4 thematic areas:

1)Women during pregnancy and after delivery

2)Newborns and under 5 children

3)Follow-up of HIV+ mothers and exposed infants

4)Postpartum family planning

** Other cross-cutting issues also addressed (such as M&E, IEC/BCC)

•CHWs conduct health education, mobilization, and referralsrather than direct service provision

Key Areas

•Trained CHW to provide healtheducation on:

oFANC including IBP

oPrevention of malaria,

oInfant feeding

oImportance of hospitaldelivery ,

oPPC for mothers, newbornsand child

oPPFP

oPMTCT/CTC services

oNetworking with otherstakeholders

oGender and maleinvolvement

•Infection prevention

1st Supervisor

XY Facility

CHW

2nd Supervisor

XY Facility

CHW

Training

•Duration of Training for CHWs: 3 weeks, residential,two weeks in class and one week field work

oTraining conducted by, district, regional, andnational trainers

•Supervisors of CHW: facility providers who superviseCHWs

•Training takes two week, includes supervision skills

•Trainers: training 3 weeks; 2 weeks cMNCH basedtraining. One week training methodology

Roles of Community Health Workers

•Planning activities in his/her catchment area

•To provide health education and basic counsellingon MNCH

•To provide referrals to clients to the back up healthfacility

•To participate in village health meetings and tocollaborate with other stakeholders in thecommunity

•Data collection and reporting

Roles of CHW Supervisors and Village Leaders

CHW Supervisors

•Selecting CHWs

•Monitoring and supervision ofCHWS as needed

•Conducting monthly meetingswith CHWs

•Attending clients referred byCHWs

•Compiling monthly reports fromCHWS

•Sending CHW reports to districtlevel through DRCHCo

Village leaders

•Selecting CHWs

•Assisting in identification ofCHW catchment areas

•Follow up of CHW performance/Provide support

•Engaging CHWs in villagemeetings

•Use of data from CHWs inplanning

Achievements at national level:

English version

•National Guidelines onIntegrated CommunityMNCH

Swahili version

•Community MNCH Training guide

•CHW Reference Guide

•Supervisor Guide

•Job Aids ( 26)+ IEC Materials

•Data collection materials

•Referral forms

•Reporting forms

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M&E Tools and Equipment for CHWs

Recording and Reporting

•Client register

•Monthly report forms

•Referral forms

•Form for births and deathsfrom the community

•Counter book

•Census summary form

Reference Materials and Equipment

•Job aids

•CHW reference Guide

•Bags

•Bicycles

•Manila Sheets

Training of Community MNCH

•25 National trainers

•132 target (134 trained) CHWsupervisors

•528 target( 535 trained)MNCH CHWs in 132 villagesfrom 6 districts

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Achievements on thecommunity programMarch-December 2013

Gairo

Kilosa

MorogoroDC

MorogoroMC

Mvomero

Ulanga

TOTAL

No. ofhouseholdvisited

483

4006

8339

3175

6822

1010

23,835

No. of healtheducationmeetings held

217

250

621

No. of peopleattending healtheducationmeetings

669

3706

9134

1159

7905

1119

23,692

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Type of clients visited by CHW’s fromMarch-December 2013

Referrals made by CHW from March-Dec 2013

Innovation – Use of mHealth (A phone based Toolfor Maternal Health

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Benefits of Technology

Two main benefits

a)capacity for immediate feedback given to the healthworker (and standardization of health care delivery); and

b)the ability to store the information that is collected(potential for tracking HIV+ mothers and infants over thecourse of pregnancy and beyond, minimizing loss tofollow-up).

Upon further development, this cell phone technology canalso allow for SMS reminders to pregnant/postnatal women(attending ANC, follow-up visit at CTC, postnatal careschedule, etc.).

Challenges and Lessons Learned

•Retention of trained providers in their areas of work

•High Work load/shortage of staff – High client load especially for first visit

•Reporting and recording difficult for high delivery sites

•PPC services provided in multiple locations (RCH and Postnatal ward)

•Some providers feel PNC services not important

•Gap in PNC register (need of review)

•Limited number of providers trained - poor knowledge sharing betweenproviders

•Drop out of CHWs – Calling for Proper retention mechanism

•Sustainability of the program in terms of

•Coverage ( need a lot of effort to reach all villages)

Lessons Learned: CHW as a strategy foster utilization of MNCHS and contributesin reduction of MNCH mortalities

Asanteni sana