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

Integrated MNCH facility andcommunity intervention

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

Program goal

•To provide a continuum of comprehensive andintegrated MNCH care especially postpartumcare (PPC) services, inclusive of follow up of HIV+ mothers and exposed infants and postpartumfamily planning (PPFP)

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 PPC package

•Pre-discharge counseling for newly delivered women,

•Routine check up of post partum care women, encouragingthem to attend PPC within: 48 hours, 3-7 days, 8-28 days and29-42 days after delivery

•Medical check up: checking for sepsis, fistula, post partumdepression, breastfeeding, cord care etc

•HIV testing for mothers and follow up of HIV + mothers andexposed infant

•Post partum Family Planning (PPFP)

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

Iringa

Morogoro

Lindi

Mtwara

Coverage Nov 2010-Feb 2014:

•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 program

Program started in 2009with GuidelinesDevelopment

2014

2012

2010

12 facilities

14 facilities

25 facilities

37 facilities

62 facilities

MOROGORO

IRINGA

LINDI

MTWARA

PHASED APPROACH METHOD OF IMPLEMENTATION

Program Achievements

1. PPC Materials developed in collaboration with the MoHSW:

•National Post Partum Care Guidelines

•Learning resources package: including Facilitators Guide, Participantsguide, PowerPoint slides, pre and mid course knowledge assessments,M&E tools

•Performance tools of PPC Standards Based Management at facilitylevel

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 andMtwara)

TrainingsPPC facility component

Peopletrained

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 shouldcome back for PPC check-ups

•More women are counselled on PPFP

•Women not tested during ANC or L&D have the option oftesting at 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/FP 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 for HIVat PPC

268

572

1,198

1,156

3,194

Women identifiedHIV+ after testing atPPC

(8%)

(4%)

(5%)

(2%)

129(4%)

HIV infected womenreceiving PPC services

597

776

1,529

710

3,612

% of PPC clientscounselled on FP atleast once during theirPPC visit

97%

95%

96%

Challenges on PPC

•Retention of trained providers in their areas of work

•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

•Some providers feel PNC services not important

•New PPC register

•Gap in PNC register (need of review)

•Limited number of providers trained - poor knowledge sharingbetween providers

Integrated Community MNCH Component

Community MNCH (cMNCH) approach

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

•Focuses on 4 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

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

Achievements at national level:

English version

•National Guidelines onIntegrated CommunityMNCH

•The package is officiallyendorsed and recognizedby MOHSW

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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Other materials and resources

M&E - Recording andReporting

•Client register – for birthand deaths registrationand service delivery

•CHW monthly summaryreport

•Referral forms

•Supervisor summary form

•Census summary form

Reference Materials andEquipment

•Job aids

•CHW reference Guide

•Bags

•Bicycles

•Manila Sheets

•Counter book

Selection Criteria of CHWs

•Selected by the community through the village government incollaboration with the back up health facility supervisor.

•To be accepted by the community

•Should be residing in the community

•To have shown a heart of voluntarism

•Above 18 years of age

•Preferable form 4

•Male or female

•A good example in RCH issues

Coverage

Dispensary

1 CHW supervisor

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Village

4-8 CHW

Dispensary

1 CHW supervisor

Dispensary

1 CHW supervisor

Dispensary

1 CHW supervisor

Dispensary

1 CHW supervisor

Health Centre

1 CHW supervisor

In each district, two health centres will oversee 10 dispensaries (5dispensaries each), and each dispensary will serve 2 villages withup to 4-8 CHWs each.

Roles of Community Health Workers

•Planning activities in his/her catchment area

•To provide health education and basic counselling on MNCH

•To provide referrals to clients to the back up health facility

•To participate in village health meetings and to collaboratewith other stakeholders in the community

•Data collection and reporting

Health education messages

•FANC including - Individual Birth Plan

•Prevention of malaria,

•Infant feeding

•Importance of hospital delivery

•PPC for mothers, newborns and child

•PPFP

•PMTCT/CTC services

•Networking with other stakeholders

•Gender and male involvement

•Infection prevention

Roles of CHW Supervisors and Village Leaders

CHW Supervisors

•Selecting CHWs

•Monitoring and supervisionof CHWS as needed

•Conducting monthlymeetings with CHWs

•Attending clients referred byCHWs

•Compiling monthly reportsfrom CHWS

•Sending CHW reports todistrict level through DRCHCo

Village leaders

•Selecting CHWs

•Assisting in identification ofCHW catchment areas

•Follow up of CHWperformance/ Providesupport

•Engaging CHWs in villagemeetings

•Use of data from CHWs inplanning

Training

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

oTraining conducted by, district, regional, and nationaltrainers

•Supervisors of CHW: facility providers who supervise CHWs

•Training takes two week, includes supervision skills

•Trainers: training 3 weeks; 2 weeks cMNCH based training. Oneweek training methodology

Training

Community MNCH

•25 National trainers

•134 CHW supervisors

•535 trained MNCH CHWs

(132 villages from 6 districts)

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Home Visits by CHWs

Antenatal home visit

•As early the CHWidentify a pregnantwoman

•About 6 months ofpregnant

•About 8 months ofpregnant

Postnatal home visit

•Day 1 after discharge from healthfacility/after delivery

•Day 3, 8 after delivery

•End of third week

•End of fifth week

•End of third month

•End of fifth months

Community Health workers visitsMarch 2013 – February 2014

FY 2012(March-Sept2013)

FY 2013(Oct 2013-Feb 2014)

TOTAL

No. of household visited

15,985

20,430

36,415

No. of health educationmeetings held

398

561

959

No. of people attendinghealth educationmeetings

16,245

18,989

35,234

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

Referrals made by CHW from March-Dec 2013

Challenges and Lessons Learned

•Drop out

•Proper retention mechanism

•Sustainability

•Coverage (need a lot of effort to reach all villages and notenough CHW per village)

•Lessons Learned

•CHW as a strategy foster utilization of MNCHS andcontributes in reduction of MNCH mortalities

Asanteni sana