Nalukenge Mariam, Public Health Nurse The Diet Clinic Streamlining health systems for improvement of MCH service through BFHI accreditation of facilities in Mpigi district, Uganda. “2nd World Breastfeeding Conference” Nalukenge Mariam, Public Health Nurse The Diet Clinic

Mpigi district: Location and statistics Country  Uganda Region Central Uganda Capital Mpigi Area  • Land 1,207.8 km2 (466.3 sq mi) Population (2012 Estimate)  • Total 215,500  • Density 178.4/km2 (462/sq mi) Time zone EAT (UTC+3) Website www.mpigi.go.ug 2002 census, 187,800pple ; 2012 215,548 pple approx; 2016 estimate 216,000 people. Annual growth rate 1.4% . It is primarily a rural district with only 8.4% people living in urban areas.. It has 8 sub-counties, 59 parishes and 280 villages.

Presentation outline Background Health system opportunities for implementation of BFHI BFHI implementation objectives in Mpigi The Diet Clinic approach; using BFHI a framework to improve MCH components Implementation processes Achievement and results Conclusion and recommendations

Background In Uganda, BFHI was launched in 1992 spearheaded by Uganda Lactation Management Education Team (ULMET). The Ministry of Health adopted the International 10 steps to 16 requirements to suit the health situation in the county Since then, over 20 health facilities have been designated “mother-baby friendly” with most recent ones being those supported by World Vision in Mpigi district. MoH has also supported a number of health facilities in the country to transform them but efforts are still needed to have them designated “mother-baby friendly”. However, the IYCF indicators among children below 59 months remain poor.

Background cont... IYCF indicators for Uganda Source: UDHS 2011

Health system opportunities for implementation of BFHI BFHI is framework to improve other interventions for the mothers and children; BFHI steps/requirements are based on strengthening health system positive practices for sustainability of programs and therefore ride on available opportunities; At National level (Ministry of Health) Basing on lessons learnt from past experience of implementing BFHI Technical officers from Nutrition, Child Health, and Reproductive Health divisions to support implementation Use of National materials (Training packages, IEC and supervisory tools) Presentation of implementation progress to Cluster meetings (MCH and Nutrition) At Mpigi district Committed district leadership Established Health facilities Human resource despite the low staffing levels Availability Partners (NGO and Local government support) Community linkages – VHT system

The Diet Clinic approach; using BFHI : a framework to improve MCH components EMNoC (Goal-oriented ANC, delivery in facility) IYCF Exclusive breastfeed, positioning and attachment Requirements 4, 5, 6, 7, 8, 9, 12, 14 Requirements 16, 3, 4, 7 Requirement 10: Fostering community support groups for improved outcomes “Mother-baby friendly” facility (BFHI) Requirements 1, 2, Requirements 11, 13, 16 Requirement 9, 15 IMCI Immunization, CHC eMTCT HIV and Infant Feeding

BFHI implementation objectives in Mpigi Equip health workers with the knowledge and skills on maternal, infant and young child feeding focusing on the 16 (Sixteen) requirements of BFHI that will transform the health facilities into “mother-baby” friendly centers of excellence. Technically support the 26 health facilities in Mpigi district using a quality improvement and behavioral approaches to improve and sustain practices geared towards promoting implementation Ministry of Health policies and guidelines through effective and timely quality improvement on BFHI linking it to EMNoC, IMCI and eMTCT. Prepare the health facilities for processes of accreditation as “mother-baby friendly” particularly internal and external assessment in accrediting them as “mother-baby friendly” as recommended by the Ministry of Health. Set a plat form for mother-baby friendly work places particularly for Mpigi district, World Vision cluster offices and the partnering CBOs.

Implementation processes Building capacity of health workers in BFHI through district based trainings – total of 60 healthcare service providers trained in MoH 5-days BFHI curriculum Quarterly BFHI on-job mentoring and coaching session;- They were spearheaded by the district and MOH national trainers These were organized in themes according to BFHI requirements Quarterly learning sessions organized by the district with technical assistance from the Diet Clinic They targeted BFHI focal persons, district leaders both technical and political Establishing and strengthening community linkages; Oriented exiting care group members and VHTs as well as other community organizations to support women referred from the health facilities Held monthly meetings with the community group Monthly BFHI self-appraisals – conducted by the BFHI focal persons Baseline survey began, average was 51.5%. Knowledge gap and community linkage gap was established. Coaching was done on quarterly basis. On scoring 80% from self appraisals, learning sessions commenced where these results were shared. Facilities would present and those that performed better would support the poorly performing through sharing views/experiences and best practices. Performance improved to 76.2% before internal assessment. Internal assessment was done a year through the implementation when facilities and the community now owned the strategy. To strengthen the community aspect, the trained health workers themselves identified and trained support groups and these were linked to facilities with on going follow ups and documentation. Existing structures were majorly used. Frequent coaching and mentorships followed the trainings, QI committees specific to breastfeeding were formed. Monthly self appraisals were done in each of the facilities .

Achievement and results

BFHI performance for health facilities at baseline and internal assessment 24 health facilities were assessed. 92% of the facilities from the beginning. 51.5% baseline, 76.2% pre internal, 90.5% at internal

External assessment results for accredited health facilities Baseline survey encompassed 26 facilities, followed by 24(92.3%) at internal assessment of which 21(87.5%) were found ready for the external assessment. Of those 3(16.7%) dropped out due to inadequate data and 18(85.7%) were assessed, of those 15 were certified. The drop out was due inadequate capacity esp in regard to human resource where some of the H/F did not even have midwives. Rare cases of lack of zeal and poor attitude were also reported. Here, there was little or no response to the mobilisation of trainings/mentorships as well as other implementation activities.

Summary of performance

Impact of BFHI – Initiation of Breastfeeding within 1 hour of birth Source: SPIN evaluation report

Conclusion The lessons learnt from the BFHI health systems strengthening approach include; Ownership of programs and interventions at the district level is key for the success of implementation Quality of MNCH services within health facilities require improvement through integration and strong linkages. BFHI ably provides an opportunity for this integration. Existence of community and health facility linkages through community structures like VHT has improved service delivery to mothers. Transforming all the health facilities depends on the mind-set change of the health workers and continued support of the health facilities through mentoring and coaching. Behavioural change approach of health workers self-realization of the gaps and finding solutions to addressing them.

Recommendations Strengthening health systems is an important approach for improvement of health services for women and children. The success of BFHI implementation requires working and improving the existing health systems like building the capacity of health workers, strengthening health facility-community linkages among others. BFHI is and remains a strong framework to improving infant and young child feeding practices.

Acknowledgements Ministry of Health, Uganda Mpigi district Local government All the health facility staff of Mpigi district World Vision International