15th November 2016 HSR 2016 Symposium Leveraging Results from Facility Assessment for Service Readiness to establish 24/7 delivery services at peripheral level facilities in Bangladesh 15th November 2016 HSR 2016 Symposium Dr. Selina Amin Senior Advisor-Health system strengthening, MCHIP, Save the children in Bangladesh

Presentation outline Context and problem What we have on the ground: findings from a national assessment Conclusion Relevance to other developing countries

Context and problem

Situation of skilled attendance at delivery 58% 42 32 37% Facility delivery Although improving, facility delivery is still low in Bangladesh. 1% 29% Facility delivery 7% Source: BDHS

Health service delivery system in Bangladesh

Why UH&FWCs are strategic for 24/7 normal deliveries Coverage: 24,000 to 30,000 population Distance: Most facilities located within 30-45 minutes from the farthest point of their catchment area Skilled provider: Designated facility with a provider (family welfare visitor) to conduct normal deliveries Service continuity: Rapport with provider through repeated interaction during antenatal check-ups Local ownership: Local committees (such as: UHFWC committee) interested to strengthen and support UH&FWCs Easy to integrate a package of services: maternal newborn and child health, family planning and nutrition Pregnant women not willing to travel if there is no complication

What we have on the ground: findings from the nationwide assessment

Methodology Union list collected from Bureau of Statistics List of union facilities collected from DGHS and DGFP at the national level and district levels List verified with upazila level managers Data collectors visited every union, collected data using Tablets Interviews with service providers at the facility Quality check through 10% re-assessment by supervisors Additional validation visits done by supervisors in a sample

Assessment Process

The sample Total Union Level Facilities 4,461 UH&FWC: 302 USC: 797 RD: 87 UH&FWC: 3,275 DGFP (3,275) DGHS (1,186) Number of Union Level facilities conducting delivery 3,590

14% 69% 17% A B C Categorization Criteria No significant inputs or resources required Criteria Availability of human resources Staff trained in midwifery skills Condition of infrastructure Availability of delivery room Availability of instruments Condition of their residences Condition of approach road B 69% Minor to moderate level of inputs required C 17% Major inputs and resources required

Delivery related conditions at the union level facilities Name of Divisions Total number of facilities equipped to conduct delivery Delivery Room available in good condition FWVs having midwifery training FWVs resides in the center   N n % Barisal 273 68 25 26 10 39 14 Chittagong 724 247 34 132 18 104 Dhaka 957 263 27 115 12 95 Khulna 487 154 32 72 15 35 7 Rajshahi 446 105 24 59 13 33 Rangpur 467 145 31 36 8 Sylhet 236 98 42 51 22 54 23 Total 3590 1080 30 523 396 11 Denominator is 3590 all through

Basic infrastructure for safe delivery: Delivery Room in good condition 30% FWV Room in good condition 29% Electricity available 70% Toilet in good condition 37% 3,590 Hand washing facility in good condition 36% Delivery table in good condition 37% Water supply available 49%

3,590 81% 71% 73% 70% Staffing: FWV Posted SACMO Posted Aya available MLSS available

3,590 59% conducting deliveries Utilization for delivery care: all facilities at the union 3,590 59% conducting deliveries “1-60” deliveries in one year: Low performing (n= 1802) “61-240” deliveries in one year: Medium performing (n=291) “240+” deliveries in a year: High performing (n=28) “No delivery”: (n=1802)

Delivery Room in good condition FWV trained in midwifery Utilization for delivery care: 3,590 Delivery Room in good condition 75% conducting deliveries 1,080 + “1-60” deliveries in one year: Low performing (n= 314) “61-240” deliveries in one year: Medium performing (n=69) “240+” deliveries in a year: High performing (n=10) “No delivery”: (n=130) FWV trained in midwifery 523 523

Delivery Room in good condition Utilization for delivery care: 3,590 Delivery Room in good condition 82% conducting deliveries 1,080 + FWV is residential 372 372

Delivery Room in good condition FWV is midwifery trained Utilization for delivery care: 3,590 Delivery Room in good condition 1,080 + 89% conducting deliveries FWV is residential 372 + FWV is midwifery trained 211 211

conclusion

Conclusion Majority of the union facilities can provide delivery care services with minor to moderate inputs– local level actions are required to address the gaps Staff availability is not a major constraint – their deployment, training, residency and performance need to be strengthened. However, vacant positions need to be recruited UH&FWC management committees need to be strengthened for local ownership and oversight Management and supervision need to be strengthened to improve the performance of facilities that are “ready” Minor repair, Deploy the support staff etc. UH&FWC management committee can look after cleanliness, staff attendance, meetings.

Conclusion There are several facilities that have all the basic elements for conducing normal vaginal delivery services, yet they are not currently providing such services. This is an important missed opportunity and also a “low hanging fruit” for increasing deliveries at union level health facilities. Most importantly, there are several facilities that have all…………….

Relevance to other developing countries The Bangladesh experience highlights: Importance of strengthening MNCH-FP services at primary level care To improve access, especially in rural and under-served areas To reduce the load in secondary and tertiary level facilities, which should focus on management of complicated cases For improved tracking and follow up for continuum of care

Relevance to other developing countries 2. Ministry of health should emphasize in their plans: Routine maintenance and repair of facilities Long-term plans for development of human resources to serve at primary levels 3. Proactive engagement of local level governance structures. It is critical for: Accountability Local ownership Resource mobilization for local level problem-solving

Thank you