National Scaling Up of Helping Babies Breathe Initiatives in Bangladesh Dr. Sayed Rubayet Project Manager, HBB and SNL Save the Children in Bangladesh

Presentation Outline Background National scale up strategy Evaluation design Results to date Quality improvement process Plans for sustainability Lessons learned

Background: Facts of Neonatal Health in Bangladesh Delivery at health facility -29% Delivery attended by a skilled provider -32% Neonatal death per year is 83,000 * Neonatal mortality rate: 32/1000 live births Neonatal deaths - 60% of all <5 deaths Source: * Bangladesh-specific mortality estimates (Liu et al. 2012, BDHS 2011

Causes of Newborn Mortality in Bangladesh Data source: Bangladesh-specific mortality estimates (Liu et al. 2012).

Background of National Scale-up of HBB in Bangladesh  HBB Pilot Study conducted in Bangladesh  Dissemination seminar on HBB Pilot Study was held on September 2010 The Honorable Minister, MOH&FW was encouraged seeing the findings of the study and  Instructed to take initiatives to scale-up the HBB interventions nationwide and  Requested development partners for necessary support. Series of national stakeholders’ consultation workshops held on to develop HBB Scale-up strategy and plan after dissemination National HBB scale-up plan developed, approved by MOH and forwarded to USAID and UNICEF for support in April 2011

National Scale-up Plan Capacity Building Training on NB resuscitation including primary management of birth asphyxia and basic ENC to all SBAs (from highest level service provider to community level) of Bangladesh (public sector) Equip all the facilities of public health sector and cSBAs with resuscitator (neonatal bag & mask with sucker) Quality Assurance Supervision and monitoring of training MIS system strengthening and evaluation of the HBB scale-up activities Sustainability Incorporate in National Health Sector Program Incorporate HBB protocol in all relevant in-service and pre-service curriculum Capacity building of the facilities for training & refreshers training Routine refreshers training for retention of skills and utilization of the NB resuscitation capacity

Background of National Scale-up of HBB in Bangladesh

 MOH&FW (DGFP, DGHS)  Overall implementation  TAX/VAT of offshore procurement  MCHIP/Save the Children  Nationwide Implementation, supervision, monitoring and Evaluation  Ensure Logistics  BSMMU  Adaptation of training materials  Organize training in all level  Monitoring and supervision  UNICEF  Equipment for district implementing maternal and NB projects,  Supervision and monitoring  ICDDRB  Evaluation of HBB scale-up activities Institutional Arrangement Funding Arrangement MOH&FW (Cash and kind) USAID through MCHIP/Save the Children UNICEF Laerdal Foundation through Save the Children

HBB Scale-up Partners in Bangladesh

Summary of HBB Training Plan Period District/ City Corp’n Training of Trainers Training on HBB Curriculum BatchTrainers Batch Doctors Nurse/ ParamedicsCSBATotal Jun 11- Sep Oct 11- Sep Oct 12- Sep Total

2 days TOT in BSMMU Trainer return and provide training to district and upazila SBAs 2 days TOT in BSMMU Trainer return and provide training to district and upazila SBAs Step-wise HBB scale-up plan 6 districts TOT- Doctors from Medical College Hosp (if any), District Hospital, District Health and FP Office and Upazila Health Complexes TOT- Doctors from Medical College Hosp (if any), District Hospital, District Health and FP Office and Upazila Health Complexes Each Step Total 11 steps 7-8 batches Medical College Hosp – 30 doctors and 40 nurses District Hospital- 6-8 doctors and 10+ nurses MCWC- all doctors and FWV UHC- 5-7 Medical Officer and all Nurses All FWVs and CSBAs Medical College Hosp – 30 doctors and 40 nurses District Hospital- 6-8 doctors and 10+ nurses MCWC- all doctors and FWV UHC- 5-7 Medical Officer and all Nurses All FWVs and CSBAs Training starts immediately after TOT

Plan of System Evaluation of Scaling-up of HBB Intervention in Facility and Community Settings in Bangladesh  Research Questions  What proportion of deliveries are attended by a skilled provider in health facilities as well as in the community?  In what proportion of deliveries attended by the skilled providers: – Were they equipped with bag-mask, suction device, etc? – They applied the resuscitation techniques appropriately?  What proportion of HBB-trained birth attendants retain key skill elements of newborn resuscitation after-training? 12  Measurements  Observation of deliveries to assess delivery, newborn care practices and asphyxia management; availability of equipments  Review of facility delivery records to obtain total number of deliveries  Post-HBB training assessment of skills during monthly retraining/practice sessions  Interview of recently delivered women at an end-of-project household survey to assess coverage of skilled birth attendants in deliveries in the community

Key assumptions, sample size and operation plan of HBB evaluation Baseline1 st quarter2 nd quarter3 rd quarter BaselineFollow-up data collection HH Survey Community Facility 3 months 9 months2 months Facility componentCommunity component InterventionComparisonInterventionComparison % of deliveries attended by SBAs100% 50%10% % of newborn received optimum quality of resuscitation 80%50%80%10% Number of newborn requiring resuscitation Actual number of deliveries to observe 953 (Baseline and in each quarter) 709 (Post HBB training target) 355 (Post HBB training target)

Results to date

Step 1 districts completed Step 2 districts completed Step 3 districts completed Step 4 districts completed Step 5 districts will be completed 20 July Status of HBB Implementation - Training TypeTargetTrained Percentage completed Trainers % Doctors % Nurse/ Paramedics % CSBA % Total % District703347%

16 Training and equipping Mannequin (NeoNatalie-Laerdal) Resuscitator & Suction device Use for training and refreshers Kept in all facilities from UHC and above for refreshers training Provided to use for training and refreshers Provided to all facilities & CSBAs for newborn resuscitation Arrangement be taken to made them readily available in all facilities.

Training and equipping Action plan – for training and hanged in delivery sites of the facilities Flipchart- for training and kept in facilities for refreshers training Learner Workbook- provided to all trainee

Type of FacilitiesNo. Facility Neonatalie Complite Bag & Musk with Sucker Medical Colleges Hospital District Hospital Maternal and Child Welfare Center Upazila Health Complexes Union Health and Family Welfare Center NGOs Facilities Community SBA Total Status of HBB Implementation – Equipment Distribution

Incorporation of HBB Protocol in Different Curriculum HBB Scale-up plan have the component to incorporate the HBB protocol in different pre-service and in-service curriculum. Following curriculum already decided to incorporate the protocol. 1.MBBS Curriculum 2.Diploma and Degree course of Nursing 3.Midwifery Training Curriculum 4.FWV training Curriculum 5.Private Paramedics Training Curriculum Initiatives also taken to incorporate in CSBA curriculum Standard Operation Procedure (SOP) for Newborn Health Care in Primary and Secondary level facilities

 National Level ( DGHS, DGFP BSMMU and SC )  Joint monitoring visit and follow-up of divisional officials visit  Divisional Level Health and FP officials  Usually 1 district/division in each phase, so feasible for divisional level to organize monitoring visit  District Health and FP officials will visit each batch as resource person  UHFPO/UFPO/RMO coordinate the training of their upazila/facilities  MNCH, MNH, MNCS and MaMoni and other similar program will provide support for supervision and supervise in the project area  Standard checklist will be used for supervision and monitoring Quality Improvement

Quality Improvement (Cont.) Supervision and monitoring of training  90% session are expected to be supervised/monitored by District level DGHS and DGFP officials  83% sessions observed by district level Health/FP managers  50% sessions will be monitored /supervised by BSMMU officials  Monitoring visits with checklist (179 out of 416 sessions) training- 43% of sessions)  QA through direct observation of master trainers (59 out of % of sessions)  15% sessions are expected to be supervised by national and divisional level DGHS/DGFP official

HBB Training Quality Assurance Checklist

HBB Training Supervision and Monitoring Checklists

Quality Improvement- Refreshers training Steps Complet e A. Prepares for birth Identifies a helper Prepares the area for delivery Cleans hands Prepares an area for ventilation Checks equipments B. Dries thoroughly Dries the baby thoroughly Removes wet cloth C. Clears airway and stimulates breathing if baby is not crying* Keeps warm Positions head and clears airway Stimulates breathing by rubbing the back D. Ventilates with bag and mask if baby is not breathing Cuts cord and moves to area for ventilation Apply the mask to make a firm seal Starts ventilation within Golden Minute (started at _________ seconds) Ventilates at 40 breaths/min (30-50 acceptable) (_________breaths per minute)* Looks for chest movement * E. Improve ventilation if chest does not move* Head: reapply mask and reposition head Mouth: clear secretions and open the mouth Bag: squeezes the bag harder  Refreshers training introduced through routine system  SBA describe the experience of resuscitation to others in the monthly meeting if any newborn was resuscitated  1/3 rd of SBAs practice with the manikins and bag & mask under observation of their trained supervisor as a routine practice  The supervisors take brief test and record it in a card given during training  All SBA have to practice and record his/her performance in the record card by every 3 rd month

Plans for sustainability  HBB program incorporated in the Health Population Nutrition Sector Development the Program (HPNSDP) and its Operation Plans (OP) of the MNC&AH (DGHS) and MCR&AH (DGFP)  Curriculums and Newborn SOP incorporated the protocol  Refreshers training introduced through routine system  Developing a video for refreshers training and distribution to all the facilities are under way  Regular review meeting in directorates are going way.  MIS incorporation under process,  A Technical Sub-Committee on Finalization of Newborn Indicator have been formed and are working  DGFP is now piloting HBB related indicators  Surveillance activities are planned

Lessons learned  Rapid scaling-up of an public health intervention became possible due to the-  Political Commitment  Systemic Linear Approach  Technical Capacity  Partnership and  Fund Availability  Still the Challenges of HBB Scale-up are-  Retention of skill  Monitoring of implementation and outcome and linking with routine system  Cleaning of the Equipment

Sabina Yasmin with her baby who was resuscitated with bag & mask on 23 rd November at Mohammadpur UHC. Dr Subol Chandra Borman, RMO resuscitating a newborn baby at Jointapur UHC on 7 th December.