1. Operations research to improve 24/7 delivery and EmONC services in public facilities by health systems strengthening in Bangladesh A collaborative study among ICDDR,B, DGHS, DGFP, EngenderHealth, MCHIP/Save the Children, JHSPH Date:13.07.2015 Principal Investigator Mahbub Elahi Chowdhury Scientist, ICDDR,B

2. Conceptual framework of the study Health system input (filling up the gaps in infrastructure and logistical supports Increased availability of providers Improved quality of care Increased utilization of delivery and EmONC services Policy advocacy to fill up HR gap Standard based monitoring and recognition (SBM-R) Sharing of public providers Input Output indicator Outcome indicator

3. Outline of the presentation Specific objectives Methodology Preliminary findings of the baseline assessment  Availability of Infrastructure, Essential drugs and Equipment for MNH services  Availability of human resources (HR) based on sanctioned post  Quantity of care  Service record of last 6 month  Daily service statistics (30 days observation)  Quality of care  Scores obtained by the providers of DH in different MNH care services  Availability of providers for MNH care services in 30 days’ observation period  Percentage of days with availability of providers by type for MNH care in each shift (morning, evening, night)  Availability of mean number of other support staff for MNH care per shift per day  Scoring on availability of providers

4. Objective 1a. To test effectiveness of a health system strengthening intervention package (filling up the gaps in infrastructure and logistical supports; sharing/hiring of providers; policy advocacy to fill-up human resource gaps; strengthening of the monitoring and supervision; provision of non-financial group incentives to attain the set targets) in Increased availability of providers for offering MNH and EmONC services at public health facilities Increased utilization of delivery and EmONC services Improved quality of care for different components of EmONC services Specific objectives

5. Methodology

6. Habiganj 1 District Hospital & 1 MCWC Habiganj 2 UHCs (Azmeriganj & Chunarughat) Study design & sites Pre-post study design Study sites

7. A four member data collection team divided into two groups is engaged in quantitative data collection. Each data collection group consists of one female medical officer and one person with quantitative background trained in respective field Another medical officer was responsible for co-coordinating the overall quantitative data collection activities in the field. A team of two members were engaged in qualitative data collection. Data collection team

8. A monitoring and supervision team, consisting of the ICDDR,B investigators made unscheduled field visits to supervise the field activities. The qualitative investigator of the study was responsible for overall data collection, monitoring and supervision of the qualitative team. Monitoring team

9. Monitoring visit

10. Data collection procedure Both baseline and 1 st periodic assessments were done in 3 phases for a duration of 30 days Data collection tools EmONC needs assessment (cross-sectional) − Face-to-face interview by using semi structured questionnaire − Extraction of service record of last 6 months from registers 30 days prospective assessment on HR availability, admission and referral and services Assessment of quality of MNH care through observation (using checklist) −ANC, NVD, PNC, FP services, Sick newborn care, C-section delivery, Maternal complications management, Blood transfusion, Infection prevention In depth interviews of program managers, providers and support staffs Baseline AssessmentPhase-1 Assessment 1st phaseApril 29-May o8, 2014April 15-April24, 2015 2nd phaseMay 18-May 27, 2014May 01-May 10, 2015 3rd phaseJune 07-June18, 2014May 15-May 24, 2015

11. Snap shot of data collection

12. Human resources (HR)

13. Availability of HR in DH : Medical doctors (No.) Medical doctors Sanctioned post In position Comment BaselinePhase-1 Sr.Consultant (Obs/Gynae) 100 Jr. Consultants of two UHCs are working through local management Jr.Consultant (Anaesthesia) 101 Jr.Consuntant (Paediatrics) 122 One consultant is placed against the post of Jr. Consultant (Eye) RMO221 Medical officer (Pathology) 111 Anaesthetist111 Medical officer (BT)200 Medical officer (MO)1488  One Obs/Gynae specialist  One is trained in Obs/Gynae EMO311  Trained in Anaesthesia

14. Availability of HR in DH : Nurses and other technical staff (No.) Technical and support staff Sanctioned post In positionEOC training Baseline Phase-1 Baseline Phase-1 Nursing staff Nursing supervisor200-- Senior staff nurse38312842 Staff nurse1601-- Staff nurse (MaMoni)10 -- Assistant nurse544-- Technical staff SACMO014-- Medical Technologist (Lab.)122-- Medical Technologist (Rad.)111-- Medical Technologist (BT)0-- Pharmacist322-- Other support staff Driver222-- MLSS1718 -- Ward Master200-- Stretcher bearer422-- Guard415-- Aya1078-- Sweeper191314--

15. Quality of care

16. Technical competency of the providers for providing commonly performed maternal and newborn health care services were assessed by observation of the related medical procedures using standardized checklists of SBM-R These checklists were filled-up by trained female medical officer/paramedic In each of the health facilities these observation were done if respective procedure was available within 30 days For each of the procedures, the total target was estimated purposively Scoring was done as percentage of activities achieved among total number of activities in each procedure Methodology

17. Total number of activities observed by procedure Type of care Number of activities observed per procedure (Total score) ANC 81 NVD 253 PNC103 Sick newborn care Preterm/LBW neoenate20 Neonatal sepsis14 Neonatal jaundice14 Umbilical infection C-section delivery 152 Maternal complications management Incomplete abortion54 Pre-eclampsia/Eclampsia58 PPH71 Blood transfusion 24 Infection prevention 156

18. Total number of procedures observed by type Type of care Number of procedure observed BaselinePhase-1 ANC36 NVD20 PNC20 Sick newborn care Preterm/LBW neoenate4 9 Neonatal sepsis77 Neonatal jaundice33 Umbilical infection-- C-section delivery15 Maternal complications management Incomplete abortion65 Pre-eclampsia/Eclampsia46 PPH54 Blood transfusion1015 Infection prevention55

19. Level of quality of care for different types of MNH-FP care services in DH

20. Percentage of score obtained in different components of antenatal care by the providers of DH Component of Antenatal Care DH BaselinePhase-1 Initial evaluation by the receiver15.59.3 Cordial and respectful receiving by the provider57.133.1 Obstetrical history taking57.154.3 General medical history taking30.224.7 Physical and obstetric examination15.335.4 Individualized care based on findings and protocols32.760.0 Birth planning1.519.9 Care planning36.148.5 Total25.635.6

21. Percentage of score obtained in different components of normal vaginal delivery by the providers of DH Components of Normal Vaginal Delivery DH BaselinePhase-1 Initial assessment45.657.2 Explanation of services to be provided67.979.8 Review and filling-up the clinical history55.367.3 Physical examinations between contractions if time allows40.159.4 Obstetric examination between contractions if time allows58.061.0 Vaginal examination62.883.5 Use of partograph and make adjustments to the birth plan9.717.9 Preparation to assist birth42.764.1 Assist the woman to have a safe and clean birth80.887.0 Initial assessment of the newborn and provides immediate newborn resuscitation if needed 78.688.1 Active management of the third stage of labor63.069.4 Immediate postpartum care68.790.3 Disposal of used instruments and medical waste43.544.0 Monitoring of newborn in immediate postpartum period32.853.9 Close monitoring of the woman for at least two hours after the birth49.557.7 Neonatal resuscitation if needed86.797.5 Total52.665.2

22. Percentage of score obtained in different components of C-section delivery by the providers of DH Components of C-Section Delivery DH BaselinePhase-1 Information to the clients regarding indication, risks and benefit of caesarean section delivery 51.775.6 Ensure fitness for surgery through physical and laboratory examinations 52.060.0 Preparation of operation theatre and provider for surgery70.977.5 Preparation of the patient for surgery62.970.5 Provide anaesthesia84.092.4 Opening of abdominal layer84.2100.0 Opening of uterus90.0100.0 Delivery of baby80.0100.0 Delivery of the placenta and exploration of the peritoneal cavity58.195.0 Closure of the uterus88.586.7 Closure of the abdominal wall98.9100.0 Completion of all post-procedure tasks55.862.7 Post-operative monitoring and ensure postnatal care71.264.8 Monitoring of newborn in immediate postpartum period34.155.1 Resuscitation of newborn if needed- 100.0 Total65.676.9

23. Percentage of score obtained in different components of postnatal care by the providers of DH Components of Postnatal Care DH BaselinePhase-1 Initial assessment35.337.0 Cordial and respectful receiving by the provider40.066.7 Verification of existed clinical records or opening of new one by appropriate history taking 41.313.5 Routine physical examination13.611.7 Individualized care based on findings and protocols28.150.7 Advices on danger signs of postpartum period6.121.6 Referral of mother if needed50.083.3 Assessment of the condition of newborn25.940.1 Management of neonates and show breast feeding position0.0 Counseling on care of baby7.222.3 Advices on baby's danger signs0.015.8 Total19.028.1

24. Percentage of score obtained in different components of maternal complications management by the providers of DH Components of Maternal Complications Management DH BaselinePhase-1 General management Availability of drugs, equipment and supplies89.582.4 Management of hypovolumic shock81.983.8 Evaluation of patient's response and next step67.770.0 Incomplete abortion Diagnosis of incomplete abortion90.597.6 Management of incomplete abortion68.883.9 Pre-eclampsia/ Eclampsia Diagnosis of pre-eclampsia/Eclampsia91.7100.0 Management of severe pre-eclampsia and/or eclampsia 76.082.4 PPH Diagnosis of PPH100.0 General management of PPH62.386.9 Cause-specific management of PPH49.0100.0 Follow-up of the PPH patient59.979.2 Total77.085.0

25. Percentage of score obtained in different components of sick newborn care by the providers of DH Sick newborn care DH BaselinePhase-1 Receiving of the patient and explanation of the condition after history taking 70.075.3 Appropriate diagnosis of a pre-term/low birth weight neonate 31.775.9 If neonatal sepsis, proper diagnosis and appropriate referral 53.081.2 If neonatal jaundice, proper diagnosis and appropriate referral if required 51.976.4 If umbilical infection, proper diagnosis and appropriate treatment -- Total54.178.4

26. Percentage of score obtained in different components of blood transfusion by the providers of DH Components of Blood Transfusion Services DH BaselinePhase-1 Cordial receive of the patient and response to any query55.073.3 Assessment of the donor for fitness of blood donation75.086.7 Blood collection procedure91.791.1 Appropriate blood transfusion procedure86.878.6 Total80.382.3

27. Percentage of score obtained in different components of infection prevention by the providers of DH Components of infection prevention DH BaselinePhase-1 Cleanliness of the facility and availability of clean running water 52.672.5 Process to clean rooms wards and clinical areas 41.766.1 Labour room Storage of equipment for reuse 48.076.0 Using of antiseptics 40.082.4 Instrument cleaning area and prevention of cross-contamination 77.891.1 Decontamination of instruments and other articles 56.072.0 Process of cleaning instruments and other items 77.188.6 OT Storage of equipment for reuse 80.0 Using of antiseptics 60.094.3 Instrument cleaning area and prevention of cross-contamination 86.797.8 Decontamination of instruments and other articles 72.0 Process of cleaning instruments and other items 80.082.9 Area for wrapping and packing instruments 60.0100.0 Process of packaging instruments and other items to be sterilized 80.0100.0 Sterilization process 71.893.2 High level disinfection process 90.0100.0 Availability of antiseptics, disinfectants and other supplies 61.494.1 Collection of soiled linen 26.766.7 Following of general biosafety and infection prevention practices in the laboratory 97.179.5 Total 64.383.2

28. Round the clock availability of provider for MNH care services

29. Methodology Round the clock availability of the providers were assessed by prospectively assessing availability of each of the members of the MNH team by the three different time slots i.e. Morning (8 am-2 pm) Evening (2 pm–9 pm) Night (9 pm–8 am) The observation were done for 30 days in three phases During daytime the timesheets were filled-up the by direct observation For presence of the providers in evening and night shift, the time-sheet were filled- out either by direct observation or by interviewing a provider who was in duty in the previous night

30. Availability of medical doctors in DH for attending patients by shift (Baseline)

31. Availability of medical doctors in DH for attending patients by shift (Phase-1)

32. Availability of medical doctors in different areas of DH for attending patients by shift (Baseline)

33. Availability of medical doctors in different areas of DH for attending patients by shift (Phase-1)

34. Baseline Phase-1 Availability of Senior Staff nurses in Obs/Gynae ward

35. Baseline Phase-1 Availability of project-hired (MaMoni) nurses in Obs/Gynae ward

36. Availability of nurses (combined) in Obs/Gynae ward Baseline Phase-1

37. Baseline Phase-1 Availability of Senior Staff nurses in paediatrics ward

38. Baseline Phase-1 Availability of Project-hired (MaMoni) nurses in paediatrics ward

39. Availability of nurses (combined) in paediatrics ward Baseline Phase-1

40. Availability of Govt. nurses in OT Baseline Phase-1

41. Availability of other technical staff in DH (Baseline)

42. Availability of other technical staff in DH (Phase-1)

43. Mean number of other support staff per day by shift available in DH Other support staff MorningEveningNight Baseline Phase-1 Baseline Phase-1 Baseline Phase-1 MLSS (obs/gynae ward) 0.61.000.31.000.21.00 Sweeper (obs/gynae ward) 1.01.001.01.000.81.00 Aya (obs/gynae ward) 0.80.760.80.790.80.52 Student Nurse (obs/gynae ward) 2.63.101.42.100.80.67 Student Nurse (Paediatric ward) 1.83.151.42.250.60.70

44. Medical doctors Present more than 3 hours (100% score) + Presence less than 3 hours (50% score) + Attending call (100 score) - Not attending call (100% score) Nurses/FWVs for ward Morning shift = Presence of at least 3 nurses (100% score) + Presence of 2 nurses (67% score) + Presence of presence of 1 nurse (33% score) Evening shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score) Night shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score) Nurses/FWVs for OT Presence of at least 2 nurses/FWVs (100% score) + Presence of 1 nurse/FWV (50% score) + 2 on call nurses/FWVs with attending emergency cases (100% score) + 1 on call nurse/FWV with attending emergency cases (50% score) - On call nurses/FWVs but not attending emergency cases (100% score) Other technical staff (MT/Pharmacist/ANA/Dai nurse) For each category Presence more than 3 hours (100% score)+ Presence less than 3 hours (50% score)+ On call attending emergency cases (100% score) - On call but not attending emergency cases (100% score) Support staff (MLSS/Aya/Sweeper/Guard) Presence of at least 2 support staff (100 score) + Presence of at least 1 support staff (50% score) Scoring system for availability of MNH care providers

45. Score on availability of providers in DH by assessment type Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift BaselinePhase-1 Medical doctors Gynae ward 40.648.9 Paed ward 28.932.2 Emergency 100.0 Anaesthesia 27.226.7 Average 49.251.9 Nurses Gynae ward95.893.3 Paediatrics ward65.468.5 OT31.125.6 Average 64.162.5 Other Technical Staff Medical Technologist (Lab/BT)84.466.7 Other Support Staff (MLSS/Aya/Sweeper/Guard)96.67100.0 Overall Average63.362.4

46. Score on availability of providers in DH by assessment type (excluding holidays) Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift BaselinePhase-1 Medical doctors Gynae ward48.856.5 Paed ward34.640.6 Emergency100.0100 Anaesthesia30.233.3 Average53.457.6 Nurses Gynae ward 96.393.7 Paediatrics ward 65.676.3 OT 32.131.2 Average64.767.1 Other Technical Staff Medical Technologist (Lab/BT) 87.771.0 Other Support Staff (MLSS/Aya/Sweeper/Guard) 96.3100.0 Overall Average 65.767.0

47. Achievement of targets

48. Type of providersBaseline Level-I TargetAchieved Medical doctors49.2% 51.9% Nurses64.1% 62.5% MT (lab/BT)84.4% 66.7% Support Staff96.7% 100.0% Overall63.3%70.0%62.4% Achievement of targets for availability of providers for 24/7 MNH care services in DH

49. Type of careBaseline Level-I TargetAchieved FP services--- ANC25.6%35.6% NVD52.6%65.2% PNC19.0%76.9% Sick newborn care54.1%28.1% C-section delivery65.6%85.0% Maternal complications management 77.0%78.4% Blood transfusion80.3%82.3% Infection prevention64.3%83.2% All procedures54.8%70.0%66.9% Achievement of targets for quality of care for MNH services in DH

50. Findings from MCWC

51. Human resources (HR)

52. Name of the post Sanctioned post In position Comment BaselinePhase-1 Medical doctors MO (clinic)111Trained in Obs/Gynae MO (MCH-FP) 0 11 Trained in Anaesthesia, Posted in Sadar Upazila FP office, attached in MCWC Other support staff FWV267All are EOC trained Staff nurse (Ma-Moni) 010 Maternity leave but no replacement was done FMA11 1 ANA/Dai nurse233 Pharmacist011 Driver11 1 Peon cum chowkider121 Sweeper13 1 Two are temporary staff were found during baseline assessment Aya 0 11 Guard 0 4 - Two are from Ansar/VDP Availability of HR in MCWC (No.)

53. Quality of care

54. Technical competency of the providers for providing commonly performed maternal and newborn health care services were assessed by observation of the related medical procedures using standardized checklists of SBM-R These checklists were filled-up by trained female medical officer/paramedic In each of the health facilities these observation were done if respective procedure was available within 30 days For each of the procedures, the total target was estimated purposively Scoring was done as percentage of activities achieved among total number of activities in each procedure Methodology

55. Total number of activities observed by procedure Type of care Number of activities observed per procedure (Total score) Birth spacing/FP Combined oral contraceptive (COC) pill 64 Progesteron only pill (POP) - Depot medoxy progrsteron acetate (DMPA) 65 Condom 40 Insertion of Intra-uterine copper device (IUCD) 61 Removal of Intra-uterine copper device (IUCD) 24 Emergency contraceptive pill (ECP) - Sterilization 45 Implant 58 ANC 81 NVD 253 PNC103 Sick newborn care Preterm/LBW neoenate20 Neonatal sepsis14 Neonatal jaundice14 Umbilical infection C-section delivery 152 Maternal complications management Incomplete abortion54 Pre-eclampsia/Eclampsia58 PPH71 Blood transfusion 24 Infection prevention 156

56. Total number of procedures observed by type Type of care Number of procedure observed BaselinePhase-1 FP services Combined oral contraceptive (COC) pill 15 4 Progesteron only pill (POP) - - Depot medoxy progrsteron acetate (DMPA)125 Condom83 Insertion of Intra-uterine copper device (IUCD)32 Removal of Intra-uterine copper device (IUCD)11 Emergency contraceptive pill (ECP)-- Sterilization118 Implant 107 ANC36 NVD20 PNC1820 Sick newborn care -- C-section delivery1415 Maternal complications management Incomplete abortion-2 Pre-eclampsia/Eclampsia-- PPH-- Blood transfusion02 Infection prevention55

57. Level of quality of care for different types of MNH-FP care services in MCWC

58. Percentage of score obtained in different components of birth spacing by the providers of MCWC Components of FP Service MCWC BaselinePhase-1 Counselling technique39.980.3 Support client's interest, needs and choice19.470.8 Providing information on all birth spacing methods and helping to choose suitable method 5.364.8 Counselling clients regarding postpartum contraception and lactational ammenorrhoea method (LAM) 3.725.0 Ruling out of the current pregnancy18.885.1 Return/follow-up visit of the client26.675.9 Combined oral contraceptive (COC) pill13.641.1 Progesteron only pill (POP)- - Depot medoxy progrsteron acetate (DMPA)24.359.7 Condom15.045.1 Insertion of Intra-uterine copper device (IUCD)34.967.7 Removal of Intra-uterine copper device (IUCD)41.771.9 Emergency contraceptive pill (ECP) Sterilization36.682.2 Implant26.589.4 Total23.869.6

59. Percentage of score obtained in different components of antenatal care by the providers of MCWC Components of Antenatal Care MCWC BaselinePhase-1 Initial evaluation by the receiver14.853.6 Cordial and respectful receiving by the provider59.492.8 Obstetrical history taking60.866.7 General medical history taking17.737.4 Physical and obstetric examination57.069.1 Individualized care based on findings and protocols32.157.3 Birth planning4.522.9 Care planning48.976.7 Total36.957.2

60. Percentage of score obtained in different components of normal vaginal delivery by the providers of MCWC Components of Normal Vaginal Delivery MCWC BaselinePhase-1 Initial assessment46.796.1 Explanation of services to be provided73.693.6 Review and filling-up the clinical history57.976.6 Physical examinations between contractions if time allows55.763.6 Obstetric examination between contractions if time allows72.079.0 Vaginal examination74.677.3 Use of partograph and make adjustments to the birth plan11.042.1 Preparation to assist birth74.579.0 Assist the woman to have a safe and clean birth85.881.7 Initial assessment of the newborn and provides immediate newborn resuscitation if needed 78.484.6 Active management of the third stage of labor71.577.4 Immediate postpartum care89.790.7 Disposal of used instruments and medical waste76.579.0 Monitoring of newborn in immediate postpartum period33.660.6 Close monitoring of the woman for at least two hours after the birth 54.856.7 Neonatal resuscitation if needed100.0 Total59.872.2

61. Percentage of score obtained in different components of C-section delivery by the providers of MCWC Components of C-section Delivery MCWC BaselinePhase-1 Information to the clients regarding indication, risks and benefit of caesarean section delivery 65.772.8 Ensure fitness for surgery through physical and laboratory examinations 81.477.0 Preparation of operation theatre and provider for surgery83.870.0 Preparation of the patient for surgery88.874.3 Provide anaesthesia95.591.4 Opening of abdominal layer100.0 Opening of uterus92.0100.0 Delivery of baby89.8100.0 Delivery of the placenta and exploration of the peritoneal cavity68.093.3 Closure of the uterus96.096.7 Closure of the abdominal wall100.0 Completion of all post-procedure tasks77.741.3 Post-operative monitoring and ensure postnatal care79.266.2 Monitoring of newborn in immediate postpartum period33.850.1 Resuscitation of newborn if needed50.0- Total76.575.4

62. Percentage of score obtained in different components of postnatal care by the providers of MCWC Components of Postnatal Care MCWC BaselinePhase-1 Initial assessment29.060.4 Cordial and respectful receiving by the provider15.675.0 Verification of existed clinical records or opening of new one by appropriate history taking 19.479.2 Routine physical examination18.350.4 Individualized care based on findings and protocols37.467.9 Advices on danger signs of postpartum period13.642.8 Referral of mother if needed- 100.0 Assessment of the condition of newborn14.235.5 Management of neonates and show breast feeding position5.926.9 Counseling on care of baby34.043.3 Advices on baby's danger signs22.051.1 Total24.552.2

63. Percentage of score obtained in different components of maternal complications management by the providers of MCWC Components of Maternal Complications Management MCWC BaselinePhase-1 General management Availability of drugs, equipment and supplies-78.6 Management of hypovolumic shock-100.0 Evaluation of patient's response and next step-70.7 Incomplete abortion Diagnosis of incomplete abortion-- Management of incomplete abortion-- Pre-eclampsia/ Eclampsia Diagnosis of pre-eclampsia/Eclampsia-- Management of severe pre-eclampsia and/or eclampsia -- PPH Diagnosis of PPH-100.0 General management of PPH-72.9 Cause-specific management of PPH-85.7 Follow-up of the PPH patient-79.2 Total-78.7

64. Percentage of score obtained in different components of blood transfusion by the providers of MCWC Components of Blood Transfusion Services MCWC BaselinePhase-1 Cordial receive of the patient and response to any query -100.0 Assessment of the donor for fitness of blood donation-87.5 Blood collection procedure-91.7 Appropriate blood transfusion procedure-73.3 Total-85.0

65. Percentage of score obtained in different components of infection prevention by the providers of MCWC Components of infection prevention MCWC BaselinePhase-1 Cleanliness of the facility and availability of clean running water 91.296.9 Process to clean rooms wards and clinical areas 70.462.6 Labour room Storage of equipment for reuse 88.084.0 Using of antiseptics 62.957.1 Instrument cleaning area and prevention of cross-contamination 80.093.3 Decontamination of instruments and other articles 84.060.0 Process of cleaning instruments and other items 94.377.1 OT Storage of equipment for reuse 100.092.0 Using of antiseptics 82.974.3 Instrument cleaning area and prevention of cross-contamination 91.188.9 Decontamination of instruments and other articles 80.068.0 Process of cleaning instruments and other items 94.389.3 Area for wrapping and packing instruments 66.786.7 Process of packaging instruments and other items to be sterilized 95.0100.0 Sterilization process 91.693.3 High level disinfection process 100.0- Availability of antiseptics, disinfectants and other supplies 78.6100.0 Collection of soiled linen 40.053.3 Following of general biosafety and infection prevention practices in the laboratory -- Total 83.081.9

66. Round the clock availability of provider for MNH care services

67. Methodology Round the clock availability of the providers were assessed by prospectively assessing availability of each of the members of the MNH team by the three different time slots i.e. Morning (8 am-2 pm) Evening (2 pm–9 pm) Night (9 pm–8 am) The observation were done for 30 days in three phases During daytime the timesheets were filled-up the by direct observation For presence of the providers in evening and night shift, the time-sheet were filled- out either by direct observation or by interviewing a provider who was in duty in the previous night

68. Availability of medical doctors in MCWC for attending patients by shift (Baseline)

69. Availability of medical doctors in MCWC for attending patients by shift (Phase-1)

70. Availability of FWVs in MCWC BaselinePhase-1

71. Availability of other technical staff in MCWC BaselinePhase-1

72. Mean number of other support staff per day by shift available in MCWC Other support staff BaselinePhase-1 MorningEveningNightMorningEveningNight Peon cum Chowkider 0.5 0.0 1.030.270.60 Sweeper 1.00.50.6 1.030.530.43 Aya 0.50.30.4 0.370.070.23 Night Guard 1.70.61.1 0.930.810.44

73. Medical doctors Present more than 3 hours (100% score) + Presence less than 3 hours (50% score) + Attending call (100 score) - Not attending call (100% score) Nurses/FWVs for ward Morning shift = Presence of at least 3 nurses (100% score) + Presence of 2 nurses (67% score) + Presence of presence of 1 nurse (33% score) Evening shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score) Night shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score) Nurses/FWVs for OT Presence of at least 2 nurses/FWVs (100% score) + Presence of 1 nurse/FWV (50% score) + 2 on call nurses/FWVs with attending emergency cases (100% score) + 1 on call nurse/FWV with attending emergency cases (50% score) - On call nurses/FWVs but not attending emergency cases (100% score) Other technical staff (MT/Pharmacist/ANA/Dai nurse) For each category Presence more than 3 hours (100% score)+ Presence less than 3 hours (50% score)+ On call attending emergency cases (100% score) - On call but not attending emergency cases (100% score) Support staff (MLSS/Aya/Sweeper/Guard) Presence of at least 2 support staff (100 score) + Presence of at least 1 support staff (50% score) Scoring system for availability of MNH care providers

74. Score on availability of providers in MCWC by assessment type Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift BaselinePhase-1 Medical doctors Obs/Gynae31.734.4 Anaesthesia36.130.0 Average33.932.2 FWVs/Nurse71.166.5 Other Technical Staff ANA/Dai nurse63.370.0 Other Support Staff MLSS/Aya/Sweeper/Guard93.987.2 Overall Average59.257.6

75. Score on availability of providers in MCWC by assessment type (Excluding holidays) Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift BaselinePhase-1 Medical doctors Obs/Gynae32.142.0 Anaesthesia35.839.1 Average34.040.6 FWVs/Nurse84.873.2 Other Technical Staff ANA/Dai nurse72.869.6 Other Support Staff MLSS/Aya/Sweeper/Guard93.287.0 Overall Average63.762.2

76. Achievement of targets

77. Type of providersBaseline Level-I TargetAchieved Medical doctors33.9% 32.2% FWVs/Nurse71.1% 66.5% Other technical staff63.3% 70.0% Support Staff93.9% 87.2% Overall59.2%70.0%57.6% Achievement of targets for availability of providers for 24/7 MNH care services in MCWC

78. Type of careBaseline Level-I TargetAchieved FP service23.8%69.6% ANC36.9%57.2% NVD59.8%72.2% PNC24.5%75.4% Sick newborn care-52.2% C-section delivery76.5%78.7% Maternal complications management - Blood transfusion-85.0% Infection prevention83.0%81.9% All procedures50.7%70.0%71.5% Achievement of targets for quality of care for MNH services in MCWC

79. icddr,b also thanks its Core Donors Acknowledgements This project was funded by the Traction project of USAID