ACIEVING MDG4/5 IN SAFOG HOW FAR ARE WE ?

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MDG is millineum development goals and 4/5 relate to women care and neonatal care..the deadline to achieve health targets is reset for 2015, but we in south east asia are still far away from these targets.....see who has done it and who will

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  • There is significant improvement in incentive received by women for institutional delivery.
  • Delivery by SBA is recorded in HMIS since last 3 years. There is significant increase in SBA delivery by 5 %, institutional delivery by 7% and decrease in home delivery . Overall total delivery by trained health worker did not increase.
  • ACIEVING MDG4/5 IN SAFOG HOW FAR ARE WE ?

    1. 1. SAFOG Panel discussion on Improving Maternal Health in South Asia AICOG Varanasi, India 28th January, 2012
    2. 2. Chair Persons Prof. H.L.Seneviratne, President SAFOG Prof. P. K. Shah, President FOGSI Moderator Prof. Alokendu Chatterjee, President Elect SAFOG
    3. 3. Panelists Bangladesh --- Prof. Saria Tasnim & Prof. Kamrun Nahar India --- Dr. Jaideep Malhotra Nepal --- Dr. Ashma Rana Pakistan --- Dr. Rubina Sohail Sri Lanka ---Dr. Hemantha Perera
    4. 4. Q 1. Progress made in achieving MDG 5 in your country • Ante Natal Care • Skilled Birth Attendance at delivery • Institutional Delivery • Functional referral system
    5. 5. Progress by Bangladesh in achieving MDG 5 • Ante Natal Care coverage at least one visit- 60% at least four visits-21 % (BDHS, 2007) • Skilled Birth Attendance at delivery-- 26.5% (BMMS,2010) • Institutional Delivery-- 23% (BMMS,2010) Delivery by medically trained person-18% (Source: BDHS 2007)
    6. 6. Progress by Bangladesh in achieving MDG 5 contd…… • Functional referral system ---- 1st tier-Upazilla health complex (416) 2nd tier-District hospital(62) and MCWC(63) 3rd tier- Medical college hospitals (14)and specialized centres • MMR ---194/100,000 live births (BMMS,2010)
    7. 7. Trend in MMR
    8. 8. Q2. a) Barriers facing now to effective implementation of agreed strategies b) Challenges ahead that needs particular attention & resources
    9. 9. Barriers Bangladesh facing now-- to effective implementation of agreed strategies * Large number of home deliveries (2.4 million annual home births) * Huge number of deliveries attended by non medically trained provider
    10. 10. Challenges ahead that needs particular attention & resources in Bangladesh Shortage of health work force (specially at rural areas) Geographical disparity Rural EmONC Team retention Logistic Financing Health seeking behavior Socio cultural factors lack of knowledge ( ? education) Social marginalization Religious factors
    11. 11. Q 3. a) Role of your National government on – maternal health care strategies & regular financial flows b) Role played by your National OBGY Society
    12. 12. Role of Bangladesh Govt on maternal health care strategies & regular financial flows • Strengthen health facilities to provide EmONC servicesStrengthen health facilities to provide EmONC services(1994) • Demand Side Financing: Maternal Health Voucher Scheme (DSF):2006 • Maternal and neonatal health (MNH) program : 2007 • Free Tetanus Toxoid for women of child bearing age:2008 • Community-based Skilled Birth Attendant (C-SBA) Program: 2003 (Target 13,500) • Nurse midwifery training :2010 (Target 3,000)
    13. 13. Regular financial flows Regular financial flow is maintained by • Government’s own fund • Aids from Donor agencies • Development partners (e.g. USAID, DFID, CIDA, WHO, UNFPA) • Partial cost recovery.
    14. 14. Role played by Bangladesh OBGY Society OGSB has been working on different components of Maternal health programs in collaboration with GOB, NGOs, UN agencies and development partners
    15. 15. Will MDG 5 targets be reached by Bangladesh Targets & indicators Unlikely Potentially No data 5A: Reduce MMR by 75% between 1990- 2015 Maternal mortality ratio ✓ most births attended by SBA ✓ 5B: Achieve universal access to reproductive health by2015 Contraceptive prevalence rate ✓ Adolescent birth rate ✓ ANC (one/ four visits) ✓ Unmet need or family planning ✓ Achieving Millennium Development Goals 4 and 5 in Bangladesh S Chowdhury, LA Banu, TA Chowdhury, S Rubayet, S Khatoon BJOG Sep, 2011
    16. 16. Q 1. Progress made in achieving MDG 5 in your country --- • Ante Natal Care • Skilled Birth Attendance at delivery • Institutional Delivery • Functional referral system • MMR
    17. 17. SBA at del 79% Inst. Del 76% source -- CES 2009 (Coverage Evaluation Survey) Trend of % of Births attended by SBA personnel 33 42.4 48.8 49 100 0 20 40 60 80 100 120 1992-93 (NFHS-1) 1998-99 (NFHS-2 2005-06 (NFHS-3) 2007-08 (DLHS-3) 2015 Year %ofbirthattendedby SBA
    18. 18. Survival in Obst emergencies depend on Functional Referral System *Emergency Ambulance (ph.108) life saving services 11 states, 40%population, started rapid, cost effective ambulance service, with a central calling system operated &managed by IT professionals, co- ordinating among ambulance providers & care provider with pt in need of emergency transfer. Cost provided by the state * All health facilities receiving these pts must have SBA, medical emergency provisions, anaesthetist & blood
    19. 19. Per100000livebirths 0 200 400 600 800 1000 1200 1400 1600 1800 2000 19 50- 57 19 57- 60 19 63- 64 19 72- 76 19 77- 81 19 82- 86 1992 1998 2001 20062008 2009 2011 186.5 CHANGING TRENDS IN MMR IN INDIA (1950-2009) Target- M M R 109 by 2015 Source-RGI ** Lancet 2011;Vol 378, Sept, 2011 **
    20. 20. Q2. a) Barriers facing now to effective implementation of agreed strategies b) Challenges ahead that needs particular attention & resources
    21. 21. Barriers to implementation of agreed strategies in India * Diversity of India –vast area 1,269,210.5 sq miles/ 3,287,240 sq.Km * Health is a state subject * lack of political will * infrastructural deficit * lop sided health economics (Public :Private exp =20.3 :77.4) * far less no of Drs(1: 2000,MCI on 31/07/2011, USA 1:548) * total Medical Colleges in India -- 301only, 60% in south +MH * Social evils –Education --41% (G) & 18% (B) never went school. Higher the literacy rates lower the MMR * Early marriage --early preg. IMR 77 in teens, 55 in post teen [ NFHS 3 (2005-2006); UNICEF(2006) State of World Children]
    22. 22. Challenges ahead in India that needs particular attention & resources Health inequalities Urgent need of increasing per capita health expenditure (Estimated 35 US $) Shortage of human resources Coordination between national and sub national level Effective collaboration between govt & private sectors, NGOs Civil societies, Local communities, Professional organization Exchanges of information between countries through SAFOG
    23. 23. Q 3. a) Role of your National government on – maternal health care strategies & regular financial flows b) Role played by your National OBGY Society
    24. 24. Role of Indian Government * National Population policy 2000 * 10th 5 yr plan(2002-07) * NRHM (2005-12) * Janani Suraksha Yojana(JSY) * Gujarat Chiranjeevi Scheme (GCS) * 11th 5 yr plan (2008-12) Regular financial flows NRHM allocated Rs 12,070 crore ( $2.5B) Health budget to have 3% of GDP (current 1.4%) Money incentives in Instn. del, Obst/ anaesthetist services Role of FOGSI –EmOC training, catalyst – you know it all
    25. 25. Will MDG 5 targets be reached by India ? Target 5A Unlikely Potentially No data Reduce MMR by 75% possible✓ between 1990 to 2015 Most births by SBA possible✓ Target 5B Increase CPR Possible✓ Reduce Adolescent birth rate Unlikely ANC 4visits 1 visit Possible✓ Unmet need for FP Possible✓ Source :--Chatterjee A, Paily VP. Achieving MDG 4 and 5 in India. BJOG 2011;118 (Suppl. 2):47–59
    26. 26. Q 1. Progress made in achieving MDG 5 in your country--- • Ante Natal Care • Skilled Birth Attendance at delivery • Institutional Delivery • Functional referral system • MMR
    27. 27. Progress of Nepal in achieving MDG 5 targets Antenatal Care(%) 1990 2000 2005 2010 2015 at least one visit NA 48.5 73.7 89.9 100 at least four visits NA 14 29 50.2 NA SBA conducted del 7 11 18.7 28.8 60 Functional referral —delayed referral due to hilly system terrain MMR 850 415 281 229 134
    28. 28. Trend of Institutional delivery and incentive received FY 2065/66 & FY 2066/67 0 50000 100000 150000 200000 250000 2005/06 2006/07 2007/08 2008/09 2009/10 Inst Delivery Incentive Received <Promotion of institution childbirth & delivery incentives)Ama surachha
    29. 29. Trained Health Worker incl. SBA Deliveries (%) 10 14.4 21.1 18.8 12.813.5 15.3 20.2 22.5 29 23.5 29.7 41.3 41.3 41.9 23.9 24.8 29.4 0 5 10 15 20 25 30 35 40 45 2005/06 2006/07 2007/08 2008/09 2009/10 THW Home THW Facility THW Total SBA Total • Delivery by SBA has increased after the implementation of Aama Program • There is significant reduction in home delivery after Aama Program SDIP initiated Ama P initiated in 2008/9 Source: HMIS/MD, DOHS: Target population for last 3 years has been revised <Promotion of SBA conducted childbirthAma surachha
    30. 30. Q2. a) Barriers facing now to effective implementation of agreed strategies b) Challenges ahead that needs particular attention & resources
    31. 31. Barriers Nepal is facing now to effective implementation of agreed Strategies Difficult terrain Long distance for communication & transportation ) FUNCTIONAL 24 HOUR BIRTHING CENTER
    32. 32. Challenges ahead that needs particular attention & resources in Nepal *HR shortages, especially surgical doctors & nurses *Deployment & retention of HR in public sector. * Strengthen system for Post Training Follow up
    33. 33. Q 3. a) Role of National government of Nepal on – maternal health care strategies & regular financial flows b) Role played by National OBGY Society of Nepal
    34. 34. Role of Nepal Govt in Maternal Health Care Strategies & Regular Financial Flows Policy-- •CEOC/BEOC/BC-24 Hr making it functional •Human resources - train/in place/transfer •Equity access/demand/need •Flow and monitoring of fund •Sustainability-tapping local resources •Involvement of Private/Medical colleges health facilities Program • 33 CEOC functioning-HR/quality to reach special groups •Integration with SRH/FP • Referral mechanisms
    35. 35. NESOG’S MAIN ROLE LIES IN ADVOCAY LINKS WITH BRINGING CHANGES IN ISSUE REGARDING MNH
    36. 36. Will MDG 5 targets be reached by Nepal? Target Unlikely Potentially No data 5A: Reduce MMR by 75% between 1990 & 2015 Maternal mortality ratio ✓ most births attended by SBA ✓ 5B: Achieve universal access to reproductive health by 2015 Contraceptive prevalence rate ✓ Adolescent birth rate ✓ ANC (one/ four visits) ✓ Unmet need or family planning ✓ Achieving Millennium Development Goals 4 and 5 in Nepal-- D S Malla, K Giri, C Karki, P Chaudhary BJOG Sep, 2011
    37. 37. Q 1. Progress made in achieving MDG 5 in your country-- • Ante Natal Care • Skilled Birth Attendance at delivery • Institutional Delivery • Functional referral system • MMR
    38. 38. PakistanPakistan ANC •ANC by SHP - 33% in1996 to 61% 2006–7 • 61% receive ANC from skilled health providers (PDHS survey) •Urban women more than twice (48%) likely to seek ANC compared with rural women (20%). •Younger mothers (<35 years) PG, more likely to receive antenatal care from a SHP
    39. 39. PakistanPakistan SBA •Nationally, 34% deliveries by SBA •urban : rural = 60% : 30% •Births in Sindh province SBA –42% Institutional Delivery •17% in 1996 Public sector –11% •23% in 2000 –1 Private sector—23% •34% in 2006–7 Home delivery –65% Urban: rural 56%: 25%
    40. 40. PakistanPakistan Referral system & Maternal mortality •Lack of efficient referral system • MMR per100,000 live births – 2010 - 260 – 2008 - 376.5 – 1990 – 541.1
    41. 41. Q2. a) Barriers facing now to effective implementation of agreed strategies b) Challenges ahead that needs particular attention & resources
    42. 42. PakistanPakistan Barriers in effective implementation •Gross under budgeting of the health sector •Demand & supply issues •Beaurocratic apathy •Adhoc ism •Lack of coordination of agencies
    43. 43. PakistanPakistan Challenges needing attention & resources •Enhanced Government ownership •Strategic prioritization and results orientation •Prioritisation of poverty as a core issue – PRSP •Adopt program approach for gender support. •Financial resources •Effective monitoring
    44. 44. Q 3. a) Role of your National government on – maternal health care strategies & regular financial flows b) Role played by your National OBGY Society
    45. 45. PakistanPakistan Role of Government on MHC strategies Programs • Health Millennium Development Goals 2015 • Medium Term Development Framework • Poverty Reduction Strategy •National Health Policy - Health Sector Reform
    46. 46. Role of Government in financial flows • Rs.15 billion to finance vertical program – Expanded Program for Immunization – Lady Health Workers – Primary Health Care – National MNCH programs • Population welfare program funded by the federal Government at a cost of Rs.4 billion. • Individual provincial allocation for health
    47. 47. Role played by National Society Sensitization & Awareness Negotiation & Mediation Policy making
    48. 48. Will MDG 5 targets be reached by Pakistan ? Target Unlikely Potentially No data 5A: Reduce MMR by 75% between 1990 & 2015 MMR ✓ Most births attended by SBA ✓ 5B: Achieve universal access to reproductive health by 2015 Contraceptive prevalence rate ✓ Adolescent birth rate ✓ ANC (one/ four visits) ✓ Unmet need or family planning ✓ source :--Mahmud G, Zaman F, Jafarey S, Khan RL, Sohail R, Fatima S.Achieving Millennium Development Goals 4 and 5 in Pakistan. BJOG2011;118 (Supp. 2):69–77.
    49. 49. Q 1. Progress made in achieving MDG 5 in your country--- • Ante Natal Care • Skilled Birth Attendance at delivery • Institutional Delivery • Functional referral system • MMR
    50. 50. Institutional deliveries Fig 2.6 Districts with a high percent of home deliveries 0.6 0.7 1.3 1.4 2.5 3.1 0.40.5 0.5 0.7 0.8 1.9 0.3 1.3 0 0.5 1 1.5 2 2.5 3 3.5 Jaffna Mannar Trincomalee NuwaraEliya Vavuniya Batticaloa SriLanka 2008 2009
    51. 51. <8week s 66% 8-12 weeks 25% >12 weeks 9% 2009 <8week s 61% 8-12 weeks 29% >12 weeks 10% 2008 Time of Registration of Pregnant mothers Family Health Bureau Annual report 2008-9 68 Specialist care hospitals 245 Obstetricians 326 Medical Officer of Health Offices 5725 Public Health Midwives 65,610 sq km 432 X 224 Km
    52. 52. 61 62 63 53 55.83 55.56 46.87 53.36 43 38 44 39.3 38.4 33.4 0 10 20 30 40 50 60 70 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Maternal Mortality Ratio (1995 – 2008) Maternal Deaths due to Direct and Indirect causes 2007 Timing of Maternal Deaths 2007 History Major regional variations of MMR
    53. 53. Q2. a) Barriers facing now to effective implementation of agreed strategies b) Challenges ahead that needs particular attention & resources
    54. 54. Five inter related gaps for achieving the MDG-5
    55. 55. Challenges ahead • Lack of good governance in health sector • Effects of Ethnic conflict • Effects of Global economic crisis • Discrepancy in regional (eg.estate sector) health policies • Inadequate health facilities (EmOC, staff, finance and infra-structure) • Poor family planning compliance and rising illegal abortions
    56. 56. Q 3. a) Role of your National government on – maternal health care strategies & regular financial flows b) Role played by your National OBGY Society
    57. 57. Strategies identified by national policies • Three policy documents released • National health Policy 1996 • Presidential Task Force 1997 • Health Master Plan 2003 • Key strategies identified by these policy documents 1. Enhancement of health care resources 2. Comprehensive health care that includes private sector 3. Decentralization 4. Recognition of service provision 5. Performance appraisal system 6. Quality of care 59
    58. 58. 0 10000 20000 30000 40000 50000 60000 70000 80000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total Health Expenditure (SLR Mn) Increase government spending on health at least 2.5-3.0 % of GDP. Private spending would continue to be about 1.5-2.0 GDP so that the total expenditure would be 4.5- 5.0 of GDP Making efforts to link national policies & the national and provincial budgets so that national policies are reflected in resource allocation.
    59. 59. The College has set 27 strategic goals to achieve in the next 05 years. Strategic Goal 2. Ensure the application of Clinical governance principles at all clinical service delivery instances Strategic Goal 3. We want the SLCOG to play the leading role in planning a workload based staff pyramid and service facilities to provide optimum reproductive health services Strategic Goal 4. By 2015 we want all children, adolescents and youth to have mandatory reproductive health education Strategic Goal 5. By 2017 we want independent adolescent and youth friendly reproductive health services Strategic Goal 6. By 2014 we want contraceptive services to be available, accessible and be utilized by all sexually capable people irrespective of age, parity and marital status Strategic Goal 9. By 2014 we want all eligible for parenthood to receive satisfactory pre conception care Strategic Goal 10. By 2014 we want all pregnant mothers to receive antenatal, intrapartum, post natal care and Emergency Obstetric care at an appropriate standard set by the SLCOG Strategic Goal 16. To mobilize necessary resources to assist women undergoing psychological repercussions of obstetrical & gynaecological events Strategic Goal 17 & 18. By 2013 & 2015 respectively , we want all maternal death & severe acute maternal morbidity inquiries to be carried out in the internationally accepted standard confidential reporting format
    60. 60. Will MDG 5 targets be reached in Sri Lanka ? Target Unlikely Potentially No data 5A: Reduce MMR by 75% between 1990 and 2015 Maternal mortality ratio ✓ Most births attended by SBA ✓ 5B: Achieve universal access to reproductive health by 2015 Contraceptive prevalence rate ✓ Adolescent birth rate ✓ ANC ( 1 & 4 visits) ✓ Unmet need or family planning ✓ Senanayake H, Goonewardene M, Ranatunga A, Hattotuwa R, Amarasekera S, Amarasinghe I. Achieving Millennium Development Goals 4 and 5 in Sri Lanka. BJOG 2011;118 (Suppl. 2):78–87.
    61. 61. CONCLUSIONS . Two thirds of all maternal deaths in Asia and Pacific occur in India and Pakistan. Some countries are, nevertheless, making very significant progress towards achievement of MDG 5 target. Except for Sri Lanka, no South Asian country has yet reached the MDG 5. Hopefully others will reach sooner than later
    62. 62. Welcome to Agra India 1-4 march 2012

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