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

1. SAFOG Panel discussion
on
Improving Maternal Health in
South Asia
AICOG Varanasi, India
28th
January, 2012

2. Chair Persons
Prof. H.L.Seneviratne, President SAFOG
Prof. P. K. Shah, President FOGSI
Moderator
Prof. Alokendu Chatterjee,
President Elect SAFOG

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. 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. 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. 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. Trend in MMR

8. Q2.
a) Barriers facing now to effective
implementation of agreed strategies
b) Challenges ahead that needs particular attention
& resources

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. 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. 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. 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. 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. 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. 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. 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

19. 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

20. 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

21. 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
**

22. Q2.
a) Barriers facing now to effective
implementation of agreed strategies
b) Challenges ahead that needs particular attention
& resources

23. 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]

24. 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

25. Q 3.
a) Role of your National government on –
maternal health care strategies
& regular financial flows
b) Role played by your National OBGY Society

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Q2.
a) Barriers facing now to effective
implementation of agreed strategies
b) Challenges ahead that needs particular attention
& resources

33. Barriers Nepal is facing now to effective
implementation of agreed Strategies
Difficult terrain
Long distance for communication &
transportation )
FUNCTIONAL 24 HOUR BIRTHING CENTER

34. 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

35. 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

36. 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

37. NESOG’S MAIN ROLE
LIES IN ADVOCAY
LINKS WITH BRINGING CHANGES IN
ISSUE REGARDING MNH

38. 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

39. 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

40. 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

41. 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%

42. PakistanPakistan
Referral system & Maternal mortality
•Lack of efficient referral system
• MMR per100,000 live births
– 2010 - 260
– 2008 - 376.5
– 1990 – 541.1

43. Q2.
a) Barriers facing now to effective
implementation of agreed
strategies
b) Challenges ahead that needs
particular attention & resources

44. PakistanPakistan
Barriers in effective implementation
•Gross under budgeting of the health
sector
•Demand & supply issues
•Beaurocratic apathy
•Adhoc ism
•Lack of coordination of agencies

45. 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

46. Q 3.
a) Role of your National government on –
maternal health care strategies
& regular financial flows
b) Role played by your National OBGY Society

47. 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

48. 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

49. Role played by
National Society
Sensitization &
Awareness
Negotiation &
Mediation
Policy making

50. 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.

51. 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

52. 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

53. <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

54. 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

55. Q2.
a) Barriers facing now to effective
implementation of agreed strategies
b) Challenges ahead that needs particular
attention & resources

56. Five inter related gaps for achieving
the MDG-5

57. 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

58. Q 3.
a) Role of your National government on –
maternal health care strategies
& regular financial flows
b) Role played by your National OBGY Society

59. 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

60. 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.

61. 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

62. 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.

63. 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

64. Welcome to Agra India 1-4 march 2012