Addressing Health Inequities in Bangladesh MaMoni Health Systems Strengthening Project

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1 Addressing Health Inequities in Bangladesh MaMoni Health Systems Strengthening Project Introduction The MaMoni Health Systems Strengthening (HSS) project is a four-year Associate Award under the Maternal and Child Health Integrated Program (MCHIP), with a period of performance from September 24, 2013 to September 23, MaMoni HSS builds upon the MCHIP MaMoni project s previous work in Bangladesh and focuses on strengthening the systems and standards for maternal, newborn and child health, family planning (FP) and nutrition that will result in declines in maternal, newborn and child mortality within six districts and 40 sub-districts (upazilas) in Bangladesh with a target population of over 12 million. MaMoni HSS supports high-intensity interventions in a total of 23 upazilas. These areas include all upazilas of Habiganj, Lakhsmipur and Jhalokathi districts, four upazilas of Noakhali, and two upazilas of Pirozepur district. Bangladesh is organized by district, upazila and union council/parishad (the lowest administrative structure). Through engagement with the Ministry of Health and Family Welfare (MOHFW), local government structures and nongovernmental organizations, MaMoni HSS focuses on improving delivery of health services and strategically partnering at the national level to build consensus around policies and standards that positively drive evidence-based interventions at all levels. The project builds on two predecessor USAID projects: MaMoni Integrated Safe Motherhood, Newborn Care Family Planning (MaMoni ISMNC-FP) from 2009 to 2013 and ACCESS Safe Motherhood, Newborn Care Project (ACCESS) from 2006 to The program objectives are to: Improve service readiness through critical gap management Strengthen health systems as the district level and below Promote an enabling environment to strengthen district-level health systems Identify and reduce barriers to accessing health services MaMoni HSS has been on the forefront of developing innovative strategies to increase equitable access to health services for mothers, newborns and children (Program Objective 4), including: Through population-based surveys and community consultation, mapping underserved communities and identifying strategically located health facilities critical to ensure services to mothers and newborns; Catalyzing the renovation of peripheral (union-level) facilities, so that services are available closer to home; Ensuring that skilled providers reside in those facilities and are trained to provide appropriate services (introduce Helping Babies Breathe neonatal resuscitation protocol, management of postpartum hemorrhage and pre-eclampia/eclampsia, and postpartum FP services); Engaging 24,000 volunteers (one community health worker [CHW] for every 50 households) and developing a community-financed transport system to ensure timely referrals, including mobilizing community action groups to generate community funds, identifying pick-up points and signing Addressing Health Inequities in Bangladesh 1

2 memorandum of understanding with the transportation owner s association to designate transport drivers, establish defined rates for transportation during night, etc. (This was mainly a MaMoni ISMNC-FP activity from 2010 to 2013); Linking the volunteers with the formal health system through community microplanning (using the Reaching Every District approach of the Expanded Program on Immunization) to identify service gaps, address gaps in information and ensure services to all the households; Developing depot holders to ensure commodities (MaMoni ISMNC-FP activity) and training women from villages without appropriate services to become private, community-based skilled birth attendants with a mutually agreed pricing structure and a mandate to ensure free services to poor women; and Supporting sub-district and district level supervisors to undertake data driven planning exercises, organize joint supervisory visits and hold quarterly performance review meetings to assess progress. Addressing Socioeconomic Inequity MaMoni HSS identified socioeconomic barriers as one of the main challenges of equitable health service utilization and took specific steps to address these unique barriers. Examples of program activities to make health services more equitable include: bringing services closer to households and communities; facilitating transport for referrals and emergencies; and allocating project and leveraged resources to hard-to-reach and poor communities. In Habiganj district, three particularly vulnerable communities (tea gardens, urban slums of Habiganj Sadar municipality, and the haor/wetland villages of Ajmiriganj, Baniachang and Nabiganj) received customized interventions. In the tea garden areas, Sunday is the only day pregnant women could receive services because of work schedules and economic pressures to continue working even while pregnant. MaMoni HSS reorganized government satellite clinics and other counseling activities to take place on Sundays so that women living and working in the tea garden areas could access services (MaMoni ISMNC-FP activity). Figure 1: Changes in population coverage for key reproductive, maternal, newborn and child health indicators, for all women and for poor women in two communities in Bangladesh Women delivering in facilities 10.3 Poor women delivering in facilities Women who sought care for delivery complication from skilled provider Poor women who sought care for delivery complication from skilled provider CPR (women) CPR (poor women) Sylhet 2010 Sylhet 2012 Habiganj 2010 Habiganj ICDDRB population-based survey, 2010 and Addressing Health Inequities in Bangladesh

3 MaMoni ISMNC-FP promoted the use of misoprostol for prevention of postpartum hemorrhage. Women who went for an antenatal care (ANC) visit during the third trimester to the Union Health and Family Welfare Centers (UH&FWCs) would receive it there. However, for women who were unable to visit the UH&FWC, they could either get the misoprostol from trained community pharmacists or community health volunteers (CHVs). MaMoni ISMNC-FP provided the necessary commodities in 26 tea gardens in Habiganj to the community pharmacists and CHVs. MaMoni HSS also organized health promotion events, including film shows in the evening to make sure that the men and women of the tea gardens could participate. Also, since incidence of eclampsia is higher due to poor dietary habits, including high salt intake, MaMoni HSS strengthened ANC services focusing on pre-eclampsia detection and referral. In three sub-districts (Ajmiriganj, Baniachang and Nabiganj), a private cadre of community-based skilled birth attendants were trained. By doing this, communities without reasonable access to health services had a private provider who could deliver health services at the community level. MaMoni ISMNC-FP and MaMoni HSS linked these private providers to the union parishad so it was jointly determined how much the private providers could charge for services. Furthermore, the union parishad was responsible for identifying poor and marginalized women in their communities who would receive the services for free. By being linked to the union parishads, the private cadre of skilled attendants also obtained social acceptance and legitimacy among the target population. This experience was replicated under MaMoni HSS in Noakhali and Lakshmipur districts. MaMoni ISMNC-FP also trained depot holders in every village so that contraceptives and other commodities are available through social marketing channels. MaMoni ISMNC-FP linked the depot holders to the BRAC distribution chain to ensure that they would have access to commodities at wholesale rates. Addressing Geographic Inequity MaMoni HSS used the Bangladesh Maternal Mortality and Health Survey 2010 to obtain district-level information and develop a composite index to prioritize and identify districts with the greatest need. The six indicators used to inform this decision were: women delivering in facilities; poor women delivering in facilities; women who sought care for delivery complication from skilled provider; poor women who sought care for delivery complication from skilled provider; contraceptive (modern method) prevalence rate; and contraceptive prevalence rate among poor women. MaMoni HSS also works in districts that are not supported by other donor funds (identified through a donor mapping exercise). To improve access to and utilization of skilled birth attendants, MaMoni HSS upgraded strategically located UH&FWCs to provide 24/7 delivery care services to laboring women and deployed private, community-based skilled birth attendants where facility-based care was not available. In collaboration with the communities and local nongovernmental organizations, MaMoni HSS identified and trained one CHV for every 250 people. These CHVs provided counseling messages to mothers in their communities on FP, recognition of maternal and newborn danger signs and referral to appropriate service provider (including facilitating transport needed for the referral). MaMoni ISMNC-FP teamed up with the Smiling Sun Franchise Project (SSFP), Urban Partnership for Poverty Reduction Project and the Mayor of Habiganj in 2012 to ensure free and discounted satellite clinics in 10 additional locations, bringing poorer women into service coverage. SSFP charges BDT.40 for their regular ANC services, but for MaMoni ISMNC-FP identified women, they charged only BDT.10. MaMoni ISMNC-FP also sensitized the district hospital staff and referral management staff to sensitively receive urban slum mothers with complications, who were previously subject to abusive behavior because of their attire. This was mentioned as a positive attribute by the communities during the program evaluation consultation conducted in May MaMoni ISMNC-FP also upgraded union parishad-level facilities, specifically in the underserved sub-districts of Ajmiriganj and Baniachang in Habiganj district, with funding leveraged from other donors, government, Addressing Health Inequities in Bangladesh 3

4 elected representatives (Union Council) and community funds. Based on MaMoni s success in union-level facilities in Habiganj district, the MOHFW tasked MaMoni-HSS to assess the service readiness of 4,463 union-level facilities nationwide and to guide the MOHFW to ensure maternal and newborn health services in these facilities. The assessment was completed in September By using the innovative approach of community micro-planning, service gaps in specific unions were identified and additional resources including staff time, supervision and referral support were allocated to ensure high-quality services for all populations. Community micro-planning brings together community members (roughly 6,000 population size) and field workers at the union level at monthly meetings to discuss operational issues at the lowest level of the health system. MaMoni HSS prioritized three upazilas in Habiganj (Ajmiriganj, Baniachang and Lakhai) because of their topography and unique vulnerability due to inferior road conditions and high levels of poverty. MaMoni HSS allocated additional resources through leveraged funding and deployed water ambulances to make it easier for populations from remote villages to access health services. Similarly, MaMoni purchased three motor vehicles (with leveraged funding) and placed them in hard-to-reach upazilas of Ajmiriganj and Baniachang. MaMoni also mapped referral timing and transport cost for both the dry and wet seasons to identify unique vulnerabilities and implemented program activities to actively address these barriers. Figure 2: Increase in ANC1+ among recently delivered women by upazila % 50.0% 40.0% 30.0% 37.1% 22.2% 21.6% 34.6% 32.8% 27.1% 34.4% 32.0% 36.3% 35.7% 50.6% 46.2% 30.7% 28.9% 32.0% 41.2% 20.0% 10.0% 0.0% Addressing Gender Inequity Through community action groups, MaMoni identified actions and roles for men in promoting safe motherhood and FP issues. In Habiganj, 27% of volunteers are men, although the groups are mixed gender. With the help of male participants, MaMoni HSS promoted various ideal behaviors, including hand washing, recognition of maternal and newborn danger signs and better awareness of maternal and newborn health and FP services. MaMoni HSS also strengthened referral services through engagement of transportation owner associations to ensure that services are available at night at a pre-determined rate that is acceptable to community members. 2 ICDDRB population-based survey, 2010 and Addressing Health Inequities in Bangladesh

5 MaMoni ISMNC-FP and MaMoni HSS activated Union Education, Health and FP Standing Committees: 77 in Habiganj and 56 in Sylhet. These committees are chaired by the female elected member of the union parishad. All the union parishads have been trained on their role in maternal and newborn health and FP issues, and as a consequence, resource mobilization has been a success. Previously, the ACCESS Project recruited 286 women from the community in Sylhet and trained them as CHWs. These CHWs provided counseling to mothers on various maternal and newborn health issues. MaMoni HSS selected 257 of them and trained them on FP, misoprostol for postpartum hemorrhage, infant and young child feeding and other components, and then deployed them within the government health system. The willingness of the MOHFW to provide these women with Family Welfare Assistant registers and commodities, including contraceptives for counseling and distribution, attests to the trust and respect these women have gained for their contribution to the communities. In Habiganj, MaMoni HSS trained 43 community-based skilled birth attendants for seven months on clinical issues, helped them set up their business to serve as private providers, and linked them to the MOHFW reporting chain so that their performance is recognized and reported in the MOHFW management information system. MaMoni HSS has also trained over 2,000 depot holders (commodity sellers) all of them women and linked them to the supply chain of BRAC and Social Marketing Company. Through social marketing, many of these women earn enough income to support their families in meaningful ways. Through the community action groups, trained traditional birth attendants, community pharmacists and community-based skilled birth attendants, MaMoni HSS has secured access to fund and transport referrals during complications. Through community micro-planning, women who have not utilized ANC and postnatal care services are identified, and MaMoni volunteers and community action group members address their individual challenges. Union parishads, because of MaMoni HSS s facilitation, contributed resources that directly benefit both clients and service providers. In many instances, union parishads built access roads, water supplies and private toilets in clinics and provided curtains to ensure privacy and dignity of mothers. MaMoni HSS worked with union parishads to strengthen birth and death registrations for mothers and newborns. Prior to MaMoni HSS, many maternal deaths were unrecorded, and no action was generated to address them. Because of death audits, and sharing the death audits with the union parishads, these women are now included in the records. Conclusion The MaMoni HSS program has been on the forefront of developing innovative strategies to increase equitable access to health services. The project financed the renovation of peripheral facilities, shifted skilled providers to those facilities and developed a transport system to ensure timely referrals. In the urban slum communities in Habiganj municipality, MaMoni HSS partnered with private, local service providers to offer discounted rates for maternal health services to poor women. MaMoni HSS facilitated negotiations between a cadre of private, community-based skilled birth attendants and union parishads to achieve consensus around the prices charged by skilled birth attendants for maternity services and to ensure that services are free to poor women in the community. Addressing Health Inequities in Bangladesh 5