Nigar Group 5 Rh

A STRATEGY TO REDUCE MATERNAL MORTALITY IN DISTRICT GUJRAT Company

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GROUP - 5 MSPH - 2009 Health Services Academy

Dr. Abdul Wali Khan

TEXT DR. Fizza

TEXT Dr. Shumaila

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Dr. Hammad

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Agenda 1. INTRODUCTION 2. PROJECT 3. STRATEGY 4. ACTIVITY PLAN & GANTT CHART 5. BUDGET 4. LIMITATIONS

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INTRODUCTION

DR. FIZZA

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INTRODUCTION  Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period  Each year over half a million women in lowincome countries die from complications associated with childbearing  99% of maternal deaths occur in developing countries.  1/3 of them occur in SEA.  Millions more suffer pregnancy-related morbidities and chronic long-term disabilities related to pregnancy and childbirth

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Introduction cont . . .  How can one integrate nutrition and reproductive health?  Programs need to go beyond the global aim of reducing fertility and mortality  Adolescent girls should be included in supplementary-feeding programs before malnutrition becomes a causative factor in maternal mortality  The nutrition component of existing prenatal programs needs to be stable measured in terms of maternal anthropometry instead of just infant survival

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PREVALENCE OF ANEMIA BY PROVINCE (PERCENT)

80 Pregnant women

All women

60

40

20

0

NWFP

Punjab

Sindh

Balochistan Pakistan

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LITERACY RATES FOR PUNJAB DISTRICTS – BY MALES AND FEMALES

Lite ra cyR a te sfo rP u n ja bD istricts – b yM a le sa n dF e m a le sa g e d1 0 +y e a rs R a n k e dfro mH ig h e sttoLo w e stR a te sfo rM a le s

M aleLiteracyRates

Fem aleLiteracyRates

Raw alpindi Chakw al Jhelum Sialkot Lahore A ttock G ujrat M ianw ali G ujranw ala Narow al Sargodha T.T.Singh Khushab Faisalabad M andi Bahauddin Hafizabad Sahiw al Khanew al Jhang Layyah Sheikhupura M ultan Vehari Pakpattan Bahaw alnagar D.G .Khan O kara Bhakkar Rahim yarKhan Lodhran Kasur M uzaffargarh Rajanpur Bahaw alpur

68

87

57

84

59

78 65

75

67 40 57

73

37

73 62

72

49

72

46

69

46

68

36

68 52

68

48

66

44

64

45

64

36

62

31

60

32

59 41

58

35

56

30

55 34

54

24

54 33

53

20

53 31

52

23

51 32

51

22

48

20

20

Fem ales

47 28

10

%E xce ss o fM a le sto F e m a le s

56

30

0

75 73

E xce sso fM a le s o v e rF e m a le s

47

30

40

50

%Lite ra te

60

70

80

90

100

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Causes of Maternal Deaths (Pakistan)

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H e p a t it is A n e m ia A b o r t io n - r e la t e d O b s t. L a b o r T o x e m ia S e p s is H e m o rrh a g e 0

5

H o s p iCt a ol m m u n i t y

10

15

20

25

30

35

40

MMR 276

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276,000 women suffer from maternal illness and disability

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GUJRAT

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 District ancient Pakistan between rivers, Jehlum Chenab Punjab

Gujarat an district of located in two famous i.e., River and River in Province

AREA

3192 Sq .km

POPULATION

2.54 MILLION

POPULATION DENSITY

642/KM (2)

URBAN POPULATION

25.62%

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GUJRAT VS PUNJAB

Gujrat vs Punjab Health Indicators (MICS-Punjab; 2007-08) Indicator

Gujrat

Punjab

Year

Care provided by LHW

75%

50%

2007-08

Total fertility rate

5.5

4.7

2003-04

Use of contraception (any method)

37%

32%

2007-08

Ante-natal care

85%

53%

2007-08

Post-natal care

65%

41%

2007-08

Skilled attendant delivery

68%

43%

2007-08

Institutional deliveries

60%

38%

2007-08

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URBAN-RURAL POPULATION DISTRIBUTION OF GUJRAT P o p u la tio n d is trib u tio n o f d is t. G u jra t

U rban 28% Rural Urban Rural 72%

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PROJECT DR. SHUMAILA

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ASSUMPTIONS FOR MATERNAL MORTALIY

Preventive

Curative

1

Nutritional deficiency

Home based deliveries

2

Lack of awareness

Lack of skilled birth attendants

3

Lack of family planning

Post-partum hemorrhage

4

Lack of proper ante-natal Infection care

5

Poverty

Prolonged labour

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“NIGAR”

 TITLE OF PROECT  Nutritional intervention in Gujrat for adolescent & reproductive age group women (NIGAR).  Aim of the project  To reduce maternal mortality and morbidity in Gujrat.  Objective of the project  To reduce maternal mortality by 40% through implementation of a nutritional intervention program in CBA in 3 years in district Gujarat.

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“NIGAR”

 Slogan of the program  “MAAN TAWAANA, KHUSH-HAAL GHARANA” “NIGARPROJECT WORKER” “NIGAR REGISTRATION CARDS” “NIGAR BAGS”

 Logo of the program

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Coverage of the project

 Three tehsils of District population of 2.54 million.  Names of the tehsils: 1). Kharian 2). Gujarat 3). Sarai alamgir

Gujrat

with

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HEALTH FACILITIES AT GUJRAT Name

No.

Aziz Bhatti Shaheed (DHQ) Hospital, Gujrat

1

T.H.Q. Hospital, Kharian

1

Maternity Hospitals

2

Civil Hospitals

2

Rural Health Centers

9

Basic Health Units

89

Blood Transfusion Centers

2

Civil Dispensaries

2

Rural Dispensaries

22

Govt. Rural Dispensaries

3

M.C.H. Centers

10

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           

UNION COUNCILS OF DISTRICT GUJRAT

Achh Addowal Ajnala, Pakistan Alamgarh Amra Kalan Bagrianwala Baharwal Bareela Barnali Baroo Beharaj Bido Bhatti Chak Jani

Chak Manju Chakori Bhalowal Chakori Sher Ghazi Chechian Chopala Deona Dhoria Fateh Bhand Gochh Haji Muhammad Jaura Khawaspur Kotla Arab Ali Khan

          

Langrial, Gujrat Malka Mandeer Miana Chak Noonanwali Panjan Kissana Sabour Sehna Sikaryali Tanda, Gujrat Thikrian Thutha Rai Bahadar Warachanwala

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INSTITUTIONAL ORGANOGRAM OF HEALTH DEPARTMENT

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PROJECT IMPLEMENTING UNIT

 Project coordinator EDO health  Assistant project coordinator - 3 DDHO of three tehsils  Training and monitoring facillators3  Office assistant- 1  Community Mobilizers 3  Lab technician supervisor1  Out reach workers18 - 20  Drivers- 3  Existing staff of the health facilities  LHWs’ of district Gujrat

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STRATEGY

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TARGET GROUP

 1).Primary target group Pregnant ladies  2).Secondary target groupWomen of child bearing age

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1.

STRATEGIC PLAN

PRIMARY TARGET GROUP (Pregnant women)

Key Strategy

Activities

Key components

2. SECONDARY TARGET GROUP (CBA women)

Key Strategy

Activities

Key components

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PRIMARY TARGET GROUP (PREGNANT WOMEN)

 Key strategy:  Improvement in anemia & malnutrition in pregnant ladies.  Improvement in ante-natal & post-natal visits of the pregnant women.  Improve FP services & TT vaccination coverage

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 Key components:  Incentive based Registration of all pregnant women for nutritional intervention.  Providing iron, folic acid, vitamin A and nutritional supplements (fortified oil) to pregnant women on monthly basis during 3rd month of pregnancy to 6th month after pregnancy.  All registered pregnant women to be counseled for family planning & given TT coverage.

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ACTIVITIES

 All ante-natal to be documented on registration cards regarding nutrition, FP & TT services along with complete checkup.  LHW to be given incentives (Rs.50/client) on bringing ante-natal to health facility (registration card will contain referral name and signature of the LHW).  Proper monitoring of anemia of high risk groups on monthly basis at BHU.  Referring to high risk groups from BHU to higher centers.  Insuring follow up of referred patients from their feedback & documenting that for future references.  Training of health facility staff to identify anemic mothers and refresher courses every 6 months.

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SECONDARY TARGET GROUP (CBA WOMEN)

Key strategy: Community based interventions: BCC intervention at community level Community mobilization Training of community based service provider  Mass media campaigns     

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 Key component:  Method to improve nutritional status of women and her family according to their own socio economic and cultural conditions.  Importance of good nutritional status for women of child bearing age and pregnancy symptoms and complications due to malnutrition and anemia.

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Activities for community based interventions:

 Arranging health education sessions at the councilors house for women of child bearing age by out reach workers.  Distribution of health education material to them.  De-worming the women in CBA group on six monthly bases.  Display of charts and health education material at sessions  Distribution of specially designed menu charts designed according to anthropological and economic conditions.

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 Meeting with influential persons, orientation of village health committee, imams and select community volunteers from each area.  Formation of community support groups.  Training of community based service provider like LHW,  School teachers & dais to be invited with incentives in these health education sessions

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Activities for mass media campaign

 Weekly based program on FM radio stations. (involving HCP, nutrition staff, community personal, role models, success stories)  Newspaper & local print media  Wall painting with slogans  Announcements in mosques by religious people

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ACTIVITY PLAN

DR. HAMMAD

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“NIGAR” ACTIVITY PLAN

WEEK 1-2

PLANNING BUDGET ALLOCATION MEETING WITH HEALTH STAFF MEETING WITH OTHER DEPT

MOU

WEEK 3-4

NUTRITION POSTS ADVERTISEMENT RENOVATION OF REQUIRED BUILDINGS

WEEK 5-6

WEEK 7-8

RECRUITMENTOF TRAINING (PHASE1) NUTRITION STAFF NUTRITION STAFFTOT FROM WFP (5 DAYS) PURCHASING

PRINTING / TRAINING MANUALS

TRAINING (PHASE 2) FACILITY STAFF (5 DAYS) TRAINING (PHASE 3) FIELD STAFF (5 DAYS)

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“NIGAR” ACTIVITY PLAN

WEEK 9-10

EVALUATION OF STAFF

PILOT TESTING

WEEK 11-12

PROJECT LAUNCHING CEREMONY

REGISTRATION OF PREGNANT WOMEN STARTS

WEEK 13-14

WEEK 15-16

REGISTRATION COMPLETES

MASS MEDIA COMPAIGN STARTS

HE SESSIONS START

FACILITIES SERVICES START

HANDING OF EQUIPMENTS & MEDICINES TO FACILITIES

DISTRIBUTION OF OIL & MEDICINES START

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“NIGAR” ACTIVITY PLAN

MONTH 5-7

ACTIVE MONITORING

MONTH 8-10

ACTIVE MONITORING

MONTH 11

ACTIVE MONITORING

MONTH 12

REFRESHER COURSES (2 DAYS) END YEAR EVALUATION

REFRESHER COUSES (2DAYS) EVERY 6TH MONTH

PASSIVE MONITORING

PASSIVE MONITORING

PROJECT 1 YEAR COMPLETION CEREMONY REPLANNING FOR NEXT YEAR

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GANTT CHART 1st YEAR

WBS

Tasks

Start

End

Duration (Day s)

1

PLANNING

3

2

BUDGET ALLOCATION

2

3

MEETING WITH HEALTH STAFF

3

4

MEETING WITH OTHER DEPT

4

5

MOU

2

6

NUTRITION POSTS ADVERTISEMENT

10

7

RENOVATION OF BUILDINGS

10

8

RECRUITMENTOF NUTRITION STAFF

10

9

PURCHASING

10

10

PRINTING / TRAINING MANNUALS

12

%

!st quarter Co mp let e

2nd quarter

3rd quarter

4th quarter

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GANTT CHART

LOGO 11TRAINING

(PHASE1)

5

12TRAINING

(PHASE 2)

10

13TRAINING

(PHASE 3)

10

14EVALUATION

5

15PILOT

5

TESTING

16PROJECT

LAUNCHING CEREMONY

5

17REGISTRATION

OF PREGNANT WOMEN

12

18REGISTRATION

COMPLETES

12

19HE

SESSIONS START

20HANDING 21MASS

OVER TO FACILITIES

MEDIA COMPAIGN STARTS

22FACILITIES

SERVICES START

23DISTRIBUTION 24ACTIVE

MONITORING

25PASSIVE

MONITORING

26REFRESHER 27END

OF OIL & MEDICINES

COURSES (2 DAYS)

YEAR EVALUATION

28PROJECT

1 YEAR COMPLETION CEREMONY

29REPLANNING

FOR NEXT YEAR

7

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PLANNING

EVALUATION EVLUATION

“NIGAR” MONITORING

IMPLEMENTATION

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BUDGET DR. ABDUL WALI KHAN

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BUDGET DISTRIBUTION FOR 3 YEARS TOTAL %

% Allocated

Remaining %

1st Year

100

40

60

2nd Year

70

30

30

3rd Year

30

30

00

Note: Initial budget subdivision will be for 1 year. At the end of 1st year, next year budget will be subdivided.

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ANNUAL BUDGET ALLOCAION

LOGO Repair and Maintenance 10%

CONTINGENCIES 10%

Salaries and Allowances 10%

TA/ DA 5% Medicine 15%

Procurement of Durable Goods 15% Utilities 10%

Others 2%

Salaries and Allowances Medicine STATIONARY Utilities Repair and Maintenance

STATIONARY 5%

Fortified Oil 18%

TA/ DA Fortified Oil Others Procurement of Durable Goods CONTINGENCIES

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SALARY BUDGET DIVISION

Line Item

Unit

No.

Unit Cost

Salaries & Allowances Regular existing staff

per month

1.10.083 million

Staff hired for project

per month

1.20.25 million

TA/ DA

Per visit

1.30.25 million/quart er

Total cost per year (millions)

% of total annual budget

4

10

2

5

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NON-SALARY BUDGET DIVISION 1.40.005 Million per faciltiy Per month

Medicine Tab. Iron

per facility/month

1.4.1

Tab. Folic acid

Per facility/month

1.4.2

Syp. M/Vit with iron

per facility/month

1.4.3

Fortified Oil

Per facility/month

1.50.006 Million per faciltiy Per month

Stationary

facility/3 months

1.60.0066 million/3 months

Others

1.70.008 million/annum

6

15

7.2

18

2

5

0.8

2

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LOGO Utilities Telephone

per month

1.8.1

Electricity

per month

1.8.2

Water

per month

1.8.3

POL

per month

1.8.4

Procurement Of Durable Goods Weighing Machines

per T & M officer

1.9.1

Essential Laboratory. Equ.

per facility

1.9.2

Suzuki jeep (total 3)

per subdivision

1.9.3

Others

1.9.4

1.80.33 million/month

4

10

1.96 million (capital budget)

6

15

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Repair and Maintenance Transport

vehicle per month

2.1.1

Equipment

per six months

2.1.2

Others

Quarterly

2.1.3

CONTINGENCIES

per annum

TOTAL

2.11 million per quarter

4

10

2.24 million per annum

4

10

40 million

40

100

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LOGO INDICATORS PROCESS

OUTCOME

1. # of pregnant women registered

1. % of maternal deaths

2. # of A/N visits

2. % of normal deliveries

3. # of P/N visits

3. % of deliveries with complications

4. # of iron & folic acid tablets distributed 5. # of fortified oil cans (5L) distributed 6. # of HE sessions held

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WHATS NEW ? ? ?

 INCENTIVES  

20% extra salary to existing involved staff T/A, D/A to all others

 REFRESHMENTS 

After each health sessions

 GIFTS 

To successful clients

 ROLE MODELS & SUCCESS STORIES 

From the community on FM radios & print media

 LAUNCHING CEREMONY  

Will involve high level officials & respected people from communities Full media coverage

 ADVOCACY  ANNUAL CEREMONY  

Awards to best ten families Awards to best facility & field staff

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LIMITATIONS

 Lack of political will, commitment & motivation  Difficulty in access to all the women at house holds level  Religious limitations for women regarding attending health sessions  Lack of motivation of HCPs’ specially lady health workers  Lack of awareness due to illiteracy and poverty  Lack of ownership among community for the project  Lack of funds  Sustainability ? ? ?

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THANKS

QUESTIONS ???

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