phil efforts on fp-mch
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MNCHN STRATEGY:MNCHN STRATEGY:
Philippine Effort to Secure Philippine Effort to Secure Benefits of FP-MCH Benefits of FP-MCH
ServicesServices
CENTER FOR HEALTH DEVELOPMENT National Capital Region
Dr Ruben SiapnoChief, Health Operations Division, CHD-NCR
Outline of PresentationOutline of Presentation• Four Parts
1. How we look at FP and MCH2. Review of how we are faring in securing FP-
MCH benefits 3. A closer look at MNCHN for guidance
4. A new look at FP Healthy Timing and Spacing of Pregnancy
FP-MCH Beyond Policies, Programs or Projects *FP-MCH Beyond Policies, Programs or Projects *• Thinking about Family Planning and Maternal and
Child Health beyond or merely as policies, programs or projects.• FP-MCH as a PUBLIC GOOD FOR ALL with
BENEFITS FOR THE FAMILIES, as DELIVERED BY THEIR COMMUNITIES• Individuals practicing FP derive their own benefits, but many
individuals doing the same, generate additional group benefits and when most do the same, the group benefits are even greater.
• Thus,• FP-MCH is about individuals, families,
communities, enterprises, and a whole nation seeking to secure for themselves the benefits of these vital services, an important part of which are their vast public health benefits.
• *culled out from the late Mario Taguiwalo presentation
Public Health Benefits of FP-MCHPublic Health Benefits of FP-MCH• Family Planning• Empowers women, prevents unintended
pregnancies, supports maternal health and helps prevent transmission of HIV-AIDS
• Maternal and Child Health• Reduces mothers’ risk from pregnancy, protects
newborn, best start for infants and children
Important:• Clinical safety, consistent quality, informed
voluntary choice and universal access
5 Indicators of Benefit Extent5 Indicators of Benefit Extent
• CPR – 34% (32.5% NCR) of MWRA• 4ANC – 77.8% national (94.4% NCR) of births • SBA – 62% (92.4% NCR) of births• EBF – 34% (69% NCR) of children below 6 mos • Vit A – 75.9% (94.8% NCR) of children below 59 mos
Except for CPR, all indicators should be 100%..
Actual CPR (34%) < than desired CPRActual CPR (34%) < than desired CPR• Not discussed FP with Health Workers: 82.5%• Highest use by education: 36% (college)• Highest use by wealth: 38.5% (2nd richest)• Highest use by regions: 46% (by Region II)• Traditional users: 16.7%• Want no more children (55%) + want
another later (19%) but are not currently using any method =
74%• Intend to use FP in the future (42%) added
= 76%• 30% of births occur less than 2 years of
previous pregnancy
Why are FP-MCH results well below what people, community
and country want?
Organization of our EffortsOrganization of our Efforts• Originally, national programs: FP, Maternal
Care, CC, nutrition (before and after LGC) through administrative mechanism operated nationally
• Implemented F1 or local health systems reforms at provinces and cities, subsuming all national programs under each P/CIPH and AOP (common framework: service delivery, governance, regulation and financing)• Recently adopted the “MNCHN Strategy”
combining the services of different programs into one integrated package within the F1 framework.
Model Program: EPIModel Program: EPI
• National specifications of clinical procedures, field activities, support services applicable nationwide (established procedures from national to region to provinces to municipalities and barangays)
• Nationwide DOH supply of essential commodity – vaccines, even syringes and needles
• Functional nationwide infrastructure of support facilities (cold chain)
• National advocacy, awareness, demand generation
• Local mobilization of actual service delivery; mainly public sector
• Result: 60% to 70% (2003-2008) or 10 points in 5 years
Comparator Program 1: FPComparator Program 1: FP
• Technical specifications contested and debated• National logistics system for contraceptives
dismantled• No nationwide infrastructure of support facilities• No national advocacy, awareness or demand
generation• Local mobilization of actual service delivery;
increasingly implicit public-private partnerships• Result: 33.4% to 34% (2003-2008) 0.6
points in 5 years
Comparator Program 2: MCComparator Program 2: MC
• Recent changes in technical specs: no more hilot delivery; BEmONC and CEmONC delivery; newborn care; unresolved roles for midwives, GPs, and specialists
• No national logistics system for commodities• Many gaps in infra of essential facilities• No national advocacy, awareness or demand
generation
• Local mobilization of actual service delivery; increasingly implicit public-private partnerships
• Result: SBA 60 to 62% (2 points in 5 years); FBD 38 to 44% (6 points in 5 years)
2. THE MNCHN STRATEGY2. THE MNCHN STRATEGY
The MNCHN StrategyThe MNCHN Strategy• DOH Administrative Order 2008-0029:
“Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality” (known as the MNCHN Strategy), addressing the 3 sources of MMR/NMR
o unintended pregnancies, o uncared pregnancies, o poorly attended deliveries
• 4 desired results: planned pregnancies, managed pregnancies, facility-based/skilled attendance deliveries, mother and newborn care
• Targets: CPR to 60%; 4ANC to 70%; SBA/FBD to 80%; FIC to 95%
The MNCHN Framework The MNCHN Framework
Demand for health care
Desired health
outcomes
Supply of quality
health care
Actions by LGUs
Issuances, actions and influence by
CHD & national agencies
1. Every pregnancy is wanted, planned and supported
2. Every pregnancy is adequately managed throughout its course
3. Every delivery is facility-based and managed by skilled birth attendants/skilled health professionals
4. Every mother and newborn pair secures proper post-partum and newborn care with smooth transitions to the women’s health care package for the mother and child survival package for the newborn
Desired Public Health Outcomes
Supply of Quality Health CareSupply of Quality Health Care Strategy #1 Ensuring universal access to and
utilization of MNCHN Core Package of services & interventions directed not only to individual WRA & newborns at different stages of life cycle
MNCHN core package of services are interventions corresponding to each life stage in the FP-MCH continuum of care: adolescence & pre-pregnancy, pregnancy, delivery/birth, and the postpartum and newborn periods (neonatal, infancy) (to illustrate....)
NeonatalInfancy
Maternal Health
PostpartumBirthPregnancyAdolescence and Pre-pregnancy
Childhood
Supply/Demand for Quality Supply/Demand for Quality Health CareHealth Care
Strategy # 2 – Establishment of a service delivery network (SDN) at all levels of care to provide the package of services and interventions
Service Delivery Network refers to the network of public and private community-level, BEmONC-capable, and CEmONC-capable facilities and providers offering MNCHN core package of services including communication and transportation support systems (MNCHN-MOP pp. vii; 30-37).
MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork
THREE Levels of Care•First level or primary: Community level service providers (RHUs, BHS, private clinics, midwives, BHWs, TBAs, CHTs, Alternative Distribution Points - BnBs)•Secondary: Basic Emergency Obstetrics and Newborn Care (BEmONC)- capable network of facilities and providers; and• Tertiary: Comprehensive Emergency Obstetrics and Newborn Care (CEmONC) - capable facility or network of facilities.
COMMUNITY HEALTH PROVIDERS
BEMONC
CEMONC
MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork
Levels of Core Service Package(Interventions)
BEMONC
CEMONC
EmONC
BEmONC level
CEmONC level
MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork
MMR
CPR
PUBLIC HEALTH
OUT-COMES
COMMUNITY
BENEFICIARIES
Men and Women of Reproductive Age with Unmet FP-MCH Needs
Special Groups:• Young people• Workplace workers
COMMUNITY HEALTH
PROVIDERSBEMONC
CEMONC
PublicNon-NHIP accredited
Private Practice
Midwives & Birthing HomesNHIP
accredited PPMs’ & Birthing Homes
Hospitals
Other Service Delivery Points – Company
Clinics, School-based clinics,
etcAlternate
Distribution Points for FP-MCH Products
Service Delivery NetworkPrivat
eCommunity or Primary Health
Providers: Community
Health Teams, Rural Health Units/
Health Centers, Barangay
Health Stations,
Public Health/Lying-
in Clinics (doctors, nurses,
midwives)
SECONDARY CARE
PROVIDERSInfirmaries, municipal,
district hospitals, out-
patient departments,
etcTERTIARY CARE :
Hospitals
DOH/CHD/LGU/PRIVATE
MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork
Actions by LGUActions by LGU
Strategy #3 Organized use of instruments for health systems development to bring all localities to create and sustain their service delivery networks, which are crucial for the provision of health services to all
Actions through Health System Instruments that the city should put in place are classified into three: Governance Regulation and Financing
and are addressed to ensure the availability of supplies and the generation and response of demand for the information, services and products.
Issuances, Actions & Influence by Issuances, Actions & Influence by CHD & National AgenciesCHD & National Agencies
Strategy #4 Rapid build-up of institutional
capacities of DOH and PhilHealth to provide support to local planning and development through appropriate standards, capacity build-up of implementers, and financing mechanisms
3. LOOKING AT MNCHN 3. LOOKING AT MNCHN CLOSELYCLOSELY
Not just another Program! Not just another Program! • Its a strategy for
o achieving health outcomes on a population scaleo mobilizing efforts from institutional structures of
society in behalf of these outcomeso using the country’s public health agencies as a
professional organization backing this social mobilization
• Reformed province/city - wide local health systems as main implementor; minimum standard services defined for pre-pregnancy, antenatal, delivery and after delivery; support by DOH at central and regional levels declared.
• Manual of Operations issued in 2009• 2010 Operational Plan also adopted• Structure and procedures of implementation
organization still evolving
MNCHN within PIPH/AOPMNCHN within PIPH/AOP • Nothing like this before! • Scope of health services involved is wide, few
service outlets can deliver the whole package: package of selected services (pre-pregnancy, pregnancy, delivery, post-delivery), account for large part of health effort
• Network approach is necessary because large populations can be reached:o 13-14 million MWRAs, more than 2 million births,
more than 4 million infants below 24 months,o at more than 100 province/city-wide local systems,
supported by 17 regional agency clusters• Best to focus at province/city-wide service
networks as the right local scale for administrative and market size reasons
• MNCHN is not really a set of activities that cities carry out but a set of operating and organizing specifications for reforming their local health systems to yield better MNCHN health outcomes
MNCHN within PIPH/AOPMNCHN within PIPH/AOP • MNCHN is not just an integrated package of services
– it is the KEY DRIVER for the urgent integration of local health systems around serving the client segment of women, mothers, infants and children.
3 Major Changes for Public Health Agencies• Change 1: horizontal integration of all activities at
levels of community, provider outlet, area network, regional support and national direction
• Change 2: vertical coordination implementing coordinated activities without depending on traditional national admin hierarchy
• Change 3: vertical execution two parts effort working for one result; first, DOH central to region; second, LGU province/city to municipal/barangay and community (including private sector)
MNCHN as Vehicle for Attaining MNCHN as Vehicle for Attaining Sustainable Improvements in Family Sustainable Improvements in Family
HealthHealth • MNCHN provides multiple other pathways
for providing FP methods, Vitamin A supplementation, promoting breastfeeding, improving quality of ANC and birth attendance and newborn care reaching all mothers there are connections among program drivers and factors to move all 5 MNCHN indicators.
• Reduces political vulnerability of some FP methods to attack or resistance FP services are also embedded into the local service package for women, mothers and couples, instead of being highlighted as a “national program.
MNCHN as Vehicle for Attaining MNCHN as Vehicle for Attaining Sustainable Improvements in Family Sustainable Improvements in Family
HealthHealth • City - wide service delivery network model
can deliver results at scaleo CHOs mobilize public and private providers to deliver
MNCHN service packageo what happens on the ground, among providers and
clients at communities, ultimately determines public health outcomes
• Larger role of local ownership, leadership and management means an effort closer to clientso Cities adopt and implement 3-year local plans to
progressively improve coverage, quality and use of MNCHN service package
• Province/City - wide network setting makes public-private partnerships for FP-MCH more feasible and sustainableo City governments/LGUs and private sector support
adoption of MNCHN framework, directions and standards with local mandates, structures and funding
• Many efficiencies: one client population; one provider community; one service package; one local health system
QUESTION: Will the MNCHN vehicle deliver?
Framework for DOH-LGU Cooperation Framework for DOH-LGU Cooperation for MNCHN for MNCHN
Local (LGU) Operations• Area network management• Provider competencies and
performance• Facility set-up and
operations• Commodities supply• IEC, BCC and advocacy• M&E• Service enhancements• Costs and financing• Local
governance/stewardship• NHIP operations
DOH central-CHD Support• Managers training and
support• Provider and supervisors
training• Facility upgrading
assistance• Commodities assistance• Support IEC, BCC,
advocacy • M&E assistance• TA on service
enhancements• Advise on costs and
financing• Local governance
assistance• Support for NHIP
implementation
““MNCHN Program of Work” MNCHN Program of Work”
MNCHN Features Important to MNCHN Features Important to ImplementationImplementation
Priority Elements within MNCHNPriority Elements within MNCHN• IEC, Behavioral Change Communication, Interpersonal
Communication/Counseling, advocacy and demand generation effort for FP and MCH practices (public and private)
• Universal availability of and access to hormonal contraceptives and referral access to LAPM (public and private sources)
• Case management procedures that link RH/FP care for WRA with care of pregnant women, with care of newborn and infants, in smooth continuum of service and referral at local level (public and private)
• Financing system that supports universal provision and use based on need and risk
• M&E system that generates consistent data on state of whole population at risk and extent of benefits
5 Essential Pre-Conditions for LGU-5 Essential Pre-Conditions for LGU-level Implementation of MNCHNlevel Implementation of MNCHN
1. Administrative arrangement for program management capable of universal service coverage of whole population
2. Local policy mandates on MNCHN standards 3. Budgetary and financing arrangement supporting
core functions and activities4. Local program of public-private partnerships5. High level of NHIP implementation
4. A New Look at FP – Healthy 4. A New Look at FP – Healthy timing and spacing of pregnancytiming and spacing of pregnancy
Who is wise, mighty, wealthy and honorable?
• Wise, not those who know everything, but who learn from everyone
• Mighty, not those who control others, but who control their wayward inclinations
• Wealthy, not those with most money, but those content with their portions
• Honorable, not those given honors, but those who honor others
• Implementing MNCHN demands wisdom, might, wealth and honor in these ways.
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