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TRANSCRIPT
Ev
Pr
Ay
Inte
Sub
Dr
M&
M&
Tel
80H
Sky
Bah
Em
Mya
valuation
ogramme
yeyarwad
ernational
bmitted by:
Myat Pan H
&PH Resear
&PH Researc
: 959-50108
H,Kanbawza
ype: m.p120
han Townsh
mail: mph.res
anmar
Report
e in Bo
ddy Regio
Organizat
Hmone
ch Consult
ch and Cons
816
a Road, Lane
04
hip, Yangon
searchconsu
on Mate
ogale an
on
tion for Mig
sulting Co. L
e 2, Golden
ernal, Ne
nd Maw
gration
Ltd.
Valley
om
eonatal a
wlamyineg
and Chil
gyun To
ld Health
ownships
h
s,
i
CONTEN
Ab
Ac
Ex
1 In
1.1 Ba
1.2 Pr
1.3 Th
2 M
3 Ke
Ar
Ar
NTS
bbreviations
cknowledgem
xecutive su
troduction
ackground
roject Descr
he purpose o
ethodology
ey findings
rea 1: Overa
Overview
Analytic A
Overall ba
Ayeyarwa
Achievem
Trends i
obstetric/c
Trends in
immunizat
Treatment
pneumoni
Trends in
mortalities
Conclusio
rea 2: Findi
Communit
Increased
Financing
Township
trainings:
and Acrony
ment
mmary
iption
of the resear
y
all Impact: A
Approach to A
aseline dem
ddy Region
ent against
n skilled
child referral
n schedulab
tion
ts received f
a cases: by
n maternal
s
ns for Area o
ngs from Q
ty mobilizatio
affordabil
and capacit
health sys
BHS, CHW,
yms
rch
Analysis of
Area of Stud
mographic an
project targe
birth atten
ble services
for under-fiv
health facilit
, neonatal,
of Study 1
Qualitative s
on approach
lity via V
ty building su
stem streng
VTHC.
f Quantitativ
dy
nd MCH situ
ets
ndance (S
s: antenata
e children d
ty and volun
infant an
studies
h via volunta
VTHC/VHC
upport.
thening via
ve data
uation: Nati
BA) and
al, postnata
iarrhoea and
nteers
nd under-fiv
ary health wo
funding m
a the capac
onwide and
emergency
l care and
d suspected
ve children
orkers.
mechanism:
city building
1
7
10
19
19
d
y
d
d
n
53
:
g
ii
Strengthe
planning c
Coordinat
vulnerable
Strengthe
Procure es
Others
Conclusio
n supply s
capacity of th
ion with go
e.
n the Health
ssential sup
ns for area o
side service
he township
overnment
h Manageme
plies for hea
of study 2
e delivery t
health depa
BHS in re
ent Informati
alth facilities
hrough enh
artments.
eaching the
on System (
and VHWs
hancing the
e poor and
(HMIS)
e
d
iii
LIST OF
List of T
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
List of F
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9
Figure 10
Figure 11
Figure 12
Figure 13
TABLES A
Tables
Study v
Numbe
townsh
Achiev
Matern
across
Compa
Progra
Novem
Progra
indicato
Compa
igures
Trends
Trends
Trends
Trends
Trends
Trends
Trend
townsh
Trend
Trend
0 Trend
birth an
1 Trend
and ye
2 Trend
3 Trend
Health
AND FIGURE
villages in B
er of FGD
hips
vements extr
nal and chi
years
arisons of Ch
am achievem
mber 2017)
am achieve
ors (2013- N
arison of sele
s in birth atte
s in birth atte
s in EmOC re
s in EmOC re
s in ECC refe
s in ECC refe
in antenatal
hips and yea
in iron suppl
in pregnant
in postnata
nd vitamin s
in postnatal
ears
in immuniza
in diarrhoea
facilities pe
ES
ogale and M
and intervi
racted from t
ld death tre
hild Mortality
ments in Bog
ments in
November 20
ected MNCH
endants- Bog
endants- Maw
eferrals in B
eferrals in M
errals in BG
errals in Maw
care covera
ars
lements rece
mother rece
l care cove
upplements
care covera
ation coverag
a and susp
r years
Mawlamyineg
ews condu
the IOM don
ends in Bo
y Rates: by y
gale Towns
Mawlamyine
017)
H data by pro
gale
wlamyinegy
ogale by yea
Mawlamyineg
L by years
wlamyinegyu
age includin
eived during
eiving vitamin
rage: postn
by township
age: vitamin
ge by townsh
pected pneu
gyun townsh
cted in Bo
nor report (as
ogale and M
years and by
hip against
egyun Tow
roject townsh
yun
ars
gyun by yea
un by years
g SBA visits
g pregnancy
n B1 by tow
natal visits w
ps and years
n supplemen
hips and yea
umonia case
hips
gale and M
s of Novemb
Mawlamyine
y townships
log frame i
wnship aga
hips, regiona
rs
s and tetanu
by township
nships and y
within three
s
nts (A and B
ars
es treatmen
Mawlamyine
ber 2017)
egyun towns
vs region
ndicators (2
ainst log fr
al and nation
us vaccinatio
ps and years
years
days after
B1) by towns
nts in Bogal
iv
gyun
ships
2013-
rame
nal
on by
s
child
ships
e by
Figure 14
Figure 15
4 Trend
Mawla
5 Compa
in diarrh
myinegyun b
arisons of M
hoea and
by Health fa
aternal Mort
suspected
cilities per y
tality Ratios:
pneumon
years
: by years an
nia cases
nd by towns
treatments
hips vs regio
v
s in
on
ABBREV
AEI & CS
AMW
ANC
BGL
EPHS
EBF
CHW
CTHP
EmOC
ECC
FGD
INGO
JI-MNCH
KII
LHV
LNGO
MCH
MLMK
MNCH
MDHS
MOHS
MW
NHP
PHS
PNC
PONREP
RHC
TBA
THD
THN
TT
UHC
VIATIONS A
S Acc
Aux
Ant
Bog
Ess
Exc
Co
Co
Em
Em
Foc
Inte
H Joi
Key
Lad
Loc
Ma
Ma
Ma
My
Min
Mid
Nat
Pub
Pos
PP Pos
Ru
Tra
Tow
Tow
Tet
Un
AND ACRON
countability,
xiliary Midwi
tenatal Care
gale
sential Pack
clusive brea
mmunity He
mprehensive
mergency Ob
mergency Ch
cus Group D
ernational N
nt Initiative o
y Informant
dy Health Vi
cal Non-Gov
aternal and c
awlamyinegy
aternal neona
yanmar Dem
nistry of Hea
dwife
tional Health
blic Health S
stnatal Care
st Nargis Re
ral health ce
aditional Birt
wnship Heal
wnship Heal
tanus Toxoid
iversal Heal
NYMS
Equity, Inclu
ife
e
kage of Healt
stfeeding (E
ealth Worker
e Township
bstetric Care
hild Care
Discussion
on-Governm
on Maternal,
Interview
sitor
vernmental O
child health
yun
atal and chil
ographic an
alth and Spo
h Plan
Supervisor
e
ecovery and
enter
h Attendant
lth Departme
lth Nurse
d
th Coverage
usion and C
th Services
EBF)
r
Health Plan
e
mental Organ
, Newborn a
Organization
d health
d Health sur
rts
Emergency
ent
e
Conflict Sens
n
nization
and Child He
n
rvey
y Preparedne
sitivity
ealth
ess Plan
vi
VHC
VHW
VTHC
Vill
Vol
Vill
age Health C
luntary Heal
age Tract H
Committee
th Worker
ealth Commmittee
vii
ACKOW
This rese
Internatio
like to ex
Township
sincere g
Health C
office for
Moe Zaw
funded b
(3MDG)
Kingdom
Services
WLEDGEMEN
earch study
onal Organiz
xpress the g
ps. Special
gratitude go
Coordinator),
r their kind co
w Thein and
by the IOM,
which is co
m and the Un
.
NTS
would not h
zation for M
ratitude to a
thanks go t
es to Ms K
, Dr Zayar
oordination
staff from B
and the pro
-funded by A
ited States o
have been p
igration (IOM
all the interv
the Basic He
ristin Parco
Lynn and M
and support
Bogale sub-o
ogram is sup
Australia, D
of America a
possible wit
M). M & PH
iew respond
ealth Staff f
(Migration
Ma Lwin Lw
t throughout
office for org
pported by t
Denmark, the
and manage
thout teamw
Research a
dents from B
from Bogale
Health Offic
in Khaing a
the study. P
ganizing dat
the three Mi
e European
ed by the Un
work and ded
and Consult
Bogale and M
e and Mawla
cer), Dr Aye
and staff fro
Particular tha
ta collection
illennium De
Union, Swe
ited Nations
dication from
tancy Firm w
Mawlamyine
amyinegyun
e Thida (Nat
om Yangon
anks go to th
. The study
evelopment
eden, The U
s Office of Pr
viii
m the
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tional
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Fund
United
roject
1
EXCUTIVE SUMMARY
Myanmar has high maternal and child mortality ratios with MMR 227 per 100,000 live births,
IMR 40, and under-five mortality 50 per 1,000 live births (Myanmar Demographic and Health
Survey (MDHS), 2016)1. MMR is not equally distributed among 15 States/Regions and
Ayeyarwaddy region has high maternal and child mortality rates1 with some underlying
reasons such as intimidating geographic constraints. Since the Cyclone Nargis, International
Organization for Migration (IOM) has been working in Delta region through various projects.
In 2013, Joint Initiative Program on Maternal, Newborn and Child Health (JI-MNCH) rolled
into the 3MDG fund, and IOM has implemented MNCH activities across all villages in Bogale
(BGL) and Mawlamyinegyun (MLMK) townships.
The project aims to increase access and availability of essential MNCH services for the
poorest and most vulnerable. IOM outsourced Delta MNCH project evaluation to an external
consultant team, ‘M&PH Research and Consultancy Firm’ led by Dr Myat Pan Hmone (
founder/lead consultant). The study employed a qualitative research design through
interviews and analysis of existing secondary MNCH data from the project. The study
evaluated the program’s relevance, efficiency, effectiveness, and sustainability through
triangulation of qualitative study findings and relevant HMIS information. The interview
method explored the service providers (BHS, AMW, VHW) perceptions on the program to
gain further insight on the changes of access to and utilisation of MNCH services, thus,
develop recommendations for the future MNCH program. Data collection was conducted
from 30th November to 5th December 2017 in five villages within BGL and nine villages within
MLMK townships (including villages with the migrant population). A total of 57 focus group
discussion (FGD), key informant interview (KII) and in-depth interviews (IDI) were conducted
among pregnant women and their families, village tract health committees, basic health
staffs, voluntary health workers and IOM staffs. The data collected from qualitative study
was then interpreted and analysed through secondary quantitative analysis and thematic
analysis approaches.
The report comprises of two sections: quantitative data analysis and qualitative interviews
findings. In general, the program has reached the target in most of the output and outcome
indicators in both townships. Achievement defines as the 90-100% reaching the set target
for 2017. There is a general trend of increasing access and utilization of MNCH services.
Both townships showed an increase use of antenatal care visit, emergency obstetric referral
and minor treatment of children with diarrhoea or pneumonia. Additionally, BGL showed an
increase access of women on postnatal care. An increase in the achievement on
1 Ministry of Health and Sports (MoHS) and ICF (2017). Myanmar Demographic and Health Survey 2015‐16. Nay Pyi Taw, Myanmar, and Rockville, Maryland USA, Ministry of Health and Sports and ICF.
2
immunization and postnatal care was seen in MLMK. IOM MNCH program effectively
promoted the institutional deliveries in both townships: 56% in BGL and 44% in MLMK.
MLMK had more geographical and transportation challenges compared to BGL and that will
be one of the possible reasons for lower institutional deliveries in MLMK. Poverty might be
another reason as respondents women from MLMK shared about their worry for the reduced
income and increased spending if their families had to accompany with them for institutional
delivery.
Also, there is an increase in SBA deliveries which considerably exceed the national level of
60% of SBA rates and 37% health facilities delivery rate (MDHS, 2015-16). Birth attendants
by Auxiliary Midwives (AMWs) reduced gradually in both Townships. The possible reasons
might be because most AMWs refer cases to the health facility for delivery because of
support services and an increase in the drop-outs or non-functioning rates of AMWs, 86% of
mothers and new-borns in BGL and 87% of mothers and new-borns in MLMK have received
postnatal care visit within three days of childbirth compared to the national figure of 71% of
mothers and 36% of new-borns. Nonetheless, the study result showed the need of vitamin
and iron supplements for post-natal treatment and care. For both townships, vitamin A, B1
(both pregnant and postnatal women) and iron intake for postnatal women were at
satisfactory level. This finding is important as in Myanmar, haemorrhage, abortion and
postpartum anaemia are top causes of maternal death2, and according to MDHS, 47%
reproductive age women in Myanmar are anaemic and of those, about 38% have mild
anaemia. Through capacity buildings training and technical support of IOM, township health
department (THD) had improved capacity in planning, management and accountability. It is
noted that more women participation in various committees and planning activities were
seen. Most outcomes and output indicators of the MNCH project showed a more positive
result comparing to the national average levels in the similar indicators. The decreased
maternal and child reported mortality rates in both townships reflect the positive impact of
the program. MLMK has better postnatal care coverage and vitamin supplments than BGL
and lowers child mortality rate. Further research and investigation should be carried out to
examine the associations of these activities and the reduction in maternal mortality after
adjusting all potential cofounders.
Qualitative data collection revealed that the program has successfully improved the supply
side problems and demand side barriers. All mothers and family members claimed that
almost all of them received ante and postnatal care visits with at least four ANC visits by
midwives. This finding is supported by the quantitative data (92% in BGL and 83% in
2 Department of Population, Ministry of Labour, Immigration and Population with technical assistance from UNFPA (Revised edition Feb 2017). Thematic Repot on Mortality. Naypyitaw, Myanmar, Department of Population, Ministry of Labour, Immigration and Population. Census Report. Volume 4‐B.
3
MLMK). All pregnant women received a free AN care service from MW or AMW while some
claimed that they had to pay for vitamin infusion or some medications to the midwife. On the
other hands, most BHS mentioned that they have to charge patients a fee if they used
medicines that were bought by the health providers’ money due to lack of certain medical
supplies. Some AMWs and MWs claimed stock-outs of essential medicines and supplies
during interviews in contrary to the quantitative data analysis in which a higher proportion of
functioning VHWs reported no-stock out than the set target. All respondents including the
community, VHWs, village/village tract health committees (VTHC) appreciated the
emergency obstetric referral system (EmOC) while not much utilization of emergency child
care system was observed. Contribution in increasing of institutional delivery because of
referral system is found, while some have a concern for the sustainability of the fund when
the project ends. Nonetheless, VTHC/VHC members are motivated to maintain the
emergency fund. For example, one of them said that they have learnt how to manage the
fund and willing to continue managing the fund. Overall, VTHCs were set up systemically
and majority of the members have the enthusiasm to continue their work. Interviews with
AMWs have found that they are motivated and have a particular role to address the
challenges to access to RMNCH services.The community feedbacks towards AMW was
good. CHWs play the role in assisting and organizing health education sessions,
immunization and treating minor ailments and other health activities to the community. On
the other hand, the results show that the drop-out rates by the VHW is a challenge, and
there is a feedbacks on the reporting format (size) used by the VHWs. IOM had facilitated
various kinds of capacity building training towards BHS staffs particularly MW, VHW, and
VHTC. Interestingly, IDI with BHS said they could access timely information via mobile
phone and received documents via Viber application3 sent by AMW to know the status of
high risk and labour care.
In general, community-based health care approach could be replicated to other states and
regions and it is important to integrate fully with public sector delivery of community-based
programming by continuing good coordination with MOHS. Creating an enabling
environment for SBA through the provision of training and transport cost, emergency referral
services and capacity building of village tract and village health committee (VTHC and VHC)
contribute the success of the program. Strengthening Comprehensive Township Health Plan
(CTHP) and coordination between different stakeholders especially supply side and demand
side is a contributing factor for the sustainability of the program and favours a good exit
strategy. There are some weaknesses to have more comprehensive strategies to maintain
3 Viber application: A window application allowing a free mobile call and sending text and picture message by using internet. Very popular in Myanmar and cost effective.
4
the active volunteers and the inconsistency in distribution of referral fund (higher
reimbursement in initial project period)
The following recommendations developed from the triangulation of the study findings.
Maternal and Child Health
To encourage the strengthening of service readiness approach and expansion of basic
essential package at township level via integrated township health plan.
To emphasize more on the postnatal care service BHS, MW and AMW should be
advocated with about the importance of postnatal care service particularly the provision
of enough vitamin supplementations to prevent anaemia, undernutrition and vitamin
deficiency in mothers and children.
To increase health seeking behaviour of the community to improve community demand
side. It is important to address the underlying cultural beliefs of the fear to deal with
hospital staffs. Deployment of active medico-socio workers in township level hospital is
suggested.
VHW
To develop a more flexible criteria for recruiting VHWs. clear roles and responsibilities of
VHWs should be defined. VHWs should be supported through incentives or merit-based
compensation, essential drugs, recognitions and performance-based rewards.
Continuous monitoring, supervision and capacity building training should be undertaken
to motivate their volunteer sprits.
To improve the efficiency use of the existing forms through reviewing feedbacks on the
form structure with all VHWs and to link the strategy of women empowerment and
capacity building of women to become VHW.
VTHC/VHC
To develop stronger collaboration between BHS staffs and VTHC/VHC in forming
strategies on long-term sustainability of the village health fund.
To strengthen data and information management system of VTHC and VHC across all
project townships.
5
Stock-outs
To manage supply chain management system effectively through training towards both
township level health staffs and front line staffs (RHC and sub RHC staffs) to avoid
stock-outs of vitamins and medical supplies.
To provide training and TOT training to MW as well as AMWs for correct calculation of
drugs needed based on the seasonal and demographic changing pattern of the
community. It is critical to narrow the gap between supply side and demand side for
drugs and medical supplies distribution.
Township health staff should prepare distribution plan in advance in coordination with
frontline and central level staff. The distribution plan should be tailored based on the
needs of individual RHC or sub-RHC.
To share among BHS about the updated national treatment guidelines.
Sustainability and Exit strategy: Post IOM MNCH program after 3 MDG fund
To provide more encouragement and promote a sense of ownership for CTHP by the
THD.
To link current projects with that is in the National Health Plan for continuation and
sustainability.
To enable a sufficient amount of transition period for the government to develop full
capacity and resources to manage the program.
To strengthen microplanning and budgeting capacity that maximizes resources in
townships and support with community engagement.
To continue capacity building among BHS for data quality assurance should be
continued with a building capacity of BHS and educate the importance of data quality
assurance.
Proper documentation for hand over process
To enhance policy engagement through lessons learned and active bridging between
implementation and policy dialogue at all levels.
Community-based health care
To strengthen the existing Community-based health care approach of IOM
(3MDG Fund Project) and replicate the model and to integrate fully with public
sector delivery of community-based programming by continuing good
coordination model of MOHS. To continue activities such as provision of
supplies, supervision and strengthening VTHC to act as a linkage between health
service providers and communities.
6
By using this community-based health care approach of IOM (3MDG Fund
Project) in Delta as a show case, as shown in the global evidence, it is suggested
to advocate for and influence MNCH/HSS policy and practice and link with
National Health Plan. Replicate model to other states and regions and link with
MOHS national community based health program strategies such as community
based newborn cares, scale up of AMWS, community case management. To
ensure budgets for volunteers is included in MOHS/HSS plan; BHS have
sufficient time and commitment to supporting volunteers; modalities for
disbursing equipment, supplies, supervision of volunteers, quality assurance and
information on services and functioning of VTHC and VHC is in place.
To build sustainable of emergency referral system
o To integrate emergency referrals approach as a MOSH led strategy and policy,
and to create means for financing emergency referrals through a payment
mechanism
o To create an enabling environment to allow a continuing effort to advance the
quality of service provision and suggest to continue and strengthen data and
information systems in digital format.
o To educate township level and BHS about the data harmonization, consistency
and quality assurance.
o To review of referral eligibility criteria, and to design of more efficient
management mechanisms led and staffed by Township Health Departments.
To develop post training monitoring mechanism to understand health staffs’ perspective
regarding training activities.
To utilize mHealth based intervention approach if possible in future programming.
7
INTRODUCTION
1.1. Background
Despite the considerable improvements in health status with a decline in maternal and child
mortality rates over the past three decades, Myanmar has the second-highest infant (IMR)
and child mortality rate and maternal mortality ratio (MMR) in ASEAN (World Bank data4,
Thematic Report on Mortality, census, UNFPA2). According to 2014 census, maternal
mortality ratio (MMR)5 in Myanmar is 282 deaths per 100,000 live births and every year,
around 2,800 women die during pregnancy or childbirth. Likewise, under-five mortality rate
(U5MR) is 72 deaths per 1,000 live births, and the infant mortality rate is 62 per 1,000 live
births6. MMR is not equally distributed across the country with rural areas exhibit higher
levels of maternal mortality than urban areas, and levels fluctuate substantially among
States/Regions. Ayeyarwaddy region has the second highest maternal mortality ratios with
354 per 100,000 live births compared to the national average of 282 per 1000,000
livebirths1. Data from the Myanmar Demographic and Health Survey (MDHS) (2015-2016)
found similar results with high maternal and under-five child mortality rates (MMR 227 per
100,000 live births, infant mortality 40 and under-five mortality 50 per 1,000 live births) and
Ayeyarwaddy region has high maternal and child mortality rates among 15 states and
regions7.
Main challenges faced in delta include limited access to the quality maternal and child health
care service, scarcity of trained health staff, lack of equipped facilities and daunting
geographic constraints. According to the “Three Delays Model”(Thaddeus and Maine, 1994;
Barnes-Josiah, Myntti and Augustin, 1998), the lowering the risk of maternal death is
strongly related to the possibility that a woman has to deliver in a facility that has services for
basic and emergency obstetric care. Numerous transportation challenges in Ayeyarwaddy
led to the delayed in reaching health service facilities by many pregnant women and
mothers.
In 2008, Cyclone Nargis struck the Ayeyarwaddy Delta and Yangon region causing a
humanitarian catastrophe. After the post-Cyclone Nargis, International Organization for
Migration (IOM) has been working in Delta region through various projects to improve the
maternal and child health status (MNCH) of the Delta population. ‘Revitalization of the
Primary Health Care services” project implemented in four townships (Bogale (BGL),
4 World Bank statistics, www.worldbank.org/en/country/myanmar/overview. Accessed February 2018. 5 Maternal mortality ratio is the number of women who die from pregnancy‐related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births 6 Census 2014. Ministry of Population and Immigration. The Republic of Union of Myanmar.
8
Mawlamyinegyun (MLMK), Dedaye and Pyapon) in 2008-2009; Post Nargis Recovery and
Emergency Preparedness Plan (PONRPEP) in Bogale Township and the Joint Initiative
program on Maternal, Newborn and Child Health (JI-MNCH) in BGL and MLMK Townships.
JI-MNCH is a collaborative programme that seeks to increase access to essential maternal
and child health services amongst hard-to-reach populations in areas that were most
affected by Cyclone Nargis and delivered MNCH services.
1.2. Project Description
Since 2011, IOM has been implementing MNCH activities across all villages in BGL and
MLMK townships in the delta region where many seasonal migrants and itinerant boat
people live, particularly by supporting the township health departments of the two townships
in the delivery of maternal and child health services. It is an innovative partnership that takes
a comprehensive approach to health service delivery at the township level and aims to
deliver an essential package of low cost, high impact maternal and child health interventions
through some service delivery partners including public health services and NGOs. The
programme prioritises an integrated township plan and monitoring framework, with a
common results framework based on international health indicators. The programme has
been evaluated as delivering genuine health benefits for the Delta populations (DFID 2012)
and delivered a significant health outputs and OCs. In 2013, at the end of the funding, JI-
MNCH was shifted to the 3MDG fund to ensure continued delivery of MNCH services in all
townships with a well-managed sustainability strategy which supports the institutionalisation
of programme actions.
Starting from January 2013 under 3MDG funding, in collaboration with the Township Health
Department (THD), IOM is currently supporting the Department of Public Health with
comprehensive MNCH program in all villages in BGL and MLMK Townships.
The project aims to increase access and availability of essential maternal and child health
services for the poorest and most vulnerable in the areas supported by 3MDG Fund (funded
by the Governments of Australia, Denmark, the Netherlands, Norway, Sweden, United
Kingdom, and the European Commission). The project approach is to promote health equity
towards the achievement of the health MDGs (at the time of proposal) via strengthening
community based systems for the delivery of quality MNCH care and developing methods for
reaching mobile and hard to reach populations.
9
Overall Objectives
To enhance provision of and access to quality basic primary health care services with a
strategic emphasis on improved maternal and child health outcomes.
To increase access and availability of essential maternal and child health services for the
poorest and most vulnerable in supported townships
Activities carried out by IOM Myanmar in delta areas include:
Undertake joint supportive supervision visits and support for planning and
coordination with township health departments
Capacity building of public health staff: Facilitate training for Basic Health Staff and
Voluntary Health Workers
Management of health services delivery including community based volunteer
interventions (supports a network of community health workers (CHW), auxiliary
midwives (AMW) and village health committees (VHC)
Strengthen the Health Management Information System (HMIS)
Revitalize village tract health committees and village health committees
Establish step-wise referral mechanism
Support public health facilities in supply side: Procure and distribute essential
supplies for health facilities
Maintain accountability and responsiveness through community feedbacks and
response mechanism
As the project is in the wrapping-up stage, IOM Myanmar evaluates the project activities
carried out in delta via external consultant team, M&PH Research and Consultancy Firm.
10
STUDY METHODOLOGY
1.1. Design and method
The evaluation study to assess the Maternal, Neonatal and Child Health (MNCH) project
was conducted in BGL and MLMK Township in November to December 2017. By M&PH
research and consultancy firm with two separate teams. Qualitative data collection was
carried out by using focus group discussion (FGD), in-depth interviews (IDI) and key
informant interviews (KII) in consultation with IOM staff from Yangon and field offices and
quantitative data analysis were conducted by analysing HMIS data obtained from routine
data collection and with consultation with IOM staff.
The objectives of the study are:
o To evaluate the MNCH program carried out by IOM in BGL and MLMK townships by
accessing its relevance, efficiency, effectiveness, and sustainability in improving the
MNCH status of beneficiaries living in that areas by using qualitative interviews for
deeper understanding.
o To analyse the HMIS data of Township Health Departments to provide the relevant
MNCH information.
o To conduct a triangulation of qualitative study findings and relevant HMIS information in
order to have a deeper insight into the changes in the access to and utilisation of MNCH
services among mothers and pregnant women and the perceptions and feedbacks of
service providers (BHS, AMW, VHW) in BGL and MLMK Townships.
o To provide recommendations which are specific and actionable and suggest strategies
for future MNCH program in Delta.
Sampling and study area
This study combines qualitative in-depth interviews and quantitative HMIS survey analysis.
Combination of these methods provides a holistic understanding of the MNCH project from
both project beneficiaries and service providers’ perspectives.
As the study is qualitative, we did not use a proportionate for sampling (PPS) method and
use crriteria to select study villages. We consider geographic area representation, population
density, volunteers type8, functioning status of voluntory health workers (VHW), a
collaboration between BHS, VHW and village tract health (VTHC) committees, MNCH
health status, hard to reach area or not, logistic reasons and the possibility to recurit the
required informants. Initially, three villages from each township were selected however
8 Volunteer refers to the Auxillary Midwive ( AMW) and Community Health Worker (CHW).
11
during the preparation perio; we learnt that it was hard to find enough sample for pregnant
women, mothers and husbands groups in one village. Finally, qualitative data collection was
carried out in five villages in BGL and nine villages in MLMK townships.
(See Annex for the maps of BGL and MLMK)
Table 1: Study villages in Bogale( BGL) and Mawlamyinegyun (MLMK) townships
Village name Village Tract RHC Popula
tion
Volunt
eer
type
Com
mittee
type
Functi
oning
or not
Towns
hip
Byu Sakhan* Byu Sakhan Kama Kalu
1175 CHW VTHC Y Bogale
Auk Lin Tine Lin Tine
Auk Hle Seik 400 CHW VTHC N Bogale
Bandula Kwin Phone
Gyi
Auk Hle Seik
535 AMW/C
HW
- Y Bogale
Shwe Sar Yan Kadon Kani Kadon Kani 1100 AMW/C
HW
- Y Bogale
Kadone Ka Ni
*ward3
Kadon Kani Kadon Kani 1354 CHW VTHC N Bogale
Ka Zaung Ka Zaung
Hlaing Bone 395 - VHC - MLMK
Ka Zaung
Phyar
Myit Kyi Boe
Hlaing Bone
142 AMW,C
HW
- Y/N MLMK
Hlaing Bone* Hlaing Bone Hlaing Bone 2017 AMW VHC/V
THC
Y MLMK
Late Chaung Hlaing Bone Hlaing Bone 1034 AMW,C
HW
- Y/N MLMK
Sa Laung Kya Yae Twin
Kone
Yae Twin
Kone
711 AMW,C
HW
- Y MLMK
Kyeik Pi* Kyeik Pi Kyeik Pi 866 VHC/V
THC
F MLMK
Pa Tee Yoe* Sa Khan Gyi
Kyeik Pi
507 AMW,C
HW/VH
C
VHC F MLMK
Da Ni Kyat Shar Da Ni 1533 AMW VHC T/F MLMK
12
Chaung* Chaung
Kyar Hone Kyar Hone
Da Ni
Chaung
525 CHW VHC/V
THC
N MLMK
*Villages with migrant population
Study population:
Primary and relevant secondary beneficiaries: Pregnant women and mothers; village tract
health committees and village health committee, Basic Health Staff and Voluntary Health
Workers.
Direct beneficiaries:
Selected beneficiaries from pregnant women and mothers who received emergency
referral service, pregnant women and mothers who received ANC services (HE,
pregnancy and delivery kits, ANC service, referral service, received money and drug
assistance for MNCH).
Husbands and/or family members of pregnant women and mothers who received
ANC /PNC/Lactation support and emergency referral service.
Indirect beneficiaries (community/service providers):
Selected staff from township health departments
Selected basic health staff at villages (BHS, MW, PHS2, HA)
Selected village tract health committees (VTHC).
Selected voluntary health workers (AMW, VHW)
Selected staff from IOM (Yangon based and field staff)
13
Collected data
Table 2: Number of FGD and interviews conducted in Bogale and Mawlamyinegyun
townships
Methods Bogale MLMK
FGD with mixed group (pregnant women, mothers) 2
FGD with pregnant women 2 2
FGD with pregnant mothers 2 1
FGD with husbands 1 1
FGD with couples 2 5
FGD with VTHC 4 3
Group discussion with AMW 1
IDI with pregnant mothers 2 2
IDI with mothers 2 2
IDI with husbands 3 1
KII with MW 1 2
KII with PHS2/HA 1 1
KII with AMW 2 3
KII with VHW, CHW 2 2
FGD with IOM Field staff 1
KI with IOM staff 2
KI with 2 Township Health Staff 2
Total interviews (Qualitative) = 57
(See Annex for Field trip plan and activity photos of field data collection in Bogale and
MLMK)
The steps taken in the study were:
1. Desk review of various documents such as project proposal, reports, assessments,
and agreements with donors, national health plan MNCH section and others to
understand the project in detail. Relevant and available documents and data
collected from MICS were used for the quantitative data assessment.
14
2. Preparation of tools for qualitative data collection:
Focus group discussion guidelines (FGD) for pregnant women and mothers
who received ANC, emergency referral, lactation, PNC, EPI and other
relevant services and those who did not receive such service.
FGD guidelines for husbands and family members of pregnant women and
mothers who received ANC, emergency referral, lactation, PNC, EPI and
other relevant services and those who did not receive such service.
KII guidelines for selected staff from township health departments
FGD/KII guidelines for selected basic health staff and voluntary health
workers
FGD/IDI guidelines for selected village tract health committees.
KII guidelines for selected staff from IOM and implementing partners
3. Data collection at project areas
4. Data management, analysis and report writing.
Tools
Qualitative data was conducted to evaluate the MNCH program in line with evaluation
research questions and to know in-depth information about respondents. Primary
beneficiaries and member of VTHC or VHC in the study villages were interviewed in IDIs on
how antenatal, postnatal and referral care services improve the maternal and child health in
their village, their perceptions on the VHW, service they received from BHS and at a health
facility. MNCH Health-care providers including MW and PHS at village and township level
staff from the public service and VHW (AMW and CHW) were interviewed in KIIs to gain
insight into their perceived roles in providing MNCH service, support received (training, kits,
facilities, etc.) and achievement, lesson learnt and experience sharing. Focus Group
Discussions (FGDs) was applied to determine the views and perceptions of the beneficiaries
as well as service providers regarding the MNCH service, achievements, met their needs or
not and suggestions. Quantitative data analysis was based on the secondary data, literature
reviews and in discussions with IOM staff.
Strengths
The strength of the study is a systematic pre-planning and coordination between IOM
Yangon office, field staff and evaluation team. IOM field staff coordinated well with village
head, different members of VTHC, AMW and BHS and communities for data collection. This
saved time to wait for respondents to come to meeting points for data collection.
Collaboration and coordination of VTHC, VHC, BHS, Township Health Department and IOM
15
Field staff have to be acknowledged. The community, VTHC, VHC and BHS actively
participated in the qualitative study.
Limitations and Lessons learned
In some villages, we could not find enough participants such as pregnant women, mothers or
husbands to conduct FGDs separately and we conducted FGDs with mixed group (mothers
and pregnant women) in addition to the FGD with pregnant women, mothers and husbands
separately. This kind of approach could have an opportunity to probe information from
primary women beneficiaries. For some village such as Ka Done Ka Ni and Shwe Sar Yan,
respondent mothers could not articulate well because they were not used to speak in pubic
and most were stay-at-home mothers. The research team had to probe with the assistance
of their mothers to break the ice and asked in-depth-interview instead of FGD.
In Bogale, though we planned to conduct KII with at least three midwives, they were not
available on that day due to the training at the township, and we, therefore, could interview
only one midwife. Another challenge would be we had to travel form one village to another
according to water flow and weather conditions, and we had to leave from village earlier on
some occasions. As the team had lunch on the boats to compensate time and a total
number of qualitative interviews was more than the one in original planned. We could not
able to interview with senior township level health staff such as Township Medical Office
because they were busy on data collection day. However, we interviewed the key person
relating to that project at the township level. Though we planned to conduct interviews with
non-functioning AMW and CHW, we could not able to interview them separately, and this
would be a limitation to interpret the reasons for drop-out.
Data management and analysis
Interviews and FGDs were noted down and recorded during data collection. Recorded
qualitative interviews (FGD, KII, and IDI) is now transcribing and analysing for draft coding.
Data were manually analysed to observe key themes. It will develop draft codes and then we
will confirm thematic codes. We use thematic analysis1. Findings will then be analysed and
triangulated with HMIS data provided by IOM.
Translation of research into practice
As this is an evaluation study of a large MNCH project, it is recommended to disseminate a
finding to all relevant stakeholders either as a single evaluation report or by conducting a
16
literature review and analysis of all reports and research conducted by IOM relating to this
project.
Ethical consideration
We follow ethical guidelines as per evaluation protocol. The research team explained the
study nature, asked for permission for an interview, voice recording and to take photos.
Interviews and FGDs were conducted only after receiving the informed signed consent
written in Burmese from the participants. Confidentiality was assured throughout the
interview and ensured service providers were not present when the team conducted FGDs
or interviews with the community women.
Data co
ollection acctivities: Bogale
17
Data co
ollection acctivities: MMawlamyainnegyun
18
19
FINDINGS
This chapter described how IOM program contributes to improve the MNCH situaiton of
women and children from Bogale and Mawlamyinegyun townships; how the program has
achieved its programme goal, intended outcomes and outputs; how the community based-
voluntary health work force approach attributes to the success of the program and how the
program could strengthen the township health department’s governance and accountability
systems through capacity building and enhancement of current structures. This chapter also
discussed how IOM MNCH program could enhance a policy engagement through the
provision of lessons learnt and active linkages between implementation and policy dialogue
at all levels.
Area 1: Overall Impact: Analysis of Quantitative data
1.1. Overview
This area of study aims to describe the evidence that IOM MNCH program has achieved its
programme goal, intended outcomes and outputs.
1.2. Analytic Approach to Area of Study
This study assesses the comprehensive MNCH program carried by IOM in BGL and MLMK
townships from 2013 to 2017. The MNCH programs deliver both supply and demand sides
interventions. Community demand side was promoted through strengthening VHC,
supporting VHW, establishing emergency referral systems and providing financial service
and medical supplies. As a supply side strengthening, the program also supports BHS
capacity building, facility-based healthcare service strengthening, township health planning
and service delivery development by working through and in partnership with the Ministry of
Health as well as state and region health departments. The evaluation study has taken 2013
as the baseline year and compared trend from 2013 to 2017. We compare baseline data,
2017 and targeted data as appropriate and if relevant, data across years were also
examined.
This report assess the evidence for increased access to the essential maternal and child
health services. The findings presented here are derived from several sources, including an
analysis of relevant indicators from HMIS data, desk reviews of various reports relating to
MNCH program in delta, program data from the evaluation field work, observations by the
evaluation team, and interviews and group discussions.
20
1.3. Overall baseline demographic and MCH situation: Nationwide and Ayeyarwaddy
Region
Ayeyarwaddy region has a total population of 6, 184, 8291 in 26 townships spread across an
area of 35,138 km2 and about 1. 2 million were migrant populations with main reasons given
for migration were employment, to follow family and marriage. It is the third most populous
state/region in Myanmar after Yangon and Mandalay and even though it is not large in area,
reflecting a relatively high population density. Eighty six percent of the population in
Ayeyarwaddy were living in rural area, and 93.8% were literate (95.9% for male and 92.0%
for female). According to the 2014 Census data, the total fertility rate9 in Ayeyarwaddy is 2.6
(union level 2.3) and crude birth rate 20.210 (union 18.8).
BGL and MLMK townships located in the south-western part of Myanmar on the mainland
section of the country. Both townships can be reached by both water transport and by land
and MLMK is an island township situated 50 miles from the seacoast. According to the 2017
township demographic data, BGL has a total population of 325,301 (urban to rural ratio is
being 13:87), and MLMK has 302,699 (urban to rural ratio is being 11:89). BGL Township
has 596 villages with 76 village tracts, and MLMK Township has 674 total villages with 108
village tracts. Agriculture is the main occupation, with fishing and commodity trading in some
population groups.
At the country level, Myanmar has high maternal, infant and under-five children mortality.
According to the 2014 census, maternal mortality ratio (MMR) is 282 per 1000,000 live births
compared to the 140 in South East Asia and 230 in developing countries. Infant and under-
five child mortality rates are also high with 62 and 72 per 1,000 live births respectively
compared to the 24 and 30 per 1,000 live births in South East Asia and 39 and 54 per 1,000
live births in developing countries (Census, 2014). According to the Census, MNCH status in
Ayeyarwaddy region is alarmingly high with MMR is the second highest in Myanmar with 354
deaths per 100,000 live births after Chin which was 357 deaths per 100,000 live births. Child
health status in Ayeyarwaddy region was low with the second highest infant and under-five
children mortality rate among 15 states and regions after Magway with 87 deaths per 1,000
live births (union level 62) for infant mortality and 105 deaths per 1,000 live births (union
level 72) (Census, 2014).
9 The Total Fertility Rate (TFR) is defined as the number of births a woman would have if she experiences the current observed age‐specific fertility rates, and if she survives to the end of her childbearing age, which ranges from 15‐49 years. 10 The crude birth rate (CBR) is defined as the number of births that occur in a particular year per 1,000 people.
21
Myanmar National Demographic and Health survey (MDHS) published in 2017 reflected the
decreasing trend of maternal and child death rates, MNCH health status in Myanmar did not
reach the satisfactory level yet. The MDHS showed that, at the national level, the pregnancy-
related mortality ratio has been decrased to 227 per 100,000 live births and the infant and
under-five mortality rates11 become 40 and 50 deaths per 1,000 live births in 2015 (MDHS,
2015-16)12. For Ayeyarwaddy region, child mortality rates are high with infant mortality rate is
66, and the under-five mortality rate is 82 per 1,000 live births (MDHS, 2015-2016).
1.4. Achievement against project targets
Technical reports and annual reports from IOM to donor provide information on achievement
against annual targets for service coverage. These set targets are based on the population-
based projections of expected pregnancies, emergency complications, numbers of children
needing vaccination and anticipated childhood illness. Secondary data analsis is based on
the HMIS data (IOM’s result monitoring feeds into the MOHS township level HMIS data
collected six monthly), various records and reports by IOM, records on referral, volunteer,
standardized VHW supervision, feedbacks and response mechanism, workshop and
records, Township Health Department (THD) and IP Reports and supervision checklist (for
VTHC and VHC) and independent evaluation.
Health facilities in both townships increased during the project period. In BGL, from 2013 to
2017, station hospitals increased from 4 to 6, RHC increased from 9 to 11 and sub-RHC
were increased from 44 to 64. MLMK has a similar pattern with increased in numbers of
station hospitals from 1 to 3 and sub-RHC from 69 to 74. Achievements of the whole
program are described in Annex 1 in this section as a table.
Table 3: Achievements extracted from the IOM donor reports
Achievement defines as the 90-100% reaching the set target for 2017 (project ends in
December 2017). If the indicator is above 100% of the target, it is ‘over achieved’; if the
indicator is between 90 to 100%, it is defined as ‘achieved’ as 10% variation is allowed in
determining whether the indicators reach the target or not. If the indicator is below 90%,
interpretation would be “under-achieved’.
11 Infant mortality: the probability of dying between birth and the first birthday Child mortality: the probability of dying between the first and fifth birthday Under‐5 mortality: the probability of dying between birth and the fifth birthday 12 Myanmar Demographic and Health Survey 2015‐16. NayPyi Taw, Myanmar, and Rockville, Maryland USA: Ministry of Health and Sports and ICF.
22
Bogale
Over Achieved
(more than 100% of target)
Achieved
(90-100 % of target)
Under-Achieved
(Less than 90% of target)
Women received at least
four antenatal care during
pregnancy
Mothers and newborn
receiving timely postnatal
care
Newborns that initiate
immediate breastfeeding
within one hour after birth
Contraceptive prevalence
rate
Appropriate EmOC referrals
supported
Under five children
diarrhoea cases treated
with ORS + Zinc at
community by volunteers
Under five children
suspected pneumonia
cases treated with
antibiotics at community by
volunteers
Number and percentage of
pregnant women
vaccinated against tetanus
toxoid (TT2)
# Doctors, nurses and
midwives participated in at
least one MNCH training
including delivery and
emergency obstetric care
# and % of AMW and CHW
Skilled birth
attendants
Births attended by
AMW
Institutional deliveries
Children immunized
with DPT3/Penta3
Under five children
diarrhoea, cases
treated with ORT at
Health Facilities
Postnatal mothers
who received iron
supplements four
times or more during
pregnancy
Pregnant mothers who
received B1 tablets
Postnatal mothers
who received B1
tablets
Events/meetings
conducted during the
reporting period with
participatory approach
Women
representatives
attending the annual
Comprehensive
Township Health Plan
(CTHP) review
workshop*
Children immunized with
Measles
Appropriate ECC referrals
supported
Under five children
treated suspected
pneumonia cases treated
with antibiotics at Health
Facilities
Postnatal mothers who
received vitamin A
supplements
23
receiving quarterly
supervision and monitoring
AMWs and CHWs who
report no stock-outs of
essential medicines and
supplies
# MOH staff and IP trained
in Accountability, Equity,
Inclusion and Conflict
Sensitivity (AEI & CS)
Feedback that was
addressed by the IP in the
reporting period based on
the IP’s procedure
Women representatives on
Township Health
Committee
Women representatives on
Village Tract Health
Committees / Village Health
Committees
*2016 figure as there is no available data for 2017
Mawlamyinegyun
Over Achieved
(more than 100% of target)
Achieved
(90-100 % of target)
Under-Achieved
(Less than 90% of target)
Skilled birth attendants
Women received at least
four antenatal care during
pregnancy
Newborns that initiate
immediate breastfeeding
within one hour after birth
Contraceptive prevalence
rate
Mothers and newborn
receiving timely
postnatal care
Children immunized
with Measles
Appropriate EmOC
referrals supported
(hard to reach)
Postnatal mothers
Births attended by AMW
Institutional deliveries
Appropriate ECC referrals
supported (total)
ECC referrals supported-
hard to reach
Under five children
diarrhoea, cases treated
with ORT at Health
24
Children immunized with
DPT3/Penta3
Appropriate EmOC referrals
supported (total)
Under five children diarrhoea
cases treated with ORS +
Zinc at community by
volunteers
Pregnant women vaccinated
against tetanus toxoid (TT2)
AMWs and CHWs who
report no stock-outs of
essential medicines and
supplies
# MOH staff and IP trained in
Accountability, Equity,
Inclusion and Conflict
Sensitivity (AEI & CS)
Feedback that was
addressed by the IP in the
reporting period based on
the IP’s procedure
Women representatives
attending the annual
Comprehensive Township
Health Plan (CTHP) review
workshop*
Women representatives on
Village Tract Health
Committees / Village Health
Committees
who received vitamin
A supplements
Pregnant mothers who
received B1 tablets
Postnatal mothers
who received B1
tablets
Number and
percentage of hard to
reach villages with
AMW
Number and
percentage of hard to
reach villages with
CHW
AMW and CHW are
receiving quarterly
supervision and
monitoring.
Women
representatives on
Township Health
Committee
Events/meetings
conducted during the
reporting period with
participatory approach
Facilities
Under five children
treated suspected
pneumonia cases treated
with antibiotics at Health
Facilities
Under five children
suspected pneumonia
cases treated with
antibiotics at community
by volunteers
Postnatal mothers who
received iron supplements
four times or more during
pregnancy
# Doctors, nurses and
midwives participated in
at least one MNCH
training including delivery
and emergency obstetric
care
*2016 figure as there is no available data for 2017
Source: Log frame indicator by IOM
25
For both townships, although some indicators shown as under achievements, in fact, all
indicators were just below the targeted level provided that 10% variations be allowed.
Indicators such as the provision of vitamin A for postnatal mothers in BGL and supply of iron
supplements for pregnant mothers, ECC referrals and institutional deliveries in MLMK were
under achievements for both consecutive two years. Some under-five children treatment
related indicators were found to be underachievement. Examples of child-related indicators
which were under-achieved were: children immunized with measles and under 5 children
treated with antibiotics for suspected pneumonia at Health Facilities in BGL and under 5
children treated with ORT for diarrhoeas at health facilities and treated with antibiotics for
suspected pneumonia at Health Facilities and community by volunteers in MLMK.
In general, the evaluation team interprets that majority indicators reached the targets in the
areas of routine schedulable services (such as vaccination and ANC), referral service, most
treatments for maternal and under five children, health service accountability, management
capacity building initiatives and women participation. The 2017 data showed that targets for
improved childbirth care such as deliveries by SBA were 71 % in BGL and 83% in MLMK for
75% target and institutional deliveries were 56% in BGL for 60% target and 44% for 55%
target in MLMK.
1.5. Trends in skilled birth attendance (SBA) and emergency obstetric/child referral
Analysis of secondary report (IOM report to 3MDG MNCH results in matrix and project
documents) revealed that skilled birth attendance rate has significantly increased from 42%
in 2013 to 71% in BGL and 62% in 2013 to 83% in 2017 in MLMK. We used WHO definitions
for the skilled birth attendant13 and included ‘doctor, nurse, lady health visitor or midwife’. In
contrast, birth attendants by AMW declined from 15% in 2013 to 9% in both 2016 and 2017
(target 10%) while there is a sharp increase of institutional deliveries from 24% in 2013, 51%
in 2016 and 56% in 2017 (target 60%) for BGL. MLMK has a similar pattern with BGL as
birth attendants by AMW was declined from 14% in 2013 to 9% in 2016 and 5% in 2017
(target 10%), however, institutional deliveries did not show great variations between 2013,
2016 and 2017 with 44%,48% and 44% respectively. Nonetheless, the pattern of increased
delivery by SBA and institutional delivery might reflect that community has more trust in
government facility/service, or there is an improvement in accessibility for health care.
According to the qualitative data collection, there is significant drop in numbers of women
delivered with Traditional Birth Attendants (TBA) and interviews with AMW revealed that they
13 WHO definitions of skilled birth attendant: “an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”
26
mostly transferred cases to health facility and presence of emergency fund makes them
easy to do so (qualitative information was described in area of study 2).
Figure 1: Trends in birth attendants- Bogale
Figure 2: Trends in birth attendants- Mawlamyinegyun
Trend in EmOC referral
Increase in institutional delivery reflects the effectiveness of referral service which is one of
the project main activities. There is an increase in community demand side for health service
associated with financial support by VTHC or VHC to reduce the delay in accessing the
essential delivery care. Trained AMW were empowered enough to identify and refer the high
risk or potentially high risk cases to the nearest health centres and CHW assists referral
15%
13%12%
9% 9%
24% 14%15%
51%56%
42%
59%65%
71% 71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2013 2014 2015 2016 2017
Birth Attendant Rates by Year‐Bogale
Births attended by trainedAMW
Institutional deliveries
Skilled birth attendance
62%68%
75% 74%
83%
14%11% 10% 9%
5%
44%
36%
56%
48%44%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2013 2014 2015 2016 2017
Birth Attendant Rates by Year‐MLMK
Skilled birth attendance
Births attended by trained AMW
Institutional deliveries
27
service by informing to either AMW or MW in a timely matter when pregnant women have
labour pain. Regarding health facility, increase the number of functioning health facilities
across years (station hospital and rural health centres as explained above). The number of
appropriate EmOC referrals increased from 1065 in 2013 to 2005 in 2017 in BGL. For
MLMK, in 2017, EmOC referral is 2066 in 2013 to 1507 in 2017, and both townships reached
targeted level. MLMK Township had referrals cases from hard to reach areas with 33 cases
in 2013, 29 cases in 2014, 17 cases in 2015 and 6 cases in 2016 and 9 cases in 2017 while
there is no hard to reach areas in BGL since 2016. Some hard to reach areas steadily
reduced in MLMK with 16 in 2013, 14 in 2014, 4 in 2015, 2016 and 2017 while there is
significantly reduced in the hard to reach areas in BGL with 17 in 2013 to zero in 2016.
Increased in the numbers of RHC, sub-RHC, more deployment of MW and PHS in village
level as well as some improvement in the infrastructure such as bridges might be the
reasons for reducing ‘hard to reach’ areas. Figures 3 and 414 describe the trend in EmOC
referral with achievements. Although BGL has a steady upward trend of referral
achievement, MLMK showed a fluctuating trend with highest in 2015 and lowest in 2016 and
2017. Though evidence is not strong due to small sample size, some qualitative interviews
and discussions reported that financial support for EmOC reduced in 2017 as the project is
ending soon and this might reduce the likelihood of pregnant mothers and husbands’
willingness to go to the hospital (refer area 2).
Figure 3: Trends in EmOC referrals in Bogale by years
14 Calculation is based on expected pregnancy for corresponding years.
10651341 1343
16902005
11%
17%
20%
24%
30%
0%
5%
10%
15%
20%
25%
30%
0
500
1000
1500
2000
2500
2013 2014 2015 2016 2017
Coverage
Number of Em
oC referrals
Years
EmoC Referral: Achievement vs Coverage‐BGL
EmoC referral Coverage
28
Figure 4: Trends in EmOC referrals in Mawlamyinegyun by years
Trend in ECC referral
Figure 5 and 6 described the trends in the emergency child referral cases (ECC) in BGL and
MLMK townships during project years against coverage15. Similar to the EmOC referrals,
BGL Township showed a steady increasing trend of ECC referrals while MLMK Township
has peak referral case in 2014 and gradually declines across years with 1.4% referral cases
in 2017. Among four hard to reach villages in MLMK, 7 cases in 2013, 10 cases in 2014, 2
cases in 2015, 3 cases in 2016 and 2 cases in 2017 were referred to the health facilities.
The possible decreasing trend of ECC in MLMK Township might be, based on the interview
with IOM staff, likely due to many reasons. Firstly, travel cost to come to the station hospital
to withdraw money is higher than the reimbursable amount (5,000 MMK is payable for travel
cost) and secondly, parents from villages located nearby Bogle, prefer to go directly to the
Boglae hospital rather than using the referral service because of the road and bridges
improvement.
15 Calculation is based on the under‐five population for corresponding years.
2066 19452085
1432 1507
28%30%
34%
25%26%
0%
5%
10%
15%
20%
25%
30%
35%
40%
0
500
1000
1500
2000
2500
2013 2014 2015 2016 2017
Coverage
Number of Em
oC referrals
Years
EmoC Referral: Achievement vs Coverage‐MLMK
EmoC referral Coverage
29
Figure 5: Trends in ECC referrals in Bogale by years
Figure 6: Trends in ECC referrals in Mawlamyinegyun by years
1.6. Trends in schedulable services: antenatal, postnatal care and immunization
BGL Township shows increasing trends of recommended antenatal care coverage (at least 4
ANC visits by SBA) during project implementation period, and MLMK Township has a similar
increasing trend except for a slight decrease in 2014. Pregnant women from both townships
had 92% (BGL) and 83% (MLMK) ANC coverage in 2017 which exceeds the targeted 75%
265332
253
515
689
0.6%
1.0%0.8%
1.6%
2.4%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
0
100
200
300
400
500
600
700
800
2013 2014 2015 2016 2017
Coverage
Number of EC
C erferrals
Years
ECC Referral: Achievement vs Coverage‐BGL
ECC Coverage
355
476415
318 325
1.3%
1.9%
1.7%
1.3% 1.4%
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
2.0%
0
50
100
150
200
250
300
350
400
450
500
2013 2014 2015 2016 2017
Coverage
Number of EC
C referrals
Years
ECC Referral: Achievement vs Coverage‐MLMK
ECC Coverage
30
in BGL and 80% in MLMK as well as a national coverage of 59% of pregnant women
receiving at least 4 ANC visits by SBA.
An alternative indicator of ANC is the coverage with two doses of tetanus toxoid (TT) vaccine
(TT2). TT is given during antenatal visits and could act as a proxy for two ANC visits.
According to the below figure (figure 7), tetanus toxoid vaccination coverage is higher than
the ANC visits in both Townships. Although there is a slight discrepancy in the ANC and TT
coverage, the variation is somewhat within an acceptable range, and ANC coverage
reported by both townships falls in a satisfactory level. For tetanus vaccine coverage, both
townships reach the targeted coverage of 90% at the end of 2017. BGL has 89% coverage
in 2016 and 92% coverage in 2017 while MLMK has 95% coverage in 2016 and 2017.
Figure 7: Trend in antenatal care coverage including SBA visits and tetanus
vaccination by townships and years
68% 70% 72% 79% 92%69% 63% 74% 81% 83%
74%
88%
104%
89% 92%
79%
90% 91%95% 95%
0%
20%
40%
60%
80%
100%
120%
0%
20%
40%
60%
80%
100%
120%
2013 2014 2015 2016 2017
Percentage
Percentage
Years
Trends in recommended ANC visits and Tentanus coverage by townships and years
BGL‐at least 4 ANC visits
MLMK‐t least 4 ANC visits
31
Figure 8: Trend in iron supplements received during pregnancy by townships and
years
Figure 9: Trend in pregnant mother receiving vitamin B1 by townships and years
Figure 8 and 9 illustrate the trends in vitamin supplements such as iron and vitamin B1
during pregnancy in both townships. Providing of vitamin supplements is critical for
determining women anaemia status and women and child wellbeing. Although MLMK had
lower iron supplements rate (4 times during pregnancy) than BGL initially, in 2016 and 2017,
MLMK has more iron supplements coverage. For each township, BGL and MLMK have an
54%
63%
71% 72%78%
50%
57%
67%
78% 79%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2013 2014 2015 2016 2017
Percen
tages
Years
Trend in iron supplements received by townships and years
BGL MLMK
63%
78%75% 74%
85%
56%63%
70% 72%
84%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2013 2014 2015 2016 2017
Percentage
Years
Trend of pregnant mothers receiving B1 by townships and years
BGL MLMK
32
increasing trend of iron supplement across years. For 2017, both of the townships did not
reach to the targeted level, BGL had 78% of iron supplements against 85% of target for 2017
and MLMK has 79% iron supplementation rate against 90% target for 2017.
A similar pattern has been observed for data for pregnant women receiving B1 tablets.
Though both townships showed increasing trends of B1 supplementation, none did reach the
targeted level in 2016 (target: 85% for BGL and 80% for MLMK). In 2017, BGL township
meet the target of 85%, however, MLMK township only achieve 84% compared with 90% of
the target.
Figure 10: Trend in postnatal care coverage: postnatal visits within three days after
child birth and vitamin supplements by townships and years
Figure 10 and 11 show the postnatal care coverage trends by townships and years.
Literatures stated the importance to receive a timely postnatal visit by the skilled health
personal. It is the most critical time for preventing maternal and child health especially
neonatal health. BGL Township has a steady increase of postnatal coverage across years
while MLMK has a fluctuating coverage. According to the available data, MLMK had a higher
postnatal coverage than BGL throughout the project. The underlying cause for the difference
should be examined and lesson learnt, and experience sharing should be reflected provided
that there is a data consistency in both townships for data collection period.
Similar to other findings, 2017 data shows a significant improvement in postnatal care visit
with 86% in BGL for 75% targeted rate and 87% for MLMK for 95% targeted rate.
56 6067
7386
100
83
10898
87
0
20
40
60
80
100
120
2013 2014 2015 2016 2017
Percentage
Years
Trends in postnatal carevisits by townships and years
BGL MLMK
33
Figure 11: Trend in postnatal care coverage: vitamin supplements (A and B1) by
townships and years
For postnatal vitamin B1 supplement, both townships had significant increasing trends
throughout the project except for 2017. As 84% of postnatal mothers from BGL Township
received B1 tablet against 85% target for 2017 and 84% of those from MLMK Township
received B1 tablet against 90% target for 2017. For 2016, BGL Township did not reach
target level for B1 supplementation in contrary to the MLMK which exceeds the targeted rate
of 80% with 95%.
Likewise, for vitamin A supplements rate, both townships did not reach the targeted level for
both consecutive years (2016 and 2017) although both townships have increasing trends.
For 90% target rate in 2017, achievement rates of 80% in BGL and 84% in MLMK each
township become under-achievement for the whole 2017. Similar to the postnatal B1
supplementation, MLMK has a vitamin A supplementation rate than BGL across the project
years. In general, MLMK Township seems to have better postnatal coverage than BGL
according to the analysis of the data available. Early initiation of breastfeeding within one
hour after birth and contraceptive prevalence rate exceeds the target set in both townships
with MLMK had far better rates. BGL has 87% and MLMK has 95% of early initiation of
breastfeeding rates. Early initiation of breastfeeding in Ayeyarwaddy region is 59.1%, and
union is 66.8% (MDHS, 2015-16), it shows that the breastfeeding promotion is succeed.
57 61 69 72 78 86 80 95 84 84
52 62 62 69 75 76 7685
80 84
0
50
100
150
200
BGL MLMK BGL MLMK BGL MLMK BGL MLMK BGL MLMK
2013 2014 2015 2016 2017
Percentage
Years
Trend in postnatal care coverage: vitamin A and B1 by townships and years
Postnatal mothers who received vitamin A supplements
Postnatal mothers who received B1 tablets
34
Figure 12: Trend in immunization coverage by townships and years
Figure 10 and 11 illustrate the DPT3/Penta 3 and measles coverage in the two project
townships. Both townships showed a steady increasing trends with a slightly decreasing
trend in BGL after 2015. However, caution should be taken care as 2015 data is 106% in
BGL for both DPT3/Penta3 and Measles vaccinations.
Baseline and set targets for BGL were higher than MLMK, and MLMK had better
immunisation coverage than BGL for both vaccines for the last two years. In 2016, it
exceeds the (95% target set for DPT3/Penta 3 and measles each) with 96% for DPT3/Penta
3 and 99% for measles in MLMK. As BGL set 100% target for 2017, immunization coverages
rates for both vaccines do not reach the target yet. According to the MDHS 2015-16, national
data of DPT3 coverage was 62%, and measles was 77% while for Ayeyarwaddy region, 40.8
% for DPT3/Penta3 and 70.6% for measles, overall this suggests that the IOM MNCH
program showed a significant achievement.
1.7. Treatments received for under-five children diarrhoea and suspected
pneumonia cases: by health facility and volunteers
Below figures (Figures 11 and 12) show the increasing trend of ORT and suspected
pneumonia treatment cases for under-five children in both townships from 2013 to 2017.
However, the number of diarrhoea and pneumonia cases treatment at health facilities in
83 85
100 98106
9791
9691
97104 104 101 99
106
95 9399
8895
0
20
40
60
80
100
120
BGL MLMK BGL MLMK BGL MLMK BGL MLMK BGL MLMK
2013 2014 2015 2016 2017
Percentage
years
Children under one immunized with DPT3/Penta3 Children under one immunized with Measles
35
2017 for both townships do not reach the targets. (Target for 2017: 1200 for diarrhoea cases
and 700 for pneumonia cases in BGL and 1850 for diarrhoea cases and 1000 for pneumonia
cases in MLMK).
Figure 13: Trend in diarrhoea and suspected pneumonia cases treatments in Bogale
by Health facilities per years
Figure 14: Trend in diarrhoea and suspected pneumonia cases treatments in
Mawlamyinegyun by Health facilities per years
1187
13831281 1283
1113
556
878783
696
362
0
200
400
600
800
1000
1200
1400
1600
2013 2014 2015 2016 2017
number of cases treated
Years
Treatments received for diarrhoea and suspected pneumonia cases by health facility : Bogale
<5 children diarrhoea cases treated with ORT at Health Facilities
< children suspected pneumonia cases treated with antibiotics at Health Facilities
1358
16491498
1702
1522
553665 625
1014
801
0
200
400
600
800
1000
1200
1400
1600
1800
2013 2014 2015 2016 2017
number of cases treated
years
Treatments received for diarrhoea and suspected pneumonia cases by health facility : MLMK
<5 children diarrhoea cases treated with ORT at Health Facilities
< children suspected pneumonia cases treated with antibiotics at Health Facilities
36
For treatment of diarrhoea and suspected pneumonia with antibiotics by community
volunteers (CHW), BGL townships exceed the target in 2017 while MLMK has exceeded
target for diarrhoea treatment. For suspected pneumonia treatment, MLMK does not reach
the targeted cases of 105 based on the 55 cases in 2017. One possible reason might be a
shortage of volunteers due to drop-out of volunteers during the project period.
1.8. Trends in maternal, neonatal, infant and under-five children mortalities
Maternal and child death in both townships decreased with maternal deaths is 14 in 2013 to
8 in 2016 with 43% reduction in BGL and 8 in 2013 to 4 in 2016 with 50 % reduction in
MLMK. Child deaths (under-five children) were declined from 144 in 2013 to 110 in 2016
with 24% reduction in BGL and 135 in 2013 with 33 in 2016 in MLMK with 75% reduction.
For 2017, MMR in BGL is 8 and MLMK are 4 in numbers while for under-five child mortality,
it was reduced to 86 in 2017 for BGL and increased to 45 in 2017 against 2016 data.
Likewise, neonatal mortality was reduced from 61 in 2013 to 51 in 2016 with 16% reduction
in BGL and 60 in 2013 to 11 in 2016 with 82% reduction in MLMK. Neonatal mortality rate
(NMR) for 2017 is 43 for BGL and 19 for MLMK.
Below table (table4) describes the trend in maternal and child mortality rates for five years.
Although MLMK seems to have significant lower under-five deaths than BGL, data
consistency assurance is improtant as there is a sudden drop between 2015 and 2016 data
for under-five children deaths.
Table 4: Maternal and child death trends in Bogale and Mawlamyinegyun townships
across years
BGL
Category Type 2013 2014 2015 2016 2017
Number of maternal death Death 14 9 10 8 8
Number of early neonatal death Death 51 60 42 37 30
Number of late neonatal death Death 10 10 11 14 13
Number of infant death ( 28
days-under 1 year) Death 55 38 58 35 18
Number of child death (1 year-
under 5 year) Death 28 43 24 24 25
37
Number of under-five children
death(0-5 year) Death 144 151 135 110 86
MLMK
Category Type 2013 2014 2015 2016 2017
Number of maternal death Death 8 11 10 4 4
Number of early neonatal death Death 45 38 21 8 16
Number of late neonatal death Death 15 14 11 3 3
Number of infant death ( 28
days-under 1 year) Death 45 57 44 8 15
Number of child death (1 year-
under 5 year) Death 30 39 18 14 11
Number of under-five children
death(0-5 year) Death 135 148 94 33 45
Table 5 and Figure 15 describe the trend of maternal and child mortality rates per townships
and regional level. According to the table below, it appears that MLMK has a higher
reduction in both maternal and child moralities however as discussed above, it is worth
noting the sharp decline in mortality of children (neonate, infant and under-five) in MLMK
after 2015 and many variations with regional mortality data. On the other hand, the reason
for sharp decrease should be explored and if applicable, should provide recommendations
based on the success story.
Table 5: Comparisons of Child Mortality Ratios: by years and by townships vs region
Neonatal Mortality Rate 2013 2014 2015 2016 2017
Ayeyarwaddy 7 6 6 7
BGL 11 12 9 8 8
MLMK 12 10 6 2 4
Infant Mortality Rate 2013 2014 2015 2016 2017
Ayeyarwaddy 14 13 11 12
BGL 21 18 19 14 11
MLMK 21 22 15 4 7
38
Figure 15: Comparisons of Maternal Mortality Ratios: by years and by townships vs
region
1.9. Strengthening service delivery at Township level
Capacity building training on MNCH care and accountability, equity, inclusion and conflict
sensitivity (AEI & CS) and supervision and monitoring activities for VHW completed and
exceeded the targets in BGL. MLMK achieves the target for AEI & CS training only and
activities such as MNCH training towards BHS and VHW supervision does not reach the
target level for 2017. For the indicator of the percentage of functioning AMWs and CHWs
who report no stock-outs of essential medicines and supplies, a higher proportion of VHW
expressed of ‘no stock-outs of supplies’ than the set target. However, the qualitative
interview provides contrary findings regarding the stock-outs issue, and detailed information
presented in the qualitative section.
0
139123
114
158
253
152
175
131144
160
221
198
80 81
0
50
100
150
200
250
300
2013 2014 2015 2016 2017
Maternal M
ortality Ratio
Maternal Mortality Ratios comparisons
Ayeyarwaddy
BGL
MLMK
Under-five mortality rate 2013 2014 2015 2016 2017
Ayeyarwaddy 18 17 14 15
BGL 26 26 24 18 16
MLMK 27 30 19 7 9
39
1.10. Conclusions for Area of Study 1
There is a general trend of increasing access to and utilization of MNCH services in the BGL
and MLMK townships, Ayeyarwaddy region according to the secondary analysis of the
available data. There is clear evidence of a successful coverage in IOM MNCH project,
supported by the 3MDG fund in particularly in the areas of antenatal care visits, emergency
obstetric referral and minor treatments of children with diarrhoea or pneumonia for both
townships and postnatal care for BGL. There is some aspect of achievements in the areas of
immunization and postnatal care in MLMK with some variations between townships.
Regarding deliveries, IOM MNCH program effectively promotes the institutional deliveries in
both township while BGL has higher institutional delivery than MLMK. Also, there is an
increase in SBA deliveries which considerably exceed the national level of 60% of SBA rates
and 37% health facilities delivery rate (MDHS, 2015-16). BGL Township has an increasing
trend of institutional delivery rate where MLMK shows a stagnant trend across years (56% vs
44% in 2017). There is a reducing trend of birth attendants by AMWs in both Townships with
MLMK has lower birth attendants rates by AMWs. Reasons might be because most AMWs
refer cases to the health facility for delivery because of support services received from the
MNCH project. Another possible reason might be an increase in the number of drop-outs or
non-functioning AMWs. No refresher training and no new traiing towards AMWs during later
part of the project cycles might contribute the high AMWs attrition rate.
Likewise, for post-natal care which is a critical point for maternal and neonate health, 86% of
mothers and new-borns in BGL and 87% of those in MLMK, received postnatal care visit
within three days of childbirth compared to the national figure of 71% of mothers and 36% of
new-borns. Nonetheless, data analysis showed that there is a need in the area of post-natal
treatment and care for pregnant women and mothers mainly for vitamin and iron
supplement. For both townships, vitamin A, B1 (both pregnant and postnatal) and iron intake
for postnatal women were at satisfactory level. This finding is important as in Myanmar,
haemorrhage, abortion and postpartum anaemia are top causes of maternal death16, and
according to MDHS, almost half of reproductive age women in Myanmar are anaemic with
47%, and of those, about 38% have mild anaemia.
Various kinds of training and activities were carried out to build government capacity to
deliver the high impact and cost-effective services, especially to the hard to reach areas.
Both townships successfully implemented the activities agreed in the log frame. Through
capacity buildings training and technical support of IOM, township health department had
16 Causes of maternal death in Myanmar: Hemorrhage 35%,abortion 17%, Postpartum anemia 7%
40
improved capacity in planning, management and accountability. More attention should be
given to increase the attendance of health care personnel in MNCH training, timely
supervision and monitoring visits towards VHWs and sufficient supply of essential medicines
and supplies. An additional finding is more women participation in various committees and
planning activities such as Comprehensive Township Health Plan (CTHP) review workshop,
Township Health Committee and Village Tract Health Committees / Village Health
Committees. There are more interactive meetings between health care providers and target
communities.
The project provides substantial outcomes. Creating enabling environment for SBA through
provision of training and transport cost contribute the success of the program. Emergency
referral services and capacity building of VTHC and VHC provides a postive outcome.
Limited workforce is a well kown problem in providing effective MNCH care ,and
development of trained AMW and CHW could improve the MNCH care at the village level.
This will lead to the increase in accessibility and utlization of health service especailly from
hard to reach areas including migrant population. Strengthening Comprehensive Township
Health Plan and coordination between different stakeholder epically supply side and demand
sides is a postive factor for the sustanability of the program and favors the good exit
strategy.
All outcome and output indicators exceed the national average levels showing the good
results which would lead to the positive impact for MNCH status in project townships.
However, some indicators are still under-achievement with variation between two townships,
and we suggest to further explore the underlying reasons via a more detailed analysis and
in-depth findings. This report is based on the analysis of the available data, and the
evaluation team suggests to check for data consistency for quality assurance purpose as, for
example, we observed a sharp decline of under-five children mortality rate in MLKM after
2015. Although several factors attribute the maternal and child deaths, the fact that both
maternal and child mortality rates decreased significantly in both townships might reflect the
success of the program. As discussed above, based on the data analysis. Further research
and investigation should be carried out to examine whether these kinds of activities
contribute to the reduction in maternal mortality. As VTHC model is based on the strength of
the active community members in the village levels and we conclude that replicating of
VTHC model in other regions would be a good approach by using appropriate strategies for
recruitment, supervision and motivation of VHC members. It is however important to ensure
the transparency, accountability and inclusion of ethnic minority groups and women in
41
VTHC. Through active VTHC members, emergency obstetric/child care and referrals and
other community health services support to BHS and CHW could be sustainable.
1.11. Annex 1: Table Program achievements in Program Townships (2013-2017)
The flowing table illustrates the program achievement from the year 2013 to November 2017
against the target. Target indicators were compared against 2017 data and categorized in
colour for over achievement (green colour), achieved (blue colour) and under achievement
(colour).
Table 6: Program achievements in Bogale Township against log frame indicators
(2013- 2017)
Indicators Baseline 2013 2014 2015 2016 2017 Target
OC*
1.1
Number and
percentage of births
attended by skilled
health personnel
(doctor, nurse, lady
health visitor or
midwife)
52% 42% 59% 65% 71% 71% 75%
OC
1.2
Number and
percentage of births
attended by trained
AMW
16% 15% 13% 12% 9% 9% 10%
OC
1.3
Number and
percentage of
institutional deliveries
17% 24% 14% 15% 51% 56% 60%
OC
2
Number and
percentage of women
attended at least four
times during pregnancy
by skilled health
personnel for reasons
related to the
pregnancy
58% 68% 70% 72% 79% 92% 75%
OC Number and 49% 56% 60% 67% 73% 86% 75%
42
3 percentage of mothers
and newborns who
received postnatal care
visit within three days
of childbirth
OC
4
Number and
percentage of
newborns that initiate
immediate
breastfeeding within
one hour after birth
(disaggregated by sex)
76% NA NA 69% 76% 87% 75%
OC
5
Contraceptive
prevalence rate (HMIS) 68% 83% 72% 76% 80% 82% 72%
OC
8.1
Number and
percentage of children
under one immunized
with DPT3/Penta3
(disaggregated by sex)
96% 83% 100% 106% 91% 91% 100%
OC
8.2
Number and
percentage of children
under one immunized
with Measles
(disaggregated by sex)
89% 104% 101% 106% 93% 88% 100%
OP
1.2.1
Number and
percentage of
appropriate EmOC
referrals supported -
Total
791 1065 1341 1343 1690 2005 1419
OP
1.2.2
Number of appropriate
EmOC referrals
supported - hard to
reach areas
94 76 11 10 0 0 0
OP Number of ECC 272 265 332 253 515 689 1012
43
1.2.3 referrals supported -
Total
OP
1.2.4
Number of ECC
referrals supported -
hard to reach areas
32 11 4 0 0 0 0
OP
1.3.1
Number of under five
children diarrhoea
cases treated with ORT
at Health Facilities
1383 1187 1383 1281 1283 1113 1200
OP
1.3.2
Number of under five
children diarrhoea
cases treated with
ORS + Zinc at
community by
volunteers
N/A 309 460 300
OP
1.4.1
Number of under five
children suspected
pneumonia cases
treated with antibiotics
at Health Facilities
878 556 878 783 696 362 700
OP
1.4.2
Number of under five
children suspected
pneumonia cases
treated with antibiotics
at community by
volunteers
N/A 52 83 50
OP
1.5.1
Number and
percentage of postnatal
mothers who received
vitamin A supplements
52% 52% 62% 75% 76% 80% 90%
OP
1.5.2
Number and
percentage of postnatal
mothers who received
iron supplements 4
times or more during
pregnancy
53% 54% 63% 71% 72% 78% 85%
OP Number and 63% 63% 78% 75% 74% 85% 85%
44
1.5.3 percentage of pregnant
mothers who received
B1 tablets
OP
1.5.4
Number and
percentage of postnatal
mothers who received
B1 tablets
53% 57% 69% 78% 80% 84% 85%
OP
1.6
Number and
percentage of pregnant
women vaccinated
against tetanus toxoid
(TT2)
98% 74% 88% 104% 89% 92% 90%
OP
2.1.1
Number of doctors,
nurses and midwives
who participated in at
least one MNCH
training including
delivery and
emergency obstetric
care
88% 51% 58% 69 85 98 86
OP
2.1.2
Number of new AMW
trained 31 30 1 0 25 0 0
OP
2.1.3
Number of new CHW
trained 192 50 1 0 0 0 0
OP
2.1.4
Number and
percentage of hard to
reach villages with
AMW
0% 65% 47% 47% 0% 0% 0%
OP
2.1.5
Number and
percentage of hard to
reach villages with
CHW
41% 94% 53% 41% 0% 0% 0%
OP
2.2
Number and
percentage of auxiliary 49% 39% 90% 25% 57% 69% 60%
45
midwives and
community health
workers receiving
quarterly supervision
and monitoring
OP
2.3
Number and
percentage of
functioning AMWs and
CHWs who report no
stock-outs of essential
medicines and supplies
NA 23% 36% 25%
OP
5.1
Number of staff from
Ministry of Health
(MoH), Implementing
Partners (IPs), local
Non-Governmental
Organisations (NGOs)
and Community-Based
Organisations (CBOs)
(at central, regional
and township level),
trained in
Accountability, Equity,
Inclusion and Conflict
Sensitivity (AEI & CS)
NA 0 79 61 169 30
OP
5.2.3
Number and
percentage of feedback
that were addressed by
the IP in the reporting
period based on the
IP’s procedure
(disaggregated by type
of feedback)
NA 0% 100% 100% 80%
OP
5.4
Proportion of women
representatives 35% 41% 40% 0% NA
46
attending the annual
Comprehensive
Township Health Plan
(CTHP) review
workshop
OP
5.5.1
Proportion of women
representatives on
Township Health
Committee
12% 12% 11% 24% 24% 17%
OP
5.5.2
Proportion of women
representatives on
Village Tract Health
Committees / Village
Health Committees
35% 34% 36% 41% 41% 35%
OP
5.6
Number of
events/meetings
conducted during the
reporting period that
include participation
and engagement
between health care
providers and target
communities
70 24 24
*OC=outcome, OP**=output
Table 7: Program achievements in Mawlamyinegyun Township against log frame
indicators (2013- 2017)
Indicators Baseline 2013 2014 2015 2016 2017 Target
OC*
1.1
Number and percentage
of births attended by
skilled health personnel
(doctor, nurse, lady
health visitor or midwife)
42% 62% 68% 75% 74% 83% 75%
OC
1.2
Number and percentage
of births attended by
trained AMW
17% 14% 11% 10% 9% 5% 10%
47
OC
1.3
Number and percentage
of institutional deliveries 36% 44% 36% 56% 48% 44% 55%
OC
2
Number and percentage
of women attended at
least four times during
pregnancy by skilled
health personnel for
reasons related to the
pregnancy
53% 69% 63% 74% 81% 83% 80%
OC
3
Number and percentage
of mothers and
newborns who received
postnatal care visit
within three days of
childbirth
88% 100% 83% 108% 98% 87% 95%
OC
4
Number and percentage
of newborns that initiate
immediate
breastfeeding within
one hour after birth
(disaggregated by sex)
80% 99% 108% 95% 90%
OC
5
Contraceptive
prevalence rate (HMIS) 42% 67% 68% 80% 81% 83% 75%
OC
8.1
Number and percentage
of children under one
immunized with
DPT3/Penta3
(disaggregated by sex)
89% 85% 98% 97% 96% 97% 95%
OC
8.2
Number and percentage
of children under one
immunized with
Measles (disaggregated
by sex)
90% 104% 99% 95% 99% 95% 95%
OP Number and percentage 1038 2066 1945 2085 1432 1507 1207
48
1.2.1 of appropriate EmOC
referrals supported -
Total
OP
1.2.2
Number of appropriate
EmOC referrals
supported - hard to
reach areas
29 33 29 17 6 9 10
OP
1.2.3
Number of ECC
referrals supported -
Total
272 355 476 415 318 325 737
OP
1.2.4
Number of ECC
referrals supported -
hard to reach areas
13 7 10 2 3 2 6
OP
1.3.1
Number of under five
children diarrhoea
cases treated with ORT
at Health Facilities
1649 1358 1649 1498 1702 1522 1850
OP
1.3.2
Number of under five
children diarrhoea
cases treated with ORS
+ Zinc at community by
volunteers
N/A 124 102 80
OP
1.4.1
Number of under five
children suspected
pneumonia cases
treated with antibiotics
at Health Facilities
665 553 665 625 1014 801 1000
OP
1.4.2
Number of under five
children suspected
pneumonia cases
treated with antibiotics
at community by
volunteers
N/A 121 55 105
OP
1.5.1
Number and percentage
of postnatal mothers
who received vitamin A
supplements
73% 62% 69% 76% 85% 84% 90%
49
OP
1.5.2
Number and percentage
of postnatal mothers
who received iron
supplements 4 times or
more during pregnancy
16% 50% 57% 67% 78% 79% 90%
OP
1.5.3
Number and percentage
of pregnant mothers
who received B1 tablets
41% 56% 63% 70% 72% 84% 90%
OP
1.5.4
Number and percentage
of postnatal mothers
who received B1 tablets
53% 61% 72% 86% 95% 84% 90%
OP
1.6
Number and percentage
of pregnant women
vaccinated against
tetanus toxoid (TT2)
98% 79% 90% 91% 95% 95% 90%
OP
2.1.1
Number of doctors,
nurses and midwives
who participated in at
least one MNCH
training including
delivery and emergency
obstetric care
100% 100 106 96 101 84 100
OP
2.1.2
Number of new AMW
trained 30 30 50 25 17 0 0
OP
2.1.3
Number of new CHW
trained 30 30 50 24 0 0 0
OP
2.1.4
Number and percentage
of hard to reach villages
with AMW
50% 100% 57% 100% 100% 100% 100%
OP
2.1.5
Number and percentage
of hard to reach villages
with CHW
30% 100% 29% 100% 100% 100% 100%
OP
2.2
Number and percentage
of auxiliary midwives NA 80% 75% 25% 63% 64% 70%
50
and community health
workers receiving
quarterly supervision
and monitoring
OP
2.3
Number and
percentage of
functioning AMWs and
CHWs who report no
stock-outs of essential
medicines and supplies
NA 9% 22% 10%
OP
5.1
Number of staff from
Ministry of Health
(MoH), Implementing
Partners (IPs), local
Non-Governmental
Organisations (NGOs)
and Community-Based
Organisations (CBOs)
(at central, regional and
township level), trained
in Accountability,
Equity, Inclusion and
Conflict Sensitivity (AEI
& CS)
NA 0 80 64 125 30
OP
5.2.3
Number and percentage
of feedback that were
addressed by the IP in
the reporting period
based on the IP’s
procedure
(disaggregated by type
of feedback)
NA 0% 100% 100% 80%
OP
5.4
Proportion of women
representatives
attending the annual
41% 54% 80% 0% NA
51
Comprehensive
Township Health Plan
(CTHP) review
workshop
OP
5.5.1
Proportion of women
representatives on
Township Health
Committee
27% 25% 27% 33% 33% 27% 30%
OP
5.5.2
Proportion of women
representatives on
Village Tract Health
Committees / Village
Health Committees
25% 20% 25% 33% 34% 33% 30%
OP
5.6
Number of
events/meetings
conducted during the
reporting period that
include participation and
engagement between
health care providers
and target communities
56 28 28
*OC=outcome, OP**=output
Over achievements ( >100% achievement)
Achievement (90-100% achievements)
Under achievement ( < 90% achievement)
1.12. Annex 2: Comparison of selected MNCH data by project townships, regional
and national
Below table provides information for easy comparison of MNCH indicators between BGL,
MLMK, Ayeyarwaddy region and Union level. Initially comparison was made via MDHS
(2015-2016 data), however, by the time of finalizing the report, the Public Health Statistics
52
Report, 201717 was available at the website, and the report provides the comparisons
between project townships, Ayeyarwaddy region and Union based on the latest report
published in September 2017. Data for the BGL and MLMK are available from the project
documents and statistics. Both townships have a higher rate of antenatal care visits than
national data and almost same as the regional figure. For tetanus vaccine coverage and
institutional delivery, both BGL and MLMK have higher rates than regional and union.
However, for the indicator of percent delivered by the SBA, both townships have a lower rate
than the union level.
Regarding vitamin supplements, both townships have higher coverage rates than regional
and union levels while MLMK has higher postnatal and vitamin supplements coverage, early
breastfeeding initiation rate and postnatal visits although more than 100% of early
breastfeeding initiation rate was reported.
Table 8: Comparison of selected MNCH data by project townships, regional and
national
2016 2016 2016
BGL MLMK Ayeyarwaddy Union **
Percentage receiving 4 or more antenatal
care visits from skilled providers
79 81 80.8 72.3
Percentage receiving two or more tetanus
vaccine
89 95 83.2 81.2
Percentage receiving iron supplements four
or more times
72 78 70.2 63.5
Perentage receiving vitamin B1 during
pregnancy
74 72 65.1 59.7
Percentage delivered by AMW 9 9 8.1 7.6
Percentage delivered by a skilled provider 71 74 78.4
Percentage of institutional delivery 51 48 41
Percentage of women with a postnatal check
up in the first two days after birth
73 98 92.8 91
Early initiation of breastfeeding within one
hour after birth
76 108 87.3 83.3
17 Public Health Statistics, Department of Public Health, Ministry of Health and Sports. The Republic of the Union of Myanmar. September 2017. Naypyitaw
53
Percentage receiving vitamin A dose post-
partum
76 85 77 73.7
Percentage receiving vitamin B1 post-partum 80 95 79.4 73.6
Children received DPT/Pentavalent 3 91 96 89.5 87.3
Children received measles 93 99 86.8 83.8
Public Health Statistics Report,2016, MOHS
Area 2: Findings from Qualitative studies
Overview
Qualitative data collection was conducted to evaluate the MNCH program carried out by IOM
in BGL and MLMK townships by accessing its relevance, efficiency, effectiveness, and
sustainability in improving the MNCH status of beneficiaries living in that areas for a deeper
understanding. The findings described in relations to the two main interventions (community
demand side and public service delivery supply sides) and continuum of care across
maternal pregnancy to child health care.
Analytical approach to the area of study 2
As described in the methodology, FGDs, IDIs and KIIs were conducted with relevant
respondents comprised of two arms:
Community- pregnant women, mothers, husbands; VHC or VTHC members;
Community who support service delivery: Voluntary- VHW (AMW and CHW)
Public sector-supporting service delivery: MW, PHS1, Township Health Assistant
(THA), THN( Township Health Nurse)
Implementing organization: IOM staff at Yangon office and BGL Township
The qualitative study findings presentation is tailored based on the nature of the program.
The analysis presented a thematic approach. This 3MDG-funded-MNCH program in Delta is
not a standalone but a continuation of JIMNCH project and implemented at whole townships
across Delta by different implementing partners. The study assesses whether the activities,
strategies and approaches were relevant to improve the MNCH status, whether the
programme reached its intended target groups especially poorest of poor and people form
the hard to reach areas and whether the program contributes to the national MNCH strategy
54
or not. The study also assesses how efficient is the programme in converting its inputs to
outputs and outcomes and attributes to the impact level, how timely is the delivery of
activities, efficiency and effectiveness of the fund utilization, and coordination between IP,
VHW and public service staff.
The study also measures the effectiveness of the IOM MNCH program based on the
implementing activities such as joint supportive supervision, training, HMIS support,
VTHC/VHC, referral mechanism and supply of medical supplies for minor illness treatments.
Good practices, lesson learned, success stories, as well as barriers and enablers, were
identified. How the sustainability of the MNCH program is considered and planning for the
exit strategy when the program stop is discussed.
2. Qualitative study findings on the evaluation study
The findings presented about facility-based/outreach service provision, community-based
health care provision and emergency referral systems (demand-side financing). In general,
IOM program focuses more on improving the MNCH status of the migrant population while
this MNCH program covers all villages in BGL and MLMK as an inclusive approach. Among
five villages in BGL and nine villages in MLMK townships, Byu Sakhan, Kadone Ka Ni in
BGL and Hlaing Bone, Kyeik Pi, Pa Tee Yoe and Da Ni Chaung in MLMK have migrant
populations18. Unlike JIMNCH, at the time of 3MDG supported MNCH program
implementation, there is no hard to reach areas in BGL and only four hard to reach areas in
MLMK because of the new rural health centre, more man power in villages and other
factors.
2.1. Improving accessibility and availability of essential maternal health services for
the poorest and most vulnerable populations
The evaluation found that the program successfully implemented in improving the supply
and demand side interventions. At townships levels, the program supports midwives to
conduct regular ante and post-natal care visits and immunization activities through various
kinds of training and provision of medical supplies and relevant travel cost to the village for
AN/PN care and EPI service. These activities lead to the motivation of MW and able to utilize
limited human resources from public health service.
18 Migrant: a person who lives away from their town or villages of origin
55
Maternal health care
a. Antenatal care
In study villages, interviews with pregnant women, mothers and family members revealed
that all of them received ante, and postnatal care visits and almost all of them had at least
four ANC visits by midwives. This finding is reinforced by the findings from the survey data
with around 80% in 2016 for both townships and 92% in BGL and 83% in MLKM for 2017. All
beneficiaries mentioned that they get free antenatal care either from the MW or AMW, but
they have to give money from 2,000 MMK to 3,000 MMK19 when they take vitamin infusion
from the midwife. On the other hands, from the supply side, most BHS mentioned that they
had to charge patients if they used medicines bought from their pocket money because
some medical supplies were not enough. All women in the study stated that they got
services such as blood pressure measurement, pregnancy examination, tetanus injection,
vitamin supplements and happy for the service they received.
A mother from BGL Township shared her experience as:
“The midwife in our village took care of my pregnancy regularly. She educates me how to
take care of pregnancy and to inform her immediately if an abnormal situation such as
dizziness, and severe headache, vaginal bleeding, reduce foetal movement, etc. As I know
my blood pressure level, I can control of diet. She helped me to give early milk (colostrum) to
my child”. (FGD member, village A, BGL Township)
“I have two children, and one is one year and three months old. Sayarma (MW) gave iron,
vitamin B1 and folic acid and take blood pressure and weight. She visits once a month to us
and sometimes two times in a month if scheduled for immunization. I delivered at home by
sayarma” (FGD member, Byu Sakhan village, BGL).
Respondents said unlike before, their knowledge to take care of pregnancy improved and
they could access health service from MW or AMW and easily go to the nearby health centre
or station hospital because of IOM supported transportation services and emergency referral
service. Level of MW availability and community reliance on the BHS rely on whether RHC
locates in their village or not and midwife stays in their village or not. Usually, if MW does not
reside in the village, pregnant women mostly rely on the AMW where AMW took pregnancy
care under the supervision of MW.
19 1 USD= 1,350 MMK
56
In general, as AMW covers for ANC in the absence of MW, ANC coverage seemed to be at
satisfactory level.
b. Delivery of skilled birth attendance and institutional deliveries20
Significant findings from the evaluation study showed that all mothers in the study, and all
pregnant mothers delivered or plan to deliver with the skilled birth attendants. More than half
of the respondents from both townships delivered at a health facility- either at nearby heath
centre or station or township hospital. The reason might be partly due to the increased
awareness and most likely because they could reimburse transportation and delivery costs
from MW or hospital staff and referral from the MW or AMW. The team noticed that AMW or
MW actively referred the high risk cases in advance to the hospital or refer cases as soon as
the labour seemed to be difficult. Some mothers responded that they delivered either with
AMW or midwives at home because the villages do not have health centres or labour room.
All respondents agreed that deliveries with traditional birth attendants (TBA) have been
reduced significantly over the years and perceived that it is due to the IOM supported
program. However, a woman from an FGD in MLMK reported that TBA had delivered her
with 60,000 MMK.
“I plan to delivery at the village if delivery is easy. There is no cost if I deliver at delivery room
at the village. If delivery is difficult, sayarma (both MW and MW) said they would refer me to
the nearby hospital. As I will get money for hospital delivery, I am not that worried but prefer
to deliver here (village) otherwise my family had to come along with me and it is costly”. ( A
pregnant woman, FGD, MLMK).
Almost all of them shared that delivering in the hospital would be expensive as there is an
extra cost for food, accommodation, transport and miscellaneous cost for accompanying
family members and as husbands could not work, they would have reduced or not income.
Challenges
Challenge expressed for not willing to deliver at the hospital would be some people
complaint that money provided for delivery by IOM did not cover the cost associated with
labour while most of them said it was enough. One reason might be a variation of financial
20 Institutional deliveries: Deliveries that take place in a health facility
57
support based on the project years. Another constraint emerged from the interviews was
some respondents were afraid to go to doctors because they were not familiar with the
hospital system, some health personal shouted at them21 ( according to them), had to spend
money for food, accommodation and other costs during a hospital stay. Interestingly, they
counted all cost including the cost for family and relatives accompanying patients and
opportunity cost of daily wages by husbands who accompany them to the city. If the
husband is the bread-earner, it was hard for them to hospitalize alone or bring husband with
them. Some claimed that if they deliver at home, they do not need to care of what other
people think about clothes they wear or food they eat, but at the hospital, they have to dress
and eat properly, and it is costly. This finding might be useful in future program design to
increase the institutional delivery rate. Due to the MNCH programs and education activities
carried by different IPs and MOHS, it is likely that community is willing to use health facility,
but underlying causes of poverty and social-economic situation and out of pocket expense
and cost due to bringing family members or AMW to the hospital hinder the facility delivery.
A group discussion with VHW supports that finding as “I have to accompany the mothers for
delivery as they would not go to the hospital unless I go with them”.
c. Delivery by auxiliary midwife
The study found that AMW plays an important role in the provision and support of maternal
and neonatal care in the study villages. They are often the first point of contact for detection
of health issues and for promoting onward referral to MW or station or township health
hospital. The community had trust in AMW abilities in delivering their baby, compounded by
the knowledge that high risk cases could be identified and referred by the AMW. Apparently,
almost all of the normal delivery were delivered by the AMW while according to the
interviews with AMW, they normally referred the cases to the hospital and one AMW shared
that the criteria for the referral slightly change this year and they refer more cases to the
health centre. The study team observed that referral by AMW depends on their age and
working experience. Interview with experienced ( about ten years) AMW said they normally
delivered a baby at home unless it is high risk while AMW form another village tract, a young
and newly trained, said she usually refer cases to the MW or the hospital.
AMW shared that “Previously, villagers normally delivered with TBA as MW could not
available day and night during labour. MWs are very busy, and unless she stays in the
village, it is not possible to deliver with MW even they want to especially at night. Now
21 Most possible reason , explained by AMW in the village, be the late arrival of the hospital.
58
because of this program, we got training from township at township hospital. The community
had more confidence in us, and TBA in the village did not dare to deliver with our
knowledge”. (MW, village B, BGL)
“I go to the woman house as soon as I hear she has labour pain. If delivery seems difficult, I
bring her to the hospital. I also inform MW and collect recommendation letter form her to
reimburse money support for delivery”. (AMW, KI, BGL)
d. Birth Spacing
Most beneficiaries use some kinds of contraceptive methods from OC pills to depot injection
and implant. They have to buy or pay from 1000 MMK to 3000 MMK to midwife for this
service although some mentioned that they get free depot injection from the midwife. Some
pregnant women and mothers of under five children mentioned “It is free to take (depot)
injection from the midwife. If it is from someone else, we have to pay 1,500 MKK to 2,000
MMK.” Because of Marie Stopes International (MSI) organization, there is an increase in the
free availability different birth spacing methods as one woman mentioned “I had put the
implant under my arm. It was free of charge from Marie Stopes”. (A mothers, IDI, MLMK).
e. Post-natal care
Similar to the antenatal care, qualitative findings showed that postnatal care service among
IOM MNCH program townships is satisfactory although there is variation in HMIS data
between BGL and MLMK. The majority said they received postnatal services from either MW
or AMW such as birth registration, immunization, vitamin supplements and support for early
initiation of breastfeeding. However, receiving a comprehensive PN care or not is a question.
According to some respondents from BGL and MLMK townships, they recalled that AMWs
did not check the abdomen or vaginal wound and this kind of information were mainly seen
by the women delivered at home.
f. Micronutrients supplementation to pregnant women and mothers
Providing of micronutrients as a nutrition promotion is an important step for the optimum
health of mothers and child. Micronutrient deficiency is a major contributor to childhood
morbidity and mortality, and anaemia is a serious concern for children because it can impair
cognitive development, stunt growth, and increase morbidity from infectious diseases.
Anaemia is a condition that is marked by low levels of haemoglobin (below 11.0 g/dl) in
pregnant women and iron supplementation is given to the pregnant mothers.
59
Respondents’ women claimed that they received vitamins from MW or AMW while some
knew the name of vitamins they took and some only aware that as a knowledgeable person
gave all medicine and pills, they should take it for their health and child health. No one
mentioned of difficulty or unwillingness to take pills. However, it is hard to identify which
kinds of vitamins they took during FGDs and IDIs for some women, and a few women said
they did not recall of taking pills or not. In general, they aware that they took an iron tablet.
MW and AMW from interviews shared that providing sufficient micronutrients is one of their
tasks and they provide vitamin A supplements to postpartum women (200,000 IU) within 42
days of their delivery, iron supplements (180 tablets during pregnancy), B1 and deworming
tablets (one tablet after the first trimester) to pregnant women. Though unlikely to happen, as
there is no monitoring system for uptake of these pills, although qualitative study findings
showed this activity is a success, quantitative data was taken into account in the analysis. In
general, both townships did not reach the targeted level of vitamin supplementation in 2016,
and there is a risk to reach the vitamin A, B1 and iron supplements in 2017 as well.
g. Service readiness
After decades of institutional neglect of the health sector, recent efforts have been made to
improve the health status of the population with government increase in public expenditure
on health from 0.2 per cent of GDP in 2009 to slightly over 1 per cent in 2014 and 3.65 in
2016. The National Health Plan (NHP) (2017-2021)22, aims to strengthen the Myanmar
health system and pave the way towards Universal Health Coverage (UHC) which is defined
as all people have access to needed health services of quality without experiencing financial
hardship. In light of this, MOHS extends access to a Basic Essential Package of Health
Services (EPHS) in the project townships. To improve the service readiness, MOHS has
been trained and deployed more BHS especially MW at village level and constructs more
health facility.
The team observed that as described in the study area 1, health facilities (station hospital,
RCH and sub-RHC) in both townships and human resources increased during the project
period. A KII with health assistant in MLMK expressed the needs of more health facility with
equipped labour room.
22 Myanmar National Health Plan (2017‐2021), Ministry of Health and Sports. The Republic of the Union of Myanmar. 2016.
60
Recommendation
Although there is a significant increase in skilled birth attendance and health facility
deliveries, some women still delivered at home either with midwife or AMW.
Strengthening of service readiness approach and expansion of basic essential
package at township level via integrated township health plan should be encouraged.
To achieve the targeted facility delivery rate, it is important to consider changing of
their perceptions and attitudes about hospitals and find solutions on how to change
their cultural norms of bringing a bunch of people from the village to the town. It
should be educated that cost of delivery is free and adding to all unrelated cost is not
correct.
The hospital should be more user-friendly and should have an active medical-social
worker who could be a liaison officer between patients and health staff and acts as a
communication officer for the hospital.
More attention should be given to postnatal care service delivery and educate the
importance of postnatal care towards the community, BHS and AMW.
There is a gap in addressing sexual and reproductive health (SRH) needs of women
particurly young people although some respondents shared of using contraceptive
pills or injections. Capacity building trainings and awareness raising sessions on
rights-based SRH, and gender-based violence ( GBV) towards VTHC members,
volunteers, WORA and males at community level as well as relevant stakeholders is
suggested.
Technical support, under the leadship of RMNCH section,MOHS, to implement the
quality RH services such as guidelines and standard operation procedures for post-
miscarriage care and GBV management at township level public sector hospitals is
suggested. Strengthen the SRH care via scaling-up of the essential reproductive
health (RH) package and developing budget lines for RH community support is
suggested.
A comprehsive perspective is needed to ackowledge the different situations around
migration and the recognition of migrant’s rights.It is important to tailor RMNCH
related education,awareness sessions and services based on the seasonal migration
pattern and nature of work.
Good practice such as AMWs inform about migrant population in the village to BHS
for immunization or other MNCH service should be maintained via incentives,
recognizion and sharing of success stories.
61
2.2. Improving accessibility and availability of essential child health services for the
poorest and most vulnerable populations
a. Immunization
Our study found that immunization coverage is well appreciated by the respondents and
study trip coincides with Japanese Encephalitis immunization week. All respondents
mentioned that EPI coverage is increasing because the community is fully aware of EPI
benefits and the service is free. They shared that midwives visit the villages every one or two
months thanks to IOM support and VTHC/VHC’s assistance.
An MW from MLMK said “It takes quite an amount of time to reach to far villages when we get
there is already half day. Transportation is always a concern, but now with the project
support, we could concentrate only on our work, not for other barriers. Presence of AMW and
VTHC is quite effective; we just have to contact them via phone”.
Challenge from immunization suggests of minor illness (fever) after immunization and
immunizations outreach visit are often deferred during the rainy season due to unsafe
weather. According to the BHS, they got information from the AMW about the migrant
population and provide immunization.
b. Breastfeeding practice
All mothers participating in the interviews responded that they gave breastmilk to a child
soon after delivery and majority said they gave breastmilk only without water, juice or food till
the child is six months (practice exclusive breastfeeding). The evaluation team
acknowledged that it needs a reasonable amount of time to answer a comprehensive
probing questionnaires format to know whether mothers practice exclusive breastfeeding
(EBF) for six months or not. As the evaluation questions cover a range of topics, probing for
EBF might not be comprehensive as a study which examines the EBF practice alone, and
there is a possibility that respondents provided a positive answer to get a favour from the
interviewer. Nonetheless, it is obvious that all village women knew the benefits of EBF due to
the educations they received and most mothers practiced EBF. Unlike previous study by
62
Hmone et al., 201723 none of them mentioned that honey was given soon after the delivery
in their villages.
A mother shared about the reason for giving breastfeeding as: “We fed rice and water to
elder children but now sayarma ( mid wife) and sayarma from health education sessions told
that breastmilk alone would cause our child to be smart, intelligent and healthy. So I gave
only breastmilk to my daughter who is now at five month-old”.
c. Minor ailment treatment and diarrhoea and suspected pneumonia treatment
The findings showed that diarrhoea and suspected pneumonia cases received early
treatment at village level by VHW and cases are referred by VHW to the health facilities if
serious. As the respondents were general laymen, they did not know about the exact reason
for getting treatment at the hospital, and the study team found only a mother who had
experienced seeking treatment at the hospital and she could not articulate well about the
case. Almost of all the respondents perceived that because of VHW and free medications,
they could access an early treatment easily without necessary to go to the hospital. Some
mothers went to the MW and majority mentioned that they had to pay BHS (MW, PHS, and
LHV) for medications fees when they took their children to them although they get free of
charge care form VHWs. A few beneficiaries mentioned that they do self-medication first for
their children before seeking care from VHWs or BHS.
Interview with VHW stated that: “I give paracetamol for normal fever and sometimes
antibiotics. I referred dengue cases last year, and there are not much diarrhoea cases.”
(VHW, female, BGL).
Some VHWs complaint that there is out-stock of drugs sometimes while the majority did not
mention of such constraint. Respondents’ women felt that because of volunteers, they could
seek help for child minor ailments and could get ORS, paracetamol or antibiotics freely and
easily.
23 Hmone MP, Dibley MJ, Li M, Alam A: A formative study to inform mHealth based randomized controlled trial intervention to promote exclusive breastfeeding practices in Myanmar: incorporating qualitative study findings. BMC Medical Informatics and Decision Making (2016) 16:60DOI 10.1186/s12911‐016‐0301‐8
63
d. Emergency child care ( ECC) referral
Interviews findings showed that support for the emergency referral for child health is
effective however emergency child health care referral cases are less commonly mentioned
compared to the cases referred for the maternal EmOC cases. AMW, VHC/VTHC and MW
said this kind of mechanism is effective and could help poor people who were reluctant to go
to health facility due to various reasons.
“Most villagers were poor and could not go to the hospital even in emergency cases. Health
seeking behaviour increased because of IOM’s financial support and VHW approach”. (An
AMW, Village A, BGL).
A mother shared how the ECC referral system helped her child as:
“About two years ago, my son had dysuria and had a high fever for a few days. He cried all
the time and could not urinate. We were so worried. Then, someone in the village, I think-
may be CHW, told us about the emergency referral fund, and we approached MW. Then, my
son was refereed to the hospital, and he had to do some surgery. We got 50,000 MMK at
that time and thanks for it till now”. (A FGD member, village A, BGL).
Recommendation: Child Health
In general, immunization coverage is good while there is a need to promote health seeking
behaviour of community when their child is sick and educate about danger sign for
pneumonia or diarrhoea. Out of pocket payment should be the cause for this behaviour and
on the other hands, need to find out the actual cost for not receiving free health service from
BHS such as MW, PHS, LHV.
One possible reason for MW charge patient might be because they have to buy medicines
out of pocket and there is also a possibility that BHS go beyond their scope because of
community demand. To improve township level LMIS about effective supply chain
management plan and regular monitoring of stock-in and out with document and record is
suggested. Training for supply china management and refresher training should be given to
MW, and effective communications between central level, township level and font line level
are important. THD supplies medicines based on the guidelines, and if the medication they (
MW) need is not within the supplies medicines, there is a possibility that BHS bought some
medications even though they are not allowed to use them.
64
2.3. Strengthening demand-side: Community based health services through
emergency referral services to reach to the poor and vulnerable populations
During IOM MNCH project, referral mechanism has been well established, functioning and
found to be the most appreciated mechanism by the community, volunteers and midwives
while the success of this approach is money-intensive. “Emergency Referral” is the term
used to define a patient who has a severe life threatening illness, or is suspected to have a
life threatening illness that needs both diagnosis and treatment by a skilled health
professional. The emergency referral pathway is the method by which a patient has been
transferred from the community level to an appropriate point of secondary care that is
capable of treating most life threatening emergencies including obstetric emergencies; this is
usually the Township Hospital and may be a Station Hospital. The principle of this pathway
is to ensure that all possible barriers are removed from the timely referral of a suspected
medical emergency to thus improve survival rates as well as preventing potential
complications24.
The team noted that IOM had successfully facilitated the accessibility of curative and
preventive health care services for the most hard-to-reach population in the study townships
through the referral support for the emergency obstetric (most succeed) and child care.
Village Tract Health Committee and Village Health Committee also play an important role in
providing finance for subsidizing the transportation cost to reach health facilities.
Most respondents mentioned that they or their relatives had received emergency referral
support from IOM. They also mentioned the referral system helps villagers to get access to
the hospital care.
The amount of money received for referral service varied as initially assisted delivery (a
lower (uterine) segment caesarean section (LSCS) ) received 150,000 MMK and normal
delivery got around 80,000 MMK however during the project wrap-up stage, in 2017, the
reimbursement for transport and hospital delivery reduced to estimated 50,000 MMK.
24 3MDGF, Implementing Partners’ Working Guidelines for Support to Emergency Referrals.
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Management and accountability
It is a good practice that to be eligible for the emergency referral support; maternal patients
need to have at least four antenatal care visited by skilled health persons. It is also
remarkable that beneficiaries were aware of that criterion as one pregnant woman mention:
“To get an emergency referral support, we need to take at least four-time antenatal care
from a midwife, and it also needs a referral letter”. Health assistant from X village confirmed
that “Emergency referral support provides to those who have taken enough number of AN
care and migrants”.
A woman and husband from IDI shared that “We have to get hospital attendance letter
issued by the attending doctor at the hospital or recommendation from the midwife to get the
money” (A couple receiving emergency referral service, village A, BGL).
On the other hand, accountability for the emergency fund managed by the VTHC or VHC
might be a challenge. Although evaluation team did not observe the complaint about
transparency in getting money from the community, the majority of committee members do
not mention of ‘book keeping, record, rules and regulations, criteria for interest rate, loan
amount, payment time and accountability’ issue.
Challenges
There were some challenges either because of difficulty to get boat or car on time and for
hard to reach and remote villages where transportation by boat is only possible, weather
situation affects the timely referral to the health centre. Some beneficiaries (similar to the
findings in the delivery section) highlighted the actual expense was beyond IOM support.
One VTHC member from MLMK mentioned “Since the beginning of 2017, the maximum
amount of money IOM support is 57,000 MMK. It is not feasible for those who have to spend
beyond that amount”. In contrary, one AMW from BGL Township mentioned: “Although they
could not reimburse full expenses, half support is also helpful.”
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Sustainability
Many respondents were worried that hospital attendance would reduce if there were not
support from the IOM in the future. Meanwhile, some VTHC/VHC members shared that they
would continue this referral mechanism even with limited funding.
A member of VTHC shared that “Even after the project end, we have an emergency
revolving fund and we could use anytime for an emergency referral. There is a loan amount
of estimated 300-400,000 MMK in each village. We borrowed that money with interest rate of
3% and this would help the VTHC to continue functioning”. (A member of VTHC, MLMK).
Another VTHC member in other study village said that if no one from the village was
interested in borrowing money, the committee members rotationally used it and gave the
interest to increase the funding amount and replenish the used money.
Recommendation
VTHC model is found to be an effective approach to strengthen the support for a sustainable
referral mechanism as it is based on the strength of the active community members in the
village levels. Financial problem is the main barrier for poor and vulnerable populations
including migrant population to access the timely MNCH and referral service. Providing
enough resources such as boat, fuel, transport cost, revolving fund, etc. might overcome
financial barrier. Recommendation for longer term would be economic development of poor
via income generation and microfinance activities. One VTHC mentioned that IOM provided
a boat for the village for emergency referral support, which could be a one of the supporting
strategy for sustainability of referral support when a project withdraws.
For the long-term sustainability, capacity building of VTHC members on referral mechanism
and managing VTHC fund and creating enabling environment such as improving
infrastructure: roads, bridges; upgrading and expansion of health facilities; deployment of
health workforce and improving community ( including husband and in-laws) health-seeking
behaviour is suggested. Another recommendation would be to develop stronger
collaboration between BHS staffs and VTHC/VHC in forming strategies on long-term
sustainability of the village health fund. The main challenge of VTHC is attrition of members
and it is important to have appropriate strategies for recruitment, supervision and motivation
of VHC members and ensure the transparency, accountability and inclusion of ethnic
minority groups and women in VTHC. IOM needs to facilitate to continue support of township
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health committee and BHS to VTHC and VHCs. Township level should plan to provide
management and financial referral support for the emergency patients.
2.4. Community mobilization approach via voluntary health workers
National Health Plan recognizes to address the reproductive, maternal, neonatal and child
health (RMNCH) as a priority in the country. As MOHS gave a clear commitment to meet the
Sustainable Development Goals (SDG) and is working towards to reach the Universal Health
Care (UHC) coverage approach, it is important to cover all population particularly those from
hard to reach area, poorest- of- poor and vulnerable population. In light of this, strong health
human resources are needed despite the fact that there is an absolute shortage of human
resources for health in the country, including in critical cadres, such as the midwife. To
address this, Ministry of Health and Sports (MOHS) has identified the strengthening and
scaling up of Auxiliary Midwives (AMWs). IOM supported more functioning of VHW
comprised of AMW and CHW, to extend health care services at community level. Both
CHWs and AMWs work alongside each other to provide services at the village level.
According to the quantitative data, although there is every village does not have a VHW, the
project helps to increase the number of VHWs in the villages by supporting township health
department to train new VHWs. Some VHWs are quite active and doing significant changes
in the community. All study villages had either AMW or CHW and some of them also
involved in VTHC or VHC. AMW are selected from the community by following the MOHS
guidelines, and according to the IDIs with AMWs, MW chose them, and most of them had
experienced in volunteering with MW before becoming CHW. They said MW encouraged
them to become volunteers, and their volunteer and social sprit makes them become
volunteers. They received training at the township and majority thought training was
adequate, all AMWs and CHWs mentioned that they received refresher training frequently.
Two AMWs specifically mentioned that they had received six kinds of training supported by
IOM. AMW received community based new-born care Training, community case
management training and nutrition training while CHW received malaria training and CHW
refresher course and varieties of training received are not much compared to the AMW.
The AMW has a particular role in addressing the challenges to access to RMNCH services,
and CHW has more role in assisting in organizing health education sessions, immunization
and treating minor ailments, etc. The study found that AMW seemed to be more effective
and functioning than the CHW and one possible bias for getting this conclusion might come
from the reason that interview guideline was developed mainly on the MNCH. The
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coordination between AMW and CHW were observed to be good, and they work closely in
assisting MW. We noticed that CHW helped AMW in delivery and referral case. AMWs have
a range of key responsibilities to ensure women are supported throughout their pregnancy
and in the immediate post-natal period including promotion of EBF and health education.
AMW identify women of childbearing age (WCBA), pregnant mother, and high risk mother
and inform MW.
“I work as an AMW because it builds my capacity and benefits for the village health. I once
had to stay at the township hospital for seven days when assisting the mothers who had to
do LSCS. The family requested me to stay at the hospital until discharge. I have kids and
sometimes my husband complaint about working as AMW as I do not earn money but I am
happy to help others.” (AMW, IDI, BGL).
“I got training in the township, and it includes VRS (voluntary record), monitor treatment
training. In addition to BP monitoring and treating minor illness, I helped immunization
activities by reminding villagers to come, recording immunized children name and checking
child name against father’s names. (CHW, IDI, MLMK).
Interviews with AMW and CHW form a village shared their history of helping a high risk
pregnant woman for a timely referral.
“There are only three tents in the paddy field which is near to the creek. As MW comes to the
village once a month only mainly for immunization, I did the ANC visit to that lady during her
pregnancy and informed MW via phone regularly. One day, I was called by CHW that that
woman is in labour and as she could not deliver easily, we made a referral. What happened
was at that time, there is no water in the creek, and we could not use the boat, and instead,
we had to carry her by using blankets with bamboo poles. VHC members helped us in
carrying her and have money to go to the hospital. It is really hard and tiresome experience,
but we were proud of what we did”. (AMW, IDI, BGL).
All interview findings showed that AMW and CHW were motivated, have passion and
confidence for their work. Community feedbacks towards them were good. It is obvious that
AMWs play an important role in increasing access to essential RMNCH services in
Myanmar. However, the team could interview with functioning AMWs mainly, and there is
only one interview with non-functioning AMW for a short period in MLMK, and main reason
given was because of the workload of child rearing and household chores.
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However, it is important to note that VHW should not replace BHS role but should be
complemented the government health service delivery by supporting MW activities. Because
interview with mothers from BGL suggested that VHW should be trained to give an injection
for high fever because nearest referral place in Setsan ( BGL) RHC and it takes one hour by
boat. VHW should be trained as per standard operation procedures, and guidelines and
regular and effective supervision and monitoring should be made to avoid them to become a
quack.
Challenges by VHW
As VHWs solely based on the volunteerism, there is also attrition because some of them
have moved to another location for income or got married to someone in another location.
Being a volunteer basic, sustainability of this approach is a risk. However, some claim that
they would continue working as VHW even the program stops as they involved for more than
ten years (AMW with many years of experience) and another VHW who is newly trained said
would continue working because she is happy to work and her husband agreed. A few of the
interviewee reported the stock-outs of drugs cases.
Regarding program challenge, some shared challenges as “We had to report some
participants attending to education sessions. As we provided similar information to them at
every session, gradually, it was hard to persuade them to come to the meeting points”. (IDI
with CHW, MLMK)
On the other hand, another AMW shared how she solves such challenges. “ If villagers do
not come to the education sessions, I go to their home and delivered health talks with house
owner and nearby women ( neighbours), at least I could share knowledge to 5-10 women
and men”. (IDI with CHW, MLMK).
All interviewee agreed that withdrawing IOM support would be the main challenge for referral
service because of financial barriers. They claimed that hospital delivery had been increased
because women were willing to go to the hospital because they received support money of
about 150,000 MMK and increased in awareness. All requested to continue IOM service
because Delta area population are poor and financial support is needed. On the other hand,
they also mentioned that they would try to continue at least emergency referral ( EmOC) with
emergency fund support while not sure of child health care support. An additional finding
was by building the capacity of VHW who are mainly women; it would empower women as
they could have the opportunity to participate in the training, workshop and township level
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meeting. This comment is in line with the findings from the secondary quantitative data about
women participation in various kinds of training and activities at the township level.
FGD with IOM staff suggests that in selecting VHW, to reduce the attrition rate, more
preference should be given to those who could give time, from the local village and people
with more experience rather than higher education. Another staff member highlighted that
they received feedbacks from VHW about the complexity of forms to be filled (volunteer
reporting system). It is worth noting that evaluation team observed that some AMW are well
experienced enough to handle delivery case while being an old age, some need to wear
glasses and to fill in one page record form would be a burden for them.
A team member from BGL office shared his concerned that;
“Monthly activity report format for AMW is quite complex for some AMWs with low education
level. As it is designed as a one-page report, where all information has to fill-in one page. It
might not be user-friendly for some people with glasses as font is small and hard to fill in
handwriting”’ (FGD member, IOM staff, BGL)
An IOM staff states that “Because of VHW, we receive the information about migrant. As
they inform about migrant status to MW via phone, MW could referral the needy case
promptly”. ( FGD member, IOM staff, BGL)
Recommendation
To provide incentive money for sustainability to the volunteers or developing an
alternative strategy to main VHWs. To develop flexible criteria for selecting VHW and
support VHW through merit-based compensation, essential drugs, recognitions and
performance-based rewards. Continuous monitoring, supervision and capacity building
training could motivate their volunteer sprits.
The selection criteria should be linked to the policy guidelines, and strategy to shape
career pathway for AMW is suggested. For example: allow them to attend bridging
course to become MW. Set specific criteria for selecting AMW for hard to reach the
area. To recruit using criteria based on the interest in work, possibility of longer stay as a
volunteer rather than the education status
To provide enough medical supplies to VHW.
Review the existing forms and collect feedbacks from all VHW about the challenges in
filling the form and based on the feedbacks, action should be carried out. Suggest
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distributing form in 2 pages for easier viewing.
To link the strategy of women empowerment and capacity building of VHW esp AMW
who are usually women. Suggest to provide key observations relating to women
empowerment because of VHW activity to the national level women plan to make IOM
activity more visible.
2.5. Increased affordability via VTHC/VHC funding mechanism: Financing and
capacity building support
All villages have village health committee, though some committees are more active than
others. Most VHCs/VTHCs mentioned that IOM has involved or initiated the establishment or
revitalization of committees. There are also a few committees which are initiated by Save the
Children in MLMK Township. They also mentioned that the purpose is to help mothers and
under five children to get necessary health care and support.
When asked about the purpose of forming VTHC, one member replied: “To help pregnant
women, under five children and abortion patient to get health care services”.
Training
The VHC/VTHC members have received training including financial management training for
the better management of community health funding. IOM provided various training to
VTHC/BHS such as fund raising, fund management and book keeping, gender equity and
women empowerment, leadership and people management, community mobilization, team
building, primary health knowledge and referral system information, hand over the process of
referral support and feedbacks response mechanism and AEI and conflict training. In
general, respondents said fund management, booking keeping, referral related training were
benefits to them.
Health Committee Fund
All VTHCs are managing fund successfully. Majority of the VTHCs have successfully
doubled or tripled the amount of initial fund which was established with contributions from
villagers and IOM. One VTHC has managed to increase initial fund of 463,200 MMK to
2,760,000 MMK in MLMK Township over the years. Although most VTHCs funds is revolving
fund with interest rate of 3% to 5% and aim to get interested rate by borrowing money
among the villagers, one VTHC from BGL Township mentioned that they have to revolve
money within the VTHC members because villagers are not borrowing money. On the other
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hand, further in-depth interviews are suggested to explore the barrier of the villagers to
borrow money. Financial accountability and transparency are somewhat satisfactory while
during interviews, respondents mentioned that committee members kept fund money. VTHC
divided fund into two, an emergency fund which amounts range from 80,000 MMK to
250,000 MMK is depending on how big is the total amount and the rest are revolving fund. In
MLMK, as some villages did not agree to transform VHC to VTHC, there is a mixture of
VTHC and VHC exist in MLMK. The reason for not agreeing is money allocated to VTHC
and VHC is same, and if they change to VTHC, each village from VTHC has to divide the
money equally, and allocated fund money would be reduced.
Activities
Their main activities are to educate and mobilize people for health activities. They help BHS
in preparing the events, recruiting and reminding communities so that BHS could implement
their activities especially EPI activities effectively.
One VTHC mentioned, “We have been supporting midwife with ice and transport cost of
13,000 MMK every month for EPI since four years ago”. All VTHC mentioned that they lend
30,000 MMK without interest to emergency maternal or under five child patient to refer to the
hospital if patients can show a referral letter. Patients need to return the money within 10 to
15 days while some responded that they could wait if women had difficulty in returning the
money.
One pregnant mother mentioned, “We need to prepare before the due date. If there is a
difficulty, there is IOM fund in the village. We can borrow it without interest and need to
return within ten days.”
Voucher Scheme
There is a maternal voucher support system for migrant pregnant women in 40 villages of
Kadonkani areas. There are paid ‘voucher distributers in each village, who is responsible for
identifying and paying voucher to pregnant women among migrants in respective village.
Each pregnant mother receives free pregnancy care and receives total money of 11,000
MMK with a breakdown of 1000 MMK for each AN care for four times, 5,000 MMK for
delivery and 1000 MMK for each PN care for two times. The study team observed that it is a
good strategy to promote the health of mothers from migrant communities although money
amount is limited.
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Effectives and accountability
In general, we found that either VHC or VTHC encouraged and supported poor mothers and
families to seek healthcare at the hospital. Although this kind of fund supports referral and
could reasonably overcome the financial barriers, social barriers as explained above could
exist, and community might be reluctant for institutional delivery. Management of
accountability funding is satisfactory based on the feedbacks from the interviewees. It was
found to be equitably distributed to women and children within the community on need basic.
Based on the interviews in BGL, although the committee members borrow fund money with
good intention, it is hard to say whether this practice affects the community trust worthiness
and falls for the category of ‘conflict of interest’.
For equity and inclusiveness, there is a reasonable women participation with limited women
leaders in the committee. As leader of the committee (particularly), VTHC is a link to the
government administrative system and leaders are usually males. A FGD member with IOM
staff found that all fund money had been collected, deposited in the bank and transferred
back again with proper legal documents, the team conclude that there is a proper fund
management mechanism.
Recommendation
As VTHC or VHC usually collapse after one or two years of withdrawal of project, existing
BHS should continue supporting and encouraging the activities of VTHC and VHC. On the
other hand, the growth of VHC or VTHC fund shows the effectiveness of the fund
mechanism. This success is contributed by the regular returns of the loans disbursed from
the revolving fund pool and effective leadership of the experienced person and village
economy status. No formal mechanism determining how this fund would be replenished if
ERF amount is reduced for some reasons and in that case, sustainability of the fund is a
question.
If any problem arises and if village level administrator could not solve at his or her level,
township health committee where the chairman is a ‘township administrator’ should
intervene and solve the problem immediately.
There is also concern among VTHC members that they could not pay voucher distributer if
IOM support would not be available.
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One member of VTHC mentioned, “It would be good if voucher distributers can be paid
continually. We cannot pay them because we mainly support migrants”. IOM should
facilitate the VTHC to identify a more viable way of distributing voucher to migrant pregnant
like through midwife when she goes to the village for immunization.
In collaborating with THD, an appropriate strategy on how BHS staff particularly MW could
support the VHCs for long-term sustainability of the village health fund should be developed.
Data and information management system of VTHC and VHC should be strengthened. An
alternative option for integrating of VTHC and VHC fund into the existing social safety net
programs in the village is suggested.
It is suggested to integrate VHC to VTHC in MLMK as VHTC will hold accountable to
Township Health Committee (THC) managed by the Township Health Department.
Success story
IDI with a village head who is also a VHC committee member provides a success story
which could lead to the fund sustainability. A member of VTHC shared how he integrates his
knowledge and skills gained from leadership and management training during the setting-up
phase of VTHC to the current village level administrative structure as:
“ I initiated a CBO called ‘Youth with Pure Heart’ when I became a village administrator in
2016. The group aims to support the maternal and child health, and the group supports
50,000 MMK for a poor household in the village for each referral case to government health
services. We work this approach in collaboration with government health department (RHC)”
This approach is a good example of how IOM project could be sustained even after the
project end. Community mobilization has been proven because the villager who was the
indirect beneficiaries of IOM project initiates the community participatory approach to
improve MNCH by mobilization village youths.
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2.6. Township health system strengthening via the capacity building training: BHS,
CHW, VTHC
The team observed that IOM had facilitated the various kinds of capacity building training
towards BHS staff particularly MW, VHW, and VHTC. Training such as financial
management training for VTHC member, a workshop on follow up and handover activities for
VTHC, VRS training for VHW, MNCH care training, and training on accountability was
relevant to the program.
Most BHS mentioned that they received various training which was supported by IOM. They
have received training such as BEMOC, CCM, Baby Breathing Helping, Nutrition, HMIS,
Child Death and Maternal Death Surveillance Respond Training. They also mentioned that
the training is relevant and helpful in their work.
Recommendation
While training was found to be relevant and most interviewees gave positive feedbacks,
there should be a post training monitoring mechanism to know whether they are applying
what they have learned. It is important to adjust the training days based on the primary task
of BHS and THD activities.
2.7. Strengthen supply side service delivery through enhancing the planning capacity
of the township health departments
The program contributes in strengthening of governance and accountability systems within
the township at all levels through the Accountability, Equity, Inclusion and Conflict Sensitivity
(AEI & CS) at township level which are the vital components in health system strengthening
approach. Due to the participation in the number of events/meetings that include
participation and engagement between health care providers and target communities
(workshop and meetings held at township level), service delivery mechanism is more
strengthened.
It is recommended to conduct a pre and post-test assessment or to introduce the
anonymous feedbacks at the end of the training, to monitor the effectiveness of the training.
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a. Coordination with government BHS in reaching the poor and vulnerable
The study team observed that IOM supported the township health planning and had an
effective coordination with township health departments.
Every year, there is a planning meeting for CTHP, which is supported by IOM. THD has also
microplanning meeting at the beginning of each year, which activities are supported by the
project, especially transport cost for BHS for EPI. There are some challenges to make CTHP
ownership of THD because they see it as work of IOM.
Staff from IOM suggest that THD should have more ownership because this program is
government lead and not the IOM and donor orientated project. Busy administrative
schedule including meetings and travels would be challenges faced by IP organization in
coordination. There is a low supervision visit from the central level to the project townships
and did not reach the targeted number for supervisory and coordination visit.
Supportive Supervision
Although joint supportive supervision visits are successful, there are some challenges for
joint supervision of VHWs by BHS and IOM because BHS are busy mostly with their other
activities. Sometimes, supervision cannot be done because there are not either enough staff
or key staff like health assistant is vacant. In contrast, an IDI with BHS said they could
access timely information via mobile phone and received documents via Viber application 25sent by AMW to know the high risk and labour care.
Recommendation
It is suggested to provide more encouragement and promote a sense of ownership for CTHP
by the THD. The proper exit strategy is needed as there is much possibility that some
project-supported regular activities could stop when the project ends. For example, if
activities such as RHC meeting with VHWs, supporting medical supplies to VHWs and
regular supervision visit to village level is reduced, VHWs would be demotivated.
Demotiavation would lead to the high drop-out of VHW and hinder accessibility of health
care by people from the remote locations and migrants. A strong plan, a continuation of
MNCH approach and funding mechanism is needed in THD to continually supports and
25 Viber application: A window application allowing a free mobile call and sending text and picture message by using internet. Very popular in Myanmar and cost effective.
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continue engagement with VHWs and initiate integration of VHW in the health system. A
suggested possible way is to link current activities with those in the National Health Plan for
continuation and sustainability.
b. Strengthen the Health Management Information System (HMIS)
According to BHS and township THD staffs, monthly reporting of ANC, PNC, EPI, PMCT,
Birth and Death register form village to the township level is functioning. With wider
availability of mobile phones even at village level, the community could use a mobile
application such as Viber application and could take pictures with the mobile phone and
send as documents to the township easily. A midwife initiatively took the phone number of
parents from the EPI register and recorded to track children for completion of immunization.
VHWs report their activities to the respective midwife with 3 MDG standardized formats.
According to the THD, the reports and returns of forms are now regular and there is also
transformation of paper based data analysis to digital system using DHIS II. The project has
supported computer training to focal persons and equipped THD office with necessary
computer and accessories.
Death Audit
There is death audit system when there is a maternal or under five child death, which is
supported by the project. The focal person for death audit is Township Helath Nurse (THN).
There are also training such as Maternity Death Surveillance and Reporting (MDSR) and
Child Death Surveillance and Reporting (CDSR), which improve capacity for follow up
actions following maternal or child death. Regarding death audit THN mentioned, “Whenever
there is the death of pregnant or under five child, I go to the village with THA for death audit”.
Recommendation
Successful digitalizing of the HMIS data should be continued with a building capacity of
BHS. It would be good if midwife can do data entry directly into the application or software
every month so that township staff can focus more on data validation and data analysis.
Consultation with all stakeholders especially understanding of mHealth is suggested as
developing mHealth related application is not similar to the IT application process. As
technology advances, mHealth is widely used in many maternal and child nutrition
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promotion studies and implemented at large scale levels26. In Myanmar, a first randomized
controlled trial intervention conducted recently (Hmone et al., 2017)27provides a promising
result in improving infant and young child feeding. It is suggested to use mobile phone
based intervention to improve MNCH status in future study and provide training to BHS as
appropriate by an experienced professional.
c. Procure essential supplies for health facilities and VHWs
Most BHS said that they received supplies mostly from township health department. Some
midwives mentioned that they request IOM for medical supplies when medicines are run out.
A midwife from X Health Center mentioned, “We got supplies such as iron tablets, CDK and
Vitamin B1 and we normally request IOM to support the essential supplies when government
supplies run out”. HA from X Health Center in MLMK expressed the need of a delivery bed
and water purification machine. Both AMW and CHW receive necessary medical supplies to
give basic care to the community. The kit refill system is also well managed though one
AMW mentions that she shares with MW or LHV if the stocks are over or low. VHWs shared
that they were worried about how to refill the medicine kit when IOM project ends.
Although all VHWs know and follow the treatment guideline, one AMW mentioned in the
interview that she gives antacid to anybody asking drugs.
Recommendation
Some health staffs mentioned that they do not get enough medical supplies, especially
nutrition supplement for children. It would be good if medical supplies are provided based on
the actual needs with appropriate calculation method and it is suggested to keep a buffer
stock of medical supplies to avoid out-of-stock for two or three months. Development of a
plan to continue supporting VHWs with medical enough supplies and proper monitoring
system to avoid misuse with a check list and cross checking system is suggested.
27 Hmone MP, Dibley MJ, Li M, Alam A. Impact of SMS Text Messages to Improve Exclusive Breastfeeding: A Randomized Controlled Trial in Myanmar, The FASEB journal, 2017. Impact factor 5.3. http://www.fasebj.org/content/31/1_Supplement/313.3.short.
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d. Others
Knowledge, attitude and behaviour of community
Most beneficiaries responded that they had attended health education talk organized by IOM
or BHS. Other respondents, especially VHWs, also highlight the behaviour change regarding
delivery with TBAs and children immunization.
One mother of under-five child mention “Because of IOM, I have known about health what I
did not know before”. However, some respondents including beneficiaries and VHWs want
more health education sessions and information.
One member of VTHC from BGL Township mentioned: “Billboard with health information
should be kept at public places like school and pamphlets should be distributed so that every
young and old person get health information”.
When asked about health education session, two migrant women replied: “As we are
migrants, we could not attend health education session frequently, but we have attended
and listened to health talk delivered by midwife team including medical doctor”. (Migrant
women, MLMK)
Recommendation
Some BHS and VHWs suggest conducting the health talks when working people are free
such as around 11 am which is lunch time because most of the villagers are farmers and
busy during the day.
Other Needs
Most respondents mentioned that they need mosquito free latrine and safe drinking water.
One pregnant woman from BGL Township claimed that “Mosquito free toilet, health center,
safe and clean water are needed”. For the question of what should be done more the village,
one VTHC VHC member replied as “Full nutrition support should be given to pregnant
woman and baby after delivery.” Another VTHC member from MLMK Township mentions
that as there are many hypertensive patients, enough antihypertensive medicine is needed.
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2.8. Conclusions for area of study 2
Overall impact:
o The intervention by IOM leads to an increase in community awareness about
maternal and child health. Almost all respondents acknowledged that the project
helps community from remote areas and migrants to get access to health care,
especially hospital care because of emergency referral support. The situation of
MNCH in the project townships improves significantly.
o Antenatal and postnatal care services improve significantly and particularly,
institutional delivery and immunization coverage significantly improved and no
delivery with TBA was observed for all interviews except women mentioned about
delivered by TBA in the previous pregnancy.
o Almost all of the respondents agreed that deaths of mothers (mainly) and under-
five children reduced significantly because of increase coverage by health work
force including BHS and AMW and financial support for the timely referral.
Increased health knowledge might be another reason for improving MNCH
status.
o Reluctant for go to the hospital is mainly due to the underlying causes of poverty
and social-economic reason rather than the lack of knowledge.
However, more effective coordination of MNCH is required, and more sense of
ownership at township and BHS level is needed.
IOM recognises the need for a shared vision, common platform and higher profile for
MNCH and proper exit strategy should be prepared when integrating with government
health plan.
Community and VHW had worried the sustainability of medical drugs, supplies and
particularity transportation cost, especially for the hard-to-reach areas when the project
stop.
In contrary, respondents representing VTHC/VHC perceived that training and
experiences gained from the MNCH project enriched them with skills to manage village
health fund and emergency fund for a future emergency referral. Respondents eagerly
expressed that ‘Referral System’ would be the good practice they could continue even
after the project.
Overall, VTHC were set up systematically, and the majority of the members and leaders
showed enthusiasm and have the motivation to continue their work while sustainability of
the VTHC is a challenge. In BGL, they had their saving –village health fund – which
would allow them to pay some referral cost while they could not allocate as much as IOM
supported the project.
81
VTHC challenge is the sustainability of the committee for the longer term. Another factor
is as a community did not borrow money from the village fund as they were poor,
members had to use the money on rotation basic. This practice could lead to the low
trustworthiness by the community, possibility of the conflict of interest as they could
enjoy the low interest rate and there is a risk of conflict among members if one could not
pay back the money.
For some minor ailments at the village level, VHW could cover some basic care such as
blood pressure monitoring, giving paracetamol, antacid and antibiotics. Caution should
be taken care to monitor VHW to avoid VHW servicing as a quack. High drop-out of
VHW is a concern.
There was a significant decrease of TBA, and almost all of the respondents mentioned
that they now rely on the SBA and at least at AMW level.
Although all services are free, some respondents shared that they had to pay for the
medicines and vitamin infusions or sometimes, for contraceptive pills to MW while on the
other hand, MW, from their sides, claimed that they have to buy medicine from their own
money.
Recommendations
Maternal and Child Health
To encourage the strengthening of service readiness approach and expansion of basic
essential package at township level via integrated township health plan.
Postnatal care: To emphasize more on the postnatal care service is recommended.
Educate MW and AMW about the importance of postnatal care service and provision of
enough vitamin supplementations to prevent anaemia, undernutrition and vitamin
deficiency in mothers and children.
To ensure BHS is following MOHS guideline when performing their GP clinic.
Health seeking behaviours
To increase health seeking behaviour or community demand side, it is important to
address the underlying cultural beliefs of afraid to deal with hospital staff. Deployment of
active medico-socio workers in township level hospital is suggested. Clear signboard
with easy and understandable signature explain about hospital should be displayed.
82
MW/AMW/CHW
Solutions should be sought how to manage the busy schedule of MW and how to
maintain MW. More investment in MW is suggested.
It is important to maintain VHW and suggest to develop flexible criteria for selecting
VHW. Sustainability of AMW is a must, and the team suggested to define clear roles and
responsibilities of VHWs, support VHW through incentives or merit-based compensation,
essential drugs, recognitions and performance-based rewards. Continuous monitoring,
supervision and capacity building training could motivate their volunteer sprits.
VHW
To develop a more flexible criteria for recruiting VHWs and clear roles and
responsibilities of VHWs should be defined. VHWs should be supported through
incentives or merit-based compensation, essential drugs, recognitions and performance-
based rewards. Continuous monitoring, supervision and capacity building training should
be undertaken to motivate their volunteer sprits.
To improve the efficiency use of the existing forms through reviewing feedbacks on the
form structure with all VHWs and to link the strategy of women empowerment and
capacity building of women to become VHW.
VTHC/VHC
In collaborating with THD, an appropriate strategy on how BHS staff particularly MW
could support the VTHC/VHC for long-term sustainability of the village health fund should
be developed.
Data and information management system of VTHC and VHC should be strengthened.
VTHC set up should be harmonised across all project townships.
Stock-outs
To manage supply chain management system effectively through training towards both
township level health staff and front line staff (RHC and sub RHS staff) to avoid stock-
outs of vitamins and medical supplies.
To provide training and TOT training to MW as well as AMWs for correct calculation of
drugs needed based on the seasonal and demographic pattern. It is critical to narrow the
gap between supply side and demand side for drugs and medical supplies distribution.
Township health staff should prepare distribution plan in advance in coordination with
frontline and central level staff. The distribution plan should be tailored based on the
needs of individual RHC or sub-RHC.
83
To share among BHS about the updated national treatment guidelines.
Sustainability and Exit strategy: Post IOM MNCH program after 3 MDG fund
Enough transition period and strategy should be formulated and developed to bridge the
time between exit strategy and government had full capacity and resources to manage
the program.
Suggest Ministry-led, Ministry-delivered Township planning and use of MoH systems, for
example, for procurement/supply chain for commodities and flow-of-funds.
Strengthen microplanning and budgeting capacity that maximizes increased resources
available in townships and support with community engagement.
Proper documentation for handover process
Enhance policy engagement through the provision of lessons learnt and active linkages
between implementation and policy dialogue at all levels ( link with national level)
Community-based health care
To strengthen the existing Community-based health care approach of IOM
(3MDG Fund Project) and replicate the model and to integrate fully with public
sector delivery of community-based programming by continuing good
coordination model of MOHS. To continue activities such as provision of
supplies, supervision and strengthening VTHC to act as a linkage between health
service providers and communities.
By using this community-based health care approach of IOM (3MDG Fund
Project) in Delta as a show case, as shown in the global evidence, it is suggested
to advocate for and influence MNCH/HSS policy and practice and link with
National Health Plan. Replicate model to other states and regions and link with
MOHS national community based health program strategies such as community
based newborn cares, scale up of AMWS, community case management. To
ensure budgets for volunteers is included in MOHS/HSS plan; BHS have
sufficient time and commitment to supporting volunteers; modalities for
disbursing equipment, supplies, supervision of volunteers, quality assurance and
information on services and functioning of VTHC and VHC is in place.
For sustainable of emergency referral system
o Integrate emergency referrals approach as a MOHS led strategy and policy and
create means for financing emergency referrals through a payment mechanism
o Create an enabling environment allowing a continuing effort to advance the
quality of service provision and suggest to continue and strengthen data and
information systems in digital format.
84
o To educate township level and BHS about the data harmonization, consistency
and quality assurance. Important to educate not to worry about an increase in
some mortality or morbidity cases because sometimes it might capture the
underreporting cases in previous years.
o Review of referral eligibility criteria, the design of more efficient management
mechanisms led and staffed by Township Health Departments.
To develop post training monitoring mechanism to explore whether health staff have
applied what they have learnt, feedbacks on trainings and make sure staff that trainings
days might not affect the routine work.
It is suggested to utilize mHealth based intervention approach if possible in future
programming.
Conclusion
The IOM MNCH project and its approach and strategy are already tested and applied
strategy as explained above ad it is highly relevant to improve the MNCH status in the study
townships. It is a government supported program in line with National Health Plan and SDG
commitment. The effectiveness of the program is of good quality in general while there is
some gap as discussed above. Activities were implemented through existing government
infrastructure and human resources. As the team did not analyse the cost, we could not
provide comment on the efficiency relating to cost and value for money. Accountability,
transparency and management system of referral mechanism is in good shape while for
VTHC and VHC, although no feedbacks on accountability and transparency, money held by
the committee members and this might be questions for accountability. However, according
to FGD with IOM staff, as an exit strategy, all fund money had been collected, deposited in
the bank and transferred back again with proper legal documents, the team conclude that
there is a proper fund management mechanism. It is hard to measure impact in the
qualitative study alone, but in triangulation with HMIS data, both townships had a significant
good impact on MNCH health with a better outcome on maternal health care. For
sustainability, it is important to be realistic about the sustainability of support for an
underfunded health system while the team assume that new NHP and more government
health spending on health as a positive factor. Ultimately sustainability will depend on the
increased Government of Myanmar funding for the health sector as well as on the
effectiveness of government and development partner efforts to strengthen the health
system. Without continuing and supporting of facility-based/outreach service provision,
community-based health care provision and emergency referral systems (demand-side
financing), sustainability of the program would be at risk. A concrete strategy to maintain the
85
AMWs and policy, guideline and monitoring mechanism to reduce stock-out of medical
supplies is critical.
In future, IOM should support MOHS and THD in Delta by i) Provision of financial support
on capacity building trainings on knowledge on RH, SHR,GBV, effective communications
with patients, stock inventory and filling forms; supply chain management and refresher
training to MW, etc. ii) Strengthening of service readiness approach and expansion of basic
essential package at township level via integrated township health plan, iii) Provision
transportation cost for essential RMNCH drugs and supplies, and support costs for
transportation and communications bills of BHS and use of mHealth based intervention in
line with global evidence iv) Facilitate to continue support of township health committee and
BHS to VTHC and VHCs; v) Support MOHS to make sure that health services are
responsive to migration population needs and to remove other barriers to reaching care and
vi) Support MOHS and THD to conduct research and studies to identify the up-to-date
information about migrant population numbers and health problems for which they are
particularly at risk and barriers in accessing emergency health care services for child.
86
Annex Annex1a: Map showing study villages in Bogale
87
Annex1b: Map showing study villages in Mawlamyinegyun
88
Annex 3: Data collection schedule
Bogalay Trip Plan
Sr
No Date Place Persons met Activities
1 01.12.2017 Yangon to Bogalay Meet with IOM Staff Travelling
2 02.12.2017 Bogalay to Byu
Sakhan Village
Pregnant, Mother, VTHC,
AMW,CHW (FGD and KII)
Data
Collection
3 03.12.2017
Bogalay to Lin Tine
Village
VTHC(female),VTHC(Male),Pregnant
and Mother, Husband, MW,PHS(2)
(FGD and KII
Data
Collection
Lin Tine to Bandula
Village
Pregnant, Mother, Husband,
Husband and Mother,AMW, CHW
(FGD and KII)
Data
Collection
4 04.12.2017
Bogalay to Shwe
Sar Yan Village
Mother, Pregnant, Husband, AMW,
CHW (FGD and KII)
Data
Collection
Shwe Sar Yan to
Kadone Ka Ni
Village
VTHC (FGD) Data
Collection
5 05.12.2017 Bogalay to Yangon Travelling Travelling
Mawlamyaing Gyun Trip Plan
Sr
No Date Place Persons met Activities
1 31.11.2017 Yangon to Mawlamyaing
Gyun Travelling Time Travelling
2 01.12.2017
Mawlamyaing Gyun to Ka
Zaung Village
Pregnant/ Mother/ Husband
(FGD)
Data
Collection
Ka Zaung to Ka Zaung Phyar
Village
Pregnant/Mother/ Husband
(FGD)
Data
Collection
3 02.12.2017
Mawlamyaing Gyun to
Hlaing Bone Village VTHC (FGD)
Data
Collection
Hlaing Bone Village to Lake
Chaung Village
Mother,Pregnant and
Husband (FGD)
Data
Collection
Lake Chaung Village to Sa AMW, CHW (KII) Data
89
Laung Kya Village Collection
4 03.12.2017
Mawlamyaing Gyun to Kyeik
Pi Village AMW, CHW (KII)
Data
Collection
Kyeik Pi Village to Pa Tee
Yoe Village
Mother, Pregnant,
Husband, MW,VTHC (FGD
and KII)
Data
Collection
5 04.12.2017
Mawlamyaing Gyun to Da Ni
Chaung Village
Mother and
Husband,Pregnant and
Husband, MW, HA, AMW
(FGD and KII)
Data
Collection
Di Ni Chaung Village to Kyar
Home
Mother / Husband/
Pregnand, VTHC (FGD and
KII)
Data
Collection
Mawlamyaing Gyun To
Yangon Travelling Travelling
90
Annex 4: Participant list: BGL and MLMK
Bogalay
Trip Plan
Sr No Date Place Persons met Activities
1 01.12.2
017
Yangon to Bogalay Meet with IOM Staff Travelling
2 02.12.2
017
Bogalay to Byu
Sakhan Village
Pregnant, Mother, VTHC,
AMW,CHW (FGD and KII)
Data
Collection
3 03.12.2
017
Bogalay to Lin Tine
Village
VTHC(female),VTHC(Male),Preg
nant and Mother, Husband,
MW,PHS(2) (FGD and KII
Data
Collection
Lin Tine to Bandula
Village
Pregnant, Mother, Husband,
Husband and Mother,AMW, CHW
(FGD and KII)
Data
Collection
4 04.12.2
017
Bogalay to Shwe Sar
Yan Village
Mother, Pregnant, Husband,
AMW, CHW (FGD and KII)
Data
Collection
Shwe Sar Yan to
Kadone Ka Ni Village
VTHC (FGD) Data
Collection
5 05.12.2
017
Bogalay to Yangon Travelling Travelling
Mawlamyaingegyun Trip Plan
Sr
No
Date Place Persons met Activities
1 31.11.2017 Yangon to Mawlamyaing
Gyun
Travelling Time Travelling
2 01.12.2017 Mawlamyaing Gyun to Ka
Zaung Village
Pregnant/ Mother/ Husband (FGD) Data
Collection
Ka Zaung to Ka Zaung
Phyar Village
Pregnant/Mother/ Husband (FGD) Data
Collection
3 02.12.2017 Mawlamyaing Gyun to
Hlaing Bone Village
VTHC (FGD) Data
Collection
Hlaing Bone Village to
Lake Chaung Village
Mother,Pregnant and Husband (FGD) Data
Collection
Lake Chaung Village to Sa AMW, CHW (KII) Data
91
Laung Kya Village Collection
4 03.12.2017 Mawlamyaing Gyun to
Kyeik Pi Village
AMW, CHW (KII) Data
Collection
Kyeik Pi Village to Pa Tee
Yoe Village
Mother, Pregnant, Husband,
MW,VTHC (FGD and KII)
Data
Collection
5 04.12.2017 Mawlamyaing Gyun to Da
Ni Chaung Village
Mother and Husband,Pregnant and
Husband, MW, HA, AMW (FGD and
KII)
Data
Collection
Di Ni Chaung Village to
Kyar Home
Mother / Husband/ Pregnand, VTHC
(FGD and KII)
Data
Collection
Mawlamyaing Gyun To
Yangon
Travelling Travelling
92
Annex: Persons met during data collection
Bogale
D1
Byu Sakhan
Village
Date/Time Name Age Education Occupation Title/Group
02.12.2017
11:45 /12:45
Ma Win Win Pine 28 8 Paddy Field Mother
Ma Aye Thidar 40 4 Paddy Field Mother
Ma Sandar 30 4 Paddy Field Mother
Ma Thin Thin Mar 35 4 Paddy Field Mother
Ma Sandar Hlaing 24 No Education Casual
Labor
Mother
Ma Ni 24 5 Casual
Labor
Mother
Ma Su 38 2 Casual
Labor
Mother
Ma Win Win Naing 29 10 Casual
Labor
Mother
Ma Soe Soe 42 4 Paddy Field Mother
Ma Khin Htay Myint 42 4 Paddy Field Mother
Date/Time Name Age Education Occupation Title/Group
02.12.2017
11:45 /12:45
Ma Aye Aye Myine 33 5 Casual
Labor
Pregnant
Ma Nyein Nyein
Phyo
35 4 Paddy Field Pregnant
Ma Tin Tin Hlaing 43 2 Casual
Labor
Pregnant
Ma Phyu Phyu 30 4 Casual
Labor
Pregnant
Ma Moe San 35 2 Casual
Labor
Pregnant
Ma Myint Myint Cho 31 4 Casual
Labor
Pregnant
Ma Thu Zar Win 28 4 Casual
Labor
Pregnant
93
Ma Khine 34 4 Casual
Labor
Pregnant
Ma Khin Swe Win 36 4 Paddy Field Pregnant
Ma Khine Tha Zin 20 8 Paddy Field Pregnant
Date/Time Name Age Education Occupation Title/Group
02.12.2017
13:10 /14:00
U Myo Kyaw Kyaw 39 6 Paddy Field VTHC
Ma Zar Zar Phyo 30 8 Casual
Labor
VTHC
Ma Zar Ni New 26 10 Casual
Labor
VTHC
U Myo Win Than 35 9 Paddy Field VTHC
U Zaw Nay Lin 25 8 Casual
Labor
VTHC
Ma Aye Po 49 4 Paddy Field VTHC
U Aaung Lwin 63 4 Paddy Field VTHC
Date/Time Name Age Education Occupation Title/Group
02.12.2017
13:15 /13:40
Daw Khin San 50 4 Paddy Field AMW
Daw San Hlaing 48 4 Paddy Field AMW
D2 Lin Tine
Village
Date/Time Name Age Education Occupation Title/Group
03.12.2017
10:40 /11:25
Ma Su Su Hlaing 30 8 Paddy Field Mother and
Pregnant
Ma NiLar Htwe 32 3 Paddy Field Mother and
Pregnant
Ma Myint Thandar 33 4 Paddy Field Mother and
Pregnant
Ma Khin Myint
Mon
42 4 Paddy Field Mother and
Pregnant
Ma Aye Myint
Khine
28 Graduated Casual Labor Mother and
Pregnant
94
Ma San San Mya 40 4 Casual Labor Mother and
Pregnant
Ma San San Myine 33 2 Casual Labor Mother and
Pregnant
Ma Ci Ci Wie 38 4 Casual Labor Mother and
Pregnant
Ma Myint Kyi 53 4 Paddy Field Mother and
Pregnant
Ma Aye Myint 58 4 Paddy Field Mother and
Pregnant
Date/Time Name Age Education Occupation Title/Group
03.12.2017
10:45 /11:20
U Thaung Myint 67 10 Village
Leader
VTHC
U Kyaw Htay 67 4 Paddy Field VTHC
U Mya Kyaw 62 8 Paddy Field VTHC
U Tin Tun 57 7 Paddy Field VTHC
U Min Hlaing 27 University Paddy Field VTHC
U Than Naing 53 4 Casual Labor VTHC
U Than Aye 58 4 Casual Labor VTHC
Date/Time Name Age Education Occupation Title/Group
03.12.2017
11:25 /11:50
Ma Nwe Nwe Win 37 10 Paddy Field VTHC
Ma Mi San 45 10 Casual Labor VTHC
Ma Naw Sar Mu
Ale
44 10 Casual Labor VTHC
Ma Thin Thin Maw 46 4 Casual Labor VTHC
Ma Wint War Soe 21 10 Casual Labor VTHC
Date/Time Name Age Education Occupation Title/Group
03.12.2017
11:00 /11:45
U Than Zaw 44 Paddy Field Husband
U Aung Zay Ya 37 Paddy Field Husband
U Tin Maung Aye 49 Education
Statt
Husband
U Aye Than 50 Paddy Field Husband
U Naing Oo 37 Casual Labor Husband
Date/Time Name Age Education Occupation Title/Group
95
03.12.2017
13:00 /13:20
Daw Cho Cho Win 21 Thard
Year
PHS(2) BHS
Daw Khin Than Nu MW BHS
D3 Bandula
Village
Date/Time Name Ag
e
Education Occupatio
n
Title/Group
03.12.2017
14:45 /15:20
Ma Ni Ni Moe 26 7 Paddy Field Mother and
Pregnant
Ma Aye Kyu 34 4 Casual
Labor
Mother and
Pregnant
Ma Kyi Kyi Thein 31 4 Casual
Labor
Mother and
Pregnant
Ma Tin Tin Wai 36 5 Casual
Labor
Mother and
Pregnant
Ma Aye Aye Htwe 20 7 Casual
Labor
Mother and
Pregnant
Ma Aye Aye Thin 32 4 Paddy Field Mother and
Pregnant
Ma Ei Ei Thin 20 9 Paddy Field Mother and
Pregnant
Ma Soe Myat Thin 26 8 Paddy Field Mother and
Pregnant
Ma La Min Moth
Moth
24 4 Paddy Field Mother and
Pregnant
Ma Ei Ei Phyu 27 4 Paddy Field Mother and
Pregnant
Ma Hla Maw 40 4 Casual
Labor
Mother and
Pregnant
Date/Time Name Ag
e
Education Occupatio
n
Title/Group
03.12.2017
14:45 /15:20
Ko San Min Zaw 34 No
Education
Casual
Labor
Mother and
Husband
Ko Min Thein 31 4 Casual Mother and
96
Labor Husband
Ma Thet Thet Khine 27 4 Casual
Labor
Mother and
Husband
Ma Nan New Oo 22 5 Casual
Labor
Mother and
Husband
Date/Time Name Ag
e
Education Occupatio
n
Title/Group
03.12.2017
15:30 /15:45
Daw Hla Moe Khine 39 8 Tailor AMW
U Lin Lin Naing 35 8 Paddy Field CHW
U Chit Soe 50 4 Paddy Field Husnand
D4 Shwe Sar Yan
Village
Date/Time Name Ag
e
Educatio
n
Occupation Title/Group
04.12.2017
10:30 /11:55
Ma Thin Thin Mar 35 5 Paddy Field Mother
Ma Aye Pone 36 3 Paddy Field Mother
Ma Mya Thandar 32 4 Fishery Mother
Ma Aye Aye Soe 25 4 Paddy Field Mother
Ma Thu Zar Khine 33 5 Paddy Field Mother
Ma Aye Myat Thu 28 10 Paddy Field Mother
Ma Hla Hla Cho 32 4 Paddy Field Mother
Ma Than Nwet 32 3 Paddy Field Mother
Ma Nyein Nyein Ei 23 4 Paddy Field Mother
Ma Aye Mu 33 2 Paddy Field Mother
Ma Khin Hla Yee 47 4 Paddy Field Mother
Date/Time Name Ag
e
Educatio
n
Occupation Title/Group
04.12.2017
12:00 /12:20
Ma Wine Chit 20 5 Casual Labor Pregnant
Ma May Thazin Khine 18 6 Fishery Pregnant
Ma Moe Thazin Oo 18 4 Casual Labor Pregnant
Ma Yu Maw 21 4 Casual Labor Pregnant
97
Date/Time Name Ag
e
Educatio
n
Occupation Title/Group
04.12.2017
13:15 /13:40
Ma Hlaing Myint Mon 31 10 Health Voluntary AMW
U Than Zaw 38 8 Paddy Field CHW
U Thein Zaw Win 50 4 Fishery Husband
U Soe Naing 43 4 Motor bike Taxi Husband
D5 Kadone Ka
Ni Village
Date/Time Name Age Education Occupation Title/Group
04.12.2017
12:45 /13:30
U Lin Myat Htet VTHC
U Htay Win VTHC
U Kyaw Khin Maung VTHC
U Soe Myint Oo VTHC
Daw Mi Mi Khine VTHC
Daw Aye Mya Thandar VTHC
Daw Zar Zar Win VTHC
Daw Khin Mar Zin VTHC
Mawlamyainegyun Team D1
Ka Zaung Village
Date/Time Name Ag
e
Educatio
n
Occupation Title/Group
01.12.2017
10:45 to 11:30
U Khine Win Aung 35 4 Paddy Field Husband
U Myint Khin 45 5 Casual
Labor
Husband
Daw Mi Wai 23 6 Casual
Labor
Mother
Daw Khin Thidar Myo 30 8 Casual
Labor
Mother
Daw Myint Myint Khine 19 8 Casual
Labor
Mother
98
Daw Zar Zar Moe 23 10 Casual
Labor
Pregnant
Daw Khin Pyone Cho 25 3 Paddy Field Pregnant
Daw Pa Pa Kyi 28 4 Paddy Field Pregnant
Daw Su Su 32 4 Casual
Labor
Pregnant
Daw Mi Thay 24 8 Casual
Labor
Pregnant
Daw Thet Htar Wai 23 8 Casual
Labor
Pregnant
Ka Zaung Phyar Village
Date/Time Name Age Education Occupation Title/Group
01.12.2017
12:15 to 13:00
U Aunt Kyaw 35 4 Paddy Field Husband
Daw Moe Moe 20 2 Paddy Field Pregnant
Daw Thandar Mon 33 4 Paddy Field Pregnant
Daw Pa Pa 34 6 Casual Labor Pregnant
Daw Nwet Yee Win 27 7 Casual Labor Mother
Daw Su Lay Pine 28 8 Casual Labor Mother
Daw Nyo Nyo 30 2 Paddy Field Mother
Daw Thidar Htwe 30 4 Paddy Field Mother
D2
Hlaing Bone Village
Date/Time Name Age Education Occupation Title/Group
02.12.2017 10:00
to 11:00
U Soe Naing 46 8 VTHC
U Thet Oo 47 10 VTHC
U Soe Win 55 10 VTHC
U Wai Lwin 56 8 VTHC
Daw Oh Chit Yar 35 4 VTHC
Daw Thi Thi 32 8 VTHC
Daw Khin Khin Htay 50 10 VTHC
99
Lake
Chaung
Village
Date/Time Name Age Education Occupation Title/Group
02.12.2017
13:35 /14:10
Daw Khin Hlaing 40 2 Paddy Field Pregnant
Daw Htet Htet Mar 23 4 Casual
Labor
Pregnant
Daw Sanay Ma 31 No Education Casual
Labor
Pregnant
U Win Naing 46 4 Casual
Labor
Husband
U Myo Nyunt 46 4 Paddy Field Husband
Date/Time Name Age Education Occupation Title/Group
03.12.2017
14:45 to 15:20
Daw Mi Su 18 2 Casual
Labor
Mother
Daw Cho Nan 18 2 Casual
Labor
Mother
Daw Kay Nyin 20 No Education Casual
Labor
Mother
Daw Aye Thandar 20 4 Casual
Labor
Mother
Daw Cho Mar Win Chit 28 4 Casual
Labor
Mother
Daw Aye Pone 26 5 Casual
Labor
Mother
Daw Mar Mar Swe 39 8 Casual
Labor
Mother
Daw Hla Hla Win 30 8 Casual
Labor
Mother
Daw Aye San 19 4 Paddy Field Mother
Daw That Htwe 20 2 Paddy Field Mother
Sa Laung Kya Village
Date/Time Name Ag
e
Educatio
n
Occupation Title/Group
100
02.12.2017
14:45 to 15:30
Daw New Nwe Myint 45 8 Paddy Field AMW
Daw Su Su Khine 32 6 Paddy Field CHW
Kyeik Pi Village
Date/Time Name Age Education Occupation Title/Group
03.12.2017
08:40 to 09:30
Daw Lwin Mar Myint 36 8 Health Volutary AMW
Daw Soe Soe Than 32 6 Paddy Field CHW
Pa Tee Yoe Village
Date/Time Name Ag
e
Education Occupation Title/Grou
p
03.12.2017
1:40 to 12:20
Daw Soe Soe Thin 35 2 Paddy Field Mother
Daw Nyein Nyein Ei 28 8 Paddy Field Mother
Daw ThuZar Aung 28 4 Casual
Labor
Mother
Daw May Si 36 2 Casual
Labor
Mother
Daw Win Mar Phyo 19 2 Casual
Labor
Mother
Daw Khine Khine Lwin 36 No
Education
Casual
Labor
Mother
Daw Wai Wai Tun 33 2 Casual
Labor
Mother
Daw Thandar Soe 38 4 Fishery Mother
Daw Khin Maw 35 4 Paddy Field Mother
Date/Time Name Ag
e
Education Occupation Title/Grou
p
03.12.2017
12:30 to
13:00
Daw Nan Ei Khine 25 4 Paddy Field Pregnant
Daw Pa Pa Win 29 2 Paddy Field Pregnant
Daw Aye Aye Khine 29 2 Paddy Field Pregnant
Daw Thin Thin Khine 31 4 Casual
Labor
Pregnant
Daw Moe Sat 18 No Casual Pregnant
101
Education Labor
Daw Ei Myat Mon 22 No
Education
Paddy Field Pregnant
Daw Kyawt Kyawt Khine 20 6 Paddy Field Pregnant
Daw Tin Htwe 23 8 Paddy Field Pregnant
Date/Time Name Ag
e
Education Occupation Title/Grou
p
03.12.2017
12:30 to
13:00
U Hlaing Min 34 4 Paddy Field Husband
U Zaw Naing Lwin 47 2 Paddy Field Husband
U Tin Zaw Oo 43 4 Paddy Field Husband
U Bo Hteik 31 8 Casual
Labor
Husband
U Zay Yar Aung 25 6 Casual
Labor
Husband
U Myo Min Thet 33 4 Casual
Labor
Husband
Date/Time Name Ag
e
Education Occupation Title/Grou
p
03.12.2017
11:20 to
12:00
U Mya Khine 60 10 Paddy Field VTHC
U Win Myint 58 4 Casual
Labor
VTHC
U Hla Win Maung 56 4 Casual
Labor
VTHC
U Than Aye 45 10 Paddy Field VTHC
U Tun Win 50 8 Casual
Labor
VTHC
U Thant Zin Oo 32 8 Paddy Field VTHC
U Thant Zaw 25 10 Paddy Field VTHC
Daw Zar Zar Hlaing 48 4 Paddy Field VTHC
Daw Wai Wai Mar 34 8 Paddy Field VTHC
Daw Thin Thin Khine 30 4 Paddy Field VTHC
U Htay Aung 28 4 Paddy Field VTHC
Date/Time Name Ag
e
Education Occupation Title/Grou
p
102
03.12.2017
13:50 to
14:20
Daw Zar Chi Tun 25 Greaduated Health Staff MW
Da Ni Chaung Village
Date/Time Name Age Education Occupation Title/Group
04.12.2017
10:30 to 11:00
Daw Myint Maw 34 4 Casual Labor Pregnant
Daw Kyu Kyu Thin 37 4 Casual Labor Pregnant
Daw Zin Moe Thu 18 2 No Pregnant
Daw May Thu Han 16 4 Casual Labor Pregnant
Daw Hla Win Mar 27 6 No Pregnant
U Aye Win 49 8 Fishery Husnand
U Aye Tun 38 4 Fishery Husnand
Date/Time Name Age Education Occupation Title/Group
04.12.2017
10:45 to 11:15
Daw Hla Htay 40 2 Paddy Field Mother
Daw Swe Zin Win 28 4 Casual Labor Mother
Daw Lae Lae Win 31 4 Casual Labor Mother
Daw Kyi Hlaing 21 4 Casual Labor Mother
U Myint Htwe 24 No Education Fishery Husband
U Htoo Aung Kyaw 18 6 Paddy Field Husband
Date/Time Name Age Education Occupation Title/Group
04.12.2017
09:15 to 10:00
11:20 to 12:10
Daw Kyi Kyi Khine 47 Greaduated Health Staff HA
Daw Myo Myo Win 36 Greaduated Health Staff MW
Daw Tin Win 60 No Education No AMW
Pa Tee Yoe Village
Date/Time Name Age Education Occupation Title/Group
04.12.2017
13:00 to
13:30
Daw May Zin Oo 31 8 Paddy Field Mother
Daw Thazin Aye 26 2 Casual
Labor
Mother
103
Daw Hnin Hnin Oo 28 No Education Casual
Labor
Pregnant
Daw May Thu Han 16 5 Casual
Labor
Pregnant
Daw Khin Win Maw 33 4 Casual
Labor
Pregnant
U Win Naing 19 4 Casual
Labor
Husband
U Naing Soe 36 No Education Casual
Labor
Husband
Date/Time Name Age Education Occupation Title/Group
04.12.2017
13:40 to
14:30
Daw Aye Aye Aung 33 8 Casual
Labor
VTHC
Daw Ni Win 36 8 Casual
Labor
VTHC
U Naing Win Aung 42 5 Paddy Field VTHC
U Thein Zaw 52 No Education Casual
Labor
VTHC
U Soe Thu Aye 31 9 Casual
Labor
VTHC
U Myo Lin Tun 35 8 Paddy Field VTHC
U Kyaw Oo 52 8 Paddy Field VTHC
U Mya Maw 37 8 Paddy Field VTHC
104
Annex 5: Key (evaluation) research questions
Relevance
• Are the activities relevant in achieving the project impacts?
• Are the strategies geared towards responding to the needs of mothers, neonate and child
health?
• To what extent has the programme reached its intended target groups?
• To what extent has the programme be consistent with the MNCH goals or organizations
strategies?
• To what extent is the programme complimentary to the efforts carried out at National level
• How relevant are the approaches used by IOM MNCH program for the 2 townships in delta
context?
Efficiency
• How efficient is the programme in converting its inputs to outputs?
• How timely is the delivery of activities?
• How is the fund utilization via activity implementation?
• How well is the coordination between IOM and partners?
Effectiveness
• How does the IOM MNCH program work as planned?
a) To undertake joint supportive supervision visits and support for planning and
coordination with township health departments
b) To facilitate trainings for Basic Health Staff and Voluntary Health Workers
c) To strengthen the Health Management Information System (HMIS)
d) To revitalize village tract health committees and village health committees
e) To establish step-wise referral mechanism
f) To procure essential supplies for health facilities
What are the most effective strategies for:
a. Improving MNCH status of beneficiaries in targeted area.
b. Improving collaboration and coordination mechanism with government health staff (
township, station, rural health centres) such as joint support ANC and EPI services at
rural health centres ( RHC).
c. Functioning of village health committee
105
d. Referral system for emergency obstetric care (EmOc),etc.
What good practices, success/failure stories can be identified?
To what extent has the programme achieved its intended outcome and what are the
facilitating and hindering factors in achieving these outcomes?
How effective is the engagement with local partners in delivering the intervention and
services?
Impact
• To what extent has/will the project contributed to its intended and unintended impact?
• What are the positive and negative effects of the project in the short and longer
perspective?
Sustainability
• How sustainable are IOM MNCH outcomes? How it contribute in National Health Plan and
Policy on MNCH?
• What are the sustainability mechanisms in place or being worked out to continue these
development efforts and results?
• How has IOM used the learning process to feed into the next MNCH programme?
106
Annex 6: Tools used in data collection
Guide for Group Discussion for mother
Purpose of the session
1. To know their access to free maternal and child care
2. To know their knowledge, attitude and behavior about maternal and child health
3. To know their awareness about the project and how much their family benefitted from
it
FGD Process
Invite 6 to 7 mothers
Facilitator need to explain what we are going to discuss and make sure everyone is
encouraged to speak
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce every participants and facilitator need to inform that this session
will last one to two hours maximum
No. Main Question Follow up question Probe
1 From whom you took
pregnancy care when you
were pregnant?
Why you took care from
that person?
How much it cost to take
pregnancy care?
AN care how many
times;
From midwife or AMW;
If not from midwife; why
not from midwife?
2 How did you deliver the
baby mostly?
Why did you deliver with
that person?
How much it cost total?
Any referral service
received?
Home or labor room
delivery;
TBA or AMW or
Midwife;
Referred or not
How? Any feedbacks?
3 Did you take postnatal
care from anybody?
If not, why?
If yes, from whom? Why?
How much it cost to take
postnatal care?
107
4 Did you use any birth
spacing method?
If yes, which method?
From whom?
How much it costed?
If not any use any
method;
Try to ask why?
5 Did your child got sick
recently?
If yes, how did you treat
him or her? How much it
cost you?
If no, why?
From whom?
Referred or not?
6 Any support you received
from VHC or IOM?
If yes, what kinds of
support and who got it,
when?
What kind of referral
patients get support from
IOM?
Is there any emergency
maternal and under five
child referral patients who
did not get support? Why?
What are the
requirements and
procedures to get
support?
This kind of emergency
referral support system
is fair?
7 Did your children get
immunization?
If yes, how many times?
Any cost to get vaccination
for children?
Complete or not?
If not complete, why?
8 Did you attended any
health education
sessions?
If yes, when?
What was health
education about?
Who provided health
education?
Do you remember any
health message you got
at that time?
9 What are the needs in
terms of health care in
the village?
What should be done for
your villagers so that poor
patients get access of
health care?
10 Any final thoughts and
suggestions?
108
Guide for Group Discussion with Pregnant
Purpose of the session
4. To know their access to free pregnancy care
5. To know their knowledge, attitude and behavior about maternal and child health
6. To know their awareness about the project and how much they benefitted from it
FGD Process
Invite 6 to 7 pregnant women
Facilitator need to explain what we are going to discuss and make sure everyone is
encouraged to speak
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce every participants and facilitator need to inform that this session
will last one to two hours maximum
No. Main Question Follow up question Probe
1 Did you take pregnancy
care?
If yes, from whom?
Why you took care from that
person?
How much it cost to take
pregnancy care?
AN care how many times;
From midwife or AMW;
Why not from midwife
2 How will you deliver the
baby?
Why do you decide like that?
How much will it cost total?
How will you cover this cost?
Home or labor room
delivery;
TBA or AMW or Midwife
3 Did you have sick recently? If yes, how did you treat? How
much it cost you?
If no, why?
From whom? Why did you
choose him or her?
Referred or not?
4 Any support you received
from VHC or IOM?
If yes, what kinds of support
and who got it, when?
What kind of referral patients
get support from IOM?
Is there any emergency
maternal and under five child
referral patients who did not
What are the requirements
and procedures to get
support?
This kind of emergency
referral support system is
fair?
109
get support? Why?
5 Did you get anti-tetanus
immunization?
If yes, how many times?
Any cost to get vaccination?
Complete or not?
If not complete, why?
6 Did you attended any health
education sessions?
If yes, when?
What was health education
about?
Who provided health
education?
Do you remember any
health message you got at
that time?
7 What are the needs in terms
of health care in the village?
What should be done for your
villagers so that poor patients
get access of health care?
8 Any final thoughts and
suggestions?
Guide for Group Discussion for husband of mother and pregnant women
Purpose of the session
7. To know their knowledge, attitude and behavior about maternal and child health
8. To know their awareness about the project and how much their family benefitted from
it
FGD Process
Invite 6 to 7 husbands of mother and pregnant women
Facilitator need to explain what we are going to discuss and make sure everyone is
encouraged to speak
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce every participants and facilitator need to inform that this session
will last one to two hours maximum
No. Main Question Follow up question Probe
1 From whom your wife took
pregnancy care when they
were pregnant?
Why they took care from that
person?
How much it cost to take
AN care how many times;
From midwife or AMW;
Why not from midwife
110
pregnancy care?
2 How did your wives deliver
the baby mostly?
Why did they deliver with that
person?
How much it cost total?
Home or labor room
delivery;
TBA or AMW or Midwife;
Referred or not
3 Did your wives take
postnatal care from
anybody?
If not, why?
If yes, from whom? Why?
How much it cost to take
postnatal care?
4 Did your wives use any birth
spacing method?
If yes, which method?
From whom?
How much it costed?
If not any use any method;
Try to ask why?
5 Did your child got sick
recently?
If yes, how did you treat him
or her? How much it cost
you?
If no, why?
From whom?
Referred or not?
6 Any support you received
from VHC or IOM?
If yes, what kinds of support
and who got it, when? From
whom?
What kind of referral patients
get support from IOM?
Is there any emergency
maternal and under five child
referral patients who did not
get support? Why?
What are the requirements
and procedures to get
support?
Does everybody get
support?
7 Did your children get
immunization?
If yes, how many times?
Any cost to get vaccination
for children?
Complete or not?
If not complete, why?
8 Did you attend any health
education sessions?
If yes, when?
What was health education
about?
Who provided health
education?
Do you remember any
health message you got at
that time?
Health message about
maternal and child health?
111
9 What are the needs in terms
of health care in the village?
What should be done for your
villagers so that poor patients
get access of health care?
Are migrants and people
from hard to reach areas
are getting necessary
maternal and child health
care?
10 Any final thoughts and
suggestions?
Guide for Group Discussion with Village Tract Health Committee (VTHC) and Village
Health Committee (VHC)
Purpose of the session
9. To know level of their participation and involvement in the project activities
10. To know their opinion and views about the changes made by the project and its
impact
11. To know their future plan so that we can assess sustainability of the project impact
FGD Process
Invite 6 to 7 members of village tract and village health committees, make sure
chairman, influential members and active members are invited. Also make sure
woman members are invited.
No need to invite midwife or health assistant or community health worker or auxiliary
midwife because we will do separate session with them.
Facilitator need to explain what we are going to discuss and make sure everyone is
encouraged to speak
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce every participants and facilitator need to inform that this session
will last one to two hours maximum
No. Main Question Follow up question Probe
1 When was VTHC and VHC
formed?
Who initiated the
establishment of VTHC and
What are the purposes of
forming VTHC and VHC?
112
VHC
2 What are the activities you
do as VTHC and VHC?
What are the regular
activities you involved in?
How you do these
activities?
VTHC meeting;
Referral of emergency
patients;
Providing health
education about maternal
and child health;
Helping EPI activities of
midwife
3 Is there any fund
established by VTHC or
VHC?
If yes,
Who initiated this fund?
What type of fund and how
much?
How fund is managed?
The fund is used for what
and who?
Referral of emergency
patients to hospital;
Future plan
4 Any support you received
from IOM?
If yes, what kinds of support
and who got it, when?
What kind of referral
patients get support from
IOM?
Is there any emergency
maternal and under five
child referral patients who
did not get support? Why?
What are the
requirements and
procedures to get
support?
This kind of emergency
referral support system is
fair?
5 Any training received from
IOM?
If yes,
What types of training?
When and who attended
these trainings?
Leadership and
management training;
Fund management
training;
Community mobilization
training
6 Where do pregnant
woman seek health care if
needed?
They take pregnancy care
from whom mostly?
How much it cost to seek
pregnancy care from that
person?
Antenatal care;
Baby Delivery;
Postnatal care
113
7 Do all under-five children
in the village get
immunization?
If no, why?
How many times midwife
came to the village within
last three months?
What do midwife do in the
village when she comes?
Knowledge and attitude
of villagers about
immunization;
Any cost to get service
from midwife (EPI)
8 What do you do when
under five children are
sick?
From whom under five
children get health care
mostly?
How much is the cost to
seek health care? What are
the costs?
health seeking behavior;
accessibility of health
care person ;
possibility of getting free
health care for under five
children
9 Any recent deaths of
pregnant mother or under
five child from the village?
If yes, when and how?
Why did death happen?
Was the death
preventable?
If yes, how?
10 What are the needs in
terms of health care in the
village?
What should be done for
your villagers so that poor
patients get access of
health care?
What are the changes
after implementation of
project by IOM here?
Changes of in terms of
health of pregnant
women and under five
children of the village
11 Any final thoughts and
suggestions?
Focus Group Discussion (IOM Staff)
Purpose of the session
12. To know how they are providing services to the community
13. To know understanding of project direction and goal
14. To know their opinion about the project result and impact
FGD Process
Invite 6 to 7 IOM staffs working at different levels of project
114
Interviewer needs to explain what we are going to discuss
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce every participants and interviewer needs to inform that this session
will last one hour maximum
No. Main Question Follow up question Probe
1 Can you explain me about
the project you are working
for?
What is the goal of the
project?
How do you develop CTHP?
Who are involved in CTHP
developing process?
2 What are the activities you
involved?
How do you plan to carry out
activities?
How do you mobilize
community?
How do you coordinate
between each staff?
3 What are the activities you
do together with THD or
BHS?
How do you coordinate with
them?
How frequently do you have
to work with them?
What are the challenges?
4 What kinds of support you
provide to Township Health
Department?
How do you provide these
supports?
Training, medical supplies
5 What kind of referral
patients get support from
IOM?
Who are eligible for referral
support?
What are the requirements
and procedures to get
support?
Is there any emergency
maternal and under five child
referral patients who did not
get support? Why?
Migrants, Hard to reach
area;
Is this kind of emergency
referral support system
fair?
What are the challenges to
implement these system?
6 What kinds of meeting or
trainings you organized with
THD or BHS?
Do you have to attend any
regular meeting?
What else workshop you
have to attend?
Coordination meeting,
RHC meeting, VHC or
VTHC meeting, BHS
training, AMW, CHW
training
115
7 Did you involve in selection
of volunteer health workers
If yes, can you tell us how
selection was done?
What are the criteria for
selection?
AMW and CHW selection
process;
Who is decision maker?
8 How did you establish or
revitalize VTHC or VHC?
Is there any fund at VTHC or
VHC?
If yes, how is it managing?
What are the main activities
of VTHC or VHC?
What is sustainability of
VHC or VTHC?
9 How do you monitor the
project activities?
How do you monitor the
progress of project?
How do you conduct
supervision visit?
Do you have to do any joint
supervision visit?
Reporting system;
M& E system ; feedback
system
10 Did you get any training
organized for your personal
development?
If yes, what kinds of training?
When?
How many training you
attended organized by
IOM?
11 Any recent deaths of
pregnant mother or under
five child from the village?
If yes, when and how?
Why did death happen?
Was the death preventable?
If yes, how?
How do you do Maternal
and child death audit?
12 What are the significant
achievements of project?
Is there any significant
changes regarding maternal
and child health after project?
Improvement of maternal
and child health status of
migrants and people from
hard to reach areas
13 What are the needs in terms
of health care here?
What should be done for the
community so that poor
patients get access of health
care?
Needs and gaps in health
system
14 Any final thoughts and
suggestions?
116
Key Informant Interview (BHS)
Purpose of the session
15. To know how they are providing services to the community
16. To know how much extent they are involving in the project
17. To know their opinion about the project result and impact
FGD Process
There should be some in-depth follow up questions depending on replies of
interviewee
Interviewer needs to explain what we are going to discuss
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce every participants and interviewer needs to inform that this session
will last one hour maximum
No. Main Question Follow up question Probe
1 What are the services you
provide?
How do you provide the
services?
AN care, Delivery, PN
care
Under-five child care, EPI
2 What kind of medical
supplies you received from
IOM?
How did you receive them?
What are the supplies?
How do you manage them?
Medicines, Equipment;
Medicine report
3 Do you have to charge
patients for your services?
If yes, how much do you
charge?
You charge for what kind of
services?
Why do you have to
charge patients?
4 What kind of referral
patients get support from
IOM?
Who are eligible for referral
support?
What are the requirements
and procedures to get
support?
Is there any emergency
maternal and under five child
referral patients who did not
get support? Why?
Migrants, Hard to reach
area;
Is this kind of emergency
referral support system
fair?
What are the challenges?
117
/5 Do you participate in other
activities related to IOM?
Do you have to attend any
regular meeting?
Did you attend any workshop
organized by IOM?
Do you have to do any joint
supervision visit? If yes, to
whom and with whom?
Coordination meeting,
RHC meeting, VHC or
VTHC meeting; Maternal
and child death audit;
Health education
6 Did you involve in selection
of volunteer health workers
If yes, can you tell us how
selection was done?
What are the criteria for
selection?
AMW and CHW selection
process;
Who are decision makers?
7 Did you get or involve in any
training organized by IOM?
If yes, what kinds of training?
When?
How many trainings you
attended organized by
IOM?
8 What do you think of project
doing by IOM?
Is there any significant
changes after
implementation of project?
Improvement of maternal
and child health of
migrants and people from
hard to reach area
9 Any recent deaths of
pregnant mother or under
five child from the village?
If yes, when and how?
Why did death happen?
Was the death
preventable?
If yes, how?
10 What are the needs in terms
of health care here?
What should be done for the
community so that poor
patients get access of health
care?
Needs and gaps in health
system
11 Any final thoughts and
suggestions?
Key Informant Interview (VHW)
Purpose of the session
18. To know how much extent they are providing services to the community
19. To know how much extent they are involving in the project
20. To know their opinion about the project
FGD Process
118
Questions should be adjusted according to AMW or CHW
Interviewer need to explain what we are going to discuss
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce the participant and interviewer need to inform that this session will
last about one hour maximum
No. Main Question Follow up question Probe
1 When did you received
initial training?
When was it?
Who organized for training?
Who supported for training?
How many times did you
receive refresher training?
CHW or AMW initial
training;
CHW or AMW refresher
training
2 What are the services you
provide?
How do you provide the
services?
AN care, Delivery, PN care
(AMW);
Under-five child care
3 What kind of medical
supplies you received?
How did you receive them?
What are the supplies?
How do you manage them?
Medicines, Equipment;
Reporting system
4 Do you have to charge
patients for your services?
If yes, how much do you
charge?
You charge for what kind of
services?
Why do you have to
charge patients?
5 Do you participate in other
activities related to IOM?
Do you have to attend any
regular meeting?
Do you provide health
education to community? If
yes, what topics?
RHC meeting, VHC or
VTHC meeting, workshop,
Health education about
maternal and child health
6 Any support you received
from IOM?
If yes, what kinds of support?
How did you get it?
Perdiem to attend meeting
, workshop, training
7 Do you help midwife in any
activities?
If yes, how do you help
midwife?
EPI activities, Family
planning services,
Nutrition activities
119
8 What kind of referral
patients get support from
IOM?
What are the requirements
and procedures to get
support?
Is there any emergency
maternal and under five child
referral patients who did not
get support? Why?
Migrants, hard to reach
area
This kind of emergency
referral support system is
fair?
What are the challenges?
9 Any recent deaths of
pregnant mother or under
five child from the village?
If yes, when and how?
Why did death happen?
Was the death
preventable?
If yes, how?
10 What are the needs in terms
of health care in the village?
What should be done for
your villagers so that poor
patients get access of health
care?
Health work force ,
transport, medicines (
sotck-outs)
11 Any final thoughts and
suggestions?
Key Informant Interview (IOM Staff)
Purpose of the session
21. To know how they are providing services to the community
22. To know understanding of project direction and goal
23. To know their opinion about the project result and impact
FGD Process
Need to interview one from field level and one from management level
Interviewer needs to explain what we are going to discuss
Need to explain also about ethic of research that this information will be kept secret
and encourage to discuss openly
Need to inform and make sure no need to worry if we are recording the discussion
Need to introduce every participants and interviewer needs to inform that this session
will last one hour maximum
No. Main Question Follow up question Probe
1 Can you explain me about
the project you are working
for?
What is the goal of the
project?
How do you develop CTHP?
Who are involved in CTHP
developing process?
120
2 What are the activities you
involved?
How do you plan to carry out
activities?
How do you mobilize
community?
How many days per
month you spend in the
field?
3 What are the activities you
do together with THD or
BHS?
How do you coordinate with
them?
How frequently do you have
to work with them?
What are the challenges?
4 What kinds of support you
provide to Township Health
Department?
How do you provide these
supports?
Training, medical supplies
5 What kind of referral
patients get support from
IOM?
Who are eligible for referral
support?
What are the requirements
and procedures to get
support?
Is there any emergency
maternal and under five child
referral patients who did not
get support? Why?
Migrants, Hard to reach
area;
Is this kind of emergency
referral support system
fair?
6 What kinds of meeting or
trainings you organized with
THD or BHS?
Do you have to attend any
regular meeting?
What else workshop you
have to attend?
Coordination meeting,
RHC meeting, VHC or
VTHC meeting; BHS
training, AMW, CHW
training
7 Did you involve in selection
of volunteer health workers
If yes, can you tell us how
selection was done?
What are the criteria for
selection?
AMW and CHW selection
process;
Who is decision maker?
8 How did you establish or
revitalize VTHC or VHC?
Is there any fund at VTHC or
VHC?
If yes, how is it managing?
What are the main activities
of VTHC or VHC?
What is sustainability of
VHC or VTHC?
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9 How do you monitor the
project activities?
How do you monitor the
progress of project?
How do you conduct
supervision visit?
Do you have to do any joint
supervision visit?
M& E system and
feedback system
10 Did you get any training for
your personal
development?
If yes, what kinds of training?
When?
How many training you
attended organized by
IOM?
11 Any recent deaths of
pregnant mother or under
five child from the village?
If yes, when and how?
Why did death happen?
Was the death preventable?
If yes, how?
How do you do Maternal
and child death audit?
12 What are the significant
achievements of project?
Is there any significant
changes regarding maternal
and child health after
project?
Improvement of maternal
and child health status of
migrants and people from
hard to reach areas
13 What are the needs in
terms of health care here?
What should be done for the
community so that poor
patients get access of health
care?
Needs and gaps in health
system
14 Any final thoughts and
suggestions?
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Annex 7: Activity Photos : Bogale
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Photos: MLMK
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