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TRANSCRIPT
The National Road Map Strategic Plan -2008 - 2015 i
United Republic of Tanzania
Ministry of Health and Social Welfare
The National Road Map Strategic PlanTo Accelerate Reduction of Maternal, Newborn
and Child Deaths in Tanzania
2008 - 2015
April 2008
2ii
When a woman
undertakes her biological
role of becoming
pregnant and undergoing
childbirth, the society has
an obligation to fulfil her
basic human rights,
which include the right to
life, liberty social
security, maternity
protection and non
discrimination.
The National Road Map Strategic Plan -2008 - 2015 iii
TABLE OF CONTENTS
Abbreviations ............................................................................................................................................ ivForeword.................................................................................................................................................... viiAcknowledgements ................................................................................................................................... viii
Chapter 1:Overview ................................................................................................................................................... 1
1.1 Introduction ..................................................................................................................................... 11.2 Initiatives to Improve Maternal, Newborn and Child Health in Tanzania ...................................... 11.3 Rationale for the Strategic Plan to Accelerate Reduction of Maternal,
Newborn and Child Deaths in Tanzania.......................................................................................... 2
Chapter 2:SituationAL Analysis of maternal, newborn and child health in tanzania ................................................ 3
2.1 Maternal Health............................................................................................................................... 32.2 Newborn Health .............................................................................................................................. 62.3 Child Health ................................................................................................................................... 82.4 Cross Cutting Issues ....................................................................................................................... 11
Chapter 3:Strategic FRAMEWORK.......................................................................................................................... 15
Chapter 4:Implementation Framework ...................................................................................................................... 18
Chapter 5:Strategic plan and activities – 2008-2015 ................................................................................................ 24
Chapter 6:MONITORING FRAMEWORK ............................................................................................................. 47
ANNEXES
SWOT Analysis ......................................................................................................................................... 57Inputs for Improving MNCH at All Levels ............................................................................................... 71Relevant Policy Documents ...................................................................................................................... 42Most Cost Effective Interventions Based on Evidence to Date for Reduction of Perinatal and Neonatal Mortality............................................................................................................... 83Evidence-Based Interventions that Influence Child Health ...................................................................... 84Evidence-Based Interventions for MNCH ................................................................................................ 85Where Does Tanzania Stand in Terms of MNCH Service Delivery?........................................................ 88Essential MNCH Medicines, Equipment and Supplies ............................................................................. 90Glossary ..................................................................................................................................................... 92
REFERENCES .......................................................................................................................................... 93
ABBREVIATIONS
ADDOS Accredited Drug Dispensing Outlets
AIDS Acquired Immuno Deficiency Syndrome
ALu Artemether Lumefantrine
AMO Assistant Medical Officer
ANC Antenatal Care
ARH Adolescent Reproductive Health
ARI Acute Respiratory Tract Infection
BCC Behaviour Change Communication
BEmOC Basic Emergency Obstetric Care
BFHI Baby Friendly Hospital Initiative
BMI Body Mass Index
CBD Community Based Distributor
CBIMS Community Based Information Management System
CBO Community Based Organization
CCHP Comprehensive Council Health Plan
CEmOC Comprehensive Emergency Obstetric Care
CHMT Council Health Management Team
c-IMCI Community Integrated Management of Childhood Illness
CPR Contraceptive Prevalence Rate
CSO Civil Society Organization
DHR Director Human Resources
DPS Director Preventive Services
EmOC Emergency Obstetric Care
ENC Essential Newborn Care
EPI Expanded Programme on Immunization
FANC Focused Antenatal Care
FBO Faith Based Organization
FP Family Planning
HIV Human Immuno Deficiency Virus
HMIS Health Management Information System
HPV Human Papilloma Virus
HSSP Health Sector Support Programme
ICPD International Conference on Population and Development
IDWE Infectious Disease Week Ending report
IEC Information Education and Communication
IMCI Integrated Management of Childhood Illness
IMR Infant Mortality Rate
IPT Intermittent Preventive Treatment
ITN Insecticide Treated Net
IYCF Infant Young Child Feeding
iv The National Road Map Strategic Plan -2008 - 2015
The National Road Map Strategic Plan -2008 - 2015 v
KMC Kangaroo Mother Care
LLINs Long Lasting Insecticide Treated Nets
LSS Life Saving Skills
MDGs Millennium Development Goals
MKUKUTA Mkakati wa Kukuza Uchumi na Kupunguza Umaskini Tanzania (The National Strategy for
Growth and Reduction of Poverty)
MMAM Mpango wa Maendeleo wa Afya ya Msingi (The Primary Health Services Development
Programme)
MMR Maternal Mortality Ratio
MNCH Maternal, Newborn and Child Health
MNT Maternal and Newborn Tetanus
MoAFSC Ministry of Agriculture, Food Security and Cooperatives
MoCDGC Ministry of Community Development, Gender and Children
MoEVT Ministry of Education and Vocational Training
MoFEA Ministry of Finance and Economic Affairs
MoHSW Ministry of Health and Social Welfare
MoICS Ministry of Information, Culture and Sports
MoID Ministry of Infrastructure Development
MoLEYD Ministry of Labour, Employment and Youth Development
MVA Manual Vacuum Aspiration
NACP National AIDS Control Programme
NBS National Bureau of Statistics
NGOs Non Governmental Organization
NMCP National Malaria Control Programme
NMW Nurse Midwife
NORAD Norwegian Development Cooperation
NPEHI National Package of Essential Health Interventions
NPERCHI National Package of Essential Reproductive and Child
Health Interventions
ORS Oral Rehydration Solution
ORT Oral Rehydration Therapy
PAC Post Abortion Care
PHAST Participatory Hygiene and Sanitation Transformation
PHC Primary Health Care
PHSDP Primary Health Services Development Programme
PMNCH Partnership for Maternal, Newborn and Child Health
PMO-RALG Prime Minister’s Office, Regional Administration and Local Government
PMTCT Prevention of Mother to Child Transmission
POPSM President’s Office – Public Service Management
QIRI Quality Improvement and Recognition Initiative
RED Reaching Every District
REC Reaching Every Child
RCH Reproductive and Child Health
RCHS Reproductive and Child Health Section
RHMT Regional Health Management Team
RTI Reproductive Tract Infection
SM Safe Motherhood
SMI Safe Motherhood Initiative
SNL Saving Newborn Lives
SRH Sexual and Reproductive Health
STI Sexually Transmitted Infection
SWOT Strengths, Weaknesses, Opportunities and Threats
TAMWA Tanzania Media Women Association
TASAF Tanzanian Social Action Fund
TBA Traditional Birth Attendant
THIS Tanzania HIV/AIDS Indicator Survey
TDHS Tanzania Demographic and Health Survey
TFNC Tanzania Food and Nutrition Centre
TFR Total Fertility Rate
TGNP Tanzania Gender Networking Group
TPMNCH Tanzanian Partnership for Maternal, Newborn and Child Health
TRCHS Tanzania Reproductive and Child Health Survey
TSPA Tanzania Service Provision Assessment
TT Tetanus Toxoid
UNFPA United Nations Population Fund
UNICEF United Nations Children Fund
VVF Vesico Vaginal Fistula
WB World Bank
WHO World Health Organization
WRATZ White Ribbon Alliance Tanzania
ZRCH Zonal Reproductive and Child Health
vi The National Road Map Strategic Plan -2008 - 2015
The National Road Map Strategic Plan -2008 - 2015 vii
FOREWORD
Reduction of maternal, newborn and child deaths is a high priority for all, given the persistently high maternal,newborn and child morbidity and mortality rates over the past two decades in African countries, Tanzaniaincluded. It is one of the major concerns addressed by various global and national commitments, as reflectedin the targets of the Millennium Development Goals, Tanzania Vision 2025, the National Strategy for Growthand Reduction of Poverty (NSGRP-MKUKUTA), and the Primary Health Services Development Program(PHSDP-MMAM), among others.
Maternal deaths are caused by factors attributable to pregnancy, childbirth and poor quality of health services.Newborn deaths are related to the same issues and occur mostly during the first week of life. Child healthdepends heavily on availability of and access to immunizations, quality management of childhood illnessesand proper nutrition. Improving access to quality health services for the mother, newborn and child requiresevidence-based and goal-oriented health and social policies and interventions that are informed by best practices.
Development of this plan for reducing maternal, newborn and child mortality is in line with the tenets of theNew Delhi Declaration 2005. Tanzania and other countries committed to develop one national MNCH plan foraccelerating the reduction of maternal, newborn and child deaths, in order to improve coordination, alignresources and standardize monitoring. Further support for incorporating child health interventions into this planwas voiced by various stakeholders and development partners following the April 2007 launch of the TanzaniaPartnership for Maternal, Newborn and Child Health (TPMNCH). The National Road Map Strategic Plan toAccelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania (2008 – 2015) was subsequentlydeveloped as Tanzania’s national response to the renewed commitment to improve maternal, newborn and childcare. The Reproductive and Child Health Section (RCHS) of the Ministry of Health and Social Welfare(MoHSW), in collaboration with a number of different stakeholders, has developed this strategic plan to guideimplementation of all maternal, newborn and child health interventions in Tanzania.
The National Road Map Strategic Plan stipulates various strategies to guide stakeholders for Maternal, Newbornand Child Health (MNCH), these include the Government, development partners, non-governmentalorganizations, civil society organizations, private health sector, faith-based organizations and communities, inworking together towards attainment of the Millennium Development Goals (MDGs) as well as other regionaland national commitments and targets related to maternal, newborn and child health
It is the expectation of the Government, particularly the MoHSW, that all stakeholders will make optimal useof this strategic framework to support the implementation of maternal, newborn and child health interventions,as this is in line with the National Health Policy and existing MNCH standards, guidelines and protocols.
The Government highly values your partnership in working towards realization of the objectives of the NationalRoad Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths. Together, we canimprove the health of Tanzanian mothers, babies and children, and build a stronger and more prosperous nation.
Professor David Homeli Mwakyusa (MP),Minister for Health and Social Welfare
viii The National Road Map Strategic Plan -2008 - 2015
ACKNOWLEDGEMENTS
The MoHSW wishes to express its gratitude to the many individuals and development partners who worked withthe Ministry in the development of “The National Road Map Strategic Plan to Accelerate Reduction of Maternal,Newborn and Child Deaths in Tanzania, 2008 – 2015”. The completion of the document is a result of extensiveconsultations and collaboration with various stakeholders including the RCHS of the MoHSW, developmentpartners, interested organizations as well as committed individuals.
The MoHSW would like to acknowledge all those stakeholders who contributed in one way or another to thesuccessful development of the document. The Ministry particularly wishes to acknowledge the invaluablecontribution of the PMNCH Country Support Working Group: Dr. Nancy Terreri (UNICEF HQ); Dr. CiroFranco (BASICS, USA); and Dr. Koki Agarwal (ACCESS/Jhpiego, USA). The MoHSW also acknowledgesthe contribution of the technical group members: Dr. Theresa Nduku Nzomo (WHO/AFRO Harare); Dr. SamMuziki (WHO/AFRO Harare); Dr. Thierry Lambrechts (WHO/HQ); and local Consultants led by Dr. Ali Mzigeand Dr. Rosemary Kigadye. Other national technical experts who contributed in the development include: Dr.Catherine Sanga (RCHS, MoHSW), Dr. Neema Rusibamayila (IMCI, MoHSW), Dr. Georgina Msemo(IMCI/SNL, MoHSW), Dr. Mary Kitambi (EPI, MoHSW); Ms. Lena Mfalila (RCHS/SMI, MoHSW); Dr.Elizabeth Mapella (ARH, MoHSW); Ms. Hilda Missano (TFNC); Dr. Rutasha Dadi and Dr. Chilanga Asmani(UNFPA); Dr. Theopista John, Dr. Josephine Obel and Dr. Iriya Nemes (WHO Tanzania); Dr. Asia Hussein(UNICEF, Tanzania); and Maryjane Lacoste (ACCESS/Jhpiego, Tanzania).
The Ministry would also like to acknowledge Ms. Hassara Maulid (MoHSW) for her secretarial work with theinitial drafts of this document.
Lastly, the Ministry would like to acknowledge technical and financial support provided by EC, WHO, UNFPA,UNICEF and One UN Fund for the development and printing of the MNCH strategic plan.
Wilson C. MukamaPermanent Secretary, MoHSW
The National Road Map Strategic Plan -2008 - 2015 1
CHAPTER 1:OVERVIEW
Purpose of the documentThis document has been conceived for various purposes. The health of the mother is closely linked to the healthand survival of the child. In addition, the socio-economic level of the mother and the maternal health status(HIV/AIDS, malaria, nutrition) has an impact on the survival of the child. Thus the primary purpose of “OneIntegrated Maternal Newborn and Child Health Strategic Plan” is to ensure improved coordination ofinterventions and delivery of services across the continuum of care. Another purpose of the document is toguide implementation across operational levels of the system so that policy drawn at national level will becarried out at the district and community levels, with support from the regional level. It is anticipated that a jointstrategy will contribute to more integrated implementation, improved services, and ultimately a significantreduction in morbidity and mortality of Tanzanian women and children.
1.1 Introduction
The total population of Mainland Tanzania is estimated to be 39,384,223 (as of July 2007)1. Most of thepopulation (75%) resides in the rural area. The annual growth rate is 2.9% with life expectancy at birth being54 years for males and 56 years for females2.
The total fertility rate in Tanzania has been consistently high over the past ten years and currently stands at 5.7children per woman. There are regional variations with urban-rural disparities, where rural women have higherfertility rates than their urban counterparts3.
The Maternal Mortality Ratio (MMR) has remained high for the last 10 years4 without showing any decline andis currently estimated to be 578 per 100,000 live births5. While significant progress has been made to reducechild mortality in Tanzania, the neonatal mortality rate remains high at 32 per 1,000 live births, and accountsfor 47% of the infant mortality rate which is estimated at 68 per 1,000 live births.
The critical challenges in reducing maternal, newborn and child morbidity and mortality comprise twocategories:
(a) Health system factors - inadequate implementation of pro-poor policies, weak health infrastructure, limitedaccess to quality health services, inadequate human resource, shortage of skilled health providers, weak referralsystems, low utilization of modern family planning services, lack of equipment and supplies, weak healthmanagement at all levels and inadequate coordination between public and private facilities.
(b) Non health system factors- inadequate community involvement and participation in planning,implementation, monitoring and evaluation of health services, some social cultural beliefs and practices, genderinequality, weak educational sector and poor health seeking behaviour.
1.2 Initiatives to improve maternal, newborn and child health in Tanzania
Maternal and child health services were established in Tanzania in 1974. In 1975 the Expanded Programme ofImmunization (EPI) was initiated to strengthen immunization services for vaccine preventable childhooddiseases. Tanzania adopted the Safe Motherhood Initiative (SMI) in 1989, following the official launch of theGlobal Safe Motherhood Initiative in 1987 in Nairobi, Kenya. Subsequently, the 1994 International Conferencefor Population and Development (ICPD) emphasized access to comprehensive reproductive health services andrights. In response to the ICPD Plan of Action, Tanzania established the Reproductive and Child Health Section(RCHS) within the Ministry of Health and developed a National Reproductive and Child Health Strategy.
1 CIA World Fact Book, March 20082 Census, 20023 TDHS 2004/05
4 Maternal Mortality ratio was 529/100,000 live births in TDHS 19965 TDHS 2004/05
In 1996 Tanzania adopted the Integrated Management of Childhood Illness (IMCI) approach for reductionof childhood morbidity and mortality. Various nutrition interventions have also been adopted including theBaby Friendly Hospital Initiative (BFHI) in 1992, the Code of Marketing Breast Milk Substitutes in 1994
and Vitamin A Supplementation in 1997. Tanzania developed its National Strategy on Infant and Young ChildFeeding and Nutrition in 2005.
In Tanzania, specific attempts have been made to address maternal, newborn and child health (MNCH)challenges through the National Health Policy (revised in 2003), the Health Sector Reforms and the HealthSector Strategic Plan (2003-2007). Furthermore, the Reproductive and Child Health Strategy (2005-2010) andthe National Road Map Strategic Plan to Accelerate the Reduction of Maternal and Newborn Mortality (2006-2010) were also formulated to respond to these challenges.
Improving MNCH is also a major priority area in the National Strategy for Growth and Poverty Reduction(NSGPR/MKUKUTA) 2005-2010 which has three major interlinked clusters6. One of the goals clearly outlinedin the second cluster of the strategy is to improve the survival, health and well being of all children and womenand of especially vulnerable groups. Under this goal, there are four operational targets related to maternal andchild health for monitoring progress towards achieving MDGs 4 and 5.
The Health Sector Support Programme III (2008 – 2012) will incorporate and address MNCH issues in termsof alignment with Government policies, resource mobilization and donor harmonization. The newly initiatedPrimary Health Service Development Programme, (PHSDP/MMAM) 2007 – 2017, will address the deliveryof health services to ensure fair, equitable and quality services to the community and is envisioned to be thespringboard for achieving good health for Tanzanians.
The Tanzania MNCH Partnership was officially launched in April 2007 to re-focus the strategies for reducingthe persistently high maternal, newborn and child mortality rates, through adopting the One Plan and settingclear targets for improved MNCH.
1.3 Rationale for the Strategic Plan to accelerate reduction of maternal, newborn and childdeaths in Tanzania
Annually, it is estimated that 536,000 women7 worldwide die from pregnancy- and childbirth-related conditions,as do 11,000,000 under-fives, of which 4.4 million are newborns. Most of these deaths occur in Sub SaharanAfrica. Tanzania is one of the ten countries contributing to 61% and 66% of the global total of maternal andnewborn deaths, respectively. In Tanzania, the estimated annual number of maternal deaths is 13,000, theestimate for under-fives is 157,000, and newborn deaths are estimated at 45,0008. In committing to MDGs 4and 5, the Government of Tanzania agreed to reduce the under-five mortality rate by two-thirds and reduce thematernal mortality ration by three-quarters, by 2015.
Maternal, newborn and child outcomes are interdependent; maternal morbidity and mortality impacts neonataland under-five survival, growth and development. Thus service demand and provision for mothers, newbornsand children are closely interlinked. Integration of MNCH services demands reorganization and reorientationof components of the health systems to ensure delivery of a set of essential interventions for women, newbornsand children. A focus on the continuum of care replaces competing calls for mother or child, with a focus onhigh coverage of effective interventions and integrated MNCH service packages as well as other keyprogrammes such as Safe Motherhood (SM), Family Planning (FP), Prevention of Mother to Child Transmission(PMTCT) of HIV, Malaria, EPI, IMCI, Adolescent Health and Nutrition. Sustained investment and systematicphased scale up of essential MNCH interventions integrated in the continuum of care are required.
2 The National Road Map Strategic Plan -2008 - 2015
6 Cluster 1: Growth and Reduction of Income Poverty; Cluster 2: Improvedquality of life and social well being; Cluster 3: Good governance andaccountability.
7 Maternal Mortality Estimates 2005, WHO, UNICEF, UNFPA, World Bank8 Opportunities for Africa’s Newborns 2006, the Partnership for MNCH
The National Road Map Strategic Plan -2008 - 2015 3
CHAPTER 2:SITUATIONAL ANALYSIS OF MATERNAL, NEWBORN
AND CHILD HEALTH IN TANZANIA
Introduction
Maternal, newborn and child health care is one of the key components of the National Package of EssentialReproductive and Child Health Interventions (NPERCHI) focusing on improving the quality of life forwomen, adolescents and children. The major components of the package include:• antenatal care; • care during childbirth; • care of obstetric emergencies; • newborn care; • postpartum care; • post abortion care; • family planning; • diagnosis and management of HIV/AIDS including PMTCT,
other sexually transmitted infections and • reproductive tractinfections (STI/RTI);
• prevention and management of infertility; • prevention and management of cancer; • prevention and management of childhood illness; • prevention and management of immunisable diseases; • nutrition care.
In spite of the good coverage of health facilities, not all components of the services are of good quality andprovided to scale; hence, maternal, newborn and child mortalities remain a major public health challenge inTanzania.
2.1 Maternal Health
• Antenatal care
According to TDHS (2004/05), 94% of pregnant women make at least one antenatal care (ANC) visitand 62% of women have four or more ANC visits. The number of pregnant mothers in Tanzania makingfour or more ANC visits appears to have declined slightly from 70% in 19999. However, the quality ofantenatal care provided is inadequate. About 65% of the women have their blood pressure measured and54% have blood samples taken for haemoglobin estimation and syphilis screening. About 41% haveurine analysis done and only 47% are informed of the danger signs in pregnancy.
Approximately 80% of pregnant women received at least 1 dose of tetanus toxoid (TT), and 56% of womenreceived two or more TT doses10. Younger mothers, women in their first pregnancy, women of the highereducation and wealth strata and urban women are more likely to receive two or more doses of TT.
Despite high ANC attendance, only 14% of pregnant women start ANC during the first trimester as per thenational guidelines. The median number of months that women are pregnant at their first visit is 5.4. One-third of women do not seek ANC until their sixth month or later11. However, early booking has an advantagefor proper pregnancy information sharing and pregnancy monitoring.
9 TRCHS 199910 TDHS 2004/0511 TDHS 2004/05
When a woman
undertakes her biological
role of becoming
pregnant and undergoing
childbirth, the society
has obligation to fulfil
her basic human rights
and that of her child.
• Malaria in pregnancy
Pregnancy alters a woman’s immune response to malaria, particularly in the first malaria-exposedpregnancy, resulting in more episodes of severe infection and anaemia, all of which contribute to ahigher risk of death. Malaria is estimated to cause up to 15 % of maternal anaemia, which is morefrequent and severe in first pregnancies. Malaria is a significant cause of low birth weight which is themost important risk factor for newborn death and is also a risk factor for stillbirth.
Efforts to combat malaria among pregnant mothers are being scaled up. Pregnant women are supposed toreceive two doses of SP for intermittent preventive treatment (IPT) of malaria during routine antenatal carevisits. However, according to TDHS (2004/05), only 22% of pregnant women attending the ANC clinicreceive the complete course of IPT, and only 16% use Insecticide Treated Nets (ITNs). Recent data fromthe National Malaria Control Programme (NMCP) indicate that the proportion of pregnant women sleepingunder ITNs has increased to 28%12.
• Intrapartum care
Only 47% of all births in Tanzania occur at health facilities and 46% of all births are assisted by a skilledhealth worker. Out of the 53% of births which take place at home, 31% are assisted by relatives, 19% bytraditional birth attendants (TBAs) and 3% are conducted without assistance. As expected, births to womenin the highest wealth quintile are more likely to be assisted by a skilled birth attendant (87%) than womenin the lowest quintile (31%)13.
Emergency obstetric care services are crucial for handling complicated deliveries. Findings from TDHS(2004/05) revealed that only 3% of all babies were delivered by caesarean section – this figure is belowthe WHO-recommended standard of 5-15%, and is partially due delay in timely referral, lack of skilledattendance and functioning blood banks at most hospitals and health centres. About 64.5% of publichospitals provide Comprehensive Emergency Obstetric Care (CEmOC), whereas only 5.5% of public healthcentres are providing Basic Emergency Obstetric Care (BEmOC)14. Furthermore, the referral system hasserious challenges including limited number of ambulances; unreliable logistics and communicationsystems; and inadequate community-based facilitated referral systems.
• Postnatal care
Postnatal care is an important component of good maternal and baby health care is not very well utilizedin Tanzania. Eighty-three percent of women who delivered a live baby outside the health facility did notreceive a postnatal check-up, and only 13% were examined within two days of giving birth asrecommended. Women in the highest income quintiles were more likely to receive a timely postnatal check-up compared to those in the lowest quintiles15.
Prevention of Mother-to- Child Transmission of HIV
The key to ensuring an HIV-free start in life is prevention of HIV transmission to children by preventingHIV in mothers. PMTCT interventions include testing and counselling for HIV, antiretroviral prophylaxisfor HIV-infected pregnant women and their exposed children, treatment of eligible women, counselling andsupport for infant feeding, safer obstetric practices and family planning to prevent unintended pregnanciesin HIV-infected women. By September 2007, there were about 1,311 PMTCT sites established withinreproductive and child health (RCH) clinics throughout the country16. Additional sites need to be establishedto provide services as close to the community as possible. The goal, objectives and strategies to scale upquality PMTCT services are stipulated in the Health Sector Strategy for HIV/AIDS (2008-2012).
4 The National Road Map Strategic Plan -2008 - 2015
12 NMCP-MoHSW 200713 TDHS 2004/0514 MoHSW, 2006. Situation Analysis of Emergency Obstetric Care for Safe
Motherhood in Public Health Facilities in Tanzania 15 TDHS 2004/0516 NACP 2007
The National Road Map Strategic Plan -2008 - 2015 5
Integration of PMTCT interventions in ANC, nutrition programmes, IMCI and other HIV/AIDSservices enhances opportunities for reducing paediatric HIV and its associated deaths.
• Nutrition
Maternal nutrition during the pre- and postnatal periods is extremely important for the outcome ofpregnancy as well as infant feeding. A good and adequate balanced diet, as well as vitamin and mineralsupplementation, improves birth outcome and maternal well-being.
Underweight status contributes to poor maternal health and birth outcomes. Overall, 10% of Tanzanianwomen of reproductive age (15–49 years) are considered to be undernourished, having a Body Mass Index(BMI) of less than 18.5. Women living in rural areas are more affected compared to those living in urbanareas17.
Maternal under-nutrition, is often reflected in the proportion of children born with low birth weight (below2.5 kg). Representative data on the prevalence of low birth weight babies is not readily available butestimates from UNICEF suggest that 10 % of Tanzanian newborns are low birth weight18.
Pregnant women are particularly vulnerable to anaemia due to increased requirements for iron and folicacid. According to TDHS (2004/05), 48% of women aged 15-49 years were found to be anaemic, whereas58% of pregnant women and 48% of breast-feeding mothers were anaemic. Ten percent of pregnant womentook iron tablets for at least 90 days, while about half (52%) took iron tablets for less than 60 days, and 38%did not take iron tablets at all. Haemorrhage is the most frequent cause of maternal deaths, and pregnantwomen who are anaemic are more vulnerable to postpartum haemorrhage.
• Family planning
Spacing the intervals between pregnancies can prevent 20 to 35% of all maternal deaths19. However, familyplanning services continue to face challenges in meeting clients’ expectations and needs. Despite havinghigh knowledge of contraceptives (90%), only 26 % of married women use any method of contraception,with only 20% using a modern method. The most commonly used methods are injectables (8%), pills (6%)and traditional methods (6%)20. Current usage of any modern method is higher among sexually activeunmarried women than among married women (41% and 26%, respectively). To be noted is the fact thatthe percentage of married women using any method of contraception has changed little from the 1999TRCHS. The total demand for FP among married women is 50%, while 22% have an unmet need for FP21.
Factors contributing to low contraceptive prevalence include low acceptance of modern FP methods, erraticsupplies of contraceptives with limited range of choices, limited knowledge/skills of providers andprovider’s bias affecting informed choice. The situation is worsened by limited spousal communication,inadequate male involvement and lack of adolescent-friendly health services and misconceptions aboutmodern family planning methods. In an attempt to improve access to family planning services, community-based programmes are being implemented in 46 mainland districts; however, this represents less than halfof all districts in the country.
• Challenges in accessing quality careData from TDHS (2004/05) revealed that the major barriers perceived by women in accessing deliveryhealth services include lack of money (40%), long distance to health facility (38%), lack of transport (37%),and unfriendly services (14%). The high rate of home deliveries is also attributable to a malfunctioningreferral system, inadequate capacity of health facilities in terms of available space, skilled attendants andcommodities, and other socio-cultural aspects affecting the pregnant women. Additional factors includegender inequalities in decision-making and access to resources at household-level.
17 TDHS 2004/0518 State of the World’s Children Report, 200819 Singh S. et al. 2004. Adding it Up: The Benefits of Investing in Sexual andReproductive Health Care. Washington D.C. and New York: The Alan Guttmacher
Institute and UNFPA.20 TDHS 2004/0521 TDHS 2004/05
• Maternal morbidity and mortalityAccording to TDHS (2004/05), the maternal mortality ratio is estimated at 578/100,000 live births.Major direct causes of maternal mortality include obstetric haemorrhage, obstructed labour, pregnancyinduced hypertension, sepsis and abortion complications.
It is estimated that abortion complications contribute to about 20% of maternal deaths worldwide22. InTanzania, induced abortion is illegal hence the actual magnitude of the problem is not known. However,several attempts have been made to document the severity of the issue – in Hai District, for example, it wasreported that nearly a third of maternal deaths are related to unsafe abortion (Mswia et al, 200323). Postabortion care (PAC) services can significantly reduce maternal mortality due to unsafe abortions; however,only 5% of health facilities in Tanzania currently provide this service24.
Indirect causes leading to poor maternal health outcomes are malaria, anaemia, and HIV/AIDS. Withspecific regard to HIV, prevalence in Tanzania is estimated to be 7% in adults aged 15-49 years, withprevalence among women being higher (8%), compared to 6% among men25.
2.2 Newborn Health
• Newborn morbidity and mortalityTanzania is among those countries that have had success in reducing child mortality, but there has been nomeasurable progress in reducing neonatal deaths. The neonatal mortality rate was 40.4 per 1,000 live birthsin 1999 and 32 per 1,000 live births in 2004/05. Up to 50% of neonatal deaths occur in the first 24 hoursof life, with over 75% of them arising in the first week of life. Newborn mortality is a sensitive indicatorof the quality of care provided during the antenatal period, delivery and immediate postnatal period.
According to modelled estimates for Tanzania, 79% of newborn deaths are due to three main causes:infections including sepsis/pneumonia (29%), birth asphyxia (27%); and complications of preterm birth(23%) (Figure 2). Sepsis was the most common cause of death noted in a study conducted in Mbulu and
6 The National Road Map Strategic Plan -2008 - 2015
Figure 1: Direct Causes of Maternal Deaths
Source: The World Health Report, 2005
22 The World Health Report, 200523 Mswia et al, 2003. Community Based Monitoring of Safe Motherhood in UnitedRepublic of Tanzania
24 TDHS 2004/0525 THIS, 2003/04
The National Road Map Strategic Plan -2008 - 2015 7
Hanang districts of rural northern Tanzania26. Many of these conditions are preventable and closelylinked to the absence of skilled birth attendance at delivery. Eighty-six percent (86%) of neonataldeaths in Tanzania are also low birth weight, many of whom are preterm. On average in Tanzania, newborn deaths are 67% higher in the poorest families as compared to the wealthier families, and themajority of deaths occur in rural areas27.
Low birth weight (birth weight less than2500 grams) and preterm birth (less than36 completed weeks of gestation) togethercontribute to 28% of neonatal deathsglobally28. The recent Tanzania DHS(2004/05) asked mothers to estimatewhether their infant was “very small,small, average, or large”. They were alsoasked to report the actual birth weight, if itwas known. The TDHS data cite aneonatal mortality of 86% in the five-yearperiod prior to the survey among“small/very small” newborns. However,other all-cause mortality estimates indicatea mortality rate of 23% for preterm infants(who are most likely also of low birthweight.).
• Continuum of careIt is important to address the coverage of interventions along the continuum of care from pregnancy,neonatal period, infancy and childhood. It is critical to note that the coverage of essential interventions islowest at the time when needed most: that is, during child birth and the early neonatal period whenmore than 50% of maternal and newborn deaths occur (Figure 3).
Source: 2004/5 TDHS
Figure 2: Estimated Causes of Neonatal Deaths
Figure 3: Coverage of Interventions along the Continuum of Care in Tanzania
Source: Opportunities for Africa’s Newborns, Lawn JE, et al 2006
26 Hinderraker et al, 200327 TDHS, 2004/0528 Lancet Neonatal Survival Series, 2005
• Other challenges
Furthermore, quality newborn and child care faces other challenges including poor health infrastructureand referral for neonatal care, child care and poor skills of service providers related to inadequateincorporation of neonatal content in pre- and in-service training curricula. A recent study conducted in Dares Salaam in 2005 showed that none of the primary and secondary level health facilities was providingbasic/essential newborn care.
2.3 Child Health
• Immunization
The Expanded Programme of Immunization (EPI) has performed well over thepast decade with immunization coverage of 71% for all vaccines for children 12-23 months (TDHS, 2004/05). Currently the policy is to provide each child withone dose of BCG, four doses of OPV, three doses of DTP-HB and one dose ofmeasles vaccine. As expected, children born to mothers in the lowest wealthquintile are less likely to be fully immunized than those born to mothers in thehighest wealth quintile.
Pneumonia is one of the major contributors towards under five mortality and it accounted for 21.1% ofunder five deaths in 2006. The Lancet series on child survival identifies Hib vaccine as an intervention thatcould reduce under five mortality due to pneumonia by 20%. Plans are under way to consider introductionof Hib and pneumococcal vaccines in the national policy.
Measles outbreaks are still happening despite high measles routine immunization coverage (above 80% inalmost all districts). Tanzania has been implementing the Reaching Every District (RED) strategy toimprove immunization coverage for all antigens including measles but also conducting periodic measlessupplementation immunization campaigns after every three years.
The achievement of TT and polio vaccines is evident by the significant reduction in neonatal tetanus deathsand polio cases. The last polio case in the country was identified in 1996; however, there is a high risk ofwild polio virus importation from polio-endemic countries. In this regard polio eradication initiatives needto be sustained until polio is eradicated.Tanzania is close to achieving Maternal Neonatal Tetanus (MNT) elimination; however, there are still
some pockets in high risk districts. Implementation of MNT elimination strategies will focus more in highrisk districts.
• Integrated Management of Childhood Illness
Case management of common childhood illness is a key step to reducing child mortality. Appropriatemanagement of malaria, pneumonia, diarrhoea and dysentery can reduce under five mortality by 5, 6, 15and 3% respectively. The IMCI strategy has been implemented at scale in Tanzania from 1996 with alldistricts implementing at different levels of coverage. Tanzania was part of an IMCI inter-country evaluationand the results were encouraging, but issues around quality of care and supervision were noted29.
IMCI has been found to be an effective delivery strategy for various child survival interventions and hascontributed to a 13% mortality reduction over a two-year period in those districts in Tanzania where it hasbeen implemented30. Management of diarrhoeal disease has been improved to include low osmolarity oralrehydration solution (ORS) and zinc supplementation. The IMCI clinical guidelines have been updatedaccordingly and have also included the newborn, HIV/AIDS and strengthened nutrition.
8 The National Road Map Strategic Plan -2008 - 2015
29 MCE Report, 200530 MCE Report, 2005
Only 20% of women
receive Vitamin A
supplementation
within 2months
after childbirth.
The National Road Map Strategic Plan -2008 - 2015 9
• Prevention and management of malaria
Malaria contributes to 23% percent of under five mortality in Tanzania31. Use of ITNs contributes to7 percent reduction of overall deaths among under-fives 32. Only 47% of under fives in Tanzania sleepunder ITNs33. ITNs are distributed through the health system by vouchers, as well as by free distribution oflong lasting insecticide treated nets (LLINs) through catch up campaigns and replacement campaigns toreplace worn out ITNs in the period 2008 – 2012 when appropriate.
Malaria management has been improved using the combination therapy of Artemether and Lumefantrine(ALu). The MoHSW is training district focal persons for both IMCI and malaria and regional focalpersons for coordination of malaria and IMCI interventions. Since a good proportion of caretakers seektreatment outside of the health facility, the MoHSW is also training the private sellers to dispense basicessential drugs to the community through Accredited Drug Dispensing Outlets (ADDOs).
• Care seeking
Care seeking for sick children needs to be improved. The TDHS 2004/05 showed that among children withsymptoms prior to the survey, half of the children (57%) with symptoms of Acute Respiratory Infection(ARI) or fever and 47% of children with diarrhoea were taken to a health facility. Those in urban areas weremore likely than rural children to be taken to the health facility. However, a vast majority of the childrenwith diarrhoea (70%) were also given some form of ORT and 54% were given a solution prepared fromORS.
In Tanzania, although access to health services is good, many people seek care when it is too late or notat all. Attention should be paid to the fact that only 57% of under-fives receive anti- malarial treatmentwithin 24 hours of developing symptoms. In this perspective the MoHSW has always prioritizedcommunity IMCI (c-IMCI) as a way of identifying danger signs among under-fives and when to seekcare.
• Nutrition
Nutrition indicators for under-fives have shown some improvement over the years but undernutrition is stillwidely prevalent in Tanzania. Stunting, underweight status and wasting among children aged 0-59 monthshave reduced from 44%, 29% and 5% in 1999 to 38%, 22% and 3% respectively34 . Anaemia is also highlyprevalent among under-fives with 72% of all 6-59 months children being anaemic. The main causes ofanaemia are nutritional deficiency, intestinal worms and malaria.
Optimal breastfeeding can reduce under-five mortality by up to 13%35. The majority of Tanzanian babiesare breastfed, for a median duration of 21 months. Fifty-four percent (54%) are breastfed up to two years.However, initiation of breastfeeding within one hour of birth is only 59% and the exclusive breastfeedingrate (0-5 months of age) is estimated to be 41%36 . Early complementary feeding is common with 39% ofinfants below 3 months already introduced to complementary foods37. About 12% of infants are notcomplemented at the age of 6-7 months. Furthermore feeding frequency during complementation is too low(about 2-3 feeds a day), nutrient density is low and the preparation and feeding practices are often unsafe38.Children 2 – 5 years old are fed family foods; however, feeding frequency and nutrient density are alsoinadequate in this group.
Coverage of health workers trained on infant and young child feeding is low and only 68 have beenaccredited as baby friendly39. Training on Essential Nutrition Actions (Vitamin A supplementation, exclusivebreastfeeding, complementary feeding, iodine) is in the early stages of implementation. Coverage of
31 Country Health System Fact Sheet 2006, WHO32 Lancet Child Survival Series, 200333 TNVS Survey, 2007
34 TDHS, 2004/0535 Lancet Child Survival Series, 200336 TDHS, 2004/05
37 TDHS, 2004/0538 TDHS, 2004/0539 Communication with TFNC, April 2008
appropriate facility management of severe malnutrition is still low and community management ofsevere malnutrition has not been implemented.
Vitamin A deficiency is the leading cause of preventable blindness in children and raises the risk of diseaseand death from severe infections. Vitamin A supplementation twice a year has been estimated by the WorldBank (1993) to be one of the most cost-effective health interventions, yet in Tanzania the coverage is only20%40. Currently the biannual Vitamin A supplementation campaign is the main strategy to combat vitaminA deficiency and it is estimated that the coverage is 85%41.
Iodine deficiency during pregnancy has a great impact on physical and mental development of the foetusand is related to poor educational outcomes and productivity. In Tanzania the prevalence of goitre amongschool children is estimated at 7%42. Salt iodation is the most effective strategy for the control of iodinedeficiency. However, currently only 75% of households consume iodated salt43.
• Child morbidity and mortality
Although the most recent Demographic Health Survey (TDHS, 2004/5) has shown decline in under-fiveand infant mortality by 24% and 31% respectively to 112 and 68 per 1,000 live births, the infant and under-five mortality rates in Tanzania are still unacceptably high. Every year about 154,000 children die beforereaching their fifth birthday. In addition, as expected, the mortality rates are highest in the lowest, secondand middle wealth quintiles (137, 156 and 147, respectively) as compared to the highest wealth quintile(93).
Although under-fives constitute about 16% of the population, they account for 50% of the total mortalityburden for all ages. Most of these deaths are due to preventable diseases. Malaria, pneumonia, diarrhoea,HIV/AIDS and neonatal conditions account for over 80% of deaths. Malnutrition is a contributory factorto about fifty percent of all deaths.
The under-five mortality rate for children whose mothers were less than 20 years of age when they gavebirth is 157/1,000, versus 120/1,000 for children whose mothers were in their twenties. Children whose birthorder is seven or higher have a mortality rate of 151/1000, compared with 121/1,000 for those born secondor third.
10 The National Road Map Strategic Plan -2008 - 2015
40 TDHS, 2004/0541 Helen Keller International, 2004/05
42 TFNC, 2004/0543 NBS and TDHS 2004/05
The National Road Map Strategic Plan -2008 - 2015 11
• Adolescents
Adolescents constitute a significant proportion of the population, at about 31% 44. A high percentage ofadolescents are sexually active and practice unsafe sex. Consequently, the majority of them are highlyvulnerable to SRH problems that include adolescent pregnancy and early child bearing, the complicationsarising from unsafe abortion, and STIs including HIV/AIDS45. In Tanzania, more than half of young womenunder the age of 19 are pregnant or already mothers, and the perinatal mortality rate is significantly higherfor young women under the age of 20 (at 56 per 1,000 pregnancies) than it is for women aged 20-29 (at 39per 1,000 pregnancies), and older women aged 30-39 (32 per 1,000 pregnancies). Obtaining permission toaccess services is a greater obstacle for young women age 15-19 than for their older counterparts. Youngwomen age 15-19 also cited not knowing where to go as a barrier to accessing services46. Hence the needto invest in adolescent sexual reproductive health (SRH) services, including HIV/AIDS is paramount giventhe fact that SRH needs are not only basic human rights but that adolescents forma significant section of the population and bear a disproportionate burden ofdisease with regards to reproductive ill-health and HIV prevalence
2.4 Cross-Cutting Issues
• National Policies and GuidelinesTanzania has mainstreamed maternal, newborn and child survival into its nationalhealth policy. The services for maternal, newborn and child health are exemptedfrom cost sharing. However, the exemption policy faces difficulties in itsimplementation at lower level due to lack of clarity on how to effect theexemption mechanisms.
Several national policy documents have been developed targeting improvement of reproductive and childhealth services, which include maternal and newborn health. However, certain professional regulationsand legislations contribute to compromised implementation of the policies.
The MoHSW and partners have developed several clinical national protocols; however, there is need to havean integrated protocol. Although training on RCH interventions has been ongoing nationally through theMoHSW, district councils and NGOs, the quality of the trainings, transfer skill to practice and follow up
Figure 4: Causes of Deaths for Children Aged less than Five Years,in the Year 2006*
Source: WHO, 2006
44 Census, 200245 National Adolescent Health and Development Strategy, 2004-2008
46 TDHS, 2004/05
Good governance is
participatory,
consensus-oriented,
accountable,
transparent,
equitable, and
follows the rule of
law.
supervision are still challenges that need to be addressed. National capacity development is alsocompromised by poor working environment; low geographical coverage; weak integration of gender and
human rights issues.
• Community Mobilization and ParticipationCommunity-based maternal, newborn and child health interventions are crucial in complementing servicesat the health facility level. Since the Alma Ata Declaration on Primary Health Care (PHC) in 1978 and thesubsequent health sector reforms initiated in 2000, there has been increased focus on communityparticipation in the delivery of health services. Community participation has been strengthened further bylocal Government reforms, which interface the health sector within the overall Government policy ofdecentralization by devolution. In Tanzania communities play an increasingly important role in thedevelopment of the Comprehensive Council Health Plans (CCHPs) through the decentralised districtplanning framework. Further community participation has been strengthened through communityrepresentation on the Council Health Service Boards and Health Facility Governing Committees.
Though a few districts have been successful in involving communities in the process of planning,monitoring and evaluation of health services, their participation is still compromised by the low capacityof health boards and health facility governing committees and inadequate outreach activities.
Other challenges include weak partnership between clients and service providers, which is compoundedby low awareness of clients’ and service providers’ rights and obligations; low public awareness ofreproductive health matters such as management of pregnancy, newborn care and child care and relatedcomplications, socio-cultural barriers; gender inequalities, low women empowerment; and myths andmisconceptions of various health-related issues.
• Water, Sanitation and HygieneThe proper sanitation, hygiene and use of safe water are vital in containing the spread of water borne andwater related diseases. The TDHS (2004/0) also showed that during the two weeks that preceded the survey13% of children under-five had diarrhoea. The rate was highest among children 6-11 months old (25%).
Less than half of all households are within 15 minutes of their drinking water supply. Nineteen percent ofurban households have water piped into their compound and 33% from neighbours’ taps while ruralhouseholds primarily rely on public wells both open and protected (43%) and rivers and streams (18%) fortheir drinking water. About a half of households (47%) have improved toilets.
Improved household water, sanitation and promotion of key hygiene behaviour changes will be critical tocomplement and strengthen the essential health package. Various community-based interventions are beingimplemented to improve hygiene and sanitation such as Participatory Hygiene and SanitationTransformation (PHAST) and c-IMCI.
• Human ResourcesHuman resources for health is a crisis in the country with only one-third of posts filled. The situation isworse especially for the lower-level health facilities, where dispensaries and health centres haveshortages of 65.6% and 71.6% respectively47. This has a major impact on maternal, newborn andchildcare, most significantly recognizable in the lack of skilled attendants during childbirth. Efforts arebeing made by MoHSW to recruit additional skilled health providers but challenges remain such as poorskills mix; non-attractive incentive and salary packages; poor motivation; inadequate performanceassessment; rewarding systems; retention of staff especially in remote and hard to reach areas;.
• Monitoring and Evaluation
12 The National Road Map Strategic Plan -2008 - 2015
47 MoHSW, 2006
The National Road Map Strategic Plan -2008 - 2015 13
Monitoring and evaluation play a critical management function by assessing whether implementationof programmes proceeds according to plan and leads to the desired outcomes. Monitoring of maternal,newborn and childhood health in Tanzania has been implemented through HMIS, annual RCH reports,TDHS, Tanzania Service Provision Assessment (TSPA), maternal and perinatal death review reports,Infectious Disease Week Ending Report (IDWE) and other health facility and household surveys. Some ofthe limitations in reporting maternal, newborn and child deaths are the problem of incorrect and incompleterecording, proper case definition, data management, source of information (i.e. facility versus community-based data) and methods of estimation. Further, the use of process indicators is critical for evaluation ofimplementation. However, process indicators are not widely used at all levels. In order to achieve coherentand useful data for monitoring and evaluation of maternal, newborn and child health in Tanzania it is crucialto strengthen the current health information system to address the information gaps for maternal, newbornand child care.
• Advocacy and Resource MobilizationAlthough there has been advocacy and commitment at different levels in addressing maternal, newborn andchild health issues, the meagre budget allocation to the health sector has been a hindrance to effectiveimplementation of the Essential RCH Package. During FY 2005/06, the health budget allocation was Tsh.453.2 billion, which is 10.1% of the total Government budget, below the recommended Abuja target of15%. Due to other competing health priorities such as malaria, HIV/AIDS and tuberculosis, the budgetallocation for reproductive and child health is still limited.
Opportunities and synergies for addressing maternal, newborn and child health include introduction andscaling up of the TASAF II initiative, which will enable communities to address their infrastructuredevelopment needs, logistics and human capacity gaps, in order to provide appropriate maternal, newbornand child care interventions and services. The existence of the Joint Rehabilitation Fund, District DemandDriven Initiative, GAVI and Global Fund for AIDS, TB and Malaria, also provide opportunities for thedistricts to strengthen maternal, newborn and child health interventions.
• Partnerships and CoordinationMaternal, newborn and child health interventions need to be addressed in the context of a multi-sectoralapproach. Partnerships, resources and more effective and coordinated programmes at all levels areincreasingly needed to reach the MDGs.
Due to other competing health priorities such as
Malaria, HIV/AIDS and Tuberculosis, Reproductive
and Child Health budget is still limited. This has
affected implementation of comprehensive
interventions on maternal, family planning and
newborn care.
14 The National Road Map Strategic Plan -2008 - 2015
Strategic Plan
The National Road Map Strategic Plan -2008 - 2015 15
CHAPTER 3: STRATEGIC FRAMEWORK
Maternal, Newborn and Child Health Strategic Plan
The development of the MNCH Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deathsis a response to the New Delhi Declaration (April 2005) which urged all countries to develop strategies toreducing the persistently high rates of maternal, newborn and child deaths in order to reach MDG 4 and 5. Thisplan is expected to contribute to the achievement of MKUKUTA and MMAM goals and targets, as well asobjectives and targets of other existing national programmes, interventions and strategies, which focus onimproving MNCH.
This strategic plan aims to address maternal, newborn and child health and accelerate mortality reduction in anintegrated manner addressing the continuum of care. The rationale for taking the integrated approach relies ona number of factors:
1. Specific interventions delivered in a specific time frame have multiple benefits.
2. Linking interventions in packages can reduce costs, facilitate greater efficiency in training, monitoring andsupervision, and strengthen supply systems.
3. Integration of services increases uptake and promotes continuation of positive behaviours
4. Integration maximizes programme achievements
3.1. VisionA healthy and well-informed Tanzanian population with access to quality MNCH services, which areaffordable, sustainable and accessible through an effectively functioning health system.
3.2. MissionTo promote, facilitate and support in an integrated manner, the provision of comprehensive, high impactand cost-effective MNCH services, in order to accelerate reduction of maternal, newborn and childmorbidity and mortality.
3.3. GoalTo accelerate the reduction of maternal, newborn and childhood morbidity and mortality, in line withMDGs 4 and 5, by 2015.
3.4. ObjectivesThe following are the objectives for the MNCH Strategic Plan, which should be met by the end of the year2015.
3.4.1. To reduce maternal mortality from 578 to 193 per 100,000 live births.
3.4.2. To reduce neonatal mortality from 32 to 19 per 1000 live births
3.4.3. To reduce under-five mortality from 112 to 54 per 1000 live births
3.5 Operational targets to be achieved by 2015
1. Increased coverage of births attended by skilled attendants from 46% to 80%.
2. Increased immunization coverage of DTP-HB 3 and Measles vaccine to above 90% in 90% of thedistricts.
3. New EPI vaccines introduced (Hib, Pneumoccocal, Human Papilloma Virus (HPV) and Rota Virus
vaccines).
4. Reduced stunting and underweight status among under-fives from38% and 22% to 22% and 14%,respectively.
5. Increased exclusive breast feeding coverage from 41% to 80 %
6. PMTCT services provided to at least 80% of pregnant women, their babies and families.
7. 90% of sick children seeking care at health facilities appropriately managed.
8. Increased coverage of under-fives sleeping under ITNs from 47% to 80%.
9. 75% of villages have community health workers offering MNCH services at community level.
10. Increased modern contraceptive prevalence rate from 20% to 60%
11. Increased coverage of CEmOC from 64% of hospitals to 100% and of BEmOC from 5% of healthcentres and dispensaries to 70%
12. Increased proportion of health facilities offering Essential Newborn Care to 75%.
13. Increased antenatal care attendance for at least 4 visits from 64% to 90%
14. Increased number of health facilities providing Adolescent friendly reproductive health services to80%
3.6.Strategies
3.6.1. Advocacy and resource mobilization for MNCH goals and agenda in order to promote, implement, andscale up evidence-based and cost-effective interventions, and allocate sufficient resources to achievenational and international goals and targets;
3.6.2. Health System strengthening and capacity development at all levels of the health sector and ensuringquality service delivery to achieve high population coverage of MNCH interventions in an integratedmanner;
3.6.3. Community mobilization and participation to improve key maternal, newborn and child care practices,generate demand for services and increase access to services within the community;
3.6.4. Fostering partnership to implement promising interventions among Government (as lead), donors,NGOs, the private sector and other stakeholders engaged in joint programming and co-funding of activitiesand technical reviews;
3.6.5.Information, education and communication /behavioural change communication (IEC/BCC).Promotion of appropriate reproductive health behaviours is critical in accelerating reduction of maternal,newborn and child deaths. With implementation of the MNCH Strategic Plan, the use of IEC/BCCapproaches for positive behaviour adoption and create demand for quality maternal, newborn and child care.
3.7.Guiding Principles
The following principles will guide the planning and implementation of the MNCH Strategic Plan in orderto ensure effectiveness, ownership and sustainability of the initiative in Tanzania:
• Continuum of Care: Ensuring provision of the continuum of care from pregnancy, childbirth andneonatal period through childhood and across all services levels from family/household, community,and primary facility to referral care.
• Integration: All efforts will be made to implement the proposed priority interventions at various levels
16 The National Road Map Strategic Plan -2008 - 2015
The National Road Map Strategic Plan -2008 - 2015 17
of the health system in a coherent and effective manner that is responsive to the needs of themother, the newborn and the child.
• Evidence-based approach: ensuring that the interventions promoted through the plan are basedon priority needs, up-to-date evidence, and are cost-effective.
• Complementarities: Building on existing programmes by taking into account the comparativeadvantages of different stakeholders in the planning, implementation and evaluation of MNCHprogrammes.
• Partnership: Promoting partnership, coordination and joint programming among stakeholdersincluding the regional secretariat, district councils, private sector, faith-based sector, academia,professional organizations, civil society organizations, as well as communities, in order to improvecollaboration and maximize on the available limited resources by avoiding duplication of effort
• Addressing underlying causes of high mortality: Taking a multi-sectoral and partnership approachto address the underlying causes of maternal, newborn and child death such as, transport, nutrition, foodsecurity, water and sanitation, education, gender equality and women empowerment to ensuresustainability.
• Shared responsibility: The family/household is the primary institution for supporting holistic growth,development and protection of children. The community has the obligation and the duty to ensure thesurvival and health of mothers and children and ensuring that every child grows to its full potential.The state, on the other hand, has the responsibility for developing a conducive legislation and publicservice provision for survival, growth and development.
• Division of labour for increased synergy: Defining roles and responsibilities of all players andpartners in the implementation, monitoring and evaluation of the activities for increased synergy.
• Appropriateness and relevance: Interventions must rely on a clear understanding of the status andlocal perceptions of MNCH in the country.
• Transparency and accountability: Promoting a sense of stewardship, accountability and transparencyon the part of the Government as well as stakeholders for enhanced sustainability.
• Equity and accessibility: Supporting scaling-up of cost-effectiveinterventions that promote equitable access to quality healthservices with greater attention to the youth, poor and mostvulnerable children and groups, especially in rural and underservedareas.
• Phased planning, and implementation: Promotingimplementation in clear phases with timelines and benchmarks thatenable re-planning for better results. Building and strengtheningexisting health infrastructures will be a priority.
• Human rights and gender in health: The right to life is a basichuman right. Mainstreaming gender throughout the programmeand adopting a human rights approach as the basis of planning andimplementation is important. It is also critical to understand thatchildren’s rights are important human rights and therefore need tobe respected at all times in order to uphold the dignity that enableschild development and participation.
For majority of women,
especially the poor and
disadvantaged groups,
the pathway to safe
motherhood is blocked
by the underlying
factors that lead to
delays in accessing
appropriate care.
CHAPTER 4: IMPLEMENTATION FRAMEWORK
4.1 Introduction
The MNCH Strategic Plan has been designed to accelerate the reduction of maternal newborn and child deathswith the aim of attaining MDGs 4 and 5 by 2015. It should be implemented jointly by all stakeholders as a multi-sectoral strategy for comprehensive reproductive and child health care.
Good governance is a critical element for successful implementation of the strategic plan, right from central levelto the grass root level. Good governance is participatory, consensus-oriented, accountable, transparent, equitable,and follows the rule of law. It assures that corruption is minimised, and voices of the most vulnerable in societyare heard in decision making.
The MNCH Strategic Plan will be implemented in collaboration with relevant stakeholders, which includerelated Ministries and agencies, development partners, the civil society, community based organisations,professional associations, faith-based organisations, voluntary agencies, and the private sector, among others.
4.2. Specific Roles and Responsibilities of Different Levels
4.2.1 Ministry of Health and Social Welfare (National Level)
The MoHSW will mobilise resources and advocate for reduction of maternal, newborn and child deaths. It willalso be responsible for the overall technical leadership, guidance and advice on the implementation andmonitoring of the strategic plan. The following will be the specific roles and responsibilities of the variousDirectorates of the MoHSW.
i) Directorate of Policy and Planning will ensure adequate budget allocation for MNCH and mainstreamingof MNCH indicators into policy frameworks. The HMIS Unit will facilitate the monitoring of all indicatorsfrom routine data collection systems including community-based data through Community BasedManagement Information System (CBMIS).
ii) Directorate of Hospital Services will ensure availability of essential drugs, supplies, equipment anddiagnostics by facilitating efficient procurement and distribution to all levels of service delivery.
iii) Directorate of Human Resource and Development. The training department will be responsible to reviewand update pre- and in-service curricula to ensure relevant issues for MNCH are adequately addressed.The department will also promote accelerated training of mid-level cadres in order to increase the availablenumber of skilled health workers, and will facilitate effective development, recruitment and deploymentof skilled health workers at health units to address the human resource crisis48. This will be done incollaboration with the Prime Minister’s Office - Regional Administration and Local Government(PMORALG) , the President’s Office - Public Service Management (POPSM) and Ministry of Financeand Economic Affairs..
iv) Directorate of Preventive Services will supervise and coordinate all activities with respect to allsections under its charge for the realisation of the strategic plan objectives. It will particularly undertakethe following activities:• Advocate for the implementation of the MNCH Strategic Plan by • Coordinate the implementation, monitoring of MNCH activities• Involve and collaborate with various stakeholders at all levels for planning and implementation of the
MNCH Strategic Plan
18 The National Road Map Strategic Plan -2008 - 2015
48 MMAM
The National Road Map Strategic Plan -2008 - 2015 19
• Facilitate capacity development at national, zonal, regional and district levels by developingprotocols and training packages for MNCH
• Design and develop IEC/BCC materials with stakeholders and disseminate them to the intendedusers
• In collaboration with the procurement unit, facilitate procurement of communication equipment andits installation at hospital, health centres and selected dispensaries
• Identify and propose disaggregated indicators and update monitoring data collection tools to includeprocess indicators for EmOC, newborn care, nutrition, postnatal care, child care and Adolescent healthincluding functioning monitoring and evaluation systems and userfirendly data base
• Review and harmonize existing CBMIS, in collaboration with the district councils• Facilitate integration of nutrition actions in maternal, newborn and child care programmes.• Promote research on MNCH including FP and nutrition• Capacity developemnt for the implementation of maternal, newborn, child and Adolescent health
4.2.2 Zonal Level• Disseminate the MNCH Strategic Plan to their respective districts• Support capacity development in MNCH in the districts• Zonal Training Centres and ZRCH coordinator maintain effective partnership with key stakeholders
(MoHSW- RCHS, RHMTs, CHMTs, NGOs, CBOs etc)• Conduct and build research capacity in the regions and districts
4.2.3 Regional Level• Provide technical support for effective planning and implementation of the integrated MNCH activities in
the CCHPs.• Coordinate, monitor and supervise MNCH activities in the region• Technical support for training and ensuring quality in service provision• Support districts in analysis and utilization of MNCH data and disseminate/report to the national level
4.2.4 District Level• Disseminate MNCH Strategic Plan to all stakeholders in the District Council including NGOs, FBOs and
other private sector partners.• Incorporate MNCH activities into the CCHPs• Coordinate and supervise all MNCH activities planned and implemented by all stakeholders in the district• Provide technical support for quality MNCH services• Capacity development for facility and community MNCH interventions• Follow up maternal, perinatal, neonatal and child death reviews at health facility (dispensaries, health
centres, district hospitals, regional hospitals, as well as voluntary agencies and private hospitals) andcommunity levels
• Council Management Teams and District Health Boards to ensure adequate resource allocation forimplementation and monitoring of the MNCH interventions
4.2.5 Health Facility (Dispensary, Health Centre and Hospital)• Incorporate MNCH activities into facility health plans• Provide quality MNCH services• Implement quality improvement approaches such as Quality Improvement and Recognition Initiative
(QIRI), Pay for Performance, Integrated Management Cascade and Collaborative Approach• Ensure timely availablity of essential equipment, supplies and drugs for service MNCH provision• Conduct maternal, perinatal, neonatal and child death reviews, involving the community• Health facility committees to monitor and ensure quality MNCH service provision• Provide technical and supportive supervision to community interventions
4.2.6 CommunityThe Village Government and Ward Development Committee through the Primary Health Care (PHC)
committee and health facility governing committee will be responsible for supervision and implementationof MNCH activities in their areas. Other responsibilities include:
• Facilitate development and monitoring of community MNCH action plans• Mobilize the community to participate in community interventions• Establish and/or strengthen CBMIS• Leverage community resources for the implementation of MNCH interventions
4.2.7 Roles and Responsibilities of other Ministries Key Ministries should be involved to ensure that the reduction of maternal, newborn and child mortality ishigh on their agenda. These include Ministry of Finance and Economic Affairs (MoFEA), PMORALG,Ministry of Community Development Gender and Children (MoCDGC), Ministry of Education andVocational Training (MoEVT), Ministry of Agriculture, Food Security and Cooperatives (MoAFSC),Ministry of Labour, Employment and Youth Development (MoLEYD), Ministry of InfrastructureDevelopment (MoID), Ministry of Communication, Science and Technology (MoCST), and Ministry ofInformation, Culture and Sports (MoICS).
i) Ministry of Finance and Economic Affairs• Give priority to health, especially MNCH, in budget guidelines for allocation of resources• Increase financial resources for health and especially implementation of MNCH activities as guided by the
MNCH Strategic Plan
ii) Prime Minister’s Office Regional Administration and Local Government• Provide technical support to regions and councils for planning and implementation of CCHPs• Mobilize funds to support implementation of CCHPs including CBMIS• Support infrastructural development, rehabilitation and maintenance to improve access for MNCH services• Include maternal, perinatal, newborn and child health indicators in the national health sector monitoring
and evaluation framework.
iii) Ministry of Education and Vocational Training• Promote universal access to education, especially education for girls and women• Review and update components of MNCH and SRH in various school and pre-service curricula in
collaboration with MoHSW particluarly on provision of adolescent friendly services
iv) Ministry of Agriculture, Food Security and Cooperation• Promote food security at household, community, district and national levels
v) Ministry of Community Development, Gender and Children• Support community development extension workers to supervise and identify problems and derive solutions
for MNCH in the local context• Facilitate the establishment of community mechanisms to support emergency transportation for MNCH
services• Advocate for gender issues to improve MNCH decision-making at all levels• Support and promote rights-based approach to programming for MNCH • Advocate for revision of laws, legislations and policies to improve MNCH• Promote parental support for adolescents to access information and health services
vi) Ministry of Infrastructure Development• Improve road networks to facilitate access to services at primary and referral levels, especially in rural
areas where the majority of Tanzanians live
20 The National Road Map Strategic Plan -2008 - 2015
The National Road Map Strategic Plan -2008 - 2015 21
vii) Ministry of Labour, Employment and Youth Development• In collaboration with the MoHSW and the MoCDGC, develop a Youth Communication Strategy• Develop capacity for life skills and livelihood young people• Advocate for adoption of maternity protection conventions (ILO, convention 183)
viii) Ministry of Communication, Science and Technology• Promote the development, availability of and access to appropriate technology to support MNCH service
provision
ix) Ministry of Information, Culture and Sports• Promote positive RH behaviours including early health care seeking for MNCH services.• Disseminate information aimed at promoting early care seeking behaviour for MNCH and use of
preventive care services
4.2.8 Roles and Responsibilities of Development Partners• Provide technical and financial support for the coordination, planning, implementation, capacity
developemnt and monitoring and evaluation of MNCH services• Advocate for increased global and national commitment to the reduction of maternal, newborn and child
morbidity and mortality• Mobilise and allocate resources for the implementation of MNCH interventions
4.2.9 Roles and Responsibilities of Civil Society Organisations (NGOs, FBOs, CBOs, ProfessionalAssociations)
• Advocate for the rights of women and children.• Forge partnership with different stakeholders including political leaders to promote MNCH• Implement community based strategies to promote healthy behaviours during pregnancy, child birth, post
partum period, childhood and adolescence• Complement governement efforts in the provision of quality MNCH services• Disseminate the MNCH Strategic Plan to accelerate the reduction of maternal, newborn and child morbidity
and mortality• Mobilize and allocate resources for implementation of the MNCH Strategic Plan
4.2.9 Roles and Responsibilities of Private Sector• Complement Government efforts in the provision of quality MNCH services• Invest in commodites and supplies for MNCH interventions
4.2.10 Role of Training and Research Institutions• Undertake relevant MNCH research to provide evidence for policy directions and implementation guidance• Review and update curricula to ensure relevant MNCH issues are adequately addressed• Provide technical advice and updates on current developments on MNCH and SRH to policy makers
4.3.Key Strategies to be Implemented
4.3.1. Advocacy and Resource MobilizationIn advocating for improved MNCH, the following issues will be emphasized:
• Increased budget allocation for MNCH interventions including FP and nutrition. The target is to mobilizeresources from internal and external sources in order to complement the Government’s efforts towardsreducing maternal, newborn and childhood deaths
• Revision of laws, legislations and policies that hinder effective provision of maternal, newborn andchildcare services
• Improved production, employment, deployment and retention of a skilled health work force at all levels
4.3.2. Health Systems Strengthening and Capacity Development
Health system strengthening for MNCH involves improving; service delivery; health workforce;information; medical products , vaccines and technologies; financing; and leadership/ governance as well asmanaging interactions among them, so that more equitable and sustained improvements across services andhealth outcomes will be achieved.
4.3.2.1 Capacity development
• The strategy aims to increase the number of skilled health work force required, as well as the knowledgeand skills of existing service providers and supervisors so that quality care is provided.
• User friendly protocols will be developed/reviewed and the mechanisms for making essential commoditiesfor MNCH, including FP, available will be strengthened
• Basic and comprehensive EmOC as well as essential newborn services will be strengthened at dispensaries,health centres and hopsitals
• Skills for planning and management of MNCH services, including FP and Nutrition, will be imparted tothe CHMTs.
• Necessary infrastructure, logistics and equipment support will be provided for the effective delivery of thecomprehensive MNCH packages.
4. 3. 2.2 Referral systems
• Referral systems will be improved to ensure equitable access to quality MNCH services through makingappropriate means of transportation available and improve linkages between community and referralfacilities
• Communications equipment (e.g., radio calls and mobile phones) will be installed in hospitals, healthcentres and selected dispensaries.
• Community emergency committees will be established and oriented to emergency preparedness andresponse.
• Maternity waiting homes will be established where appropriate.
4.3.2.3 Research, Monitoring and Evaluation
• Capacity building for conducting operational research will be strengthened at all levels. Districts will beencouraged to identify research priority areas according to their needs.
Essential monitoring tools and indicators will be developed and mainstreamed into the HMIS. Data will begenerated periodically to monitor the milestones and improvement of services provided at health facilities.
• Periodic reviews and reporting will be carried out every two years to assess progress. A mid-term reviewwill be conducted between 2010 – 2011, and an end of term review will be conducted in 2015 to report onthe attainment of the MDGs.
4.3.3. Community Mobilization
• Communities will be mobilised to participate fully in initiatives aimed at improving maternal, newborn andchild care by:
• Educating and sensitising them on community-based MNCH interventions
• Mobilizing resources at the village level for MNCH including emergency referral as well as building and
22 The National Road Map Strategic Plan -2008 - 2015
The National Road Map Strategic Plan -2008 - 2015 23
strengthening health facilities.
• Orienting the facility governing committees to the MNCH Strategic Plan to ensure effectiveimplementation of the plan at the health facility and community levels
• Re-institutionalizing quarterly village health days
4.3.4: Information Education and Communication (IEC)/Behaviour Change Communication (BCC)
• Use of IEC/BCC approaches will be intensified towards adoption of positive behaviours for quality MNCHincluding nutrition and adolescent sexual reproductive health.
• The IEC/BCC activities will target community-based initiatives particularly in addressing birthpreparedness, with an emphasis on birth planning for individual couples, transport in case of emergency,and promotion of key MNCH practises at the household and community levels.
4.3.5: Fostering Partnership and Accountability
Effective implementation of the MNCH Strategic Plan will entail fostering and establishing strategicpartnerships to improve coordination and collaboration between communities, partners and among programmesas well as galvanizing resources for long term sustainable actions for MNCH.
• Coordinate regular planning, implementation, monitoring and evaluation of MNCH activities to assessprogress towards attainment of the MDGs
The goal of this National
Strategic Plan is to accelerate
the reduction of maternal,
newborn and child mortality and
morbidity, and the atteinment of
the MDGs 4 and 5 in Tanzania.
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.1
Ad
voca
cy a
nd
Res
ourc
e M
obil
isat
ion
5.1.
1.1C
ost t
he p
acka
ge fo
r m
ater
nal,
new
born
and
chi
ld
hea
lth
incl
ud
ing
FP a
nd n
utr
itio
n b
y es
tabl
ishi
ng:
•
Un
it c
ost p
er in
terv
enti
on p
er
area
; •
Op
erat
iona
l cos
ts;
•R
ecu
rren
t cos
ts.
X
X
X
T
he
pac
kage
for
mat
erna
l, ne
wbo
rn a
nd
child
hea
lth
incl
ud
ing
FP a
nd n
utr
itio
n co
sted
an
d in
pla
ce.
MoH
SW
(RC
HS,
Pol
icy
and
P
lan
nin
g)
Dev
elop
men
t Par
tner
s
Res
earc
h In
stit
utio
ns
80,0
00
5.1.
1.2.
Con
du
ct A
dvo
cacy
for
m
ater
nal n
ewbo
rn a
nd c
hild
car
e th
rou
gh D
eliv
er N
ow f
or
Wom
en a
nd
Chi
ldre
n ca
mp
aign
5.1.
1.3
Dev
elop
an
advo
cacy
p
acka
ge ta
rget
ing
the
follo
win
g:
MoH
SW, P
MO
-RA
LG
, MoF
EA
an
d o
ther
rel
evan
t lin
e m
inis
trie
s,
par
tner
s, p
arlia
men
tari
ans
(usi
ng
RE
DU
CE
/A
LIV
E an
d ot
her
mat
eria
ls) t
o m
obil
ise
hum
an a
nd
fina
ncia
l res
ourc
es fr
om
Gov
ern
men
t, po
litic
al a
nd
com
mu
nit
y le
ader
s.
X X
X X
XX
X
X
X
X
X
X
Nu
mbe
r of
ad
voca
cy
even
ts c
ond
ucte
d an
nual
ly
Ad
voca
cy p
acka
ge
dev
elop
ed a
nd
dis
sem
inat
ed.
MoH
SW
(RC
HS,
HE
U)
Dev
elop
men
t Par
tner
s
CSO
s P
rofe
ssio
nal
Ass
ocia
tions
Aca
dem
ic
and
Res
earc
h In
stit
utio
ns
Med
ia
200,
000
5.1.
1 B
ud
get a
lloc
atio
n fo
r h
ealt
h,
par
ticu
larl
y fo
r m
ater
nal
, n
ewb
orn
& c
hild
h
ealt
h in
clu
din
g FP
an
d n
utri
tion
in
crea
sed
at a
ll
leve
ls.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Bud
get f
or
mat
erna
l, ne
wbo
rn
and
child
hea
lth
incl
udin
g FP
and
n
utri
tion
incr
ease
d by
50%
by
2015
.
5.1.
1.4
Iden
tify
foca
l per
sons
am
ong
mem
bers
of p
arlia
men
t an
d o
ther
infl
uen
tial
lead
ers
to
advo
cate
for
mat
erna
l, ne
wbo
rn
and
chi
ld h
ealt
h.
5.1.
1.5
Pro
vid
e su
ppo
rt to
MN
CH
ch
amp
ion
and
oth
er fo
cal p
erso
ns.
X
XX
X XX
XX
XX
Num
bers
of i
nflu
enti
al
lead
ers
advo
cati
ng
for
mat
erna
l, ne
wbo
rn a
nd
child
hea
lth
iden
tifi
ed.
MoH
SW (R
CH
S)
Dev
elop
men
t Par
tner
s C
SOs
-
24T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
CH
AP
TE
R 5
: S
TR
AT
EG
IC P
LA
N A
ND
AC
TIV
ITIE
S: 2
008
-201
5
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.1.
1.6
Con
duc
t ad
voca
cy m
eeti
ngs
to
pol
icy/
dec
isio
n - m
aker
s on
the
MN
CH
Str
ateg
ic P
lan,
to s
up
port
im
ple
men
tati
on o
f the
str
ateg
y at
the
cent
ral,
regi
onal
and
dis
tric
t lev
els.
5.1.
1.7
Lobb
y w
ith
the
gove
rnm
ent f
or
subs
idy
on IT
Ns
in o
rder
to e
nsu
re
equ
itab
le a
cces
s to
the
mat
eria
ls b
y al
l vu
lner
able
gro
up
s.
X X
X X
X X
X X
X X
X X
X X
X X
Nu
mbe
r of
ad
voca
cy
mee
tin
gs c
ond
ucte
d
Subs
idy
pol
icy
on IT
N fo
r al
l vu
lner
able
gro
up
in p
lace
MoH
SW (R
CH
S)
CSO
s P
rofe
ssio
nal A
ssoc
iatio
ns
Dev
elop
men
t Par
tner
s
680,
000
5.1.
1.8
Esta
blis
h an
d c
ond
uct M
othe
r-B
aby
Day
/ W
eek,
ann
ual
ly a
t all
leve
ls th
rou
gh:
•P
ubl
ic a
war
enes
s ca
mp
aign
s (m
edia
/ra
llie
s/d
ebat
es).
•P
rogr
amm
e co
mm
uni
catio
n d
evel
opm
ent.
X
X
X
X
X
X
X
X
Mot
her-
Bab
y D
ay/
Wee
k co
mm
emor
ated
M
oHSW
, Min
iste
rial
D
epar
tmen
t Age
ncie
s (M
DA
s)
Med
ia
Dev
elop
men
t Par
tner
s
CH
MT
s
Pro
fess
iona
l Ass
ocia
tions
C
SOs
400
,000
5.1.
1.9
Ad
voca
te fo
r bi
-ann
ual
Chi
ld
and
vil
lage
hea
lth
day
s at
all
leve
ls
thro
ugh
: •
Pu
blic
aw
aren
ess
cam
pai
gns
•P
rogr
amm
e C
omm
un
icat
ion
dev
elop
men
t
5.1.
1.10
Sen
siti
ze R
HM
Ts a
nd C
HM
Ts
of th
e im
por
tanc
e of
incl
udin
g ch
ild
and
vil
lage
hea
lth
day
s in
the
CC
HPs
5.1.
1.11
Tra
in, e
stab
lish
and
su
ppo
rt
Med
ia G
rou
ps
to r
epor
t on
MN
CH
X X X
X X X
X X X
X X X
X X X
X X X
X X X
X X X
Pro
port
ion
of v
illag
es
cond
ucti
ng
sem
i ann
ual
ch
ild h
ealt
h d
ay
Pro
port
ion
of C
CH
Ps
wit
h bu
dge
t allo
cati
on fo
r Vill
age
Hea
lth
Day
s
Nu
mbe
r of
est
ablis
hed
m
edia
gro
up
s
MoH
SW, M
DA
s M
edia
R
HM
Ts
CH
MT
s N
GO
s,
Pro
fess
iona
l Ass
ocia
tions
V
illag
e G
over
nm
ents
D
evel
opm
ent
Par
tner
s
600,
000
100,
000
25T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
Nee
ded
in
US
dol
lars
5.1.
2.1
Rev
iew
reg
ula
tion
s an
d le
gisl
atio
ns r
elat
ed to
the
pro
visi
on o
f m
ater
nal,
new
born
an
d c
hild
car
e.
X
X
X
N
um
ber
of
regu
lati
ons,
law
s an
d
pol
icie
s to
su
ppo
rt
effe
ctiv
e p
rovi
sion
of
qual
ity
mat
erna
l, n
ewbo
rn a
nd c
hild
ca
re r
evie
wed
.
MoH
SW (R
CH
S)
Pro
fess
iona
l A
ssoc
iatio
ns
Dev
elop
men
t Par
tner
s M
edic
al C
ounc
il N
urs
es &
Mid
wiv
es
Cou
ncil
CSO
s
60,0
00
5.1.
2 R
egu
lati
ons,
law
s an
d p
olic
ies
to
sup
por
t eff
ecti
ve
impl
emen
tati
on o
f m
ater
nal
, new
bor
n
and
Chi
ld h
ealt
h re
view
ed.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Nu
mbe
r of
reg
ulat
ions
ap
prov
ed b
y re
gula
tory
bo
dies
.
Nu
mbe
r of
law
s ap
prov
ed b
y re
gula
tory
bo
dies
. 5.
1.2.
2 A
dvo
cate
for
revi
ew a
nd
adop
tion
of la
ws
such
as
the
Mar
riag
e A
ct o
f 197
0, a
nd th
e Se
xual
Off
ence
Sp
ecia
l Pro
visi
on
Act
(SO
SPA
) of 1
998
that
in
flu
ence
mat
erna
l, ne
wbo
rn a
nd
child
hea
lth.
X
X
Law
s af
fect
ing
mat
erna
l and
n
ewbo
rn h
ealt
h re
view
ed a
nd
adop
ted.
MoH
SW,
Min
istr
y of
Just
ice
and
Con
stit
utio
nal A
ffai
rs
MC
DG
C, M
DA
s,
Dev
elop
men
t Par
tner
s,
Pro
fess
iona
l A
ssoc
iatio
ns
CSO
s
120,
000
26T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
STR
AT
EG
IC P
LA
N A
ND
AC
TIV
ITIE
S: 2
008
-201
5
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.1.
3
Imp
lem
enta
tion
of
the
exem
pti
on
pol
icy
for
mat
ern
al
and
chil
d h
ealt
h st
ren
gth
ened
.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Exe
mpt
ion
polic
y ef
fect
ivel
y im
plem
ente
d.
5.1.
3.1
Ad
voca
te fo
r ex
emp
tion
pol
icy
on M
NC
H to
be
effe
cted
in v
olu
ntar
y an
d p
ubl
ic h
ealt
h fa
cilit
ies
( Ser
vice
Agr
eem
ent)
XX
Pro
port
ion
of p
ubl
ic
and
vol
unt
ary
hea
lth
faci
litie
s im
ple
men
tin
g th
e E
xem
pti
on P
olic
y.
MoH
SW (R
CH
S &
Pol
icy
and
Pla
nnin
g)
Hea
lth
pro
fess
iona
l as
soci
atio
ns
Pri
vate
sec
tor
CSO
s
25,0
00
27T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
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2015
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.1.
4.1
Ad
voca
te fo
r re
view
of t
he
1999
Hu
man
Res
ourc
es
Est
abli
shm
ent (
and
2006
pro
pose
d re
visi
on) i
n lin
e w
ith
skil
led
at
tend
ance
req
uir
emen
ts fo
r m
ater
nal,
new
born
and
chi
ld c
are.
X
X
Hu
man
Res
ourc
e E
stab
lish
men
t of
MoH
SW (1
999)
re
view
ed.
MoH
SW (D
HR
, DA
P)
PMO
-RA
LG
P
O- P
ubl
ic S
ervi
ce
Man
agem
ent
MoF
EA
H
ealt
h p
rofe
ssio
nal
asso
ciat
ions
, CSO
s
Dev
elop
men
t Par
tner
s
62,0
00
5.1.
4.2
Ad
voca
te fo
r re
cru
itm
ent a
nd
dep
loym
ent o
f ski
lled
hea
lth
wor
kers
at a
ll le
vels
of c
are.
X
X
X
X
X
X
X
X
Pro
port
ion
of
dis
tric
ts w
ith
app
rop
riat
e nu
mbe
r of
ski
lled
h
ealt
h w
orke
rs.
MoH
SW
PMO
-RA
LG
H
ealt
h p
rofe
ssio
nal
asso
ciat
ions
D
evel
opm
ent P
artn
ers
CSO
s
37,0
00
5.1.
4
Em
plo
ymen
t, d
eplo
ym
ent a
nd
rete
ntio
n of
ski
lled
h
ealt
h w
ork
ers
at a
ll
leve
ls o
f ca
re
imp
rove
d.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Nu
mbe
r of
ski
lled
heal
th w
orke
rs
incr
ease
d to
100
% o
f es
tabl
ishe
d ne
ed b
y
2015
5.1.
4.3
Ad
voca
te to
the
Gov
ern
men
t to
mot
ivat
e sk
ille
d h
ealt
h w
orke
rs
by
pro
vid
ing
a p
acka
ge o
f inc
enti
ves
in o
rder
to e
nsu
re o
ptim
um
p
erfo
rman
ce.
X
X
X
X
X
X
X
X
Typ
es o
f Inc
enti
ve
pac
kage
pro
vid
ed
by
the
Gov
ern
men
t at a
ll le
vels
.
Pro
port
ion
of
dis
tric
ts p
rovi
din
g in
cent
ive
pac
kage
s
MoH
SW (D
HR
, DA
P,
Pol
icy
& P
lan
nin
g)
PMO
-RA
LG
P
O-P
ubl
ic S
ervi
ce
Man
agem
ent
MoF
EA
H
ealt
h p
rofe
ssio
nal
asso
ciat
ions
C
SOs
66,0
00
28T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
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2015
STR
AT
EG
IC P
LA
N A
ND
AC
TIV
ITIE
S: 2
008
-201
5
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
Nee
ded
in
US
dol
lars
5.2.
Hea
lth
Sys
tem
s St
ren
gth
enin
g an
d C
apac
ity
Dev
elop
men
t5.
2.1
K
now
led
ge a
nd
skil
ls o
f su
perv
isor
s an
d se
rvic
e p
rovi
der
s on
mat
ern
al,
new
bor
n a
nd
chil
d ca
re
incl
udi
ng
FP a
nd
nut
riti
on
incr
ease
d.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Mat
erna
l, ne
wbo
rn
and
child
hea
lth
serv
ice
prov
ided
ac
cord
ing
to
stan
dard
s.
5.2.
1.1
Rev
iew
/d
evel
op u
ser-
frie
ndly
p
roto
cols
for a
nten
atal
car
e, p
ostn
atal
ca
re, n
ewbo
rn a
nd c
hild
car
e, E
mO
C,
FP a
nd n
utr
itio
n. S
pec
ific
act
ivit
ies
incl
ude:
•
Dev
elop
/ad
apt/
revi
ew a
nd
dis
sem
inat
e C
omm
un
ity
Mat
erna
l, N
ewbo
rn a
nd C
hild
C
are
pac
kage
s •
Dev
elop
/ad
apt/
revi
ew
stan
dar
ds
job
aid
es a
nd to
ols f
or
MN
CH
ser
vice
pro
visi
on
•D
evel
op/
adap
t/re
view
and
d
isse
min
ate
Nu
trit
ion
Pac
kage
s in
clu
din
g E
NA
, SA
M, I
YC
F/B
FHI
•R
evie
w E
PI g
uid
elin
es fo
r in
clus
ion
of n
ew v
acci
nes
•
Ad
apta
tion
of E
ssen
tial
New
born
C
are
(EN
C) a
nd K
anga
roo
Mot
her
care
gu
idel
ines
(KM
C)
•A
dap
tati
on a
nd a
dop
tion
of th
e n
ew c
hild
gro
wth
sta
ndar
ds
and
ch
arts
X
X
X
X
Pro
toco
ls o
n an
tena
tal c
are,
E
mO
C, n
ewbo
rn
care
, sev
ere
mal
nutr
itio
n,
grow
th m
onit
orin
g,
child
car
e an
d p
ostn
atal
car
e d
evel
oped
and
ad
opte
d by
the
MoH
SW.
MoH
SW (R
CH
S,
DH
S H
EU
) D
evel
opm
ent
Par
tner
s H
ealt
h p
rofe
ssio
nal
asso
ciat
ions
C
SOs
147,
000
29T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
Nee
ded
in
US
dol
lars
5.2.
1.2
Sup
port
pre
-ser
vice
trai
nin
g in
stit
uti
ons
to p
rovi
de
up
dat
ed a
nd
com
pet
ency
-bas
ed te
achi
ng
on
mat
erna
l, ne
wbo
rn a
nd c
hild
car
e in
clud
ing
FP a
nd n
utri
tion
(LSS
-E
mO
C, E
NC
, KM
C F
AN
C, P
AC
, FP
, n
ewbo
rn c
are,
nu
trit
ion,
BFH
I, IY
CF,
SA
M, P
MT
CT
, IM
CI,
ET
AT
, Ref
erra
l C
are
Pac
kage
, Im
mu
niz
atio
n) b
y:
•U
pd
atin
g p
re-s
ervi
ce c
urr
icu
la to
ad
dre
ss c
urr
ent c
han
ges
in
mat
erna
l, ne
wbo
rn a
nd c
hild
ca
re in
clu
din
g FP
and
nu
trit
ion
•D
evel
opin
g an
d p
rovi
din
g an
or
ient
atio
n p
acka
ge a
nd o
ther
ed
uca
tiona
l mat
eria
ls to
tuto
rs a
nd
clin
ical
pre
cep
tors
. •
Up
dat
e an
d s
tand
ard
ize
know
led
ge, c
linic
al a
nd te
achi
ng
skil
ls o
f tu
tors
and
clin
ical
p
rece
pto
rs a
t med
ical
, nu
rsin
g an
d
par
amed
ical
sch
ools
. •
Pro
vid
e sc
hool
s an
d c
linic
al
pra
ctic
e si
tes
wit
h ne
cess
ary
teac
hin
g an
d c
linic
al p
ract
ice
mat
eria
ls a
nd e
quip
men
t
X
X
X
X
X
X
X
X
1000
tuto
rs/c
linic
al
pre
cep
tors
from
va
riou
s in
stit
utio
ns
up
dat
ed o
n m
ater
nal a
nd
new
born
car
e in
clud
ing
FP a
nd
nutr
itio
n.
All
pre
serv
ice
MN
CH
cu
rric
ula
r co
mp
onen
ts
up
dat
ed
All
pre
serv
ice
inst
itu
tion
s p
rovi
ded
wit
h n
eces
sary
teac
hin
g m
ater
ials
, eq
uip
men
t and
su
pp
lies
MoH
SW (R
CH
S,
PMT
CT,
TFN
C)
Hu
man
Res
ourc
e D
evel
opm
ent
and
Tra
inin
g H
ealt
h T
rain
ing
Inst
itut
ions
R
egu
lato
ry
bod
ies
Pri
vate
in
stit
uti
ons
CSO
s D
evel
opm
ent
Par
tner
s
680,
000
5.2.
1.3
Up
dat
e kn
owle
dge
and
ski
lls
of s
up
ervi
sors
on
mat
erna
l, ne
wbo
rn
and
chi
ld c
are
incl
ud
ing
FP, n
utr
itio
n an
d s
up
ervi
sory
ski
lls (L
SS-E
mO
C,
EN
C, K
MC
, FA
NC
, PA
C, F
P,
new
born
car
e, n
utr
itio
n, B
FHI,
IYC
F,
PMT
CT
, IM
CI,
ET
AT
, Ref
erra
l Car
e P
acka
ge, i
mm
un
izat
ion)
X
X
X
X
X
X
X
X
910
CH
MT
mem
bers
(130
C
ounc
ils),
and
147
Z
onal
and
RH
MT
mem
bers
, all
up
dat
ed in
su
per
viso
ry s
kills
.
MoH
SW (R
CH
S,
DR
H)
Dev
elop
men
t P
artn
ers
CSO
s
1,52
5,00
0
30T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
STR
AT
EG
IC P
LA
N A
ND
AC
TIV
ITIE
S: 2
008
-201
5
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
Nee
ded
in
US
dol
lars
5.2.
1.4
Up
dat
e kn
owle
dge
and
ski
lls
of s
ervi
ce p
rovi
der
s on
mat
erna
l, n
ewbo
rn a
nd c
hild
car
e in
clu
din
g FP
and
nu
trit
ion
(LSS
-Em
OC
, EN
C,
KM
C, F
AN
C, P
AC
, PN
C, F
P, E
NA
, IM
CI,
ET
AT
, BFH
I, IY
CF,
PM
TC
T,
SAM
, im
mu
niza
tion
) and
lin
k th
e in
terv
enti
ons
to m
alar
ia, H
IV/
AID
s,
and
STIs
con
trol
pro
gram
mes
.
X
X
X
X
X
X
X
X
Nu
mbe
r of
ser
vice
p
rovi
der
s tr
ain
ed in
M
NC
H s
ervi
ce
del
iver
y
MoH
SW (R
CH
S),
Dis
tric
t Cou
ncils
, an
d D
evel
opm
ent
Par
tner
s.
CSO
s P
riva
te in
stit
uti
ons
Hea
lth
pP
rofe
ssio
nal
asso
ciat
ions
7,00
0,00
0
5.2.
1.5
Rev
iew
mat
erna
l, p
erin
atal
an
d c
hild
dea
ths
at a
ll le
vels
(fac
ility
&
com
mu
nit
y).
•T
rain
ser
vice
pro
vid
er o
n m
ater
nal,
per
inat
al a
nd c
hild
d
eath
rev
iew
s
•D
evel
op a
sys
tem
to r
evie
w c
hild
d
eath
s •
Em
plo
y/tr
ain
the
com
mu
nity
h
ealt
h w
orke
rs to
con
duc
t ver
bal
auto
psi
es
Pro
duc
e w
eekl
y, m
onth
ly, q
uar
terl
y an
d a
nnu
al s
um
mar
y re
por
ts o
f m
ater
nal,
per
inat
al a
nd c
hild
dea
th
revi
ews
X
X
X
X
X
X
X
X
Pro
port
ion
of h
ealt
h fa
cilit
ies
wit
h m
ater
nal,
per
inat
al
and
chi
ld d
eath
s re
view
rep
orts
.
Pro
port
ion
of
faci
litie
s w
ith
heal
th
wor
kers
trai
ned
in
mat
erna
l, p
erin
atal
an
d c
hild
dea
th
revi
ew
MoH
SW (R
CH
S)
PMO
RA
LG
M
oCD
GC
R
HM
Ts
CH
MT
s C
MTs
700,
000
The
Nat
iona
l Roa
d M
ap S
trat
egic
Pla
n -2
008
- 20
15
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
5.2.
2 Pl
anni
ng
and
man
agem
ent
cap
acit
y fo
r m
ater
nal
an
d n
ewb
orn
car
e in
clu
din
g FP
an
d n
utri
tion
st
ren
gth
ened
.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Rel
evan
t sec
tor
(Min
istr
y of
Fin
ance
, M
oHSW
) allo
cati
ng
15%
of t
he H
ealt
h bu
dget
for
mat
erna
l an
d ne
wbo
rn c
are.
5.2.
2.1
Tra
in C
HM
T/
RH
MT
s on
ev
iden
ce-b
ased
pla
nn
ing
1in
ord
er to
en
sure
that
str
ateg
ic in
terv
enti
ons
on
mat
erna
l new
born
and
chi
ld c
are
incl
ud
ing
FP a
nd n
utr
itio
n ar
e in
corp
orat
ed in
the
CC
HP
and
imp
lem
ente
d.
X
X
X
X
X
X
X
X
Pro
port
ion
of
CH
MT
s an
d R
HM
T’s
trai
ned
on
pla
nnin
g fo
r M
NC
H
Pro
port
ion
of
dis
tric
ts w
ith
incr
ease
d b
ud
get
allo
catio
n fo
r m
ater
nal
new
born
and
ch
ild h
ealt
h in
terv
enti
ons
in
CC
HP
s.
MoH
SW
(RC
HS,
P
olic
y an
d
Pla
nn
ing
Un
it) D
istr
ict
Cou
ncils
D
evel
opm
ent
Par
tner
s.
290,
000
1 Exa
mpl
es o
f to
ols
to b
e us
ed in
clud
e P
lan
Rep
, cos
tin
g to
ols
and
othe
r re
leva
nt s
ourc
es o
f inf
orm
atio
n
32T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
STR
AT
EG
IC P
LA
N A
ND
AC
TIV
ITIE
S: 2
008
-201
5
Tim
efra
me
Str
ateg
ic O
bje
ctiv
e/
Ou
tpu
t A
ctiv
itie
s
08
09
10
11
12
13
14
15
Pro
cess
In
dic
ato
rs
Res
po
nsi
ble
P
erso
n
Res
ourc
es
Nee
ded
in
U
S d
olla
rs
X
X
X
X
X
X
X
X
Pro
port
ion
of
heal
th fa
cili
ties
p
rovi
din
g B
asic
E
mO
C in
the
MoH
SW
(Dir
ecto
rate
s of
Pre
vent
ive
80,8
00,0
00
X
X
X
X
X
X
X
X
Pro
port
ion
of
heal
th fa
cili
ties
p
rovi
din
g
MoH
SW
(Dir
ecto
rate
s of
Pre
vent
ive
and
H
osp
ital
Se
rvic
es),
48,4
00,0
00
5. 2
.3
Bas
ic (B
Em
OC
) an
d
Com
pre
hen
sive
E
mO
C
(CE
mO
C)a
nd
n
ewb
orn
ser
vice
s at
al
l lev
els
stre
ngt
hen
ed.
Str
ateg
ic O
utp
ut
Ind
icat
or:
%
of h
ealt
h fa
cili
ties
pr
ovid
ing
BE
mO
C
and
CE
mO
C a
nd
Ess
enti
al N
ewbo
rn
care
and
P
MO
-RA
LG
. A
PHT
A
PRIN
MA
T
Dev
elop
men
t P
artn
er a
nd
U
N A
genc
ies
esse
ntia
l new
born
ca
re
Com
pre
hens
ive
Em
OC
an
d
esse
ntia
l new
born
ca
re
Nu
mbe
r of
AM
Os
trai
ned
usi
ng
tail
or m
ade
curr
icu
lar
and
Hos
pit
al
Serv
ices
) P
MO
-RA
LG
, C
SOs
Pri
vate
sec
tor
4E
ver
y p
opu
lati
on o
f 50
0,00
0, a
t lea
st 4
Bas
ic E
mO
C a
re n
eed
ed (S
ee G
loss
ary
for
com
pon
ents
of
Bas
ic a
nd
Com
pre
hen
siv
e E
mO
C)
5E
ver
y p
opu
lati
on o
f 50
0,00
0, a
t lea
st 1
com
pre
hen
sive
Em
OC
is n
eed
ed (S
ee G
loss
ary
for
com
pon
ents
of
Bas
ic a
nd C
omp
reh
ensi
ve E
mO
C)
5.2.
3.1
Stre
ngth
en th
e ca
paci
ty o
f all
dis
pens
arie
s an
d a
ll he
alth
cen
tres
to
prov
ide
BE
mO
C, e
ssen
tial
new
born
car
e an
d K
MC
thro
ugh:
•
Dep
loym
ent o
f ski
lled
hea
lth
wor
kers
(Nur
se m
idw
ives
, Clin
ical
Off
icer
s,
la
bora
tory
ass
ista
nts)
•
Prov
isio
n of
ess
enti
al e
quip
men
t and
supp
lies.
•
Infr
astr
uctu
ral i
mpr
ovem
ent f
or
se
rvic
e d
eliv
ery
(Del
iver
y ro
om,
po
stna
tal r
oom
, lab
orat
ory)
5.2.
3.2
Stre
ngth
en th
e ca
paci
ty o
f all
ho
spit
als
and
upg
rad
e 50
% o
f hea
lth
cent
res
to p
rovi
de
CE
mO
C a
nd
es
sent
ial n
ewbo
rn c
are
thro
ugh:
•
D
eplo
ymen
t of s
kille
d h
ealt
h w
orke
rs
(N
urse
mid
wiv
es, M
O, A
MO
s,
A
naes
thet
ists
, Lab
orat
ory
tech
nici
ans)
•
Pr
ovis
ion
of e
ssen
tial
equ
ipm
ent a
nd
su
pplie
s.•
In
fras
truc
tura
l im
prov
emen
t for
serv
ice
del
iver
y (O
pera
ting
thea
tres
,
Lab
our
war
d, B
lood
sto
rage
faci
litie
s,
in
cine
rato
rs)
•
Est
ablis
h ne
onat
al a
nd K
MC
uni
ts
5.2.
3.3
Dev
elop
and
con
duc
t tai
lor
mad
e
trai
ning
for
AM
Os
and
Nur
ses
to
pr
ovid
e C
Em
OC
, Ess
enti
al N
ewbo
rn
an
d c
hild
hea
lth
serv
ices
33T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
5.2.
4.1
Fore
cast
dem
and
, pro
cure
and
su
pp
ly e
ssen
tial
com
mod
itie
s an
d su
pp
lies
for
mat
erna
l, ne
wbo
rn a
nd
child
car
e6 in
clu
din
g co
ntra
cep
tive
s.
Em
pha
sis
to b
e p
ut o
n:
•E
ssen
tial
obs
tetr
ic s
up
plie
s a
nd
med
icin
es fo
r A
NC
, del
iver
y an
d
pos
tpar
tum
. •
New
born
res
usc
itat
ion
kits
, su
pp
lies
and
dru
gs.
•C
ontr
acep
tive
s (p
ills,
IUC
D,
imp
lant
s, in
ject
able
s an
d co
ndom
s).
•V
acci
nes
•
Lab
orat
ory
reag
ents
. •
Pae
dia
tric
em
erge
ncy
equ
ipm
ent
(oxy
gen
conc
entr
ator
, glu
com
eter
s,
ambu
bag
s, s
uctio
n, in
fusi
on p
um
ps)
an
d IM
CI d
rugs
and
su
pp
lies
•Su
pp
lies
for t
hera
peu
tic
feed
ing
for
man
agem
ent o
f sev
ere
acu
te
mal
nutr
itio
n
X
X
X
X
X
X
X
X
Per
cent
age
of
hea
lth
faci
litie
s w
ith
stoc
k-ou
ts o
f es
sent
ial
com
mod
itie
s,
sup
plie
s an
d
med
icin
es f
or
mat
erna
l, n
ewbo
rn a
nd
child
car
e in
clu
din
g co
ntra
cep
tive
s.
MoH
SW
(Dir
ecto
rate
of
Hos
pit
al S
ervi
ces,
R
CH
S an
d M
SD)
Dis
tric
t Cou
ncils
, D
evel
opm
ent
Par
tner
s
CSO
s P
riva
te s
ecto
r
400,
000,
000
5.2.
4 M
ech
anis
ms
for
avai
labi
lity
of
esse
ntia
l co
mm
odit
ies,
su
ppl
ies
and
med
icin
es f
or
mat
ern
al,
new
bor
n
and
chil
d h
ealt
h in
clu
din
g fa
mil
y pl
anni
ng
st
ren
gth
ened
.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Ess
enti
al
com
mod
itie
s, s
uppl
ies
and
med
icin
es fo
r m
ater
nal,
new
born
an
d ch
ild c
are
avai
labl
e al
l the
tim
e at
eve
ry h
ealth
faci
lity
5.2.
4.2
Rev
ive
and
/or
est
abli
sh
mai
nten
ance
uni
ts fo
r va
riou
s eq
uip
men
t at
the
hosp
ital
leve
l.
XX
X
X
X
X
X
X
P
ropo
rtio
n of
ho
spit
als
wit
h fu
nctio
nin
g eq
uip
men
t m
aint
enan
ce
uni
ts.
MoH
SW (R
CH
S,
Dir
ecto
rate
of H
S)
RH
MT
s
Dis
tric
t Cou
ncils
100,
000,
000
6 Ess
enti
al N
ewbo
rn e
quip
men
t an
d s
uppl
ies
(See
An
nex
8)
34T
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AT
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tegi
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utp
ut
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ivit
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Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
5.2.
5.1
Pro
cure
and
inst
all c
omm
un
icat
ion
equ
ipm
ent (
Two
way
rad
io
com
mu
nic
atio
n, p
hone
s) in
dis
tric
t ho
spit
als,
sel
ecte
d he
alth
cen
tres
and
d
isp
ensa
ries
.
X
X
X
X
X
X
X
X
Pro
port
ion
of
hea
lth
uni
ts w
ith
2way
Rad
io
com
mu
nic
atio
n eq
uip
men
t
MoH
SW/
R
CH
S D
istr
ict
Cou
ncils
D
evel
opm
ent
Par
tner
s C
SOs
Pri
vate
sec
tor
2,80
0,00
0
5.2.
5.2
Pro
cure
and
uti
lise
ambu
lanc
es fo
r re
ferr
al p
urp
oses
, at l
east
one
per
dis
tric
t ho
spit
al a
nd o
ne p
er h
ealt
h ce
ntre
and
se
lect
ed d
isp
ensa
ries
.
5.2.
5.3
Pro
cure
mot
orbi
ke A
mbu
lanc
e fo
r H
ealt
h C
entr
e /
dis
pen
sari
es w
here
ap
plic
able
5.2.
5.4
Pro
vid
e su
ffic
ient
fuel
for
ve
hic
les/
mot
orbi
kes
5.2.
5.5
Con
duc
t mai
nten
ance
ser
vice
s fo
r co
mm
un
icat
ion
equ
ipm
ents
and
ve
hic
les/
mot
orbi
kes
X
X
X
X
X
X
X
X
Pro
port
ion
of
hea
lth
faci
litie
s w
ith
func
tion
ing
ambu
lanc
es a
nd
mot
orbi
kes
for
refe
rral
.
MoH
SW
RC
HS
PMO
RA
LG
M
oID
D
istr
ict
Cou
ncils
D
evel
opm
ent
Par
tner
s C
SOs
Pri
vate
sec
tor
6,00
0,00
0
5.2.
5 R
efer
ral s
yste
m a
t al
l lev
els
stre
ngt
hen
ed.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Fu
ncti
onal
ref
erra
l sy
stem
s in
pla
ce a
t all
leve
ls
5.2.
5.6
Ori
ent r
egio
nal a
nd d
istr
ict h
ealt
h co
mm
itte
es o
n ob
stet
ric,
new
born
and
ch
ild e
mer
genc
y p
rep
ared
nes
s
X
X
X
X
X
X
X
X
Pro
port
ion
of
regi
onal
/d
istr
ict
hea
lth
com
mit
tees
or
ient
ed o
n em
erge
ncy
pre
par
edn
ess.
MoH
SW/
R
CH
S Z
TC
s R
HM
Ts
CH
MT
s
Dev
elop
men
t P
artn
ers
CSO
s
1,00
0,00
0
35T
he N
atio
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oad
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ateg
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Tim
efra
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Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
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tegi
c O
bjec
tive
/ O
utp
ut
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ivit
ies
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1011
1213
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5.
2.5.
7 O
rien
t oth
er s
up
port
sta
ff
(com
mu
nity
hea
lth
wor
kers
, am
bula
nce
dri
vers
and
att
end
ants
) on
emer
genc
y an
d r
esp
onse
p
rep
ared
nes
s.
X
X
X
X
X
X
X
X
Nu
mbe
r of
hea
lth
faci
litie
s w
ith
sup
port
sta
ff
orie
nted
on
emer
genc
y an
d
resp
onse
p
rep
ared
nes
s.
MoH
SW/
R
CH
S Z
TC
s,
RH
MT
s C
HM
Ts,
Dev
elop
men
t Par
tner
s C
SOs
1,00
0,00
0
5.2.
5.8
Esta
blis
h/re
vive
com
mu
nity
em
erge
ncy
com
mit
tee
in e
very
vi
llage
to m
obil
ise
com
mu
nit
y re
sou
rce
for
emer
genc
y tr
ansp
ort a
nd
for
bloo
d do
nors
.
X
X
X
X
X
X
X
X
Pro
port
ion
of
villa
ges
wit
h fu
nctio
nin
g em
erge
ncy
com
mit
tees
for
MN
CH
PMO
RA
LG
M
oCD
GC
M
oHSW
/ R
CH
S,
Dis
tric
t C
ounc
ils
CH
MT
V
illag
e G
over
nm
ent
Dev
elop
men
t Par
tner
s C
SOs
300,
000
5.2.
5.9
Esta
blis
h m
ater
nity
wai
tin
g ho
mes
whe
re a
pp
licab
le.
X
X
X
X
X
X
X
X
Pro
port
ion
of
hea
lth
faci
litie
s (w
here
ap
plic
able
) li
nke
d to
fu
nctio
nin
g m
ater
nit
y w
aiti
ng
hom
es.
MoH
SW/
RC
HS
Dis
tric
t C
ounc
ils
CH
MT
s V
illag
e G
over
nm
ent
Dev
elop
men
t Par
tner
s C
SOs
Pri
vate
sec
tor
500,
000
36T
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atio
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ateg
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AT
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efra
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Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
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Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
Res
earc
h, M
onit
orin
g an
d E
valu
atio
n5.
2.6.
1 D
evel
op a
nd u
pd
ate
mon
itor
ing
and
eva
luat
ion
fram
ewor
k fo
r MN
CH
5.2.
6.2
Up
dat
e m
onit
orin
g d
ata
colle
ctio
n to
ols
to in
clud
e E
mO
C
pro
cess
ind
icat
ors
and
othe
r m
issi
ng
info
rmat
ion
on n
utr
itio
n, p
ost a
bort
al
care
, pos
tnat
al c
are,
new
born
and
ch
ild c
are
and
refe
rral
form
s, r
egis
ter
for
refe
rral
, l
og-b
ooks
.
X X
X X
X
X
Mon
itori
ng
and
ev
alu
atio
n fr
amew
ork
for
MN
CH
in p
lace
Mon
itori
ng
dat
a co
llect
ion
tool
s u
pd
ated
MoH
SW (H
MIS
U
nit
) N
BS (P
over
ty
Mon
itori
ng
Un
it)
CH
MT
and
Dev
elop
men
t P
artn
ers
45,0
00
5.2.
6
HM
IS c
apac
ity
to
capt
ure
info
rmat
ion
on
mat
ern
al, n
eon
atal
an
d ch
ild
indi
cato
rs
incl
udi
ng
FP a
nd
nut
riti
on im
pro
ved
.
Stra
tegi
c O
utp
ut
Ind
icat
or :
Key
Mat
erna
l, ne
wbo
rn
and
child
hea
lth
indi
cato
rs r
epor
ted
an
nua
lly th
roug
h H
MIS
5.2.
6.3
Pro
duc
e, d
isse
min
ate
,dis
trib
ute
up
dat
ed d
ata
colle
ctio
n to
ols
at a
ll le
vels
.
X
X
X
P
ropo
rtio
n of
fa
cilit
ies
usi
ng
up
dat
ed d
ata
colle
ctio
n to
ols
MO
HSW
(R
CH
S, H
IS)
MSD
C
HM
Ts
CSO
s P
riva
te s
ecto
r
500,
000
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ateg
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utp
ut
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ivit
ies
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Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
5.2.
7.1
Ori
ent h
ealt
h se
rvic
e p
rovi
der
s/su
per
viso
rs o
n M
NC
H
mon
itor
ing
and
eva
luat
ion
fram
ewor
k an
d e
ffec
tive
dat
a m
anag
emen
t (da
ta c
olle
ctio
n, a
naly
sis
and
uti
lizat
ion.
)
X
X
X
X
X
X
X
X
Nu
mbe
r of
hea
lth
serv
ice
pro
vid
ers/
su
per
viso
rs
orie
nted
on
data
m
anag
emen
t.
MoH
SW (H
MIS
U
nit
) R
HM
Ts
CH
MT
s
1,00
0,00
0
5.2.
7.2.
Con
du
ct s
up
port
ive
sup
ervi
sion
for M
NC
H in
bot
h p
ubl
ic
and
pri
vate
hea
lth
faci
litie
s.
5.2.
7.3
Con
duc
t fol
low
up
of h
ealt
h w
orke
rs a
fter
trai
nin
g on
MN
CH
p
acka
ges.
X X
X X
X X
X X
X X
X X
X X
X X
Pro
port
ion
of
hea
lth
faci
litie
s re
ceiv
ing
qu
arte
rly
sup
port
ive
sup
ervi
sion
.
Pro
port
ion
of
hea
lth
wor
kers
th
at r
ecei
ved
fo
llow
up
afte
r tr
ain
ing
on
MN
CH
pac
kage
s ye
arly
MoH
SW
(Ins
pec
tora
te
Un
it, R
CH
S)
RH
MT
s C
HM
Ts
C
SOs
.
850
,000
5.2.
7
Mon
itor
ing
and
eval
uat
ion
fram
ewor
k
for
MN
CH
st
ren
gth
ened
an
d im
plem
ente
d.
Stra
tegi
c O
utp
ut
Ind
icat
or :
Pro
gres
s on
Mat
erna
l, ne
wbo
rn a
nd c
hild
hea
lth
stat
us/t
rend
s r
epor
ted.
5.2.
7.4
Con
duc
t per
iod
ic s
urv
eys
on
qual
ity
of c
are,
clie
nt s
atis
fact
ion
and
ca
re s
eeki
ng
beha
viou
r in
sel
ecte
d d
istr
icts
and
fact
ors
faci
litat
ing
or
hind
erin
g ac
cess
for
mat
erna
l, n
ewbo
rn a
nd c
hild
car
e.
5.2.
7.5
Con
duc
t Bie
nn
ial R
evie
w
mee
tin
gs to
ass
ess
pro
gres
s on
the
imp
lem
enta
tion
.
X
X
X
X
X
X
X
N
um
ber
of
surv
eys
cond
ucte
d on
qu
alit
y as
sura
nce
of s
ervi
ce
del
iver
ed.
Nu
mbe
r of
re
view
mee
tin
gs
cond
ucte
d
MoH
SW
PMO
RA
LG
D
evel
opm
ent
Par
tner
s R
esea
rch
inst
itu
tion
s
NBS
A
cad
emic
in
stit
uti
ons,
H
ealt
h p
rofe
ssio
nal
asso
ciat
ions
C
SOs
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tegi
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utp
ut
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ivit
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cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
5.2.
7.6
Doc
um
ent a
nd s
hare
bes
t p
ract
ices
on
mat
erna
l, ne
wbo
rn a
nd
child
hea
lth.
X
X
X
X
X
X
X
X
Nu
mbe
r of
bes
t p
ract
ices
d
ocu
men
ted
and
sc
aled
up.
MoH
SW/
RC
HS
CSO
s D
evel
opm
ent
Par
tner
s
Pri
vate
sec
tor
100,
000
5.2.
7.7
Inst
itu
tiona
lize
mat
erna
l, n
ewbo
rn a
nd c
hild
mor
talit
y re
view
ap
pro
ache
s at
all
leve
ls
•V
ital
reg
istr
atio
n sy
stem
(b
irth
and
dea
th)
•C
onfi
den
tial
en
quir
y •
Nea
r m
iss
surv
eys
•M
orta
lity
surv
eys
•V
erba
l au
top
sy
•O
ther
ap
pro
pri
ate
revi
ew
mec
hani
sms
X
X
X
X
X
X
X
X
Nu
mbe
r an
d ty
pe
of M
NC
H
mor
talit
y re
view
re
por
ts.
MoH
SW/
RC
HS
RH
MT
s,
CH
MT
s Fa
cilit
ies
Vill
age
Gov
ern
men
ts
RIT
A
NBS
R
esea
rch
and
acad
emic
in
stit
uti
ons
Dev
elop
men
t P
artn
ers
CSO
s
200,
000
39T
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ateg
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efra
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Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
5.
2.8.
1 R
evie
w a
nd h
arm
oniz
e ex
isti
ng
com
mu
nit
y ba
sed
man
agem
ent
info
rmat
ion
tool
s.
X
X
X
H
arm
oniz
ed
com
mu
nit
y ba
sed
m
anag
emen
t in
form
atio
n to
ols
in p
lace
RC
HS
HM
IS
PMO
-RA
LG
, R
HM
Ts
C
HM
Ts
Dev
elop
men
t P
artn
ers
C
SOs,
V
illag
e G
over
nm
ents
18,
000
5.2.
.8.2
Ori
ent v
illa
ge G
over
nm
ents
on
the
com
mu
nit
y ba
sed
man
agem
ent
info
rmat
ion
tool
s.
X
X
X
X
X
X
X
X
Pro
port
ion
of
villa
ge
Gov
ern
men
t m
embe
rs
orie
nted
on
com
mu
nit
y ba
sed
d
ata
man
agem
ent.
RC
HS
HM
IS
PMO
-RA
LG
R
HM
Ts
CH
MT
s D
evel
opm
ent
Par
tner
s
CSO
s V
illag
e G
over
nm
ents
600
,000
5.2.
8 C
omm
un
ity
bas
ed
man
agem
ent
info
rmat
ion
sys
tem
st
ren
gth
ened
.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Com
mu
nit
y ba
sed
data
effe
ctiv
ely
colle
cted
and
use
d in
pl
anni
ng
5.2.
8.3
Tra
in c
omm
un
ity
hea
lth
wor
kers
an
d o
ther
ser
vice
pro
vid
ers
on
com
mu
nit
y ba
sed
info
rmat
ion
man
agem
ent.
X
X
X
X
Pro
port
ion
of
com
mu
nit
y h
ealt
h w
orke
rs
and
ser
vice
p
rovi
der
s tr
ain
ed
on d
ata
man
agem
ent.
RC
HS
HM
IS
PMO
-RA
LG
R
HM
Ts
C
HM
Ts
Vill
age
Gov
ern
men
ts, D
evel
opm
ent
Par
tner
s
CSO
s
900,
000
40T
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atio
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ateg
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AT
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efra
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tegi
c O
bjec
tive
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utp
ut
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ivit
ies
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1011
1213
1415
Pro
cess
In
dic
ator
s
Res
pon
sibl
e P
erso
n
Res
ourc
es
Nee
ded
in
US
dol
lars
5.
2.9
Cap
acit
y fo
r co
nd
uct
ing
MN
CH
op
erat
ion
al
rese
arch
st
ren
gth
ened
Stra
tegi
c ou
tput
in
dica
tor:
E
vide
nce
on M
NC
H
avai
labl
e fo
r pl
ann
ing
and
prog
ram
me
deve
lopm
ent
5.2.
9.1
Iden
tify
MN
CH
op
erat
iona
l re
sear
ch p
rior
itie
s
5.2.
9.2
Con
duc
t MN
CH
op
erat
iona
l re
sear
ch a
nd d
ocu
men
t and
dis
sem
inat
e re
sult
s
X X
X XX
XX
XX
X
Nu
mbe
r of
M
NC
H
oper
atio
nal
rese
arch
es
cond
ucte
d
MoH
SW-
RH
CS,
R
esea
rch
and
acad
emic
in
stit
uti
ons
1,00
0,00
0
41T
he N
atio
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oad
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ateg
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Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
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1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.2.
10.1
Ad
apt q
ual
ity
assu
ranc
e ap
pro
ache
s fo
r MN
CH
(QIR
I, PI
A, C
OP
E,
Col
labo
rati
ve)
X
X
Nu
mbe
r of
qu
alit
y as
sura
nce
app
roac
hes
adap
ted
MoH
SW
(RC
HS,
In
spec
tora
te
uni
t) R
HM
Ts
Dis
tric
t C
ounc
ils
CH
MT
s D
evel
opm
ent
Par
tner
s C
SOs
50,0
00
5.2.
10
Qu
alit
y as
sura
nce
and
man
agem
ent
(su
per
visi
on, c
lien
t sa
tisf
acti
on,
per
form
ance
as
sess
men
t)
stre
ngt
hen
ed.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Pro
port
ion
of h
ealt
h fa
cilit
ies
deliv
erin
g M
NC
H s
ervi
ces
acco
rdin
g to
na
tion
ally
def
ined
se
rvic
e st
anda
rds
5.2.
10.2
Ori
ent s
up
ervi
sors
and
ser
vice
p
rovi
der
s on
qu
alit
y as
sura
nce
met
hod
s fo
r MN
CH
ser
vice
s.
5.2.
.10.
3 O
rien
t ser
vice
pro
vid
ers
on th
e C
lien
t Hea
lth
Cha
rter
as
tool
to im
pro
ve
rela
tion
ship
wit
h cl
ient
.
5.2.
10.4
Up
dat
e co
de
of c
ond
uct a
nd jo
b d
escr
ipti
on.
5.2.
10.5
Ori
ent h
ealt
h fa
cilit
y co
mm
itte
es
and
dis
tric
t hea
lth
boar
ds
on C
lient
Se
rvic
e C
hart
er to
ens
ure
sat
isfa
ctor
y cl
ient
-ser
vice
rel
atio
nsh
ip.
X X X X
X X X X
X X X
X X X
X X X
X X X
X X X
X X X
Nu
mbe
r of
su
per
viso
rs a
nd
serv
ice
pro
vid
ers
orie
nted
on
qual
ity
assu
ranc
e ap
pro
ache
s.
Pro
port
ion
of h
ealt
h se
rvic
e p
rovi
der
s or
ient
ed o
n C
lient
Se
rvic
e C
hart
er a
t al
l lev
els.
Cod
e of
con
duc
t and
jo
b d
escr
ipti
on
up
dat
ed.
Pro
port
ion
of h
ealt
h fa
cilit
y co
mm
itte
es
and
dis
tric
t hea
lth
boar
ds
orie
nted
on
clie
nt-s
ervi
ce
rela
tion
ship
at a
ll le
vels
.
MoH
SW(R
CH
S,
Insp
ecto
rate
u
nit)
RH
MTs
D
istr
ict
Cou
ncils
C
HM
Ts,
D
evel
opm
ent
Par
tner
s C
SOs
400,
000
42T
he N
atio
nal R
oad
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ateg
ic P
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AT
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IC P
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TIV
ITIE
S: 2
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efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.3
Com
mu
nit
y M
obil
isat
ion
5.
3.1
Com
mu
nit
y b
ased
m
ater
nal
, ne
wb
orn
an
d ch
ild
hea
lth
care
incl
udi
ng
FP
and
nut
riti
on
stre
ngt
hen
ed
Stra
tegi
c O
utp
ut
Ind
icat
or:
Mat
erna
l, n
ewbo
rn
and
child
hea
lth c
are
serv
ices
pro
vide
d at
co
mm
uni
ty le
vel
5.3.
1.1
Tra
in c
omm
un
ity
base
d h
ealt
h w
orke
rs o
n M
NC
car
e in
clu
din
g
com
mu
nit
y IM
CI.
5.3.
1.2
Tra
in E
mp
loye
d C
HW
on
Com
pre
hen
sive
Mat
erna
l, N
eona
tal a
nd
child
Pac
kage
.
5.3.
1.3
Re-
inst
uti
onal
ize
quar
terl
y vi
llage
h
ealt
h d
ays
5.3.
1.4
Con
du
ct m
onth
ly o
utre
ach
and
mob
ile
clin
ic s
ervi
ces
for M
NC
H.
5.3.
1.5
Pro
vid
e co
mm
uni
ty h
ealt
h w
orke
rs w
ith
nece
ssar
y eq
uip
men
t, co
mm
odit
ies,
su
pp
lies
and
tran
spor
t.
5.3.
1.6
Dev
elop
and
imp
lem
ent
ince
ntiv
e m
echa
nism
for
com
mu
nit
y h
ealt
h w
orke
rs
X
X
X
X
X
X
X
X
Pro
port
ion
of
villa
ges
wit
h co
mm
un
ity
hea
lth
wor
kers
7,
trai
ned
on
mat
erna
l, n
eona
tal a
nd c
hild
h
ealt
h is
sues
in
clu
din
g nu
trit
ion
and
FP
.
Pro
port
ion
of
villa
ges
cond
ucti
ng
villa
ge h
ealt
h d
ays.
Pro
port
ion
of
dis
pen
sari
es a
nd
hea
lth
cent
res
cond
ucti
ng
mon
thly
ou
trea
ch
and
mob
ile
clin
ic
serv
ices
.
Pro
port
ion
of
villa
ges
wit
h in
cent
ive
mec
hani
sm fo
r co
mm
un
ity
hea
lth
wor
kers
.
MoH
SW/
RC
HS
, MoC
DG
C
PMO
RA
LG
R
HM
Ts,
D
istr
ict
Cou
ncils
C
HM
Ts,
V
illag
e G
over
nm
ents
, D
evel
opm
ent
Par
tner
s C
SOs
2,80
0,00
0
7 Req
uire
d ra
tio 1
/30
hous
ehol
ds
43T
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ateg
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tegi
c O
bjec
tive
/ A
ctiv
itie
s
Tim
efra
me
Pro
cess
R
esp
onsi
ble
Res
ourc
es
Out
put
08
0910
1112
1314
15In
dic
ator
s
Per
son
N
eed
ed in
U
S d
olla
rs
5.3.
2.1
Sens
itiz
e co
mm
un
ity
lead
ers
and
com
mu
niti
es o
n p
arti
cip
ator
y p
lan
nin
g ,
imp
lem
enta
tion
and
mon
itor
ing
of c
omm
un
ity
base
d M
NC
H
inte
rven
tion
s.
X
X
X
X
X
X
Pro
port
ion
of
villa
ges
wit
h co
mm
un
ity
lead
ers
and
m
embe
rs
sens
itis
ed o
n m
ater
nal,
new
born
and
ch
ild h
ealt
h is
sues
.
Pro
port
ion
of
villa
ges
pla
ns
wit
h M
NC
H
acti
viti
es.
MoH
SW/
RC
HS,
M
oCD
GC
PM
OR
AL
G
Dis
tric
t C
ounc
ils
CH
MT
s, C
omm
uni
ties
C
SOs
Dev
elop
men
t P
artn
ers
2, 5
00,0
00
5.3.
2
Com
mu
nit
y p
arti
cipa
tion
in
mat
ern
al n
ewb
orn
an
d ch
ild
hea
lth
care
incr
ease
d.
Stra
tegi
c O
utp
ut
Ind
icat
ors
Com
mu
nit
y le
ader
s an
d m
embe
rs
part
icip
atin
g ac
tive
ly
in M
NC
H is
sues
5.3.
2.2
Ori
ent h
ealt
h fa
cilit
y co
mm
itte
es
and
dis
tric
t hea
lth
boar
ds
on
Cli
ent S
ervi
ce C
hart
er to
ens
ure
sa
tisf
acto
ry c
lient
-ser
vice
re
lati
onsh
ip
X
X
X
X
X
X
X
X
Pro
port
ion
of
hea
lth
faci
lity
com
mit
tees
and
d
istr
ict h
ealt
h bo
ard
s or
ient
ed
on c
lient
-se
rvic
e re
lati
onsh
ip a
t al
l lev
els.
MoH
SW,
Dis
tric
t C
ounc
ils
500,
000
44T
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ateg
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AT
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ITIE
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efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
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1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.4
Beh
avio
ur
Ch
ange
5.
4.1
Key
com
mu
nit
y an
d h
ouse
hol
d p
ract
ises
for
m
ater
nal
, ne
wb
orn
an
d ch
ild
care
im
pro
ved
.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Impr
oved
pra
ctis
es
for
mat
erna
l, ne
wbo
rn a
nd c
hild
he
alth
car
e at a
ll le
vels
.
5.4.
1.1
Des
ign,
dev
elop
IEC
/B
CC
m
essa
ges
and
mat
eria
ls fo
r com
mu
nit
y m
embe
rs (m
en, w
omen
and
ado
lesc
ents
) fo
r sp
ecif
ic m
ater
nal
new
born
and
chi
ld
issu
es, w
ith e
mp
hasi
s on
: •
Pos
tnat
al a
nd N
ewbo
rn c
are;
•
Ad
vant
ages
of e
arly
att
end
ance
to
hea
lth
faci
litie
s (A
NC
); •
Bir
th p
rep
ared
nes
s;
•E
ssen
tial
nut
riti
onal
pra
ctic
es a
nd
actio
ns fo
r m
ater
nal
new
born
and
ch
ild;
•C
ause
s of
mat
erna
l, ne
wbo
rn a
nd
child
dea
ths
and
iden
tifi
catio
n of
D
ange
r si
gns;
•
Ear
ly C
are
seek
ing
and
com
plia
nce
•H
ome
man
agem
ent o
f com
mon
ch
ildho
od il
lnes
s •
Dis
ease
pre
vent
ion
(IT
N’s
, im
mu
niz
atio
n, h
ygie
ne
and
sa
nita
tion
) •
Inte
rven
tion
s to
pre
vent
HIV
and
M
othe
r to
Chi
ld tr
ansm
issi
on o
f HIV
•
Rep
osit
ioni
ng
fam
ily
pla
nn
ing
•P
reve
nti
on o
n ea
rly
and
unw
ante
d
pre
gnan
cies
•
Rol
e of
men
in M
ater
nal n
ewbo
rn
and
chi
ld h
ealt
h ca
re
X
X
X
XX
IEC
/B
CC
mes
sage
s an
d m
ater
ials
ad
dre
ssin
g sp
ecif
ic
mat
erna
l and
n
ewbo
rn is
sues
d
evel
oped
for
com
mu
nit
y m
embe
rs.
MoH
SW,
PMO
RA
LG
, M
oCD
GC
, M
oEV
T, M
oISC
D
istr
ict
Cou
ncils
, C
HM
T’s
, V
illag
e G
over
nm
ent,
Dev
elop
men
t P
artn
ers
, M
edia
, C
SOs,
100,
000
45T
he N
atio
nal R
oad
Map
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ateg
ic P
lan
-200
8 -
2015
Tim
efra
me
Stra
tegi
c O
bjec
tive
/ O
utp
ut
Act
ivit
ies
0809
1011
1213
1415
Pro
cess
In
dica
tors
R
esp
onsi
ble
Per
son
R
esou
rces
N
eed
ed in
U
S d
olla
rs
5.4.
1.2
Dis
sem
inat
e an
d d
istr
ibu
te
IEC
/B
CC
mes
sage
s an
d m
ater
ials
for
com
mu
nit
y m
embe
rs th
rou
gh d
iffer
ent
med
ia.
5.4.
1.3
Dev
elop
the
cap
acit
y of
co
mm
un
ity
thea
tre
grou
ps
to
dis
sem
inat
e M
NC
H m
essa
ges
Pro
port
ion
of IE
C/
BC
C
mat
eria
ls d
isse
min
ated
th
rou
gh d
iffer
ent m
edia
(R
oad
show
s, T
V, R
adio
et
c).
Nu
mbe
r of
com
mu
nity
th
eatr
e gr
oup
s es
tabl
ish
ed to
dis
sem
inat
e M
NC
H m
essa
ges
MoH
SW ,
PMO
RA
LG
M
oCD
GC
M
oEV
T, M
oISC
D
istr
ict C
ounc
ils
CH
MT
s, V
illag
e G
over
nm
ents
, D
evel
opm
ent
Par
tner
s , M
edia
C
SOs.
4,00
0,00
0
350,
000
5.5
Fost
erin
g P
artn
ersh
ip 5.5.
1.1
Ori
ent p
artn
ers
on O
ne
MN
CH
St
rate
gic
Pla
n
5.5.
1.2
Con
duc
t joi
nt p
lann
ing
and
co
ord
inat
ion
mee
tin
gs w
ith
stak
ehol
der
s/p
artn
ers
for
mat
erna
l, n
ewbo
rn a
nd c
hild
car
e at
all
leve
ls
5.5.
1.3
Con
duc
t qu
arte
rly
PM
NC
H
com
mit
tee
mee
tin
gs
5.5.
1.4
Con
duc
t bi-
annu
al P
MN
CH
fo
rum
X X X X
X X X X
X X X
X X X
X X X
X X X
X X X
X X X
Num
ber
of o
rien
tati
on
sess
ions
on
One
MN
CH
St
rate
gic
Pla
n c
ond
ucte
d
Nu
mbe
r of
join
t pla
nnin
g an
d c
oord
inat
ion
mee
tin
gs c
ond
ucte
d
Nu
mbe
r of
PM
NC
H
com
mit
tee
mee
tin
gs h
eld
an
nual
ly
Nu
mbe
r of
PM
NC
H f
ora
hel
d
MoH
SW/
RC
HS
MO
CD
GC
, PM
OR
AL
G
Reg
iona
l Se
cret
aria
t D
istr
ict C
ounc
ils
Dev
elop
men
t P
artn
ers
Hea
lth
pro
fess
iona
l as
soci
atio
ns
CSO
‘s
65,0
00
5.5.
1 P
artn
ersh
ip a
nd
coor
din
atio
n f
or
MN
CH
act
ivit
ies
at
all l
evel
s im
pro
ved
.
Stra
tegi
c O
utp
ut
Ind
icat
or:
Coo
rdin
ated
res
pons
e an
d le
vera
ging
of
reso
urce
s fo
r M
NC
H
acti
viti
es.
5.5.
1.4
Pro
vid
e su
ppo
rt to
the
PMN
CH
se
cret
aria
t for
Par
tner
ship
co-
ordi
nati
on
X
X
X
X
X
X
X
X
Func
tiona
l sec
reta
riat
for
par
tner
ship
in p
lace
M
oHSW
D
evel
opm
ent
Par
tner
s H
ealt
h p
rofe
ssio
nal
asso
ciat
ions
C
SO ‘s
-
GR
AN
D T
OT
AL
US
$674
,030
,000
46T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
STR
AT
EG
IC P
LA
N A
ND
AC
TIV
ITIE
S: 2
008
-201
5
The National Road Map Strategic Plan -2008 - 2015 47
CHAPTER 6MONITORING FRAMEWORK
Maternal, newborn and child care programmes will be evaluated based on an agreed set of indicators, bothqualitative and quantitative. Routine health information systems currently track outputs such as number ofadmissions, management of childhood illnesses, immunization, antenatal care, births, and caesarean sections.There is little information on quality of maternal and newborn care, such as intrapartum care, stillbirth rate,babies receiving resuscitation and outcome, and percentage of newborns receiving essential newborn care.
List of indicators to assess MNCH Progress
a) Indicators at National level:Sources of data will be a combination of HMIS, District Health Surveys, Household surveys, Health Facilitysurveys, Demographic Health Surveys (DHS), Tanzania Service Provision Assessment surveys (TSPA),Roll back Malaria M&E surveys and financial records. Collected data will be grouped according to gender,age groups, income/wealth quintiles, geographical location (rural and urban) as well as ethnic groups.
.b) Community Indicators:
• Proportion of communities that have set up functional emergency preparedness committees and plansfor MNCH including FP and nutrition
• Proportion of pregnant women that have birth preparedness plans
• Proportion of women and children who needed referral who went for referral
• Proportion of women with knowledge of danger signs of obstetric, neonatal and child healthcomplications
• Proportion of district management task forces and committees with representation from communities
• Proportion of facilities with a designated staff responsible for community health services
• Proportion of villages conducting quarterly village health days
• Proportion of villages with community health workers implementing MNCH interventions
• Coverage of access to potable water (improved drinking water source)
• Coverage of improved latrines
• Use of solid fuels for cooking
• Households’ care-seeking rate for diarrhoea, malaria and pneumonia• ITN use in under-fives and pregnant women
c) Neonatal Indicators
• Neonatal mortality rate
• Prevalence of low birth weight
• Early initiation of breast feeding (within the first hour)
• Proportion of district hospitals that have functional newborn resuscitation facilities in the deliveryroom
• Number of perinatal deaths (still births, deaths within the first seven days of life)
• Postnatal care attendance rate
• Proportion of district hospitals implementing Kangaroo Mother Care for management of Low BirthWeight
• Proportion of district hospitals that are accredited baby friendly
• Postnatal vitamin A coverage
48 The National Road Map Strategic Plan -2008 - 2015
d) Family Planning Indicators
• Contraceptive prevalence rate by method, by age group, by socio economic quintiles
• Met need for FP by age group.
• Total fertility rate.
• Age specific fertility rates
• Number of individuals accepting contraceptives new acceptors
• Number of FP service delivery points per 500,000 population offering full range of contraceptiveinformation counselling and supplies.
e) Maternal Health Indicators:
• Maternal mortality ratio
• Proportion of deliveries taking place in a health facility
• Proportion of births assisted by a skilled attendant
• Proportion of facilities offering BEmOC services and CEmOC services
• Coverage of met need for obstetric complications (coverage of women with obstetric complications thathave received EmOC out of all women with obstetric complications)
• Caesarean sections as a percentage of all live births
• Case Fatality Rate for obstetric complications
• Proportion of first level facilities (PHC) with two or more skilled attendants
• Percentage of pregnant women attended at least once by skilled personnel; percentage attended byskilled personnel at least four times
• Proportion of HIV positive women provided with ARV’s during pregnancy
• Proportion of pregnant women with access to PMTCT services
• Prevalence of positive syphilis serology in pregnant women
• Percentage of pregnant women tested and treated for syphyllis
• Percentage of pregnant women receiving two doses of SP
• Percentage of service delivery points providing youth friendly services
f) Child Health Indicators
• Under-five mortality rate
• Exclusive breastfeeding rate <4 and <6 months
• Continued breastfeeding rate 6-23 months
• Timely complementary feeding rate
• Under-weight prevalence
• Stunting prevalence
• Wasting prevalence
• Vitamin A supplementation coverage (under-fives)
• Anti-malarial treatment in under-fives (within 24 hours of onset of fever, appropriateness)
• Antibiotic treatment for pneumonia and dysentery
• ORS and zinc treatment in management of diarrhoea
• Proportion of health facilities with 60% of health workers trained on IMCI
The National Road Map Strategic Plan -2008 - 2015 49
• Measles immunization coverage
• DTP- HB3 immunization coverage (Hib coverage after introduction)
• Proportion of HIV positive children accessing ARV
• Proportion of HIV exposed infants accessing ARV prophylaxis
g) Increased Political Will and Commitment Indicators:
• Proportion of Government budget allocated to health
• Proportion of MoHSW/ district budget allocated to MNCH and FP
• Availability of policies addressing increased coverage for skilled care
• Development plans integrating MNCH (Development Vision 2025, MKUKUTA, MMAM,HSSP)
h) Indicators for Measuring Progress of the MNCH Strategic Plan
• Existence of Partnership for Maternal Newborn and Child Health (Partnership)
• Total resources mobilized for MNCH Strategic Plan
• Biennial implementation report tracking progress on indicators listed above
Tab
le 2
: R
esul
ts b
ased
Mat
rix
MK
UK
UT
A b
road
out
com
es:
•Im
prov
ed q
ualit
y of
life
and
soc
ial w
ell-
bein
g, w
ith
part
icul
ar fo
cus
on th
e po
ores
t an
d m
ost v
ulne
rabl
e gr
oups
. •
Red
uced
ineq
ualit
ies
in o
utco
mes
(e.g
. edu
cati
on, s
urvi
val,
heal
th)
acro
ss g
eogr
aphi
c, in
com
e, a
ge, g
ende
r an
d ot
her
grou
ps.
MK
UK
UT
A (G
oal 2
.2):
To
impr
ove
surv
ival
and
wel
l-be
ing
of a
ll c
hild
ren
and
wom
en a
nd o
f esp
ecia
lly
vuln
erab
le g
rou
ps.
MK
UK
UT
A (G
oal 2
.5):
To
ensu
re e
ffec
tive
sys
tem
s to
per
mit
uni
vers
al a
cces
s to
qua
lity
an
d af
ford
able
pub
lic
serv
ices
.
Roa
dmap
Ope
rati
on t
arg
ets:
1.
Incr
ease
d co
vera
ge o
f bir
ths
atte
nded
by
skil
led
atte
ndan
ts fr
om 4
6% in
200
4/5
to 8
0%.
2.In
crea
sed
imm
uniz
atio
n co
vera
ge o
f DT
P-H
B 3
and
Mea
sles
vac
cine
to a
bove
90%
in 9
0% o
f the
dis
tric
ts.
3.In
trod
uced
new
vac
cine
s to
EP
I (H
ib, P
neum
occo
cal,
Hum
an p
apil
oma
(HP
V)
and
rota
vir
us v
acci
ne)
. 4.
Red
uced
stu
ntin
g an
d un
derw
eigh
t am
ong
unde
r-fi
ves
from
_38
% a
nd 2
2% to
22%
and
14%
res
pect
ivel
y.
5.In
crea
sed
excl
usiv
e br
east
feed
ing
cove
rage
from
41%
to 8
0 %
6.
PM
TC
T s
ervi
ces
prov
ided
to a
t lea
st 8
0% o
f pre
gnan
t wom
en, t
heir
bab
ies
and
fam
ilie
s.
7.90
% o
f sic
k ch
ildr
en s
eeki
ng c
are
at h
ealt
h fa
cili
ties
app
ropr
iate
ly m
anag
ed.
8.In
crea
sed
cove
rage
und
er-f
ives
sle
epin
g un
der
ITN
’s fr
om 1
6% to
80%
.
9.75
% o
f vill
ages
hav
e co
mm
unity
hea
lth w
orke
rs o
fferi
ng M
NC
H s
ervi
ces
at c
omm
unity
leve
l. 10
.In
crea
sed
mod
ern
cont
race
ptiv
e pr
eval
ence
rat
e fr
om 2
0% t
o 6
0%
11.
Incr
ease
d co
vera
ge o
f com
preh
ensi
ve E
MO
C fr
om 6
4% o
f hos
pita
ls to
100
% a
nd b
asic
EM
OC
from
5%
of H
ealth
cen
tres
and
Dis
pens
arie
s to
70%
12
.In
crea
se th
e nu
mbe
r of
hea
lth fa
cili
ties
off
erin
g E
ssen
tial N
ewbo
rn C
are
to 7
5%.
13.
Incr
ease
d an
tena
tal c
are
atte
ndan
ce fo
r at
leas
t fou
r vi
sits
from
64%
to 9
0%
Foc
us
Are
a In
dic
ator
s of
Res
ults
M
ean
s of
Ver
ific
atio
n
Ass
um
pti
ons
6.1
Ad
voca
cy a
nd
Res
ourc
e M
obil
isat
ion
Incr
ease
d b
udge
t all
ocat
ion
for
heal
th
espe
cial
ly fo
r m
ater
nal
an
d n
ewbo
rn
serv
ices
at a
ll le
vels
.
•15
% o
f Gov
ernm
ent b
udge
t al
loca
ted
to h
ealt
h
•%
Hea
lth
bud
get
avai
labl
e to
ca
ter
for
mat
ern
al, n
ewbo
rn a
nd
ch
ild
hea
lth
serv
ices
at
all l
evel
s
•B
ud
get
for
mat
erna
l, n
ewbo
rn a
nd
ch
ild
hea
lth
incl
ud
ing
FP a
nd
n
utr
itio
n in
crea
sed
by
50%
by
2015
.
•M
ediu
m T
erm
Exp
end
itu
re
Fram
ewor
k (M
TE
F) c
ash
flow
at
cent
ral l
evel
. •
Com
preh
ensi
ve C
ounc
il H
ealt
h Pl
an c
ash
flow
at d
istr
ict l
evel
. •
Cas
h an
d r
ecei
pt a
t all
leve
ls.
•Pu
blic
Exp
end
itur
e R
evie
w
repo
rts
•H
IPC
fund
s al
loca
ted
to h
ealt
h.
•St
able
eco
nom
ic g
row
th.
•B
aske
t fun
d a
vai
labl
e •
Com
mit
men
t by
don
ors/
par
tner
s
50T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Tabl
e 2:
Res
ults
bas
ed M
atri
x
Foc
us
Are
a In
dic
ator
s of
Res
ults
M
ean
s of
Ver
ific
atio
n
Ass
um
pti
ons
Reg
ulat
ions
/ la
ws/
poli
cies
that
hi
nder
eff
ecti
ve im
plem
enta
tion
of
mat
ern
al a
nd
new
born
car
e by
re
leva
nt r
egul
ator
y bo
die
s re
view
ed.
•N
umbe
r of
reg
ulat
ions
an
d l
aws
appr
oved
by
regu
lato
ry b
odie
s •
Poli
cy d
ocum
ents
av
aila
ble
for
impl
emen
tati
on.
•W
illi
ngne
ss o
f reg
ulat
ory
bod
ies
to
revi
ew a
nd
end
orse
pol
icy
doc
umen
ts.
Imp
lem
enta
tion
of
the
exem
pti
on p
olic
y fo
r m
ater
nal
an
d c
hil
d h
ealt
h
stre
ngt
hen
ed.
.
•E
xem
ptio
n po
licy
eff
ecti
vely
im
plem
ente
d•
Exe
mpt
ion
poli
cy g
uid
elin
es i
n pl
ace
at a
ll f
acil
ity
leve
ls.
•Su
rvey
fin
din
gs.
•E
xem
ptio
n m
ech
anis
ms
impl
emen
ted
ac
cord
ing
to p
olic
y.
Em
plo
ymen
t, d
eplo
ymen
t an
d r
eten
tion
of
sk
ille
d h
ealt
h w
ork
ers
at a
ll l
evel
s of
ca
re i
mp
rove
d.
Num
ber
of s
kill
ed h
ealt
h w
orke
rs
incr
ease
d to
100
% b
y 2
015
•
•H
uman
res
ourc
e su
rvey
•
Hea
lth
Stat
isti
cs A
bstr
act
•
6.2
Hea
lth
Sys
tem
s S
tren
gth
enin
g an
d C
apac
ity
Dev
elop
men
t K
now
led
ge a
nd
sk
ills
of
sup
ervi
sors
an
d
serv
ice
pro
vid
ers
on m
ater
nal
, n
ewb
orn
an
d c
hil
d c
are
incl
ud
ing
FP a
nd
n
utr
itio
n i
ncr
ease
d.
•Pr
opor
tion
of h
ealt
h fa
cili
ties
pr
ovid
ing
qual
ity
mat
ern
al a
nd
ne
wbo
rn c
are.
•
Mat
ern
al, n
ewbo
rn a
nd
chi
ld
heal
th s
ervi
ce p
rovi
ded
ac
cord
ing
to s
tan
dar
ds.
•
Prop
orti
on
of
und
er-f
ives
re
ceiv
ing
corr
ect
anti
-mal
aria
l tr
eatm
ent.
•Pr
opor
tion
of
un
der
-fiv
es
rece
ivin
g ap
prop
riat
e an
ti-b
ioti
c tr
eatm
ent
for
pneu
mon
ia
and
d
ysen
tery
. •
Prop
orti
on
of
und
er-f
ives
re
ceiv
ing
OR
S an
d z
inc
trea
tmen
t in
man
agem
ent o
f dia
rrh
oea
•Pe
rcen
tage
of
pr
egn
ant
wom
en
rece
ivin
g to
dos
es o
f SP
•Pe
rcen
tage
of
pr
egn
ant
wom
en
test
ed a
nd
tre
ated
for
syph
ilis
•T
rain
ing
and
foll
ow u
p re
port
s •
Hea
lth
faci
lity
sur
vey
•Se
rvic
es s
tati
stic
s •
Tan
zan
ia S
ervi
ce P
rovi
sion
A
sses
smen
t (T
SPA
), •
Serv
ice
Ava
ilab
ilit
y M
appi
ng
(SA
M)
•R
oll b
ack
mal
aria
(RB
M) s
urve
y
•R
esou
rces
for
upd
atin
g kn
owle
dge
an
d
skil
ls a
vail
able
. •
Ava
ilab
ilit
y of
per
sonn
el to
be
trai
ned
.
51T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Foc
us
Are
a In
dic
ator
s of
Res
ults
M
ean
s of
Ver
ific
atio
n
Ass
um
pti
ons
•R
elev
ant s
ecto
rs (
Min
istr
y of
Fi
nan
ce, M
oHSW
) all
ocat
ing
at
leas
t 15%
of G
over
nmen
t bud
get
for
.hea
lth
• M
oHSW
all
ocat
ing
15%
of t
he
Hea
lth
budg
et f
or m
ater
nal a
nd
new
born
car
e
•T
rain
ing
repo
rts
MT
EF
cash
fl
ow a
t al
l lev
els.
•
CC
HP
cash
flow
at d
istr
ict l
evel
. •
Cas
h an
d r
ecei
pt a
t all
leve
ls.
•Pu
blic
Exp
end
itur
e R
evie
w
repo
rts
•Pl
anni
ng a
nd
man
agem
ent t
ools
av
aila
ble.
•
Stab
le e
cono
mic
gro
wth
. •
Bas
ket f
und
av
aila
ble
•C
omm
itm
ent b
y d
onor
s/ p
artn
ers
•E
vid
ence
-bas
ed m
ater
nal
an
d
new
born
car
e pl
anni
ng a
t RC
HS
and
CH
MT
•Pl
anni
ng d
ocum
ents
. •
CC
HPs
•
MT
EF
•Pe
rson
nel a
vai
labl
e.
Pla
nn
ing
and
man
agem
ent
cap
acit
y fo
r m
ater
nal
an
d n
ewb
orn
car
e in
clu
din
g FP
an
d n
utr
itio
n s
tren
gth
ened
.
•Pr
opor
tion
of d
istr
icts
wit
h in
crea
sed
bu
dge
t allo
cati
on f
or m
ater
nal
new
born
an
d c
hild
hea
lth
in
terv
enti
ons
in C
CH
P
•C
CH
P ca
sh fl
ow
•St
able
eco
nom
ic g
row
th.
•B
aske
t fun
d a
vai
labl
e
•%
of
hea
lth
fac
iliti
es p
rovi
din
g B
asic
an
d c
omp
reh
ensi
ve
Em
OC
an
d
Ess
enti
al N
ewbo
rn c
are
•H
ealt
h fa
cili
ty s
urve
y •
serv
ice
stat
isti
cs (T
SPA
, SA
M)
•C
HM
T a
nd
HF
man
ager
s tr
aine
d o
n ho
w
to m
easu
re/
use
the
ind
icat
ors.
•
Ava
ilab
ilit
y of
fund
s
•A
vail
abil
ity
of s
kill
ed a
tten
dan
ts
•P
ropo
rtio
n of
bi
rths
as
sist
ed
by
a sk
ille
d at
tend
ant
•D
emog
raph
ic H
ealt
h Su
rvey
, H
ouse
hold
su
rvey
s •
Ava
ilab
ilit
y of
ski
lled
att
end
ants
•Pr
opor
tion
of c
aesa
rean
sec
tion
s as
a p
erce
ntag
e of
live
bir
ths.
•
Serv
ice
stat
isti
cs
•A
vail
abil
ity
of s
kill
ed a
tten
dan
ts
•C
ase
fata
lity
rat
e d
ue to
obs
tetr
ic
com
plic
atio
ns.
•Se
rvic
e st
atis
tics
•
Ava
ilab
ilit
y of
ski
lled
att
end
ants
Bas
ic a
nd
Com
pre
hen
sive
Em
OC
an
d
new
born
ser
vice
s at
all
leve
ls
stre
ngth
ened
.
•E
ssen
tial
com
mod
itie
s, s
up
pli
es
and
med
icin
es f
or m
ater
nal
, n
ewb
orn
an
d c
hil
d c
are
avai
lab
le
all
the
tim
e at
eve
ry h
ealt
h f
acil
ity
•In
vent
ory
repo
rts
•H
ealt
h fa
cili
ty s
urve
ys (T
SPA
) •
Ann
ual C
ontr
acep
tive
Pr
ocur
emen
t Tab
les
(CPT
s)
•M
onth
ly c
ontr
acep
tive
sto
ck
stat
us r
epor
ts fr
om M
SD
•A
deq
uat
e re
sour
ce a
vail
able
•
Poli
tica
l wil
l an
d c
omm
itm
ent
52T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Res
ults
bas
ed M
atri
x
Foc
us
Are
a In
dic
ator
s of
Res
ults
M
ean
s of
Ver
ific
atio
n
Ass
um
pti
ons
Mec
han
ism
s fo
r av
aila
bil
ity
of e
ssen
tial
co
mm
odit
ies,
su
pp
lies
an
d m
edic
ines
fo
r m
ater
nal
, n
ewb
orn
an
d c
hil
d h
ealt
h
incl
ud
ing
fam
ily
pla
nn
ing
st
ren
gth
ened
.
•E
ssen
tial
com
mod
itie
s, s
up
pli
es
and
med
icin
es f
or m
ater
nal
, n
ewb
orn
an
d c
hil
d c
are
avai
lab
le
all
the
tim
e at
eve
ry h
ealt
h f
acil
ity
•In
vent
ory
repo
rts
•H
ealt
h fa
cili
ty s
urve
ys (T
SPA
) •
Ann
ual C
ontr
acep
tive
Pr
ocur
emen
t Tab
les
(CPT
s)
•M
onth
ly c
ontr
acep
tive
sto
ck
stat
us r
epor
ts fr
om M
SD
•A
deq
uat
e re
sour
ce a
vail
able
•
Poli
tica
l wil
l an
d c
omm
itm
ent
Ref
erra
l Sys
tem
Ref
erra
l sy
stem
at a
ll l
evel
s st
ren
gth
ened
. •
Fun
ctio
nal
ref
erra
l sys
tem
s in
p
lace
at
all l
evel
s•
Perc
enta
ge o
f all
wom
en w
ith
maj
or o
bste
tric
com
pli
cati
ons
trea
ted
in E
mO
C fa
cili
ties
(met
ob
stet
ric
need
) •
Perc
enta
ge o
f ref
erre
d u
nder
-fi
ves
who
act
ual
ly g
o fo
r re
ferr
al
•Sp
ecia
l Su
rvey
•
Serv
ice
stat
isti
cs r
epor
ts
•A
vail
abil
ity
of f
und
s to
impr
ove
refe
rral
sy
stem
•
Wil
ling
ness
of c
omm
unit
y m
embe
rs to
p
arti
cip
ate
in e
mer
genc
y pr
epar
edne
ss
Res
earc
h, M
onit
orin
g an
d E
valu
atio
n
HM
IS c
apac
ity
to c
aptu
re i
nfo
rmat
ion
on
m
ater
nal
, neo
nat
al a
nd
ch
ild
in
dic
ator
s in
clu
din
g FP
an
d n
utr
itio
n i
mp
rove
d.
•K
ey M
ater
nal,
new
born
and
chi
ld
heal
th i
ndic
ator
s re
port
ed a
nnua
lly
thro
ugh
HM
IS
•H
ealt
h st
atis
tics
rep
orts
•
Hea
lth
Stat
isti
cs A
bstr
act
•H
MIS
rev
iew
ed to
inco
rpor
ate
mat
ern
al
and
new
born
hea
lth
ind
icat
ors
53T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Foc
us
Are
a In
dic
ator
s of
Res
ults
M
ean
s of
Ver
ific
atio
n
Ass
um
pti
ons
Mon
itor
ing
and
eva
luat
ion
fra
mew
ork
for
M
NC
H s
tren
gth
ened
an
d i
mp
lem
ente
d.
•Pr
ogre
ss o
n M
ater
nal,
new
born
an
d
chil
d h
ealt
h st
atus
/tr
end
s r
epor
ted
. o
Mat
ern
al m
orta
lity
rat
e o
Un
der
-fiv
e m
orta
lity
rat
e o
Infa
nt m
orta
lity
rat
e o
Neo
nat
al m
orta
lity
rat
e o
Con
trac
epti
ve
pre
vale
nce
ra
te
by
met
hod
, by
ag
e gr
oup
, by
so
cio
econ
omic
qu
inti
les
oU
nd
er w
eigh
t, s
tun
ting
ra
te
oE
xclu
sive
Bre
ast F
eed
ing
ra
te
oM
easl
es
imm
uni
zati
on
cov
erag
e o
DT
P-H
B3
imm
uni
zati
on
cov
erag
e
•Pr
opor
tion
of
hea
lth
fac
iliti
es
rece
ivin
g qu
arte
rly
sup
por
tiv
e su
per
visi
on.
•Pr
opor
tion
of
hea
lth
wor
kers
tha
t re
ceiv
ed f
ollo
w u
p a
fter
tra
inin
g on
M
NC
H p
acka
ges
year
ly
•N
um
ber
of s
urv
eys
con
du
cted
on
qual
ity
assu
ran
ce o
f ser
vice
del
iver
ed.
•N
um
ber
and
typ
e of
MN
CH
m
orta
lity
revi
ew r
epor
ts.
Bir
th r
egis
trat
ion
rate
•Sp
ecia
l rep
orts
/sur
veys
•
Serv
ice
stat
isti
cs r
epor
ts
•Su
perv
isio
n re
port
s •
Mor
tali
ty r
evie
w a
nd
no
tifi
cati
on r
epor
ts
•D
emog
raph
ic h
ealt
h su
rvey
, •
Cen
sus
•V
ital
sta
tist
ics
•A
deq
uat
e re
sour
ces
to c
ond
uct
Ope
rati
onal
Res
earc
h •
Cap
acit
y to
con
duc
t res
earc
h
Com
mu
nit
y b
ased
man
agem
ent
info
rmat
ion
sys
tem
str
engt
hen
ed.
•C
omm
un
ity
bas
ed d
ata
effe
ctiv
ely
coll
ecte
d a
nd
use
d i
n p
lann
ing.
•
Com
mun
ity
dev
elop
men
t pla
ns.
•
CB
MIS
dat
a av
aila
ble
•A
deq
uat
e re
sour
ces
to fa
cili
tate
pla
nnin
g at
com
mun
ity
leve
l. •
Cap
acit
y an
d c
apab
ilit
y of
the
com
mun
ity
mem
bers
to u
se e
vid
ence
bas
ed
info
rmat
ion
for
plan
ning
. Q
ual
ity
assu
ran
ce a
nd
man
agem
ent
(su
per
visi
on, c
lien
t sa
tisf
acti
on,
per
form
ance
ass
essm
ent)
str
engt
hen
ed.
•Pr
opor
tion
of
hea
lth
fac
iliti
es
del
iver
ing
MN
CH
ser
vice
s ac
cord
ing
to n
atio
nally
def
ined
ser
vice
st
and
ard
s
•Pr
opor
tion
of c
lien
ts s
atis
fied
w
ith
mat
ern
al a
nd
new
born
se
rvic
es
•H
ealt
h fa
cili
ty a
nd
hou
seho
ld
Surv
eys
•Se
rvic
e st
atis
tics
•
Supe
rvis
ion
repo
rts
•St
and
ard
s fo
r qu
alit
y im
prov
emen
t wil
l be
impl
emen
ted
.
54T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
Res
ults
bas
ed M
atri
x
Foc
us
Are
a In
dic
ator
s of
Res
ults
M
ean
s of
Ver
ific
atio
n
Ass
um
pti
ons
to h
ealt
h fa
cili
ty f
or c
are
sick
/ po
stn
atal
•P
erce
nta
ge
of
pre
gnan
t w
omen
at
ten
ded
at
le
ast
once
by
sk
illed
p
erso
nn
el;
per
cen
tage
at
ten
ded
by
sk
illed
per
son
nel
at
leas
t fo
ur
tim
es•
Hou
seho
lds
care
se
ekin
g ra
te
for
diar
rhoe
a,
mal
aria
, pn
eum
onia
an
d ne
onat
al c
ondi
tion
s
The
Nat
iona
l Roa
d M
ap S
trat
egic
Pla
n -2
008
- 20
1555
56 The National Road Map Strategic Plan -2008 - 2015
The National Road Map Strategic Plan -2008 - 2015 57
ANNEX 1 SWOT ANALYSIS
(A) M
ater
nal
Car
e
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
(i)
Pol
icy
Issu
es
••E
xist
ence
of n
atio
nal
pol
icie
s w
hic
h ad
dre
ss m
ater
nal
hea
lth
such
as
the
Nat
ion
al H
ealt
h Po
licy
, Rep
rod
ucti
ve a
nd
Chi
ld
Hea
lth
Poli
cy, M
KU
KU
TA
,M
MA
Met
c.
•T
he N
atio
nal
Hea
lth
Poli
cy a
nd
th
e R
epro
du
ctiv
e an
d C
hild
H
ealt
h Po
licy
em
phas
ise
a m
ulti
sect
oral
app
roac
h to
re
prod
ucti
ve h
ealt
h is
sues
, wh
ich
incl
ud
e m
ale
invo
lvem
ent.
•T
he N
atio
nal
Hea
lth
Poli
cy
prom
otes
the
righ
t of a
ll w
omen
to
acc
ess
qual
ity
repr
oduc
tive
he
alth
ser
vice
s.
•E
xist
ence
of v
ario
us to
ols
such
as
the
RC
H S
trat
egy,
RC
H E
ssen
tial
P
ack
age
and
pol
icy
guid
elin
es
wh
ich
add
ress
mat
ern
al h
ealt
h.
•M
ater
nal
hea
lth
is r
efle
cted
in
the
Dis
tric
t Pla
nnin
g G
uid
elin
e as
one
of t
he k
ey r
epro
duc
tive
an
d c
hild
hea
lth
inte
rven
tion
s.
•E
xist
ence
of e
stab
lish
men
t/
man
ning
leve
l (19
99) o
f hea
lth
staf
f for
hea
lth
del
iver
y ti
ers
•So
me
exis
ting
hea
lth
cad
res
hav
e be
en r
evie
wed
(MC
HA
, R
MA
/CA
upg
rad
ing)
•M
inim
al b
ud
get a
lloc
atio
n to
hea
lth
sect
or
espe
cial
ly m
ater
nal
hea
lth
(at a
ll le
vels
) •
Wea
k m
ulti
sect
oral
link
ages
at a
ll le
vels
in
add
ress
ing
mat
ern
al h
ealt
h •
The
RC
H s
trat
egy
hav
e no
t bee
n ab
le to
pr
iori
tise
key
inte
rven
tion
s to
red
ucin
g m
ater
nal
dea
th
•In
adeq
uat
e d
isse
min
atio
n an
d in
terp
reta
tion
to
use
r-fr
iend
ly fo
rmat
s of
RC
H p
olic
ies,
st
rate
gy a
nd
gui
del
ines
.
•So
me
man
ager
s an
d s
uper
viso
rs a
t al
l lev
els
ar
e no
t fam
ilia
r w
ith
poli
cies
an
d g
uid
elin
es
rela
ted
to R
CH
•
CC
HP
do
not c
ompr
ehen
sive
ly a
dd
ress
ing
RH
/mat
ern
al a
nd
chi
ld h
ealt
h in
terv
enti
ons
•R
CH
Coo
rdin
ator
not
full
mem
ber
of C
HM
T
but m
ore
of c
o-op
ted
mem
ber
(in
som
e d
istr
icts
) as
such
not
abl
e to
infl
uenc
e d
istr
ict
heal
th p
lans
•
Man
ning
leve
l not
imp
lem
ente
d a
ccor
din
gly
due
to in
suff
icie
nt li
nkag
es a
nd
mix
ed r
oles
of
HS
and
LG
. •
Est
abli
shm
ent/
man
ning
leve
l of s
taff
has
not
be
en r
evie
wed
acc
ord
ing
to r
ecen
t d
evel
opm
ents
in R
CH
car
e (P
MT
CT
, VC
T,
AR
H/Y
FS)
•C
urre
nt d
eplo
ymen
t sys
tem
doe
sn’t
foll
ow th
e m
anni
ng le
vel g
uid
elin
es.
•D
evel
opm
ent p
artn
ers
and
G
over
nmen
t ali
gnin
g to
jo
int s
uppo
rt a
ccor
din
g to
Jo
int A
ssis
tan
ce S
trat
egy.
•
Exi
sten
ce o
f Hea
lth
bask
et
fund
s to
sup
port
dis
tric
t he
alth
ser
vice
s •
Est
abli
shm
ent o
f MN
C
par
tner
ship
at c
entr
al le
vel
•E
xist
ence
of G
over
nmen
t le
d S
WA
Ps, M
OH
Tec
hnic
al
com
mit
tee
and
su
bcom
mit
tee
that
can
be
used
to p
ush
Mat
ern
al a
nd
N
ewbo
rn h
ealt
h is
sues
•
Exi
stin
g A
nnua
l Hea
lth
Sect
or R
evie
ws
hav
e ta
ken
into
con
sid
erat
ion
RH
/Mat
ern
al h
ealt
h is
sues
•
Poli
tica
l wil
l an
d
com
mit
men
t is
show
ing
posi
tive
sig
ns to
war
ds
add
ress
ing
mat
ern
al h
ealt
h (D
HA
tool
) •
Exi
sten
ce o
f Hea
lth
SWA
PS
•Z
onal
RC
H r
evie
ws
Car
e an
d T
reat
men
t Pla
n gi
ves
oppo
rtun
ity
to m
ains
trea
m
mat
ern
al h
ealt
h ca
re
•M
ore
focu
s on
HIV
/AID
S th
an
RH
/Mat
ern
al h
ealt
h •
Shor
t tim
e to
war
ds
atta
inm
ent o
f MD
Gs
•B
igge
r pr
opor
tion
of h
ealt
h se
ctor
bu
dge
t is
don
or
dep
end
ant.
•D
onor
dri
ven
init
iati
ves
•R
epro
duc
tive
hea
lth
conc
ept
may
be
over
rid
den
by
mat
ern
al h
ealt
h (t
hrea
t of
retu
rnin
g to
old
MC
H c
once
pt)
•C
ompe
ting
pri
orit
y pr
ogra
mm
es
•H
IV/A
IDS
•H
uman
res
ourc
es
• L
ogis
tic
Man
agem
ent
cap
acit
y •
TB
A p
olic
y re
view
an
d p
art o
f th
e A
nnu
al H
ealt
h Se
ctor
R
evie
w m
iles
tone
58T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
AN
NE
X 1
: SW
OT
AN
ALY
SIS
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
••E
xem
ptio
n po
licy
for
del
iver
ies
and
all
RC
H s
ervi
ces
•D
ecen
tral
isat
ion
of h
ealt
h se
rvic
es to
dis
tric
t lev
el (a
dv
ance
he
alth
sec
tor
refo
rms)
•
Exi
sten
ce o
f var
ious
fin
anci
al
reso
urce
s to
hea
lth
sect
or a
t the
d
istr
ict l
evel
(Bas
ket,
Blo
ck,
Dis
tric
t ow
n so
urc
e, c
ost s
har
ing,
N
HIF
, CH
F et
c)
•E
xist
ence
of P
aram
edic
al,
Med
ical
an
d N
ursi
ng
Inst
itut
ions
for
pre
-ser
vice
tr
ain
ing
•E
xist
ence
of t
rain
ing
guid
elin
es
on P
AC
, LSS
, FP,
PM
TC
T+,
ST
I, FA
NC
•
Ava
ilab
ilit
y of
com
mit
ted
D
evel
opm
ent P
artn
ers
supp
orti
ng R
H/m
ater
nal
hea
lth
•
MT
EF
allo
cate
d fu
nds
for
proc
urem
ent o
f con
trac
epti
ves
•M
ater
nal
nut
riti
on li
nked
wit
h ch
ild
nut
riti
on in
the
RC
H
pac
kag
e •
Com
mun
ity
base
d R
CH
gu
idel
ines
, str
ateg
ic p
lan
(dra
ft)
avai
labl
e •
Infr
astr
uct
ure
at a
ll le
vels
ov
erse
eing
hea
lth
serv
ices
- n
atio
nal
, reg
ion
al, d
istr
ict
and
co
mm
unit
y
•In
adeq
uat
e nu
mbe
r of
ski
lled
ser
vice
pr
ovid
ers
that
can
be
trai
ned
an
d c
aptu
re th
e kn
owle
dge
req
uire
d o
n sp
ecif
ic s
kill
s.
•So
me
skil
led
pro
vid
ers
are
not a
llow
ed to
do
life
sav
ing
skil
ls p
roce
dur
es d
ue to
sta
tuto
ry
regu
lati
ons
e.g.
IV d
rip
givi
ng, m
anu
al
rem
oval
of r
etai
ned
pla
cent
a, M
VA
usa
ge.
•T
here
's n
o m
echa
nis
m to
ass
ess
pre-
qual
ific
atio
n of
ser
vice
pro
vid
ers
in te
rms
of
atti
tud
e an
d p
sych
olog
ical
beh
avio
ur
befo
re
join
ing
nurs
ing
and
med
ical
sch
ools
. •
Wea
k in
cent
ive
pac
kage
to s
ervi
ce p
rovi
der
s •
Poor
mot
ivat
ion
and
inad
equ
ate
perf
orm
ance
as
sess
men
t and
rew
ard
ing
of s
ervi
ce
prov
ider
s •
Inco
nsis
tenc
y of
Ski
lled
att
end
ance
def
init
ion
and
how
do
we
atta
in S
kill
ed a
tten
dan
ce in
ou
r se
ttin
gs
•In
adeq
uat
e Pl
ans
for
hum
an r
esou
rce
dev
elop
men
t inc
lud
ing
cont
inui
ng e
duc
atio
n on
mat
ern
al h
ealt
h is
sues
•
Lac
k of
con
tinu
ing
educ
atio
n am
ong
tuto
rs a
t pr
e-se
rvic
e an
d r
egio
nal
inst
itut
ions
. •
Poor
inte
rpre
tati
on a
nd
impl
emen
tati
on o
f ex
empt
ion
poli
cy fo
r m
ater
nal
hea
lth
•In
form
al p
aym
ents
hin
der
s im
ple
men
tati
on o
f ex
empt
ion
poli
cy
•D
ue to
min
imal
all
ocat
ion
to R
CH
ser
vice
s,
wom
en a
re a
sked
to p
urch
ase
or c
ome
wit
h es
sent
ial s
uppl
ies/
dru
gs fo
r d
eliv
ery
sinc
e th
ey a
re fr
eque
ntly
out
of s
tock
•E
xist
ence
of A
nnu
al R
MO
s,
DM
Os
and
RC
H M
eeti
ngs
as f
ora
to d
iscu
ss
RH
/mat
ern
al a
nd
new
born
is
sues
•
Incr
easi
ng G
over
nmen
t an
d D
Ps a
tten
tion
on
add
ress
ing
Hum
an
reso
urce
cri
sis
•Pr
esen
ce o
f gui
del
ines
from
FC
I on
cari
ng b
ehav
iou
rs
amon
g se
rvic
e pr
ovid
ers
•O
ngoi
ng r
evie
w o
n in
cent
ive
pac
kage
for
heal
th
care
pro
vid
ers
•In
trod
uct
ion
of O
PRA
at a
ll
leve
ls.
•M
KU
KU
TA
•
Exi
stin
g pl
ans
of
stre
ngth
enin
g an
d
exp
and
ing
ZT
C fo
r in
-se
rvic
e tr
ain
ings
.
•O
vers
tret
chin
g of
hea
lth
syst
em a
s pe
r cu
rren
t d
evel
opm
ent w
hic
h is
alr
ead
y co
mpr
omis
ed.
59T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
••L
ack
of c
oste
d R
CH
pac
kage
incl
ud
ing
mat
ern
al h
ealt
h th
at c
an ju
stif
y ho
w m
uch
is b
eing
exe
mpt
ed
• •A
t all
leve
ls th
ere
has
bee
n sl
ow fo
llow
up
and
sca
ling
up
of in
terv
enti
ons
rela
ted
to
mat
ern
al h
ealt
h • •
Inad
equ
ate
doc
umen
tati
on o
f evi
den
ce
base
d in
terv
enti
on fo
cusi
ng o
n m
ater
nal
he
alth
• •
Unt
imel
y/Ir
regu
lar
revi
ew o
f Pre
-Ser
vice
tr
ain
ing
curr
icu
lum
to in
clu
de
curr
ent
mat
ern
al h
ealt
h d
evel
opm
ents
. • •
Lac
k of
pos
tnat
al g
uid
es
• •Po
licy
not
all
owin
g M
VA
kit
to b
e m
ade
avai
labl
e ex
cept
whe
n th
ere'
s pr
esen
ce o
f sk
ille
d a
tten
dan
t an
d a
fter
bei
ng tr
aine
d.
• •
Poor
coo
rdin
atio
n an
d li
nkag
es b
etw
een
dif
fere
nt a
ctor
s fr
om c
entr
al t
o lo
cal l
evel
.
• •E
xist
ence
of v
erti
cal p
rogr
amm
e/pr
ojec
ts
supp
ort t
o R
H (i
nclu
din
g FP
/mat
ern
al
heal
th)
• •W
eak
link
ages
bet
wee
n D
irec
tora
tes
of
Prev
enti
ve, H
ospi
tal
and
Tra
inin
g at
MO
H
••PM
NC
H p
rom
otes
nee
d
for
MN
CH
Str
ateg
ic P
lan
whe
re a
ll p
artn
ers
buy
in
• •E
xist
ence
of R
epro
du
ctiv
e H
ealt
h C
omm
odit
y Se
curi
ty c
omm
itte
e un
der
G
ovt l
ead
ersh
ip
• •E
xist
ence
of I
YC
F st
rate
gy
• •M
ater
nal
nut
riti
on
aspe
cts
inte
grat
ed in
to
Infa
nt a
nd
you
ng c
hild
fe
edin
g st
rate
gy
• •E
xist
ence
of H
ealt
h in
sura
nce
(NH
IF) a
nd
som
e co
min
g up
• •
Bir
th a
nd
dea
th
regi
stra
tion
(vit
al
stat
isti
cs) i
n pl
ace
in fe
w
vill
ages
wh
ich
can
be
adop
ted
in th
e re
st o
f the
co
untr
y.
• •E
xist
ing
heal
th M
CH
st
ruct
ure
from
co
mm
unit
y to
hos
pita
l le
vel
• •U
se o
f alt
ern
ativ
e se
rvic
e pr
ovid
ers
to s
uppo
rt
heal
th s
yste
m s
uch
as
reti
red
hea
lth
skil
led
st
aff,
perf
orm
ance
co
ntra
ct a
nd
Ret
enti
on
sche
mes
in M
KU
KU
TA
••In
adeq
uat
e li
nkag
es a
nd
col
labo
rati
on
betw
een
RC
H S
ecti
on w
ith
TFN
C a
nd
PM
TC
T U
nit
60T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
••R
ole
of T
BA
in p
reve
ntio
n of
mat
ern
al
mor
tali
ty is
unc
lear
. (R
ole
rem
ains
unc
lear
in
the
stra
tegi
es. W
eakn
esse
s in
SW
OT
sh
ould
gui
de
stra
tegi
es
•C
HF
exis
t in
mos
t are
as b
ut w
ith
lim
ited
us
e of
the
fund
s fo
r m
ater
nal
hea
lth
care
•
Few
dis
tric
ts h
ave
impl
emen
ted
com
mun
ity
base
d R
CH
pro
gram
•
Vil
lage
hea
lth
com
mit
tee
not l
egal
ly
reco
gnis
ed.
•Sh
orta
ge o
f Ski
lled
att
end
ance
(mor
e pr
onou
nced
in r
ural
are
as)
•U
nat
trac
tive
wor
king
con
dit
ion
espe
cial
ly in
ru
ral
area
s
(ii)
Hea
lth
Sys
tem
s•
Pres
ence
of Z
RC
HC
O, R
RC
H C
o an
d D
RC
HC
o •
Serv
ice
del
iver
y po
ints
wel
l d
istr
ibut
ed to
con
sult
ant,
regi
onal
an
d d
istr
ict h
ospi
tals
fo
llow
ed b
y he
alth
cen
tres
an
d
dis
pens
arie
s.
•In
den
t sys
tem
for
obta
inin
g es
sent
ial d
rugs
an
d s
uppl
ies
•In
tegr
atio
n of
FP
and
HIV
/AID
S co
nd
om s
uppl
y/re
ques
t at
dis
tric
t lev
el
•H
ealt
h se
rvic
es in
clu
din
g m
ater
nal
car
e no
t op
erat
ing
for
24 h
ours
•
Low
kno
wle
dge
on
SRH
am
ong
serv
ice
prov
ider
s •
Des
pite
trai
nin
g on
Foc
used
AN
C, t
here
's s
till
pr
oble
m in
its
imp
lem
enta
tion
due
to a
ttit
ud
e an
d lo
w e
duc
atio
nal
bac
kgro
und
of
prov
ider
s w
ho c
anno
t cap
ture
the
skil
ls;
inad
equ
ate
supp
lies
suc
h as
Hb,
RPR
, co
ntra
cept
ives
etc
. •
Lim
ited
trai
nin
g of
Ser
vice
pro
vid
ers
on P
AC
, FP
, LSS
•
RH
ser
vice
s no
t you
th fr
iend
ly
•In
adeq
uat
e/in
appr
opri
ate
Em
OC
(bas
ic a
nd
co
mpr
ehen
sive
ser
vice
s) a
t fac
ilit
y le
vel
•E
xist
ence
of b
oth
priv
ate
and
pub
lic
heal
th fa
cili
ties
th
at p
rovi
de
mat
ern
al
heal
th s
ervi
ces.
•
Plan
to s
tren
gthe
n Z
TC
•
Exi
sten
ce o
f goo
d p
ract
ices
on
you
th fr
iend
ly s
ervi
ces
(AY
A, U
MA
TI,
UN
ICE
F su
ppor
ted
inte
rven
tion
s)
•E
xist
ence
of g
ood
pr
acti
ces/
rese
arch
on
mat
ern
al c
are
imp
rove
men
t (t
houg
h a
few
)- F
CI,
WD
P,
Car
e, T
EH
IP, Q
IRI
•O
verw
helm
ing
the
ZT
C
cap
acit
y •
Cul
tura
l bar
rier
s
61T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
••L
ocal
Gov
ernm
ent a
utho
riti
es
refo
rms
are
supp
orti
ng
impl
emen
tati
on o
f HSR
• •
Pres
ence
of r
efer
ral s
truc
ture
w
ith
in th
e he
alth
del
iver
y sy
stem
• •
Mos
t of e
ssen
tial
RC
H s
ervi
ces
are
in p
lace
(AN
C, I
ntra
par
tum
/ ob
stet
ric,
FP,
ST
I, Im
mun
izat
ion,
PM
TC
T, P
ost p
artu
m) I
MC
I at
all
le
vels
.
••L
ack
of fu
ncti
onin
g of
blo
od b
anks
at h
ospi
tal
and
hea
lth
cent
re le
vel
• •In
adeq
uat
e co
vera
ge o
f PA
C s
ervi
ces
• •E
ssen
tial
equ
ipm
ent,
supp
lies
and
dru
gs o
n m
ater
nal
car
e in
clu
din
g FP
not
rea
dil
y av
aila
ble
• •B
ottl
enec
ks i
n pr
ocur
emen
t of d
rugs
, sup
plie
s an
d e
quip
men
t (bo
th w
ays
dis
tric
t lev
el a
nd
M
SD)
• •Fr
agm
ente
d p
rogr
am s
uppo
rt in
pro
visi
on o
f es
sent
ial s
uppl
ies
e.g.
syp
hili
s sc
reen
ing
reag
ents
• •
Faci
lity
bu
ild
ings
an
d p
rovi
der
s’ a
ttit
ude
not
acco
mm
odat
ing
mal
e an
d y
outh
frie
ndly
se
rvic
es• •
Pres
ence
of v
ast G
eogr
aphi
cal a
rea
wit
h po
or
tran
spor
t/ro
ads,
inad
equ
ate
heal
th fa
cili
ties
an
d th
eref
ore
poor
geo
grap
hic
al a
cces
sibi
lity
to
EM
OC
• •
Inad
equ
ate
ambu
lanc
es w
ith
in th
e co
untr
y
• •M
any
heal
th u
nits
do
not h
ave
reli
able
co
mm
unic
atio
n sy
stem
(rad
io c
all,
mob
ile)
• •
Lac
k of
pro
toco
ls o
n sp
ecif
ic m
ater
nal
he
alth
/obs
tetr
ic c
are
• •
Cou
nsel
ling
ski
lls
on F
P, P
AC
, PM
TC
T a
nd
m
ater
nal
nut
riti
on n
ot a
deq
uat
ely
prov
ided
by
ser
vice
pro
vid
ers
• •L
imit
ed p
ostn
atal
car
e d
ue to
lack
of g
uid
elin
es
••B
lood
saf
ety
prog
ram
me
• •E
xist
ence
of R
HM
T a
nd
C
HM
T w
hic
h co
ord
inat
es
dis
tric
t hea
lth
acti
viti
es
incl
ud
ing
mat
ern
al h
ealt
h ca
re
• •C
urre
ntly
Join
t R
ehab
ilit
atio
n Pr
ogra
mm
e h
as b
een
init
iate
d a
t dis
tric
t le
vel w
hich
can
be
used
to
acco
mm
odat
e st
ruct
ure
impr
ovem
ent f
or m
ater
nal
an
d n
ewbo
rn c
are
• •E
xist
ence
of m
obil
e co
mm
unic
atio
n ne
twor
k in
ru
ral
area
s • •
Pres
ence
of j
ob a
id fo
r E
MO
C
(iii
) S
up
por
t S
yste
ms
•E
xist
ence
of C
omm
unit
y d
evel
opm
ent o
ffic
ers
at d
istr
ict
and
war
d le
vel.
•Pr
emis
es o
f mos
t hea
lth
faci
liti
es a
re
inad
equ
ate
and
non
-use
r fr
iend
ly (p
riv
acy,
sp
ace)
•
Inad
equ
ate
awar
enes
s an
d a
dvo
cacy
on
mat
ern
al c
omp
lica
tion
s/ca
re a
t all
leve
ls
incl
ud
ing
heal
th fa
cili
ties
sup
port
sta
ff
62T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
(iv)
Pla
nn
ing,
Mon
itor
ing
and
Ev
alu
atio
n•
Plan
ning
dec
entr
alis
ed to
d
istr
ict l
evel
•
Mon
itor
ing
of M
ater
nal
dea
th
don
e th
roug
h w
eek
end
ing
repo
rtin
g, H
MIS
, DH
S an
d
Ann
ual Z
RC
H C
o re
port
s •
Pres
ence
of H
MIS
in a
ll h
ealt
h d
eliv
ery
syst
ems
•Su
perv
isio
n sy
stem
in p
lace
•
Pres
ence
of h
ealt
h fa
cili
ty
com
mit
tee
and
dis
tric
t boa
rds
in
maj
orit
y of
dis
tric
ts
•Pr
esen
ce o
f CH
MT
in a
ll d
istr
icts
•Po
or m
ain
stre
amin
g of
mat
ern
al h
ealt
h in
terv
enti
on in
to C
CH
P an
d th
erea
fter
into
O
vera
ll C
ounc
il P
lan
s as
suc
h in
terv
enti
on is
no
t ad
dre
ssed
Mu
ltis
ecto
ral.
•C
entr
aliz
atio
n of
ser
vice
s/he
alth
pla
ns a
t C
HM
T le
vel a
nd
less
on
low
er le
vel
•D
istr
ict H
ealt
h pl
ann
ing
proc
ess
rare
ly t
ake
into
con
sid
erat
ion
incl
usio
n of
oth
er r
elev
ant
mul
ti s
ecto
ral o
ffic
ers
(Ed
uca
tion
, A
gric
ultu
re, E
ngin
eer,
Com
mun
ity
dev
elop
men
t) in
ad
dre
ssin
g m
ater
nal
hea
lth
issu
es.
•In
adeq
uat
e ca
pac
ity
of C
HM
T t
o pl
an fo
r R
CH
ac
tivi
ties
incl
ud
ing
mat
ern
al h
ealt
h •
Poor
rec
ord
kee
ping
and
ther
efor
e pl
anni
ng is
no
t evi
den
ce b
ased
•
Mos
t CH
MT
s s
till
see
RC
H in
clu
din
g m
ater
nal
hea
lth
inte
rven
tion
s as
d
onor
/pro
ject
sup
port
ed a
nd
not
re
spon
sibi
lity
of d
istr
ict b
ud
gets
•
Fam
ily
Plan
ning
giv
en le
ss p
rior
ity
in
plan
ning
at d
istr
ict l
evel
(CC
HP)
. •
Con
flic
ting
pri
orit
ies
du
ring
join
t sup
ervi
sion
•D
istr
ict h
ealt
h bo
ard
s an
d
heal
th fa
cili
ty c
omm
itte
es
pres
ent a
ccor
din
g to
set
gu
idel
ines
•
Exi
sten
ce o
f TE
HIP
tool
th
ough
has
lim
itat
ion
on
RC
H in
terv
enti
on p
ack
age
•Pr
opos
al f
or r
ecor
ds
man
agem
ent i
mpr
ovem
ent
has
bee
n m
ade
to M
oHSW
•
Proc
ess
and
imp
act
ind
icat
ors
hav
e be
en
iden
tifi
ed a
nd
def
ined
in
rece
ntly
rel
ease
d R
CH
st
rate
gy
•E
xist
ence
Nat
ion
al E
MO
C
surv
ey d
ocum
ent w
ill
prov
ide
benc
hmar
k of
E
MO
C s
itu
atio
n co
untr
ywid
e.
•In
suff
icie
nt in
volv
emen
t of o
ther
sta
keho
lder
s in
the
dis
tric
t du
ring
pla
nnin
g pr
oces
s,
mon
itor
ing
and
eva
luat
ion
•V
illa
ge a
nd
war
d p
lan
s no
t cap
turi
ng
mat
ern
al a
nd
new
born
inte
rven
tion
s/is
sues
•
Mat
ern
al h
ealt
h in
dic
ator
s us
ed a
re m
ain
ly
imp
act a
nd
less
/non
e on
pro
cess
ind
icat
ors
•So
me
EM
OC
pro
cess
ind
icat
ors
are
dif
ficu
lt
to c
alcu
late
sin
ce s
ome
dat
a is
not
cap
ture
d in
th
e ro
utin
e H
MIS
/fac
ilit
y ba
sed
dat
a re
cord
s.
•In
adeq
uat
e ut
ilis
atio
n of
dat
a/in
dic
ator
s fo
r pl
anni
ng p
urpo
se a
nd
pri
orit
isat
ion
at a
ll
•In
trod
uct
ion
of m
ater
nal
an
d p
erin
atal
dea
th
revi
ews
•E
xist
ence
of v
ario
us
nat
ion
al s
urve
ys (C
ensu
s,
DH
S, T
HIS
) th
at c
an g
ive
pict
ure
on
RC
H s
itu
atio
n •
Cur
rent
ther
e's
dem
and
d
rive
n ca
pac
ity
buil
din
g in
itia
tive
(pil
oted
in la
ke
zone
reg
ions
) th
at r
equi
res
dis
tric
t to
dem
and
for
63T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
leve
ls.
•In
adeq
uat
e fu
ncti
onin
g of
HM
IS
•L
ack
of d
isag
greg
ated
dat
a by
sex
an
d a
ge
spec
ific
•
Insu
ffic
ient
ly c
aptu
ring
dat
a fr
om p
riv
ate
heal
th fa
cili
ties
•
Wea
k/ab
senc
e of
Com
mun
ity
Bas
ed
Man
agem
ent I
nfor
mat
ion
Syst
em
•Po
or d
ocum
enta
tion
of c
lien
ts n
otes
incl
udin
g tr
eatm
ent p
lan,
ref
erra
l not
es a
t fac
ilit
y le
vel
•L
ow c
over
age
of s
uper
visi
on
•L
ack
of c
omp
rehe
nsiv
e an
d in
tegr
ated
Su
perv
isio
n to
ol a
nd
pro
cess
•
Inad
equ
ate
acco
unta
bili
ty a
mon
g se
rvic
e pr
ovid
ers
and
man
ager
s/su
perv
isor
s
•W
eak
syst
em fo
r m
onit
orin
g an
d a
dd
ress
ing
clie
nts
com
pla
ints
/sug
gest
ions
•
Poor
sup
port
ive
supe
rvis
ion
due
to
inad
equ
ate
skil
ls, c
omm
itm
ent a
nd
att
itu
de.
trai
nin
gs (u
nder
DA
NID
A
supp
ort)
•
Qu
alit
y of
Car
e fr
amew
ork
to c
onso
lid
ate
supe
rvis
ory
tool
s
•Pr
esen
ce o
f Cli
ent h
ealt
h se
rvic
e ch
arte
r an
d
Gui
del
ines
on
role
s an
d
resp
onsi
bili
ties
of H
F co
mm
itte
es/d
istr
ict
boar
ds.
(v)
Com
mu
nit
y•
Pres
ence
of P
rim
ary
Hea
lth
Com
mit
tee/
Vil
lage
hea
lth
com
mit
tees
that
dis
cuss
issu
es o
n m
ater
nal
hea
lth.
•
Pres
ence
of c
-IM
CI c
orps
•
Pres
ence
of C
omm
unit
y B
ased
R
CH
Str
ateg
ic p
lan,
gui
del
ines
•
Com
mun
ity
reco
gnis
ed a
s ke
y st
akeh
old
ers
in b
oth
Loc
al G
ovt
and
hea
lth
sect
or r
efor
ms.
•
Loc
al G
over
nmen
t ref
orm
s h
ave
a st
ruct
ure/
link
dow
n to
the
vill
age
leve
l.
•W
eak
impl
emen
tati
on o
f dis
tric
t gui
de
of
invo
lvin
g co
mm
unit
y •
Low
pop
ulat
ion
cove
rage
•
Lim
ited
mal
e in
volv
emen
t on
issu
es r
elat
ed to
m
ater
nal
hea
lth
•O
bste
tric
em
erge
ncie
s ar
e no
t con
sid
ered
by
the
Com
mun
ity
emer
genc
y co
mm
itte
e
•C
omm
unit
y pl
ans
not i
ncor
pora
ted
into
the
CC
HP.
•
Wea
k ca
pac
ity
of h
ealt
h fa
cili
ty c
omm
itte
es
and
dis
tric
t boa
rds
•
The
pro
cess
of d
evel
opin
g by
law
s an
d th
e ti
me
it t
akes
to b
e ef
fect
ed.
•In
adeq
uat
e ou
trea
ch s
ervi
ces
due
to p
oor
plan
ning
, in
adeq
uat
e re
sou
rces
. •
Inad
equ
atel
y fu
ncti
onin
g vi
llag
e he
alth
co
mm
itte
es s
ince
they
're
not f
acil
itat
ed.
•Pr
esen
ce o
f O&
OD
pl
anni
ng p
roce
ss
•A
lloc
atio
n of
10%
of C
CH
P fu
nds
to c
omm
unit
y in
terv
enti
ons.
•
Pres
ence
of T
ASA
F II
that
pr
ovid
es fi
nan
cial
sup
port
fo
r co
mm
unit
y ba
sed
soc
ial
serv
ice
del
iver
y.
•Pr
esen
ce o
f com
mun
ity
mob
iliz
atio
n an
d
empo
wer
men
t ini
tiat
ives
on
repr
oduc
tive
hea
lth.
•
Exi
sten
ce o
f the
CB
D
prog
ram
me
•H
ealt
h fa
cili
ties
com
mit
tees
an
d d
istr
ict h
ealt
h bo
ard
s
•Pr
esen
ce o
f har
mfu
l tr
adit
ion
al p
ract
ices
that
can
ad
vers
ely
affe
ct m
ater
nal
an
d
new
born
e.g
. tak
ing
herb
s th
at
hav
e ox
ytox
ic e
ffec
ts c
an le
ad
to r
uptu
red
ute
rus.
64T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
•K
now
led
ge o
n B
irth
pre
par
edne
ss is
poo
r am
ong
com
mun
itie
s
•C
omm
unit
y no
t aw
are
of th
eir
righ
ts a
nd
ob
lig
atio
ns
in im
pro
ving
mat
ern
al h
ealt
h ca
re
•G
end
er in
equ
alit
ies
exis
ting
in th
e co
mm
unit
y co
ntri
bute
s to
poo
r m
ater
nal
hea
lth
outc
omes
•
Low
aw
aren
ess
on r
epro
duc
tive
sys
tem
fu
ncti
ons
and
pre
gnan
cy r
elat
ed is
sues
suc
h as
dan
ger
sign
s/co
mpl
icat
ion
s
reco
gnis
ed le
gall
y •
Abi
lity
of c
omm
unit
ies
to
dev
ise
by-l
aws
to a
dd
ress
is
sues
rel
ated
to m
ater
nal
he
alth
suc
h as
vio
lenc
e,
del
iver
y at
hom
es, e
tc.
•E
xist
ence
of C
omm
unit
y ba
sed
mat
ern
al h
ealt
h ca
re
syst
em in
som
e ar
eas
•E
xist
ence
of c
lien
t hea
lth
serv
ice
char
ter
•E
xist
ence
of C
SOs/
NG
Os
(vi)
Pu
bli
c-P
riv
ate
Par
tner
ship
•O
ne o
f com
pone
nts
of H
SR
stra
tegy
•
Pres
ence
of a
ctiv
e A
ssoc
iati
on o
f Pr
ivat
e H
ospi
tals
in T
anza
nia
an
d P
RIN
MA
T
•N
on-f
or p
rofi
t sec
tor
(FB
Os)
pr
ovid
ing
mat
ern
al c
are
espe
cial
ly in
ru
ral a
reas
. •
•In
adeq
uat
e co
ord
inat
ion
in p
lann
ing
and
im
plem
enta
tion
am
ong
par
tner
s at
cen
tral
an
d d
istr
ict l
evel
•
Par
tner
ship
pol
icy
guid
elin
es p
rese
nt b
ut
mor
e vi
sibl
e/kn
own
at c
entr
al le
vel a
nd
less
at
dis
tric
t lev
el.
•So
me
Priv
ate
heal
th fa
cili
ties
/CSO
s no
t su
bmit
ting
dat
a to
dis
tric
t/ce
ntra
l lev
el
•M
ajor
ity
of P
riv
ate
for
Prof
it p
rovi
de
serv
ices
on
oth
er h
ealt
h is
sues
an
d le
ss o
n m
ater
nal
he
alth
car
e •
Fait
h ba
sed
org
aniz
atio
ns
prov
idin
g li
mit
ed
mat
ern
al s
ervi
ces
(no
FP s
ervi
ce p
rovi
ded
) •
Som
e C
SOs
that
are
pro
-lif
e pr
ovid
e ne
gati
ve
info
rmat
ion
on c
ontr
acep
tive
s.
•E
xist
ence
of P
rofe
ssio
nal
as
soci
atio
ns (A
GO
TA
, T
AM
A)
•E
xist
ence
of a
dvo
cacy
gr
oups
that
are
non
-hea
lth
prof
essi
onal
s (T
AM
WA
, T
GN
P, T
AW
LA
, Pri
vat
e m
edia
com
pan
ies,
WR
A)
•C
ompe
titi
on fo
r re
cogn
itio
n an
d r
esou
rces
bet
wee
n pu
blic
an
d p
riv
ate
sect
or.
65T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
(B) N
ewb
orn
Car
e S
TR
EN
GT
HS
W
EA
KN
ES
SE
S
OP
PO
RT
UN
ITIE
S
TH
RE
AT
S
(i)
Pol
icy
Issu
es
•N
atio
nal
hea
lth
poli
cy in
clu
des
ch
ild
hea
lth
•
Nat
ion
al s
trat
egy
on In
fant
an
d
Chi
ld N
utri
tion
an
d p
lan
of a
ctio
n in
pla
ce
•Po
licy
gui
del
ine
on R
CH
av
aila
ble
and
ref
lect
ing
neon
atal
hea
lth
care
•
Ava
ilab
ilit
y of
PM
TC
T a
nd
HIV
C
are
and
trea
tmen
t gui
des
that
in
tegr
ates
neo
nat
al c
are
•E
xem
ptio
n po
licy
for
und
er-f
ives
in
clu
des
neo
nat
al h
ealt
h se
rvic
es/c
are
•In
stit
utio
nal
isat
ion
of IM
CI w
ithi
n th
e M
oHSW
str
uctu
re/R
CH
S •
IMC
I dea
ls w
ith
neon
ate
from
8th
day
of l
ife
•C
-IM
CI p
rom
otes
com
mun
ity
mat
ern
al c
are
and
lac
tati
on
•E
stab
lish
ed p
ostn
atal
foll
ow u
p fi
rst w
eek
of li
fe
•E
stab
lish
men
t of b
aby
frie
ndly
ho
spit
al s
ervi
ces
wit
hin
som
e ho
spit
als
•R
evie
wed
LSS
man
ual
in
corp
orat
ed N
ewbo
rn c
are
acco
rdin
g to
WH
O g
uid
elin
es
•A
vail
abil
ity
of c
omm
itte
d
dev
elop
men
t par
tner
s su
ppor
ting
ne
wbo
rn h
ealt
h
•N
eona
tal c
are
obta
inin
g li
mit
ed
bud
get a
lloc
atio
n w
ith
in th
e he
alth
se
ctor
/RC
H s
ervi
ces
•N
ursi
ng tr
ain
ing
not c
ompr
ehen
sive
ly
add
ress
ing
neon
atal
car
e •
Age
spe
cifi
c in
terv
enti
ons
for
0-1
mon
ths
are
not w
ell s
pelt
out
in p
olic
y gu
ides
on
RC
H
•Po
licy
gui
del
ine
to m
anag
e ne
wbo
rn
care
is l
acki
ng
•R
outi
ne h
ealt
h d
ata
lack
s ne
onat
al
heal
th p
rogr
ess
incl
ud
ing
com
mun
ity-
base
d d
ata.
•
Lac
k of
und
erst
and
ing
on th
e m
agni
tud
e of
neo
nat
al h
ealt
h pr
oble
ms
•IM
CI d
oes
not a
dd
ress
firs
t wee
k of
li
fe
•Fa
cili
ty IM
CI d
oes
not i
nclu
de
hom
e ca
re a
nd
car
e se
ekin
g fo
r ne
wbo
rns
•L
ack
of c
once
ntra
tion
on
mat
ern
al
care
an
d im
mun
izat
ion
and
abs
ence
of
a g
uid
e •
Inad
equ
ate
avai
labi
lity
of
pae
dia
tric
ian
s an
d n
eon
atal
nur
ses
•L
ack
of c
osti
ng o
f Neo
nata
l car
e p
ack
age
•L
ack
of p
ostn
atal
gui
de
thus
not
in
corp
orat
ing
new
born
car
e
•D
ecen
tral
isat
ion
of h
ealt
h se
rvic
es to
dis
tric
t le
vel (
adva
nce
hea
lth
sect
or r
efor
ms)
can
ac
com
mod
ate
new
born
car
e •
Fin
anci
al r
esou
rce
allo
cati
on to
the
dis
tric
t le
vel (
from
var
iou
s so
urce
s)
•E
stab
lish
men
t of M
NC
par
tner
ship
at c
entr
al
leve
l•
On
goin
g re
view
s of
MoH
SW in
ad
dre
ssin
g hu
man
res
ourc
e cr
isis
•
Exi
sten
ce o
f ZT
C, N
ursi
ng a
nd M
edic
al
scho
ols
•H
IV C
are
and
Tre
atm
ent P
lan
give
op
port
unit
y to
mai
nstr
eam
new
born
car
e.
•C
over
age
of IM
CI c
ase
man
agem
ent H
igh
add
ing
firs
t wee
k co
uld
rap
idly
incr
ease
co
vera
ge
•D
onor
s, p
artn
ers
inte
rest
ed to
sup
port
in
corp
orat
ion
of n
ewbo
rn c
are
•Po
licy
gui
de
on In
fant
an
d e
arly
feed
ing
for
new
born
intr
oduc
ed
•E
xist
ence
of H
ealt
h ba
sket
fund
s to
sup
port
d
istr
ict h
ealt
h se
rvic
es
•E
xist
ence
of G
ovt l
ed S
WA
Ps, M
oHSW
T
echn
ical
com
mit
tee
and
sub
com
mit
tee
that
ca
n be
use
d to
pus
h M
ater
nal
an
d N
B h
ealt
h is
sues
•
Exi
sten
ce o
f Ann
ual
RM
Os,
DM
Os
and
RC
H
Mee
ting
s a
foru
m to
dis
cuss
RH
/mat
ern
al
and
new
born
issu
es
•Sh
ort t
ime
tow
ard
s at
tain
men
t of M
DG
s •
For
mot
her
not a
war
e of
thei
r H
IV s
ero-
stat
us
•M
ult
ipli
city
of
guid
elin
es
over
whe
lms
serv
ice
prov
ider
s •
HIV
pre
gnan
t mot
hers
fa
ce s
tigm
a/d
ilem
ma
in in
fan
t fee
din
g op
tion
s •
Big
ger
prop
orti
on o
f he
alth
sec
tor
bud
get i
s d
onor
dep
end
ant
•D
onor
dri
ven
init
iati
ves?
? •
Har
mfu
l pra
ctis
es
and
bel
iefs
•
Wom
en n
ot
empo
wer
ed
•T
rad
itio
nal
pra
ctis
es
hind
erin
g po
stn
atal
at
tend
ance
66T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
(ii)
Hea
lth
Sys
tem
s•
Infr
astr
uct
ure
at a
ll le
vels
ov
erse
eing
hea
lth
serv
ices
- n
atio
nal
, reg
ion
al, d
istr
ict
and
co
mm
unit
y •
Pres
ence
of Z
RC
HC
O, R
RC
H C
o an
d D
RC
HC
o •
Serv
ice
del
iver
y po
ints
wel
l d
istr
ibut
ed to
con
sult
ant,
regi
onal
an
d d
istr
ict h
ospi
tals
foll
owed
by
heal
th c
entr
es a
nd
dis
pens
arie
s.
•L
ack
of a
ppro
pri
ate
resu
scit
atio
n eq
uipm
ent a
nd
sup
plie
s e.
g. in
fusi
on
pum
ps, i
njec
tabl
es p
heno
barb
iton
e et
c •
Un
attr
acti
ve w
orki
ng c
ond
itio
n es
peci
ally
in r
ura
l are
as
•H
ealt
h se
rvic
es in
clu
din
g ne
onat
al
care
not
ope
rati
ng fo
r 24
hou
rs
•H
MT
are
un
awar
e in
ad
dre
ssin
g ne
onat
al h
ealt
h is
sues
•
Lim
ited
trai
nin
g of
Ser
vice
pro
vid
ers
on L
SS w
hic
h h
as a
com
pone
nt o
f ne
onat
al c
are
•In
adeq
uat
e/in
appr
opri
ate
EM
OC
(b
asic
an
d c
omp
rehe
nsiv
e se
rvic
es) a
t fa
cili
ty le
vel
•So
me
neon
atal
sup
plie
s/ e
quip
men
ts
are
not m
ade
avai
labl
e at
MSD
•
Poor
sup
ply
plan
at s
ervi
ce d
eliv
ery
poin
t/d
istr
icts
•
Neo
nata
l ser
vice
s ar
e no
t ad
equ
atel
y pr
ovid
ed b
y m
ajor
ity
for
publ
ic a
nd
pr
ivat
e he
alth
faci
liti
es
•Fa
cili
ty b
uil
din
gs n
ot s
uita
ble
prov
idin
g ne
onat
al s
ervi
ces
•K
anga
roo
met
hod
for
low
bir
th
wei
ght b
abie
s in
res
ourc
e po
or
coun
trie
s h
as n
ot b
een
adop
ted
. •
Und
er-f
ives
car
e d
oes
not f
ocus
age
sp
ecif
ic w
ith
spec
ial n
eed
s, a
s a
resu
lt
neon
atal
are
not
take
n in
to
cons
ider
atio
n, e
spec
iall
y th
e 1st
wee
k
•E
xist
ence
of P
aed
iatr
ic A
ssoc
iati
on o
f T
anza
nia
(PA
T) a
nd
oth
er h
ealt
h pr
ofes
sion
al a
ssoc
iati
ons.
•
The
ong
oing
Join
t Reh
abil
itat
ion
Fund
s w
ith
in d
istr
icts
can
fac
ilit
ate
impr
ovin
g bu
ild
ings
to p
rovi
de
neon
atal
car
e •
Pres
ence
of D
istr
ict N
ursi
ng O
ffic
er a
nd
H
ospi
tal m
atro
n th
at c
an fo
cus
on n
eon
atal
ca
re
•Pr
esen
ce o
f Ind
ent s
yste
m fo
r ob
tain
ing
esse
ntia
l dru
gs a
nd
sup
plie
s •
Plan
to s
tren
gthe
n Z
TC
•
Exi
sten
ce o
f RH
MT
an
d C
HM
T w
hic
h co
ord
inat
es d
istr
ict h
ealt
h ac
tivi
ties
in
clu
din
g m
ater
nal
& n
ewbo
rn c
are
•R
ehab
ilit
atio
n of
hea
lth
faci
liti
es
•P
artn
ers
read
y to
sup
port
•O
verw
helm
ing
the
ZT
C
cap
acit
y
(ii)
Sys
tem
s S
up
por
t •
Loc
al G
over
nmen
t aut
hori
ties
re
form
s ar
e su
ppor
ting
im
plem
enta
tion
of H
SR
•T
here
's v
ast G
eogr
aphi
cal
area
wit
h po
or tr
ansp
ort/
road
s, in
adeq
uat
e he
alth
faci
liti
es a
nd
ther
efor
e po
or
geog
raph
ical
acc
essi
bili
ty to
EM
OC
•C
urre
ntly
Join
t Reh
abil
itat
ion
Prog
ram
me
has
bee
n in
itia
ted
at d
istr
ict l
evel
whi
ch c
an
be u
sed
to a
ccom
mod
ate
stru
ctur
e im
prov
emen
t for
mat
ern
al a
nd
new
born
car
e
67T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
ST
RE
NG
TH
S
WE
AK
NE
SS
ES
O
PP
OR
TU
NIT
IES
T
HR
EA
TS
•Pr
esen
ce o
f ref
erra
l str
uctu
re
wit
hin
the
heal
th d
eliv
ery
syst
em
•In
adeq
uat
e am
bula
nces
wit
hin
the
coun
try
•
Man
y he
alth
uni
ts d
o no
t hav
e re
liab
le c
omm
unic
atio
n sy
stem
(r
adio
cal
l, m
obil
e)
•In
adeq
uat
e aw
aren
ess
and
ad
voca
cy
on N
eona
tal c
are
at a
ll le
vels
in
clu
din
g he
alth
faci
liti
es s
uppo
rt
staf
f
•E
xist
ence
of m
obil
e co
mm
unic
atio
n ne
twor
k un
til r
ura
l are
as
(iv)
Pla
nn
ing,
Mon
itor
ing
and
Ev
alu
atio
n•
Plan
ning
dec
entr
alis
ed to
dis
tric
t le
vel
•Po
or m
ain
stre
amin
g of
neo
nat
al
heal
th in
terv
enti
on in
to C
CH
P
•C
entr
aliz
atio
n of
ser
vice
s/he
alth
pl
ans
at C
HM
T le
vel a
nd
less
on
low
er le
vel
•In
adeq
uat
e ca
pac
ity
of C
HM
T t
o pl
an
for
RC
H a
ctiv
itie
s in
clu
din
g ne
onat
al
heal
th
•Po
or r
ecor
d k
eepi
ng a
nd th
eref
ore
plan
ning
is n
ot e
vid
ence
bas
ed
•D
istr
ict h
ealt
h bo
ard
s an
d h
ealt
h fa
cili
ty
com
mit
tees
pre
sent
acc
ord
ing
to s
et
guid
elin
es
•Pr
opos
al f
or r
ecor
ds
man
agem
ent
impr
ovem
ent h
as b
een
mad
e to
MoH
SW
•In
trod
uct
ion
of m
ater
nal
an
d p
erin
atal
dea
th
revi
ews
(v)
Com
mu
nit
y
•Pr
esen
ce o
f HM
IS in
all
hea
lth
del
iver
y sy
stem
s •
Supe
rvis
ion
syst
em in
pla
ce
•Pr
esen
ce o
f hea
lth
faci
lity
co
mm
itte
e an
d d
istr
ict b
oard
s in
m
ajor
ity
of d
istr
icts
•
Pres
ence
of C
HM
T in
all
dis
tric
ts
• •
•In
adeq
uat
e fu
ncti
onin
g of
HM
IS
•L
ack
of d
isag
greg
ated
dat
a by
sex
an
d a
ge s
peci
fic
•W
eak/
abse
nce
of C
omm
unit
y B
ased
M
anag
emen
t Inf
orm
atio
n Sy
stem
•
Supe
rvis
ion
und
erta
ken
is n
ot
com
preh
ensi
ve a
nd
doe
s no
t cap
ture
ne
onat
al c
are
•W
eak
impl
emen
tati
on o
f dis
tric
t gu
ide
of in
volv
ing
com
mun
ity
•Q
ual
ity
of C
are
fram
ewor
k to
con
soli
dat
e su
perv
isor
y to
ols
•
Pres
ence
of C
lien
t hea
lth
serv
ice
char
ter
and
G
uid
elin
es o
n ro
les
and
res
pons
ibil
itie
s of
HF
com
mit
tees
/dis
tric
t boa
rds.
•
Pres
ence
of O
& O
D p
lann
ing
proc
ess
wh
ich
invo
lves
the
com
mun
ity
•A
ccor
din
g to
dis
tric
t hea
lth
plan
ning
gui
des
th
ere'
s 10
% fu
nds
allo
cate
d fo
r co
mm
unit
y in
terv
enti
on
•C
onfl
icti
ng p
rior
itie
s d
uri
ng jo
int
supe
rvis
ion
•Pr
esen
ce o
f har
mfu
l tr
adit
ion
al p
ract
ices
th
at c
an a
dve
rsel
y af
fect
mat
ern
al a
nd
ne
wbo
rn
68T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
69T
he N
atio
nal R
oad
Map
Str
ateg
ic P
lan
-200
8 -
2015
70 The National Road Map Strategic Plan -2008 - 2015
The National Road Map Strategic Plan -2008 - 2015 71
ANNEX 2
INPUTS FOR IMPROVINGMATERNAL, NEWBORN AND
CHILD HEALTH AT ALLLEVELS
AN
TE
NA
TA
L C
AR
E
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SAR
Y
HE
AL
TH
CE
NT
RE
H
OSP
ITA
L
SUG
GE
STE
D I
NP
UT
S
Pro
vide
IE
C, h
ealth
edu
catio
n an
d co
unse
lling
to w
omen
, men
, fa
mili
es a
nd c
omm
uniti
es a
bout
: •
The
nee
ds o
f pr
egna
nt w
omen
•
Dan
ger
sign
s an
d ap
prop
riat
e ac
tion
•B
irth
pre
pare
dnes
s, in
clud
ing
loca
l tra
nspo
rtat
ion
for
emer
genc
ies
•W
ork,
res
t and
nut
ritio
n •
HIV
/ST
D p
reve
ntio
n •
The
impo
rtan
ce o
f so
cial
su
ppor
t
Invo
lve
the
husb
and/
part
ner
in I
EC
an
d co
unse
lling
ses
sion
s
Pla
nnin
g fo
r bi
rth
and
emer
genc
ies
Ado
lesc
ent g
irls
enc
oura
ged
to
cont
inue
to g
o to
sch
ool
Pro
mot
e be
nefi
cial
trad
ition
al
prac
tice
s an
d ad
vise
aga
inst
ha
rmfu
l one
s
Pro
mot
e IT
Ns
Iden
tify
preg
nant
wom
en a
nd r
efer
ea
rly
to a
nten
atal
clin
ic
Pro
vide
fol
low
up
care
and
sup
port
be
twee
n sc
hedu
led
ante
nata
l clin
ic
visi
ts
Iden
tify
prob
lem
s an
d co
mpl
icat
ion
and
refe
r
Rec
ord
com
mun
ity-b
ased
hea
lth
info
rmat
ion
(e.g
. num
ber
of
wom
en r
efer
ral f
or a
nten
atal
car
e)
As
at c
omm
unity
leve
l, pl
us:
Obt
ain
targ
eted
his
tory
and
pe
rfor
m p
hysi
cal e
xam
inat
ion,
m
onito
r pr
ogre
ss o
f pre
gnan
cy a
nd
asse
ss m
ater
nal a
nd f
etal
wel
l-be
ing
Dev
elop
an
indi
vidu
alis
ed b
irth
pl
an (
e.g.
pla
ce o
f de
liver
y, b
irth
at
tend
ant,
emer
genc
y pr
epar
edne
ss)
Perf
orm
sta
ndar
d te
stin
g:
•S
yphi
lis (
incl
udin
g tr
eatm
ent a
s ne
eded
) •
Uri
naly
sis
•H
aem
oglo
bin
•P
regn
ancy
con
firm
atio
n
Scr
een
for
othe
r S
TD
s w
here
ap
plic
able
and
pro
vide
app
ropr
iate
tr
eatm
ent a
nd c
ouns
ellin
g
Ass
ess
Fem
ale
geni
tal m
util
atio
n
Man
age
min
or c
ompl
icat
ions
suc
h as
m
ild a
naem
ia, u
ncom
plic
ated
uri
nary
tr
act i
nfec
tion
and
mild
vag
inal
in
fect
ions
, unc
ompl
icat
ed m
alar
ia
Pro
vide
teta
nus
toxo
id im
mun
izat
ion
Pro
vide
inte
rmitt
ent p
resu
mpt
ive
trea
tmen
t of
mal
aria
Sel
l/dis
pens
e IT
Ns
Tre
at in
test
inal
par
asit
es a
s ne
eded
Pro
vide
iron
, fol
ic a
cid
and
othe
r m
icro
nutr
ient
sup
plem
enta
tion
Man
age
cert
ain
prob
lem
s an
d co
mpl
icat
ions
(e.
g. a
naem
ia, P
IH,
As
at d
ispe
nsar
y le
vel,
plus
:
Man
age
cert
ain
prob
lem
s an
d co
mpl
icat
ions
(e.
g. m
ild p
re-e
clam
psia
, in
com
plet
e ab
ortio
n); r
efer
mor
e se
riou
s co
mpl
icat
ions
Off
er v
olun
tary
cou
nsel
ling
and
test
ing
for
HIV
as
poss
ible
Prov
ide
FP a
nd p
ost a
bort
ion
care
Pre
-ref
erra
l tre
atm
ent o
f se
vere
co
mpl
icat
ions
-
pre-
ecla
mps
ia
-ec
lam
psia
-
blee
ding
-
infe
ctio
n -
com
plic
ated
abo
rtio
n
Supp
ort o
f w
omen
with
spe
cial
nee
ds
e.g.
ado
lesc
ents
and
wom
en li
ving
with
vi
olen
ce
Man
age
or r
efer
for
PM
TC
T
Tre
atm
ent o
f m
ild to
mod
erat
e op
port
unis
tic in
fect
ions
in p
regn
ant
wom
en w
ith H
IV
As
at h
ealth
cen
tre
leve
l, pl
us:
Man
age
maj
or p
robl
ems
and
com
plic
atio
ns
- e
ctop
ic p
regn
ancy
-
Ana
emia
-
seve
re p
re-e
clam
psia
-
ecla
mps
ia
- bl
eedi
ng
- in
fect
ion
- ot
her
med
ical
com
plic
atio
ns
Tre
atm
ent o
f ab
ortio
n co
mpl
icat
ions
Tre
atm
ent o
f se
vere
HIV
infe
ctio
n
Tre
atm
ent o
f se
vere
mal
aria
Com
mun
ity
leve
l IE
C m
essa
ges/
mat
eria
ls a
bout
: •
The
nee
ds o
f pr
egna
nt w
omen
•
Dan
ger
sign
s an
d ap
prop
riat
e ac
tion
•B
irth
pre
pare
dnes
s, in
clud
ing
loca
l tra
nspo
rtat
ion
for
emer
genc
ies
•H
IV/S
TD
pre
vent
ion
•In
sect
icid
e-tr
eate
d be
d ne
ts (
ITN
s)
•T
he im
port
ance
of
mal
e in
volv
emen
t
Ref
resh
er in
-ser
vice
trai
ning
for
com
mun
ity-l
evel
hea
lth
wor
kers
abo
ut u
sing
IE
C m
essa
ges/
mat
eria
ls
In-s
ervi
ce tr
aini
ng f
or s
uper
viso
rs o
f co
mm
unity
-lev
el
heal
th w
orke
rs to
ena
ble
them
to c
ondu
ct r
efre
sher
on
job
trai
ning
of
com
mun
ity-l
evel
wor
kers
In-s
ervi
ce tr
aini
ng f
or c
omm
unity
-lev
el h
ealth
wor
kers
in
volv
ed in
ant
enat
al c
are,
incl
udin
g pr
oble
m/c
ompl
icat
ion
iden
tific
atio
n an
d re
ferr
al; f
ollo
w u
p su
ppor
t, re
cord
ing
Dis
pens
ary
leve
l In
-ser
vice
trai
ning
for
hea
lthca
re p
rovi
ders
res
pons
ible
for
an
tena
tal c
are
abou
t: •
Con
tent
of
ante
nata
l car
e •
Rev
ised
sch
edul
e of
vis
its
•A
sses
smen
t ski
lls (
hist
ory
taki
ng a
nd p
hysi
cal
exam
inat
ion;
rou
tine
test
ing)
•
Car
e pr
ovis
ion,
incl
udin
g th
e de
velo
pmen
t of
indi
vidu
aliz
ed b
irth
pla
n, h
ealth
edu
catio
n an
d co
unse
lling
Supp
lies
for
syph
ilis
test
ing,
uri
naly
sis,
hae
mog
lobi
n, a
nd
othe
r ST
D te
sts
as n
eces
sary
Con
sist
ent s
uppl
y of
TT
vac
cine
, syr
inge
s/ne
edle
s,
antih
elm
inth
ic d
rugs
, bas
ic d
rugs
suc
h as
ant
imal
aria
l dru
gs
(SP)
, ant
ibio
tics
and
fung
icid
es (
(SP
) an
d IT
Ns,
iron
, fol
ic
acid
and
oth
er m
icro
nutr
ient
sup
plem
ents
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SAR
Y
HE
AL
TH
CE
NT
RE
H
OSP
ITA
L
SUG
GE
STE
D I
NP
UT
S
slig
ht b
leed
ing)
; ref
er o
ther
pr
oble
ms
Prov
ide
addi
tiona
l hea
lth
educ
atio
n an
d co
unse
lling
abo
ut:
•Pr
epar
atio
n fo
r br
east
feed
ing
•Pr
even
tion
and
reco
gniti
on o
f ST
Ds/
HIV
/AID
S •
Prev
entio
n of
mal
aria
and
he
lmin
th in
fest
atio
n M
othe
r-to
-chi
ld tr
ansm
issi
on o
f H
IV/A
IDS
Hea
lth
Cen
tre
leve
l A
ll of
the
abo
ve a
nd:
•
Supp
lies
for
HIV
test
ing,
IV
flu
ids,
par
enta
l dru
gs
(ant
ibio
tics,
MgS
O4,
ant
imal
aria
ls)
Su
pplie
s an
d tr
aini
ng f
or M
anua
l Vac
uum
Asp
irat
ions
In-s
ervi
ce tr
aini
ng f
or h
ealth
care
pro
vide
rs r
espo
nsib
le f
or
ante
nata
l car
e ab
out:
•C
onte
nt o
f an
tena
tal c
are
and
trea
tmen
t mild
co
mpl
icat
ions
as
wel
l as
pre-
refe
rral
trea
tmen
t •
Rev
ised
sch
edul
e of
vis
its
•A
sses
smen
t ski
lls (
hist
ory
taki
ng a
nd p
hysi
cal
exam
inat
ion;
rou
tine
test
ing)
•
Car
e pr
ovis
ion,
incl
udin
g th
e de
velo
pmen
t of
indi
vidu
alis
ed b
irth
pla
n, h
ealth
edu
catio
n an
d co
unse
lling
Hos
pita
l lev
el
All
of t
he a
bove
and
: C
ompe
tenc
y-ba
sed
trai
ning
for
doc
tors
in th
e m
anag
emen
t of
ecl
amps
ia, s
ever
e an
aem
ia, e
ctop
ic p
regn
ancy
Supp
lies,
equ
ipm
ent a
nd d
rugs
for
the
man
agem
ent o
f co
mpl
icat
ions
(bl
ood
tran
sfus
ion,
labo
rato
ry te
sts,
obs
tetr
ic
care
and
sur
gery
)
CA
RE
DU
RIN
G C
HIL
DB
IRT
H in
clud
ing
obst
etri
c em
erge
ncy
sit
uat
ion
s
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SA
RY
H
EA
LT
H C
EN
TR
E
HO
SP
ITA
L
SU
GG
ES
TE
D I
NP
UT
S
Pro
vide
a w
arm
and
car
ing
appr
oach
to
the
wom
an
Mon
itor
prog
ress
of
labo
ur u
sing
si
mpl
e ai
de
If d
eliv
ery
occu
rs a
t com
mun
ity le
vel:
Fol
low
cle
an a
nd s
afe
deliv
ery
prac
tice
s
Dis
cuss
and
rea
ch c
onse
nsus
on
the
labo
ur a
nd b
irth
ing
posi
tion
of
mot
her’
s ch
oice
Rec
ogni
se p
robl
ems
or c
ompl
icat
ions
ea
rly
and
refe
r
Insp
ect p
lace
nta;
exa
min
e pe
rine
um
for
inju
ries
and
ref
er a
s ne
eded
Aft
er d
eliv
er, n
otif
y m
ater
nal a
nd
foet
al o
utco
mes
and
rep
ort t
o ne
xt
leve
l
Car
e fo
r th
e ne
wbo
rn b
aby
incl
udin
g K
MC
, rec
ogni
se d
ange
r si
gns
and
refe
r as
app
ropr
iate
Per
form
obs
tetr
ic f
irst
aid
incl
udin
g st
abili
satio
n
Arr
ange
for
tran
spor
t and
acc
ompa
ny
mot
her
to th
e ne
xt le
vel
Rec
ord
com
mun
ity-b
ased
hea
lth
info
rmat
ion
(e.g
. num
ber
of w
omen
w
ith c
ompl
icat
ions
ref
erre
d
As
at c
omm
unity
leve
l, pl
us:
Obt
ain
targ
eted
his
tory
and
pe
rfor
m p
hysi
cal e
xam
inat
ion
Dia
gnos
e la
bour
and
mon
itor
prog
ress
usi
ng a
dapt
ed W
HO
pa
rtog
raph
Pro
vide
sup
port
ive
care
and
pa
in r
elie
f P
erfo
rm in
terv
entio
ns s
uch
as
amni
otom
y an
d ep
isio
tom
y,
only
if n
eces
sary
Insp
ect p
lace
nta
and
vagi
na f
or
inju
ries
Rep
air
min
or la
cera
tion
s an
d ep
isio
tom
ies
Act
ivel
y m
anag
e th
e th
ird
stag
e of
labo
ur (
oxyt
ocin
, co
ntro
lled
cord
trac
tion,
fun
dal
mas
sage
)
Car
e fo
r th
e ba
by a
fter
bir
th
incl
. KM
C, m
onito
r th
e ba
by
and
trea
t or
refe
r as
app
ropr
iate
N
ewbo
rn r
esus
cita
tion
Rec
ogni
ze c
ompl
icat
ions
ear
ly
(e.g
. mal
pres
enta
tions
, pr
olon
ged
or o
bstr
ucte
d la
bour
, hy
pert
ensi
on, b
leed
ing
and
infe
ctio
n) a
nd m
anag
e or
ref
er
as a
ppro
pria
te
Per
form
em
erge
ncy
obst
etri
c pr
oced
ures
incl
udin
g:
•R
epai
r of
vag
inal
and
cer
vica
l la
cera
tion
s •
Vac
uum
ext
ract
ion
•M
anua
l vac
uum
asp
irat
ion
(MV
A)
Man
ual r
emov
al o
f th
e pl
acen
ta
As
at d
ispe
nsar
y le
vel,
plus
:
Tre
atm
ent o
f ab
norm
aliti
es a
nd
com
plic
atio
ns (
prol
onge
d la
bour
, va
cuum
ext
ract
ion,
bre
ach
pres
enta
tion,
epi
siot
omy,
rep
air
of
geni
tal t
ears
, man
ual r
emov
al o
f pl
acen
ta a
nd tr
eatm
ent o
f m
oder
ate
post
-hae
mor
rhag
ic a
naem
ia
Pre
-ref
erra
l man
agem
ent o
f se
riou
s co
mpl
icat
ions
(ob
stru
cted
labo
ur,
feta
l dis
tres
s, p
rete
rm la
bour
, sev
ere
peri
- an
d po
stpa
rtum
hae
mor
rhag
e)
Em
erge
ncy
man
agem
ent o
f co
mpl
icat
ions
if b
irth
is im
min
ent
Sup
port
for
the
fam
ily in
cas
e of
m
ater
nal d
eath
As
at h
ealt
h ce
ntre
, plu
s:
Tre
atm
ent o
f se
vere
com
plic
atio
ns i
n ch
ildbi
rth
and
the
imm
edia
te
post
part
um p
erio
d, in
clud
ing
caes
area
n
sect
ion,
blo
od tr
ansf
usio
n an
d hy
ster
ecto
my)
-
obst
ruct
ed la
bour
-
mal
pres
enta
tion
s -
ecla
mps
ia
- se
vere
infe
ctio
ns
- bl
eedi
ng
Indu
ctio
n an
d au
gmen
tatio
n of
labo
ur
Man
agem
ent o
f co
mpl
icat
ions
rel
ated
to
FG
M
Pre
vent
ion
of M
othe
r to
Chi
ld
tran
smis
sion
of
HIV
by
mod
e of
de
liver
y, p
rovi
sion
of
AR
V’s
, gu
idan
ce
and
supp
ort f
or c
hose
n in
fant
fee
ding
op
tion.
Com
mu
nit
y le
vel
In-s
ervi
ce tr
aini
ng f
or c
omm
unity
-lev
el h
ealt
h w
orke
rs
abou
t app
ropr
iate
inte
rper
sona
l sup
port
for
the
wom
an
duri
ng c
hild
birt
h; s
impl
e la
bour
mon
itori
ng; c
lean
and
sa
fe d
eliv
ery
prac
tices
; ear
ly r
ecog
nitio
n of
and
res
pons
e to
obs
tetr
ic c
ompl
icat
ions
Bas
ic d
eliv
ery
kits
WH
O a
dapt
ed p
arto
grap
h fo
rms
Dis
pen
sary
leve
l A
s fo
r th
e co
mm
unity
leve
l, pl
us:
In-s
ervi
ce tr
aini
ng a
bout
: •
Ass
essm
ent o
f w
oman
in la
bour
•
Cle
an a
nd s
afe
deliv
ery
prac
tices
•
Use
of
WH
O a
dapt
ed p
arto
grap
h •
Am
niot
omy/
epis
ioto
my
•A
ctiv
e m
anag
emen
t of
thir
d st
age
•R
ecog
nitio
n of
and
res
pons
e to
pro
blem
s/
com
plic
atio
ns
•E
ssen
tial n
ewbo
rn c
are
•K
MC
C
onsi
sten
t sup
ply
of
Glo
ves,
apr
ons,
soa
p an
d w
ater
, ant
isep
tic s
olut
ion,
bas
ic
inst
rum
ents
for
am
niot
omy
and
epis
ioto
my,
oxy
toci
n,
Vita
min
A b
asic
ora
l dru
gs, p
arto
grap
h fo
rms,
sut
ure
mat
eria
ls/n
eedl
e ho
lder
, Vag
inal
spe
culu
m,,
sutu
re
mat
eria
ls/n
eedl
e ho
lder
, vac
uum
ext
ract
or, M
VA
eq
uipm
ent,
IV
flu
ids
and
infu
sion
set
s In
-ser
vice
trai
ning
abo
ut:
Com
pete
ncy-
base
d sk
ills
trai
ning
for
clin
ical
off
icer
s an
d nu
rse-
mid
wiv
es in
: •
Rep
air
of v
agin
al a
nd c
ervi
cal l
acer
atio
ns
•V
acuu
m e
xtra
ctio
n •
MV
A
•M
anua
l rem
oval
of
the
plac
enta
•
Em
erge
ncy
man
agem
ent o
f co
mpl
icat
ions
if b
irth
is
imm
inen
t •
Pre
-ref
erra
l man
agem
ent o
f se
riou
s co
mpl
icat
ions
•
Tre
atm
ent o
f m
inor
com
plic
atio
n •
Ess
entia
l new
born
car
e
Ava
ilabi
lity
of
New
born
res
usci
tatio
n eq
uipm
ent
Hea
lth
Cen
tre
leve
l
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SAR
Y
HE
AL
TH
CE
NT
RE
H
OSP
ITA
L
SUG
GE
STE
D I
NP
UT
S
Initi
ate
man
agem
ent a
nd r
efer
pa
tient
s w
ith:
•H
aem
orrh
age
•E
clam
psia
•
Obs
truc
ted
labo
ur
Puer
pera
l inf
ectio
ns
Del
iver
y an
d im
med
iate
car
e of
th
e ne
wbo
rn in
clud
ing
KM
C
and
imm
edia
te in
itiat
ion
of
brea
stfe
edin
g
Imm
edia
te p
ostp
artu
m c
are
of
the
mot
her:
-
Ass
essm
ent o
f m
ater
nal w
ell
bein
g an
d de
tect
ion
of
com
plic
atio
ns (
e.g.
ble
edin
g,
infe
ctio
ns, h
yper
tens
ion
and
anae
mia
) -
Adv
ice
on d
ange
r si
gns,
em
erge
ncy
prep
ared
ness
and
fo
llow
-up
Vita
min
A a
dmin
istr
atio
n
Rec
ordi
ng a
nd r
epor
ting
on
deliv
ery
All
of th
e ab
ove
plus
: C
ontin
uous
Sup
ply
of: V
acuu
m e
xtra
ctio
n eq
uipm
ent,
IV
flui
ds a
nd I
V s
ets,
MG
SO4,
par
enta
l ute
roto
nics
and
an
tibio
tics,
dru
gs a
nd e
quip
men
t for
ess
entia
l new
born
ca
re.
Hos
pita
l lev
el
All
of th
e ab
ove
plus
:
Hea
lth w
orke
rs tr
aine
d in
: •
Man
agem
ent o
f ob
stet
ric
com
plic
atio
ns a
nd
emer
genc
ies
incl
udin
g Su
rger
y (c
aesa
rean
sec
tion
an
d ot
her
abd
omin
al o
bste
tric
sur
gery
ect
opic
pre
gnan
cy,
hyst
erec
tom
y)
•Pr
ovid
ing
safe
ana
esth
esia
for
pre
gnan
t wom
en
•Sa
fe b
lood
tran
sfus
ion
•PM
TC
T
Stab
le s
uppl
y of
: E
quip
men
t and
dru
gs f
or a
naes
thes
ia, i
nstr
umen
ts a
nd
cons
umab
le s
uppl
ies
for
obst
etri
c su
rger
y, b
lood
tr
ansf
usio
n eq
uipm
ent ,
Oxy
gen,
labo
rato
ry e
quip
men
t for
bo
th b
ioch
emic
al a
nd m
icro
biol
ogic
al a
sses
smen
ts a
nd
AR
V’s
.
NE
WB
OR
N C
AR
E
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SA
RY
H
EA
LT
H C
EN
TR
E
HO
SP
ITA
L
SU
GG
ES
TE
D I
NP
UT
S
Pro
vide
imm
edia
te c
are
of th
e ne
wbo
rn, i
nclu
ding
the
follo
win
g:
• K
MC
st
imul
ate
and
war
m
baby
• C
lear
air
way
if
nec
essa
ry to
est
abli
sh
r
espi
rati
on
• T
ie, c
ut a
nd c
are
of c
ord
usin
g cl
ean,
saf
e pr
oced
ures
• E
stab
lish
bre
astf
eedi
ng
imm
edia
tely
aft
er b
irth
Avo
id c
onta
cts
wit
h si
ck
fam
ily
mem
bers
Ext
ra c
are
for
low
-bith
wei
ght
babi
es in
clud
ing
KM
C
Rec
ogni
tion
of
dang
er s
igns
an
d re
ferr
al
Cou
nsel
ling
on
hom
ecar
e,
dang
er s
igns
, saf
e di
spos
al o
f ba
by s
tool
s, n
utri
tion
, IT
N
and
hygi
ene
for
new
born
, ne
ed f
or g
row
th m
onit
orin
g an
d im
mun
izat
ions
As
at c
omm
unity
leve
l, pl
us:
Ens
ure
war
mth
of
sick
or
pret
erm
/low
bir
th w
eigh
t bab
ies
as
nece
ssar
y
Per
form
bas
ic n
ewbo
rn
Res
usci
tati
on
Pro
vide
new
born
imm
uniz
atio
ns a
nd
adm
inis
ter
eye
care
Pro
vide
cou
nsel
ling
and
supp
ort f
or:
•C
are
of th
e ne
wbo
rn
•C
are
of p
rete
rm/lo
w b
irth
wei
ght
babi
es, i
nclu
ding
ski
n-to
-ski
n m
etho
d •
Bre
astf
eedi
ng
•C
ouns
ellin
g an
d su
ppor
t on
feed
ing
fro
HIV
pos
itive
mot
hers
Mon
itori
ng a
nd a
sses
smen
t of
wel
lbei
ng, d
etec
tion
of
com
plic
atio
ns (
brea
thin
g, in
fect
ions
, pr
emat
urel
y, lo
w b
irth
wei
ght,
inju
ry, m
alfo
rmat
ion)
Infe
ctio
n pr
even
tion,
con
trol
and
ro
omin
g-in
Imm
uniz
atio
n ac
cord
ing
to n
atio
nal
guid
elin
e
Initi
ate
man
agem
ent o
f ne
wbo
rn
illne
ss a
nd r
efer
to a
ppro
pria
te le
vel
of c
are
Add
ition
al f
ollo
w-u
p vi
sits
for
hig
h ri
sk b
abie
s (p
rete
rm, a
fter
sev
ere
com
plic
atio
ns, l
ow-b
irth
wei
ght
babi
es H
IV-e
xpos
ed b
abie
s, b
abie
s w
ith f
eedi
ng p
robl
ems
and
bab
ies
on r
epla
cem
ent f
eedi
ng
Sup
port
ing
mot
her
if p
erin
atal
dea
th
As
at d
ispe
nsar
y le
vel,
plus
:
Car
e if
mod
erat
ely
pret
erm
, low
bir
th
wei
ght o
r tw
in; s
uppo
rt f
or
brea
stfe
edin
g, w
arm
th, f
requ
ent
asse
ssm
ent o
f w
ellb
eing
and
det
ecti
on
of c
ompl
icat
ions
e.g
. fee
ding
di
ffic
ultie
s, ja
undi
ce o
r ot
her
peri
nata
l pr
oble
ms.
Tre
atm
ent o
f m
ild to
mod
erat
e:
- lo
cal i
nfec
tions
(co
rd, s
kin,
eye
, th
rush
) -
birt
h in
juri
es
Pre
ref
erra
l man
agem
ent o
f in
fant
s w
ith s
ever
e pr
oble
ms:
-
very
pre
term
bab
ies
And
/or
low
bir
th
wei
ght
- se
vere
com
plic
atio
ns
- m
alfo
rmat
ions
Pre
sum
ptiv
e tr
eatm
ent o
f co
ngen
ital
syph
ilis
Man
agem
ent o
f m
inor
to m
oder
ate
prob
lem
s su
ch a
s fe
edin
g di
ffic
ultie
s
pre-
refe
rral
man
agem
ent o
f se
vere
pr
oble
ms
such
as
conv
ulsi
ons
and
inab
ility
to f
eed
Rec
ogni
ze d
ange
r si
gns
give
ap
prop
riat
e pr
e-re
ferr
al tr
eatm
ent a
nd
refe
r as
app
ropr
iate
As
at h
ealt
h ce
ntre
leve
l, pl
us:
Man
agem
ent o
f se
vere
new
born
pr
oble
ms
such
as:
-
neon
atal
sep
sis
- ne
onat
al J
aund
ice
- ne
onat
al T
etan
us
- br
eath
ing
diff
icul
ties
- se
vere
bir
th tr
aum
a an
d as
phyx
ia
- co
rrec
tabl
e m
alfo
rmat
ions
-
Neo
nata
l syp
hilis
-
failu
re to
thri
ve
Ref
er f
or f
urth
er c
are,
if n
eces
sary
Com
mu
nit
y le
vel
In-s
ervi
ce tr
aini
ng f
or c
omm
unity
-lev
el h
ealt
h w
orke
rs
in e
ssen
tial n
ewbo
rn c
are
IEC
mes
sage
s/m
ater
ials
abo
ut:
•T
he d
ange
r si
gns
of n
ewbo
rn il
lnes
s an
d th
e ne
ed to
see
k im
med
iate
car
e
•T
he im
port
ance
of
imm
uniz
atio
ns, g
row
th
mon
itori
ng a
nd f
ollo
w u
p •
Infa
nt a
nd y
oung
chi
ld f
eedi
ng
In-s
ervi
ce tr
aini
ng f
or c
omm
unity
-lev
el h
ealt
h w
orke
rs
in e
ssen
tial n
ewbo
rn c
are
Dis
pen
sary
leve
l A
ll of
the
abov
e pl
us:
Tra
inin
g of
hea
lth w
orke
rs in
ess
entia
l new
born
car
e
Con
tinuo
us s
uppl
y of
: Ess
entia
l dru
gs a
nd v
acci
nes
and
equi
pmen
t for
new
born
res
usci
tatio
n (m
ucou
s ex
trac
tor,
new
born
tube
and
mas
k de
vice
for
new
born
re
susc
itati
on)
Hea
lth
cen
tre
leve
l A
ll of
the
abov
e pl
us:
Con
tinuo
us s
uppl
y of
: oxy
gen,
I.V
. flu
ids,
par
enta
l an
tibio
tics
Hos
pit
al:
All
of th
e ab
ove
plus
:
Tra
inin
g of
hea
lth w
orke
rs a
nd la
b-te
chni
cian
s in
: -
man
agem
ent o
f th
e se
vere
ly s
ick
new
born
bab
y
Con
tinuo
us s
uppl
y of
labo
rato
ry te
st e
quip
men
t, eq
uipm
ent a
nd s
uppl
ies
for
anae
sthe
sia
and
surg
ery
PO
STP
AR
TU
M C
AR
E
TR
AIN
ED
H
EA
LT
HC
AR
E P
RO
VID
ER
A
T C
OM
MU
NIT
Y
DIS
PE
NSA
RY
H
EA
LT
H C
EN
TR
E
HO
SPIT
AL
SU
GG
EST
ED
IN
PU
TS
Prov
ide
IEC
to w
omen
, men
, fa
mil
ies
and
com
mun
ities
abo
ut:
•
the
need
s of
po
stpa
rtum
wom
en
•
bre
astf
eedi
ng
•
dan
ger
sign
s fo
r m
othe
r an
d ba
by
•
the
impo
rtan
ce o
f so
cial
su
ppor
t -
ITN
Prom
ote
bene
fici
al
trad
ition
al p
ract
ices
and
di
scou
rage
har
mfu
l one
s
Ref
er f
or f
irst
pos
tpar
tum
car
e vi
sit
with
in 4
8 ho
urs
of d
eliv
ery
Prov
ide
follo
w-u
p ca
re a
nd
supp
ort b
etw
een
post
part
um c
linic
vi
sits
an
d re
fer
for
prob
lem
s an
d co
mpl
icat
ions
Rec
ord
com
mun
ity-b
ased
hea
lth
info
rmat
ion
(e.g
., nu
mbe
r of
w
omen
re
ferr
ed f
or p
ostp
artu
m c
are)
As
at c
omm
unity
leve
l plu
s:
Obt
ain
preg
nanc
y/bi
rth
hist
ory
and
perf
orm
ph
ysic
al e
xam
inat
ion
of
mot
her
and
baby
Rec
ogni
se p
robl
ems
or
com
plic
atio
ns e
arly
(i
nfec
tions
, ble
edin
g an
d an
aem
ia)
and
man
age
appr
opri
atel
y or
ref
er f
or
furt
her
care
Iron
and
fol
ic a
cid
supp
lem
enta
tion
Prov
ide
vita
min
A a
nd
Mic
ronu
trie
nt
supp
lem
enta
tion
whe
re
App
ropr
iate
Prov
ide
coun
selli
ng a
bout
: -
Bre
astf
eedi
ng a
nd b
aby
care
-
Mat
erna
l nut
ritio
n -h
ome
care
-
ITN
-
Dan
ger
sign
s an
d ap
prop
riat
e ca
re s
eeki
ng
C
ontr
acep
tion
and
resu
mpt
ion
of s
exua
l act
ivity
•
Oth
er R
H c
once
rns
(e
.g.,
STD
s/H
TV
)
As
at d
ispe
nsar
y le
vel,
Man
age
mod
erat
e po
stpa
rtum
pr
oble
ms/
com
plic
atio
ns
incl
udin
g:
• m
ild to
mod
erat
e an
aem
ia
- M
ild p
uerp
eral
dep
ress
ion
Pre
-ref
erra
l tre
atm
ent o
f se
vere
pr
oble
ms
such
as
seve
re p
ost p
artu
m
blee
ding
, pue
rper
al s
epsi
s an
d se
vere
pu
erpe
ral d
epre
ssio
n.
As
at h
ealth
cen
tre
leve
l,
Man
age
seve
re p
ostp
artu
m
com
plic
atio
ns p
robl
ems
-
seve
re h
aem
orrh
age
-
seve
re p
ost p
artu
m in
fect
ions
-
seve
re p
ost p
artu
m d
epre
ssio
n -
fem
ale
ster
iliza
tion
Com
mu
nity
Lev
el:
IEC
mes
sage
s ab
out:
•
the
nee
ds o
f po
stpa
rtum
wom
en
•br
east
feed
ing
•im
mun
izat
ion
• d
ange
r si
gns
for
mot
her
and
baby
•
ben
efic
ial t
radi
tiona
l pra
ctic
es a
nd th
e im
port
ance
of
avoi
ding
har
mfu
l one
s I
n-se
rvic
e tr
aini
ng f
or c
omm
unity
-lev
el
heal
th w
orke
rs a
bout
the
impo
rtan
ce o
f ea
rly
post
part
um
refe
rral
and
fol
low
up
care
, rec
ordi
ng
Dis
pen
sary
leve
l In
-ser
vice
trai
ning
for
hea
lthca
re p
rovi
ders
res
pons
ible
for
po
stpa
rtum
car
e ab
out:
•C
onte
nt o
f po
stpa
rtum
car
e •
Sche
dule
of
visi
ts
•A
sses
smen
t ski
lls (
hist
ory
taki
ng a
nd p
hysi
cal
exam
inat
ion
of m
othe
r an
d ba
by
•C
are
prov
isio
n, in
clud
ing
mic
ronu
trie
nt
supp
lem
enta
tion
and
coun
selli
ng a
bout
bre
astf
eedi
ng,
baby
car
e, m
ater
nal n
utri
tion,
con
trac
eptio
n, a
nd o
ther
R
H c
once
rns
I(e.
g. S
TD
s/H
IV)
•P
re-r
efer
ral t
reat
men
t and
ref
erra
l of
wom
en w
ith
com
plic
atio
ns
Con
sist
ent s
uppl
y of
vit
amin
A a
nd o
ther
m
icro
nutr
ient
s an
d ba
sic
oral
dru
gs
Hea
lth
cen
tre
leve
l A
ll o
f th
e ab
ove
plus
: C
onsi
sten
t sup
ply
of I
V. F
luid
s, P
aren
tal d
rugs
(a
ntib
iotic
s, a
ntim
alar
ials
, MgS
O4)
, glo
ves,
soa
p an
d ot
her
equi
pmen
ts f
or m
anua
l rem
oval
of
plac
enta
Hos
pita
l Lev
el
All
of th
e ab
ove
plus
: T
rain
ing
of h
ealth
wor
kers
in m
anag
ing
seve
re
com
plic
atio
ns in
clud
ing
surg
ical
, lab
orat
ory
and
anae
sthe
siol
ogic
al p
roce
dure
s C
ontin
uous
sup
ply
of e
quip
men
t and
uti
litie
s fo
r su
rger
y , l
abor
ator
y te
sts
both
mic
robi
olog
y an
d bi
oche
mis
try,
ox
ygen
, equ
ipm
ent a
nd u
tilit
ies
for
bloo
d tr
ansf
usio
n.
PO
STA
BO
RT
ION
CA
RE
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SAR
Y
HE
AL
TH
CE
NT
RE
H
OSP
ITA
L
SUG
GE
STE
D I
NP
UT
S
Pro
vide
IE
C to
wom
en, m
en,
adol
esce
nts
and
com
mun
ities
abo
ut:
•T
he d
ange
rs o
f un
safe
abo
rtio
n •
The
nee
d to
see
k im
med
iate
car
e at
a
heal
th f
acil
ity f
or c
ompl
icat
ions
Rec
ogni
se s
igns
of
abor
tion
earl
y
Rap
idly
ass
ess
cond
ition
of
patie
nt
Sta
bilis
e an
d re
fer
imm
edia
tely
As
at c
omm
unity
leve
l, pl
us:
Rap
idly
ass
ess
con
ditio
n of
pa
tient
Initi
ate
man
agem
ent o
f sh
ock
Initi
ate
trea
tmen
t of
seps
is
Ref
er p
atie
nt f
or f
urth
er c
are,
if
nece
ssar
y
Prov
ide
post
abo
rtio
n co
unse
lling
and
fam
ily
plan
ning
met
hods
Prov
ide
othe
r R
H s
ervi
ces
as
nece
ssar
y (e
.g. t
reat
men
t of
STD
s)
As
at d
ispe
nsar
y le
vel,
plus
:
Perf
orm
man
ual v
acuu
m a
spir
atio
n (M
VA
)
Ref
er c
ases
not
app
ropr
iate
for
MV
A
Initi
ate
pre-
refe
rral
trea
tmen
t of
and
refe
r fo
r fu
rthe
r ca
re a
s ne
eded
As
at h
ealth
cen
tre
leve
l, pl
us:
Man
age
com
plic
atio
ns, i
nclu
ding
:
•In
tra-
abdo
min
al in
jury
•
Ute
rine
per
fora
tion
•
Tra
nsfu
sion
for
bloo
d lo
ss
•Sh
arp
cure
ttage
•
Infe
ctio
n
Initi
ate
man
agem
ent o
f sh
ock
Initi
ate
trea
tmen
t of
seps
is
Ref
er p
atie
nt f
or f
urth
er c
are,
if
nece
ssar
y
Pro
vide
pos
t-ab
ortio
n fa
mily
pla
nnin
g (F
P)
coun
selli
ng a
nd m
etho
ds a
nd
othe
r R
H s
ervi
ces
as n
eces
sary
(e.
g.
ST
Ds/
HIV
)
Com
mun
ity
leve
l
IEC
mes
sage
s/m
ater
ials
abo
ut:
•T
he d
ange
rs o
f un
safe
abo
rtio
n •
The
nee
d to
see
k im
med
iate
car
e at
a h
ealth
fac
ility
for
co
mpl
icat
ions
•
Opt
ions
for
fam
ily p
lann
ing
and
acce
ss to
FP
serv
ices
In s
ervi
ce tr
aini
ng f
or C
omm
unity
hea
lth w
orke
rs a
bout
th
e ea
rly
reco
gniti
on o
f an
d re
spon
se to
sig
ns o
f ab
ortio
n
Dis
pens
ary
leve
l In
-ser
vice
trai
ning
for
hea
lthca
re p
rovi
ders
abo
ut th
e ea
rly
reco
gniti
on o
f an
d re
spon
se to
sig
ns o
f ab
ortio
n In
-ser
vice
ser
vice
trai
ning
for
hea
lth c
are
prov
ider
s ab
out
post
abo
rtio
n FP
cou
nsel
ling
and
met
hods
C
onsi
sten
t sup
ply
of I
V f
luid
s an
d in
fusi
on s
ets,
in
tram
uscu
lar(
IV/A
M)
antib
iotic
s, s
yrin
ges
Hea
lth
cent
re
All
of th
e ab
ove
plus
: Se
rvic
e pr
ovid
ers
trai
ned
in a
sses
smen
t of
com
plic
atio
ns
rela
ted
to p
ost a
bort
ion,
per
form
ance
of
MV
A ,
earl
y re
cogn
ition
of
dang
er s
igns
, pre
-ref
erra
l, re
ferr
al
man
agem
ent a
nd p
ost a
bort
ion
coun
selli
ng o
f w
omen
on
FP C
onsi
sten
t sup
ply
of I
V f
luid
s an
d in
fusi
on s
ets,
in
trav
enou
s/in
tram
uscu
lar
(IV
/IM
) an
tibio
tics,
sy
ring
es/n
eedl
es, c
ontr
acep
tives
(or
al p
ills,
inje
ctab
les,
co
ndom
s), M
VA
equ
ipm
ent,
glov
es, s
oap
and
wat
er,
antis
eptic
sol
utio
n
Hos
pita
l lev
el
All
of th
e ab
ove
plus
: C
ompe
tenc
y-ba
sed
skill
s tr
aini
ng f
or d
octo
rs in
sur
gica
l pr
oced
ures
for
intr
a-ab
dom
inal
inju
ry a
nd u
teri
ne
perf
orat
ion
Equ
ipm
ent a
nd d
rugs
for
ana
esth
esia
, ins
trum
ents
and
co
nsum
able
sup
plie
s fo
r ob
stet
ric
surg
ery,
blo
od
tran
sfus
ion
equi
pmen
t
FA
MIL
Y P
LA
NN
ING
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SA
RY
H
EA
LT
H C
EN
TR
E
HO
SP
ITA
L
SU
GG
ES
TE
D I
NP
UT
S
Pro
vide
IE
C to
wom
en, m
en,
adol
esce
nts
and
com
mun
ities
abo
ut
the
heal
th b
enef
its
of:
•D
elay
ing
firs
t pre
gnan
cy
•S
paci
ng b
irth
s an
d lim
iting
fam
ily
size
Cou
nsel
cli
ents
for
FP
, inc
ludi
ng a
ll m
etho
ds
Pro
vide
con
trac
eptiv
e pi
lls
Pro
vide
bar
rier
met
hods
(co
ndom
s,
foam
s, je
llies
)
Ref
er c
lien
ts f
or o
ther
FP
ser
vice
s as
ne
cess
ary
Rec
ord
com
mun
ity-b
ased
hea
lth
info
rmat
ion
(e.g
. num
ber
of c
lient
s re
crui
ted
for
FP
)
As
at c
omm
unity
leve
l, pl
us:
Obt
ain
targ
eted
his
tory
; pe
rfor
m p
hysi
cal e
xam
inat
ion
Scr
een
for
ST
Ds;
trea
t as
nece
ssar
y
Pro
vide
cou
nsel
ling
abou
t all
met
hod
and
prov
ide
met
hod
of
choi
ce, i
nclu
ding
IU
D a
nd
inje
ctab
les
(whe
re s
kills
and
su
pplie
s ar
e av
aila
ble)
Ref
er a
s ne
eded
As
at d
ispe
nsar
y le
vel,
plus
:
Pro
vide
Nor
plan
t ins
ertio
n an
d re
mov
al
Ref
er c
lien
ts w
ho d
esir
e su
rgic
al
ster
iliza
tion
As
at h
ealt
h ce
ntre
leve
l, pl
us:
Per
form
sur
gica
l ste
riliz
atio
n (p
erm
anen
t met
hods
)
Com
mu
nit
y le
vel
IEC
mes
sage
s/m
ater
ials
abo
ut th
e he
alth
ben
efits
of:
•
Del
ayin
g fi
rst p
regn
ancy
•
Spa
cing
bir
ths
and
limit
ing
fam
ily s
ize
In-s
ervi
ce tr
aini
ng f
or c
omm
unity
leve
l hea
lth w
orke
rs
abou
t FP
cou
nsel
ling
for:
•
Con
dom
s an
d ot
her
barr
ier
met
hods
•
Spe
rmic
ides
•
Ora
l and
inje
ctab
le c
ontr
acep
tives
•
IUD
•P
erm
anen
t met
hods
In
-ser
vice
trai
ning
for
com
mun
ity le
vel h
ealth
wor
kers
ab
out
•D
istr
ibut
ion
of p
ills
and
barr
ier
met
hods
•
Ref
erra
l •
Rec
ordi
ng
Dis
pen
sary
leve
l A
ll of
the
abov
e pl
us:
In-s
ervi
ce tr
aini
ng f
or h
ealth
care
pro
vide
rs r
espo
nsib
le f
or
FP
ser
vice
s ab
out a
sses
smen
t and
scr
eeni
ng, i
nclu
ding
hi
stor
y an
d ph
ysic
al e
xam
inat
ion;
cou
nsel
ling;
ST
D
scre
enin
g an
d tr
eatm
ent,
met
hod
prov
isio
n; r
efer
ral
Con
sist
ent s
uppl
y of
Vag
inal
spe
culu
m, g
love
s, s
oap
and
wat
er, I
UD
inse
rtio
n ki
ts, a
ntis
epti
c so
luti
on
Hea
lth
Cen
tral
leve
l A
ll of
the
abov
e pl
us:
Con
tinuo
us s
uppl
y of
ora
l and
inje
ctab
le c
ontr
acep
tive
s,
IUD
s, c
ondo
ms,
foa
ms,
jelli
es, N
orpl
ant a
nd e
quip
men
t for
re
mov
al.
Hos
pit
al le
vel
All
of th
e ab
ove
plus
:
Com
pete
ncy-
base
d sk
ills
trai
ning
for
doc
tors
in m
ale
and
fem
ale
ster
iliz
atio
n pr
oced
ures
and
ana
esth
esio
logy
Con
tinuo
us s
uppl
y of
Sur
gica
l ins
trum
ents
and
sup
plie
s as
w
ell a
s su
pplie
s an
d dr
ugs
for
loca
l and
gen
eral
an
aest
hesi
a
PR
EV
EN
TIO
N A
ND
MA
NA
GE
ME
NT
OF
CH
ILD
HO
OD
IL
LN
ES
S
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SA
RY
H
EA
LT
H C
EN
TR
E
HO
SP
ITA
L
SU
GG
ES
TE
D I
NP
UT
S
Pro
vide
IE
C to
mot
hers
, fat
hers
, fa
mili
es a
nd c
omm
uniti
es a
bout
: •
Rec
ogni
tion
of d
isea
ses
•T
he d
ange
r si
gns
of il
lnes
ses
•P
rom
otio
n of
key
hea
lthca
re
prac
tice
s •
Ava
ilabi
lity
and
use
of o
ral
rehy
drat
ion
solu
tion
(OR
S)
•
Nut
ritio
n •
Bre
astf
eedi
ng
•Im
mun
izat
ion
•In
sect
icid
e tr
eate
d be
dnet
s •
Wat
er a
nd s
anit
atio
n •
Hou
seho
ld p
repa
redn
ess
for
prev
entio
n an
d tr
eatm
ent o
f ill
ness
As
at c
omm
unity
leve
l, pl
us:
Ass
ess
and
man
age
acc
ordi
ng
to th
e IM
CI
guid
elin
e un
com
plic
ated
cas
es o
f::
•D
iarr
hoea
•
Acu
te r
espi
rato
ry in
fect
ion
(AR
I)
•M
alar
ia
•M
alnu
trit
ion
•O
ther
chi
ldho
od il
lnes
ses
•P
aedi
atri
c H
IV
Use
of
oral
and
IM
ant
ibio
tics
, m
edic
atio
ns
Rec
ogni
tion
of d
ange
r si
gn a
nd
pre-
refe
rral
trea
tmen
t and
re
ferr
al a
ccor
ding
to I
MC
I gu
idel
ine.
Cou
nsel
car
egiv
er o
n ap
prop
riat
e ho
mec
are
and
nutr
ition
Pro
vide
gro
wth
mon
itori
ng,
vita
min
A s
uppl
emen
tatio
n
and
vacc
inat
ion
serv
ices
Ens
ure
all c
hild
ren
are
asse
ssed
and
man
aged
co
mpr
ehen
sive
ly d
urin
g al
l po
ints
of
cont
act w
ith th
e he
alth
fac
ility
incl
udin
g (a
sses
smen
t and
trea
tmen
t of
illne
sses
, gro
wth
mon
itori
ng
and
nutr
ition
al c
ouns
ellin
g,
imm
uniz
atio
n st
atus
)
As
at d
ispe
nsar
y le
vel,
plus
:
Use
of
IV f
luid
s m
edic
atio
ns
As
at h
ealt
h ce
ntre
leve
l, pl
us:
Lab
orat
ory
diag
nosi
s of
res
pira
tory
in
fect
ions
, dia
rrho
ea, m
alar
ia, a
naem
ia
Tre
atm
ent o
f ch
ild w
ith c
ompl
icat
ed
illne
sses
Pro
visi
on o
f H
IV te
stin
g an
d tr
eatm
ent
for
Chi
ldre
n w
ith H
IV
Com
mu
nit
y le
vel
IEC
mes
sage
s/m
ater
ials
abo
ut:
•R
ecog
nitio
n of
dis
ease
s •
The
dan
ger
sign
s of
illn
esse
s •
Pro
mot
ion
of k
ey h
ealth
care
pra
ctic
es
•A
vaila
bili
ty a
nd u
se o
f O
RS
•
Nut
ritio
n •
Bre
astf
eedi
ng
•Im
mun
izat
ion
•In
sect
icid
e tr
eate
d be
dnet
s •
Wat
er a
nd s
anit
atio
n •
Hou
seho
ld p
repa
redn
ess
for
prev
entio
n an
d tr
eatm
ent o
f ill
ness
Com
mun
ity-l
evel
hea
lth w
orke
rs w
ith im
prov
ed s
kills
abo
ut
the
prev
entio
n, r
ecog
nitio
n, h
ome
care
and
ref
erra
l of
com
mon
chi
ldho
od d
isea
ses
Dis
pen
sary
leve
l In
-ser
vice
trai
ning
for
hea
lthca
re p
rovi
ders
in T
he
prev
entio
n an
d m
anag
emen
t of
child
hood
illn
ess,
gro
wth
m
onito
ring
, im
mun
izat
ion
serv
ices
, cou
nsel
ling
for
pare
nts
of s
ick
child
ren,
rec
ogni
tion
of d
ange
r si
gns,
pre
-ref
erra
l tr
eatm
ent a
nd ti
mel
y re
ferr
al
Con
sist
ent s
uppl
y of
: Inj
ecta
ble
med
icat
ions
, Ant
imal
aria
ls,
Ant
ibio
tics,
Syr
inge
s/ne
edle
s, O
RS
, Zin
c
Hea
lth
cen
tre
leve
l A
s ab
ove
plus
:
Tra
inin
g of
lab
assi
stan
t in
bio
chem
ical
and
m
icro
biol
ogic
al te
sts
Con
tinuo
us s
uppl
y of
IV
set
s, s
yrin
ges,
nee
dles
and
par
enta
l dr
ugs
(ant
icon
vuls
ants
, ant
ibio
tics,
ant
imal
aria
ls, I
V f
luid
s),
equi
pmen
t and
util
itie
s fo
r bi
oche
mic
al a
nd m
icro
biol
ogic
al
labo
rato
ry te
sts
Hos
pit
al le
vel
All
of th
e ab
ove
plus
:
Tra
inin
g of
hea
lth w
orke
rs in
man
agem
ent o
f se
vere
ly il
l ch
ild in
clud
ing
tria
ge, e
valu
atio
n of
x-r
ays
TR
AIN
ED
HE
AL
TH
CA
RE
P
RO
VID
ER
CO
MM
UN
ITY
D
ISP
EN
SAR
Y
HE
AL
TH
CE
NT
RE
H
OSP
ITA
L
SUG
GE
STE
D I
NP
UT
S
Con
tinuo
us s
uppl
y of
ess
entia
l dru
gs f
or m
anag
emen
t of
the
seve
rely
sic
k ch
ild, n
asog
astr
ic tu
bes,
oxy
gen
equi
pmen
t, se
lf in
flat
ing
resu
scita
tion
bags
with
mas
ks, f
olly
cat
hete
rs,
Glo
ves,
dis
infe
ctan
ts, n
ebul
iser
, equ
ipm
ent f
or lu
mba
r pu
nctu
re, f
orm
ulas
for
man
agem
ent o
f se
ver
acut
e m
alnu
triti
on, e
quip
men
t for
blo
od tr
ansf
usio
n,
X-r
ay f
acili
ty
82 The National Road Map Strategic Plan -2008 - 2015
ANNEX 3RELEVANT POLICY DOCUMENTS
MoHSW (2004). Reproductive and Child Health Strategy, 2005-2010..
MoHSW- Expanded Programme on Immunization (2005). Comprehensive Multiyear Plan, 2006-2010.
MoHSW (1999). Staffing Levels for Health Facilities and Institutions.
MoHSW (2002) EPI Multi Country Evaluation Report
MoHSW (2004). National Adolescent Health and Development Strategy, 2004 -2008.
MoHSW (2005). Guidelines for Reforming Hospitals at Regional and District Levels.
MoHSW (2005). Communication Strategy for Child Health, 2005-2010.
MoHSW (2005). National Tracer Standards and Indicators for Quality Improvement in Health Care (Draft).
MoHSW (2005). Proposed Staffing levels for Health Facilities and Training Institutions.
MoHSW (2006). The National Road Map Strategic Plan to Accelerate Reduction of Maternal and NewbornDeaths in Tanzania, 2006-2010.
MoHSW (2006). Situation Analysis of Emergency Obstetric Care for Safe Motherhood in Public HealthFacilities in Tanzania
MoHSW (2007). Primary Health Services Development Programme (PHSDP/MMAM), 2007-2017.
MoHSW (2007). Tanzania National Health Policy (draft).
MoHSW (2007) Tanzania National Voucher Scheme Survey.
MoHSW (2008). Human Resource for Health Strategic Plan, 2008-2013.
MoHSW (2008). National Supervision Guidelines for Quality Health Care Services (Draft).
MoHSW (2007) Postnatal Care Guidelines (draft)
MoHSW (2007) Maternal and Perinatal Death Audit Guidelines (draft)
MoHSW (2007) Kangaroo Mother Care Guidelines (draft)
MoHSW, Prime Ministers Office Regional Administration and Local Government (2007). ComprehensiveCouncil Health Planning Guidelines.
MoPE (2006). Tanzania Population, Reproductive Health and Development. Population and Planning SectionTanzania Partnership for Maternal Newborn and Child Health Work Plan, 2007-2008.
Vice President’s Office ( 2005). National Strategy for Growth and Reduction of Poverty (NSGRP).
The National Road Map Strategic Plan -2008 - 2015 83
ANNEX 4
MOST COST EFFECTIVE INTERVENTIONS BASED ON EVIDENCE TO DATE FORREDUCTION OF PERINATAL AND NEONATAL MORTALITY
Source: Neonatal Survival 2 Darmstadt, G. Bhutta, ZA, Cousens, S, Taghreed, A, Walker, N, de Bernis, L, Evidence-Based, Low-costinterventions: How many newborn babies can we save? www.the lancet.com published on line 3 March 2005 http:// image. The lancet.com/extras/05 art 17 web. The authors use scale rangingfrom 1 to 5, with 5 having the most evidence of effectiveness1
Pre conceptionAmount ofEvidence
Reduction (%) in all cause neonatalmorbidity and mortality/major riskfactor if specified (effect range)
Folic acid supplementation 1V Incident in neural tube defect: 72% (42-87%)
Antenatal
Tetanus toxoid immunization. V 1V
33%-58% Incidence of neonatal tetanus 88-100%
Syphilis screening and treatment 1V Prevalence dependant Pre eclampsia and eclampsia. prevention (calcium supplementation
1V Incidence of prematurity 34%(-1-57%) Incidence of low birth weight31%(-1-53%)
)%35-1-(%23V1.airalamrofTPIDetection and treatment of symptomatic bacteriuria
1V Incidence of prematurity, low birth weight 40 %( 20-55%)
Intrapartum
Antibiotics for pre term rupture of membranes.
1V Incidence if infections 32 %( 13-47%)
Corticosteroids for preterm labour 1V 40 %( 25-52%) Detection and treatment of breech (c-section)
1V 40%(25-52%
Labour surveillance (including partograph)
1V Early neonatal death40%
Clean delivery practices 1V Incidence of neonatal tetanus.55-90%latantsoP
Resuscitation of new born V 6-42% %78-55VgnideeftsaerB
Prevention and management of hypothermia
1V 18-42%
Kangaroo mother care 1V Incidence of infections52 %( 7-75%) Community based pneumonia case management.
V 27% (18-35%).
84 The National Road Map Strategic Plan -2008 - 2015
ANNEX 5Evidence-Based Interventions that Influence Child Health
Various evidence-based child health interventions have been identified. These interventions can contribute toreduction in neonatal and under-five mortality when implemented in high coverage 90%. The packaging ofthese interventions results into great/significant impact.
Community mobilization and engagement and antenatal and postnatal domiciliary. Behaviour change communication to promoteevidence-based neonatal care practices (breastfeeding, thermal care, clean and cord care), care seeking, demand for quality clinicalcare) Promotion of clean delivery and referral of complications (home birth) Kangaroo mother care.
Interventions Preventive % of reduction Neonates Child Pregnantmother
Lactatingmother
XX%31gnideeftsaerB XComplementary feeding 6% X Vitamin A supplementation 2% X X XVaccination-measles 1% XFamily and Community care package 10-20% X X X X
%7NTI X X X Water, sanitation and hygiene 3% X X X X KMC for low birth weight 2% X Resuscitation of newborn 4% X
%5cniZ XX%4yrevilednaelC X
Nevirapine and replacement feeding 2% X Treatment interventions Antibiotics for dysentery 3% xAntibiotic for sepsis 6% X X
XX%51noitardyherlarOAntibiotic for pneumonia 6% X X
%5airalamitnA X X %4cniZ X
Emergence neonatal care: managementOf serious illness (infections Asphyxia, prematurity,jaundice)
X
The National Road Map Strategic Plan -2008 - 2015 85
ANNEX 6
EVIDENCE-BASED INTERVENTIONS FOR MATERNAL, NEWBORN AND CHILD HEALTH
Intervention packageThe following evidence based interventions are expected to be provided at all levels.
1. For Adolescent girls and women in childbearing age (Pre-pregnancy)• Adolescent friendly health services• Family planning• Folic acid.• Iron tablets• Tetanus toxoid• Prevention, care and treatment for HIV/AIDS
2. Post abortion care• Manual vacuum aspiration and if not available sharp curettage• Uterotonic drug (ergometrin or misoprostol)• I.V. antibiotics if infection suspected
3. During Antenatal period: at least 4 antenatal care visits for normal pregnancies, including one visitwithin the first 3 months of pregnancy.
Key ante-natal services include• Confirmation of pregnancy• Monitoring of progress of pregnancy and assessment of maternal fetal well-being• Prevention, care and treatment for HIV/AIDS (PMTCT).• Tetanus toxoid immunization.• Counselling on nutrition, breastfeeding, healthy life style.• Insecticide treated bed nets• Development of birth preparedness plan, emergencies, referral care in case of complication,
breastfeeding and advice on danger signs.• Screen for protein and anaemia including blood group• Iron and folic acid supplementation.• Deworming• Identification and treatment of bacteriuria • Identification and treatment of problems complicating pregnancy: hypertension, bleeding,
malpresentation, multiple pregnancy, etc.• Screening and treatment of syphilis and malaria. (IPT and promotion of ITN).• Assessment for female genital mutilation
4. Services delivered during Labour, delivery, and first 1 to 2 hours• killed attendance at birth• Monitoring progress of labour, maternal and fetal well being with partograph• Providing supportive care and pain relief• Clean and safe delivery • Temperature maintenance of mother and child including Kangaroo Mother Care.• Immediate and exclusive breast-feeding.• Cord and eye care.• Emergency obstetric care for complications including*:
86 The National Road Map Strategic Plan -2008 - 2015
• Treatment of abnormalities and complications (prolonged labour, vacuum extraction, breechpresentation, episiotomy, repair of genital tears, manual removal of placenta)
• Pre-referral management of serious complications (e.g. obstructed labour, fetal distress, preterm labour,severe peri- and postpartum haemorrhage)
• Emergency management of complications if birth is imminent• Treatment of severe complications in childbirth and immediate postpartum period, including caesarean
section, blood transfusion and hysterectomy:• Induction and augmentation of labour• Antibiotics for premature rupture of membranes*• Neonatal resuscitation. *• Management of newborn complications. *• Prevention, care and treatment of HIV/AIDS(PMTCT) • Active management of third stage of labour• Vitamin A supplementation
5. Maternal care: 1 to 2 hours care and after delivery to six weeks.• Prevention and detection of complications (e.g. infections, bleeding and anaemia)• Anaemia prevention and control (iron and folate supplementation)• Information and counselling on nutrition, safe sex and family planning• Advice on danger signs and emergency preparedness• Provision of contraceptive methods• Promote use of ITN• Pre-referral treatment of complications (e.g. severe postpartum bleeding and puerperal sepsis)*• Treatment of complications (anaemia, postpartum bleeding, infections and postpartum depression)*
6. Newborn care: 1 to 2 hours care and after delivery to 2 months.• Promotion, protection and support for exclusive breast-feeding.• Monitoring and assessment of wellbeing and detection of complications• Rooming-in• Eye care• Temperature management (kangaroo mother care)• Cord care and hygiene.• Information and counselling on home care, breastfeeding, hygiene and advice on danger signs and care
seeking.• Promotion of ITN • Recognition of danger signs and prompts care seeking.• Detection and management of local infections, diarrhoea, and feeding problems• Special care for the small baby (low birth weight). *• Treatment of infections*• Pre-referral management of infants with severe problems (Very preterm babies and/or very low birth
weight; severe complications; malformations)*• Presumptive treatment of congenital syphilis*• Prevention, care and treatment of HIV/AIDS (PMTCT). *• Management of complication, serious infections, severe jaundice, very low birth weight babies, preterm
birth, breathing difficulties, severe birth trauma and asphyxia*.• Management of correctable malformations*• Treatment of neonatal tetanus*• Follow up of new born in need of special care*
The National Road Map Strategic Plan -2008 - 2015 87
7. Older infants and children (2 month to 5 years)Preventive
• Assessment of infants wellbeing, detection of complications and responding to maternal concerns• Information and counselling on home care• Additional follow-up visits for high risk babies (pre-term or after complicated delivery or neonatal
period)• Exclusive breast-feeding up to 6 months• Continued breastfeeding (at least up to 2 years)• Nevirapine and replacement feeding (PMTCT)• Safe and appropriate complementary feeding (from 6 months)• Insecticide treated nets• Immunization• Vitamin A supplementation twice a year• De worming twice a year• Water, sanitation, hygiene.• Growth monitoring and follow-up interventions• Salt iodation
Curative• Integrated management of childhood illnesses• Oral rehydration therapy and Zn for diarrhoea*• Antibiotics for dysentery*• Antibiotics for pneumonia*• Treatment of malaria with recommended combination therapy*• Vitamin A for measles*• Detection and management of severe and moderate malnutrition*• Care and treatment of HIV/AIDS*• Pre-referral management of severe conditions*• Quality management of seriously sick children*
Note: All interventions should be available for all pregnant women, newborns and children except thosemarked* which need to be provided only for illness or complications.
*Indicates care if condition arises adapted from: Newborn Health; Policy and Planning Framework, Part 1, 2004/5 WHO and
Save the Children.
88 The National Road Map Strategic Plan -2008 - 2015
PROCEDURE SCORE % DEFICIT EXPECTED 2015 Antenatal care four visit 68% 32% 90% Blood Pressure taken 65% 35% All must have BP checked Blood taken for Haemoglobin and Syphilis screening
50% 50% More than 70% must be screened
Urine Analysis 41% 59% All must have urine checked if equipment available
Information of danger signs in pregnancy childbirth
47% 53% At risk mothers should be identified
Delivery at health facilities 47% 53% Health facility deliveries 80%
Skilled birth attendant deliveries
46% 54% Skilled birth attendant 80%
Delivery by Caesarean Section
3% 12% 15% should be delivered by C/S
Emergency Obstetric Care in hospitals
64.5% 35.5% All first referral centres must provide EmOC
Emergency Obstetric Care Health Centres
5.5% To achieve MDG 5 all Health Centres must provide EmOC
Breastfeeding at any given time
95% 5% All women should breast feed
Exclusive breastfeeding rate 0 – 6ms
41% 58% EBF rate 0-6 mo 80%
Vitamin A supplementation within 2 months after delivery
20% 80% All post delivery mothers should receive Vitamin A
Iron tablets for at least 90 days to pregnant mothers
10% 90% All women for ANC must be given Iron/Folic acid
Tetanus Toxoid Current usage of contraceptives
26% married, 41% unmarried
Family planning to address unmet needs
Community Based Programmes RCH
46 districts out of 124
78 districts have no CBD Programme
All districts should target to have CBD
ANNEX 7
WHERE DOES TANZANIA STAND IN TERMS OF MNCHSERVICE DELIVERY?
The National Road Map Strategic Plan -2008 - 2015 89
Basic Essential Newborn Care with Resuscitation equipment like AMBU BAGS and Oxygen
None in DSM for secondary and primary health facilities
Municipalities hospitals in DAR and health centres must establish Basic Essential Newborn Care to decongest MNH neonate ward
All labour wards in the country must have a small unit for care of neonates
PMTCT Plus 700 sites so far established by Sept. 2007
Ideally all hospitals and health centres country wide should have PMTCT established and coordinated through RCH services
Paediatric HIV care and treatment
Integrated case management of Childhood Illnesses
60% of sick children seen by IMCI trained HW
100% of sick children seen by IMCI trained HW
80% of health facilities have 60 % of health workers trained in IMCI
Community IMCI 41 out of 114 LGA’s implementing
73 LGA’s All districts should have c-IMCI CORP’s in at least 75% of villages
ORS use rate 54% 46% 90% ORS use rates Zinc supplements for diarrhoea
0% 100% 80%
Anti- Malarial treatment within 24hrs of fever onset
57% 43% 80% prompt treatment
ITN coverage for under-fives
21% 79% 80%
Immunization coverage for all antigens
71% 29% Over 85%
Facility management of severe malnutrition
6 hospitals All hospitals
Community Management of Severe Malnutrition
0 LGA’s 114 LGA’s Established in all LGA’s
Baby friendly health facilities
28% 72% All hospitals baby friendly
90 The National Road Map Strategic Plan -2008 - 2015
ANNEX 8
ESSENTIAL MATERNAL NEWBORN AND CHILD HEALTHMEDICINES, EQUIPMENT AND SUPPLIES
A. Neonate and Child medicines1. Chloramphenicol inj 1g2. Benzathine Penicillin inj 5 MU3. Gentamicin inj 40mg4. Procaine Penicillin Fortified inj; 4 MU/vial5. Cotrimoxzole syrup 200/40 mg /5 ml susp6. Cotrimoxzole tab 400/80mg7. Cotrimoxzole paediatric tab 100/20mg8 Amoxycillin 250mg tab9 Amoxycillin syrup 250mg/5ml or 125mg/5ml10 Salbutamol metred dose inhaler 100µg/puff
(0.1mg/enhale)11. Salbutamol tab 1mg12. IV infusion Ringers Lactate 250mls13. IV infusion Normal Saline14. Low Osmolarity Oral Rehydration Solution sachets15. Zinc dispersable tablets 20mg16. Quinine injection 300mg/ml; 2ml17. Quinine tab 300mg18. Quinine syrup 150/300mg 19. 25% Dextrose IV infusion20. Artemether Lumefantrine (Alu) (paediatric21. Paracetamol tab 500mg22. Paracetamol syrup 120mg23. Vitamin A 200,000 IU oil capsule with nipple24. Vitamin A 100,000 IU oil capsule with nipple25. Vitamin A 50,000 IU oil capsule with nipple26. Oxytetracycline eye ointment 0.1% 5g tube27. Ciprofloxacin ear drops28. Ferrous Sulphate 100mg/ml29. Ferrous fumarate 20mg/ml30. Fe/folic acid tab 200mg/0.25 mg31. Nystatin oral susp 100,000IU/ml32. Gentian Violet paint 0.5%33. Mebendazole tab 500mg34. Formula 100 (F100)35. Formula 75 (F-75)36. Combined Mineral Vitamin Mix37. Metronidazole 250mg38. Daizepam inj 5mg/ml; 2ml vial39. Phenobarbitone inj 200mg/ml;40. Vitamin K1 inj41. Savlon solution42. Povidone Iodine solution10%43. Water for inj44. Metered infusion giving sets45. Cannula size 25G46. Cannula size 24G47. Scalp vien 23 G48. Blood infusion giving sets
B. Child Essential equipment and supplies1. Oxygen concentrator2. Haemoglobimometers3. Glucometers4. Glucostics5. Suction Machines6. Suction catheters 6FG, 8FG7. Paediatric resuscitation kit8. Nebulisers9. Paediatric infusion pump10. Warming devices11. Thermometers- normal reading12. Thermometers-low reading13. NGT, 5-814. Feeding cups15. Nasal prongs16. Weighing scale17. Syringes, disposable- 2mls/5mls18. Feeding syringes 20mls19. Feeding syringes 50mls20. Cotton wool absorbent non sterile 500gm21. Plaster adhesive, plastic perforated 25mm x 10m22. RCH 1 card23. Methylated spirit24. Inpatient record book25. Inpatient monitoring form
C. Neonatal Essential Equipments and supplies:1. Towels2. Cord ties or clamp, sterile blade3. Container of eye ointment/drops4. Clock with second hand5. Clinical thermometers (preferably low reading6. Secca weighing scales7. Newborn size Masks, size 0 and 18. Self inflating bag9. Suction machine10. Suction tubes11. Surgical blades12. Surgical gloves and clean gloves13. Canulas14. Bucket of water15. Small graduated feeding cups16. Container for expressed breast milk17. Kettle or jug18. Gallipot19. Heater radiant/movable20. Resuscitation tables21. Phototherapy machines22. Pulse Oxemetry23. Stands24. Exchange blood transfusion set
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25. Linen Baby Package, blankets, sheets and pillowsfor mothers
26. Scissors27. Waste disposal containers
D. Maternal medicines1. Ergometrine 0.5mg inj2. Oxytocin 5 IU/ml , 10 IU/ml;3. Frusemide 10mg / ml4. Magnesium Sulphate inj 50% (500mg / ml)5. Fe/ Folic acid 200mg /0.250mg tab6. Folic acid 5mg tab7. Ferrous Sulphate 100mg/ml8. Ferrous fumarate 20mg/ml9. Lidocaine inj 1% 10ml vial10. Mebendazole 100mg tab11. Aminophyline 100mg tab12. Aminophyline 25mg/ml 10ml inj13. Amoxycillin 250mg tab14. Methlydopa (Aldoment) 250mg15. Chloramphenicol inj 1g16. Co-trimoxazole 400/80mg tabs17. Cloxacillin 250mg tab 18. Clotrimazole vaginal pessary19. Ceftriaxone 500mg tab20. Erythromycin 500mg tab21. Ciprofloxacin 500mg tab22. Tetracycline or doxycycline500mg tab23. Diazepam 5mg/ml 2ml inj24. Doxycycline 100mg tabs25. Epinephrine (Adrenaline) 1mg/ml inj; 1ml26. Metronidazole 250mg tab27. Procaine penicillin Fort. 4MU/vial28. Sulfadoxine 500mg/Pyrimethamine 25 mg (SP) tabs29. Nevirapine (adult, infant) 30. Zidovudine (AZT) (adult, infant) 31. Lamivudine (3TC) 32. FP contraceptive - pills (COC,POC), injectables,
IUCD, condoms ( FP & HIV prevention)33. Vaccine - Tetanus toxoid , BCG, OPV, DTP, Measles 34. Dextrose 5% (IV infusion)35. Normal Saline 0.9% (IV infusion)36. Ringers lactate IV infusion37. Glucose 50% solution38. Water for injection
E. Maternal essential equipment and supply1. Infusion giving sets (I.V giving set)2. Blood infusion giving sets3. Cannula size 14 – 18 G4. Catgut chromic 2.0, 3.0 5. Cotton wool absorbent non sterile 500g6. Gauze absorbent BPC 90 cm x 100m hosp quality7. Surgical latex rubber sterile gloves 7.58. Syringe disposable 5ml + needle9. Syringe disposable 2ml + needle10. Catheters 30cc two ways11. Umbilical cord tie, cotton, (Ligature) 3mm; 100m12. Sheeting rubber Mackintosh 1 meter13. Cotton sheet / green 1 meter14. Savlon solution15. Povidone Iodine solution 10%16. Bleach (chlorine base compound) 17. Soap bar 113g18. Impregnated bed net 19. Register Books for – ANC, FP, Delivery, Neonatal,
Child, Postnatal 20. Client cards - Ante-natal cards -RCH 4, FP card -
RCH 5
F. Maternal equipment1. Blood pressure machine and stethoscope 2. Foetal stethoscope 3. Delivery kit 4. Laparatomy set5. IUCD insertion kit6. Manual Aspiration kit 7. Vacuum extractor, Bird, manual/SET,8. D&C curettage /SET:9. Dressing Tray, sets, 300 x 200 x 30 mm
G. Maternal tests reagents1. RPR testing kit; 2. Test strips for urinalysis, glucose ,protein ,; 3. HIV testing kit (2 types), 4. Hemoglobin testing kit 5. Container for catching urine,
92 The National Road Map Strategic Plan -2008 - 2015
GLOSSARY
Basic emergency obstetric care: Functions that can be provided by an experienced nurse/midwife or physician, saving the lives of many women, and stabilizing women who need to go further for more sophisticated treatment
Caesarean section rate Number of caesarean section performed per total number of births
Comprehensive emergency obstetric care
Includes basic EMOC functions as well as blood transfusion and caesarean sections Comprehensive Post Abortion Care
Contraceptive Prevalence rate The percentage of women using method of family planning
Exclusive breast feeding An infant receives only breast milk and no other liquids or solids, NOT even water, with the exception of drops or syrups consisting vitamins, mineral supplements of medicines.
Infant mortality rate The probability of dying before the first birthday expressed per 1000 live births
Maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy
Maternal mortality ratio The number of pregnancy rated deaths per 100,000 live births
Neonatal death Probability of dying within the first 28 days birth.
Neonatal mortality rate Probability of dying within the first month of life expressed per 1000 live birth
Perinatal deaths Death of a foetus from 28 weeks of gestation to seven completed days of life including still births
Reproductive health Reproductive health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity, in all matters relating to reproductive system and its functions and process. This implies the rights to have satisfying and safe sex life, the capability to reproduce and the freedom to decide if, when and how often to do so.
Skilled care Refers to the care provided to the woman and her newborn during pregnancy, childbirth and immediately after, by an accredited and competent provider who has at her/his disposal necessary equipment and the support of a functioning health system including transport and referral facilities for emergency obstetric and newborn care.
Skilled attendants Is an accredited health professional such as the midwife, doctor or a 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 complication in women and newborns.
Under-five mortality rate The probability of dying between birth and fifth birthday
ANNEX 9
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REFERENCES
Ajibola S. (2004). African Health Monitor: Reducing Maternal and Newborn Mortality in Africa; WHORegional Office for Africa, Brazzaville; AFRICAN HEALTH MONITOR.
Bale J.R. Stall B.J. Lucas A.O. (eds.) (2003). Improving Birth Outcomes: Meeting the Challenges in DevelopingWorld, A Committee on Improving Birth Outcome Board on Global Health; Washington D.C. THE NATIONALACADEMIC PRESS.
Hinderraker et al., BJOG, 2003
Liljestrand, J. and Gryboski, K. Maternal mortality as a Human Rights Issue. In Murphy, E. And Ringheim,K, eds. Reproductive Health and Rights: reaching the Hardly Reached. Washington, DC: PATH (2001).
Mswia R., Lewanga M et al, (2003). Community Based Monitoring of Safe Motherhood in United Republic ofTanzania, WHO Bulletin 81:87-94.
National Bureau of Statistics, Dar-es-Salaam, ORC Macro, Calverton, Maryland, USA: Tanzania Demographicand Health Survey, 1996.
National Bureau of Statistics, Dar-es-Salaam, ORC Macro, Calverton, Maryland, USA: Tanzania ServiceProvision Assessment Survey 2006 (TSPA).
National Bureau of Statistics, Dar-es-Salaam, ORC Macro, Calverton, Maryland, USA: Tanzania Demographicand Health Survey, 2004-2005.
Regional Reproductive Health Newsletter (2004). Road Map: African Union resolves to tackle MaternalMortality: DIVISION OF FAMILY AND REPRODUTIVE HEALTH (DRH) – WHO/AFRO.
UNICEF. State of the World Children Report 2008.
The Lancet Child Survival Series, Vol 362, 2003
The Lancet Neonatal Series, Vol 365, 2005.
The Lancet Maternal Series, Vol 368, 2006
The Partnership for Maternal Newborn and Child Health (2006). Opportunities for Africa’s Newborns.
Urassa E, Carlstedt A, Nystrom L, Massawe S, Lindmark G. 2002 Quality assessment of the antenatalprogram for anaemia in rural Tanzania. International Journal for quality in Health Care 14: 441-448.
World Bank (1993). Human Development Report.
WHO, UNICEF, UNFPA, WB (2005). Maternal Mortality Estimates.
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