National Scaling Up of Helping Babies Breathe Initiatives in Bangladesh Dr. Sayed Rubayet Project Manager, HBB and SNL Save the Children in Bangladesh Presentation Outline • • • • • • • Background National scale up strategy Evaluation design Results to date Quality improvement process Plans for sustainability Lessons learned Background: Facts of Neonatal Health in Bangladesh • • • • • Delivery at health facility -29% Delivery attended by a skilled provider -32% Neonatal death per year is 83,000 * Neonatal mortality rate: 32/1000 live births Neonatal deaths - 60% of all <5 deaths Source: * Bangladesh-specific mortality estimates (Liu et al. 2012, BDHS 2011 Causes of Newborn Mortality in Bangladesh Data source: Bangladesh-specific mortality estimates (Liu et al. 2012). Background of National Scale-up of HBB in Bangladesh 2010 - HBB Pilot Study conducted in Bangladesh Dissemination seminar on HBB Pilot Study was held on September 2010 The Honorable Minister, MOH&FW was encouraged seeing the findings of the study and • • Instructed to take initiatives to scale-up the HBB interventions nationwide and Requested development partners for necessary support. Series of national stakeholders’ consultation workshops held on to develop HBB Scale-up strategy and plan after dissemination National HBB scale-up plan developed, approved by MOH and forwarded to USAID and UNICEF for support in April 2011 National Scale-up Plan Capacity Building • • Training on NB resuscitation including primary management of birth asphyxia and basic ENC to all SBAs (from highest level service provider to community level) of Bangladesh (public sector) Equip all the facilities of public health sector and cSBAs with resuscitator (neonatal bag & mask with sucker) Quality Assurance • • Supervision and monitoring of training MIS system strengthening and evaluation of the HBB scale-up activities Sustainability • • • • Incorporate in National Health Sector Program Incorporate HBB protocol in all relevant in-service and pre-service curriculum Capacity building of the facilities for training & refreshers training Routine refreshers training for retention of skills and utilization of the NB resuscitation capacity Background of National Scale-up of HBB in Bangladesh Institutional Arrangement Funding Arrangement MOH&FW (Cash and kind) UNICEF Laerdal Foundation Children Adaptation of training materials Organize training in all level Monitoring and supervision UNICEF through Save the Nationwide Implementation, supervision, monitoring and Evaluation Ensure Logistics BSMMU Children Overall implementation TAX/VAT of offshore procurement MCHIP/Save the Children USAID through MCHIP/Save the MOH&FW (DGFP, DGHS) Equipment for district implementing maternal and NB projects, Supervision and monitoring ICDDRB Evaluation of HBB scale-up activities HBB Scale-up Partners in Bangladesh Summary of HBB Training Plan Period Jun 11Sep 11 Oct 11Sep 12 Oct 12Sep 13 District/ City Corp’n Training on HBB Curriculum Training of Trainers Batch Trainers Batch Doctors Nurse/ Paramedics 13 11 210 168 507 1583 1028 2908 33 30 598 513 1546 4929 3096 8863 24 19 370 319 1126 2934 1764 5454 70 60 1178 1000 3179 9446 5888 17225 CSBA Total Total Step-wise HBB scale-up plan Total 11 steps Each Step TOT- Doctors from Medical College Hosp (if any), District Hospital, District Health and FP Office and Upazila Health Complexes 7-8 batches 6 districts •2 days TOT in BSMMU • Trainer return and provide training to district and upazila SBAs Training starts immediately after TOT • • • • • Medical College Hosp – 30 doctors and 40 nurses District Hospital- 6-8 doctors and 10+ nurses MCWC- all doctors and FWV UHC- 5-7 Medical Officer and all Nurses All FWVs and CSBAs Plan of System Evaluation of Scaling-up of HBB Intervention in Facility and Community Settings in Bangladesh Research Questions What proportion of deliveries are attended by a skilled provider in health facilities as well as in the community? In what proportion of deliveries attended by the skilled providers: – Were they equipped with bag-mask, suction device, etc? – They applied the resuscitation techniques appropriately? What proportion of HBB-trained birth attendants retain key skill elements of newborn resuscitation after-training? 12 Measurements Observation of deliveries to assess delivery, newborn care practices and asphyxia management; availability of equipments Review of facility delivery records to obtain total number of deliveries Post-HBB training assessment of skills during monthly retraining/practice sessions Interview of recently delivered women at an end-of-project household survey to assess coverage of skilled birth attendants in deliveries in the community Key assumptions, sample size and operation plan of HBB evaluation Facility component Community component Intervention Comparison Intervention Comparison % of deliveries attended by SBAs 100% 100% 50% 10% % of newborn received optimum quality of resuscitation 80% 50% 80% 10% Number of newborn requiring resuscitation 43 43 32 16 Actual number of deliveries to observe 953 (Baseline and in each quarter) 953 (Baseline and in each quarter) 709 (Post HBB training target) 355 (Post HBB training target) Facility Community Baseline 1st quarter 2nd quarter 3rd quarter 3 months 3 months 3 months 3 months Baseline Follow-up data collection 3 months 9 months HH Survey 2 months Results to date Status of HBB Implementation - Training Type Target Trained Percentage completed Trainers 1178 763 65% Doctors 3179 1300 41% Nurse/ Paramedics 9446 4731 50% CSBA 5888 2599 44% Total 19691 9393 48% 70 33 47% District Step 1 districts completed Step 2 districts completed Step 3 districts completed Step 4 districts completed Step 5 districts will be completed 20 July Training and equipping • Use for training and refreshers • Kept in all facilities from UHC and above for refreshers training Mannequin (NeoNatalie-Laerdal) • Provided to use for training and refreshers • Provided to all facilities & CSBAs for newborn resuscitation • Arrangement be taken to made them readily available in all facilities. Resuscitator & Suction device 16 Training and equipping Action plan – for training and hanged in delivery sites of the facilities Flipchart- for training and kept in facilities for refreshers training Learner Workbookprovided to all trainee Status of HBB Implementation – Equipment Distribution Type of Facilities Neonatalie Complite No. Facility Bag & Musk with Sucker Medical Colleges Hospital 10 24 39 District Hospital 29 32 67 Maternal and Child Welfare Center 30 30 64 Upazila Health Complexes 193 357 337 1386 - 1386 46 - 113 - - 2599 1694 443 4595 Union Health and Family Welfare Center NGOs Facilities Community SBA Total Incorporation of HBB Protocol in Different Curriculum • HBB Scale-up plan have the component to incorporate the HBB protocol in different pre-service and in-service curriculum. • Following curriculum already decided to incorporate the protocol. 1. 2. 3. 4. 5. MBBS Curriculum Diploma and Degree course of Nursing Midwifery Training Curriculum FWV training Curriculum Private Paramedics Training Curriculum • Initiatives also taken to incorporate in CSBA curriculum • Standard Operation Procedure (SOP) for Newborn Health Care in Primary and Secondary level facilities Quality Improvement National Level (DGHS, DGFP BSMMU and SC ) Divisional Level Health and FP officials Joint monitoring visit and follow-up of divisional officials visit Usually 1 district/division in each phase, so feasible for divisional level to organize monitoring visit District Health and FP officials will visit each batch as resource person UHFPO/UFPO/RMO coordinate the training of their upazila/facilities MNCH, MNH, MNCS and MaMoni and other similar program will provide support for supervision and supervise in the project area Standard checklist will be used for supervision and monitoring Quality Improvement (Cont.) Supervision and monitoring of training 90% session are expected to be supervised/monitored by District level DGHS and DGFP officials 50% 83% sessions observed by district level Health/FP managers sessions will be monitored /supervised by BSMMU officials Monitoring visits with checklist (179 out of 416 sessions) training- 43% of sessions) QA through direct observation of master trainers (59 out of 416 - 14% of sessions) 15% sessions are expected to be supervised by national and divisional level DGHS/DGFP official HBB Training Quality Assurance Checklist HBB Training Supervision and Monitoring Checklists Quality Improvement- Refreshers training Refreshers training introduced through routine system SBA describe the experience of resuscitation to others in the monthly meeting if any newborn was resuscitated 1/3rd of SBAs practice with the manikins and bag & mask under observation of their trained supervisor as a routine practice The supervisors take brief test and record it in a card given during training All SBA have to practice and record his/her performance in the record card by every 3rd month Steps A. Prepares for birth B. Dries thoroughly C. Clears airway and stimulates breathing if baby is not crying* Identifies a helper Prepares the area for delivery Cleans hands Prepares an area for ventilation Checks equipments Dries the baby thoroughly Removes wet cloth Keeps warm Positions head and clears airway Stimulates breathing by rubbing the back Cuts cord and moves to area for ventilation Apply the mask to make a firm seal D. Ventilates with bag and mask if baby is not breathing Starts ventilation within Golden Minute (started at _________ seconds) Ventilates at 40 breaths/min (30-50 acceptable) (_________breaths per minute)* Looks for chest movement * Head: reapply mask and reposition head E. Improve ventilation if chest does Mouth: clear secretions and open the not move* mouth Bag: squeezes the bag harder Complet e Plans for sustainability HBB program incorporated in the Health Population Nutrition Sector Development the Program (HPNSDP) 2011-2016 and its Operation Plans (OP) of the MNC&AH (DGHS) and MCR&AH (DGFP) Curriculums and Newborn SOP incorporated the protocol Refreshers training introduced through routine system Developing a video for refreshers training and distribution to all the facilities are under way Regular review meeting in directorates are going way. MIS incorporation under process, A Technical Sub-Committee on Finalization of Newborn Indicator have been formed and are working DGFP is now piloting HBB related indicators Surveillance activities are planned Lessons learned Rapid scaling-up of an public health intervention became possible due to the Political Commitment Systemic Linear Approach Technical Capacity Partnership and Fund Availability Still the Challenges of HBB Scale-up are Retention of skill Monitoring of implementation and outcome and linking with routine system Cleaning of the Equipment Sabina Yasmin with her baby who was resuscitated with bag & mask on 23rd November at Mohammadpur UHC. Dr Subol Chandra Borman , RMO resuscitating a newborn baby at Jointapur UHC on 7th December.