Decreasing Maternal Mortality and Morbidity through Safe Delivery and the NSDP Home-Based Delivery Initiative

Transcription

1 Decreasing Maternal Mortality and Morbidity through Safe Delivery and the NSDP Home-Based Delivery Initiative The NGO Service Delivery Program in Bangladesh

2 Acknowledgements I want to thank Ms. Sara Lewis Espada, Senior Program Manager, IntraHealth International, for documenting our maternal health activities and supporting NSDP s design and implementation of Home Delivery services. I also thank Dr. Jahangir Hossain, CARE Bangladesh, for bringing CARE s experience in community participation to NSDP and enhancing our home delivery services. I thank Dr. Umme Salma Jahan Meena, Director, Clinical Services Team, for her tireless efforts, and Dr. Fahmida Banu, Reproductive Health Coordinator. Many staff at NSDP and at participating NGOs assisted in piloting and expanding home delivery by trained paramedics at Smiling Sun clinics. I thank them too. Last, I thank NSDP s former CTO at USAID, Mr. Moslehuddin Ahmed, current CTO, Mr. Belayet Hossain, and Ms. Sheri-Nouane Johnson, OPHN Director, who have provided sound advice and support. Any deficiencies in the scheme are the product of NSDP s efforts. Ms. Jennifer Wilder, Senior Technical Communications Advisor of Pathfinder International, edited the report. Dr. Robert Timmons Chief of Party

3 Decreasing Maternal Mortality and Morbidity through Safe Delivery and the NSDP Home- Based Delivery Initiative The NGO Service Delivery Program in Bangladesh Technical Report Cooperative Agreement No. 388-A April 2007 NGO Service Delivery Program House No. NE(N) 5, Road No. 88 Gulshan - 2, Dhaka Bangladesh The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

4 Acronyms and Abbreviations BDHS C-EmOC CSG DH GOB NSDP SBA TBA Bangladesh Demographic and Health Survey Comprehensive Emergency Obstetric Care Community Support Group Depot Holder Government of Bangladesh NGO Service Delivery Program Skilled Birth Attendant Traditional Birth Attendant 2

5 Table of Contents Page Executive Summary Introduction Maternal Health in Bangladesh NSDP in Bangladesh Home Delivery Pilot Initiative The Training Model Payment Assessment and Reimbursement Scheme Year One Results Use of Services Lessons Learned Recommendations and Conclusions Tables and Charts Chart 1. Antenatal care sources (previous 3 years): Market share by socioeconomic group, rural project areas Chart 2. Causes of maternal deaths in Bangladesh Chart 3. Home delivery performance and referral in 10 pilot sites (July 2005 Dec. 2006) Table 1. Knowledge levels of trained paramedics Table 2. Skill levels of trained paramedics Appendix A: Learning for Performance

6 Executive Summary The realities of maternal health conditions in Bangladesh continue to challenge providers and health care planners. The Government of Bangladesh has committed to meet 2015 Millennium Development Goals of reducing the maternal mortality ratio by 75 percent between 1990 and 2015 by increasing the number of births attended by medically-trained providers by more than 35 percent. Photo: NSDP staff Yet, in 2007, only 13 percent of births are attended by medically-trained providers, and the mortality figures remain high. In 2005, the USAID-funded NGO Service Delivery Program (NSDP) launched a new pilot effort to expand the availability of medically-trained paramedics, who would be prepared to provide skilled services to women delivering in their homes, especially those women who are poor and live in remote areas. Based on a careful assessment of needs, as well as resources (human and material) available, NSDP trained a pilot group of 24 paramedics in 10 of their Smiling Sun clinics operated by partner NGOs around the country. The training provided to the paramedics drew on their existing knowledge and skills, and focused on preparing them to address some of the most persistent causes of maternal morbidity and mortality. Three areas of training were most prominent: Antenatal care, and use of the partograph for early identification of potential complications; Active management of Third Stage of Labor (AMTSL); and Essential newborn care, including resuscitation. To promote commitment and enthusiasm for the project on the part of paramedics, as well as to ensure its sustainability, a payment reimbursement scheme was developed with the support and participation of the paramedics. Fees are charged to the delivering family, part of which go to the paramedic, and the rest of which go to the affiliated clinic. Between July 2005 and December 2006, the 24 paramedics have delivered 817 babies and have made 168 referrals of cases in need of facility care. Indications for referral included retained placenta, obstructed labor, prolonged labor, and malpresentation. Though still a pilot project, the statistical record for safe deliveries is promising. The three components of AMTSL were practiced successfully at all of the deliveries attended by NSDP-trained paramedics. Community acceptance of the paramedics and appreciation of the value they add to the safety of mother and child are promising, though the concepts of training and safety are foreign to many in remote areas and must be learned through example and experience, rather than just persuasion. Community and religious leaders, women s groups, teachers, and others with community trust have been trained and persuaded to reinforce the value of the paramedics. Resistance from traditional birth attendants, their existing familiarity and trust in the 4

7 community, pose a barrier that will take time to overcome. Traditionally, medical care at government facilities and other services and commodities, such as contraceptives, have been free, which leaves people resistant to paying a fee. The fact that the paramedics are usually not from their immediate neighborhoods and not familiar faces, makes many women uncomfortable, as they live their lives in relative isolation and seldom interact with strangers, much less have that person attend to something as personal as the birth of a baby. The major and undeniable success of this first phase of the Home Delivery Pilot Initiative is that the paramedics have shown that their basic skills though not on a par with international skilled birth attendant criteria allow them to make major inroads against the unrelenting mortality and morbidity that is endemic throughout so much of Bangladesh. The trained paramedics represent a realistic, available, first line of defense one that is available and affordable now in the broader battle that Bangladesh has to fight to bring quality health care to its poor and isolated communities around the country. Introduction Maternal Health in Bangladesh Bangladesh has an adjusted maternal mortality ratio of 322 deaths per 100,000 live births (about 12,000 deaths per year) and a neonatal mortality rate of 41 deaths per 1,000 live births, according to the 2004 Bangladesh Demographic and Health Survey (BDHS). While these statistics have improved markedly in recent years, only 10 percent of deliveries take place in facilities, and only 13 percent of births nationwide are attended by a medically-trained skilled birth attendant (BDHS 2004). The target of the United Nations Millennium Development Goal 5 is to reduce the maternal mortality ratio by 75 percent between 1990 and To meet this goal, the Government of Bangladesh (GOB) is committed to increasing the percentage of deliveries attended by a medically-trained birth attendant from 13 percent to 50 percent by Traditional cultural patterns in Bangladesh limit acceptance of any kind of unknown outsider as a birth attendant. Many women return to their parental home to give birth, where they are attended by a family member, friend, or a known Traditional Birth Attendant (TBA). Understanding and respect for the value of medical training in a birth attendant is limited, and this knowledge gap remains a major challenge to meeting the GOB and Millennium Development Goals. NSDP in Bangladesh The USAID-funded NGO Service Delivery Program (NSDP) promotes and supports more than 30 Bangladeshi NGOs, which manage a network of 318 static Smiling Sun clinics, 8,200 satellite clinics, and 6,000 community health workers (Depot Holders (DHs)) in urban and rural areas. This network serves a catchment area of roughly 20 million people (14 percent of the population of Bangladesh). In addition, at each clinic, NSDP has trained an average of three service promoters, who market the clinic s services to their communities, and two or three medically-trained paramedics, who provide assistance with facility-based care. 5

8 Given the realities of Bangladeshi tradition and culture, NSDP has spent decades developing a robust and widespread system of healthcare delivery that focuses on local ownership and service at the community level. The extended network of DHs is well-positioned to bring isolated and poor women and families into satellite and static Smiling Sun clinics. Because they live within the communities, they provide contraception methods and expand basic knowledge about safe delivery, child health and nutrition, and how to follow up on referrals. This kind of reach is essential to bring the poorest families into the healthcare system. In addition, the service providers affiliated with each clinic mobilize women to attend public meetings at satellite clinics, where they can learn about antenatal care and safe delivery, and understand how to take care of newborns and young children. Facility-Based Care Seeking to provide the highest quality maternal and child health services, NSDP initially focused on developing skills and services at the facility level. In addition to safe delivery services, the Smiling Sun clinic staff provide quality antenatal, postnatal, and postabortion services. According to a 2005 Measure Survey, the NSDP clinics were found to be providing the majority of antenatal services to those who receive them in the poorest rural project areas. (See Chart 1.) % of women with live birth in last 3 years Chart 1. Antenatal Care Sources (previous 3 years): Market share by socioeconomic group, rural project areas 100% 80% 60% 40% 20% 0% Poorest Richest Socioeconomic Group NSDP Satellite NSDP Static GOB Private Other Newborn and postnatal care are taught to paramedics through ongoing refresher training, and the clinic staff are schooled in various behavior change communication approaches to marketing and community mobilization, so they can deliver postnatal care messages. They are well-versed in the physical examination and assessment of mother and child, identification of complications and making referrals, counseling the mother on newborn care and nutrition, and counseling on postpartum contraception. In addition, because 19 percent of maternal deaths in Bangladesh are due to complications from abortion, paramedics have been trained in counseling and preparation and assistance for manual vacuum aspiration procedures for use in postabortion care. The majority of Smiling Sun clinics around the country provide family planning, ante- and postnatal care, TT and child immunization, treatment for acute respiratory tract infection, diarrheal diseases, and reproductive tract and sexually transmitted infections, Vitamin A supplementation, infectious disease case management and limited curative care services, integrated management of childhood illnesses, and HIV/AIDS counseling. They do not provide safe delivery services or any surgery. 6

9 Since 2001, NSDP has developed two types of facilities focused on safe delivery within the Smiling Sun network, namely Safe Delivery and Comprehensive Emergency Obstetric Care Chart 2. Causes of maternal deaths in Bangladesh (C-EmOC) centers. Until 2006, there were 16 Safe Delivery Centers and 6 C- EmOC centers. There are now 28 Safe Delivery Centers and 21 C-EmOC Centers. Safe Delivery Centers perform only normal vaginal deliveries, identifying and referring complicated cases where necessary. The C-EmOC centers manage complicated cases by using a pool of specialists (obstetrical surgeons and anesthetists) so they can perform C- sections and other surgical procedures. As of June 2006, 16 Safe Delivery Centers were performing a total of 315 deliveries monthly. (Final figures are not yet available as of June 2006.) Only 10 percent of all delivering mothers seek facility care, and most of these involve complications. Hence, referrals outnumber those that can be performed vaginally. (Source: Bangladesh Maternal Health and Maternal Mortality Survey 2001) Fully 68 percent of even the wealthiest quintile of women deliver at home, and only 40 percent of them are attended by someone who is medically trained. Within the poorest quintile, 98 percent deliver at home, and 96 percent are attended by someone who is not medically trained. One percent deliver alone (BDHS, 2005). (See Chart 2.) These figures so far outweigh facility availability particularly in rural areas that NSDP decided to simultaneously focus on a wider network of home-based delivery services. It is essential to provide basic services where they are needed in order to save lives today. The Home Delivery Pilot Initiative The Training Model In early 2005, a Home Delivery Pilot Initiative was launched, designed to build on the basic knowledge and skills of paramedics currently working in facilities and to make them available to provide safe deliveries in the home. Each Smiling Sun clinic employs three to four paramedics as clinical assistants, who have already received 18 months to 4 years of basic medical training. One of these from each clinic was trained in home delivery. Considering the time and monetary requirements for such an undertaking, NSDP conducted an assessment of current paramedic skills and knowledge on which expanded training could be built. During an assessment it was revealed that they had fair knowledge on management of three stages of labor, controlled cord traction, and uterine massage, but limited knowledge on eclampsia management by using magnesium salt. The training was designed to address the primary cause of maternal death in Bangladesh, namely hemorrhage, identifying obstructed/prolonged labor by using partograph, and essential skills to resuscitate newborn. 7

10 A six-day abbreviated version of the GOB s Skilled Birth Attendant (SBA) curriculum was designed, focusing on addressing the primary cause of maternal death in Bangladesh (hemorrhage) through use of the partograph, as well as newborn resuscitation and care. By advancing these three areas of competency, major reduction in maternal mortality and neonatal deaths could be realized. A set of detailed checklists was developed outlining the specific actions to be performed during delivery, which, while they are not used as job aids, do enable providers to refresh their knowledge. The checklists cover: Antenatal care, Infection prevention, Delivery (three stages), Examination/assessment of newborn, Newborn resuscitation, Postnatal care, Aortic compression, and External bimanual compression. These three trained paramedics report that they use the partograph for all home deliveries to assess the woman s possible need for referral. As the only medically-trained providers in hard-to-reach rural communities, they spend much of their time encouraging TBAs to change some of their harmful practices, to pay attention to hygiene and maternal nutrition, and to encourage breastfeeding, and keeping the newborn warm. These basic lessons can make a major difference in infant and maternal survival rates. Ten NGOs were selected for participation in the Home Delivery Initiative, based on their effective existing referral systems, community initiatives to promote birth preparedness, and capacity to manage the new activities, as well as their willingness to promote their paramedics. Payment Assessment and Reimbursement Scheme As part of the planning for the pilot Home Delivery Initiative, NSDP carried out a needs assessment in ten NSDP catchment areas to determine willingness to pay for home-based deliveries. The results showed that 95 percent of respondents in ten NSDP service areas were willing to pay for a skilled paramedic to attend a home birth. Photo: Jennifer Wilder, Pathfinder International 8

11 Photo: Jennifer Wilder, Pathfinder International Managed by NSDP partner Swanirvar, this clinic in Savar at Modhya Rajason Village introduced home delivery service in June As of January 2007, 54 deliveries had been performed by three trained paramedics. Five paramedics provide clinical assistance at the clinic. They also join the clinic team that rotates through 51 satellite, or outreach, clinics throughout their catchment area that covers a population of 88,271. In a population with an average of 2,700 pregnant women at any one time, the paramedics are stretched thin. The sign in the photo below lists the home delivery services provided and gives the name and mobile numbers of each of the trained paramedics. An innovative, and potentially sustainable, scheme for the charging of fees was developed that preserves the private practice model. Practitioners keep a portion of the fees charged, turning the balance over to the NGO. This system is intended to encourage paramedics to include prenatal care and home delivery services in their practices over the long term. The paramedics had significant input in the decision regarding the earnings sharing. The amount shared varies from one NGO to another, but most give 50 percent to the NGO if the delivery is conducted during the day and 25 percent if it is conducted after hours. This system acknowledges that they already receive a normal salary during working hours. 9 Photo: Jennifer Wilder, Pathfinder International Results of this willingness-to-pay assessment also revealed unresolved concerns. Community respondents showed varied misconceptions of the services that paramedics can provide. They were vague about arrangements for their transportation, as well as reimbursement and security for travel at night. People are willing to pay, but not all can or will pay the same amount. How should the payment structure be organized to ensure paramedic willingness to serve poorer families, and how does the outcome of the delivery affect family willingness to pay the fees? Community expectations need to be realistic to ensure trust and support of the trained paramedics over time.

12 Year One Results Between July 2005 and December 2006, 24 trained NSDP paramedics delivered 817 babies and made 168 referrals in need of facility care. (Final data is not available for the full 50 additional sites operating in 2006.) Indications for referral included retained placenta, obstructed labor, prolonged labor, and malpresentation. There were no recorded referrals for postpartum hemorrhage, but given the limited data available, this may be the result of misdiagnosed postpartum hemorrhages, since this is the leading cause of maternal deaths in Bangladesh. Community access to and knowledge of the trained paramedics has become widespread. Altogether, the DHs, Study results show community interest in paying for skilled care during delivery. However, NSDP experienced some deviation during the implementation period. The reasons for the variation might be because the service charge is higher compared to other services available in a Smiling Sun clinic. Customers must pay the paramedics for their home delivery service, but it is commonly believed that paramedics are paid by the NGOs and should provide the service free of cost. To address these problems, an appropriate and detailed marketing of the services should be conducted at the community level. paramedics, and service promoters, as well as a clinic aide, compromise clinic teams, which are trained to reach out into poor and hard-to-reach communities, educating and encouraging people on preventive reproductive health care and the use of healthcare facilities. Trained paramedics receive obstetric delivery kit boxes, which are resupplied by the NGOs with necessary drugs and supplies. Chart 3: Home delivery performance and referral in 10 pilot sites (July 2005-Dec 2006) (AMTSL was practiced in all deliveries.) Number (performnace and referral) When implementing home delivery, NSDP trained only clinical staff and expected them to start the new intervention. However, the most successful sites were where paramedics oriented KAJUS SOPIRET SSKS FDSR UPGMS PSF JTS Swanirvar Proshanti PSKS Name of NGOs HD performance Referral

13 Photo: Jennifer Wilder, Pathfinder International clinic managers and other clinic staff. In the second year, NSDP organized orientations for project managers and clinic managers on the role of team work. Support from the clinic managers, in particular, was important. Where significant marketing activities for the new intervention were undertaken by service promoters, and where community mobilization involved Community Support Groups (CSGs), the utilization of home delivery was much improved. NGOs that followed NSDP selection criteria meticulously were more successful, especially in selecting paramedics from the communities they serve, who had been providers as a part of their private practice, who had a strong educational background (nurse midwives), and who were committed to this special kind of service. NSDP has established a community support system intended to support pregnant women and their families during an obstetric emergency. DHs are the first to know of a pregnancy in the community. They seek out the pregnant mother, counsel her about pursuing antenatal care at the nearest satellite or Smiling Sun clinic, and teach her about the services of the paramedics. NSDP has furnished each of these paramedics with mobile phones, and the DH checks regularly with the mother to make sure she still has the phone number. She also informs the mother if she has access to one of the 29 ambulances or vans that are available in case of an emergency, and she arranges for a potential blood donor in the community to be available at the time of the birth, in case of need. This paramedic (left) has become an important part of the family, as she came to their home and delivered their baby girl a month ago. We wanted to have the paramedic help with the delivery because we knew that she had more skills and would be able to take care of any emergency, in case something went wrong, said the baby s mother. The service promoters engage women throughout the community in meetings to discuss danger signals and the process of referrals and to promote the work of the paramedics. Local religious and community leaders were brought into CSGs, where they were given workshops on pregnancy and potential complications of delivery. They in turn worked with the families and decision-makers around pregnant women to make them aware of the signs of potential problems. Some CSGs were inspired to raise a community fund to help families in trouble at the time of delivery. DHs are trained to support this educational process, while posters and other materials communicate the fact that these services (like all others at the Smiling Sun clinics) are free to the poorest five to six percent of the population. In one community around the Hajiganj Clinic, local leaders initiated a community fund to purchase a rickshaw van, dedicated to taking women to a referral in an emergency, but otherwise available for other passengers. 11

14 A strong tradition in Bangladesh forbids a new mother and/or her child to leave the home for 42 days after the birth. In light of this cultural dictate, the paramedics go to the home within 72 hours after the birth for a postpartum examination of both mother and child. As currently structured, this service is included within the basic fee paid for the delivery. Paramedic evaluation: In 2006, an evaluation study was conducted by ICDDR/B to assess the skill and knowledge levels of the NSDP-trained paramedics. The study reported that the NSDP paramedics scored 68 percent on overall SBA knowledge. The skill assessment included a skill demonstration and two case studies, and the paramedics scored 65 percent in the overall skill test. Knowledge and skill levels broke down as shown in Tables 1 and 2. Table 1. Knowledge levels of trained paramedics Knowledge Component Level of Knowledge Antenatal Care 91% Labor and Delivery 57% Newborn Care & Resuscitation 70% Management of Complications 72% Postnatal Care & Family Planning 78% Partograph 52% Postpartum Hemorrhage 48% Management Table 2. Skill levels of trained paramedics Skill Component Level of Competency Antenatal Care 84% Postnatal Care 76% Labor & Delivery 83% Newborn Resuscitation 52% Post Partum 56% Hemorrhage Case Study Manual Removal of >10% Placenta A community survey portion of the evaluation revealed that service recipients perceive NSDPtrained paramedic performance and quality favorably. The quality portion of the assessment found that 78 percent of clients judged provider quality of care as good, and 17 percent as excellent. Their behavior was judged as good by 64 percent and excellent by 35 percent of clients, and their services are generally appreciated as saving women from going to the hospital for oxytocin or episiotomies. Use of Services Despite the overall positive evaluation of the newly-trained paramedics, families remain more inclined to call on a provider they already know, whether it is a TBA, SBA, or a trained paramedic. They tend to seek out TBAs for normal deliveries and only seek SBAs or paramedics when complications arise and the woman needs evaluation for referral to an appropriate facility. Lessons Learned Logistics: Paramedic performance hinges on her 24-hour availability, so her service area must be near her home. If she is near her home, she is more likely to continue the service, but most would prefer delivery huts or upgrading of facilities so that deliveries could be performed at their affiliated Smiling Sun clinic. Most paramedics are reluctant to attend births in the 12

15 middle of the night, both for personal reasons and because of safety and transportation issues. TBAs are sought for normal births because they are locally available (and the value added of the trained paramedic is not perceived). TBAs are also valued because they are known members of the local community, while the paramedic may not be a personal acquaintance. Paramedics find it difficult, if not impossible, to attend births during their 48 hour, 6 daysper-week clinic hours. They are reluctant to spend several hours (average 2 hrs, 51 minutes) on a home delivery in the middle of the night when they face a full work day as well. On average, paramedics can answer one home call after hours per week. Only 40 percent of those calls were for births. The rest were for pain or discomfort. As of 2007, NSDP has ensured the availability of a motorized van or rickshaw to all home delivery sites, thus enabling the paramedics to visit the mother and newborn within 72 hours after delivery. Attitudes and Perceptions: Twenty-one percent of husbands did not understand the value of having a paramedic present at delivery. Eight percent of pregnant women were uneasy with a stranger (paramedic they did not know) at their delivery. Elderly family members are resentful towards paramedics, who are often young and viewed as inexperienced in the profession. Community support of a paramedic depends on her reputation. TBAs sometimes view paramedics as competition to their profession. Families sometimes pressure paramedics to use IV saline or pitocin and/or perform an episiotomy to speed the delivery. Infrastructure Effective referrals between the home delivery program and EmOC facilities require paramedics to accompany the woman and follow up after delivery. NGO management commitment to the program is essential, since paramedics spend the majority of their time working at the clinics, and the clinic needs to support them logistically. The majority (52.6 percent) of women seek care from an appropriate doctor, when they experience complications during delivery, because women in NSDP catchment areas show improved health seeking behaviors and availability of services is better than in other areas percent of referrals are to private clinics or hospitals, 21.4 percent are to NGOs, and 14.3 percent are to district hospitals. Paramedics attend only 4 percent of the home-deliveries in their areas. Individual catchment areas are very large and more paramedics are needed. Cost NGOs may provide funding for paramedic skill development, but cannot provide other financial support; however, some level of organizational support is critical for program sustainability. 13

16 Lower fees will increase utilization of paramedics during home deliveries. NSDP s policy is to provide services free of charge if the client is unable to pay. Household cost for normal vaginal birth by an unskilled birth attendant is 456 Taka and 865 taka for a paramedic. However this cost is less than other skilled care-givers (qualified physician 6,326 Taka, private nurse 2,923 Taka, family welfare visitor 2,618 Taka, and government nurse 1,724 Taka). Home-based paramedics are used more by the middle class than extreme socioeconomic groups. Recommendations and Conclusions Paramedic Training Under the current WHO/UNFPA/UNICEF/World Bank definition, A skilled birth attendant is an accredited health professional, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborns. Photo: NSDP staff At the Bangladesh national level, there is no clear consensus on the definition of SBA and the minimum set of skills required in home-based vs. facilitybased deliveries. Considerable debate continues over including specific skills in SBA training, such as manual removal of the placenta, using oxytocin for prolonged labor, vacuum extraction, and care of chronic diseases in pregnancy. These competencies represent a higher level of skilled attendance than core midwifery skills, but in regions like Bangladesh and the rest of South Asia, where the proportion of institutional deliveries is low, the demands placed on SBAs may be different. NSDP has great respect for the rationale behind the demand for these high skill levels. Nevertheless, NSDP is highly experienced with working in communities that are poor and hard to reach, where there is no question of service availability from someone with these advanced skills. Given the realities of both the available workforce and the conservative traditions of the local communities, NSDP has developed a training package that focuses on three major aspects of delivery: Active Management of the Third Stage of Labor (AMTSL), Use of the partograph, and Newborn resuscitation. Every delivery that has been performed under the Home Delivery pilot project has addressed these three components. All births have included the administration of 10 IU of oxytocin 14

17 immediately after delivery, delivery of the placenta by controlled cord traction, and the use of uterine massage. Paramedics have experienced no problems with AMTSL, being adequately supplied with uterotonics and syringes by NGOs, and having the necessary skills from their background and training. NSDP could assist the GOB in finding consensus on SBA training, drawing on their experience which is unique and well-documented, where staff have much to offer to the larger perspective. NSDP could develop a mechanism for certification or registration for paramedic training from the Bangladesh Nursing Council. Supportive or Facilitative Supervision In the current project, NSDP mentored the NGO program managers on clinical training and the monitoring officers responsible for quality assurance in supervision. Clinic managers were also trained on supervision and documentation. Although NSDP created a basic supervision plan and provided checklists for all levels of supervisors, it would be beneficial to adopt a more supportive or facilitative supervision approach with the NGOs. Such an approach involves implementation by many people, including official and informal supervisors, peers, and the providers themselves. Supportive supervision promotes quality outcomes by strengthening communication, focusing on problem solving, facilitating team work, and enabling providers to monitor their own performance. Workforce Planning NSDP experienced a high turnover of paramedics and other NGO staff throughout the project, requiring continual training of new providers. NSDP could take the lead in helping NGOs assess human resource problems, and plan and evaluate interventions. Initial research should question the numbers and reasons for attrition within the health care workforce, and what current initiatives are in place that are effective at keeping them where they are needed. Given the lack of defined tasks related to skilled attendance, NSDP-trained paramedics are multi-purpose workers and often pulled in different directions. Each has regular full-time Essential Service Package-related work at a static or satellite clinic, and many home deliveries occur at night. Expectations as to where they place priorities, how much they should work overtime, and related problems require analysis and solutions to ensure their long-term commitment to these demanding positions. The environment in which the paramedic provider must work (the home) remains challenging, and transportation remains a constraint, as is security at night or over long distances. Access to community support (transportation and emergency loans) would increase the credibility and use of paramedics for home delivery, and effective workforce planning will help solve the problems of turnover. Essential Marketing and Communication Needs Additional community outreach, marketing, and education must be carried out for community members to perceive and be willing to pay for the value added of a medically-trained paramedic to perform a delivery. In the catchment area of the pilot program, 40 percent of pregnant women had an attendant at delivery, but only four percent of these were NSDPtrained paramedics. Despite current promotional activities, community awareness and knowledge of the program is low. Community members have high expectations for paramedic 15

18 services and the appropriate behavior change communication activities could correct community assumptions so that they do not feel misled or disappointed. Payment for Services The cost of home delivery services is a deterrent to clients. Even though trained paramedic service is perceived as better than that of a TBA, the cost is perceived as high, especially if medicine is necessary for delivery. Thus, for cost reasons, women still report preferring TBAs for home deliveries. 16

19 Appendix A: Learning for Performance Learning for Performance is a systematic instructional design process that helps: Tie learning to specific identified job responsibilities and competencies; Eliminate unnecessary topics from training which reduces curriculum bloat ; Identify the most appropriate ways to develop health workers (approaches, methods, assessments, etc.); Plan for skills practice and application of new skills and knowledge on the job; and Address the performance factors that determine whether new skills and knowledge can be applied on the job. Learning for Performance is for individuals and teams who are developing or strengthening training or education programs: instructors, trainers, instructional designers, curriculum developers, supervisors, and training managers. The process can be used to develop training of any scale, e.g., preservice education, inservice training, strengthening existing training programs or targeted training to meet a specific need. It can support human resources for health goals, such as re-aligning tasks among existing health cadres, creating new cadres, introducing new priority health services, or developing fasttrack bridging programs to assist existing health workers advance to more priority health cadre positions. The steps in the Learning for Performance process are listed below in the order they are typically performed. The Learning for Performance process is flexible, and depending on the situation, it may be possible to use only portions of the process. The Steps to Learning for Performance 1. Specify the learning goal related to the gap in skills and knowledge. 2. Learn about the learners and their work setting. 3. Identify existing resources and requirements for training and learning. 4. Determine job responsibilities (or competencies) and major job tasks related to the gap in skills and knowledge. 5. Specify essential skills and knowledge. 6. Write learning objectives. 7. Decide how to assess learning objectives. 8. Select the learning activities, materials and approaches, and create the instructional strategy. 9. Develop, pretest and revise lessons, learning activities and materials, and learning assessment instruments. 10. Prepare for implementation. 11. Implement and monitor learning and logistics. 12. Assess effectiveness of the learning intervention, and revise. 17

20 Benefits of the Learning for Performance process Using the Learning for Performance process can: Improve performance of the workforce. Learning interventions developed with the Learning for Performance process prepare workers for specific job tasks where there is a performance problem or gap and a priority health need. Improve the quality of services. Learning interventions that are delivered within a performance improvement context, addressing the five key performance factors, can improve the overall quality of services. Contribute to worker satisfaction. When learning interventions are relevant to specific job responsibilities and tasks, health workers may be more engaged and involved in learning, and more motivated to perform well on the job. Increase the effectiveness of learning. When learning interventions focus on what is most important, learning can improve. Learners do not have to guess what they are expected to learn. Trainers, teachers and preceptors know what they are expected to teach. Increase the efficiency of training. Learning interventions will use the learners and trainers time efficiently by focusing on essential content, skills and knowledge, while delivering specific outcomes. The time required for training is generally shorter than when the intervention is developed without following the Learning for Performance process. Improve decision-making. Decisions about learning interventions are based on specific, practical, relevant criteria when the Learning for Performance process is used. Learning for Performance: A Guide and Toolkit for Health Worker Training and Education Programs, published by IntraHealth International, explains how to carry out each of the steps and provides job aids and worksheets to complete the process. An English version will be available in March

21 NGO Service Delivery Program (NSDP) NSDP is a USAID-funded consortium of eight international organizations, led by Pathfinder International, which provides technical assistance and support to a network of Bangladeshi health care NGOs. The program focuses on delivery of essential public health services to 20 million people through training, quality assurance, NGO institutional development, management, and financing. NSDP partners with more than 30 NGOs whose 320 Smiling Sun clinics and 8,000 satellite clinics work in both disadvantaged rural areas and urban slums. About 6,000 community volunteers augment services in rural areas. Smiling Sun clinics play a major national role in providing families with high-quality, low-cost family planning, reproductive, maternal, and child health care, treatment for reproductive tract and sexually transmitted infections, tuberculosis diagnosis and treatment, and limited curative care services. There are more than two million visits to NSDP health care providers each month. Health benefit cards offer free services at Smiling Sun clinics to members of very poor families. Over 60 percent of the poorest Bangladeshis who receive health care in NSDP s catchment areas are served by NSDP providers. Performance-based reimbursement is increasing access of the poorest of the poor to services and increasing the number of able-to-pay customers as well. Smiling Sun clinics are expanding services that generate income for the clinics, including safe delivery at clinics and at home by trained paramedics, emergency obstetric care, laboratory and pharmacy services, health care marts, ultrasonograms, and specialized physician care. Mass media and local behavior change communication campaigns include the popular entertainment-education TV drama serial Enechhi Shurjer Hashi (Bringing the Smiling Sun). Billboards and advertisements of clinic services in cinemas and on city buses and rickshaws, promote health and family planning. Branding and the reputation of Smiling Sun clinics have led to corporate sponsorship of clinics and services. NSDP Partners: Bangladesh Center for Communication Programs (BCCP) CARE Bangladesh EMG, (Emerging Market Group) IntraHealth International Inc. Pathfinder International Research Triangle Institute (RTI) International Save the Children University Research Co., LLC. (URC)

22 NGO Service Delivery Program (NSDP) Pathfinder International House No. NE (N) 5 Road No. 88 Gulshan-2 Dhaka-1212 Tel: or Pathfinder International/Headquarters 9 Galen Street, Suite 217 Watertown, MA USA Tel: K/0407