July
HFOMC members meeting to p lan yearly activities during HFOMC training program
CHAO Foundation Grant Report May – July, 2016
1 8 1 8 P a c h e c o S t . S a n F r a n c i s c o , C A 9 4 1 1 6
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Background: Bhojpur is a hill district located in the northeastern part of Nepal. It is home to 172,098 people, and reports 4,474 pregnancies per year. In 2014, One Heart World-‐Wide started the needs assessment process for this district, but due to the earthquakes that destroyed parts of Nepal in 2015, we had to pause our initial program activities and focus on districts such as Dhading and Sindhupalchok, where over 90% of the health facilities sustained either full or partial damage. In late 2015, we started up our program activities in Bhojpur again and in 2016, we have started rolling out the second phase of our Network of Safety – Program Implementation. Over the next three years, we will train community outreach providers, implement a community outreach program, upgrade health facilities into birthing centers, and train Skilled Birth Attendants. We will also develop a basic health infrastructure, provide health education, and foster community empowerment in collaboration with the local District Health Department. Our goal for the next five years is to double the rate of deliveries with a Skilled Birth Attendant, and reduce the maternal and neonatal mortality by at least 50%. Project Activities: Solar Suitcase Installation: Nepal heavily depends on hydropower and rivers dry out during the winter. This results in huge electricity outages up to 18 hours a day during the winters and dry season of the year. For the birthing centers that are located in the more remote areas of Nepal, the sporadic electricity compromises the ability of the skilled birth attendants to provide safe delivery services during the nighttime, and increases the risk of complications during delivery. In order to fulfill the power needs of the rural birthing centers, we have currently installed 15 solar suitcases in birthing centers around Bhojpur. These suitcases not only provide essential lighting for the delivery and waiting rooms, they also contain a fetal Doppler, mobile chargers and two sets of rechargeable headlamps. Needs assessment to expand new birthing centers: Many women don’t receive emergency care immediately as needed because of three delays: 1. Delay in deciding to seek care 2. Delay in reaching care 3. Delay in receiving adequate care The ability to reach a birthing center in a timely manner is a major delaying factor because of the geographic barriers resulting from the mountainous and hilly regions of Bhojpur. Birthing centers are far and wide and as there are not many roads in the Bhojpur district, reaching a birthing center often requires several hours of walking. Our aim is to increase the number of birthing centers in strategically located existing health posts. We will work in collaboration with the local community to renovate and upgrade existing birthing centers for women seeking emergency obstetrics as well as antenatal and postnatal healthcare services. With the help of the district health offices, we plan to
identify 8 to 10 new sites to provide delivery services in the next three years. Quality of Care (QoC) Assessment of Birthing Centers: The quality of care received by mothers and babies in remote area is often reported as poor. Poor sanitation and bad hygienic practices can lead the infection to the mother and newborns. Infection is one of major cause of maternal and newborn death globally and locally. Quality care assessment is one of the routine activities completed so that all women and newborn clean and dignified care during the delivery. SBA Training: Pregnancy is a natural process for which medical assistance is not considered as a need or requirement in Nepal. As a result, many Nepalese women, especially those residing in more rural areas of Nepal deliver at home. In most communities, traditional birth attendants are usually primary service providers who have never received modern training in midwifery. The lack of training poses a risk to the lives of the women and newborn. Currently, there are only a few SBAs that serve about 45,000 women per year in Bhojpur. One Heart World-‐Wide has identified several eligible nurses that are on their way to becoming certified skilled birth attendants. Post-‐ training, they will be able to provide the maternity care necessary to conduct safe deliveries in this district.
2015 •
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In early 2015, we started discussion with the District Health Office (DHO) of Bhojpur and drafted a Memorandum of Understanding (MOU) between One Heart World-‐Wide and the DHO. We were able to sign all the necessary MOUs and agreements to start work in Bhojpur. However, the earthquakes delayed the start of our regular programs in Bhojpur, which included the baseline data collection process, hiring a field team, and setting up the field office. We re-‐started the activities listed above again in Quarter 4 of 2015, and successfully hired staff and set up the field office in Bhojpur. One Heart World-‐ Wide also conducted a Rapid Assessment and started a comprehensive data collection process before creating a program roll-‐out plan to share with the DHO.
2016 – Quarter 1 •
• • •
In 2016, OHW committed to partially supporting the construction of Birthing Center at the Tiwaribhanjyang Health Facility in addition to providing essential delivery equipment and Solar Suitcases. On February 1st, OHW Network of Safety program was formally launched. We have enrolled nine Auxilliary Nurse Midwives into a two-‐month training program for skilled birth attendance at the Sagarmatha Zonal Hospital. We have installed Solar Suitcases in a total of 15 health posts in Bhojpur.
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•
We have conducted Quality of Care assessments and needs assessments for 11 birthing centers, along with plans for future improvement and partnership with the HFOMCs at these existing facilities. These include: Charambi Health Post, Pyauli Health Post, Basteem Health Post, Annapurna Health Post, and Chinnamakhu Health Post, Ghoretar PHC, Patlepani BC, Helaucha BC, Bhojpur District Hospital, Pawala BC, and Pangcha BC. 6 Birthing Centers Joint Monitoring visit -‐ The purpose of these visits was to determine the overall status of each birthing center, and also monitor maternal and neonatal mortality. The District Health Officer of Bhojpur, Dr. Nawal Kishor Jha, joined the OHW team to supervise thie visits. These Health Facilities include: Ranibas PHC, Patlepani HP, Basteem HP, Tiwaribhanjyang HP, and Pyauli HP, Ghoretar PHC. Annual targets and deliverables are set for 2016.
2016 – Quarter 2 • •
•
•
•
•
Quality of Care (QOC) assessments were conducted in eight birthing centers Community outreach activities on safe motherhood and health education were disseminated throughout local communities using two local FM channels (Bhojpur FM and Chumulunga FM) to effect behavior change Bulletin boards containing messages regarding danger signs to watch out for during antenatal, intranatal, and postnatal periods of pregnancy were posted throughout local communities to raise awareness Health Facility Organizing Management Committee (HFOMC) training was held among health workers and local health facility management committee members. We were able to train 208 members from 15 different health facilities. Health Management Information System (HMIS) Review meeting was conducted on July 23, 2016 – it was organized by the Bhojpur DHO and financially supported by One Heart World-‐Wide We have finished the cost estimation for the renovation of Mulpani PHC
Data: Activities for 2016
Q1
Q2
0 0 Community Outreach Providers trained 0 208 Local stakeholders trained 0 0 Birthing centers fully upgraded 0 0 Birthing centers partially upgraded 0 0 Birthing centers newly upgraded 9 0 SBAs trained rd th * The majority of the trainings and upgrades scheduled for 3 and 4 quarter of 2016
Target for 2016 786 760 5 10 5 35
Baseline Data Appropriate Antenatal Care Visits
31%
Delivery with Skilled Birth Attendant
17%
Institutional Deliveries
24%
Upcoming Plans: •
•
• •
• • •
We have planned a weeklong Breast-‐feeding week celebration from August 1st to 7th during which we will be airing relevant information through local FM channels. We will continue our community outreach activities through the installation of bulletin boards and wall paintings, along with and messages on the radio in order to increase awareness and effect faster behavior change. The majority of our training programs and upgrades are scheduled for the 3rd and 4th quarter of 2016 We are planning to continue with the Quality of Care assessments, along with a needs assessment and plans for future improvement at additional birthing centers that have been identified. District level HFOMC Train the Trainer on HFOMC strengthening for District Supervisors. We will be focusing on Community Mobilization (Local stakeholders) on Under Performing VDCs. We will focus on renovation work and infrastructure support to Birthing Centers.
Challenges: •
So far, we have been lucky enough not to have faced any major challenges since re-‐ starting our program activities in Bhojpur. There are always challenges related to travel/transport when operating in such remote conditions; Air travel is often delayed due to the weather and roads are oftentimes blocked due to landslides. However, these are all challenges that our team is familiar with.
Story from the Field: “We are HFOMC members of the health post but we don’t know what we are supposed to do. We are here just because there is government policy that there should be HFOMC members in every health facility.” The above was a statement made by one of the Health Facility Operation and Management Committee (HFOMC) members of the Annapurna Birthing Center during an initial Quality of Care Assessment visited conducted by One Heart World-‐Wide. Annapurna Village Development Community (VDC) is one of the more remote VDCs of Bhojpur District. It has one birthing center, Annapurna BC, which sees patients from four other VDCs. There are a total of 9 HFOMC members in Annapurna BC. The Health Facility Operation and Management Committee is a committee specifically organized to support the respective health facility both directly and indirectly. The main roles and responsibilities of HFOMC members consist of supporting health facilities through management, staffing, supplying equipment and drugs, and resource management. The committee typically consists of 9 to 13 members in the Health Post (HP) and Primary Health Center (PHC). Comments such as the one above are the reason behind the three-‐day HFOMC training that OHW conducts. The training goes over the roles and responsibilities of the members to ensure that there would be no confusion in the future. On the last day of their training, the secretory of Annapurna VDC announced that they would provide equipment valued at approximately 50,000 Nepali rupees (USD 5,000) related to delivery services and the other members of the committee committed to support and renovate the birthing center room using funds that have been collected by the VDC and other members of the community.
Story #2 from the Field: This is the story of Mrs. Anjana Rai, a 20 years old pregnant mother from Timma VDC, which is one of the more remote VDCs of Bhojpur. She had completed her four prenatal visits and she arrived at the district hospital on June 5th, 2016 around 12:10 pm, and I [Sophia Khanal] was the only one on duty at the time. I examined the mother and fetus - the cervix was almost fully dilated and the fetal condition was normal. At 1 pm, she delivered a healthy little girl, however she did not deliver the placenta. Untreated, a retained placenta can be life-threatening for the mother, mostly through infection and blood loss. Using the skills that I had learned through the SBA training provided to me by One Heart World-Wide, I provided active management of third stage labor to Anjana, and after an hour to everybody’s relief, the placenta was finally delivered. I kept Anjana under supervision at the birthing center for 24 hours. Her condition gradually improved and the next day Anjana was discharged from the hospital. “I feel so proud of myself as I handled this care independently and succeeded in keeping a mother safe. I see the happiness in my patients’ and families’ faces. I could confidently handle the case because I have received the Skilled Birth Attendant (SBA) training from One Heart World-Wide, Bhojpur. If I was not an SBA, I would not have been able to handle the situation. Thank you One Heart World-Wide for making me capable, and I think every nursing staff should get training like this to save life of mothers and newborn of remote areas.” – Sophia Khanal, Staff Nurse, District Hospital, Bhojpur Story contributed by: Ms. Sophia Khanal, Staff Nurse, District Hospital, Bhojpur. She recently received SBA training through the support of One Heart World-Wide. Quote from the field: Mrs. Sushila Rai, is the Auxiliary Nurse Midwife at Pawala Birthing Center, one of the remotest Birthing Centers of Bhojpur. She has been working here for the past two years and typically examines 20 to 25 Antenatal mothers every week. In the past she used a fetoscope to hear the fetal heart rates during these ANC checkups. However, it was sometimes difficult for her to clearly and accurately identify the baby’s heart sounds through the fetoscope. One Heart World-‐Wide recently upgraded this birthing center with a Fetal Doppler machine. “One of the most important devices we got is the Fetal Doppler. In emergencies it is hard to put
Fetoscope in order to listen baby’s heartbeat and the result is not always accurate. The fetal Doppler that we received from One Heart World-‐Wide comes with the display machine. Pregnant mother and her family members also can listen to the baby’s heartbeat now. It is especially helpful during emergency as I can listen the baby’s heart beat from distance while doing other essential work. The Doppler has eased my work and saved time. Thank you One Heart World-‐ Wide for providing the Doppler machine to Pawala Birthing Centre.” Pictures:
* Rs. 50,000 worth of equipment donated by the VDC
* HMIS review meeting organized by DHO, Bhojpur and supported by One Heart World-‐Wide
Quarter
Major Milestones Goals for each quarter
Project Key Indicators
2016 Q1
Training of skilled birth attendants (SBA) Annual Target: 35 Upgrade of birthing centers (BC) Annual Target: 10
Number of SBA trained: 9 Number of BC upgraded: 0
2016 Q2
Training of skilled birth attendant (SBA) -‐ continued Upgrade of birthing centers (BC) – continued Quality assessment program for BC
Number of SBA trained: 0 Number of BC upgraded: 0 Number of BC assessed: 0 Number of local stakeholders trained: 208
2016 Q3
Training of skilled birth attendant (SBA) -‐ continued Upgrade of birthing centers (BC) – continued Quality assessment program for BC
Number of SBA trained Number of BC upgraded Number of BC assessed
2016 Q4
Training of skilled birth attendant (SBA) -‐ continued Upgrade of birthing centers (BC) – continued Quality assessment program for BC
Number of SBA trained Number of BC upgraded Number of BC assessed
2016 Whole Year
Increase the number of women delivering their babies in a health facility that is equipped for this purpose (birthing center or referral hospital). Decrease maternal deaths (defined as "The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.") Decrease neonatal deaths (defined as the death of a baby within the first 28 days of life).
We expect an increase of at least 15% over three years. We expect a minimum of a 50% decline over 3 years. We expect a minimum of a 50% decline over 3 years.
QUARTERLY REPORT April 1, 2016 – June 30, 2016
Quarter 2
Current districts where we operate
PHASE 1
PHASE 2
PHASE 3
Taplejung Bhojpur Khotang
Baglung Dhading
Terhathum
Dolpa Sindhupalchok
Panchtar
Phase 1: Program Set-Up – OHW gets approval from the District Health Offices for programs; hires district level team; sets up field office; conducts a baseline study and needs assessment; and establishes a plan of action for program activities. Phase 2: Program Implementation – OHW implements all training programs and facility upgrade activities. We train Skilled Birth Attendants (SBAs), community outreach providers and local stakeholders. Health facilities are upgraded into fully functioning government certified birthing centers. Phase 3: Program Transition – OHW transitions program activities to the local District Health Office (DHO). We maintain regular contact with the DHO, trainees, and birthing centers; monitor relevant impact indicators to assess long-term program maintenance; offer refresher trainings; perform quality assessments for birthing centers and provide them with support when necessary. One Heart World-Wide: Saving lives of mothers and newborns world-wide.
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Snapshot of our operations Community Outreach Providers Trained:
Q1
Q2
Total
Variance
267
Annual Target 280
Dhading
267
0
Sindhupalchok
665
0
665
775
-‐110
Bhojpur
0
0
0
786
-‐786
Taplejung
0
0
0
480
-‐480
Khotang
0
0
0
690
-‐690
-‐13
* No community outreach provider training programs were planned for Baglung, Dolpa, Terhathum, and Panchtar in 2016. ** The majority of the community outreach provider trainings are scheduled for 3rd and 4th quarter.
Local Stakeholders Trained:
Q1
Q2
Total
Variance
891
Annual Target 890
Dhading
891
0
Sindhupalchok
1,105
599
1,704
1,195
+509
Bhojpur
0
208
208
760
-‐552
Taplejung
0
0
0
550
-‐550
Khotang
0
0
0
500
-‐500
Terhathum
0
0
0
40
-‐40
Panchtar
0
0
0
40
-‐40
+1
* No local stakeholder training programs were planned for Baglung and Dolpa. ** The majority of the local stakeholder trainings are scheduled for 3rd and 4 th quarter.
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Snapshot of our operations (continued)
Skilled Birth Attendants Trained:
Q1
Q2
Total
Variance
20
Annual Target 0
Baglung
0
20
Dolpa
2
0
4
2
+2
Dhading
35
41
76
122
-‐46
Sindhupalchok
29
0
29
73
-‐44
Bhojpur
9
0
9
35
-‐26
Taplejung
0
0
0
20
-‐20
Khotang
0
0
0
20
-‐20
Terhathum
0
0
0
20
-‐20
Panchtar
0
0
0
20
-‐20
+20
** The majority of the skilled birth attendant trainings are scheduled for 3rd and 4th quarter.
Birthing Centers Fully Upgraded:
Q1
Q2
Total
Variance
6
Annual Target 5
Dhading
1
5
Sindhupalchok
1
0
1
4
-‐3
Bhojpur
0
0
0
5
-‐5
Taplejung
0
0
0
2
-‐2
Khotang
0
0
0
2
-‐2
1
* No full upgrades for birthing centers were planned for Baglung, Dolpa, Terhathum, and Panchtar in 2016. ** The majority of birthing center upgrades are scheduled for 3rd and 4th quarter.
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District level operations Districts in Phase 1: Set Up Taplejung I Khotang I Therathum I Panchtar 1. The hiring process to meet our HR needs for our scale up plan continues. Positions for our four new districts and our eastern regional office were listed and interviews were started. 2. The initial needs assessment was completed in Khotang.
Districts in Phase 2: Implementation Dhading I Sindhupalchok I Bhojpur Dhading (earthquake zone): 1. Five birthing centers that sustained heavy damages during the earthquake were repaired, and upgraded 2. Three temporary birthing centers have received additional medical equipment and supplies (Bhumisthan, Madevshtan, Dhola) 3. Our team participated in the District Project Advisory Committee (DPAC) meeting led by the local Development Officer and District Health Officer in order to share achievements and compare them against planned activities 4. Community outreach activities on safe motherhood were conducted through local FM radio channels to effect faster behavior changes 5. Quality of Care (QoC) assessments were conducted in seven birthing centers 6. A reproductive health medical camp was conducted, serving 1,371 patients 7. The construction of the maternity waiting home was completed in Salayantar. Sindhupalchok (earthquake zone): 1. Quality of Care (QoC) assessment were conducted in 22 birthing centers 2. Community outreach activities on safe motherhood to effect faster behavior changes were conducted through local FM radio channels and through school health program in eight schools. 3. The construction of the maternity waiting home was completed in Melamchi. Bhojpur 1. Quality of Care (QoC) assessments were conducted in eight birthing centers 2. Community outreach activities on safe motherhood were conducted through local FM radio channels to effect faster behavior changes
One Heart World-Wide: Saving lives of mothers and newborns world-wide.
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District level operations (continued) Districts in Phase 3: Transition Baglung I Dolpa 1. The OHW team and the District Health Office jointly conducted quality of care assessments in twelve birthing centers of Baglung. They assessed the sustainability and quality of services provided by these service delivery points. All twelve facilities were performing within acceptable range. 2. Additional SBA training was provided to newly hired nursing staff in Baglung district. 3. Solar suitcases were deployed in six birthing centers in Baglung (Kharbang, Bhimghithe, Darling, Khunga, Rajkut and Argal) 4. Three birthing centers received additional medical equipment support in Baglung (Dhaulagiri zonal hospital, Amarbhumi, Jaljala) 5. Birth outcome data was collected from both districts to monitor program indicators and transition process 6. A needs assessment of current equipment/supplies available in each birthing center was completed in both districts
Center of Excellence: 1. The Memorandum of Understanding for The Ama Center of Excellence in Maternal and Neonatal Health was drafted and signed with Dhulikhel Hospital. 2. An initial needs assessment of the necessary logistics and equipment necessary for operation of the Center of Excellence training center was conducted 3. 20 SBA participants have been identified from OHW program districts to enroll in the first COE SBA training program
Center level and scale-‐up plan: 1. A five-‐year project agreement (budget and plan) outlining our scale-‐up program in 13 new districts was submitted to the Social Welfare Council for approval 2. OHW was invited by the MoH to participate in a conference on the Lessons Learned Post-‐ Earthquake 3. The report of our post-‐earthquake recovery activities in Dhading and Sindhuplachok was submitted to the MoH.
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Integration of New Technology: 1. OHW and Medic Mobile agreed to partner in order to scale up the mhealth program in Dhading district in 2016. Medic Mobile will provide the necessary funding. OHW will implement the program. A MoU is being drafted. in order to formalize the partnership.
Organizational Capacity: New Hires in Nepal Ø Kathmandu Office: § Ms. Bidhya Maharjan, HR Officer § §
Mr. Jayas Shrestha, EHealth Manager Mr. Radhe Shyam Sharma, Field Engineer/BC Construction Consultant
Fundraising and Expenses (Quarter 2, 2016):
New Donors in Q2: •
Vitol -‐ $100,000
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