National Scaling Up of Helping Babies Breathe Initiatives in Bangladesh

Prof. Mohammad Shahidullah Chairman Neonatology Department and Pro-Vice Chancellor, Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka, 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 79,000 * 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 by BSMMU
National Dissemination & Stakeholder Meeting

Political leadership, commitment

Series of stakeholders consultation to develop HBB Scale-up strategy

HBB curriculum Adaptation to incorporate ENC and translated in Bangla

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 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

Sustainability

Background of National Scale-up of HBB in Bangladesh

HBB Scale-up Partners in Bangladesh

MOH&FW (DGFP, DGHS)

Overall implementation TAX/VAT of offshore procurement Nationwide Implementation, supervision, monitoring and Evaluation Ensure Logistics Adaptation of training materials Organize training in all level Monitoring and supervision Equipment for district implementing maternal and NB projects, Supervision and monitoring Evaluation of HBB scale-up activities

Funding Arrangement MOH&FW (Cash and kind) USAID through MCHIP/Save the Children

MCHIP/Save the Children

BSMMU

UNICEF
Laerdal Foundation through Save the Children

UNICEF

ICDDRB

Step-wise HBB scale-up plan

Total 11 steps

Each Step

6 districts
2 days TOT in BSMMU Trainer return and provide training to district and upazila SBAs

TOT- Doctors from Medical College Hosp (if any), District Hospital, District Health and FP Office and Upazila Health Complexes

7-8 batches

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

10

Results to date

Status of HBB Implementation - Training

Category Received Training Percentage

Doctor
Nurse Paramedics

3570
4104 3783

23%
26% 24%

CSBA Total

4080 15537

26% 100%

Training and equipping

Use for training and refreshers Kept in all facilities from UHC and above for refreshers training Mannequin (NeoNatalie-Laerdal)
Type of Facilities
Medical Colleges Hospital District Hospital Maternal and Child Welfare Center Upazila Health Complexes Union Health and Family Welfare Center NGOs Facilities Community SBA Total

No. Neonatalie Bag & Musk Facility Complite with Sucker

18 38 43 76 54 86

40

80

80

Resuscitator & Suction device

302

604

604

Provided to use for training and refreshers Provided to all facilities & CSBAs for newborn resuscitation .

2372

2372

69 2839

70 873

123 4380 7699

13

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

Incorporation of HBB Protocol in Different Curriculum

HBB Scale-up plan have the component to incorporate the
HBB protocol in all relevant pre-service and in-service curriculum. Following curriculum already incorporated the HBB protocol.
1. 2. 3. 4. 5. 6. MBBS Curriculum Diploma and Degree course of Nursing Midwifery Training Curriculum FWV training Curriculum Private Paramedics Training Curriculum CSBA Training Curriculum

Incorporated in Standard Operation Procedure for Newborn Health Care in Primary and Secondary level facilities In the process of incorporation in Maternal Health SOP

Quality Improvement

National Level (DGHS, DGFP BSMMU and SC )

Joint monitoring visit and follow-up of divisional officials visit

Divisional Level Health and FP officials

Usually 1 district/division in each phase, so feasible for divisional level to organize monitoring visit

District Health and FP officials 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 providing support for supervision and supervise in the project area Standard checklist use 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
83% sessions observed by district level Health/FP managers

50%

sessions will be monitored /supervised by BSMMU officials

Monitoring visits with checklist (219 out of 786 sessions) training- 28% of sessions) QA through direct observation of master trainers (159 out of 786 - 20% of sessions)

15%

sessions are expected to be supervised by national and divisional level DGHS/DGFP official

Quality Improvement- Refreshers training

Refreshers training introduced through routine system

Steps 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)* Complet e

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

A. Prepares for birth

B. Dries thoroughly

C. Clears airway and stimulates breathing if baby is not crying*

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

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. 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

MIS incorporation under process,

Lessons learned

Rapid scaling-up of an public health intervention became possible due to the

Political Commitment Systemic Cascade Approach Technical Capacity Partnership and Fund Availability Retention of skill Monitoring of implementation and outcome and linking with routine system Cleaning of the Equipment

Still the Challenges of HBB Scale-up are

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.