phil efforts on fp-mch

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MNCHN STRATEGY: MNCHN STRATEGY: Philippine Effort to Philippine Effort to Secure Benefits of FP-MCH Secure Benefits of FP-MCH Services Services CENTER FOR HEALTH DEVELOPMENT National Capital Region Dr Ruben Siapno Chief, Health Operations Division, CHD-NCR

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Page 1: Phil Efforts on FP-MCH

MNCHN STRATEGY:MNCHN STRATEGY:

Philippine Effort to Secure Philippine Effort to Secure Benefits of FP-MCH Benefits of FP-MCH

ServicesServices

CENTER FOR HEALTH DEVELOPMENT National Capital Region

Dr Ruben SiapnoChief, Health Operations Division, CHD-NCR

Page 2: Phil Efforts on FP-MCH

Outline of PresentationOutline of Presentation• Four Parts

1. How we look at FP and MCH2. Review of how we are faring in securing FP-

MCH benefits 3. A closer look at MNCHN for guidance

4. A new look at FP Healthy Timing and Spacing of Pregnancy

Page 3: Phil Efforts on FP-MCH

FP-MCH Beyond Policies, Programs or Projects *FP-MCH Beyond Policies, Programs or Projects *• Thinking about Family Planning and Maternal and

Child Health beyond or merely as policies, programs or projects.• FP-MCH as a PUBLIC GOOD FOR ALL with

BENEFITS FOR THE FAMILIES, as DELIVERED BY THEIR COMMUNITIES• Individuals practicing FP derive their own benefits, but many

individuals doing the same, generate additional group benefits and when most do the same, the group benefits are even greater.

• Thus,• FP-MCH is about individuals, families,

communities, enterprises, and a whole nation seeking to secure for themselves the benefits of these vital services, an important part of which are their vast public health benefits.

• *culled out from the late Mario Taguiwalo presentation

Page 4: Phil Efforts on FP-MCH

Public Health Benefits of FP-MCHPublic Health Benefits of FP-MCH• Family Planning• Empowers women, prevents unintended

pregnancies, supports maternal health and helps prevent transmission of HIV-AIDS

• Maternal and Child Health• Reduces mothers’ risk from pregnancy, protects

newborn, best start for infants and children

Important:• Clinical safety, consistent quality, informed

voluntary choice and universal access

Page 5: Phil Efforts on FP-MCH

5 Indicators of Benefit Extent5 Indicators of Benefit Extent

• CPR – 34% (32.5% NCR) of MWRA• 4ANC – 77.8% national (94.4% NCR) of births • SBA – 62% (92.4% NCR) of births• EBF – 34% (69% NCR) of children below 6 mos • Vit A – 75.9% (94.8% NCR) of children below 59 mos

Except for CPR, all indicators should be 100%..

Page 6: Phil Efforts on FP-MCH

Actual CPR (34%) < than desired CPRActual CPR (34%) < than desired CPR• Not discussed FP with Health Workers: 82.5%• Highest use by education: 36% (college)• Highest use by wealth: 38.5% (2nd richest)• Highest use by regions: 46% (by Region II)• Traditional users: 16.7%• Want no more children (55%) + want

another later (19%) but are not currently using any method =

74%• Intend to use FP in the future (42%) added

= 76%• 30% of births occur less than 2 years of

previous pregnancy

Why are FP-MCH results well below what people, community

and country want?

Page 7: Phil Efforts on FP-MCH

Organization of our EffortsOrganization of our Efforts• Originally, national programs: FP, Maternal

Care, CC, nutrition (before and after LGC) through administrative mechanism operated nationally

• Implemented F1 or local health systems reforms at provinces and cities, subsuming all national programs under each P/CIPH and AOP (common framework: service delivery, governance, regulation and financing)• Recently adopted the “MNCHN Strategy”

combining the services of different programs into one integrated package within the F1 framework.

Page 8: Phil Efforts on FP-MCH

Model Program: EPIModel Program: EPI

• National specifications of clinical procedures, field activities, support services applicable nationwide (established procedures from national to region to provinces to municipalities and barangays)

• Nationwide DOH supply of essential commodity – vaccines, even syringes and needles

• Functional nationwide infrastructure of support facilities (cold chain)

• National advocacy, awareness, demand generation

• Local mobilization of actual service delivery; mainly public sector

• Result: 60% to 70% (2003-2008) or 10 points in 5 years

Page 9: Phil Efforts on FP-MCH

Comparator Program 1: FPComparator Program 1: FP

• Technical specifications contested and debated• National logistics system for contraceptives

dismantled• No nationwide infrastructure of support facilities• No national advocacy, awareness or demand

generation• Local mobilization of actual service delivery;

increasingly implicit public-private partnerships• Result: 33.4% to 34% (2003-2008) 0.6

points in 5 years

Page 10: Phil Efforts on FP-MCH

Comparator Program 2: MCComparator Program 2: MC

• Recent changes in technical specs: no more hilot delivery; BEmONC and CEmONC delivery; newborn care; unresolved roles for midwives, GPs, and specialists

• No national logistics system for commodities• Many gaps in infra of essential facilities• No national advocacy, awareness or demand

generation

• Local mobilization of actual service delivery; increasingly implicit public-private partnerships

• Result: SBA 60 to 62% (2 points in 5 years); FBD 38 to 44% (6 points in 5 years)

Page 11: Phil Efforts on FP-MCH

2. THE MNCHN STRATEGY2. THE MNCHN STRATEGY

Page 12: Phil Efforts on FP-MCH

The MNCHN StrategyThe MNCHN Strategy• DOH Administrative Order 2008-0029:

“Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality” (known as the MNCHN Strategy), addressing the 3 sources of MMR/NMR

o unintended pregnancies, o uncared pregnancies, o poorly attended deliveries

• 4 desired results: planned pregnancies, managed pregnancies, facility-based/skilled attendance deliveries, mother and newborn care

• Targets: CPR to 60%; 4ANC to 70%; SBA/FBD to 80%; FIC to 95%

Page 13: Phil Efforts on FP-MCH

The MNCHN Framework The MNCHN Framework    

Demand for health care

Desired health

outcomes

Supply of quality

health care

Actions by LGUs

Issuances, actions and influence by

CHD & national agencies

Page 14: Phil Efforts on FP-MCH

    1. Every pregnancy is wanted, planned and supported

2. Every pregnancy is adequately managed throughout its course

3. Every delivery is facility-based and managed by skilled birth attendants/skilled health professionals

4. Every mother and newborn pair secures proper post-partum and newborn care with smooth transitions to the women’s health care package for the mother and child survival package for the newborn

Desired Public Health Outcomes

   

Page 15: Phil Efforts on FP-MCH

Supply of Quality Health CareSupply of Quality Health Care    Strategy #1 Ensuring universal access to and

utilization of MNCHN Core Package of services & interventions directed not only to individual WRA & newborns at different stages of life cycle

   

MNCHN core package of services are interventions corresponding to each life stage in the FP-MCH continuum of care: adolescence & pre-pregnancy, pregnancy, delivery/birth, and the postpartum and newborn periods (neonatal, infancy) (to illustrate....)

NeonatalInfancy

Maternal Health

PostpartumBirthPregnancyAdolescence and Pre-pregnancy

Childhood

Page 16: Phil Efforts on FP-MCH

Supply/Demand for Quality Supply/Demand for Quality Health CareHealth Care

    Strategy # 2 – Establishment of a service delivery network (SDN) at all levels of care to provide the package of services and interventions

   

Service Delivery Network refers to the network of public and private community-level, BEmONC-capable, and CEmONC-capable facilities and providers offering MNCHN core package of services including communication and transportation support systems (MNCHN-MOP pp. vii; 30-37).

Page 17: Phil Efforts on FP-MCH

MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork

THREE Levels of Care•First level or primary: Community level service providers (RHUs, BHS, private clinics, midwives, BHWs, TBAs, CHTs, Alternative Distribution Points - BnBs)•Secondary: Basic Emergency Obstetrics and Newborn Care (BEmONC)- capable network of facilities and providers; and• Tertiary: Comprehensive Emergency Obstetrics and Newborn Care (CEmONC) - capable facility or network of facilities.

COMMUNITY HEALTH PROVIDERS

BEMONC

CEMONC

Page 18: Phil Efforts on FP-MCH

MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork

Levels of Core Service Package(Interventions)

BEMONC

CEMONC

EmONC

BEmONC level

CEmONC level

Page 19: Phil Efforts on FP-MCH

MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork

MMR

CPR

PUBLIC HEALTH

OUT-COMES

COMMUNITY

BENEFICIARIES

Men and Women of Reproductive Age with Unmet FP-MCH Needs

Special Groups:• Young people• Workplace workers

COMMUNITY HEALTH

PROVIDERSBEMONC

CEMONC

PublicNon-NHIP accredited

Private Practice

Midwives & Birthing HomesNHIP

accredited PPMs’ & Birthing Homes

Hospitals

Other Service Delivery Points – Company

Clinics, School-based clinics,

etcAlternate

Distribution Points for FP-MCH Products

Service Delivery NetworkPrivat

eCommunity or Primary Health

Providers: Community

Health Teams, Rural Health Units/

Health Centers, Barangay

Health Stations,

Public Health/Lying-

in Clinics (doctors, nurses,

midwives)

SECONDARY CARE

PROVIDERSInfirmaries, municipal,

district hospitals, out-

patient departments,

etcTERTIARY CARE :

Hospitals

DOH/CHD/LGU/PRIVATE

Page 20: Phil Efforts on FP-MCH

MNCHN Service Delivery MNCHN Service Delivery NetworkNetwork

Page 21: Phil Efforts on FP-MCH

Actions by LGUActions by LGU   

Strategy #3 Organized use of instruments for health systems development to bring all localities to create and sustain their service delivery networks, which are crucial for the provision of health services to all

   

Actions through Health System Instruments that the city should put in place are classified into three: Governance Regulation and Financing

and are addressed to ensure the availability of supplies and the generation and response of demand for the information, services and products.

Page 22: Phil Efforts on FP-MCH

Issuances, Actions & Influence by Issuances, Actions & Influence by CHD & National AgenciesCHD & National Agencies

    Strategy #4 Rapid build-up of institutional

capacities of DOH and PhilHealth to provide support to local planning and development through appropriate standards, capacity build-up of implementers, and financing mechanisms

   

Page 23: Phil Efforts on FP-MCH

3. LOOKING AT MNCHN 3. LOOKING AT MNCHN CLOSELYCLOSELY

Page 24: Phil Efforts on FP-MCH

Not just another Program! Not just another Program! • Its a strategy for

o achieving health outcomes on a population scaleo mobilizing efforts from institutional structures of

society in behalf of these outcomeso using the country’s public health agencies as a

professional organization backing this social mobilization

• Reformed province/city - wide local health systems as main implementor; minimum standard services defined for pre-pregnancy, antenatal, delivery and after delivery; support by DOH at central and regional levels declared.

• Manual of Operations issued in 2009• 2010 Operational Plan also adopted• Structure and procedures of implementation

organization still evolving

Page 25: Phil Efforts on FP-MCH

MNCHN within PIPH/AOPMNCHN within PIPH/AOP    • Nothing like this before! • Scope of health services involved is wide, few

service outlets can deliver the whole package: package of selected services (pre-pregnancy, pregnancy, delivery, post-delivery), account for large part of health effort

• Network approach is necessary because large populations can be reached:o 13-14 million MWRAs, more than 2 million births,

more than 4 million infants below 24 months,o at more than 100 province/city-wide local systems,

supported by 17 regional agency clusters• Best to focus at province/city-wide service

networks as the right local scale for administrative and market size reasons

• MNCHN is not really a set of activities that cities carry out but a set of operating and organizing specifications for reforming their local health systems to yield better MNCHN health outcomes

Page 26: Phil Efforts on FP-MCH

MNCHN within PIPH/AOPMNCHN within PIPH/AOP    • MNCHN is not just an integrated package of services

– it is the KEY DRIVER for the urgent integration of local health systems around serving the client segment of women, mothers, infants and children.

3 Major Changes for Public Health Agencies• Change 1: horizontal integration of all activities at

levels of community, provider outlet, area network, regional support and national direction

• Change 2: vertical coordination implementing coordinated activities without depending on traditional national admin hierarchy

• Change 3: vertical execution two parts effort working for one result; first, DOH central to region; second, LGU province/city to municipal/barangay and community (including private sector)

Page 27: Phil Efforts on FP-MCH

MNCHN as Vehicle for Attaining MNCHN as Vehicle for Attaining Sustainable Improvements in Family Sustainable Improvements in Family

HealthHealth    • MNCHN provides multiple other pathways

for providing FP methods, Vitamin A supplementation, promoting breastfeeding, improving quality of ANC and birth attendance and newborn care reaching all mothers there are connections among program drivers and factors to move all 5 MNCHN indicators.

• Reduces political vulnerability of some FP methods to attack or resistance FP services are also embedded into the local service package for women, mothers and couples, instead of being highlighted as a “national program.

Page 28: Phil Efforts on FP-MCH

MNCHN as Vehicle for Attaining MNCHN as Vehicle for Attaining Sustainable Improvements in Family Sustainable Improvements in Family

HealthHealth    • City - wide service delivery network model

can deliver results at scaleo CHOs mobilize public and private providers to deliver

MNCHN service packageo what happens on the ground, among providers and

clients at communities, ultimately determines public health outcomes

• Larger role of local ownership, leadership and management means an effort closer to clientso Cities adopt and implement 3-year local plans to

progressively improve coverage, quality and use of MNCHN service package

• Province/City - wide network setting makes public-private partnerships for FP-MCH more feasible and sustainableo City governments/LGUs and private sector support

adoption of MNCHN framework, directions and standards with local mandates, structures and funding

• Many efficiencies: one client population; one provider community; one service package; one local health system

Page 29: Phil Efforts on FP-MCH

QUESTION: Will the MNCHN vehicle deliver?

Page 30: Phil Efforts on FP-MCH

Framework for DOH-LGU Cooperation Framework for DOH-LGU Cooperation for MNCHN for MNCHN

    Local (LGU) Operations• Area network management• Provider competencies and

performance• Facility set-up and

operations• Commodities supply• IEC, BCC and advocacy• M&E• Service enhancements• Costs and financing• Local

governance/stewardship• NHIP operations

DOH central-CHD Support• Managers training and

support• Provider and supervisors

training• Facility upgrading

assistance• Commodities assistance• Support IEC, BCC,

advocacy • M&E assistance• TA on service

enhancements• Advise on costs and

financing• Local governance

assistance• Support for NHIP

implementation

““MNCHN Program of Work” MNCHN Program of Work”    

Page 31: Phil Efforts on FP-MCH

MNCHN Features Important to MNCHN Features Important to ImplementationImplementation

Page 32: Phil Efforts on FP-MCH

Priority Elements within MNCHNPriority Elements within MNCHN• IEC, Behavioral Change Communication, Interpersonal

Communication/Counseling, advocacy and demand generation effort for FP and MCH practices (public and private)

• Universal availability of and access to hormonal contraceptives and referral access to LAPM (public and private sources)

• Case management procedures that link RH/FP care for WRA with care of pregnant women, with care of newborn and infants, in smooth continuum of service and referral at local level (public and private)

• Financing system that supports universal provision and use based on need and risk

• M&E system that generates consistent data on state of whole population at risk and extent of benefits

Page 33: Phil Efforts on FP-MCH

5 Essential Pre-Conditions for LGU-5 Essential Pre-Conditions for LGU-level Implementation of MNCHNlevel Implementation of MNCHN

1. Administrative arrangement for program management capable of universal service coverage of whole population

2. Local policy mandates on MNCHN standards 3. Budgetary and financing arrangement supporting

core functions and activities4. Local program of public-private partnerships5. High level of NHIP implementation

Page 34: Phil Efforts on FP-MCH

4. A New Look at FP – Healthy 4. A New Look at FP – Healthy timing and spacing of pregnancytiming and spacing of pregnancy

Page 35: Phil Efforts on FP-MCH

Who is wise, mighty, wealthy and honorable?

    • Wise, not those who know everything, but who learn from everyone

• Mighty, not those who control others, but who control their wayward inclinations

• Wealthy, not those with most money, but those content with their portions

• Honorable, not those given honors, but those who honor others

• Implementing MNCHN demands wisdom, might, wealth and honor in these ways.