sm2015 - belize sm2015 initiative innovative approaches may 2012

SM2015 - BELIZE

SM2015 Initiative

Innovative Approaches

May 2012

Content

—Health profile—Health System

SM2015

—Objective—Components—Methodology

Demographic transition

— A reduction in the fertility rate (3.3 to 2.7) and increase in life expectancy (73 years) have resulted in population aging

— More than half of the population is below 25 years – 55.6%

Epidemiological transition

— Double burden – increasing non-communicable and degenerative diseases related to lifestyle, behaviors and a longer life-span, combined with the continued occurrence of communicable diseases related to poverty, sanitation, environmental conditions, malnutrition and sexual risk behaviors

— NCD’s are among the main causes of morbidity and mortality

— Maternal and infant mortality are low compared to other countries of the region and appear to be declining

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Maternal Mortality Ratio 1991-2011

04-05 Surveillance system

05 Protocols Training

09 Quality improvement MNC

10 Protocols Training

Source: MOH, Health Statistical abstracts

Skilled birth attendance is high (96%)

Source: MICS, 2006

Process—Planning and resource mobilization—Standards and indicators—Training —Policy—Framework—Monitoring tools

Demonstration phase in 2 hospitals—70% reduction in neonatal death—65% reduction in birth asphyxia

Spread to rest of hospitals in 2011

Adapted from University Research Company LLC., maternal and neonatal care package [Nicaragua Office]

Quality improvement of maternal and neonatal care since 2009

Monthly monitoring Quality of process of care in all hospitals

Strategy sample: random selection and convenience,

-Staff sensitization

-peer coaching

Partograph modified

-Revisited monitoring tool- Post reminders

In-service training and practical sessions

‘High season’

Midwife: patientSource: medical records

Refresher training at SRH

Audit sessions with midwives

New partograph form

Median =90

Source: MoH, Belize, May 2011

Under-5 mortality rate

Source: MoH, Belize, May 2011

Analysis of protected cohorts against Measles/Rubella by year of birth and Vaccination

Strategies 1962-2010

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Routine MMR1 coverage MMR2 coverage 2nd dose MMR 2000 (1-4yrs)95% Measles vaccine 1986 (9mths-3yrs) 91%Measles F/U 1995 (1-4yrs) 85%

Rubella Mass

campaign

(females)

(1998)

MMR vaccine

5-35 yrs

Rubella Mass

Campaign (males)

(2004)

MMR vaccine

5-35 yrs

Coverage 97%

Measles "Big

Bang" (1991)

MMR vaccine

9mths-14 yrs

Coverage 82%

Source: MOH reports to EPI-CAREC

Under nutrition (low height for age) is persistent among certain populations – MICS2006

Poorest/richest– three foldIndigenous / Maya12-23 months of age

Stunting in < 5 year old LSMS 2001 – 17.9MICS 2006 – 17.6

Stunting Standard I Class1996 – 13.72009 - 12.2

Unmet need for reproductive health services, and teenage pregnancy is a priority concern

Adolescent birth rate / 1,000 females 15-19

1995 - 992010 - 73

Contraceptive use prevalence rate MICS2006:

1999 – 56%2006 – 34%

Adolescent Health

• There were 1,356 live births to mothers in the 15-19 year age group, which represents 18.1% of the total live births.

• There was an average of 24 live births to mothers under 15 years.

• From 2001-2005, there were 145 (41 males and 104 females) new HIV Infections in adolescents 10-19 years

• 6.9% of total new HIV Infections (16 ) occurred in the 10-14 age-group;

• Early initiation of sexual activity and the prevalence of STIs are public health concerns in this age group.

• Fourteen suicides and self-inflicted injuries were reported in the 10-19 age group during 2001-2005.

Belize Health Agenda, 2007-2011

Objective

The SM2015 Operation in Belize seeks to:

Increase the coverage of quality reproductive, maternal, neonatal and child health care in the poorest geographic areas and increase the use of information in decision making to reduce neonatal death and increase the use of family planning among adolescents

Where?

Districts with highest increase in poverty rates [2001/2009]

—Corozal—Orange Walk—Cayo

National Poverty Assessment, 2009

•Living Standards Measurements Survey

•% of poor and indigent households per rural/urban districts

Component 1: Strengthening use of data to improve MCH service quality

• Expansion of the Collaborative Improvement Model to reduce maternal and child mortality

• Expansion and Utilization of the Belize Health Information System in decision making at the local level

• System of facility based-incentives at the MoH Clinics in the Northern and Western Regions for expanding coverage and quality

• Cross-country exchange and training to improve quality of care

Component 2: Improving Community Based Care

• Monitoring and Evaluation of Community Health Workers (CHW)• Currently rolling out community based nutrition initiatives

that include breast-feeding promotion, growth-monitoring, and waiting for results to decide about rolling out sprinkles

• Incentives for Community Health Workers who reach targets• Currently receive $50 US, exploring incentives that would

improve working conditions such as Basic supplies and equipment for CHW and developing a recognition system

• Improved coordination and training of CHW (recognition of high-risk cases)

Component 3: Increasing the Coverage of Reproductive Health Services

• Increased access to 5 modern family planning methods

• Capacity-building in counseling for Patient/Users

• Differentiated services designed and used by adolescents

Making pregnancy safer : Prenatal, postnatal care, skilled birth attendance, managing complicated pregnancy, childbirth and patients in postnatal period, managing complications

Immediate and routine newborn care, Managing Complicated neonates

Multiple micronutrient supplementation: females 15-49, children

Fortified food: pregnant women and children

Growth promotion and development: community, facilities

5/7 hospitals certified as baby Friendly

Contraceptive methods: public sector and NGO

Supplies procured thru UN Agencies [UNFPA, UNICEF] and IDA Foundation.

Prevention mother to child transmission: HIV & syphilis…….

Interventions

Technical assistance in Maternal and child health including reproductive

health services

Quality improvement of services utilizing collaborative model

—Updating of protocols, standards and indicators, framework and tools for the monitoring of process of care in all areas under the project

Integrated RH services for adolescents

Management of RH supplies

Data management [Belize Health Information System]

Community based care

Health System Structure

Ministry of Health

• Operates in six districts: Belize, Corozal, Orange Walk , Cayo Stann Creek and Toledo

• Employs Service Level Agreements with District Level

• Limited planning function, financing of health supply

• Interest in introducing incentives

National Health Insurance • Started in 2001 and operates in

three areas: Toledo, Stann Creek and South Side Belize

• Utilizes P4P through contracts with PCP in private and public health centers

• Provides free services to all eligible (poorest) populations

• Focuses on pre-natal and postnatal care and deliveries, and primary care for chronic illnesses such as diabetes, hypertension, and asthma.

Health System Network

1 National Referral Hospital

3 Regional Hospitals

Stann Creek, Beloman,

Orange Walk

3 Community Hospitals

Toledo, Corazol, y San Ignacio

Poly-Clinic 2

Health Posts-no

permanent staff

Mobile Units Community

Health Workers

Poly-Clinic 1 (primary care)

NHI Details (1)

• The NHI pays the clinics a monthly member capitation payment• Clinics have an incentive to register as many people as they can

• Each month, the NHI pays clinics 70 percent of the member capitation payment upfront.

• The remaining 30 percent of the payment depends on how the clinic performs on groups of indicators that lead to scores for efficiency• 70 percent of the withheld amount

• quality (20 percent of the withheld amount)

• and administrative processes (10 percent of the withheld amount)

• If an indicator is not fully achieved, then the proportional weight is deducted from the clinic’s total potential payment for that month

Source: Michelle Vanzie, Natasha Hsi, Alix Beith, and Rena Eichler (2010): Using Supply-side Pay for Performance to Strengthen Health Prevention Activities and Improve Efficiency: The Case of Belize. USAID Health Systems 2020, P$P Case Studies.

NHI Details (2)


NHI Details (3)


Goals 18 monthsIndicador Target Source of verification

Health facilities that have the necessary inputs for providing emergency obstetric and neonatal care according to the norms

75% Health Facility Survey

Health facilities that have the necessary inputs for providing pre- and post natal care according to the norms


Health facilities that have submitted a Quality Improvement Fund (QIF) proposal to the national quality audit team


Health facilities that have the necessary inputs to provide child health care according to the norms


Health facilities that have implemented Quality of Care job aid tools for reproductive health


Health facilities that can submit and receive data from the Belize Health Information System (BHIS)


Health facilities that have permanent availability of all 5 types of modern family planning methods (injectable, barrier, oral, IUD, permanent) according to the norms


Health facilities that have sexual and reproductive health (SRH) educational materials specifically targeted at adolescents


Norms for improving the quality of reproductive and child health and nutrition services and for the establishment of a community platform of services adopted

Yes Norm Approved

Community health workers (CHW) trained in the community platform85% Health Facility Survey

District HECOPAB Officers that are currently monitoring the CHWs 85% Health Facility Survey

Health facilities with a mechanism in place for carrying out patient satisfaction surveys85% Health Facility Survey

Goals 36/54 months

Indicator Baseline Target PP change Source of verification

Institutional deliveries for which oxytocin was administered immediately following birth as part of Active Management of the Third Stage of Labor (AMTSL) in the last two years for the most recent delivery

80% 15 Health Facility Survey

Pregnancies for which the woman attended at least one antenatal care visit during the first trimester that was carried out according to the norms for the most recent pregnancy in the last two years


Institutional deliveries for which immediate neonatal care (within 24 hours) was provided to the infant according to the norms in the last two years for the most recent pregnancy


Neonatal complications (prematurity, low birth weight, asphyxia and sepsis) handled according to norms in the last two years


Obstetric complications (sepsis, hemorrhage, severe pre-eclampsia and eclampsia) handled according to the norms in the last two years


C-sections as a proportion of childbirths in the last two years 30% -20 Health Facility Survey

Female health facility patients of reproductive age that are given family planning counseling according to the norms in the last two years


Women of reproductive age (15-49 years) who were not using/unable to obtain contraception during last year

31% -5 Household-based survey

Infants 0–5 months of age who were fed exclusively with breast milk the previous day 23% 10 Household-based survey

Mothers with a child 0-23 months that that can recognize 3 out of 5 signs of danger 20% 40 Household-based survey

Percentage of children aged 6-23 months that consumed 60 sachets of micronutrients in the last 6 months

0 30 Household-based survey

Mothers who gave their children (0-5 9 months) ORS and zinc supplements during the last episode of diarrhea in the two weeks

0 40 Household-based survey

sm2015 - belize sm2015 initiative innovative approaches may 2012

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