Presentation on theme: "Scaling Up Malaria in Pregnancy Services in Tanzania"— Presentation transcript:
1 Scaling Up Malaria in Pregnancy Services in Tanzania Patricia P. GomezClinical Specialist, ACCESS Program/JHPIEGO
2 Acknowledgments The ACCESS/Tanzania team: The ACCESS/Baltimore team: Maryjane LacosteMuthoni Magu-KariukiGaudiosa TibaijukaThe ACCESS/Baltimore team:Natalie HendlerNancy CaiolaBarbara RawlinsSarla ChandSteve Bruno
3 Overview What is the ACCESS Program? Why is MIP important to address? What are Tanzania’s health indicators?Why scale up MIP services?How are MIP services being scaled up?What has the program accomplished and learned, and where does it go from here?
4 The ACCESS ProgramAccess to clinical and community maternal, neonatal and women’s health services5-year, $75 million USAID flagship maternal and newborn health programPartners: JHPIEGO, Save the Children-US, Constella Futures, Academy for Educational Development, American College of Nurse-Midwives, IMA World HealthGoals: advocacy and policy in maternal/newborn health issues at the global level; scale up known cost-effective evidence-based interventions to reduce maternal and newborn mortality
5 The ACCESS Program (2) Currently working in 25 countries Collaborate with Ministries of Health; international bodies (WHO, UNICEF, UNFPA, PMNCH, CDC, etc.) and USAID-funded global and bi-lateral programsSpecial InitiativesPrevention of postpartum hemorrhageNewborn survival - KMCPrevention and treatment of malaria in pregnancyPre-service educationSafe Birth Africa Initiative, RwandaBased on household-hospital continuum of care
6 Household-to-Hospital Continuum of Care Model Intersectoral Stakeholders/PartnersCommunity Groups (e.g., FBOs) * Community LeadersService Providers * Policymakers * Private SectorDonors/Partners * USAID Missions and other CAsHouseholdWomenNewbornsFamilyHospitalPeripheral FacilityCommunity Champions and Change AgentsSociocultural EnvironmentPolicy
7 Anticipated Funding Level President’s Malaria Initiative Launched 2005: Funding Levels and CoverageYearAnticipated Funding LevelCoverage2006$30 million3 countries2007$135 million*7 countries2008$300 million15 countries20092010$500 millionTOTAL$1.265 billionPossible plus-up of $25 million
8 PMI Goal and Targets Goal: To reduce malaria-related mortality by 50% in 15 selected countriesTargets:To achieve 85% coverage of vulnerable groups with four key interventions
10 Addressing MIP90% of all malaria illness and death in the world occurs in sub-Saharan Africa50 million women who live in malaria-endemic regions become pregnant each year; over 50% of them live in sub-Saharan AfricaMost common and virulent species of the malaria parasite is Plasmodium falciparumInfection with P. falciparum may result in:maternal anemia (2 – 15%)fetal loss, IUGR (13 – 70%), and low birth weight (8 – 36%)
11 Why should MIP be addressed? (2) Malaria is usually asymptomatic but leads to severe maternal anemia and low birthweightUp to 200,000 infant deaths/year could be prevented by control of MIPHIV increases risk of contracting malaria and worsens the disease; reduces antimalarial efficacy
12 Characteristics of Malaria Transmission Stable areas, e.g. TanzaniaPeople are frequently bitten by infective mosquitoesLevels of acquired immunity are high (pregnant women are semi-immune to malaria)Low peripheral parasitemiaHeavy placental infectionUnstable areas, e.g. South AfricaPeople are infrequently exposed to malariaLevels of acquired immunity are low (pregnant women are not immune)Heavy peripheral parasitemiaLow or undetectable placental infectionThe intensity of malaria transmission in an area determines the effect of malaria on pregnancy. In areas of stable transmission, malaria is frequently transmitted by mosquitoes from one person to another resulting in high levels of acquired immunity. Pregnant women in these areas are semi-immune to malaria and have a low prevalence of peripheral parasitemia but a high prevalence of placental infection.On the other hand, in areas of unstable transmission, malaria is infrequently transmitted from one person to another. Therefore, pregnant women in these areas have low levels of acquired immunity with heavy peripheral parasitemia and low or undetectable levels of placental infection.
13 Effect of MIP in Stable Transmission Areas Plasmodium falciparum malariaAsymptomatic InfectionPlacental SequestrationAltered Placental IntegrityReduced Nutrient and Oxygen TransportHow does malaria infection lead to low birth weight newborns?This slide summarizes the sequence of events in stable areas of malaria transmission. In these areas, women have a high level of acquired immunity to Plasmodium falciparum malaria and are often asymptomatic due to low peripheral parasitemia. Pregnancy naturally lowers cell-mediated immunity and causes immunosuppression. In areas of stable transmission, the placenta is a protected site for parasite sequestration and growth. Its effect during pregnancy appears to be “parity-specific”. During the first malaria-exposed pregnancy (that is, in primigravida), local immunity to malaria develops in the placenta. This immunity has no effect in the first pregnancy but is retained in the uterus and increases cumulatively in subsequent pregnancies. This is why women in their first and second pregnancies are more affected by malaria than women in subsequent pregnancies.The malaria parasites in the placenta damage placental integrity and interfere with the ability of the placenta to transport nutrients and oxygen to the fetus, thereby causing intrauterine growth retardation, a factor for delivery of low birth weight newborns. A low birth weight newborn is defined as one that is born weighing 2500 grams or less. Another pathway to low birth weight is severe maternal anemia which is also caused by the malaria infection. In general, low birth weight babies have a higher risk of dying in infancy.AnemiaLow Birth Weight (IUGR)Risk of Newborn MortalitySource: WHO 2002.
14 Effect of MIP Unstable Transmission Areas Acquired Immunity – LowClinical IllnessSevere DiseaseRisk to MotherRisk to FetusWhat happens in areas of unstable malaria transmission?Women in these areas have lower levels of acquired immunity. Therefore, they have an increased frequency and severity of malaria and anemia. Delayed recognition and inappropriate treatment may lead to a progression to severe disease, which has serious consequences for both the mother and the fetus. This effect is seen in virtually all pregnancies, irrespective of parity.Source: WHO 2002.
15 Effects on the Pregnant Woman Primigravidae in Stable areasAll parities in Unstable areasHigh fever (symptomatic)Placental infectionPuerperal sepsisComplicated malariaSevere anemiaCerebral malariaHypoglycemiaPulmonary edemaAcute renal failureIncreased maternal mortality++++++-As stated earlier, the effect of malaria infection depends on the intensity of malaria transmission in the area, which in turn determines the woman’s level of acquired immunity to malaria. Furthermore, birth order is also known to be a determining factor in the frequency and severity of malaria during pregnancy.This table shows that primigravid women living in areas of stable malaria transmission have an increased risk of placental infection and severe anemia. They are less likely to suffer from complicated malaria which may present in the form of cerebral malaria, hypoglycemia, pulmonary edema and acute renal failure. On the other hand, women of any parity living in areas of unstable transmission have a higher risk of malaria fever illness, severe anemia and complicated malaria.Anemia lowers the woman’s resistance to infection, thereby increasing the likelihood of puerperal sepsis. The risk of maternal mortality from malaria is higher among women living in areas of unstable malaria. The causes of death may include severe anemia, postpartum haemorrhage, puerperal sepsis or anemic heart failure.( +++ =Very Common, ++ =Common, + =Infrequent, -- =Rare)
16 Effects on the Fetus and Newborn Primigravidae in stable malaria areasAll parities in unstable malaria areasLow birth weightIUGRPrematurityAbortionStillbirthCongenital malariaFetal anemiaInfant mortality++++-?++With regards to the fetus and the newborn, primigravid women living in areas of stable malaria transmission are at higher risk of delivering low birth weight babies due to intrauterine growth retardation. Women of all parities living in areas of unstable malaria are at higher risk of premature delivery (that is, delivery before 37 completed weeks of gestation). They are also at higher risk of spontaneous abortions, stillbirths and congenital malaria. The consequences of these adverse effects is an increased risk of infant mortality among all babies born to mothers living in areas of unstable malaria transmission.( +++=Very Common, ++=Common, +=Infrequent, -- =Rare)
17 Placental MalariaPrevalence of Placental Malaria in African Women by Gravidity in Eight StudiesThis slide summarizes results from studies in eight countries in Africa. In virtually all the countries listed, primigravid women had a higher prevalence of placental parasitemia when compared to multigravid women.
18 Low Birth WeightFrequency of Low Birth Weight by Placental Malaria Infection5101520253035With placental parasitesWithout placental parasites% Low Birth WeightThis slide summarizes another study from Malawi examining the relationship between birth order, presence of malaria parasites in the placenta and the incidence of low birth weight. As shown, newborns with malaria parasites in their placenta (represented by the left bar in each cluster) had a higher risk of being born with a low birth weight when compared with newborns with no malaria parasites in their placenta (represented by the right bar in each cluster). This is true regardless of the birth order, which could be the first, the second or later pregnancy.FirstPregnancySecondPregnancyThree or morepregnanciesSource: Steketee 2001: Malawi
19 Placental Parasitemia and HIV Placental Parasitemia by HIV Status and Pregnancy Number, Kenya, (N = 2263)Parasite density/mm3% parasitemic231What is the relationship between HIV/AIDS and malaria during pregnancy?HIV infection, which is becoming more prevalent in women of reproductive age, may diminish a pregnant woman’s capacity to control Plasmodium falciparum malaria infections and lead to decreased efficacy of antimalarial interventions.This graph summarizes the findings from a study in Kenya. The cluster of bars to the left represent HIV-positive mothers, and the bars to the right represent HIV-negative mothers. The data shows that, irrespective of placental parasite density or whether the women are in their first, second or later pregnancies, those who are HIV-positive are more likely to have malaria parasitemia when compared with those who are HIV-negative. Because the HIV virus is an immunodeficiency virus, HIV-positive women have lower levels of acquired immunity for all infections including malaria. The implication of this finding for treatment is that HIV-positive women have a reduced efficacy to antimalarial medication and need more doses of the medication than their HIV-negative counterparts.159197772402479HIV (+)HIV (-)Summary RR = 1.63 ( ), p <0.001Source: van Eijk AM et al 2001.
20 Intermittent Preventive Treatment in Pregnancy IPTp is an approach for effectively preventing and controlling malaria during pregnancy thatIs based on an assumption that every pregnant woman in a malaria-endemic area is infected with malaria, andRecommends that every pregnant women receive at least two treatment doses of an effective antimalarial drug as a preventive measureSulfadoxine-pyrimethamine (SP) currently considered the most effective drug for IPTpThe second component of the strategic framework for malaria control during pregnancy is “intermittent preventive treatment”. Intermittent preventive treatment is an intervention for effectively preventing and controlling malaria during pregnancy. It is based on the assumption that every pregnant woman living in an area of stable or unstable malaria transmission has malaria parasites in the blood or in the placenta, and therefore, should be treated to minimize its effects on the mother and her fetus. Intermittent preventive treatment with SP is currently the most effective approach for the use of antimalarial drugs during pregnancy and is particularly attractive for use in areas with a high level of chloroquine resistance.
21 IPTp with Sulfadoxine-Pyrimethamine SP is a combination of two different drugs. Each tablet of SP contains:500 mg of sulfadoxine, and25 mg of pyrimethamineA single dose consists of three tablets taken at once, preferably under direct observation of the healthcare providerFansidar is the most common brand name. Others include Falcidin, Laridox, Maladox, Orodar, MaloxineSP is generally more effective than chloroquine which is no longer effective in most countries because of parasite resistanceSulfadoxine-pyrimethamine is the drug of choice in many countries for intermittent preventive treatment of malaria. SP, as it is often called, is a combination of two drugs. Each tablet contains 500 mg of sulfadoxine and 25 mg of pyrimethamine. A single dose consists of three tablets taken at once, preferably under direct observation by the healthcare provider. Fansidar is the most common brand of SP, but there are other brands such as Falcidin, Laridox and Maladox. SP is generally more effective than chloroquine due to the increasing prevalence of chloroquine resistance in many parts of Africa.
22 Effect of IPTp with SPCase management alone does not reduce effects of malaria in pregnancy as well as IPTpNot all women with malaria parasites have symptoms, and therefore would not receive treatment if we relied solely on case managementIPTp produced better outcomes in terms of reducingMaternal and placental parasitemiaLow birth weightIPTp is as effective as case management in terms of improving hemoglobin levelsNOTE – former slide was table – changed to text:Shown here is evidence in support of the use of intermittent preventive treatment with SP. This table summarizes a study from Kenya in which data from three groups of pregnant women were analyzed. These were women who had case management for malaria illness, women who were protected by the two-dose SP regimen, and women protected by a monthly SP regimen. The groups protected with the two-dose or monthly SP regimens had higher mean blood hemoglobin levels than those in the malaria group. Also, the groups protected with SP had lower incidence rates of Shown here is evidence in support of the use of intermittent preventive treatment with SP. This table summarizes a study from Kenya in which data from three groups of pregnant women were analyzed. These were women who had case management for malaria illness, women who were protected by the two-dose SP regimen, and women protected by a monthly SP regimen. The groups protected with the two-dose or monthly SP regimens had higher mean blood hemoglobin levels than those in the malaria group. Also, the groups protected with SP had lower incidence rates of maternal parasitemia (9 and 7%) and placental parasitemia (12 and 9%) compared to women seen with malaria illness (27%).maternal parasitemia (9 and 7%) and placental parasitemia (12 and 9%) compared to women seen with malaria illness (27%).The incidence of low birth weight newborns among those who were protected with SP (8%) was also lower than among those not protected with SP (which was 14%). The conclusion is that intermittent preventive treatment offers some protection from the adverse consequences of malaria during pregnancy.
23 Rationale for the Timing of the SP Doses Fetal growth velocity RxRxLastmonthQuickeningThe World Health Organization or WHO recommends a schedule of four antenatal clinic visits, with three visits occurring after quickening. At least two doses of IPT should be delivered at scheduled antenatal care visits after quickening until delivery. SP should not be given more frequently than every four weeks. The concern about neonatal jaundice resulting from SP given after 36 weeks of gestation does not appear to be a major one at this time.Kenya, Malawi, Tanzania, Uganda and Zambia have embraced a two-dose SP regimen. In these countries, the first dose of SP is given between weeks and the second dose is given between weeks of pregnancy. No SP is given after 36 weeks. Countries with no policy should consider adopting a three-dose regimen that is in line with WHO’s 3 recommended scheduled antenatal visits after quickening.10162030Weeks of gestationBirthConceptionSource: WHO 2002.
24 Key Issues About Timing of Doses SP should be avoided during the first 16 weeks of pregnancy which is the period of initial development of the fetusIt is best to clear the placenta of parasites during the period of maximum fetal growthIPTp allows the mother to recover from anemia by clearing peripheral parasitemiaA note for the future – SP resistance is growing, and at some point a new medicine for IPTp will be foundSP should be avoided during the first 16 weeks of pregnancy which corresponds to the period of organ formation in order to avoid congenital malformations. It is best to clear the placenta of parasites during the period of maximum fetal growth as shown in the previous graph. IPT of malaria during pregnancy allows the mother to recover fully from anemia by clearing peripheral parasitemia.The question arises as to what protection a woman can have during these early weeks of pregnancy. The answer lies in early attendance at ANC where an Insecticide Treated Net can be received.
25 Steps for Providing IPTp with SP Determine quickening has occurredInquire about history of severe skin rash from previous SP useInquire about use of SP in last monthProvide three tablets of SP with clean water in a clean cupObserve the patient swallowing all three tablets (Directly Observed Treatment or DOT strategy)DOT is one reason to ensure that IPTp is an essential component of an integrated ANC programDo not encourage women to undertake IPTp on their ownWhat are some of the steps that should be taken when providing IPT with SP?Determine that quickening has occurredInquire about any history of allergy to sulfonamides, including severe skin rashInquire about the use of SP or any sulfonamides in the past month.If there are no contraindications for giving SP,Provide three tablets of SP with clean water in a clean cup, andDirectly observe the woman taking the SP tablets in the clinic. This helps to ensure compliance.
26 Steps for Providing IPTp with SP (2) Ask about side effects from previous dose before giving the next dose, which should not be less than 4 weeks from the last doseRecord SP on the antenatal card and the clinic recordInstruct client to return at next scheduled visit or earlier if she is feeling illDrop-out is a major challenge for successful IPTp programsFrom 20-50% of women do not receive a second doseRecord “SP given” in the woman’s antenatal card and clinic recordInstruct the woman to return at her next scheduled visit or earlier if she is feeling ill.Before giving any follow-up dose at the next visit, ask about side effects from the previous dose. A follow-up dose should not be given less than 4 weeks from the last dose.
27 Use ITNs/LLINsThe use of ITNs/LLINs have been shown to result in reduction of low birth weight or prematurityITNs reduce transmission by physically preventing vector mosquitoes from landing on sleeping personsThe use of insecticide-treated nets have been shown to result in a reduction in the proportion of newborns born with low birth weight or born prematurely (that is, before 37 completed weeks of pregnancy). Insecticide-treated nets also reduce malaria transmission by serving as a physical barrier between the vector mosquitoes and people sleeping inside the nets. They repel or kill mosquitoes that land on the net and can also kill bed bugs, lice, ticks, cockroaches and other insects around the house. They should be used by pregnant women as early as possible during pregnancy and their use should be continued throughout pregnancy and in the postpartum period.A study from western Kenya showed that women who were protected by insecticide-treated nets every night during their first four pregnancies delivered approximately 25% fewer newborns who were either small for gestational age or born prematurely when compared to women who were not protected by insecticide-treated nets.
28 ITN/LLIN BenefitsRepel and kill mosquitoes that come in contact with the netKill other insects like cockroaches, lice, ticks and bed bugsShould be used by pregnant women as early during pregnancy as possible and use should be encouraged throughout pregnancy and in the postpartum periodNets have a variety of benefits and should be provided to a pregnant woman as early in pregnancy as possible.
29 ITN: Impact on Fetal Growth and Duration of Gestation Pregnant women protected by insecticide-treated nets were less likelyTo deliver prematurely orTo have small-for-gestational-age newbornsCompared to control groups who were not protected by the netsThis finding holds true irrespective of the woman’s parity, except for the incidence of small-for-gestational-age babies born to women with 4 or more pregnanciesShown here is the result of a study that examined the impact of insecticide-treated nets on fetal growth and the duration of gestation. The study showed that pregnant women protected by insecticide-treated nets (represented by the right bar in each cluster), were less likely to deliver prematurely or to have small-for-gestational-age newborns compared to control groups who were not protected by the nets (represented by the left bars). This finding holds true irrespective of the patient’s parity, except for the incidence of small-for-gestational-age babies born to women with 4 or more pregnancies.Source: ter Kuile et al 1999
30 ITN/LLIN Procurement and Management ITNs are often provided during childhood immunization campaignsIt is less common to find ITNs allocated in adequate numbers to be an essential component of focused ANCThe district health management team needs to meet and plan for adequate nets for children <5 as well as pregnant womenITN/LLIN provision can be an important incentive to attend ANCA woman should get a net on her first ANC visit when it can offer the most protection during pregnancyIssues of subsidized v. free ITNsAlthough ITNs have been around for over a decade, their use as a staple component of ANC has been less common. Countries are under pressure to report numbers, and campaigns are a fast way to get nets out into the community, primarily to children under five years of age. Rarely are ITNs part of routine child immunization programs or ANC. Therefore there are major logistical challenges to overcome if ITNs are to be supplies to ANC clinics on a regular basis.
32 Health Indicators in Tanzania GENERALPopulation: millionCrude birth rate: 43Crude death rate: 14Total fertility rate: 6.3Life expectancy: 51 yearsMMR: 578/100,000 live birthsNMR: 32/1000 live birthsIMR: 68/live birthsHIV prevalence: 7%MALARIA-RELATEDMalaria illness accounts for 40% of all outpatient visitsITN ownership: 23%Use of ITN by pregnant women: 16%One ANC visit: 94%Four ANC visits: 62%1st ANC visit by 16 weeks: 14%IPTp1: 52%IPTp2: 22%SBA: 56%Source: Tanzania DHS
33 How to ensure MIP services WHO recommends four ANC visits for women experiencing normal pregnancyFirst visit should be before 16 weeksUsing ANC as a platform women receive:Basic ANC services – iron/folate; syphilis testing/treatment; tetanus toxoid vaccination; PMTCT; health counseling – nutrition, birth spacing, breastfeeding, etc.Counseling on use of ITNsITNs or vouchers to buy them at subsidized priceIntermittent preventive treatment (IPTp)Appropriate case management of malarial illness
34 How to ensure MIP services (2) Orientation package developed: Focused ANC/Syphilis/Malaria in pregnancy (FANC/SIP/MIP)Providers (midwives) trained as clinical trainers at national, provincial, and district levelsModule on quality improvement added and process integrated
35 Building the training system Advanced Training Skills Workshop for FANC (One 2-week course)Participants: ZPOs, ZTC Counterparts and ZRCH Coordinators ( from all 8 zones + Zanzibar)Trainers: ACCESS StaffFANC orientation and Clinical Training Skills Workshops/FANC TOTs (Multiple 2-week courses)Participants: Regional and District RCH Coordinators; ANC in-charges; strong service providers; goal is 5 trainers/district, or 20 – 40 in each regionTrainers: National trainers with support from ACCESS staffBasic FANC Orientation Workshops(Multiple 6-day courses)Participants: all FANC providers from hospitals, HCs and dispensariesTrainers: all FANC trainers
36 Issues in scaling up training Orientation package needs approval by MOH/MCH section as well as the NMCP and must incorporate new guidelines as they come outDistricts had to commit funds to get providers trained at all levels of the system – to health center and health post levelsTension between MOH desires for sustainable training framework and USG emphasis on numbers trained
37 Issues in scaling up (2)Monitoring of all facilities was difficult, so system of sentinel sites (30) was introduced, but each is at a different level of developmentStockouts of SP more frequent than MOH admitted; now reported through EPI systemZonal, regional, and district supervisors must be involved in monitoring and supervision so that providers can provide care they learned in training
38 How are MIP services being scaled up? A total of 441 in-service trainers have been trained since 2004415 from facilities in 21 regions26 are Zonal and Regional RCH Coordinators from all 8 zones2,431 providers (41% of those offering FANC) have been trained since 200425% of facilities (1,199) offering FANC have trained providers
39 How are MIP services being scaled up? (3) Tutors and preceptors trained from all 51 nursing and midwifery schools (includes FBOs)28 diploma level23 certificate levelThis year 1600 students will graduate from these programs, exposed to FANC/MIP/SIP
40 Scaling up with FBOsAbout 42% of health care in Tanzania is provided by faith-based organizations21 providers from 15 FBO facilities trained in Mwanza regionAdvocacy meetings targeting religious leaders carried out to increase dissemination of health messages to men and women
41 Scaling up through demand creation Communities must be aware of the importance of FANC and must demand the servicesPartnership formed with media groups to formulate radio messagesAdvocacy to religious leadersSome training of community workers and good support through the White Ribbon Alliance
42 How are MIP services being scaled up? (4) Thus in sentinel sites coverage is:IPT1 = 59% (52% DHS)IPT2 = 41% (22% DHS)ITN voucher distribution = 93% (75% TDHS)Challenges includeStock outs of SPData reporting/collectingSupervisionSource: TDHS 2004/5
43 How are MIP services being scaled up? (5) Quality improvement process using performance standards is incorporated into provider training
44 VERIFICATION CRITERIA ANC QI Assessment ToolPERFOMANCE STANDARDSThe health care provider properly conducts individualized care based on national guidelines and according to findingsVERIFICATION CRITERIAPROVIDE ROUTINE CARE – TAKE ACTIONGives on DOT 3 tablets of sulfadoxine–pyrimethamine according to the national guidelinesExplains that in case she vomits within 30 minutes, the dose should be repeatedProvides ferrous sulfate and folic acid or FEFOL in enough amounts to last until next visitProvides mebendazole tablets 500 mg DOT once by mouth after first trimesterGive tetanus toxoid (TT) based on woman’s need according to standard guidelinesY,N, NA____COMMENTSANC QI tool is completed at each assessment through observation, interview or records review against each performance standard by N, Y or NA.Comments are written especially where there is a N for No to help facility staff to understand actual performance gap followed by developing strategies to address the gaps.In this case the performance standard is …. And one of the verification criteria is provider gives…. Followed by a Y if ….or N… or NA if the gestational age is before 20 weeks or had finished the 2 doses of SP.
45 Assessed Sections in the ANC QI TOTALPERFORMANCESTANDARDSACHIEVED%1. FOCUSED ANTENTAL CARE1712712. INFORMATION, EDUCATION AND COMUNICATION (IEC)54803. INFECTION PREVENTION3754. MANAGEMENT SYSTEM7575. HUMAN, PHARMACY AND LABORATORY RESOURCES10504328ANC QI is comprised of 5 sections. Sec 1 is actual client care while others are core support and supply processes to provide FANC servicesAchieved standards are calculated against the total and converted into score in % for objective comparison by section, by facility or by type of assessmentThe slide is a simulated situation where a facility score is 58% in baseline assessmentType of assessment: Baseline= 58% Internal Assessment # : External Assessment #: Date:% ACHIEVED = ACHIEVED STANDARDS / ASSESSED STANDARDS x 100N.B. ALL STANDARDS HAVE TO BE ASSESSED THROUGH OBSERVATION, INTERVIEW OR RECORD REVIEW
46 Lessons LearnedScale up = coverage + systems strengthening; FANC must be platform for integration of servicesTraining systems must be sustainable and should include both in-service and pre-service systemsQuality improvement processes should be built in but must be supported at the outsetLink with faith-based and private sectorsM&E paramount to guide understanding of program results and next steps
47 Conclusions MIP coverage improves through interventions that Strengthen the service provision platform of ANCMobilize community acceptanceCoverage is remarkable in districts/provinces where technical support has been offeredEffective training with simple messagesA comprehensive approach leads to improved coverage and must be adapted to country needs
49 Provoking thoughtWhat is the role of community-based distribution in meeting the PMI goal of 85% coverage of IPTp2?Should ITNs be given free to all pregnant women or should they have to pay a fee through social marketing?