Sri Lanka Sharing the success story 1.Dr Deepthi Perera, Director MCH, Family Health Bureau, Ministry of Health 2.Dr Srilal de Silva, President of the Sri Lanka College of Paediatricians 3.Dr Dhammica Rowel, National Programme Manager Newborn Care, Family Health Bureau, Ministry of Health 4.Dr Deepika Attygalle, Health Nutrition Specialist, UNICEF, Sri Lanka

< 5 Mortality Rate – 11.3 /1000 LB (2009 RG) NNMR – 6.2 /1000 LB (2009 RG) IMR – 9.0 /1000 LB (2009 RG) < 5 Mortality Rate – 11.3 /1000 LB (2009 RG) TFR – 2.3 (2006/2007 DHS) CPR – 68% MMR – 31.13 /100000 LB (2010, FHB) Still Birth Rate – 8.8/1000 Births (2007, MSU) LBW – 17.6% (2008, MSU) Total Population 20.2 Million (2012) Women (15-49 years) – 15% Children <5 years – 2% GNP per capita US$ 2866 (2012a) Life Expectancy at Birth (2010) Male – 70.3 y Female – 77.9 y Adult Literacy Rate (2010) Male : 93.2 % Female : 90.8 % 2

Trend in MMR (1911 – 1995) MD/100000LB (Registrar General’s Department Data)  

Trend in MMR (1995 – 2010) MD/100000LB (Family Health Bureau)

(Source; Registrar General) Trends in IMR and NNMR (Source; Registrar General)

Why do newborns die? Causes of Child Mortality in Sri Lanka- 2009 Source: Registrar General’s Office

KEY MNH Process Indicators : Sri Lanka (Family Health Report 2007 & DHS 2006) AN TT coverage 100% (2010, FHB) AN screened for syphilis 92% (2010, FHB) At least 1 post natal visit by PHM during first 10 days 69.9% (2010, FHB) Children ever breastfed of all children < 5 years – 99.3% (2006/7 DHS) Breastfeeding initiation within 1 hr – 79.9% (2006/7, DHS) Exclusive breastfeeding under 6 months – 76% (2006/7, DHS) ANC: registered before 8 weeks – 70 % (2010, FHB) ANC clinic more than 4 visits -92.5% (2006/7, DHS) ANC clinic visits :avg– 7 (2010, FHB) ANC home visits: av no of– 5 (2010, FHB) Pregnant women visited at least once by PHM – 94.7% (2010, FHB) Skilled Birth attendance – 98.6% (2006/7 DHS) 95% Govt 3.6% Private Pregnant mothers protected with rubella 91.4% (2010, FHB)

Provincial District National Preventive Care Curative Care Level of Health system Preventive Care Curative Care National Secretary Health DHGS DDG- PHS Provincial CCP District MOMCH RE SPHIDD RSPHNO Divisional (MOH) Unit Tertiary Care Hospital FHB Provincial General Hospital Provincial Director Regional Director District General Hospital Base Hospital A/B MOH PHNS SPHI Divisional Hospital A/B/C Primary Medical care Units (CD &MH/CD/MH) SP_HM PHI PHM Field Clinic Home

Curative Institutions

Organized and continued MCH care Care for Eligible couples Family unit with women 15-49 yrs of age/ FU with under five child Pre-pregnancy care Antenatal care Domiciliary/clinic Family Planning and other RH services Through integrated package at community/clinic and institutional level Intra natal care Post natal care Institutional/Domiciliary

Implementation 1879 – Construction of First Maternity Hospital (De Zoysa Maternity Hospital) in Colombo Organization of health unit system in 1926 1968–Family Health Bureau 1983 – Breastfeeding Code 1987- Safe motherhood concept 1992 – BFHI 2000 - MDG 2007 - External Review on MNH

Supportive national MNH Policies and Guidelines

Role of Development Partners Government in the main driving seat works in collaboration with; WHO UNICEF UNFPA World Bank SAARC Development Fund In developing technical capacity, infrastructure, equipment, evaluation, operational research

Coordinating Mechanisms Central level – National Nutrition Council and Presidential Task Force National Committee on Family Health National Nutrition Steering Committee Breastfeeding code monitoring committee Food Advisory Committee Technical Advisory Committees - Newborn and Maternal Health Maternal & Child Nutrition Sub committee

Coordinating Mechanisms Central – Provincial Dialogue - Planning meetings Monitoring meetings, MOMCH reviews, MCH reviews at the districts Regional – MOH monthly meetings with the RDHS, Monthly conference at the MOH, Supervision visits of RDHS, MOMCH, MOH, RSPHNO, PHNS, SPHM SPHI etc Government and Private – Through Directorate of Private Sector Development

Health Financing Free health service Government health expenditure is 1.3 % of GDP Invest in training skilled health staff – doctors, nurses, midwives Sustain funding for the key areas and increasing the budget allocation for curative and preventive health Ensure fund allocation for priority implementations and to scale up Funds are identified for activities at the national and district levels

Human Resource Cadre positions for Institutions and field deployment of officers on a routine basis Pre and In service training for the staff caring for newborns organized (MOs, NOs, Mid wives in institutions and field) All major hospitals include Neonatologists and/or Pediatricians Medical officer and Nursing Officer cadre positions to the SCBUs and NICUs identified

Health Service Delivery Service delivery model Widely dispersed network of NICUs and SCBUs Establishment of MBC and LMC for cost effective delivery of services Reduce disparities - Estate health sector was absorbed to government service, government staff eg; MOs, PHMs appointed for duties Remote areas – recruiting PHMs for training from the underserved areas, early transfer possibilities to doctors working the N and E during the war

Technology, Medicines and Equipment Guideline for NICU, SCBU, MBC, LMC and for LR on standard infrastructure, equipment, drugs at each level NALS, CPAP ventilation, Surfactant was introduced in 2008 Essential medicines and supply needs assessment conducted annually – gaps and reasons for gaps identified and rectify at routine planning

Community Ownership and Participation Public Health Midwife is the key worker – Provide domiciliary MCH care One PHM for 3000-5000 population Every house hold in Sri Lanka is identified under PHM area BCC planning within the MCH/FP programme at National , Provincial, Divisional and Health worker (PHM) levels

Monitoring and Evaluation Well defined MIS system for monitoring and evaluation of MCH FP program Situation analysis completed; National EmONC survey completed in 2011/2012 In built system of auditing and monitoring and evaluation - Monthly Perinatal audits Infant death investigations, Maternal death audits

Success factors/ Tipping points Policies – Free health, free education - female literacy Policy to non training TBAs and invest in professional training of health staff Keeping up with the innovative global developments – ANC, BF code, BFHI, Planning Incorporation the concepts of good governance – Accountability - Formats Health Financing – successive governments have ensured Human Resource – focus on developments according to needs Over all socio-economic development over the years and after the end of the war Infrastructure development through government and donor funding

Remaining challenges To provide high quality MNH services across the country Sustaining the current status of care while focusing on new developments Inter district disparities in MMR, IMR, NMR and other MCH related indicators Timely availability of funds Parallel developments of newborn care with other relevant medical specialties eg; ROP services, Pediatric surgery, Pediatric Cardiac surgery etc.

Present status of critical interventions Preparatory Early Mature  1.Management of pre-term birth                            √  2. Skilled care at birth                           3. Basic Emergency Obstetric Care                            4. Comprehensive Emergency Obstetric Care            5. Basic Newborn Care                                        6. Neonatal resuscitation 7. Kangaroo mother care                                        8. Treatment of severe infections                              9. Inpatient supportive care for sick and small newborns

Acknowledgments Hon Minister and Deputy Minister of Health Ministry of Health and Provincial Ministries of Health Family Health Bureau Sri Lanka College of Community Physicians Sri Lanka College of Pediatricians Sri Lanka College of Obstetricians Perinatal Society of Sri Lanka WHO UNICEF UNFPA World Bank SAARC Development Fund

Thank you!!