1. Applying simplified approaches for quality improvement in MNCH/FP/N: Early experiences from MCHIP Bangladesh Joby George Chief of Party, MCHIP Save the Children Bangladesh

2. To improve utilization of integrated Maternal, Newborn, Child Health, Family Planning and Nutrition (MNCH/FP/N) services Goal To increase availability and quality of high impact interventions through strengthening district level local management and health system Objective 4. Identify and reduce barriers to accessing health services 1. Improve service readiness through critical gap management 2. Strengthen health systems at district level and below 3. Promote enabling environment to strengthen district level health system Intermediate Results MaMoni HSS: Overview

3. Technical Priorities Health systems: Leadership and management, Decentralized planning and management, HRH, RHIS, QA, Logistics management, National advocacy, Local government Newborn Health: Chlorhexidine, Helping Babies Survive (CNCP), Kangaroo Mother Care, Sepsis Management, antenatal corticosteroids, Advanced newborn care Maternal Health: ANC/PNC, SBA, CEmONC/BEmONC, PPH, PE/E, referral strengthening FP: Informed choice, PPFP, LARC, LAPM Nutrition: IYCF, maternal nutrition, SAM, MAM, WASH Child Health: ORT/Zinc, IMCI, CCM, EPI Community mobilization: CVs, CAG, interface with systems mHealth: MAMA/Aponjon, automated RHIS

4. Total population: 12.2 million Children under-five: 1.3 million Births per year: 0.43 million ~ 8% of the country population Population reach

5. Quality improvement: context Competitive environment Project’s history of several disjointed approaches to QI – SBM-R as the key approach to QI – Other approaches: regional quality improvement teams, MPDR, joint supervision – Large scale roll out of new interventions/ QI components Project’s national technical leadership in MNCH/FP/N Government has prioritized quality of care – New sector plan – QI strategy and QI Secretariat – Institutionalized QI support structures

6. Early lessons Successful in bringing QoC issues to the forefront – national, district and health facilities Challenges: – Co-existence of multiple QI approaches: branded models pose a barrier – Importance of coherence and coordination of various QI components – Low levels of local ownership and motivation – The standards and tools were too complex for certain levels of facilities – Unsurmountable health system challenges: absence of local solutions – Impossible to improve to address MNCH/FP/N issues in isolation

7. Simplified QI approach: Principles Keep it simple and generic Focus on improving crucial MNCH/FP/N services Strengthen local ownership of QI process Apply simple QI concepts and tools Engage local stakeholders – beyond MOH providers Improve quality of health services incrementally in stages Link the multiple QI initiatives to complement each other QI at all levels of service provision – facility and community Promote use of QoC data for local level reviews, planning and action

8. Application of generic QI models Leadership Ownership Motivation Identify Gaps Analyze causes Develop Action Plan Measure Impact

9. Implementation by stages Stage 1 Basic cleanliness Bio-waste management Minimum infection prevention Stage 2 Advanced infection prevention Organization of services, crowd management, logistics Minimum clinical standards: EMEN, SBM-R Stage 3 Comprehensive clinical standards & patient rights Health systems: staff, commodities, supplies Recognition/ Accreditation

10. MaMoni HSS Quality Improvement Model Sentinel QoC Assessment QI Action Plans In-service training and refresher Joint Supervision Visits Accreditation/ recognition Death reviews (MPDR) Improved logistics planning and mgt Clinical Supervision (RRQIT) QI Committees Program reviews Facility Mgt Committees Local Government Leadership and accountability Motivation and Ownership Essential MNH Standards (EMEN, SBM-R) Standard Operating Procedures (MNH & FP-SOPs, IMCI, Nutrition) IP, waste management, patient flow mgt, Info Mgt, cleanliness Facility Management High quality MNCH/FP/ N services

11. EMEN Standards Clinical Care Evidence-based safe antenatal care is provided. Evidence-based safe care is provided during labor and childbirth. Evidence-based safe postnatal care is provided for all mothers and the newborns. Patient Rights Human rights are observed and the experience of care is dignified and respectful for every woman and newborn. Cross-cutting Governance system to support the provision of quality maternal and newborn care. Safe physical environment of the health facility Qualified and competent staff are available in adequate numbers Essential drugs, supplies and functional equipment and diagnostic services Health information systems Continuity of care for all pregnant women, mothers and newborns.

12. SBM-R Tools Birth spacing and family planning Antenatal care Normal labor, child birth, and immediate newborn care Management of obstetric complications Postpartum care Sick newborn care Infection prevention Facility management

13. District level Health Systems Strengthening A joint district quarterly performance review meeting of Health and FP Managers Decentralized upazila level planning session Automated MIS tools on computer tablets to collect and use real-time data Local government constructed a new UH&FWC in Horni, Hatiya upazila, Noakhali spending BDT 1.1 million Joint supervision visit by MOHFW officials in Madhabpur, Habiganj

14. Physical infrastructural preparedness: Union FWCs renovated, staffed to provide 24/7 services

15. Staffing, Renovation and Waste Management Kakailseo UH&FWC

16. Community level initiatives 24,000 community volunteers, and community groups Interface between community volunteers and frontline health workers – monthly community microplanning meetings Local elected representatives mobilized to take action on MNCH-FP-N issues and strengthen governance Voice

17. Thank You