CENTER FOR HEALTH DEVELOPMENT National Capital Region

MNCHN STRATEGY:

Philippine Effort to Secure Benefits of FP-MCH Services

Dr Ruben Siapno
Chief, Health Operations Division, CHD-NCR

Outline of Presentation
Four Parts
1. How we look at FP and MCH 2. Review of how we are faring in securing FPMCH benefits 3. A closer look at MNCHN for guidance 4. A new look at FP Healthy Timing and Spacing of Pregnancy

MCH Beyond Policies, Programs or Projec

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 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

5 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%..

Actual 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

Organization 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.

Model 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

Comparator 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

Comparator 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)

2. THE MNCHN STRATEGY

The 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%

The MNCHN Framework

Demand for health care

Desired health outcome s

Supply of quality health care

Actions by LGUs

Issuances, actions and influence by CHD & national agencies

Desired Public Health Outcomes

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 womens health care package for the mother and child survival package for the newborn

Supply 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

Adolescence and Prepregnancy

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....)
Pregnancy

Birth

Postpartum

Maternal Health

Childhood

Infancy

Neonatal

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 (MNCHNMOP pp. vii; 30-37).

Supply/Demand for Quality Health Care

MNCHN Service Delivery Network

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

MNCHN Service Delivery Network

Levels of Core Service Package (Interventions)

EmON C

BEmONC level CEmONC level

BEMONC

CEMONC

PUBLI C HEALT H OUTCOMES

CP R

MNCHN Service Delivery Network Service Delivery Network

BENEFICIARI ES Men and Women of Reproductive Age with Unmet FPMCH Needs

Public
Community or Primary Health Providers: Community Health Teams, Rural Health Units/ Health Centers, Barangay Health Stations, Public Health/LyingSECONDARY inCARE Clinics (doctors, PROVIDERS Infirmaries, nurses, municipal, midwives) COMMUNITY HEALTH PROVIDERS BEMONC CEMONC

Privat e Non-NHIP
accredited Private Practice Midwives & Birthing NHIP Homes accredited PPMs & Birthing Homes Hospitals Other Service Delivery Points
Company Clinics, Schoolbased clinics, etc

MMR

Special Groups:

Young people Workplace workers

district hospitals, outpatient departments, TERTIARY CARE : etc Hospitals

Alternate Distribution Points for FPMCH Products

COMMUNITY

DOH/CHD/LGU/PRIVATE

MNCHN Service Delivery Network

Actions 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.

Issuances, Actions & Influence by CHD & 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

3. LOOKING AT MNCHN CLOSELY

ot just another Program!

Its a strategy for
o achieving health outcomes on a population scale o mobilizing efforts from institutional structures of society in behalf of these outcomes o using the countrys 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

MNCHN 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

MNCHN 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)

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.

MNCHN as Vehicle for Attaining Sustainable Improvements in Family Health

MNCHN as Vehicle for Attaining Sustainable Improvements in Family Health City - wide service delivery network model
can deliver results at scale
o CHOs mobilize public and private providers to deliver MNCHN service package o 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 clients
o 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 sustainable

o City governments/LGUs and private sector support adoption of MNCHN framework, directions and standards with local mandates, structures and funding

QUESTION: Will the MNCHN vehicle deliver?

Framework for DOH-LGU Cooperation 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

MNCHN Program of Work

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

MNCHN Features Important to Implementation

Priority 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

5 Essential Pre-Conditions for LGUlevel 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 activities 4. Local program of public-private partnerships 5. High level of NHIP implementation

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

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.