Workshop on Monitoring System for Maternal and Child Mortality in Public Health Care Facilities, Kunming, China 24-28 September 2001 : report

(WP)RPH/ICP/RPH /002-E Report series number: RS/200 I /GE/23(CHN) English only

REPORT WORKSHOP ON MONITORING SYSTEMS FOR MATERNAL AND CHILD MORTALITY IN PUBLIC HEALTH CARE FACILITIES

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Kunming, China 24-28 September 200 I

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines January 2002

NOTE

The views expressed in this report are those of the participants in the Workshop on Monitoring Systems for Maternal and Child Mortality in Public Health Care Facilities.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Workshop on Monitoring Systems for Maternal and Child Mortality in Public Health Care Facilities, which was held in Kunming, China from 24 to 28 September 2001.

CONTENTS

SUMMARY ...... ..... .. ... ........................ ... .. .. ....... ...... .... .... ...... ..... ................. .. .. .. .. ...... ............ ... ... .. ! I. INTRODUC TION .. ................ .... .. ...... ...... ..... .. .. ................ ........ ... ....... .......... .. ...... .. ............... 2 1.1 Objectives ............................. .. ..... ..... .... ........... ......... ............. ... ................................... ..2 1.2 Participants and resource persons ............. ..... ......... ......... ............. ......... ...... .......... .... .... 2 1.3 Organizatio n ......... ............ ...... ......... ................................ ............................... ..... ... ....... 3 1.4 Opening ceremony ..... ................................................ ......... ..... .......... ................... ....... . 3 2. PROCEEDI NGS ..... ....... ......................... .. .......... ... ............. .... ...... .................. ...... ......... .. ... .. . 4 2. 1 2.2 2.3 2.4 2.5 2.6 2. 7 2.8 2.9 2.10 3. Regional overview ... ..... ... .... ....... ..... ... ................. .. ..... ............................... ... ........ ........ . 4 Maternal and Child Health Indicators ....................... ............... .. .. ... .. ............................ 6 Data collection and quality of data ......... ..... ........ ..... ... ........... .. .. ..................... .. ........... .9 Monitoring systetn ......... .. .... ................. .. .......... .... .......... ...... .. ........... .. ............ ............ 10 Use of data ............................................... .. .. ......... .... ........... ..... ............. ... ................... 12 Building partnerships ...... ........ ....... .... .. .... .... .... ................ ..... .......... .. ........ ...... ..... .. ..... . 13 Safe motherhood and HIV .. ....................... ..... ........... .. .... ............. ... .... ... ... .. ......... ....... 14 Field trip ............ .. .................. .... ............. ......... .......... ......... ........ ............................. .... 14 Planning for next steps ............... ......... ~... ... ........ ........................ .. .. .. ........................... 14 Workshop evaluation ............. ....... .......... ................ .. .......... ......... .......... ......... .... ... ... ... 14

CONCLUS IONS ..... .. ........ ................. ... ...... ............ ...... ..... .... .... .......... .. .......................... ... . IS ANNEXES: ANNEX I LIST OF PARTICIPA NTS, CONSULTA NTS, TEMPORA RY ADVISER. RESOURCE PERSON, OBSERVER S. AND SECRETAR IAT ....................................................................... .. .... ........ ... 17 AGENDA ...................................... ......... ......................... .... ........... ..... ....... 23 OPENING REMARKS OF THE REGIONAL DIRECTOR ......... ........... 25 LIST OF INDICATO RS .............. .. .......................................... ... .... ........... 27 USE OF MUL Tl-DIMENS IONAL TABLES IN IDENTlFYI NG ESSENTIA L INDICATO RS ..................................................... .. .. .... ........ 29 GROUP WORK .................. .. ........................................................ ...... ...... . 33 PLANNING FOR NEXT STEPS ................................................. ... ......... . 39

ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5

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ANNEX 6 ANNEX 7

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Keywords: Child mortality I Maternal mortality I China

SUMMARY Workshops on Integrated Management of Childhood Illness (IMCI) in 1999 and maternal mortality reduction in May 2000 led to varied in-country activities to promote maternal and child health. There has been an expressed need to assess the progress of these efforts in seven priority countries of Western Pacific Region and to examine the feasibility of developing efficient monitoring systems. In response, WHO and the United Nations Children's Fund (UNICEF) co-sponsored a regional workshop from 24 to 28 September 2001 in Kunming, China. The workshop was organized by staff from three focuses of WHO's Western Pacific Regional Office: Health Information and Evidence for Policy; Child and Adolescent Health and Development; and Reproductive Health.

Sixty professionals participated, which included representatives from WHO, UNICEF and the United Nations Population Fund (UNFPA). The workshop was opened by the WHO Representative for China on behalf of the Regional Director, the UNICEF Representative for China and the Director of Primary Health Care and Maternal and Child Health of China. The objectives of the workshop were to: I) review the process of implementation of the national plans to reduce maternal and child mortality, 2) agree on the definition of maternal death and the list of selected priority indicators for the measurement of maternal and child mortality, 3) discuss and understand the mechanics and methods of data collection based on each country's existing systems to ensure compliance with full reporting of deaths, 4) discuss and learn how to institutionalize measures to improve data quality and analysis related to their selected indicators, .and 5) identify steps to use information for decision-making, programme planning and monitoring quality of data at different management levels. In order to achieve these objectives, the workshop discussed six session topics including regional status of maternal and child health, priority indicators, data collection and quality of data, monitoring system, data utilization, and country plans. The countries in the Region, while exerting efforts to comply with their commitments to the International Conference on Population and Development (ICPD) and the World Summit tor Children. have achieved some progress in mortality reduction but still need to strengthen programmes and strategies on maternal and child health to achieve greater impact. There are also some problems with the current health information systems which need to be addressed like misclassification and under-reporting of deaths, improvement of data collection, how to transform data into useful information and how to use information to improve programme management, upgrade health care delivery and increase facility utilization. Definitions of selected indicators were discussed and priority impact, morbidity and process indicators in maternal and child health were identified. Concepts on data collection and monitoring were elucidated with the introduction of multidimensional tables and outcome-impact sequence models. Solutions to problems of incompatibility between health information systems and new interventions, specifically IMCI, were forwarded. Problem solving with the use of existing country data was practiced in session and group work. Partnerships were recognized as important in attaining common goals and in maximizing limited resources. Countries prepared their "next steps" geared for the improvement of their monitoring systems focusing on improving data collection for the priority indicators and strengthening country capability to disseminate and make use of information for programme planning and implementation. In general, the workshop objectives were met but more time to interact among participants was requested, as well as the opportunity to observe more closely the monitoring system demonstrated in the three levels of health facility in Shilin county which were visited. The workshop also demonstrated the value of collaborative efforts among focuses and agencies in carrying out common activities toward the attainment of joint outcomes.

-2I. INTRODUCTION

Following the regional workshop on maternal mortality reduction held in May 2000 in Manila, where the regional strategy on maternal mortality reduction was reviewed, the participating countries developed national work plans and service protocols on essential and emergency obstetric care to address this issue. With respect to child health, the first regional workshop on the Integrated Management of Childhood Illness strategy was held in close collaboration with the United Nations Children's Fund (UNICEF) in HaNoi, VietNam in October 1999, after which the implementation of the strategy had been strengthened in the Region. How to monitor and evaluate the outcome of efforts in countries and improvements in services for mothers and children have become challenges. A workshop to review the progress made so far in selected priority countries, share experiences in assessing progress of reducing maternal and child mortality, and examine the feasibility of developing an efficient monitoring system based on existing systems and emphasizing evidence based decision making processes, was held on 24 to 28 September 2001 in Kunming, Yunnan Province, China. I. I Objectives At the end of the workshop, the participants will have: (I) reviewed the process of implementation of their national plans to reduce maternal and child mortality; (2) agreed on the definition of maternal death and the list of selected priority indicators for the measurement of maternal and child mortality; (3 ) discussed and understood the mechanics and methods of data collection, based on each country's existing systems, to ensure compliance with full reporting of deaths; (4) discussed and learned how to institutionalize measures to improve data quality and analysis related to these selected indicators; and (5) identified ways to use information for decision-making, programme planning and monitoring quality of care at different management levels. 1.2 Participants and resource persons

Thirty-two participants from seven priority countries (Cambodia, China, Lao People's Democratic Republic, Mongolia, Papua New Guinea, Philippines and VietNam) attended the workshop. These country representatives were teams of health information, maternal and child health programme responsible officials and national clinicians in child and maternal health. There were ten observers, among which representatives from the International Planned Parenthood Federation (IPPF), United Nations Population Fund (UNFPA), and the Ministry of Health of China. The Secretariat, which totalled 13, consisted of WHO's Representative for the Regional Office in China, the Regional Advisers in Reproductive Health (RPH) and Health Information and Evidence for Policy (HIN), the Medical Officer for Child and Adolescent Health and Development (CHD), the Responsible Officer for Monitoring and Evaluation of Child and Adolescent Health (CAH) in WHO, the UNICEF Representative for China, the Senior Adviser in Health and Nutrition and other representatives from UNICEF's East Asia and Pacific Regional Office. There were three consultants and one temporary adviser. Overall 60 professionals participated in the workshop (Annex I).

-3Dr Gilbert Hiawalyer of Papua New Guinea was designated workshop chairperson with Dr Wang Bin of China as vice chairperson and Professor Chhour Y. Meng as rapporteaur. 1.3 Organization

A pre-workshop meeting was held in Kunming with the consultants, resource persons and members of the secretariat to prepare for the workshop. The sessions of the workshop were divided into six main topics. Each session, with the exception of the regional overview, consisted of the topic introduction by consultants, followed by country presentation, group discussions and session summary. Session objectives and expected outcomes were discussed and agreed upon. The participants were grouped into four for the first three group discussions. Two groups were made up of participants engaged in child health while another two groups were composed ofthose working on maternal health. Health information professionals were distributed to the four groups. Similarly, the facilitators (consultants and resource persons) were assigned to the groups according to their field of expertise (Annex 2). Daily facilitators' meetings were held after the sessions to review the events of the day and make any necessary adjustments. Facilitators were also assigned to specific countries for technical assistance especially in preparing country presentation. Each country was requested to prepare country reports specific to the workshop topics in poster formats. These posters were set up as exhibits. Three participants from three countries were asked to select the best poster exhibits after the country representatives have made their one-minute marketing presentation to "sell" their respective posters. The awarding of prizes was done on the last day. The overall winner was Mongolia with the Philippines winning for "content", Cambodia for "creativity" and Papua New Guinea for "marketing presentation". A field visit took place on the fourth day to Shit in Yi autonomous county to observe the monitoring system in the three levels of health care. An evaluation questionnaire was administered to the participants on the last day. 1.4 Opening ceremony

Dr Janos Annus, WHO Representative for China, opened the workshop on behalf of the Regional Director (Annex 3). He expressed support for the WHO-UNICEF co-sponsored workshop which was jointly organized by three focuses at WHO's Regional Office for the Pacific, namely Reproductive Health (RHP), Child and Adolescent Health and Development (CHD) and Health Information and Evidence for Policy (HIN). He reminded the participants of the commitment of countries to reduce maternal and child mortality and the need to monitor the progress. He emphasized the importance of strengthening the health information systems of countries for them to be able to collect accurate data, which can be used for policy setting and programme planning. He cited the importance of process indicators, which should be disaggregated by age, sex and by urban/rural residence in monitoring the progress of mortality reduction. According to him, data utilization was of paramount importance to both users and producers of data. He expressed appreciation for the support extended by the government ofthe People's Republic of China. Mr Edwin Judd, UNICEF Representative for China, gave a message on behalf of UNICEF as workshop co-sponsor. He also reiterated the need for countries to pay attention to their global commitment to reducing maternal and child mortality. He stressed the need for good surveillance systems to accurately assess country progress in attaining the agreed goals ofthe International Conference on Population and Development (ICPD) and the World's Summit for Children. He raised a number of issues like the use of surveillance data to improve access, coverage and quality of maternal and child health services, progress which has been achieved in helping families fulfil their right to know about practical, low cost ways of protecting women and children's lives, and the impact of gender equity on the health and development of women. He

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also referred to the HIV threat for both the mother and the child and the significant role maternal and child health programmes can play in the prevention and control ofHIV/AIDS among women and children. He thanked WHO for the preparatory work on the workshop and the Yunnan Provincial Bureau for hosting the workshop. Mr Li Changming, Director of the Department of Primary Health Care and MCH, Ministry of Health of China gave words of welcome. He said that China had been a long time partner of WHO and UNICEF in the promotion of maternal and child health which resulted in the reduction of their maternal and child mortalities. The maternal mortality ratio declined to 53.01100 000 live births in 2000 from 94.81100 000 in 1990 while the infant mortality rate (IMR) was reduced to 32.2/1000 live births from 50.2/1000. Since they recognized the importance of the monitoring system, China developed a monitoring network to track maternal mortality, child mortality and birth defects in 1990. This network involves the MCH department at the central and local government levels. He enumerated some challenges in China, such as improving the collection and quality of data, appropriate use of data and improvement in the use of internet technology nationwide. The Deputy Director of Yunnan Provincial Health Bureau, Dr Du Kelin welcomed the participants to Yunnan province and to the city ofKunming. She said that the province had a population of 42.8 million. One third ofthe population belonged to the cultural minority of which there were more than 25 groups. Because ofthe cool climate, the province had been a good resource for animals, plants and metals. A monitoring system, together with the reporting forms and regulations had been developed by the Health Bureau. She looked forward to being able to improve their data quality as a result of the expected technical and cultural exchanges during the workshop. 2. PROCEEDINGS

A summary of the presentations are given in this section. Detailed presentation outlines may be requested from concerned focuses like RPH, CHD and HIN . 2.1 Regional overview

2.1 .1 Maternal Health. Dr Pang Ruyan, Regional Adviser for Reproductive Health reviewed the status of maternal health. According to her, 30 000 to 50 000 women die annually from preventable pregnancy-related complications. More than 40% of these deaths occur in Cambodia, Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam . The maternal mortality ratios ofthese countries (MMR) ranged from 120 to 6541100 000 live births. She demonstrated the positive correlation among MMR, total fertility rate and lifetime risk of pregnancy. She outlined the objectives of the RPH Focus which were to achieve substantial reduction of MMR and IMR, to stabilize population growth rates, to meet changing reproductive health needs over the life cycle and to improve the health and nutritional status of women, especially pregnant and nursing women. Part of the strategy of the RPH Focus is to elicit political commitment from countries to reduce MMR and IMR. Priority countries were requested to develop national action plans on safe motherhood. Some of the problems and constraints which she identified in countries were inadequate health resources, low health facility utilization rates, high rate of unwanted and teenage pregnancy, as well as unsafe abortion, new risks of some diseases like tuberculosis, malaria, etc. and lack of information on MMR. The last constraint was attributed to inadequate government support to the information system, insufficient utility of existing information, duplication of data collection by vertical projects and the low capacity for data analysis and utilization. She outlined the major activities which the Focus would undertake in the next

- 5biennium, namely, the integration of Safe Motherhood/Makin g Pregnancy Safer into health system reform and poverty alleviation programmes, strengthening of the health information system to monitor progress of maternal mortality reduction programmes, promotion of family and community involvement in safe motherhood, and consultation on preventing unsafe abortion, unwanted and teenage pregnancy and the promotion of emergency contraception. Child Health. Dr Marianna Virtanen-Trias discussed the observed decline in under five 2.1.2 mortality in the Region. There are, however, large variations between and within countries, showing that child health is an important indicator of inequality. The tragedy is that over 50% of child deaths in developing countries are due to malnutrition and five communicable diseases (pneumonia, diarrhoea, measles, malaria and HIV/AIDS) for which effective and affordable interventions are available. These disease conditions have been aggravated by poor access to child health services, lack of quality care, non-availability or irrational use of drugs, limited knowledge and inappropriate practices of caregivers, and weak links between child health and general health sector development. In addition, in many countries, child health had not been considered a national priority. In response to these problems, she cited the objectives of the Child Health Programme which were to significantly reduce global mortality and morbidity associated with the major causes of deaths in children and to contribute to the healthy growth and development of children. A key strategy to improve child health was identified as the Integrated Management of Childhood Illness (IMCI). IMCI combines the integrated management of sick children with improvement of nutrition, ensuring immunization and other disease prevention and the promotion of child growth and development. The main components of IMCI are: improvement of health workers skills on integrated case management of children, strengthening health system like capacity building at the district level, improvement of referral and referral care, etc. and improvement of family and community practices like changes in care seeking behaviour. The countries in the Region are in different stages of implementing IMCI. The experience to date has resulted in increased interest, enthusiasm, commitment and capacity in child health with strengthened collaboration among all stakeholders. However, there is a need for the balanced implementation of all components ofthe strategy while expanding coverage, and a systematic integration of child health in health sector reform efforts. She proposed a model for IMCI implementation and the life cycle approach to improve women and children's health. Health Information System. DrY. C. Chong, Regional Adviser for Health Information 2.1.3. and Evidence for Policy, classified the countries in the Region into three as far ·as the health information system was concerned. These categories were: I) routine health information system established, supplementing information by surveys and extensive applications of information technology, 2) routine health information system in place, actively developing research/survey capability supported by information technology, and 3) health information system still needed streamlining and strengthening, with survey as the primary source of information and information technology being used. While there still existed some problems regarding data coverage and quality as well as data burden due to the parallel data collection system, there had been positive developments. These were the acceptance by a number of countries of evidencebased decision making, the institutionalization of health planning and programme management with information support and the emergence of better-trained health leaders at the central and provincial levels. Dr Chong also noted the problems of misclassification and under-reporting of maternal deaths thereby putting some doubts on the value of the maternal mortality ratio as a measurement tool. He suggested the integration of the data system into the management system to boost the former's importance. The investigation of all maternal and child deaths was necessary as well as the establishment of routine monitoring and reporting systems. He also recommended that before setting up a monitoring system for maternal and child health, one should determine the prime users, the country requirements, the implications involved and how to institutionalize the

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system into programme management. The technical, economic and operational feasibility for putting up a monitoring system should be reviewed. He urged maximizing information use as a management tool. 2.1.3 UNICEF Programme. Dr Ray Yip discussed UNICEF's framework for assisting countries to deal with maternal and child survival, child development and child protection. He said that most ofthe problems were related to poverty, which contributed to people's lack of knowledge and education, thereby impeding access to food, water and sanitation. All these were aggravated by poor health practices and inadequate health services. Taking these into consideration, their country programmes have been field-based and made use of situation analysis (assessment, analysis and action) and a strategy mix of advocacy, service and delivery, capacity building and communication for behaviour change for improved care. Dr Yip stated that a formal cooperation with government was needed based on a five-year master plan of operation. Implementation could be through local governments, institutions and nongovernmental organizations with joint planning and monitoring of key projects. Technical assistance could also be provided from the regional and headquarter levels. He gave examples of projects like safe motherhood and CDD/ARI-IMCI. 2.2 Maternal and Child Health Indicators

Maternal and child mortality indicators was presented by Dr Stephen Lwanga who said that maternal and child mortality indicators were markers as well as measures of equity of health status, service access and utilization, service performance or resource availability. However, he cautioned that the data needed for the indicator must be feasible to obtain and obtainable in an ethical manner. Indicators must be simple, understandable, and should be "scientific", that is, a true expression of the phenomena it is measuring, objective, specific and sensitive. He gave examples and definition of some indicators (Annex 4).

Indicator Maternal mortality ratio

Definition Maternal deaths in a year/total live births in the year X I 00.000

Use I. monitor trend in maternal health and service performance

Data Source Routine death notification

Presentation Additional information on place of death, age. parity, reference year. and source of data should be included Dis-aggregation between geographical and administrative divisions

2. Identify geographic areas and population groups which require more focused attention and resources

Sisterhood method

Availability of essential obstetric care (EOC) (basic essential care at the health centre should include parenteral antibiotics. anaesthesia, blood

Number of facilities with functioning essential obstetric care per 500 000 population

I. Measures the extent of the availability of health services providing essential obstetric care 2. To assess the progress being made in extending EOC to the entire population

Routine statistics

Mapping is helpful

Maternity reports Health facility survey

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transfusion in addition to manual removal of placenta or retained products of conception and assisted vaginal delivery) Infant mortality rate

Under five mortality rate (USMR)

Number of deaths of infants under one year of age in a given period of time/number of live births in the same period of time X 1000 Number of deaths of children below 5 years of age in a given period of time/number of live births in the same time period X I000

I . Establish public health importance of different · possible determinants or causes of death 2. Evaluate trends over time 3. Select place and programme of intervention 1. Measure of pre-school child health as a proxy for child development 2. To evaluate trends over time and impact of interventions 3. To devise effective actions for mortality reduction 4. To investigate differing rates in different geographical areas. 1. Measure of care during delivery and the immediate perinatal period 2. Reflects general maternal health status and pregnancy care

Vital registration Sample registration system Surveillance system Census Demographic surveys

Graphical presentation for trends

Vital registration Sample registration systems Surveillance systems Census Demographic surveys

Should be presented as cause specific

I

Perinatal mortality (PMR) (perinatal period starts at 22 completed weeks ( 154 days) of gestation (birth weight normally 500 gms) up to 7 completed days after birth

Proportion of perinatal deaths in a specified period/number of total births (live births and stillbirths) during the specified period X 1000

Vital registration Routine service data Survey of service records

Disaggregated by data source (facility or community, urban/rural), sex and birth weight

2.2.1

Child Health Indicators. Dr Thierry Lambrechts focused on global and national indicators from a programme perspective. He suggested that data users should first identify their needs and possible use of indicators, to be followed by a review of existing indicators and measurement tools before coming up with a selection criteria for additional indicators. He described IMCI as an intervention with critical steps which should be monitored. In view of this, he presented the different types of indicators such as input, outputs/process, outcome and impact indicators together with examples. These indicators could effectively measure the progress or impact in the three components of IMCI. As far as new indicators were concerned, he suggested that they be field tested first to determine their sensitivity, ease of measurement and their logical and empirical relationship with child mortality or morbidity. Such field tests had been conducted in Bolivia, Tanzania, Peru and Bangladesh.

- 8For IMCI, II priority indicators have been proposed to be used for the assessment of health worker performance including correct assessment, treatment and counselling within the first component of IMCI (improving health workers' skills), four indicators and three indices have been identified for supervision, drugs, equipment and supplies, training coverage and caretaker satisfaction (within improving health system component) and eight indicators for nutritional status, prevention, home case management and care seeking practices (improving family and community practices). Dr Lambrechts concluded with the importance of sustaining consensus on indicators and coordination of measurement efforts. He also emphasized progress in monitoring coverage and reduction of inequities, and importance of making information available on which to base policy decisions. 2.2.2 Country perspectives. The Cambodian representative presented the health status of women and children in his country with the use of health indicators. He gave the status of core child and maternal health indicators used globally, such as total fertility, tetanus toxoid coverage for pregnant women, under five mortality, neonatal mortality, etc. He cited several problems in data collection. 2.2.2.1 The representative from VietNam listed the child and mortality indicators being collected in her country but pointed out that they collected only facility-based data on women and children who died in health facilities. This was according to the definition of the mortality indicators they had been using. She noted that the problem was that many more deaths occurred outside the health facilities as moribund patients were brought home to die as part of a cultural practice. There was also misclassification of maternal deaths due to inadequate knowledge/information of health workers. She proposed a number of solutions among which was compulsory certification of births and deaths. 2.2 .3 Group work: Indicators

Participants worked in four groups discussing and producing ten key indicators in maternal and child health. They were presented and further discussed in a plenary session. There were three categories of indicators proposed by the working groups : a) Traditional indicators, clearly and correctly defined, for example, MMR, PMR, IMR, and USMR. b) Traditional indicators poorl y or incorrectly defined. For example, indicators of immunization coverage. exclusive breastfeeding, deliveries assisted by skilled attendants, prevalence of sexually transmitted infections (STI) among pregnant women, etc. c) New indicators not fully defined or tested. For example, indicators of referrals and childhood deaths in the home. There were also areas that were not included among the lists often indicators presented by the groups, which may be very important, at least for some countries to consider. For example, it would have been good to see indicators of hospital or facility delivery, cause-specific maternal mortality etc. The presentations by the two pairs of groups (child and maternal health) were in such agreement that the results must be taken as genuine expressions of the views of the participants concerning indicators for monitoring and evaluation of these two areas. There were expressions of a need to revise cut-off points for some indicators to make them more sensitive to country needs, for example, the perinatal mortality indicator that stipulates a cut-off point of22 weeks of gestation (regarded as too low by some countries that would rather use a 28-week cut-off point).

-9The group work exercise demonstrated the problems faced in defining functional and useful indicators. It was easy to make statements about indicators but an entirely different exercise to comprehensively define them, for example, the indicator of abortion. However, it was important to define key elements of indicators, such as: essential obstetric care, antenatal care, skilled health worker, etc. The reports of the groups pointed to areas in which the countries might want WHO's support in developing indicators. Examples of areas requiring further work were abortion and delivery (process indicators), as more work need to be done to develop indicators related to maternal health and mortality beyond the traditional maternal mortality ratio. At the session summary, the consultant suggested that participants should work on indicators for child and maternal services, health and mortality on their return home, seeking support from WHO in areas they may have problems with, particularly improvements in their health information systems for the provision of the data needed for the indicators. Generally, more work would be needed on indicators of maternal and child health, morbidity and mortality. Also, areas that had been omitted in the lists of indicators that were discussed during the workshop should be addressed. 2.3 Data collection and quality of data

Dr Brian McCarthy of the Centers for Disease Control and Prevention, spoke on data collection and quality. He said that generally what were being obtained as data were not what were wanted. Hence, there should first be a determination of what were needed, a consensus building of what data were desired, before planning for data collection. A surveillance framework was presented. This should be a dynamic process consisting of systems of data collection, analysis and response (CAR). Data response referred to data based dissemination and corresponding action taken. These three systems should be adaptable, responsive, cost effective and simple. He stressed that data quality and integrity could be achieved through careful planning, and meticulous documentation especially during the first few months of implementation ofthe system . Training would be needed as well as long term support both technically and financially. He presented basic concepts on data collection as well as the "BABIES" matrix (Birth weight, Age at death, Boxes, Indicators, Evaluation and System), community monitoring, use of delivery room logs, tick tables and the multidimensional table (Annex 5). He stressed that there should always be total cohort accountability which meant that every pregnancy counted so each pregnancy should be accounted for or that every newborn had weight so each baby will have to be weighed, to be followed by analysis and evaluation. He emphasized that service quality should be the main focus of concern and that management should be based on facts as derived from quality data. Information should be used not only on the national level for advocacy but for improving management at the facility level, for instance at the district level. In these activities, he advocated the five "R"s which were having the right person at the right time, doing the right thing at the right place. He advised that efforts should be exerted to close the opportunity gap in person, time and place between those areas where mortality/morbidity rates had already been reduced and those still with high rates. A local indicator system should be developed to improve programme quality. Dr McCarthy spent additional hours providing information to interested participants on the concepts he presented, especially the "BABIES" matrix and the multidimensional tables. Maternal Death Review. Dr. Rebecca Ramos presented an overview on maternal death 2.3.1 review. She stated that maternal deaths should not only be counted but there was a continuing need to know why women were dying. She presented the definition of several terms : I) maternal death which refers to the death of a woman while pregnant or within 42 days of

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termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management excluding accidental or incidental causes, 2) pregnancy-related death which is the same definition as maternal death but it includes all cases including accidental and incidental causes, and 3) late maternal deaths which refers to the death of a woman from direct and indirect causes more than 42 days but less than one year after the termination of pregnancy. She said that a maternal death review was an in-depth investigation of the causes and circumstances surrounding a small number of maternal deaths occurring at selected health facilities. It could either be a stand alone activity or as part ofthe safe motherhood needs assessment. She described the different steps involved in conducting a death review, the underlying principles and the purposes of the activity. The investigation should be extended to the community so that key informants would have to be identified and interviewed by competent data collectors as the subject would be highly sensitive. Dr Ramos explained that the challenge was accurately quantifying maternal deaths so that various sources of information like vital records, hospital records, hospital ward records, etc should be searched. All deaths which occurred during or within a year after pregnancy should be found and then categorized whether they were pregnancy related or not and the causal relationship between pregnancy and death determined. There were both medical and non medical causes of death which could lead to a conclusion of "substandard care". The Criterion Based Clinical Audit (CBCA) may also be utilized which required that a pre-agreed standard of care or clinical protocol should exist against which the findings of the investigation would be compared. After analysis and interpretation of the findings, it was essential that action should be instituted to reduce further maternal deaths. 2.3.2 Country perspectives

Mongolia's representative explained that computer hardware and software had been 2.3.2.1 provided to all statistical offices at all aimag, district and city levels to hasten collection and submission of data from the different health facilities at specified periods of time. In spite of these reporting schedules, data collection was still incomplete because registration forms were not completely filled out and the private sector health facilities were not providing the required information. The Papua New Guinea representative stated that data for maternal mortality came 2.3.2.2 from surveys and the Ministry of Health. There had been difficulty in collection because only 53% of women deliver under professional supervision and maternal death rep01ting was not compulsory. The national health information management system had been set up and provinces had been provided with computers. Data collection was expected to improve but there existed a need to strengthen data analysis and presentation to the concerned decision makers. 2.4 Monitoring system

Dr Brian McCarthy gave a presentation on monitoring and evaluation. Monitoring was defined as an ongoing systematic process that provided information to make programme management decisions based on the collected and tracked process indicators; while evaluation was the systematic and scientific process of determining the extent to which an action or sets of actions were successful in the achievement of predetermined objectives. In the monitoring process, the question asked should be "is the programme doing things right?", while in evaluating outcome, the question should be "is the programme doing the right thing?" Indicators were necessary as they provided information about a health outcome or management process. They should be linked in an outcome-impact-sequence model like "BABIES" to create the indicator matrix, which was actually a flow diagram of the different types of indicators.

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He categorized the input indicators as manpower, materials, money and methods while output indicators were coverage, referral pattern, matching skill with need, altering risk factors, identifying training needs, assessing community education and attitudes, assessing quality of services and supporting planning and policy determinations. Output indicators should be available, accessible, acceptable, affordable and appropriate (5 As). The local indicator process was described as a series of interrelated activities involving all stakeholders that produced a set of outcome, impact and process indicators for a local indicator system which would consist of indicators which fit the local needs. The essential elements of the local indicator system were listed as follows: 1) local indicator system indicators were derived from the local BABIES matrix, 2) in this system, maternal, perinatal and child death events would trigger reviews that involved representatives from all the stake holders that would be the basis for facility and district performance assessment, and 3) the process for determining districtspecific indicators should be present in every district as well as the training for the translation of data into information even ,at least, as a home-based course for health workers. He outlined the steps in the development of a local indicator system and suggested that the system should be simple, of good quality and participatory. 2.4.1 Challenges in child health was presented by Dr Thierry Lambrechts. He categorized the types of information available for programme management as mortality data, health information system data and periodic measures of child health programme outcome. The different data sources were enumerated but the discussion was focussed on the health information system. Questions were raised by him on the accuracy, timeliness, and completeness of health facility reports, their ability to monitor health system performance and quality of care and their limited compatibility with new interventions like IMCI, Integrated Management of Pregnancy and Childbirth (IMPAC) and Adult Lung Health Initiative (ALHI). IMCI was selected as an example to show the constraints in the current health information system. He pointed out that the limited compatibility had resulted in the confusion of health workers which might undermine the effective use of either IMCI or the health information system or both. The incompatibilities were in their respective purposes, in those related to disease classification such as the differences in the names of disease conditions, or the non convergence of the classifications and the other differences like age groupings, multiple visits for the same episode, etc. To avoid more confusion, Dr Lambrechts suggested the following options: 1) to translate IMCI classification into health information system categories, 2) change the health information system to include IMCI classifications, 3) classify children in both systems, or 4) change IMCI classifications. After weighing the advantages and disadvantages of each option, the speaker posed the following challenges: 1) on mortality data: harmonize definitions and reporting procedures; make mortality data available and useful to programme managers; identify simple/affordable methods for mortality monitoring in communities; 2) health information data system: reconcile "first line health interventions" like IMCI, IMPAC, ALHI, harmonize monitoring efforts within Ministry of Health and across partners, build on health information system achievements to develop monitoring systems useful for programme management and public health planning; and 3) programme outcome indicators: improve/increase measurement of programme outcomes and make better use of results for programme management, and integrate neonatal and adolescent age groups into periodic measures of programme outcome. 2.4.2 Country perspectives

The representative from China presented their programme on monitoring which 2.4.2.1 focussed on under 5 mortality, maternal mortality and on birth defects or malformations. There were three levels of monitoring network in both the rural and urban sites which started from the most primary to the central levels. Different tools for data collection and monitoring were being used with adequate supervision. The National MCH Surveillance Office evaluated the quality of data and was responsible for information dissemination on the national level.

- 12-

2.4.2.2 The Lao People's Democratic Republic representative presented the status of maternal and child health in her country as well as the health care delivery system. She explained that data from health facilities were submitted to the central office on a quarterly basis but were being received late because of the many bureaucratic levels which needed to clear the data. The vertical format was also a problem. 2.4.3 Group Work. The four groups were asked to create multidimensional tables (see Annex 6 for results). There were some difficulties in making the tables, and Dr McCarthy held additional tutorial sessions. The participants' opinions were divided as to ease and utility of the tables but the consultant explained that the tables would facilitate analysis of the data collected once the district level data users understood the concept. 2.5 Use of data

MCH surveillance was discussed by Dr Ray Yip from a national perspective. His propositions were that there already existed a lot of useful data so that the challenge was to take advantage of these data and transform them into useful information. In addition, data from multiple sources can be used together for expanded use. He thought there was no perfect surveillance system but learning to use the information was more important than designing a perfect system. Surveillance data could be used for advocacy, strategy planning and to stimulate the development and implementation of local action programmes. The common forms of MCH surveillance data presented were rates, trends, maps, cause specific data and process and service indicators to monitor programme efforts. To illustrate how data could be used, he chose two countries as examples- Mongolia and China. In Mongolia 98.5% of deliveries took place in health facilities but the MMR was still relatively high. The implication was that improvement of the obstetrical service could be the key to MMR reduction. Another case example was China wherein a majority of the western rural women had home deliveries because ofthe high cost of facility delivery. Postpartum haemorrhage was the main cause of mortality. The Safe Motherhood Programme promoted facility-based delivery, however the issue of reasonable charges for delivery services remained to be addressed by the programme. The value of mapping for visual comparison for advocacy and programme action were also stressed. 2.5.1 Country examples. The representative from the Philippines presented their sources of data like the field health statistics information system, Philippine health statistics, hospital reports, National Demographic Health Survey and other special surveys. These data were used in guiding policy, strategic plans, programmes and the development of information, education materials for safe motherhood, and child health and development, among others. They were also used for advocacy purposes to generate political commitment for health programmes. The problems and constraints on data collection and analysis were also presented. 2.5.2 Group work: use of data

Group 1 discussed the country report of Lao People's Democratic Republic. Participants picked up several data from the report to practice data analysis and utilization like IMR, malnutrition rate and expanded programme on immunization (EPI). They agreed that the problems in data uti! ization were: lack of awareness of importance of data, poor quality of data, lack of feedback to the government and low level and poor interpretation of data. The recommendations from this group for Lao were: to elicit more political commitment from the national level down to the local level; to focus on MCH programmes; to strengthen implementation of the IMCI strategy; to focus on high-risk and problem areas; and to ensure appropriate legislation to address certain issues.

- 13Group 2 discussed the country report of Cambod ia. This group did a situation analysis s and based on the report. They found two main problems in us ing data: the number of deliverie in abortions were underreported. The unreported deli veries accounte d for 60%, which happened the private sector, or were handled by traditional birth attendants and others. Their licensed recomme ndations for solving this problem were as follows: private facilities could be and licenses; their and be required to report births, deaths, and major morbidities to maintain rural health workers should be trained and compensated for supervising births. a Induced abortion accounted for 20% of maternal deaths. The recomme ndations included and study of abortion as an antenatal care issue; implementation of the new abortion law; to attending for ts attendan birth al tradition and ners retraining and licensing of private practitio abortion cases. Group 3 used the country report of the Philippines and did an analysis ofthe IMR trends n for the past 14 years including factors which affe:cted the IMR. The problem in data utilizatio IMR risk, at was data discrepancies. More information was needed on nutritional status, children target, leading causes of morbidity, lead ing causes of mortality (urban vs. rural), and school plan enrolmen t rate by region. The recomme ndation s from this group were to: rev iew strategic support; political for advocacy n strengthe on child health, such as target and priorities for IMR; increase expand IMCI, Early Child Growth (ECG) and Functional Female Literacy (FFL); and enrolmen t among girls. Group 4 did a situation analys is on th e country report of VietNam , which included its were: geography, IMR U5-MR ,MMR, a nd cause specific fatality rates. The problem s identified no data on the definition of MMR included o nl y maternal deaths in health facilities and there was total deliveries .. the The group recomme nded to: select national priority indicators; clarify the definition of and ng monitori improve indicators; revise registration forms; develop health documentation; on time; feedback systems; train staff of the health information departments; submit information and improve technical support for policy makers. Dr Yip concluded the session by saying that a number of facilities in countries were 2.5.3 and data rich but information poor so concerne d people should learn to use data effectively . ntation impleme me should ensure that data did not impede but strengthen program 2.6 Building partnersh ips

Partnersh ips in MCH was discusse d by Dr Mariann a Virtanen-Trias. Partnerships are important to enable people/o rganizati ons to work together towards comm on goals without ation among duplication of work but instead maximizing the use of ava ilable resources. Collabor based on all key pattners also e nsures the developm ent of co nsistent policies, strategie s and plan at the rmed fo be n ca ips partnersh that ized shared experien ces and responsibilities. She emphas rnmental nongove and nal local, national and international levels with government, internatio of agencies. A list of major partner agencies in MCH was given as well as potential areas collaboration. To establish and/or maintain partnership, she suggested forming and committ ees/work ing groups with involvem ent of all relevant programmes, institutions work plans, joint upon agree and ces experien e partners early in the planning process to exchang me program main for support policy towards consisten t program me policies and obtain formal strategies. Dr Trias presented some issues for consideration like: mechani sms for collaboration, sustainability of partnerships (real coordination and follow up, sharing of experiences, effective implementation of activities as part of an overall plan, delegation of responsibilities and ent. use of resources) and the key coordina ting role ofthe governm

- 142.6.1 IPPF was represented by Ms Patricia Matthews who explained that their organization worked through the family planning agencies in countries. Country programmes were accredited and given support in terms of contraceptives equipment and funds. They had been working in six regions and there are 22 member countries in the East and South-East Asia Region where most of the participants came from . She stated some of the areas of interest of their organization which were family planning (demand and unmet need), unsafe abortion, equipment, youth, self sufficiency, quality of care and effective regional assistance. 2.7 Safe motherhood and HIV

Dr Jean Louis Excler presented data from Thailand and African countries to demonstrate that AIDS was an important direct factor in maternal deaths and that HIV infection was an indirect cause of maternal deaths. This infection had been a contributor to other indirect causes of maternal mortality like tuberculosis, other opportunistic infections and malaria. Data from some studies were also presented which showed the adverse consequences on the pregnant mother and the child of HIV infection as well as factors which increased the probability of mother to child transmission. Dr Excler also presented the different epidemiological, process and programme indicators of safe motherhood used in HIV endemic areas. Management, care and support packages for HIV infected women during and after pregnancy were presented. 2.8 Fielf) triQ

The participants visited Shilin Yi Minority Autonomous County to observe the monitoring system in their three levels of care- the MCH County Hospital, the Township Hospital and the village clinic. The Deputy Governor of the County and the Director ofShilin Health Bureau welcomed the participants who later toured the three health facilities. All three, including the village clinic, had facilities for essential obstetric care. Cases from the village were referred to the township hospital which referred complicated cases to the county hospital. The information network was established at the three levels with standard recording cards, tables and graphs. Patient data were collected in recording books at the village level, in the township facility and in the county level. All facilities made use of boards functioning like tickler files. Monthly meetings were held by the Township Hospital with the village health staff for information sharing. Shilin Yi county, in the outskirts of Kunming city, had a population of 220 000 with 33% considered as minorities. There were hospitals in each township and clinics in every village . The MCH county hospital was responsible for training, supervision, technical guidance, data collection and analysis for the other health facilities. 2.9 Planning for next steQS

During the third day of the workshop the participants were requested to develop a plan on the next steps to be developed by each participating country. Since this was the first time three vertical programmes are working together, the discussed was focused more on the cooperation and communication among the three focuses. Every country developed a framework on the next steps to be undertaken and gave a presentation during the last day of the workshop. The country working plan on the next steps is attached as Annex 7. 2.10 Workshop evaluation

Evaluation questionnaires were administered to the participants. There were 35 respondents, 88.6% said that the workshop objectives were met but the rest felt that there were some aspects which were not achieved like agreements on the definition of maternal death, and

- 15 -

priority indicators for the Region. Twenty-six percent of the respondents thought that they wanted more time for group discussions and field visits. Ninety-seven percent said they learned new concept and skills like "BABIES', data collection, monitoring and data use as well as priority indicators for IMCI and the use of maps. The participants also expressed the hope that their respective governments will provide support to their "Next Steps" to be able to develop/strengthen their health information systems. They also expressed the desire to have WHO and other collaborating agencies like UNICEF, UNFPA and other partner agencies to extend both technical and financial support to their countries. 3. CONCLUSIONS

The Workshop has demonstrated that both maternal and child health programmes at 1. country and regional levels would benefit from a better coordination of their monitoring efforts. Many MCH indicators already exist, are widely used and have been agreed upon 2. internationally. Definitions of the key global indicators should be maintained to ensure comparability of data across sites. Local levels may need additional indicators to address specific programme needs and goals within their resources . Both impact and outcome indicators are needed for priority setting, strategic planning 3. and appropriate programme management. Process and outcome indicators are useful for routine decision-making in MCH programmes and complement impact indicators such as mortality. They are likely to vary faster than impact indicators and are easier to measure. Health information systems in countries vary widely in quality and coverage. The health 4. information system needs to be flexible to accommodate new health interventions such as IMCI, IMPAC and ALHI. To improve the quality and coverage of the health information system as well as increase its usefulness for programme management, efforts will be needed to reconcile the health information system and new health interventions. Approaches to data collection, analysis and usage were discussed. One methodology 5. was data analysis through a multidimensional table. This has potential application for the development of local indicators to improve the management of health service delivery. Many data on maternal and child health have already been collected. The challenge is to 6. take advantage of existing data, transform them into useful information for decision making, and provide feedback to all levels of the health system. Priority should be given to strengthening existing and integrated systems rather than to developing multiple programme specific systems. Countries should further develop their action plans for improving their monitoring 7. systems which include clearly defined key indicators and established data system and flow. Monitoring maternal and child mortality reduction requires team work and collaboration 8 among related programmes and partner agencies.

- 16-

- 17ANNEX 1

LIST OF PARTICIPANTS, CONSULTANTS, TEMPORARY ADVISER, RESOURCE PERSON, OBSERVERS, AND SECRETARIAT

1. PARTICIPANTS

CAMBODIA

Professor Chhour Y. Meng, Director, National Pediatric Hospital No. 100, Federation of Russia Blvd., Phnom Penh Telephone: (855) 11 813 899. Facsimile: (855)23 880 475 E-mail address: cymeng.nph@bigpond.com.km Dr Tan Vuoch Chheng, Deputy Director, National Maternal and Child Health Center, French Street, Sangkat Sras Chak, Khan Daun Penh, Phnom Penh Telephone: (855)023 724 257 Dr Hong Rathmony, Head of Communicable Disease Control and Prevention Bureau, Ministry of Health, 151-153 Kampuchea Krom Avenue, Phnom Penh Telephone: (855)23 880 532. Facsimile: (855)23 880 532 E-mail address: rathmonyh@yahoo.com Dr Paou Linar, Chief of the MCH Programme, Municipality of Phnom Penh Pkhan Chamkai Mon, Phnom Penh Telephone: (855)012 926 358

CIDNA

Dr Wang Bin, Deputy Director, Maternal Health Division of PHC/MCH Ministry of Health, No. 1 Xinzhimen Wai Nanlu, Beijing 100044 Telephone: (86 10)68792310. Facsimile: (86 10)68792321 E-mail address: wangbinzzd@hotmail.com Dr Cao Bin, Project Officer, Maternal Health Division of PHC/MCH Ministry of Health, No. 1 Xinzhimen Wai Nanlu, Beijing 100044 Telephone: (86 10)68792305. Facsimile: (86 10)68792321 Dr Wang Yanping, Vice Professor, National MCH Surveillance Office Huaxi Medical University, Sichuan Province Telephone: (86 28)5501363. Dr Huang Xinghua, Professor, Beijing Obstetric and Gynecological Hospital No. 17 Qihelou, Beijing 100006 Telephone: (86 10)65250731 313. Facsimile: (86 10)65121602 E-mail address: ogh@163bj.com

LAO PEOPLE's DEMOCRATIC REPUBLIC

Dr Bounleua Oudavong, Depty Director, Mother and Child Health Centre Vientiane Dr Anan Sacpraseuth, Head of Gynaecology-Obstetric Department Mahosot Central Hospital, P.O. Box 2501, Vientiane Telephone: (856)21 412116. E-mail address: eedgon@laotel.com Dr Manesone Oudome, Manager of Safe Motherhood Project c/o Mahosot Central Hospital, P.O. Box 2501, Vientiane Telephone: (856)21 412116

-18Annex 1 Ms Alivanh Phanlavong, Chief of Hospital Statistics, Statistics Division Planning and Finance Department, Ministry of Health, Vientiane Dr Khammeung Vonsiprasom, Chief of Pediatric Ward c/o Mittaphab Hospital, P.O. Box 6035, Vientiane

MONGOLI A

Dr Yadamsuren Buyanjargal, Medical Officer for Maternal Health Care Ministry of Health, Olympic Street, Ulaanbaatar-48 Telephone: 976011-325961. Facsimile: 976-11-311601 E-mail address: buyan99@yahoo.com; buyangargal@yahoo.com Dr Gochoo Soyolgerel, Officer for Child Health and National IMCI Coordinator, Ministry of Health, Olympic Street 2, Ulaanbaatar Telephone: 976-99150655. Facsimile: 976-11-360509 E-mail address: ebold@mongolnet.mn Dr D. Malchinkhuu, Senior Lecturer of National Medical University Chief Pediatrician, Ministry of Health, Pediatrics Consultant Maternal and Child Health Research Center, Choidog Street 3, Ulaanbaatar Telephone: 976-11-313814; 976-99299945 E-mail address: dmalchinkhuu@yahoo.com Dr Damia Nyamkhorol, Health Statistician, National Centre for Health Development, P. 0. B-48 Enkhtaivan-13, Ulaanbaatar Telephone: 976-1-321485. Facsimile: 976-1-320633 E-mail address: hsic@magicnet.mn Dr Daram Dariima, Senior Research Worker, Mother and Child Health Rsearch Center, Ministry of Health, Ulaanbaatar Telephone: 976-11-687806. Facsimile: 976-11-687806

PAPUA NEW GUINEA

Dr Gilbert Hiawalyer, Director, Monitoring and Research Department of Health, P.O. Box 807, Waigani, NCO Telephone: (675)301-3660. Facsimile: (675)323-0022 E-mail address: ghiawaly@health.gov .pg Dr Job Hawab, Technical Adviser, Child Health, Family Health Services, Department of Health,P.O. Box 807, Waigani, NCO Telephone: (675)301 3711. Facsimile: (675)323 9710 Dr Grace Kariwiga, Specialist Medical Officer, Obstetric and Gynaecology Port Moresby General Hospital, FMB Boroko Telephone: (675)3248310. Facsimile: (675)3250342 Dr Glen Mola, Head of Obstetric and Gynaecology, University of Papua New Guinea, Box 1421, Boroko, Telephone: (675)3248310. Facsimile: (675)3258212

-19Annex 1 of r Manage Program Dr Ma. Nerissa Dominguez, Medical Officer VII, Women 's Health and Development, Center for Family and Environmental Health, Department of Health, Bldg. 13, San Lazaro Compound, Sta. Cruz, Manila Telephone: (632)711 6130; 732 9956. Facsimile: (632)732 9961 E-mail address: ma_noviel@yahoo.com Dr Ma. Joyce Ducusin, Medical Specialist IV, Center for Family and Environmental Health, Department of Health, Bldg. 13, San Lazaro Compound, Sta. Cruz, Manila Telephone: (632)712 8118 Dr Nelita Salinas, Medical Specialist II, Department of Pediatrics Eastern Visayas Regional Medical Center, Magsaysay Blvd. Tacloban City Telephone: (053)321-4182; 321 3131. Facsimile: (053)321 8724 E-mail address: evrmc@mozcom.com Ms Vicenta Borja, Supervising Health Program Officer Center for Family and Environmental Health, Department of Health Bldg. 13, San Lazaro Compound, Sta. Cruz, Manila Telephone: (632)732 9956. Facsimile: (632)732 9961 E-mail address: mchs@doh.gov .ph Dr Corazon Almirante, Head, Division of Perinatology, Philippine Childre n's Medical Center, Quezon Avenue, Quezon City Telephone: 372 3356. Facsimile: 372 3358; 924 7952 E-mail address: cora313@yahoo.com Dr Nguyen Thi My Huong, Scientific Research Department Institute for the Protection of the Mother and Newborn 43 Trang Thi, Ha Noi Telephone: 04 8249213. Facsimile: 04 8254638 Dr Tran Thi Thanh, Head, Technical Guidance Department, Institute for the Protection of Mother and Newborn 43 Trang Thi, HaNoi Telephone: 04 9346741. Facsimile: 04 8254638 Dr Thuong Tang Chi, Vice Director, Pediatric Hospital No. 1 2 Su Van Hanh, District 10, Ho Chi Minh City Telephone 84 8 8351119 Dr Duong Thi Hai Ngoc, Officer of MCH/F P Department, Ministry of Health, 138A Giang Vo St., HaNoi Telephone: 84 4 8231042/8469060. Facsimile: 84 4 431271 E-mail address: vnbmte@moh.gov.vn Mrs Nguyen Thi Tinh, Health Statistics, Ministry of Health 138A Giangvo Street, Ha Noi Telephone: 84 4 8464914

PIDLIPPINES

VIETN AM

-20Annex 1 2. CONSULTANTS

Dr Rebecca Ramos, Institute of Community and Family Health, 11 Banawe Ave, Quezon City Philippines Telephone no.: 743-6645. E-mail address: ramosr@pacific.net.ph . Mr Stephen Lwanga, 1890 Lwanga Close (off Kusugu Road), Tank Hill, P.O. Box 5381, Kampala Uganda Telephone: +256-77 77 00 99 (mobile). +256-41 26 78 31 E-mail address: sl wanga@africaonline. co. ug. ; tephen_lwanga@hotmail.com Dr Dai Yaohua, Head, WHO Collaborating Centre for Child Health, and Professor Department of Child Health Care, Capital Institute of Pediatrics, No. 2 Ya Bao Road, Beijing 100020, China Telephone: (86-10)65270833. Facsimile: (86-10)65128367. E-mail address: yh.dai@263.net

3. TEMPORARY ADVISER Dr Brian McCarthy, Supervisory Medical Officer, WHO Collaborating Centre in Reproductive Health Centers for Disease Control Prevention, 4770 Buford Highway, N.E., Atlanta, GA 30341-3724 United States of America. Telephone: (404)488-5229.

4. RESOURCE PERSON Dr Jean-Louis Excler, Consultant, Est Asia and Pacific Regional Office, UNICEF, P.O. Box 2-154, 19 Phra Atit Road, Bangkok, 10200, Thailand Telephone : (66 2)356 9417. Facsimile: (66 2)280-3563-4

4. OBSERVERS/REPRESENTATIVES

INTERNAT IONAL PLANNED PARENTH OOD FEDERAT ION MINISTRY OF HEALTH, CHINA

Ms Patricia Matthews, Kuala Lumpur Regional Office, 246 Jalan Ampang 50450 Kuala Lumpur, Malaysia Telephone : (603)425 6122, 42566246. Facsimile: (603)4256 6386 E-mail address: rk@ippf.po.my Dr Han Zhen, Lecturer of MCH, Department of Xian Medical University No. 1 Jian Kang Road, Xian, 710061 Telephone : (86 29)5235492. Facsimile: (86 29)5263190 Dr Yang Wenfang, Lecturer of MCH, Department of Xian Medical University, No. 1 Jian Kang Road, Xian, 710061 Telephone : (86 29)5235492. Facsimile: (86 29)5263190 Dr Zhu Jun, Associate Professor, National MCH Surveillance Office The National MCH Surveillance Office in Huaxi Medical University Sichuan Province Telephone: (86 28)5501363

-21Annex 1 Professor Wu Yanqiao, Associate Professor of National MCH Surveillance Office, Huaxi Medical University, Sichuan Province Telephone: (86 28)5501363 Professor Liang Juan, Associate Professor of National MCH Surveillance Office, Huaxi Medical University, Sichuan Province Telephone: (86 28)5501363 Professor An Lin, Associate Professor, Public Health School of Peking University, No. 38 Xue Yuan Road, Haidian District, Beijing 100083 Telephone: (86 10)62091173. Facsimile: (86 10)62023133 Professor Gao Yanqiu, Assistant Professor. Public Health School of Peking University, No. 38 Xue Yuan Road, Haidian District, Beijing 100083 Telephone: (86 10)62091173. Facsimile: (86 10)62023133 Dr He Jing, Deputy Director, Obstetric Department, Zhe Jiang MCH Institution, No.2 Xue Shi Road, Hangzhou City, Zhejiang Province 310006 Telephone: (86 571)7061501. Facsimile: (86 571)7061878 Dr Estrella Serrano, RH/FP Specialist, UNFPA-Beijing Telephone: (8610)65323731 ext. 203. Facsimile: (8610)65322510 E-mail: eserrano@public.un.org.cn; drserrano2k@yahoo.com

UNFPA

5. SECRETARIAT

WHO/WPRO

l Office Dr Pang Ruyan (Responsible Officer), Regional Adviser, Reproductive Health, WHO Regiona for the Western Pacific, Manila, Philippines Telephone: (63-2) 528 9876. Facsimile: (63-2) 526 0279, 526 0362, 521 1036 E-mail: pangr@wpro. who.int nt Health Dr Marianna Virtanen-Trias (Co-responsible Officer), Medical Officer, Child and Adolesce es Philippin and Development (CHD), WHO Regional Office for the Western Pacific, Manila, Telephone: (63-2) 528 9868. Facsimile: (63-2) 526 0279, 526 0362, 521 1036 E-mail address: triasm@wpro.who.int l Dr Y.C. Chong (Co-responsible Officer), Regional Adviser, Health Information, WHO Regiona Office for the Western Pacific, Manila, Philippines Telephone: (63-2) 528 9812. Facsimile: (63-2) 526 0279, 526 0362, 521 1036 E-mail address: chongc@wpro.who.int tic Dr J. Annus, WHO Representative, World Health Organization, 9-2-151 Ta Yuan Diploma Compound, 1 Xindonglu Dongzhimen Wai, 100600 Beijing, China Telephone: (8610)6532 6491; 6532 5633; 6532 5634. Facsimile: (8610)6532 2359 E-mail address:who@chn. wpro. who.int

-22Annex 1 Dr Kim Wheeler, Technical Officer, Safe Motherhood, WHO Regional Office for the Western Pacific Manila, Philippines Telephone: (63-2) 528 9878. Facsimile: (63-2) 526 0279, 526 0362, 521 1036 E-mail address: wheelerk@wpro. who. int Dr Severin von Xylander, Medical Officer, Child Health, World Health Organization, House 120 Street 228, Sankat Chadomuk Khan Daun Penh, Phnom Penh , Cambodia Telephone: (855)23-215464; 23-216610. Facsimile: (855)23-216211 Dr Salik Govind, Programme Management Officer, World Health Organization, 4rh Floor, AOPI Centre, Waigani Drive, Papua New Guinea Telephone: (675)325-7827; 301-3698; 325-2035. Facsimile: (675)325-0568 E-mail address: govinds@png.wpro.who.int Dr Sergey Sargsyan, Short-term Professional, Child Health, World Health Organization, 9-2-151 Ta Yuan Diplomatic Compound, 1 Xindonglu Dongzhimen Wai, 100600 Beijing, China Telephone: (8610)6532 6491; 6532-5633. Facsimile: (8610)6532-2359 WHO/HQ

Dr Thierry Lambrechts, Responsible Officer for Monitoring and Evaluation, Department of Child and Adolescent, Health and Development, World Health Organization, CH-1211 Geneva 27 , Switzerland UNICEF Mr Edwin Judd, UNICEF Representative, China, 12, Sanlitun Lu, Beijing 100600, China Telephone: (86-1 0)65323131 ext. 133. Facsimile: (86-10)65323107 Dr Ray Yip, Senior Adviser, Health and Nutrition, Area Office for China and Mongolia, UNICEF 12, Sanlitun Lu, Beijing 100600, China Telephone: (86-10)65323131 ext. 133. Facsimile: (86-10)65323107 . E-mail address: ryip@unicef.org Dr Sieng Nam, Assistant Project Officer, Health Section, United Nations Children's Fund, No. 11 , Street 75, Sraschark Quartier, Phnom Penh , Cambodia Telephone: (855-23)4 26214/5. Fax: (855-23)4 26284. E-mail address: unicef Phnom penh@unicef.org Dr Martha Cayad-an, Maternal Health and Nutrition, UNICEF, Manila, P.O. Box 1076 Makati Central Post Office, _ 1250 Makati City, Philippines Dr Zhu Bao-ping, UNICEF Consultant, 12, Sanlitun Lu, Beijing 100600, China Telephone: (86-10)65323131 ext. 133. Facsimile: (86-10)65323107 E-mail address: ryip@unicef.org

-23-

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WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

UNITED NATIONS CHILDREN'S FUND REGIONAL OFFICE FOR EAST ASIA AND PACIFIC

WORKSHOP ON MONITORING SYSTEMS FORMATERNAL AND CHILD MORTALITY IN PUBLIC HEALTH CARE FACILITIES Yunnan Province, China 24-28 September 2001

WPRJICPIRPH(2)/2001!1 15 September 2001

ENGLISH ONLY

AGENDA

(1)

(2) (3)

(4)

(5) (6)

(7)

(8) (9)

(10) (11) (12) (13) (14)

Opening ceremony Adoption of meeting objectives and agenda Regional overviews • Maternal health • Child health • Health information system • UNICEF Maternal and child health indicators • Maternal health • Child health • Country's perspective (Cambodia and VietNam) Group work on indicators (4 groups) Data collection and quality of data • Introduction • Maternal death audit • Country example (Mongolia and Papua New Guinea) Monitoring system • Introduction • Challenge in child health • Country example (China and Laos) Group work on data collection and monitoring system (4 groups) Use of data • Introduction • Country example (Philippines) Group work and presentation Country work on planning the next steps Building partnership and resource mobilization (UNICEF, UNFPA, ADB and NGOs) Summary and conclusion of the workshop Closing ceremony

- 24-

- 25 ANNEX3

OPENING REMARKS OF THE REGIONAL DIRECTOR

It is my pleasure to welcome all the participants to this "Workshop on Monitoring Systems for Maternal and Child Mortality in Public Health Care Facilities." I would like to express my appreciation to the Government of the People's Republic of China, particularly the Ministry of Health, for co-hosting this important workshop in the beautiful city of Kunming.

Many of us are visiting Kunming for the first time. This visit will be twice as memorable because it is the first time that we have conducted this kind of workshop, organized by three focuses of the Western Pacific Regional Office namely: Health Information and Evidence for Policy, Child and Adolescent Health and Development and Reproductive Health, and with the East Asia and Pacific Regional Office of UNICEF. The United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF) will also be represented. This workshop aims to support priority Member States to attain the goals adopted at the International Conference on Population and Development as well as the World Summit for Children and the Convention on the Rights of the Child. At those important meetings, all countries were urged "to reduce maternal mortality and morbidity to levels where they no longer constitute a public health problem; and to narrow disparities within countries and between geographical regions, socioeconomic and ethnic groups." Between 1990 and 2015, the maternal mortality ratio needs to be reduced by three-quarters, and infant and child mortality rates by two-thirds. The Western Pacific Regional Office has been supporting countries in adapting and implementing the Integrated Management of Childhood Illness (IMCI) and Making Pregnancy Safer (MPS) as major maternal and child health strategies. It has also supported the preparation and implementation of action plans to reduce mortality in selected priority countries. There is a need, therefore, to monitor progress in the implementation of these programmes. I understand that there are differences among and within countries in the Region in the availability of adequate health information systems, including vital registration systems for accurate birth and death records. This creates problems for many countries in estimating maternal and child mortalities. In addition, there exists an incompatibility in the classification of childhood diseases between health information systems (HIS) for disease surveillance and IMCI, which causes confusion to health workers. In the same way, there is a high incidence ofmisclassification of the causes of maternal death, which makes maternal mortality estimation difficult. The fact that maternal death is a relatively rare occurrence makes it costly to measure, as a huge sample size is needed to be able to come up with a reliable estimate. In order to monitor the progress of interventions toward mortality reduction and determine programme impact, it may be necessary to conduct mandatory investigations of all maternal deaths, especially at the health facility level, to determine the causes of deaths- both the clinical and administrative aspects. Facility-based estimations of maternal and child mortality would be helpful in tracking changes brought about by dynamic interventions. This would be easy to do and would be beneficial for the staff of the facility, especially in the absence of a good vital registration system. It is also important that a minimum number of critical or core process indicators are identified. These core indicators would be able to provide countries with information essential for guiding policy setting and programme development. Preferably, they should be those already being used by countries, regularly available, especially in health facilities, and disaggregated by gender (where it applies), broad age group and possibly by urban/rural residence. Considering the countries represented today, it may be difficult to come to a consensus. However, it is worth trying.

- 26 Annex 3

While data collection will be an important ongoing activity, I consider data interpretation as even more important. For example, the finding of a high rate of female infant deaths may denote discriminatory health care provision due to gender bias. Each country may have unique experiences and situations which may give different implications to the data collected. It is, therefore, essential that policy and programme planners and implementors be involved in data analysis and utilization. I believe that this workshop will provide an excellent opportunity to discuss the above challenges. I hope you will gain much from your interactions with each other and from the field visit. I would also like to take this opportunity to thank the Yunnan authorities for the local arrangements and in demonstrating to us their nformation system model. It is also interesting to note that Yunnan has a very diverse mix of ethnic groups which will enhance both the cultural and scientific values of this workshop. Good luck and good day.

- 27 -

ANNEX4

LIST OF INDICATORS A. Maternal

• • • • • • • • • • • • • • • •

Maternal Mortality Ratio Perinatal Mortality Rate Number of women availing essential obstetric care Number of deliveries assisted by skilled health workers % of pregnant women attending antenatal care four times starting on first trimester %of pregnant women given receiving iron supplement Number of facilities providing essential/emergency obstetric care Birth weight specific mortality rate % of OB-Gyn admission due to abortion/ abortion rate among pregnant women Contraceptive prevalence rate Number of women availing of family planning services Cause specific mortality rate Syphilis serology positive rate % of women screened for STI/HIVI AIDS Caesarean section rate Referral rate

B. Child

• • • • •

•

• • •

Infant Mortality Rate Under 5 Mortality Rate Neonatal Mortality Rate Home Deaths Rate Cause specific mortality rate EPI coverage Exclusive breastfeeding rate Malnutrition prevalence First level referral

- 28 -

- 29 -

ANNEXS USE OF MULTI-DIMENSIONAL TABLES IN IDENTIFYING ESSENTIAL INDICATORS Programme managers routinely organize their data in simple frequency tables and use percentages to describe the data, e.g., 40% of pregnant women begin the antenatal care (ANC) in by the second trimester, or 10% have had less than 3 ANC visits. Program managers might combine the two variables into a core table in which one of the variables is a column (when ANC began) and the other a row (number of ANC visits) to describe the interaction of the two variables. Each cell in this table would 51 provide data on both variables, e.g., 25% ofthe women began their ANC in the 1 trimester and have 3 or more visits. Rarely would a program manager then use a third variable to create a multi-dimensional table in which a cell in the core table becomes an indicator that is nested within additional variables to be used in comparison in both monitoring process and evaluating outcome. Session 8 contained an exercise to provide the participants with some experience in creating a core table, identifying a cell in the table that would be used as an indicator, and then nesting the core table in additional variables for comparison use. For monitoring, the core table is nested within three additional variables, the skill of the attendant during ANC, the distance from home and the place of delivery of the ANC, and the site of delivery of the ANC. For evaluation, the indicator from the core table is then used with BABIES to begin a similar process to link intervention with outcome and this is nested within the other variables. The following set of steps has been defined to illustrate the exercise. Group 4's table on ANC initiation and ANC visits is used in the example. Two tables are on the following pages, one for monitorng and one for evaluation. Only the monitoring table will be used in the example. 1. Decide on the question that needs to be answered. a. Example: Question: Is the Antenatal Care (ANC) Program successful? The programmatic objective is to have all women begin ANC in the 1st trimester and to have at least three visits. (refer to Group 4 table) 2. Decide on the core table that gives the answer to the question. It is usually a basic 2x2 table that contains 2 variables that are essential to answer the question. For monitoring these may be process variables, but for evaluation one must be outcome varibale. (The core table can have more the 2 values for a variable, but for the example here, only 2 values for each variable will be used.) a. Example (monitoring Table Group 4a): Trimester ANC begins (columns) by No. ANC visits. b. Example (evaluation Table Group 4b): BABIES by ANC index (a crosstabulation of the monitoring table with the program objective cell being one of the values ofthe ANC index).

- 30 -

Annex 5

3. Determine other determinants that are thought to affect the core table. They are usually categorized in terms of time, place and person. a. Example determinants: Skilled attendant, distance from place of delivery (POD) of ANC, site of ANC delivery. 4. Define the values for each of the other determinant variables (these will be the rows). The columns are the values of the columns of the core table. a. Example: The core table columns are the values chosen for when the ANC began (1 51 trimester, 2"d trimester, 3rd trimester), and the rows are the number of prenatal visits (0 visits, <3 visits, 3+ visits). It is very important the make sure there are no overlapping values in either the columns or the rows. Each woman should be eligible for only one cell in the core table.

5. Decide the cell that will used as the indicator cell. The number of women in the indicator cell divided by the total number is the indicator which can be expressed as a proportion(%) or a rate (o/00). The value of the indicator will be used in comparison between the other determinants. The difference between the indicators is what the program manager responds. There are two cells that are frequently chosen to be the indicator cells. The first cell is the cell that defines program success. The second cell is the one which defines program failure. a. Example: Program objective: 1. ANC begins in the first trimester and women needs to have 3+ number of visits during the course of the pregnancy. In Table Group 4a, this is cell AA. When comparison is made AA is numerator, and cell DA is the denominator. For the entire program the indicator is the sum of AA thru AH, the denominator is the sum of DA thru DH. (Refer to the highlighted cells in the Table Group 4a.) b. Example: Program failure 1. Women who begin ANC in the last trimester and have less than 3 visits (this would be used if the data was originating from the ANC site.). In Table Group 4a, this is cell BA. When comparison is made BA is numerator, and cell DA is the denominator. For the entire program the indicator is the sum ofBA thru BH, the denominator is the sum of DA thru DH. . (Refer to the highlighted cells in the Table Group 4a.) n. Women with no ANC. This would be used ifthe data of the ANC site could be linked with the place of delivery site so that a woman who had received no ANC care was identified at delivery.

- 31 Annex 5

6. Determine a cut-off value of the indicator that triggers a response on the part of the program manager. This a value that which usually corresponds to a defined short or long term objective of the program. 7. Decide on who, will do what, and when at the time when the indicator is reviewed and the value of the indicator is unacceptable. Fill out the accompanying table for each of the indicators that may be derived from the core table or the multidimensional table. Example: What percentage of women begin ANC in the 1st trimester and have 3+ visits Indicator Indicator cut-off 40% Who will respond? Head nurse in the clinic. What will the response be? Focus group discussion with staff and potential clients. When will the response take place? Quarterly

Percentage of women begin ANC in the 1st trimester and have 3+ visits Etc ... .

A similar process is carried out for the other potential indicators for the monitoring table. In a like manner, an indicator cell is agreed upon for the evaluation table (Table 4b).

- 32 -

- 33 ANNEX 6

GROUP WORK

Group 1 ANC ~ ~

Sex Male

(.)

u.

as

Female

z 0

~

~

Male

(.)

~ I s:::::

Female

Group 2 POD Trained Attn Transport

Yes

cu 0

Yes

~ Q.

No Yes

tn :I:

No No Yes Yes CD

No Yes

E 0

:I:

No No Indicator to measure whether PPH+ can be handled successfully

- 34 -

Annex 6 Group 2 Table x: Title Var 6 POD VarG POD ANC Parity Maternal d~ath

~Total . ':::

·;::::: ( .)

c; fJ)

PG Yes

::' l.liQ_ MG

·a 0

::: c. fJ) No

"' 0

IYes Total I No !Yes Total I No les Total No Yes Total !iQ_

::I:

(.)

(.)

PG No MG

::I:

'i: (.)

c

.!!!

.!!!

c

PG Yes

E ::I: 0

G>

E ::I: No

G>

MG

Yes Total ~0

0

PG

MG

•Yes Total INo IYes Total

POD

ANC Parity PG

;;_•m1a No Yes Tota l No IYes Tela I INo les To~

b'il == ~ ~ ~

Maternal death

Yes

Yes

MG GMG PG

s ·c.. Ill

s ·c.. Ill

::t:

0

::t:

0

No

No

MG GMG

No les Total No les Total

POD

ANC

POD

ANC Parity PG

~ Outcome ~

-

_~,~·m . -". ::

Total

ii?:i~ii@•ii•: ::::"

··.·· ..

'}"::•·::'":~·::;::

:;m::~~~t:R:::

::m::Mii:~=:~:

Yes Ill Ill

Yes

MG

E ::t: 0

E ::t: 0

IIi<>_ GMG IYes

PG

No

No

MG GMG

, ;:. DIJ' ! Total

. :·-.: ··;:·.

Total I No IYes Total No les Total _ li<>_ Yes r ot;

~

=

M•:•':m~~:!':'

::::'•?::::Mi%:• ·.·.···::

Group 3 Place Facility

Immunization status checked Sex Male

=ISC Place

Received all immunizations needed Facility sex

=RAIN

Facility A

ns .a ....

c

Female

:::J Facility 8

Male

Female Male Facility C Female

Male Facility C

ns .... ~ :::::s

ns .... ~ :::::s

w Male Facility D

lJ1

Male Facility D Female

1. Proportion of children needing vacinations leaving health facilities with all needed vaccinations . 2. Proportion of sick children visiting health facilites having their immunization status checked

- 36 -

Annex 6

Group 4 Outcome linked Birth Plan Table 4B: District "'· Var6 POD .:.: BABIES by ANC ~ POD/ANC b_t_ POD Outcome POD/ANC App. ANC Total <2499 App. ANC HC No App Total ~2500

ca c: +:. "i: (.) t/)

···~-iiit . ;::: ..: :::::

:c:?:: :;_ :_:_,_, :::i:: L):''i ·;-~,: :::~

: ·: ·

... (.)

... +:. :::l

0

App. ANC Home NoApp

<2499 :>_2500 I Total 1<2499 1:>.2500

'

'\

9\..

c:

t/)

ITotal 1<2499 1~2500

...... -&

'\

~Pro W'

gram objective

ITotal 1<2499 App. ANC Var4a 1~2500

1/'Xorogram failure

Cl

~tal

tl.

:c Var4b

0

E

cu

No App

<2499 !:_2500 Total <2499 ~2500

!L. ,... , I J.. ,. I I

App. ANC

No App

Total <2499 .:!_2500 Total

.L ,..

- 37 -

Annex 6

Group 4 ANC begii'ls by No. Visits by Attendant by distance by POD/ANC POD ANC Distance Attn

#Visits 0

Skilled Attn <3Km TBA HC

<3 3+ Total 0 1-2

3+ Total 0

1st

2nd

3rd

T

BA ~

-Program objective Program failure

·'0

C') s:::::

Skilled Attn 3+Km TBA

<3 3+ Total 0

·0 s:::::

...... ~

<3 3+ Total 0

Skilled Attn <3Km TBA Home Skilled Attn 3+Km TBA

<3 3+ Total 0

<3 3+ Total 0

<3 3+ Total 0

<3 3+ Total

POD/ANC

Table 4b: District Speclflc BABIES by ANC b POD/ANC by POD Outcome Attn App. ANC Distance App. ANC

I I I

88 ~

BC ~

I I L I I I

BD ~

BE ~

I I I I

I

BF ~

I I I I

BG

I I BH

~

~

~Alive <2499 >2500 Total <2~9 9

Total

~

E

Skilled Attn NoApp

C"')

v (.)

App. ANC

TBA NoApp

> 2500 Total .<2499 ~2500

:X: Skilled Attn

App. ANC

s:::::

...... ·ca

0

~

E TBA

Total '2499 >2500 Tota l ,<2499 1 ~250 0

NoApp

+ C"')

App. ANC

ca >

::::s

NoApp

Total =2.499 1 >2500 Total 1 <2490 1>2500

App. ANC

I~ <2499 >2500 Total <2499 >2500 Total =2499 1~2500

w (1,)

~

E

Skilled Attn NoApp

C"')

v 0 :X:

App. ANC

TBA NoApp

E Skilled Attn ~

Total :24!1!1 App. ANC 1 ~2SQO

ITotal =2499 NoApp ~250 0

E TBA

C"')

+

App. ANC

Total <2499 :>:2500 Total

NoApp

·~ill. ,~2 500

Total

- 38 -

Next Steps CAMBO DIA Priority Problem(s) identified

PLANNING FOR NEXT STEPS

Proposed Solutions/activities

Responsible organization

Support Required Country Cambodia Other or2anization WHO UNICEF

Target Date

1. Completene ss of data obtained through health information system-lack of technical and financial supports

Strengthening integrated HIS: • Strengthening HIS' structure (introduction of computerized system to lower level: provincial and district), the • Establish mechanism of improving accuracy and quality of data in the system (role ofNSC of HIS, tools for data collections, private health facilities), Building of sustainable and effective disease surveillance system, • Strengthening the capacity of central level, 2. Usefulness of data/information-Limited • Improving the quality and integrity of information use of health information • Decentralization of data management to provincial level, level, • Building capacity of provincial to system d computerize of • Introduction provincial level, Regular feedback, • Increasing the utilization of information for management and planning, • Improving coordination mechanism 3. Large discrepancy between data through strengthening the structure and obtained through HIS and that obtained roles of the National Sub-Committee of from survey (DHS ... ) HIS, • Improving the quality of integrated information system

• • •

Planning & Health Information Department (MoH), NSC of HIS Communicable Disease Control Department (MoH),

•

•

•

•

•

Planning & Health Information Department (MoH), NSC ofHIS

Cambodia

• •

WHO UNICEF

•

• •

Planning & Health Information Department (MoH), NSC of HIS

Cambodia

• •

WHO UNICEF

Next Steps PEOPLE'S REPUBLIC OF CHINA Priority Problem/s identified l.Underreporting (over reporting) 2.Less sites in the western part 3.Lack of accuracy of cause 4.Timeless 5.Not enough information in the death cards 6.Limited. financial support 7.Unadequate Training and supervising of surveillance workers 8.Need to define associated terms Responsible organization Support Required Other nizations Start Date Oct. 1

Proposed Solutions/activities

NGOs(Women's federation)

county health bureaus MCH center at each level Expert team

Priority Problem/s identified .Web data, poor information

Proposed Solutions/activities l.Mapping on MMRIIMR by province 2.Referral situation analysis 3.Distrritiution of leading causes by place of -delivery, tim·e, education and income 4.Correlation between leading causes and income, education and so forth 5.Correlation between MMRIIMR and social factors 6.Surve~llance summary

Respon. Org MOH NSO Expert team

~------~~~~~--------~

Support Required Other nizations State Statistic Agency (SSA)

Start Date Oct. 2001

Priority Problem/s identified Inadequate use o:f information

Proposed Solutions/activities

Support Required Media Administration Advertisement company Enterprises

Start Date Oct. 2001

Next Steps LAO PEOPLE'S DEMOCRATIC REPUBLIC Priority Problems Identified Data collection and coverage Proposed Solutions/activities Responsible Organization MOH (Planning Dept.,Statistic Division MOH.MOI .other Ministries MOH (Planning Dept.,Statistic Division) MCHC/MOH Support Required Other Org. Country Target Date Present WHO, UNICEF End of2001

Strengthen routine health statistics • Review and develop unique data collection/form/guideline Pretest of forms Strengthening of civil registration • Advocating/coordinating meeting

I

•

I 2002

Quality of data

Utilization of data

Improve accuracy/reliability of data • Training of health data collectors • Provision of computers for all provinces Interpretation of data • Mapping (by levels of MMR, IMR, availability of care) • Meeting on data analysis for collectors, users, planners Dissemination of information • National meeting on MMR and IMR • Through Mass Media (TV, NSP, talk shows, leaflets

I

WHO, UNICEF

Mid 2002

I

Consultant

End of2001

MCHC/MOH MOH/MCHC MOH/MCT

I I I

Province/ District

-

RETA

November

Next steps MONGOLIA Prepared by: Ya Buyanjargal (MOH), G. Soyolgerel (MOH), D. Nyamkhorol (NCHD), D.Malchinkhuu (MCHRC, MMU), D. Daariimaa (MCHRC), Resource person: Dr. Rebecca Ramos, Dr. Y. C.Chong

Priority problem/ identified Poor capacity building

Proposed solution/ Activities

Responsible organization

Support required Country Other organization WHO (technical) UNFP A (technical and financial )

Target date

-

Strengthen HMIS , including to complete computerization at the aimag level Training for trainers on HIMS Improve communication between aimag-soum-bagh Monitoring, analysis and disseminate of information to soum levels Assess needs to monitoring system to be able to indicators for implementation of RH national programme and IMCI programme Review and revise all registration form Develop new registration form Training for record's officers in the all soum (334) and family doctors post (93 7), hospitals (34 ),

MOH, NCHD, Local gover

MOH, NCHD, Government

2002-2006

-

Lack of feedback from province to gross root levels

-

MOH,NCHD, MCHRC,MMU MOH,NCHD, Local gover MOH,NCHD MCHRC

2002 2003-2006 MOH, NCHD, Local Gover UNICEF, UNFPA, GTZ, 2002-2006

-

2003

Lack of data collection and quality /incomplete filling registration form/

-

MOH, NCHD, MCHRC

Government and local governor

WHO, UNICEF, UNFPA GTZ

2002-2003

2003 2003-2006

Lack of utilization on planning, decision of strategy

-

MCHRC on quality data collection Organize meeting on advocacy for decision makers Develop and distribute IEC materials to decision makers and leader of HC Organization meeting for staff of private hospitals Training for record's officer Distribute registration form to private hospital Strengthen on data collection from private sectors

MOH,NCHD Local gover

MOH, NCHD, Local gover and NGO

2002-2003

2003-2006

Lack of report from private sector

-

MON,NCHD MMU,NCHD NCHD MOH,NCHD

MOH, NCHD, Local gover and NGO

20002 2002-2003 2003 2002-2006

Next steps PAPUA NEW GUINEA Priority Problems Identified High Maternal Mortality Ratio Proposed Solutions/activities Responsible organization MOH, UPNG & Provincial doctor in charge of maternal health Support Required Country Other org. MOH UNFPA WHO US AID W&CP INICEF Target Date 2002 Jan. To begin

• • •

• • High Infant Mortality Rate

• •

• • • •

Reactivate the maternal mortality register Make maternal death a notifiable condition Produce a training module on maternal death investigation and reporting for distribution to training schools Produce forms Conduct training Supplies and equipment Data on child health- IMCI strategy will need additional information for programme monitoring. Need to adapt the NHIS to incorporate IMCI need. IMCI implementing districts to adapt the NHIS to IMCI data need. Design forms and registers Train staff Supplies and equipment

Health Improvement Branch (NDOH) Family, particularly those involved in IMCI Working Group

WHO WCHP (AUSAID) HSIP

2002

PHILIPPINES: The Country's "Next Steps" Priority Problem/s identified Weak Reporting Mechanism from all levels of health system - delayed submission of reports Coordinate with the BLHD, DOH/CHDs to advocate the timely and complete submission of reports. Coordinate with the NEC, HOMDOH to include in the FHSIS (Revised 200 I) data on the maternal, infant, underfives perinatal deaths, its causes, according to age, gender, residence (urban/rural) including hospital reports. Strengthen the capacity of the LGUs to process the data thru appropriate training. Feedback to CHDs during PIR Consultative workshop and other health fora. - Lack of commitment of some LGUs Advocate to DILG, LCEs (ULAP) the importance of the timely submission of reports I st wk December DOH-National CFEH UNICEF PCMC WHO I st wk October

Proposed solutions/activities

Responsible organization

Support Required Other Country Organizatios

Target Date

- Non-inclusion of maternal, infant, underfives, perinatal deaths in the routine reporting system of DOH

- Low capacity to process and analyze data at all levels of health deli very system.

Poor Monitoring system

- Outdated MCH monitoring tool

Review the Integrated MCH Monitoring, surveys and Quality Assurance Assessment Tools for Health Facilities to include data needed for the reduction of the maternal, infants and underfives morbidity and mortality. Enhanced Monitoring System at all levels thru team approach (national, regional, provincial reps program, FHSIS, Health Promotion Coordinators) using the updated monitoring checklist Conduct regular monitoring and feedback activities at all levels. Improve the monitoring and evaluation documentation at all levels of health service delivery (esp. best practices)

DOH

CFEH NEC HOM

3rd

wk October

- Poor utilization ofthe MCH monitoring tool

-do-

CFEH CHDs FHSIS Health Promotion

Next steps VIETNAM Priority Problems Identified Proposed solutions/Activities Responsible Organization HID of Planning Dept-MOH Support Required Country Other org. WHO for technical support to 1mprove capacity in central level Target Date

•

• • • • •

Under reported and poor quality data on child and maternal mortality Overlap of information (many kinds of forms) Lack of integration between HIS and other programs Lack of information feedback system Poor utilization of information in decision making and planning Low capacity to process and analyze data

Strengthen HIS • Development of integrated information system • Construct a standard list of health indicators • Develop unified reporting forms as statistical regulation • Develop skill on data management and data processing • Computerize data processing and analysis Conduct national health surveys

•

MCH/FP Dept. MOH

Therapy Dept. MOH

UNICEF to develop CBM UNFPA-new forms WORLD BANKconduct of national health survey

• • •

•

Complete and issm the list of health indicators, unified reporting form and statistical regulatio by the end Application of the new reporting fom at the beginning of 2002 Regularly update skills on data collecting and processing Computerize the health information system step by ster Complete the national health survey by 2003