(WP)HIN/ICP/HST/005/FP/87-E
ENGLISH ONLY
~RKSHOP ON INTEGRATION OF MATERNAL AND CHiLD HEALTH/FAMILY PLANNING INFORMATION SYSTEM WITH GENERAL INFORMATION SYSTEM SUPPORT TO PRIMARY HEALTH CARE IN THE SOUTH PACIFIC
Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Vila, Vanuatu 27 July - 1 August 1987
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2 ti JAN 1988 Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines December 1987
NOTE The views expressed in this report are those of the participants in the workshop on integration of maternal and child health/family planning information system with general information system support to primary health care in the South Pacific and do not necessarily reflect the policies of the Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Members States in the Region and for those who participated in the Workshop on Integration of Maternal and Child Health/Family Planning Information System with General Information System Support to Primary Health Care in the South Pacific, which was held in Vila, Vanuatu, from 27 July to 1 August 1987.
CONTENTS
1.
INTRODUCT ION .......•...•.••.•...••...................... OBJECTIVES ............................................. . DURATION, SCHEDULE AND PARTICIPANTS ..........•..•....... PROCEEDINGS
1 1
2.
3.
1
4.
.............................................
2
4.1 Country situation reports (summary) 4.2 Review of sources of data on health services and status ................................• 4.3 Programme managemen t .................•..........•... 4.4 Information on maternal health care ..••............. 4.5 Working group session 4.6 Information on infant health care ...•••.•.......•..• 4.7 Creation of an integrated MCH/FP data base ..........
2
3 3 4 4
5
5 6
5.
RECOMMENDED GUIDELINES ANNEXES ANNEX 1 - AGENDA AND PROGRAMME OF ACTIVITIES ANNEX 2 - LIST OF PARTICIPANTS, CONSULTANT, OBSERVERS, REPRESENTATIVES AND SECRETARIAT ANNEX 3 - OPENING ADDRESS BY DR I. GEIZER, WHO COUNTRY LIAISON OFFICER, VILA, ON BEHALF OF THE REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC ANNEX 4 - CLOSING ADDRESS BY DR I. GEIZER, WHO COUNTRY LIAISON OFFICER, VILA, ON BEHALF OF THE REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC
9
13
17
19
ANNEX 5 - COUNTRY PRESENTATIONS ..............•..••...... 21/22 COOK ISLANDS ........................•....•..•• 23 KIRIBATI •...•.........•••.•................... 37/38 FEDERATED STATES OF MICRONESIA ...............• 39 PAPUA NEW GUINEA .................•...•........ 43/44 VANUATU •..........••..•....................... 45
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ANNEX 6 - IDENTIFICATION OF MINIMUM DATA SET AND DATA SOURCES .............................. 51/52 ANNEX 7 - IDENTIFYING DATA REQUIRED FOR PROGRAMME MANAGEMENT .......................... 65/66 ANNEX 8 - MATERNAL HEALTH CARE INFORMATION .............. 73/74 ANNEX 9 - BASIC MCH DATA FOR 11 ISLAND NATIONS .......... 77/78 ANNEX 10- POPULATION POLICY IN 11 ISLAND NATIONS ........ 83/84
1.
INTRODUCTION
The medium-term objectives of the programme on health statistics is to support Member States in reorienting existing health statistics services to support programme development and management. WPRO collaborative activities have focused on the development or reorientation of national health information systems, specifically in support of the primary health care approach. The Regional Workshop on Innovative Approaches to Maternal and Child Health and Family Planning, 22-26 September 1986, Manila, felt that there was a need to determine the minimum MCH/FP information required for monitoring and evaluation. The participants suggested that such information be incorporated in the overall health information system. They believed it important that information about maternal and child health and family planning programmes be integrated with data used by other programmes to evaluate non-MCH/FP health problems. All Member States have made progress in extending primary health care. Furthermore, some countries are already using microcomputers for processing health care data. The guidelines may therefore be relevant to all Member States. Countries where microcomputers are already in use may find the guidelines helpful for their further utilization. States not yet using microcomputers for health data processing may find the guidelines helpful in future decisions concerning implementation.
2.
OBJECTIVES
The objectives of the workshop were as follows: {1) to discuss the relevance and feasibility of shifting from the development of separate information systems for maternal and child health/family planning programmes to an integrated information system for all primary health care programmes; to prepare guidelines for the further development or modification of existing maternal and child health/family planning information systems and/or PHC information systems with a view to the development of integrated health information systems for all primary health care programmes.
(2)
3.
DURATION, SCHEDULE AND PARTICIPANTS
The workshop was held from 27 July to 1 August 1987 at the Intercontinental Island Inn at Port Vila, Vanuatu. No sessions were held on 30 July, Vanuatu's Independence Day. The agenda is given in Annex 1. There were 15 participants from eight countries; several observers also participated (Annex 2).
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4.
PROCEEDINGS
The workshop was opened by Dr I. Geizer, WHO Country Liaison Officer in Vanuatu, who delivered an opening address on behalf of Dr Hiroshi Nakajima, Regional Director, WHO Regional Office for the Western Pacific. The text of that address is given in Annex 3. This was followed by an address by the Minister of Health of Vanuatu, the Honourable Edward Natapei, who welcomed the Workshop to Vanuatu and wished the participants success in their undertaking. Dr J. Robey, Regional Adviser in Health Information, WHO Regional Office for the Western Pacific, then described the need for the workshop and the objectives to be achieved. Dr Robey functioned as Chairman and Moderator for the workshop. 4.1 Country situation reports
At least one participant from each of the eight Member States represented at the workshop provided a report (Annex 5). Views were expressed by participants with varied backgrounds. Among the participants were at least one statistical clerk and one chief medical officer. The countries themselves likewise differed widely Papua New Guinea has a population of over three million, whereas that of Cook Islands is 18 000. It was therefore to be expected that the health information systems described by the participants should differ. Nevertheless, there were several aspects common to many countries. Several participants noted that the demand for data from various programme areas required some nurses to spend unreasonable amounts of time filling out forms. The representative from Fiji believed that some nurses in his country may spend 30% to 50% of their time complying with the required recording. Several of the participants believed that the greatest obstacle to obtaining reliable and timely data was that much of the population in their country was not readily accessible. The Federated States of Micronesia and Cook Islands, for instance, consist of many islands with small and scattered populations and separated from each other by considerable distances. Much of the population of Papua New Guinea is also quite inaccessible. This inaccessibility has contributed to incomplete reporting of vital events - a problem among many Member States. It was felt, however, that the reporting of births was more complete than that of deaths. In contrast, the participants from Fiji observed that their population was quite accessible, and that 95% of births in Fiji occur in hospitals, making the reporting of births more or less complete. The participants described how their countries are attempting to utilize the primary health care approach. Some countries have selected a village resident in each village as the primary health care worker;
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other countries have a system utilizing health-post aides who are responsible for several villages; in others again, the public health nurse provides primary health care for an area. Since systems of primary health care differ from one country to another, the designs of health information systems intended to support primary health care are bound to vary also. Several countries, such as Tonga and the Federated States of Micronesia, have begun to use microcomputers for the processing of health statistics information. Others, such as Fiji, are still considering how best to proceed with computerization. 4.2 Review of sources of data on health services and status
Mr Hedrick reviewed all the sources of health information (Annex 6). He listed sources from which data of interest for MCH/FP programme management could be obtained. 4.3 Programme management
Dr Berman discussed the data needed for programme management and how they should be used (Annex 7). He made a distinction between "data" and "information" - information being data which answer specific questions. Managers should avoid collecting data not needed as a basis for decisions. After a health problem had been singled out, a rational decision on how to alleviate it could only be taken if sufficient information was available to define the extent of the problem. Decisions about the outcomes desired could then be made. A thorough evaluation of the health problem should reveal the factors that determine its magnitude; these factors, whether causes or risk factors, were termed "determinants". Action to alleviate the health problem shOUld be directed against specific determinants. It is therefore necessary to be able to measure the determinants to be acted upon, and to set goals, called "impact objectives" for acting on them. In addition, the effectiveness of the activities undertaken to affect those determinants should be evaluated; the performance goals of these activities are called "process objectives". If the process objectives are not achieved, the activities have not been properly carried out. On the other hand, if process objectives are achieved but impact or outcome objectives are not, the wrong things have been done. It was emphasized that it was important for health managers not to settle for achieving process objectives, while neglecting the lack of improvement in measurements of the determinants or of the health problem. Programme managers should ask four questions: (1) (2) (3) Where are we and where do we want to be? Are we doing things right? Are we doing the right things?
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(4)
What are we doing that we need to measure? (Sometimes erroneously put us "What are we doing that we can measure?") A distinction was drawn between clinical data that only list the number of visits made, and those specifying the number of different individuals visited.
4.4
Information on maternal health care
Dr R. Thapa described the information that it was important for MCH programme managers to have available (Annex 8). She also described the usefulness of the home-based maternal record, an instrument which would improve, standardize and document antenatal care. It would enable risk factors to be determined and guide management. A pilottested version also enables family planning information to be recorded. Furthermore, such an instrument may serve to improve women's own awareness of their health problems and, therefore, improve preventive care. This data-collection instrument provides a means for gathering reliable information about pregnancy history --especially in the case of women who may have received antenatal care but deliver their babies in the village. The card, if filled out by the traditional birth attendants provides a nurse or health post aide viSiting the village, with information on the pregnancy and delivery.
4.5 Working group session The workshop participants were divided into three working groups with instructions to evaluate a maternal care problem and lay down the outcome objectives, determinants, strategies and process objectives. The groups discussed the problem "Anaemia in pregnancy". It was decided that the magnitude of the problem could be evaluated by determining the prevalence of anaemia among women who received antenatal care. Two broad approaches were suggested: (1) One sought to reduce the risk of adverse pregnancy outcome associated with anaemia by screening for that condition during pregnancy and providing anaemic women with iron or arranging referral. A reduction in risk would be assessed by a reduction in the rates of low birthweight or perinatal mortality. The other approach attempts to reduce the prevalence of anaemia among all women of childbearing age, and thereby reduce the prevalence of anaemia among pregnant women. In the discussion of this approach, it was pointed out that there were multiple determinants of anaemia among women - such as parasite infection, eating habits (frequently culturally determined), short pregnancies intervals between numerous pregnancies, and malaria. The campaign to prevent anaemia may be directed at all these determinants - improvement of sanitation, education, the support of women's groups, the control of malaria, improvement in family planning services and the promotion of breast-feeding.
(2)
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The workshop participants felt that this was a good example of the need for integrated information. The appropriate management of the problem of anaemia in pregnancy requires information about the health of the entire community - not just MCH data. 4.6 Information on infant health care
The participants discussed what data items were important for evaluating infant health and pointed out the need to determine the early neonatal mortality rate, the neonatal mortality rate and the postneonatal mortality rate. The determinants of neonatal mortality were mostly related to maternal care; the ways and means of reducing neonatal mortality reflected that observation - prevention and treatment of anaemia in pregnancy, improved birth-spacing, recognition and appropriate referral of at-risk pregnancies, tetanus immunization during pregnancy, and appropriate care during delivery and of the umbilical cord. Measures to reduce neonatal mortality therefore require community-wide efforts, as in the case of reducing anaemia in pregnancy. Postneonatal mortality is related to factors such as family size, malnutrition, diarrhoea, measles and low birth-weight. As in the previous examples, to exert an effect on these determinants requires community efforts to feed children appropriately (to reduce malnutrition), to improve sanitation (to reduce diarrhoea) and to improve family planning (to increase the birth interval; prolong breast-feeding and decrease family size). These examples indicated the types of information that an integrated data base should provide for evaluating MCH/FP programmes and problems. 4.7 Creation of an integrated MCH/FP data base
It was felt that since primary health care is provided at community level, data on services and health status, based on selected indicators, should likewise be available for analysis at that level. It was considered that an integrated data base should have information pertaining to each village or other suitable geographical unit consisting of a limited number of important data items relating to each programme or aspect of health. Since they were to be limited in number, the items to be included must be considered carefully. The following example was given of data that could be regularly 'compiled for a particular village: Village population, population of child-bearing age, number of births, number of parturients who had had no antenatal care, number of ,women who had had 3 or more antenatal visits, number of women with ,anaemia, percentage of births with medical attention, birthweights under 2500 g., stillbirths, early neonatal deaths, neo-natal deaths, postneonatal deaths, infants completely immunized by 12 months, percentage of infants seen after nine months who are more than 5~ below the standard weight for age.
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In the discussion the sources of data for this hypothetical data set were determined. It was agreed that birth certificates could be expanded to include data items pertinent to maternal care. Such an approach, accompanied by complete recording of births, would provide much of the information required concerning maternal care, delivery, birth weight and pregnancy outcome. Furthermore, widespread acceptance and use of the home-based maternal card would permit accurate completion of the birth certificate, particularly if the two forms were coordinated. Information about infant deaths requires better recording of deaths in general; it was suggested in the discussion that the nurse should solicit the aid of the village chiefs or village welfare group in reporting births and deaths; such a procedure requires the chief or group to be convinced of the significance and usefulness of reporting vital events. The public health nurse or health-post aide could maintain a cohort-based list of infants in each village who had had the full course of immunizations and whose weight for age was low. The village population and the number of women of childbearing age would be obtained from the census figures. It was recognized that efficient compilation and optimal utilization of such a data base could be enhanced by the use of microcomputers, although steps could be taken to improve the recording of vital events and to determine which data items were of importance even without computerization. Furthermore, it was felt by the participants that the integration of the data sources required an integration of the goals and objectives of the programmes; a central group or committee to coordinate data collection would make this easier.
5.
RECOMMENDED GUIDELINES
5.1 The partiCipants affirmed the importance of integrating information about maternal and child health with information about other important aspects of primary health care. Ideally the information compiled should be provided on a community-by-community basis. The individual circumstances of each Member State should dictate which data items would be compiled. Member States which have not taken steps to integrate data systems should be encouraged to do so. 5.2 Since many of the data to be compiled must be obtained by a single person providing care at primary level, only those that are essential should be recorded. This means that the data items that are essential for managing programmes and for assessing community health status should be determined so as to form minimum data sets consisting of items that accurately measure:
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(a) (b) (c)
the specific health problems targeted; the associated determinants on which programmes are intended to have an impact; and the effectiveness of the activities intended to produce that impact.
5.3 Sources of such data include, but are not limited to, census returns, birth certificates (especially if reporting is complete and the content of certificates is expanded), death certificates, records from hospitals and dispensaries, and records from the villages. 5.4 A national health statistics unit should be formed or designated which would coordinate the collection and integration of data.
5.5 Member States should consider the adaptation of home-based maternal records; such records not only strengthen maternal and neonatal health care during pregnancy, parturition and the postnatal and interpregnancy periods, but can also supply community and health care providers with health information useful to programme management. 5.6 Efforts should be made to enable the data to be analysed and interpreted at the peripheral level, where they were initially collected. Such a system would improve the quality of the data collected by providing feedback to the workers who actually obtain them.
5.7 At the national or central level, the analyses should be presented to the decision-makers together with an interpretation of the data. It is important that analyses and interpretations carried out centrally should be distributed to all levels at which those results are relevant.
5.8 The importance of having valid and timely data must be recognized. This means that regular training programmes and support activities should be organized to ensure accurate collection, analysis and use of the data at all appropriate levels. 5.9 Decisions made concerning information systems should be regularly reviewed. The design of a health information system depends on health care priorities and the data processing capacity of the Member State concerned; since either of these factors may change, the information system may have to be redesigned.
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ANNEX 1
AGENDA AND PROGRAMME OF ACTIVITIES
1.
Introduction and orientation Welcome address Introduction of participants, observer, representatives and secretariat History and background Review of the agenda and work plan Objectives of the workshop Group picture taking
2. 3. 4. 5. 6,.
Country presentations Programme Management (Dr S. Berman) Maternal Care Information (Dr R. Thapa) Family Planuing Information Infant Health Information Identification of minimum data set and sources (Mr P. Hedrick) Data processing, analysis and use Presentation of draft guidelines Closing ceremony
7. 8. 9. 10.
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Annex 1
PROGRAMME 27 July, Monday AM
0800 - 0900 0900 - 1000
Registration Opening Ceremony Welcome Address by the WHO Country Liaison Officer in Vila Welcome Address by the Minister of Health 1.
Introduction and orientation - Dr James Robey History and background Review of agenda and work plan Objectives of workshop Group picture taking
1()OO - 1030 1030 - 1200
COFFEE
BREAK
2.
Country presentations LUNCH
PM 1200 - 1400 1400 - 1630 BREAK
Country presentations (continued)
28 July, Tuesday AM
0800 - 1000
3.
Programme Management - Dr S. Berman Discussion
1000 - 1030
COFFEE
BREAK
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Annex 1
1030 - 1200
4.
Maternal Care Information - Dr R. Thapa Discussion Working groups
PM 1200 - 1400 1400 - 1630 LUNCH BREAK
Maternal Care Information Working groups (continued) Plenary session
29 July, Wednesday AM
0800 - 1000
5.
Family Planning Information Discussion Working groups
1000 - 1030 1030 - 1200
COFFEE
BREAK
Family Planning Information Working groups (continued) Plenary sess~on
PM 1200 - 1400 1400 - 1630 6. LUNCH BREAK
Infant Health Information Discussion Working groups Plenary sess~on
- 12 Annex 1
30 July, Thursday 31 July, Friday AM
INDEPENDENCE DAY
0800 - 1000
7.
Identification of minimum data set and sources - Mr P. Hedrick Discussion
1000 - 1030 1030 - 1200
COFFEE
BREAK
Data sets and sources Working groups Plenary session
PM 1200 - 1400 1400 - 1630 8. LUNCH
BREAK
Data processing. analysis and use Discussion Working groups Plenary session
1 August, Saturday AM
0800 - toDD
Presentation of draft guidelines Discussion
1000 - 1030 1030 - 1200
COFFEE
BREAK
Draft guidelines Discussion (continued) Plenary session
1200
Closing ceremony
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ANNEX 2
LIST OF PARTICIPANTS, CONSULTANT, OBSERVERS, REPRESENTA'rIVES AND SECRETARIAT
1. COOK ISLANDS
PARTICIPANTS
Mr Tupou Faireka Director for Administration c/o Ministry of Health Rarotonga Dr Frank Obeda Medical Officer c/o Ministry of Health Rarotonga
FIJI
Dr Salesi Katoanga National Coordinator Family Planning and Population Control Programme Ministry of Health Suva Mr Eseroma Rausuvanua Acting Medical Statistics Offic.er Medical Statistics Section Ministry of Health Suva
KIRIBATI
Dr Tetaua Taitai Chief Medical Officer Ministry of Health P"O. Box 268 Bikenibeu Tarawa
Mr Atata Timea Statistics Clerk Ministry of Health P.O. Box 268, Bikenibeu Tarawa
- 14 Annex 2
FEDERATED STATES OF MICRONESIA
Mr Amato Elymore Public Health Statistician FSM National Government Office. of Health Services Federated States, of Micronesia Kolonia, Pohnpei Ms Shirley Gideon Administrative Nursing Officer Family Health Services Department of Health P.O. Box 3991 Boroko, N.C.D. Mr Raka Guma Statistician, Policy Planning and Evaluation Division Department of Health P.O. Box 3991 ·Boroko, N.C.D.
PAPUA NEW GUINEA
SOLOMON ISLANDS
Ms Grace Rannie Statistical Clerk Ministry of Health and Medical Services P.O. Box 349 Honiara Mr Stanley Waisi Senior Nursing Officer/MCH Coordinator Ministry of Health and Medical Services P.O. Box 349 Honiara
TONGA
Dr Maika Kinahoi Acting Chief Medical Officer Public Health Division Ministry of Health P.O. Box 59 Nuku'alofa Mr Penaia K. Moa Health Statistics Officer Health Statistics Section Ministry of Health P.O. Box 59 Nuku'alofa
- 15 Annex 2
VANUATU
Ms Marina Laklota1 Acting National Primary Health Care Coordinator Preventive Department Ministry of Health P.O. Box 207 Vila Dr Edward T. Tambisari Principal Medical Officer-Epidemiology Ministry of Health P.O. Box 55 Vila 2.
CONSULTANT
Dr S. Berman Pediatrician and Perinatal Epidemiologist Centre for Disease Control Atlanta. Georgia United States of America 3.
OBSERVERS
AUSTRALIAN DEVELOPMENT ASSISTANCE BUREAU
Ms Vicki Poole ADAB (Australian High Commission) Australian Development Assistance Bureau
Vila SAVE THE CHILDREN FUND AUSTRALIA Ms Chris Maher SCFA Project Manager P.O. Box 283 Vila Ms
Tanya Mark SCFA MCH Nurse P.O. Box 283 Vila
Ms Jane Paterson SCFA Nutritionist Nutrition Section P.O. Box 207 Vila
MINISTRY OF HEALTH, VILA
Dr B. Montaville Epidemiologist Ministry of Health Vila
- 16 Annex 2
Ms Winnie Yakam
Acting Maternal and Child Health Coordinator Ministry of Health Vila 4~:
REPRESENTATIVES
SOUTH PACIFIC COMMISSION
Dr Francois Bach Health Surveys Epidemiologist South Pacific Commission Post Box D5 Noumea Cedex Ms Jyoti Ramsey UNFPA Senior Programme Assistant United Nations Fund for Population Activities in the Western Pacific Private Mail Bag . Suva 5. SECRETARIAT
UNITED NATIONS FUND FOR POPULATION ACTIVITIES IN THE WESTERN PACIFIC
Dr 1. Geizer Country Liaison Officer World Health Organization Vila Mr Paul Hedrick Statistician Office of the WHO Representative World Health Organization ·Suva Dr James M. Robey (Operational Officer) Regional Adviser in Health Information WHO Regional Office for the Western Pacific Manila Dr Rita Thapa (Co-operational Officer) Regional Adviser in Maternal and Child Health (Family Planning) WHO Regional Office for the Western Pacific Manila Dr J. Wooda 11 Scientist/Epidemiologist Development of Epidemiological and Health Statistical Services WHO Headquarters, Geneva
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ANNEX 3 OPENING ADDRESS BY DR I. GEIZER, WHO COUNTRY LIAISON OFFICER, VILA, ON BEHALF OF DR HIROSHI NAKAJIMA REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC AT THE I-«>RKSHOP ON INTEGRATION OF MATERNAL AND CHILD HEALTH/' FAMILY PLANNING INFORMATION SYSTEM WITH GENERAL INFORMATION SYSTEM SUPPORT TO PHC IN THE SOUTH PACIFIC , VILA, VANUATU, 27 JULY - 1 AUGUST 1987 Participants, Observers, WHO Colleagues, On behalf of Dr Hiroshi Nakajima, our Regional Director, it gives me great pleasure to welcome you to the Workshop on Integration of Matsrnal and Child Health/Pamily Planning Information System with General Information System Support to Primary Health Care in the South Pacific. As you know, developing countries, in their efforts to achieve health for all by the year 2000, are attempting to make effective and efficient use of all available resources to reach this goal. One of the most significant resources.which must be brought to bear on health programme implementation, is our national information resources. Successful administration of the health services, even at the primary health care level, requires that a periodiC review be made of the demands on the health service, the manner in which the workload is handled, the resources required to deal with the workload, and the outcome of care provided. Such reviews are generally carried out at weekly or monthly intervals. At the higher or national levels of our health systems, such monitoring may also take place monthly but a more comprehensive study of the total functioning of the health system in all districts need only take place on an annual basis. You will be dealing in this workshop with the issues and problems associated with the need to obtain relevant and t1mely data for maternal and child health and family planning programmes, within the framework of a national health information system deSigned to meet multiple needs for data by all health programmes. The need for such data at the different levels of management and the requisite time-freme for management reviews will also be addressed. Two recent workshops sponsored by WHO in the Region, one on innovative approaches to maternal and child health and family planning, held in Manila in September of last year, and a second on assessment and development of national health information system, held in Suva in October 1985, pointed to the need for integration of health data activities across health programmes. The need to formulate guidelines for integrated programme implementation, including methods of data set determination, data processing and flow, automation and training, were strongly recommended. The participants in this workshop represent both the areas of maternal and child health/family planning and health information system development. Together, for the next several days, you will be addressing the problems and constraints associated with the need for such guidelines. We are confident that thl'ough your discussions specific guidelines will be developed for us to follow in our future national health information system development in support of primary health care.
- 18 Annex 3 You have a very ambitious programme of work ahead of you this week and I would like to conclude these brief remarks by wishing you a successful and pleasant week of discussions and an enjoyable stay in the beautiful islands of Vanuatu. Thank you.
- 19 ANNEX 4
CLOSING ADDRESS BY DR I. GEIZER, WHO COUNTRY LIAISON OFFICER, VILA, ON BEHALF OF DR HIROSHI NAKAJIMA, REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC, AT THE Io.K)RKSHOP ON INTEGRATION OF MATERNAL AND CHILD HEALTH/ FAMILY PLANNING INFORMATION SYSTEM WITH GENERAL INFORMATION SYSTEM SUPPORT TO PHC IN THE SOUTH PACIFIC, VILA, VANUATU, 27 JULY - 1 AUGUST 1987
Participants, Observers, WHO Colleagues, For the past week you have been participants in the first WHO workshop in the South Pacific bringing together those persons responsible for family health care programmes and those responsible for providing the statistics generated by those programmes. It is clear that the result has been a better appreciation by both groups of their common interests and the requirements for information for programme managemen t • As mentioned during my opening address, this workshop was a response to recommendations formulated by two previous regional workshops dealing with new approaches to maternal and child health and family planning and the development of national health information systems, reepectively. You have discussed the feasibility of obtaining input of infDrmation from the village health worker or other community sources, from the Census Bureau and the department that handles the registration of births and deaahs. You have considered the needs for data from other ministries such as those concerned with nutrition, sanitation and education, all of these agencies have been identified as important sources of supplemental data to the routine statistics generated through the health services or by means of special surveys conducted by the government or other agents. In addition, you have reviewed a method for identifying health problems, their determinants and specific contributing factors. The consideration of ways to measure such factors as a way to measure progress in dealing with the determinants and thereby reducing the health problems have been presented. You have recognized the need to specit'y minimum data sets for programme management purposes and you have touched on the application of informatics to data collecting, processing and analysis. We are confident that the guiding principle you have formulated during the course of this workshop will serve the countries of the South Pacific well. Thus, enabling the Member States throughout this area, within the constraints of their unique differences and characteristics, to develop and strengthen their information support to programme management in an integrated fashion consistent with their primary health care approach to the provision of health services.
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Annex 4
Some of you during the discussions, mentioned the need for further training or other support to your health information system development. We assure you that WHO will continue to do everything it can to collaborate with your governments in meeting these needs. You have also learned from the representatives of UNFPA, UNDP and the South Pacific Commission at this meeting that further support is also available from those sources. We are extremely pleased that the representatives of these agencies were able to participate in this workshop. We thank all of you for sharing your expertise and experiences with us, and for the high level of openness and frank discussions which were the result. The WHO secretariat has learned a great deal from you during the course of the last six days. We would like to give special thanks to the Honourable Mr Edward Natapei, Minister of Health of Vanuatu for agreeing to host this meeting on such short notice when it was found necessary to change the venue from Fiji. Also, we are very pleased at the readiness exhibited by Dr Stuart Berman to assist as a consultant, also on very short notice. We were also pleased to have the participation of observers from the Australian Development Assistance Bureau and the Save the Children Fund Australia. We extend our best wishes to all of you for continued success in your important work in improving the data support to family health programmes through primary health care, and wish you a safe journey home.
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ANNEX 5
COUNTRY PRESENTATIONS
Cook Islands Kiribati Federated States of Micronesia Papua New Guinea Vanuatu
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Annex 5
MOTHER AND CHILD HEALTH AND FAMILY PLANNING COOK ISLANDS 1. General Information The Cook Islands are divided into 14 districts for purposes of health administration. Each district comprises one island and these districts are Rarotonga, seat of the central government and the health department, Aitutak, Atiu, Mangaia, Mauice, Manuae, Mitiaro, Manihiic, Nassau, Palmerston, Penrhyn, Pukapuka, Rakahanga and Suwarrow. The first seven islands mentioned comprise the southern group and the remainder, the northern group. All the islands except Rarotonga, are known as outer islands. On the outer islands, except Mitiaro, Nassau, Palmerston and Rakahanga, there are small hospitals under the charge of a medical officer. The islands without hospitals have a dispensary (clinic) under the care of a staff nurse. Hospitals have staff nurse and staff aids; the staff nurse could be a registered nurse or a public health nurse. 2.
Population The Cook Islands' population as of December 1986 was 17,185 compared with 17,754 at the last census of December 1981. This represented a decrease of 569 persons (3.2%) over the 1981 figure. The average annual rate of decrease in population over the past five years was 0.6%.
3. 3.1
Background information Inhabited Islands - Southern group - Northern group Area of distribution of ocean 12
7 islands 5 islands 2,600,000 km 17,754 (1981 census) 17,600 (1985 estimate) 9,530 5,918 1,306 9,172 (51.7%) 8,582 (48.3%) 7,586 (47.7%) 9,391 (52.9%) 7Tf (4. 1 1%) 3,494 2,309
3.2
Total population - Rarotonga - Southern group excluding Rarotonga - Northern group By sex - male - female By age - 14 years and under - 15 years to 64 - 65 years and over
Women in reproductive age (Rarotonga alone)
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Annex 5
3.3
15-19 20-24 25-29 30-34 35-39 40-44
years years years years years years
1,124 (32.1%) 691 (19.7%) 458 (18.8%) 395 (11.3%) 428 (12.2%) 398 (11.3%)
Some national health indication - birth rate - infant mortality rate - death rate 23.6 14.8 6.5
3.4
MCH and FP programme The above programme consists of: (a) Ante-natal care Natal care (hospital delivery) Post natal care Family planning Pre-school health care - clinics in districts for well baby care and immunizations School health care Health education
(b) (c) (d) 4. 4.1
Mother child health and family planning approach and problems Health education
The MCH/FP programme over the years attached great importance to the education efforts by health personnel in promoting the health status of the mother, child and family. The important role the mother and father could play in the home is recognized as a key factor in our promotive efforts. However, at this stage of our development it is still obvious that community understanding of personal hygiene, nutrition, basic sanitation, sex education and healthy way of life is still very limited particularly in the outer islands. This is a top priority area and is receiving the utmost attention in our approach and is growing in strength over the years. 4.2 Transportation and communication
The fact that the islands are scattered poses a problem in the quality of MCH/FP service where the outer islands are disadvantaged by distance or isolation. The farther the islands from the main island, Rarotonga, (the northern group) the lower the quality of service.
- 25 -
Annex 5
4.3
Ante-natal problem
Late attendance to the clinic especially in the outer islands is a common problem. This is basically due to lack of understanding of pregnancy which also hinders the effective risk factor classification of cases. Risk factor identification is very important in the outer islands due to lack of facilities and specialized knowledge of management especially when caesarian section delivery is required, there is a need to refer to base hospitals. 4.4 Breast feeding
Every effort is being made to promote breast feeding. However, in view of our life style where a great number of mothers work and the high incidence of teenage pregnancy. this group poses problems. A working mother often shifts to bottle feeding after six weeks post partum on returning to work and a young teenager also shifts to bottle feeding when she leaves her baby to someone to look after. 4.5 Immunization
The routine immunization programme is achieving almost 100~ cover on Rarotonga but the coverage in outer islands is below 80~. Effort is being made to improve coverage of outer islands.
4.6 Family planning acceptance The family planning programme is still a controversial subject between the traditional cultural values, religion and economic and social realities. The health department's concern is the general health of the population and in particular, the mother and child by the promotion of spacing of child birth and limitation of family. The choice to accept F/p is an individual choice of the man and wife, therefore every encouragement is given during ante-natal and post-natal period for mothers to consider F/P seriously. Approximately 50~ of reproductive women on the main island Rarotonga ape taking some form of contraceptive and about 30~ of reproductive women in the outer islands do the same. In view of our declining population in the Cook Islands over the last 10 years, the major emphasis is on the improvement of life. 4.7 Teenage pregnancy
There is great concern on the number of teenage and single girls pregnancy over the years. About 40~ of our ante-natal cases are in this group. This is no doubt due to restrictions on our promotion of F/p because of traditional beliefs and religion. 4.8 International agencies assistance to our health programme
- 26 -
Annex 5
4.8.1
United Nations Fund for Population Activities
The UNFPA had provided assistance to our MCH and FP since 1986 and is ongoing. The assistance given are in financial support for training workshop for health staff, Child Welfare Association members and youth, including overseas training of nurses in Public Health, Obstetrics and management of women activities. Also, financial support was given to set up our radio telephone network in our northern group of islands, the provision of vehicles to enable our MCH/FP services to be taken to the community, the provision of funds to assist and enable supervisory visits by senior staff to outer islands and the provision of contraceptive pills and materials. 4.8.2 World Health Organization
The World Health Organization of which the Cook Islands is a member, provides on top of our MCH/FP programme a wide range of technical advice including asistance in training of most health staff. They also provided tremendous assistance in our PHC approach, provision of funds for water supply and sanitation, provision of vehicles and equipment, and supplies drugs for special projects. World Health Organization has also acted as executing agency for other agencies in special health projects. 4.8.3 United Nations Children's Fund
The UNICEF had continued to provide assistance in the prOVision of vaccine for our immunization programme and also assisted in the provision of funds for our sanitation projects in the northern group islands. 4.8.4 South Pacific Commission
The South Pacific Commission had provided us with various technical assistance including water supplies and sanitation for some of the islands. 4.8.5 Australian Development Assistance Bureau
The Australian Development Assistance Bureau, on top of many other assistance to the Cook Islands, has also provided assistance in the development of our water supplies to our outer islands. 4.8.6 United Nations Development Programme
The United Nations Development Programme, on top of many other assistance to the Cook Islands, assists Health in the provision of medical and dental manpower. 4.8.7 International Human Assistance Programme
The International Human Assistance Programme, on top of many asistance to the Cook Islands, provided assistance to Health in the form of scholarships, construction of a clinic and the provision of vegetable seeds to support the promotion of home gardening to support our nutrition programme.
- 27 -
Annex 5
4.8.8
New Zealand Aid
Last but not least, the generous assistance from our mother country, New Zealand in many form of aid, and to the health ministry the provision of hospitals, the assistance to our referral cases to New Zealand, hospitals for super-specialist management, the periodic visits of experts and special medical and surgical equipment.
5.
Local agencies
On the local scene we get tremendous cooperation and support in our MCH/FP from the Child Welfare Association.
6.
Conlusion
On behalf of the Ministry of Health and the Government of the Cook Islands we wish to take this opportunity to thank all the international agencies mentioned above for the assistance rendered to the Cook Islands, particularly the Ministry of Health in the field of Mother and Child Health and Family Planning. We also wish to thank the International Planned Parenthood Federation for the invitation extended to the Cook Islands and for accepting us to this important lDeeting. Thank you.
Annex 5 1986 JANUARY - DECEMBER ANNUAL FIGURES 0 & G FjP CLINIC PRENATAL CARE:-
, ':': 28 -
"
1st Visits Re-visits F.B.C. VPRL V.D.R.L. Positive Anaemia 1st visit Anaemia Repeat at ~4 wweks TETANUS TOXOID 1st Dose 2nd Dose Booster TOTAL TRIW,ESTER 1st Trimester 2nd Trimester 3rd Trimester Cytology Smears Gyanaecology High Risks at 1st Visit A/N P.L!!.
235 1218 235 NIL 22 4
83 78 51 215
18 110 107 315 375
Anaemia less than 10gms Heart disease Diabetic Stilbirth Breech delivery 14 years - 16 years Senior Primip Elderly Multip Preggancy according to age 14 17 20 25 30 35 40 years years years years years years years 16 years 19 years 24 years 29 years 34 years 39 years & Over . TOTAL Pregnancy According to gravida 1 4 - 3 - 6
22 4 1
6
2 1 8
3 12 No. 8
52 83 43 29 13
-.2 234
7
10 +
- 9 TOTAL
186 36 10 2 234
- 29 ~ost
natal 6 weeks
Annex
5
Mothers Hb check Babies Hb che~k Low Hb 10gms and under Breast Feeding Breast Feeding with Formula Formula Working mothers Low Working mothers Ante-natal Bookings 1st Bookings Obstetric and Gynae Nurses P.H.Nurses
203 2 239 189 72 82 100
17 132
71
163
75
Family Planning
ole
New Acceptance He-visit ' Total Women on
ole
247 1062 737
N/A according to age 13 17 20 25 30 35 40 years years years years years years years years years years years years ~.39 years & Over 16 19 24 29 34
106: 1 46 11 2 247
7 56
19
T0'1' AIJ
Depo Provera lilA
Re-vi!::it Total women on Depo
144 197
.75
N/A According to age 13 years - 16 years 17 years 19 years 20 years - 24 years 25 years - 29 years' 34 years 30 years 39 years 35 years 40 years & Over
-
-
1 19 30 17 6 1 1
TOTAL
22
- 30 Annex 5
N/A Depo Brovera according to gravida
0 1 - 3 gravida 4 - 6 gravida 7 - C) gravida 10 & Over
8 NIL NIL TOTAL 75
59
e
NLA LU.C.D. N/A Check up Failure Total Women on IoU. C. D. NLA loU.C.D. according to age
16 100 212
13 17 20 25
years years years years 3<> years 35 years 40 years
&
16 years 19 years 24 years 29 years 34 years 39 years Over
NIL 4
5
TOTAL
2 2 2 1 16
NLA 1.U.C.D. according to gravida 0
1 - 3 4 - 6 7 - 9 10 & over TOTAL Barrier method Condom D1aph.1!' am Rytbm Vascectomy T/L Natural F/Planning O/G Depa Provera LU.C.D.
NIL 13 1 2 NIL 16
7
10 10 737 197 212 TOTAL 1122
2
Nln!E~R
OF BIRTHS, DEATHS, INFANTS DEATH AND NATURAL INCREASE BY RATE COOK ISLAN!)S 1979- 1985
YR4.R
MID YEAR POPULATION
BIRTHS NO. RATE
DEATHS NO. RAT3
INFANT NO
DEATHS
NATURAL NO.
INCREASES
RATE
RA ml;' ...~
1979 1980 1981 1982 19,83 1984 1985
18,000 18,500 17,754 18.074 18,050 17,600 17,600
447 452 462 437 417 405 404
24.8 24.4 26.0 24.2 23.1 23·0 23.0
120 118 103 117 121 115 126
6.6 6.4 5·8 6.5 6.7 6.5 6.5
16 10 10 9 7 6 13
35.8 22.1 21.6 20.6 16.8 14.8 32.2
327 334 359 320 296 290 278
18.2 18.0 20.2 17.7 16.4 16.5 16·5 VJ
.....
[
- 32 Anne~
5
1986 CENSYS PR.OVISIONAL RESULTS GEOa. AREA TOTAL POPULATION Cook Islands Rarotonga Southern Group Excl. Rarotonga Northern Group 5668 2228 BROA~
BOTH SEXES 17177 9281
MALES 8862 4800 2900 1162
FEMALES 8315 4481 2768 1066
PERCENTAGE DISTRIBUTION BY Age Group 0-14 15-59 60plus 38.76%
AGE GROUPS
54.24% 7.0\fYo
PERCENTAGE DISTRIBUTION OF WOMEN IN REPRODUCTIVE AGE FOR RAROTONGA
Not tabulated as yet in Format asked for RAROTONGA Total Females 4481 % in 15 - .44 1981 BIRTH RATE (per 1000) DEATH RATE (per 1000) INFANT DEATHS (Under 12 mths) 26.0 5.7 48.4% 1982 25.4 7.9 1983 23.7 7.6 9 1984 24.6 1985 24.6 7.7 12 1986 24.0 5.2 9
6.9 5
- 33 MINI~)'l'RY
OF HEALTH
Annex 5
HEAL'rH INFOID'.ATION SYS'l'EM (HIS) COOK ISLANDS - FAl-IILY PLANNING ISLAND: ••••••••••••• \I • • • • \I \I •
•
•
•
•
•
•
•
•
•
YF.AR ~'NDING 31 DECEMBER: ••••••••• ,
\I
•
\I
••
\I
\I •
\I •
\I • • • • \I
\I \I
\I \I
A. MON'l'H
NEW ACCEPTORS Dip IUD
B.
CURRENT USERS
olc JANUARY FEBRUARY
ALL METHODS
olc
Dip
IUD
ALl
METJI(
MARCH
APRIL MAY JU'ftE
JULY
AUGUST SEP'l'EMBER OC'roBER NOVEMBl"~
DroEmER 'roTAL
34 Annex
5 DEPARTMENT OF JUSTICE
NOTIFICATION OF BIRTH (To be delivered or posted to the Registrar of Births within forty-el,ht hou" .Iter the birth)
the REGISTRAR OF BIRTHS.
KE NOTICE that a (Hale or 'emal.,
child was born at"-_---,_ _ _ _ _ _ _ __ (Place of Birth in full)
- - - -_ _ _ _ _ _ _ _ 19 _ __ I name 3nd postal ddress of parent:
(Signed): _ _ _ _ _ _ _ _ _ _ _ _ _ __ (Occupier of pr.mi .... '
te: - _ _ _ _ _ _ _ Endorsed by (Signed): _ _ _ _ _ _ _ _ _ __ (To be endorsed by the mid·wif. or mnrrnll~
nurse in atundancl! at the confinement)
FURTHER PARTICULARS REQUIRED: irth Weight: ---Ib.--_oz. ength of gestation (Irom rst day 01 last menstrual ,• .,od}: weekJ -1arlu,1 status of mother: NOllE-r.wc,.)' live borth lnd ever)" ".II.lurch m",n b. nOl,(,.d b,.. the occup,er of the pre""'!:l ," ..... 1,,,;10 t"'~, bIrth ,,,r,.et .and 'eL0ltered by tk. hot"'.r or IT'iolh.r or, in d'l. 01 deuh, lbur.c::t, or ,""bd,ty oi the fll"H or uh"r. b) the Otcupl.r or PIII"on preul''It It ("'III bifl"', ~ birth .!\ ont .... her. Itle child ,lltr complUII! uPatation from the r"Otl"l~r I'''n::,pc(t, .. ~ of the (lur",o'" of e, .. ;af'lC.,), brelth\ >;or ShONS .. n.,. other ev'dence of hI., , ... en u bClt'''~ of Ihe heln. P' I)',,')n of ""~ ..••. rd, or der'n'lC! m<l,,~ment 01 "oluntary mUh.IIH. whetl"ler or not the "m~d,(,,1 cor;::! hn been Cu', or ,t C ... ·Jttll~1
: Degree of Maori
II thild is still-born, please staU so:
blood (il any): If still·born, give name and address practitioner attending confinement
or
medicJ.1
(I'.
tached. ~ i. che birch where a child i, bor" .her t .... e.PH,l:io'1 of the twe'lc)", ... "nth .............. 01 ",I nOl treuhe or .he .... an)' other cvidance 01 life .h.r c.omplete H::PH1',en Iro<l"l (he mo:hcr.
pI'"
ilI'\j
FOR USE OF REGISTRAR OF BIRTHS ONLY Notification Register No. _ _ _ _ _ __ lotice to Register sent Irst reminder (Da,e) Seco~d
rcmindcr ___________ (Date)
N? I
1724
1. To
ilL
\
1724 Section 28
j
, Form No.5.
DEPARTMENT OF JUSTICE
I Section 281 Form No.5.
DEPARTMENT OF JUSTICE
I I I I I I I I I
NOTICE TO THE FUNERAL DIRECTOR
I hereby give notice that I have this day issued to the I Registrar of Births and Deaths" Medical Certificate as I to the cause of death of: I .............................................................................. Deceased. I
I I I
Death Entry No: ............ /19 ...... .. THE BIRTHS AND DEATHS REGISTRATION ACT 1973. To the Registrar of Births and Deaths at ........................................................................................... . I, the undersigned, a duly qualified Medical Offil.:er, do
I I
I Signature of I Medical Officer: .................................... Date: .................... I I CERTIFICATE AS TO BURIAL
1 1 1 1
I I I
VJ 1.11 VJ
....... 0'1
I I I 1
! I
I, ............................................................................................. I of ............................................................................................ I Funeral Director (or other person having charge of the I burial) do herebv certifv that the body of: _ . • f was on the .................... day of ........................... 19 ........ in my presence. duly buried at ........................................ (or placed in the crematorium at .................................... for the purpose of cremation). V!lTNESS
hereby certify that I attended ........................................... . ................................................................................ Deceased in his/her last illness. Date of Death: ....................................................... . Place: ............................................................ Age: ............... . I last saw him/her before death/after death. To the best of my knowledge and belief, the causes of death were:
i
.......................................... ··· .. · .. •.. ········ ..... · .. · ........................... 1
1
1 1
I I I I
I
1. (a) ........................ ..
.. Duration: .................... ..
~\'
hand this ............ day of ................ 19 ...... 1
1. (b) ............................................ Duration: .................... .. 1. (c) ............................................ Duration: ..................... . 2 ..................................................... Duration: ..................... . WITNESS my hand this ........ day of .................... 19 .... ..
§ >< 1.11 ~
I I I
I I I I
.... ·.. ···· .. ·.. ·.. ·· .. ·.. ·...... ·· .. ·...... ·· .............. ·.. ·1I Funeral Director (or person as aforesaid)
I
1
f M' . 1 lnlster or .................................................... I other witnesses of burial .................................................... I · SIgnature 0
I 1
I
Medical Officer
1 I
- 37/38 -
Annex 5
INTEGRATION OF MCH/FP INFORMATION SYSTEM WITH OVERALL PHC SYSTEM IN KIRIBATI Through WHO support, the PHC approach was adopted in Kiribati in 1981 as a means whereQy the 13 priority problems which have been identified could be solved using community participation as the main strategy to reach the national goal of health for all by the year 2000 which is in line with WHO global goal. The establishment of community groups known as Village Welfare Groups (VWGs) throughout the islands has done a lot to help the Public Health Nurses (PHN) and medical assistants in the collection and recording of necessary data. The integrated nature of the system does not permit MCH/FP records to be dealt with in isolation to the rest of the other problems and diseases. All the forms that have been found necessary to bring out the minimum required data will be consolidated into three main type of forms for island health centres/dispensaries monitoring of cases they are managing: 1. 2. Monthly Statistical Returns (MS I) Monthly Statistical Returns II (MS II) Operational forms
3.
The consolidation of the forms is an effort to improve compliance and reporting rates. The Evaluation of PHC in 1984/1985 showed weakness in the Health Information System (HIC). The likely problems associated with the weakness in the HIC could be: 1. 2. 3. Communication Frequency of staff movements Difficulty of filling in the forms, etc.
The possible solutions to the above problems which have been incorporated in the PHC system are: 1. 2. 3. Assessment of the problem Maintenance of progress Training of staff: - orientation courses 1982, 1983, 1984 - supervisory visits by Technical Task Force (TTF) - supervisory housing forms Primary health care workers course Computerization
4. 5.
With more assistance from WHO and confirmation of the PHC implementation, as well as relevant training of staff, it is anticipated that improvement in the health information system will ensue in the foreseeable future.
- 39 -
Annex 5
COUNTRY REPORT - FEDERATED STATES OF MICRONESIA
Main priorities of MCH/FP programme The people in the priority group are the under four years age group, the school children and all women in the child-bearing age group. 0-4 group main priorities are: (1) All infants should complete their vaccination doses in OPT, polio and measles by 18 months of age. Revision had been made for 15 months. That every child is breastfed during the first year of age and up to 2 years preferably. That every child is seen regularly at clinics or at home.
(2) (3)
5-12 main priorities are: (1) (2) That every child is examined on a regular basis, at least annually. That every child has complete immunization before entering into a school. That every child is eating balance meals and free of intestinal parasites.
(3)
13-44 main priorities are: (1) (2) (3) Prenatal cases to be seen regularly and as scheduled and that they get two doses of TD during pregnancy. Post parturR cases to be seen at 6 weeks post up and have them accept Family Planning methods before leaving the clinics. Family planning motivation in general with comprehensive teaching on family planning methods for the patient or couples to understand and accept and able to make options to use.
Main Problems of MCH/FP programmes: (1) (2) Not returning for appointments Lack and/or no coordination of transportation Shortage of supplies Lack or little "sex education" to unmarr.ied younger group due to cuI t ural be lie fs
(3) (4)
- 40 -
Annex 5
(5) (6)
Inaccuracy in reporting of information due to lack of coordination and efficient system of recordings Increasing rate of single mothers (? concern? problem) Insufficient utilization of local teaching aids and materials, etc. Lack or little support by men for the women's health
(7) (8)
Health status indicators for CY 1985: Updates as of 1 June 1987: Neonatal mortality rate .••.•••..•••••••• Infant mortality rate •••.••••.•••••••••• Maternal mortality rate ••••••••••••••..• Crude birth rate •••••••...••••••••••.••• Crude death rate ••••••••••••••••.••.•••• Age 60 + mortality rate .•••.•••••••••••• Rate of national increase ••••••••••••••• Total fertility rate •••••.••.••..••.•••. Life expectancy at birth: Male •••••••••• Female •••••••• Average birth weight: Percentage of newborn with birth Weight less than 2.500 grams Weight more than 2,500 grams GNP per capita: Per capital public expenditures on health ..•........•••••••••.•••••••••. $163.00 Public expenditure on health as % of GNP •• No. of health workers per population No. of doctors per population No. of nurses per population
12.8/1000 22.1/1000 0.05/1000 30.8/1000 3.6/1000 22.0/1000 139.3/1000 56 years 59 years
4.5% 95.5%
. ... . ..........
1/262 1/2758 1/414 1/6.500 1/1.685
............
No. of dental doctorB per population No. of dental nurses/technicians per population
..........................
- 41/42 -
Annex 5
FSM immunization coverage-level as of January 1987: (3+DPT, 3+0PV, 1MMR) Two years old ...................... 44.2% Headstart 61.5% Kindergarten .......•••.•....•....••..•.. 50.5% It ••••
(CY 86)
Firs t grade ............................ . 59.7%
- 43/44 -
Annex 5
PROBLEMS FACED IN PAPUA NEW GUINEA
Maternal and child health Antenatal care Post-natal care (inadequate) (3) Infection (4) APH (5) PPH (6) Anemia (7) Malaria (8) Toxemia of pregnancy (9) L.B.W. (10) Respiratory tract infection (11) Malnutri tion Family planning (1) (2) (3) (4) (5) Inadequate FP services to remote areas Traditional beliefs Religion (Catholic) Men not interested in FP Inadequate FP lectures to the communities (1) (2)
- 45 Annex 5
COUNTRY REPORT - VANUATU 1. Background
Vanuatu is formerly New Hebrides, an archipelago of 82 islands, 80 of which are inhabited with a population of 138,oqo people. The introduction of foreign missionaries and planters into the island dates from the last century. The country was jointly administered by French and Great Britain at that time. The last 20 years of New Hebrides Condominium were marked by contending influence of the two powers deeply aggravating the long standing rivalries along political and religious lines. The country's independence on 30 July 1980 marked the beginning of a national unity. 1.1 Language
Approximately 110 different dialects are spoken in the country. Bislama and/or Pidgin English is the language of communication, while education is in French and English. 1.2 Area of division
Vanuatu is divided into five districts, eleven local government councils and municipal town - Vila and Santo. 1.3 Health system
The health system has undergone a very rapid evolution in the country in the last 20 years with very heavy investment on curative side. The medical service at that time were divided among the English and French missionaries and private entities without any real coordination. At the time of independence the first concern was to unify service hospitals, pharmacy, teaching programmes, etc. The present Ministry of Health is headed by the Minister assisted by three secretaries, a Director of Health who is responsible for curative and general administration of health services, and a Deputy Director as prinCipal medical officer preventive department. The five district administrative health centres are headed by district supervisors who are responsible to the Director of Health. The district supervisors work closely with the MCH nurses and general ['egistered nurses based in health centres or dispensaries and village health aid workers in aid posts. 2. Brief background on maternal and child health/family planning
During the early years of health care system in Vanuatu, the MCH/Family Planning ppog.['amme was incorporated into previolls health services. This meant that mater-lUll and child health/family planning work was not considered one of the health priorities. In the past, we had a nwnber of different authorities, therefore, different training cour-ses wer-e given to nurses w()['king in the fields, and different ellpectations and health priorities were cllpected of them.
- 46 -
Annex 5
3.
1980 onwards - Vanuatu's single health system
1980 marked the beginning of a new reorganization of the health system in Vanuatu, being one of many countries that adopted the worldwide social goal of "health for all by year 2000". The Ministry of Health is now focusing on the elements of primary health care and one of the priorities is to unite different health care systems and reorientate the staff to the concept of primary health care. The government of Vanuatu strongly supports the declaration of AlmaAta, Union of Soviet Socialist Republic, that health is a fundamental human right and adopted primary health care strategies to enable everyone to enjoy a better life through intersectoral collaboration, community involvement, etc. While the primary health care in Vanuatu is still on its early stage, it shows promise. The existing health staff have undergone reorientation to primary health care approach. A landmark achievement was the holding of the national workshop on primary health care in 1984 which resulted in a national policy statement on PHC, and approval by the National Development Councill of an implementation plan for primary health care development. The review and/or second national workshop on primary health care development was held on 8-11 June 1987 which resulted in a district and regional plan to help the district supervisors and local government secretaries in supporting PHC activities in each district and regions. At present, seven island regions have ongoing primary health care activities. The implementation of research and development activities in North Efate Island by the School of Nursing, has made a notable contribution to make the PHC approach operational, including the training of nurses, community leaders and officials from the other sectors concerned. 4. Progress of PHC implementation plan since 1984
The Ministry of Health has achieved a lot from the plan of actions drawn up by the participants at the first national workshop on PHC development in 1984 based on the priority needs. Although we have achieved a lot of activities we have not cOlDe as far as examining the existing health information system.
5.
Present health information system in MCH/FP
The information system and/or reports in the field of MCH/FP were normally carried out by nurses in health centres or dispensaries, then quarterly report is sent to statistics office at the Ministry of Health. The statistics and/or record forms consist of: (1) (2) (3) (4) (5) Family folders Child health records School health records Ante Natal records MCH work sheet
- 47 -
Annex 5
( 6)
(7) (8) (9) (10) (11) (12)
Vaccination work shee ts Family planning work sheets Treatment work sheets Family planning records Death register book Birth register Immunization card
The birth and death registry books are kept by the nurses but the birth and death certificates are issued by the local government secretaries and kept at each local government council headquarters and two municipal town councils, Santo and Vila. In order to improve and upgrade maternal and child health/family planning programmes throughout the country, personnel in the rural dispensaries and health centres needed retraining and orientation on maternal and child health/family planning activities. Nurses need following up visits on their work and at the same time provide supervision. Since 1985-1986, 150 nurses have been trained in maternal and child health and primary health care, the courses were held at the district level. It is visualized that on-the-job training in maternal and child health will continue at district level. The district supervisors were the overall supervisor but seeing that he/she has a lot of responsibilities efforts have been made to establish the MCH coordinator's post in each region in order to improve the MCH/FP activities.
Annex 5
- 48 -
°ttTOIIIIII "':. "
..
•
• Ollt:IIS I TOnr:ES •
O";"I",ar. Q
--. --. '!I""ITI'
'11\"u.... U\v... ( \
\PSoII ___ • _ _
'" ~A"U I•
:.~.t
... LeWI
• __ L:J
.-,....- .....,.. I i "Ol~;V.~ tlo!JO- V ;
~ "~T'" ~Anl"
'"10
~
AOOA / r~~.e:~. L''>'U'O •. /
•/
SA!nO/"'ALO
-.-
~', ~IGII' .. -.-.-~.-~ -.... ,
./.~ r£!'T[CO!.Y 'lNnCOTl
\'-
..
,.,.,.I.AltIlI.A
La, I
KALAr;ULA
,~'~~~~~~._,.,
.~ \
'\ ~ ..rlly.. £t
.----.~.
A'iu.'IYM
-.-
._.-'-
/
, .,1 :...t __ .-..... _ till . 1 - "--.-... _ , E. . . , III' • C!' ••
ftl;
,.~r,
,
:0 ..
/
.. / './' ./
/"
.."".....-._-"tun, 0 ."--.--.. __
If ERD '
rorl.~ • ,"'/
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.,..., .. ",,-.--. .-...... .. -....--... ... .,./
.....
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'-' TJ',fEA ...r•••••
./
,AN"
I·q. r..,,~
~"HHIt
.... J. HUllt., .1.
49/50 Annex
'2
HEALTH DISTRICTS IN VANUA'rU ,. J" T<l.~R!S .. "0 .. MOIO LOta
.
"
IANKS "
VANUAeLAYAQ
•
~NORTH 30.3~O
-- ---ESPIRITU
'---- -- - - - - - - / EASTERN 22.330
".
CD2
25:430
------
-- -- --
C D I
36,360
--- ----
------------- - ----
'.
~.AO"AHGO
qfUI"r. o
ISUD/SOUTH
21,060
(tllfl .. : 1/4000000 ~km
C -.-:.-_:-
. . _ _ _2:.;00:; .. ,11\
I'"~
1'"
110'
- 51/52 -
ANNEX 6
IDENTIFICATION OF MINIMUM DATA SET AND DATA SOURCES by
Mr Paul Hedrick 1
lWHO Statistician, ICP/PHC/002, Suva
- 53 Annex 6 COMPONENTS OF MCH/FP INFORMATION SYSTEM
1.
Programme Delivery (1) (2) (3)
Prograllllle Management Impact of Programme Monitoring and Evaluation Budgeting Reporting Special Areas of Concern
(4) (5) (6)
2.
Health Status of Mothers and Children (1)
Non-pregnant Women Pregnancy Delivery Post-Natal-Mother Infancy Spedal Areas of Concern
(2) (3)
(4) (5)
(6)
- 54 Anriex·6 .
Figure 1 - Stages in Sequential Approach to Family Health Care
Non-Pregnancy
I Pregnancy Adolescence
Delivery _ _
School
Post Natal Mother
---
Pre-School
Infancy
I
- 55 Annex 6 1• PROGRAMME DELIVERY
( 1)
ProgralDllle Management
Resourcas
Facilities Manpower Financial Logistics
(2)
Impact of Programme
Component Areas
ANC
Deliveries PNC FP Child Health EPI
Diarrhoeal Disease Control (3) Monitoring and Evaluation Detailed Programming Objectives Targets Activities Achievements Milestones Broad
• TPRs Indicators
ProgralDllling
- 56 Anriex 6 . (4) Budgetting Financial Programming Implementation
(5)
Reporting
(a) Government
Nature of Services Extent of Services by
(b) Donors and International Agencies
Health Facility and PrograDllle Area
(6)
Special Areas of Concern Accessibility of MCH Services Role of TBAs Knowledge of Health Staff Knowledge Attitude and Practices of Mothers Application of PHe Approach
- Teenage Pregnancies ~
Resistance of Men to FP
•
- 57 Annex 6 2. HEALTH STATUS OF MOTHERS AND CHILDREN General Population Service Population
Examples of Information on Health Status of Mothers and Children Group (1)
General Information Non-Pregnant Women Morbidity and Mortality
Specific Information Haemoglobin, Fertility rates, Age at Menarche, etc.
Special Areas of -Concern Continuation rate for FP FP Services to Teenagers Immunization coverage of Mothers
(2)
Pregnant Women
Morbidity and Mortality
ANC attendance, "At risk" Cases, Complications
(3)
Women Delivering Post Natal Mothers
Outcome of pregnancy Morbidity and Mortality
Birth weight, Comp lications PNC attendance
Maternal mortality from PPH Inadequate FP services
(4)
(5)
Infants
Morbidity and Mortality
Child health clinic attendance, EPI coverage, Growth and development
Diarrhoea among infants
- 58 Annex 6.
NEED FOR HEALTH INFORMATION AT VARIOUS LEVELS OF MANAGEMENT Figure 2 - Data requirements at different levels - Single Component Primary care clinic data (See page 27 of WPR/MCH/INF./1)
Figure 3 - Traditional flow of Health information
Figure 4 - Flow of Information on. Primary Health Care
- 59 Annex 6 SOURCES OF MCH/FP INFORMATION 1. Service Records Health Centre Records Household Health Records PHC Worker Records 2. Statistical Returns Activity Returns Morbidity Returns Notification of Diseases Family Planning Returns 3. 4. 5. Births and Deaths Censuses Surveys People Records -Prospective ( - Retrospective
6.
Information from Other Sectors
Community Affairs Education Agriculture Social Welfare Planning Office Statistics Office
- 60 Annex 6 TYPES OF MCH/FP SERVICE RECORDS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Hospital Admissions Register Hospital Records 0 & G Registers Hospital Births Register OP or Health Centre Treatment Record ANC Record Delivery Record PNC Record Reports of Births and Deaths Registers of Births and Deaths Civil Registration Records Child Health Record EPI Record Household Register or Card Census of CBA Women Women's Register Register of Infants Child's Register School Health Record Family Planning Record Register of F.P. Users
- 61 Annex 6 RELIABILITY OF INFORMATION (1) (2) (3) (4) Reporter Reportee Definitions and Procedures Form Design
FLOW OF INFORMATION (1) (2) (3)
Standard of Records SWllllarising and Collating Reporting Analysis Feed-back
(4) (5)
- 62 -
Annex 6 General Information from MCR/to Information System
Availability
Item of Information
Source
Already Available
New Record Required
Inform ation on Speci al Areas of Concern to MCH/FP Programme Managers
Area
Pertin ent Quest ions
Inform ation Requi red
Sourc e of .Infor matio n
'0\ ~
\.JJ
0\
;:I
~ (1)
>c
0\
- 65/66 -
ANNEX 7
IDENTIFYING DATA REQUIRED FOR PROGRAMME MANAGEMENT by Dr Stuart Berman 1
IMedical Epidemiologist, Division of Sexually Transmitted Diseases, Centers for Disease Control, United States Public Health Service, Atlanta, Georgia
- 67 -
Annex 7
During this workshop we will be attempting to devise guidelines concerning the gathering and the analyzing of data relevant to MCH\FP programs. We will want to identify effective but efficient ways to accomplish these information-related tasks. An important step toward accomplishing these goals is to identify the data critical to these programs. Maxmimum efficiency is achieved when only the data which are needed are collected; data which are not needed for program management are luxuries which may not be affordable. In this portion of the workshop we will describe one approach to program management and the necesary information that the approach requires. • Step 1. Identify a goal. This is a 'timeless statement of aspiration', an expression of policy which is not quantified, for example, 'It is the goal of this administration to reduce infant mortality'. A generalized statement expressing a program's intended effect on one or more health problems. Ideally,goals should be selected and resources directed toward them after an evaluation of priorities. People and countries may differ in perception of what the priority problems of mothers and children are. The following criteria are commonly used in identifying the main health problems to be attacked: 1. 2. 3. The extent of the problem--how 'big' is it? The seriousness of the problem. The 'preventability' of the problem--by how much can the problem be reduced through health and related actions? Is it worth spending scarce resources trying to solve it? Is the technology available to prevent it? The concerns of the community--does the population think it a major problem? Time trends. Health problems are not static and changes over time must be taken into consideration.
4. 5.
Step 2. Determine the 'desired outcome objective'. Desired outcome objective: The level to which a health problem should be reduced and/or maintained within a specified time period. The outcome objective should be long term, realistic, and measureable. It is the quantitative measurement of the health problem at some future date. An example: "By 1995, reported rubella incidence in the United States be less than 1 000 cases per year." To determine an appropriate outcome objective requires a determination of what the current circumstances are. The outcome objective essentially identifies the following: "Where we are and where we want to be".
- 68 Annex 7
Step 3. Devise an intervention strategy. Intervention strategy: The technical basis for predicating that expenditure of resources on specified activities and objectives will have a positive effect on a health problem. The intervention strategy is the mechanism for accomplishing the outcome objective, and thus improving the health problem. The next step addresses how a strategy may be designed. Step 4. In order to select the best available strategy, the health problem should be analyzed in terms of its most direct determinants and the factors that contribute either directly or indirectly to those determinants. Health problem: Defined above; specific in terms of incidence, prevalence, and distribution. Determinants: Direct causes and risk factors which, based on scientific evidence or theory, are thought to influence directly the level of a specific health problem. Contributing factors: Those factors that directly or indirectly influence the level of a determinant. The direct determinants which may be addressed through available technology are selected as points of intervention. Figure 1 demonstrates the relationship of these components. Step 5. Once it is decided which determinants will be addressed, impact objectives must be identified. Impact objectives: The level to which a determinant is expected to be reduced within a specified period of time. The objective is intermediate (1-5 years) in duration, realistic, and measureable. The impact objective must relate directly to the determinants. It is the statement of 'how much' and 'when' the determinant should be affected by the program. In the current example: Outcome objective: "By 1995, incidence of reported rubella in the United States will be less than 1000 cases per year". Key determinant (the focus of the strategy): Susceptibility of host Impact objective:"By December 31, 1985 90% of schoolage children in the United states will have been immunized against rubella". Step 6. Process objectives must be determined. Process objectives: Action statements aimed at affecting one or more of the contributing factors that influence the level of the determinants. Process objectives should be short term (usually one year), realistic, and measureable.
- 69 -
Annex 7
In our example: Outcome objective: "By 1995, incidence of reported rubella in the United states will be less than 1000 cases per year". Key determinant: Susceptibility of host Impact objective:"By December 31, 1990, 90% of schoolage children in the United States will have been immunized against rubella". Process objective: "Increase the proportion of school districts that are effectively enforcing the school entry immunization from 75\ to 90\ by October 31, 1988". Process objectives identify the expected performance of the specific actions designed to achieve the impact objective, and thereby the outcome objectives. Figure 2 refects these relationships in the stategy. Step 7. The monitoring of the program then should proceed by:
a) Determining if the process objectives are being met; if they are not, management evaluation must take place. b) Determine if impact objectives are being met; if these are not being met--but the process objectives are--then the whole strategy must be reconsidered. (If process objectives are not met, one should not expect that impact objectives will be achieved). c) Determine if outcome objectives are being met; if impact objectives are met, but outcome objectives are not, the strategy must be reconsidered. (Again, if impact objectives are not met, do not be surprised if outcome objectives are not met, either). Such an approach allows us to determine which data are critical to the management of programs--data are needed that allow evaluation of how well outcome ojectives, impact objectives, and process objectives are being achieved. Other data, interesting though they may be, are not essential. (It should be pointed out that designated 'targets' and 'indicators' may be outcome, impact, or process objectives; although a process objective or impact objective may be identified as an 'indicator', the outcome objective--the specific health problem which is being addressed--should not be overlooked). The charge to this workshop will be to produce guidelines about obtaining data which accurately measure the MCH\FP outcomes of concern, the associated determinants of these health problems which the programs intend to impact upon, and the specific--and measureable--actions by which the programs may achieve the objectives. The minimum dataset required by MCH\FP programs is that which provides such information.
· Annex 7
- 70 Figure 1
HEALTH PROBLEM
DETERMINANTS
CONTRIBUTING FACTORS
HEALTH PROBLEM
DETERMINANTS
CONTRIBUTING FACTORS
- 71/72 Annex 7
Figure 2
OUTCOME OBJECTIVE
IMPACT OBJECTIVE PROCESS OBJECTIVES
Less Than 1000 Cases of Rubell" By 1995
Rubella Immunity Will Be 90% By December 31, 1990
- 73/74 -
ANNEX 8
MATERNAL HEALTH CARE INFORMATION by
Dr Rita Thapa
1
1tegional Adviser in Maternal and Child Health (Family Planning), WHO Regional Office for the Western Pacific, Manila
- 75 -
Annex 8
The WHO long-term programme for maternal and child health care urges the Member States "to promote the development of primary health care progrwrunes with concrete plans for maternal and child health care as its essential components that includes care during pregnancy and childbirth, family planning, infant and child care with appropriate focus on improvement of nutrition, prevention of infections, promotion of physical and psychological development of the child and education for family life". The target population consists of women of reproductive age, children and adolescents which constitute two third of the total population in developing countries. The MCH/FP programme clearly plays a decisive role in attaining the health for all goal/2000 in the countries of the Region. Nineteen countries/areas of the region are technically supported by WHO in strengthening and expanding maternal and child and family planning care as described above. UNFPA provides funding support to strengthening MCH/FP care in these countries/areas. Impressive progress has been made in the imprOVement of mothers and children within the Western Pacific Region. During the past two decades, decline in infant mortality has ranged from 30 to 70 percent. In the majority of the countries of the Region, the infant mortality varies from 25 to 100 per 1000 live births. Despite the impressive achievement made in the infant mortality reduction, the maternal mortality, however, exists at unacceptably high level in the developing countries of the Region. The maternal mortality rates in the countries of the Region vary from 6 to 900 per 100,000 live births. This obviously reflects the inadequate maternal and family planning care accorded to the maternal component of MCH/FP care. Besides, without the improvement in maternal health care, further reduction in infant mortality will be impossible. For it is well established that more than half of infant mortality occur within the neonatal period. The major causes of the existing high level of maternal and perinatal morbidity and mortality and fertility in the Region are as follows in alphabetial order: Anaemia Complications of labour Congenital disorders Diabetes Jlaemorrhage Infection Low birthweight Malaria Malnutrition Toxaemia of pregnancy Unregulated fertility
Ninety percent of causes leading to maternal mortality in developing countries of the Region can be prevented with the technologies already proven for their safety and cost effectiveness. One of the eXisting technologies applied inadequately relate to the areas of maternal health care informati.on. As a result, the MCH/FP programme suffers from the inadequate infor-mation to measure the MCH/FP hea1th indicators leading to HFA.
- 76 -
Annex 8
Regional MCH/FP care health indicators leading to HFA by year 2000 1. 2. 100 percentage of pregnant women will have at least 3 prenatal visits. 95 percentage of deliveries will be attended by trained health personnel including trained traditional birth attendants. 95 percentage of children will be immunized against diptheria, tetanus, whooping cough, measles, poliomyelitis and tuberculosis. 100 percentage of children up to at least one year of age will be given routine child care by trained health personnel. Infant mortality rate for all identifiable sub-groups will be reduced to below 50 per 1000 live births. The population growth rate will be reached to less than 1%.
3. 4.
5. 6.
Home-based maternal record The next question relates whether we have a reliable information tool to monitor these MCH/FP care health indicators. The information mechanism for child health component exists reasonably. A reliable information mechanism to measure the maternal health and family planning care, however, is grossly inadequate. Home-based maternal record is an innovative technology that can meet this need if adapted locally. The detail guideline for adaptation of home-based maternal record is given in Annex 1. Conclusion 1. Home-based maternal record is a simple PHC-based information tool which - promotes people's partiCipation for maternal health care - promotes timely intervention for a health problem - promotes continuity of health care throughout the reproductive cyle of a woman - provides a link between various health care facilities and family - function as a teaching tool for MCH/FP care. 2. 3. 4. It is less expensive to maintain than the health centre-card based. It is a reliable information for programme management at household survey. WHO programme on safe motherhood operation research supports the adaptation of home-based maternal record to the local situation. also provides financial support to the adaptation of home-based maternal record under the MCH/FP programme related research activities. UNFPA I I
- 77/78 -
ANNEX 9
BASIC MCH DATA FOR 11 ISLAND NATIONS by
Dr J. Woodall
1
Iscientist/Epidemiologist, Development of Epidemiological and Health Statistical Services, WHO Headquarters, Geneva
- 79 -
Annex 9 There is a certain amount of basic data that is essential for planning primary health care programmes in any country. The Member States of WHO have agreed on a series of global indicators for measuring their progress towards health for all by the year 2000. using the PHC approach. and the countries of the Western Pacific Region have also established some additional regional indicators to help them in the same task. The following is a review of those data relating to the indicators specific to MCH/FP programmes in the 11 countries participating in this Workshop. The data are shown in Table 1. 1. Population
This is the most basic statistic of all. The size of population of the 11 countries represented in this Workshop ranges from 14 000 for the Republic of Palau to 3 228 000 for Papua New Guinea. These are estimates compiled by the governments and projected from the most recent census. In some cases the last census may have been almost 10 years ago, which means that the estimates may not be very reliable. Another important factor to notice is that for populations of under 300 000, which means everyone except Papua New Guinea and Fiji, the rates are likely to be not very stable from year to year. 2. Birth rate
Bearing in mind that because of relatively small populations. birth rates for most of the countries represented in this Workshop may fluctuate widely from year to year, the estimates range from a low of 22.5 for Cook Islands to a high of 44.6 for the Solomon Islands and 45.0 for Vanuatu, a two-fold difference. It might be preferable to use 3-year or 5-year moving averages to determine the birth rate. We have not been able to find disaggregated figures for 3 of the countries in the Trust Territory of the Pacific Islands (TTPI). It would be interesting to discover if these greatly differing birth rates relate to government popUlation policy (see WPR/MClI/87.3) and cultural factors. 3. Population growth rate
This rate takes into account the natural increase rate (basically crude birth rate minus crude death rate as percent), plus illuuigration and minus emigration. The country with the lowest growth rate, Tonga (0.9%), is not the country with the lowest birth rate. It is, however, the only country of the 11 with a rate below that of Regional Indicator No. 7 - "The population growth rate is reduced to less than 1%". The highest rates are given by the Solomon Islands (3.4%) and Vanuatu (3.2%), which are also the countries with the highest birth rates. These high population growth rates will lead, unless modified, to a doubling of the popUlation in 20 years. In contrast, at its present growth rate, Tonga will take 77 years to double its population.
- 80 Annex 9
4.
Infant mortality rate (IMR)
This is recorded as ranging from 11.1 in Tonga to 72.0 in Papua New Guinea, and 75.0 in Vanuatu, with Kiribati not reporting. However, a special survey is currently under way in Vanuatu which may reveal a large reduction in that country's figure, while the rates for the smaller countries may be subject to great annual fluctuations. In all countries, it is important to attempt to obtain IMR data by sex, to determine whether there is an excessive differential mortality between boy and girl infants, and by community in case there are some deprived groups with infants at higher risk. Global Indicator No. 9 states "The infant mortality rate for all identifiab Ie subgroups is below 50 per 1000 live births". All except the 2 countries mentioned above have the IMRs below this level. 5. Birth weight
Global Indicator No. 8 states "At least 90% of newborn infants have a birth weight of at least 2500 grams". The rates shown range from 98% for Cook Islands and Tonga to 75% for Papua New Guinea (PNG) , with all except PNG, Fiji and Kiribati above the 90% level. But the data from those 3 countries date from 1979 and, therefore, the situation could be better today. The Solomon Islands did not report. This is a very important indicator because it reflects the state of nutrition of the mother and influences the probability of survival of the baby. It provides a good measure of the impact of MCH services. 6. Maternal mortality rate
Regional Indicator No.5 says "Maternal mortality rate is below 3 per thousand live births". All 11 countries fall well below this level, ranging from a low of 0.03 for Fiji to a high of 1.57 for TTPI (no disaggregation available). Kiribati, PNG and Tonga have not reported. All these countries could have a rate of zero for one year and a rate higher than 3 for another, just because of the relatively small numbers of women giving birth in anyone year. As with infant mortality, a 3-year or 5-year moving average might be more meaningful. However, the cuases of maternal deaths should always. be monitored with the object of determining whether intervention a.ctivities are having any effect. 7. Care during pregnancy
Global Indicator No. 7 says that care by trained personnel s.hQuld be available to all pregnant women. The regional interpretation
- 81 -
Annex 9 of this is that all expectant mothers should have at least 3 visits for antenatal care. On this definition, care ranges from 54% in Papua New Guinea to 100% in Cook Islands. which is the only reporting country to reach the target, but 6 countries gave no data. This is obviously important data to collect. It should not be obtained by dividing the total number of visits by the number of first antenatal visits, since some mothers may have more and some less than 3 visits. 8. Care during childbirth and infancy
Global Indicator No. 7 also says that all women should be attended by trained personnel during childbirth. The regional indicator level is 95%, and this level is achieved by Cook Islands (100%) and Fiji (97%). Eight other countries are below this, with only 34% attended in Papua New Guinea. Disaggregated data are not available for TTPI, and Kiribati did not report. Global Indicator No. 7 also says that all children below one year of age should receive care from trained personnel. Only Cook Islands (100%), Tonga (60-80%), and PNG (18%) are able to give figures for this. This means that the other countries have no way of monitoring the infant care component of their MCH programmes. Global Indicator No.8, besides referring to birth weight, states that at least 90% of children will have a weight for age corresponding to WHO-defined reference values. Only Papua New Guinea, Tonga and Vanuatu have been able to provide figures for this, all of around 80%. There is clearly a need for more data in this area.
Table 1 MCH/FP Statistics of Participating Nations (Latest available year since 1980) Pop. (1000's) Cook Islands Fiji Kiribati Marshall Islands Micronesia Papua New Guinea Solomon Islands Tonga Northern Marianas Palau Vanuatu 18 700 62 39 90 3228 275 97 21 14 130 6.6 6.0 7.3 TFR 4.2 3.4 CBR (/1000) 22.5 29.8 34.9 31 .3 31.3 35.3 44.6 28.6 34.3 31 .3 c 45.0 c c Pop.GR ( %)
Doubling Time(yr) 43 39 41
IMR (/1000) 16.4 22.5
BWT (%~2500g)
Mat.MR ANC (/1000) (%bths) 1.00 0.03 100 97
Bths
(%)
Att'~::l (D
><
.
1.6 1.8 .7
a
98 86 b 82 b
100 97
1.9
c
36 36 30 20 77
14.9 14.9 72 .0
94 90 75 b
1.57 c 1.57 c 54 0.10
89 c 89 c 34 80 80 60 8g e 89 c CD
1.9 c 2.3 3.4 0.9 2.4 c 1. 9 3.2 b
46.0 11 .1 23.8 14.9 75.0 98 + 91 90 95
N
29 36 22 Sources:
1.57 c 1 • 57 c 1.07 90
72
TFR - Total fertility rate CBR - Crude birth rate Pop. GR - Population gro~th rate IMR - Infant mortality rate BWT - Birth weight Hat. MR - Maternal mortality rate ANC - Antenatal care Bths Att. - Percentage of births attended by trained personnel. aUnderlined figures do not meet global or regional indicator levels b
WHO/WPRO Data Bank on Socioeconomic and Health Indicators, Rev/Mar. 1987 WHO Evaluation of the Strategy for Health for All by the Year 2000, Vol. 7, 1986 (birth weight and IMR in TTPI) US Dept. of State, Trust Territory of the Pacific Islands, 1986 (population data) WHO/WPRO Country Health Information Profiles, Rev/Dec. 1986 (Northern Marianas)
1979
D~ta
~ata for Trust Territory of the Pacific Islands .... Data not available
- 83/84 -
ANNEX 10
POPULATION POLICY IN 11 ISLAND NATIONS by
Dr J. Woodall
1
l~cientist/Epidemiologist, Development of Epidemiological and Health Statistical Services, WHO Headquarters, Geneva
- 85 Annex 10
The U.N. Population Division provides the following summaries of governments' views regarding population: Cook Islands (CBR 22.5, NIR 1.6, PGR 1.6) *
The authorities stated (1981): "The high rate of population increase, combined with the limited land resources available in the Cook Islands, means support for population activities is imperative if the land available is to continue supporting the people". The longterm objective of the family health project was stated as follows: "To educate the public to grasp the real meaning of family planning, that every child born is a wanted child". The Government is pursuing the development of a family planning programme integrated with the overall maternal and child health service. Fiji (CBR 29.8, NIR 2.4, PGR 1.8)
The Eight National Development Plan (1981-1985) calls for a reduction in popUlation growth and an improvement in the average level of welfare. The national family programme, which focuses on health and well-being, is included in the nine health priority areas and is operating to meet the target of a crude birth rate of 25 per 1,000 in 1985. The rate of family planning protection is expected to increase to 35 per cent of eligible couples by 1985. Kiribati (CBR34. 9, NIR 1. 7, PGR 1. 7)
The Government indicated (1982) that the rate of popUlation growth is too high and that the policy objective is to reduce the level of fertility, thereby leading to population growth rates of 1.6 by 1986 and 0 by the year 2000. The reductions are to be achieved by means of family planning programmes and measures for improving the status of women. Papua New Guinea (CBR 35.3, NIR 2.2, PGR 2.3)
The Government has stated its intention to formulate a popUlation policy regarding popUlation growth in line with its National Development Strategy, which states that the Government recognizes the need to examine all longer-term implications of population growth. The proposed popUlation policy will be designed to modify fertility indirectly. A Family Planning Programme is under way, the main goals being to ensure the well-being of families and to promote responsible parenthood. Solomon Islands (CBR 44.6, NIR 3.3, PGR 3.4)
The objective of the Government is to reduce the rate of popUlation growth, currently estimated at 3.4 per cent (Government Evaluation Report 1985)
*CBR - Crude birth rate (live births per thousand population) NIR - Natural increase rate (CBR - crude death rate as percent) PGR - Population growth rate (NIR + immigration - emigration as percent) Note: All are latest available figures.
- 86 Annex 10
through voluntary family planning. The basic goal is to achieve a better balance between population and resources with a population growth rate of 2.0 per cent per annum. There has been a continuing attempt to promote greater awareness among parents of population. issues, through formal education and radio programmes. The second Five-Year Development Plan (1980-1984) emphasized the integration of family planning within the health services, including hygiene, sanitation, nutrition, environmental health and maternal/child health care.
(CBR 28.6, NIR 0.9, PGR 0.9)* The Fourth Development Plan (1980-1985) proposed a specific demographic target for the reduction of the birth rate to 25 per thousand by 1985, putting emphasis on the provision of effective family planning services, in-service training of health department personnel and traditional birth attendants and health educators. Trust Territory of the Pacific Islands (CBR 31.3, NIR 2.7, PGR 1.9)
The Government's policy is to control the rate of population growth by reducing fertility. Family planning education is provided within the maternal/child and public health programmes. Vanuatu (CBR 45.0, NIR 3.2, PGR 3.2)
The Government seeks to improve the living conditions of the inhabitants by reducing morbidity and mortality, with special attention to the needs of mothers and children, by improving health conditions and by organizing and expanding preventive services. It also seeks improvement in the delivery of family and community health services, including family planning.
*CBR
- Crude birth rate (live births per thousand population) NIR - Natural increase rate (CBR - crude death rate as percent) PGR - Population growth rate (NIR + immigration - emigration as percent) All are latest available figures.
Note: