Health System Strengthening, Planning & Management,Human

resource,Hard to reach In 20 townships

• Kachin State - Bamaw,Shwegu• Mon State - Thaton, Mudon• Shan - Nyaung shwe, Hsipaw, KyaingTong• NayPyiTaw - Pyinmana, Lewe• Bago - Yedarshay, Thayarwaddy• Sagaing - Ye-Oo• Kayah - Demawsoh• Kayin - Hlaing Bwe• Chin - Hakah• Yachine - Maungdaw• Irrawaddy - NgaPutaw• Tanintaryi - Myeik• Yangon - Kawmhu

Health Systems Assessments in 20 townships

•HSS Assessment Guidelines-training given to all surveyors in NPT/Ygn •Conducted during 1st week of May 2010 simultaneously in first 10 townships with 60 Investigators (14 from DOH + 3 from DHP + 43 from UOPH)10Townships: Bamaw, Shwe ku, Ye Oo, Hsipaw, Nyaung Shwe, Mudon, Thaton, Pyinmana, Yedarshay, Tharawaddy

• Conducted in 2011, October to December for second 10 townships. (Lewe, Kawmhu, Ngaputaw, Demawsoh, Maungdaw, Myeik, Htilin, Hakah, Hlaingbwe, Kyaingtone)

Objectives• To identify health system needs and gaps, with a

particular focus on hard to reach areas

• To provide a baseline for measuring impact of health system and program investments

• To provide the evidence base for the development of a Township Coordinated Health Plan

4 main research instruments

• A facility and management questionnaire for Townships and RHCs

• Infrastructure and essential drug and equipment questionnaires and inventories.

• Mapping of hard to reach areas

• Use of questionnaires and registers for assessment of data quality and quality of services at household level.

Research Methods• Collection and analysis of quantitative health system data (e.g.

infrastructure , human resources ratios, population data, essential drugs lists etc)

• Conducting of in depth interviews with health staff regarding availability and accessibility of services (hard to reach areas, human resource issues and motivation, management and planning supervision etc)

• Conducting of Focus Group Discussion (FGD) with Township Health Committee in order to understand more deeply issues effecting community participation and THC function.

• Conducting Data Quality Assessment and Service Quality Assessment survey

For description and analysis of health system gaps and bottlenecks at the Township level the following system areas were surveyed:

Planning & ManagementService DeliveryHuman ResourcesCommunity ParticipationInfrastructureEssential Drugs & Logistics SystemTransportFinance & Financial Management

COORDINATED TOWNSHIP HEALTH PLANSTATION HOSPITAL & RHC COORDINATED PLANS

Broad findings of Assessments in 20 townships

1. Planning and Management

a) PlanningTMO and staff have no experience in drawing integrated micro plan for the township

health service

Vertical micro plans were drawn for different projects according to their targets/expectations eg: EPI/ TB/Malaria (Top down)

No experience for drawing costed micro plan; even for EPI they calculated cost for TA , cold chain maintenance and carrying vaccines for CRASH program. Calculated by each MW for those costs

The only integrated service mentioned was NID/sub NID with vitamin A supplementation

SupervisionRegular supervision was not seen in all townships except for Mudon

Pyinmana and Hsipaw townships .

TMO reach at least 2-3 RHC/sub RHC which are easily accessible, no check list was used during supervision (eg- Mudon)

THN/HA1 also tour to RHCs which are accessible, some developed own checklist; but no tour program at township/RHC levels, no tour notes written (eg- Hsipaw)

Supervision visit to one RHC per week by HA1 according to tour plan drawn by TMO. But no support for TA and fuel cost for supervisory visits (eg- Pyinmana )

2. Service DeliveryPlanning for achieving MDG goal 4 and 5 at townships (Active AN Search Micro plan found in Mudon, Hsipaw, Ye Oo )With the leadership of TMO, all MWs have drawn a micro-plan for “Active AN

search and Health Talk” ( eg. Mudon, YeOo) All midwives have planned dates for health talks ,supervisors were identified in

the micro-plan documentThere should be a well set information pamphlet/documents for Health

Education/ some township have vinylIn the case of referral, some TMO said there are many social organizations that

help people to reach hospital in time RHC/subcenters have labour room but utilization varies with each township; TMO

were trying to institutionalize RHC/Sub-Center with labor rooms

2. Hard To Reach Villages

TownshipHealth Unit

including MCH

No of villages /

Wards

Hard To Reach villages

Physical % Economic % Social B %

Bamaw 6 114 13 11.4 47 41.2 17 14.9

Shwegu 6 89 17 19.1 35 39.3 0 0

Demawsoe 9 162 28 17.3 76 46.9 22 13.6

Hlaingbwe 9 307 108 35.1 92 29.9 86 28

Hakha 5 74 36 48.6 29 39.2 30 40.5

Thaton 5 192 26 13.5 59 30.7 0 0

Mudon 7 58 0 0 9 15.5 0 0

Maungdaw 10 430 103 23.9 150 34.9 147 34.2Nyaung-Shwe 8 462 66 14.3 21 4.5 18 3.9

Kengtong 6 589 164 27.8 48 8.1 3 0.5

2. Hard To Reach Villages

Township

Health Unit

including MCH

No of villages / Wards

Hard To Reach villages

Physical % Economic % Social B %

Hsipaw 6 519 273 52.6 227 43.7 141 27.2

Ye-U 7 189 37 39.4 8 8.5 0 0

Pyinmana 6 137 29 21.2 24 17.5 20 14.6

Lewe 8 221 32 14.5 32 14.5 9 4.1

Htilin 6 92 50 54.3 22 23.9 11 11.9

Yedeshay 9 325 70 21.5 42 12.9 4 1.2

Thayawady 8 287 12 4.2 31 10.8 14 4.9

Kawhmu 6 130 33 25.4 9 6.9 4 3.1

Ngaputaw 6 230 33 14.3 0 0 1 0.4

Myeik 6 152 21 13.8 121 79.6 31 20.4

Total 139 4759 1151 24.2 1082 22.7 558 11.7

2. Mapping Hard to Reach Villages

Hard To Reach Villages

Mapping hard to reach noted the following barriers in access to health:

• Physical Barriers was found to be more in Hakha, Hsipaw, Ye U,

Htilin, Hlaingbwe and Pyinmana

• Social barriers like language barrier and some religious beliefs

restraining from seeking health was found in Maungdaw, Hakha,

Hlaingbwe, and Hsipaw

• Economic barrier was found in almost all townships, highest in

Myeik and lowest in Nyaung Shwe.

• This information is based on the group discussion with the Basic

Health Staff including midwives from the sub RHC.

Physical barriers- Pyinmana, Bamaw :

• In Pyinmana, half of the RHCs are situated in hard to reach areas where roads are dusty in mountainous areas which become muddy roads during rainy season.

• In Bamaw, HTR as BHS have to cross the rivers/streams by boat and continue on foot but these areas are accessible through out the year.

• Midwives could not go there during the hot and dry season when the rivers/streams have dried up and have to walk on foot on the dust road.

Physical barriers- Tharawaddy, ShweGu, Yedashay:

Roads are dusty road/ become muddy road during rainy season and only transportation mean is by bullock cart at that time.

Midwife has to walk three to four hours to reach this area for immunization.

• In rainy season, there are streams formed from water falling from the mountains (taung kya chaung) and could not accessible to the villages beyond the streams/rivers as water is running turbulently. Dry season-have sand islands in middle of river (Thaung)

• If the people living in Bago Yoma areas want to go to Yedarshay , it will take (3) to (4) hours by boat to pass through the Swa Dam. From Yedashay to the areas such as Myayoe Yone and ChinYu villages, they have to cross the streams for (32) times.

Physical barriers- Hsipaw: Nyaung Shwe, YeOo:• Hard to reach areas are those areas where there are many hilly region and

deep mud roads during rainy season/accessible by trailer jeep.Dusty road which become muddy road during rainy season/only transportation mean is by bullock cart at that time.Boats are only means for midwife to reach the community around the lake.

• Paluzawa RHC is HTR that needs (8) hours to get to that area by car/ trailer jeep for all seasons. Roads are very rough and cannot access during rainy season. Only transportation mean is by Bullock carts.

• •

(b) Economic

barrier

Economic barrier

• People in some remote villages are poor yet the midwives said they give services sometimes free/ sometimes within their affordability (such as 1000 kyats per visit for minor illness). They earn 1200 kyats per day and for them to reach the hospital transportation cost was 35,000 k.

• The main economic problem in this area is high transportation cost that hinders the referral of patients to the hospital.

• Even though there were mechanisms in the communities as providing cash to those in need in case of emergency, the bearer has to repay all the costs after recovery.

• Poor people being unable to access to health care and use to rely on traditional medicine. Even in geographically easily accessible areas like peri-urban slum poor people cannot reach to health care facilities due to financial problem

(c) Social barrier

Language barrier found in • Maungdaw (Yachine, Bingale), Demawsoe (Kayah) , Hlaingbwe

(Kayin)Hsipaw (Shan, Kokant, Wa, Lahu), Bamaw (Kachin, Chinese)Mudon (Mon),Nyaung Shwe , KyaingTone(Shan), Myeik

Traditional belief in health care Shrines everywhere in Hsipaw Bamaw -traditional, spiritual belief in healing in remote areasYedarshay- People in the community have faith in the traditional

healers such as Shwe Yin Kyaw gang /they do not want to take early treatment with health personnel.

Nyaung Shwe- In the Inle lake there are a lot of quacks and people are still sticking to spiritual healing procedures.

Maungdaw (Yachine, Bingale), Demawsoe more Christian(Kayah)

Assessment Maungdaw Demawsoh

Myeik

Social Barrier

Mapping Hard to Reach

EPIFixed/Outreach -Mudon, Kawmhu, NgaPutaw

Fixed/Outreach/Mobile- Shwegu, Yedarshay, Nyaung Shwe, Bamaw, Thaton, Demawsoh, Maungdaw,

Hakah, Myeik, Lewe, Htilin

Fixed/Outreach/Mobile/Crash- Hsipaw, Pyinmana, Tharawaddy, Ye Oo, Kyaingtone, Hlaing Bwe

HTR

HTRETR

Mone tai pin RHCEasyTR

Kwin ohn RHC HTR

Tamindwin RHC HTR

MCH

HTR

HTR

Easy To Reach

Easy To Reach

•There are large in equities in human resources distribution as Midwife: population is 1:10000 - 1:14000 in some places of some Townships

• Increase in workload of Midwives has to be taken care of by other BHS such as HA, LHV, PHS 2 and even by some neighborhood midwives. This issue has to be put up as solving the HR problem in coordinated township health planning.  • The health care coverage which could be solved by using volunteers in the community.

MW : PHS 2 ratio

89%

11%

HR analysisMW PHS2

Midwife: PHS II ratio is many variation 43:10 to 22: 2 according to appointed staff, but in total 20 townships , it was 10 : 1. TMO suggested increasing PHS II posts so that there will be balance between the two categories and PHS II might take up a lot of workload from the midwife

Skill Mix MW : PHS2 in 20 TownshipsTownship MW PHS2

Bamaw 27 1

Shwegu 23 0

Demawsoe 41 5

Hlaingbwe 47 1

Hakha 24 1

Thaton 43 0

Mudon 35 10

Maungdaw 32 2

Nyaung-Shwe 35 3

Kengtong 34 2

Township MW PHS2

Hsipaw 19 2

Ye-U 32 4

Pyinmana 17 5

Lewe 38 4

Htilin 28 1

Yedeshay 31 2

Thayawady 33 15

Kawhmu 24 1

Ngaputaw 29 1

Myeik 32 2

Total 624 62

Ratio 10: 1

Objectives of FGDTo identify the community participation level at the township as

regards THC in future development of CTHP

Themes of FGD1. Function of THC

2. Perception on health by community

3. Health Care coverage

4. Accessibility of health care services

5. Availability of health care services

6. Utilization of health care services

7. Quality Services

8. Involvement in Township Health Planning

9. Role of THC

10.Future perspectives of THC

11.Communication and supervision

12.Suggestion for forming budgetary sub committee

HsipawTharawaddy

PyinmanaFGD in Maungdaw

Functions of Township Health Committee• THC members thought it was to carry out the tasks assigned by the

TMO/local authority Representative from• Local authority- giving down the line instructions to village heads to

carry out prevention and control of d/s• Development Affairs , MCWA , Red cross and NGOs • Designated duties by the committee and if possible to assign

separate staff to implement the administrative work such as recording and reporting.

• THC members also helped in supervision / field visits of TMO and BHS at every level.

• After Discussion in Township Health Committee, unanimous decision was set up to use the seed money as the Hospital Equity Fund for poor mothers and children