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Developing a program on Maternal and Child Health Care in Battambang province, Cambodia Jul 16, 2012 Seoul National University Department of Health Policy and Management KOFIH
Transcript of Developing a program on Maternal and Child Health Care in ...snu-dhpm.ac.kr/pds/files/120716...
Developing a program on Maternal and Child
Health Care in Battambang province,
Cambodia
Jul 16, 2012
Seoul National University
Department of Health Policy and Management
KOFIH
Dear President of KOFIH
We are submitting the final fulfillment on
Developing a program on Maternal and Child Health Care in
Battambang province, Cambodia
Jul 16, 2012
Seoul National University
Department of Health Policy and Management
Principal Investigator Dr Juhwan Oh Co-investigator Dr Minah Kang Co-investigator Dr Yoon Kim
Research Assistant Chaeeun Lee Research Assistant Kim-Ngan Do Research Assistant Karen Lee Research Assistant Ashley Younger Research Assistant Jiyoung Lee Research Assistant Sooyoun Yoo Research Assistant Pouv Salem
Contents
Ⅰ. Introduction ..………………………………………………… 1
1. Cambodia ………………………………………………………………… 1 1.1. Demographic information ...………………………………………… 1 1.2. Administrative system...……………………………………………… 4 1.3. General health situation …...………………………………………… 5 1.4. Health system………………………………………………………… 7 1.5. Current situation of MNCH in Cambodia……………………………. 13 1.6. Road map for reducing maternal and newborn mortality – Fast track
initiative 2010-2015 ..………………………………………………………….. 15
2. Battambang province...…………………………………………………… 17
2.1. Demographic information…………………………………………… 17 2.2 MNCH situation………………………………………………………. 18 2.3. MNCH intervention………………………………………………….. 19
3. Research objectives and methods………………………..………………... 20
3.1. Need assessment……………………………………………………… 20 3.2. Health center resource assessment……………………………………
(1) MR OD……………………………………………………………… (2) SK OD ………………………………………………………………
21 22 26
3.3. Maternal death review………...……………………………………… 30 3.4. On-going program assessment…..…………………………………… 31
Ⅱ. Situation analysis……………………………………………… 38
1. Qualitative analysis..……………………………………………………… 38 1.1. Survey description……………………………………………………. 38 1.2. Qualitative analysis …………………………………………………...
1.2.1. Demand of services ……………………………………………… 1.2.2. Supply of services………………………………………………..
40 40 43
2. Quantitative analysis……………………………………………………… 50
2.1. Quantitative survey description……………………………………… 50 2.2. Quantitative analysis results ………………………………………….
2.2.1. Maternal mortality ratio (MMR)…………………………………. 2.2.2. Service utilization………………………………………………... 2.2.3. Supply sides investigation results ………………………………..
2.2.4. Barriers to appropriate access-to-care …………………………………...
51 52 53 59 62
III. Program development………………………………………... 64
1. Goal……………………………………………………………………….. 64 2. Objectives ………………………………………………………………… 64
3. Principles………………………………………………………………….. 64 4.Targets …………………………………………………………………….. 65 5. Strategy and interventions ………………………………………………... 66 6. Monitoring and Evaluation……………………………………………….. 78 7. Budget allocation plan…………………………………………………….. 85 Annex 1. Document for MOU Attachment………………………………….. 86 Annex II. Qualitative questionnaires………………………………………… 102 References …………………………………………………………………... 135
1
Ⅰ. Introduction
1. Cambodia
1.1. Demographic information
Located in Southeastern Asia, as a portion of the Indochina peninsula, the Kingdom of
Cambodia has a total landmass of 181.035 square kilometers. It borders with Thailand,
Vietnam, Laos, and the Gulf of Thailand with a coastline of 443 kilometers. With a tropical
climate, the country experiences two main seasons. The rainy season, often known as
monsoon season, is from May to November, and the dry season is from December to April
with low temperature variation between the two seasons.
A population census in Cambodia is conducted once in ten years. Cambodia
population is estimated to be 14.952.665 in 2012 (CIA factsheet), in which 90% of them
are Khmer, 5% are Vietnamese, 1% is Chinese, and other ethnics account for 4% of the
whole population. The official religion in the country is Buddhism, accounting for 96.4%
of population, and the rest is Muslim and other religions. Cambodia is experiencing a
young population with the median age for male is 22.6 and 24 years old for female. Almost
65% of the population is in the working age, under 14 accounts for more than 30% and the
elderly (more than 65 years old) just accounts for about 4% of the population. Fertility
rates is almost 3.4 in 2010 compares to 5.6 in 1993. About 60% of the population is
married and the portion of single people is 31%. Among 85% of the population live in
rural areas with a significant disparity among areas so that the density in provinces such as
Battambang province is high while other mountainous areas such as Ratanakiri is low.
2
With a GDP real growth rate of 6.1%, GDP of Cambodia reached 12.86 billion USD in
2011 (CIA factsheet) in relevant with the purchasing power parity (PPP) of 33.89 billion
USD. GDP per capital is 2.200USD in 2011 with a labor force of 8.8 millions. Agriculture
accounts for 30% of GDP with the main products of rice, rubber, corn, vegetables, cashews,
cassava, and silk. Industry accounts for 30% of GDP with main products of garments,
construction, wood and wood products, cement, textiles. Services accounts for 40% of
GDP thanks to the development of tourism industry with famous world heritage landscapes
such as the Angcor temples. Every year, on average, there are more than 2 millions of
international tourists coming to Cambodia. Unemployment rate is about 4% however, the
3
level of under-employment is high. Among the employed, 62% are in agriculture, 10% in
manufacturing, and 28% in services. The majority of women in most regions are employed
in full-time or seasonal occupations, and employment rates are high among women in rural
areas. The major economic challenge for Cambodia would be fashioning an economic
environment in which the private sector can create enough jobs to handle Cambodia’s
demographic imbalance. The portion of population ages 15 and over who can read and
write is 73% (2004), showing lacks of education and productive skills of labor, particularly
in the poverty-ridden countryside, which suffers from an almost total lack of basic
infrastructure.
Even though, the number of people living under the poverty line in Cambodia is 31%
(2007) and 20% are under food poverty line. According to the UN Human Poverty index,
Cambodia ranks 73rd out of 78 developing countries. The mean daily per capita household
consumption is low at 0.9USD and even lower in rural areas of 0.79USD/day.
Measure related to poverty National
average
Urban Rural
Total poverty rate 2.4% 39.7%
Food poverty rate 20% 11% 22.2%
Share of food in total expenditure 55% 39% 59%
Cereals as % of all food item expenditure 31% 11% 35%
Source: A public health profile of Cambodia, Public Health Development 2008
Poverty is predominantly a rural issue, with poverty being recorded as 40-45% in rural
areas and 10-15% in Phnom Penh. Besides living in rural areas, the poor tend to have low
levels of education, limited access to land and other productive assets, and be highly
concentrated in low-paying, physically demanding and socially unattractive occupations.
Both the poor in rural and urban areas have low access to basic services such as safe water
and improved sanitation, which is the main causes of diarrheal diseases.
4
1996/8 2005 2010 2015
MDG
Safe drinking water access
Urban (% of urban population) 60 (1998) 75.8 85 80
Rural (% of rural population) 24 (1998) 41.6 45 50
Sanitation access
Urban (% of urban population) 49 (1998) 55 67 74
Rural (% rural population) 8.6 (1996) 16.4 25 30
1.2. Administrative system
The capital city of the Kingdom of Cambodia is Phnom Penh. The country is
composed of the capital city and 23 provinces. These provinces are further subdivided into
districts, and municipalities. There are 159 districts and 26 municipalities in total.
Under districts are communes and quarters. The lowest administrative unit in
Cambodia is village. Village is headed by a village chief or village leader who is elected
since 2006. Before 2006, village leader was appointed by the government and required
ministerial approval.
Administrative areas of Cambodia
No. Province Province Capital Area(km²) Population
1 Banteay Meanchey Province Sisophon 6,679 678,033
2 Battambang Province Battambang 11,702 1,036,523
3 Kampong Cham Province Kampong Cham 9,799 1,680,694
4 Kampong Chhnang Province Kampong Chhnang 5,521 472,616
5 Kampong Speu Province Kampong Speu 7,017 716,517
6 Kampong Thom Province Kampong Thom 13,814 708,398
7 Kampot Province Kampot 4,873 585,110
8 Kandal Province Ta Khmao 3,568 1,265,805
5
9 Kep Province Kep 336 40,208
10 Koh Kong Province Koh Kong 11,160 139,722
11 Kratie Province Kratié 11,094 318,523
12 Mondulkiri Province Senmonorom 14,288 60,811
13 Oddar Meanchey Province Samraong 6,158 185,443
14 Pailin Province Pailin 803 70,482
15 Phnom Penh Province Phnom Penh 758 2,234,566
16 Preah Sihanouk Province Sihanoukville 868 199,902
17 Preah Vihear Province Tbeng Meanchey 13,788 170,852
18 Pursat Province Pursat 12,692 397,107
19 Prey Veng Province Prey Veng 4,883 947,357
20 Ratanakiri Province Banlung 10,782 149,997
21 Siem Reap Province Siem Reap 10,229 896,309
22 Stung Treng Province Stung Treng 11,092 111,734
23 Svay Rieng Province Svay Rieng 2,966 482,785
24 Takéo Province Takéo 3,563 843,931
1.3. General health situation
Life expectancy
Life expectancy has been increasing, which is 59 years for male and 64 years for
female. In 2004, the adult mortality rate was recorded as 430/1.000 for men and 276/1.000
for women. The pattern of mortality at different ages shows a high rate of death in young
children.
Life expectancy 1998 2005 2011
Men 51.8 61.0 64.5
6
Women 55.8 65.4 68.9
Main causes of death
In Cambodia, infectious diseases account for 36% of all deaths and perinatal
conditions are responsible for 7%. Non-communicable diseases such as ischaemic heart
disease, cerebrovascular disease, and hypertension account for 11% of deaths. Main cause
of death in Cambodia is HIV/AIDS, responsible for 10% of death nationwide. HIV/AIDS
rapidly grows in Cambodia with the prevalence rate of 6.3% (2009 UNICEF). Mother to
child HIV/AIDS transmission is 3.5%.
The second cause of death is TB and diarrhoeal diseases, respectively account for 8%
and 7% of death. The death rate for TB is arount 92/100.000 per year and is responsible for
around 12.000 deaths each year. 10% of TB cases have been tested for HIV and 9.6% of
new cases were found to be positive, but virtually none of these are multiple drug
resistance. In contrast, 3.1% previously of treated TB cases are multiple drug resistance.
All referral hospitals and health centers with hospital beds provide DOTS to treat TB
patients. There are about 186 laboratories, with 3 able to culture and 1 performing DST. In
1998, the case detection in Cambodia reached 50% and cure rate is 89%.
The number of reported cases of malaria fell from 123.796 in 1990 to 46.902 in 2002.
Malaria fatality rate fell from 0.7% in 1996 to 0.4% in 1998. Malaria is a major concern
for people living in forested environment with high level of multi-drug resistance present
in affected areas.
Cause of death Death
Years of life
lost
000’s % %
HIV/AIDS 15 10 11
TB 12 8 6
7
Diarrhoeal diseases 11 7 10
Perinatal conditions 11 7 10
Lower respiratory tract infections 8 5 5
Ischaemic heart disease 7 5 2
Meningitis 6 4 5
Cerebrovascular disease 5 4 2
Hypertension heart disease 3 2 1
Malaria 3 2 3
All others 79 46 45
Total 160 100 100
1.4. Health system
Since 1994, the MoH has been committed to reorganizing the health system, placing an
emphasis on the district. The MoH’s main objective for the health system reform is “to
improve and extend primary health care through the implementation of a district based
health system.” (The MoH’s Master Plan, 1994-1996).
- Improving the population’s confidence in public health services.
- Clarifying and reinforcing the role of hospitals and health centers.
- Establishing each facility’s catchment area to ensure coverage of the population.
- Rationalizing the allocation and use of resources.
Reform of the health sector entails important transformations, both financial and
organizational, such as:
- Rational distribution of resources based on the health coverage plan: financial,
infrastructure, drugs, equipment and human resources
- Reorganization of the MoH institutional framework at central, provincial, and district
levels
- Budgetary reform e.g. changes to formula based budget allocation
8
- A new definition of the health system and the types of services expected at each level
of the system
- Redistribution and retraining of health staff
- Introduction of new ways to finance health services
- Rearrangement of institutional framework by level of central, provincial and district
- New definition for health system and service by the level
Fig. Structure of the Ministry of Health of Cambodia
9
Fig. Structure of the health system in Cambodia The operational district (OD) is the most peripheral sub-unit within the health system
closest to the population. It is composed of health centres and a referral hospital. It’s main
role is to implement the operational district objective through:
- Interpreting, disseminating and implementing national policies and provincial health
strategies
- Maintaining effective, efficient, and comprehensive services (promotive, preventive,
curative and rehabilitative) according to the needs of the community.
- Ensuring equitable distribution and effective utilization of available resources.
- Mobilizing additional resources for district health services, e.g. NGO support.
- Working with communities and local and administrative authorities.
Human resources in health
10
- Although a number of actions have been taken to address recruitment and retention of
midwives, and the challenge of mal distribution of staff between urban and rural areas,
there remain shortfalls in the numbers and distribution of midwives. Unless
recruitment and training capacity is increased from 2008 and to 2010, the shortfall
may become worse, at the same time, there is need to improve quality of the training
- The Midwifery Review demonstrated that the levels of competency amongst primary
midwives are inadequate. In addition, placing primary midwives in rural areas has
failed to address broader health needs, in particular those of children. Rural areas need
a more multi-skilled staff cadre, such as a secondary nurse/ midwife.
- The relationship between public and private service delivery needs to be addressed in
the HSP2, especially the difference in remuneration between public and private
sectors. Results from the studies of contracting indicate that strong improvements may
be expected once a constructive approach to remuneration of health staff is found and
implemented. The experience of contracting of health services and their management
has demonstrated that of better pay for staff based on good performance provided a
way forward for improving district and facility organizational management and
delivery of care. Human resource strategies must therefore include a significant salary
increase component within the framework of the health system consolidation package.
These strategies will also need to include improved national human resource planning,
special incentives for service provision in ‘hard to reach’ areas, and an effective in-
service training system to which health partners will be asked to contribute to avoid
fragmentation.
Human resources for health Total
Physicians Number 3351
Ratio per 1000 population 0.25
Dentists Number 245
Ratio per 1000 population 0.02
Pharmacists Number 547
Ratio per 1000 population 0.044
Nurses Number 8720
Ratio per 1000 population 0.65
Midwives Number 3322
Ratio per 1000 population 0.24
Paramedical staff Number 518
11
Ratio per 1000 population 0.4
Community health workers Number 1638
Ratio per 1000 population 0.13
Annual number of graduates
Physicians 290
Dentists 50
Pharmacists 100
Annual number of graduates
Nurses 349
Midwives 208
Paramedical staff -
Community health workers -
Workforce losses/Attrition
Physicians 119
Dentists -
Pharmacists -
Nurses 117
Midwives 81
Paramedical Staff -
Community health workers -
12
1.5. Current situation of MNCH in Cambodia
According to Fast Track Initiative Road-Map for maternal mortality reduction,
developed by the Ministry of Health Cambodia, MDG 5 is the most under-funded
of all health related MDGs. Cambodia Government hoped to increase investments
in maternal health, and called upon donors to channel more funds into this area so
that Cambodia would achieve its MDG5 by 2015. Above and following indicators
are the baseline and goals of Cambodia government.
13
Health status of infant and child
- There are improving of health status and service utilization among infant and children. Past 5
years, infant and under-five children mortality are decreased. However it is not enough to get
a goal of MDG4, we have to strive for it.
14
Mortality of infant and under-five Anemia of 6-59 month infant
- Reproductive, maternal and new born health services
-
Child health service
※ANC: Ante Natal Care/HC: Health Center/IMCI: Integrated Management of Childhood Disease
There are many efforts to reform a health status through national maternal and child
health project and other ODA project. But still deviation between regions
(OD/District/Village) is huge, especially SK OD never have been a recipient OD, MCH
project is a core need of them.
-
15
1.6. Road map for reducing maternal and newborn mortality – Fast track
initiative 2010-2015
Maternal newborn and child health (MNCH) is one of the top priorities of the health
sector in the Kingdom of Cambodia. This is emphasized several times in important legal
documents of the country. Moreover, the government has promulgated National Strategy
for reproductive and sexual health to have specific policies toward MNCH. The
importance of MNCH is proved again with the coming into being of the Fast Track
Initiative Road Map for reducing maternal and newborn mortality which is a part of the
broader context of the continuum of care for MNCH with focus on maternal and newborn
mortality. Many interventions have been made to ameliorate the situation of reproductive
health in Cambodia, however, specific interventions on rapidly reduce the maternal and
newborn mortality is believed to be of urgent need by the government.
The road map is in-line with Cambodia’s Millennium Development Goal (MDG) on
maternal and child health committed at MDG summit meeting. As a result, the overall goal
of the road map is to “contribute to the achievement of Cambodia’s Millennium
Development Goal 5 target of less than 250 maternal deaths per 100.000 live births by
2015”.
The objective of the road map is to equip each province has at least one fully
operational comprehensive EmONC facility and that each operational district (OD) has at
least one fully functioning basic EmONC facility following the UN standards of at least 1
CEmONC facility per 500.000 population and at least 1 BEmONC facility per 100.000
population.
In order to achieve the overall goal, the Road Map focuses on seven main components:
(1) Emergency Obstetric and Newborn care
(2) Skilled birth attendance
(3) Family Planning
(4) Safe Abortion
16
(5) Behavior change communication
(6) Removing financial barriers to access
(7) Maternal death surveillance and response
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2. Battambang province
2.1. Demographic information
Battambang province locates in the northwest of Cambodia, bordering with Banteay
Meanchey to the north, Pursat to the east and south, Siem Reap to the northeast, and Pailin
to the west. The northern and southern extremes border with Thailand, making many
Battambang people going to Thailand to work, including women.
Battambang has a population of 1.036.523 people, ranking number four in terms of
populous province in Cambodia. Battambang is the fifth largest province in Cambodia.
The main economic sector of Battambang is agriculture. The province is known as the
“Rice Bowl of Cambodia”. Battambang has a young population of 49% are in the working
age, from 18 to 60 years old. Under 18 years of age are 45% of the province population
and the old (over 60) accounts for just 6%. The number of households increases at about 4%
per year reaching 205.351 household in 2008. Eighty percent of families in Battambang
province work in agriculture, 10% in services and 10% have no clear occupation. There
are about 7% of households that have a family member who is a government officer and 3%
of households that have a family member who is working for the private sector.
Battambang province has 14 districts of which the four largest in terms of population
are Battambang district, Thma Koul district, Shangkae district, Moung Ruessei district
whose population are over 100.000 people. Among those four districts, our study will
focus on three of them to implement qualitative and quantitative survey (Battamang
district, Shangkae district, and Moung Ruessei district).
Sixty percent of the houses in the province are zinc/fibro roofs and 32% are thatched
roofs while only 6% have tiled roofs. The percentage of households that have electricity is
23%, however, 61% of them have TV. In terms of transportation, every two family have a
bicycle and every three households have one motorbike and/or tuk-tuk.
Within 14 districts of the provinces, there are 131 kindergartens, 629 primary schools,
and 103 secondary schools. There are 84% of children age 6 to 11 are attending schools
and only 77% of children of 6 years of age are in schools. Until 2008, there are only 41%
of households that get drinking water from clean and safe sources while 59% of
18
households that get drinking water from unsafe sources.
2.2. MNCH situation
According to the Battambang Provincial Data Book 2009, each year there are about 13
thousands infants. The number of infants died within one month per 1000 births is 74 and
the under 5 mortality rate is 71 (2008). However, the immunization in the province is quite
good with 94% of infants from 9 to 12 months receive full immunization. Within
Battambang province, the situation of infant mortality has been ameliorated. Several
districts almost reach the MDG goal 4 for reaching more than 90% of the goal. Even
though there are still districts that still cannot reach 50% of the goals.
Source: Ministry of Planning, UNDP, Commune database and implementation of
CMDG at sub-national levels, 2010
Compared to infant mortality reduction, the rate of maternal mortality reduction shows a
slower speed with lower percentage of goal achieved. Within the period from 2007 to 2010,
only one district almost achieved 90% of the goal while most of the other districts just
achieve about 60-70% of the goal. There is no reverse case as all of the districts in the
province experience and increase of the percentage of goal achieved. Districts like Moung
Ruessei and Koas Krala show impressive increase of the percentage of goal achieved of
more than 30% in the period of three years.
19
2.3. MNCH intervention
Various MNCH activities have been implementing in Battambang province over the
past years. Acknowledging the seriousness of the MNCH situation in the province, the
provincial government has been pro-active in looking for support from international
community in both financial and technical support. Each district has the list of projects that
need supporting, extracting from the community needs of the district. To be specific,
within the MNCH, needs focus on reproductive health, health campaign, immunization,
health service delivery, health capacity building, and TBA support/training.
20
3. Research objectives and methods
The main objective of this study is to develop a program on Maternal Newborn and
Child health care in Battambang province in Cambodia, especially for two ODs: Mong
Ruessei operational district and Sankae operational district. To answer the most important
research question of what should be done to increase MNCH in Battambang, we
implemented a need assessment and on-going program assessment as situation analysis.
3.1. Need assessment
In order to assess needs of MNCH in Battambang, we implemented qualitative and
quantitative survey in three districts within the province: Battambang district, Sangkae
district, and Moung Ruessei district. Apart from that we also evaluate health centers to
understand the supply of services, and finally we implemented a maternal death review.
We study both the demand and the supply side of MNCH to assess needs as we believe
that the supply does influence on the demand of services, especially in MNCH.
(1) Qualitative survey
We implemented interviews with pregnant women, mother of young child or children,
their spouses and relatives (mother in law) to examine the delivery and pregnancy
experience that they themselves had or their spouses or relatives had. By asking questions,
we can figure out whether the women received sufficient and appropriate delivery services,
pre and post delivery care to evaluate the objective needs of services. Also we can
understand their own opinion about the services and experience and their objective needs
of MNCH services. The reason why we interview spouses and relatives is that we believe
that these people would have certain influence on the seeking of care of the women both
mentally and financially.
We also interviewed service providers and evaluated their skills and knowledge in the
field because it would affect not only the supply of services but also the demand of
services as well.
The results of the qualitative survey will be presented in the next section. However we
strongly believe that the qualitative study plays an important role in understanding the
21
needs of the Battambang people on MNCH services.
(2) Quantitative survey
Based on the preliminary study of qualitative survey we implemented a quantitative
survey in a larger scale to further understand the needs of the Battambang people in
MNCH. We tried to have a more objective view on the needs and the situation of MNCH
services in the province through the quantitative research to avoid the potential bias of
information of qualitative survey. The results of the quantitative study will be presented in
detail in the next section.
3.2 Health center resource assessment
The operational district (OD) boundaries are different from the administrative district
boundaries meaning that it can receive patients from other districts, not just the patients
within the administrative district that it locates in. According to District Data Book 2009,
there are only 3 operational districts in the three studied districts, two referral hospitals and
50 health centers and there is no health post.
District Population
(people)
Operational
district
Referral
hospital
Health
center
Battambang 151.656 1 1 22
Moung Ruessei 116.644 1 1 13
Sangkae 117.164 1 15
Source: District Data Book 2009: Services and Organizations
Within the 13 health centers of Mong Ruessei district there is no doctor, 38 nurses, and
24 midwives. In Battambang district, there are 2 doctors, 85 nurses, and 68 midwives.
22
Sangkae has better human resource situation of 5 doctors, 276 nurses, and 161 midwives.
It is clearly seen that there is a serious shortage of health human resources and the
allocation of health staffs is not equal among places. The shortage of health facilities and
human resources are main barriers of access to MNCH care. That is the reason why the
first objective of the Fast Track Initiative Road Map emphasizes the important of
supplying standard services with sufficient facilities.
(1) MR OD
Health Center Profile- (1) Human Resources
ល.រ
No
ឈ្មោះមណ្ឌលសុខភាព
Health Center name
ធនធានមនុស្ស Human Resource
ល.រ No វេជ្ជ
. MD
គ្រូពេទ្យ
MA
គិ.មធ្យម
Sec.Nur
គិ.បថម Pri.Nu
r
ឆ្មប.មធ្យម
Sec.MW
ឆ្មប.បថម
Pri.MW
1 Prey Svay 0 0 2 2 1 2 1
2 Russey Krang 0 0 3 2 0 3 2
3 Chrey 0 0 0 3 1 3 3
4 Talaos 0 0 0 1 0 5 4
5 Ko Koh 0 0 0 0 1 3 5
6 Thibadei 0 0 0 1 0 4 6
7 Robas Mongkol 0 0 1 3 0 2 7
8 Maung 0 0 0 2 3 2 8
9 Kea 0 0 1 2 0 2 9
10 Prey Tauch 0 0 2 2 1 2 10
11 Prey Tra Lach 0 1 5 2 0 2 11
12 Prekchik 0 0 2 1 0 3 12
13 Koh Kralar 0 0 1 2 1 1 13
Sum 0 1 17 23 8 34
23
Health Center Profile- (2) General equipments
ល.រ No
ឈ្មោះមណ្ឌលសុខភាព
Health Center name
Compute
r
ប្រភពទឹក Water Source
បង្គន់ toillet
អគ្ីគសនី Electricity
ប្រភេទ Type
ចំនួន Number
ប្រភព
Source
រយៈពេលអាចប្រើបាន
Hour Availability
1 Prey Svay 1 Lake Standard 1 Public 24h
2 Russey Krang 0 Lake Standard 1 Public 24h
3 Chrey 1 Lake Standard 1 Public 24h
4 Talaos 0 Pumping well Standard 1 Public 24h
5 Ko Koh 0 Lake Standard 1 Public 24h
6 Thibadei 1 Lake Standard 1 Privat
e 24h
7 Robas Mongkol 0 Lake Standard 1 Solar 4h
8 Maung 1 Public Water
Suply No ០ Private 24h
9 Kea 1 Lake Standard 1 Privat
e 24h
10 Prey Tauch 1 Well Standard 1 Privat
e 24h
11 Prey Tra Lach 1 Lake Standard 1 Privat
e 8h
12 Prekchik 0 River Standard 2 Privat
e 4h
13 Koh Kralar 1 Lake Standard 3 Privat
e 24h
8
24
Health Center Profile- (3) Obstetric equipments
ល.រ No
ឈ្មោះមណ្ឌលសុខភាព
Health Center name
ចំនួនប្រអប់សំរាល
Number of Delivery
kits
ចំនួនគ្រែសំរាល Number of
Delivery Beds
ចំនួនគ្រែរង់ចា ំ
Number of waiting
Beds
ឧបករណ៏សំរាប់steril/ Sterilizer
ប្រភេទ Type
ចំនួន Number
1 Prey Svay 2 1=Old 0 Autoclave 1
2 Russey Krang 2 1=Old 0 Autoclave 1
3 Chrey 3 1 0 Autoclave 1
4 Talaos 2 1=Old 0 Autoclave 1
5 Ko Koh 2 1=Old 0 Autoclave 1
6 Thibadei 4 1 4 Autoclave 1
7 Robas Mongkol 2 1 4 Autoclave 1
8 Maung 0 0 0 Autoclave 1
9 Kea 3 1 0 Autoclave 1
10 Prey Tauch 2 1 0 Autoclave 1
11 Prey Tra Lach 3 1 4 Autoclave 1
12 Prekchik 4 1 8 Autoclave 1
13 Koh Kralar 4 1=Old 12 Autoclave 1
25
Health Center Profile- (4) Obstetric equipments (cont’)
No
Health
Center
name
Number
of
stethoscope
Number
Of
BP
Measure
device
Fetal
Monitoring
device
Size
Of
Delivery
room
Three top MCH needs by
health center
1 Prey Svay 1 1 0 4m x4m Fetal monitoring device
2 Russey
Krang 1 1 0 4m x48m Fetal monitoring device
3 Chrey 1 1 0 3.5m x4m Fetal monitoring device
4 Talaos 1 1 0 3.50m x4m Fetal monitoring device
5 Ko Koh 1 1 0 3.50m x4m Fetal monitoring device
6 Thibadei 1 1 0 4m x4m Fetal monitoring device
7 Robas
Mongkol 1 1 0 4m x4m Fetal monitoring device
8 Maung 1 1 0 No
9 Kea 1 1 0 3.50m x4m Fetal monitoring device
10 Prey
Tauch 1 1 0 2.5m x4m Fetal monitoring device
11 Prey Tra
Lach 1 1 0 3m x4m Fetal monitoring device
12 Prekchik 1 1 0 2.50m x4m Fetal monitoring device
13 Koh Kralar 1 1 0 3.5m x4m Fetal monitoring device
26
(2) SK OD
Health Center Profile- (1) Human Resources
ល.រ No
ឈ្មោះមណ្ឌលសុខភាព
Health Center
name
ធនធានមនុស្ស
Human Resource
វេជ្ជ.
MD
គ្រូពេទ្យ
MA
គិ.មធ្យម
Sec.Nur
គិ.បថម
Pri.Nur
ឆ្មប.មធ្យម
Sec.MW
ឆ្មប.បថម
Pri.MW
1 Anlong Vil 2 1 5 7 10 0
2 Wat Tameum 0 0 5 1 2 1
3 Kg.Preang 0 0 1 2 2 2
4 Kg. Preah 0 1 2 2 3 1
5 Odambang 2 0 0 4 2 2 2
6 Roka 0 1 4 1 0 2
7 Odambang 1 0 1 4 4 1 3
8 Reangkesey 0 0 3 2 0 2
9 Tapon 0 0 3 1 0 4
10 Prek Norin 0 1 9 6 5 0
11 Samrong Khnong 0 0 2 2 1 2
12 Prek Luong 0 0 5 2 4 1
13 Peam Ek 0 0 5 1 3 2
14 Prey Chas 0 0 0 3 1 1
15 Koh Chiveang 0 0 1 1 1 2
27
Health Center Profile- (2) General equipments
ល.រ
No
ឈ្មោះមណ្ឌលសុខភាព
Health Center
name
Computer
ប្រភពទឹក
Water
Source
បង្គន់
toillet
អគ្ីគសនី
Electricity
ប្រភេទ
Type
ចំនួន
Num
ber
ប្រភព
Source
រយៈពេលអាចប្រើបាន
Hour Availability
1 Anlong Vil 1 Public Water
Supply Standard 4
Public
Supply 24h
2 Wat Tameum 1 Generator Standard 1 Public
Supply 24h
3 Kg.Preang 0 Well Standard 1 Public
Supply 24h
4 Kg. Preah 0 Lake Standard 1 Public
Supply 24h
5 Odambang 2 0 Canal Standard 4 Public
Supply 24h
6 Roka 0 Well Standard 1 Solar 24h
7 Odambang 1 1 Canal Standard 3 Public
Supply 24h
8 Reangkesey 0 Well Standard 3 Public
Supply 24h
9 Tapon 0 Lake Standard 2 Public
Supply 24h
10 Prek Norin 1
Private
Water
supply
Standard 4 Private
supply 24h
11 Samrong Khnong 1
Private
Water
supply
Standard 3 Public
Supply 24h
12 Prek Luong 1
Private
Water
supply
Standard 1 Private
supply 24h
13 Peam Ek 1
Private
Water
supply
Standard 1 Public
Supply 24h
14 Prey Chas 0 River Standard 1 Solar 12h
15 Koh Chiveang 0 River Standard 2 Private
supply 12h
28
Health Center Profile- (3) Obstetric equipments
ល.រ No
ឈ្មោះមណ្ឌលសុខភាព
Health Center name
ចំនួនប្រអប់សំរាល
Number of
Delivery kits
ចំនួនគ្រែសំរាល
Number of
Delivery Beds
ចំនួនគ្រែរង់ចាំ Number of
waiting Beds
ឧបករណ៏សំរាប់steril/ Sterilizer
ប្រភេទ
Type
ចំនួន
Number
1 Anlong Vil 2 1 6 Autoclave 1
2 Wat Tameum 2 1 2 Autoclave 1
3 Kg.Preang 2 1 3 Autoclave 2
4 Kg. Preah 2 1 1 Autoclave 1
5 Odambang 2 2 1 (old) 0 Autoclave 2
6 Roka 1 2 (old) 0 Autoclave 1
7 Odambang 1 3 1 2 Autoclave 1
8 Reangkesey 2 2 4 Autoclave 1
9 Tapon 3 2 1 Autoclave 1
10 Prek Norin 5 2 3 Autoclave 2
11 Samrong Khnong 3 1 0 Autoclave 2
12 Prek Luong 5 1 0 Autoclave 2
13 Peam Ek 2 1 1 Autoclave 1
14 Prey Chas 1 1 2 Autoclave 1
15 Koh Chiveang 1 0 1 Autoclave 1
29
Health Center Profile- (4) Obstetric equipments (cont’)
ល.រ
No
Health
Center
name
Number
Of
stethoscop
es
Number
Of
BP
measuring
Fetal
Monitoring
device
Size
Of
Delivery
room
MCH Three Top MCH Needs
By Health center
1 Anlong Vil 3 3 1 3mx4m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
2 Wat Tameum 1 1 1 3mx4m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
- 3 rooms of maternal waiting house
3 Kg.Preang 1 1 2 3mx3.5m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
- Repair delivery room
4 Kg. Preah 3 3 2 NA - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
5 Odambang 2 1 1 1 3.5mx3.7m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
6 Roka 1 1 1 NA - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
- Build maternal waiting house
7 Odambang 1 1 0 1 3.1mx3.2m - Need waiting beds
- Need BP measuring
- Water pumping machine
8 Reangkesey 3 2 1 3.5mx3.5m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
9 Tapon 1 1 1 3mx3.7m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
10 Prek Norin 1 1 2 12m quare - Room for midwife staying
- Tuk Tuk for referral system
11 Samrong
Khnong 1 3 1 4.3mx4.1m
- One tuk tuk
- Need 5 waiting beds
- Need 1 delivery bed
12 Prek Luong 4 2 1 4mx4m - One tuk tuk
- Need 3 waiting beds
- Need 1 delivery bed
13 Peam Ek 1 0 1 3mx3m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Tuk Tuk for referral system
14 Prey Chas 1 1 1 2mx3m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for Electricity during delivery
15 Koh Chiveang 1 1 1 2mx3m - Support ANC & BS out reach(Far Village)
- Provide training to midwife
- Request for delivery bed and Electricity during delivery
30
(3) Delivery in some districts in Battambang province, 2007
3.3 Maternal death review
Within the framework of the study, we implemented a maternal death review of 7
cases in Sangkae and Moung Russei districts. The documents of death review had no
sufficient information to diagnose precise cause of death. However, considering
insufficient information inevitable then, three of avoidable death pattern could be found
out from the review.
First pattern were the women who had delivered at home with TBA, and some
problem (probably bleeding) appeared. However, the problems were not treated in the
health facility until near dying. Program support to enhance delivery service utilization at
health facility is highly recommended to save this pattern of loss.
Second pattern were the cases who admitted at Provincial hospital due to uncertain
diagnosis (probably preeclampsia) based on physician’s recommendation; however, the
patient escaped from the hospital due to unknown reason (probably worrying about burden
of hospital fee if admission were prolonging).
Third pattern were the cases with placental accident related death. Coming to hospital,
diagnosis, and treatment onset would be delayed. The possibility of delayed diagnosis of
placental accident were accepted in the interview with Obstetrician in Battambang since
they have limited capacity and equipment to diagnose the placental accident timely and
properly.
In most of the cases, the women had dangerous symptom such as bleeding. However
because of the lack of knowledge they had not gone to health care facilities for emergency
31
services causing deaths. The knowledge and attitude of a woman and her spouse led to a
regretful behavior of self-discharge from the hospital earlier than recommendation of
health staff. Another case chose traditional medicine on purpose and delayed to go the
referral hospital for the lack of knowledge toward safe motherhood and delivery. Therefore,
more than half of the cases were imposed by the inappropriate knowledge and attitude
toward MNCH. That is a very important assessment in finding the factors affecting MNCH
needs of the community. Another case is very regretful since the mother has no money to
be transferred to a health facility and she delivered at home alone in the morning. Apart
from knowledge and attitudes, financial barriers as well as access to emergency services
would be also factors affecting the maternal mortality in Battambang province.
3.4. On-going program assessment
The government has been implementing the national strategy on reproductive health
focusing on the Fast Track Initiatives Road Map in reducing maternal and newborn
mortality. Many interventions and activities have been implemented to fulfill the targets.
Apart from the financial subsidy from the government, a significant portion of funding for
MNCH activities in Cambodia is from international donors. This is the same trend in
Battambang province. Under the instruction of the Ministry of Health, the provincial
health department works directly with donors and community to implement relevant health
programs and projects to improve MNCH in the province. We studied the interventions
that had been done to avoid duplication in developing our program so that our program
would fill the gaps of needs that are still neglected.
Most of the government projects and supports focus on allowance and utility costs for
the health facilities to operate and referral transportation costs to national hospital. The
amount of government support is relatively small compared to foreign donors financially.
Multilateral donors interested in propaganda campaign on nutrition, safe motherhood; and
training for health workers. International donors concern about the governance and
supervision activities of MNCH. The areas and activities received the most financial
support are antenatal care, vaccination, nutrition, and HR development such as training for
health center staffs, midwives, and village health workers.
Some donors sponsored transportation for the patients in the form of vehicles like cars.
32
However, there is no budget for the vehicles to operate causing the waste of resources
while the patients still could not access to care. On the other hand, transportation is a main
barrier of access to care, especially emergency care. Therefore, such a gap is noticed by
our team to develop the program.
Although supervision is important, we focus on improving community understanding
subjectively to behavior change through community training sections through mass media
and village communication tools such as radio. This is still neglected by the government as
well as other donor.
There are projects and activities aiming at supplying office supply for MCH however
the medical equipment is of severe shortage. Based on health center assessment we will
provide essential equipment for MNCH services of high utility in reasonable costs.
Despite the fact that there have been many training activities for health workers we
found that training on emergency situation is still of shortage. Therefore, our program will
also take this issue into consideration.
33
Annual Operating Plan of MR and SK OD in Battambang Province in 2012
No Activity ODName BILATERAL
GLOBAL FUND
GOVERNMENT
HSSP2
MULTILATERAL NGO USER
FEE (blank)
Grand Total
1 Allowance for receiving maternal books and slips for OD Sangkae 4,846
4,846
2 Allowance for receiving vaccin at OD and PHD
Mong Russei 1,974
450
3 Allowance for receiving vaccin at OD and PHD Sangkae 9,304
46
4 Annual review on reproductive health at PHD
PHD Battambang
3,145 3,145
5 Bi monthly supervision on nutrition from OD to HCs and community Sangkae 1,050
1,050
6 Buy gas for refrigerating system Sangkae 7,143 7,143
7 Communication MCH sevice from ODs to PHD
Mong Russei 463
463
8 CommunicationwithNationalMCHonvaccination
PHD Battambang
2,547 2,547
9 Conduct ANC outreach Mong Russei 4,827
1,200 1,200
10 Conduct campaign on ANC in Sampov Luon OD
PHD Battambang
7,619 7,619
11 Conduct campaign on nutrition in Sangker OD
PHD Battambang
16,605 16,605
12 Conduct campaign on tatol for reproductive women in risky villages
PHD Battambang
3,333 3,333
13 Conduct Vit A and Mebendazole campaign Sangkae 5,804 5,804
14 Incentive for CBDs Mong Russei 1,000
1,000
15 Investigation on chil ill (prevented by vaccination)
PHD Battambang
1,829 1,829
16 Maternal death investigation PHD Battambang
1,421 1,421
17 Meeting for pre-campaign of VitA and Mebendazole to children 6 to 59 months
Mong Russei 8,070
7,387
18 Meeting for pre-campaign of VitA and Mebendazole to children 6 to 59 months Sangkae 3,407
1,409
19 Meetingon2013reproductiveplaining PHD Battambang
475 475
20 Meeting on maternal and child tatanus eradication at Sampov LuonOD
PHD Battambang
2,857 2,857
21 Meeting on vaccination planing PHD Battambang
2,467 1,176
22 Meeting with CBD at HCs Mong Russei 2,713
2,713
23 Meeting with committe of maternal death investigation
PHD Battambang
2,094 2,094
24 Meeting with maternal suporting group on Baby Friendly Community Initiative Sangkae
10,48
6 10,486
25 Meeting with midwife on MCH at OD Mong Russei 1,646
1,646
26 Meternal death investigation Mong Russei 781
781
27 Meternal death investigation Sangkae 288 288
28 Office suply for MCH service to ODs and HCs
Mong Russei 700
700
34
29 Office suply for MCH service to PHD PHD Battambang
400 400
30 Orientation meeing to four HCs Mong Russei 541
541
31 Post training supervision on IMCI and quartely meeting
PHD Battambang
2,857 2,857
32 Printing document for CBD Mong Russei 381
381
33 Promotion on infant nourish decree PHD Battambang
2,407 2,407
34 Promotion on prevention maternal death peri delivery
PHD Battambang
1,421 1,421
35 Provision ARV/ART to women during delivry
Mong Russei 2,520
2,520
36 Provision ARV/ART to women during delivry
PHD Battambang
- -
37 Provision birth spacing method at HCs Sangkae 171 171
38 Provision delivery sevice Mong Russei 27,286
6,714
39 Provision delivery sevice PHD Battambang
25,000 25,000
40 Provision delivery sevice at HCs Sangkae 32,381 71
71
41 Provision ferrous and folic acid to post delivery women
PHD Battambang
- -
42 Provision gynicologic service PHD Battambang
- -
43 Provision Mebendazole to post delivery women
PHD Battambang
- -
44 Provisionpostabortioncare PHD Battambang
- -
45 Provision treatment to malnutrition children
PHD Battambang
3,732 3,732
46 Provision tubectomy and vasectomy service
PHD Battambang
3,8
70 3,870
47 Provision vaccination to children in remote area Sangkae
15,56
3 5,898 3,981
48 Provision vaccination to newborn (BCG, Hep B)
PHD Battambang
- -
49 Provivision tubectomy and vasectomy service
Mong Russei
3,1
83 3,183
50 Qarterly meeting on IMCI implementation at OD Sangkae 1,791
1,791
51 QuarerlymeetingwithVHV at HCs Sangkae 4,576 4,576
52 Quartely IMCI supervsion Mong Russei 1,607
1,607
53 Quartely meeting on IMCI result Mong Russei 1,631
1,631
54 Quartely supervision on IMCI implementation
PHD Battambang
1,743 1,743
55 Quarterly meeting on Baby Friendly Community Initiative in Maung Russey OD
PHD Battambang
1,124 1,124
35
56 Quarterly meeting on Baby Friendly Community Initiative in Sang Ker OD
PHD Battambang
1,600 1,600
57 Quarterly meeting on vaccination with HCs Sangkae 1,569
1,569
58 Quarterly meeting with CBD team leader Sangkae 1,212 1,212
59 Quarterly meeting with health midwife on tetanus eradiction at Sampov luon OD
PHD Battambang
1,983 1,983
60 Quarterly meeting with OD on IMCI at PHD
PHD Battambang
1,276 1,276
61 Quarterly meeting with OD on nutrition at PHD
PHD Battambang
1,276 1,276
62 Quarterly meeting with OD on reproductive health at PHD
PHD Battambang
874 874
63 Quarterly meeting with OD on vaccination at PHD
PHD Battambang
1,296 1,296
64 Quarterly supervision from OD to HCs Sangkae - -
65 Quarterly supervision on IMCI from OD to HCs Sangkae 2,637
2,637
66 Quarterly supervision on PNC intergration at OD and HCs
PHD Battambang
952 952
67 Quarterly supervision on Reproductive and birth spacing from PHD to HCs
PHD Battambang
2,163 2,163
68 Quarterlysupervisiononsafetyabortion PHD Battambang
1,943 1,943
69 Quarterly supervision on vaccin and refrigerating system from OD to HCs Sangkae 1,050
1,050
70 Quarterly supervision on youth reproductive at ODs
PHD Battambang
1,371 1,371
71 Quarterly supervison on nutrition at OD and HCs
PHD Battambang
2,004 2,004
72 Quarterlysupervisononvaccination PHD Battambang
2,324 2,324
73 Referbloodsample(PMTCT-HIVtesting) Mong Russei
5,581 3,840 9,421
74 Referbloodsample(PMTCT-HIVtesting) Sangkae 4,730 114
75 Refer patient to national hospital PHD Battambang
1,509 1,509
76 Supervision birth spacing at HCs and CBD in community
Mong Russei 2,797
2,797
77 Supervision birth spacing CBD in community
Mong Russei 3,075
3,075
78 Supervisiononchildgrowth(6to24months) PHD Battambang
1,030 1,030
79 Supervision on continum of care to women with HIV to receive PMTCT service Sangkae 229
229
80 Supervision on life saving skill tom health centers
Mong Russei 3,703
3,703
81 Supervision on life saving skill tom health centers
PHD Battambang
1,874 1,874
82 Supervision on life saving skill tom health centers Sangkae 1,570
1,570
83 Supervision on suplementary vaccination (CIP)
PHD Battambang
1,055 1,055
84 Supervision on the world breast feeding event in community
PHD Battambang
648 648
36
85 Supervision on VitA and Mebendazole campaign Sangkae 960
960
86 Supervision to VHV on IMCI implementation Sangkae 1,665
190
87 Supervision VitA and Mebendazol campaign
Mong Russei 1,053
1,053
88 Suply medical equipment to health centers Mong Russei -
-
89 Training CBD Mong Russei 4,410
4,410
90 Training CBD Sangkae 10,77
2 10,772
91 Training CBD Team leader Mong Russei 1,576
1,576
92 Training CBD Team leader Sangkae 1,035 1,035
93 Training health center staffs on management of refrigerating system and 7 kinds of deseases
PHD Battambang
2,134 2,134
94 Training health center staffs on MPA module 10 in Battambang OD
PHD Battambang
4,013 4,013
95 Training health center staffs on MPA module 10 in Maung Russey OD
PHD Battambang
4,061 4,061
96 TraininghealthcenterstaffsonvaccinationatPHD
PHD Battambang
2,151 2,151
97 Training marternal supporting group on Baby Friendly Community Initiative (BFCI) in Maung Russey OD
PHD Battambang
7,362 7,362
98 Training MD, Midwife of health center and referral hospital on implant at PHD
PHD Battambang
3,681 3,681
99 Training MD, Midwife of health center and referral hospital on key intervention and ostetric emergency
PHD Battambang
2,090 2,090
100 TrainingmidwifeonbasicobstetricemergencyatPHD
PHD Battambang
1,529 1,529
101 Training midwife on helping baby breath PHD Battambang
3,127 3,127
102 Training midwife on PNC intergration in Maung Russey OD
PHD Battambang
3,810 3,810
103 Training midwife on supervision maternal and child care in community
PHD Battambang
1,616 1,616
104 Training of Trainer to health center staff on Baby Friendly Community Initiative (BFCI) in Maung Russey OD
PHD Battambang
2,936 2,936
105 Training on obsteric emergency to HC midwife Sangkae 571
571
106 Training on PNC intergration to HC midwife Sangkae 2,301
2,301
107 Training Patograph to midwife Mong Russei 844
844
108 Training referral hospital and health center staffs on birth spacing at PHD
PHD Battambang
1,449 1,449
109 Training to maternal supporting group on PNC intergration Sangkae 2,314
2,314
110 Training to VHVs on PNC intergration Sangkae 3,224 3,224
111 Training VHV on ANC in community at OD
PHD Battambang
1,424 3,604 3,604
112 Training VHV on PNC in community at OD
PHD Battambang
1,424 4,305 4,305
37
113 Vaccination children under one year and women in the remote area
Mong Russei
16,61
1 1,200 1,200
114 Vit A and Mebendazole campaign for children 6 to 59 months
Mong Russei 733
733
Total 5,581 6,360 111,989 180,9
00 52,320
42,95
5 243
7,0
53 407,401
Grand Total 5,581 6,360 111,989
180,9
00 52,320
42,95
5 243
7,0
53 407,401
38
Ⅱ. Situation analysis
1. Qualitative analysis
1.1. Survey description:
One of the main parts of the project is to implement the qualitative research to
fully understand the needs of service users, service providers, and service manager
in the field, which is Battambang province in this case. In-depth interview with
each target group is an effective need assessment tool for this purpose.
Interviews were made at three districts using snowball sampling method within
the Battambang province which were Sangkae operational district, Moung Ruessei
operational district, and Battambang operational district. On February 2012, a pre-
test of interview guideline was conducted at a health center and a village in Moung
Ruessei operational district and from February 20 to March 2 of 2012, semi-
structured in-depth interviews were conducted at other sampling sites of all three
operational districts. Interviewed health centers were selected quasi-randomly from
the lists provided by the operational district who manages all the health centers in
the district. On the same principle, the interviewed villages were selected quasi-
randomly from the lists provided health centers. People in these listed villages often
visit the health center for healthcare services.
To assess service management, director level (director/vice-director) of
provincial health department, operational districts, and health centers were
interviewed. They were asked questions related to understanding the basic
information of health indicators and demographic situation, management skills,
operational management in their working agents and the health system within the
province and the operational districts as well as the health centers. Apart from that,
these managers were asked questions related to the MCH services being provided,
the understanding of the needs of service users, and cultural and knowledge gaps
39
between providers and users.
There are several kinds of service providers to be interviewed: clinician
working in the health centers, skilled birth attendant (SBA), traditional birth
attendant (TBA), and village health volunteer (VHV). They were asked general
questions on their job description, basic information on services being delivered by
them, and their skillfulness on MCH. The interview also tried to figure out how
much service providers understand the needs, the knowledge on MCH, the
satisfaction of healthcare services at health centers, and the common symptoms of
service users. Above all, providers’ opinion on factors affecting quality of care at
health centers was also investigated.
The targets of accessing service users were to understand their needs in MCH
services, their knowledge on MCH, their behaviors, and barriers of access to MCH
care. As a result, interviews were made with service users (those who visit health
centers – interview was made at health center), and non or infrequent service users
(interview was made in their house with the assistance of the VHV). To investigate
factors affecting the behaviors of service users, village leaders, husbands and family
members were also interviewed.
A sample size of 32 people in which 12 of them are service users, 11 of them
are service providers, 8 of them are service managers, and 1 official in the
Provincial Health Department (a planning officer of Battambang operational
district at the interview period).
Table 1: Qualitative survey sample description
Service users 12
Service providers 11 Clinician (doctors, nurse, MW, SBA)
TBA 6
1
40
VHV 4
Managers Director/vice director 8
Officer 1
Total 32
1.2. Qualitative analysis:
1.2.1. Demand of services
In assessing demand of MCH services, we presumed that delivery and neonatal
care should be done at health centers or antenatal healthcare centers for safe
motherhood. Therefore, we tried to figure out what are the barriers that prevent
women from accessing to safe MCH care. Some of our findings are similar while
some are different from previous studies.
a. Cognition and social culture factors
Since the main objective of our study is to assess the needs of MCH services,
therefore we started with the cognition and psychological and social-culture barriers
where we found some differences with previous studies. Sadatoshi Matouka et.al
(2010) conducted a qualitative study in Kampong Cham province and found that
women did not want to delivery at health centers because they are more
comfortable with TBA. However, positive attitude toward antenatal care services
and delivery at health centers was revealed. Our study found that people preferred
health centers to delivery at home with a TBA because it was faster, safer, and more
comfortable. Besides, VHV and even TBA tried to persuade them to deliver at
health centers instead of delivering at home.
We chose to go to health center for delivery because we feel that it is more comfortable
than delivery at home. Said a husband and wife waiting for the second baby to be
delivered at the health center.
Sadatoshi’s research figured out that participants had not known what medical
41
equipment was available at the health centers. They also did not know what health
professional and maternal health services were available in their communities.
Therefore, the utilization of MCH services at health centers is low as women
contacted conveniently with TBA. On the contrary, participants in our study have a
good understanding of the availability and quality of MCH services provided at
health centers. The utilization rate of MCH services at health centers is relatively
high as people believe that modern services are better than the traditional delivery
methods provided by TBA.
Pregnant women should go to health center because it’s their life, and if you love your
life, you should go to the health center. Also, if the baby got delivered healthy, that
would be good for many other generations. There are many benefits for going to HC:
vaccinations, iron, and education. Said a VHV.
Still people got influenced by social culture, especially relatives for information
on safe motherhood. However, according to Sadatoshi, women often receive
negative influence on accessing to health center while we found that they receive
positive influence and information on delivery, prenatal care, and how to take care
of the child after being born.
If she delivered at home, she had her mother, her mother in law, and a TBA to help her.
But she decided to go to the health centers because they all believe that delivering at
home is not safe and she will be healthier to deliver at health center. Said a VHV about
a case in her village.
In short, we found that the knowledge on MCH of Cambodian people,
especially those in the study sites got improved and were on the right track. It is not
the social culture or cognition or wrong perception that prevent them from
accessing to MCH care. The demand for MCH care is existing, which is influenced
by other factors rather than cognition and social culture.
b. Transportation - geography
Although there is demand for health services at health centers there are several
42
factor affecting the access to care of Cambodian people, especially those in remote
areas. Barriers of access to care derived from the interviews are transportation on
both affordability and availability.
Transportation is the common problem for everyone because of bad road
conditions especially in rainy season. Furthermore, this issue is more severe to
poorer people who own no means of transportation such as motorcycle. They often
have to borrow motorcycle from their relatives or friends or neighbor, which
reduces the activeness of access to health centers. Some health centers have
motors/motorcycles or cars, however, they are un-utilizable as drivers are not
available or the car is broken, misplaced, or misused. Some villages have
transportation fee schedules collectively so that drivers are not over or underpaid.
However, this practice appears arbitrary and not available throughout the
operational district.
Apart from the availability issue, affordability is also a big problem as people
have no money to hire a motor-taxi (tuk-tuk in Khemer) or cannot afford the high
cost of gasoline in Cambodia. Cambodia has to import gasoline from other country
making gasoline expensive to the common living standard in the country. Even in
referring patients between health center and referral hospital, ambulance does not
function well due to low budget for maintenance and gasoline.
Transportation is a burden to me. When I have money I go to health center. When I don’t
have money, there is no way to go there. Said a mother of 6 children.
Despite the frequently mentioned transportation problem, according to the VHV
or HC directors that we interviewed, most women still managed to come to health
centers for ANC and delivery. In case the pregnant women cannot go to the health
centers, under the request of VHV, the staffs of health centers would visit the
pregnant women for check-up at home.
However, those who work far away from home, in the border of Thailand or in
43
Thailand could not access to care because of the geographical barrier for having no
health centers in these areas. Especially, those who work in other countries as a
foreigner, it is also hard for them to access to care in the working country. Some of
them earn a living by fishing which is quite far from the dwelling. Usually, it takes
them around one day to get back home from their working place.
c. Financial barrier
Pregnant women do not have enough money to afford a visit to health center for
delivery or check-up. They have to spend their income on food and essential
commodities for other kids or other member of the family. Therefore they cannot
exchange MCH services for food. The cost of MCH services is high compared to
other alternatives such as TBA or VHV.
With a card of the equity fund (issued for the poor), delivery service at health
center is free of charge. It releases quite a burden on service costs for pregnant
women and their family. Some women could not receive the equity fund card
because they were not available on the day the card is issued to them for having to
work far away from home or far away from the place where the card is issued.
Besides, opportunity cost is also a barrier in preventing women from receiving
MCH services at health center. Many of them have many children to take care of so
there is no one to take care of the kids while the mother is away for MCH care. In
most cases when women can visit health center, they have their relatives or
neighbor to take care of their kids. More importantly, visiting health center reduces
the income they can earn for that day which affects the amount of food of other
members of the family.
1.2.2. Supply of services
Supply of services has always been a problem in developing countries for
largely affects the utilization of health care services of the citizens. Our study also
found the correlation between the supply and the utilization of MCH services in
44
Battambang province.
a. Quality of care
Most of the service users (pregnant women and their kids) and the relatives of
the service users (mother, mother in law, husband, and other related people) are
very satisfied with the services provided at health centers. The medical staffs are
reported to be friendly and helpful in delivering services as well as giving them
more information on safe motherhood and child care. Most of the participants felt
comfortable when receiving services at health centers.
When I go to the health center, I feel comfortable because the staffs are very friendly. I
try to do the things they teach me and feel that it is not too hard to do.
Most health centers are available at night for delivery. Apart from that some
people complained about the waiting time since there was a shortage of waiting
space. Besides, the cleanness of the health center was also mentioned for
improvement.
When it is not crowded, I just have to wait 10 minutes for delivery. However when
there are many other patients, I have to wait for 20-30 minutes. There is only one
operational chair which is used not just for delivery but also for ICU. Said a pregnant
woman.
In terms of child care, like many other developing countries, the concept of
regular check-up for babies is not yet largely observed as parents only bring their
kids to health centers when the babies are sick or not in a common status. This is
also the mindset of the service providers as they do not provide medical check-up
for healthy children. However, immunization has been implementing very
effectively with specific immunization schedule. The parents aware of the
immunization schedule and they acknowledge that immunization is needed for their
kids. The immunization coverage is quite good with immunization outreach
programs in villages every 1-3 month.
45
b. Human resource training
Although most of health centers have midwives their ability sometimes is
limited for not being able to handle difficult cases or under-skilled. As a result,
many cases were transferred to higher level such as district hospitals or provincial
hospitals. Therefore, training for health staff is emphasized by all the interviewed
directors/vice directors, and service providers themselves.
Internally, we need to strengthen the capacity of the staff in the maternal service such
as how to train the doctor or surgeon to have higher capacity in doing procedures in
serious cases. Another thing is to provide training of up-to-date practice and
knowledge to all the staff and midwives, and train on neonate resuscitation/survival.
Said referral hospital director.
However, human resource training in this area is unstable and unpredictable
because it relies on foreign aid. There is a training program of the government;
however, the lack of funding for training sections make this activity depends on
NGOs’ support. Even directors of health center, district hospital, and provincial
hospital were not clear about the implementation plan for the next year apart from
the training program provided by the government. Many international organizations
and NGOs support on training, however, the lack of foreign aid coordination
capacity resulted in fragmented training programs, which is less effective for both
donor and local people.
Training is not from the hospital budget. It is not from the provincial health
department’s budget either. It is the NGO who finance for training activities. We had a
lot of training during 2004 funded by UNFPA but until now (2012) we had only 2
trainings per year. There is training for live-saving skills but I have not received any
information related to this issue this year because it depends on the supporter. Said
RH director.
c. Lack of facilities and medical equipment
Seriously lack of facilities and medical equipment is observered by interviewers
46
and is reported in different level of interviews. At health center level, interviewees
expressed demand for more equipment but were unclear which equipment is most
needed.
We had a scale in the health center but it was broken. We need some emergency
equipment but I don’t know in exact because it’s a midwife-related issue.
At the hospital level, more specific demands were expressed. Equipment is not
sufficient in terms of quantity. More equipment for neonatal resuscitation for
example for babies born with asphyxia is needed. Apart from that, the lack of the
ability to operate and maintenance medical equipment is also reported suggesting
for a package of equipment supply and training.
We don’t have the ability to use some machines here because no one knows how to use
it. Said a PH director.
1.2.3. Planning, management, and governance
a. Planning capacity
• Lack of planning capability: planning limited to predicting how many
consultations/visits or deliveries they will have
• Heavy dependence on NGOs support and user fees rather than government
budget
• Shortage of staff is sometimes expressed but we cannot confirm the validity
of the statements only based on qualitative interviews.
Interviewer: Do you think you have enough staff here to provide the care that you
want?
HC Director 1: No, not enough. The staff don’t want to come here to work
because of low salary and because they need to pay 10,000 riel ($2.50 USD) for
transportation from Battambang [town] to here.
47
• Reported number of staff does not reflect true numbers of providers who are
working at the HC. Often, staffs are away due to personal matters but listed
as staff members so the number can be inflated.
b. Link between HC, RH, and PH (referral, communication, collaboration,
etc)
PH Director 1: “There are 2 problems. The first one is related to referral service—
some patients don’t have enough money/lack of transportation to get from rural areas
to HC…. Some problems/cases that are late from HC to RH or PH are due to lack of
transportation. We have no money to pay for transportation.”
• Good working relationships or communication channels need to be
established between HC, RH, and PH.
Interviewer: Do you have any difficulties between communicating between the RH,
PH, and central government? How do you communicate with the different levels?
HC Director: Because of the distance from here to the RH (far) the relationship is
not so good.
• Transportation system between the facilities needs better maintenance and
improvement to allow for early referrals and immediate intervention
Interviewer: Besides that, what other things do you think your hospital needs in
order to function well (at the level that you want it to)?
RH Director: There are 2 factors: [external and internal]. First, we need to
strengthen the referral system from the HC to the RH. We need active referral. And, we
need a new ambulance because our current ambulance is old enough.
• Need to train the staff at HCs on when to transfer patients to higher level
hospitals
c. Budget shortage
• Concerns on insufficient government support
48
PH Director 1: The government support for drugs is not enough—only 70%. So, 30%
we use the money from the client to buy drugs, equipment, repairs, etc. Everything is
not the government budget but also the user fee budget…. The income from the MOH
to buy medication is not enough. Sometimes the money only supplies us for 23 days
out of the month so all the income we get from patients, we use to buy medication for
the rest of the 7 days of the month.
d. Public and private divide/duplicate
• Many providers offer private services as well. Some staffs encourage
patients to use private services: “sometimes the staffs at the HC want the
patient to go home.”
PH Director 1: Some staff work at private clinics and go to patients’ houses to give
injections, etc. and get money. They tell patients to leave early without permission
(stating that it would be difficult to wait for proper permission for discharge) and run
away to home, saying that they will go to their home and give injections, medication,
or anything else.
• Some go for outreach services via their private practice, so women get
confused when they are asked pay (they think that because this is the same
provider they saw at the public facility, that the service should be free as it
would be if they were seen at the health facility)
• Perception that private services are better for complicated cases of disease.
Short wait and total visit time at private clinics
Interviewer: Okay, but what do people generally think about private clinics?
VILLAGERS: Because of our anxiety. Heard that private clinics cure the disease.
My neighbor went there and was cured. We borrowed money to treat her mother.
Interviewer: What about delivering or ANC at private clinics. Have you heard of
anything with pregnant women’s experience there?
OTHER VILLAGER: There are many people who go for ANC care and delivery at
private clinics. When I go to the private clinic, I would see 4-5 pregnant women who
49
just delivered.
Interviewer: What is their experience there [at private clinics] versus the HC?
VHV 1: Good service and can come home early. If you go to the HC you need to
wait for a long time, but if you go to the private clinic you can come back home
early….. The main point is that they can come back home early (short wait and total
visit time).
Interviewer: [Rephrasing] What made you choose the private clinic over the HC?
GRANDMOTHER: [Interesting timid looking reaction where woman was looking
down] Because we heard that the private clinic had better service than the HC.
• On the other hand, providers or directors at HC or PH believe that quality of
care at public facility is better than that of private clinic due to regulation.
There is a discrepancy in what HC staff and common people believe about
the private clinics
• Difficult to assess the true quality of care at private clinic as there is no
monitoring system for that sector.
e. Monitoring system
• Need a well designed monitoring system: HC quality assessment protocol
exists, but not sure how well it is operating.
• Data collection system needs to be strengthened and continuously funded
Interviewer: How do you get the information from the women in the villages who
don’t use the HC?
RH Director: In the past we had one activity that was ANC mobilization where we
went straight to the villages that are very far from the HC. But last year we didn’t
have money, so we didn’t do it…. some indicators (like ANC) have declined because of
no budget.
50
2. Quantitative analysis
2.1. Quantitative survey description
Quantitative survey was implemented at three districts (Sangkae operational
district – SK -and Mong Ruessei operational district – MR -, and Battambang
district – BB -) within Battambang province with people from 15 villages on May.
Sk and MR are project site and BB were investigated as a reference site. One
commune (subdistrict) which is equivalent adminstrative unit for health center
catchment area were selected for each operational district based on distance from
the referal hospital (half distance of the farthest commune per each operational
district) from three operational district respectively. Once a commune was selected
as a sample, whole villages in the commune were sampled. All the currently
pregnanant women (A) and the women who gave birth in 2011 (B) in the whole
villages were selected as an individual sample. A total number of 604 women
representing service users were interviewed. Among those, 245 of them (41%) are
pregnant (A) and 359 of them (59%) delivered last year (2011) (B), see table below.
The survey focuses on service users and service providers. In order to improve
the MCH status (regarding MDG goal 4 and 5), we think that MCH service
utilization and MCH service quality should be improved. Based on that basic frame,
we develop our quantitative survey on four main performance indicators: maternal
mortality ratio (MMR), antenatal care, facility delivery service utilization, and
postpartum service utilization. We quantitively analyze the barriers of access to care
from the view of both service users and service providers, people’s knowledge and
attitude toward MCH, and provider’s knowledge and skillfulness.
Table: Service users description
51
OD name Village name Total number of
survey
(A+B)
Current
pregnancy
(A)
Births in 2011
(B)
MR Kon khlong 34 18 16
Dop krarsang 42 14 28
Thmey 32 5 27
Prey tauch 34 13 21
Prean nil 21 5 16
Steung chark 23 9 14
Boeung Pring 14 5 9
Prey damrei 47 17 30
BB Thngor 17 5 12
Daung 47 19 28
SK Boeung teum 40 18 22
Svay sar 49 24 25
Samdach 56 31 25
Baseth 98 41 57
Tapon 50 21 29
Total 604 245 359
Provider survey was also done at the every health centers in MR and SK.
The respondents consisted of 74 primary nurses, 43 secondary nurses, 63
primary midwives, 61 secondary midwives, 4 doctors, 6 medical
assistances, and 4 persons with no disclosing of qualification.
2.2. Quantitative analysis results
There is a gap between our survey data and announced data of the
government of Cambodia. The statistic system being used by the government is on
report base which might differ from the real time data. According to the current
52
provincial government projection, the number of live birth in 2011 is supposed to
be 3% of total projected population while our date shows a rate of 1.24%. Official
statistics projected by local government on the number of delivery at health
facilities show a significant discrepancy with the surveyed data. In Battambang
district, the official rate of delivery at health facilities is 25% while our data reveals
the rate of 80%. It has been under-estimated because of overestimated denominator:
total pregnancies (see table below).
[policy implication] Adjustment of projection percentage to get number of
birth per year from 3% to 1.5% would be helpful to get more plausible and
precise estimation of official statistics.
Delivery at health facilities in 2011
Govt. data (%) Survey data (%)
MR 57 89.4
BB 25 80
SK 47 78.5
2.2.1 Maternal mortality ratio (MMR)
With such a small sample of data set, MMR is a very sensitive indicator to
measure stable program performance results in the near future. Nonetheless, it is
fundamental impact indicator to be calculated regardless of the interpretation
usefulness.
53
Our denominator is live births in 2011 and the numerator is maternal deaths in
the same year. With the same projection method, announced data from the
government is much lower (2-3 times) than our projection (see table below). The
census based projection may overestimate the true live births, which might be
explained by 1) any accelerated decreasing of fertility, or 2) any longer birth
spacing than before. On the other hand, the survey based projection may a bit
underestimate the true live births because 1) there might be more moving-out after
delivery than moving-in, or 2) VHV omitted last year delivery cases.
Projection of MMR in 2011
Govt. data Survey data
SK 69/100.000 191/100.000
MR 51/100.000 109/100.000
Even though it is clear to us that the real maternal death situation in the
studied areas is much more severe than the expectation of the government
projection based MMR. Unlike maternal deaths, there has been no registry of
childhood deaths so IMR could not be taken precisely. However, IMR has been
declared as on-track so it was not an urgent indicator to be closely monitored.
2.2.2 Service utilization
a. ANC 4 or more
In order to measure the utilization of MNCH we measure the utilization of
antenatal care and delivery services. The knowledge of the women toward MNCH
would mainly affect the practical utilization of services. Almost 98% of the
participants think that pregnant women should receive antenatal care even if she
feels healthy. Health centers are the most appropriate place for healthy and low-risk
54
pregnant women to deliver. 90% of them express that delivery with midwife is the
most appropriate way while only 1% choose TBA. On top of that, women have
good knowledge on safe motherhood and antenatal care during pregnancy as more
than 90% of the interviewees think that a healthy pregnant woman should receive
antenatal care during pregnancy more than 4 times. In real practice, little more than
60% of them went for antenatal care 4 times or more during pregnancy showing
discrepancy between knowledge and practice on utilization of MCH services during
pregnancy. MR had 73% while SK showed 51%. There was quite big room to be
filled to achieve sufficient number of antenatal care (at least more than 4:ANC4) to
detect and treat high-risk pregnancy status in the third trimester such as
preeclampsia, early enough
ANC4 BB MR SK Total
NO 16 42 76 134
% 40 26.1 48.1 37.3
YES 23 118 80 221
% 57.5 73.3 50.6 61.6
response missing 1 1 2 4
% 2.5 0.6 1.3 1.1
Total 40 161 158 359
b. ANC 1
Regarding at least one ANC, rather good knowledge on MCH, however, has
brought positive behavior on ANC1 and delivery at health facility. According to our
study, more than 90% of women have the health centers to monitor the health status
of themselves and their children. Almost 100% of women in Battambang district go
to health facilities (provincial hospital, referral hospitals, and health centers)
while yet there is a some women (less than 2%) in MR and SK rely on TBA for
55
MCH or some of them (around 1%) receive no service from any kind of service
provider either traditional nor modern. This indicator was already achieved so that
this is not good for follow-up performance indicator in Battambang province.
Among those who did not receive services at health facilities, the most
frequent reason is the lack of means of transportation which accounts for 40% of
the respondents. Second largest reason for not having services at health facilities is
“no money” for both healthcare costs and transportation, accounting for 30.8%.
Only 4% reported that they prefer traditional practice and 2% reported that there is
nobody taking care of the house, which is much less severe that what had been
found in the qualitative analysis.
c. facilities delivery rates
Facility delivery rate in 2011
Delivery
at facility BB MR SK Total
No 1 8 26 35
% 2.5 5 16.5 9.8
Yes 32 144 124 300
% 80 89.4 78.5 83.6
Response missing 7 9 8 24
% 17.5 5.6 5.1 6.7
Total 40 161 158 359
Utilization rate of delivery service at health facilities is significantly high of
more than 80%. There are about 10% of the respondents did not have delivery at
health facilities and the main reason is that the birth was so quick and they had not
56
time to go to health facilities for delivery (37.3%). SK, which had more remote
areas, had 44.1% of the aforementioned reason (quick delivery) while MR had
29.4%. Small percentage was reported as there is no means of transportation (about
6% in SK) or money (about 3% in SK) or nobody taking care of the house. The
qualitative analysis reveals the lack of space for waiting before delivery at health
facilities as one of the factors affecting the quality of care. The quantitative analysis
again confirms the seriousness of the problem with regard to remoteness (other side
of quick delivery considering distance to reach). Therefore, we could recommend
an active utilization of waiting home after delivery “show” appears unless more
construction of health facility is feasible for the scattered remote area people.
The reason of no facility delivery
BB MR SK Total
Birth was so quick 2 5 15 22
% 25 29.4 44.1 37.3
no need to go 0 2 3 5
% 0 11.8 8.8 8.5
no vehicle 1 0 2 3
% 12.5 0 5.88 5.08
no money 0 0 1 1
% 0.0 0.0 2.9 1.7
no body to keep home 0 0 1 1
% 0 0.0 2.9 1.7
other 2 2 6 10
% 25 11.8 17.7 17.0
response missing 3 8 6 17
% 37.5 47.1 17.7 28.8
Total 8 17 34 59
57
d. postpartum care
On the other hand, the utilization of postpartum care is much smaller than the
utilization of delivery service, accounting for only 50%. Methods such as training
health care staffs to encourage women to come back to health facilities for
postpartum care or outreach program should be considered to save the women’s life
from the abnormal condition such as postpartum bleeding because of various
reasons (including remained placenta), postpartum infection during the postpartum
period.
Postpartum care in 2011
Postpartum care BB MR SK Total
YES 31 85 58 174
% 79.5 56.7 38.2 51
NO 8 65 94 167
% 20.5 43.3 61.8 49
Total 39 150 152 341
e. Low weight of children
With regard to low weight considering malnutrition potential, we weigh all
the children of 2011-born in the sample. We defined low weight of
children using 2 standard deviation methods (recommended by WHO) and
identified about 30% of children as low weight. Prospective project sites
(MR and SK) had higher prevalence compared to reference site (BB).
These results called for proper concern and measure to reduce low weight
to prevent avoidable child death in the near future using grant allocation
even though MDG 4 has been on track in Cambodia.
58
Low weight of children between 5-17 months
Low wt BB MR SK Total
No 31 106 104 241
% 83.8 68.4 68 69.9
Yes 6 49 49 104
% 16.2 31.6 32 30.1
Total 37 155 153 345
[Indicator summary]
Five major indicators of reproductive health
% BB MR SK Total
MMR 109 191
Delivery at facility 80 89.4 78.5 83.6
ANC1 100 96.3 96.2 96.7
ANC4 57.5 73.3 50.6 61.6
PPC 79.5 56.7 38.2 51
Low weight of child 16.2 31.6 32.0 30.1
SK had worse states compared to MR in major performance indicators so
more institutional efforts are necessary to improve the MCH.
To summarize, MMR is lower than recent national official statistics (in
other words, lowering would be fast); however, yet mortality is high.
Delivery rates at health facility were not optimal yet even though they are
59
quite higher than recent national statistics (in other words, fast decreasing
would be happening as well). Sufficiently high ANC1 have been achieved;
however, the appropriate numbers of ANC has not been achieved yet.
Therefore, ANC4 would be the most proper indicator to follow-up
appropriateness of repetitive utilization of antenatal services to prevent
avoidable pregnancy risk. Low weights were rather high so proper concern
and action was crucial to normalize the prevalence of low weight so that
child mortality would be reduced.
[policy implication] more demand creation via various way of community
mobilization is still need to fill out perfect utilization of proper extent of
MCH services.
2.2.2 Supply sides investigation results
a. Summary findings
• Very supportive attitude and knowledge on the agenda about routine work
of MNCH
• Insufficient knowledge to detect the cases for active treatment or potential
referral during routine check-up
• Insufficient referral preparedness
• Self-rating qualities: suboptimal level
• Not-sufficient but also not-infrequent supervisions and on-site trainings
60
b. Quality of services
To evaluate the quality of care we analyze the knowledge and skillfulness of
providers, the preparedness of health facilities for practice, and perceived quality of
service providers.
To assess the knowledge and skillfulness of service providers at health
facilities we provided several technical questions concerning the signs indicating a
newborn baby is ill and needs watching. Only 40% of the respondents got the right
answer and the rest 60% got the wrong answer. However, 61% got the right answer
for series of technical questions regarding the signs of danger after giving birth
indicating the need for the woman to seek health care while 39% of them got the
wrong answers. 31% of respondents got the right answer for danger symptoms
during pregnancy indicating the need to seek healthcare whereas 50% of them got
the wrong answers. Basic method in child care such as prepare ORS (oral
rehydration solutions) is known to 89% respondents and 10% don’t know how to
prepare it. Most of the respondents think that the most appropriate place for a
pregnant woman to deliver is health center for low-risk case (83%), and provincial
hospital for high-risk case (65%).
Most of the respondents strongly supportive for many healthy measures such
as importance of colostrums (yellow first milk), early breast-feeding after birth,
absolute breast-feeding during first 6 months, at least 2 year breast-feeding, and
importance of vaccination.
Most of the respondents reported that their working institution has well-
working clinical guideline (84%) and good plan for referral (82%). However, only
39% of patients were referred by ambulance (car or boat) and 54% of them user
their own means of transportation for referring.
Regarding prenatal care, common service such as weight, blood pressure are
carried out at a high rate of more than 80% while urine sample or blood sample are
61
more than 60% in BB and almost ignored in MR and SK. Almost 80% of women
buy and take iron/folic during pregnancy.
Concerning perceived quality, we asked perceptions of quality of provincial
hospitals, referral hospitals, and health centers. Most of them chose average to good
quality for the quality of services being provided at their health facilities. They also
found training is helpful to increase the quality of care. Many of them (around 60%)
received training at least once while 28% never experienced any type of training to
improve their skills.
With respect to training on MNCH care in the last 1 year, 28% of the
respondents answered no training, 30% responded once, 31% replied that they
received MNCH training more-than once last year. Most of the health center staffs
(76%) rate their computer skill as “insufficient”.
[policy implication] Health center staffs need various kinds of skill-and-
knowledge refresher training to improve capacity to properly act as a life-saver
for the risk pregnancy. Timely finding of risky pregnancy status and proper
referral them to the referral or provincial hospital were crucial to lower MMR.
Strengthening on-site training and near-by institution refresher training are
crucial components to guarantee the lowering of MMR soon.
c. Understanding and attitude towards community
Compared to perceived quality of different level of health facility, perceived
level of understanding of the community need for MNCH were lower. It would say
they need to investigate or communicate more with community. The level of
support for community outreach services were higher compared to other perceived
quality scores. Most of the respondents, health center staffs, perceived their waiting
62
house for pregnant women work well.
[policy implication] The health center staffs need more communication
activities with community with regard to MNCH. Village conference, continuous
village investigation via VHV would be helpful. Variety of micro-planning
activities is necessary for stickier bonding between community and health center
staffs.
2.2.4 Barriers to appropriate access- to- care
a. Provider perception
The quantitative survey results confirmed the results with the qualitative
interviews for the most common barrier which hinder proper access to care. With
respect to most significant barrier to using the referral or provincial hospitals, firstly,
no transportation vehicle; secondly, high transportation fee; and thirdly,
dissatisfaction with the staff; and fourthly, service and drug fee were mentioned as
barriers. For accessing to higher level of care such as provincial hospital or district
hospitals, apart from transportation and service fee, no satisfaction to the staff and
service or opportunity cost are also revealed as barriers. Respondents reported that
they had no time to visit those facilities because they have to work.
b. Villagers’ perceived barriers
• Money for transportation: somewhat burdensome (50-60%)
• Getting transportation: somewhat difficult (50-60%)
• Money for user-fee at HC: somewhat burdensome (50-60%)
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c. Villager knowledge and perception
Good for immunization practice
Good for seeking treatment service if necessary (in cases of diarrhea
and respiratory symptom)
Satisfaction for MNCH service milieu: high
Good to know the necessity of ANC4-or-more (MR 95% knows > SK
86% knows)
[policy implication] This circumstance calls for improvement of emergency
referral system with proper maintaining strategies. Barriers were not there with
regard to villager’s knowledge shortage.
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III. Program development
Based on need assessment through qualitative and quantitative analysis, we develop a
three year program on “Capacity building for maternal neonatal and child health care in
Battambang province, Cambodia”
1. Goal
Improve the quality, availability, and accessibility of maternal neonatal and child health
care services in the Kingdom of Cambodia
2. Objectives
• Support the “National Strategy for Reproductive and Sexual Health in Cambodia”
of the government of Cambodia to achieve its main goals
• Promote health system strengthening in Cambodia
• Use limited resources to leverage key programs and strengthen MNCH platform in
Cambodia
• Reduce the maternal, neonatal and child mortality ratio and accelerating the
progress toward achieving Millennium Development Goals (MDGs) goal 4 and 5
in the Kingdom of Cambodia
• Overcome the constrains related to the delivery of health services at 1) community
and household level, and 2) health service delivery level
3. Principles
Follow the Paris Principles:
• Need based approach for the people in recipient society
• Participatory approach: strengthen national ownership of programs
• Align with ongoing policy: recipient country program based approach
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• Harmonize with currently ongoing program by other developmental partners
• Scale-up via evidence based approach to improve maternal and neonatal health
• Provide technical leadership in improving maternal, neonatal, and child health
Competitive approach between donors for better visibility ignoring redundancy or gap
problem in the recipient society
Participatory approach between donor and recipient is efficient since “No-one knows what
you need better than yourself”
• Encourage recipient to build the plan based on their own need with the technical
support of need assessment tools if necessary
• Recipient set priority considering different cost-effectiveness with regard to MCH
improvement
• It is the recipient to set up an intervention plan to improve MCH because they
know better than donors what to do to solve existing problem in their society. Other
donors came to Cambodia with development plans based on what they believe that
would be helpful in the recipient country while we believe that no-one know about
you than yourself.
• Donors would kindly provide technical support in plan-making and specialty if
requested.
This program carries the health system strengthening objectives to ensure achievement will
be sustained in medium to long term
4. Targets
• Increase the demand for services at health facilities
• Mobilize community via coming into the village by health professions constantly
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• Overcome barriers to access to MNCH care at health facilities
• Focused interventions along the MNCH continuum of care from pre-pregnancy to
age five, by linking communities, first-level facilities, and hospitals
• Promote and support the integration of family planning and malnutrition program
towards whole MNCH program as appropriate
• Solve the problem of shortage and distribution of appropriately qualified staff
• Improve the quality of care
• Improve technical guidance, program management and supervision
• Provide equipment, supplies, and infrastructure for health facilities
• Improve information management capacity by health staffs providing education
and skill
5. Strategy and interventions
A. Operational Framework
The strategy is built around three main components: demand, supply, and
governance. The main components are unchanged over time while interventions can be
consolidated yearly based on the implementation results of the previous year. Also, the
interventions can be changed to be consistent with newly confronting situation and new
policies of the government. All the sufficiently large changes in interventions, organization,
and budgeting must be approved by KOFIH.
Each intervention with specific activities is coded for convenience in implementation,
monitoring, surveillance, revision, and amendment if necessary.
A program steering committee (PSC) will be established to manage, monitor, and
implement the components and interventions if necessary. KOFIH would technically
67
support Battambang Provincial Health Department with WHO-Cambodia office, Ministry
of Health of Cambodia, and Cambodia National MCH Center, and. The budget to operate
is subtracted from the capital of the program following international norms.
WHO-Cambodia office will be responsible for reporting to KOFIH the progress of
the program bi-annually and program results annually by documents written in English.
The accounting and auditing system used in the program will be Cambodian
accounting and auditing system with no conflict with the accounting and auditing system
of the Republic of Korea.
B. Components and interventions
1. Demand side strategy
The main focus of the demand side strategy of this program is to increase the
utilization of essential service package of maternal and neonatal care not only with a
trained provider but also in a health facility. The most crucial thing is to increase the
knowledge of people so that they themselves understand the importance of self-protection,
how to take care of the neonatal and babies, and quick response to emergency situation.
The roles of community health workers are emphasized not only to help people
increase the knowledge on MCH but also increase the demand for seeking care at health
facilities with trained staff.
Therefore, interventions would emphasize on community participation and
accessibility so that barriers of access to care would be reduced, as follow:
1.1. Community participation (CP)
Community participation includes activities implemented at community level. The
involvement of community people is the key point of this intervention. There are two main
targets of community participation: 1) through social marketing to educate the people on
MCH knowledge and healthy behavior, 2) direct interaction of trained village health
workers with village people to provide more information on the availability of services at
health centers, to understand the needs of the community so that these needs would be
68
reflected in the community’s health strategies.
CP1:
Health education for the community/social marketing:
Health education messages on pre-pregnancy,
pregnancy, delivery, neonatal care, and child care
through 3 radio channels, broadcasted at all the villages
in the Battambang province every day, 3 times a day for
one year
IEC materials for complementary feeding campaign for
children 6-24 months
CP2: Direct interaction:
Community health forum in 30 villages in SK and 30
villages in MR
Conduct Child Health Fair for CFC campaign 4 times a
year in both SK and MR
Meeting with VHSG every 4 month and mother supporting
groups every 2 month
1.2. Increase access to care (AC)
Increase access to care is the crucial intervention not only in this program but also in
the national strategy on reproductive health of the government. Our intervention focuses
on erasing the barriers of access to MNCH care, especially for people of financial and
geographical difficulties. Within the dimension of this program, we provide support for
transportation and part of user fee for poor people. However, we believe that more
resources with long term strategy on system strengthening to increase the access to care in
69
Cambodia.
AC1:
Transportation cost:
Provide transportation cost for poor women to deliver at
health centers or other health facilities
Provide transportation cost for poor women to come to
health facilities for ANC4
Provide transportation cost for poor women to come to
health facilities for PNC2
Prepare village referral transportation (tuktuk) to bring
patients to health centers (Preyloung, Raingkessey, and
Tapon health center)
AC2:
Reduce financial barrier:
Provide financial support for poor women hospitalizing in
provincial hospitals
1.3. Demand creation (DC)
One of the typical interventions of the demand strategy in this program is to create or
promote demand for services in health facilities. Although there are barriers of access to
care, especially transportation, 80% of our respondents tried to deliver in the health
facilities. However, the utilization rate for pre-delivery and antenatal care is significantly
low pushing us to try to increase the demand for MCH care with trained health workers
through community outreach activities, and public media education. Both the people and
the health workers think that only a sick child should seek for care while we believe that
any kind of regular check-up for healthy child should be encouraged. That would be the
main purpose of the propaganda campaign through village radio network.
70
DC1: Community outreach activities:
ANC and PNC outreach to remote villages
Vaccination outreach to remote villages
Provide bicycles for VHSGs
Mass screening to identify malnutrition children and
assessment
Food demonstration for severe malnutrition children
DC2: Propaganda through village radio networks
Encourage health care seeking activities at health facilities
Remind of community health activities: immunization
schedules, safe abortion
2. Supply side strategy
Supply side strategy focuses on improving availability and quality of care. We
emphasize on supply as a very important components because we believe that good care
would push demand and reduce mortality of both mother and child. By improving
availability of care we concentrate on essential package of services at health facilities,
especially at health centers. In order to improve the quality of care, we focus on
strengthening skills and knowledge for health workers currently working at health facilities.
Moreover, providing sufficient working materials such as medical equipment and supplies
for MNCH services is crucial in increasing the quality of care because the lack of medical
equipment and supplies at MNCH centers is so serious a problem in Cambodia in general
and Battambang province in particular. This project also tries to increase the availability of
71
services by constructing new buildings of better condition for quality of care improvement.
2.1. Human resource development (HRD)
As the most important activities within supply strategy, MNCH human resource
development aims at improving the medical skills and knowledge for both health workers
currently working at health facilities and community health workers. Training focuses on
improving the skills to respond to emergency and complications of pregnancy, delivery,
and antenatal care.
HRD1: Training for medical skills upgrade
Training on anesthesia at provincial hospital
Training to physicians on post emergency care to
newborn
Training to physicians on obstetric emergency
Training midwives on obstetric emergency
Training midwives on hemoglobin and albumin test
Training on C-IMCI
TOT training on management of acute malnutrition
On-site training to strengthen skills of midwives on ANC,
delivery, and PNC
TOT training on IPC
Coaching section on Immediate Newborn Care
Training on MPA (Minimum Package of Activities)
72
module 9
Supportive supervision on ANC, delivery, and nutrition
HRD2: Training for community health workers:
Training for village health support groups (VHSG) on C-
IMCI, management of acute malnutrition, IPC for
complementary feeding, multi-micronutrient powder,
CCMN, Vitamin A and Mebendazol distribution
Training for mother support groups on BFCI; training for
representatives of villages (VHV/VHSG/mother support
group) at health centers on CBD, growth monitoring and
growth promotion.
2.2. Provide medical supplies and equipment (ME)
Lacking medical equipment and supplies directly affect the quality of services,
especially in emergency and complications situations. Many deaths were caused by lack of
medical equipment and supplies calling for support in equipment for operation, delivery,
and pre-birth tests.
ME1: Medical supplies and equipment for operation
Operation table
Oxygen extractor
Manual vacuum extractor (ventouse)
Operating lamp
73
Anesthetic machine
Cesarean section kits
Oxygen extractor
ME2: Medical supplies and equipment for delivery and procedures
Delivery bed
Delivery kits
Autoclave
Trolley
Trolley for transferring patient
Projector lamp for delivery
Vaginal hysterectomy kits
Radian warmer
Fetal doppler
ME3: Medical device for testing:
Hemocue machine
Alburniuria testing device
Ultrasound for PH
2.3. Construction (CT)
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Construction of buildings in SK and MR for MNCH activities accounts for one-fourth
of the total budget of the program. New construction would increase the availability of
services of better condition in terms of sanitation and facilities. Pregnant women will have
more space for waiting before delivery so that the delivery out of health facilities because
of the incident of quick delivery would be reduced.
CT1: Construction of maternity ward and child rehabilitation
room for severe malnutrition children
Construct new maternal waiting room
2.4. Strengthen referral system (RE)
Strengthening referral system would not only help the MNCH services but also play
an important role in health system strengthening objective of the program. Better
transportation would be utilized for other kinds of services as well.
RE1: Tuktuk service at health centers
Provide ambulance with gasoline/maintaining service
Motorboat (SK)
2.5. Incentives for malnutrition activities (MN)
MN1: Preparation meeting with VHGS on Vitamin A and
Mebendazol distribution
Preparation meeting with health centers for vitamin A and
Mebendazol distribution
Per diem for VHSGs during distribution campaign
75
Quarterly meeting on management of severe malnutrition
Supportive supervision during Vitamin A distribution at
health centers and community
Supplies for in-patient management of severe malnutrition
3. Governance side strategy
3.1. Information system (IS)
Weak health information system is not only a problem in Cambodia but also is a
chronic disease of many other developing countries. Information is basis for all kinds of
interventions and policies asking for sufficient investment. This program will focus on the
software of the information system rather than hardware investment by improving
information collecting skills, reporting skills, and managing skills through training.
IS1: Data collection:
Conduct information collection on pregnant women and
children under 2
Monitoring, consultative meeting and data entry on
pregnant women and children under 2
IS2: Training to improve information system
Training on HIS to health centers
Training AOP
Training midwives on updated MCH registers
Workshop on MNCH AOP
76
3.2. Governance activities (GV)
Governance capacity needs improving as it is considered as one of the factors
affecting the performance of health services. Improving governance capacity would help
strengthen not only MNCH but also the healthcare system.
GV1: Surveillance and monitoring
Spot check on MCH HIS
Biannual meeting to review the result of implementation
with OD and HC
Monitoring the implementation of MCH project
GV2: Mentoring:
Quarterly supportive supervision on child health fair
Bi-monthly supportive supervision to OD and HC on ANC,
delivery, PNC, and nutrition
3.3. Office supplies (OS)
OS1: Equipment and supplies for office work
LCD screen
Laptop computer
Desktop computer
Scanner
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Projector, projector screen
Digital camera
Voice recorder
Photocopy machine
Air conditioner
Stationary and supply
Utilities: communication cost: phone, internet
OS2: Office transportation
Car (Toyota) for PHD
Motor-cycle for OD, RH
78
6. Monitoring and Evaluation
Following indicators would represent implementation status. There are three types of
indicators: impact indicator (2); outcome indicators (4); output indicators (11). Some
indicators would be used monthly, and some annually.
Mid-term evaluation could be done after finishing 1-year whole cycle of
implementation. Probably it would be in 2014 or 2015. Mid-term evaluation needs
quantitative and qualitative assessment as well and baseline questionnaire (Annex II-2)
could be re-accessed for capturing the changes with partial adding of new questions.
Before scaling up new project site need to be reference area for previous site program
effect evaluation so that scientific evaluation and appropriate scaling-up based on
effectiveness of the program could be achieved continuously.
These outcome indicators are used mainly for program performance evaluation.
Identification Indicators Year 0
(2012)
Year 1
(2013)
Year 2
(2014)
Year 3
(2015)
Impact indicators (2)
1
Maternal
mortality ratio
(MMR)
o
Annually Annually Annually Annually
2 Low weight
(under 2 year) Annually Annually Annually Annually
79
Outcome indicators (4)
Utilization of services at health facilities
3
Antenatal care
(1)
Proportion of
women attended
more than four
during pregnancy
by trained health
worker for
reasons related to
pregnancy
(ANC4)
Annually Annually Annually Annually
4
Antenatal care
(2)
Proportion of
women attended
more than four
during pregnancy
by trained health
worker for
reasons related to
pregnancy
(ANC1)
Annually Annually Annually Annually
5 Delivery Annually Annually Annually Annually
80
services
Proportion of
delivery by
trained health
worker at health
facility
6
Postpartum
care
Proportion of
women having a
postpartum care
visit at least once
after delivery
Annually Annually Annually Annually
Output indicators
Improve
access to care
(AC1,2): 7, 8,
9
o Number of
vouchers used
for
transportation to
health facilities
o Number of
women received
financial support
for
hospitalization
Monthly Monthly Monthly Monthly
81
o Time of hospital
maternal death
from time of
admission
Outreach
services
(DC1): 10, 11
o Number of
women received
outreach
services
o Number of
children
received
outreach
services
Monthly Monthly Monthly Monthly
Quality of
care: 12, 13,
14
o Case of fatality
rate (all
complications)
o Time of hospital
maternal death
from time of
admission
o Time from
admission to
delivery
Annually
Monthly
Annually
Monthly
Annually
Monthly
Annually
Monthly
82
Emergency
care: 15, 16,
17
o Number of
emergency
admission
o Number of
ambulance
service
utilization for
referral
o Percentage of
delivery with C-
section
Monthly Monthly Monthly Monthly
Mid-term Evaluation
After finishing 1 year cycle of implementation
Before scale-up
Provider
Knowledge
And
Skill
o Detection of
risky pregnancy
o Treatment of
risky pregnancy
o Treatment of
child illness
No No
Skill Audit
Qualitative
inter
view
Quantitative
survey using
baseline
questionnaire
83
(With some
additional
question if
necessary)
Community
knowledge
o Percentage of all
adults
knowledge about
maternal
complications of
pregnancy and
childbirth
o Percentage of all
adults
knowledge about
neonatal
complications
o Percentage of all
adults with
knowledge of
the location of
essential
obstetric
services
o Percentage of
women of
reproductive age
with knowledge
No No
Qualitative
inter
view
Quantitative
survey using
baseline
questionnaire
(With some
additional
question if
necessary)
84
of the location of
essential
obstetric
services, and
intent to use
these services if
needed
o Percentage of all
adults who know
how to make
ORS
o Percentage of all
adults who know
the symptoms
and how to deal
with
malnutrition
85
7. Budget allocation plan
Activities Amount (USD)
Construction
- Maternal and malnutrition rehabilitation ward in MR OD
- Maternal waiting room in SK OD
Medical equipment and furniture
- For new maternal and malnutrition rehab ward in MR OD
- For new maternal waiting room in SK OD
Community activities
- PHD
- SK OD
- MR OD
Service providing activities
- PHD
- Provincial hospital
- SK OD
- MR OD
Governance activities
- PHD
- Provincial Hospital
- SK OD
- MR OD
Operational budget for WHO Cambodia office
199.000
180.000
19.000
21.000
19.810
1.190
243.485
25.690
104.618
113.177
226.271
56.280
65.230
19.420
85.341
208.844
136.126
5.320
41.128
26.270
101.400
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Annex 1
Document for MOU Attachment
87
A proposal for KOFIH Develop a program on Maternal and Child Health Care
in Battambang province, Cambodia
Background and rationale
Located in Southeastern Asia, as a portion of the Indochina peninsula, the Kingdom of Cambodia has a total landmass of 181.035 square kilometers. It borders with Thailand, Vietnam, Laos, and the Gulf of Thailand with a coastline of 443 kilometers. With a tropical climate, the country experiences two main seasons. The rainy season, often known as monsoon season, is from May to November, and the dry season is from December to April with low temperature variation between the two seasons. As the matter of fact that the infrastructure in Cambodia has not yet developed making transportation in rainy season very difficult. People often have to use boat as a main vehicle for in-land transport. This geographical factor seriously affects the access to care of health services in the country.
One of the top causes of death in Cambodia is diarrhoeal diseases resulting from the lack of access to clean water and sanitation. According to the government statistics, only 60% of households in urban areas are using clean drinking water while the in rural areas, only 24% of households are accessing to safe drinking water and sanitation. Apart from that poverty is a chronic disease of Cambodia as well for having 31% of population under poverty line and 20% of them are under food poverty line. The United Nations Human Poverty index ranks Cambodia number 73rd out of 78 developing countries. The mean daily per capita household consumption is low 0.9USD and even lower in rural areas of 0.79USD/day.
Consequently, Cambodia health index is comparative low compared to other countries in the region. Especially Maternal Newborn and Child health care (MNCH) situation is quite serious. Under five mortality rate is reported to be 82 deaths per 1000 live births (WHO World Health Statistics, 2008). Most of the deaths in under five occurred within the first year of life, hindering some problem of newborn and antennal care. Importantly, the death rate for the poor is higher than that of the rich. Although there is a trend of reduction in the under five mortality rate of the two groups the reduction rate of the rich is higher than that of the poor. The chances of dying for poor children became three times greater than children in a rich family. Education levels of the mother are also very important in reducing the mortality rate of under five children as the death rate per 1000 live births of highest education level of mother is 53 while the rate for lowest education level of mother is 136. Thirty percent of deaths of under five are neonatal. The main causes of deaths are pneumonia (21%) and diarrhoeal diseases (17%). Perinatal conditions are responsible for 7% of all deaths and 10% of all years of life lost. Neonatal deaths are caused by severe infection (includes deaths from pneumonia, meningitis, sepsis/septicaemia and other infections), birth asphyxia, and preterm birth.
Compared to infant moratality, maternal mortality in Cambodia is relative more serious of 472 per 100.000 in 2005 (WHO World Health Statistics). The situation of maternal death in Cambodia show slow progress, threatening the possibility of achieving millennium development goal number 5. The National Strategic Development Plan of
88
Cambodia noted that thirty-two percents of births in 2000 were attended by skilled birth attendant and this figure is expected to rise to 70% by 2010. At present, the government pays tremendous attention to maternal mortality issue showing in relevant legal documents and strategic plan in the hope of ameliorating the maternal mortality in Cambodia. The National Strategic Development Plan 2006-2010 includes:
- Increase recruitment and training of midwives and ensure their appointment to areas of need
- Increase the proportion of deliveries attended by skilled health personnel; and improve emergency obstetric care
- Improve child health through universal coverage of the Child Survival Scorecard interventions, including nutrition interventions and integrated management of childhood illnesses
- Improve reproductive health services and information, including maternal child health and birth spacing; address youth sexual and reproductive health issues and services
To further increase the importance of the issue of maternal and child mortality in the country, the government promulgated the Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality 2010-2015 aiming to achieve Cambodia’s Millennium Development Goal 5 targeting of less than 250 maternal deaths per 100.000 live births by 2015. The Road Map has three main objectives:
- To scale up as fast as possible to achieve universal coverage with the most essential maternal, newborn and reproductive health services
- To improve accessibility and affordability of maternal and reproductive health services by removing financial barriers to care
- To improve individual, family and community care practices before and during pregnancy, childbirth and postpartum, including appropriate care seeking and increased demand for priority RMNH services
As one of the top priority of the government in the health sector, MNCH receives huge concern from the international community to provide support financially and technically for Cambodia. Organizations such as WHO, the Global Fund, UNFPA, Paths are playing important role in MNCH in Cambodia to help the country achieve the MDG goal 5 by 2015. Most of the support goes to antenatal care, vaccination, nutrition, and human resource development such as training for health center staffs, midwives, and village health workers. Some donors sponsored transportation for the patients in the form of providing vehicles for the villages or the health center. Others take care of the monitoring and supervision activities of health facilities and community.
Based on the National Strategic Plan and Fast Track Initiative Road Map to reduce Maternal and Child Mortality of the government of Cambodia, and based on the results of qualitative and quantitative studies on MNCH need assessment in Battambang province,
89
and based on the gap analysis of existing programs on MNCH, we develop a program on Maternal, Newborn, and Child Health care in Battambang province. The program aims to contribute to the effort of the government of Cambodia to achieve MDG goal 5 by 2015 by reducing unmet need of MNCH services in remote areas of Cambodia and fulfill interventions gaps to increase access to care and improve quality of MNCH care.
Results of analysis and interpretation of data and information collected through the project will be presented to the Ministry of Health of the Kingdom of Cambodia. Good practices and success stories will be properly documented to provide evidence for the project’s cost effectiveness. Successful models of these approaches if proven to be effective can be replicated and may contribute to effective model for nationwide scale-up.
The WHO office in Phnom Penh will support the KOFIH project in Battambang province by providing technical, administrative and logistical assistance in terms of implementing program activities, monitoring and evaluating the performance of the program, and building capacity of staffs at health centers, provincial health office, and provincial hospital.
Objective
To improve the quality, availability, and accessibility of maternal neonatal and child health care services in the Kingdom of Cambodia
Specific Objectives: - Support the “National Strategy for Reproductive and Sexual Health in Cambodia”
of the government of Cambodia to achieve its main goals
- Promote health system strengthening in Cambodia
- Use limited resources to leverage key programs and strengthen MNCH platform in Cambodia
- Reduce the maternal, neonatal and child mortality ratio and accelerating the progress toward achieving Millennium Development Goals (MDGs) goal 4 and 5 in the Kingdom of Cambodia
- Overcome the constrains related to the delivery of health services at 1) community and household level, and 2) health service delivery level
Products/Outcomes - Reduce the maternal mortality ration of the province to below 100
- Increase the utilization of services at health facilities with 80% of delivery with skilled health workers at health facilities, consultation with trained health workers more than four times during pregnancy for reasons related to pregnancy. Increase the proportion of women having a postpartum care visit at least once after delivery
- Improve access to care: increase the utilization of provided vehicles to health
90
facilities
- Increase community knowledge on maternal complications of pregnancy, childbirth, and neonatal. Increase the knowledge of the location of essential obstetric services. 100% of all adults know how to make ORS.
- Reduce the number of malnutrition children
Proposed activities
Demand side interventions
- Community participation: through social marketing to educate people on MNCH knowledge and healthy behavior, direct interaction of trained village health workers with the community
- Increase access to care: provide financial support for transportation, for poor women hospitalizing in provincial hospitals
- Demand creation: Community outreach activities, propaganda through village radio networks
Supply side interventions
- Human resource development: training for medical skills upgrade, training for community health workers
- Provide medical supplies and equipment: medical supplies and equipment for operation, for delivery, and clinical testing
- Construction: Construct a maternal and malnutrition rehabilitation ward in Moung Russey operational district and a maternal waiting room for one health center in Sangkae operational district
- Strengthening referral system: Provide vehicles: tuktuk, ambulance with gasoline/maintaining service, and motorboat
- Incentives for malnutrition activities
Governance side intervention
- Information system: data collection, training to improve information system management
- Governance activities: surveillance and monitoring, mentoring
- Office supplies: equipment and supplies for office work, transportation
91
Collaborating organizations Ministry of Health, Kingdom of Cambodia
Battambang provincial health department
Operational districts of Battambang(some), Sangkae, and Moung Russey
WHO (World Health Organization) Cambodia office
KOFIH (Korea Foundation for International Healthcare
Program duration
The program will be implemented in a period of three year from 2012 to 2014
Program budget (See Appendix 1)
The total estimated budget is 1.000.000 USD
Funding and implementation agencies
This project will be funded by the Government of the Republic of Korea, through the Ministry of Health and Welfare and the Korea Foundation for International Healthcare (KOFIH), and implemented by Department of Health of Battambang province, Kingdom of Cambodia, in close collaboration with WHO Cambodia country office.
Program Performance indicators per annum (See Appendix 2)
Performance will be measured per annum using proposed performance six indicators
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Appendix 1
(1) Budget allocation plan
Activities Amount (USD)
Construction
- Maternal and malnutrition rehabilitation ward in MR OD
- Maternal waiting room in SK OD
Medical equipment and furniture
- For new maternal and malnutrition rehab ward in MR OD
- For new maternal waiting room in SK OD Community activities
- PHD
- SK OD
- MR OD
Service providing activities
- PHD
- Provincial hospital
- SK OD
- MR OD
Governance activities
- PHD
- Provincial Hospital
- SK OD
- MR OD
Operational budget for WHO Cambodia office
Total
199,000 180,000
19,000
21,000 19,810
1,190
243,485 25,690
104,618
113,177
226,271 56,280
65,230
19,420
85,341
208,844 136,126
5,320
41,128
26,270
101,400 1,000,000
93
(2) Budget allocation for Provincial Health Department
Activities Unit Unit Cost Total
USD USD
Activities list for Provincial Healt Department 25,690
Health education message through 3 radio channels, broadcast every day for 1 year 3 730 2,190
Material printing for complementary feeding campaign 1 23,500 23,500
Service provider 56,280 Training MWs on hemoglobine and albumine test for 2 days at PHD 2 3,000 6,000
Coaching session on Immediate Newborn Care to MR RH staffs 2 3,250 6,500 Training on C-IMCI to 10 HCs staffs (3 days training at PHD) 1 2,100 2,100 Training on Key intervention of obstetric emergency to midwifes 2 2,000 4,000 Workshop on Management of Acute Malnutrition for MR and SK OD 1 3,500 3,500
TOT training on Management of Acute Malnutrition 1 2,900 2,900
TOT training on Management of Acute Malnutrition for MR and SK OD 2 3,000 6,000
On site training to MWs on ANC, delivery and PNC 1 5,000 5,000
TOT training on IPC for CFC to 10HCs (2days training) at PHD 1 1,100 1,100 Training on MPA module 9 at operational district 2 4,000 8,000 Training on supervision of CCMN in SK OD 4 1,400 5,600 Conduct Complementary Feeding Campaign in MR OD 1 2,180 2,180 Training on Inpatient Management of sever malnutrition 2 1,700 3,400
Governance 136,126 Spot check on MCH HIS at MR and SK OD, 2 times per year 2 3,000 6,000 Biannual implementation review meeting 2 2,800 5,600 Information collection on pregnant women and children under 2 years (Battambang OD) 1 8,099 8,099
Monitoring, consultative meeting and data entry on pregnant women and children under 2 years 1 4,169 4,169
Monitoring the implementation of MCH project 1 10,000 10,000 PHD bi-monthly supportive supervision to Ods and HCs 2 400 4,800 PHD conduct quartely supportive supervision to Ods and HCs on IPPC and CCMN 1 200 800
Quartely supportive supervision on Child Health Fair for CFC at Ods, HCs and community 4 400 1,600
Training on HIS to HCs staff in BTB, THK and SPL OD (5 days training at each OD) 3 2,000 6,000
Training on AOP to HC staffs in BTB, THK and SPL (5days training at each OD) 3 2,000 6,000
Supplies for in-patient management of severe manultrition at MR 1 1,500 1,500
94
RH
Purchase LCD to provincial MCH 1 1,300 1,300 Provide LCD screen for PHD 1 300 300 Provide motor (Honda) to provincial MCH 2 2,100 4,200 Provide Toyota (Vigo) to PHD 1 45,000 45,000 Provide computer laptop to provincial MCH 2 1,300 2,600 Provide computer desktop and printer to provincial MCH 2 1,250 2,500 Provide Scanner for provincial MCH 1 300 300 Provide camara digital 2 340 680 Provide voice recorder 1 120 120 Stationary and supply 1 200 2,400 Provide Photocopy machine 1 5,000 - Provide Airconditioner (1.5 ) 1 600 - Communication cost 1 150 1,800 Program operating cost (KOFIH-WHO-MOH-NMCH-PHD)-3% 1 20,358 20,358
Grand Total $218,096
(3) Budget allocation for Provincial hospital
Activity Unit Unit Cost Total
1-Community 2-Service provider 65,230 Provide operation table 1 2,800 2,800 Provide Oxygen extractor 1 1,000 1,000 Provide manual vacuum extractor (ventouse) 2 350 700 Provide projector lamp for delivery 6 30 180 Provide delivery bed 4 1,400 5,600 Provide vaginal hysterectomy kits 2 400 800 Provide cesarean section kits 3 350 1,050 Provide radian warmer 2 800 1,600 Provide anesthetic machine (with halotane) 1 23,000 23,000 Provide operating lamp 2 500 1,000 Provide Ultrasound 1 27,500 27,500
3-Governance 5,320 Provide computer desktop for HIS 2 1,000 2,000 Provide computer laptop for MCH officers 1 1,300 1,300 Provide LCD projectors 1 1,300 1,300 Provide screen (projector) 1 300 300 Communication cost (internet) 1 35 420
95
Grand Total $70,550
(4) Budget allocation for Sangkae operational district
Activities Unit Unit Cost Total
Community 104,618
Community health forum in 30 villages of all 13 HCs 30 400 12,000
Conduct Child Health Fair for CFC campaign 4 time per year 3 2,470 7,410
Training on C-IMCI to VHSGs (3days trainng) at SK OD 5 750 3,750 Training on Management of Acute Malnutrition to VHSGs (2days) in 5 HCs 5 325 1,625
Prepare village referral system (tuktuk) in Preyloung, Raingkessey and Tapon HC 2 2,100 4,200
Provide gasoline and maitainning service for tuktuk 2 32 768 Conduct mass screening to identify malnutrition children and assessment in 5 HCs 5 134 670
Growth monitoring and growth promotion in all 15 HCs 95 8 3,040
Training on multi-micronutient powder to VHGS (2days training) in 15 HCs 15 400 6,000
Provide bicycle to VHSGs in 95villages 190 70 13,300 Preparation meeting with VHSGs for Vit A and Mebandazole distribution 2 1,600 3,200
Perdiem for VHSGs during distribution campaign 2 520 1,040 Training VHSGs on CCMN (5days training) in 5HCs 5 700 3,500 Provide transportation cost for poor women who come for ANC4 2027 5 10,135 Provide transportation cost for poor women who deliver baby at HCs 2027 5 10,135
Provide transportation cost for poor women who come for PNC 2 2027 5 10,135 Provide daily support cost for poor women hospitalyze in provincial 100 30 3,000
Outreach on vaccination in remote village in Tonle Sap area 3 2,150 6,450
ANC and PNC outreach activities in remote village in Tonle Sap area 6 710 4,260
Service provider 19,420 Training MWs on updated MCH registers (2days training) 1 1,330 1,330 Construct new maternal waiting room and provide medical equipment and furniture for functioning 1 20,000 -
Provide fetal doppler 4 250 1,000
96
Provide delivery bed 3 1,400 4,200 Provide delivery kits 6 45 270
Provide autoclave 2 250 500
Provide troley 15 30 450
Provide projector lamp for delivery 15 30 450
Provide Hemocue machine 15 700 10,500 Provide Alburniuria test to SK OD 180 4 720
Governance 41,128 Quartely review meeting with HCs (1day) 3 600 1,800 Prepartion meeting with HCs for Vit A and Mebendazole distribution (1day) 2 600 1,200
Supportive supervision 2 time during Vit A distribution at HCs and community 2 300 600
Quartely supervision from OD to HC (ANC, Delivery, PNC and Nutrition) 1 400 1,600
Conduct information collection on pregnant women and children under 2 years. 1 5,438 5,438
Workshop on NMCH AOP 2013 development (2days) 1 1,250 1,250 Training on HIS to HC's staff (5days) at each Ods 1 1,600 1,600 Training on AOP for 5days at Ods 1 1,600 1,600 Provide LCD to OD MCH 1 1,300 1,300 Provide LCD screen 1 300 300 Provide motor Honda to OD MCH 1 2,100 2,100 Provide computer laptop to OD MCH 2 1,300 2,600 Provide computer desktop and printer to OD MCH 1 1,000 1,000 Provide computer desktop and printer to HCs 6 1,000 6,000 Provide camara digital 1 340 340 Communication cost 1 50 600 Stationary and supply 1 50 600 Provide motorboat 1 8,200 8,200
Provide gasoline and maintaining service for motorbaot 1 250 3,000
Grand Total $165,165
97
(5) Budget allocation for Moung Russey operational district
Activities Unit Unit Cost Total
Community 113,177
Training on C-IMCI to VHSGs (3days trainng) at MR OD 5 750 3,750
Community health forum in 30 villages of all 13 HCs 30 400 12,000
Conduct Child Health Fair for CFC campaign 4 time per year 4 2,470 9,880
Training on BFCI to mother support group (5days) in Muoung, Prey Touch and Kokoh HC 3 3,500 10,500
Conduct mass screening to identify malnutrition children and assessment10HC 1 700 700
Training on Management of Acute Malnutrition to VHSGs (2days) in 5HCs 5 800 4,000
Training IPC for complementary Feeding to VHSGs (2days) 5HCs 5 335 1,675
Training CBD for 5days 20 villages in 5 HCs 2 1,400 2,800
Refresher training on CBD for 5days to 60villages in 13 HCs 3 1,400 -
Meeting with VHSGs every 4months in 174 village of 13HCs 3 1,300 3,900
Growth monitoring and growth promotion in 5HCs 50 8 1,600
Meeting with mother support group every 2months in 50 villages of 5HCs and CFC 6 150 900
Training on multi-micronutrin powder to VHSGs for 13HCs for 2 days 13 400 5,200
ANC and PNC outreach to remote village in 35 villages of 2 HCs 4 570 2,280
Vaccination outreach to remote village for in 47 villages of 13 HCs 4 700 2,800
Provide bicycle to VHSGs in 174 villages 190 70 13,300
Preparation meeting with VHGS on Vit A and Mebendazol distribution 2 times a year 2 1,300 2,600
Perdiem for VHSGs during Vit A distribution 2 times a year 2 696 1,392
Provide transportation cost for poor women who come for ANC4 2000 5 10,000
Provide transportation cost for poor women who deliver baby at HCs 2000 5 10,000
Provide transportation cost for poor women who come for PNC 2 2000 5 10,000
Provide daily support cost for poor women hospitalyze in provincial 100 30 3,000
98
Provide daily support cost for poor women hospitalyze in provincial 30 30 900
Service provider 85,341 Training on anesthesia to RH staffs at provincial hospital (3 months training) 2 1,540 3,080
Training to physicians on post emergency care to newborn (2 months) in Phnom Penh 1 1,500 1,500
Training physicians on obstetric emergency (3months) in Phnom Penh 1 2,250 2,250
Training MWs on Obstetric emergency in Phnom Penh 2 1,500 3,000 Cost for follow up and food demonstration for severe malnutrition children at Muong RH 12 400 4,800
Quartely meeting with RH staffs on management of severe malnutrition 4 500 2,000
Construction of maternity ward and child rehabilitation room for severe malnutrition children (including medical equipment and furniture for functioning)
1 200,000 -
Provide ambulance 1 50,000 50,000
Provide gasoline and maitaining service for ambulance 1 350 4,200
Provide fetal doppler 2 250 500
Provide delivery bed 2 1,400 2,800
Provide delvery kits 3 45 135
Provide autoclave 2 250 500
Provide troley 5 30 150
Provide troley for transfer patient 2 100 200
Provide projector for delivery 7 30 210
Provide hemocue 12 700 8,400
Provide albuminuria test 154 4 616
Provide oxygene extractor 1 1,000 1,000
Governance 26,270 Quarterly review meeting with OD and HCs at OD (1day) 4 700 2,800 Conduct information collection on pregnant women and children under 2 years. 1 5,870 5,870
Supportive supervision every 3 months from OD to HCs (ANC, Delivery, PNC and Nutrition) 4 440 1,760
Training on HIS to HC at OD (5days) 1 1,500 1,500 Training AOP at OD (5days) 1 1,500 1,500 Provide LCD to OD MCH 1 1,300 1,300 Provide LCD screen 1 300 300 Provide motor (Honda) to OD MCH and RH 1 2,100 2,100 Provide computer Laptop to OD MCH 2 1,300 2,600 Provide computer desktop and printer to OD MCH 1 1,000 1,000 Provide computer desktop and printer to HCs 4 1,000 4,000
99
Provide camara digital 1 340 340 Communication cost 1 50 600 Stationary and supplies 1 50 600
Grand Total $224,787
100
Appendix II Performance indicators per annum
Impact indicators (2)
1
Maternal
mortality ratio
(MMR)
o
Annually Annually Annually Annually
2 Low weight
(under 2 year) Annually Annually Annually Annually
Outcome indicators (4)
Utilization of services at health facilities
3
Antenatal care
(1)
Proportion of
women attended
more than four
during pregnancy
by trained health
worker for
reasons related to
pregnancy
(ANC4)
Annually Annually Annually Annually
4 Antenatal care Annually Annually Annually Annually
101
(2)
Proportion of
women attended
more than four
during pregnancy
by trained health
worker for
reasons related to
pregnancy
(ANC1)
5
Delivery
services
Proportion of
delivery by
trained health
worker at health
facility
Annually Annually Annually Annually
6
Postpartum
care
Proportion of
women having a
postpartum care
visit at least once
after delivery
Annually Annually Annually Annually
102
Annex II
1. Qualitative questionnaires
Women in Health Facilities (users of ANC services)
A. DEMOGRAPHIC INFORMATION
1. What is your name?
2. Where do you live (name of village)?
3. How old are you?
4. Do you have any children? (Obtain number of children, ages, gender.)
5. What is the name of your household head?
6. Did you come here alone? (If not, ask about relationship to whoever accompanied
her.)
B. ACCESSIBIITY
1. How long did it take for you to get here (this health facility) today?
2. How did you get here (type of transportation)? Was it hard for you to find
transportation?
3. How much did you pay for transportation?
4. What do you do for work (job/occupation)?
5. What else does your household (or family) do to make money for living costs?
6. Who is taking care of your job responsibilities while you are here today?
7. Who is taking care of your baby/children while you are here today?
C. PROCESS OF HELP SEEKING
1. What brought you here today?
2. Have you visited any other places (persons) or health care facilities besides here in
order to take care of the concerns that you have now? (If so, try to obtain a list of
the other places/people she consulted.)
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D. PROCESS OF ARRIVING AT THE DECISION TO VISIT THE HEALTH
FACILITY
1. You mentioned you came here due to _________ (concerns). What were the
reasons you chose this particular health facility (health center, hospital, etc.) over
others?
2. What were your expectations for your visit?
3. Who recommended you to come here for your ________?
4. Who decided that you would come here today for your_________?
5. What were some problems or barriers, if any, that may have discouraged you from
making a visit to this health facility today or in the past?
E. SATISFACTION OR DISSATISFACTION WITH THE HEALTH FACILITY
1. What services did you receive here today?
2. Who are the people who took care of you?
3. Did you experience any problems or trouble conversing or interacting with the
service providers such as doctors, nurses, or other staff here?
4. What are some things you are most satisfied with about your visit today?
5. What are some things you are most dissatisfied with about your visit today?
Can probe with the following questions if answers to #3 and 4 are unrevealing:
- Did you experience any problems or discomfort with the services (e.g. getting a
shot, checking your body, etc.) you received here today?
- Did you experience any problems or discomfort with the health care facilities
(e.g., clinic room, sick bed, delivery table, surgery room, toilet, waiting room,
or restaurant) you used here today?
- Did you have any difficulty finding the clinic, reception desk, or pharmacy at
this hospital? Have you ever gotten lost in the hospital?
6. Overall, would you say you are happy or unhappy with your visit here today?
F. SERVICE FEE
1. How much did you pay for your visit today? How much did you expect to pay?
2. How much have you paid for your visits to this facility since you first began
treatment or care here?
3. Are you satisfied with the service fees that this facility charges?
4. Who paid for the services you received today?
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G. MATERNAL HEALTH CONCERNS & BELIEFS
1. Tell me about your thoughts and beliefs about visiting a health facility like this one
for check-ups during pregnancy. (Probe for thoughts on frequency and timing of
visits.)
2. What sorts of behaviors did you change while pregnant? (Probe for eating habits,
smoking, and drinking.)
3. What are your thoughts on smoking and drinking alcohol during pregnancy?
4. Did you receive (or have you ever received) vitamin A supplementation (injection,
pills, etc.) from this or another health facility?
Women in the Villages (non- or infrequent (< 4 visits) users of ANC and SBA attended delivery)
A. DEMOGRAPHIC INFORMATION
1. Name of village:
2. What is your name?
3. How old are you?
4. Do you have children? (Obtain number of children, ages, gender.)
5. What is the name of your household head?
B. PREGNANCY AND PRENATAL CARE
1. When was your last pregnancy? How old were you at that time?
2. How did you find out you were pregnant with your youngest child?
3. While you were pregnant, what did you do to keep yourself healthy?
Can probe with the following questions if answer is unrevealing:
- Did you change your eating habits?
- Did you change any other particular behaviors?
4. Were there any problems with your pregnancy?
5. What are your thoughts on smoking and drinking alcohol during pregnancy?
6. Did you receive (or have you ever received) vitamin A supplementation (injection,
pills, etc.) during or after pregnancy?
7. Did you work while you were pregnant? What was your job during pregnancy?
C. DELIVERY
105
1. Please tell me about your delivery.
Can probe with the following questions if answer is unrevealing:
- Where did you deliver your children? Where did you want to deliver?
- Who decided where you would give birth?
- Who assisted you with your delivery?
- How did the delivery go?
- Were there any problems during delivery or immediately after giving birth?
- If so, what was done about that problem? Did you go to a health facility (health
center, hospital, etc.)?
D. POSTPARTUM CARE
1. What did you do to keep yourself healthy after giving birth?
Can probe with the following questions if answer is unrevealing:
- Did you change your eating habits? **If so, obtain list of foods the woman ate
or avoided eating.
- Did you change any other particular behaviors (e.g. smoking, drinking, etc.)?
2. How long did you rest before going back to your normal daily activities (including
work) after giving birth?
3. Did you ever visit a health facility (health center, hospital, etc.) or other healer for a
health check after giving birth?
4. Tell me about your plans for using contraception after giving birth.
Can probe with the following questions if answer is unrevealing:
- Did you have plans to get pregnant again soon after giving birth?
E. NEWBORN FEEDING AND CARE
1. How was the baby's health at birth?
2. Did you breastfeed the baby?
3. How soon after birth did you breastfeed the baby and for how many months?
4. Tell me about your experience with breastfeeding your baby.
Can probe with the following questions if answer is unrevealing:
- Were there any problems?
- What methods/techniques did you use to ensure proper feeding?
5. Did you receive (or have you ever received) instructions on how to breastfeed? (If
so, from whom?)
106
F. HEALTH COMMUNICATION NETWORK AND CHANNELS
1. What kind of health information did you receive about your pregnancy, delivery, or
postpartum period?
G. REASON FOR NON- OR INFREQUENT USE OF SERVICES
1. Tell me about your thoughts and beliefs about visiting a health facility for check-
ups during pregnancy. (Probe for thoughts on frequency and timing of visits.)
2. Tell me about your thoughts and beliefs about delivering a baby at a health facility
or with a skilled birth attendant (SBA). (Define SBA for the woman—clarify the
difference from TBA.)
3. What were the reasons you delivered at _______ (home or other non-health facility
location)?
H. UNMET NEEDS OR BARRIERS
*Follow up questions for those who express need for services (above) but were
unable to obtain them.
1. Please describe the problems or difficulty you experienced in obtaining:
- antenatal care services
- delivery at a health facility or with an SBA
- postpartum services
- vaccinations for your baby
2. What things would have better helped you obtain these services?
Health Facility Medical Professionals or Staff
A. DEMOGRAPHIC AND JOB INFORMATION
1. Name:
2. Age:
3. Sex:
4. Occupation:
5. Job responsibilities:
6. How long have you worked here?
7. Training background and license:
107
B. BASIC INFORMATION ON MCH SERVICES PROVIDED
1. Can you tell me about the maternal and child health services that are provided at
your facility?
2. Can you tell me about any equipment, programs/services, and/or facilities you
think you need here to provide better care?
C. INFORMATION ON MCH SERVICE USERS (THEIR PATIENTS)
1. Can you tell me about the types of patients you see here?
2. Where do they live?
3. What usually brings them here for advice or help?
D. POTENTIAL CULTURAL OR KNOWLEDGE GAPS BETWEEN PROVIDERS
AND USERS
1. How do you feel about your patients?
2. Do you experience any problems or difficulty when conversing and/or taking care
of your patients?
3. What is the most significant problem or difficulty? What is the least significant
problem or difficulty?
4. In your opinion, what should the local women know about prenatal care, child
delivery, and postpartum care?
5. Are there some behaviors or practices you think they should change for better
prenatal care, delivery, and postpartum care?
6. In your opinion, what should the local mothers know about child health and
immunization?
7. Are there some behaviors or practices you think the mothers should change in order
to improve their child’s health?
8. In your opinion, what aspects about your health facility are your patients most
satisfied with?
9. In your opinion, what aspects about your health facility are your patients most
dissatisfied with?
Traditional Birth Attendant (TBA) A. DEMOGRAPHIC INFORMATION
1. Name of village:
108
2. Name of interviewee:
3. Age:
4. Education: Have you ever attended school? How long did you attend school?
5. Occupation: Is being a birth attendant your full-time job? What else do you do?
B. BECOMING A TBA
1. How long have you lived in this village?
2. Tell me about how you became a TBA.
Can probe with the following questions to help guide the answer:
- When did you begin your practice of delivering babies?
- Where or how did you learn the skills and knowledge to deliver a baby?
- Who taught you these skills?
3. Have you ever attended training courses for midwives or birth attendants?
4. Are you licensed or certified as a midwife or birth attendant?
5. What do you like or not like about your job as a birth attendant?
C. JOB PERFORMANCE
1. How many deliveries do you usually attend a year?
2. Please describe your involvement with a pregnant woman’s care prior to delivery.
Probe with the following questions, if necessary:
- Do you help pregnant women with their prenatal care too?
- Do women also seek your help or advice for health problems during their
pregnancy?
3. What is your involvement with the woman and newborn’s care after giving birth?
What happens if she or the baby is experiencing problems after birth?
4. Can you tell me about any equipment, services/programs, and/or facilities do you
think you need to provide better care?
D. DELIVERY PROCESS
1. Where do the deliveries you attend usually take place (your home or your client’s
home)?
2. Who else attends the delivery? How are they related to one another?
3. How many people attend the delivery on average? What do they do during delivery?
4. Please describe the process of delivery step by step.
109
5. What are your specific responsibilities during delivery?
6. What sorts of tools or instruments do you use for delivery?
7. Do you perform any ceremonies during and/or after delivery? What do they entail?
E. DELIVERY SKILLS AND KNOWLEDGE
1. What do you do when a delivery does not go smoothly?
2. What are the signs indicating that a woman in labor is in danger?
3. What do you do about the woman if you think she is in danger?
4. Have you ever had cases where a woman in labor needed the help of medical
professionals like doctors or nurses?
5. What are the signs indicating that a newborn baby is ill or has a problem?
6. What do you do with newborn babies who are ill or having problems?
F. VILLAGE WOMEN’S BELIEFS AND PRACTICES ABOUT MNCH
Pregnancy and prenatal care
1. In your experience, how do most women keep themselves healthy during
pregnancy? (Probe for behaviors they change or avoid.)
2. What are the main concerns or fears of pregnant women you have worked with?
3. Tell me about the diet/eating practices and beliefs of the pregnant women in your
village.
Can probe with the following questions if answer is unrevealing:
- What food or drinks do they try to eat?
- What food or drinks do they avoid eating?
4. What are your dietary recommendations for pregnant women? Delivery
5. We understand that some women give birth alone without anyone's help. If you
know of such a case, please describe what happened.
6. Can you list the main places where a pregnant woman might give birth?
Newborn feeding and care
7. In your experience, how long do mothers generally breastfeed their babies?
8. What do mothers do if they experience problems with breastfeeding?
110
9. What do you think mothers should do in order to successfully breastfeed their
babies?
Postpartum care
10. In your experience, what are the main concerns or fears women have after giving
birth?
11. How do most women keep themselves healthy during the postpartum period?
(Probe for behaviors they change or avoid.)
12. How long after delivery do they rest from work?
13. Tell me about the diet/eating practices and beliefs of the postpartum women in your
village.
Can probe with the following questions if answer is unrevealing:
- What food or drinks do they try to eat?
- What food or drinks do they avoid eating?
14. What are your dietary recommendations for postpartum women?
G. POTENTIAL KNOWLEDGE GAPS BETWEEN TBAs AND VILLAGE
WOMEN
1. In your opinion, what should the local women know about prenatal care, child
delivery, and postpartum care?
2. Are there some behaviors or practices you think they should change for better
prenatal care, delivery, and postpartum care?
Village Women Leaders, Husbands, Village Health Volunteers (VHVs) A. DEMOGRAPHIC INFORMATION
1. Name:
2. Age:
3. Position:
4. Years of education:
B. HEALTH COMMUNICATION NETWORKS AND CHANNELS AMONG
VILLAGE RESIDENTS, PARTICULARLY WOMEN
111
1. Where or from whom do your village women get information on family planning,
pregnancy, prenatal care, delivery, and postpartum care?
2. Where or from whom do your village women get information on child health care?
C. WOMEN’S DAILY ACTIVITIES AND WORK
1. What does a wife do in order to earn money or make a living?
2. What does a husband do in order to earn money or make a living?
3. What are the wife’s responsibilities for taking care of the family?
4. What are the husband’s responsibilities for taking care of the family?
D. GROUP LEVEL VILLAGE PARTICIPATION OR MOBILIZATION FOR
IMPROVED MCH
1. Were there any health campaigns (e.g. a national campaign day) held in your
village this past year?
2. Did you ever hold any health education programs in your village? How was
information disseminated to the villagers?
3. What do village health volunteers do in your village?
4. How are they selected? What are their qualifications?
5. How do the village members interact with village health volunteers?
6. How are cases of medical emergency handled in your village?
112
2 Quantitative questionnaires
Community Questionnaire
Assessment for Maternal and Child Health Social Assessment on the Provision and Utilization of Maternal, Newborn, Child Health and Reproductive Health Services in Sangkae and Moung Ruessei Operational Districts in Battambang Province, Cambodia INFORMED CONSENT Hello. My name is __________________, and I am working with the Korean Foundation for International Healthcare (KOFIH). We are conducting an assessment in your area and would appreciate your participation. I would like to ask you questions about maternal and child health. This information will help the Battambang provincial government, the Cambodian central government, and KOFIH plan health services to improve mothers’ and children’s health in Sangkae and Moung Ruessei Operational Districts in Battambang Province. The survey usually takes 30 to 40 minutes to complete. Whatever individual information you provide will be kept strictly confidential and will only be used for statistical analysis. Participation in this assessment is voluntary and you can choose not to answer any or all of the following questions. However, we hope that you will participate in this assessment since your views are important. At this time, do you have any questions? Signature of interviewer: _________________________ Date: ____________________ Start time: _________________
□ RESPONDENT AGREES TO BE INTERVIEWED
Signature/mark of interviewee: _______________ Date: _________________
□ RESPONDENT DOES NOT AGREE TO BE INTERVIEWED
Reschedule interview? IF YES → Date and time: ____________________
HOUSEHOLD IDENTIFICATION Village:_____________________________________ _ Household identification number:_________________ Name of household head: _______________________________ Number of total household members ( ) Number of live childeren ( ) Name of child born in 2011 (last year): ____________________ Gender: Male(1) vs. Female(2), Age: |___|___| months old ( ).( )( )kg If interviewee has more than one child under 1 year old, include the child’s name here: __________________ Gender: Male(1) vs. Female(2), Age: |___|___| months old ( ).( )( )kg RESPONDENT
113
HOUSEHOLD IDENTIFICATION Name of the respondent:______________________________ Age: |___|___| years old Are you currently pregnant? □No □Yes LOGIC for WHERE TO START INTERVIEW
If respondent is the mother of the youngest child who is born last year (2011), START HERE. Circle responses clearly. NO. QUESTIONS AND FILTERS CODING CATEGORIES Directions PRACTICE: PRENATAL
CARE
PA1 While you were pregnant with (NAME of the youngest child born last year (2011), same hereafter), who primarily monitored the health status of you and your baby?
Health professional in PH 1 Health professional in RH 2 Health professional in HC 3 Health professional in Private clinic 4 Non-health professional: Traditional birth attendant 5 Village health volunteer 6 Family/Relative/Friend 7 Other 8 No one 9
If the answer is 1,2,3,4 go to PA3
PA2 Why didn’t you take ANC from professional practice?
I preferred traditional practice 1 There was no available vehicle 2 I had no enough money to go there 3 Nobody took care of the house 4 Other (specify) 5
PA3 (If you used health center) How long did you usually have to wait to get the ANC service in the health center after arrival?
( ) minute(s)
PA4 How many times did you go for care during the pregnancy?
Number of times 1 (once) 1 2 (twice) 2 3 (three times) 3 4 or more 4
114
NO. QUESTIONS AND FILTERS CODING CATEGORIES Directions PA 5 PA5a PA5b PA5c PA5d
As part of your prenatal care, were any of the following done at least once?
Yes No Weight 1 2 Blood pressure 1 2 Urine sample 1 2 Blood sample 1 2
PA 6 PA6a PA6b PA6c PA6d PA6e PA6f PA6g PA6h PA6i
During your prenatal check, were you counseled on the following:
Yes No Delivery preparations 1 2 Expected due date 1 2 Nutrition/dietary recs 1 2 Breastfeeding 1 2 Hygiene 1 2 Child spacing/contraception1 2 EPI 1 2 Danger signs of pregnancy 1 2 Use of home/herbal remedies 1 2
PA7 Before you gave birth to (NAME), did you receive an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
Yes 1 No 2 Don’t know 8
PA8 When you were pregnant with (NAME), did you receive or buy Iron/folic acid?
Yes No Don’t know 1 2 8
PA9 When you were pregnant with (NAME), did you USE/TAKE Iron/folic acid?
Yes No Don’t know 1 2 8
PA10 Is there any public radio (local broadcasting) in your village?
Yes 1 No 2
If No go to PA12 question
PA11 Does the village radio broadcast (local broadcasting) any program on the following?
Safe motherhood 1 Immunization schedule 2 Nutrition guideline 3 Neonatal care 4 Family planning 5 Others in MNCH 6 None of the above 7
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NO. QUESTIONS AND FILTERS CODING CATEGORIES Directions PA12 Where did you have abortion
lastly (if any)? Health professional in PH 1 Health professional in RH 2 Health professional in HC 3 Health professional in Private clinic 4 TBA 5 Never had abortion 9
PRACTICE: DELIVERY,NEWBORN FEEDING, AND FOOD RESTRICTION
PD1 Where did you give birth?
in PH 1 in RH 2 in HC 3 in Private clinic 4 Non-health professional: Traditional birth attendant 5 Village health volunteer 6 Family/Relative/Friend 7 Other (specify) 8
If the answer is 1,2,3, 4 go PD3
PD2 Why didn’t you go to HC for delivery?
Giving birth was so quick 1 I didn’t feel that I need to go 2 There was no available vehicle 3 I had no enough money to go there 4 Nobody took care of the house 5 Other (specify) 6
PD3 Were there any problems during your delivery?
Yes 1 No 2 Don’t know 8
If no, go to PD7
PD4 Were you transferred to RH or PH?
Yes 1 No 2
PD5 How were you transferred? By an ambulance 1 By tuktuk 2 By motorcycle 3 By bicycle 4 Taxi ______________ 5 Other 6
PD6 Did you want to use the waiting house (hotel service before the beginning of labor for those who live in remote areas)?
Yes 1 No 2
If no, go to PD8
PD7 How long were you willing to stay in the waiting house (until the beginning of labor)?
( )day(s)
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NO. QUESTIONS AND FILTERS CODING CATEGORIES Directions PD8 Was (NAME) weighed at birth? Yes 1
(if yes fill the weight)__________ ( )kg No 2 Don’t know 8
PD9 Did you ever breastfeed (NAME)?
Yes 1 No 2
PD10 When did you first breastfeed (NAME)? RECORD NUMBER OF HOURS OR DAYS, IF APPROP.
□ IMMEDIATELY AFTER BIRTH □ IN | | HOURS □ IN | | DAYS
PD11 How old was (NAME) when you stopped breastfeeding?
MONTHS |___|___|
PD12 Did you restrict the intake of any foods following the delivery of your last child?
Yes 1 No 2 Don’t know 8
PRACTICE: POSTPARTUM CARE
PP1 After (NAME) was born, did anyone check on your health?
Yes 1 No 2
If NO, go to PV1
PP2 How many days or weeks after the delivery did the first check take place?
□ After | | days □ After | | weeks □ Don’t know 8
PP3
Who checked on your health at that time?
in PH 1 in RH 2 in HC 3 Non-health professional: Traditional birth attendant 4 Village health volunteer 5 Family/Relative/Friend 6 Other (specify) 7
PP4 At that time, did the person bring her baby for health check up?
Yes 1 No 2 Don’t know 8
PP5 During your postpartum check, were you counseled on the following:
Yes No Child spacing/contraception 1 2 Maternal nutrition 1 2 Infant nutrition 1 2 Hygiene 1 2 Child immunization 1 2 Signs of infant illness 1 2
PRACTICE:
IMMUNIZATION
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NO. QUESTIONS AND FILTERS CODING CATEGORIES Directions PV1 Do you have a vaccination record
book for (NAME’s)?
Yes (confirmed by interviewer) 1 Not available/misplaced 2 Never had a yellow book 3
PV2 Do you follow well the vaccination schedule for (NAME’s)?
Yes 1 No 2 Don’t know 8
PRACTICE: CHILDHOOD ILLNESS
PC1 Has (NAME) had diarrhea in the last 2 months?
Yes 1 No 2 Don’t know 8
If no, go to PC5
PC2 Did you seek advice or treatment from health facility for diarrhea?
Yes 1 No 2
If no, go to PC5
PC3 How long after you noticed (NAME’S) diarrhea did you seek treatment?
Within 3 days 1 3 days to 1 week 2 1 week or more 3
PC4 Where did you first go for advice or treatment?
in PH 1 in RH 2 in HC 3 Private clinic 4 Non-health professional: Traditional healer 5 VHV 6 Family/Relative/Friend 7 Other 8
PC5 Has (NAME) had an illness with a cough at any time in the last 2 months?
Yes 1 No 2 Don’t know 8
If no, go to KA1
PC6 When (NAME) had an illness with a cough, did he/she have trouble breathing or breathe faster than usual with short, fast breaths?
Yes 1 No 2 Don’t know 8
PC7 Did you seek advice or treatment for the cough/fast breathing?
Yes 1 No 2
PC8 How long after you noticed (NAME’s) cough and fast breathing did you seek treatment?
Same day 1 Next day 2 After 2 days 3 After 3 or more days 4
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NO. QUESTIONS AND FILTERS CODING CATEGORIES Directions PC9
Where did you first go for advice or treatment?
in PH 1 in RH 2 in HC 3 Private clinic 4 Non-health professional: Traditional healer 5 VHV (with drug kit) 6 Family/Relative/Friend 7 Other 8
SATISFACTION Strongly Agree, Agree, Disagree,
Strongly Disagree, or check the box for Don’t Know (DK)
SA A D SD DK
PS1 Maternal, Newborn, and Child Health Services of health center generally satisfied you?
+2 +1 -1 -2 □
If respondent has answered the preceding questions, proceed with the following. For currently pregnant women, START HERE. Circle responses clearly. NO. QUESTIONS AND FILTERS CODING CATERGORIES Directions Knowledge-Attitudes:
PRENATAL CARE
KA1 What are the symptoms during pregnancy indicating the need to seek health care except routine care? RECORD ALL MENTIONED.
Yes No
Fever 1 2 Shortness of breath 1 2 Bleeding 1 2 Swelling of the body/hands/face 1 2 Other (specify) 1 2 Don’t know 8
KA2 Where is the first place to go for care if a pregnant woman had these symptoms?
in PH 1 in RH 2 in HC 3 Private clinic 4 Non-health professional: Traditional healer 5 VHV 6 Family/Relative/Friend 7 Other 8
KA3 Do you think that a pregnant woman should receive antenatal care even if she feels healthy?
Yes 1 No 2 Don't know 8
If no, go to KP1
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KA4 How many times do you think a healthy pregnant woman should receive antenatal care during pregnancy?
1 (once) 1 2 (twice) 2 3 (three times) 3 4 or more 4
KA5 When to begin receiving antenatal care?
1. Immediately after skip of expected menstruation period 2. 1 month later 3. 2 month later
KA6 Do you think smoking while pregnant is good or bad for the baby?
Good 1 Bad 2 Indifferent/don’t care 3 Don’t know 8
KA7 Do you think drinking alcohol while pregnant is good or bad for the baby?
Good 1 Bad 2 Indifferent/don’t care 3 Don’t know 8
Knowledge-Attitudes: DELIVERY AND NEWBORN CARE KP1 Where do you think is the most
appropriate place for a healthy, low-risk pregnant woman to deliver?
Provincial Hospital 1 Referral 2 Health Center 3 Home 4 Private Clinic 5 Other (specify) 6
KP2 Who do you think is the most appropriate person to help a healthy, low-risk pregnant woman to deliver?
Midwife 1 Nurse 2 Doctor 3 TBA 4 Don’t know 8
KP3 Where do you think is the most appropriate place for a sick, high-risk pregnant woman to deliver?
Provincial Hospital 1 District Hospital 2 Health Center 3 Home 4 Other 5
KP4 When should every new mother receive postnatal care from a health professional?
( ) week(s) Don’t know 99
KP5 What are the signs of danger after giving birth indicating the need for the woman to seek health care? RECORD ALL MENTIONED.
Yes no
Fever 1 2 Excessive bleeding 1 2 Smelly vaginal discharge 1 2 Other (specify) 1 2 Don’t know 8
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KP6 What are the signs to watch for that may indicate a newborn baby is ill? RECORD ALL MENTIONED.
Yes no
Poor feeding 1 2 Fast breathing 1 2 Not active 1 2 No urine or stool output 1 2 Redness around the cord 1 2 Red/discharging eye 1 2 Diarrhea/vomiting 1 2 Other (specify) 1 2 Don’t know 8
KP7 Have you heard of oral rehydration solution (ORS), which is a home-prepared treatment for dehydration?
Yes 1 No 2
KP8 Do you know how to prepare ORS?
Yes 1 No 2
Knowledge-Attitudes: NUTRITION
Strongly Agree, Agree, Disagree, Strongly Disagree, or check the box for Don’t Know (DK)
SA A D SD DK
KN1 Colostrum (yellow first milk) benefits infant. +2 +1 -1 -2 □
KN2 It is good to start breastfeeding within one hour of birth. +2 +1 -1 -2 □ □
KN3 For the first six months after delivery, it is good to only breastfeed.
+2 +1 -1 -2 □
KN4 After six months, it is good to breastfeed and additional food +2 +1 -1 -2 □
KN5 Young children should be breastfed for at least 2 years. +2 +1 -1 -2 □
KN6 Children with malnutrition are more likely to get sick. +2 +1 -1 -2 □
Knowledge-Attitudes: IMMUNIZATION
Strongly Agree, Agree, Disagree, Strongly Disagree, or check the box for Don’t Know (DK)
SA A D SD DK
KV1 Vaccines have no adverse effects. +2 +1 -1 -2 □
KV2 Vaccines are beneficial to children. +2 +1 -1 -2 □
KV3 HC staffs taught potential adverse events associated with vaccinations.
+2 +1 -1 -2 □
KV4 Vaccinations are necessary. +2 +1 -1 -2 □
KV5 Vaccinations should be given when the child is healthy +2 +1 -1 -2 □
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KV6 I can control the pathogen my child may be exposed to without vaccinations.
+2 +1 -1 -2 □
POTENTIAL BARRIERS: HEALTH CENTER
HC1 How far are you from the nearest health center?
( ) kilometers (km)
HC2 How would you get there during the dry season? (Choose one of the following)
Walk 1 Car 2 Motorcycle/Tuktuk 3 Animal-drawn cart 4 Bicycle 5 Boat 6 Cannot go 8
HC3 How long would it take you to get there during the dry season?
( ) hours
HC4 How would you get there in bad weather/the rainy season? (Choose one of the following)
Walk 1 Car 2 Motorcycle 3 Animal drawn-cart 4 Bicycle 5 Boat 6 Not possible at all in severe weather 7
HC5 How long would it take you to get there in bad weather/during the rainy season?
( ) hours
HC6 Apart from the subsidized amount of money (if any) how much do you still have to pay to get to HC?
( ) riel
HC7 Is the out-of-pocket money for transportation a burdensome to you?
Yes 1 Somewhat 2 No 3
HC8 Is it difficult to get the vehicle to go to the HC?
Yes 1 Somewhat 2 No 3
HC9 How much would you earn if you don't go to the health center?
( ) Riel
HC10
Is the fee for ANC or delivery at HC affordable for you?
Yes 1 Somewhat 2 No 3
HC11
Do you have poverty card (supported by Equity Fund)?
Yes 1 No 2
If yes go to HC13
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HC12
Why don’t you have it? I am not poor 1 I was not in the village when the evaluation happened 2 Other (specify) 3
HC13
In case of emergency where would you go?
Health center 1 TBA in the village 2 Private clinic 3 RH or PH 4
HC14
Have you ever experience a private clinic?
Yes 1 No 2
If no go to HC16
HC15
Why did you try private clinic? (choose one main reason)
Doctor in HC advices me to go there 1 Service/equipment there is better 2 Practitioner home visit is available 3 It is closer to my house 4 Less expensive than others 5 Others (specify) 6
HC16a
In general, what is the most significant barrier to using the health center for health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment 5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to go 8 No barrier 9
HC16b
In general, what is the second most significant barrier* to using the health center for health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment 5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to go 8 No barrier 9
*Answer should differ from prior question
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POTENTIAL BARRIERS: REFERRAL HOSPITAL OR PROVINCIAL HOSPITAL
RH1 Have you ever visited the referral hospital or provincial hospital?
Yes 1 No 2
RH2 What made you go there? Referred by HC staff 1 Personal/family decision w/o referral 2
If answer 1, go to RH4a
RH3 If your visit was due to personal/family decision, what was the main reason you chose the RH?
More convenient location than HC 1 Better quality services than HC 2 Emergency 3 Other (specify) 4
RH4a
In general, what is the most significant barrier to using the referral hospital or provincial hospital for health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to go 8 No barrier 9
RH4b
In general, what is the second most significant barrier* to using the referral hospital or provincial hospital for health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment 5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to go 8 No barrier 9
*Answer should differ from prior question
RH5 Has your village organized to ensure transportation for women with obstetrical emergencies?
Yes 1 No 2 Don’t know 8
RH6 How far are you from the nearest referral hospital or provincial hospital?
( ) Kilometers (Km)
RH7 How would you get there? RECORD ALL RESPONSES.
Walk 1 Car 2 Motorcycle 3 Animal drawn-cart 4 Other (specify) 5
RH8 How long would it take you to get there?
( ) hours ( ) minutes
RH9 How much would it cost you to get there?
( ) Riel
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RH10
How would you get there in bad weather/the rainy season? (Choose one of the following)
Walk 1 Car 2 Motorcycle 3 Animal drawn-cart 4 Other (specify) 5 Boat 6 Not possible at all in severe weather 7
RH11
How much would you be able to make if you worked for the same hours required to visit and return from the referral hospital or provincial hospital?
( ) Riel
INFORMATION-EDUCATION-COMMUNICATION
IEC1 Have you ever been a member of any type of village organization? (IF YES, CHECK ONE.)
1. Village head or traditional leader 2Traditional healer 3 Religious leader 4 Village health volunteer 5 Health center staff 6 Teacher 7 Agricultural agent 8 Women’s Union leader 9 Youth Union leader 10 Other community group leader 11 No experience
IEC2 Did you receive any training on maternal, newborn, and child health care in the past year?
Yes 1 No 2
IEC3 Did you attend any regular meetings for maternal, newborn, and child health in your village in the past year?
Yes 1 No 2
IEC4 Did you see any campaigns or events for maternal, newborn, and child health in your village in the past year?
Yes 1 No 2
IEC5 Did you see any health education materials disseminated in your village in the past year?
Yes 1 No 2
IEC6 (If YES to any or all of the questions IEC3-6): Were you able to read and/or understand the information you were given?
Yes 1 No 2
IEC7 Have you had any person visit your home for maternal, newborn, and child health in the past year?
Yes 1 No 2
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IEC8 Do you feel you now have a better knowledge of maternal, newborn, and child health than you did a year ago?
Yes 1 No 2
IEC9 Do you think that there should be a public radio in the village to broadcast programs on maternal, newborn, and child health?
Yes 1 No 2
Social Support from Neighborhood
Strongly Agree, Agree, Disagree, Strongly Disagree, or check the box for Don’t Know (DK)
SA A D SD DK
SS1 In general, would you say your neighbors are willing to help each other?
+2 +1 -1 -2 □
SS2 Would you say that you live in a close-knit village?
+2 +1 -1 -2 □
SS3 In general do you feel that your neighbors can be trusted?
+2 +1 -1 -2 □
SS4 If there was a problem in the village, do you feel that your neighbors could work together to solve the problem?
+2 +1 -1 -2 □
SS5 Would your village people agree for establishing village fund to buffer some kind of big family matter such as unexpected hospitalization?
+2 +1 -1 -2 □
SS6 How easily would you get assistance from your neighbor when you need (such as going to Health Center for urgent delivery)?
Very easily, 1 Somewhat easily, 2 Somewhat difficult, 3 Very difficult. 4
SS7 How many neighbors would give you help when needed (such as taking care of your children while your going to HC for regular ANC visit or lending motocycle without lent-fee only with gasoline fee)?
Every people 1 Many people 2 Some people 3 A few people 4
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SS8 Do you have anyone to turn to for advice and comfort during times of need?
yes, 4 OR MORE 1 TWO OR THREE 2 ONLY ONE 3 NONE 4
SS9 Do you have people in your village from whom you can borrow money to pay for your urgent need (such as medical fee for hospitalization due to pre-eclampsia)?
yes, 4 OR MORE 1 TWO OR THREE 2 ONLY ONE 3 NONE 4
PERSONAL CHARACTERISTICS
PCH1
Have you ever attended school? Yes 1 No 2
PCH2
How many years of school have you attended?
( ) years
PCH3
Now I would like you to read this sentence to me. Show sentences to respondent. If respondent cannot read whole sentence ask if they can read part of the sentence. “The child is reading a book.” (in Khmer)
Cannot read at all 1 Able to read only parts of sentence 2 Able to read whole sentence 3 Can’t read in Khmer but can read in another language (specify) 4 Visually/speech impaired 5
PCH4
How is your health in general? Very good 1 Good 2 Fair 3 Poor 4 Very poor 5
PCH5
Have you ever smoked? Yes, currently a smoker 1 No, but smoked in the past 2 No, never smoked before 3
If current smoker, go to PC8.
PCH6
What was the reason you quit? Pregnancy 1 Other reason (specify) 2
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PCH7
How many cigarettes do you smoke a day?
Fewer than 10 1 11 to 20 2 More than 20 3
PCH8
How often do you drink alcohol? Daily 1 A few times per week 2 A few times per month 3 Never 4
HOUSEHOLD CHARACTERISTICS HH1 What is the religion of the head of
this household? Buddhist 1 Christianity 2 Islam 3 Other religion (specify) 4 No religion 5
HH2 How many rooms are in your home?
( ) rooms
HH3 How much does your family earn in a day?
( ) riel
HH4 What type of fuel does your household mainly use for cooking?
Electricity 1 Liquid Propane Gas (LPG) 2 Natural gas 3 Kerosene 4 Charcoal 5 Wood/Straws/Shrubs/Grass6 Other (specify) 7
HH5 In this household, is food cooked on an open fire, an open stove or a closed stove? Probe for type.
Open fire 1 Open stove 2 Closed stove 3 Other (specify) 4
HH6 Does the fire/stove have a chimney or a hood?
Yes 1 No 2
HH7 Where do you cook? In the same room used for sleeping 1 In a separate room 2 Outdoors 3 Other (specify) 4
HH8 Does your household have electricity?
Yes 1 No 2
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HH9 Does your household have a:
Yes No Clock 1 2 Calendar 1 2 Radio 1 2 TV 1 2 Water pump 1 2 Non-mobile telephone 1 2 Refrigerator 1 2
HH10
Does any member of your household own a:
Yes No Toilet 1 2 Bicycle 1 2 Animal-drawn cart 1 2 Motorcycle/Scooter 1 2 Tuktuk/Taktak 1 2 Car/Truck 1 2 Mobile telephone 1 2 Watch 1 2 Cow machine 1 2 Boat 1 2
HH11
Does any member of this household own any land that can be used for agriculture?
Yes 1 No 2
HH12
Does this household own any livestock, herds, or farm animals?
Yes 1 No 2
Thank you for your time and cooperation! End time: _________________
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Provider Questionnaire Assessment for Service Providers in Maternal and Child Health Social Assessment on the Provision and Utilization of Maternal, Newborn, Child Health and Reproductive Health Services in Sangkae and Moung Ruessei Operational Districts in Battambang Province, Cambodia INFORMED CONSENT Hello. This assessment is being conducted by a team working for the Korean Foundation for International Healthcare (KOFIH), with support from Battambang provincial government and Cambodian central government. We are conducting an assessment aimed at developing maternal and child health (MCH) in Sangkae and Moung Ruessei Operational Districts in Battambang Province and would appreciate your participation. In this assessment, you will be asked questions about MCH and potential barriers to community residents’ use of MCH services. This information will help the Cambodian government and KOFIH plan health services to improve mothers’ and children’s health. The assessment usually takes 15 to 20 minutes to complete. Whatever individual information you provide will be kept strictly confidential and will only be used for statistical analysis. Participation in this assessment is voluntary and you can choose not to answer any or all of the following questions. However, we hope that you will participate in this assessment since your views are important. Signature/mark of participant: _______________ Date: _________________
Please circle your answer. Do not concern yourselves with the letter/number combinations to the left of the questions, as they will be used for our organizational and analysis purposes only. NO. QUESTION CODING CATEGORIES Directions PC1 Your gender? Male 1
Female 2
PC2 What type of health facility are you currently working in?
Health center 1 Referral 2 Provincial hospital 3
PC3 What operational district (OD) is your health facility located in?
Moung Ruessei OD 1 Sangkae OD 2 Battambang OD * 3
*not to be confused with Battambang province
PC4 What is your qualification? Nurse (primary) 1 Nurse (secondary) 2 Midwife (primary) 3 Midwife (secondary 4 Doctor 5 Medical assistant 6
PC5 Do you own a private clinic and work there after work?
Yes 1 No 2
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NO. QUESTION CODING CATEGORIES Directions KA1 What are the symptoms during
pregnancy indicating the need to seek health care? (Choose one or multiple items)
Fever 1 Shortness of breath 2 Bleeding 3 Swelling of the body/hands/face 4 Other 5 Don’t know 8
KA2 Where do you think is the most appropriate place for a healthy, low-risk pregnant woman to deliver?
Provincial Hospital 1 District Hospital 2 Health Center 3 Private clinic 4 Other 8
KA3 Where do you think is the most appropriate place for a sick, high-risk pregnant woman to deliver?
Provincial Hospital 1 Referral 2 Health Center 3 Private clinic 4 Other 8
KA4 What are the signs of danger after giving birth indicating the need for the woman to seek health care? (Choose one or multiple items)
Fever 1 Excessive bleeding 2 Smelly vaginal discharge 3 Other (specify) 4 Don’t know 8
KA5 What are the signs to watch for that may indicate that a newborn baby is ill? (Choose one or multiple items)
Poor feeding 1 Fast breathing 2 Not active 3 No urine or stool output 4 Redness around the cord 5 Red/discharging eye 6 Diarrhea/vomiting 7 Other (specify) 8 Don’t know 9
KA6 Do you know how to prepare ORS?
Yes 1 No 2
KA7 Does your institution operate well working clinical guideline to detect case for referral?
Yes 1 No 2
KA8 Does your institution have well working referral plan?
Yes 1 No 2
Life Saving Skill Capacity: Can your institution provide following services? LS1 Safe C/Sec Yes 1
No (we need to refer for it) 2
LS2 Blood Transfusion Yes 1 No (we need to refer for it) 2
LS3 Assisted Vaginal Delivery Yes 1 No (we need to refer for it) 2
LS4 Manual removal of placenta Yes 1 No (we need to refer for it) 2
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NO. QUESTION CODING CATEGORIES Directions LS5 Removal of retained material in
uterus Yes 1 No (we need to refer for it) 2
LS6 Parenteral injection of oxytocin Yes 1 No (we need to refer for it) 2
LS7 Parenteral injection of anticonvulsant
Yes 1 No (we need to refer for it) 2
LS8 Parenteral injection of antibiotics Yes 1 No (we need to refer for it) 2
(For each question, choose only one among the following four.) Strongly Agree(SA) = +2 Agree(A) = +1 Disagree(D)= -1 Strongly Disagree(SD) = -2 Or, check Don’t Know (DK)
SA A D SD DK
KN1 Colostrum (yellow first milk) benefits infant. +2 +1 -1 -2 □
KN2 It is good to start breastfeeding within one hour of birth. +2 +1 -1 -2 □ □
KN3 For the first six month after delivery, it is good to only breastfeed.
+2 +1 -1 -2 □
KN4 After six months, it is good to breastfeed and additional food +2 +1 -1 -2 □
KN5 Young children should be breastfed for at least 2 years. +2 +1 -1 -2 □
KN6 Children with malnutrition are more likely to get sick. +2 +1 -1 -2 □
KN7 Vaccines have no adverse effects. +2 +1 -1 -2 □
KN8 Vaccines are beneficial to children. +2 +1 -1 -2 □
KN9 HC staffs teaches potential adverse events associated with vaccinations.
+2 +1 -1 -2 □
KN10
Vaccinations are necessary. +2 +1 -1 -2 □
KN11
Vaccinations should be given when the child is healthy +2 +1 -1 -2 □
HC1a
In general, what do you think is the most significant barrier to using the health center for health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment 5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to come 8 No barrier 9
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NO. QUESTION CODING CATEGORIES Directions HC1b
In general, what do you think is the second most significant barrier* to using the health center for health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to come 8 No barrier 9
*Answer should differ from prior question
RH1 Have you ever referred someone to the referral hospital or provincial hospital?
Yes 1 No 2
If no, go to RH4a
RH2 What was the main reason you referred them?
Could not provide necessary services at HC 1 Patient/family request 2 Other (specify) 3
RH3 How was the patient referred? By an ambulance (car/boat) 1 Use their own means of transportation 2 I didn’t care 3
RH4a
In general, what do you think is the most significant barrier to using the referral hospital or provincial hospital for health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to go 8
RH4b
In general, what is the second most significant barrier* to using the referral hospital or provincial hospital lfor health care?
Fees for drugs and services 1 High transportation costs 2 No transportation available 3 No time to visit because of work 4 Not satisfied with facility/equipment5 Not satisfied with staff/services 6 Feel pressured not to go by others 7 Don’t see the need to go 8
*Answer should differ from prior question
RH5 Would you recommend that a “high-risk” pregnant woman deliver at the referral hospital or provincial hospital?
Yes 1 No 2
MCH1
On a scale of 0 (worst possible) to 10 (best possible), how would you rate the quality of Maternal, Newborn, and Child Health (MNCH) care in Battambang Province? (Give a number between 0 and 10)
( ) score
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NO. QUESTION CODING CATEGORIES Directions MCH2
On a scale of 0 (worst possible) to 10 (best possible), how would you rate the quality of MNCH care in your operational district? (Give a number between 0 and 10)
( ) score
MCH3
On a scale of 0 (worst possible) to 10 (best possible), how would you rate the quality of MNCH care at your health facility? (Give a number between 0 and 10)
( ) score
MCH4
How many times did you receive training on MNCH care in the last one year?
None 1 1 time 2 More than 1 time 3
If no, go to MCH6
MCH5
On a scale of 0 (worst possible) to 10 (best possible), how would you rate your level of satisfaction with the training program you received? (Give a number between 0 and 10)
( ) score
MCH6
On a scale of 0 (worst possible) to 10 (best possible), how would you rate your level of satisfaction with the equipment and supplies currently available for MNCH services in your facility? (Give a number between 0 and 10)
( ) score
MCH7
On a scale of 0 (worst possible) to 10 (best possible), how would you rate the level of support for community outreach services? (if any) (Give a number between 0 and 10)
( ) score □ Not applicable
MCH8
On a scale of 0 (worst possible) to 10 (best possible), how do you rate your understanding of the community need for MNCH?
( ) score
MCH9
How do you rate your proficiency of computer skills?
Very good 1 Good 2 Moderate 3 Insufficient 4
MNC10
Overall, do you feel you are now better prepared for providing MNCH services than you were a year ago?
Yes 1 No 2
MNC11
How many times did you receive supervision visit last year? ( ) time(s)
MNC12
How many times did you receive on-place training in your institution last year?
( ) time(s)
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NO. QUESTION CODING CATEGORIES Directions MNC13
Do you think that the waiting house for pregnant women in your institution is working well?
Yes 1 No 2 We don’t have waiting house 3
MNC14
In what circumstance did you work here?
Assigned regardless of my preference 1 Assigned based on my preference 2 Volunteer 3
Thank you for your time and cooperation! For research team use only District: Moung Ruessei ( ) or Sangkae ( ) or Battambang ( ) Coder’s name __________________________________ Coding checked by:
1. _______________________ (on , 2012)
2. _______________________ (on , 2012)
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References:
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