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Emergency Obstetric and Newborn Care (EmONC)
Improvement Plan of Action Timor-Leste 2016-2019
Ministry of Health
Oecusse
Bobonaro
Cova Lima
Ermera
ManufahiAinaro
ManatutoAileu
DiliLiquiçá
Baucau
Viqueque
Lautém
Atauro
IEmONC Improvement Plan of Action 2016 - 2019
A PLAN TO EXTEND AND FURTHER STRENGTHEN THE PROGRESS OF THE EmONC PROGRAMME IN TERMS OF AVAILABILITY, ACCESSIBILITY, UTILIZATION AND QUALITY OF SERVICES THROUGHOUT TIMOR-LESTE FROM 2016 TO 2019
MINISTRY OF HEALTH
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II EmONC Improvement Plan of Action 2016 - 2019
IIIEmONC Improvement Plan of Action 2016 - 2019
FOREWORD
While we acknowledge the significant efforts that have led to the decrease of maternal mortality in Timor-Leste between 1990 and 2015 according to the evaluation of the Millennium Development Goal on improving maternal health, we all know that the task is far from being finished, and more efforts are needed in the next fifteen years to further decrease it along with our commitment to the Sustainable Development Goals.
In addition, we welcome the current focus on the survival of newborns, especially in the very early period of life, since their survival and the interventions to ensure it are very much linked to those of their mothers.
The findings of the recent Emergency Obstetric and Newborn Care (EmONC) Needs Assessment reveal a country-wide deficit in facilities capable of delivering all life saving signal functions. This single evidence leads to the present EmONC improvement Plan of Action for the years 2016 to 2019, in line with the targets of the National Reproductive Health Strategy, and the Health Sector Development Plan
I like to urge all relevant health staff to look carefully into the recommendations of the present Plan of Action and to contribute to its success from the first to the fourth year.
We also thank our development partners for their contribution, whether technical, material or financial, so that we can proudly and jointly assess our expected progress at the end of the Plan.
Dili, November 06, 2017
Dr. Odete da Silva ViegasDirector General of Health ServiceMinistry of HealthDemocratic Republic of Timor-Leste
IV EmONC Improvement Plan of Action 2016 - 2019
VEmONC Improvement Plan of Action 2016 - 2019
TABLE OF CONTENTFOREWORD III
TABLE OF CONTENT V
LIST OF FIGURES VII
LIST OF TABLES VIII
ACRONYMS IX
EXECUTIVE SUMMARY XI
1. BACKGROUND AND CONTEXT 1
1.1 Maternal and Newborn Health in Timor-Leste 1
1.2 Neonatal and Newborn Mortality in Timor-Leste 3
1.3 Policy context 4
1.4 Progress since 2008 6
2. RATIONALE FOR EMONC IMPROVEMENT PLAN OF ACTION 2016 - 2019 9
2.1 Vision 12
2.2 Goal 12
2.3 Outcome 12
2.4 Objectives and targets 12
2.5 Guiding Principles 13
2.6 Outputs: 14
3. COMPONENTS OF THE EMONC IMPROVEMENT PLAN OF ACTION 19
3.1 Output 1 – Policies norms and standard in place for a supportive enabling environment 19
3.2 Output 2 –Complete availability of EmONC facilities and their accessibility in all parts of the country: facilities and infrastructure 20
3.3 Output 3 –Technical and managerial capacity strengthened to ensure high
quality of care:Staffing and training 23
3.4 Output 4 - Increased Access and utilization of EmONC services: Strengthening service delivery –Quality 28
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3.5 Output 5 – Referral system in place and operational in all parts of the country: Network of referral, communication and transport 30
3.6 Output 6 –Municipality EmONC plans developed, fully operationalized and monitored by DSMs and 31
3.7 Output 7 – Community participation strengthened for improved awareness and increased utilization of EmONC services 31
4. EXECUTION, CALENDAR, AND IMPLEMENTATION RESPONSIBILITIES 33
5. COSTING, MONITORING AND EVALUATION 37
5.1 Executive summary of the Costing Report 37
5.2 Monitoring and evaluation 47
6. ANNEXES 49
Annex 1 - Process Indicators 49
Annex 2 – Summary findings of the EmONC NA in 2015 50
Annex 3 – Direct Obstetric Complications (DOC, to be used for process indicators 4, 6, and 8); Operational definitions and Signal Functions to manage them 52
Annex 4 – List of Municipalities with population (in 2014) 55
Annex 5 - Logframe – Monitoring and evaluation framework for outputs 56
Annex 6 – Time line for the implementation of the EmONC Improvement Plan of Action 2016-2019 59
Annex 7 – Norms and Standards for Minimum Enabling Environment to Support EmONC 62
Annex 8 – Lists of Equipment, Supplies and Medicines for EmONC with unit cost 63
Annex 9 – Special features for Newborn care 67
Annex 10 – Quality Improvement Strategy and Processes 71
Annex 11 – Monitoring sheet for assessing the functionality of EmONC facilities 74
Annex 12 – Estimates for Costing 75
Annex 13 - Key Findings and Recommendations of the EmONC NA Report 82
Annex 14 – Maps Showing EmONC Facilities by Characteristics and Selected Candidates for BEmONC Upgrade 89
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Annex 15 – Municipality Profiles Showing Existing Resources and Needs for The Implementation Plan 97
A. Aileu Municipality 97
B. Ainaro Municipality 100
C. Baucau Municipality 103
D. Bobonaro Municipality 106
e. Covalima Municipality 110
F. Dili Municipality 114
G. Ermera Municipality 118
H. Lautem Municipality 121
I. Liquica Municipality 124
J. Manatuto Municipality 127
K. Manufahi Municipality 131
L. Special Region Oecusse 134
M. Viqueque Municipality 137
7. BIBLIOGRAPHY 141
8. ACKNOWLEDGEMENTS 143
9. CONTRIBUTORS 145
LIST OF FIGURES
Figure 1: Trends of Maternal Mortality in Timor-Leste 1990-2015 and Projections till 2030 2
Figure 2: Trends in Neonatal Mortality in Timor-Leste between 1990 and 2015, and Projections till 2030 3
Figure 3: Network of government facilities providing maternal health services 5
Figure 4: Map showing the distribution of 75 facilities assessed in 2015 17
Figure 5: Map showing the distribution of the functional EmONC facilities in 2015 17
Figure 6: Distribution of costs over time 38
Figure 7: Radar chart showing relative costs related to different cost elements by Municipality 45
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LIST OF TABLES
Table 1: MMR in South East Asian countries in 2015 2
Table 2: Neonatal mortality rate in South East Asian countries in 2013 – All rates are per 1000 live births 4
Table 3: Summary of the main progress in EmONC between 2008 and 2015 comparison of indicators collected during the EmONC Needs Assessments 6
Table 4: Summary of recommendations stemming from the Needs Assessment conducted in 2015 9
Table 5: Seven outputs in the EmONC Improvement Plan 14
Table 6: The Signal Functions of Emergency Obstetric and Newborn care 15
Table 7: Availability of EmONC facilities by Municiplaity and Region 16
Table 8: Level of decision and components of the policies and enabling environment for the optimal delivery of EmONC services in Timor-Leste 19
Table 9: Candidates for BEmONC upgrade in EmONC Plan of Action 2016-2019: 8 CSIs and 28CHCs) 21
Table 10: Midwives and doctors actually present and needed in each candidate BEmONC facility (Type 2 - CSI; Type 3 - CHC) 25
Table 11: Midwives and doctors actually working in the maternities of the CEmONC facilities in Timor-Leste, and recommended numbers 26
Table 12: Indications of the order of priorities and calendar distribution of implementation 33
Table 13: Summary of the estimated costs over four years by Municipality 38
Table 14: Estimated cost of IPA in the Municipalities by cost components 46
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ACRONYMSAMDD Averting Maternal Death and Disability (Columbia University, New York)
AMTSL Active Management of Third Stage of Labour
ANC Antenatal Care
BEmONC Basic Emergency Obstetric and Newborn Care
CBR Crude Birth Rate
CEmONC Comprehensive Emergency Obstetric and Newborn Care
CFR Case Fatality Rate
C-S Cesarean Section
CTC Clinical Training Centre
DHS Demographic and Health Survey
DPHO SMI District Public Health Officer – Maternalnal and Child Health (MCH)
Dr Doctor
DSM Delegadu Saúde Munisipiu (Municipality Health Delegate)
EmONC Emergency Obstetric and Newborn Care
GoTL Governement of Timor Leste
IPA Improvement Plan of Action
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HRH Human Resources for Health
HSDP Health Sector Development Plan
HSSP Health Sector Strategic Plan
LBW Low Birth Weight
MCHD Maternal and Child Health Department (in MoH)
MDG Millennium Development Goals
MNH Maternal and Newborn Health
MoH Ministry of Health
MW Midwife
MWH Maternity Waiting Home
NGO Non-Governmental Organization
NNMR Neo Natal Mortality Rate
OHT One Health Tool
RH Referral Hospital
RMNCAH Reproductive, Maternal, Newborn Child and Adolescent Health
SBA Skilled Birth Attendant
SpR Special Region
SDG Sustainable Development Goals
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Children Fund
WHO World Health Organization
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XIEmONC Improvement Plan of Action 2016 - 2019
EXECUTIVE SUMMARYTimor-Leste is committed to the health of its women and Children since Independence. The Government and its Development Partners united under the H4+ initiative have improved the situation since 2008. The good achievements of the Millennium Development Goal 5 (MDG5) on improvement of maternal health, however, should not lead to a decrease of efforts to address maternal and newborn mortality, which remain unacceptably high. The existing strategies have now been enriched with the integration of a Plan of Action to improve Emergency Obstetric and Newborn Care (EmONC) 2016-2019.
A complete assessment of the current EmONC situation was undertaken in 2015 to review progress and identify gaps and needs. In order to address these gaps and needs, an EmONC Improvement Plan of Action (IPA) is being proposed, to be implemented from 2016 to 2019 in the whole country.
The Goal of the EmONC IPA 2016-2019 is to further save lives of mothers and newborns affected by complications of pregnancy, delivery and postpartum, and contribute to the Reduction of Maternal and Newborn Mortality and Morbidity.
The objectives and targets to be achieved by the year 2019 are:
1. To have increased the availability of EmONC facilities by rationalizing the coverage throughout the country with a network of interconnected facilities beyond the global standards. It is recommended to reach by 2019 a total of 43 functional EmONC facilities, including the 6 Comprehensive facilities already existing that need to be strengthened;
2. To have ensured accessibility for all, including in the remote parts of the country, through improved distribution of EmONC facilities and a functional referral system 24/7 linking these facilities;
3. To have ensured effective utilization of EmONC services to over 90% of the needs, through community participation, strong communication, effective referral, delivery of quality services by competent providers (to prevent the 3 delays). The target is 80% of all births in institutions and 60% in EmONC facilities;
4. To have strengthened the capacity of Municipality health authorities (DSMs and DPHO-SMIs) as well as lower level administrative services to plan, manage, monitor, and support EmONC services;
5. To have expanded the knowledge and awareness of communities about the need to seek assistance from health services and particularly EmONC services.
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Outputs to be achieved:
The objectives, outputs and the key interventions proposed in the Plan of Action must be integrated into the existing health system and build on current major national health programmes such as MCH, Human Resources, Central Medical Stores, Laboratory and Blood Bank. They must be implemented in partnership with the civil society and international development partners. They must also contain their own processes for continues monitoring and periodic evaluation.
OUTPUT 1: Policies, norms and standards revised by adapting international standards and high level commitment and support demonstrated for the optimal delivery of EmONC services;
OUTPUT 2: Distribution of network of BEmONC facilities ensured and CEmONC facilities strengthened for effective coverage of all signal functions in all parts of the country;
OUTPUT 3: Human resources strengthened; Staff redistributed, competencies enhanced at all EmONC facilities prioritizing those serving as clinical training sites and job satisfaction ensured for the benefit of clients;
OUTPUT 4:
Enhanced positive supervision, improved data recording and increased focus on newborn that has relatively been neglected so far for further strengthened systems to support increased utilization and continuous quality improvement of EmONC services;
OUTPUT 5: Referral system operationalized in all parts of the country with improved communication and conditions of transport so that no frontline facility should be at more than 2 hours of a referral facility;
OUTPUT 6: Management competencies strengthened at municipality and national level; EmONC coordinator appointed for improved planning, implementing and monitoring EmONC services; quality of data recording enhanced;
OUTPUT 7: Community involvement further strengthened through Primary Health Care program, village committees, Local NGOs, and community leaders (Suco and Aldeia Chiefs) for improved awareness and increased utilization.
Key interventions to achieve these seven outputs will be implemented synergistically at national and municipality levels, and regularly monitored through national meetings, municipality supervision and field visits.
The three delays model will be kept in mind (delay to make decision to use the health system, delay to access the health system, and delay to provide services while in the health system). The emphasis however is on the third delay once the patient has arrived at a facility.
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The AMDD “Building Blocks” model will also be kept in mind, to articulate the different components and achieve effective coverage, utilization and quality.
The Improment Plan of Action has been costed, focusing on extra costs that are not already covered by the regular MCH and hospital services programmes. The extra costs to be considered belong to 4 categories:
1. Cost of infrastructure to upgrade EmONC facilities
2. Cost of equipment to contribute to the upgrade in EmONC facilities
3. Cost of drugs and supplies for the same
4. Cost of human resources, including additional staff to be posted in EmONC facilities, and inservice training to upgrade competencies
These costs were apportioned by year during the four years of the Plan
The total estimated cost for implementing IPA over 4 years will be around 7,983,081 US $.
Budget details can be found in the accompanying costing report.
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1 https://www.mof.gov.tl/timor-leste-the-millennium-development-goals-report-2014/?lang=en 2 WHO et al. 2015. Trends in maternal mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. National Statistics Directorate and UNFPA 2011. Timor-Leste 2010 Population and Housing Census.3 National Statistics Directorate and UNFPA 2012. Analytical Report on Mortality. Volume 6. Timor-Leste 2010 Population and Housing Census.4 WHO et al. 2015. Trends in maternal mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division.
1. BACKGROUND AND CONTEXT Timor-Leste is a post conflict state that has recently emerged as a lower middle income country. It became an independent nation in 2002, following over four hundred years of Portuguese colonization, twenty four years of Indonesian occupation, and three years of United Nations transitional administration. The country’s economy is heavily dependent on petroleum. Overall the Millennium Development Goals (MDG) indicators show that living standards and human development have improved significantly in Timor-Leste since independence.1 Selected MDG targets for gender equality, child mortality, maternal health, malaria and tuberculosis have been achieved. Out of 29 indicators and sub-indicators, 9 have achieved their targets and 14 show significant improvement. However, despite Timor Leste’s considerable development progress, deeply rooted economic and social issues remain with considerable disparities in key maternal health indicators between municipalities, education and wealth quintiles.
1.1 Maternal and Newborn Health in Timor-LesteRegarding maternal health, the country has made substantial progress on MDG 5, but the maternal mortality ratio is still one of the highest (if not the highest) in the Asia Pacific region. Estimates of the maternal mortality ratio in 2015 range from 215 to 570 deaths per 100,000 live births.2 Among young women aged 15 to 19, the maternal mortality ratio is 1,037 per 100,000 live births.3 The UN estimates that the lifetime risk of maternal death in Timor-Leste is 1 in 82, almost four times greater than the lifetime risk of maternal death in Indonesia.4
The trends in maternal mortality reduction during the MDG period 1990-2015 are clear and encouraging (see Figure 1). To the extent that surveys and estimates can be trusted in the absence of a complete study of maternal death in the country, the MDG Target 5 A has been reached and this is a rare achievement worldwide, appraised by international health authorities.
The Figure 1 shows these trends and extends them to the values expected during and at the end of the next SDG era, in 2030. Under SDG 3 “Ensure healthy lives and promote wellbeing for all at all ages”, target 3.1 states by 2030, reduce the global maternel mortality ratio to less than 70 per 100,000 live births. This is what Timor-Leste should aim at. It is to be appreciated that none of the figures in this graph are based on a direct assessment of mortality, which could only be given by a direct method such as during a Census of Population. All the values have wide confidence intervals.
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TrendsofMaternalMortalityinTimor-Leste1990-2015andProjectionstill2030
For international comparison with the countries in the South East Asia region, Timor-Leste still belongs to the group of highest Maternal Mortality Ratios (MMRs) in South East Asia (see Table 1).
Table 1: MMR in South East Asian countries in 2015
CountryMMR (confidence
interval)Maternal Deaths
Life time risk of maternal death 1 in
Timor Leste 215 (150-300) 94 82
Lao PDR 197 (136-307) 350 150
Myanmar 178 (121-284) 1700 260
Indonesia 126 (93-179) 6400 320
Cambodia 161 (117-213) 590 210
Vietnam 54 (41-74) 860 870
Thailand 20 (14-32) 140 3600
Philippines 114 (87-175) 2700 280PNG 215 (98-457) 460 120
Figure 1: Trends of Maternal Mortality in Timor-Leste 1990-2015 and Projections till 2030
Source WHO et al 2015
Source WHO et al Trends in Maternal Mortality 1990 - 2015
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While the majority of pregnant women use antenatal care, EmONC Needs Asssesment 2015 revealed that institutional deliveries are less common at 50%. The 2009-10 Demographic and Health Survey reported that nearly 86% of pregnant women received antenatal care from skilled health personnel with 55 percent having the recommended four or more antenatal visits.5 However, a smaller percentage, 30 percent delivered with the assistance of a skilled health provider. While 68 percent of women in the wealthiest quintile delivered with a skilled health provider, only 11 percent of women in the poorest quintile obtained such assistance.
Institutional delivery rate, the proportion of all births in a health facility, is a subset of “Skilled birth attendance”, and usually lower than it. It should be the ambition of all health systems to have all women giving birth in an institution capable of providing Emergency Obstetric and Newborn Care. Currently, according to the 2015 EmONC Needs Assessment, 48 percent of women in Timor-Leste deliver in health facilities, but only one quarter (25 percent) deliver in a functional EmONC facility.
1.2 Neonatal and Newborn Mortality in Timor-LesteNeonatal mortality, deaths of infants from birth to 28 days of life, is much easier to measure than maternal mortality because it is more frequent and less sensitive, and it is a classical internationally used indicator. Globally, 75% of neonatal deaths occur during the first week of life, and 25 to 45% in in the first 24 hours, the “very early newborn period”.
Figure 2 shows the trends of neonatal mortality rate between 1990 and 2015, and extends projected values till 2030, at the end of the SDG era. Again these values are approximate, probably underestimated, and subject to caution. However, they follow reasonable expectations, while not decreasing as fast as maternal mortality.
Figure 2: Trends in Neonatal Mortality in Timor-Leste between 1990 and 2015, and Projections till 2030
5 National Statistics Directorate and ICF Macro 2010.Timor-Leste Demographic and Health Survey 2009-10.
Source Levels and trends in child mortality 2015 UNICEF, WHO and World Bank
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TrendsinNeonatalMortalityinTimor-Lestebetween1990and2015,andProjectionstill
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Table 2: Neonatal mortality rate in South East Asian countries in 2013 – All rates are per 1000 live births
Country NNMR 2000 NNMR 2013Newborn
Deaths 2013Stillbirth
rate First Day
mortality rate
Lao PDR 40 29 5 400 13 11
Myanmar 35 26 23 400 20 9
Timor Leste 37 24 600 14 10
Cambodia 36 18 6 600 18 6
Indonesia 22 14 66 000 14 5
Vietnam 17 13 17 700 12 5
Thailand 13 8 5 500 4 3
Source Levels and trends in child mortality 2015 UNICEF, WHO and World Bank
However, it would be far more interesting to measure and express very early newborn mortality, deaths during the first 24 hours, because it is closely linked with maternal mortality, and paradoxically less measured and less reported.
Newborn mortality, or very early neonatal mortality within 24 hours, the target of this report, has never been precisely measured in Timor-Leste, for reasons of inadequate quality of recording. Neonatal mortality, which comprises early and late neonatal mortality has been assessed as 25 per 1000 live births in the year 2010, and 22 in the year 2015 (with a wide confidence interval for the reasons highlighted above). It is difficult to assess the progress in newborn mortality but it is likely to have been very limited. One of the aims of this EmONC improvement plan of action is to address this neglected area of public health.
Similarly the measure of intrapartum mortality or intrapartum stillbirths, an interesting indicator of quality of intra partum care, has rarely been reported in Timor-Leste because of issues of underreporting and misclassification.
1.3 Policy contextIn Timor-Leste, the policy environment concerning MNH is very enabling: Since 2000 the Government has publicized its commitment to the MDGs 4 and 5, and demonstrated very positive improvements. The National Health Sector Strategic Plan covering 2011 to 2030 has been augmented by the National RMNCAH Strategy 2015-2019, encouraging institutional delivery, guaranteeing free services for all at the point of delivery, and offering a reasonable standard of staffing for Referral Hospitals, Community Health Centres, CSIs and Health Posts with teams of midwives and medical doctors. The results of this policy have been impressive, but lots of challenges remain.
In terms of neonatal mortality rate (NNMR), Table 2 shows that Timor-Leste was doing better in 2013 than Lao PDR and Myanmar, but remained far from Indonesia, Cambodia, Vietnam and Thailand.
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Besides Municipality health budgets on the rise, the central level of the MoH remains responsible for national programs, for both budget and financing. The national policy on human resources for MNH is coherent, but must take into account the inconsistencies in pre-service training, both for midwives and for doctors, with serious gaps in practice, that will be addressed in this Improvement Plan of Action (IPA).
The health system in Timor-Leste rests on a pyramid of interlinked facilities, as shown in the figure 3.
Figure 3: Network of government facilities providing maternal health services
LEVELS DESCRIPTION OF DIFFERENT LEVELS
Level 4 Central Level or National hospitals (Tertiary level services)
The National Hospital situated in the capital Dili is the principal tertiary care institution that provides specialist care for the whole population of Timor-Leste;
Level 3 Referral hospitals
There are 5 referral hospitals. They also provide municipality coverage to the adjacent municipalities;
Level 2 Community Health Centres and CSIs
There are 59 Community Health Centres (CHCs) and 8 Centro Saude Internamento; CSIs differ from CHCs as they have inpatient facilities and generally can keep a patient for about three days There are 7 CSIs in each of the municipality without a Referral Hospital and Ainaro;
Level 1 Health Posts (Primary Health Care Level)
There are 252 health posts which are divided into two categories. The Health post is a basic unit for providing Primary Health Care services at village (suco) level and provides outpatient care;
Community level Communities
PHC guidelines discuss about domiciliary visits by the staff of the health post; two visits /year with more frequent visits to high risk families.
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Item EmOC NA 2008 EmONC NA 2015 remarks
Selection of facilities to be assessed
6 Hospitals + 65 CHCs = 71 facilities in 13 districts
6 Hospitals + 8 CSIs + 59 CHCs + 2 Private hospitals = 75 facilities in 13 districts
Choice of toolsPerformance of Signal Functions 12 months before assessment
Performance of Signal Functions 12 months before assessment
For comparability.3 months was not realistic
Indicator 1 Availability/ 500.000 population
4.6 EmONC Facilities per 500,0002.8 CEmONC Facilities 4 BEmONC Facilities only
3.7 EmONC facilities per 500,0002.6 CEmONC2 BEmONC Facilities only
Fewer functional BEmONC facilities in 2015
Indicator 2Geographic Distribution
7 Municipalities have no functional EmONC Facilities
7 Municipalities have no functional EmONC Facilities
No progress
Indicator 3Births in EmONC facilities
18% in all facilities12% in EmONC facilities
48% in all facilities25% in EmONC facilities
Progress; but should increase
Indicator 4Met Need for EmONC services
8% 53% in all facilities34% in EmONC facilities
Progress; but should increase
Table 3: Summary of the main progress in EmONC between 2008 and 2015 comparison of indicators collected during the EmONC Needs Assessments
1.4 Progress since 2008A landmark initiative took place in 2008 with the conduct and the publication of the first EmOC Needs Assessment, which marked the interest of the Government of Timor-Leste for improving maternal and newborn health6. The progress and remaining challenges in the implementation of the first improvement plan have been analyzed in the Second EmONC Needs Assessment completed 7 years later in 2015 (note that “N” for Newborn has been added).
Table 3 summarizes the changes in selected indicators when comparing data collected in 2008 and in 2015 and identifies gaps that make the basis of the present Improvement Plan of Action. Among other gaps, those in data collection due to insufficient quality of recording remain barriers to the reliability of some indicators.
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Item EmOC NA 2008 EmONC NA 2015 remarks
Indicator 5Cesarean sections
1.1% 3.5% Majority in DiliShould double
Indicator 6Direct Obs CFR 1.3% 0.9%
Not reliable; data quality poor
Indicator 7IPVENDR 0.4% 1%
Not reliable; data quality poor
Indicator 8% maternal deaths of Indirect Causes
12.5% 25%Not reliable; data quality poor
Most problematic Signal Functions
Blood transfusion, Assisted Vaginal Delivery, Anticonvulsant
Blood transfusion, Assisted Vaginal Delivery, Anticonvulsant
No change
Other services
Guidelines and protocols HMIS largely incomplete
HMIS incomplete, Poor availability and visibility of EmONC protocols
No progress
24/7, Referral,Communication Access problematic
Poor access for the poor, poor referral the newborn, travel time too long
Cell phone communication much improved
Human resources for Mat Health
21 CHCs have 1 MWUnderstaffing
All CHCs have >1 MW, >1 Dr. Misssing Lab Tech and Anesthetists
Progress in coverage
Drugs, Equipment and Supplies
No maintenance of equipmentMissing MgSO4
Stock outs +++, esp MgSO4Missing newborn resuscitation equipment
Little progress
Partograph Very poor compliancePoor compliance for AssisVaginDelivery and C/S
Some progress
C/S Reviews No data No prior data for comparison
MD Reviews No data No prior data for comparison
Expected births No data 40,486
MMR 317 215 UN estimatein italics: unreliable data
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2. RATIONALE FOR EmONC IMPROVEMENT PLAN OF ACTION 2016 - 2019
In response to the review of the EmONC Needs Assessment conducted in 2015, a number of observations have been made, followed by recommendations. They focused on achievements but also on delays in implementation, on insufficient progress, on barriers to availability, accessibility, utilization and quality of EmONC services. Table 4 summarizes recommendations based on the results of the Assessment.
Table 4: Summary of recommendations stemming from the Needs Assessment conducted in 2015
Category Recommendations
1. Policy level
• Name a National EmONC Coordinator to oversee, coordinate and monitor the Plan of Action, ensuring that all inputs are aligned with the National Strategy ;
• Integrate EmONC into the wider approach of RMNCAH and existing health strategies;
• Highlight the Newborn, neglected until now;
• Set up targets for 80% of all births institutional and 60% in EmONC facilities by 2019;
• Address the lack of BEmONC facilities in priority, with 8 CSIs and 28CHCs to upgrade before 2019;
• Adopt and implement the Policy for Blood Transfusion; all CEmONC facilities should have stored blood 24/7 with a lab technician on site;
• Define national standards and norms for the management of EmONC, with a focus on providers performing signal functions;
• Plan the strategy according to the “Golden Rules”: No village more than two hours of a health facility and no health facility more than 2 hours travel time from a higher level referral EmONC facility;
• All facilities to be encouraged to keep patients in their premises before and after delivery either in maternity waiting homes or in wards where patients can receive or prepare food, have a minimum of comfort and dignity.
10 EmONC Improvement Plan of Action 2016 - 2019
Category Recommendations
2. Enabling environment
• Advocate, show commitment for EmONC at highest level;
• Integrate EmONC in to the National Strategies and Health Sector Development Plan;
• Improve physical and infrastructural conditions of facilities for the comfort of patients (rooms and beds for pre-natal and post natal care, curtains, tap water, toilets and sanitation, cleanliness and infection control, etc).
3. Quality of care
• Standardize signal functions and other essential obstetric and newborn care and ensure that all providers follow the National guidelines and protocols;
• Ensure that all obstetric and newborn complications are recognized, diagnosed, properly recorded, and reported to HMIS by introducing uniform registers and records and ensure these complications are competently managed in fully functional EmONC facilities;
• Reinforce the concept and practice of “readiness” for all staff on duty, so that the third delay is less of a constraint.
4. UN indicators • Shift the benchmark for performing signal functions from 3 months to 12 months, to take into account local conditions.
5. Essential drugs supplies and equipment
• Review the Essential Medicines List to ensure that lifesaving medicines are available at all levels of facilities (antibiotics, oxytocics, anticonvulsants, details provided below);
• Ensure through periodic monitoring that no essential supplies, equipment and medicines are missing in EmONC facilities;
• Maintain an emergency stock (trolley or box) of key drugs (in operating theatres, labour wards and maternity wards) in all EmONC facilities, even where pharmacies are always open. The emergency stock could then be refilled when necessary.
6. Emergency communication and referral transport
• Review the communication system through cellphones and ensure vehicles are 24/7 ready to transport patients.
• Do not let patients by themselves in referral vehicles: accompany with qualified health staff.
• Train ambulance drivers in first aid and ensure their availability.
11EmONC Improvement Plan of Action 2016 - 2019
Category Recommendations
7. Human resources
• Reallocate midwives and doctors in BEmONC facilities according to standards (4 midwives and 2 doctors for facilities with less than 300 del per year, double if between 300 and 600, triple between 600 and 900, etc);
• Ensure that a general surgeon can perform C sections in the absence an obstetrician in CEmONC facilities;
• Ensure 24/7 coverage of services through a system of shifts.
8. Knowledge, training and supportive supervision
• Review the existing training materials and establish a national training package on BEmONC. Ensure that all midwives and doctors in EmONC facilities have had inservice BEmONC training;
• Establish at least three clinical training sites in the country with space, trainers, coaches, and equipment;
• Provide training opportunities, training equipment (anatomical models) and tutoring/mentoring in all large facilities, in order to maintain skills and quality;
• Strengthen the pre-service training of doctors and midwives to acquire the necessary knowledge and competencies on BEmONC;
• Integrate quality indicators on BEmONC into existing supportive supervision tools.
9. Partograph• Run frequent partograph reviews with senior supervisors to
improve quality and assist in decision making for assisted vaginal delivery and C section
10. Death reviews• Perform maternal and newborn death reviews to analyze
causes of death, prevent reccurrence, and improve quality of care.
11. Community involvement
• Suco and Aldeia chiefs to promote birth preparedness, institutional delivery and EmONC;
• Village Committees and local NGOs to raise awareness and utilization of EmONC;
• Health Posts to integrate EmONC in their PHC programme.
12 EmONC Improvement Plan of Action 2016 - 2019
The present EmONC Improvement Plan of Action 2016-2019 responds to these recommendations and to an indepth examination of challenges. Vision, goal, purpose, objectives, targets and output are presented below.
2.1 VisionAll women in Timor-Leste go through pregnancy, childbirth and the postpartum period safely and all their newborns are alive and healthy. See the 2010 Declaration for Affirmative Action to Reduce Maternal and Child Death, Birth Rate and Teenage Pregnancy;
• “No Timorese mother will die needlessly from pregnancy and childbirth”
• “No Timorese baby will die needlessly before, during and after birth”
• “All Timorese women shall have access to correct and complete information and quality services to ensure their full maternal rights“
2.2 GoalTo sustain and further contribute to the improvement of maternal and newborn health in Timor-Leste towards the Sustainable Development Goals (SDGs).
2.3 OutcomeUniversal availability, coverage and utilization of quality EmONC services, not leaving any woman or any newborn in Timor-Leste unassisted.
2.4 Objectives and targetsBy the year 2019 :
• To have increased availability of EmONC facilities to cover rationally the whole country, with a network of interconnected EmONC facilities up to UN standards;
• To have ensured accessibility for all, including in the remote parts of the country, according to the Golden Rule of two hours, through a functional referral system;
• To have ensured effective utilization of EmONC services to over 90% of the needs, through community participation, strong communication, effective referral, and delivery of quality services (the 3 delays);
• To have developed the capacity of DSMs and all level administrative services to plan, manage, monitor EmONC services;
• To have reached or surpassed the UN standards for the relevant EmONC process indicators, measured through a strengthened monitoring system.
13EmONC Improvement Plan of Action 2016 - 2019
2.5 Guiding Principles1. Evidence based
All components must be based on well known and proven interventions that have worked in other countries and have been the subject of international consensus.
2. Health system integration
The EmONC Improvement Plan of Action (IPA) must be fully consistent with and integrated into the National Health Strategies, building on existing programs, and not been perceived as a vertical program.
3. Partnership
The IPA remains connected with programs initiated and supported by the partners of the Ministry of Health but also must look for new partnerships.
4. Clear definition of roles and responsibilities
The plan must define clearly the roles and responsibilities of each category of staff, up to supervisors, managers and leaders. In turn, the persons must have agreed on their terms of reference and accepted responsibility for any mishaps (as well as for success).
5. Transparency and accountability
All staff must act in full transparency, so that they can be found accountable for the consequences of their decisions and interventions. A register of complaints can be placed in each facility for collecting facts against these principles, eventually leading to investigation.
6. Equity
At all steps of the chain of case management, attention will be given to equity in treatment and access, without discrimination or stigmatization.
7. Continuous monitoring and periodic evaluation
It is a duty of program managers and department heads to set continous monitoring procedures, so that they can keep an eye on the dashboard under their responsibility. Periodic evaluation is also warranted and must be integrated into the plan at each level, so that it does not require a whole new search for resources every time.
14 EmONC Improvement Plan of Action 2016 - 2019
2.6 Outputs:Seven outputs are proposed to guide policy makers, program managers, development partners, training institutions, and service providers in the attainment of the objectives and reaching target.
Table 5: Seven outputs in the EmONC Improvement Plan
OUTPUT 1: Policies, norms and standards revised by adapting international standards and high level commitment and support demonstrated for the optimal delivery of EmONC services.
OUTPUT 2: Distribution of network of BEmONC facilities ensured and CEmONC facilities strengthened for effective coverage of all signal functions in all parts of the country.
OUTPUT 3: Human resources strengthened; Staff redistributed, competencies enhanced at all EmONC facilities prioritizing those serving as clinical training sites and job satisfaction ensured for the benefit of clients.
OUTPUT 4: Enhanced positive supervision, improved data recording and increased focus on newborn that has relatively been neglected so far for further strengthened systems to support increased utilization and continuous quality improvement of EmONC services.
OUTPUT 5: Referral system operationalized in all parts of the country with improved communication and conditions of transport so that no frontline facility should be at more than 2 hours of a referral facility.
OUTPUT 6: Management competencies strengthened at municipality and national level; EmONC coordinator appointed for improved planning, implementing and monitoring EmONC services; quality of data recording enhanced.
OUTPUT 7: Community involvement further strengthened through Primary Health Care program, village committees, Local NGOs, and community leaders (Suco and Aldeia Chiefs) for improved awareness and increased utilization.
The overall target of ALL births attended by a skilled attendant in or very near to a EmONC facility is still applying, but the concept of “skilled attendant” should be replaced by the more modern concept of “competent provider”, which entails a fully trained professional with a state recognized diploma and appropriate inservice BEmONC training. Competency is the sum of Knowledge+Skills+Attitude, and not merely the capacity to deliver a service. In addition, the plan should specify that midwives and doctors work as a team, so that they can help each other and cover the 24/7 time frame. Investing in midwives is the “best bet” in modern EmONC strategic planning.
Key interventions to achieve the seven outputs will be implemented synergistically at national and municipality levels, and regularly monitored through national meetings and municipality supervisory visits.
15EmONC Improvement Plan of Action 2016 - 2019
The three delays model will be kept in mind (delay to make decision to use the health facilities, delay to access the health facilities, and delay to provide services while in the health facilities). The emphasis however is on the third delay once the patient has arrived at a facility. Emphasis will also be put on the newborn that has been relatively neglected so far.
To the extent that the number of obstetric and newborn complications can be projected as estimates, it is possible to attach a unit cost to the management of each complication. An attempt has been made and is presented in Annex 12.
Table 6 recalls the 7 Basic EmONC signal functions and the additional 2 Comprehensive EmONC signal functions. The EmONC guidelines specify that in order to qualify for Basic or Comprehensive EmONC status, all the corresponding signal functions must have been performed in the 3 months before the survey. This rule has been modified to use the 12 month benchmark in view of the situation and population of Timor Leste.
Table 6: The Signal Functions of Emergency Obstetric and Newborn care
Signal Functions to be performed at all BASIC EmONC facilities
Signal Functions to be performed at all COMPREHENSIVE EmONC
facilities
1. Parenteral administration of Antibiotics ALL the BASIC Signal Functions, plus:
2. Parenteral administration of Oxytocics 8. Surgery, Cesarean section
3. Parenteral administration of Anticonvulsants (MgSO4) 9. Safe Blood Transfusion
4. Manual removal of Placenta
5. Removal of retained products through Manual Vacuum Aspiration,
6. Assisted vaginal delivery by vacuum extractor
7. Basic Newborn resuscitation with Ambu bag and mask
The Assessment’s most important finding was about the classification, availability and distribution of EmONC facilities (Basic and Comprehensive) in the country. As expected, 6 facilities were classified as CEmONC and well distributed, but the assessment found only 2 facilities responding to the definition of BEmONC, both in the Capital Dili (Comoro CHC and the private clinic Biropete).
16 EmONC Improvement Plan of Action 2016 - 2019
None of the 8 CSIs and 58 out of 59 CHCs visited had not performed the whole set of basic signal functions in the year preceding the assessment. Table 7, Figure 4 and 5 show the details of this finding.
The first and most obvious conclusion stemming out of this finding is to improve this performance by upgrading a selection of facilities to the level of BEmONC.
Table 7: Availability of EmONC facilities by Municiplaity and Region
Region and Municipality
Population6
Based on Recommended UN 12 month standard for use in Timor Leste
Shortfall (GAP) CEmONC and BEmONC facilities
CEmONC BEmONC
Region 1: The standard for CEmONC facilities has been met. No further CEmONC facilities are required.
There is a serious gap in the coverage and distribution of BEmONC facilities.
At least 13 BEmONC facilities are recommended according to UN standards.
At least obstetric first aid needs to be offered where there is a gap in service delivery.
Every woman in Timor-Leste should be within two hours of help, if only to stabilise condition before referring on.
Baucau 124,061 1 0
Lautem 64,135 0 0
Viqueque 77,402 0 0
Total 265,598 1 0
Region 2:
Ainaro 66,397 1 0
Alieu 48,554 0 0
Manufahi 52,246 0 0
Total 167,197 1 0
Region 3:
Dili* 252,884 1 2
Ermera 127,283 0 0
Liquica 73,027 0 0
Manatuto 45541 0 0
Total 498,735 1 2
Region 4:
Bobonaro 98,932 1 0
Covalima 64,550 1 0
Total 163,482 2 0
Special Region:
Oecusse 72,230 1 0
Total 1,167,242 6 2
*Includes 2 private facilities in Dili
6 National Institute of Public Health and National Institute of Statistics, (2008) General Population Census of Timor-Leste
17EmONC Improvement Plan of Action 2016 - 2019
Figure 4: Map showing the distribution of 75 facilities assessed in 2015
Figure 5: Map showing the distribution of the functional EmONC facilities in 2015
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18 EmONC Improvement Plan of Action 2016 - 2019
The “Golden Rules” specify that every woman in Timor-Leste should be able to reach an EmONC facility within 2 hours, and every frontline health facility should be within 2 hours of a referral facility.
It is estimated that 73% of maternal deaths occur as a result of direct obstetric complications7. The rest, called “indirect complications”, are the result of aggravation of pre –existing conditions.
The urgency required for the management of obstetric complications is highlighted in the following thumb rules:
If untreated, death occurs on average in:
2 hours : From postpartum haemorrhage
6 hours : From eclampsia
12 hours : From antepartum haemorrhage
2 days : From obstructed labour and pre-eclampsia
6 days : From infection
7 Lalesay at al global causes of maternal death: a WHO systematic analysis; Lancet global health 2014; 2; e 323-33
19EmONC Improvement Plan of Action 2016 - 2019
3. COMPONENTS OF THE EmONC IMPROVEMENT PLAN OF ACTION
3.1 Output 1 – Policies norms and standard in place for a supportive enabling environment
Table 8: Level of decision and components of the policies and enabling environment for the optimal delivery of EmONC services in Timor-Leste
Level Components
At national level -
Government of Timor-Leste
• Highlevelcommitmentandshowofinterest;
• raisevisibilitye.g.NationalSafeMotherhoodDay,mediacoverage,popularstars;
• Reviewof the legislation supportiveof incentives for retentionofprofessionalstaffinremoteposts.
National Level - Ministry of
Health
• High level commitment and show of interest with InternationalvisibilityandparticipationofDevelopmentPartners;
• Resourcemobilization–NationalBudget+Donors;
• Name an EmONC Coordinator and a Core Technical Group toreview Norms and Standards. Both should meet twice a year toreviewachievementsandaddressconstraints;
• Strategicguidanceandregulationfornewprocedures,newdrugsandnewequipment;
• Production/revision of Standards and Protocols for casemanagement;
• Production/revisionofstandardsforstaffingandtrainingdifferentlevelsofhealthfacilities;
• Overallmonitoringandevaluationatnationallevel,withanannualnationalreview;
• Centralmedicalstores–procurementanddistributionofequipment,drugsandsupplieswithwarningsystemstopreventstockouts;
• Pharmacyandlaboratories–StandardsandQualityControl;
• BloodBank–BloodTransfusion:EndorsementandImplementationof the Blood Strategy: expansion of the network of regionalstructuresandblooddepotsineachdesignatedCEmONCfacility;
20 EmONC Improvement Plan of Action 2016 - 2019
Level Components
• Strengthening leadership forEmONCatMCHdepartmentandatMunicipalitylevel–DSMandDPHO-SMI;
• Selection of CHCs to upgrade as BEmONC facilities, accordingto criteria of population covered, travel time, resources, staffing,communicationforreferral.
Municipality Level
• Strengthening of PHC activities performed at Health Posts inrelationtoEmONC;
• Relationswithlocaladministrationsandcivilsocietyatcommunityandvillagelevel(Suco,Aldeia);
• ReconsiderPostingof staff, reshuffling ifnecessary, rotating,andmonitoringvacantposts;
• Regular monitoring of EmONC services: Annual Report withindicatorsofservicesdelivered;
• Organizationofthecommunicationandreferralsystem,regulationofvehicles,driversandmaintenance;
• PartnershipwithprivatesectorandNGOsregulation;
• Protectionofstaffifandwhennecessary,andpreventionofcrisis;
• Strengthenmanagementofresourcesatmunicipalitylevel.
3.2 Output 2 –Complete availability of EmONC facilities and their accessibility in all parts of the country: facilities and infrastructure
While therewasno lackof facilities, thefindingsof theAssessmenthighlighta severedeficitoffunctionalBEmONCfacilitiesinthewholecountry.ThenumberanddistributionofCEmONCfacilities isadequate,providedtheymaintain theirattention to improvingquantity and quality of services provided (the 9 CEmONC Signal Functions). A list ofmissingstaff,equipment,suppliesandmedicinesaswellasmissingcompetencieswerederivedfromtheassessmentdata,andcorrectivemeasureswillneedtobeimplementedbyhospitals’managementauthorities(ExecutiveDirectorandClinicalDirector).
TheselectionofCSIsandCHCstobeupgradedtobecomeBEmONCfacilitieshasbeenmadeinconsultationwiththeMunicipalityhealthauthoritiesusingcriteriaofpopulationcovered,distanceandtraveltime,staffingandreferralcapacity.ComoroCHCinDilithatwasfoundtobeafunctionalBEmONCfacilityistobemaintainedandimprovedinquality.
21EmONC Improvement Plan of Action 2016 - 2019
Table 9: Candidates for BEmONC upgrade in EmONC Plan of Action 2016-2019: 8 CSIs and 28CHCs)
Region MunicipalityREF
HOSPITALCSI
CHC priority 1
CHC priority 2
CHC priority 3
CHC priority
4
1
BAUCAU Baucau* Quelicai** Baguia
LAUTEM Baucau LosPalos Iliomar Luro
VIQUEQUE Baucau Viqueque Uatulari Lacluta Uatucarbau
2
AILEU Maubisse AileuVila Remexio
AINARO Maubisse*AinaroVila
Hautio***
MANUFAHI Maubisse Same Fatuberlihu
3
DILI**** HNGV Atauro Becora VeraCruz Centro
ERMERA Gleno Gleno Atsabe Hatolia
LIQUICA HNGV Liquica Fatumasi Maubara
MANATUTO HNGV Manatuto Laclubar Natarbora
4BOBONARO Maliana Lolotoe Atabae Bobonaro
Marco(caliaco)
COVALIMA Suai* Zumalai Tilomar Fohorem
SpR OECUSSI Passabe
*Candidates for 3 more Clinical Training Centres ** Will be upgraded to CSI*** KOICA has already committed**** Comoro CHC in Dili Municipality that was found to be a functional BEmONC facility to be improved in quality
InviewoftheVisionthatultimatelyALLbirthsshouldtakeplace inanEmONCfacility,and according to all international recommendations, it makes sense to stop investinginfacilitiesforsocalled“normaldeliveries”thatarenotwellequipped,notwellstaffedand not well connected. Therefore it is not recommended to invest further in labourroomswithinHealthPosts.TheHealthPosts,however,shouldbeupgradedtoCentresofExcellenceforpreventive,educativeandsurveillanceactivities:AnteNatalCare,PostNatalCare,FamilyPlanning,otherRHpathologies,HIV/AIDS,andcounselling.MidwivesandGPsarethemostsuitedpersonneltoperformthesefunctionsclosetothecommunity.
22 EmONC Improvement Plan of Action 2016 - 2019
Mostfacilitieswillneedeffortstoupgradecomfortand“humanization”fortheirclients:It isnotacceptable tohaveBEmONCfacilities (oranyhealth facility)withoutaproperandfunctionalwatersystem,toilets,sewage,refusedisposal,electricsystem,incinerator,used needle containers, decent furniture and all items serving thematernity. Similarlyfacilitymanagerswillhavetohaveafreshlookatlabourrooms,(light,space,furniture,basicequipment,postersandwallchartsonthewalls,wheelchairs,dignitycurtains).Theequipmentrequiringmaintenancemustbedealtwithwithoutdelay,andatechnicianmustbeavailableatalltimes.Largerfacilitiesmusthaveafulltimetechnician(ortechnicians)andaworkshoplocatedonthepremises.Thistechnicianmustbeavailabletovisitperipheralfacilitieswheneverrequested.
Inaddition,inanticipationofanincreaseinnumberofpatients,itisnecessarytorevisittheflowofpatients,waitingrooms,post-natalward,spaceforaccompanyingfamilymembers,restingplace fordutystaff,aswellas the intrafacility transportationnetworke.g. fromlabourroomtooperationtheatreorfromoperationtheatrebacktomaternity.Seeannex9forminimuminfrastructuralenablingenvironment.
Maternity waiting homes (MWHs)
TheEmONCNeedsAssessment2015didnotspecificallyexplorethepresenceofMWHsinTimorLeste.AfewMWHshavebeeninstalledinsomeDistrictsonapilotbasis(inSameandLospalos).Abefore-and-afterdistanceanalysisoftheuseofthefirsttwomaternitywaitinghomestobeimplementedinTimor-Lestehasdemonstrtaedthatcontrarytoitsobjectives,thestrategyofimplementingsuchhomesdidnotresultinahigherproportionof women from remote areas giving birth in health facilities in Lospalos and Same8.Meanwhile ithasbeendemonstrated inothercountries thatMWHsareusefulonlyoncertainconditions:1)Theymustbelocatedinthepremises(orliterally“acrosstheroad”fromEmONCfacilities.Sothattheparturienthasnotransportproblemwhencomesthetimetoreachthematernity;2)Theymustbemanagedinsuchawaythatthefamiliesfindthem sufficiently comfortable and appealing,with cooking place, cleaning equipment,andsecurity.ItissometimespreferabletogivethemanagementofMWHstolocalNGOs(althoughthisoptionmaynotbesustainable).
In Timor-Leste, a prenatal room installed near to the labour room in each facility isconsideredafeasibleoptionasthecostismanageable.
Equipment
TheessentialequipmentforeffectivedeliveryofEmONCserviceswillberevisedattheearlystagefortheImprovementPlan,withafocusonnewequipmentjudgedessentialor just usefulby theTechnicalCommitteeof theMoH.Special attentionwill begiventoequipment foradvancednewbornresuscitation inComprehensiveEmONCfacilities.(laryngoscopes,positivepressuremachines(CPAP),oxymeters)
Mobile battery operated incubators are often necessary to transport newborns withcomplications.
8 Kayli Wild, Barclay B b, Paul Kelly P and Martins N 2012. The tyranny of distance: maternity waiting homes and access to birthing facilities in rural Timor-Leste. Bulletin of the World Health Organization 2012; 90:97-103.
23EmONC Improvement Plan of Action 2016 - 2019
Standards forsurgicalequipment, includingsterilizationandanesthesia,willbe revisedinorder to includeotheremergencysurgicalproceduressuchashysterectomy,uterinerupture,ruptureofovariancysts,etc.
TheroleofultrasonographyinEmONCwillbereassessedandadjustedtoneeds,suchas identification of multiple pregnancies, identification of abnormal presentations andidentificationofdangerousmalformations.TheuseoffoetalDopplermustbeencouragedto detect and measure the foetal heart rate at admission, identify the presentation,detecttwins,andfollowFHRduringlabour.Thepurchaseofcheaperversionswillallowdistributingagreaternumberofdevicessothateverydeliverywardcanuseone.
Municipalityhealthauthoritiesmustensurethatallequipmentprovidedis installedandoperating:Mobilemaintenanceteamsshouldbeorganizedwithappropriatetransport,tools, instruction manuals and spare parts to visit all facilities and assist in rendingequipmentoperational.
Essential drugs and supplies
ThelistofessentialdrugsandsupplieswillberevisedbytheNationalTechnicalCommitteeandadjustedifnecessary.SpecialattentionwillbegiventoavoidshortagesandstockoutsofEmONCdrugsandsuppliesbyinstallingsoftwarescapableofsendingwarningswhenexpirydatesapproach.
The policies concerning certain drugs (Parenteral antibiotics including metronidazole,oxytocicsincludingmisoprostol,anticonvulsantsincludingMagnesiumSulphate)willneedtoberevisedbythesameCommitteetoallowtheirprescriptionbymidwivesinEmONCfacilities.
3.3 Output 3 –Technical and managerial capacity strengthened to ensure high quality of care:Staffing and training
Teambuildingand teamworkare crucial componentsof theEmONCservicedelivery.Regularstaffmeetingsarerecommendedforteambuildingandforconstructivereviewofcomplicatedcases.
Staffingstandardswillberevisedtoensureavailabilityofstaff24/7forfulldeliveryofqualityservices.At least 4 midwives and 2 doctorsshouldstaffaBEmONCfacilityperforminglessthan300deliveriesperyear,anddoublethesenumbersformorethan300deliveriesperyear,andtriplebetween600and900deliveriesperyear,etc.Inthiscase,therearealwaystwocompetentprovidersworkinginteamsduringeachshiftofduty.
24 EmONC Improvement Plan of Action 2016 - 2019
Box 1 Proposed Staffing Levels for EmONC Teams
Table 10 below provides the balance between the actual numbers of midwives anddoctors in thematernitiesof the36candidates forupgrade intoBEmONC facilities. Ifitwaspossible to reshuffle toa certainextent theactualmidwivesanddoctorswithintheir region, itwouldmeanthat35midwivesaremissingand27doctorsare inexcess(totheextentthatthequestionsaboutdoctors’availabilityhavebeenwellunderstoodduringtheassessment).Similarly,Table11showstheactualandrecommendedstaffinginthehospitalsofthecountry,indicatingadeficitof19doctorsbutanadequatenumberofmidwives.TheEmONCPlanofActioncontributes,butisnottheonlycontributor,toplanningpre-servicetrainingofhumanresourcesinthecomingyears.
1: BEmONC facilities with less than 300 deliveries per year
4midwivesand2doctorstotakeshiftsof12hoursinteamsPlus:CleanerandSecurityGuardandbackupstaff24hoursaday1or2driverstocoverfor24/7
2 BEmONC facilities with between 300 and 600 deliveries per year
8midwivesand4doctorstotakeshiftsof12hours(teamsoftwo)PlusauxiliariesinLabourroomPlus:InfectionControlOfficer,LabTechnicianandAssistants,PharmacistCleanerandSecurityGuardandbackupstaff24hoursaday1or2driverstocoverfor24/7
3: For facilities with more than 600 del per year :
Increaseto12midwivesand6doctors,etc
4: CEmONC facilities (presumably more than 600 deliveries per year, with many referred compllcations)
Atleast12midwivesand6doctorsworkingin12hourshiftsinteams,(oneextrateamifhighworkload)1Ob/Gynand1generalSurgeontocoverforOb/Gynabsences2TheatreNursesand1Assistant1CirculationNurse(extrapairofhandstogetthings),plus1extraforheavyworkload1Anaesthetistand1NurseAnaesthetist1LabtechniciantoensurebloodtestingandmatchingPlus:InfectionControlOfficer,LabTechniciansandAssistants,Pharmacist2driverstocoverfor24/71coach(seniororretired)whoisrespectedandexperiencedSeveralstudentstowatch,assist,becoachedatthebedsideandinthelabourward,andintheOperationTheatre
25EmONC Improvement Plan of Action 2016 - 2019
Table 10: Midwives and doctors actually present and needed in each candidate BEmONC facility (Type2-CSI;Type3-CHC)
Region Municipality Facility TypeN°
Births
Actual
MW
Actual
Dr
Norm
MW
Norm
Dr
Balance
MW
Balance
Dr
1 Baucau Quelicai 2 238 5 3 4 2 +1 +1
Baguia 3 215 1 1 4 2 -3 -1
Lautem LosPalos 2 586 10 7 8 4 +2 +3
Iliomar 3 48 1 2 4 2 -3 0
Luro 3 24 1 7 4 2 -3 +5
Viqueque Viqueque 2 383 7 4 8 4 -1 0
Uatulari 3 277 2 3 4 2 -2 +1
Lacluta 3 78 2 1 4 2 -2 -1
Uatucarbo 3 96 2 3 4 2 -2 +1
2 Aileu AileuVila 2 554 5 5 8 4 -3 +1
Remexio 3 177 4 3 4 2 0 +1
Ainaro AinarVila 2 199 7 6 4 2 +3 +4
Hautio 3 4 1 2 4 2 -3
Manufahi Same 2 370 8 2 8 4 0 -2
Fatuberlih 3 121 3 1 4 2 -1 -1
3 Dili Atauro 3 104 3 2 4 2 -1 0
Becora 3 557 17 9 8 4 +9 +5
VeraCruz 3 655 13 8 12 6 +1 +2
Centro 3 313 8 1 8 4 0 -3
Ermera Gleno 2 324 6 1 8 4 -2 -3
Atsabe 3 147 2 3 4 2 -2 +1
Hatolia 3 55 2 4 4 2 -2 +2
Liquica Liquica 2 304 4 1 8 4 -4 -3
Fatumasi 3 90 2 1 4 2 -2 -1
Maubara 3 176 5 1 4 2 +1 -1
Manatuto Manatuto 2 204 8 9 4 2 +4 +7
Laclubar 3 82 3 2 4 2 -1 0
26 EmONC Improvement Plan of Action 2016 - 2019
Table 11: Midwives and doctors actually working in the maternities of the CEmONC facilities in Timor-Leste, and recommended numbers
CEmONC Facilities (Hospitals)
Region Municipality Facility TypeN°
Births
Actual
MW
Actual
Dr
Norm
MW
Norm
Dr.Balance MW
Balance
Dr.
1 Baucau Baucau 1 1286 16 3 16 8 0 -5
2 Ainaro Maubisse 1 351 7 0 8 4 -1 -4
4 Bobonaro Maliana 1 655 12 1 12 6 0 -5
4 Covalima Suai 1 573 11 0 8 4 +3 -4
SpR Oecusse Oecusse 1 349 8 2 8 4 0 -2
3 Dili HNGV 1 4302 20 10 20 10 0 0
3 Dili Private 1 293 10 5 8 4 +2 +1
Total Hospitals 7809 84 21 80 40 +4 -19
Jobsatisfactionbeingacrucialfactorforretention,alleffortswillbemadetoimproveitatlowcost.“Takecareofyourstaff;theywilltakebettercareofyourpatients”.Studiesinallcountriesconcurtoshowtheimportanceoftheconditionsofworkandlifeonstaffretention.
Region Municipality Facility TypeN°
Births
Actual
MW
Actual
Dr
Norm
MW
Norm
Dr
Balance
MW
Balance
Dr
Natarbora 3 23 2 3 4 2 -2 +1
4 Bobonaro Lolotoe 3 24 2 2 4 2 -2 0
Atabe 3 90 2 4 4 2 -2 +2
Bobonaro 3 60 2 3 4 2 -2 +1
Marco 3 76 3 3 4 2 -1 +1
Covalima Zumalai 3 154 3 6 4 2 -1 +4
Tilomar 3 150 1 3 4 2 -3 +1
Fohorem 3 48 1 1 4 2 -3 -1
SpR Oecusse Passabe 3 25 1 2 4 2 -3 0
Total 36 candidates BEmONC facilities
36 7031 149 119 184 92 -35 +27
27EmONC Improvement Plan of Action 2016 - 2019
ANationalTechnicalCommitteewillreviewtheNormsandStandardsforthemanagementofobstetricandNewborncomplications,adaptingtheinternationalstandardsprovidedbyWHOtothelocalspecificities.ThesameCommitteewillalsoreviewtheTrainingPackageforEmONCin-servicecurricula.TrainingneedsforEmONCwillberegularlyevaluatedbysupervisorsateachfacility,sothatallcadreswillbeappropriatelysenttotrainingsessions.Eachlargefacility(CEmONCfacilities)shouldhavemannequinsandanatomicalmodelsfor thepractical trainingof studentsandof the staffondutywhen idle.Coachingwillbedevelopedtoensurethatthebenefitsoftrainingareusefulinfurtherpractice,usingretiredseniorprofessionalswithupgradedcompetencies.
EmONC should become an essential part of pre-service education for midwifery andmedicine,sothatfreshlycertifiedmidwivesanddoctorshavebeenexposedtotheconceptbeforestartingtheirduties.
ItisessentialthatEmONCorientationandtrainingisalsodispensedtostaffotherthanmidwives,whoparticipateintheservicedelivery,suchasnurses,OTstaff,labtechnicians,managers,ambulancedrivers.
The participation of all concerned EmONC staff atMaternalDeathAudits andAuditsofNearMissedcases is stronglyencouragedandshouldbe formalized, inviewof thepowerfultrainingbenefitsoftheseprocedures.
TheEmONCtrainingand lifesavingskillscoachingshouldbeconducted inevery largematernitywithmannequinsandanatomicalmodels,inparalleltothedailyservice.
It is recommended to upgrade three (3) additional Clinical Training Sites, in 3 referralhospitals (Baucau, Suai and Maubisse) with training rooms and accommodationarrangementsfortraineesandcoaches.Theywillalsobeusedbystudents(medicalandmidwiferystudents)aswellasformidlevelprofessionalswhojustfinishedaspecializedtrainingsessionandneedcoaching.
Thisinservicetraining/coachingshouldbefocusedonlesspracticedsignalfunctionssuchasmanualvacuumextraction,manualremovalofplacenta,managementofpre-eclampsia,newbornresuscitation.
28 EmONC Improvement Plan of Action 2016 - 2019
3.4 Output 4 - Increased Access and utilization of EmONC services: Strengthening service delivery –Quality
AllEmONCsignalfunctionsarelifesaving. Iftherearenotenoughpatientspresentingwitheachobstetriccomplications,supervisorsmustorganizesmallrefreshersessionstoremindstaffofthenecessaryprotocolsandpracticewithinstruments.
Allsignalfunctionsmustbeavailablewithoutdelay24hoursperdayand7daysperweek(24/7).Thecalendarofduties for thestaffmustbeavailable toall staffand frequentlysupervised.Measurestoreplaceinvalidorsickstaffmusthavebeenprepared.
TheMoHwillissueanddistributenationallyapprovednorms,protocolsandprocedurestomanageallpossiblecases:theseprotocolsaretaughtinclinicaltrainingsessions,buttheymustbeavailableinallunitsatalltimesforconsultation.
Accordingtoneeds,anumberofadditionalfunctionscanbeaddedinthelistoffunctionsreadytouseinEmONCfacilitiese.g.PMTCT,partograph,repairoftears,foetalmonitoringduring labor, dexamethasone and prematurity, antibiotics for premature rupture ofmembranes,KangarooMotherCare,NewbornCorners
Surgery
TheimprovementofEmONCandparticularlyCEmONCfacilitieswillleadtoanincreaseintheproportionofbirthsneedingaCesareansection(C-section).Thiswillneed:
1. Anincreaseinthenumberoftrainedsurgeons,andtrainedanesthetists,andtrainedinstrumentation.AllgeneralsurgeonsmustbecompetenttoperformC-section;
2. Improvementof the indications forC-section,especiallyonC-section for thesakeofthenewborn;
3. Improvementofthecapacityandauthorityofmidwivestodecidereferralandtoactuallyrefer;
4. Improvementofcommunicationsandreferralsystems;
5. Increasedattentiontoqualityoftheprocedure,infectioncontrol,andcareforadverseeffects.
TheincreaseinthenumberofCesareansectionsmustnotinduceanincreaseofthenumberof complications of C-section. Themore interventions themore risks, and the highertheneedforsupervising,checkingforquality,andpreventaccidents(sepsis,ruptureofarteries,haemorrhage,ruptureofscars,etc.)
Anotherareaforconsiderationisthepossibilityforobstetriciansandsurgeons,ifproperlytrained, toperformotheremergency surgicalprocedurese.g. hysterectomy for severePPH,explorationofhemoperitonium,uterinerupture,ruptureofovariancysts,repairoflargeperinealtears,andectopicpregnancy.
29EmONC Improvement Plan of Action 2016 - 2019
Blood transfusion
Asaprinciple,whenindicated,bloodshouldbetransfusedwithinonehourwithinCEmONCfacilitiesand2hourswhenrequestedbyBEmONCfacility.
TheNationalBloodBankStrategyshouldbeimplementedimmediately.Itisresponsibleforpoliciesandproceduresforcollectingblood,testing,grouping,crossmatchingandtransfusing.Blood shouldbe available24/7 at allCEmONC facilities, stored in specialfridgeskeepingsmallprovisionsofbagsofeachgroupforimmediateuse.
ThereshouldbeaLabTechnicianwith fullknowledgeofbloodtransfusionproceduresalwayspresentinCEmONCfacilities.
TrainingIssuesabouttestingandcrossmatching,qualitycontrol,testingforHIV,HepBandotherdiseasesareundertheresponsibilityofBloodBank, incoordinationwithhospitalmanagement.
Where is the “N” in EmONC?
The“N”inEmONChasbeentoooftenneglected,limitedtotheseventhsignalfunction“basicnewborncare”.Infactthissignalfunctionisonepartofacompleteseriesoflifesavinginterventions,collectivelyandjointlycalledEssentialNewbornCare(ENBC).Thisisapackageofinterventionsdeliveredtothemotherandthenewbornbetweendeliveryandthefirst3daysafterbirth.UNICEFhasalreadyinitiatedandwillcontinuetocontributetothissection.Box2andAnnex9detailtheinterventions.InthesamewayasMaternalDeathAudits,thereshouldbeNewbornDeathAudits,aswellasreviewsof“nearmisses”.
BOX - 2 Care for all mothers and newborns
Intrapartum and Immediate Newborn Care
(INC)
The First Embrace.Interventionsincludeimmediateandthoroughdrying;immediateskintoskincontact;appropriatelytimedcordclamping;andnonseparationofmotherandnewbornforearlyexclusivebreastfeeding.
Care for high risk mothers and newborns
Management of newborn infants who are not breathing despite thorough drying.Interventionsincludemanagementofasphyxiausingbagandmaskventilation.Carefullychecktherhythmandintensityofblowingviaobservationofthethoraxandabdomen.Checkforairleakagearoundface.
Expanded INC Prevention and management of prematurity–forpretermandlowbirthweight babies (7-8% of all newborns). Interventions include preventingunnecessaryinductionsandcaesariansections;antibioticsforprematurepre-laborruptureofmembranes;antenatalsteroids;tocolyticswhenindicated;andtheKangarooMotherCareapproach.
Care for Sick Newborns–forbabieswithbirthasphyxia,neonatalsepsisandcomplicationsofdelivery(10-15%ofallnewborns).Interventionsincludemanagement of asphyxia using bag and mask ventilation; identificationof babies at high risk, management of sepsis through antibiotics, andmanagement of other common problems i.e check for malformations,neurologicalexamination.
30 EmONC Improvement Plan of Action 2016 - 2019
3.5 Output 5 – Referral system in place and operational in all parts of the country: Network of referral, communication and transport
Referralistheproductofthreefactorscommunication,roadsandvehicles.
InTimor-Lestemostmajorinter-municipalityroadsarenowbeingpavedandcanbeusedatallseasons.Alotofimprovementremainstobedoneinsecondaryroads.Thetelephonenetwork has also improved, now covering almost all villages and at least all locationswhereHealthPostsaresituated.Theambulancesandmultipurposevehiclesarenowmoreavailable,andthepopulationmayalsoinsomecasestakeadvantageofprivatevehicles,aswellaslocalsmallvehiclesinvillages.
Theminimumtraveltimeof2hoursfromanypointofthecountrytoahealthfacilityisrespectedinthegreatmajorityofvillages.Effortsshouldbemadetorespectiteverywhere.Theother“GoldenRule”specifiesthatallhealthfacilitiesshouldbelessthantwohoursfromahigherlevelreferralfacility.
Whatremainstobeconsiderablydeveloped,however,aretheconditionsofreferral,thecomfort of the patient, the competency of the accompanying personnel, the first aidtrainingofthedrivers,andthereceptionattheendpoint.
ThesepointsmustbesubjectedtoaseriesofauditsledbytheMunicipalityauthorities,andfollowedbyinstructionstominimizetherisksofdeathsduringtransport.
FirstaidtrainingofdriverscanbeperformedbytheRedCrossortheRoyalAustralianCollegeofSurgeons.MoreimportantistheobligationforeachreferralofemergencycasetobeaccompaniedbyanEmONCtrainedperson,equippedwithaminiemergencykitallowinghim/hertoprovidecomforttothepatient.
Many countries in theworld are nowequippedwith “CallCenters”, that is a toll freemobilephonenumberallowinganymidwifeorhealthpersonnelinaremotelocalityorinadifficultsituatione.g.facingaseverecomplication,toobtain24/7anadviceandasupporttohelpmakingthebestdecision.Acontractofhumanitariannaturewiththecellphonecompaniespresentinthecountrywouldprovidethefinancialsupportforsuchanetworkofcallcenters.
31EmONC Improvement Plan of Action 2016 - 2019
3.6 Output 6 –Municipality EmONC plans developed, fully operationalized and monitored by DSMs and MoH: Management, budgeting and financing
Managing an EmONC facility, particularly CEmONC, requires a strong backgroundof administrative processes, which is usually not present among medical doctors.Experience and specialized training are necessary, whichmay require the involvementofretiredmanagersandspecialistsinmanagementofhealthorganizations.It is indeedtheresponsibilityoftheMinistryofHealthandtheExecutiveDirectorstoensurepropermanagementoftheirEmONCfacilitiesandtoensuresupportivesupervision.
DSMsshouldalsoreceiveacertainamountofautonomytoraiseresourcesatmunicipalitylevelforimprovingEmONC.
Annualactivityplanswithcorrespondingbudgetsandannualreportsareessentialtoolsofagoodmanager
Quality control
ManagersareresponsibleforensuringthatqualityproceduresarefollowedforallEmONCservices. Infectioncontrol isoneof themost importantmeasures.AgoodexampleofastrategyforQualityImprovementisproposedinAnnex10.
Annex11alsoprovidesanexampleofamonitoringsheetthatDPHO-SMIofficersshouldapplytoallEmONCfacilitieseveryyeartomonitortheperformanceofsignalfunctions.
Maintenanceof teamspiritandconflictprevention/resolutionarealsoamongtheskillsneededfrommanagers.
3.7 Output 7 – Community participation strengthened for improved awareness and increased utilization of EmONC services
Thecommunityisthefirsttargetofaprogrammetoreducematernalandnewbornmortality.Itisthereforelogicaltoinvolveitsrepresentativesinawarenessraising,informationsharing,andqualitycontrol.
TheHealthPostsremainthemostimportantentitiestoensurecommunityparticipation,awareness,andallpreventiveandeducativeactivities. InthecontextofPrimaryHealthCare,doctorsandmidwivesperformantenatalandpostnatalhomevisits,duringwhichtheycanraiseawarenessofdangersigns,encourageinstitutionaldeliveryandfacilitatetransporttothenearestfacility.
VillagecommitteesaswellaslocalNGOsshouldalsoparticipateintheawarenessofthepopulationaboutEmONC.
32 EmONC Improvement Plan of Action 2016 - 2019
33EmONC Improvement Plan of Action 2016 - 2019
4. EXECUTION, CALENDAR, AND IMPLEMENTATION RESPONSIBILITIES
The EmONC improvement Plan of Action covers four years, and not everything can be implemented at once or the first year. It will be the responsibility of DSMs and their DPHO-SMI to build Annual Plans at the beginning of each year and to prepare Annual Reports at the end of each year. As an example, it may not be possible to upgrade all desired BEmONC facilities in a municipality the first year. Priorities have to be fixed. The table on “candidates for upgrade” can be used to indicate priorities over the 4 years. Maps have been prepared to help planning the networks. Regional and municipality maps are presented in Annex 14.
The MCH Department remains the focal point for implementation and monitoring and evaluation of the EmONC Improvement Plan, as well as keeping an eye on finances. They will receive continuous support and technical assistance from international donor agencies.
To that effect, an attempt will be made to cost the management of each obstetric and newborn complication, and estimate the incidence of each complication.
Table 12 Indications of the order of priorities and calendar distribution of implementation
Items Year one Year two Year three Year four
Policy decisions
and Enabling Environment
- Name a National EmONC Coordinator
- Establish National EmONC Technical Committee to review Norms and Standards, including for staffing, training and management
- Enact Blood Transfusion Strategy and implement it with WHO technical Assistance
- Instructions to DSMs to start upgrading action
- Revise and introduce uniformized Registers to monitor EmONC, in coordination with HMIS
- Issue national norms and guidelines for Referral (Golden Rules) using the same Technical Committee
- Monitor implementation
- Disseminate quality improvement strategy
- Review general situation and adjust for pending priorities
- Calculate EmONC Process indicators
- End of Plan of Action Evaluation
- Plan a national assessment focusing on Signal Functions
Upgrading facilities to BEmONC :
infrastructure
- Finalize selection of Candidates for upgrade, prioritize.
- DSMs to initiate infrastructural work in priority facilities
Continue infrastructural work in second priority facilities
Continue infrastructural work in third priority facilities
Continue infrastructural work in fourth priority facilities
34 EmONC Improvement Plan of Action 2016 - 2019
Items Year one Year two Year three Year four
Strengthening CEmONC facilities
- Initiate infrastructural improvements in all CEmoNC
- Review surgical conditions
Human Resources Staffing/Training
- Review essential staffing of selected BEmONC facilities and reshuffle staff if /when/where necessary
- The National Technical Committee for EmONC will standardize BEmONC inservice Training Package
- Recruit trainers and tutors for clinical training from among senior midwives from all municipality
- Start BEmONC training - Review Pre-service Training to
include BEmONC for Doctors and Midwives, with University of Timor-Leste and Directors of Schools
- Review staffing in view of increased activity of facilities and react accordingly
- Supervise staff performance and provide coaching where necessary
- Continue BEmONC Training
- Review staffing in view of increased activity of facilities and react accordingly
- Supervise staff performance and provide coaching where necessary
- Continue BEmONC Training
- Review staffing in view of increased activity of facilities and react accordingly
- Supervise staff performance and provide coaching where necessary
Equipment and Supplies
- Collect and review lists of missing equipment/supplies provided by candidates facilities and start procurement
- Send maintenance units to facilities
- Supervise distribution and utilization of old and new equipment and supplies
- Review missing and non-functioning equipment and supplies: respond.
- Review missing and non-functioning equipment and supplies: respond
Procurement and
distribution of EmONC medicines
- Collect and review lists of missing medicines provided by candidate EmONC facilities and start procurement
- Set up monitoring and warning systems to prevent stock outs
- Supervise distribution and utilization of medicines
- Check Emergency Trolleys in labour rooms
- Supervise distribution and utilization of medicines
- Check Emergency Trolleys in labour rooms
- Supervise distribution and utilization of medicines
- Check Emergency Trolleys in labour rooms
Referral - DSMs Review human and material resources for referral
- Order missing vehicles and spare parts
- Initiate First Aid training for drivers
- DSMs Review human and material resources for referral
- Implement First Aid training for drivers
- DSMs Review human and material resources for referral
- DSMs Review human and material resources for referral
Quality Improvement
- Start planning supervision teams to review quality at all levels of EmONC management. Involve Medical Association and Midwives Association
- Respond to needs identified by supervision visits
- Respond to needs identified by supervision visits
- Respond to needs identified by supervision visits
35EmONC Improvement Plan of Action 2016 - 2019
Items Year one Year two Year three Year four
Partograph - Review deficiencies and plan remedial action at National and municipality levels
- Implement remedial actions
- Implement remedial actions
- Implement remedial actions
Maternal/newborn
Death Reviews
- Review deficiencies and plan remedial action at National and municipality levels
- Implement remedial actions
- Implement remedial actions
- Implement remedial actions
Community Involvement
- MoH to link with Ministry of Local Administration to involve Suco and Aldeia Chiefs in awareness and promotion of EmONC in their communities
- MoH issue circulars and instructions to Health Posts to raise awareness and utilization of EmONC facilities
- Liaise with local leaders and local civil society organizations to raise awareness and utilization of EmONC
- Implement community involvement around EmONC facilities
- Liaise with local leaders and local civil society organizations to raise awareness and utilization of EmONC
- Implement community involvement around EmONC facilities
- Liaise with local leaders and local civil society organizations to raise awareness and utilization of EmONC
- Implement community involvement around EmONC facilities
- Liaise with local leaders and local civil society organizations to raise awareness and utilization of EmONC
36 EmONC Improvement Plan of Action 2016 - 2019
37EmONC Improvement Plan of Action 2016 - 2019
5. COSTING, MONITORING AND EVALUATION
5.1 Executive summary of the Costing Report In order to be implemented and supported by development partners, the EmONC Improvement Plan of Action (IPA) was costed.The costing of the following components were considered;
1. Costing of additional infrastructure, to build, including pre-natal rooms
2. Cost of upgrading the BEmONC candidate facilities (rehabilitation)
3. Cost of remunerating newly recruited health workers
4. Cost of purchasing and distribution (logistics) of drugs and supplies required by the additional patients (pregnant mothers and newborns) presented to BEmONC and CEmONC facilities resulting from improvement plans of actions;
5. Costing of Programme Management functions (including developing norms, standards and other guidelines development, capacity building, system reorientations, community awareness/advocacy, M & E activities, and supply logistics), presented at national level and not by municipality.
WHO One Health Tool (OHT) was used for the cost estimates. Unit costs were obtained from relevant Directorates of Ministry of Health, values presented in the IPA, the cost assumptions used in the RMNCAH strategy 2015-2019 cost assessment report, UNICEF and UNFPA product catalogues, and OHT default data base. For few items, for which the unit cost was not available from any of the above sources, respective costs were obtained by perusing the commercial costs quoted in the internet.
Findings are summarized by 13 Municipalities, with the exception of the program management cost, which is estimated at national level.
The total estimated cost for implementing the Improvement Plan of Action (IPA) over 4 years will be around 7,983,081 US $ (Table 13). The expenditure will be highest during the first 2 years, which will be around 2.6 and 2.2 million US$ respectively (Table 13). This is because investments related to priority one and two BEmONC institutions, will be made during these 2 years. Year 3 and 4 require around 1.98 and 0.9 million US$ respectively.
At Municipality levels, infrastructure construction, rehabilitation and utility costs together became the largest cost driver, which is around 2.4 million US$ (34%). Equipment supplies also amounted to 2.2 million US$ (31%). Human resource salaries amounted to 2 million US$ (28%) while the incremental cost of drugs and supplies required for IPA will be around 0.5 million US$ (7.4%) (Table 14)
Figure 6 shows how different cost elements drive total cost over time.
38 EmONC Improvement Plan of Action 2016 - 2019
Figure 6 Distribution of costs over time
Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total
Aileu
Drugs & Supplies 4,815 5,045 5,257 5,445 20,562
Human resource costs 24,000 24,000 24,000 24,000 96,000
Equipment cost 14,249 22,297 - - 36,546
Infrastructure construction cost (pre-natal rooms)
33,000 33,000 - - 66,000
Infrastructure rehabilitation cost
6,784 20,086.00 - - 26,870
Infrastructure utility cost (Pre -natal rooms)
1,650 3,300 3,300 3,300 11,550
Total for the Municipality 84,498 107,728 32,557 32,745 257,528
Table 13 Summary of the estimated costs over four years by Municipality
Sub-Total 2,675,443 2,258,694 1,950,806 1,098,138TOTAL 7,983,081
Year1 Year2 Year3 Year4Drugs&supplies 105,368 126,390 146,583 165,643
Humanresourcecosts 347,856 500,233 615,073 615,073
Equipmentcost 727,889 826,591 612,931 67,197
Infrastructureconstructioncost(Pre-natalrooms) 951,000 390,000 291,000 33,000
Infrastructurerehabilitationcost 313,590 95,421 82,774 12,362
Infrastructureutilitycost(Pre-natalrooms) 47,850 67,650 84,150 80,850
Programmemanagementcost 181,890 252,409 118,295 124,013
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
39EmONC Improvement Plan of Action 2016 - 2019
Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total
Ainaro
Drugs & Supplies 5,546 7,005 8,571 10,242 31,364
Human resource costs 51120 69480 69480 69480 259560
Equipment cost 91,112 90,943 - - 182,055
Infrastructure construction cost (pre-natal rooms)
66,000 33,000 - - 99,000
Infrastructure rehabilitation cost
34,659 3,500 - - 38,159
Infrastructure utility cost (Pre -natal rooms)
3,300 4,950 4,950 4,950 18,150
Total for the Municipality 251,737 208,878 83,001 84,672 628,288
Baucau
Drugs & Supplies 10,072 10,852 11,594 12,287 44,805
Human resource costs 24,000 24,000 24,000 24,000 96,000
Equipment cost 13,135 109,320 - - 122,455
Infrastructure construction cost (pre-natal rooms) 148,500 33,000 - - 181,500
Infrastructure rehabilitation cost 3,734 3,734 - - 7,468
Infrastructure utility cost (Pre -natal rooms) 7,425 9,075 9,075 9,075 34,650
Total for the Municipality 206,866 189,981 44,669 45,362 486,878
40 EmONC Improvement Plan of Action 2016 - 2019
Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total
Bobonaro
Drugs & Supplies 8,067 10,100 12,073 13,961 44,201
Human resource costs 26,640 38,880 56,520 56,520 178,560
Equipment cost 8,453 63,806 105,456 - 177,715
Infrastructure construction cost (pre-natal rooms) 148,500 33,000 66,000 - 247,500
Infrastructure rehabilitation cost - 24,137 34,748 - 58,885
Infrastructure utility cost (Pre -natal rooms) 7,425 9,075 12,375 12,375 41,250
Total for the Municipality 199,085 178,998 287,172 82,856 748,111
Covalima
Drugs & Supplies 6,841 7,332 7,792 8,214 30,179
Human resource costs 42,840 66,600 90,360 90,360 290,160
Equipment cost 87,228 95,717 93,899 - 276,844
Infrastructure construction cost (pre-natal rooms)
148500 33000 33000 - 214,500
Infrastructure rehabilitation cost
1650 6355 13475 - 21,480
Infrastructure utility cost (Pre -natal rooms)
7,425 9,075 10,725 10,725 37,950
Total for the Municipality 294,484 218,079 249,251 109,299 871,113
41EmONC Improvement Plan of Action 2016 - 2019
Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total
Dilli
Drugs & Supplies 35,099 39,603 43,929 47,999 166,630
Human resource costs 6,120 6,120 6,120 6,120 24,480
Equipment cost 111,172 73,363 86,200 67,197 337,932
Infrastructure construction cost (pre-natal rooms) 33000 33000 33000 33000 132,000
Infrastructure rehabilitation cost 3,860 5,775 3,980 12362 25,977
Infrastructure utility cost (Pre -natal rooms) 1,650 3,300 6,600 8,250 19,800
Total for the Municipality 190,901 161,161 179,829 174,928 706,819
Ermera
Drugs & Supplies 7,565 11,223 14,484 17,271 50,543
Human resource costs 42,120 72,000 84,240 84,240 282,600
Equipment cost 47,583 97,413 22,903 - 167,899
Infrastructure construction cost (pre-natal rooms) 33,000 33,000 33,000 - 99,000
Infrastructure rehabilitation cost 6,835 7,026 4,294 - 18,155
Infrastructure utility cost (Pre -natal rooms) 1,650 3,300 4,950 4,950 14,850
Total for the Municipality 138,753 223,962 163,871 106,461 633,047
42 EmONC Improvement Plan of Action 2016 - 2019
Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total
Lautem
Drugs & Supplies 5,479 6,483 7,454 8,378 27,794
Human resource costs 12,240 30,600 48,960 48,960 140,760
Equipment cost 65,559 62,373 88,706 - 216,638
Infrastructure construction cost (pre-natal rooms) 30,000 30,000 30,000 - 90,000
Infrastructure rehabilitation cost 127,500 3,664 - - 131,164
Infrastructure utility cost (Pre -natal rooms) 1,650 3,300 4,950 4,950 14,850
Total for the Municipality 242,428 136,420 180,070 62,288 621,206
Liquica
Drugs & Supplies 5,427 7,184 8,894 10,537 32,042
Human resource costs 29,880 47,520 65,880 65,880 209,160
Equipment cost 30,946 36,377 99,082 - 166,405
Infrastructure construction cost (pre-natal rooms) 33,000 33,000 33,000 - 99,000
Infrastructure rehabilitation cost 6,260 5,700 19,500 - 31,460
Infrastructure utility cost (Pre -natal rooms) 1,650 3,300 4,950 - 9,900
Total for the Municipality 107,163 133,081 231,306 76,417 547,967
43EmONC Improvement Plan of Action 2016 - 2019
Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total
Manatuto
Drugs & Supplies 2,975 3,962 4,924 5,847 17,708
Human resource costs - 6,120 18,360 18,360 42,840
Equipment cost 12,386 42,937 42,334 - 97,657
Infrastructure construction cost (pre-natal rooms) 30,000 30,000 30,000 - 90,000
Infrastructure rehabilitation cost 4,909 3,221 3,624 - 11,754
Infrastructure utility cost (Pre -natal rooms) 1,650 3,300 4,950 4,950 14,850
Total for the Municipality 51,920 89,540 104,192 29,157 274,809
Manufahi
Drugs & Supplies 1,883 2,281 2,667 3,035 9,866
Human resource costs 7,656 21,433 21,433 21,433 71,955
Equipment cost 77,620 73559 - - 151,179
Infrastructure construction cost (pre-natal rooms) 33000 33,000 - - 66,000
Infrastructure rehabilitation cost 32,899 7299 - - 40,198
Infrastructure utility cost (Pre -natal rooms) 1650 3,300 3,300 3,300 11,550
Total for the Municipality 154,708 140,872 27,400 27,768 350,748
44 EmONC Improvement Plan of Action 2016 - 2019
Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total
Oecusse
Drugs & Supplies 5,059 7,420 9,727 11,953 34,159
Human resource costs 57,240 57,240 57,240 57,240 228,960
Equipment cost 31,359 - - - 31,359
Infrastructure construction cost (pre-natal rooms) 148500 - - - 148,500
Infrastructure rehabilitation cost* NA NA NA NA NA
Infrastructure utility cost (Pre -natal rooms) 7425 7,425 7,425 7,425 29,700
Total for the Municipality 249,583 72,085 74,392 76,618 472,678
Viqueque
Drugs & Supplies 6,540 7,900 9,217 10,474 34,131
Human resource costs 24000 36,240 48,480 48480 157,200
Equipment cost 137,087 58,486 74,351 - 269,924
Infrastructure construction cost (pre-natal rooms) 66000 33,000 33,000 - 132,000
Infrastructure rehabilitation cost 84,500 4,924 3,153 - 92,577
Infrastructure utility cost (Pre -natal rooms ) 3300 4,950 6,600 6,600 21,450
Total for the Municipality 321,427 145,500 174,801 17,074 658,802
All 13 Municipalities
Total cost from all cost elements
2,493,553 2,006,285 1,832,511 974,125 7,306,475
Overall program management cost -
As national estimate181,890 252,409 118,295 124,013 676,607
Grand Total for IPA implementation 2,675,443 2,258,694 1,950,806 1,098,138 7,983,081 Engineering unit was unable to to visit Oeucusse to callect this data
45EmONC Improvement Plan of Action 2016 - 2019
The following radar chart (Figure 7) and Table 14 describes the cost of proposed improvement plans of actions according to their relative sizes of expenditures by different cost elements. It shows that infrastructure construction costs in Bacau, Bobonaro, Covalima and OeCusse Municipalities. The reasons for these high estimates are the building of new training sites in these institutions. The equipment costs of Municipalities that have relatively larger number of EmONC institutions seemed to be relatively high. (E.g. in Dili, Viqueque)
Figure 7 Radar chart showing relative costs related to different cost elements by Municipality
46 EmONC Improvement Plan of Action 2016 - 2019
Tabl
e 14
Est
imat
ed c
ost o
f IPA
in th
e M
unic
ipal
ities
by
cost
com
pone
nts
Mun
icip
ality
D
rugs
&
Supp
lies
Hum
an
reso
urce
co
sts
Equi
pmen
t co
st
Infr
astr
uctu
re
cons
truc
tion
cost
(pre
-na
tal r
oom
s)
Infr
astr
uctu
re
reha
bilit
atio
n co
stIn
fras
truc
ture
util
ity
cost
(Pre
-nat
al ro
oms)
Tota
l
Aili
eu20
,562
96
,000
36,5
4666
,000
26,8
7011
,550
257,
528
Ain
aro
31,3
64
2595
6018
2,05
599
,000
38,1
5918
,150
628,
288
Bauc
au44
,805
96
,000
122,
455
181,
500
7,46
834
,650
486,
878
Bobo
naro
44,2
0117
8,56
017
7,71
524
7,50
058
,885
41,2
5074
8,11
1
Cova
lima
30,1
7929
0,16
027
6,84
421
4,50
021
,480
37,9
5087
1,11
3
Dili
166,
630
24,4
8033
7,93
413
2,00
025
,977
19,8
0070
6,82
1
Erm
era
50,5
4328
2,60
016
7,89
999
,000
18,1
5514
,850
633,
047
Laut
em27
,794
140,
760
216,
637
90,0
0013
1,16
414
,850
621,
205
Liqu
ica
32,0
4220
9,16
016
6,40
599
,000
31,4
609,
900
547,
967
Man
atut
o17
,708
42,8
4097
,657
90,0
0011
,754
14,8
5027
4,80
9
Man
ufah
i9,
866
71,9
5515
1,17
966
,000
40,1
9811
,550
350,
748
Oec
usse
34,1
5922
8,96
031
,359
148,
500
029
,700
472,
678
Viq
uequ
e34
,131
157,
200
269,
924
132,
000
92,5
7721
,450
707,
282
Tota
l 5
43,9
84
2,0
78,2
35
2,2
34,6
09
1,6
65,0
00
504
,147
2
80,5
00
7,30
6,47
5
Perc
enta
ge7.
428
.430
.622
.86.
93.
810
0.0
47EmONC Improvement Plan of Action 2016 - 2019
5.2 Monitoring and evaluationMonitoring is an on going activity, while evaluation is periodic and intermittent. Both must be integrated in the annual plans, and funds must be set apart for these activities.
It is the responsibility of the DSMs to monitor and evaluate the implementation of the EmONC program, and monitor it in coordination with HMIS and DHIS 2.
It is recommended to conduct a mini survey of signal functions performed at each BEmONC facility every year to follow progress and identify training needs. A sample of a monitoring form is provided in Annex 11. The AMDD has proposed a methodology for a mini EmONC assessment that might be worth considering.
Monitoring quality is also part of the responsibility of managers: A Quality improvement initiative is presented in Annex 10.
A midterm Review is proposed at the end of second year of implementation, with a focus on availability, access and utilization of EmONC in each municipality. Remaining gaps and challenges will need to be addressed in the following two years.
Indicators and Log frame are presented in Annexes 1 and 5, respectively
48 EmONC Improvement Plan of Action 2016 - 2019
49EmONC Improvement Plan of Action 2016 - 2019
6. ANNEXES
Annex 1 - Process Indicators
Annex 1 Table 1: Summary of the EmONC Process Indicators (PI) and calculation
PI Indicator Description Numerator Denominator Acceptable Levels
1 & 2 Availability of EmONC facilities and geographic distribution (national or Municipality)
Ratio of facilities providing EmONC to population and geographical distribution of EmONC facilities
No. of facilities providing Basic or Comprehensive EmONC
Population of area divided by 500,000
≥ 5 EmONC facilities per 500 000 population
No. of facilities providing Comprehensive EmONC
Population of area divided by 500,000
≥ 1 Comprehensive per 500 000 population
3 Proportion of all births in EmONC facilities
Proportion of all expected births in EmONC facilities In catchementarea
No. of women giving birth in EmONC facilities in specified time period (1 year)
Expected no. of births in the same catchment area in same time period
15% to 100% (if ALL births should take place in EmONC facilities)
4 Met Need for EmONC
Proportion of women with direct obstetric complications treated at EmONC facilities
No. of women with major direct obstetric complications treated in EmONC facilities in specified time period
Expected no. of women with major direct obstetric complications in area in same time period (expected)
100%
5 Caesarean sections as a proportion of all births
Proportion of all births by Caesarean section taking place in EmONC facilities
No. of Caesarean sections in EmONC facilities in specified time period
Expected no. of births in area in same time period
5% – 15%
6 Direct obstetric case fatality rate (DOCFR)
Proportion of women with major direct obstetric complications who die in an EmONC facility
No. of maternal deaths due to direct obstetric causes admitted in EmONC facilitiy in specified time period
No. of women admitted and treated for direct obstetric complications in EmONC facilitiy in same time period
< 1%
50 EmONC Improvement Plan of Action 2016 - 2019
PI Indicator Description Numerator Denominator Acceptable Levels
7 Intrapartum and very early neonatal death rate
Proportion of births that result in an intrapartum death or a very early neonatal death occurring within the first 24 hours in EmONC facilities
No. of intrapartum deaths (fresh stillbirths; > 2.5 kg) and very early neonatal deaths (≤ 24 hours; > 2.5 kg) in EmONC facilities in specified time period
No. of women giving birth in EmONC facilities in same time period
To be decided but normally < 1%
8 Proportion of maternal deaths due to indirect causes
Out of all maternal deaths in EmONC facilities, what % are due to indirect causes
No. of maternal deaths due to indirect causes in EmONC facilities in specified time period
All maternal deaths (from direct and indirect causes) in EmONC facilities in same time period
None set (depends on the local epidemiology)
Annex 2 – Summary findings of the EmONC NA in 2015
Indicator Finding UN standard/Comments
Current availability
of functional EmONC facilities
3.4 EmONC facilities per 500,000 population ≥ 5 EmONC facilities per 500,000 population
2.6 CEmONC facilities per 500,000 population Of which ≥ 1 Comprehensive per 500,000 population
Geographical distribution of functional
EmONC facilities
EmONC coverage is poor at the sub-national level. Coverage for CEmONC facilities is
sufficient but BEmONC coverage is largely insufficient
Seven Municipalities have no functional EmONC facilities
BEmONC is clustered around urban areas
27 (37%) of facilities assessed are more than two hours travel time from higher level referral
facilities
100% of sub-national areas have the minimum acceptable numbers of
basic and comprehensive EmONC facilities
Proportion of all births in EmONC
facilities
All facilities assessed
47.8% of all expected live births
Functional EmONC facilities
24.6% of all expected live births
Minimum should be 15% but the optimum should be close to 100%
Annex 2 Table 1: Indicators for all facilities assessed and for functional* EmONC facilities Timor-Leste 2015
51EmONC Improvement Plan of Action 2016 - 2019
Indicator Finding UN standard/Comments
Met need for EmONC
services
All facilities assessed
54.7 % of the expected number of women who will develop complications
Functional EmONC Facilities
33.8% of the expected number of women who will develop complications
100% of the estimated complications which is 15% of all
births
Caesarean sections as a
percentage of all births
All facilities assessed
3.5% of all births were by caesarean section
Functional EmONC facilities
3.4% of all births were by caesarean section (1.6% if Dili was excluded)
Minimum 5% Maximum 15%
Direct Obstetric Case Fatality Rate
(DOCFR)
All facilities assessed
0.8 % of women treated with obstetric complications
Functional EmONC facilities
0.9% of women treated with obstetric complications
Standard set at less than 1%
Note: This indicator is not reliable as maternal mortality data is
incomplete.
Intrapartum and very early
newborn death rate
All facilities assessed
0.7% of intrapartum and very early and late newborn deaths
Functional EmONC facilities
1.0% of intrapartum and very early and late newborn deaths
Standard set at less than 1%
Note: The reliability of this data is questionable due to under reporting
Proportion of maternal
deaths due to indirect causes
All Facilities assessed
21.9% of total deaths from all indirect causes
Functional EmONC facilities
26.9% of total deaths from all indirect causes
No standard set –depends on local epidemiology
Note: Data is questionable due to under reporting.
52 EmONC Improvement Plan of Action 2016 - 2019
Annex 3 - Direct Obstetric Complications (DOC, to be used for process indicators 4, 6, and 8); Operational definitions and Signal Functions to manage themIt is highly recommended to enter the cause of admission to the maternity in a separate column in the Admission Register, using the below definitions.
Operational definitions of major direct obstetric complications
1. Antepartum Haemorrhage
• severe bleeding before and during labour: placenta praevia, placental abruption
2. Postpartum Haemorrhage (any of the following)
• bleeding that requires treatment (e.g. provision of intravenous fluids, uterotonic drugs or blood)
• retained placenta
• severe bleeding from lacerations (vaginal or cervical)
• vaginal bleeding in excess of 500 ml after childbirth
• more than one pad soaked in blood in 5 minutes
3. Prolonged or obstructed labour (dystocia, abnormal labour) (any of the following)
• prolonged established first stage of labour (> 12 h)
• prolonged second stage of labour (> 1 h)
• cephalopelvic disproportion, including scarred uterus
• malpresentation: transverse, brow or face presentation
4. Postpartum sepsis
• A temperature of 38 °C or higher more than 24 h after delivery (with at least two readings, as labour alone can cause some fever) and any one of the following signs and symptoms: lower abdominal pain, purulent, offensive vaginal discharge (lochia), tender uterus, uterus not well contracted, history of heavy vaginal bleeding. (Rule out malaria)
53EmONC Improvement Plan of Action 2016 - 2019
5. Complications of abortion (spontaneous or induced)
• haemorrhage due to abortion which requires resuscitation with intravenous fluids, blood transfusion or uterotonics
• sepsis due to abortion (including perforation and pelvic abscess)
6. Severe pre-eclampsia and eclampsia
• Severe pre-eclampsia: Diastolic blood pressure ≥ 110 mm Hg or proteinuria ≥ 3 after 20 weeks’ gestation.
Various signs and symptoms: headache, hyperflexia, blurred vision, oliguria, epigastric pain,
• Eclampsia: Convulsions; diastolic blood pressure ≥ 90 mm Hg after 20 weeks’ gestation or proteinuria ≥ 2. Signs and symptoms of severe pre-eclampsia may be present
7. Ectopic pregnancy
• Internal bleeding from a pregnancy outside the uterus; lower abdominal pain and shock possible from internal bleeding; delayed menses or positive pregnancy test
8. Ruptured uterus
• Uterine rupture with a history of prolonged or obstructed labour when uterine contractions suddenly stopped. Painful abdomen (pain may decrease after rupture of uterus). Patient may be in shock from internal or vaginal bleeding
Major complications Signal Functions or Life Saving Skills to manage them
Haemorrhage
If Antepartum: Cesarean section for placenta praevia – Blood transfusionIf Postpartum: Uterotonics
Manual removal of placentaRemoval of retained productsBlood transfusionEmergency surgery (Hysterectomy)
Annex 3 Table 1: Signal Functions used to manage the major Obstetric and Newborn complications
54 EmONC Improvement Plan of Action 2016 - 2019
Major complications Signal Functions or Life Saving Skills to manage them
Prolonged or obstructed labor
Assisted vaginal delivery
Cesarean section
Uterotonics
Newborn resuscitation
Postpartum sepsis
Parenteral antibiotics
Removal of retained products
Surgery for pelvic collection drainage
Complication of abortion
Removal of retained products
Blood transfusion if hemorrhage
Parenteral Antibiotics
Pre-eclampsia and Eclampsia
Parenteral anticonvulsants (MgSO4)
Cesarean section
Newborn resuscitation
Ectopic pregnancy
Emergency surgery (laparotomy)
Blood transfusion
Parenteral antibiotics
Ruptured uterus
Emergency surgery (laparotomy)
Blood transfusion
Parenteral antibiotics
Newborn distress at birth
Newborn resuscitation (basic and advanced)
Cesarean section
Parenteral antibiotics on newborn
Intrapartum stillbirth Induction of labor (if not spontaneous)
55EmONC Improvement Plan of Action 2016 - 2019
Annex 4 - List of Municipalities with population (in 2014)
Municipality RegionPopulation (in 2014, before
Census)Expected.
Births per yearExpected
complications per year
Expected complications
per day
Baucau
1
122152 4214 632 2
Lautem 67690 2335 350 1
Viqueque 74907 2584 388 1
Aileu
2
51733 1785 268 1
Ainaro 67357 2324 349 1
Manufahi 55735 1923 288 1
Dili
3
312700 10788 1618 4
Ermera 133457 4604 691 2
Liquica 73131 2523 378 1
Manatuto 47521 1639 246 1
Bobonaro4
99954 3448 517 1
Covalima 65032 2244 337 1
Oecussi SpR 73716 2543 381 1
ALL TIMOR LESTE 1245085 42955 6443 18
Place of birth N %
Total Institutional births 21192 52.3
in Health Posts 1831 4.5
in 8 CSIs 2924 7.2
in 59 CHCs 7719 19.1
in 5 Referral Hospitals 3214 7.9
in National Hospital 4302 10.6
in 2 private facilities 1202 3.0
Estimated Home births 19294 47.7
Total estimativa nacidos 40486 100.0
Annex 4 Table 1: expected births and expected obstetric complications
Annex 4 Table 2: Summary of Births during one year as reported by the 2015 EmONC Assessment
56 EmONC Improvement Plan of Action 2016 - 2019
Anne
x 5 -
Logf
ram
e – M
onito
ring
and
evalu
atio
n fra
mew
ork f
or o
utpu
ts
Out
puts
Obj
ectiv
ely
Verifi
able
In
dica
tors
Mea
ns o
f ve
rifica
tion
Targ
et 2
019
Act
iviti
esRe
spon
sibl
eTi
min
g
Out
put 1
Polic
ies
in p
lace
fo
r a s
uppo
rtiv
e
and
enab
ling
envi
ronm
ent f
or
EmO
NC
EmO
NC
Impr
ovem
ent
Plan
of A
ctio
n pu
blish
ed,
dist
ribut
ed, t
o al
l st
akeh
olde
rs in
clud
ing
in
13 M
unic
ipal
ities
Endo
rsem
ent l
ette
rsAl
l st
akeh
olde
rs
info
rmed
Advo
cacy
for i
ncre
ased
visi
bilit
y an
d fin
anci
al c
ontri
butio
n fo
r Em
ON
C ac
tiviti
es
Diss
emin
atio
n of
Em
ON
C Im
prov
emen
t Pla
n to
all
stak
ehol
ders
MdS
DSM
s
2016
Hig
h le
vel c
omm
itmen
t ex
pres
sed
in sp
eech
es,
artic
les,
TV e
vent
s
Med
ia,
Nat
iona
l Day
Advo
cacy
MoH
2016
- 20
19
Partn
ersh
ips e
stab
lishe
d,
MoU
sCo
ntra
cts a
nd
colla
bora
tive
agre
emen
ts
Advo
cacy
Reso
urce
mob
iliza
tion
MoH
2016
- 20
19
Mun
icip
ality
lead
ersh
ip
for E
mO
NC
Impr
oved
Min
utes
of m
eetin
gsfu
llAn
nual
Wor
kpla
ns, a
nnua
l Rep
orts
, su
perv
isory
visi
ts, s
uppo
rtive
ac
tiviti
es
DSM
s
% o
f Em
ON
C fa
cilit
ies
follo
win
g na
tiona
l st
anda
rds a
nd p
roce
dure
s
Mun
icip
ality
repo
rts10
0%Iss
uanc
e an
d di
strib
utio
n to
all
EmO
NC
faci
litie
s of s
tand
ards
and
pr
otoc
ols f
or st
affin
g, e
quip
men
t, an
d ca
se m
anag
emen
t
DSM
s20
16 -
2019
N° S
tock
outs
of e
ssen
tial
med
icin
es a
nd su
pplie
sEl
ectro
nic
data
base
s0
Vigi
lanc
e sy
stem
s put
in p
lace
Ce
ntra
l and
M
unic
ipal
ity
2016
- 20
19
Bloo
d av
aila
bilit
y 36
5/7/
24Re
cord
s of B
lood
tra
nsfu
sion
100%
Expa
nsio
n of
ope
ratio
nal B
lood
D
epot
s in
ALL
CEm
ON
C fa
cilit
ies
Bloo
d Ba
nk/
MO
H
2016
- 20
19
57EmONC Improvement Plan of Action 2016 - 2019
Out
puts
Obj
ectiv
ely
Verifi
able
In
dica
tors
Mea
ns o
f ve
rifica
tion
Targ
et 2
019
Act
iviti
esRe
spon
sibl
eTi
min
g
Out
put 2
Ava
ilabi
lity
and
acce
ssib
ility
of
EmO
NC
faci
litie
s an
d se
rvic
es, i
n al
l par
ts o
f the
co
untr
y
CEm
ON
C fa
cilit
ies
Mun
icip
ality
reco
rds
At le
ast 6
Hos
pita
l adm
inist
ratio
n /D
G to
re
view
stat
us a
nd n
eeds
Hos
pita
l H
eads
/MoH
20
16 -
2019
BEM
ON
C fa
cilit
ies
Mun
icip
ality
reco
rds
At le
ast 3
6 at
the
end
of
IPA
DSM
s to
sel
ect
for
upg
rad
ing
DSM
s20
16 -
2019
Out
put 3
Tech
nica
l and
m
anag
eria
l ca
paci
ty
stre
ngth
ened
to
ens
ure
high
qu
ality
of c
are
% o
f BEm
ON
C fa
cilit
ies
with
at l
east
4 m
idw
ives
an
d 2
doct
ors
DSM
reco
rds
100
%D
SMs t
o re
view
and
adj
ust
DSM
s20
16 -
2019
% o
f mid
wiv
es a
nd
doct
ors t
rain
ed o
n BE
mO
NC
INS
/ MoH
/ D
SM
reco
rds
100%
INS/
MoH
/DSM
s to
revi
ew a
nd
adju
stIN
S/H
ospi
tal
Hea
ds/D
SMs
2016
- 20
19
% o
f mat
erna
l and
ne
wbo
rn d
eath
s rev
iew
ed
thro
ugh
Audi
ts
MoH
/Hos
pita
l /D
SM
reco
rds
50%
MoH
/Hos
pita
l/DSM
s to
revi
ew a
nd
adju
stM
oH/
Hos
pita
l H
eads
/DSM
s
2016
- 20
19
Dire
ct O
bste
tric
Case
Fa
talit
y Ra
teFa
cilit
y re
cord
s, D
SM
reco
rds
< 1%
Impr
oved
iden
tifica
tion
and
reco
rdin
g of
DO
CFa
cilit
y m
anag
ers,
Hea
ds o
f ob
stet
ric
depa
rtmen
ts
2016
- 20
19
% o
f Em
ON
C fa
cilit
ies
with
an
infe
ctio
n pr
even
tion
prog
ram
in
plac
e an
d op
erat
iona
l
Faci
lity
reco
rds
100%
Impr
oved
follo
w u
p of
refe
rred
case
sD
SMs
2016
- 20
19
58 EmONC Improvement Plan of Action 2016 - 2019
Out
puts
Obj
ectiv
ely
Verifi
able
In
dica
tors
Mea
ns o
f ve
rifica
tion
Targ
et 2
019
Act
iviti
esRe
spon
sibl
eTi
min
g
Out
put 4
Util
izat
ion
of
EmO
NC
serv
ices
by
all
in n
eed
% o
f birt
hs in
Em
ON
C fa
cilit
ies
Faci
lity
reco
rds
60%
Advo
cacy
and
boo
king
dur
ing
ANC,
Ref
erra
l sys
tem
ope
ratio
nal
DSM
s/ fa
cilit
y he
ads
2016
- 20
19
% o
f del
iver
ies b
y Ce
sare
an se
ctio
n Fa
cilit
y re
cord
s10
%Re
ferra
l sys
tem
ope
ratio
nal,
OTs
in
ord
er, S
urge
ons i
n pl
ace
24/7
An
esth
etist
s
DSM
s/
Hos
pita
l H
eads
2016
- 20
19
% o
f fac
ilitie
s im
plem
entin
g Es
sent
ial
New
born
Car
e
Faci
lity
reco
rds
100%
Tech
nica
l tra
inin
g in
New
born
car
eD
SMs/
H
ospi
tal
Hea
ds
2016
- 20
19
UN E
mO
NC
Proc
ess
indi
cato
r N° 4
: Met
nee
d fo
r Dire
ct O
bste
tric
Com
plic
atio
ns
DSM
s rec
ords
Faci
lity
reco
rds,
100%
Impr
oved
iden
tifica
tion
of D
irect
O
bste
tric
Com
plic
atio
ns
Impr
oved
refe
rral s
yste
m
Refe
rred
patie
nts a
re a
ccom
pani
ed
by a
trai
ned
mid
wife
DSM
s
Faci
lity
man
ager
s
2016
- 20
19
Out
put 5
Refe
rral
sys
tem
in
pla
ce a
nd
oper
atio
nal i
n al
l par
ts o
f the
co
untr
y
% o
f Em
ON
C fa
cilit
ies
with
insit
u am
bula
nce
read
y 36
5/7/
24 w
ith
train
ed d
river
s
DSM
reco
rds
Faci
lity
reco
rds
100%
Avai
labi
lity
and
mai
nten
ance
of
ambu
lanc
es, a
nd a
vaila
bilit
y of
tra
ined
driv
ers a
roun
d th
e cl
ock
DSM
s Fac
ility
m
anag
emen
t20
16 -
2019
Out
put 6
Mun
icip
ality
Em
ON
C pl
ans
deve
lope
d, fu
lly
oper
atio
naliz
ed
and
mon
itore
d by
DSM
s
% o
f DSM
s with
ann
ual
EmO
NC
Impr
ovem
ent
Plan
and
ann
ual r
epor
ts
DSM
reco
rds
100%
Trai
ning
and
tech
nica
l ass
istan
ce
for D
SMs t
o im
prov
e Em
ON
C m
anag
emen
t, re
cord
kee
ping
, an
alys
is of
cha
lleng
es a
nd re
porti
ng
DSM
s20
16 -
2019
Out
put 7
Com
mun
ity
part
icip
atio
n st
reng
then
ed
for o
ptim
al
utili
zatio
n
% o
f Hea
lth P
osts
with
aw
aren
ess o
f Em
ON
C an
d pr
omot
ion
of
inst
itutio
nal d
eliv
ery
DSM
reco
rds
100%
DSM
s to
enco
urag
e H
CMC
and
Com
mun
e Co
mm
ittee
to m
eet a
nd
disc
uss i
mpr
ovem
ents
of E
mO
NC
DSM
s20
16 -
2019
59EmONC Improvement Plan of Action 2016 - 2019
Anne
x 6 –
Tim
e lin
e fo
r the
impl
emen
tatio
n of
the
EmO
NC Im
prov
emen
t Plan
of A
ctio
n 20
16-2
019
Item
sYe
ar o
neYe
ar tw
oYe
ar th
ree
Year
four
Polic
y de
cisi
ons
and
Enab
ling
Envi
ronm
ent
• N
ame
a N
atio
nal E
mO
NC
Coor
dina
tor
• Es
tabl
ish N
atio
nal E
mO
NC
Tech
nica
l Com
mitt
ee to
re
view
Nor
ms a
nd S
tand
ards
, inc
ludi
ng fo
r sta
ffing
, tra
inin
g an
d m
anag
emen
t
• En
act B
lood
Tra
nsfu
sion
Stra
tegy
and
impl
emen
t it
with
WH
O te
chni
cal A
ssist
ance
• In
stru
ctio
ns to
DSM
s to
star
t upg
radi
ng a
ctio
n
• Re
vise
and
intro
duce
uni
form
ized
Regi
ster
s to
mon
itor E
mO
NC,
in c
oord
inat
ion
with
HM
IS
• Iss
ue n
atio
nal n
orm
s and
gui
delin
es fo
r Ref
erra
l (G
olde
n Ru
les)
usin
g th
e sa
me
Tech
nica
l Com
mitt
ee
• M
onito
r im
plem
enta
tion
• D
issem
inat
e qu
ality
im
prov
emen
t stra
tegy
• Re
view
gen
eral
sit
uatio
n an
d ad
just
fo
r pen
ding
prio
ritie
s
• Ca
lcul
ate
EmO
NC
Proc
ess i
ndic
ator
s
• En
d of
Pla
n of
Act
ion
Eval
uatio
n
• Pl
an a
nat
iona
l as
sess
men
t foc
usin
g on
Sig
nal F
unct
ions
Upg
radi
ng
faci
litie
s to
BE
mO
NC
: in
fras
truc
ture
• Fi
naliz
e se
lect
ion
of C
andi
date
s for
upg
rade
, pr
iorit
ize.
• D
SMs t
o in
itiat
e in
frast
ruct
ural
wor
k in
prio
rity
faci
litie
s
Cont
inue
infra
stru
ctur
al
wor
k in
seco
nd p
riorit
y fa
cilit
ies
Cont
inue
infra
stru
ctur
al
wor
k in
third
prio
rity
faci
litie
s
Cont
inue
infra
stru
ctur
al
wor
k in
four
th p
riorit
y fa
cilit
ies
Stre
ngth
enin
g CE
mO
NC
faci
litie
s•
Initi
ate
infra
stru
ctur
al im
prov
emen
ts in
all
CEm
oNC
• Re
view
surg
ical
con
ditio
ns
Mon
itor i
mpl
emen
tatio
n M
onito
r im
plem
enta
tion
End
of
Plan
of
Ac
tion
Eval
uatio
n
60 EmONC Improvement Plan of Action 2016 - 2019
Item
sYe
ar o
neYe
ar tw
oYe
ar th
ree
Year
four
Hum
an R
esou
rces
St
affin
g/Tr
aini
ng•
Revi
ew e
ssen
tial s
taffi
ng o
f sel
ecte
d BE
mO
NC
faci
litie
s and
resh
uffle
staf
f if /
whe
n/w
here
nec
essa
ry
• Th
e N
atio
nal T
echn
ical
Com
mitt
ee fp
r Em
ON
C w
ill
stan
dard
ize B
EmO
NC
inse
rvic
e Tr
aini
ng P
acka
ge
• Re
crui
t tra
iner
s and
tuto
rs fo
r clin
ical
trai
ning
from
am
ong
seni
or m
idw
ives
from
all
Mun
icip
aliti
es
• St
art B
EmO
NC
train
ing
• Re
view
Pre
serv
ice
Trai
ning
to in
clud
e BE
mO
NC
for
Doc
tors
and
Mid
wiv
es, w
ith U
nive
rsity
of T
imor
-Le
ste
and
Dire
ctor
s of S
choo
ls
• Re
view
staf
fing
in v
iew
of
incr
ease
d ac
tivity
of
faci
litie
s and
reac
t ac
cord
ingl
y
• Su
perv
ise st
aff
perfo
rman
ce a
nd
prov
ide
coac
hing
whe
re
nece
ssar
y
• Co
ntin
ue B
EmO
NC
Trai
ning
• Re
view
staf
fing
in v
iew
of
incr
ease
d ac
tivity
of
faci
litie
s and
reac
t ac
cord
ingl
y
• Su
perv
ise st
aff
perfo
rman
ce a
nd
prov
ide
coac
hing
w
here
nec
essa
ry
• Co
ntin
ue B
EmO
NC
Trai
ning
• Re
view
staf
fing
in v
iew
of
incr
ease
d ac
tivity
of
faci
litie
s and
reac
t ac
cord
ingl
y
• Su
perv
ise st
aff
perfo
rman
ce a
nd
prov
ide
coac
hing
w
here
nec
essa
ry
• Co
ntin
ue B
EmO
NC
Trai
ning
Clin
ical
trai
ning
Ce
ntre
s•
Plan
and
impl
emen
t inf
rast
ruct
ural
wor
k to
tra
nsfo
rm 3
hos
pita
ls in
to C
linic
al tr
aini
ng C
entre
s (B
auca
u, M
aubi
sse,
Sua
i).
• Pr
ocur
e tra
inin
g eq
uipm
ent (
com
pute
rs, p
roje
ctor
s, m
anne
quin
s, an
atom
ical
mod
els,
etc)
• Im
plem
ent a
nd im
prov
e cl
inic
al tr
aini
ng in
thes
e 3
hosp
itals
and
in D
ili
HN
GV
• Im
plem
ent a
nd
impr
ove
clin
ical
tra
inin
g in
thes
e 3
hosp
itals
and
in D
ili
HN
GV
• Im
plem
ent a
nd
impr
ove
clin
ical
tra
inin
g in
thes
e 3
hosp
itals
and
in D
ili
HN
GV
Proc
urem
ent a
nd
dist
ribut
ion
of
equi
pmen
t and
su
pplie
s
• Co
llect
and
revi
ew li
sts o
f miss
ing
equi
pmen
t/su
pplie
s pro
vide
d by
can
dida
tes f
acili
ties a
nd st
art
proc
urem
ent
• Se
nd m
aint
enan
ce u
nits
to fa
cilit
ies
• Su
perv
ise d
istrib
utio
n an
d ut
iliza
tion
of o
ld
and
new
equ
ipm
ent a
nd
supp
lies
• Re
view
miss
ing
and
nonf
unct
ioni
ng
equi
pmen
t and
su
pplie
s: re
spon
d.
• Re
view
miss
ing
and
non-
func
tioni
ng
equi
pmen
t and
su
pplie
s: re
spon
d
Proc
urem
ent
and
dist
ribut
ion
of E
mO
NC
med
icin
es
• Co
llect
and
revi
ew li
sts o
f miss
ing
med
icin
es
prov
ided
by
cand
idat
e Em
ON
C fa
cilit
ies a
nd st
art
proc
urem
ent
• se
t up
mon
itorin
g an
d w
arni
ng sy
stem
s to
prev
ent
stoc
kout
s
• Su
perv
ise d
istrib
utio
n an
d ut
iliza
tion
of
med
icin
es
• Ch
eck
Emer
genc
y Tr
olle
ys in
labo
ur ro
oms
• Su
perv
ise d
istrib
utio
n an
d ut
iliza
tion
of
med
icin
es
• Ch
eck
Emer
genc
y Tr
olle
ys in
labo
ur
room
s
• Su
perv
ise d
istrib
utio
n an
d ut
iliza
tion
of
med
icin
es
• Ch
eck
Emer
genc
y Tr
olle
ys in
labo
ur
room
s
61EmONC Improvement Plan of Action 2016 - 2019
Item
sYe
ar o
neYe
ar tw
oYe
ar th
ree
Year
four
Refe
rral
• D
SMs R
evie
w h
uman
and
mat
eria
l res
ourc
es fo
r re
ferra
l
• O
rder
miss
ing
vehi
cles
and
spar
e pa
rts
• In
itiat
e Fi
rst A
id tr
aini
ng fo
r driv
ers
• D
SMs R
evie
w h
uman
an
d m
ater
ial r
esou
rces
fo
r ref
erra
l
• Im
plem
ent F
irst A
id
train
ing
for d
river
s
• D
SMs R
evie
w h
uman
an
d m
ater
ial r
esou
rces
fo
r ref
erra
l
• Co
ntin
ue F
irst A
id
train
ing
for d
river
s
• D
SMs R
evie
w h
uman
an
d m
ater
ial r
esou
rces
fo
r ref
erra
l
• Co
ntin
ue F
irst A
id
train
ing
for d
river
s
Qua
lity
Impr
ovem
ent
• St
art p
lann
ing
supe
rvisi
on te
ams t
o re
view
qua
lity
at
all l
evel
s of E
mO
NC
man
agem
ent.
Invo
lve
Med
ical
As
soci
atio
n an
d M
idw
ives
Ass
ocia
tion
• Re
spon
d to
nee
ds
iden
tified
by
supe
rvisi
on
visit
s
• Re
spon
d to
nee
ds
iden
tified
by
supe
rvisi
on v
isits
• Re
spon
d to
nee
ds
iden
tified
by
supe
rvisi
on v
isits
Part
ogra
ph•
Revi
ew d
efici
enci
es a
nd p
lan
rem
edia
l act
ion
at
Nat
iona
l and
Mun
icip
ality
leve
ls•
Impl
emen
t rem
edia
l ac
tions
• Im
plem
ent r
emed
ial
actio
ns•
Impl
emen
t rem
edia
l ac
tions
Revé
Mor
atlid
ade
mat
erna
/Beb
e fo
in m
oris
• Re
view
defi
cien
cies
and
pla
n re
med
ial a
ctio
n at
N
atio
nal a
nd M
unic
ipal
ity le
vels
• Im
plem
ent r
emed
ial
actio
ns•
Impl
emen
t rem
edia
l ac
tions
• Im
plem
ent r
emed
ial
actio
ns
Com
mun
ity
Invo
lvem
ent
• M
oH to
link
with
Mo
Loca
l Dev
elop
men
t to
invo
lve
Suco
and
Ald
eia
Chie
fs in
aw
aren
ess a
nd p
rom
otio
n of
Em
ON
C in
thei
r com
mun
ities
• M
oH Is
sue
circ
ular
s and
inst
ruct
ions
to H
ealth
Po
sts t
o ra
ise a
war
enes
s and
util
izatio
n of
Em
ON
C fa
cilit
ies
• Li
aise
with
loca
l lea
ders
and
loca
l civ
il so
ciet
y or
gani
zatio
ns to
raise
aw
aren
ess a
nd u
tiliza
tion
of
EmO
NC
• Im
plem
ent c
omm
unity
in
volv
emen
t aro
und
EmO
NC
faci
litie
s
• Li
aise
with
loca
l lea
ders
an
d lo
cal c
ivil
soci
ety
orga
niza
tions
to
raise
aw
aren
ess a
nd
utili
zatio
n of
Em
ON
C
• Im
plem
ent c
omm
unity
in
volv
emen
t aro
und
EmO
NC
faci
litie
s
• Li
aise
with
loca
l le
ader
s and
loca
l civ
il so
ciet
y or
gani
zatio
ns
to ra
ise a
war
enes
s and
ut
iliza
tion
of E
mO
NC
• Im
plem
ent c
omm
unity
in
volv
emen
t aro
und
EmO
NC
faci
litie
s
• Li
aise
with
loca
l le
ader
s and
loca
l civ
il so
ciet
y or
gani
zatio
ns
to ra
ise a
war
enes
s and
ut
iliza
tion
of E
mO
NC
62 EmONC Improvement Plan of Action 2016 - 2019
Annex 7 – Norms and Standards for Minimum Enabling Environment to Support EmONC
Minimum Requirement Basic EmONC Comprehensive EmONC
Clinical hours At least one midwife and one doctor with EmONC competencies present 24/7, working as Team
Same as for BEmONC PLUS OB/GYN, Emergency surgical team, OT, and blood transfusion Lab Tech present 24/7
Infrastructure • Separate Rooms for essential services (labour, sterilization, surgery, postop)
• Rooms and beds for prelabour and postpartum, incl kitchen for serving meals
• Running water
• Electricity (alternative backup)
• Sewage system
• Waste disposal (placenta pit) and sharp objects disposal
• Secure staff quarters
• Shower and Latrines for patients
• Curtains and partitions for patients
• Basic laboratory, including blood screening
• Pharmacy
Personnel for the Maternity
• Doctor
• Midwife, nurse
• Auxiliaries and cleaners
• Lab and pharmacy staff
• Administrative staff
• Security staff
• OB/GYN and another surgeon Backup
• Anesthetists
• Midwives, nurses and supporting staff
• Lab and pharmacy staff
• Administrative staff
• Security staff
Infection control • Safe water, soap
• Disinfectants
• Boiler/autoclave
• Universal precautions to prevent the spread of HIV and other infections
• Laundry facilities
• Staff’s attitudes (hand washing, etc)
Referral • Reliable referral system 24/7 with trained drivers (incl back up)
• If vacuumassisted vaginal delivery is carried out, Cesarean section backup within 30 minutes is recommended, in case of failure
• Communication facilities: cellphone or landline
63EmONC Improvement Plan of Action 2016 - 2019
Minimum Requirement Basic EmONC Comprehensive EmONC
Registers and records
• ANC register
• ADMISSION REGISTER (including information on obstetric/newborn complications)
• Delivery/maternity (including information on obstetric/newborn complications)
• OT register (for comprehensive EmONC facility)
• Blood Transfusion register (for comprehensive EmONC facility)
• Referral register In and Out
• Monthly summary
• ANC card
• Individual patient records
• Partographs
• Others; example Maternal death reviews
Annex 8 - Lists of Equipment, Supplies and Medicines for EmONC with unit cost
No Items Name Dosage Form Unit Price (USD)
ESSENTIAL DRUGS
1 Ampicilin 1gr Injection -
2 Metronidazole 500mg Injection 0.0143
3 Gentamicin 80mg Injection -
4 Magnesium Sulphate 50% Injection -
5 Hydralazine 20mg Injection 0.4744
6 Methyldopa 250 mg Tablet 0.0879
7 Oxytocin Injection 0.3325
8 Ergometrin Injection -
9 Misoprostol Tablet 0.0214
10 Adrenaline Injection 0.2244
11 Atropine Injection 0.1625
12 Calcium Gluconate Injection 0.2308
13 Furosemide Injection -
14 Hydrocortisone Injection -
15 Vitamin K 1mg/mL Injection 0.9000
16 Tetarcycline 1% Eye Ointment 0.3100
64 EmONC Improvement Plan of Action 2016 - 2019
No Items Name Dosage Form Unit Price (USD)
17 Amoxicillin 500mg Tablet 0.0385
18 Paracetamol 500mg Tablet 0.0060
19 Multivitamin Tablet 0.0100
20 Ferrous Sulphate Tablet 0.0031
21 Folic Acid Tablet 0.0080
22 Tetanus Toxoid - 226.8255
23 Erythromycin 500mg Tablet 0.0641
24 Mebendazole Tablet -
25 Sterile Water for Injection - -
26 Metoclopramide Injection 0.2500
27 Metroclopramide Tablet 0.0090
IV FLUID
1 Normal Saline 0.9%, 1L 0.6452
2 Ringer Lactate 500mL 1.6353
3 Dextran 10.1816
4 Glucose 5% 1.1875
MEDICAL SUPPLIES
1 Syringe (disposable) 2.5mL 0.1042
2 Syringe (disposable) 5mL 0.1046
3 Syringe (disposable) 10mL 0.1582
4 Infusion Set adult - -
5 Infusion Set for newborn (Burete) - -
6 IV Cannula 16 G Not Qouted
7 IV Cannula 18 G 0.5020
8 IV Cannula 20 G 0.4212
9 IV Cannula 24 G 0.4980
10 Vicryl 2/0 (36 ‘’ Needle) - 2.8514
11 Tubing for Oxygen (adult) - -
12 Tubing for Oxygen (newborn) - -
13 Suction Catheter 8Fr 0.3800
14 Suction Catheter 10Fr 0.3800
15 Suction Catheter 12Fr 0.3800
16 Suction Catheter 14Fr 0.3800
17 Endotracheal Tube 6 Fr 2.7959
65EmONC Improvement Plan of Action 2016 - 2019
No Items Name Dosage Form Unit Price (USD)
18 Endotracheal Tube 6.5 Fr 2.7959
19 Endotracheal Tube 7 Fr 2.7992
20 Endotracheal Tube 7.5 Fr 2.7959
21 Endotracheal Tube for newborn (uncuffed) - 1.8304
22 Measuring Tape - -
23 Wall Clock - -
24 Foley Catheter 16 Fr 1.1000
25 Ambu Bag (Adult) - 36.0000
26 Mouth Guard - -
27 Urine dipstick - -
28 Bed Linens - -
29 Blankets - -
30 Baby Towel (100cm x 50 cm) - -
31 Delivery drapes (120cm x 75 cm) - -
32 Cord Clamps - 0.2800
33 Infant Face Mask (Size 0.1) - -
34 Plaster - -
35 Urine Bag - 0.3100
36 Face Mask - 0.0400
37 Apron (plastic) - -
38 Draw Sheet, Plastic 90 x 180 cm - -
39 Waterproof foot ware - -
40 OS (Roll) - -
41 Cotton (Roll) - 3.9884
42 Hand Towel - -
43 Plastic Bag - 0.0100
Medical equipment
I Item Packaging Description Unit Cost
1 Fetal doppller 1 Unit 100.00
2 Spygnomanometer 1 Unit 100.00
3 Stehethoscope 1 Unit 150.00
4 Clinical Thermometer 1 Unit 5.00
5 Infusion stand 1 Unit 30.00
66 EmONC Improvement Plan of Action 2016 - 2019
No Items Name Dosage Form Unit Price (USD)
6 Stretcher 1 Unit 150.00
7 Wheelchair 1 Unit 150.00
8 Laringoscope [adult] 1 Unit 250.00
9 Laringoscope [Pediatric & Nenat] 1 Unit 250.00
10 Suction Machine 1 Unit 250.00
II Delivery room
1 Delivery table 1 Unit 500.00
2 Hospital Bed 1 Unit 1,000.00
3 Mayo tray 1 Unit 100.00
4 Mayo Stand 1 Unit 50.00
5 Examination light 1 Unit 200.00
6 Instrument tray 1 Unit 20.00
7 Instrument trolley 1 Unit 200.00
8 Trash Bins 1 Unit 50.00
9 Stool with rollers 1 Unit 50.00
10 Bowl, round, stainless, 4 L 1 Unit 20.00
11 Bowl, round, stainless, 6 L 1 Unit 50.00
III Newborn
1 Weighing scale 1 Unit 50.00
2 Newborn resuscitation table 1 Unit 250.00
3 Radiant Warmer 1 Unit 17 000.00
4 Suction Mahine 1 Unit 250.00
5 Ambu Bag Newborn 1 Unit 150.00
6 Autoclave with temperatur and preasure gauza 1 Unit 20 000.00
7 Incinerator 1 Unit 50 000.00
IV Instruments
A Delivery Set
1 Artery Forceps 1 Unit 5.00
2 Sponge Forceps 1 Unit 5.00
3 Cord Cutting, Scissor Curved 1 Unit 10.00
4 Episiotomy Scissor, Curved 135 mm 1 Unit 10.00
5 Needle Holder 1 Unit 5.00
6 Dissecting Forceps with teeth 1 Unit 5.00
67EmONC Improvement Plan of Action 2016 - 2019
No Items Name Dosage Form Unit Price (USD)
7 Suture Scissor 1 Unit 5.00
B Manual Vacuum Aspiration Set
1 Manual Vacuum aspiration with diferent sizes of flexible cannule 4 - 12 mm 1 Unit 150.00
2 Lubricant/oil O-Ring 1 Unit 5.00
3 Cuso Speculum [small, Medium, Large] 1 Unit 5.00
4 Volsullum Forceps 1 Unit 10.00
C Dressing Set
1 Gallipot bowl or Jar 1 Unit 10.00
2 Dissecting forceps with teeth 1 Unit 5.00
3 Scissor flat, curved 1 Unit 5.00
4 Scissor , sharp, straight 1 Unit 5.00
5 Artery forceps 1 Unit 5.00
6 Sponge forceps 1 Unit 5.00
7 Kidney basin 1 Unit 5.00
8 Bowl,round,stainless, 100 ml 1 Unit 50.00
9 Manual vacuum extractor with caps 1 Unit 50.00
Annex 9 - Special features for Newborn careAnnex 9 Table 1: Immediate Newborn Care
Intrapartum and Immediate Newborn Care (INC)
Care for all mothers and newborns
The First Embrace. Interventions include immediate and thorough drying; immediate skin to skin contact; appropriately timed cord clamping; and non-separation of mother and newborn for early exclusive breastfeeding.
Care for high risk mothers and newborns
Management of newborn infants who are not breathing despite thorough drying. Interventions include management of asphyxia using suction, bag and mask ventilation. Carefully check the rhythm and intensity of blowing via observation of the thorax and abdomen. Check for air leakage around face.
Expanded INC
Prevention and management of prematurity – for preterm and low birth weight babies (7-8% of all newborns). Interventions include preventing unnecessary inductions and caesarian sections; antibiotics for premature prelabor rupture of membranes; antenatal steroids; tocolytics when indicated; and the Kangaroo Mother Care approach.
Care for Sick Newborns – for babies with birth asphyxia, neonatal sepsis and complications of delivery (10-15% of all newborns). Interventions include management of asphyxia using bag and mask ventilation; identification of babies at high risk, management of sepsis through antibiotics, and management of other common problems i.e check for malformations, neurological examination.
source UNICEF
68 EmONC Improvement Plan of Action 2016 - 2019
Designation of a Newborn Care Corner in a Labour Ward
Adapted from: Toolkit for Setting Up Special Care Newborn Units, Stabilisation Units and Newborn Care Corners UNICEF 2009
Labour rooms in every facility at every level are required to have appropriate facility for providing essential care to newborns and for resuscitating those who might require it. Newborn care corner in this document refers to the space within the labour room for providing immediate newborn care to all newborns.
Services at the corner
Newborn care corner provides an acceptable environment for all infants at birth. Services provided in the Newborn care corner include;
Essential Care at birth: breath, warm, move, first examination for detection of birth problems Resuscitation.
• Provision of warmth.
• Early initiation of breastfeeding.
• Weighing the newborn.
• Oxygen not essential
Configuration of the corner
• Clear floor area should be provided for in the room for newborn care corner. It should be within the labour room, 20-30 sq ft in size, where a radiant warmer is kept.
• Resuscitation kit should be placed under the radiant warmer. Availability of oxygen source is desirable but not essential.
• The area should be away from draughts of air and should have appropriate power connection for plugging in the radiant warmer or other devices.
69EmONC Improvement Plan of Action 2016 - 2019
Item No. Item Description Essential/Desirable Quantity
1 Open care system: radiant warmer, fixed height, with trolley, drawers, O2-bottles E 1
2 Newborn Ambu bag and Mask E 1
3 Weighing Scale, spring E 1
4 Pump suction, foot operated D 1
5 Room Thermometer E 1
6 Light examination, mobile, 220-12 V D 1
7 I/V Cannula 24 G, 26 G E 20
8 Extractor, mucus, 20ml, ster, disp Dee Lee E 1
9 Towels for drying and wrapping the baby E 50
10 Sterile equipment for cutting and tying the cord E 50
11 Tube, feeding, CH07, L40cm, ster, disp E 50
12 Oxygen cylinder 8 F D 1
13 Sterile Gloves E 200
Human resources for the Newborn Corner:
Staffing:
One staff (Doctor) is desirable in addition to the one conducting the delivery for providing appropriate care at birth.
Training:
All staff posted at the labour rooms should be trained in providing essential care at birth and basic resuscitation.
Annex 9 Table 2 Equipment and Renewables Required for the Newborn Corner
70 EmONC Improvement Plan of Action 2016 - 2019
In Summary - General Guide for Newborn Care
This summary provides guidance for setting a newborn care.
All EmONC facilities must have skilled staff and facilities for care at birth to all newborns and to provide resuscitation of those who require it.
• In addition, CEmONC service should be equipped to provide initial care and stabilisation of sick newborns, and care of most low birth weight newborns that do not require intensive care.
• Hospitals that conducts more than 3000 deliveries should have a Special Care Newborn Unit that is equipped to provide special care to most sick newborns (except those requiring mechanical ventilation or surgical interventions).
• There should be agreed procedures for transport of sick newborns (using portable battery operated incubators when necessary.
• Newborn care in EmONC facilities must have continuous availability of qualified medical and nursing staff, and resources to meet the needs of all sick babies.
• Technical specification standards for the expected levels of equipment should be established and should be adhered to. Local systems for procurement, maintenance and replacement of equipment will be necessary.
Newborn care should comply fully with:
• Clinical guidelines • Quality assurance • Follow up of high survivors• Monitoring service provision and access• Training and continuing education
Mothers should be encouraged to be involved in care of their sick newborns at every level.
One time establishment cost
Equipment and furniture $ 1,700.00
Capacity building $ 130.00
Sub Total $ 1,830.00
Recurrent or running cost per year
Consumables $ 130.00
Maintenance cost $ 490.00
Sub Total $ 620.00
Annex 9 Table 3 Indicative Cost of Setting up a Newborn Care Corner
71EmONC Improvement Plan of Action 2016 - 2019
Annex 10 - Quality Improvement Strategy and ProcessesBased on examples of other countries, the Quality Improvement strategy is designed to:
• Enhance service provider self confidence and performance
• Institute a team approach to support better quality EmONC
• Involve communities in quality improvements, and
• Maintain quality through a system of certification and reward at all levels of the health system
Rationale: The quality of EmONC needs improvement. EmONC in Municipalities continue to be underutilized. Typically, low utilization occurs when service quality is poor and trust has not been established.
The Strategy: The strategy is through a system of certification and/or public recognition. The strategy involves 6 steps:
1. Improve quality of services:
The EmONC improvement Plan of Action (IPA) will support:
• Renovation and maintenance of facilities
• Provision of essential supplies and equipment
• Facility setup to meet standards and guidelines
• Improving record keeping, data collection and analysis
• Provide training
• Staff facilities
• Encourage teambuilding
2. Set EmONC standards of Quality
The Ministry of Health will develop EmONC standards which will include a small number of essential standards that all health facilities must meet. These standards will include quality indicators from the client’s perspective as well as the provider’s perspective. For example, in Brazil the Proquali Project developed a set of 61 “accreditation criteria” that could be monitored regularly. These criteria included 18 on service delivery; 9 on infection prevention; 12 on interpersonal communication; 14 on physical plant and supplies; and 8 on management systems. One can choose to have less.
72 EmONC Improvement Plan of Action 2016 - 2019
3. Communicate EmONC standards throughout the Health Care System
Once a set of “EmONC standards” has been agreed upon, posters and handouts describing the program and listing the “EmONC standards” will be developed. These materials will be distributed during briefing meetings with Municipality managers, health facility managers, community leaders, and development partners and incorporated into existing supportive supervision tools and mechanisms. Posters and materials will be developed for clients and community members in the local language, which can be posted on health facility walls and distributed to clients attending the health facilities. The intention is to familiarize all members of the health care system with the “EmONC standards” and gain commitment to the strategy.
4. Monitor and reward facilities that meet and maintain “EmONC standards”
Initially standards will be monitored by health facilities themselves using a team approach. When a facility meets the standards the team will invite the local governor to inspect their facility.
Attainment of the “EmONC standards” will be monitored during routine integrated supervision visits, using checklists. A database of all facilities will be established to track which standards each health facility has attained during each supervisory visit. Once a health facility has met all the “EmONC standards” on two consecutive quarters, Municipality health management will verify that the health facility is meeting all the criteria, and award the facility with a “Seal of Quality” during a public ceremony. Municipality management will also award certificates to each health provider working at the health facility. In order to retain the “Seal of Quality”, health facilities will have to continue to maintain the “EmONC standards.” If the standards are not met during a supervisory visit, the seal will be removed.
5. Promote Facilities with “Seal of Quality” as Sites with Good Quality Services
Health facilities that meet the “EmONC standards” on two consecutive quarters will receive the “Seal of Quality” during highly publicized ceremonies in the communities. During the ceremonies, community members will learn about the standard of care they should expect and demand at the health facility. Mass media messages will be employed to inform the public about the quality of care activities and the meaning of the “Seal of Quality.” This is a bit similar to the Mother Baby Friendly Hospital.
6. Evaluate Impact of the Strategy
Baseline and final evaluation surveys will be conducted by the MoH.
The comparison will look at facilities which have implemented all elements of the strategy with those that have not yet completed elements 3, 4, and 5. In other words, the surveys will evaluate the impact of the entire strategy and compare facilities which have instituted the certification and reward system with those which have not.
73EmONC Improvement Plan of Action 2016 - 2019
Quality Cesarean Delivery
Source: Dujardin B, Delvaux T. Céariennes de qualité de déterminants. Communication to the 5th Congress of the Société Africaine de Gynécologie et d’Obstétrique (SAGO). Senegal: Dakar; 1998.
Functioning referral system
Financial Access
Acceptability of health services
Geographic access
Temporal Access
Quality admission examination
Correct supervision of labor
Respect of operating indications
Necessary resources available
Staff available and team complete
Respect of operating protocol
Quality of anesthesia
Quality of training
Protocol respected
Quality of postop supervision
Absence of treatment delays
Quality of nursing
Access of the mother to the
referral maternity is made easy
The correct diagnosis is
reached without delay
The procedure is performed correctly and without delay
Postsurgical care is performed
correctly
Teamwork, Commitment, Compliance, and Client Orientation
In order for this strategy to succeed in improving the quality of services, the entire health system must work as a team. Each level in the system must be committed to attaining and maintaining the “EmONC standards” and must know its role in supporting the health facilities. In addition, all members of the team must comply with the strategy. Only those facilities that attain and maintain the standards should receive the “Seal of Quality”, otherwise the public will lose trust in the health system as a whole. Finally, we have to learn to measure our performance in the eyes of our clients—the women, children, and men who we serve. We have to value their input and find ways to respond.
7. Criteria of quality C-Sections
74 EmONC Improvement Plan of Action 2016 - 2019
Annex 11: Monitoring sheet for assessing the functionality of EmONC facilities Every year the MoH/ DSM (DPHO-SMI) must conduct an assessment of all its EmONC facilities in order to accredit them into BEmONC, CEmONC or No EmONC category according to the number of Signal Functions performed in the past one year, as reported in the facility service records.
The following control sheet can be used for each facility visited:
Signal function performance report for the year …………………….
Municipality:
Name of facility:
Designated category (Basic or Comprehensive)
Name of agent:
Signal Function Yes/No If Yes, number of cases last 12 mths
1 Parenteral Antibiotics
2 Parenteral Oxytocics
3 Parenteral anticonvulsants
4 Manual removal of placenta
5 Removal of retained products (MVA)
6 Assisted vaginal delivery (v. extractor)
7 Newborn resuscitation
8 Cesarean section
9 Blood transfusion
Reasons why one or more signal function could not be performed (e.g. lack of skills, lack of equipment, lack of drugs, lack of cases, absence of agent, etc: ……………
Conclusion: EmONC functionality: BASIC or COMPREHENSIVE (Circle one)
Recommendations e.g. procure missing equipment, offer BEmONC training, improve practice,
…………..
Submitted by (Name) :………………………..Date: ………….
Signature of supervisor:……….............................
75EmONC Improvement Plan of Action 2016 - 2019
Annex 12 – Estimates for CostingThe budget of the MCH Department of the MoH and its partners covers the major part of the needs. What needs to be costed and mobilized is the additional part to improve EmONC in the selected facilities for the 4 years of the Plan of Action, including:
1. Costing of additional infrastructure, equipment, supplies for to upgrading the EmONC facilities
2. Costing of additional staff to be posted in EmONC facilities
3. Costing of upgrading competencies, through inservice training in BEmONC and supervision with coaching
4. Costing of the management of common obstetric complications to be expected in EmONC facilities
5. The annual budgets to be envisaged during the 4 years of the Plan of Action
The following few tables provide background information for the costing exercise.
Below Table was constructed with data provided by the Municipality health authorities. It helps determining the number of each type of professional staff needed in each candidate EmoNC facility starting in 2016.
Region Municipality facility Type N° Births Actual MW
Actual Dr
Norm MW
Norm Dr
Balance MW
Balance Dr
1
BaucauQuelicai 2 238 5 3 4 2 +1 +1
Baguia 3 215 1 1 4 2 -3 -1
Lautem
LosPalos 2 586 10 7 8 4 +2 +3
Iliomar 3 48 1 2 4 2 -3 0
Luro 3 24 1 7 4 2 -3 +5
Viqueque
Viqueque 2 383 7 4 8 4 -1 0
Uatulari 3 277 2 3 4 2 -2 +1
Lacluta 3 78 2 1 4 2 -2 -1
Uatucarbo 3 96 2 3 4 2 -2 +1
2
AileuAileu Vila 2 554 5 5 8 4 -3 +1
Remexio 3 177 4 3 4 2 0 +1
AinaroAinaro Vila 2 199 7 6 4 2 +3 +4
Hautio 3 4 1 2 4 2 -3 0
ManufahiSame 2 370 8 2 8 4 0 -2
Fatuberlih 3 121 3 1 4 2 -1 -1
Annex 12 Table 1: Midwives and doctors actually present and needed in each EmONC facility
76 EmONC Improvement Plan of Action 2016 - 2019
Region Municipality facility Type N° Births Actual MW
Actual Dr
Norm MW
Norm Dr
Balance MW
Balance Dr
3
Dili
Atauro 3 104 3 2 4 2 -1 0
Becora 3 557 17 9 8 4 +9 +5
Vera Cruz 3 655 13 8 12 6 +1 +2
Centro 3 313 8 1 8 4 0 -3
Ermera
Gleno 2 324 6 1 8 4 -2 -3
Atsabe 3 147 2 3 4 2 -2 +1
Hatolia 3 55 2 4 4 2 -2 +2
Liquica
Liquica 2 304 4 1 8 4 -4 -3
Fatumasi 3 90 2 1 4 2 -2 -1
Maubara 3 176 5 1 4 2 +1 -1
Manatuto
Manatuto 2 204 8 9 4 2 +4 +7
Laclubar 3 82 3 2 4 2 -1 0
Natarbora 3 23 2 3 4 2 -2 +1
4
Bobonaro
Lolotoe 3 24 2 2 4 2 -2 0
Atabe 3 90 2 4 4 2 -2 +2
Bobonaro 3 60 2 3 4 2 -2 +1
Marco 3 76 3 3 4 2 -1 +1
Covalima
Zumalai 3 154 3 6 4 2 -1 +4
Tilomar 3 150 1 3 4 2 -3 +1
Fohorem 3 48 1 1 4 2 -3 -1
SpR Oecusse Passabe 3 25 1 2 4 2 -3 0
Total 36 candidates BEmONC facilities 36 7031 149 119 184 92 -35 +27
CEMONC
2 Baucau Baucau 1 1286 16 3 16 8 0 -5
2 Ainaro Maubisse 1 351 7 0 8 4 -1 -4
4 Bobonaro Maliana 1 655 12 1 12 6 0 -5
4 Covalima Suai 1 573 11 0 8 4 +3 -4
SpR Oecusse Oecusse 1 349 8 2 8 4 0 -2
3 Dili HNGV 1 4302 20 10 20 10 0 0
3 Dili Private 1 293 10 5 8 4 +2 +1
Total Hospitals 7809 84 21 80 40 +4 -19
77EmONC Improvement Plan of Action 2016 - 2019
The below table shows the training needs expressed by 160 provides; doctors (53) and midwives (107) during the Needs Assessment conducted in 2015 for different categories of procedures. It helps determining the volume of training needs for the duration of the Plan of Action.
TRAINING TOPICS Number expressing need
Bleeding in Pregnancy
Manage bleeding in early pregnancy 59% (95)
Manage bleeding in late pregnancy and in labor 60% (96)
Manage post partum bleeding 50% (80)
High Blood Pressure Problems
Manage pre-eclampsia 59% (95)
Manage eclampsia 61% (97)
Fever during Pregnancy and after delivery
Manage a fever before delivery (amnionitis) 57% (91)
Manage a fever after delivery (endometritis) 60% (96)
Procedures for Early Pregnancy Problems
Perform Manual Vacuum Aspiration 65 (104)
Annex 12 Table 2: Midwives and doctors actually present and needed in Hospitals (CEmONC Facilities)
Region Municipality Facility Type N° Births Actual MW
Actual Dr
Norm MW
Norm Dr
Balance MW
Balance Dr
2 Baucau Baucau 1 1286 16 3 16 8 0 -5
2 Ainaro Maubisse 1 351 7 0 8 4 -1 -4
4 Bobonaro Maliana 1 655 12 1 12 6 0 -5
4 Covalima Suai 1 573 11 0 8 4 +3 -4
SpR Oecusse Oecusse 1 349 8 2 8 4 0 -2
3 Dili HNGV 1 4302 20 10 20 10 0 0
3 Dili Private 1 293 10 5 8 4 +2 +1
Total Hospitals 7809 84 21 80 40 +4 -19
Annex 12 Table 3: Training needs per topic expressed by 160 providers 53 Doctors and 103 Midwives in 13 Municipalities in 2015 (EmONC Needs Assessment)
78 EmONC Improvement Plan of Action 2016 - 2019
TRAINING TOPICS Number expressing need
Normal Labor and Labor Problems
Assess the fetal position 50% (80)
Assess progress of labor 43% (68)
Use a partograph correctly and completely until Fourth Stage 45% (72)
Manage normal labor 45% (72)
Manage abnormal early labor (latent phase) 54% (87)
Manage abnormal active labor (first stage) 53% (85)
Manage abnormal second stage 56% (89)
Manage abnormal third stage 58% (93)
Induce labor 58% (93)
Manage labor after prior cesarean section 84% (134)
Manage normal birth 39% (63)
Perform vacuum delivery 66% (106)
Abnormal Presentations
Recognize breech presentation 56% (90)
Manage a breech delivery 62% (99)
Manage a transverse presentation 71% (114)
Manage a prolapsed cord 64% (103)
Other Conditions Affecting Labor and Delivery
Manage malaria 64% (102)
Identify heart problem 75% (120)
Procedures for Labor and Delivery
Perform an amniotomy 58% (93)
Make and repair an episiotomy with absorbable sutures 51% (81)
Repair first degree tears 49% (79)
Repair second degree tears 52% (83)
Repair third degree tears 73% (117)
79EmONC Improvement Plan of Action 2016 - 2019
TRAINING TOPICS Number expressing need
Repair a cervical tear 89% (143)
Complicated Delivery
Perform maneuvers for shoulder dystocia 60% (96)
Manage twin delivery 62% (99)
Perform manual removal of placenta 60% (96)
Perform curettage or MVA for retained products 63% (100)
Perform bimanual compression 58% (93)
Perform abdominal aortic compression 64% (102)
Post partum Care
Perform an IUD insertion after delivery or abortion 60% (96)
Pain Management
Perform local anesthesia of perineum 56% (89)
Procedures for Newborn Care
knowledge of 10 danger signs) 36% (58)
Perform newborn resuscitation 40% (64)
Other Emergencies
Conduct rapid initial assessment for emergencies 65% (104)
Manage shock from bleeding 51% (82)
Manage shock from sepsis 64% (102)
Perform adult resuscitation 78% (125)
Implement infection prevention measures 44% (70)
Maternal deaths review 88% (140)
The majority of these items can be included in the BEmoNC training curriculum
Additional short refesher courses can be added as needed.
The following table shows an estimate of the Costing of the management of obstetric complications, based on the estimated incidence and presumptive unit costs for each type of complication. The unit cost of C-section has been estimated at US$ 300 and the emergency referral at US$ 80.
80 EmONC Improvement Plan of Action 2016 - 2019
Com
plic
atio
nIn
cide
nce
per 1
00
preg
nanc
ies
(%)
Num
ber
in T
imor
-Le
ste
in
one
year
Cont
ents
of c
urat
ive
proc
edur
eU
nit C
ost
of c
urat
ive
proc
edur
e(s)
(U
S$)
Cost
of
cura
tive
proc
edur
e(s)
(U
S$)
Cost
of
refe
rral
(U
S$)
Tota
l co
st
(US$
)
Pre-
part
um H
rg0.
520
0IV
flui
ds4
800
1600
016
800
Post
par
tum
Hrg
(not
sev
ere)
*1.
352
0AM
TSL,
IV fl
uids
631
2020
800
2392
0
Post
par
tum
Hrg
(sev
ere)
0.4
160
AMTS
L, IV
Flu
ids,
BT57
9120
1280
021
920
3rd-
4th
degr
ee p
erin
eal t
ears
0.4
160
Surg
ical
repa
ir15
2400
1280
015
200
Pre-
part
um S
epsi
s*0.
520
0An
tibio
tics
1020
0080
0010
000
Post
par
tum
Sep
sis*
280
0An
tibio
tics,
IV F
luid
s20
1600
032
000
4800
0
Post
abo
rtio
n ca
re*
140
0M
anua
l Vac
cum
Asp
iratio
n15
6000
1600
022
000
Prel
abou
r rup
ture
of m
embr
anes
*0.
624
0IV
Flu
ids,
Antib
iotic
s, st
eroi
ds15
3600
9600
1320
0
Pre-
Ecla
mps
ia0.
728
0M
ag/s
ulph
, IV
Flui
ds, n
ursin
g40
1120
022
400
3360
0
Ecla
mps
ia0.
280
IV F
luid
s, M
ag su
lpha
te, C
/S, n
ursin
g63
050
400
6400
5680
0
Prol
onge
d L
abou
r*2
800
Assis
t Vag
inal
Del
iver
y20
1600
032
000
4800
0
Obs
truc
ted
Labo
ur0.
624
0IV
Flu
ids,
C/S
630
1512
0019
200
1704
00
Ann
ex 1
2 Ta
ble
4: C
ost o
f man
agem
ent o
f obs
tetr
ic c
ompl
icat
ions
bas
ed o
n es
timat
ed in
cide
nce
81EmONC Improvement Plan of Action 2016 - 2019
Com
plic
atio
nIn
cide
nce
per 1
00
preg
nanc
ies
(%)
Num
ber
in T
imor
-Le
ste
in
one
year
Cont
ents
of c
urat
ive
proc
edur
eU
nit C
ost
of c
urat
ive
proc
edur
e(s)
(U
S$)
Cost
of
cura
tive
proc
edur
e(s)
(U
S$)
Cost
of
refe
rral
(U
S$)
Tota
l co
st
(US$
)
Plac
enta
Acc
reta
0.3
120
Man
ual R
emov
al o
f Pla
cent
a10
1200
9600
1080
0
Rupt
ured
ute
rus
0.2
80IV
Flu
ids,
Surg
ery,
Bloo
d Tr
ansf
usio
n65
552
400
6400
5880
0
Ecto
pic
preg
nanc
y0.
312
0IV
Flu
ids,S
urge
ry61
073
200
9600
8280
0
Ute
rine
Inve
rsio
n0.
140
IV F
luid
s, m
anua
l cor
rect
ion
2510
0032
0042
00
New
born
Asp
hyxi
a*2.
510
00Re
susc
itatio
n.25
2500
040
000
6500
0
Man
agem
ent o
f pre
mat
ure/
LBW
*2
800
New
born
car
e, K
angg
aroo
Mot
her C
are,
fe
edin
g13
010
4000
3200
013
6000
Pulm
onar
y Em
bolis
m0.
140
IV F
luid
s, An
ti Co
agul
ants
.30
1200
3200
4400
Oth
ers
0.2
80TB
S50
4000
6400
1040
0
Tota
l 15
.963
60
5338
4031
8400
8522
40
Not
e:*
Onl
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82 EmONC Improvement Plan of Action 2016 - 2019
Finally, the following table shows the 4-year estimate of the cost of managing obstetric complications. It appears that the cost of managing up to 80% of all complications will amount to US$ 2.2 million for the 4-yr Plan of Action. Similar estimates can be done for each Municipality using the same rules and the findings of the EmONC Assessment.
Annex 12 Table 5: Estimation of the cost of managing incremental complications each year during the Plan of Action (in US$)
YearEstimated proportion
of all expected complications
Expected number of complications seen
Estimated cost of managing these
complications US$
Year One 50% 3180 426120
Year Two 60% 3816 511344
Year Three 70% 4452 596568
Year Four 80% 5088 681792
Total four years 16536 2215824
Annex 13 - Key Findings and Recommendations of the EmONC NA ReportA. Key Findings
• Performance of signal functions
While Timor-Leste has been successful in developing a network of functional CEmONC facilities which meets UN standards, only 2 functional BEmONC facilities have been identified. All BEmONC facilities are in Dili (CHC Comoro and Bairo-Pite Clinic). More facilities are needed at Municipality level
With the exception of the administration of uterotonic drugs, most signal functions were insufficiently performed, particularly at CHC level. The most poorly performed signal function was assisted vaginal delivery, with only 10% of CHCs performing, followed by administration of parenteral anticonvulsants for pre-eclampsia and eclampsia (<15%).
Seven Municipalities have no functional EmONC facilities
• Utilization of Services
In Timor-Leste during the one year preceding the survey 19361 (48%) of all expected births took place in all facilities assessed. Over half of these (9938 or 24.6%) were in functional EmONC facilities. At the same time 1831 births (4.5%) were reported in Health Posts and the rest were home births (19294 or 48%). The National Health Sector Development Plan 2011-2030 had identified a target of more than 40% deliveries to be in Health facilities
83EmONC Improvement Plan of Action 2016 - 2019
(not necessarily in EmONC facilities) to be achieved by 2015. In order to ensure that all women who develop complications have access to services, the MOH should consider raising this target, which should ultimately reach 100%.
• Obstretic complications treated in the health facilities
Over one half (3316 or 54.6%) of all women who were estimated as having obstetric complications (15% of all pregnancies) during the assessment were treated in the health facilities assessed; 2051 or 33.8% of these complications were treated in the functional EmONC facilities. This is far below the recommended level of 100%. This means the needs of women with obstetric complications of pregnancy are not being met.
• Performance of critical services: C-Sections
This indicator has been calculated by region and for the whole country, as hospitals providing C-sections service a region, made of 3 or 4 contiguous Municipalities. Only 3.4% of all expected births (1385) in all hospitals assessed and functional CEmONC facilities were by C-section. This is well below the globally recommended minimum level of 5% for all expected births in a country. If Dili is excluded from the analysis, the proportion of all births delivered by C-section falls from 3.4% to 1.6%. There are women who require C-sections, who are not receiving them.
• Availability of Blood for transfusion
The data also suggests there are issues with the availability of blood: None of the Referral Hospitals had any stored blood despite the availability of refrigerators and reagents.
• Access, referral and communications
Remote and isolated populations have little access, the “golden rule of two hours” is not respected in many Municipalities, 27 (37%) of all facilities were more than two hours from a higher level facility; 17 health posts were more than two hours from a CHC. Four CHCs were not providing obstetric and newborn services. Ambulances are in adequate numbers but second delay is still a constraint. Cellphone communication has greatly improved. There were no referrals recorded for newborn complications.
• Human Resources
Numbers have improved and meet current needs for midwives and doctors, but 24/7 availability is not guaranteed and competencies need to be reviewed in view of the increasing demand. Three CHCs and 2 hospitals have no doctor in the maternity. Midwives are the main providers of BEmONC signal functions.
• Knowledge, training and experience
Guidelines and protocols, although issued by the MoH, were not available nor consulted in one half of facilities, particularly in CHCs. Knowledge had serious gaps and training needs for EmONC were acknowledged for all categories of providers, including among the newly passed out midwives and doctors trained in Cuban education system.
84 EmONC Improvement Plan of Action 2016 - 2019
• Availability of basic infrastructure
Considerable gaps in the physical availability of premises, the quality of buildings, the essential water, sanitation and electric supply, the beds for waiting patients, the post-partum observation beds, the newborn corners. One CHC had no electricity and 6 had no running water.
• Essential drugs supplies and equipment
There were many stock outs reported, with shared responsibility between the central store and the hospitals supply systems. Among the most missing essential drugs was magnesium sulphate and among equipment was neonatal resuscitation. Infection control had serious gaps.
• Case Reviews of Partographs
In the 75 facilities assessed, 180 partograph case studies were undertaken. Many gaps were observed in the use (in 20% of facilities) and in the interpretation, particularly in CSIs and CHCs
• Case Review of caesarean deliveries
Twenty one (21) C-section case studies were undertaken; 19 cases were emergencies and 2 were elective. Only 2 cases were managed with a partograph. Four cases only (20%) met the optimal time between decision and execution, and more than 50% were more than 2 hours. Newborn outcomes were seldom reported. The low use of partograph is a concern.
• Case Reviews: Maternal death Reviews
Ten maternal deaths, from 6 Referral hospitals were reviewed; nine of them were due to direct obstetric causes.
B. Key Recommendations
In considering how Timor-Leste should proceed, and how poor coverage, poor quality, and gaps in EmONC services should be addressed, three areas need to be considered:
1. Policy recommendations
2. Coverage, availability, geographic distribution of EmONC facilities and accessibility
3. Improving quality of care
4. Human resources
85EmONC Improvement Plan of Action 2016 - 2019
1. Policy recommendations
• First of all, the leadership of the MoH in MNH issues, including EmONC of course, should be strengthened, and all contributors to the National RMNCAH Strategy should support this leadership and conform to the guidelines issued by the Department.
• It is crucial to raise the visibility and public health importance of EmONC in Timor-Leste, but at the same time to highlight that EmONC is only a part of the overall strategy and programme of the country to reduce maternal and newborn mortality and morbidity. EmONC in particular does not cover the actions at village level, except for advocacy and awareness activities. Of the “Three Delays” approach, EmONC is mostly concerned with the third one, at facility level. It should be “integrated in the broader approach to improve MNH.
• It is recommended to name a National EmONC Coordinator at the MoH. The job of this coordinator will be to centralize the EmONC-related information, coordinate the implementation of the Plan of Action, and monitor the progress. A profile will be proposed.
• All BEmONC facilities (as well as CHCs before they are upgraded into BEmONC) should be authorized and encouraged to keep patients in their premises for a few days BEFORE and AFTER delivery, either in maternity waiting homes or in wards where patients can receive or prepare food, have a minimum of comfort and dignity (beds and linen, toilets, separation curtains, etc.)
• All registers related to EmONC should be uniformized and harmonized, and utilised in all EmONC facilities as well as maternity units in CHCs. This should be integrated and coordinated with HMIS and/or DHIS-2. The proper identification and recording of obstetric and newborn complications is key to the calculation of quality process indicators.
• Taking into consideration the specificities of Timor-Leste population and geography, it is recommended to use the 12 month benchmark for all further assignment of EmONC facilities, based on the performance of signal functions. Once the 12 month benchmark is met, then the 3 month period could be adopted in the future, but this is not feasible at the moment.
• In response to the critical shortage of BEmONC facilities at sub-national level (only 2 facilities have been designated as functional BEmONC facilities, both in Dili), there is a need for a policy to prioritise sub-national BEmONC facilities and strategically strengthen them one by one. Annexes provide a list of criteria, as well as a list of “candidate facilities” to be upgraded in priority in each district. The “Golden rules” specify that no health facility should be more than 2 hours from villages, and no health facility should be more than 2 hours travel time from a higher level referral facility.
86 EmONC Improvement Plan of Action 2016 - 2019
• Norms and standards for EmONC, as well as guidelines and protocols will need to be revised and disseminated so they are available to all providers and their supervisors.
• The staffing of each category of EmONC facility will need to follow standards, and flexibility will be exercised to re-allocate staff when needed from one facility to another one.
• The policy about the proportion of all births that should take place in EmONC facilities must evolve over time, according to the progress of this indicator. The National RMNCAH Strategy recommends reaching a target of 75% skilled birth attendance by 2019 with 65% of deliveries in health facilities. The Plan of Action for improving EmONC should specify 65% of all deliveries in functional EmoNC facilities.
• There should be a renewed and strongly expressed focus on newborn health. The number of expected newborn deaths is far greater than the number of maternal deaths (500 Vs 100 each year). Equipment and skills for newborn care at birth are readily available and are potentially very effective: They need to be used.
• The Blood Transfusion Policy drafted in 2015 must come to approval and implementation. The strategic choices must be fixed so that all the CEmONC facilities have access to blood units within less than one hour of the decision to transfuse blood. A Lab technician must be available on-site 24/7.
2. Coverage, availability and geographic distribution of EmONC facilities
• According to UN standards, Timor-Leste should have 3 CEmONC and 12 BEmONC facilities. The survey reveals that there are 6 CEmONC and only 2 functional BEmONC facilities responding to the criteria (none in the districts). In response to this distortion, and taking into account the specificities of the population and geography of Timor -Leste, it is recommended that the 6 CEmONC facilities are maintained and strengthened, while all the 8 CSIs and as many as 36 among the CHCs are upgraded to become BEmONC facilities.
• The criteria to select which facilities need to be upgraded in priority, after discussions with DSM and DPHO-SMI officials, are technical and logistical. Priority should be given to the 8 or 9 CSIs and the 7 districts without any EmONC facility. The “Golden Rule” of less than 2 hours referral time must be one of the top criteria.
• “Upgrading” means raising the number and quality of EmONC services to standards. There are several components of the upgrading process, belonging to the physical/infrastructural category, equipment/drugs category, communication/transport category, staffing/training category, and quality of care category. Details will be in the Plan of Action for Improvement of EmONC Services.
87EmONC Improvement Plan of Action 2016 - 2019
3. Improving quality of care
• Several tables throughout this report show deficiencies in the care provided by different levels of health facilities. No lower level facilities (CHCs and CSIs outside of Dili) are functional BEmONC. Facilities at different levels must be upgraded, to provide a standardised package of EmONC along a continuum of care. The concepts of standardisation and facility readiness 24/7 should be introduced, and managers and clinical staff trained in a standard-based management approach.
• Lack of recognition, and under diagnosis of obstetric and newborn complications, is a key limiting factor for full functionality of EmONC facilities. Once conditions are recognised and diagnosed, good care is required. This may require immediate interventions and/or stabilisation and timely referral. Additional strategies are required to ensure correct diagnoses and timely interventions, which support EmONC improvement.
• Supportive supervision has been introduced in many programmes: it is particularly important when lives of mothers and newborns are at in the balance and stress is frequent. The MoH could consider undertaking observations of clinical skills as part of supervision.
• Facility management committees have been found a good management practice elsewhere. Involve the local community in evaluating the quality of care as they perceive it.
• Quality of care involves quality of data, both data recording and data management. Improve HMIS training, supervision and mentoring, especially in regard to the classification of obstetric complications, stillbirths and early newborn deaths, direct and indirect maternal deaths, as well as civil registration. In addition, routine maternal death and newborn death review/audits should help improve the correct classification of cause of death.
• For those facilities that are missing one or two EmONC signal functions, a plan should be made to ensure that staff have the skills and the enabling environment to perform the signal functions. Training is needed on manual removal of placenta, assisted vaginal delivery, removal of retained products, and provision of parenteral anticonvulsants to all birth attendants, in all the partially functioning health facilities with more than 10 deliveries per month.
• Continue to strengthen national guidelines for the clinical management protocols for obstetric and newborn complications. Where guidelines exist, training, and supervision for quality improvement should follow. Where they do not exist, they should be distributed. Every facility needs a complete set of these guidelines and accompanying posters, wall charts, or complication specific charts that designate the appropriate treatment at each level.
88 EmONC Improvement Plan of Action 2016 - 2019
• Guidelines and protocols were available in less than 50% of the facilities. The biggest gap in guidelines and protocols was in CHCs. Clearly there is a need to review and ensure 100% of all guidelines and protocols are present and used in all facilities.
• Emergency patients should be accompanied by a qualified health professional. All drivers should have had“first aid” training and the vehicle used for transport should also have telecommunications available (cell phone or radio communication).
• All hospitals should record referrals in and out and collect information concerning each woman who is referred on. Where was she coming from? and going to? What was the purpose of the referral? What is the outcome for the patient?
• Maintain an emergency stock (trolley or box) of key drugs (in operating theatres, labour wards and maternity wards) in all facilities, even where pharmacies are always open. The emergency stock could then be refilled at re-order level.
• Whenever possible, maintain the practice of partograph reviews, C-section reviews, and Maternal/newborn deaths reviews with intention of raising competencies and prevent re-occurence of adverse events.
4. Human Resources
• Ensure availability of adequate qualified and competent staff at CHCs and hospitals providing BEmONC and CEmONC services respectively. In addition to midwives and doctors, essential staff should also include:
• Qualified/trained lab technicians
• Pharmacists
• At specific hospitals: paediatrician or pediatric nurse, at least one back-up surgeon to cover for the obstetrician’s absence, anaesthetists and OT technicians
• Health managers and administrators
• A lab technician should be available in all the CEmONC facilities 24/7 to group and match blood for urgent transfusion.
• Increase availability of national staff to support EmONC and essential maternal and newborn care. Provide opportunities, scholarships, for nationals to acquire missing competencies in specialized areas such as obstetrics, neonatology, anaesthesiology, emergency medicine.
• Recruit and train 2-3 senior medical doctors and/or midwifes per district, to support skills based clinical training and practice in the workplace, through facilitative supervision and/or clinical training; and/or consider a rotation system which allows staff to practice essential interventions to support EmONC and essential newborn care on a regular basis to avoid losing their skills.
• Consider increasing the number of Clinical Training Centres in the country (at least 3 additional) so that trainees have more opportunities to practice.
89EmONC Improvement Plan of Action 2016 - 2019
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Annex 14 – Maps Showing EmONC Facilities by Characteristics and Selected Candidates for BEmONC Upgrade
90 EmONC Improvement Plan of Action 2016 - 2019
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Map of Proposed Health Facilities for Upgrade to BEmONC for Region III(Dili, Ermera, Manatuto & Liquica Municipal)
#
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®
0 50 10025
Kilometers
1:560,000
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94 EmONC Improvement Plan of Action 2016 - 2019
^
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®
0 20 4010
Kilometers
1:253,000
CHC#* 7 S ignal Funtions
#* 6 S ignal Funtions
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(# CHC > 2 hours to CSI
RoadsMajor Road
Minor Road
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95EmONC Improvement Plan of Action 2016 - 2019
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Map of Proposed Health Facilities for Upgrade to BEmONC for Region IV(Bobonaro & Covalima Municipal)
®
0 20 4010
Kilometers
1:253,000
Health Facilities
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96 EmONC Improvement Plan of Action 2016 - 2019
(#
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CHC#* 7 S ignal Funtions
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RoadsMajor Road
Minor Road
Hospitals
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0 20 4010
Kilometers
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Map of Proposed Health Facilities for Upgrade to BEmONC for Region V(Oecusse Special Region)
0 20 4010
Kilometers
®
1:202,000
Health Facilities
G Hospital
^CSI
# CHC
RoadsMajor Road
Minor Road
97EmONC Improvement Plan of Action 2016 - 2019
Annex 15: Municipality Profiles Showing Existing Resources and Needs for The Implementation PlanA. Aileu Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 48,554
Estimated number of births 2014-2015 (1 year) (Crude Birth Rate : 30/1000) 1,457
Reported number of births August 2014- July 2015 (in the assessed health facilities) 874
Reported number of births in Health Posts 105
Annex 15A Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCSI Aileu
Vila*CHC
NamolesoCHC
Remexio*CHC
Laulara
Number of births from August 2014-July 2015 554 55 177 88
Institution to which the patients with obstetric complications are referred
HR Maubisse
HR Maubisse
HNGV Dili HNGV Dili
Travel Time to higher level facility 1 hour30
minutes1 hour 30 minutes
30 minutes
Annex 15A Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCSI Aileu
Vila*CHC
NamolesoCHC
Remexio*CHC
Laulara
Parenteral antibiotics (12months) Yes Yes Yes Yes
Parenteral Oxytocics (12months) Yes Yes Yes Yes
Parenteral Anticonvulsant (12months) Yes No Yes No
Manual Removal of Placenta (12months) Yes No Yes No
Removal of Retained product (12months) Yes No Yes No
Assisted Vaginal Delivery (12months) No No No No
Newborn resuscitation (12months) Yes Yes Yes Yes
98 EmONC Improvement Plan of Action 2016 - 2019
Annex 15A Table 3: Availability of Human Resources
DescriptionCSI Aileu
Vila*CHC
NamolesoCHC
Remexio*CHC
Laulara
Midwife (Currently employed) 5 0 4 3
Availability of midwives 24 hours Yes No No No
Medical Doctor (Currently employed) 5 2 3 3
Availability of medical doctor 24 hours Yes No No No
Nurse (Currently employed) 3 2 3 0
Availability of nurse 24 hours Yes No No No
Laboratory technician (Currently employed) 1 0 1 1
Availability of lab technician 24 hours No No No No
Nurse anesthetist (Currently employed)
Availability of Nurse anesthetist 24 hours
Obstetrician (Currently employed)
Availability of obstetrician 24 hours
Anesthesiologist (MD) (Currently employed)
Availability of anesthesiologist (MD) 24 hours
Annex 15A Table 4: Availability of general facilities for EmONC services
DescriptionCSI Aileu
Vila*CHC
NamolesoCHC
Remexio*CHC
Laulara
Electricity Yes Yes Yes Yes
Back up generator No No No No
Running water Yes Yes Yes Yes
Functioning toilet Yes Yes Yes Yes
Total bed in the facility 10 5 5 6
Total bed for obstetric patient 4 3 3 3
Total delivery table 2 2 2 2
Delivery room Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes
Laboratory room Yes Yes Yes Yes
Operating Theater
Neonatal care room
Blood Bank
99EmONC Improvement Plan of Action 2016 - 2019
DescriptionCSI Aileu
Vila*CHC
NamolesoCHC
Remexio*CHC
Laulara
Availability of stored blood for use in emergencies
General anesthesia
Spinal anesthesia
Functional fan/air conditioning No No No No
Curtains/means of providing patient privacy Yes No Yes Yes
Annex 15A Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCSI Aileu
Vila*CHC
NamolesoCHC
Remexio*CHC
Laulara
Length of stay for normal delivery (day) 1 1 1 0
Food for maternity patient Yes Yes Yes Yes
Food for family No Yes No No
Waiting area for visitors and family Yes Yes Yes Yes
Lodging for maternity patient Yes No Yes Yes
Lodging for family No No No No
Annex 15A Table 6: Availability of communication and transport facilities for referral
DescriptionCSI Aileu
Vila*CHC
NamolesoCHC
Remexio*CHC
Laulara
Telephone at maternity ward No No No No
Telephone in the facility Yes No No No
Cell phone (own by facility) Yes Yes Yes Yes
Cell phone (own by staff) Yes Yes Yes Yes
Ambulance No No Yes No
Multi purpose vehicle Yes Yes Yes Yes
Other transport for referral No No No No
100 EmONC Improvement Plan of Action 2016 - 2019
B. Ainaro Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities - (KOICA has already undertaken the construction of CHC Hautio)
Population 66,397
Estimated number of births 2014-2015 (1 year) (Crude Birth Rate : 30/1000) 1,992
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 613
Reported number of births in Health Posts 52
Annex 15B Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCSI
Ainaro*CHC
Hautio*CHC
Maubisse CHC Hatu-
UdoHR
MaubisseNumber of birth from August 2014-July 2015 199 4 0 59 351
Institution to which the patients with obstetric complications are referred
HR Maubisse
HR Maubisse
HR Maubisse CSI Same HNGV Dili
Travel Time to higher level facility 1 hour 30 minutes 1 hour 15 minutes 30 minutes 3 hours
Annex 15B Table 2: Performance of Signal Functions during preceding 12 months of the assessment
Description CSI Ainaro*CHC
Hautio*CHC
Maubisse CHC Hatu-
UdoHR
Maubisse
Parenteral antibiotics (12months) No No No Yes Yes
Parenteral Oxytocics (12months) Yes Yes No Yes Yes
Parenteral Anticonvulsant (12months) No No No No Yes
Manual Removal of Placenta (12months) Yes No No Yes Yes
Removal of Retained product (12months) Yes No No No Yes
Assisted Vaginal Delivery (12months) No No No No YesNewborn resuscitation (12months) Yes No No Yes Yes
101EmONC Improvement Plan of Action 2016 - 2019
Annex 15B Table 3: Availability of Human Resources
DescriptionCSI
Ainaro*CHC
Hautio*CHC
Maubisse CHC
Hatu-UdoHR
Maubisse
Midwife (Currently employed) 7 1 3 1 7
Availability of midwives 24 hours Yes No No No Yes
Medical Doctor (Currently employed) 6 2 1 2 0
Availability of medical doctor 24 hours Yes No No No No
Nurse (Currently employed) 0 0 2 0 0
Availability of nurse 24 hours No No No No No
Laboratory technician (Currently employed) 1 1 1 1 6
Availability of lab technician 24 hours No No No No Yes
Nurse anesthetist (Currently employed) 2
Availability of Nurse anesthetist 24 hours No
Obstetrician (Currently employed) 2
Availability of obstetrician 24 hours No
Anesthesiologist (MD) (Currently employed) 0
Availability of anesthesiologist (MD) 24 hours No
Annex 15B Table 4: Availability of general facilities for EmONC services
Description CSI Ainaro*CHC
Hautio*CHC
Maubisse CHC Hatu-
UdoHR
Maubisse
Electricity Yes No Yes Yes Yes
Back up generator No No Yes Yes Yes
Running water Yes Yes Yes Yes Yes
Functioning toilet Yes Yes Yes Yes Yes
Total bed in the facility 15 2 0 6 40
Total bed for obstetric patient 2 1 0 2 10
Total delivery table 2 1 0 3 2
Delivery room Yes No No Yes Yes
Postpartum room Yes No No Yes Yes
Laboratory room Yes No Yes Yes Yes
Operating Theater Yes
Neonatal care room Yes
102 EmONC Improvement Plan of Action 2016 - 2019
Description CSI Ainaro*CHC
Hautio*CHC
Maubisse CHC Hatu-
UdoHR
Maubisse
Blood Bank Yes
Availability of stored blood for use in emergencies No
General anesthesia Yes
Spinal anesthesia Yes
Functional fan/air conditioning No No No No Yes
Curtains/means of providing patient privacy No Yes Yes Yes Yes
Annex 15B Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCSI
Ainaro*CHC
Hautio*CHC
Maubisse CHC
Hatu-UdoHR
Maubisse
Length of stay for normal delivery (day) 1 0 0 0 1
Food for maternity patient Yes No No No Yes
Food for family No No No No No
Waiting area for visitors and family Yes Yes Yes Yes Yes
Lodging for maternity patient Yes No No Yes Yes
Lodging for family No No No No Yes
Annex 15B Table 6: Availability of communication and transport facilities for referral
DescriptionCSI
Ainaro*CHC
Hautio*CHC
Maubisse CHC
Hatu-UdoHR
Maubisse
Telephone at maternity ward No No No No No
Telephone in the facility No No Yes No No
Cell phone (own by facility) No Yes Yes Yes Yes
Cell phone (own by staff) Yes Yes Yes Yes Yes
Ambulance Yes No No No Yes
Multi purpose vehicle Yes Yes No Yes No
Other transport for referral No No No No Yes
103EmONC Improvement Plan of Action 2016 - 2019
C. Baucau Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 124,061
Estimated number of births 2014-2015 (1 year ) (Crude Birth Rate: 33/1000) 4,094
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 2,481
Reported number of births in Health Posts 387
Annex 15C Table 1: Reported births during preceding 12 months of the assessment and referral information
Description
CHC
Uai
lili
CHC
Laga
CHC
Que
licai
*
CHC
Bagu
ia*
CHC
Vem
ase
CHC
Veni
lale
CHC
Ream
ari
HR B
auca
u
Number of birth from August 2014-July 2015
83 285 238 215 161 122 91 1286
Institution to which the patients with obstetric complications are referred
HR Baucau
HR Baucau
HR Baucau
HR Baucau
HR Baucau
HR Baucau
HR Baucau
HNGV Dili
Travel Time to higher level facility
20 minutes
45 Minutes
1 hour 3 hours 1 hour 1 hour 5
minutes 2 hours
Annex 15C Table 2: Performance of Signal Functions during preceding 12 months of the assessment
Description
CHC
Uai
lili
CHC
Laga
CHC
Que
licai
*
CHC
Bagu
ia*
CHC
Vem
ase
CHC
Veni
lale
CHC
Ream
ari
HR B
auca
u
Parenteral antibiotics (12months) No No No Yes No Yes No Yes
Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months) No Yes No No No No No Yes
Manual Removal of Placenta (12months) Yes Yes Yes Yes No Yes Yes Yes
Removal of Retained product (12months) Yes Yes No Yes Yes No Yes Yes
Assisted Vaginal Delivery (12months) No No No No No No No Yes
Newborn resuscitation (12months) No No Yes Yes Yes Yes Yes Yes
104 EmONC Improvement Plan of Action 2016 - 2019
Annex 15C Table 3: Availability of Human Resources
Description
CHC
Uai
lili
CHC
Laga
CHC
Que
licai
*
CHC
Bagu
ia*
CHC
Vem
ase
CHC
Veni
lale
CHC
Ream
ari
HR B
auca
u
Midwife (Currently employed) 3 3 5 1 4 5 4 16
Availability of midwives 24 hours No No No No Yes Yes No Yes
Medical Doctor (Currently employed) 0 0 3 1 0 7 9 3
Availability of medical doctor 24 hours No No No Yes No No No No
Nurse (Currently employed) 0 3 2 1 0 3 0 0
Availability of nurse 24 hours No No No Yes No No No No
Laboratory technician (Currently employed) 1 1 1 0 1 0 0 7
Availability of lab technician 24 hours No No No No No No No Yes
Nurse anesthetist (Currently employed) 5
Availability of Nurse anesthetist 24 hours No
Obstetrician (Currently employed) 1
Availability of obstetrician 24 hours No
Anesthesiologist (MD) (Currently employed) 1
Availability of anesthesiologist (MD) 24 hours
No
Annex 15C Table 4: Availability of general facilities for EmONC services
Description CHC
Uai
lili
CHC
Laga
CHC
Que
licai
*
CHC
Bagu
ia*
CHC
Vem
ase
CHC
Veni
lale
CHC
Ream
ari
HR
Bauc
au
Electricity Yes Yes Yes Yes Yes Yes Yes Yes
Back up generator Yes No No Yes No Yes No Yes
Running water Yes Yes No Yes Yes Yes Yes Yes
Functioning toilet Yes No Yes Yes Yes Yes Yes Yes
Total bed in the facility 1 6 5 7 9 9 10 114
Total bed for obstetric patient 1 5 3 6 8 7 8 20
Total delivery table 1 1 1 3 2 2 3 5
Delivery room Yes Yes Yes Yes Yes Yes Yes Yes
Postpartum room No Yes Yes Yes Yes Yes Yes Yes
Laboratory room Yes Yes Yes Yes Yes No No Yes
Operating Theater Yes
105EmONC Improvement Plan of Action 2016 - 2019
Description CHC
Uai
lili
CHC
Laga
CHC
Que
licai
*
CHC
Bagu
ia*
CHC
Vem
ase
CHC
Veni
lale
CHC
Ream
ari
HR
Bauc
au
Neonatal care room Yes
Blood Bank No
Availability of stored blood for use in emergencies
No
General anesthesia Yes
Spinal anesthesia Yes
Functional fan/air conditioning No Yes No No Yes Yes No No
Curtains/means of providing patient privacy
Yes Yes Yes Yes Yes Yes Yes Yes
Annex 15C Table 5: Availability facilities for accommodation and length of stay after normal delivery
Description
CHC
Uai
lili
CHC
Laga
CHC
Que
licai
*
CHC
Bagu
ia*
CHC
Vem
ase
CHC
Veni
lale
CHC
Ream
ari
HR B
auca
u
Length of stay for normal delivery (day) 0 1 1 1 1 1 1 1
Food for maternity patient No No No Yes No No No Yes
Food for family No No No Yes No No No Yes
Waiting area for visitors and family Yes Yes Yes Yes No No Yes Yes
Lodging for maternity patient Yes Yes Yes Yes Yes Yes Yes Yes
Lodging for family Yes Yes Yes Yes Yes Yes Yes Yes
Annex 15C Table 6: Availability of communication and transport facilities for referral
Description CHC
Uai
lili
CHC
Laga
CHC
Que
licai
*
CHC
Bagu
ia*
CHC
Vem
ase
CHC
Veni
lale
CHC
Ream
ari
HR
Bauc
au
Telephone at maternity ward No No No No No No No No
Telephone in the facility No No No No No No No Yes
Cell phone (own by facility) Yes Yes Yes Yes Yes No Yes Yes
Cell phone (own by staff) Yes Yes Yes Yes Yes Yes Yes Yes
Ambulance No No No No No No No Yes
Multi purpose vehicle Yes Yes Yes Yes Yes Yes Yes Yes
Other transport for referral No No No No No No No No
106 EmONC Improvement Plan of Action 2016 - 2019
D. Bobonaro Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 98,932
Estimated number of births 2014-2015 (1 year ) ( Crude Birth rate 36/1000) 3,562
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 1,025
Reported number of births in Health Posts 100
Annex 15D Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCHC
Maliana Vila
CHC Cailaco*
CHC Balibo
CHC Atabae*
CHC Lolotoe*
CHC Bobonaro*
HR Maliana
Number of birth from August 2014-July 2015
0 76 120 90 24 60 655
Institution to which the patients with obstetric complications are referred
HR Maliana
HR Maliana
HR Maliana
HR Maliana
HR Maliana
HR Maliana
HNGV Dili
Travel Time to higher level facility
15 minutes
45 minutes
40 minutes
2 hours 3 hours 1 hour 3 hours
Annex 15D Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCHC
Maliana Vila
CHC Cailaco*
CHC Balibo
CHC Atabae*
CHC Lolotoe*
CHC Bobonaro*
HR Maliana
Parenteral antibiotics (12months)
No No No Yes No Yes Yes
Parenteral Oxytocics (12months)
No Yes Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months)
No No No No No No Yes
Manual Removal of Placenta (12months)
No No No No Yes No Yes
Removal of Retained product (12months)
No Yes Yes No No No Yes
Assisted Vaginal Delivery (12months)
No No No No No No Yes
Newborn resuscitation (12months)
No Yes Yes Yes No No Yes
107EmONC Improvement Plan of Action 2016 - 2019
Annex 15D Table 3: Availability of Human Resources
DescriptionCHC
Maliana Vila
CHC Cailaco*
CHC Balibo
CHC Atabae*
CHC Lolotoe*
CHC Bobonaro*
HR Maliana
Midwife (Currently employed)
5 3 2 2 2 2 12
Availability of midwives 24 hours
No No No No No No Yes
Medical Doctor (Currently employed)
4 3 3 4 2 3 1
Availability of medical doctor 24 hours
No No No No No No No
Nurse (Currently employed)
2 1 0 5 4 3 0
Availability of nurse 24 hours
No No No No No No No
Laboratory technician (Currently employed)
0 1 1 1 1 0 3
Availability of lab technician 24 hours
No No No No No No No
Nurse anesthetist (Currently employed)
3
Availability of Nurse anesthetist 24 hours
No
Obstetrician (Currently employed)
1
Availability of obstetrician 24 hours
No
Anesthesiologist (MD) (Currently employed)
0
Availability of anesthesiologist (MD) 24 hours
No
108 EmONC Improvement Plan of Action 2016 - 2019
Annex 15D Table 4: Availability of general facilities for EmONC services
DescriptionCHC
Maliana Vila
CHC Cailaco*
CHC Balibo
CHC Atabae*
CHC Lolotoe*
CHC Bobonaro*
HR Maliana
Electricity Yes Yes Yes Yes Yes Yes Yes
Back up generator No No No Yes Yes Yes Yes
Running water Yes Yes Yes Yes Yes Yes Yes
Functioning toilet Yes Yes Yes Yes Yes Yes Yes
Total bed in the facility 3 4 9 6 4 2 34
Total bed for obstetric patient
3 2 7 1 4 4 12
Total delivery tables 0 2 2 2 1 2 3
Delivery room No Yes Yes Yes Yes Yes Yes
Postpartum room No Yes Yes Yes Yes Yes Yes
Laboratory room No Yes Yes Yes Yes No Yes
Operating Theater Yes
Neonatal care room No
Blood Bank Yes
Availability of stored blood for use in emergencies
No
General anesthesia Yes
Spinal anesthesia Yes
Functional fan/air conditioning
No No Yes Yes Yes Yes Yes
Curtains/means of providing patient privacy
Yes Yes Yes Yes Yes Yes Yes
109EmONC Improvement Plan of Action 2016 - 2019
Annex 15D Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCHC
Maliana Vila
CHC Cailaco*
CHC Balibo
CHC Atabae*
CHC Lolotoe*
CHC Bobonaro*
HR Maliana
Length of stay for normal delivery (day)
0 2 0 1 1 1 1
Food for maternity patient No No No No No No Yes
Food for family No No No No No No Yes
Waiting area for visitors and family
Yes Yes Yes Yes Yes Yes Yes
Lodging for maternity patient
No Yes Yes Yes Yes Yes Yes
Lodging for family No No Yes No No No No
Annex 15D Table 6: Availability of communication and transport facilities for referral
DescriptionCHC
Maliana Vila
CHC Cailaco*
CHC Balibo
CHC Atabae*
CHC Lolotoe*
CHC Bobonaro*
HR Maliana
Telephone at maternity ward
No No No No No No Yes
Telephone in the facility No No No No No No Yes
Cell phone (own by facility)
Yes Yes No Yes Yes Yes No
Cell phone (own by staff) No Yes Yes Yes No Yes Yes
Ambulance No No No No No No Yes
Multi purpose vehicle Yes Yes Yes Yes Yes Yes Yes
Other transport for referral
No No No No Yes No Yes
110 EmONC Improvement Plan of Action 2016 - 2019
E. Covalima Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 64,550
Estimated annual number of births ( Crude Birth Rate : 29/1000) 1,872
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 974
Reported number of births in Health Posts N/A
Annex 15E Table 1: Reported births during preceding 12 months of the assessment and referral information
Description CHC
Fatu
lulik
CHC
Fatu
Mea
CHC
Foho
rem
*
CHC
Mau
cata
r
CHC
Suai
Vila
CHC
Tilo
mar
*
CHC
Zum
alai
*
HR
Suai
Number of birth from August 2014-July 2015
1 43 48 5 0 150 154 573
Institution to which the patients with obstetric complications are referred
HR Suai HR Suai HR Suai HR Suai HR Suai HR Suai HR SuaiHNGV
Dili
Travel Time to higher level facility
3 hours 2 hours 1 hour45
minutes10
minutes35
minutes
1 hour 30
minutes10 hours
Annex 15E Table 2: Performance of Signal Functions during preceding 12 months of the assessment
Description CHC
Fatu
lulik
CHC
Fatu
Mea
CHC
Foho
rem
*
CHC
Mau
cata
r
CHC
Suai
Vila
CHC
Tilo
mar
*
CHC
Zum
alai
*
HR
Suai
Parenteral antibiotics (12months)
No No No No No No Yes Yes
Parenteral Oxytocics (12months)
Yes Yes Yes No No Yes Yes Yes
Parenteral Anticonvulsant (12months)
No No Yes No No No Yes Yes
Manual Removal of Placenta (12months)
No No Yes No No No Yes Yes
Removal of Retained product (12months)
No No Yes No No Yes No Yes
Assisted Vaginal Delivery (12months)
No No No No No No No Yes
Newborn resuscitation (12months) No Yes Yes No No No Yes Yes
111EmONC Improvement Plan of Action 2016 - 2019
Annex 15E Table 3: Availability of Human Resources
Description CHC
Fatu
lulik
CHC
Fatu
Mea
CHC
Foho
rem
*
CHC
Mau
cata
r
CHC
Suai
Vila
CHC
Tilo
mar
*
CHC
Zum
alai
*
HR
Suai
Midwife (Currently employed) 1 1 1 1 3 1 3 11
Availability of midwives 24 hours
No No No No No No Yes Yes
Medical Doctor (Currently employed)
1 2 1 2 6 3 6 0
Availability of medical doctor 24 hours
No No No No No No Yes No
Nurse (Currently employed) 0 2 0 0 0 0 0 0
Availability of nurse 24 hours No No No No No No No No
Laboratory technician (Currently employed)
0 0 1 0 2 1 1 4
Availability of lab technician 24 hours
No No No No No No No No
Nurse anesthetist (Currently employed)
3
Availability of Nurse anesthetist 24 hours
No
Obstetrician (Currently employed)
0
Availability of obstetrician 24 hours
No
Anesthesiologist (MD) (Currently employed)
0
Availability of anesthesiologist (MD) 24 hours
No
Annex 15E Table 4: Availability of general facilities for EmONC services
Description CHC
Fatu
lulik
CHC
Fatu
Mea
CHC
Foho
rem
*
CHC
Mau
cata
r
CHC
Suai
Vila
CHC
Tilo
mar
*
CHC
Zum
alai
*
HR
Suai
Electricity Yes Yes Yes Yes Yes Yes Yes Yes
Back up generator Yes Yes No No Yes No No Yes
Running water Yes No No Yes Yes Yes Yes Yes
Functioning toilet Yes Yes Yes Yes Yes Yes Yes Yes
Total bed in the facility 7 8 11 3 6 6 9 46
Total bed for obstetric patient 2 4 5 1 2 1 4 12
112 EmONC Improvement Plan of Action 2016 - 2019
Description CHC
Fatu
lulik
CHC
Fatu
Mea
CHC
Foho
rem
*
CHC
Mau
cata
r
CHC
Suai
Vila
CHC
Tilo
mar
*
CHC
Zum
alai
*
HR
Suai
Total delivery table 2 2 2 1 1 2 2 2
Delivery room Yes Yes Yes Yes Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes Yes Yes Yes Yes
Laboratory room Yes No Yes Yes Yes Yes Yes Yes
Operating Theater Yes
Neonatal care room No
Blood Bank No
Availability of stored blood for use in emergencies
No
General anesthesia No
Spinal anesthesia No
Functional fan/air conditioning
No No No No No No No Yes
Curtains/means of providing patient privacy
No Yes No Yes Yes Yes Yes Yes
Annex 15E Table 5: Availability facilities for accommodation and length of stay after normal delivery
Description CHC
Fatu
lulik
CHC
Fatu
Mea
CHC
Foho
rem
*
CHC
Mau
cata
r
CHC
Suai
Vila
CHC
Tilo
mar
*
CHC
Zum
alai
*
HR
Suai
Length of stay for normal delivery (day)
0 0 1 1 0 0 0 1
Food for maternity patient No No No No No No No Yes
Food for family No No No No No No No No
Waiting area for visitors and family
Yes Yes Yes Yes Yes Yes Yes No
Lodging for maternity patient
Yes Yes Yes Yes Yes Yes Yes Yes
Lodging for family No No No No No No No No
113EmONC Improvement Plan of Action 2016 - 2019
Annex 15E Table 6: Availability of communication and transport facilities for referral
Description CHC
Fatu
lulik
CHC
Fatu
Mea
CHC
Foho
rem
*
CHC
Mau
cata
r
CHC
Suai
Vila
CHC
Tilo
mar
*
CHC
Zum
alai
*
HR
Suai
Telephone in the facility Yes No No No Yes Yes No Yes
Cell phone (own by facility) No Yes Yes No No No No No
Cell phone (own by staff) Yes Yes Yes Yes Yes Yes Yes Yes
Ambulance No No No No No No No Yes
Multi-purpose vehicle Yes Yes Yes Yes Yes Yes Yes Yes
Other transport for referral No No No No No No No No
114 EmONC Improvement Plan of Action 2016 - 2019
F. Dili Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities(Comoro CHC was found to be a functional BEmONC Facility and needs quality
improvement)
Population 252,884
Estimated number of births 2014-2015 (1 year ) ( Crude Birth Rate: 33/1000) 8,345
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 8,724
Reported number of births in Health Posts 156
Annex 15F Table 1: Reported births during preceding 12 months of the assessment and re ferral information
DescriptionCHC
Centro*CHC
MetinaroCHC
Atauro*CHC
ComoroCHC
Becora*
CHC Vera Cruz*
NH HNGV
Number of birth from August 2014-July 2015
313 78 104 1513 557 655 4302
Institution to which the patients with obstetric complications are referred
HNGV Dili HNGV Dili HNGV Dili HNGV Dili HNGV Dili HNGV Dili HNGV Dili
Travel Time to higher level facility
10 minutes
45 minutes
4 hours20
minutes10
minutes15
minutesN/A
Annex 15F Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCHC
Centro*CHC
MetinaroCHC
Atauro*CHC
ComoroCHC
Becora*
CHC Vera Cruz*
NH HNGV
Parenteral antibiotics (12months)
Yes No Yes Yes Yes Yes Yes
Parenteral Oxytocics (12months)
Yes Yes Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months)
Yes No Yes Yes No Yes Yes
Manual Removal of Placenta (12months)
Yes No Yes Yes Yes Yes Yes
Removal of Retained product (12months)
Yes Yes Yes Yes Yes Yes Yes
Assisted Vaginal Delivery (12months)
Yes No No Yes No No Yes
Newborn resuscitation (12months)
No Yes Yes Yes Yes Yes Yes
115EmONC Improvement Plan of Action 2016 - 2019
Annex 15F Table 3: Availability of Human Resources
DescriptionCHC
Centro*CHC
MetinaroCHC
Atauro*CHC
ComoroCHC
Becora*
CHC Vera Cruz*
NH HNGV
Midwife (Currently employed) 8 3 3 20 17 13 20
Availability of midwives 24 hours
Yes No No Yes Yes Yes Yes
Medical Doctor (Currently employed)
1 5 2 22 9 8 10
Availability of medical doctor 24 hours
Yes No No Yes Yes Yes Yes
Nurse (Currently employed) 0 2 2 0 4 0 0
Availability of nurse 24 hours No No No No Yes No No
Laboratory technician (Currently employed)
1 1 2 2 1 3 18
Availability of lab technician 24 hours
No No No No No No Yes
Nurse anesthetist (Currently employed)
3
Availability of Nurse anesthetist 24 hours
No
Obstetrician (Currently employed)
6
Availability of obstetrician 24 hours
No
Anesthesiologist (MD) (Currently employed)
4
Availability of anesthesiologist (MD) 24 hours
Yes
Annex 15F Table 4: Availability of general facilities for EmONC services
DescriptionCHC
Centro*CHC
MetinaroCHC
Atauro*CHC
ComoroCHC
Becora*
CHC Vera Cruz*
NH HNGV
Electricity Yes Yes Yes Yes Yes Yes Yes
Back up generator Yes No Yes No No No Yes
Running water Yes Yes Yes Yes Yes Yes Yes
Functioning toilet Yes Yes Yes Yes Yes Yes Yes
Total bed in the facility 8 8 11 10 12 18 260
Total bed for obstetric patient 4 7 5 5 9 7 55
Total delivery table 2 2 1 2 3 2 12
116 EmONC Improvement Plan of Action 2016 - 2019
DescriptionCHC
Centro*CHC
MetinaroCHC
Atauro*CHC
ComoroCHC
Becora*
CHC Vera Cruz*
NH HNGV
Delivery room Yes Yes Yes Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes Yes Yes Yes
Laboratory room Yes Yes Yes Yes Yes Yes Yes
Operating Theater Yes
Neonatal care room Yes Yes
Blood Bank Yes
Availability of stored blood for use in emergencies
100
General anesthesia Yes
Spinal anesthesia Yes
Functional fan/air conditioning
Yes Yes Yes Yes Yes Yes Yes
Curtains/means of providing patient privacy
Yes Yes No Yes Yes Yes Yes
Annex 15F Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCHC
Centro*CHC
MetinaroCHC
Atauro*CHC
ComoroCHC
Becora*
CHC Vera Cruz*
NH HNGV
Length of stay for normal delivery (day)
1 0 0 0 1 1 0
Food for maternity patient Yes Yes Yes Yes Yes Yes Yes
Food for family No Yes No No No No No
Waiting area for visitors and family
Yes Yes Yes Yes Yes Yes Yes
Lodging for maternity patient Yes Yes Yes No Yes Yes Yes
Lodging for family No Yes No No No No No
117EmONC Improvement Plan of Action 2016 - 2019
Annex 15F Table 6: Availability of communication and transport facilities for referral
DescriptionCHC
Centro*CHC
MetinaroCHC
Atauro*CHC
ComoroCHC
Becora*
CHC Vera Cruz*
NH HNGV
Telephone at maternity ward No No No No No Yes Yes
Telephone in the facility Yes No Yes No No No Yes
Cell phone (own by facility) Yes No No No Yes No Yes
Cell phone (own by staff) Yes Yes Yes Yes Yes Yes Yes
Ambulance No No No No No No Yes
Multi purpose vehicle Yes Yes Yes Yes Yes Yes No
Other transport for referral No No Yes No Yes No No
118 EmONC Improvement Plan of Action 2016 - 2019
G. Ermera Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 127,283
Estimated number of births 2014-2015 (1 year ) ( Crude Birth Rate: 40/1000) 5,091
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 789
Reported number of births in Health Posts 75
Annex 15G Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCHC
RailacoCSI
Gleno*
CHC Ermera Lama
CHC Letefoho
CHC Atsabe*
CHC Hatolia*
Number of birth from August 2014-July 2015 79 324 97 87 147 55
Institution to which the patients with obstetric complications are referred
CSI Gleno
CSI Gleno
CSI Gleno
CSI Gleno
CSI Gleno
CSI Gleno
Travel Time to higher level facility15
minutes1 hour
30 minutes
2 hours 4 hours 2 hours
Annex 15G Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCHC
RailacoCSI
Gleno*
CHC Ermera Lama
CHC Letefoho
CHC Atsabe*
CHC Hatolia*
Parenteral antibiotics (12months) No Yes Yes No Yes Yes
Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months) No Yes No No No No
Manual Removal of Placenta (12months) No Yes No Yes Yes Yes
Removal of Retained product (12months) No Yes Yes No Yes No
Assisted Vaginal Delivery (12months) No No No No No No
Newborn resuscitation (12months) No Yes Yes No Yes Yes
119EmONC Improvement Plan of Action 2016 - 2019
Annex 15G Table 3: Availability of Human Resources
DescriptionCHC
RailacoCSI
Gleno*
CHC Ermera Lama
CHC Letefoho
CHC Atsabe*
CHC Hatolia*
Midwife (Currently employed) 2 6 3 2 2 2
Availability of midwives 24 hours No Yes No No No No
Medical Doctor (Currently employed) 4 1 3 3 3 4
Availability of medical doctor 24 hours No Yes No No No No
Nurse (Currently employed) 4 0 2 1 5 1
Availability of nurse 24 hours No No No No No No
Laboratory technician (Currently employed) 1 1 1 0 0 1
Availability of lab technician 24 hours No No No No No No
Nurse anesthetist (Currently employed)
Availability of Nurse anesthetist 24 hours
Obstetrician (Currently employed)
Availability of obstetrician 24 hours
Anesthesiologist (MD) (Currently employed)
Availability of anesthesiologist (MD) 24 hours
Annex 15G Table 4: Availability of general facilities for EmONC services
DescriptionCHC
RailacoCSI
Gleno*
CHC Ermera Lama
CHC Letefoho
CHC Atsabe*
CHC Hatolia*
Electricity Yes Yes Yes Yes Yes Yes
Back up generator No No Yes No No No
Running water Yes Yes Yes No Yes Yes
Functioning toilet No Yes Yes Yes No Yes
Total bed in the facility 1 20 1 5 11 7
Total bed for obstetric patient 1 4 1 2 8 5
Total delivery table 1 2 1 2 2 2
Delivery room Yes Yes No Yes Yes Yes
Postpartum room Yes Yes No Yes Yes Yes
Laboratory room Yes Yes No No No Yes
Operating Theater
Neonatal care room Yes Yes Yes
120 EmONC Improvement Plan of Action 2016 - 2019
DescriptionCHC
RailacoCSI
Gleno*
CHC Ermera Lama
CHC Letefoho
CHC Atsabe*
CHC Hatolia*
Blood Bank
Availability of stored blood for use in emergencies
General anesthesia
Spinal anesthesia
Functional fan/air conditioning No No No No No Yes
Curtains/means of providing patient privacy Yes Yes Yes Yes Yes Yes
Annex 15G Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCHC
RailacoCSI
Gleno*
CHC Ermera Lama
CHC Letefoho
CHC Atsabe*
CHC Hatolia*
Length of stay for normal delivery (day) 0 0 0 0 0 0
Food for maternity patient Yes Yes No No No Yes
Food for family No No No No No No
Waiting area for visitors and family Yes Yes Yes Yes Yes Yes
Lodging for maternity patient Yes Yes No Yes Yes Yes
Lodging for family Yes No No Yes Yes No
Annex 15G Table 6: Availability of communication and transport facilities for referral
DescriptionCHC
RailacoCSI
Gleno*
CHC Ermera Lama
CHC Letefoho
CHC Atsabe*
CHC Hatolia*
Telephone at maternity ward No No No No No No
Telephone in the facility Yes No No Yes No No
Cell phone (own by facility) Yes No Yes No Yes No
Cell phone (own by staff) Yes Yes Yes Yes Yes Yes
Ambulance No Yes No No No No
Multi purpose vehicle Yes Yes Yes Yes Yes Yes
Other transport for referral No No No No No No
121EmONC Improvement Plan of Action 2016 - 2019
H. Lautem Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 64,135
Estimated number of births 2014-2015 (1 year ) ( Crude Birth Rate: 37/1000) 2,373
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 816
Reported number of births in Health Posts 43
Annex 15H Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCSI
Lospalos*CHC
LautemCHC
Iliomar*CHC
Luro*CHC
Tutuala
Number of birth from August 2014-July 2015 586 116 48 24 42
Institution to which the patients with obstetric complications are referred
HR BaucauCSI
LospalosCSI
LospalosCSI
LospalosCSI
Lospalos
Travel Time to higher level facility 2 hours45
minutes2 hours 30
minutes1 hour 30 minutes
45 minutes
Annex 15H Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCSI
Lospalos*CHC
LautemCHC
Iliomar*CHC
Luro*CHC
Tutuala
Parenteral antibiotics (12months) Yes Yes Yes No No
Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months) No No No No No
Manual Removal of Placenta (12months) Yes Yes Yes No Yes
Removal of Retained product (12months) Yes Yes No No No
Assisted Vaginal Delivery (12months) No No No No No
Newborn resuscitation (12months) Yes Yes No No Yes
122 EmONC Improvement Plan of Action 2016 - 2019
Annex 15H Table 3: Availability of Human Resources
DescriptionCSI
Lospalos*CHC
LautemCHC
Iliomar*CHC
Luro*CHC
Tutuala
Midwife (Currently employed) 10 3 1 1 1
Availability of midwives 24 hours Yes Yes Yes No No
Medical Doctor (Currently employed) 7 3 2 7 3
Availability of medical doctor 24 hours Yes Yes No No Yes
Nurse (Currently employed) 0 0 2 0 0
Availability of nurse 24 hours No No No No No
Laboratory technician (Currently employed) 2 1 1 1 0
Availability of lab technician 24 hours No No No No No
Nurse anesthetist (Currently employed)
Availability of Nurse anesthetist 24 hours
Obstetrician (Currently employed)
Availability of obstetrician 24 hours
Anesthesiologist (MD) (Currently employed)
Availability of anesthesiologist (MD) 24 hours
Annex 15H Table 4: Availability of general facilities for EmONC services
DescriptionCSI
Lospalos*CHC
LautemCHC
Iliomar*CHC
Luro*CHC
Tutuala
Electricity Yes Yes Yes Yes Yes
Back up generator Yes Yes Yes Yes Yes
Running water Yes Yes Yes Yes Yes
Functioning toilet Yes Yes Yes Yes Yes
Total bed in the facility 32 8 7 4 7
Total bed for obstetric patient 11 6 5 2 6
Total delivery table 3 2 2 1 2
Delivery room Yes Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes Yes
Laboratory room Yes Yes Yes Yes No
Operating Theater
Neonatal care room
Blood Bank
123EmONC Improvement Plan of Action 2016 - 2019
DescriptionCSI
Lospalos*CHC
LautemCHC
Iliomar*CHC
Luro*CHC
Tutuala
Availability of stored blood for use in emergencies
General anesthesia
Spinal anesthesia
Functional fan/air conditioning Yes No Yes No Yes
Curtains/means of providing patient privacy No Yes Yes Yes No
Annex 15H Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCSI
Lospalos*CHC
LautemCHC
Iliomar*CHC
Luro*CHC
Tutuala
Length of stay for normal delivery (day) 3 1 1 1 1
Food for maternity patient Yes No No No No
Food for family No No No No No
Waiting area for visitors and family Yes No Yes Yes No
Lodging for maternity patient Yes Yes Yes Yes Yes
Lodging for family No No Yes No No
Annex 15H Table 6: Availability of communication and transport facilities for referral
DescriptionCSI
Lospalos*CHC
LautemCHC
Iliomar*CHC
Luro*CHC
Tutuala
Telephone at maternity ward No No No No No
Telephone in the facility Yes No No Yes Yes
Cell phone (own by facility) No Yes Yes No No
Cell phone (own by staff) Yes Yes Yes Yes Yes
Ambulance Yes No No No No
Multi purpose vehicle Yes Yes Yes Yes Yes
Other transport for referral No No No No Yes
124 EmONC Improvement Plan of Action 2016 - 2019
I. Liquica Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 73,027
Estimated number of births 2014-2015 (1 year) (Crude Birth Rate: 36/1000) 2,629
Reported number of births August 2014- July 2015 (in the assessed health facilities) 570
Reported number of births in Health Posts 618
Annex 15I Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCHC
Fatumasi*CSI
Liquica*CHC
Maubara*
Number of birth from August 2014-July 2015 90 304 176
Institution to which the patients with obstetric complications are referred HNGV Dili HNGV Dili HNGV Dili
Travel Time to higher level facility 1 hour 1 hour 2 hours
Annex 15I Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCHC
Fatumasi*CSI
Liquica*CHC
Maubara*
Parenteral antibiotics (12months) No No Yes
Parenteral Oxytocics (12months) Yes Yes Yes
Parenteral Anticonvulsant (12months) Yes No No
Manual Removal of Placenta (12months) No Yes Yes
Removal of Retained product (12months) No No Yes
Assisted Vaginal Delivery (12months) No No No
Newborn resuscitation (12months) No Yes Yes
Annex 15I Table 3: Availability of Human Resources
DescriptionCHC
Fatumasi*CSI
Liquica*CHC
Maubara*
Midwife (Currently employed) 2 4 5
Availability of midwives 24 hours Yes Yes Yes
Medical Doctor (Currently employed) 1 1 1
Availability of medical doctor 24 hours No No Yes
125EmONC Improvement Plan of Action 2016 - 2019
DescriptionCHC
Fatumasi*CSI
Liquica*CHC
Maubara*
Nurse (Currently employed) 1 0 1
Availability of nurse 24 hours No No Yes
Laboratory technician (Currently employed) 0 1 1
Availability of lab technician 24 hours No No No
Nurse anesthetist (Currently employed)
Availability of Nurse anesthetist 24 hours
Obstetrician (Currently employed)
Availability of obstetrician 24 hours
Anesthesiologist (MD) (Currently employed)
Availability of anesthesiologist (MD) 24 hours
Annex 15I Table 4: Availability of general facilities for EmONC services
DescriptionCHC
Fatumasi*CSI
Liquica*CHC
Maubara*
Electricity Yes Yes Yes
Back up generator Yes Yes No
Running water Yes Yes Yes
Functioning toilet Yes Yes Yes
Total bed in the facility 4 12 3
Total bed for obstetric patient 4 4 2
Total delivery table 2 2 2
Delivery room Yes Yes Yes
Postpartum room Yes Yes Yes
Laboratory room Yes Yes Yes
Operating Theater
Neonatal care room Yes
Blood Bank
Availability of stored blood for use in emergencies
General anesthesia
Spinal anesthesia
Functional fan/air conditioning No Yes No
Curtains/means of providing patient privacy Yes Yes Yes
126 EmONC Improvement Plan of Action 2016 - 2019
Annex 15I Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCHC
Fatumasi*CSI
Liquica*CHC
Maubara*
Length of stay for normal delivery (day) 0 0 0
Food for maternity patient Yes Yes Yes
Food for family No No No
Waiting area for visitors and family Yes Yes Yes
Lodging for maternity patient Yes No Yes
Lodging for family No No No
Annex 15I Table 6: Availability of communication and transport facilities for referral
DescriptionCHC
Fatumasi*CSI
Liquica*CHC
Maubara*
Telephone at maternity ward No No No
Telephone in the facility No Yes No
Cell phone (own by facility) Yes Yes Yes
Cell phone (own by staff) Yes Yes Yes
Ambulance No Yes No
Multi purpose vehicle Yes Yes Yes
Other transport for referral No Yes Yes
127EmONC Improvement Plan of Action 2016 - 2019
J. Manatuto Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 45,541
Estimated number of births 2014-2015 (1 year ) ( Crude Birth Rate: 35/1000) 1,594
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 383
Reported number of births in Health Posts 64
Annex 15J Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCSI
Manatuto*CHC
LaleiaCHC Laclo
CHC Soibada
CHC Natarbora*
CHC Laclubar*
Number of birth from August 2014-July 2015
204 40 13 21 23 82
Institution to which the patients with obstetric complications are referred
HNGV DiliCSI
ManatutoCSI
ManatutoCSI
ManatutoCSI
ManatutoCSI
Manatuto
Travel Time to higher level facility
1 hour 30 minutes
30 minutes1 hour 30 minutes
4 hours 30 minutes
6 hours3 hours 30
minutes
Annex 15J Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCSI
Manatuto*CHC
LaleiaCHC Laclo
CHC Soibada
CHC Natarbora*
CHC Laclubar*
Parenteral antibiotics (12months)
Yes No Yes Yes No Yes
Parenteral Oxytocics (12months)
Yes Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months)
No No No No No No
Manual Removal of Placenta (12months)
Yes No Yes No No No
Removal of Retained product (12months)
Yes Yes Yes Yes No Yes
Assisted Vaginal Delivery (12months)
No No No No No No
Newborn resuscitation (12months)
Yes No No Yes No No
128 EmONC Improvement Plan of Action 2016 - 2019
Annex 15J Table 3: Availability of Human Resources
DescriptionCSI
Manatuto*CHC
LaleiaCHC Laclo
CHC Soibada
CHC Natarbora*
CHC Laclubar*
Midwife (Currently employed)
8 1 1 1 2 3
Availability of midwives 24 hours
Yes No No No No No
Medical Doctor (Currently employed)
9 3 3 4 3 2
Availability of medical doctor 24 hours
Yes No No No No No
Nurse (Currently employed)
0 2 2 1 0 0
Availability of nurse 24 hours
No No No No No No
Laboratory technician (Currently employed)
2 0 1 2 1 1
Availability of lab technician 24 hours
No No No No No No
Nurse anesthetist (Currently employed)Availability of Nurse anesthetist 24 hoursObstetrician (Currently employed)Availability of obstetrician 24 hoursAnesthesiologist (MD) (Currently employed)Availability of anesthesiologist (MD) 24 hours
Annex 15J Table 4: Availability of general facilities for EmONC services
DescriptionCSI
Manatuto*CHC
LaleiaCHC Laclo
CHC Soibada
CHC Natarbora*
CHC Laclubar*
Electricity Yes Yes Yes Yes Yes Yes
Back up generator Yes No No No No No
Running water Yes Yes Yes Yes Yes Yes
Functioning toilet Yes Yes No Yes Yes Yes
Total bed in the facility 18 7 5 10 9 10
Total bed for obstetric patient
6 4 2 8 7 7
Total delivery table 2 2 1 1 2 3
129EmONC Improvement Plan of Action 2016 - 2019
DescriptionCSI
Manatuto*CHC
LaleiaCHC Laclo
CHC Soibada
CHC Natarbora*
CHC Laclubar*
Delivery room Yes Yes Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes Yes Yes
Laboratory room Yes Yes Yes Yes Yes Yes
Operating Theater
Neonatal care room
Blood Bank
Availability of stored blood for use in emergencies
General anesthesia
Spinal anesthesia
Functional fan/air conditioning
Yes Yes Yes Yes No No
Curtains/means of providing patient privacy
Yes Yes Yes Yes Yes Yes
Annex 15J Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCSI
Manatuto*CHC
LaleiaCHC Laclo
CHC Soibada
CHC Natarbora*
CHC Laclubar*
Length of stay for normal delivery (day) 1 0 0 1 0 1
Food for maternity patient Yes Yes Yes No No Yes
Food for family No No No No No Yes
Waiting area for visitors and family Yes Yes Yes Yes Yes Yes
Lodging for maternity patient Yes Yes Yes Yes Yes Yes
Lodging for family No No No No No No
130 EmONC Improvement Plan of Action 2016 - 2019
Annex 15J Table 6: Availability of communication and transport facilities for referral
DescriptionCSI
Manatuto*CHC
LaleiaCHC Laclo
CHC Soibada
CHC Natarbora*
CHC Laclubar*
Telephone at maternity ward
Yes No No No No No
Telephone in the facility Yes No No No No No
Cell phone (own by facility)
No No No No No No
Cell phone (own by staff) Yes Yes Yes Yes Yes Yes
Ambulance Yes No No No No No
Multi purpose vehicle Yes Yes Yes Yes Yes Yes
Other transport for referral
No No No Yes No Yes
131EmONC Improvement Plan of Action 2016 - 2019
K. Manufahi Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 52,246
Estimated number of births 2014-2015 (1 year ) ( Crude Birth Rate: 33/1000) 1,724
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 612
Reported number of births in Health Posts N/A
Annex 15K Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCSI
Same*CHC Alas
CHC Fatuberlio*
CHC Turiscai
Number of birth from August 2014-July 2015 370 35 121 86
Institution to which the patients with obstetric complications are referred
HR Maubisse CSI Same CSI Same HR Maubisse
Travel Time to higher level facility1 hour 20 minutes
1 hour 2 hours 1 hour
Annex 15K Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCSI
Same*CHC Alas
CHC Fatuberlio*
CHC Turiscai
Parenteral antibiotics (12months) Yes No No No
Parenteral Oxytocics (12months) Yes Yes Yes Yes
Parenteral Anticonvulsant (12months) Yes No No No
Manual Removal of Placenta (12months) Yes No No No
Removal of Retained product (12months) Yes No Yes No
Assisted Vaginal Delivery (12months) No No No No
Newborn resuscitation (12months) Yes No No No
132 EmONC Improvement Plan of Action 2016 - 2019
Annex 15K Table 3: Availability of Human Resources
DescriptionCSI
Same*CHC Alas
CHC Fatuberlio*
CHC Turiscai
Midwife (Currently employed) 8 2 3 2
Availability of midwives 24 hours Yes No No No
Medical Doctor (Currently employed) 2 1 1 1
Availability of medical doctor 24 hours Yes No No No
Nurse (Currently employed) 0 1 1 0
Availability of nurse 24 hours No No No No
Laboratory technician (Currently employed) 1 1 0 0
Availability of lab technician 24 hours No No No No
Nurse anesthetist (Currently employed)
Availability of Nurse anesthetist 24 hours
Obstetrician (Currently employed)
Availability of obstetrician 24 hours
Anesthesiologist (MD) (Currently employed)
Availability of anesthesiologist (MD) 24 hours
Annex 15K Table 4: Availability of general facilities for EmONC services
DescriptionCSI
Same*CHC Alas
CHC Fatuberlio*
CHC Turiscai
Electricity Yes Yes Yes Yes
Back up generator Yes Yes No Yes
Running water Yes Yes Yes No
Functioning toilet Yes Yes Yes No
Total bed in the facility 29 5 5 3
Total bed for obstetric patient 5 4 4 1
Total delivery table 2 2 2 2
Delivery room Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes
Laboratory room Yes Yes Yes Yes
Operating Theater
Newborn care room Yes
Blood Bank
133EmONC Improvement Plan of Action 2016 - 2019
DescriptionCSI
Same*CHC Alas
CHC Fatuberlio*
CHC Turiscai
Availability of stored blood for use in emergencies
General anesthesia
Spinal anesthesia
Functional fan/air conditioning Yes Yes Yes No
Curtains/means of providing patient privacy Yes Yes Yes Yes
Annex 15K Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCSI
Same*CHC Alas
CHC Fatuberlio*
CHC Turiscai
Length of stay for normal delivery (day) 0 0 0 0
Food for maternity patient Yes Yes No No
Food for family Yes Yes No No
Waiting area for visitors and family Yes Yes Yes Yes
Lodging for maternity patient Yes Yes Yes No
Lodging for family Yes Yes Yes No
Annex 15K Table 6: Availability of communication and transport facilities for referral
DescriptionCSI
Same*CHC Alas
CHC Fatuberlio*
CHC Turiscai
Telephone at maternity ward Yes No Yes No
Telephone in the facility Yes No No No
Cell phone (own by facility) Yes Yes Yes Yes
Cell phone (own by staff) Yes Yes Yes Yes
Ambulance Yes No No No
Multi purpose vehicle Yes Yes Yes Yes
Other transport for referral No Yes No No
134 EmONC Improvement Plan of Action 2016 - 2019
L. Special Region Oecusse
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 72,230
Estimated number of births 2014-2015 (1 year) ( Crude Birth Rate: 40/1000) 2889
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 531
Reported number of births in Health Posts 72
Annex 15L Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCHC
BaquiCHC
BaocnanaCHC
BobometoCHC
Passabe*HR
Oecusse
Number of birth from August 2014-July 2015 71 19 67 25 349
Institution to which the patients with obstetric complications are referred
HR Oecusse
HR Oecusse
HR Oecusse
HR Oecusse HNGV Dili
Travel Time to higher level facility 30 minutes 1 hour 45 minutes 2 hours 12 hours
Annex 15L Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCHC
BaquiCHC
BaocnanaCHC
BobometoCHC
Passabe*HR
Oecusse
Parenteral antibiotics (12months) No No No Yes Yes
Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months) No No No No Yes
Manual Removal of Placenta (12months) Yes No No No Yes
Removal of Retained product (12months) No No No No Yes
Assisted Vaginal Delivery (12months) No No No No Yes
Newborn resuscitation (12months) No Yes No Yes Yes
Annex 15L Table 3: Availability of Human Resources
DescriptionCHC
BaquiCHC
BaocnanaCHC
BobometoCHC
Passabe*HR
Oecusse
Midwife (Currently employed) 5 2 2 1 8
Availability of midwives 24 hours No No No No Yes
Medical Doctor (Currently employed) 5 4 3 2 2
Availability of medical doctor 24 hours No No No No No
Nurse (Currently employed) 2 0 0 2 0
135EmONC Improvement Plan of Action 2016 - 2019
DescriptionCHC
BaquiCHC
BaocnanaCHC
BobometoCHC
Passabe*HR
Oecusse
Availability of nurse 24 hours No No No No No
Laboratory technician (Currently employed) 0 1 0 1 3
Availability of lab technician 24 hours No No No No No
Nurse anesthetist (Currently employed) 2
Availability of Nurse anesthetist 24 hours No
Obstetrician (Currently employed) 1
Availability of obstetrician 24 hours No
Anesthesiologist (MD) (Currently employed) 0
Availability of anesthesiologist (MD) 24 hours No
Annex 15L Table 4: Availability of general facilities for EmONC services
DescriptionCHC
BaquiCHC
BaocnanaCHC
BobometoCHC
Passabe*HR
Oecusse
Electricity Yes Yes Yes Yes Yes
Back up generator Yes Yes Yes No Yes
Running water Yes Yes No Yes Yes
Functioning toilet Yes Yes Yes Yes Yes
Total bed in the facility 2 11 8 17 37
Total bed for obstetric patient 2 7 6 10 11
Total delivery table 1 2 2 2 3
Delivery room Yes Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes Yes
Laboratory room No Yes Yes Yes Yes
Operating Theater Yes
Neonatal care room Yes
Blood Bank Yes
Availability of stored blood for use in emergencies
No
General anesthesia Yes
Spinal anesthesia Yes
Functional fan/air conditioning No Yes Yes No Yes
Curtains/means of providing patient privacy Yes Yes Yes Yes Yes
136 EmONC Improvement Plan of Action 2016 - 2019
Annex 15L Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCHC
BaquiCHC
BaocnanaCHC
BobometoCHC
Passabe*HR
Oecusse
Length of stay for normal delivery (day) 0 1 1 0 1
Food for maternity patient No No No No Yes
Food for family No No No No Yes
Waiting area for visitors and family Yes Yes Yes No Yes
Lodging for maternity patient Yes Yes Yes Yes Yes
Lodging for family Yes Yes Yes Yes Yes
Annex 15L Table 6: Availability of communication and transport facilities for referral
DescriptionCHC
BaquiCHC
BaocnanaCHC
BobometoCHC
Passabe*HR
Oecusse
Telephone at maternity ward No No No No No
Telephone in the facility No No No No Yes
Cell phone (own by facility) Yes No No No Yes
Cell phone (own by staff) Yes Yes Yes Yes Yes
Ambulance No No No No Yes
Multi purpose vehicle Yes Yes Yes Yes No
Other transport for referral No No No No Yes
137EmONC Improvement Plan of Action 2016 - 2019
M. Viqueque Municipality
Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities
Population 77,402
Estimated number of births 2014-2015 (1 year ) ( Crude Birth Rate: 37/1000) 2,864
Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 969
Reported number of births in Health Posts 159
Annex 15M Table 1: Reported births during preceding 12 months of the assessment and referral information
DescriptionCHC
Uatucarbau*CHC Ossu
CHC Uatolari*
CSI Viqueque*
CHC Lacluta*
Number of birth from August 2014-July 2015 96 135 277 383 78
Institution to which the patients with obstetric complications are referred
HR Baucau HR Baucau HR Baucau HR Baucau HR Baucau
Travel Time to higher level facility 4 hours 1 hour 2 hours 30 minutes 3 hours 2 hours
Annex 15M Table 2: Performance of Signal Functions during preceding 12 months of the assessment
DescriptionCHC
Uatucarbau*CHC Ossu
CHC Uatolari*
CSI Viqueque*
CHC Lacluta*
Parenteral antibiotics (12months) Yes Yes No Yes Yes
Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes
Parenteral Anticonvulsant (12months) No No No No No
Manual Removal of Placenta (12months) No Yes No Yes No
Removal of Retained product (12months) No Yes No Yes No
Assisted Vaginal Delivery (12months) No No No Yes No
Newborn resuscitation (12months) Yes Yes Yes Yes Yes
138 EmONC Improvement Plan of Action 2016 - 2019
Table 3: Availability of Human Resources
DescriptionCHC
Uatucarbau*CHC Ossu
CHC Uatolari*
CSI Viqueque*
CHC Lacluta*
Midwife (Currently employed) 2 3 2 7 2
Availability of midwives 24 hours No No No Yes No
Medical Doctor (Currently employed) 3 2 3 4 1
Availability of medical doctor 24 hours No No No Yes No
Nurse (Currently employed) 1 2 2 4 1
Availability of nurse 24 hours No No No Yes No
Laboratory technician (Currently employed) 1 1 1 1 1
Availability of lab technician 24 hours No No No No No
Nurse anesthetist (Currently employed)
Availability of Nurse anesthetist 24 hours
Obstetrician (Currently employed)
Availability of obstetrician 24 hours
Anesthesiologist (MD) (Currently employed)
Availability of anesthesiologist (MD) 24 hours
Annex 15M Table 4: Availability of general facilities for EmONC services
DescriptionCHC
Uatucarbau*CHC Ossu
CHC Uatolari*
CSI Viqueque*
CHC Lacluta*
Electricity Yes Yes Yes Yes Yes
Back up generator No No No Yes Yes
Running water Yes Yes Yes Yes Yes
Functioning toilet Yes Yes Yes Yes Yes
Total bed in the facility 7 4 8 24 9
Total bed for obstetric patient 6 3 1 4 5
Total delivery table 1 1 1 2 3
Delivery room Yes Yes Yes Yes Yes
Postpartum room Yes Yes Yes Yes Yes
Laboratory room Yes Yes Yes Yes Yes
139EmONC Improvement Plan of Action 2016 - 2019
DescriptionCHC
Uatucarbau*CHC Ossu
CHC Uatolari*
CSI Viqueque*
CHC Lacluta*
Operating Theater
Neonatal care room
Blood Bank
Availability of stored blood for use in emergencies
General anesthesia
Spinal anesthesia
Functional fan/air conditioning Yes No No No No
Curtains/means of providing patient privacy Yes Yes Yes Yes Yes
Annex 15M Table 5: Availability facilities for accommodation and length of stay after normal delivery
DescriptionCHC
Uatucarbau*CHC Ossu
CHC Uatolari*
CSI Viqueque*
CHC Lacluta*
Length of stay for normal delivery (day) 1 0 0 1 0
Food for maternity patient No No No No No
Food for family No No No No No
Waiting area for visitors and family Yes Yes Yes Yes Yes
Lodging for maternity patient No No No No No
Lodging for family No No No No No
Annex 15M Table 6: Availability of communication and transport facilities for referral
DescriptionCHC
Uatucarbau*CHC Ossu
CHC Uatolari*
CSI Viqueque*
CHC Lacluta*
Telephone at maternity ward No No No No No
Telephone in the facility No No No No No
Cell phone (own by facility) No No No Yes No
Cell phone (own by staff) Yes Yes Yes Yes Yes
Ambulance No No No Yes No
Multi purpose vehicle Yes Yes Yes Yes Yes
Other transport for referral No Yes Yes No Yes
140 EmONC Improvement Plan of Action 2016 - 2019
141EmONC Improvement Plan of Action 2016 - 2019
7. BIBLIOGRAPHYNational Statistics Directorate, Ministry of Finance and ICF Macro. Timor-LesteDemographic and Health Survey 2009-10. Dili, Timor Leste: NSD [Timor Leste] and ICF Macro.2011.
https://www.mof.gov.tl/TimorLeste-the-millennium-development-goals-report-2014/?lang=en
Quoted from Timor-LesteChild Health Factsheet. WHO-SEARO. Unpublished. 2013.
UNICEF (2003) Multiple Indicator Cluster Survey 2002, Dili, UNICEF Timor Leste.
Democratic Republic of Timor Leste. Health Management Information on System (HMS) 2012 and Final Statistical Abstract
Abstract: Timor-Leste Survey Living Standar 2007
WHO et al. 2015.Trends in maternal mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division.
National Statistics Directorate and UNFPA 2011.Timor-Leste2010 Population and Housing Census.
National Statistics Directorate and UNFPA 2012.Analytical Report on Mortality.Volume 6.Timor-Leste2010 Population and Housing Census.
UNFPA, WHO and ICM State of the World’s Midwifery Report 2014
UNFPA and WHO (Dr Neil Thalagala). Estimated costs of the EmONC Improvement Plan of Action 2016-2019 in Timor-Leste(June 2016)
Ministry of Health of Timor Leste.HMIS 2015. Table 4 Data for January-September 2015.
Ministry of Health of Timor Leste.National strategy on Reproductive, Maternal, Newborn, Child and Adolescent Health, 2015-2019; MOH
General Directorate of Statistics. Population and Housing Census 2015: Preliminary Results. 2015.
Countdown to 2015 decade report: Taking stock of maternal newborn and child survival. Lancet 2010, 375: 2031-2044.
Wagstaff A, Claeson M: The Millennium Development Goals for Health: Rising to the challenges. World Bank, Washington; 2004
WHO, UNFPA, UNICEF and AMDD. Monitoring emergency obstetric care: A handbook, WHO, 2009
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143EmONC Improvement Plan of Action 2016 - 2019
8. ACKNOWLEDGEMENTSThe preparation of this EmONC Improvement Plan of Action 2016-2019 is the product of several inputs that need to be acknowledged:
1. First and foremost H.E. Dr. Maria do Ceu Sarmento Pina da Costa, Minister of Health and Dr. Odete da Silva Viegas, Director General for Service Delivery for providing leadership.
2. UNFPA Representative Mr. John M. Pile, WHO Representative Dr Rajesh Pandav and Assistant UNFPA Representative Dr Domingas Bernardo for the excellent support in the successful completion of the EmONC Needs Assessment and in development of this plan.
3. UNICEF for the partnership.
4. Partner Organizations; Health Alliance International, USAID/JSI Hadiak project and USAID/JSI HAKBIT project for participating in the assessment and in the planning exercise.
5. Mr. Francisco Borges, National Director of Logistic, Procurement and Assets MoH for allocating the engineering teams to estimate the infrastructure rehabilitation costs in the CHCs that are identified for upgrading.
6. Mr. Marcelo Amaral, National Director of Finance, MoH for providing the unit cost for drugs, equipment and supplies.
7. Delegacia Saúde Municipio and District Public Health Officers (DPHO) MCH in 13 Municipalities who gave the orientation for the Plan.
8. All members of the Data collection team, who contributed in numerous ways to competently perform 2015 EmONC Needs Assessment and to develop the Plan of Action.
9. Members of the core team on EmONC Needs Assessment for providing their inputs from planning stage until the completion of this improvement plan.
144 EmONC Improvement Plan of Action 2016 - 2019
145EmONC Improvement Plan of Action 2016 - 2019
9. CONTRIBUTORSTechnical Team
1. Dr Vincent Fauveau, UNFPA Consultant
2. Dr Mao Bunsot, UNFPA Consultant
3. Ms Jenny Middleton, UNFPA Consultant
4. Dr Neil Thalagala, WHO costing expert
5. Dr. Chandani Galwaduge, UNFPA Timor Leste
Core Team
1. Dr. Triana do Rosario, Head of MCH Department, MoH
2. Ms. Florencia Corte-Real Tilman, Safe Motherhood Officer, MoH
3. Ms. Norberta Belo, Advisor, MoH
4. Dr. Carla Jesuina do Carmo Quintão, Health Officer UNICEF
5. Dr. Arun Malik, WHO
6. Dr. Sudath Peiris, WHO
7. Ms. Nelinha do Santos, INS
8. Dr. Amita Pradhan Thapa, OBGyn-MoH/HNGV
9. Ms. Lurdes Vidigal-MoH/HNGV
10. Ms. Antonia Mesquita Fernandes, HADIAK
11. Ms. Teresinha Quevedo Sarmento, HAI
12. Dr. Domingas Ângela Sarmento-UNFPA
13. Dr. Chandani Galwaduge- UNFPA
Data Collection Team
1. Dr. Francis Saison, OBGyn-MoH/HR Maubisse – Team leader
2. Dr. Amita Pradhan Thapa, OBGyn-MoH/HNGV- Team leader
3. Dr. Jannatul Ferdous-MoH/ MCH Advisor – Team leader
4. Dr. Domingas Ângela Sarmento-UNFPA – Team leader
5. Ms. Florencia Corte-Real Tilman-MoH/ MCH Department
6. Ms. Fatima Isabel Gusmão-MoH/MCH Department
146 EmONC Improvement Plan of Action 2016 - 2019
7. Ms. Emilia Ayati-MoH/CHC Comoro
8. Ms. Nelinha dos Santos-INS
9. Ms. Filomena Mendonca do Espirito Santo-MoH/Vera Cruz
10. Ms. Lurdes Vidigal-MoH/HNGV
11. Ms. Maria Lucia Godinho F. Soares-MoH/HNGV
12. Ms. Filomena de Carvalho-HADIAK
13. Ms. Antónia Maria R. M. Fernandes-HADIAK
14. Ms. Teresinha Quevedo Sarmento-HAI
15. Ms. Rara Deathicta A. S. S. Dethan-HAI
16. Ms. Maria Jacinta Araújo Chang-HAI
17. Ms. Paulina de A. Pereira de Neri-MoH/DPHO Maliana
18. Ms. Justa Pereira-MoH/ CSI Same Vila
The team that selected the health facilities for upgrading
(Consultations held on 22 and 24 February 2016 )
1. Antonio da Costa, Health Delegate Aileu
2. Alda Quintão Falcão, DPHO MCH Aileu
3. Agostinho da Costa, Health Delegate Ainaro
4. Jacinta Barros, DPHO MCH Ainaro
5. Leonel Guterres, Health Delegate Baucau
6. Maria Alice da Costa, DPHO MCH Baucau
7. Victor Soares Martins, Health Delegate Bobonaro
8. Paulina de A. P. Neri, DPHO MCH Bobonaro
9. Felipe Pereira Lemos, Deputy Health Delegate Covalima
10. Maria de Fatima Moniz, DPHO MCH Covalima
11. Agostinha da Costa Saldanha Segurado, Health Delegate Dili
12. Maria Bernardo, DPHO MCH Dili
13. Higinia Maria E. M. Carvalho, DPHO MCH Ermera
14. Bernardo Amaral Lopes, Health Delegate Lautem
147EmONC Improvement Plan of Action 2016 - 2019
15. Lolalina da C. Freitas, DPHO MCH Lautem
16. Apolonia dos Santos, Health Delegate Liquica
17. Beatriz Filomena, DPHO MCH Liquica
18. Mateus Vicente Correia, Health Delegate Manatuto
19. Otilia Joana A.M. Pereira, DPHO MCH Manatuto
20. Florencia Corte-Real Tilman, Health Delegate Manufahi
21. Francisco de Carvalho, Health Delegate of Viqueque
22. Adelaide Maria Tilman, DPHO MCH Viqueque
23. Dr. Vincent Fauveau- UNFPA consultant
24. Dr Mao Bunsoth – UNFPA Consultant
25. Dr. Chandani Galwdauge –UNFPA
26. Dr. Domingas Ângela Sarmento-UNFPA
Partcipants of the stakeholder workshop on 29th Feburay and 1st March 2016
1. Dr. Horacio Sarmento, Director of Hospital Services, MoH
2. Mr. António Bonito, Director of Training, INS
3. Dr. Triana de Oliveira, Head of MCH Department
4. Ms. Fatima Isabel Gusmão, Gnerela Reproductive Health (GRH-MCH) MoH
5. Mr. Manuel Mausiry, EPI officer MoH
6. Dr. Benedita M. de Araújo, Head of ….
7. Ms. Lucia Taeki, Regional Secretary for Health, RAEOA Oecusse
8. Ms. Batista Punef, Executive Director HR. Oecusse
9. Mr. Manuel da Costa, Executive Director Hospital Regional Oecusse
10. Mr. Herminia B. Seto, DPHO MCH Hospital Regional Oecusse
11. Dr. José António Gusmão Guterres, Executive Director HNGV
12. Ms. Maria Lucia de F.G.Soares, Midwife, HNGV
13. Ms. Lourdes Gonzaga Vidigal, Midwife, HNGV
14. Dr. Amita Pradhan Thapa, OBGyn, HNGV
15. Dr. Hermenigildo Pereiar, Executive Director HR. Suai
148 EmONC Improvement Plan of Action 2016 - 2019
16. Dr. Alipio Gusmão Lopes, Health Delegate Covalima
17. Ms. Maria de Fatima Moniz, DPHO MCH Covalima
18. Dr. Elisabeth Leto Mau, Executive Director HR Baucau
19. Dr. Salesiano P. Fernandes, Executive Director HR. Baucau
20. Mr. Leonel Guterres, Health Delegate Baucau
21. Ms. Maria Alice da Costa, DPHO MCH Baucau
22. Dr. Gabriela da C. M. Pereira, Executive Director HR Maubisse
23. Dr. Virgilio M. Pereira, Clinical Director HR. Maubisse
24. Ms. Lolalina da Conceição Freitas, DPHO MCH Lautem
25. Mr. Bernardo Amaral Lopes, Health Delegate Lautem
26. Mr. Mateus Vicente Correia, Health Delegate Manatuto
27. Ms. Otilia G. de A.M. Pereira, DPHO MCH Manatuto
28. Mr. Agostinho da Costa, Health Delegate Ainaro
29. Ms. Jacinta Barros, DPHO MCH Ainaro
30. Mr. Francisco de Carvalho, Health Delegate Viqueque
31. Ms. Adelaide Maria Tilman, Deputy Health Delegate/ DPHO MCH Viqueque
32. Mr. Graciano da C. Cruz, Deputy Health Delegate Ermera
33. Ms. Higinia Maria E. M. Carvalho, DPHO MCH Ermera
34. Ms. Apolonia dos Santos, Health Delegate Liquica
35. Ms. Beatriz F. da Silva dos Santos, DPHO MCH Liquica
36. Ms. Agostinha da C. S. Segurado, Health Delegate Dili
37. Ms. Maria de F.A. Bernardo, DPHO MCH Dili
38. Ms. Filomena Mendonça E. Santo, Midwife, CHC Vera Cruz
39. Ms. Francisca Cardoso, Midwife, CHC Vera Cruz
40. Ms. Emilia Ayati de Sousa, Midwife, CHC Comoro
41. Ms. Florencia C.R. Tilman, Health Delegate Manufahi
42. Ms. Dulce C.R. Tilman, DPHO SMI Manufahi
43. Ms. Justa Pereira, Midwife, CSI Same
149EmONC Improvement Plan of Action 2016 - 2019
44. Dr. Adilia O.T. Moniz, Clinical Director HR Maliana
45. Mr. Victor Soares Martins, Health Delegate Bobonaro
46. Ms. Paulina de A. p. De Neri, DPHO MCH Bobonaro
47. Dr. Francis Saison, UNFPA
48. Mr. Alipio Cardoso Moniz, Mapping Analyst, GDS
49. Mr. João Soares Gusmão, Mapping Analyst, GDS
50. Mr. Dirce Sarmento, Child Fund
51. Mr. John M. Pile, Representative to UNFPA
52. Dr. Domingas Bernardo, Assistant Representative UNFPA
53. Dr. Chandani Galwaduge, RH Specialist, UNFPA
54. Dr. Vincent Fauveau, Consultant, UNFPA
55. Dr. Domingas Ângela Sarmento, RH Program Analyst, UNFPA
Mapping Team
1. Mr. João Soares Gusmão, Department of Census and Statistics
2. Mr. Alipio Cardoso Moniz, Department of Census and Statistcs