Midway Rapid Assessment of ProgrammeIntegrated Management of Neonatal and Childhood Illness

(IMNCI)

Ministry of HealthRoyal Government of BHUTAN

13-24 June2011Supported by UNICEF Thimphu,

By: Dr. K Suresh, MD, DIH, DF, FIAP, FIPHA, FISCD,

Public (Child) Health Consultant, INDIA

Acknowledgments

At the outset I like to acknowledge the advocacy and support of Dr.Gepke Hingst, Representative, Ms.Vathinee Jitjatrunt (VJ) Deputy Representative and Dr. Shukhrat Rakhimdjanov, Health & Nutrition Specialist and Dr. Chandralal Mongar Health and Nutrition Officer, UNICEF Bhutan for the efforts made to initiate follow-up actions on the IMNCI implementation and getting approval for the same from Royal Government of Bhutan in 2011.

My thanks are due to Dr. DorjiWangchuk, Director General Medical services and Dr. Ugen Dophu the Director Public Health for their patient hearing and technical inputs.

My heartfelt appreciations go to Mr. Sonam Zanpo Programme Officer-IMNCI, DoPH, for organizing 8 days of field visits in 8 districts and accompanying me throughout visits. My thanks also go to Dr. Chandralal Mongar Health and Nutrition Officer, for joining the trip for 2 days and Mr. B. S. Thapa, Driver of UNICEF Thimphu who drove us through the 8 districts for his untiring efforts.

I also convey my thanks to Dr. Dhrupthob Sonam, Medical Superintendent and Dr. K. P.Tshering, Neonatologist and doctors in the District Hospitals of Trongsa and Bumthnag and District Health Officers of all the 8 districts we met during our visits for sharing their experiences, technical inputs and insights that enriched the document.

Last but not the least my heartfelt thanks go to all the Health assistants at the BHUs visited and those who work elsewhere in the country for their sincere efforts in driving IMNCI towards successful implementation.I bow to thousands of Bhutan’s parents for making their best efforts for the survival and development of children.

Dr. K SureshPublic (Child) Health ConsultantNew Delhi919810631222

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Table of Contents

Acknowledgments 2

Table of Contents 3

Abbreviations and Acronyms 4

Executive Summary 5

I. Background 8

II. Integrated Management of Neonatal and childhood Illnesses 10

a) IMNCI Concept 10b) Bhutan’s Adaptation 10

III. Object of Evaluation 12

IVEvaluation Methodology 13

VFindings 15

VI Recommendations 20

VII References 22

VII Annexes 23

i. Terms of References 23ii. Final Schedule of Field Visits 24

iii. Persons met and Places visited 25iv. Persons Consulted 27v. Bhutan’s Response to the Continuing Child Health 29

and Nutrition Challenges

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List of Abbreviations and Acronyms

AIDS Acquired Immune Deficiency Syndrome

ARIBHU Gr. IIBHU Gr. IBHW

Acute Respiratory InfectionBasic Health Unit Grade II, managed by Health assistants onlyBasic Health Unit Grade I, managed by Medical Officer/sBasic Health Worker

BTHABTF

Basic IMNCI training for Health AssistantsBasic Training for Physicians (Doctors)

CDD Control of Diarrhoeal Diseases

CMRDGHSDIs

Child Mortality RateDirector General of Health Services (HOD & I/C of Hospitals)In-depth Interviews

DoPHDzongkhagEPIF-IMNCIFTS

Department of Public HealthDistrictExpanded Programme of ImmunizationFacility Based IMNCIFollow-up Training course for Supervisors

IEC Information, Education and Communication

IMCI Integrated Management of Childhood Illnesses

IMNCI Integrated Management of Neonatal and Childhood Illnesses

IMRMDG

Infant Mortality RateMillennium Development Goals

NND Neonatal death

NNT Neonatal Tetanus

ORS Oral Rehydration Salt

ORTRoGBSFGD

Oral Rehydration TherapyRoyal Government of BhutanSmall Focus Groups Discussions

ToT Training of Trainers

UIP Universal Immunization Programme

U5MR Under 5 Mortality Rate

UNICEFVDCPVHWWHO

United Nations Children’s FundVector borne Disease Control ProgrammeVillage Health WorkerWorld Health Organization

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Executive Summary:

Bhutan’s development planning is based on the philosophy of Gross National Happiness (GNH) and is aimed at achieving broad based and sustainable growth, improving the quality of life, ensuring the conservation of the natural environment, preserving country’s rich culture and strengthening good governance. The National Health Policy has laid down goals for maternal and child health initiatives that are more ambitious than the Millennium (MDG) Development Goals, to which Royal Kingdom of Bhutan (RKB) is a signatory.The MDG 4 calls to reduce under-five child mortality by two-thirds between 1990 and 2015.

In Bhutan 16 key evidence based interventions are implemented at different periods based on Lancet/BMJ/Cochran Series thatinclude the midwifery standard, essential new born care protocol, intermittent presumptive treatment for malaria, detection and treatment of asymptomatic bacteriuria and community based pneumonia case management.

Global IMCI strategy was started in Bhutan in the year 2000 with the first batch of Training of Trainers with technical and financial support from WHO. During the following few years, series of trainings were conducted to equip the health workers of Basic Health Units (BHU Gr. II) of four pilot districts (Wangdue, Thimphu, Sarpang and Trashiyangtse).The program did not take off well at all levels of health system due to inadequate supportive supervision and lack of appropriate supplies.Since the year 2009, extensive interventions were carried out in the form of capacity building of health workers and provision of supplies to revitalize this dormant initiative. Health workers of 9 districts were trained in 2009 and the rest were trained in 2010.In the context of implementation of IMNCI for three years with no formal assessment, internal or external, that thisassessment of IMNCI is planned by RGoBwith support from UNICEF, Bhutan. Theobjective of the assessment of IMNCI was to analyze the status / progress of IMNCI implementation and to provide appropriate recommendations for moving forwards. (Phase I)

This is the report of phase I i.e.rapid assessment of IMNCI in RGoB.

This evaluation was carried out mainly by the consultant, hired by UNICEF Bhutan in consultation with RGoB, facilitated by the IMNCI Program officer at DoPH and Health Specialist UNICEF Thimphu. District health officers also joined in 3 districts.

Evaluation methodology involved direct observations of IMNCI practices, availability of drugs and equipment and their functional status, assessing the knowledge of the health workers through interviews. In-depth interviews and Focus Group Discussions with various stake holders formed an important approach.Eight districts, a total of 10 BHUs selected by the IMNCI program officer of RGoB, were covered. In addition we looked at child care servicesand had discussions with medical officers of three district hospitals. In each BHU skillassessment was done by using the WHO/UNICEF protocols,as the health assistants assessed a sick child and completed the treatment and counseling, whenever there was a sick

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child.Breastfeeding assessment skills andthe counseling skills (to enable mothers to give treatment at home and to decide when to return)were given due importance. Consultant also reviewed all the case records (protocols) for young infants (0-59 days) and of sick children managed in last one month in each facility. The consultative process included trainers at district and National referral hospital Thimphu, program officers in DoPH and continued to get inputs form Director General of Medical Services and Director of Public Health Services in MOH and the country representative and health specialists in UNICEF Thimphu.

The findings of this rapid assessmentrevealed that:General advantages:a) IMNCI in Bhutan started with clear advantage as the health workers were used to running clinics regularly and examining and treating patients empowered by their basic training and authorized by RGoB before start of IMNCI.b) Absence of private health sector in the country all most all patients reach some or the other Govt. clinic (very few may opt for household remedies /traditional therapy). c) Main hurdles like terrain, management of frequent landslides and road blockades, transport and communication are also improving in recent years.

Practice of IMNCI on 2-59 monthschildren:Good practices: This is universal. On an average 4.9 cases per Health Unit Week are seen. Almost every health worker is doing a good job of case assessment like identifying danger signs and dehydration, Respiratory Rate counting and inferring.The management aspects like classification, identifying treatment, treatment & advice for home level care were also done satisfactorily by most of the workers. All Drugs (except Zinc) and equipment are available in all most all facilities. The review of case sheets and the discussions with the health workers reveal that the practice of prescribing antibiotics particularly for ARI cases has been rationalized since the utilization of IMNCI tool. This can be an immediate outcome of the IMNCI implementation.Limitations: Few workers do classify without circling appropriate signs /symptoms (e.g. fever by history), practice of breast feeding assessment, feedback questions and nutrition counseling are areas of concern where many workers need to improve. Not many workers are in the habit of writing the child / condition specific danger signs in the case sheet, though majority did explain to the attendants. All most all Workers gave drugs for 5 days and asked client to return after 2 days or when parents see danger signs, however not many kids are brought back for follow up.Follow up is universally poor.Standards treatment guidelines for other conditions, though available in basic training materials are rarely referred.

Practice of IMNCI on 0-59 day’s young infants: Very few sick young infants reach BHU, with an average one sick young infant reaching a BHU once in 13 BHU weeks. Only a few workers recalled having seen demonstration of or had an opportunity to assess a sick young infant during training too. Therefore only a few workers are able to assess, classify and treat or refer and majority of workers are not comfortable assessing a young infant. Even normal babie’s (particularly for breast feeding) assessment is rarely done.

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Supervision: Supportive supervision has been streamline since 2010. Scheduled March 2011 & Sept/Oct 2010 supervisory visits were done as per plan by ADHO/DHO/ACO/CO/Nurse and HA (F). However most of the supervisory visits especially by ADHO/DHOs appeared to be administrative oversight in nature with checking of forms filled up and availability of drugs and equipment. Time spent was generally short and observing case assessment and treatment was rarely done. Record reviews werealso cursory as mistakes were not pointed out by most supervisors

Training Issues: a) Good practices:Most of the trainings were conducted as per schedule. Classroom methods of training (reading, exercise, use of photo books, Videos , video exercises, role play, demonstrations and filling in case sheets based on case studies were recalled by workers interviewed both during sick child and sick young infant sessions. Clinical exposure of sick children (2-59 months), demonstration and opportunity to assess sick children with Cough & Cold and diarrhea were adequate as reported by majority of the workersb) Limitations: Clinical exposure of either the sick or even normal young infants was poor as hardly any worker recalled the same.Another key problem of training was lack of Clinical instructor’s demonstration of an ideal assessment, classification, identification of treatment , treatment and counseling and filling up forms. Logistics issues:Over all the logistic of equipment drugs and supplies has been good so far. However the supply of timers may need replacement soon and periodically. There was no supply of Zinc wherever we visited which was due to procurement challenge as the country’s demand was small. The same has been sorted out and Zinc supply is expected to arrive soon.

Recommendations:Based on the observations / discussions following are suggested:Policy and Advocacy:a) Introducing mandatory postnatal visits is highly recommended (for both newborn and mother to address the neonatal mortality, reduction of which is the key) for achieving the child mortality goal of the country as committed to MDG. b) Consider a week long internship in regional hospitals for already trained supervisors and health workers to cover the gaps and enhance the skills of sick young infant care. c)Expanding IMNCI to cover all hospitals and ensuring the practice of the same as soon as possible. c) Formalizing the village health workers scheme with performance based incentive for parenting; psychosocial care, breastfeeding and nutrition counseling to strengthen community systems.

Capacity Development:Recommendations for moving forwards include a) planning a weeklong internship to all workers and supervisor’s as second opportunity to strengthen sick young infant care. b) Future trainings to include exposing all health workers to normal young infant assessment during training (in post natal wards and vaccination sessions and if required by home visit) and sick young infants subject to availability. c) The training venues may be revisited to make sure availability of such clinical material. d) All future courses to ensure Clinical instructor’s demonstration of an ideal assessment, classification, identification of and treatment, counseling and filling up relevant forms. Feedback questions, child specific counseling for breast feeding and when to return also need to be part of demonstrated by the facilitators. e)Participation of a national level trainer as observer in divisional trainings will ensure quality of training. f) Nominating area specific IMNCI mentors would help

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consultations and strengthen on job support. g) Finally it may be a good idea to startdoctors training with Sick Young Infant component to give due priority.

Service Delivery: The hospital and BHU level recommendations includea) regular practice of IMNCI and enhancing skills of colleagues to save the children. b) Filling the assessment forms for key conditions at least (if there be heavy OPD) and comparing the findings in the initial case sheets with that in the follow up to infer the improvement. c) Mobilize / motivate village health volunteers for postnatal and young child care and referral with due recognition. d) The program officers at national and district level need continue to monitor with improved quality.Other key recommendations suggested include e) the Sick Newborn Care Units (SNCU) in district hospitals to create a better child survival opportunities in the country and f) Initiating F-IMNCI an integration of the existing IMNCI package with facility based care package in to one to provide a continuum of quality care for severely ill newborns and children referred from the community or directly reaching the facility. This is expected to bridge the gap of acute shortage of Paediatricians in the country.

Service Utilization:a) Improving the quality of services provided at all facilities is the best way to improve utilization. b) Maintaining regular supplies of equipment, drugs and other supplies and periodical updating of the skills of the workers will go a long way in service utilization. c) IEC over national television and mobile phones will add value to utilization.

Community Empowerment:a)Motivating the existing village health workersby all BHU with immediate effect with some recognition b)delegating community to monitor IMNCI activities particularly home visits of newborns will enhance the quality of services and boost the morale of the workers c) introduction community system strengthening in the form of formalizing village health volunteer’s scheme with performance linked incentive for Integrated Child Developmentwould go a long way.

1.Background

1.1 IntroductionReduction of infant and child mortality has been an important tenet of the Health and Population policies of the Government of Bhutan and it has tried to address the issue right from the early stages of planned development. Among the initiatives launched to reduce morbidity and mortality amongst children have been programs on immunization, control of diarrheal disease, acute respiratory infections, essential newborn care, promotion of breastfeeding & complementary feeding, prevention of anemia and vitamin A deficiency.

Bhutan’s development planning is based on the philosophy of Gross National Happiness (GNH) is aimed at achieving broad based and sustainable growth, improving the quality of life, ensuring the conservation of the natural environment, preserving country’s rich culture and strengthening good governance.

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1.2The New Evidence & HopeIn June 2003, a series of articles in the Lancet Papers on child survival brought new evidence to light on specific strategic interventions that make the difference to children’s survival and development. In 42 countries where 90% of child deaths worldwide had occurred in 2000, 63% of those deaths could have been prevented through a full implementation of a few known and effective interventions. 1There is a worldwide consensus that the household and community practices ought to become the cornerstone for newborn care. When considering the recent evidence, a series of simple interventions that can be delivered at household level and which have positive impact are: (i) Newborn temperature management; (ii) Exclusive breast feeding; (iii) Oral rehydration; (iv) Education on complementary feeding; (v) Recognition of illness and care seeking; and, finally, (vi) Demand generation for existing interventions e.g. measles vaccine, vitamin A. When considered altogether, they are shown to potentially prevent 33% of the total burden of infant deaths (Lancet, 2003). Similarly the lancet neonatal survival series (2005) have shown light on evidence on effective neonatal interventions.

Within the Bhutan’s experience, successful implementation of the Universal Immunization Program, (UIP), Control of Diarrheal Diseases (CDD/ORT) and cotrimoxazole therapy for pneumonia in the regular clinics run at BHU and Hospitals has contributed to significant reduction in child deaths, but not universally throughout the country. While each of these interventions have shown some success, accumulating evidence suggested that a more integrated approach to managing sick children is needed to achieve better outcomes. Because many children present with overlapping signs and symptoms of diseases, a single diagnosis can be difficult, and may not be feasible or appropriate, particularly at community, sub-center and first-level health facilities (BHU). Further, as neonatal mortality claims a growing share of the infant mortality burden, progress will depend on achievements in this area as well.

1.3 Guiding principlesThe principles governing the planning and implementation of the Child Health Strategy include: inclusion of evidence-based interventions, integration with maternal health and family planning strategies, equity-driven implementation and monitoring and a rational mix of population centered (outreach) and individual-centered (clinical) interventions, community mobilization through involvement Village health volunteers. There is already a pressure to introduce family-centered (home level) postnatal (mother and baby) services too. In keeping with the overall approach MNCH program, the child health component will be driven by district level decentralized priority setting, planning and implementation.

1.4 Accelerating BIG WIN actions through existing and new grassroots workers Evidence suggests that early contact with families of young infants by a health care provider skilled in counseling families about appropriate child health and feeding practices; recognition of illness and providing basic care for sick children including referral to appropriate health care institutions has significant impact on child health outcomes.Post-natal contacts, which is insignificant at present, have the potential of having a positive impact for both maternal and neonatal health indicators.

1THE LANCET.Vol 361, 362. June- July 2003 www.thelancet.com9

1.5 IMNCI strategy:A two-pronged strategy for child health is proposed in MNCH, namely

a)STRENGTHENING EXISTING CHILD HEALTH SERVICESlike Immunization, institutional deliveries, trained birth attendance for home deliveries, BHU based care of diarrhea and ARI management and Facility-based care of newborns and children,Infant and young child feeding (IYCF) and Micronutrient supplementation.

b) PHASED SCALING UP OF INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESSES (IMNCI) : IMNCI was originally launched in Bhutan in 2000, but extensive interventions and accelerated efforts were made since Mid-2009.This document details out present implementation status, supportive supervision and available operational guidelines taking into consideration the implementation assessment in 10 BHUs of 8 districts in Bhutan between 13-25June 2011 and consultation with various stake holders in the districts and Thimphu Bhutan. It also provides some recommendations for moving forwards

2. Integrated Management of Neonatal and childhood Illnesses IMNCI

2.1 The concept:

During the mid-1990s, the World Health Organization (WHO) and UNICEF with many other agencies, institutions, and individuals responded to this challenge by developing a strategy known as the Integrated Management of Childhood Illness (IMCI). This global strategy focuses on preventing and treating illness in children 7 days – 59 months of age.

IMCI was designed to cater the most common causes of child mortality – diarrhea, pneumonia, measles, malaria and malnutrition. It adopts an algorithmic approach that encourages health providers to address a sick child in a systematic manner to address several medical conditions, that often co-exist, rather than only the presenting symptom only which often is the case when child health programs are implemented in a vertical fashion. Apart from treating medical conditions, the strategy insists that each contact with the sick child be utilized for preventive and promotive health interventions. For instance, all children are screened for malnutrition and the immunization status assessed and age appropriate feeding advice and immunization services are offered.

The IMCI strategy has three components: Improving health worker skills through hands-on training, Strengthening the health system for delivering the interventions effectively, Promotion of healthy family and community behaviors.

2.2 Bhutan Adaptation of IMCI:

The department of Public Health, Ministry of Health,Royal Government of Bhutan revitalized the training materials and formulated an adapted version of IMCI renamed as Integrated

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Management of Neonatal and Childhood Illnesses (IMNCI) giving more thrust to neonatal component (64%), the most critical period affecting IMR in Bhutan. The main adaptations to the package were:

a. Insertion of the algorithm for identification, classification, referral, and treatment of disease conditions affecting the newborn 0-7 days old in addition to the entire period 0-5 years covered

b. Reducing training duration to 8 days with separate training materials for physicians and frontline health workers.

c. Adjusting case management protocols to be consistent with current policies of the Child Health division, RH division, and VDCP

Unfortunately the recommendations did not include a. Adding home-based care of young infants by health workers.b. inclusion of 50% of training time of workers for case management of young infants

(0-2 months)RGoB does not view or advocate IMNCI approach as a mere training program. Its implementation would encompass primary, secondary and tertiary care health system. Therefore ensuring supplies, on job supervision, monitoring and evaluation are tailored to promote aggressive and effective implementation of IMNCI. BCC strategy would be strengthened to improve healthy family practices and care seeking.

A simple algorithm on post-partum maternal care can be added to the home-based newborn care module because care of the mother-baby dyad cannot be separated at the point of contact.

Box 1: The Integrated Management of Neonatal and Childhood Illnesses

BackgroundRecognising newborn care as critical for improving child survival, Bhutan adapted the Integrated Management of Childhood Illnesses to strengthen the newborn care, transforming “IMCI” to “IMNCI”. IMCI started in 2000 and in the initial yearsmany trainings were conducted for health workers, with no serious implementation.

Delay in taking off: Unfortunately the year 2000-2008 saw a stagnant period on IMNCI implementation mainly attributable to lack of resources for oversight responsibility of implementation. Lack of drugs and case sheets (protocols) at BHU level and most importantly monitoring slackened resulting in delay in taking off.

ProgressHowever since the year 2009, extensive interventions were carried out in the form of capacity building of health workers and provision of supplies to revitalize this once dormant initiative. Health workers of 9 districts were trained in 2009 and the rest were trained in 2010. Three years have passed since the start of IMNCI and no formal assessment, internal or external, was carried out.

By the year 2011, all districts of the country have completed the training of health workers

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at all BHU Gr. Iand had initiated IMNCI implementation andsupportive supervision since 2010. Programme monitoring reports show that nearly 500 health workers were trained in intensive skill-based training. These workers have provided care to about 10,000 children. The quality of care is claimed to be adequate in over90 per cent of workers supervised.

Challenges AheadThe main and immediate challenge is to establishhome visits for all newborns to teach the mother ways to prevent illnesses through exclusive breastfeeding, keeping baby warm, and other essential newborn care. During these visits, mothers are also to be taught to recognize illnesses early and to know when and where to seek timely care. IMNCI also contributes to building appropriate referral mechanism. A large number of additional frontline workers (Village Health Workers) provide new opportunities making home visits to every newborn in the country possible. However it also appears to be block for many as these are unpaid workers. Improving the quality of care in general, with proper assessmentand identifying sick young infants in particularand children requiring referral remains a challengeas IMNCI is not being practiced at BHU Gr. I and district and other referral hospitals. The facilities at institutions to manage referred children will be another key challenge to be addressed. F-IMNCI if implemented in earnestness will offer a great solution.

By June 2011 alldistricts of Bhutan are implementing IMNCI and the country hopes to expand it to all BHU Gr. I and district hospitals during 2011-12.

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3. Object of Evaluation

The object of evaluation is to assess the training, implementation and supervision status of IMNCI in Bhutan since its acceleration in mid-June 2009. Recognising newborn care as critical for improving child survival and enable the country to meet MDG goal. Given the difficult terrain and lack of all weather roads and transport, the challenge of achieving 100% institutional deliveries and ensuring postnatal visits in the first 10-15 days the IMNCI is not able to fructify. The contribution of Hospitals in child survival is also not optimal as neither have they qualified paediatricians nor do they practice IMNCI.

3.1The logical model and the expected results:

The model followed for evaluation was to make on site visits of select BHUs and observe implementation, review records of sick children managed and also supervisory visits. It was desired to look into logistics of drugs and protocols etc. It was also to assess the process of capacity building of health workers (training) through discussions at BHU and district hospitals to learn about strengths, weaknesses, opportunities and threats. An attempt to assess the feasibility of the plan of expanding IMNCI to the hospital set up was also made. The consequences of lack of community based newborn care and quality sick child care at hospitals complicate the situation. The results of the evaluation are expected to be used by the country in strengthening the IMNCI particularly at district hospitals and community level.

3.2 The key social, political, economic, demographic, and institutional factors:

Three years have passed since the acceleration of IMNCI training and implementation including supervisory visits and no formal assessment, internal or external, was carried out. It is in this context that a midway rapid assessment of IMNCI program is planned by RGoB with a support from UNICEF, Bhutan with following objectives:

To conduct assessment of IMNCI program and to analyze the status and progress and to provide appropriate recommendations for the future steps.(Phase I) To support the development of modules for professionals at the hospital level to practice IMNCI approach and basic pediatric care, especially for children referred from the BHUs through IMNCI approach. (Phase II)Support the development of IMNCI pre–service training materials for RIHS (Phase II)Conduct training of trainers (ToT) for doctors/ nurses of 6 selected hospitals (Phase II)

This report covers only the first phase activities of assessment.

3.3 Thekey stakeholders involved in the object implementation, are Royal Government of Bhutan, UNICEF, WHO country offices in Thimphu.

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4. Evaluation Methodology

4.1 Field visits for direct observation and consultations were the key methods used in the evaluation.The districts were selected by the program officer of RGoB, especially in east and central part of the country. Eight BHU Gr. II in the countrywere selected in same number of districts. We actually covered 10 facilities in 8 districts.We also covered three district hospitals.

4.2The data of skills assessment capacity was collated in two ways. First, where a sick child was present at the time of visit, the health assistants were asked to assess the child and complete the treatment as they do normally. The entire process was observed by the consultant and the program officer DoPH and health specialist of UNICEF Thimpu (last 2 days only). Breastfeeding assessment skills and the counseling skill (for mother to give treatment at home and when to return with the baby)were given due priority.Second, apart from the cases, reviewed all case sheets (protocols) for young infants (0-59days) in records and of sick children managed in last one month only.Workers were asked to explain some of findings written.

4.3The observations of the skills of the workers were done using the WHO/UNICEF protocol for supervision. Record reviews standard WHO/UNICEF guidelines and protocols. The annual survey data was tallied with raw information in some facilities to validate the quality of data

4.4The consultation process involved Health Assistants (M & F) at the BHU, Supportive Supervisors like doctors, nurses and clinical officers and the District Health Officers and Doctors in3 district Hospitals and parents of the sick babies present during our visit. The consultative process also included trainers at district and National referral hospital Thimphu, Program officers (Vector Borne Diseases Control program (VDCP) at Gelephu, RCH and Immunization program officers in DoPH ,Director General of Medical Services and Director of Public Health Services in MoH and the country representative and health specialists in UNICEF Thimpu.

4.5In-depth interviews (in local language where the health assistants were not able to converse in English or with parents of the clients), supervised performance,demonstration of use of equipments (weighing scales, timers, thermometers etc) and small focus group (as getting 8-10 workers in one site in Bhutan situation was practically difficult) discussions of 3-4 personswith key stakeholders in spoken English/Hindi were the other methods used.Small focus group discussions were the main source of assessing training methods used, opportunities of demonstration, actual assessment and management of sick children and counseling skill practice.

4.6 The methods employed for analyzing gender and human rights issues were presence of a female worker when breastfeeding was assessed and the proportion of girls and boys managed at each BHU.Similarly the gender combination among the supervisors was also taken note of.

4.7 The evaluation design was ethical and included ethical safeguards where appropriate, including protection of confidentiality, dignity, rights and welfare of human subjects particularly children, and respect of the values of the beneficiary community.

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4.8 Gender and Human Rights, including child rights: The evaluation team kept key gender issues like the sensitivity of assessing breastfeeding in the absence of a female worker, (as nearly one thirds of BHU do not have a female worker on the board of BHU staff) ,community’s gender bias if any talking to clients. Discrimination if any to treat based on gender, religion, caste, and creed and paying capacity.

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4.9The findings of the evaluation and inference drawn are described in semi-quantitative and semi-qualitative terms. The secondary data like household survey information’s, record review used qualitative techniques. The observations, DIs and SFGD were mainly qualitative in nature. The following qualitative are used in this report.The findings are classified in to six groups:

i. General issuesii. Observations of assessment of 2-59 months sick children

iii. Observations of assessment of 2-59 days sick young Infantsiv. Supportive Supervisory visitsv. Training issues

vi. Logistic issuesvii. Other Relevant Data

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Qualitative Terms used to describe inferences

All Most All = All except 1-2 (5%)Most/Universal = More than 80-95%Majority = 61-79%Nearly (about) half = 40-60%Some = 25-40%Few = Less than 25%Rarely/Hardly = 1-2 (5%)

5. Findings

5.1. General issues

IMNCI in Bhutan started with clear advantage as the health workers were used to running clinics regularly and examining and treating patients empowered by their basic training and authorized by RGoB before start of IMNCI

As there is no private health sector in the country all most all patients reach some or the other Govt. clinic (very few may opt for household remedies /traditional therapy)

Drugs & equipment supply to BHUs & Hospitals has been witnessed to be good during last 2 consultancies of the consultant for Cold Chain and Vaccine wastage (June 2007) and TOT for Immunization (December 2007)

Main constraints like terrain, management of frequent landslides and road blockades, transport and communication are also improving in recent years.

5.2 Observations of assessment of 2-59 months sick children:

The good practices observed are: Practice of IMNCI is universal. An average 4.9 cases per Health Unit Week are managed Almost every health worker is doing a good job of case assessment and management Almost every health worker is doing a good job of case assessment like identifying danger

signs and dehydration and Respiratory Rate counting. The management aspect like Classification, identifying treatment, treatment & advice for

home care were also done satisfactorily by most of the workers. All Drugs (except Zinc) and equipment are available in all most all facilities Case Sheets (both Young infants & 2-59 months Children) are available Most health workers recalled having got opportunities to practice on 1-2 children during

training apart from demonstration by facilitators. It is heartening to report that no gender discrimination is explicit in child care at homes and

management at BHUs. The team did not observe any reservation on the part of the mothers in breastfeeding the baby even when the health assistants assessing were male.

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Shortcomings Needing Improvement:• Few workers did classify a case without circling appropriate finding (e.g. fever by history)• Practice of breast feeding assessment, feedback questions and nutrition counseling are

areas where some are good but many workers lack adequate skills.• All most all Workers gave drugs for 5 days and asked clients to return after 2 days or when

parents see danger signs. However not many workers are in the habit of writing the child / condition specific danger signs in case sheet, though majority did explain to the attendant.

• Almost no mother returned for follow up, as we saw only one follow-up case sheet • Follow up is universally poor, as workers assume that child got OK • Standards treatment guidelines for other conditions are in basic training materials

which were available in all facilities but rarely referred by most of the workers• The opportunities available during growth monitoring, immunization, natal and postnatal

visits to maximize the chances of identifying sick child are not being utilized at all.

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On an average around 5 sick children in the age group of 2-59 months are seen per health unit week. The range of cases seen was between 9 and 39 per month in the 10 BHUs visited. The types of the cases managed at BHU’s indicate that majority (53%) were upper respiratory infections (cough &cold) followed by Pneumonia (15.3%), Fever but Not malaria (9.2%) and diarrhea with No dehydration. Danger signs were seen and referred in only one (<0.5%) case. The review of case sheets and the discussions with the health workers reveal that the practice of prescribing antibiotics particularly for ARI cases has been rationalized. In fact there has been a reduction (at least by one thirds) in the use of antibiotics since the utilization of IMNCI tool especially in ARI case management. This can be claimed as an immediate outcome of the IMNCI implementation. Records review indicates some people misclassifying occasionally leading to mismanagement. The standard management guidelines for other conditions like Eye infections, sore throat, Injury, tooth ache mouth ulcers, Burns and Napkin rashes need reiteration by annexing them to IMNCI modules.

5.3 Observations of assessment of 0-59 Days Sick Young Infant:There was no god practice to report as only one cohort of this age was seen during the visit.

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Shortcomings Needing Improvement:• Very few sick young infants reach BHU, on an average one sick young infant is

reaching a BHU for every 13 BHU weeks • Only a few workers are able to assess, classify and treat or refer.• Even normal babie’s (particularly for breast feeding) assessment is rarely done• Only a few workers recalled having seen a demonstration or assessed a sick young

infant during training • As a consequence majority of workers are not comfortable assessing a young infant

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Table-2 Number and Types of Sick Young infants seen in BHU’s Visited

Sl No Name of BHU PSB LBIDia/No Dh

Severe Jaundice * Others Total

Records for Weeks

1 Case/ per Wks

1 Drukgyel 2 1 1 2 0 6 46 7.5

2 Darla 1 1 1 0 0 3 26 9

3 Chengmari 1 1 2 0 0 4 52 13

4 Ghumauney 1 1 1 0 0 3 52 175 Tendru 0 0 0 0 0 0 8 -

6 Norbuling 1 0 1 1 0 3 78 29

7 Jigmecheoling 2 1 1 0 0 4 78 19.58 K. Rabten 0 1 1 0 2 4 40 10

9 Chumey 0 1 1 0 0 2 26 13

10 Sephu 0 1 0 2 0 3 11 3.7

Total 8 5 7 3 2 32 417 13* Others= Skin rash & Distended abdomen. PSB= Possible Severe bacterial infections, LIB= Local Bacterial infections, Dia/No Dh= Diarrhea with No Dehydration.

As one can see intable-2, hardly one sick young infant of 0-59 days is likely to reach any one BHU every 13 weeks (3 Months). Only 32 such young infants were seen in 10 BHUs over a period of 417 BHU weeks. The number of sick young infants with danger signs (possible severe bacterial infections) constituted major portion (25%), followed by diarrhea with no dehydration, local bacterial infections (mainly umbilical cord or some boil over the body) and severe Jaundice. Two conditions (distension of abdomen and Skin rash) that are not described in IMNCI modules were also managed.

5.4Supportive Supervision: Good Practices: Supportive supervision has been streamlined since mid-2010 Scheduled March 2011 & Sept/Oct 2010 supervisory visits were done by

DHO/MO/CO/ACO/HA(f) MO’s, CO, ACO& Nurses and Sr. HA (F) appeared most suitable for

supervisory taskShortcomings needing Attention:• Most of the supervisory visits appeared to be administrative oversight in nature

with checking if forms were filled up or not, drugs and equipment availability.Time spent was around 2-3 hours.

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• Observing case assessment was rarely done, one reason being the visits were not necessarily during OPD hours.

• Record review wasalso not satisfactory as mistakes were not pointed out always by most supervisors as we observed only one supervisor (n-8)had done that task.

• The case observation skills of majority DHO’s & ADHO’s are doubtful for want of practice

5.5 Training Issues:The evaluating team did not have an opportunity of observing the actual training. The national manager had informed that majority of the trainings were done in 2009 and 2010. Therefore these issues were culled out of In-depth interviews (DIs) and small group discussions (SFGD) at BHU, district hospitals and DHO offices.

Table-3 The Timing of Training of Health Assistants & Supervisors met22

Category of staff April 2009 Oct/Nov2009

Aug/Sept 2010 Nov 2010 Jan 11

BTHA 1 8 8 2 2FTS 0 0 0 3 2

BTHA= Basic training of Health assistants (M & F), FTS= Follow-up training for supervisorsThe participants were asked to recall the sessions day by day and how they were conducted (methods i.e. reading, photo book exercise, video demonstration, video exercise etc). The exercise was done both for regular training and supervisory training. Table 3 is an analysis of the training of 20 health workers and 5 supervisors evaluators met, that substantiated the claims that most trainings were done between Mid- 2009 and 2010. The major finding are:Good Practices noticed: Most trainings were conducted as per schedule Classroom methods of training (reading, exercise, use of photo books, Videos , video

exercises, role play, demonstrations and filling in case sheets based on case studies were recalled for, both during sick child and sick young infant sessions by all most all interviewed

Clinical exposure of sick children (2-59 months), demonstration and opportunity to assess sick children with Cough & Cold and diarrhea were recalled by majority

Clinical instructor’s demonstration of an ideal assessment classification, identification of treatment and treatment and counseling and filling up forms was recalled by only half of the Health workers.

Shortcomings Needing Improvement:• The demonstration by facilitators or emphasis on feedback questions, child specific

counseling for nutrition and when to return for sick child or sick young infant were recalled by some or few health workers respectively.

• Nobody could recall clinical demonstration leave alone opportunity to assess sick young infants (0-59 days olds) with PSBI or LBI

• Hardly anybody reported that assessing normal young child was ever stressed or allowed to practice during the training, which is the basis for identifying sickness among these cohorts

• Clinical instructor’s demonstration of an ideal assessment, classification, and identification of treatment / treatment, counseling and filling up forms was recalled by some health workers.

5.6Logistic Issues:Good Practices noticed: In all the 10 BHUs and 3 hospitals visited no complaints of stock out or lack of

drugs was heard. The satisfying part was equipment (timer) required were there in all facilities and worker knew how to use it.

Over all the logistic of drugs and supplies has not been a hurdle so far. Shortcomings needing attention:• All facilities did complain of no supply of Zinc (the program officer had narrated

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that the country did face Zinc procurement problem as no supplier was ready to supply directly)

• In 2 facilities baby weighing scales were not available• Two BHUs also complained of shortage of Iron and Folic acid tablets since last

3 months.• Timers for respiration countingmay need replacement soon and periodically.

5.7 Other Relevant Data collation:The department of Public Health of Royal Government of Bhutan annually conducts household survey through the health workers at BHU. Year 2005 survey data forms the main source of vital statistics data in the country. The evaluating team collated in each of the basic health unit visits such data for year 2010. The key data looked at pertained to Pregnant women, live births, deaths by age and nutrition status.

The annual survey data for the select 10 BHU’s indicate that a total population of 43,202 was enumerated in 149 villages. It gives an average of 4,320 persons per BHU, while the range 2050 and 10,213. The gap of 60 between pregnant women (738) and number of live births (678) gives rise to doubt of missing pregnancies. This is possible only if some home deliveries were not counted. Counting only 678 live births registered one gets a birth rate of 15.7 per 1000 population. Given the fact that some deliveries occurred at homes may go unaccounted this is acceptable. If the number of pregnant women is considered deemed to have delivered the birth rate would be 17.1/1000 population, which is close to the national birth rate of 20/1000 population. However the child deaths in general and neonatal and infant deaths in particular appear to be under-enumerated. With recorded 678 live births only 1 NND, 3 ID give rates of neonatal mortality as 1.5/1000 LB and that of IMR as 4.4/1000 LB. and the proportion of NMR to be around 30%.

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Table-4 Key data from annual survey 2010 in the BHU’s visited

The average out patients in the BHUs visited works out to be 36.3 of which 27.7 are new patients. The range of total daily patients treated was between 20 and 50 of which only 2-5 were children. The average number of sick under 5 children (39) works out to be 10.7%. The data on nutrition status appears to be acceptable with an under nutrition of 10.4% and over nutrition of 3.5%.

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6. Recommendations The recommendations were finalized after consultation with the stakeholders at the district level, technical experts in Thimphu, and district hospitals at Trongsa, Bhumthang and national program officers. The methodology of rapid appraisal and the findings were and proposed recommendations were presented in a meeting at national level to national program officers and experts on 24 June 2011. All most all the recommendations were seconded by the participants.

Policy and Advocacy:

RGoB Level:Considering introducing mandatory postnatal visits is highly recommended (for both newborn and mother to address the neonatal mortality reduction) for achieving the child mortality goal of the country as committed to MDG. Consider a week long internship in regional hospitals for already trained supervisors and health workers to cover the gaps and enhance the skills of sick young infant care. Expanding IMNCI to cover all hospitals and ensuring the practice of the same as soon as possible. Formalizing the village health workers scheme with performance based incentive for parenting; psychosocial care, breastfeeding and nutrition counseling to strengthen community systems are also put forth. Train adequate number of doctors in all hospitals and ensure they practice and support skill enhancement (mentoring) among BHWs nearby.Entrust Supportive supervision to CO, ACO, Nurses and HA(f) providing sufficient funds, in addition to doctors with appropriate resource allocationContinue commitment for IMNCI and related mother and child health care activities

MOH, DMS & DPH & Program Officer level:Continue commitment for IMNCI at BHU level and Initiate and monitor IMNCI use in hospitals. Nominate area specific IMNCI mentors for tele-consultation by health workers when in need of help especially while assessing and managing sick young infantsEncourage doctors across the country to practice IMNCI by deputing for training and supervisory tasksCollate or prepare in consultation with specialists and share standard guidelines for management of other conditions not covered under IMNCI Involve all state program officers in IMNCI / integrated MCHN monitoring Prepare a strategic policy paper and plan for RGoB to consider introducing village health volunteers scheme with performance based incentive for Integrated Child Development (Parenting skills, personal and food hygiene, Psychosocial development, Early childhood Development (ECD) and breastfeeding and nutrition counseling care of differently able children) with support from BHUs

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Capacity Development: Recommendations for capacity development include:Planning and proposing to the RGoB a weeklong internship to all workers and supervisor’s as second opportunity to strengthen sick young infant care. Future trainings to include exposing all health workers to normal young infant assessment during training (in post natal wards and vaccination sessions and if required by home visit) and sick young infants subject to availability. The training venues may be revisited to make sure availability of requisite clinical material, especially 0-59 day’s sick young infants. All future courses to ensure Clinical instructor’s demonstration of an ideal assessment, classification, identification of and treatment, counseling and filling up relevant forms. Feedback questions, child specific counseling for breast feeding and when to return also need to be part of demonstration by the facilitators. Given the priority it is suggested to start doctors training with Sick Young Infant .Participation of a national level trainer as observer in divisional trainings will ensure quality of training. Nominating area specific IMNCI mentors for consultations and on- job support.

Service Delivery:The recommendations for improving the service delivery include:

All BHUS and Hospital staff to practice IMNCI regularly and enhancing skills of colleagues to save the children. Filling the assessment forms for key conditions at least (if there be heavy OPD) and comparing the findings in the initial case sheets with that in the follow up to infer the change. Mobilize / motivate village health volunteers for postnatal and young child care and referral with due recognition. The program officers at national and district level need continue to monitor with improved quality.Strengthen Sick Newborn Care Units (SNCU) in district hospitals to create a better child survival opportunities in the country. To initiate F-IMNCI is an integration of the existing IMNCI package and facility based care package in to one package, to provide a continuum of quality care for severely ill newborns and children referred from the community or directly reaching the facility. This is expected to bridge the gap of acute shortage of Paediatricians in the country.

Service Utilization:The suggestions to improve utilization of services provided include:

Improving the quality of services provided at all facilities Maintaining regular supplies of equipment, drugs and other supplies and periodical updating of the skills of the workers will go a long way in service utilization.

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IEC over national television channels and mobile phones will add-value to utilization. Mobilization of sick babies by Village health workers during house visits.

Community Empowerment:

Motivating the existing village health workers by all BHU staff with immediate effect Introduction community system strengthening in the form of formalizing village health volunteer’s scheme with performance linked incentive for Integrated Child Development counseling would go a long way. Community monitoring of IMNCI activities particularly home visits of newborns by village leaders will enhance the quality of services and boost the morale of the workers.

References:

1. Short Program Review of Child Health Program, College of Natural Resources, Lobesa, Bhutan, September 2010

2. IMNCI Modules Royal Government of Bhutan 20093. Follow up Training for Supervisors RGoB 20104. IMNCI Modules , MOHFW, GOI 20045. Follow up Training for Supervisors Govt. of India 20056. IMNCI ToT and Training Reports7. IMNCI Follow up reports of March 2011 & October 20108. Bhutan Multiple Indicator Survey 2010

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UNICEF Bhutan Country OfficeTerms of References (ToR) for International Consultant for the following activities:

Phase I: Midway Rapid Assessment of Integrated Management of Neonatal and Childhood Illness (IMNCI) Program,

Background: IMNCI Program was started in Bhutan in the year 2000 with the first batch of Training of Trainers with technical and financial support from WHO. During the following few years, series of trainings were conducted to equip the health workers of Basic Health Units (BHU) of four pilot districts (Wangdue, Thimphu, Sarpang and Trashiyangtse).The program did not take off well at all levels of health system due to inadequate supportive supervision at the health facility level and lack of appropriate supplies. Since 2009, extensive interventions were carried out in the form of capacity building of health workers and provision of supplies to revitalize this once dormant program. Health workers of 9 districts were trained in 2009 and the rest in 2010.

Prior to implementation of the program at district level, availability of IMNCI modules, Treatment charts, photograph booklets, posters and recording forms were ensured to all the health facilities of the 20 dzongkhags. Equipment for ORT corner and ARI timers have been supplied for all the health facilities in the country. Training of District Health Officers and Medical Officers on Supportive Supervision has improved the capacity of managers to undertake quality supervision at district and BHU levels. In 2011, health facilities across the country are applying the IMNCI approach in child health care. There is a plan to supply zinc supplements to be used for children with diarrhea.

Three years have passed since the start of IMNCI and no formal assessment, internal or external, was carried out. It is critical at this stage to conduct midway rapid assessment. It will give an idea of how the programme is progressing, obstacles for improvement and if any additional intervention is required.

Currently when sick children are referred to hospitals under IMNCI protocols, doctors do not provide basic pediatric care as per the standard. Therefore, the introduction of Hospital based IMNCI module for the hospital staff to manage the children under-five years especially those referred from BHUs will ensure the program quality as well as sustainability. Objectives: 1. To conduct assessment of IMNCI program and to analyze the status and progress and to provide

appropriate recommendations for the future steps. Tasks:Phase I: May-June 2011 (10 working days)

1. Meeting with:a. Director, DoPH and relevant program officers in the Ministry of Healthb. DVED officials,WHO officials, National resource persons and technical experts. c. Representative, Dy. Representative and Relevant staff of UNICEF

2. Desk review of IMNCI documents, Child Health Review Report, Supportive Supervision reports, IMNCI ToT and Training Reports, and other feedback/recommendation

3. Field visits to Hospitals, BHUs and DHO offices in the districts 4. Make a presentation of the draft report to the stakeholders and incorporate the comments /

feedback5. Submit the final assessment report with recommendations for next steps/way forward

Annexure-1

Annexure-2

Rapid Assessment of IMNCI Program in Bhutan.Program for Dr. Suresh Kishanrao, International Consultant,

29

13-25 June 2011Date Time Program13 June 2011 11:15

13:00 Arrival in Paro Visit Drukgyel BHU and halt in Paro

14 June 2011 07:00 12:00 14:00

Travel to Chukha district Visit Darla BHU Travel to P/ling and halt

15 June 2011 07:00 09:30 12:00

Travel to Samtse Visit Chengmari BHU Visit Ghumauney BHU and halt in Samtse

16 June 2011 07:00 BHU Tendru and Sipsu Hospital halt @ phunstling

17 June 2011 09:00 12:00

Travel to Gelephu (postponed by a day due to security reasons)

Visit Norbuling BHU and Halt in Gelephu

18 June 2011 07:00 Travel to Trongsa Consultation with DHO DzZhemgang Visit Jigmechholing BHU Halt at Trongsa

19 June 2011 Rest. Dr. ChnadralaMongar UNICEF Thimphu joins the team

20 June 2011 09:00 13:00

Visit KuengaRabten BHU Visit Dzongkha HospitalTrongsa Visit Chumey BHU Visit Dz. Hospital & DHO Bumthang Halt at Bumthang

21 June 2011 09:00 11:00

BHU Sephu, DzWangdue Travel to Thimphu& halt

22 & 23 June 2011 Report Preparation at Thimphu24 June 2011 14:30 Presentation at MoH25 June 2011 08:25 Departure to New Delhi

Annexure-3List of Places visited & Persons Met

Sl. No Date Place Name Designation Remarks

1 13/6 Paro -AP Sonam Zanpo Program OfficerDPOH, MOH

Accompanied entire field visit

2 -do- Paro Hospital Ms. Dechenmo DHO, Paro Accompanied toBHU, Drugyel

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3 -do- DrugyelBHU

Mr. Tashi DendupMs. Meera Chhetri

Health Assistant (M)Health Assistant (F)

4 14/6 ChukaDzongkhag

Mr. Tshewang Rinzin

DHO, Chukha Accompanied toBHU, Darla

5 -do- DarlaBHU

Mr. Ngowo ChenpoMs. Dema

Health Assistant (M)Health Assistant (F)

Dz. Chukha

6 15/6 SamtseMO Quarter

Mr. Sonam Dorji DHO, Samtse Accompanied toBHU, ChengmariBHU, Ghumauney

7 -do- ChengmariBHU

Mr.Tshering PhuntshoMs. Tshering Dema

HA (M)

AN

Dz. Samtse

8 -do- GhumauneyBHU

Mr. PlumoWangdiMs. Dhan Maya

HA (M)

HA (F)

Dz. Samtse

9 -do- SamtseMO Quarter

Mr. SangayDorji

Ms. PemChoden

Clinical Officer,Hosp. SipsuANM

Feedback on follow-up in April Skills good but slow in documenting needs improving

Hospital Samtse -do- -do- Assessed skills of Supervisors <5 children (Asthma & GE)

10 16/6 TendruBHU

YeshiWangdiTsheringLhamo

HA (M)HA (F)

Dz. Samtse

11 17/6 Norbuling BHU Mr. MelamDorjiRatna Maya ThapaMr. BirBdr.Gurung

HA(M)HA (F)BHW

Dz. Sarpang

12 18/6 Jigmechoeling Mr. SampaDusjurMr. Ramlal SharmaMs Karma Yangki

HA (M)BHWHA (F)-Leave

Dz. Sarpnag

13 18/6 Zhemgang Mr. Karchung DHO DzZhemgang14 19/6 Trongsa Dr. Chandralal Health &

Nutrition Officer UNICEF accompanied rest of trip

15 20/6 K .Rabten Mr. LethoDulipaPemaTewzew

Sr. HAHA

Dz. Trongsa

16 20/6 Dzongkha Hospital

Dr. TashiWangchukDr. ThinleyWorbuMr. NechuDorji

Dist Medical OfficerSr. Medical OfficerDHO

Dz. Trongsa

17 20/6 BHU Chumey Karma NorbuSonamWangdi

HA(M)BHW

Dz. Bumthang

18 20/6 Dz Hospital KinzangNamgyalTenzimDr. TandinZangpo

DHOADHOMedical Officer

Dz. Bumthang

19 21/6 BHU Sephu TashiNarbuUgyenTshering

HABHW

DzWangdue

20 22/6 UNICEF Thimpu Dr. Shukhrat Health Specialist Unicef Office

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21 22/6 DGMS Dr. DorjiWangchukMs. DeepikaAdhikari

DGHSBio-informatic office

State Directorate (MOH)

22 22/6 State Hospital Dr. DhrupthobSonamDr. K P Tshering

SuperintendentNeonatologist

JSW Hospital

23 22/6 UNICEF Thimphu

DrGepkeHingst UNICEF Representative

UNICEF Office

24 23/6 MoH Dr.UgenDophu DPH MOH

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Annexure-4List of Persons Met for Key consultations

Sl. No Date Place Name Designation

1 13/6 Paro-AP SonamZanpo Program OfficerDPOH, MOH

2 -do- Paro Hospital Ms. Dechenmo DHO, Paro

3 14/6 ChukaDzongkhag

Mr. TsgwangRinzin DHO, Chuka

4 15/6 Samtse Mr. SoanmDorji DHO, Samtse

5 -do- SamtseMO Quarter

Mr. SangayDorji

Ms. PemChoden

Clinical Officer,Hosp. SipsuANM

6 18/6 Zhemgang Mr. Karchung DHO

7 19/6 Trongsa Dr. Chnadralal Health Specialist UNICEF

8 20/6 Dzongkha Hospital Dr. TashiWangchukDr. ThinleyWorbuMr. NechuDorji

Dist Medical OfficerSr. Medical OfficerDHO

9 20/6 Dz Hospital KinzangNamgyalTenzimDr. TandinZangpo

DHOADHOMedical Officer

10 22/6 UNICEF Thimpu Dr. ShukhratRakhimdjanov Health Specialist, UNICEF

11 22/6 MoH Dr. DorjiWangchukMs. DeepikaAdhikari

DGHSBio-informatic officer

12 22/6 State Hospital Dr. DhrupthobSonamDr. K P Tshering

SuperintendentNeonatologist

13 22/6 UNICEF Thimphu DrGepkeHingst UNICEF Representative

14 23/6 MoH Dr.UgenDophu DPH

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Annexure 5

Bhutan’s Response to the Continuing Child Health and Nutrition Challenges

Program Goals Program Objectives1. Reduce child mortality and morbidity

2. Reduce maternal mortality

1.Reduce IMR to 20 per thousand live births by20152. Reduce under five mortality to 30 per thousand live births by 20153. Reduce MMR to less than 140 per 100,000 live births 20154. Reduce micronutrient deficiencies 5. Sustain immunization coverage above 95% 6. Promotion of infant and young child feeding practices 7. Improve access to safe sanitation to near 100% 8. Sustain access to safe drinking water to near 100% 9. Expand comprehensive EmONC services from 7 to 15 by 2013 10. Universalize IMNCI coverage by 2011

The Vision of Maternal, Newborn and Child Health (MNCH) Bhuta):

o The vision statement of MNCH lays down the following objectives for child health:

o Reduce IMR to 20 and under 5 year’s (U5MR) per 1000 live births by 2015.

o Improve coverage of fully immunized children to at least 95% by 2011

o Improve quality, coverage and effectiveness of the existing and essential RCH services with special focus on eastern districts.

o Concentrate on intensive development of the human resources through strengthening of institutions and enhancement of skills, complemented by an efficient support system to enhance the quality of monitoring and evaluation, procurement, financial management and service delivery.

o Expand essential RCH services through universalization of a package of essential services in the country. RGoB is determined to implement simple Continuum of Care at all BHUs Gr. II & Gr. I, district hospitals, Regional and national referral hospital in the entire country.

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Indicators of Maternal, newborn and child health status

Data Required Measures Baseline data (year and source)

Most recent data (year and source)

Target Differences by region or group (highest/lowest)

Child deaths Under 5 mortality rate

61.6/1000 Awaits BMICS 2010

30 (10fy plan)

Causes of death NA NA NA NA Child morbidity

Prevalence of childhood illnesses: pneumonia, diarrhea, malaria (fever), measles

P=20% D=21% Malaria: 1/10,000 (2009 program report)

4.3% (2007) 11% (2006)

15% (10fy plan) 10% (10fy plan)

Proportion of children who are positive among the total HIV positive

9.5% (program report 2007)

8.2% (program report 2010)

NA HIV to look into the target

Under nutrition

Prevalence of low weight for height (z-score -2 or less)

2.6% Anthropometric survey 1999

4.6% National Nut and IYCF study 2008

Sustain at <5%

H=western regional L=central region

Prevalence of low height for age (z-score -2 or less)

40% Anthropometric survey 1999

37% National Nut and IYCF study 2008

30% (10FYP) H=eastern region L= central

Prevalence of low weight for age (z-score -2 or less)

18.7% Anthropometric survey 1999

11.1% National Nut and IYCF study 2008

15% (MDG) H=western region L=eastern region

Micronutrient deficiencies

Prevalence of anemia among children age between 6-36 months (Hb ,11g/dl)

81% National anemia survey 2002

60% (10fy plan)

For this particular study the Hb cut off level used is 11g/dl

Source: Short Program Review of Child Health Program, College of Natural Resources, Lobesa, Bhutan, September 2010

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Fig.: IMNCI - the centerpiece of newborn and child health strategy in MNCH

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Otherhealth programs like VDCP, TB HIV/AIDS influencing child survival

FACILITYLEVEL:- Outpatient care- Inpatient care – Care at birth -Assessment of every newborn & requisite care -establishing breast feeding before discharge- SNCU- FIMNCI- Nutrition

counseling & rehabilitation

- Immunization clinic

Age at marriage Avoid teenage pregnancies Birth spacingSmall family normPost-partum care of mothers

Health system strengthening

BCC & Community Participation

Maternal Newborn and Child Health (MNCH)

IMNCI

HOME AND COMMUNITY LEVEL*:

NOT IMPLEMENTED IN BHUTAN

SKILLED CAREAt / afterBIRTH for babiesInstitutionalDeliveries beingPromoted

UNIVERSAL

IMMUNIZATION

Employment guarantee, Minimum labor wages, Food Security, gender equity / Women’s Empowerment