9. Service delivery models

Comments

1. John Moor says:

   August 12, 2010 at 3:26 pm

   Enrol a corps of middle age local mothers who are trained to engage with young mothers and discuss with them the merits of family planning.
   In Botswana these ladies were called
   “family welfare educators” They also emphasised the importance of attending antenatal clinics and clinics for children under 5 years
2. Merrill Wolf says:

   October 7, 2010 at 3:12 pm

   In addressing the issue of unsafe abortion, integration of such care into broader reproductive health services is important to ensure that women can obtain the full range of care they need (including contraception) and to help destigmatize unintended pregnancy and abortion.

   While more work is needed to identify effective models of care, it is already clear that more investment is needed in ensuring that women can obtain such care in their own communities, since many do not have the means to go elsewhere. Among others, an essential strategy for achieving this will be authorizing and training nurses, midwives and other midlevel health professionals – who are often women’s only sources of care in their communities – to offer abortion services.
3. Steven Fouch says:

   October 19, 2010 at 4:43 pm

   Improving the national health services is obviously essential and, in particular, training and empowering health professionals to provide the best level of care possible is vital.

   In many countries, levels of knowledge and skills among medical professionals are often very basic at best, and not necessarily up to an acceptable standard. The attitudes of staff are also often shaped by local beliefs, by working in a resource poor context where their work is not valued (or perceived to be valued) by government or wider society. And while many health professionals desire to do good, they are often overwhelmed by the need, and worn down by the lack of supplies (and other resources, including ongoing training) available. As Christian Medical Fellowship has stated before, we also see the vital need to have not only good supply chains, but means of monitoring and ensuring that essential and basic supplies (such as magnesium sulphate and prostaglandins) are actually available in maternity hospitals.

   As one of our members says: ‘The doctors we trained in Cure Hospital in Kabul all, without exception, expressed gratitude for the opportunity and responded well to the discipline and structure of accountability put in place. Good mentoring and modelling makes all the difference. We watched these young doctors blossom and grow in astonishing ways during their years with us.’

   However, we have seen from many different examples that just focusing on training individual health practitioners rather than focusing on teams has less impact. If health workers are selected by, and then serve within, their own communities and are trained as a team, then these health workers and professionals become agents for change in their own communities, and engage in local political activity, including addressing violence against women. Training needs to be practical and ‘hands on’, as well as theoretical, depending on the skills mix needed. These approaches lead to lower staff turnover and staff who are more empowered and motivated.
   We would argue that first training and then establishing family doctors and midwives in rural health facilities can make a significant difference to maternal and child mortality in that area. Obviously that is only the case if the health facility (and personnel) continues to be supported and supplied, and there are referral options. Experience suggests that it is far more cost effective to have two well trained family medicine doctors locally who have basic training in obstetrics, gynaecology and paediatrics, than to have a few ‘specialists’ in each of these fields in a remote secondary care institution. Family medicine doctors can be trained to perform caesarean sections, give spinal anaesthetics or ketamine, and resuscitate the newborn, etc. Local midwives can also intervene directly in ways that minimise the need for referral to secondary or tertiary centres.

   However, our members’ experiences suggest that it is almost impossible to get funding for postgraduate and post-basic training for health professionals or for community health workers. DFID could definitely do more to indentify training schemes for community health workers and post-registration doctors, nurses and midwives that will directly address maternal and child mortality, and which are already running in country, and help fund and expand them.
   Some of our members have worked at the LAMB project in northwest Bangladesh, a Lutheran Mission Hospital which has developed a Home to Hospital continuum of care, including:

   • the training of village health workers in basic health education for pregnancy, birth planning, child care and family planning

   • training of community skilled birth attendants

   • the provision of safe delivery units within the community, with transport to comprehensive emergency obstetric care (CEOC) in the hospital

   • the provision of 24/7 CEOC – including advanced trained midwives and non-physician anaesthesia providers (the lack of anaesthesia provision is a major barrier to the provision of emergency obstetric care).

   This continuum of care, which empowers the communities themselves to take responsibility for the health of their own women and children, has been shown to reduce perinatal and maternal mortality significantly. This has been achieved by making health care accessible by the rural poor – LAMB has reduced the rich-poor gap in accessing maternal health care.

   This is one example of a continuum of care approach, and the success of such projects is due in part to the holistic approach, to addressing the system as a whole, not in a piecemeal fashion. Each part of the system works, and each health worker feels a part of the bigger picture.
4. Sandra Mutuma says:

   October 20, 2010 at 3:57 pm

   For the issue of undernutrition, delivery of services at the point of delivery for children’s services should be considered. Women who bring their children for treatment or screening should also be screened and treated for any undernutrition that they may have themselves. Hence maternal and child health services should be integrated so that a woman should be able to make one trip for herself and her children. As indicated previously, the reality is that most women give birth at home and as such community based models of care delivery – similar to the Community-based management of acute malnutrition (CMAM) should be considered for pregnant women. Again, the key here is for Community Health Volunteers and TBAs with advanced skills in diagnosing, referring and instituting initial treatment where required of obstetric complications. The power of community awareness should not be underestimated. For example, radio can offer a cost-effective method to reach even remote areas. Messages about infant feeding (the importance of breastfeeding, the quality and timing of complementary feeding), basic hygiene and sanitation and early presentation to health facilities can be extremely effective for preventative programmes.

   However, optimal models of service delivery for reproductive, maternal and newborn health outcomes should be defined according to the context. Action Against Hunger (AAH) wherever possible delivers the treatment of acute malnutrition through existing health services and structures and encourages the multisectoral approach to the prevention of acute malnutrition. We have found that this fosters sustainability and strengthens the health system through human resource capacity building as ownership of services provided belong to the health ministry. AAH works in conjunction with national staff in a technical advisory capacity, supporting the health system where needed and as required.
5. Dr. Sultana Mustafa Khanum says:

   October 20, 2010 at 11:15 pm

   Working with private and other non-state providers, NGOs would be more effective to deliver reproductive, maternal and neonatal health services. One of such organisations is BRAC which provides maternal health services through partnership with the Government and communities. In our previous study in 2003 we found that the referral system was extremely poor but our ongoing study shows that after the intervention of BRAC the referral system has become quite satisfactory. The project of BRAC also provides financial assistance to women in labour which increases the number of child births at health facilities.