Operationalizing Healthy Timing and Spacing of Pregnancy (HTSP) in Child Health Services: BASICS Experience in Rwanda - PowerPoint PPT Presentation

Operationalizing Healthy Timing and Spacing of Pregnancy (HTSP) in Child Health Services: BASICS Experience in Rwanda

Gloria Ekpo, MD, MPH

Issakha Diallo, MD, MPH, DrPH

Diana Silimperi, MD, MPH

Mathias Yameogo, MD, MPH

Moses Ahabwe, MD MPH

May 24, 2008

Justification for On-going Advocacy and Implementation of HTSP

Infant Mortality Rate per 1000

Source: Rwanda, Mali, Cambodia, Timor Leste DHS data

Fertility Rate: 6.1

Knowledge of a method of FP: 98%

Contraceptive Prevalence:10%

Unmet Need for pregnancy spacing: 41%

HIV Prevalence: 3.6% (women and 2.3% in men)

Life Expectancy at birth: 47.3 years

RWANDA: BACKGROUND

Source: Rwanda DHS III 2005

Week in Review

After So Many Deaths, Too Many Births

Laura Hoemeke/Twubakane Decentralization and Health Program

BABIES, NOT GHOSTS A crowd at a health campaign rally in northern Rwanda.

Population control has been controversial because survivors of the genocide have felt it was a family’s right to replenish what was lost. By STEPHEN KINZER Published: February 11, 2007

Source-IntraHealthFP-Rwanda Dec 2007

% women in union, age 15 to 49

Important proportion of women have short birth intervals – case of Rwanda

23% Birth Interval < 2 years

41% 2 < Birth Interval < 3 years

36% Birth Interval ≥ 3 years

Source: Rwanda DHS-III, 2005

Children are paying the Highest Toll from the Short Birth Intervals In Rwanda

Mortality ratio per 1000

Source: Rwanda DHS-III, 2005

Integrating HTSP into HIV Programs

* Excluding one case of no reply

Source; Livinus Bangendanye, FHI/RwandaPregnancy, Pregnancy Desires, and Contraceptive Use Among HIV-infected Women 3rd Pediatric HIV Conference Dec 2007

p=.02

• 365 (81%) out of 450 health facilities offer Family Planning services
• FBOs own 133 (30%) health facilities of which 47% (62) of these offer FP services (i.e 17% of total FP facilities are owned by FBOs)
• FP services are not offered daily in most health facilities
• FBO facilities willing to counsel clients for FP but may not offer full package for FP at their facilities
• Secondary FP Post erected to accommodate clients needs from FBO facilities
• High client demand for long-term methods (Implants and injectables)
• Most services are free
• Incentive-Motivation: Performance-based Financing for FP services

• Readily available quality and complete data from the DHS III 2005
• Functional PHC activities with increasing performance for the essential MCH package
• Political will and Partnership in management and leadership functional structures
• Partnership and collaboration in HTSP activities
• Appropriate tools and approaches for quality assurance
• Training and capacity building of health care workers on HTSP integration
• Supportive supervision, mentorship and monitoring

• Advocacy: Encouraging governments and partners to adopt integration strategy, guidelines, or policy;
• Integration: Development/Strengthening of guidelines in HTSP, development of tools, dissemination of revised guidelines, policies, tools to relevant officials and partners;
• Implementation: Training of trainers and on-the-job-training of service providers on integration of HTSP in child health at central and district levels;
• Supervision, mentorship and Monitoring: Supportive supervision and mentoring of HTSP service providers;
• Expansion and Scale-up: To improve coveragein additional districts and provinces in the countries.
• Partnership and Collaboration: Global and Country level
• USAID, ESD, ACCESS-FP, IMMbasics
• Ministry of Health and Maternal and Child Health department of ;
• Intrahealth/Twubakane project; Intrahealth/Capacity project;
• Extended Impact Project (EIP: IRC, WorldRelief, Concern), EGPAF, Population Council

• IMNCI-Sick baby clinics at MCH (Rwanda, Malawi)
• Immunization and Well baby clinics (Rwanda)
• Essential newborn and postnatal care (Swaziland, East Timor, Cambodia)
• PMTCT programs (Malawi)
• Pediatric HIV care and support services (Rwanda)
• Pre-service and In-service training curriculum (Rwanda, Malawi)

Advocacy and Capacity Building in HTSP

• Methodological guide for HTSP integration at child health entry points to care
• Rapid Facility Functionality Assessment Guide
• Supervision and Mentorship checklist
• Framework for monitoring and evaluation at global and country level of HTSP results
• Training Manual for integration of HTSP into child health programs

HTSP:

• You have just given birth, waiting at least 24 months before trying to become pregnant again, but not more than five years is better for your health and your children’s health;
• Choosing a secure and effective contraceptive method that you can easily use is the best way to prevent unplanned pregnancy;
• This facility provides support for healthy timing and spacing of pregnancy and for more information about how you can access these services, please meet with our counselors before you leave this facility today.

• Key messages developed for use at group education sessions for women/parents/guardian
• 5 Pilot sites identified for the implementation of HTSP integrated messages
• Explore holding Immunization and FP services on same days
• Use of Secondary FP posts for close to FBO health facilities
• Conduct mobile FP clinic during community immunization outreaches and campaigns
• Expectations:
• One-stop shop for child and maternal health needs in IMM and FP
• Mothers looking forward to immunization days
• Access FP services in addition to child immunization
• Increased in uptake and retention of services

ADVOCACY

Policy Makers

Program Planners

Men

Civil Society,

ADVOCACY

Couples

Grand-mothers/fathers

Women

Health Care Workers

Rwanda:

1. Integration and strengthening HTSP in:

• IMCI Training Manual,
• pre-service nursing curriculum,
• pediatric HIV job aids and tools
• Comprehensive referral form for health facilities

2. Development of key HTSP messages for utilization at immunization sites

3. Training of trainers on IMNCI-HIV -HTSP integrated manual

• 275 HCWs and 25 Supervisors
• 42 Health Facilities
• 15/30 Districts in the country

4. Supervision and quality assurance visits to monitor integrated services

5. Partners: MOH, TRAC, MCH, EPI, IntraHealth Twubakane, CAPCITY project.

Rwanda: Exit Interview results from clients visiting health centers in two districts

Rwanda: Entry points to care where HTSP messages are delivered at health facilities.

Constraints & Issues:

Engaging child health providers to integrate preventive measures such as HTSP activity into their daily busy child survival activities

Limited human resources for implementation of activities- Point person is required to facilitate program implementation, data collection and supervision of HTSP activities at all levels of care in the country

Limited funds for expansion and scale up of HTSP integration in child health programs

Monitoring impact of activities through partners who have other multiple activities and programs

• Integration of HTSP in child health services is crucial to reinforcing child and maternal health services
• HTSP in child health contributes to expand the access and use of FP services by reducing the missed opportunities to educate women/couples in contraception for birth spacing
• HTSP is an essential component of the Repositioning FP Initiative and should receive more attention and commitment from the FP program managers, policy makers and donors

USAID Washington

USAID Mission-Rwanda

MCH/MOH Rwanda

BASICS HTSP Partners- ESD, IMMbasics, ACCESS-FP

Implementing Partners:

Intrahealth Twubakane, CAPACITY Project

BASICS Country and HQ HTSP Team

Thank you

Photo credit: Intrahealth/Twubakane