improvement of mother and child health services in · pdf fileimprovement of mother and child...

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Ministry of Healthof the Republic of Uzbekistan

This project is co-funded by the European Union

PartnershiP in action

Improvement of mother and chIld

health servIces In UzbekIstan

phase II

This document has been produced with the financial assistance of the European Union. The views expressed in this publication do not necessarily reflect the views of the European Union.

A Word from Project Partners

L. N. Tuychiev Deputy Minister of Health of the Republic of Uzbekistan

The joint “Improvement of Mother and Child Health Services in Uzbekistan” Phase 2 project, is an example of productive coop-eration and strong partnership between the Ministry of Health of the Republic of Uzbekistan, the European Union, UNICEF and WHO. A successful implementa-tion of the first and then second phases of the project, is yet anoth-er proof of high efficiency of state policy implemented by Uzbekistan from the first days of independ-ence, with top priority to bring up a healthy and harmoniously devel-oped generation. Our joint work will help to further development and strengthening of mother and child health sector; ensure better coordination and close coopera-tion between the state, public and international organizations, and create the environment for chil-dren in our country to be born and grow up healthy.

y. STerk Ambassador, Head of the EU Delegation to Uzbekistan

We are happy to see the health sec tor reforms being undertaken by the Government of Uzbekistan particularly in improving the health of mothers and children. Within this framework a successful and effective partnership has been established between the European Union, the Ministry of Health and UNICEF which started back in 2008. We are confident that our joint action aimed at strengthening the mother and child healthcare system in line with highest inter-national standards, enhancing the skills of health professionals and improving parental skills through community based approaches, have significantly contributed to MDG 4 and MDG 5.

r. Fuderich UNICEF Representative to Uzbekistan

This Project was an instrumen-tal part of the nation’s effort to reduce maternal and child mortali-ty. It supported the ongoing health system reforms in Uzbekistan, and introduced scalable and cost-effective solutions for ensur-ing equitable access to health services for mothers and children in urban and rural areas alike. We have also been able to demon-strate that with the right attitude and a comprehensive strategy in place, we can reach every mother and child who are in need of qual-ity healthcare. I hope that we will be able to continue our joint effort on further improvement of mother and child health, ultimately con-tributing to the health, well-being and steady development of the entire nation.

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What the Project AchievedInstitutional Strengthening

IMPROvEMENT OF MOTHER AND CHIlD HEAlTH SERvICES IN UzbEkISTAN

The skills and operational capacity of the Ministry of health and its three tiers (primary, secondary, and tertia-ry) have been enhanced to effectively support the health reform process concerning the Mother and child health services in accordance with international standards.

The project supported the Ministry of Health (MoH) in revision and development of the policies, major regulatory frame-work and clinical guidelines aiming to improve the quality of Maternal, New born and Child Health services.

MaiN achieveMeNTS

Under the stewardship of the Ministry of Health (MoH), the Mother and Child Health Coordination Council (MCHCC) is a viable platform promoting better coordination of the MCH sector activities between the MoH, government agencies, and interna-tional partners and contributing to the sys-tem level changes and sustainability of the interventions implemented with support of different partners.

The project supported the MoH in deve-loping the “State Programme on Streng-the ning and Development of System of Protection of Reproductive Health of Popu la tion, Health of Women, Children, and Adolescents in Uzbekistan for years 2014–2018” approved by Pre sidential decree No. 2221 in Sep tember 2014. It now constitutes the framework for reforms in the mother and child health care sector, including international col-laboration.

The project provided technical assistance to the MoH in development and revision of the major regulatory MCH framework (decrees, clinical standards and guide-lines), aimed at improving the quality of the MCH services at all levels of health system:

# The Order No. 225: the Clinical guide-line for inpatient care for children under age of 5, approved by the Minister of Health in July 2013

# The Order No. 185 on Regionalization of Perinatal Services in the Republic of

The UNICEF Representative in Uzbekistan, Mr. R. Fuderich and the Head of EU Delegation to Uzbekistan, H. E. Ambassador Mr. Y. Sterk communicate with mass-media during the Joint Monitoring Team visit to the training centre in Tashkent region.

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Uzbekistan, approved by the Minister of Health in May 2014

# The National Standards on Obstetric Care in the Hospitals, approved by the Minister of Health in December 2014

# The National Guideline on Neonatal Resuscitation, approved by the Minister of Health in February 2015

# The National Standard on Nation-wide Implementation of the Near Miss Ca se Review (NMCR) metho do lo gy and the Confidential Enqui ry in Ma ter nal Deaths (CEMD), app roved by the Minis ter of Health in July 2015

# The Order No. 405: the Clinical Gui-de line for outpatient care for children under age of 5, approved by the Mi nis-ter of Health in October 2015

# The Order No. 183 on Organization of Neo na tal Care in the Republic of Uzbe-kistan

# The Order on Actions to reduce child mortality in the Republic of Uzbe kistan

# The Clinical Guideline on Essential Newborn Care

# The MoH National Standard on Sup-portive Supervision

The evidence generated by the project on the Quality of MCH Services, through the Health Facility Assessment nationwide, shared with the MoH and regional health authorities, to provide the body of the knowledge to guide future improvement of the quality of MCH services.

The project supported the MoH in devel-opment of the National QI Concept, QI

Strategic Plan, and development, elab-oration and piloting of tools for quality improvement (QI), certification, and sup-portive supervision.

To help strengthen the MCH informa-tion system two databases have been designed: (i) for data collection and anal-ysis of the Health of women giving birth and Neonatal Health and Mortality, and (ii) on Child mortality. Application of this software will allow the users to standard-ize the indicators, automate data collec-tion at the regional and sub-district levels, and streamline the data analysis process at sub-regional, regional and the national levels.

The project supported the MoH in estab-lishment of two national QI resource cen-tres, to assist the MCH care profession-als in implementing the QI tools in their institutions, and ensure sustainability of Project interventions after its completion. The first centre is based at the Republican Specialized Scientific Practical Medical Centre of Paediatrics, and the second one—at the Republican Perinatal Centre.

A mother with her newborn baby.

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1. What were the goals of the «Improve ment of Mother and Child Health Servi ces in Uzbekistan Project, Phase 2 (IMCHS 2)?”

L. N. Tuychiev: IMCHS 2 is the continu-ation of successful cooperation between the Ministry of Health (MoH), the UNICEF and the European Union (EU) initiated in 2008. The project supported social development of Uzbekistan, contributed to MDGs 4 and 5, and supported health-care reforms aimed at improvement of quality medical services provided to mothers and children, starting from deliv-ery up to postnatal period and childhood. Implemented in Ferghana, bukhara, khorezm, Tashkent regions, a long with Tashkent City and the Republic of karakalpakstan, Phase 2 completed nationwide scale up of cost effective

for the Deputy Minister of Health Mr. L. N. Tuychiev

The health care professionals, trained by the project, encourage an early skin-to-skin contact between the mother and her baby.


medical interventions to improve survival of newborn and children.

2. What are the perspectives of sustainability of Project achievements after its completion?

L. N. Tuychiev: Sustainability of results was ensured by three key areas of work:

At the national level, the Project assis-ted the Government of Uzbekistan and Ministry of Health in development, revi-sion and implementation of the main poli-cy and regulatory framework aiming to improve the quality of Mother and Child Health (MCH) services, including the Sta-te Programme (SP) on Strengthening and Development of System of Protec tion of Reproductive Health of Population, Health of Women, Children, and Adoles cents in Uzbekistan for years 2014–2018.

The Project supported updating clini-cal protocols and national guidelines in line with the modern international stan-dards, enabling improved mother and child survival at all healthcare system levels, along with reduction of mother and child mortality. Introduction of these protocols and guidel ines into prac-tice demonstrated substantial change in daily practices of medical staff and improvement in provision of medical services. To ensure sustainabil ity of training results, newborn and children survival modules have been integrated into pre-service training of eight medical universities in Uzbekistan and approved by the Ministry of Higher and Secondary Special Education in 2013.

As a new program element, at the house-hold and communities level, the Phase 2 included educational component on nutrition and family care practices in

Four Questions

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order to increase demand for medical services and expand access to them.

3. What is the Project’s contribution to strengthening the international partnership to improve quality of MCH services?

L. N. Tuychiev: For efficient mobilization of resources and avoiding duplication of efforts by the international organizations in the MCH sector, within the framework of the project the MoH has created a Mother and Child Health Coordination Council (MCHCC). The MCHCC includes the MoH, international organizations and donors, and served as a platform for exchange of experiences, discussion of activities aim-ing to strengthen healthcare system and project results implemented by the vari-ous international agencies.

Giving each child the best start in life.


4. What is the role of IMCHS Project in improving quality of services provided in the MCH Sector?

L. N. Tuychiev: In addition to technical assis-tance provided to develop and revise the MCH policy and legal framework, introduce new clinical approaches and guidelines, the Project supported the MoH in development of tools and methodologies for supportive supervision, certification of medical facilities, and the key documents, such as the National Concept on quality improvement (QI), and Strategic Plan on QI in the MCH sector.

The Project carried out the nationwide Health Facility Assessment of quality of medi cal ser-vices in the MCH sector. Results and rec-ommendations of this study will be used to further improve the quality of care ren dered to mothers and children.

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What the Project AchievedCapacity Development and Empowerment


A comprehensive educationtrai ning process dealing with mother and child health care has been developed and put in place, at medicalinstitutional and family level.

Improving the quality of health care inva-riab ly involves building the capacity of health providers at all levels of healthcare system. With focus on standard clinical pro tocols and guidelines for Newborn and Child Survival, the training program at the medicalinstitutional level, utili zed holis-tic approaches to Maternal New born and Child Health (MNCH) care, comp lemented by the newly developed and piloted sup-portive supervision system.

MaiN achieveMeNTS

The following training materials have been updated in accordance with the latest WHO standards, carefully tailored to the Uzbek context, and approved by the MoH:

Newborn survival package

# Effective Perinatal Care (EPC): the trai ning module designed for obstetri-

cians/gynaecologists, neonatologists, midwives, and paediatric nurses to improve the quality and outcome of care for mothers and their babies

# Neonatal Resuscitation (NR) and Essen tial Newborn Care (ENC): this trai ning module covers the early care for newborn baby, reduction of birth as phy xia, neonatal infection and mana-ging complications of newborn arising from birth.

# Baby Friendly Hospital Initiative (BFHI): this training module covers breast feeding of newborns in materni-ty hospitals.

# BABIES and NearMissed Case Review (NMCR): training modules aiming to improve data collection and ana lysis, and provide information for managers for evidence-based decision making on quality improvement.

child survival package

# Primary IMCI: a training module with holistic Integrated Management of

Tashkent City Perinatal Centre, Deputy Director, M.S. Usmanova oversees the training in Neonatal Resuscitation.

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Republic of Karakalpakstan

Navoi

Samarkand

Djizzakh

Sirdarya

Tashkent City

Namangan

Khorezm

Bukhara

Kashkadarya

Surkhandarya

Tashkent

Fergana

Andijan

2560696

525546443

502

1899

2234

618

606

22682397

547

1578

TOTAL17,419

Doctors 11,561 Midwives 1167 Nurses 4691

Improvement of mother and ChIld health ServICeS In UzbekIStan

Number of Medical Professionals Trained in Uzbekistan Information as of November 1, 2015

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Childhood Illnesses (IMCI) approach to child survival at outpatient level.

# Hospital IMCI: a training module for management of severe cases of child-hood illnesses which needs hospitaliza-tion and inpatient care.

# Community IMCI: training module de- sig ned to build up the interpersonal com munication and counselling skills of pat ro nage nurses on growth and de ve-lop ment, exclusive breastfeeding and in-fant and young child feeding promotion.

# Growth and Development Moni toring (GDM) and Breast Feeding (BF) Promotion: these modules cover nut-rition and assessment of growth and development of children under 5.

To support capacity building efforts, a total of 12 training centres have been established and renovated in 6 pilot regions, including provision of the office and training equipment.

Up to date, over 17,000 health care professionals, including over 865 national and local trainers enhanced their knowledge on newborn and child survival packages. With support of the National Trainers, the oblast level trainers carried out the cascade trainings on Newborn and Child Survival packages, and covered 2254 medical facil-ities with supportive supervision visits

to help medical professionals apply newly acquired knowledge and skills in their day to day work. In addition, a total of 843 managers of MCH services nationwide had been trained to become more effective leaders and supervisors.

Combination of capacity building activities and supportive supervision contributed to improvement of quality of MCH care. The assessment of quality of the MCH ser-vices at targeted health facilities showed a notable positive change in health practices: e. g. 40.5 per cent increase in maternities correctly applying newborn survival pack-ages recommended by WHO and UNICEF; 75.4 per cent increase in paediatric hospitals/wards that correctly apply child survival packages recommended by WHO and UNICEF; 49.5 per cent increase in proportion of children 2–5 years old that were examined by GP doctors according to approved protocols/standards.

The project supported institutionalization of the Newborn and Child Survival and Nutrition modules in the pre-service academic curricula that was approved by the Ministry of Higher and Special Secondary Education in August 2013. To ensure a critical mass of professors is able to teach the revised graduate curricu-la, more than 500 pedagogical personnel from medical institutes and medical col-leges have been trained.

The WHO E-learning Tool for the MNCH managers was adapted with support of the project to strengthen capacity of MNCH program managers at oblast and district levels in Namangan and Republic of karakalpakstan.

Jointly with the MoH, the project organized 4 exchange visits for health professionals to enable dissemination of best practices and learning from each other. Each event also included a site visit to medical institutions. The scope of the experience exchange visits was linked with the broader context of MCH sector reform in Uzbekistan, and contributed to further improvement of the quality of health care system and evi-dence-based decision-making.

A nurse, trained within capacity building component of the project, provides care to a newborn child in the Syrdarya Regional Perinatal Centre.


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Friendly Care for Premature and Vulnerable Babies

Young mother Elena Ten stands beside her newborn baby in a maternity ward of the Tashkent Regional Perinatal Cent re, in the town of Chirchik. Like Ms. Ten’s first child, her new arrival is pre ma ture. However, this time she feels mo re secure, knowing that her baby will recei ve the right care.

“My first baby was also born before term. At that time, the doctors wouldn’t allow me to stay with my child,” Ms. Ten said. “Today, they allow me to stay with my daughter and take care of her. I have more confidence, and I hope that we will both be well soon.”

Through phase II of the IMCHS project, the Tashkent Regional Perinatal Centre staff have changed how they care for newborn children using modern medical equipment, some of which has been provided by complimentary projects. Changing the roles played by mothers and health practitioners in hospitals has been a key component of this change. Breastfeeding, even with expressed milk, and early skintoskin contact between mothers and their babies is encouraged wherever this is possible and practicable. The results of these changes have been noticed by doctors and nurses.

“In previous times, we placed more emphasis on drugs and equipment. Of course they are very important, but prematurely born and vulnerable babies lack first of all contact with their mothers,” said Director of the Tashkent Regional Perinatal Centre Lola Karabaeva. “Once we allowed mothers to become more involved in the care of their premature babies, we noticed better and faster recoveries in the majority of cases. We needed less traumatic interventions and less drugs. In all cases breast milk proved to be extremely beneficial, even if it was expressed. The duration of hospital stays has shortened, and even the workload of our personnel has decreased.”

The project has also updated the knowledge and practical skills of doctors and nurses in

line with best international practices. This has resulted in the better monitoring of the condition of babies, and the delivery of more individualised care.

“Together with my colleagues I attended several training courses on newborn and child survival topics. Due to the availability of training equipment, we refreshed our skills regarding lifesaving interventions, such as lung ventilation and intubation,” said nurse at the Neonatal Intensive Care Unit Dilfuza Joldosova.

In the end, the people who directly benefit from these improvements are the children who receive better care, and the mothers like Elena Ten whose confidence in standards of mother and child care have increased.

“The approaches they use give children the will to live and survive,” Ms. Ten said. “Even though my child was born premature, I know he will live.”


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What the Project AchievedCapacity Development and Empowerment


A comprehensive educationtraining process dealing with mother and child health care has been developed and put in place, at medicalinstitutional and family level.

Increasing demand for quality Mother and Child Health (MCH) services requires strat-egies and approaches that will help provide caregivers and community members with the essential information, and promote a collective deliberation regarding the health and well-being behaviors at family level.

Resulting from a consultative process, between the project, Ministry of Health, Women’s Commit tee and Makhal la Foundation, the following five key house-hold behaviors have been identified for promotion among the caregivers of chil-dren aged zero to five years old:

# Caregivers recognize and respond to ‘danger signs’ of childhood illnesses;

# Mothers practice exclusive breastfeed-ing for the first six months of a baby’s life and provide proper complimentary feeding thereafter;

# Families practice a balanced diet with nutritional variation, with focus on pregnant women, lactating mothers and children aged six months to five years old;

# Communities practice proper hygiene behaviours with focus on hand wash-ing with soap and water at critical times during the day;

# Parents and other primary caregivers create early emotional bonding with young children, play with them and stimulate their cognitive development.

The Participatory learning and Action (Pl A) approach, wh ich is new in Uzbekistan, was introduced in select-

Healthy nutrition is one of the key behavior promoted through the PLA.

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ed communities of Namangan region and the Republic of karakalpakstan, to empower families and communities to adopt and sustain the 5 key behaviours, to assure the health and well-being of their children and themselves too.

MaiN achieveMeNTS

The end-line study of knowledge, Atti-tude and Practices (kAP) conducted in 2015, showed the following changes in applying the five key behaviours as com-pared to the 2013 baseline survey:

# The average rate of mothers and care-givers recognizing the danger signs of childhood illnesses improved from 31 per cent to 52 per cent;

# The proportion of mothers who exclu-sively breastfeed their children aged zero to six months old increased from 39 per cent to 50 per cent;

# The proportion of children aged six months to 23 months consu ming four or more groups of food improved from 66.5 per cent to 70.4 per cent;

# The proportion of children aged zero to five years old whose hands are being washed at critical times during the day increased from 35 to 47 per cent; and

# Average time spent for the stimula-tion and development of a child aged under five years old increased from 2 hours to 5.9 hours a day.

coMMuNiTy-baSed acTioN

The package of key behaviours was pilot-ed through the Participatory lear ning and Action methodology in:

# 3 rural communities and 3 urban com-munities of Namangan region

Cooking master class in progress in one of the pilot communities in Chimbay district, the Republic of Karakalpakstan.

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# 3 rural communities and 3 urban com-munities of karakalpakstan

A tota l number of populat ion out-reached in the pilot communities is about 36,000 persons.

The PlA process, facilitated by trained patronage nurses and community advi-sors, enabled community groups to assess their situations with regards to the five behaviours and identify barriers to changing them.

To keep families motivated, and ensure sustainability of the adopted behaviours, the community support and monitoring groups were established in each com-munity.

FuTure acTioN

Develop a plan of action for institution-alizing the main elements of the PlA by the health care system and other partners engaged, so that all regions of Uzbekistan could benefit from the PlA methodology.

Beneficiaries in the pilot communities are encouraged to plant their own fruits and vegetables in Chimbay district, the Republic of Karakalpakstan.


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“Our patronage nurse used to visit us regularly in the past, checked on the children’s health and asked if we had any complaints”,—says Juldyzkhan, a mother of two daughters aged 4 and 1, who lives in MolBozor village, Chimbay District, Karakalpakstan. “Now, in addition to the regular home visits, our patronage nurse and the community advisor invite me and my family members to take part in the regular community discussions around the practices that are essential for our children’s health and wellbeing”.

According to Juldyzkhan, her older daughter used to get sick very often, especially with diarrhea. She admits that she had little knowledge about the advantages of exclusive breastfeeding, and was hardly able to recognize the symptoms of dangerous illnesses that required immediate visit to a doctor for her children. She was not alone in this; her neighbours have been experiencing similar challenges.

Things started to change gradually for Juldyzkhan’s family and her entire community with the introduction of the Participatory learning and Action (PLA) methodology, brought to the village by the IMCHS 2 Project—the collaborative alliance of the Ministry of Health, Women’s Committee, Makhalla Foundation, the European Union and UNICEF.

Piloted in the selected urban and rural communities of Namangan region and the Republic of Karakalpakstan, in the period of 2013–2015, the PLA methodology encourages and empowers communities to start assessing health and well being needs of mothers and children aged 0 to 5 years old, gain necessary knowledge, plan action for improvement that is relevant in their local context, and regularly monitor the progress of applying the positive practices, through establishment of the communitybased monitoring groups.

The PLA methodology builds on the enthusiasm of the influential community members and channels the messages through the religious leaders, reti

Participation: a Path to Healthier Communities

red teachers and doctors, young active students and others who are respected and ready to de dica te their free time for the wellbeing of their community.

Facilitated by patronage nurses and community advisors trained in the PLA methodology, the community dialogues have been held regularly to discuss the community situation with regards to five key essential behaviours for mother and child health: exclusive breastfeeding until the age of six months and continued breastfeeding with complimentary feeding until the age of 2; recognizing danger signs of illnesses in children aged 0 to 5 years old; practicing a balanced diet; washing hands with soap at critical times during the day; and developing bonds with a child as well as stimulating the child’s early learning and development.

“Through this experience we learned that the community members and activists are in the best position to advise and guide their own health, wellbeing and development,”—says Juldyzkhan. “The methodology builds on trust and ensures access to community members and others who serve as information providers. My community peers and I are empowered to take charge of our children’s wellbeing and development, and to demand better healthcare services from service providers. Most importantly, I feel confident in my girls’ healthy future.”


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Notes


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united Nations children’s Fund16, Sharof Rashidov Str., 100029, Tashkent, Uzbekistanbusiness Center “Poytaht”Tel.: +998 (71) 233-9512Fax: +998 (71) 140-6508Email: [email protected]

Ministry of health of the republic of uzbekistan12, Alisher Navoi Str., 100011, Tashkent, UzbekistanTel.: +998 (71) 239-4608Fax: +998 (71) 244-1033Email: [email protected]

delegation of the eu to the republic of uzbekistan107-b, Amir Temur Str., 100084, Tashkent, UzbekistanInternational business CenterTel.: +998 (71) 120-1601Fax: +998 (71) 120-1608Email: [email protected]

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