· web viewthey may mention supplies (soap, vaccines, vitamin supplements), delivery of those...

Session 12: Systems Strengthening, Integration, and Maternal and Newborn Health

Session Rationale This session provides basic information on health systems (including supply chain management, as an example), why this is important for MNH, and what Volunteers are doing to strengthen health systems in the context of MNH. Participants also review different types of integration within MNH care and services. Participants develop and share innovative ways to integrate care and services and strengthen health systems relevant to their work.

Time 105 minutes

Audience Peace Corps trainees/Volunteers assigned to Health sector programs during

PST/IST

Terminal Learning ObjectiveAfter learning about the continuum of care model for Maternal and Newborn Health and the three delays that increase the risk of maternal and/or newborn death, participants will describe the ideal journey of a woman of reproductive age throughout her lifecycle, from pre-pregnancy all the way through delivery and motherhood, including at least three potential barriers to achieving a successful journey

After conducting a community assessment and learning about antenatal care, PMTCT, labor and delivery, and post-partum and newborn care, participants will demonstrate the steps they will follow to implement at least one evidence-based practice to improve maternal and newborn health outcomes, including steps to engage their communities.

Session Learning Objectives 1. Through a case study and small group work, participants identify at least three components of a

health system and three elements of a strong supply chain system that contributed to improved contraceptive prevalence rates in Rwanda.

2. Through an individual task and ranking game, participants identify at least five innovative ideas to strengthen health systems and integrate messages and services that a Volunteer can feasibly support or implement.

Session Knowledge, Skills, and Attitudes (KSAs)1. Appreciate how components (or building blocks) of a well-functioning health system work

together for maternal and newborn health. (A) 2. Review definitions, elements, and examples of a health system and of integrated MNH services

and care. (K)3. Identify at least three components of a health system and three elements of a strong supply

chain system for a family planning project in Rwanda. (K,S)

MNH: Systems Strengthening, Integration and MNH |Version: Oct-2014| of 21

4. Identify at least five innovative ideas to strengthen health systems and integrate messages and services that a Volunteer can feasibly support or implement. (S)

Prerequisites Global Health Training Package: What Is Health? What Is Public Health? Global Health Challenges, International Responses, and Determinants of Health The Peace Corps’ Role in Global Health and Guiding Principles for Health Volunteers

Maternal and Newborn Health Training Package Introduction to Maternal and Newborn Health Conducting a Maternal and Newborn Health Community Assessment Healthy Timing and Spacing of Pregnancies Pregnancy and Antenatal Care Preparing for Labor and Delivery Community Mobilization for Emergencies Postnatal Care for the Mother and Essential Newborn Care Breastfeeding Engaging Influential Actors HIV and Maternal and Newborn Care

Sector: HealthCompetency: Foster Improved Maternal, Neonatal, and Child HealthTraining Package: Maternal and Newborn HealthVersion: Oct-2014Trainer Expertise: Trainer has a health background. Trainers could include a Health sector

program manager/APCD or Health technical trainer.


Session Outline

Motivation 15 min............................................................................................................................6

Introduction to Health Systems....................................................................................................................................6

Information 25 min............................................................................................................................6

An Overview of Health Systems and Integration and How They Relate.......................................................................6

Practice 35 min..............................................................................................................................12

Responding to Increased Demand for Contraceptives in Rwanda..............................................................................12

Application 30 min..........................................................................................................................14

What Can We Do? Ideas to Integrate Messages and Services and to Strengthen Health Systems.............................14

Assessment..............................................................................................................................................15

Trainer Notes for Future Improvement.....................................................................................................15

Resources.................................................................................................................................................15

Handout 1: How Volunteers Can Strengthen Health Systems....................................................................16

Trainer Material 2: This is Maya Crying: Introduction to Health Systems...................................................18

Trainer Material 4: Diagrams and Small Group Task..................................................................................19

Trainer Material 5: Innovative Idea Individual Task...................................................................................21

Contributing External Experts: Claudia Conlon (USG lead, Saving Mothers, Giving Life), Joan Haffey (independent consultant, Advancing Partners and Communities Project)


Session: Systems Strengthening, Integration, and Maternal and Newborn HealthDate: [posts add date]Time: [posts add xx minutes]Trainer(s): [posts add names]

Trainer Preparation1. Review the entire session plan, handouts, and PowerPoint presentation and plan the session

according to the time you have available.2. Organize participant seating in small groups, if possible at café-style tables with 5-6 participants per

group/tables.3. Write session learning objectives on a sheet of flip chart paper and tape to the wall.4. Tape the continuum of care framework wall chart (developed in Session 1 of this training package) to

the wall.5. Photocopy Handouts 1, 2 (separate file), and 3 (separate file) -- one copy per participant.6. If using the video option for the Motivation section, play the video from Trainer Material 1 (see

separate file) or download that same video “Healthy Systems Create Healthy Futures: Meet Maya” from https://www.youtube.com/watch?v=PFVCNUOM5Us (2.5 mins). Test for sound and quality.

7. If using the story option (see Trainer Material 2) instead of the video for the Motivation section, before the session, identify a participant who can practice reading the story and who will then read it aloud to the rest of the participants during the session. If possible, he or she should listen to the narrator in the video and imitate this style of reading.

8. Prepare all equipment necessary to show Trainer Material 3: PowerPoint (separate file).9. Prepare Trainer Material 4 and Trainer Material 5 for use in the Practice and Application sections of

this session (prepare charts and task on flip charts).

MaterialsEquipment Flip chart and flip chart stands LCD projector and laptop Speakers for video (if feasible) Screen or wall space Markers and masking tape Index cards/notecards (three per participant)

Handouts Handout 1 : How Volunteers Can Strengthen Health Systems Handout 2: Using Last Mile Distribution to Increase Access to Health Commodities (separate

file) Handout 3: Case Study from Rwanda (separate file)

Trainer Materials Trainer Material 1: Video: Health Systems Create Healthy Futures: Meet Maya (separate file) Trainer Material 2 : This is Maya Crying: Introduction to Health Systems Trainer Material 3: PowerPoint (separate file) Trainer Material 4 : Diagrams and Small Group Task Trainer Material 5 : Innovative Idea Individual Task


https://www.youtube.com/watch?v=PFVCNUOM5Us

Motivation 15 minIntroduction to Health Systems

A video (or story), using simple language, tells how a well-functioning health system contributes to healthy newborns. Participants identify the components (building blocks) and qualities of a well-functioning health system and relate this to their own experience and observations.

1. Introduce the session. Tell participants that the session will begin with a quick introduction to health systems

2. Show the 2 minute, 31 second-long video from Trainer Material 1 (see separate file), “Healthy Systems Create Healthy Futures: Meet Maya” (or read the story aloud as per Trainer Material 2: This is Maya Crying: Introduction to Health Systems).

3. Large group discussion. Ask participants: “What are the components of a health system that contributes to

maternal and newborn health? What did you observe in the video (or hear from the story)?”

Note: Let participants respond. They may mention supplies (soap, vaccines, vitamin supplements), delivery of those supplies, human resources (skilled providers who were educated), infrastructure (hospitals and clinics), health financing, governance and accountability, health information systems, and service delivery.

Ask participants: “According to this video (or story), what makes a strong health system?”

Note: Let participants respond. They will likely mention that a strong health system involves all its components working together. For example, if there is no truck or transport, vaccines cannot be delivered to reach pregnant women and newborns.

Ask participants: “What are some of your own observations from your community about health system components and their functioning that affect maternal and newborn health?”

Note: Let participants respond. Their answers will be very context specific. Participants may mention stock-outs of family planning products, medicines, and ITNs; lack of fuel/transport for health personnel to reach certain communities or to effectively supervise community health workers; lack of health workers with current skills in emergency obstetric and neonatal care, lack of health infrastructure in remote communities, etc.

Information 25 minAn Overview of Health Systems and Integration and How They RelateThis section provides basic information on health systems (including supply chain management as one example) and integration, how these concepts are related, and why this is important for MNH. The session includes a Volunteer’s story on how she strengthened health systems (data and information management) in the context of MNH.


1. Transition by introducing the two learning objectives of the session, to let participants know what they will do for the rest of the session, and explain how this session might help their work at site:

Through a case study and small group work, participants identify at least three pieces of a health system and three elements of a strong supply chain system that contributed to improved contraceptive prevalence rates in Rwanda.

Through an individual task and ranking game, participants identify at least five innovative ideas to strengthen health systems and integrate messages and services that a Volunteer can feasibly support or implement.

2. Introduce this section by opening Trainer Material 3: PowerPoint (separate file) while explaining to participants that this session focuses on health systems and the importance of integrated services and that you will look at each separately in more detail and discuss how these concepts are related.

3. [SLIDE 2]: Definition of a Health System

Possible Script: WHO states that a health system consists of all organizations, people, and actions whose primary interest is to promote, restore, or maintain health i.

4. Ask participants: “What are the most important building blocks of a health system?” Take a few responses, then show Slide No. 3.

5. [SLIDE 3]: Six Building Blocks of a Health System

Possible Script:

The six building blocks of a health system are:

Leadership/governance: ensuring policy frameworks exist, provision of appropriate regulations, accountability, effective oversight, and coalition-building

Health care financing: a good health financing system raises adequate funds for health to ensure people can use needed services and that they are protected from impoverishment associated with having to pay for these services

Health care workforce: sufficient numbers and mix of competent, responsive, and productive staff

Medical products and technologies: equitable access to essential medical products, vaccines, and technologies that are safe and cost-effective and have assured quality and efficacy

Information and research: a well-functioning health information system ensures the production, analysis, dissemination, and use of reliable and timely information on health determinants, health systems performance, and health status

Service delivery: delivery of effective, safe, and high-quality health interventions to those who need them, when and where needed, with minimum waste of resources ii

6. [SLIDE 4]: Health System Stakeholders

Possible Script: A health system is more than just the government – it includes all stakeholders, such as associations of medical professionals, private sector actors such as health insurers, and families who care for sick members.iii


7. [SLIDE 5]: Health Systems Strengthening

Possible Script: Health systems strengthening is improving the six health system building blocks and managing their interactions in ways that achieve more equitable and sustained health improvements across health services and health outcomes.iv

8. How Volunteers are Involved in Health Systems Strengthening Distribute Handout 1 Ask participants to read it silently Ask participants how this Volunteer helped to strengthen the health system in the district

where she worked, and what else they might have considered doing in that situation

Note: Let participants respond. Possible responses include:

Strengthening the information and research element which, in turn, strengthens leadership—the district health office can make better decisions based on data

Strengthening health care work force by training health staff to use GPS to gather, analyze, and use health information

9. Introduce the concept of integration to participants.

10. [SLIDE 6]: Definition of Integration and Integrated Health Services

Possible Script: The dictionary definition of integration means bringing together or combining parts into a whole. WHO defines integrated health services as: the management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.v

11. [SLIDE 7]: What Integration may Involve

Possible Script: Integration may involve:

a package of interventions for a specific group

providing a range of services in one location (or by one CHW) for a catchment population

providing continuity of care over time

integrating services at different levels through linkages and referral systemsvi

12.Solicit Thoughts from Participants.

Possible Script: Considering the definition and what integration involves, and reflecting on what you’ve learned, name some ways that maternal and newborn care and services are integrated.

Note: Let participants respond. They will likely provide the following examples:

The MNH continuum of care illustrates how maternal and newborn care is integrated over time (from adolescence to postpartum) and at different levels (household, community, and facility).

Focused ANC care and services include a package of interventions for pregnant women, including screening for HIV and STIs, healthy timing and spacing of pregnancies, nutrition counseling, malaria prevention and


treatment, etc. Likewise, postnatal visits integrate a range of care and services for both the mother and newborn.

Family planning is integrated across time – at each stage.

A women experiencing complications during delivery at a lower-level facility is referred to a hospital that provides comprehensive obstetric emergency care.

13. [SLIDE 8]: Example of Integrated MNH: Family Planning and Nutrition Counseling

Possible Script:

This table shows an example of how two different interventions are integrated over time. (Read from the table a few examples of family planning and nutrition counseling services.)

14. [SLIDE 9]: Why is Integration Important to MNH?

Possible Script:

While primary health care from the start envisioned integrated and comprehensive care and services, some health services focus on a single disease or health concern (e.g., malaria, HIV/AIDS, family planning, or nutrition). Integration of health care and services can help avoid missed opportunities and improve health equity and impact.

Linking interventions across time and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings) is important because it can reduce costs by allowing greater efficiency, increase uptake, and provide opportunities for promoting related health care elements (e.g., postpartum and newborn care).vii

This responds to client needs. A study in South Africa found that HIV-positive women want access to “everything you need under one roof.” Integrated services help women avoid costly and time-consuming multiple visits to a health provider and reduces their waiting time. In addition, integrated services usually mean that clients are less subject to stigma and discrimination than when they go to stand-alone HIV services or stand-alone family planning services.viii

However, integration is difficult and donors and health managers continue to address priorities by supporting vertical programs addressing one disease or service specifically.

15. [SLIDE 10]: Examples of the Impact of Integrated Services

Possible Script:

In Kenya, Jhpiego worked with the Ministry of Health to introduce and scale up focused ANC to deliver prevention and treatment services for malaria in pregnancy. As a result, the number of providers updated on malaria in pregnancy virtually doubled. In turn, uptake of intermittent preventive treatment in pregnancy (IPTp) increased from 19 percent to 61 percent in the intervention area. ix

In Guinea, Save the Children integrated family planning into its community-based child health activities. They established village health committees (with religious leaders, traditional heath workers, chiefs, and elders) and trained community-based distributors of family planning methods. Within four years, modern contraceptive use by women with a child under two tripled from 16 percent to 49 Percent.x

Post Adaptation: Include examples from your own country that demonstrate the successful impact of integrated services.


16. [SLIDE 11]: Health Systems and Integration are Linked

Possible Script: Opportunities for integration require a well-functioning health system. For example, if malaria and family planning are integrated within MNH services, it requires trained staff (both at facility and community levels) and continuous access to commodities such as ITNs and contraceptive supplies.xi

17. [SLIDE 12]: Supply Chain Management

Possible Script: Maternal and Newborn Health care and services require a number of life-saving commodities, including contraceptives, oxytocin, misoprostol, magnesium sulfate, antenatal corticosteroids, injectable antibiotics, chlorhexidine, and neonatal resuscitation devices. Supply chain management helps ensure that these medicines and supplies are consistently available.xii

18. [SLIDE 13]: The Six Rights of Supply Chain Managementxiii

The ultimate goal of a strong supply chain is to have the uninterrupted availability of quality commodities from manufacturer to service-delivery levels, so that opportunities to provide preventative and curative services are not missed because commodities are unavailable. This requires a system to achieve the six rights of supply-chain management: The right goods In the right quantities In the right conditions Delivered… To the right place At the right time For the right cost

19. [Slide 14]: Ensuring Commodities Reach The Last Mile

Possible Script:

The last mile, or last 10 kilometers, is the final delivery leg to the point of service delivery or retail sale. For many countries, the last mile for health commodities is the service delivery point (health center, health post, community health worker, etc.) at the community level.

The last mile presents a critical challenge in ensuring access to health commodities at the community level.

Good family planning, treatment of illness, and other health services all depend on availability of health commodities for the end user or patient. When a patient travels to a health clinic or hospital and cannot receive services because his or her commodity isn’t there, it represents a failure of the health system—unplanned pregnancies, prolonged illness, and unnecessary death.

In different developing countries, the last mile of product delivery may involve different processes, different strategies, and different modes of transportation.

In some places, it might involve deliveries to urban hospitals by truck, while in others it might require use of ox-drawn carts through flooded fields to an isolated clinic or village health post.

In some places, the health worker at the service delivery point decides when to place and retrieve an order for commodities; in others, the service delivery point might receive regular predetermined deliveries.xiv

20.Distribute Handout 2 (separate file) and explain to participants that this handout provides further information on last mile distribution of health commodities. Encourage them to read this handout on their own time.


21. [SLIDE 15] Community Level Supply Chainsxv

Possible Script:

In some countries, community health workers are allowed to provide drugs and other health commodities to mothers, newborns, and children.

For example, CHWs and/or TBAs or other Community Health Volunteers trained in the use of the drug may provide misoprostol to prevent postpartum hemorrhage to women who have home births, they may give chlorhexidine to prevent sepsis in newborns, or they may give antibiotics to children demonstrating signs of pneumonia. In some countries, CHWs are also responsible for community-based distribution of family planning commodities.

Post Adaptation: At this point, explain what the policy in your country is regarding distribution of drugs and commodities (family planning) by CHWs.

Often, supply chains cannot consistently deliver low cost commodities at the community level.

Investing in proven strategies to improve community health supply chains is critical for achieving better health outcomes for mothers, newborns, and children.

22. [SLIDE 16] When Does a Community-Based Supply Chain Work Bestxvi?

Note: This slide has animations, with each bullet appearing following a click.

Possible Script: A community-based supply chain works best when the following occurs:

CHW resupply is based on demand using consumption data

Data is available and consistently used for decision making

Formalized structures exist to facilitate teamwork and motivate staff across all levels of the supply chain

Tools and training are created and utilized to drive group problem solving

Leadership exists that is committed to product availability at CHW level

Overall supply chain system is functional and provides products at adequate levels

You achieve the greatest benefit from your supply chain when all these factors are in place and working together

23. [SLIDE 17] Three Essential Elements for a Functional Supply Chainxvii

Note: This slide has animation, with each description appearing following a click.

Possible Script: The three essential elements to making the supply chain function are:

Product flow: Products flow effectively and efficiently through the system based on CHW need

Data flow: Consumption and stock data are available and usable for supply chain decision making and problem solving

Effective people: A skilled and motivated work force utilizes teamwork to problem solve and achieve their supply chain goals


24.Explain to participants that they will be reviewing these essential elements in the context of a Volunteer case study in just a few minutes. Before transitioning to the Practice section, invite participants to reflect on the supply chain challenges or successes they have observed at their sites (if session is delivered at an IST). Ask for a few Volunteers to share their thoughts with the larger group.

25.Wrap up by asking participants for questions of clarification on what has been discussed so far in the session.

Practice 35 minResponding to Increased Demand for Contraceptives in Rwanda Using a case study, participants identify building blocks of an effective health system and elements that contributed to a strong supply chain for contraceptives in the Rwandan context.

1. Distribute Handout 3: Success Story: A Strong Supply Chain Responds to Increased Demand for Contraceptives in Rwanda (separate file).

Introduce the handout. Tell participants: Rwanda took a number of measures to increase demand for family

planning at the local level. More and more women and men in Rwanda are choosing to use a modern contraceptive method and plan their families. A strong health system and a robust supply chain were instrumental to successfully respond to this growing demand for contraceptives.

2. Small Group Task Show the flip chart with the small group task (Trainer Material 4) Read the task aloud and give the end time. Ask: “Is the task clear?” If not, clarify. If yes, let

small groups work.

3. Large group discussion Invite each small group to share its answers.

Note: Let participants respond. Possible answers follow:

Groups 1-2:

Leadership/governance: The Government of Rwanda showed high levels of commitment to family planning – they upgraded documents to emphasize FP’s impact on health improvement and poverty reduction and translated policy into action.

Health care financing: A family planning technical work group advocated to secure financial resources for family planning; particularly contraceptive supply security; Rwanda got donor funding and also committed its own funds, which shows unusual commitment.

Medical products and health work force: Rwanda smoothed the procurement process for contraceptives and strengthened its MOH’s logistics management capacities.

Group 3: The contraceptives logistical system was strengthened to improve forecasting and quantification, logistics reporting rates, and improved quality of essential logistics data.


Group 4: The project built contraceptive logistics management capacity; a logistics committee was formed to address problems as they arose (problem-solving capacities were improved) and improve coordination between services; and increased capacity of stock managers.

Group 5: New standard operating procedures, established min-max inventory levels at all levels and improved reporting resulted in fewer stock-outs at all levels; contraceptive products transferred to warehouses managed by trained personnel.

Note: Learning Objective 1 is assessed through the large group debrief.

4. Implications and wrap up: Ask participants about Volunteer roles in a similar health system and supply chain scenario.

Possible Script:

Where would Volunteers fit in this picture?

If you were a Volunteer in a country with a health system and supply chain similar to Rwanda, how do you think you could contribute to strengthening the health system to support family planning, to strengthen integration of family planning, and/or to strengthen the supply chain of contraceptives?

What challenges would you anticipate related to your contribution?

Who or what could help you respond most effectively amidst those challenges?

Note: Let participants respond. Possible answers are listed below. Support trained staff in their newly acquired skills (help to problem solve, provide refresher training) Train counterparts to manage improved logistics management information systems Provide on-the-job training and coaching for counterparts to master tasks related to reporting, resupply,

storage, and inventory control Provide support to clinics, health centers, and community health workers involved in supply chain

management

Post Adaptation: If Volunteers are involved in systems strengthening, integration, or supply chain management, share what they have done, including successes and lessons learned.

Application 30 minWhat Can We Do? Ideas to Integrate Messages and Services and to Strengthen Health Systems Participants develop and exchange innovative ideas to strengthen health systems and integrate messages and services in their specific situation.

1. Individual Task Show the flip chart (Trainer Material 5) and read the task aloud. Ask: “Is the task clear?” If not, clarify. If yes, let participants work.


Ensure participants have written what they think is their one most innovative idea on a notecard.

2. Ranking Ideas Ask participants to stand up, move around the room, and trade their notecard with

someone else. Now they should have a new card. Ask them to move around again, find someone else, and trade their card. Each participant

should trade his or her card at least 2-3 times. Allow 1-2 minutes for the card trading. Next, get participants’ attention. Tell them to stop in front of another person and provide

them with instructions.

Possible Script: Read the card in your hand to your partner in a way that “sells” this idea persuasively. Then you will trade cards. Each of you will rate the idea on the card in your hand (the card your partner gave you) on a scale of 1-5 with 1 being less innovative and 5 extremely innovative. Write your rating (1, 2, 3, 4, or 5) on the back of the card.

Repeat this series of steps (move around, exchange cards with 2-3 people, stop in front of another person, sell the idea on your card, trade cards, rate the idea on the card in their hand on a scale of 1-5) four more times. This means that each card will have five ratings of 1-5 on the back.

After allowing participants to trade and rank ideas five times, tell them to stop and add the scores on the back of the card they are holding after the fifth round.

3. Review scores and identify the winning ideas Ask participants who has a card with a score of 25, 24, 23, and so on until you get a yes. Ask that person to read his or her card aloud. Continue with the countdown until you get another yes. Invite that person to read his or her card aloud. Identify the top five cards in this way. Post these winning ideas on the wall so people can review the winning ideas after the

session ends.

4. Wrap up Once participants have reviewed the winning ideas, ask them to select 1-2 ideas as a group

and discuss what might be some of challenges they may face while implementing these ideas in their village and what strategies they could use to overcome these challenges.

Close the discussion by thanking participants for their ideas.

Note: If you are able, type up all the ideas provided by participants on a document and share with them prior to the end of their training. This will be a useful document for them to refer to for inspiration and ideas once back at their sites.

Note: Learning Objective 2 is assessed once the group has identified the final set of winning ideas


AssessmentLearning Objective 1 is assessed in the Practice section when small groups present their responses in the large group debrief.

Learning Objective 2 is assessed in the Application section after the ranking activity identifies winning innovative ideas.

Trainer Notes for Future ImprovementDate and Trainer Name: [What went well? What would you do differently? Did you need more/less time for certain activities?]

ResourcesWHO 2007. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: WHO.


Handout 1: How Volunteers Can Strengthen Health Systems

Birth Attendants & Maternal Health in MalawiBy LAUREN GOODWIN, Peace Corps Response/Malawi, 2010–2011; Peace Corps/Botswana, 2007–2008

A Malawian woman's risk of maternal death is one in 36; by comparison, maternal mortality in the U.S. is one in 2,100 and in Norway it is one in 7,600. High maternal mortality in Malawi is due in part to the fact that only 54 percent of deliveries have a skilled medical professional present. Traditional birth attendants (TBAs) fill the gap in rural, resource-deprived areas, where maternal health facilities are not accessible. The use of TBAs has a tumultuous history in Malawi.

In September 2010, President Bingu Wa Mutharika of Malawi lifted a two-year ban against TBAs that was implemented to curb Malawi's exceptionally high maternal mortality rate by ending unskilled deliveries. The ban drove TBAs underground and further skewed the understanding of maternal health. When I arrived in Malawi in December 2010, it was clear that knowledge about and accessibility to TBAs was an area where I could make a positive impact.

I arrived in Mangochi as an HIV technical advisor and soon after met with Mangochi District Health Officer Dr. Nyirenda, who leads the district’s health facilities for all 850,000-plus residents. In my discussions with him, I learned the situation: Mangochi has many practicing TBAs, but the record keeping was outdated. The district needed to know the following: who was practicing and where; the number of deliveries; their distance to the nearest maternal health facility; if they had been previously trained; if they provided prenatal, antenatal, and referral services; if they took measures to prevent HIV transmission; and if they accompanied women to the health facility in the event of an emergency and for routine prenatal visits.


Prior Peace Corps Response Volunteers (PCRVs) worked on GPS mapping projects and I saw an opportunity to apply that practice to make a contribution. Dr. Nyirenda and I developed a questionnaire and initiated the TBA mapping project. He mobilized his team. I trained them in GPS and wrote and executed a successful grant to fund transportation and lunches for extension workers. They rode on motorcycles, bicycles, and were sometimes on foot in the far reaches of the district to collect each of the 315 TBAs’ GPS locations and answers for the questionnaire. After we collected the data, the environmental health team for the hospital, in partnership with UNICEF, created Malawi’s first-ever mapping system for TBAs. The Ministry of Health has a TBA policy in development, which will provide

refresher courses for trained birth attendants and new trainings for untrained birth attendants. Our work will no doubt be vital in the implementation of this new policy.

PCRVs in Malawi have an opportunity to contribute toward cutting-edge, lifesaving policies by getting leaders the data they need to move forward. Each PCRV adapts to meet the needs of his or her district. Maternal health is where I was needed. I had incredible experiences with mothers. I saw a delivery in the crowded district hospital and, afterwards, an episiotomy repair. I also visited the home of a TBA, arriving just after two women

delivered their perfect babies. I felt inspired and proud of my impact when I left Malawi. I highly recommend providing your expertise to make one in 36 a thing of the past.

Lauren Goodwin served in Malawi from December 2010 to July 2011.


Trainer Material 2: This is Maya Crying: Introduction to Health SystemsThis is Maya crying: introduction to health systems

This is Maya. Crying. Her first cry ever. For Maya’s mother it’s the best cry ever. Because that’s the sound that every mother hears when her baby is born healthy.

It took a lot of work to make Maya cry! It took soap. One bar of soap. To wash the hands of a trained health worker. It took a trained health worker to staff a local clinic. It took a local clinic to provide affordable prenatal care to Maya’s mother. It took Maya’s mother to plan for a healthy baby by sleeping under a bed net, taking vitamins, eating nutritious foods, and receiving vaccines. It took vaccines traveling to the clinic in a refrigerated truck. It took a lot to make Maya cry.

But it wasn’t just the clinic, just the vitamins, or the nutritious foods, or the bed net, or the vaccines. It wasn’t even the bar of soap. It was all of these pieces working together in a system, a health system. To deliver Maya into the hands of a trained health worker who helped her to take her first breath and cry. Her first healthy, beautiful cry. So yeah, it’s not easy to make a baby cry. But it’s worth it.

It’s worth it to ensure that supplies move from the storage room in the city to the exam room in the country. It’s worth it to make a hospital there and do a clinic here. It’s worth it to provide skilled care so that expecting mothers become excited mothers.

And most of all, it’s worth it to turn the sound of one crying baby into the sound of millions of crying babies. Millions of crying babies! Ah, that’s the sound of knowledge, of resources, of people all working together to bring a good health system to life. Health systems create healthy futures where everybody grows up strong, goes to school, thrives, and makes a village, a country, and the world a better place.


Trainer Material 4: Diagrams and Small Group Task 1. Draw the two diagrams below on a sheet of flip chart paper and post them in the room so participants can see them as they complete the small group task.

Building Blocks of a Health System

Three Essential Elements of a Functional Supply Chain


2. Write the small group task below on a sheet of flip chart paper, in large clear writing

Small Group Task

1. Individually read the success story: “A Strong Supply Chain Responds to Increased Demand for Contraceptives in Rwanda”

2. Tables 1-2: Identify at least three elements of a strong health system that supported this project’s positive results.

3. Table 3: Regarding supply chain improvements, describe how data flow was improved

4. Table 4: Regarding supply chain improvements, describe how people become more effective

5. Table 5: Regarding supply chain improvements, describe how product flow became more effective and efficient


Trainer Material 5: Innovative Idea Individual Task Write the individual task on a sheet of flip chart paper, in large clear writing.

Individual Task1. You will now come up with innovative ideas to improve health systems and/or integration that

support improved maternal and newborn health in your situation.

2. To do this, consider the information we just reviewed (see the posted diagrams of the health system’s building blocks and community health supply chain), as well as your specific situation, worksite, and counterparts.

3. For example, to strengthen health systems, you might help put in place a system that reduces waiting time at the clinic. You might integrate family planning messages in training women’s groups on MNH.

4. Write your best, most innovative idea on a notecard. Be sure it’s specific and descriptive because afterwards, we’ll be ranking these ideas to choose the best ones.


i http://www.wpro.who.int/health_services/health_systems_framework/en/ii Ibid.iii WHO. 2007. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: WHO.iv Ibid.v Waddington, C, and D. Egger. 2008. Integrated health services – what and why? Geneva: World Health Organization.vi Ibid.vii http://www.who.int/pmnch/about/continuum_of_care/en/ viii Ringheim, K. 2012. Better Together: Linking Family Planning and Community Health for Health Equity and Impact. Washington DC: CORE Group.ix http://www.globalhealth.org/integration-of-health-services-ensures-no-missed-opportunities/x Ringheim, K. 2012. Op. cit.xi Roman, E., et al. 2014. “Moving malaria in pregnancy programs from neglect to priority, experience from Malawi, Senegal, and Zambia.” Global Health: Science and Practice. www.ghspjournal.org and PMNCH. 2012. Opportunities for Africa’s Newborns. Geneva: WHO.xii http://sc4ccm.jsi.com/tools-publications/managers-tool/xiii USAID | DELIVER PROJECT, Task Order 1. 2009. The Logistics Handbook: A Practical Guide for Supply. Chain Managers in Family Planning and Health Programs. Arlington, Va.: USAID | DELIVER PROJECT.xiv USAID | DELIVER PROJECT, Task Order 4. 2011. Using Last Mile Distribution to Increase Access to Health Commodities. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 4. http://villagereach.org/vrsite/wp-content/uploads/2011/12/UsinLastMileDist.pdf xv JSI. Making Products Available in the Community: A Manager’s Tool to Improving Community Health Supply Chains. http://sc4ccm.jsi.com/files/2013/12/Managers-Tool.pdfxvi Ibid.xvii Ibid.

http://sc4ccm.jsi.com/files/2013/12/Managers-Tool.pdf

http://villagereach.org/vrsite/wp-content/uploads/2011/12/UsinLastMileDist.pdf

http://www.ghspjournal.org/

http://www.who.int/pmnch/about/continuum_of_care/en/

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