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Family Planning Practice in Unintended Pregnancy: Rural Women in Bangladesh

Author(s) Forhana Noor1, Ubaidur Rob2
Affiliation(s) 1Reproductive Health, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary This article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh. The study was a cross-sectional survey of 3,300 women. Findings suggest that among the respondents about 29 percent of the pregnancies were unintended. Analysis was found that those who did not use contraceptive methods before their last pregnancy had reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Advocacy is needed to promote longer acting and permanent methods among the eligible couples to avoid unintended pregnancy.
Background In Bangladesh most of the reproductive health programs are directed towards improving maternal health and family planning. These efforts lead to the decline of maternal mortality by 40% from 322 deaths in 2001 to 194 deaths in 2010 per 100000 live births, which may be attributable to remarkable progress in fertility decline, from a high level of 6.3 births per woman in the mid-1970s to 2.3 births per woman in 2011. Contraceptive use rate has also increased from only 8 in 1975 to 61 in 2011. Despite these recent achievements, maternal mortality still remains one of the prime challenges and also unintended pregnancy remained same for last three decades. Unintended pregnancy is typically exposed to the risk of abortion. In Bangladesh, abortion-related complications contribute to about one-fourth of all maternal deaths. Besides this, the rate of unintended pregnancy is also one of the most basic measures of the situation of women's reproductive health, and of the level of women’s autonomy and capacity for self-determination. It signifies a woman’s capacity to determine whether and when to have pregnancies.
Objectives According to 2011 Bangladesh Demographic and Health Survey (BDHS), in Bangladesh, 30 percent of pregnancies were unintended. The total intended fertility rate was 1.6 which is quite lower than the total fertility rate (TFR) 2.3. This means that if all unintended pregnancies could be eliminated, the TFR would drop below the replacement level of fertility immediately. High discontinuation rate, low use of long acting and permanent methods, erroneous use of family planning methods and unmet needs of family planning, in part or combined all contribute to the incidence of unintended pregnancies. Considering the situation, this article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh.
Methodology This article used data from the follow-up survey of evaluation of the Reproductive Health Voucher Evaluation project in Bangladesh. It was a quasi-experimental research design with pre and post studies in intervention and control areas and the assignment to the intervention was non random. It was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas. The other 11 sub-districts were selected as control areas. In this study a baseline survey was conducted in 2010 and a follow-up survey was conducted in 2012. A total of 3,300 women of 18-49 years of age were interviewed who gave birth in the previous 12 months from the starting date of data collection. Respondents’ socioeconomic and demographic characteristics as well as service utilization and perception of each service were collected by using a structured questionnaire in this survey. In this article, both bi-variate and multivariate analyses were used to examine strength of the relationship between the unintended pregnancy and use of family planning methods.
Results Findings suggest that among the respondents (women) 68 percent wanted to become pregnant, 20 percent women wanted to wait or mistimed and another 12 percent did not want children any more. In other words, about 32 percent of the pregnancies were unintended. It was found that almost fifty percent (49 percent) of respondents were using a contraceptive method before their last pregnancy. Among them only one percent used a traditional method and rest 48 percent used a modern contraceptive method. Interestingly, the women who used (49 percent) any contraceptive before their last pregnancy, among them 46 percent experienced unintended pregnancy. On the other hand, non-users (51 percent) of contraceptive methods reported relatively lower proportion of unintended pregnancy (20 percent). The rate of unintended pregnancy also varied according to the use of contraceptive methods. The proportion of unintended pregnancy was comparatively higher among injectable users (51 percent) as compared to other method users.Logistic regression analysis was used to examine the odds of unintended pregnancy for each of the risk factors controlling for the others. It was found that those who did not use contraceptive methods before their last pregnancy had a reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Among contraceptive users, the likelihood of reporting unintended pregnancy was 1.6 times higher among the women who used traditional method as compared to modern contraceptive method users.
Conclusion Findings suggest that the unintended pregnancy rate was higher among the contraceptive users before their last pregnancy than non-users. Again, the rate was higher among traditional and temporary modern method users as compared to longer acting modern method users. From several studies it has been explored whether the incidence of unintended pregnancy might decline more slowly than expected, and might even rise for a while, as countries move through the fertility transition. So, it can be assumed that the improvement of quality of family planning services is likely to decrease the level of unintended pregnancies in the future and advocacy is needed to promote longer acting and permanent methods among eligible couples to avoid unintended pregnancy.

Impact of Voucher Scheme: Delivery Care Services in Rural Bangladesh.

Author(s) Forhana Noor1, Ubaidur Rob2.
Affiliation(s) 1Reproductive Health, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary This paper examined the impact of the intervention of a demand-side financing scheme on the utilization of services as well as out-of-pocket expenses incurred by women for availing of delivery care services. A quasi-experimental research design was conducted for this study. Findings reveal that there was a significant (p<0.0001) increase in the utilization of delivery care at public facilities in the intervention areas compared to the control areas. The average out-of-pocket cost or money required for a normal or caesarean delivery decreased over thirty percent over the time period. Demand-side financing had a positive effect on both utilization and cost.
Background In rural Bangladesh, around 71% of births take place at home. Home delivery is preferred as it is associated with low cost and delivery care at facilities are only considered for emergency obstetric care (EmOC). Bangladesh is predominantly a rural, low income country with a vast majority of its people living in poverty. The utilization of skilled attendants at delivery was almost three times less in rural areas compared to urban areas and also it is seven times less among the poorest (9%) compared to the richer (63%) households. Borrowing, using household savings, and financial assistance from relatives were also found to be important sources in paying for the delivery care.
In the health sector of Bangladesh, the primary source of finance is out of pocket (OOP) expenditure and it is primarily spent in the private sector. Here 64% of total health care expenditure is paid by individuals and the rest by the government. In many situations, OOP payments for health care can cause households to incur catastrophic expenditures, which in turn can push them into poverty. Bangladesh has one of the highest rates of catastrophic illnesses which drives 3.8% of the population into poverty every year.
Objectives To address this equity issue, the Government of Bangladesh piloted a demand-side financing (DSF) scheme (popularly known as the maternal health voucher program) in 21 upazilas (sub-districts) from 2006 and expanded to 33 upazilas in 2007. The selected poor women under DSF scheme receive a package of essential maternal health care services, as well as treatment of pregnancy and delivery related complications. This program also provides supply side financing to service providers. This program has been expanded to another 11 upazilas in 2010. Population Council, with funding from the Bill and Melinda Gates Foundation, has been evaluating the impact of voucher programs in five countries including Bangladesh. As part of evaluation activities, Population Council conducted a baseline survey in 2010 and a follow-up survey in 2012 in new 11 DSF (intervention) and 11 non DSF areas (control). This article used information from the baseline and follow-up survey to examine the impact of this intervention on utilization as well as out-of-pocket expenses incurred by women for availing delivery care services at facility.
Methodology A quasi-experimental research design with pre and post studies in intervention and control areas was conducted to evaluate the impact of demand side financing vouchers on maternal health care services. The assignment to the intervention was non random. A baseline survey was conducted in 2010 with a follow-up survey in 2012. The study was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas where demand-side financing scheme was implemented. The other 11 sub-districts were selected as control areas where the demand-side financing scheme was not implemented. To draw a sample population, the national facility-based births figure was considered for baseline and follow-up survey and a total of 3300 women with 1650 experimental subjects and 1650 control subjects were selected. From each sub district, three of nine unions and three villages from each union were selected through probability proportional to size and finally, from each selected village, required numbers of respondents were interviewed. Women from 18-49 years of age were interviewed who had given birth in the previous 12 months from the starting date of data collection. Respondents’ socio-economic and demographic characteristics as well as service utilization and cost of each service were collected by using a structured questionnaire. Following the same sampling procedure, we interviewed the same numbers of respondents in the follow-up survey.
Out-of-Pocket Expenses: To examine the expenditure pattern, women were requested to report expenses on card/registration fees, consultation fees, laboratory examination, medicine, round trip transportation and any other associated costs to avail maternity care services. These expenses have been divided into three broad categories: medical cost at the facility, medical cost outside the facility, and transportation cost. “Medical cost at the facility” or internal medical cost includes card/ registration fee, consultation fee (unofficial), laboratory charges, drug cost (unofficial), tips to support staff for expediting services, and attendant expenditures for staying at the facility. Expenditures to purchase drugs and get laboratory services from the other private sector are considered as “medical cost outside the facility” and the actual cost women pay to transport providers is calculated as “transportation cost”.
Results Information on the utilization of delivery presented in Table 1 indicates an increase in the proportion of the deliveries that occurred at the facility from 19 percent in 2010 to 31 percent in 2012 in the intervention areas with the control sites experiencing almost the same increase. Use of public-sector facilities for delivery services increased in intervention sites while control sites experienced greater increase in using the private sector. It has emerged from the 2010 & 2012 expenditure pattern that all delivery services involved OOP payments and the average volume of expenditure is higher in control than in intervention. Findings illustrated  the average cost of different OOP expenses for receiving normal delivery services from public health facility. Cost incurred outside the facility (purchasing drugs and laboratory services) is the largest component (about half) of OOP expenditure for normal and cesarean delivery services in both areas. For that reason total average cost for normal delivery decreased a little bit in control areas also. Commonly, transportation cost increased in both intervention and control for normal or cesarean delivery.In the intervention group there has been a decline in the OOP cost for cesarean delivery that women incurred as medical cost both inside and outside the facility while an increase was reported for control. Reduction in both internal and external cost implies a positive impact of demand side financing benefits on women in receiving cesarean deliveries. With a mixed pattern of expenditure, the differences in OOP expenses between intervention and control that women incurred in 2012 cannot be explained with the effect of the DSF program.In the intervention areas, the average OOP cost for receiving normal delivery service reduced by 44% (from $40 to $22), and money required for a caesarean delivery decreased by 30% (from $115 to $80). Comparisons within public and private and voucher non-voucher has been made only in DSF upazillas.  For the women external medical costs at private facilities were double compared to public facilities. Internal medical cost was four times higher at private facilities than at public facilities. In a two-year period, this expense remained same for public facilities while it increased three times for private facilities. Again, voucher clients spent much less money than non-voucher clients.
Conclusion The recent shift in program development has taken place from being supply-side driven to being demand-side driven which improves the situation of non-accessibility of poor pregnant mother to the health facility. Findings reveal that there was a significant increase in the utilization of delivery care at the facility but it was also observed that the use of public-sector facilities for delivery services increased in only intervention sites while control sites experienced greater increase in the use of the private sector. The demand-side incentive package for the poor covers essential costs for maternal health care services and related to transportation cost also, while other costs like the purchase of additional medicine, unofficial provider fees and incidental costs incurred at facility are not covered under the program. Therefore, in DSF upazillas, there is no woman who did not incur any cost to utilize delivery services. Findings suggest the average volume of expenditure in receiving normal or cesarean deliveries is higher in control than in intervention areas. So, cost implies a positive impact of DSF benefits on women and this leads to the conclusion that DSF may have contributed to lower OOP payments. These findings necessitate the allocation of resources to subsidize the cost women incur to purchase medicine and undergo laboratory services that are not available in government facilities. Increased transportation expenses strongly justifies the need to increase the existing amount of financial assistance the government provides to poor clients. Without making normal delivery fully subsidized, it will be difficult to increase the institutional delivery rate  as women still spends a large share of their family income for receiving normal delivery services.Besides this, implementing programs at the upazila hospital alone cannot raise the rate of delivery in rural areas. Additionally, for optimum utilization of the existing health structure in rural areas, other govt. facilities need to incorporate it. It was also observed that a large proportion of women are receiving services from private health facilities. Therefore, the national health financing strategies should engage the private health sector in a way that enables poor women to receive services from the private sector more easily. With the right types of interventions, maternal health-related MDG may not be very difficult to achieve in Bangladesh.

Causes, determinants, andtrends in maternal mortality among Palestine refugees during 2000-2010

Author(s) Ali Khader1, Majed Hababeh2, Wafaa Zeidan3, Irshad Shaikh 4, Yousef Shahin 5, Akihiro Seita6, 7, 8
Affiliation(s) 1Health, UNRWA, Amman, Jordan, 2Health, UNRWA, Amman, Jordan, 3Health, UNRWA, Amman, Jordan, 4Health, UNRWA, Amman, Jordan, 5Health, UNRWA, Amman, Jordan, 6health, UNRWA, Amman, Jordan, 7, , , , 8, , ,
Country - ies of focus Palestine
Relevant to the conference tracks Women and Children
Summary Despite the hardship socioeconomic status, the patern of Maternal mortality among palestine refugee population is similar to that among stable midle income countries, A shift was observed during the last decade from causes related to poor obstetric care such as hemorrage and infection to thromboemblic diseases.
Background The United Nations Relief and Works Agency for Palestine Refugees in the Near East has for over 60 yearsprovided comprehensive primary health care to 5.2 million Palestine refugees in five fields of operation: Gaza, Jordan, Lebanon, Syria and the West Bank. Despite the contextual challenges of chronic instability and poverty, the agency maintains high standards of antenatal care supported with subsidy of delivery in local hospitals, with comprehensive follow up of all registered pregnant women.
During the period 2000-2010 a total of 978,446 pregnant women were registered and followed up through UNRWA antenatal care services. A system to trace the outcome of each pregnancy was established. During the first year (2000) of implementation, 2145 (2.8%) pregnancies were with unknown outcome that was reduced to only 199 (0.2%) cases in 2010 and during this period a total of 230 maternal deaths were reported.
Objectives The aim of this analysis is identify the main causes and determinents of maternal mortality among Palestine refugees women served by UNRWA PHC system
Methodology UNRWA uses the Confidential Maternal Mortality Enquiry method for in-depth investigation of the direct and indirect causes of each maternal death. This retrospective study examines 230 confidential enquiry reports on maternal deaths of Palestine refugee women in five fields of operation during one decade. The confidential enquiry is completed immediately after a maternal mortality. A thorough investigation is conducted by a special committee established to investigate and reoprt on each maternal mortality
Results Analysis of the confidential enquiry reports revealed a maternal mortality ratio of 24/100000 with significant variations among fields (Lebanon and Syria the highest at 34, followed by Gaza and West Bank at 25 and Jordan at 19). 1.8% delivered at home while 14.8% of deaths occurred at home. 53% of them died in hospitals during the intra-post-partum period. 88% received 4 or more antenatal visits. Maternal deaths increased with higher parity. There was a shift in the leading documented causes of maternal deaths from pre-eclampsia and hemorrhage to pulmonary embolism. Thromboembolism was the first cause of death with 41% followed by toxemia and hypertensive disorders at 12, heart diseases at 11.8%, hemorrhage at 10.5% and infection and sepsis at 7.4%
Conclusion Maternal Mortality has plateaued over the last 10 years among Palestine Refugees. We have managed to reduce the deaths from infections, hemorrhage and pregnancy induced hypertension but the deaths from obstetric embolism and medical disorders in pregnancy have either stayed the same or have increased over the years. This can be partially attributed the lack of embolism prophylaxis in high risk cases as well as poor care of high risk women with medical disorders prior to pregnancy

Performance of Community Health Workers in Community Case Management: Uganda

Author(s) Agnes Nanyonjo1, Edmound Kertho2, Seyi Soremekun3, Frida Kastenge 4, Guus TenAsbroek 5, James Tibenderana6, Karin Kallander7
Affiliation(s) 1Technical, Uganda Country Office, Malaria Consortium, Kampala, Uganda, 2Technical, Uganda Country Oficce, Malaria Consortium, Kampala, Uganda, 3Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom, 4Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom, 5Population Health, London School of Hygiene and Tropical Medicine, Amsterdam, Netherlands, 6Technical, Africa Region Ofiice, Malaria Consortium, Kampala, Uganda, 7Technical, Africa Region Office, Malaria Consortium, Kampala, Uganda.
Country - ies of focus Uganda
Relevant to the conference tracks Health Workforce
Summary Integrated community case management is key child survival strategy in resource poor settings. There is paucity of data on performance of community health workers in this strategy and how this performance can be measured. We report on a study that evaluated the performance of community health workers using case vignettes. Overall community health workers perform well with respect to treatment. However omissions in terms of probing for danger signs and other illness symptoms and provision of general health education required by the treatment guidelines deter community health worker performance.
Background Integrated community case management for malaria, pneumonia and diarrhoea (iCCM) is one of the key interventions tailored towards curbing child mortality in low income countries. In iCCM lay community health workers (CHWs) use a given algorithm provided in a job aid to ask about illness symptoms, assess signs, classify and treat disease or refer severely ill children. They treat malaria with artemether lumefantrine combination, pneumonia with amoxycillin and diarrhoea with oral rehydration salts (ORS) and zinc. They are also required to offer health education regarding disease prevention. Although measurement of performance in itself poses key challenges in terms of choice of method used, assessment and understanding of the performance of CHWs is crucial to ensure high quality care of the sick children.
Objectives The objective of the study was to assess the performance of CHWs while managing children with solitary disease such as malaria alone or mixed infections such as malaria and pneumonia by using case vignettes.
Methodology The study was conducted among a sample of 360 CHWs who had been practicing iCCM for at least three to eight months in eight districts in Midwestern Uganda. CHWs were given four case vignettes; one after the other. Using probing questions the CHWs were asked to describe the actions they would take from the time they encountered the sick child and his/her caregiver to the time they finished the consultation. The CHWs were allowed to use their job aid during the evaluation. One case vignette emulated a 6 months old child with an uncomplicated malaria classification presenting with fever, poor appetite and no danger signs; requiring a malaria rapid diagnostic test, malaria treatment and health education. Another vignette depicted a 3 year old child with diarrhoea and no blood in stool; requiring zinc, ORS and health education. The third vignette was about a child with both cough fast breathing and fever and a history of stiff feet early that morning depicting a child with pneumonia and complicated malaria requiring referral and pre-referral treatment due to the danger sign. The last case was about a child with fever and cough, essentially with uncomplicated malaria but no pneumonia. Each appropriate action, i.e. questions the CHW should have asked, test CHW should have performed and treatment and health education CHW should have given basing on the guidelines, was assigned a weight of one. The average performance score for each CHW was generated on a scale of 0-100. Scores were also sub-analyzed per case managed as well as association with socio-demographic factors, such as sex, literacy and district of the CHWs.
Results Out of all actions that should have been taken for each case, the overall mean performance score of the CHWs was 41.5 (SD 8.6). The mean performance score based on case scenarios was 46.6 (SD 16.3) for the uncomplicated malaria case, 59.3 (SD 15.6) for the case of uncomplicated malaria with cough, 36.5 (SD 13.6) for the diarrhoea case, and 23.5 (SD 14.4) for the case with pneumonia and complicated malaria and. Overall, CHWs ability to state the correct treatment and dose for the simulated case was high, with 93.3% sating the correct treatment for a child case with malaria alone; 94.4% stating the appropriate treatment for a child case with diarrhoea, and 84.4% being able to suggest referral for a child case with a history of a danger sign. However, the problematic areas in the management algorithm that appeared to decrease the overall mean performance score included: a) failure to ask about dangers signs and symptoms that are not mentioned by the caregiver. Overall only 1% of the CHWs remembered to probe for the presence of any danger signs and other symptoms not automatically volunteered by the care taker in at least one of the case scenarios; b) Failure to assess for key illness symptoms. In the pneumonia and complicated malaria case only 22.7% of CHWs mentioned that they would assess the respiratory rate of the child; c) Failure to give pre-referral treatment. Only 28.1% and 9.7% CHWs mentioned that they would give pre-referral treatment for malaria and pneumonia, respectively; d) Failure to give instructions on how to administer the drug, especially in the diarrhoea case scenario where only 40% mentioned at least one instruction they would give to the caretaker regarding how to mix and give ORS; e) Failure to provide general health education and information on when to take the child to the health facility for further treatment. Twenty percent of CHWs did not give caretakers any of the recommended advice. Performance levels were positively associated with the district of the CHWs (p<0.001) and to the increasing number of patients the CHW had seen in the last week (p=0.015).
Conclusion If the case scenarios where a reflection of a real life situation our data suggest that majority of children seen by CHWs would get the appropriate curative treatment or action required. However they would not be able to benefit optimally from their visit to the CHWs due to omitted actions, such as provision of pre-referral treatment, health education and counseling, and demonstration to caregivers on how to give the first dose. Supportive supervision and refresher training of CHWs should which emphasizes strict adherence to treatment algorithms, and which offers strengthening of interpersonal communication skills should be implemented.

Introducing Kangaroo Care in an urban district hospital of Bonassama – Cameroon.

Author(s) Danièle Kedy Koum1, Cristina Exhenry2, Riccardo Pfister3.
Affiliation(s) 1Paediatrics, District Hospital Bonassama, Douala, Cameroon, 2none, noen, Geneva, Switzerland, 3Neonatology and Intensive Care Services , Geneva University Hospitals, Geneva, Switzerland.
Country - ies of focus Cameroon
Relevant to the conference tracks Women and Children
Summary In sub-Saharan Africa neonatal mortality in LBWI (<2500g) is one of the highest worldwide. Kangaroo Care (KC) is an alternative to incubators recommended by the WHO. However, most published reports originate from central reference hospitals. In low-resource countries, a large proportion of LBWI remain at district level such that KC at this level seems an obvious necessity. We have successfully introduced KC in the urban district hospital of Cameroon. At one year, 30 LBWI were included. Mortality was 3%, considerably lower than previous years (14.5%). Parental acceptability was subject to social and financial circumstances that are potentially more easily solved at the district level.
Background In Douala, Cameroon's economic capital of 2 million people, some 20,000 of 100,000 new-borns are low birth weight infants (LBWI)
Objectives To implement Kangaroo Care in an urban district hospital in order to reduce neonatal mortality and morbidity in a low resource setting. An additional aim was to study the implementation of this method, anticipating an extension to other peripheral structures initially in the same district.
Methodology In July 2012, we launched a pilot project introducing Kangaroo Care in the urban district hospital Bonassama. It is a two year project approved by the ethics committee of the Ministry of Health of Cameroon and the University Hospitals of Geneva (HUG), with the following main steps: 1. Identifying local site management; 2. Obtaining support of the local health authorities and ethics committees (ownership); 3. Public and private funding; 4. Functional reorganization of the neonatal unit; 5. Staff training; 6. Patient recruitment; 8. Patient follow-up of until the age of 2 years; 9. Data analysis (particularly data referring to difficulties in introduction of Kangaroo Care).
Results The project is under the direction of a Cameroon physician trained at HUG. The site has been restored and reorganized with funding from the Ministry of Health of Cameroon, the political district authorities and HUG. Twelve staff members, mostly nurses, were trained in Kangaroo Care during one week. Recruitment of LBWI began 9/25/2012 with 30 LBWI included at one year. The mortality rate was 3%, considerably lower than the average of the previous two years (14.5%). The inclusion rate was 40% of potentially eligible patients. Parental refusal, often resulting in hospital dismissal against medical advice, was the main cause of non-inclusion.
Conclusion Kangaroo Care has been successfully introduced and is practiced in a district hospital with limited resources. Its decentralisation, closer to the families, is an advantage. However, many obstacles remain and require new strategies. The acceptability of Kangaroo Care, little known to the public, requires a community-based communication emphasizing its undeniable benefits. A unique hospital package and financing alternatives for the poorest could increase acceptability. Finally, maternal work, often vital for the family, requires early relocation of Kangaroo Care to the family household, with local support more readily available in the district.

Risk Factors and Practices contributing to Newborn Sepsis in Buyende District, Uganda.

Author(s) John Bua1, David Mukanga2, Elizabeth Nabiwemba3
Affiliation(s) 1Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 2Bill & Melinda Gates Foundation, Bill & Melinda Gates Foundation, Kampala, Uganda, 3Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda.
Country - ies of focus Uganda
Relevant to the conference tracks Women and Children
Summary This was a facility based cross sectional study in Kidera sub-county, Buyende district, Uganda. It aimed at identifying potential risk factors and describing practices contributing to newborn sepsis in Buyende district in order to make recommendations that will influence behaviour change at community level. 174 newborns participated. 21.8% were laboratory confirmed to have sepsis. The main causative agent was staphylococcus aureus (31.6%). Risk factors included inappropriate cord care (77.6%) and not practicing routine hand washing (78.2%). Therefore health education messages should target importance of hand washing and cord care for newborns in the communities.
Background In Uganda, it’s estimated that newborn deaths contribute to over 38% of all infant deaths (92,000 in 2010). Despite different mitigation interventions over years, the newborn mortality rate is high at 27/1000 and newborn sepsis contributes to 31% of mortality in Uganda. Therefore, improved strategies that will contribute to the reduction of newborn sepsis need to be developed. However we need to understand the actual practices and risks present that contribute to new cases of sepsis. These need to be put in context, for without reliable evidence it’s difficult to know whether proposed interventions will work.
Objectives To identify potential risk factors and describe practices contributing to newborn sepsis in Buyende district so that recommendations can be made that will influence behaviour change at community level.
The specific study objectives were;
 To assess the prevalence of risk factors for newborn sepsis in Kidera County, Buyende district.
 To describe practices contributing to newborn sepsis within the health facilities.
 To describe practices of mothers or caregivers of newborn contributing to newborn sepsis.
Methodology The study was conducted at Kidera Health Centre, a level IV facility located in Kidera County, Buyende District Eastern Uganda. Kidera health centre is the highest and main referral unit for Buyende District. Kidera Health Centre serves the 5 counties in the district with an estimated population of 248,000 people.This was a health facility based cross sectional study in Kidera sub county, Buyende district. Mothers or care takers of sick newborns and health workers were interviewed. The dependent variable was a newborn having laboratory confirmed sepsis. Independent variables include; social demographics, mother’s ANC, delivery and PNC history, birth weight, gestation age and newborn care practices. Semi-structured questionnaires and Key informant guides were used to collect quantitative and qualitative data.
Results 174 mothers and 174 newborns participated in the study. The majority of the mothers (73%) were peasant farmers. Few of the mothers had attained an education level above primary school (33.9%). The age range for the mothers was from 16 to 44 years (mean: 26.3 years).21.8% of the admitted newborns with signs and symptoms for sepsis were laboratory confirmed. The identified causative agents included; staphylococcus aureus (31.6%), Neisseria meningitides (21.%), streptococcus pyogenes (10.5%) and Haemophilus influenza (5.3%). The causative agents were found to be resistant to some of the commonly used drugs that included; penicillin, chloramphenicol, cloxacillin and gentamycin.Prevalent risk factors included delivery outside the health facility (43.1%), inappropriate cord care (77.6%), care givers not practicing hand washing before handling the newborn (78.2%) and lack of knowledge about newborn care (39.7%).The interview of key informants revealed that the health facility didn’t have resources to offer routine screening for bacterial infections among pregnant women during ANC visits. The available resources were for vertical programs targeting only HIV and malaria. The health facility also had no equipment or a special room were sick newborns in critical condition could be managed appropriately. The other health system challenges identified included lack of antibiotic syrups for treating newborns and inadequate supply of laboratory reagents to investigate causes of ill health in newborns.

Since the study was facility based some sick newborn cases that weren’t brought to the health unit for care could have been missed. However, community health workers in areas served by the health facility were encouraged to refer all cases of sick newborns for care.

Conclusion Most common aetiological agent for newborn sepsis was Staphylococcus aureus followed by Neisseria meningitides. The practice of not routinely washing hands before touching the newborn and inappropriate cord care were leading factors contributing to spread of infection to newborns in the community. Therefore all pregnant women and women in postnatal positions need to be health educated about the importance of hygienic cord care and washing hands before touching the newborn. The health education can be given to mothers attending antenatal, delivery or postnatal at the facility by the health workers. Community health workers, where they exist, can be used to educate mothers in the community about proper newborn care and how to prevent spread of sepsis.

Health as an indicator of sustainable development: How health can contribute to and benefit from sustainable policies.

Author(s) Natalie Mrak1, Callum Brindley2
Affiliation(s) 1Development studies, The Graduate Institute for International and Development Studies, Geneva, Switzerland, 2Development Studies , The Graduate Institute for International and Development Studies, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Environment and Sustainability
Summary This study highlights how health can be a cross-sectoral indicator for the proposed 2015 sustainable development goals. The impacts of environmental changes on human wellbeing have been clearly established but insufficient work has been done to show how sustainable policies can also benefit health. This study recommends health indicators that can be used to measure sustainable progress in the sectors of water, food, energy, housing and transportation within the urban environment. It also provides suggestions on accountability and governance mechanisms that should put be in place at local, national and global levels to ensure that everyone takes responsibility for sustainable development.
Background Growing concerns about the impact of environmental changes on health have emerged as middle-income countries have adopted the consumption and greenhouse gas emission behaviours of high-income countries. The same economic trajectory that has created a global marketplace dependent on increasing volumes of production, consumption and the long-distance transport of goods, has also led to the overexploitation of finite natural resources, energy shortages and the overburdening of the natural environment. The affects from this trajectory not only pose challenges to the sustainability of the environment but to human health as well. About 24 per cent of the global burden of disease and 23 per cent of deaths are attributable to environmental causes and around 36 per cent of the disease burden in children is caused by environmental factors. Despite this information, health has been an omitted aspect in climate policies. The collective health benefits that can be gained from a low carbon economy have been overlooked when they can actually be motivation for further cutting greenhouse emissions. Emphasizing the joint benefits could make reducing greenhouse emissions attractive since they serve as a means towards achieving both public health and climate goals.
Objectives The primary objective of this study is to demonstrate how health is a cross-sectoral theme of sustainable development that can be used to motivate behaviour change. The secondary objective is to show how human wellbeing will be impacted if sustainable approaches to development are not pursued. Since the MDGs were established in 2000, tremendous progress has been made to improve health outcomes but this progress will become compromised if measures are not taken to improve the current state of the environment. Everyone will be impacted but particularly the poorest and most vulnerable whose already scarce access to public goods could be further compromised as governments grapple with economic devastation as result of changes in the climate and environment. Urban areas will continue to grow, unable to accommodate their expanding population, which could lead to increased food insecurity as dry arable rural lands become incapable of producing crops. Prolonged drought conditions and increased occurrence of natural disasters could also lead to water insecurity. This situation, combined with poor housing conditions, unsustainable energy sources and carbon-motorized transport will negatively impact health and the environment. The tertiary objective is to show how policies across diverse sectors can improve human wellbeing and the environment. Health can be used to measure the effectiveness of policies in various sectors as well as benefit from policies that also improve the environment. In order to tackle the health risks that environmental changes pose, an integrated, cross-sectoral approach needs to be taken since human wellbeing is not only affected by such factors as health systems as but also other factors like pollutants and physical activity. The additional objective is to analyse the opportunities and challenges to promoting more sustainable behaviour. Everyone can contribute to a sustainable future from healthcare workers to businesses as well as governments and civil society. The post-2015 development agenda provides an opportunity to implement accountability mechanisms that do not currently exist. As cities become centres of human settlement, there is also a need to implement environmental-friendly policies that enhance rather than detract from economic growth.
Methodology The main question of this study is to see how health is a cross-sectoral indicator of sustainable development. The study was conducted between June and September 2013. The search strategy sourced reports and articles primarily published by the United Nations, especially the WHO, UNICEF and UNEP as well as the below leading health and development journals. We reviewed only articles published in English and concentrated on the period from 1990 to 2012. Our principal search terms were: “health” AND “sustainable development”; “environmental burden of disease”; “healthy environment”; “urban health”; “healthy cities”; “health” and “results-based management”; “health indicators.” In total, we closely reviewed over 100 reports and articles. To analyse the literature, the following questions were posed:• How can health and sustainable development be linked?
• How is health positioned in the post-2015 development agenda and the sustainable development goals debate?
• What are the strengths and limitations of indicators
• What current health indicators exist and what are their merits?
• What lessons can be drawn from the WHO’s Healthy Cities programme?
• How can inter-sectoral cooperation be promoted?The study looks at sustainable development within the context of urban areas, focusing on five key areas – food, water, energy, households and transport. Cities were selected as the geographic area of focus since their populations are expected to continue to increase over the course of this century. The five areas of focus were selected on the basis of their strong cross-sectoral communications with health and the burden of disease from their associated risk factors. The study demonstrates how the relationship between health and sustainable development can be thought of in three ways: health contributes to the achievement of sustainable goals, health can benefit from sustainable development and health is a way to measure progress across all three pillars of sustainable development policy.
Results The results of the study clearly demonstrate that health is an integral part of sustainable development whose contributions should be considered more seriously in the post-2015 development agenda discussions. First, climate change is contributing to the increased incidence of natural disasters and disease outbreaks, increasing the global burden of disease. Second, urban areas will endure great burdens as a result of climate change, which will be primarily due to the increased migration to cities. Third, there are measures that can be implemented across sectors, which can reduce greenhouse gas and pollutant emissions as well as improve human well-being. Last, this study also found that while there is an abundance of data on health as an indicator of sustainable development and the distinctiveness of each country’s context make it difficult to discern which existing indicators are most practical and useful, there are a series of assessments that can be carried out to develop a fit-for-purpose complement of indicators. The below tool outlines the method for conducting these assessments by focusing on a country’s:• Burden of disease
• Level of economic and social development, and
• Environmental condition and pressuresTables of indicators by income-level for the health-sustainable development nexus were created. It was found that each indicator has the following four strengths;

• Relates closely to both health and sustainable development
• Relies on data that is easily accessible and reliable
• Communicates clearly a development challenge
• Facilitates practical policy interventions

The primary limitation of this study was the lack of first-hand qualitative data which is due to the top-down approach of the study. A complementary bottom-up study containing ethnographic work could help confirm these findings and provide a people centered-approach to seeing how health is an integral part of sustainable development.

Conclusion Health can be a useful focal point to promote inter-sectoral cooperation at the local level but there is unfortunately no set of health indicators that are relevant to all contexts. A drawback to the work that has been done on health as an indicator of sustainable development in urban settings has been the emphasis on the quantitative aspect of indicators. This has made it difficult to single out a set of best practices and to actually see whether these interventions improve well-being. As urban populations continue to expand in the coming decades, new approaches to urban planning need to be taken which engage a variety of stakeholders and adapt to the dynamic nature of cities. Small-scale interventions in urban areas can be key to providing insights into what does and does not work. To ensure the work on health and sustainable development continues, health needs to be an integral component of the post-2015 development agenda. The sustainable development goals of the post-2015 agenda will not be achieved if a concerted effort is not made to assist low and middle-income countries in developing and implementing renewable energy techniques as their populations and economies continue to grow in the coming decades. Mechanisms should be created that not only transfer funds but knowledge and technology as well. Governance mechanisms need to be set in place, which marry policy and scientific evidence and impose accountability. Increasing public awareness of the intricate relationship between public health and the environment could help promote sustainable behaviour and raise attention to the need of holding all stakeholders accountable. Ultimately, there needs to be commitment at all levels of government and society in order for sustainable development to become a reality.

Distance to basic services and Retention of Health Workers in Tanzania: A multivariate logistic and GIS Model Approach.

Author(s) Benjamin Mayala1, Jonathan Mcharo2, Vitus Nyigo3.
Affiliation(s) 1Disease Surveillance and GIS, NIMR, Dar es Salaam, Tanzania, 2HRH, NIMR, Dar es Salaam, Tanzania, 3Traditional Medicine, NIMR, Dar es Salaam, Tanzania.
Country - ies of focus Tanzania
Relevant to the conference tracks Health Workforce
Summary Lack of basic services in some areas of the country is one of the major reasons for health workers to migrate to areas with better services but this causes other areas to remain with few health staffs, and resultant poor health care. A simple analysis to determine the availability of these services and at what distance a health worker can access them can be a great solution to policy makers.
Background Tanzania has been implementing the Primary Health Service Development Program policy to increase the accessibility of health care services to its people at a distance of 5km. Although this policy has been introduced in the various districts in the country, its implementation has been a challenge due to the fact that retaining health workers at these facilities remains problematic. Lack of basic services in some areas of the country is one of the major reasons for health workers to migrate to areas with better services which results in other areas retaining fewer health workers with poorer health care provision in the country. Lack of health care provision in terms of health workers can present barriers to patient’s access to health facilities, who might be forced to travel long distances to access health care. Understanding the problems of health workers, including the availability of basic services in their localities, is important. Distance to basic services has an impact on health worker retention. Travel times, lack of access to transportation, and seasonally inaccessible roadways can present barriers to health workers access to important services such as banks, security or schools for their children.
Objectives We hypothesized that the lack of basic services was a key factor for health worker migration to other districts that possessed better services. The main goal of this study was to determine the availability and distribution of basic key services that are important to health workers and how close they can be accessed. Specifically, we used spatial analysis to establish a network that considers geographic position and the existence of basic services that could influence the retention of health workers.
In order to achieve this goal we focused on the following questions:
• Is there a reliable water supply source and what is the nearest distance to this source?
• How accessible are the health facility (your place of work)?
• Are there roads which can easily access different routes to services?
• Are there schools that can be accessible by health workers?
• Is there reliable transport (public) that can be used by health workers to move from one point to another?
In particular Euclidian distances from health workers houses to the basic services were computed. Using data on health workers moving in/out of a particular district, we applied multivariate spatial logistic regression to determine the variables that were statistically significant.
Methodology The study was undertaken in 16 selected district in Tanzania in 2007. Districts were chosen to represent the spatial zonal distribution of the country. Four of the districts (Kigoma Urban, Mtwara Urban, Nymagana and Temeke) were considered urban and the other 12 (Biharamulo, Kilwa, Kondoa, Lushoto, Mafinga, Manyoni, Mbinga, Mpanda, Same, Ulanga, Urambo and Rungwe) were rural districts. Four villages were selected in each district, and three to four health workers houses were selected for inclusion in the mapping exercise. For each district we first assessed all the basic services available, then a hand held Global Positioning System (GPS) was used to map the geographic locations of those services, this includes banks, water source, post office, police post, shops/open market location, schools and bus stops. Other features that located were the health facilities and health worker households. We used ArcGIS 10.1 analysis tools to map the locations of basic services and distances to the nearest services from each health worker household was calculated using simple Euclidean distance. Multivariate logistic regression were used to model the distances to bank, post office, police, schools, referral hospital, water sources and bus stops. Then we compared the significance variables to the data on overall district move in/out of health workers.
Other covariate variables of interest that we included in the spatial logistic model that could be important in our analysis included elevation, rainfall and temperature data.
Results Main sources of Water: Our results indicated that most of the health worker households and the health facilities they work were not connected to piped water, because there was no such services in the districts. Therefore, health workers are forced to walk long distances (up to 15km) to access water services.
Distance to bank, police and post office services: Most of the health workers in public health facilities collect their salaries through a bank. Our analysis indicated some health workers travel a distance of 160 km to obtain bank, post or police services. This was seen to be a burden especially in those areas where public transport is a major problem (i.e. one bus a day), and that health workers had to take two or three days off, spend nights in a guest house near the bank, and also incur costs for fare and food, which are deducted from their salary.
Accessibility of Health facilities: in most the districts visited during the research, quite large number of health facilities are located near to the roads (0.2 to 3 km). This means that they (in principle) can be accessed by public transport. However, this is not the situation in most of the rural areas where we conducted this research. As mentioned before, public transport is not reliable and the situation is worse during rainy season.
Distance to School: The distance analysis to access schools indicated that schools can be accessed up to 12 km which is also a burden for most children in the rural areas without transport.
Our initial logistic regression models confirmed a statistical significance of distance to basic services and moved in/out of health workers.
Conclusion In this study we have used GIS and spatial logistic analysis to determine the spatial distribution of existing basic services for health workers. Apart from others, issues like better salary, promotion and various ways of motivating a health worker and understanding the distance to access basic service is important. This is due to the fact that lack of services in some area may cause health workers to migrate to those areas with better services. The application of GIS technology has shown how a health worker can access basic services in terms of travel distance. A multivariate analysis indicated the significance of some variables to the migration of health workers.

Understanding the Growing Complexity of Governing Immunization Services in Kerala, India.

Author(s) Joe Varghese1, Raman Kutty2, Ligia Paina3, Taghreed Adam 4
Affiliation(s) 1D 43 NCD Lifespan Training Program, Centre for Chronic Disease Control , New Delhi, India, 2Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology , Thiruvananthapuram, India, 3International Health, Johns Hopkins University School of Public Health, Baltimore, United States, 4Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary This study tries to understand the complex phenomena related to the governance of immunization services in Kerala, India where, after basic immunization reached high coverage in the late 1990s, started to decline in some of the regions. The study applied system thinking lens and used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low coverage. The study identified four phenomena that influenced change in vaccination coverage.
Background Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. The conventional approaches often fail to take this complexity into account and expect that technically sound programs ensure successes when necessary management processes are in place. In India, the Universal Immunization Program (UIP), introduced in 1985, targets around 27 million infants and 30 million pregnant women every year and is one of the largest in the world. In one of the high performing Indian states, Kerala, after basic immunization had reached high coverage in the late 1990s, it started to decline in some of the regions.
Objectives We applied a systems thinking lens to understand the contexts, processes and complex phenomena which led to changes in vaccination coverage over the past three decades in Kerala and the reasons underlying these changes. The analysis expands our understanding of the governance of immunization programs operating in a complex system and thus, enables an understanding of, not only for Kerala but also for the other contexts, where public health programs are showing similar complex behavior.
Methodology We used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low immunization coverage. Data collection included in-depth interviews with private and public providers; beneficiaries and other stakeholders, as well as focus group discussions with mothers of under-five children and observations of vaccination-related activities. Content analysis for the qualitative data aimed to identify and describe the complex, adaptive phenomena resulting from immunization programs in our study area. Causal loop diagrams were developed to depict the phenomena, key actors, and their interactions.
Results We identified several complex phenomena that influenced change in vaccination coverage levels in the two districts. For example, we identify a phase transition from acceptability to resistance of receiving vaccination services due to the involvement of new actors. The causal loop diagram illustrated several balancing and reinforcing feedback loops that resulted from actions of actors attempting to regain vaccine acceptability and others who counteracted these actions. For instance, mothers who played a major role in decision making during the acceptance phase were replaced by the male members of the household during the resistance phase. The male members were influenced mainly through media which used a negative incident related to child vaccination to create a polemic that influenced their behavior and stance with respect to child vaccination all together. The conventional public health approach that is designed to target mothers through health information and female community health workers did not manage to counteract the influence of media since they are not designed to directly target the male members of the household.Path dependence is another phenomenon where new events influenced the way the decision to vaccinate by households was shaped in two different regions and the speed by which this happened. For instance, the special vaccination campaigns where the entire state machinery mobilized its resources to increase smooth operations were seen as a soft target by groups among naturopathy and homeopathy systems that traditionally opposed vaccination and propagated their misgivings against immunization programs. Finally, the emergence of social networks and their power to influence the change in either direction was detected. Health Worker’s status as a local woman known to the other members of the community gives her special advantage in influencing community perceptions on immunization issues
Conclusion This study offered a rich understanding of the interactions between multiple actors and contexts and the various phenomena that resulted from these interactions, influencing households' decision to vaccinate their children. Understanding these interactions, including the power exercised by each actor at different points in time, the factors determining the exchange of information, and the norms guiding the institutional mechanisms for immunization functions, clarified how the societal actions changed from acceptance to resistance to vaccinate. Understanding vaccination coverage using a systems thinking lens offered a robust framework to explore the underlying complex mechanisms and contexts that influence policies. The framework also emphasized the importance of considering all the actors beyond health systems. It can be applied in other public health contexts to define problems and guide the analysis.

MOTHER: A Mobile-Based Voice Health Alert Tool to Create Awareness on Young Child Feeding Habits.

Author(s) Suneetha Sapur1, Kathiresan Chinnusamy2, Girija Vadlamudi3
Affiliation(s) 1Nutrition, AkkshayaFoundation Society, Hyderabad, India, 2Indian Development Gateway, Center for Development of Advanced Computing, Hyderabad, India, 3Health, Health Management Reaserch Institute, Hyderabad, India, 4
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary Background: Malnutrition in Children is extensively prevalent in India. Poor feeding practices may lead to the burden of malnutrition, infant and child mortality.Objectives: To create awareness and demand generation in the community of government health services for infant and child feeding practices with the help of Information Communication Technology (ICT)Methods: Centre for Development of Advanced Computing and the Ministry of Communications and Information has developed the ‘MOTHER’ tool to capitalize the mobile phone’s core utility of ‘voice calls’ to create health awareness among the illiterate rural community. The project was taken up where the 80% of the population owned mobile phones.
What challenges does your project address and why is it of importance? •Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. Our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal Headquarters.• Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system. To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registration.
•In many families, mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team. As part of MOTHER project, we organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
•Compared to SMS, voice calls are costlier.
How have you addressed these challenges? Do you see a solution? Challenge: Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. The solution was that our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal HeadquartersChallenge: Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system.Solution: To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registrationChallenge: In many families mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team.
Solution: We organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
Challenge: Compared to SMS, voice calls are costlier. Moreover, service providers charge based on call duration and number of calls made per month.
Solution: We designed the voice alerts such a way that each call will be less than one minute and each alert will be sent two times in a day. Only critical alerts (such as expected date of delivery) will be repeated more than 3 times.
How do you know whether you have made a difference? Who were targeted:
• pregnant women, husbands of beneficiaries, fathers of children, health care providers,
Why:
• To create demand for the health services in the community, better utilization of health services by the beneficiaries and timely monitoring by the health officials.
How was this delivered:
• Apart from better infant and child feeding practices as presented in the abstract we observed positive changes after implementations of the project.
• Repeated voice calls sensitized the family members, particularly husbands, to understand the importance of pregnancy and the care to be taken at critical stages. Improved participation of husbands and fathers in health care activities was observed.
Have you or the project mobilized others and if so, who, why and how? The project mobilized community participation and awareness created by the project helped to create demand for health services, especially for immunization as the Mother call voice alert reaches the beneficiary (pregnant women, Mother's of below 18 months) on the days of immunisation schedule as well as nutritional supplementation through the Integrated Child development Surveillance program. Beneficiaries were demanding the village health workers for immunization and the food supplements such as Egg, fruit and calorie and protein mix.It also helped to improve health workers participation as it increased the responsibility of Health workers to follow-up with registered members. The number of visits by health workers to the beneficiary house reduced, in turn helping them to effectively utilize their time in other productive works. As to corruption, beneficiaries were sensitized about the entitlements and monetary benefits from health department along with voice health alerts. The better utilization of health as well as monetary benefits was observed.There was online monitoring of the beneficiaries details by higher government health authorities especially about high risk cases of pregnancy.
When your donor funding runs out how will your idea continue to live? In spite of a few limitations and challenges faced by the Mother tool implementation, the Mother project is a successful program that creates awareness on infant and child feeding habits. The Mother pilot project has been initiated with the goal of being integrated into the national level health services, so the pilot has been implemented by involving State National Rural health Mission and the antenatal and child data collection formats used in mother project were also of National Rural health Mission (NRHM) as these formats are common across the country. The NRHM people were involved at each step of the implementation program which helped the Mother project to be taken up by the state NRHM. The scale up of the Mother project to state level has been assisted by the NRHM officials involved witnessing the effectiveness of this innovative tool to create awareness across community, in particular to rural illiterate women. At the National level NRHM is considering a scale up to entire nation in a phased manner. Considering the level of mobile penetration in India and literacy level among rural women, voice calls (MOTHER) is the best model to reach-out towards the target beneficiaries directly at an affordable cost.  The projected has been scaled up to the state level and National Rural Health Mission is adopting this tool and scaling up to the different states in phases at national level. This project has been awarded "eIndia 2012’ Public Choice Award under Health category.