Reconvening Bangkok: Online Journal

Saturday, March 6

Sawasdee Khah!

As ESD Project staff leading the meeting—Reconvening Bangkok: 2007 to 2010—Progress Made and Lessons Learned in Scaling-UP FP/MNCH Best Practices in Asia and the Middle East (AME) Region—we are at the Shangri-La Hotel in Bangkok, Thailand with more than 400 health managers, service providers and program planners. On Saturday night, we welcomed the participants and heard words of inspiration and challenge at the opening ceremonies. Dr. Siriwat Tirapodol, Deputy Permanent Secretary, Thailand Ministry of Health, Ms. Milka Dinev, Director of the ESD Project, Dr. Jeff Spieler,  Senior Technical Advisor in Science and Technology in Population and Reproductive Health for USAID’s Bureau for Global Health and Dr. Barbara Krell, USAID/RDMA Mission Director, all spoke during the opening ceremony. The speeches spurred us forward in our quest to improve the health status and save the lives of women and children in 13 Asia and Middle Eastern countries. Dr. Spieler set the stage with a scientific presentation that explained the major elements of the five-day meeting, including challenges to meeting the Millennium Development Goals, why 

change is difficult, the elements of successful  family planning, and President Obama’s Global Health Initiative. Dr. Salwa Bitar, ESD's AME Regional Advisor and Ms. Dinev then expressed warm votes of thanks to USAID/Washington and Missions, partners, donors, planners, facilitators, presenters, and to ATOP, the conference organizer, for making the meeting possible.

Participants will spend the next five days seeking state-of-the-art updates in evidence-based medicine and management, and learning about the efforts of neighboring countries, which have been introducing and scaling-up new interventions since ESD’s previous AME conference in 2007. It's not all work though—we enjoyed the beauty of traditional Thai music and dance while munching a scrumptious dinner. A few of us even followed the lead of the striking performers onto the dance floor.

Sunday, March 7 

During day one of the conference, we heard international experts in maternal health outline the issues inherent in attempts to reduce maternal mortality and achieve Millennium Development Goal (MDG) 5. The plenaries and concurrent sessions were well planned and successful, evident in the packed rooms and the commitment of participants and presenters.

Among the concerns mentioned by presenters was the competency in relevant skills of newly graduated doctors, nurses and allied health care professionals and the persistence of harmful practices while proven ones languish. We heard about innovative strategies to engage communities, such as baby picnics, and the need to link health centers to the community to reduce the number of maternal deaths. Speaker after speaker mentioned the importance of ensuring competency in skilled providers. We learned about commonalities among systematic approaches to scaling-up and why the focus must include the "how" of applying new interventions, and not just the "what." Participants spent the afternoon gathering in country teams to discuss how they could absorb the most relevant ideas and create a plan to implement them, or how they could scale-up current interventions. Many country teams grappled with the challenge of
narrowing their focus to just one issue that can be developed into an action plan.

The country teams expressed gratitude for all they learned during the maternal plenary, and everything they had already gathered about scaling-up approaches. Many of them started applying the scaling-up approaches while developing their action plans.

Monday, March 8

The second day of plenaries focused on family planning. Dr. Malcolm Potts of the School of Public Health, UC-Berkeley, a passionate advocate of women’s health, demonstrated impressive support for the notion that family planning is truly critical for the health of the earth, not just its people. Dr. Potts said it would be difficult or impossible to achieve any of the Millennium Development Goals without family planning, and told us that one dollar spent on family planning saves finance ministers six dollars, expressing the urgent need to place family planning at the top of the global agenda. Following Dr. Potts, Dr. Sarah Clark of the Health Policy Institute provided evidence from John Stover and John Ross’ recent study, which illustrates the links between increased contraceptive use and a reduction in maternal mortality. In the next presentation, Dr. Maureen Norton demonstrated how moving research on the healthy timing and spacing of pregnancy (HTSP) into practice saves lives.  Dr. Rema Nanda of the PRACHAR project in India then explained how PRACHAR has taken evidence on delayed first births and spacing and turned it into a highly effective programming reaching young people in a challenging environment. Elizabeth (Beth) Elson described how Health Alliance International's child spacing initiative made a difference for couples in a post-conflict setting in East Timor, which has one of the highest fertility rates in the world.  Next, Dr. Jamila Al Raebi, Yemen’s Deputy Minister of the Ministry of Health and Population, described some challenges to delivering reproductive health services, including a shortage of female staff that can cover hospital shifts 24 hours/day; women who leave the hospital within two hours of delivering, and; limited male involvement. She said Yemen is rectifying some of these problems by scaling-up best practices in postpartum care, such as postpartum family planning counseling in male-friendly rooms.

Dr. Gadde Narayana of Futures Group kicked off the second family planning plenary, illustrating how certain factors—such as a limited method mix and a shift of attention to other programs—can contribute to a plateau in the contraceptive prevalence rate. Dr. Mario Festin of the World Health Organization followed, describing the elements of successful family planning programming and updating the crowd on the latest medical eligibility criteria. Next, Dr. Rashid Jooma, Pakistan’s Director General of Health gave a presentation on his country’s experience scaling-up FP/MNCH best practices, including AMTSL, HTSP, ORS and zinc, and many more that required changes in procurement, training, and protocols. He said the commitment to these changes by the officials of the federal and provincial government is embodied in the Karachi Declaration, which they all signed.  Next, Mr. Kazi Moksedur Rahman of Shimantik talked about Bangladesh’s experience in scaling-up best practices in healthy fertility and postpartum family planning to fill the unmet need in rural areas. To do this, Mr. Rahman said it has been crucial to address the influence of husbands, senior family members, and religious leaders when promoting birth spacing.

Tuesday, March 9

The plenaries focused on neonatal, infant and child health. Dr. Uzma Syed of Save the Children, Bangladesh, began with an update on MDG4 and newborn survival in Asia. Dr. Syed focused on the fact that the growing proportion of neonatal deaths and under-five mortality is a huge challenge to countries around the world, and a large proportion of those deaths are in Asia. She said some of the proven interventions needed involved national level changes in policy and national plans. Dr. Syed said it was necessary to integrate newborn interventions into broad-scale health programs; however, the challenge of birth notifications and the tradition of 40-day seclusion remained. Next, Dr. Steve Hodgins of MCHIP explained the need for “smart” integration of services to make it easier for the user, which would lead to better outcomes and higher coverage in key services for mothers and newborns. Dr. Mohammod Shahidullah of Sheikh Mujib Medical University in Bangladesh spoke of efforts to scale-up resuscitation skills for workers at all levels, and in the community, in particular, and the University’s feasibility study of the Helping Babies Breathe tool. Dr Rajiv Bahl of the World Health Organization led the crowd through the recommendations of the new Joint Statement on Home Visits for Newborn Care, from WHO and UNICEF, and supported by USAID and Save the Children, USA, which is based on evidence from multiple studies. He said a training course called "Caring for the Newborn at Home" had been developed for community health workers. Dr. Mukesh Kumar of CARE India presented the experience of scaling-up newborn care in India, which focused on prevention, including safe and clean delivery; clean and minimal handling of the neonate; clean-cord, thermal care; early and exclusive breast-feeding; extra care of sick and weak newborns, and; early recognition and referral of sick neonates.

The second plenary focused on the “big picture” of child health, opening with Dr. Festo Kavishe of UNICEF, who illustrated the current statistics and gaps in child health and what is needed in health system strengthening to achieve MDG4, including the use of alternate cadres of workers; community-based case management of newborns; newborn skin and cord care; uniject for postpartum hemorrhage; the shock garment, and the wider use of MgSO4 and calcium for eclampsia and pre-eclampsia. Mr. Camille Saadé of the POUZN Project spoke about scaling-up diarrhea treatment using zinc and ORT, and the partnership between the public and private sectors. Dr. Saadé noted how much more widely available over-the-counter zinc is than just a few years ago. Mr. Robert Steinglass of MCHIP, speaking on routine immunization, made the point that 25 percent of under-five mortality is vaccine-preventable and how a mix of strategies is needed. He also showed techniques for reaching the population through a catchment mapping tool that could be adapted for other purposes, such as identifying eligible clients for family planning. Dr. Yashovardhan Pradhan, Nepal’s Director General of Ministry of Health and Population evoked a hearty round of applause when he announced that Nepal is likely to achieve MDG4. Other country teams were also inspired by Nepal’s successful use of female community health workers to achieve coverage of MNCH services at scale. Dr. Pradhan described Nepal’s birth preparedness package of ANC, iron/folate, preparedness for delivery, attention to hypothermia and low-birth weight, and other critical interventions.

Wednesday, March 10 

Today, we first heard from Dr. Jeffrey Smith of Jhpiego, who reviewed the global guidance on prevention of postpartum hemorrhage, for which the key intervention is Active Management of Third Stage of Labor (AMTSL), which every skilled birth attendant should be allowed to provide. Dr. Smith reminded the crowd that an intervention’s application (the “how”) and the enabling environment are of utmost importance and explained how to integrate the steps of AMTSL in a logical manner. He taught the audience about delayed cord clamping (for about two to three minutes until the pulses cease) can reduce anemia in newborns and infants. Next, Dr. Nowrozy Kamar Jahan of EngenderHealth illustrated how Bangladesh safely scaled-up the distribution of misoprostol by government and NGO staff. Dr. Harshad Sanghvi then asked provocative questions, such as: “What are the three most important words a doctor can say?”  He showed how to tackle the second biggest killer of women, eclampsia and pre-eclampsia, which has shown little decline 75 percent of low-resource countries. Even though magnesium sulfate is readily available in most locales, we still have not overcome operational and managerial barriers and challenges. Dr. Sanghvi said that there would soon be an answer to Mary Ellen Stanton’s question, “Iron distribution has largely failed so what makes you think that you can do better with calcium (which reduces pre-elcampsia)?” We were informed that acceptability is expected to be much higher with calcium sprinkles, which do not have a chalky taste, and field trials will take place in 2010. Dr. Sanghvi said we need to broaden our vocabulary in the direction of “convince, persuade, mobilize, motivate!”  For the country team presentation, Dr. Sabry Hamza of the HSS Project explained how Jordan scaled-up magnesium sulfate for patients with pregnancy induced hypertension (PIH) in all public hospitals in Jordan, which required major efforts such as developing guidelines for physicians and midwives, providing competency-based training as well as on-the-job training (OJT), monitoring performance, and procuring the product more cheaply by projecting needs for five years ahead. One of the novel lessons learned was that staff behavior (compliance) was enhanced by reviewing evidence, which they then could integrate into their clinical practice. Dr. Hamza echoed the quote from the renowned advocate for women's reproductive health and past president of FIGO, Dr. Mahmoud Fathalla of Egypt said on International Women’s Day:  “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”

Our second plenary of the day focused on family planning/reproductive health integration. The first speaker was Ms. Carolyn Curtis, the USAID team leader for postabortion care (PAC). Ms. Curtis informed us that PAC needs to be seen as bothcurative and preventative—curative in that it treats hemorrhage and sepsis, the associated complications of miscarriage and unsafe abortion, and preventative in that postabortion family planning has been proven to prevent repeat abortions, and to decrease a woman’s chance of complications related to pregnancy and unsafe abortion. Unmet need for family planning is the primary cause of induced abortion and all postabortion clients should receive voluntary postabortion family planning counseling. Dr. Catharine McKaig of ACCESS-FP then presented a thought-provoking title: “The Very Best Intentions: Family Planning in the First Year Postpartum,” and led a discussion on how family members, such as mothers, mothers-in-law, and husbands play important roles in decisions regarding contraception. In facilities, she said there are misconceptions, such as providers’ misconceptions about return to fertility and their assumptions about sexual activity; how they often do not offer family planning to amenorrheic women, and; how busy providers often do not have the time to counsel women on family planning. Dr. McKaig spoke of several best practices for postpartum family planning, such as:  family planning offered immediately postpartum and at multiple points during maternal care, the Lactational Amenhorrea Method (LAM) as very effective for up to six months, after which users should transition to other methods, and; postpartum family planning being integrated into mother and child care, such as immunizations. Dr. McKaig said several interventions are ready for scaling-up, including postpartum tubal ligation, IUCD, and systematic minimal packages such as LAM and postpartum family planning counseling. Next, Ms. Caroline Francis of Family Health International spoke about the needs and challenges of FP/HIV integration for the concentrated epidemic in Asia. Ms. Francis informed us that dual methods must be promoted for “entertainment workers” and people living with HIV, and linked family planning and HIV services for those two groups, along with having staff who can support them. Finally, Dr. Halida H. Akhter of Management Sciences for Health outlined a health systems approach to integrating family planning with other services, such as maternal health services and HIV/AIDS screening and treatment. Dr. Akhter focused on how the six pillars for health can help us overcome barriers to integration and how Bangladesh’ s family planning program used the Sector Wide  Approach (SWAP),  where donors pooled resources to cover a range of services in an integrated way.

Wednesday evening, March 10

Tonight, we had our farewell dinner and found it hard to believe the week was almost over. We gathered with our friends, both old and new, and listened to a chamber orchestra play lovely music while we ate. Crowds leapt to their feet and formed a conga line that snaked across the floor as an enthusiastic group sang “Scaling-Up is Hard to Do” (the title of Dr. Hamouda Hanfi’s presentation) to the tune of Neal Sedaka’s “Breaking Up Is Hard to Do.” We felt sad as we thought of leaving our friends and talk turned to the possibility of our coming back together in 2012!

Thursday, March 11

Shortly after our last plenary today, an announcement was made of terrible news—six World Vision workers were murdered in Pakistan. A moment of silence in was held, as the participants mourned. We felt the grief of our World Vision colleagues here with us in Bangkok.

Our first speaker in the last plenary of the conference was Dr. Daniel Kraushaar, whose presentation focused on the “how” of delivering interventions to reach scale and have a health impact. Dr. Kraushaar spoke of the “science of implementation” and enlightened the audience on the topic of causal analysis, a methodology for linking desired outcomes or impact to health system requirements, while using specific policy and management levers against systemic problems. He illustrated his case with the example of Thailand, which overcame system bottlenecks by using insurance and changes in risk pooling to increase access to health services for the rural poor. He said the Pareto principle is at work here—usually taken to mean that 20 percent of factors are responsible for 8 percent of the effect. Next, Ms. Rebecca Kohler presented a simple and coherent explanation of task-shifting and task-sharing, and explained how, in this era of reduced workforce, we should take opportunities to move health promotion and treatment to community workers, either new or existing, thereby increasing access in under-served communities. Ms. Kohler showed us how, at four different levels of workers, ranging from specialist doctors to paraprofessionals, tasks could be shifted downwards safely in many services, including emergency obstetric care, IUD, DMPA, ANC, and newborn care; however, she said we must pay attention to policy and regulations, with competency-based training, adequate supervision,  incentives and client acceptance of new roles. Next, we heard from Mr. David Collins on measuring cost-effectiveness. He reminded us that finance folks often ask that pesky question of why we need additional money each year and how it would be helpful to be able to justify our answer. He emphasized that it is critical that we understand costs so we can accurately price user fees, allocate resources equitably, and figure out how much to pay in incentives. He used a study in Cambodia to illustrate how a whole package of care was costed across the continuum of care. Cambodia was able to save money by bundling services and shifting certain tasks to community volunteers. By providing supervision for the volunteers, they used one fewer staff member. Finally, we heard from Dr. Mubarakshah Mubarak of Management Sciences for Health. Dr. Mubarak described a concrete success story from Afghanistan with over eight years of results. In a difficult environment with a very weak health system and poor health statistics, the government contracted out basic health package of services to NGOs with community health workers. Using the six pillars of health systems, or building blocks, Afghanistan broadened services to cover the country. As a result, Afghanistan has seen a reduction in under-five mortality of 25 percent from 2000 to 2005 and an enormous increase in the availability and use of primary care services, an enormous improvement in a very short time.

Following a short break, the country teams rushed to their presentation rooms to prepare for a peer review of their situational analyses and action steps. Country teams presented their plans to two other groups for questions, comments, and feedback regarding feasibility, practicality, likelihood of success and impact, and so forth.

After the presentations, we enjoyed our final lunch, which was “aroi mak,” or “very delicious” in Thai, and reconvened one last time in the Ballroom for our closing ceremony. We applauded madly for the teams and individuals who won prizes for having completed the most e-learning sessions—two people tied for first place with 34 completed this week! Accolades, certificate, and presents were distributed before we dispersed for shopping, massage, sight-seeing, or leaving for the airport.