Planning MCH Programs

Analysing the situation

Analysing the situation finds out what the problems are and their causes, and what resources are available through a systematic process of examining health and health-related information.

Reviewing the general health situation
Study of the general health situation provides a more comprehensive view of maternal and child health and a better understanding of maternal and child health problems. The review requires collecting and analysing data on population, its health status, health resources and the socioeconomic factors affecting health. Data sources include office records on health services and resources, programme evaluation results, national health office, demographic and health surveys and reports of other institutions which collect health-related information, such as the civil registry, records of nongovernmental health organizations, etc.
Other information may be obtained through discussions with local government and community leaders, interviewing clients or attending meetings of sectoral organizations working in the community or conducting surveys.
It is important to ensure that information for review is accurate and up to date.
Below is a summary of information that is needed for maternal and child health planning:
Population
• size and dynamics
• age and sex structure
• size of target groups
• geographical distribution
Health status
• number, causes, and patterns of illnesses
Health resources
• national health policies and programmes
• available health facilities
• available health services and coverage
• population with and without access to health facilities
• available technology
• available drugs and sources
• information system
• organizational structure and staff complement
• staff competence
• infrastructure, supplies and equipment
• income generated from services
• budget allocation from the government
• funding from donors and other sources
Socioeconomic factors affecting health
• political structure
• family size and authority structure
• social ethics and religious affiliations
• income level and sources
• educational level and facilities
• means of communication and transport
• water supply and excreta disposal
• health practices and food habits
• food availability and consumption patterns
• attitudes and customs related to health
• quality of health services provided to people
Reviewing this information should provide a good background to identifying maternal and child health problems.

Setting expectations/forecasting
Maternal and child health managers should know what to expect based on past and current population and the health situation.
Setting expectations allows preparation of enough resources beforehand, thus preventing problems during implementation. It also helps determine measures early, before a problem arises.
Example of setting expectations:
If the number of under-five clinic consultations increases by an average of 15 per year and if last year’s total number of under-five clinic consultations was 975, then the expected number of consultations this year is 990.
Identifying problems
Problem identification should start with an analysis of maternal and child illnesses and deaths.
Maternal and child illnesses and deaths are the main concerns of maternal and child health programmes. Their numbers, causes and trends should be ascertained.
If the problem is high maternal mortality due to postpartum haemorrhage, the causes should be identified, whether they are a result of placental retention, uterine atony, birth canal lacerations or others. Other elements may have also contributed. It is necessary to know who assisted the deliveries, if the women were referred to a higher level of care, if the women had antenatal care, etc. Apart from the underlying and contributing factors, it is also very important to identify areas where high numbers are occurring and to find out what makes the women and children in these areas more vulnerable. This is significant in establishing priorities and developing strategies. In most countries, there are marginalized sectors of the population where most of the diseases and deaths occur. Usually these people are the poorest, those living in difficult areas not accessible to means of transportation or where there is war, or those belonging to cultural minorities. Only special strategies will reach these population groups. In areas with smaller populations, the numbers of maternal and child deaths and illnesses may be deceiving. It is important that rates and ratios are used to analyze them.
Maternal and child health services should be assessed.
Setting up effective and efficient maternal and child health services will answer most problems in maternal and child health. Effective and efficient services though will have many requirements.
In terms of health services
• Are services technically sound?
• Are services technically appropriate?
• Are there guidelines and measures to ensure quality control?
• Are services cost-effective?
• Do communities actively participate in health care activities?
• Do services help in solving the identified problems?
In terms of resources
• Are health providers competent ?
• Are facilities and equipment appropriate, adequate and in good condition?
• Are supplies and materials adequate and used efficiently?
In terms of delivery
• Are services geographically accessible to the population?
• Are services reaching the population needing them most?
• Are services acceptable?

Continued from above........


Opportunites and limitations should be identified.
There are factors which may pose as opportunities or limitations in carrying out strategies and activities. A high level of community participation can be considered an opportunity because it facilitates mobilization and conduct of health promotion activities. However, harmful traditional practices may cause considerable limitations in promoting safe deliveries.
A good turnout during child immunization days is an opportunity to give women tetanus immunization. Where tetanus immunization is only given during antenatal visits, poor antenatal care coverage is a limitation to increasing tetanus immunization coverage.
Programme opportunities and limitations should be closely looked into, as they facilitate the formulation of sound strategies and activities.
When determining programme opportunities and limitations, the following criteria may be considered:
• factors in the organizational structure that facilitate or hinder implementation of activities;
• degree of participation of staff and the community in programme planning and evaluation processes;
• availability of qualified staff to handle assigned roles and responsibilities;
• level of expertise of staff contributing to increased efficiency;

• assessment of workload of staff, whether under-utilized or overworked;
• system of supervision, feedback mechanism, and other means of support and assistance to personnel;
• training opportunities and staff development;
• presence of a reliable information system to monitor and evaluate performance and guide decision-making;
• presence of an organized logistic system;
• capacity to provide services, training and education activities;
• capacity for expanding services through increased efficiency;
• level of client satisfaction and community participation;
• programme strengths and weaknesses;
• level of financing; and
• level of community support such as volunteers, fund-raising activities and donations of materials and supplies.
Maternal and child health problems should be listed.
To ensure that problems and underlying causes stay in focus for planning effective programme support and to have common terms of reference, they should be written down.

Prioritizing problems
Problems in maternal and child health are numerous and it may not be possible to address all of them at the same time. In case of severe limitations in resources, problems of lesser priority may be excluded from the programme. Prioritizing problems, though, should not automatically result in the exclusion of problems with lesser rank.
Managers prioritize problems to set targets and allocate resources for each problem.
Prioritizing problems entails ranking the identified problems according to pre-determined criteria. The selection of criteria depends upon what the management team considers important factors for prioritization. The following criteria may be considered:
• Magnitude - in case of health status, this refers to how many deaths and cases are caused by the problem.
• Seriousness - refers to the severity of the effects of the problem.
• Scope - this refers to the proportion of the population who will benefit if the problem is considered a priority.
• Feasibility - refers to the probability of the problem being solved with existing technology which can be applied in the locality, available resources, etc.
• Social concern - this refers to the significance attached by the community to the problem.
• International commitment - this refers to the existence of a global mandate for action and support.

To facilitate decision-making about which problems deserve most attention, a scoring system may be used. Developing a scoring system starts with setting criteria for ranking and assigning a weight for each criterion. This becomes the basis for scoring problems. The problem with the highest points is ranked as priority #1, the second highest as #2, and so on.

Formulating solutions
Solutions should be directed at correcting identified problems and/or their causes.
Using globally accepted strategies or interventions
Formulating solutions to specific health problems is one of the most difficult skills to learn. For new health managers, this will be more difficult because of inexperience. However, there are globally accepted strategies or interventions on maternal and child health that health managers can adopt.
Testing of these strategies need not be extensive and in some instances may be done away with.
Examples of interventions/strategies that health managers can use:
• adoption of the case management protocols for control of diarrhoeal disease and acute respiratory infection;
• provision of basic maternity care;
• the risk approach in antenatal care;
• use of partograph during labour;
• use of Home Based Mother’s Record (HBMR); and
• use of growth charts for children.
Choosing and sequencing interventions
If several interventions have been identified to solve a problem, the most effective and efficient measures should be chosen to ensure that only activities with the best results at reasonable cost are carried out. This will also prevent the programme from embarking on too many activities which may become more difficult to implement, will require more material and human resources, and which may compromise results.
Once the interventions are selected, activities should be sequenced step by step.

Example of choosing and sequencing interventions:
To encourage women to use the health facility for maternity care, the district management team proposed the following activities:
1. improving the capability of midwives and nurses through training;
2. training traditional birth attendants to identify women at risk during pregnancy and encourage them to refer pregnant women at risk to the health centre;
3. providing the necessary supplies and materials; and
4. conducting outreach activities.

A more thorough study and discussion revealed the following:
• Although there was a need to train nurses and midwives on obstetric emergencies, they were already capable of providing care for normal pregnancy, labour and delivery, and during the postpartum period.
• Most women preferred the services of traditional birth attendants, and, if trained, the traditional birth attendants would be in the best position to identify and refer pregnant women at risk to higher levels of care, but training resources were very limited.
• Most of the time, the health centre did not have the basic supplies and materials needed to perform maternity care.
• Outreach activities would reach women and help to inform them of available maternity services at the health centre.

The management team decided that the most immediate and pressing need was to have supplies and materials available to the health centre so that nurses and midwives would be able to deliver the maternity services they were capable of, and to conduct outreach services to encourage women to use the maternity services. The training of nurses and midwives was suggested to be done in the next planning year when more women were using the services.
The training of traditional birth attendants on identification and referral of pregnant women at risk was deferred not only because of resource constraints but also because midwives and nurses would not be able to respond well to referrals until they had been trained.
The management decided to put into the plan remedies and activities outlined under points 3, 4 and 1 and suggested that they should be accomplished in that order.

Contined from above.......



Learning from the experiences of neighbouring communities

A problem is often not totally new. Neighbouring communities may have encountered the same problem. Sharing experiences among neighbouring communities provides an opportunity for health managers to consult and learn from each other, thus arriving at better strategies to solve problems.

Creative thinking and innovative strategies
Thorough and in-depth analysis of every problem are keys to finding innovative solutions to maternal and child health problems.
Simple and practical strategies are much more likely to succeed.
Example of a simple and practical strategy:
In places where most women suffer from iron deficiency and laboratory facilities are scarce, haemoglobin determination may be done away with except among those with severe anaemia, all pregnant women may be given iron supplementation and a more intensive nutrition campaign may be used to encourage pregnant women to eat iron-rich foods. The funds for the haemoglobin examinations may be used to purchase iron supplies. If the iron supply is insufficient, priority should be given to women with pallor.
Some problems may be answered by new technology and management concepts.
Example of a new technology which may answer problems in data collection and analysis:
Simple and standardized reporting forms and computerization will facilitate collection and interpretation of health information.

Selective coverage
This is done to achieve greater effectiveness at the least cost. Specific strategies and activities are directed to the vulnerable population.
The characteristics of the vulnerable population should be identified. Susceptible individuals are often differentiated from the rest of the population by location, age, biological attributes, surrounding social conditions, cultural and religious practices, etc.

Example of when selective coverage may be applied:
A supplemental feeding programme is an accepted strategy for malnourished infants and children. When faced with scarce resources, a good option is to limit this service to a district with the highest malnutrition rate or to the population segment with the lowest socio-economic status.

Steps in formulating solutions
There should be an objective for every prioritized problem that has been identified.
For an objective to be useful it should be:
• specific - it should state exactly the result that is desired;
• measurable - results to be achieved should be observable;
• appropriate - it should relate to the problem being solved and should not be contrary to the health policy of the country;
• realistic - it can be achieved given the constraints and with available resources; and
• time bound - it should state when the desired results should be achieved.

Examples of maternal and child health programme objectives:
To reduce the maternal mortality ratio to half of 1990 levels by the year 2000.
To reduce the neonatal mortality rate by 40 per cent from 1990 levels by the year 2000.
To reduce the infant mortality rate from 130 per 1000 livebirths in 1996 to 70 per 1000 live births by the year 2000.
To reduce nutritional anaemia by 50 per cent from 1996 levels by the year 2000.
To increase prenatal coverage (at least four visits per woman) from 40 per cent in 1996 to 80 per cent by the year 2000.
Operational targets based on the objectives should be identified.
An operational target identifies how an objective could be achieved and should indicate the following:
• specific measures to effect the desired change;
• priority population group; and
• target dates.

Strategies should be determined.
Strategies are approaches or techniques to facilitate accomplishment of set objectives and targets. One strategy may apply to one or several objectives, or sometimes to the whole programme. Multiple strategies may be applied to one objective.
Health problems have many factors. If strategies focus on only one factor that contributes to the problem, no matter how effective the strategies are, they will not solve the entire problem. In the same manner, a single strategy may be used to help solve more than one problem.

Examples of using multiple strategies to solve one problem and a single strategy to solve several problems:
Training health workers on emergency management of obstetrical problems may not lower maternal deaths if no referral system is in place. The strategy of following up women who do not come back to the clinic for their scheduled antenatal care visits will find out not only why they failed to return but also give the health worker the chance to assess the family situation, and to show their concern for the woman and her family. Involving volunteer health workers as health promoters may not only encourage pregnant women to attend antenatal clinics but may also motivate other women to seek family planning and other services.
Consideration of programme opportunities and limitations will dictate sound strategies.
Strategies should take advantage of opportunities and address limitations in the programme. Health education campaigns in schools will gain support from school officials and the faculty and will also reach teenagers who do not avail of the services in the clinic.
Strategies should take advantage of the strengths and offset the weaknesses of the programme. A strong immunization programme, for example, can be used as a venue for other health services such as provision of micronutrients for children or tetanus toxoid immunization for women.

Developing workplans
A workplan is a list of all planned activities, specifying the dates when the activities will be accomplished, how they should be accomplished, the required resources, and the persons or institution responsible for carrying out the activities.
A workplan is essential for effective and efficient programme implementation because:
• it gives clear direction to the health team;
• it is a means of communicating to the staff the range of activities to be carried out;
• it fosters teamwork and cooperation; and
• it serves as a basis for monitoring and evaluating performance.
Steps in developing a work plan:
• List the activities to be implemented.
• Determine in what sequence the activities should be carried out.
• Determine the time-frame for each activity.
• Assign personnel who have the skills and time to carry out the activity effectively.
• Determine the cost and other resources to carry out activities.
Developing a workplan requires patience and time. There should be extensive discussions on what the priority activities are, how the activities will be carried out, who will be responsible for the activities and how much of the available resources should be spent on each activity. A general maternal and child health workplan may be developed to ensure that all problems and activities will be carried out. It may be stated in broader terms, provided specific workplans are developed for specific strategies or operational targets.
Long-term programme workplans of five to ten years may be needed for forecasting long-term budget allocation. Short-term workplans are important for programme operation. An annual workplan provides members of the health staff with direction for the whole year. Monthly or weekly workplans may also be developed by people in charge of specific activities.
Activities should match with budget and other resources. If the budget is not sufficient for the activities, cost-cutting or foregoing other activities which are of lower priority may be needed. If there are a lot of activities which the staff are unable to do, alternatives include hiring a temporary person to augment the workforce or channelling the rest of the activities to private health organizations who are willing and able to do the activities.
Summarizing and tabulating workplans make them easier to follow.