Emergency Obstetric and Newborn Care (EmONC) …timor-leste.unfpa.org/sites/default/files/pub-pdf/Emergency... · Table 9: Candidates for BEmONC upgrade in EmONC Plan of Action 2016-2019:

Emergency Obstetric and Newborn Care (EmONC)

Improvement Plan of Action Timor-Leste 2016-2019

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IEmONC Improvement Plan of Action 2016 - 2019

A PLAN TO EXTEND AND FURTHER STRENGTHEN THE PROGRESS OF THE EmONC PROGRAMME IN TERMS OF AVAILABILITY, ACCESSIBILITY, UTILIZATION AND QUALITY OF SERVICES THROUGHOUT TIMOR-LESTE FROM 2016 TO 2019

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II EmONC Improvement Plan of Action 2016 - 2019

IIIEmONC Improvement Plan of Action 2016 - 2019

FOREWORD

While we acknowledge the significant efforts that have led to the decrease of maternal mortality in Timor-Leste between 1990 and 2015 according to the evaluation of the Millennium Development Goal on improving maternal health, we all know that the task is far from being finished, and more efforts are needed in the next fifteen years to further decrease it along with our commitment to the Sustainable Development Goals.

In addition, we welcome the current focus on the survival of newborns, especially in the very early period of life, since their survival and the interventions to ensure it are very much linked to those of their mothers.

The findings of the recent Emergency Obstetric and Newborn Care (EmONC) Needs Assessment reveal a country-wide deficit in facilities capable of delivering all life saving signal functions. This single evidence leads to the present EmONC improvement Plan of Action for the years 2016 to 2019, in line with the targets of the National Reproductive Health Strategy, and the Health Sector Development Plan

I like to urge all relevant health staff to look carefully into the recommendations of the present Plan of Action and to contribute to its success from the first to the fourth year.

We also thank our development partners for their contribution, whether technical, material or financial, so that we can proudly and jointly assess our expected progress at the end of the Plan.

Dili, November 06, 2017

Dr. Odete da Silva ViegasDirector General of Health ServiceMinistry of HealthDemocratic Republic of Timor-Leste

IV EmONC Improvement Plan of Action 2016 - 2019

VEmONC Improvement Plan of Action 2016 - 2019

TABLE OF CONTENTFOREWORD III

TABLE OF CONTENT V

LIST OF FIGURES VII

LIST OF TABLES VIII

ACRONYMS IX

EXECUTIVE SUMMARY XI

1. BACKGROUND AND CONTEXT 1

1.1 Maternal and Newborn Health in Timor-Leste 1

1.2 Neonatal and Newborn Mortality in Timor-Leste 3

1.3 Policy context 4

1.4 Progress since 2008 6

2. RATIONALE FOR EMONC IMPROVEMENT PLAN OF ACTION 2016 - 2019 9

2.1 Vision 12

2.2 Goal 12

2.3 Outcome 12

2.4 Objectives and targets 12

2.5 Guiding Principles 13

2.6 Outputs: 14

3. COMPONENTS OF THE EMONC IMPROVEMENT PLAN OF ACTION 19

3.1 Output 1 – Policies norms and standard in place for a supportive enabling environment 19

3.2 Output 2 –Complete availability of EmONC facilities and their accessibility in all parts of the country: facilities and infrastructure 20

3.3 Output 3 –Technical and managerial capacity strengthened to ensure high

quality of care:Staffing and training 23

3.4 Output 4 - Increased Access and utilization of EmONC services: Strengthening service delivery –Quality 28

VI EmONC Improvement Plan of Action 2016 - 2019

3.5 Output 5 – Referral system in place and operational in all parts of the country: Network of referral, communication and transport 30

3.6 Output 6 –Municipality EmONC plans developed, fully operationalized and monitored by DSMs and 31

3.7 Output 7 – Community participation strengthened for improved awareness and increased utilization of EmONC services 31

4. EXECUTION, CALENDAR, AND IMPLEMENTATION RESPONSIBILITIES 33

5. COSTING, MONITORING AND EVALUATION 37

5.1 Executive summary of the Costing Report 37

5.2 Monitoring and evaluation 47

6. ANNEXES 49

Annex 1 - Process Indicators 49

Annex 2 – Summary findings of the EmONC NA in 2015 50

Annex 3 – Direct Obstetric Complications (DOC, to be used for process indicators 4, 6, and 8); Operational definitions and Signal Functions to manage them 52

Annex 4 – List of Municipalities with population (in 2014) 55

Annex 5 - Logframe – Monitoring and evaluation framework for outputs 56

Annex 6 – Time line for the implementation of the EmONC Improvement Plan of Action 2016-2019 59

Annex 7 – Norms and Standards for Minimum Enabling Environment to Support EmONC 62

Annex 8 – Lists of Equipment, Supplies and Medicines for EmONC with unit cost 63

Annex 9 – Special features for Newborn care 67

Annex 10 – Quality Improvement Strategy and Processes 71

Annex 11 – Monitoring sheet for assessing the functionality of EmONC facilities 74

Annex 12 – Estimates for Costing 75

Annex 13 - Key Findings and Recommendations of the EmONC NA Report 82

Annex 14 – Maps Showing EmONC Facilities by Characteristics and Selected Candidates for BEmONC Upgrade 89

VIIEmONC Improvement Plan of Action 2016 - 2019

Annex 15 – Municipality Profiles Showing Existing Resources and Needs for The Implementation Plan 97

A. Aileu Municipality 97

B. Ainaro Municipality 100

C. Baucau Municipality 103

D. Bobonaro Municipality 106

e. Covalima Municipality 110

F. Dili Municipality 114

G. Ermera Municipality 118

H. Lautem Municipality 121

I. Liquica Municipality 124

J. Manatuto Municipality 127

K. Manufahi Municipality 131

L. Special Region Oecusse 134

M. Viqueque Municipality 137

7. BIBLIOGRAPHY 141

8. ACKNOWLEDGEMENTS 143

9. CONTRIBUTORS 145

LIST OF FIGURES

Figure 1: Trends of Maternal Mortality in Timor-Leste 1990-2015 and Projections till 2030 2

Figure 2: Trends in Neonatal Mortality in Timor-Leste between 1990 and 2015, and Projections till 2030 3

Figure 3: Network of government facilities providing maternal health services 5

Figure 4: Map showing the distribution of 75 facilities assessed in 2015 17

Figure 5: Map showing the distribution of the functional EmONC facilities in 2015 17

Figure 6: Distribution of costs over time 38

Figure 7: Radar chart showing relative costs related to different cost elements by Municipality 45

VIII EmONC Improvement Plan of Action 2016 - 2019

LIST OF TABLES

Table 1: MMR in South East Asian countries in 2015 2

Table 2: Neonatal mortality rate in South East Asian countries in 2013 – All rates are per 1000 live births 4

Table 3: Summary of the main progress in EmONC between 2008 and 2015 comparison of indicators collected during the EmONC Needs Assessments 6

Table 4: Summary of recommendations stemming from the Needs Assessment conducted in 2015 9

Table 5: Seven outputs in the EmONC Improvement Plan 14

Table 6: The Signal Functions of Emergency Obstetric and Newborn care 15

Table 7: Availability of EmONC facilities by Municiplaity and Region 16

Table 8: Level of decision and components of the policies and enabling environment for the optimal delivery of EmONC services in Timor-Leste 19

Table 9: Candidates for BEmONC upgrade in EmONC Plan of Action 2016-2019: 8 CSIs and 28CHCs) 21

Table 10: Midwives and doctors actually present and needed in each candidate BEmONC facility (Type 2 - CSI; Type 3 - CHC) 25

Table 11: Midwives and doctors actually working in the maternities of the CEmONC facilities in Timor-Leste, and recommended numbers 26

Table 12: Indications of the order of priorities and calendar distribution of implementation 33

Table 13: Summary of the estimated costs over four years by Municipality 38

Table 14: Estimated cost of IPA in the Municipalities by cost components 46

IXEmONC Improvement Plan of Action 2016 - 2019

ACRONYMSAMDD Averting Maternal Death and Disability (Columbia University, New York)

AMTSL Active Management of Third Stage of Labour

ANC Antenatal Care

BEmONC Basic Emergency Obstetric and Newborn Care

CBR Crude Birth Rate

CEmONC Comprehensive Emergency Obstetric and Newborn Care

CFR Case Fatality Rate

C-S Cesarean Section

CTC Clinical Training Centre

DHS Demographic and Health Survey

DPHO SMI District Public Health Officer – Maternalnal and Child Health (MCH)

Dr Doctor

DSM Delegadu Saúde Munisipiu (Municipality Health Delegate)

EmONC Emergency Obstetric and Newborn Care

GoTL Governement of Timor Leste

IPA Improvement Plan of Action

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HRH Human Resources for Health

HSDP Health Sector Development Plan

HSSP Health Sector Strategic Plan

LBW Low Birth Weight

MCHD Maternal and Child Health Department (in MoH)

MDG Millennium Development Goals

MNH Maternal and Newborn Health

MoH Ministry of Health

MW Midwife

MWH Maternity Waiting Home

NGO Non-Governmental Organization

NNMR Neo Natal Mortality Rate

OHT One Health Tool

RH Referral Hospital

RMNCAH Reproductive, Maternal, Newborn Child and Adolescent Health

SBA Skilled Birth Attendant

SpR Special Region

SDG Sustainable Development Goals

UN United Nations

UNFPA United Nations Population Fund

UNICEF United Nations Children Fund

WHO World Health Organization

X EmONC Improvement Plan of Action 2016 - 2019

XIEmONC Improvement Plan of Action 2016 - 2019

EXECUTIVE SUMMARYTimor-Leste is committed to the health of its women and Children since Independence. The Government and its Development Partners united under the H4+ initiative have improved the situation since 2008. The good achievements of the Millennium Development Goal 5 (MDG5) on improvement of maternal health, however, should not lead to a decrease of efforts to address maternal and newborn mortality, which remain unacceptably high. The existing strategies have now been enriched with the integration of a Plan of Action to improve Emergency Obstetric and Newborn Care (EmONC) 2016-2019.

A complete assessment of the current EmONC situation was undertaken in 2015 to review progress and identify gaps and needs. In order to address these gaps and needs, an EmONC Improvement Plan of Action (IPA) is being proposed, to be implemented from 2016 to 2019 in the whole country.

The Goal of the EmONC IPA 2016-2019 is to further save lives of mothers and newborns affected by complications of pregnancy, delivery and postpartum, and contribute to the Reduction of Maternal and Newborn Mortality and Morbidity.

The objectives and targets to be achieved by the year 2019 are:

1. To have increased the availability of EmONC facilities by rationalizing the coverage throughout the country with a network of interconnected facilities beyond the global standards. It is recommended to reach by 2019 a total of 43 functional EmONC facilities, including the 6 Comprehensive facilities already existing that need to be strengthened;

2. To have ensured accessibility for all, including in the remote parts of the country, through improved distribution of EmONC facilities and a functional referral system 24/7 linking these facilities;

3. To have ensured effective utilization of EmONC services to over 90% of the needs, through community participation, strong communication, effective referral, delivery of quality services by competent providers (to prevent the 3 delays). The target is 80% of all births in institutions and 60% in EmONC facilities;

4. To have strengthened the capacity of Municipality health authorities (DSMs and DPHO-SMIs) as well as lower level administrative services to plan, manage, monitor, and support EmONC services;

5. To have expanded the knowledge and awareness of communities about the need to seek assistance from health services and particularly EmONC services.

XII EmONC Improvement Plan of Action 2016 - 2019

Outputs to be achieved:

The objectives, outputs and the key interventions proposed in the Plan of Action must be integrated into the existing health system and build on current major national health programmes such as MCH, Human Resources, Central Medical Stores, Laboratory and Blood Bank. They must be implemented in partnership with the civil society and international development partners. They must also contain their own processes for continues monitoring and periodic evaluation.

OUTPUT 1: Policies, norms and standards revised by adapting international standards and high level commitment and support demonstrated for the optimal delivery of EmONC services;

OUTPUT 2: Distribution of network of BEmONC facilities ensured and CEmONC facilities strengthened for effective coverage of all signal functions in all parts of the country;

OUTPUT 3: Human resources strengthened; Staff redistributed, competencies enhanced at all EmONC facilities prioritizing those serving as clinical training sites and job satisfaction ensured for the benefit of clients;

OUTPUT 4:

Enhanced positive supervision, improved data recording and increased focus on newborn that has relatively been neglected so far for further strengthened systems to support increased utilization and continuous quality improvement of EmONC services;

OUTPUT 5: Referral system operationalized in all parts of the country with improved communication and conditions of transport so that no frontline facility should be at more than 2 hours of a referral facility;

OUTPUT 6: Management competencies strengthened at municipality and national level; EmONC coordinator appointed for improved planning, implementing and monitoring EmONC services; quality of data recording enhanced;

OUTPUT 7: Community involvement further strengthened through Primary Health Care program, village committees, Local NGOs, and community leaders (Suco and Aldeia Chiefs) for improved awareness and increased utilization.

Key interventions to achieve these seven outputs will be implemented synergistically at national and municipality levels, and regularly monitored through national meetings, municipality supervision and field visits.

The three delays model will be kept in mind (delay to make decision to use the health system, delay to access the health system, and delay to provide services while in the health system). The emphasis however is on the third delay once the patient has arrived at a facility.

XIIIEmONC Improvement Plan of Action 2016 - 2019

The AMDD “Building Blocks” model will also be kept in mind, to articulate the different components and achieve effective coverage, utilization and quality.

The Improment Plan of Action has been costed, focusing on extra costs that are not already covered by the regular MCH and hospital services programmes. The extra costs to be considered belong to 4 categories:

1. Cost of infrastructure to upgrade EmONC facilities

2. Cost of equipment to contribute to the upgrade in EmONC facilities

3. Cost of drugs and supplies for the same

4. Cost of human resources, including additional staff to be posted in EmONC facilities, and inservice training to upgrade competencies

These costs were apportioned by year during the four years of the Plan

The total estimated cost for implementing IPA over 4 years will be around 7,983,081 US $.

Budget details can be found in the accompanying costing report.

XIV EmONC Improvement Plan of Action 2016 - 2019

1EmONC Improvement Plan of Action 2016 - 2019

1 https://www.mof.gov.tl/timor-leste-the-millennium-development-goals-report-2014/?lang=en 2 WHO et al. 2015. Trends in maternal mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. National Statistics Directorate and UNFPA 2011. Timor-Leste 2010 Population and Housing Census.3 National Statistics Directorate and UNFPA 2012. Analytical Report on Mortality. Volume 6. Timor-Leste 2010 Population and Housing Census.4 WHO et al. 2015. Trends in maternal mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division.

1. BACKGROUND AND CONTEXT Timor-Leste is a post conflict state that has recently emerged as a lower middle income country. It became an independent nation in 2002, following over four hundred years of Portuguese colonization, twenty four years of Indonesian occupation, and three years of United Nations transitional administration. The country’s economy is heavily dependent on petroleum. Overall the Millennium Development Goals (MDG) indicators show that living standards and human development have improved significantly in Timor-Leste since independence.1 Selected MDG targets for gender equality, child mortality, maternal health, malaria and tuberculosis have been achieved. Out of 29 indicators and sub-indicators, 9 have achieved their targets and 14 show significant improvement. However, despite Timor Leste’s considerable development progress, deeply rooted economic and social issues remain with considerable disparities in key maternal health indicators between municipalities, education and wealth quintiles.

1.1 Maternal and Newborn Health in Timor-LesteRegarding maternal health, the country has made substantial progress on MDG 5, but the maternal mortality ratio is still one of the highest (if not the highest) in the Asia Pacific region. Estimates of the maternal mortality ratio in 2015 range from 215 to 570 deaths per 100,000 live births.2 Among young women aged 15 to 19, the maternal mortality ratio is 1,037 per 100,000 live births.3 The UN estimates that the lifetime risk of maternal death in Timor-Leste is 1 in 82, almost four times greater than the lifetime risk of maternal death in Indonesia.4

The trends in maternal mortality reduction during the MDG period 1990-2015 are clear and encouraging (see Figure 1). To the extent that surveys and estimates can be trusted in the absence of a complete study of maternal death in the country, the MDG Target 5 A has been reached and this is a rare achievement worldwide, appraised by international health authorities.

The Figure 1 shows these trends and extends them to the values expected during and at the end of the next SDG era, in 2030. Under SDG 3 “Ensure healthy lives and promote wellbeing for all at all ages”, target 3.1 states by 2030, reduce the global maternel mortality ratio to less than 70 per 100,000 live births. This is what Timor-Leste should aim at. It is to be appreciated that none of the figures in this graph are based on a direct assessment of mortality, which could only be given by a direct method such as during a Census of Population. All the values have wide confidence intervals.

2 EmONC Improvement Plan of Action 2016 - 2019

0

200

400

600

800

1000

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1990 1995 2000 2005 2010 2015 2020 2025 2030

TrendsofMaternalMortalityinTimor-Leste1990-2015andProjectionstill2030

For international comparison with the countries in the South East Asia region, Timor-Leste still belongs to the group of highest Maternal Mortality Ratios (MMRs) in South East Asia (see Table 1).

Table 1: MMR in South East Asian countries in 2015

CountryMMR (confidence

interval)Maternal Deaths

Life time risk of maternal death 1 in

Timor Leste 215 (150-300) 94 82

Lao PDR 197 (136-307) 350 150

Myanmar 178 (121-284) 1700 260

Indonesia 126 (93-179) 6400 320

Cambodia 161 (117-213) 590 210

Vietnam 54 (41-74) 860 870

Thailand 20 (14-32) 140 3600

Philippines 114 (87-175) 2700 280PNG 215 (98-457) 460 120

Figure 1: Trends of Maternal Mortality in Timor-Leste 1990-2015 and Projections till 2030

Source WHO et al 2015

Source WHO et al Trends in Maternal Mortality 1990 - 2015


While the majority of pregnant women use antenatal care, EmONC Needs Asssesment 2015 revealed that institutional deliveries are less common at 50%. The 2009-10 Demographic and Health Survey reported that nearly 86% of pregnant women received antenatal care from skilled health personnel with 55 percent having the recommended four or more antenatal visits.5 However, a smaller percentage, 30 percent delivered with the assistance of a skilled health provider. While 68 percent of women in the wealthiest quintile delivered with a skilled health provider, only 11 percent of women in the poorest quintile obtained such assistance.

Institutional delivery rate, the proportion of all births in a health facility, is a subset of “Skilled birth attendance”, and usually lower than it. It should be the ambition of all health systems to have all women giving birth in an institution capable of providing Emergency Obstetric and Newborn Care. Currently, according to the 2015 EmONC Needs Assessment, 48 percent of women in Timor-Leste deliver in health facilities, but only one quarter (25 percent) deliver in a functional EmONC facility.

1.2 Neonatal and Newborn Mortality in Timor-LesteNeonatal mortality, deaths of infants from birth to 28 days of life, is much easier to measure than maternal mortality because it is more frequent and less sensitive, and it is a classical internationally used indicator. Globally, 75% of neonatal deaths occur during the first week of life, and 25 to 45% in in the first 24 hours, the “very early newborn period”.

Figure 2 shows the trends of neonatal mortality rate between 1990 and 2015, and extends projected values till 2030, at the end of the SDG era. Again these values are approximate, probably underestimated, and subject to caution. However, they follow reasonable expectations, while not decreasing as fast as maternal mortality.

Figure 2: Trends in Neonatal Mortality in Timor-Leste between 1990 and 2015, and Projections till 2030

5 National Statistics Directorate and ICF Macro 2010.Timor-Leste Demographic and Health Survey 2009-10.

Source Levels and trends in child mortality 2015 UNICEF, WHO and World Bank

0

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30

40

50

1990 1995 2000 2005 2010 2015 2020 2025 2030

TrendsinNeonatalMortalityinTimor-Lestebetween1990and2015,andProjectionstill

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Table 2: Neonatal mortality rate in South East Asian countries in 2013 – All rates are per 1000 live births

Country NNMR 2000 NNMR 2013Newborn

Deaths 2013Stillbirth

rate First Day

mortality rate

Lao PDR 40 29 5 400 13 11

Myanmar 35 26 23 400 20 9

Timor Leste 37 24 600 14 10

Cambodia 36 18 6 600 18 6

Indonesia 22 14 66 000 14 5

Vietnam 17 13 17 700 12 5

Thailand 13 8 5 500 4 3

Source Levels and trends in child mortality 2015 UNICEF, WHO and World Bank

However, it would be far more interesting to measure and express very early newborn mortality, deaths during the first 24 hours, because it is closely linked with maternal mortality, and paradoxically less measured and less reported.

Newborn mortality, or very early neonatal mortality within 24 hours, the target of this report, has never been precisely measured in Timor-Leste, for reasons of inadequate quality of recording. Neonatal mortality, which comprises early and late neonatal mortality has been assessed as 25 per 1000 live births in the year 2010, and 22 in the year 2015 (with a wide confidence interval for the reasons highlighted above). It is difficult to assess the progress in newborn mortality but it is likely to have been very limited. One of the aims of this EmONC improvement plan of action is to address this neglected area of public health.

Similarly the measure of intrapartum mortality or intrapartum stillbirths, an interesting indicator of quality of intra partum care, has rarely been reported in Timor-Leste because of issues of underreporting and misclassification.

1.3 Policy contextIn Timor-Leste, the policy environment concerning MNH is very enabling: Since 2000 the Government has publicized its commitment to the MDGs 4 and 5, and demonstrated very positive improvements. The National Health Sector Strategic Plan covering 2011 to 2030 has been augmented by the National RMNCAH Strategy 2015-2019, encouraging institutional delivery, guaranteeing free services for all at the point of delivery, and offering a reasonable standard of staffing for Referral Hospitals, Community Health Centres, CSIs and Health Posts with teams of midwives and medical doctors. The results of this policy have been impressive, but lots of challenges remain.

In terms of neonatal mortality rate (NNMR), Table 2 shows that Timor-Leste was doing better in 2013 than Lao PDR and Myanmar, but remained far from Indonesia, Cambodia, Vietnam and Thailand.


Besides Municipality health budgets on the rise, the central level of the MoH remains responsible for national programs, for both budget and financing. The national policy on human resources for MNH is coherent, but must take into account the inconsistencies in pre-service training, both for midwives and for doctors, with serious gaps in practice, that will be addressed in this Improvement Plan of Action (IPA).

The health system in Timor-Leste rests on a pyramid of interlinked facilities, as shown in the figure 3.

Figure 3: Network of government facilities providing maternal health services

LEVELS DESCRIPTION OF DIFFERENT LEVELS

Level 4 Central Level or National hospitals (Tertiary level services)

The National Hospital situated in the capital Dili is the principal tertiary care institution that provides specialist care for the whole population of Timor-Leste;

Level 3 Referral hospitals

There are 5 referral hospitals. They also provide municipality coverage to the adjacent municipalities;

Level 2 Community Health Centres and CSIs

There are 59 Community Health Centres (CHCs) and 8 Centro Saude Internamento; CSIs differ from CHCs as they have inpatient facilities and generally can keep a patient for about three days There are 7 CSIs in each of the municipality without a Referral Hospital and Ainaro;

Level 1 Health Posts (Primary Health Care Level)

There are 252 health posts which are divided into two categories. The Health post is a basic unit for providing Primary Health Care services at village (suco) level and provides outpatient care;

Community level Communities

PHC guidelines discuss about domiciliary visits by the staff of the health post; two visits /year with more frequent visits to high risk families.


Item EmOC NA 2008 EmONC NA 2015 remarks

Selection of facilities to be assessed

6 Hospitals + 65 CHCs = 71 facilities in 13 districts

6 Hospitals + 8 CSIs + 59 CHCs + 2 Private hospitals = 75 facilities in 13 districts

Choice of toolsPerformance of Signal Functions 12 months before assessment

Performance of Signal Functions 12 months before assessment

For comparability.3 months was not realistic

Indicator 1 Availability/ 500.000 population

4.6 EmONC Facilities per 500,0002.8 CEmONC Facilities 4 BEmONC Facilities only

3.7 EmONC facilities per 500,0002.6 CEmONC2 BEmONC Facilities only

Fewer functional BEmONC facilities in 2015

Indicator 2Geographic Distribution

7 Municipalities have no functional EmONC Facilities

7 Municipalities have no functional EmONC Facilities

No progress

Indicator 3Births in EmONC facilities

18% in all facilities12% in EmONC facilities

48% in all facilities25% in EmONC facilities

Progress; but should increase

Indicator 4Met Need for EmONC services

8% 53% in all facilities34% in EmONC facilities

Progress; but should increase

Table 3: Summary of the main progress in EmONC between 2008 and 2015 comparison of indicators collected during the EmONC Needs Assessments

1.4 Progress since 2008A landmark initiative took place in 2008 with the conduct and the publication of the first EmOC Needs Assessment, which marked the interest of the Government of Timor-Leste for improving maternal and newborn health6. The progress and remaining challenges in the implementation of the first improvement plan have been analyzed in the Second EmONC Needs Assessment completed 7 years later in 2015 (note that “N” for Newborn has been added).

Table 3 summarizes the changes in selected indicators when comparing data collected in 2008 and in 2015 and identifies gaps that make the basis of the present Improvement Plan of Action. Among other gaps, those in data collection due to insufficient quality of recording remain barriers to the reliability of some indicators.

6 EmOC Needs Assesment Report 2008


Item EmOC NA 2008 EmONC NA 2015 remarks

Indicator 5Cesarean sections

1.1% 3.5% Majority in DiliShould double

Indicator 6Direct Obs CFR 1.3% 0.9%

Not reliable; data quality poor

Indicator 7IPVENDR 0.4% 1%

Not reliable; data quality poor

Indicator 8% maternal deaths of Indirect Causes

12.5% 25%Not reliable; data quality poor

Most problematic Signal Functions

Blood transfusion, Assisted Vaginal Delivery, Anticonvulsant

Blood transfusion, Assisted Vaginal Delivery, Anticonvulsant

No change

Other services

Guidelines and protocols HMIS largely incomplete

HMIS incomplete, Poor availability and visibility of EmONC protocols

No progress

24/7, Referral,Communication Access problematic

Poor access for the poor, poor referral the newborn, travel time too long

Cell phone communication much improved

Human resources for Mat Health

21 CHCs have 1 MWUnderstaffing

All CHCs have >1 MW, >1 Dr. Misssing Lab Tech and Anesthetists

Progress in coverage

Drugs, Equipment and Supplies

No maintenance of equipmentMissing MgSO4

Stock outs +++, esp MgSO4Missing newborn resuscitation equipment

Little progress

Partograph Very poor compliancePoor compliance for AssisVaginDelivery and C/S

Some progress

C/S Reviews No data No prior data for comparison

MD Reviews No data No prior data for comparison

Expected births No data 40,486

MMR 317 215 UN estimatein italics: unreliable data



2. RATIONALE FOR EmONC IMPROVEMENT PLAN OF ACTION 2016 - 2019

In response to the review of the EmONC Needs Assessment conducted in 2015, a number of observations have been made, followed by recommendations. They focused on achievements but also on delays in implementation, on insufficient progress, on barriers to availability, accessibility, utilization and quality of EmONC services. Table 4 summarizes recommendations based on the results of the Assessment.

Table 4: Summary of recommendations stemming from the Needs Assessment conducted in 2015

Category Recommendations

1. Policy level

• Name a National EmONC Coordinator to oversee, coordinate and monitor the Plan of Action, ensuring that all inputs are aligned with the National Strategy ;

• Integrate EmONC into the wider approach of RMNCAH and existing health strategies;

• Highlight the Newborn, neglected until now;

• Set up targets for 80% of all births institutional and 60% in EmONC facilities by 2019;

• Address the lack of BEmONC facilities in priority, with 8 CSIs and 28CHCs to upgrade before 2019;

• Adopt and implement the Policy for Blood Transfusion; all CEmONC facilities should have stored blood 24/7 with a lab technician on site;

• Define national standards and norms for the management of EmONC, with a focus on providers performing signal functions;

• Plan the strategy according to the “Golden Rules”: No village more than two hours of a health facility and no health facility more than 2 hours travel time from a higher level referral EmONC facility;

• All facilities to be encouraged to keep patients in their premises before and after delivery either in maternity waiting homes or in wards where patients can receive or prepare food, have a minimum of comfort and dignity.



2. Enabling environment

• Advocate, show commitment for EmONC at highest level;

• Integrate EmONC in to the National Strategies and Health Sector Development Plan;

• Improve physical and infrastructural conditions of facilities for the comfort of patients (rooms and beds for pre-natal and post natal care, curtains, tap water, toilets and sanitation, cleanliness and infection control, etc).

3. Quality of care

• Standardize signal functions and other essential obstetric and newborn care and ensure that all providers follow the National guidelines and protocols;

• Ensure that all obstetric and newborn complications are recognized, diagnosed, properly recorded, and reported to HMIS by introducing uniform registers and records and ensure these complications are competently managed in fully functional EmONC facilities;

• Reinforce the concept and practice of “readiness” for all staff on duty, so that the third delay is less of a constraint.

4. UN indicators • Shift the benchmark for performing signal functions from 3 months to 12 months, to take into account local conditions.

5. Essential drugs supplies and equipment

• Review the Essential Medicines List to ensure that lifesaving medicines are available at all levels of facilities (antibiotics, oxytocics, anticonvulsants, details provided below);

• Ensure through periodic monitoring that no essential supplies, equipment and medicines are missing in EmONC facilities;

• Maintain an emergency stock (trolley or box) of key drugs (in operating theatres, labour wards and maternity wards) in all EmONC facilities, even where pharmacies are always open. The emergency stock could then be refilled when necessary.

6. Emergency communication and referral transport

• Review the communication system through cellphones and ensure vehicles are 24/7 ready to transport patients.

• Do not let patients by themselves in referral vehicles: accompany with qualified health staff.

• Train ambulance drivers in first aid and ensure their availability.



7. Human resources

• Reallocate midwives and doctors in BEmONC facilities according to standards (4 midwives and 2 doctors for facilities with less than 300 del per year, double if between 300 and 600, triple between 600 and 900, etc);

• Ensure that a general surgeon can perform C sections in the absence an obstetrician in CEmONC facilities;

• Ensure 24/7 coverage of services through a system of shifts.

8. Knowledge, training and supportive supervision

• Review the existing training materials and establish a national training package on BEmONC. Ensure that all midwives and doctors in EmONC facilities have had inservice BEmONC training;

• Establish at least three clinical training sites in the country with space, trainers, coaches, and equipment;

• Provide training opportunities, training equipment (anatomical models) and tutoring/mentoring in all large facilities, in order to maintain skills and quality;

• Strengthen the pre-service training of doctors and midwives to acquire the necessary knowledge and competencies on BEmONC;

• Integrate quality indicators on BEmONC into existing supportive supervision tools.

9. Partograph• Run frequent partograph reviews with senior supervisors to

improve quality and assist in decision making for assisted vaginal delivery and C section

10. Death reviews• Perform maternal and newborn death reviews to analyze

causes of death, prevent reccurrence, and improve quality of care.

11. Community involvement

• Suco and Aldeia chiefs to promote birth preparedness, institutional delivery and EmONC;

• Village Committees and local NGOs to raise awareness and utilization of EmONC;

• Health Posts to integrate EmONC in their PHC programme.


The present EmONC Improvement Plan of Action 2016-2019 responds to these recommendations and to an indepth examination of challenges. Vision, goal, purpose, objectives, targets and output are presented below.

2.1 VisionAll women in Timor-Leste go through pregnancy, childbirth and the postpartum period safely and all their newborns are alive and healthy. See the 2010 Declaration for Affirmative Action to Reduce Maternal and Child Death, Birth Rate and Teenage Pregnancy;

• “No Timorese mother will die needlessly from pregnancy and childbirth”

• “No Timorese baby will die needlessly before, during and after birth”

• “All Timorese women shall have access to correct and complete information and quality services to ensure their full maternal rights“

2.2 GoalTo sustain and further contribute to the improvement of maternal and newborn health in Timor-Leste towards the Sustainable Development Goals (SDGs).

2.3 OutcomeUniversal availability, coverage and utilization of quality EmONC services, not leaving any woman or any newborn in Timor-Leste unassisted.

2.4 Objectives and targetsBy the year 2019 :

• To have increased availability of EmONC facilities to cover rationally the whole country, with a network of interconnected EmONC facilities up to UN standards;

• To have ensured accessibility for all, including in the remote parts of the country, according to the Golden Rule of two hours, through a functional referral system;

• To have ensured effective utilization of EmONC services to over 90% of the needs, through community participation, strong communication, effective referral, and delivery of quality services (the 3 delays);

• To have developed the capacity of DSMs and all level administrative services to plan, manage, monitor EmONC services;

• To have reached or surpassed the UN standards for the relevant EmONC process indicators, measured through a strengthened monitoring system.


2.5 Guiding Principles1. Evidence based

All components must be based on well known and proven interventions that have worked in other countries and have been the subject of international consensus.

2. Health system integration

The EmONC Improvement Plan of Action (IPA) must be fully consistent with and integrated into the National Health Strategies, building on existing programs, and not been perceived as a vertical program.

3. Partnership

The IPA remains connected with programs initiated and supported by the partners of the Ministry of Health but also must look for new partnerships.

4. Clear definition of roles and responsibilities

The plan must define clearly the roles and responsibilities of each category of staff, up to supervisors, managers and leaders. In turn, the persons must have agreed on their terms of reference and accepted responsibility for any mishaps (as well as for success).

5. Transparency and accountability

All staff must act in full transparency, so that they can be found accountable for the consequences of their decisions and interventions. A register of complaints can be placed in each facility for collecting facts against these principles, eventually leading to investigation.

6. Equity

At all steps of the chain of case management, attention will be given to equity in treatment and access, without discrimination or stigmatization.

7. Continuous monitoring and periodic evaluation

It is a duty of program managers and department heads to set continous monitoring procedures, so that they can keep an eye on the dashboard under their responsibility. Periodic evaluation is also warranted and must be integrated into the plan at each level, so that it does not require a whole new search for resources every time.


2.6 Outputs:Seven outputs are proposed to guide policy makers, program managers, development partners, training institutions, and service providers in the attainment of the objectives and reaching target.

Table 5: Seven outputs in the EmONC Improvement Plan

OUTPUT 1: Policies, norms and standards revised by adapting international standards and high level commitment and support demonstrated for the optimal delivery of EmONC services.

OUTPUT 2: Distribution of network of BEmONC facilities ensured and CEmONC facilities strengthened for effective coverage of all signal functions in all parts of the country.

OUTPUT 3: Human resources strengthened; Staff redistributed, competencies enhanced at all EmONC facilities prioritizing those serving as clinical training sites and job satisfaction ensured for the benefit of clients.

OUTPUT 4: Enhanced positive supervision, improved data recording and increased focus on newborn that has relatively been neglected so far for further strengthened systems to support increased utilization and continuous quality improvement of EmONC services.

OUTPUT 5: Referral system operationalized in all parts of the country with improved communication and conditions of transport so that no frontline facility should be at more than 2 hours of a referral facility.

OUTPUT 6: Management competencies strengthened at municipality and national level; EmONC coordinator appointed for improved planning, implementing and monitoring EmONC services; quality of data recording enhanced.

OUTPUT 7: Community involvement further strengthened through Primary Health Care program, village committees, Local NGOs, and community leaders (Suco and Aldeia Chiefs) for improved awareness and increased utilization.

The overall target of ALL births attended by a skilled attendant in or very near to a EmONC facility is still applying, but the concept of “skilled attendant” should be replaced by the more modern concept of “competent provider”, which entails a fully trained professional with a state recognized diploma and appropriate inservice BEmONC training. Competency is the sum of Knowledge+Skills+Attitude, and not merely the capacity to deliver a service. In addition, the plan should specify that midwives and doctors work as a team, so that they can help each other and cover the 24/7 time frame. Investing in midwives is the “best bet” in modern EmONC strategic planning.

Key interventions to achieve the seven outputs will be implemented synergistically at national and municipality levels, and regularly monitored through national meetings and municipality supervisory visits.


The three delays model will be kept in mind (delay to make decision to use the health facilities, delay to access the health facilities, and delay to provide services while in the health facilities). The emphasis however is on the third delay once the patient has arrived at a facility. Emphasis will also be put on the newborn that has been relatively neglected so far.

To the extent that the number of obstetric and newborn complications can be projected as estimates, it is possible to attach a unit cost to the management of each complication. An attempt has been made and is presented in Annex 12.

Table 6 recalls the 7 Basic EmONC signal functions and the additional 2 Comprehensive EmONC signal functions. The EmONC guidelines specify that in order to qualify for Basic or Comprehensive EmONC status, all the corresponding signal functions must have been performed in the 3 months before the survey. This rule has been modified to use the 12 month benchmark in view of the situation and population of Timor Leste.

Table 6: The Signal Functions of Emergency Obstetric and Newborn care

Signal Functions to be performed at all BASIC EmONC facilities

Signal Functions to be performed at all COMPREHENSIVE EmONC

facilities

1. Parenteral administration of Antibiotics ALL the BASIC Signal Functions, plus:

2. Parenteral administration of Oxytocics 8. Surgery, Cesarean section

3. Parenteral administration of Anticonvulsants (MgSO4) 9. Safe Blood Transfusion

4. Manual removal of Placenta

5. Removal of retained products through Manual Vacuum Aspiration,

6. Assisted vaginal delivery by vacuum extractor

7. Basic Newborn resuscitation with Ambu bag and mask

The Assessment’s most important finding was about the classification, availability and distribution of EmONC facilities (Basic and Comprehensive) in the country. As expected, 6 facilities were classified as CEmONC and well distributed, but the assessment found only 2 facilities responding to the definition of BEmONC, both in the Capital Dili (Comoro CHC and the private clinic Biropete).


None of the 8 CSIs and 58 out of 59 CHCs visited had not performed the whole set of basic signal functions in the year preceding the assessment. Table 7, Figure 4 and 5 show the details of this finding.

The first and most obvious conclusion stemming out of this finding is to improve this performance by upgrading a selection of facilities to the level of BEmONC.

Table 7: Availability of EmONC facilities by Municiplaity and Region

Region and Municipality

Population6

Based on Recommended UN 12 month standard for use in Timor Leste

Shortfall (GAP) CEmONC and BEmONC facilities

CEmONC BEmONC

Region 1: The standard for CEmONC facilities has been met. No further CEmONC facilities are required.

There is a serious gap in the coverage and distribution of BEmONC facilities.

At least 13 BEmONC facilities are recommended according to UN standards.

At least obstetric first aid needs to be offered where there is a gap in service delivery.

Every woman in Timor-Leste should be within two hours of help, if only to stabilise condition before referring on.

Baucau 124,061 1 0

Lautem 64,135 0 0

Viqueque 77,402 0 0

Total 265,598 1 0

Region 2:

Ainaro 66,397 1 0

Alieu 48,554 0 0

Manufahi 52,246 0 0

Total 167,197 1 0

Region 3:

Dili* 252,884 1 2

Ermera 127,283 0 0

Liquica 73,027 0 0

Manatuto 45541 0 0

Total 498,735 1 2

Region 4:

Bobonaro 98,932 1 0

Covalima 64,550 1 0

Total 163,482 2 0

Special Region:

Oecusse 72,230 1 0

Total 1,167,242 6 2

*Includes 2 private facilities in Dili

6 National Institute of Public Health and National Institute of Statistics, (2008) General Population Census of Timor-Leste


Figure 4: Map showing the distribution of 75 facilities assessed in 2015

Figure 5: Map showing the distribution of the functional EmONC facilities in 2015

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The “Golden Rules” specify that every woman in Timor-Leste should be able to reach an EmONC facility within 2 hours, and every frontline health facility should be within 2 hours of a referral facility.

It is estimated that 73% of maternal deaths occur as a result of direct obstetric complications7. The rest, called “indirect complications”, are the result of aggravation of pre –existing conditions.

The urgency required for the management of obstetric complications is highlighted in the following thumb rules:

If untreated, death occurs on average in:

2 hours : From postpartum haemorrhage

6 hours : From eclampsia

12 hours : From antepartum haemorrhage

2 days : From obstructed labour and pre-eclampsia

6 days : From infection

7 Lalesay at al global causes of maternal death: a WHO systematic analysis; Lancet global health 2014; 2; e 323-33


3. COMPONENTS OF THE EmONC IMPROVEMENT PLAN OF ACTION

3.1 Output 1 – Policies norms and standard in place for a supportive enabling environment

Table 8: Level of decision and components of the policies and enabling environment for the optimal delivery of EmONC services in Timor-Leste

Level Components

At national level -

Government of Timor-Leste

• Highlevelcommitmentandshowofinterest;

• raisevisibilitye.g.NationalSafeMotherhoodDay,mediacoverage,popularstars;

• Reviewof the legislation supportiveof incentives for retentionofprofessionalstaffinremoteposts.

National Level - Ministry of

Health

• High level commitment and show of interest with InternationalvisibilityandparticipationofDevelopmentPartners;

• Resourcemobilization–NationalBudget+Donors;

• Name an EmONC Coordinator and a Core Technical Group toreview Norms and Standards. Both should meet twice a year toreviewachievementsandaddressconstraints;

• Strategicguidanceandregulationfornewprocedures,newdrugsandnewequipment;

• Production/revision of Standards and Protocols for casemanagement;

• Production/revisionofstandardsforstaffingandtrainingdifferentlevelsofhealthfacilities;

• Overallmonitoringandevaluationatnationallevel,withanannualnationalreview;

• Centralmedicalstores–procurementanddistributionofequipment,drugsandsupplieswithwarningsystemstopreventstockouts;

• Pharmacyandlaboratories–StandardsandQualityControl;

• BloodBank–BloodTransfusion:EndorsementandImplementationof the Blood Strategy: expansion of the network of regionalstructuresandblooddepotsineachdesignatedCEmONCfacility;


Level Components

• Strengthening leadership forEmONCatMCHdepartmentandatMunicipalitylevel–DSMandDPHO-SMI;

• Selection of CHCs to upgrade as BEmONC facilities, accordingto criteria of population covered, travel time, resources, staffing,communicationforreferral.

Municipality Level

• Strengthening of PHC activities performed at Health Posts inrelationtoEmONC;

• Relationswithlocaladministrationsandcivilsocietyatcommunityandvillagelevel(Suco,Aldeia);

• ReconsiderPostingof staff, reshuffling ifnecessary, rotating,andmonitoringvacantposts;

• Regular monitoring of EmONC services: Annual Report withindicatorsofservicesdelivered;

• Organizationofthecommunicationandreferralsystem,regulationofvehicles,driversandmaintenance;

• PartnershipwithprivatesectorandNGOsregulation;

• Protectionofstaffifandwhennecessary,andpreventionofcrisis;

• Strengthenmanagementofresourcesatmunicipalitylevel.

3.2 Output 2 –Complete availability of EmONC facilities and their accessibility in all parts of the country: facilities and infrastructure

While therewasno lackof facilities, thefindingsof theAssessmenthighlighta severedeficitoffunctionalBEmONCfacilitiesinthewholecountry.ThenumberanddistributionofCEmONCfacilities isadequate,providedtheymaintain theirattention to improvingquantity and quality of services provided (the 9 CEmONC Signal Functions). A list ofmissingstaff,equipment,suppliesandmedicinesaswellasmissingcompetencieswerederivedfromtheassessmentdata,andcorrectivemeasureswillneedtobeimplementedbyhospitals’managementauthorities(ExecutiveDirectorandClinicalDirector).

TheselectionofCSIsandCHCstobeupgradedtobecomeBEmONCfacilitieshasbeenmadeinconsultationwiththeMunicipalityhealthauthoritiesusingcriteriaofpopulationcovered,distanceandtraveltime,staffingandreferralcapacity.ComoroCHCinDilithatwasfoundtobeafunctionalBEmONCfacilityistobemaintainedandimprovedinquality.


Table 9: Candidates for BEmONC upgrade in EmONC Plan of Action 2016-2019: 8 CSIs and 28CHCs)

Region MunicipalityREF

HOSPITALCSI

CHC priority 1

CHC priority 2

CHC priority 3

CHC priority

4

1

BAUCAU Baucau* Quelicai** Baguia

LAUTEM Baucau LosPalos Iliomar Luro

VIQUEQUE Baucau Viqueque Uatulari Lacluta Uatucarbau

2

AILEU Maubisse AileuVila Remexio

AINARO Maubisse*AinaroVila

Hautio***

MANUFAHI Maubisse Same Fatuberlihu

3

DILI**** HNGV Atauro Becora VeraCruz Centro

ERMERA Gleno Gleno Atsabe Hatolia

LIQUICA HNGV Liquica Fatumasi Maubara

MANATUTO HNGV Manatuto Laclubar Natarbora

4BOBONARO Maliana Lolotoe Atabae Bobonaro

Marco(caliaco)

COVALIMA Suai* Zumalai Tilomar Fohorem

SpR OECUSSI Passabe

*Candidates for 3 more Clinical Training Centres ** Will be upgraded to CSI*** KOICA has already committed**** Comoro CHC in Dili Municipality that was found to be a functional BEmONC facility to be improved in quality

InviewoftheVisionthatultimatelyALLbirthsshouldtakeplace inanEmONCfacility,and according to all international recommendations, it makes sense to stop investinginfacilitiesforsocalled“normaldeliveries”thatarenotwellequipped,notwellstaffedand not well connected. Therefore it is not recommended to invest further in labourroomswithinHealthPosts.TheHealthPosts,however,shouldbeupgradedtoCentresofExcellenceforpreventive,educativeandsurveillanceactivities:AnteNatalCare,PostNatalCare,FamilyPlanning,otherRHpathologies,HIV/AIDS,andcounselling.MidwivesandGPsarethemostsuitedpersonneltoperformthesefunctionsclosetothecommunity.


Mostfacilitieswillneedeffortstoupgradecomfortand“humanization”fortheirclients:It isnotacceptable tohaveBEmONCfacilities (oranyhealth facility)withoutaproperandfunctionalwatersystem,toilets,sewage,refusedisposal,electricsystem,incinerator,used needle containers, decent furniture and all items serving thematernity. Similarlyfacilitymanagerswillhavetohaveafreshlookatlabourrooms,(light,space,furniture,basicequipment,postersandwallchartsonthewalls,wheelchairs,dignitycurtains).Theequipmentrequiringmaintenancemustbedealtwithwithoutdelay,andatechnicianmustbeavailableatalltimes.Largerfacilitiesmusthaveafulltimetechnician(ortechnicians)andaworkshoplocatedonthepremises.Thistechnicianmustbeavailabletovisitperipheralfacilitieswheneverrequested.

Inaddition,inanticipationofanincreaseinnumberofpatients,itisnecessarytorevisittheflowofpatients,waitingrooms,post-natalward,spaceforaccompanyingfamilymembers,restingplace fordutystaff,aswellas the intrafacility transportationnetworke.g. fromlabourroomtooperationtheatreorfromoperationtheatrebacktomaternity.Seeannex9forminimuminfrastructuralenablingenvironment.

Maternity waiting homes (MWHs)

TheEmONCNeedsAssessment2015didnotspecificallyexplorethepresenceofMWHsinTimorLeste.AfewMWHshavebeeninstalledinsomeDistrictsonapilotbasis(inSameandLospalos).Abefore-and-afterdistanceanalysisoftheuseofthefirsttwomaternitywaitinghomestobeimplementedinTimor-Lestehasdemonstrtaedthatcontrarytoitsobjectives,thestrategyofimplementingsuchhomesdidnotresultinahigherproportionof women from remote areas giving birth in health facilities in Lospalos and Same8.Meanwhile ithasbeendemonstrated inothercountries thatMWHsareusefulonlyoncertainconditions:1)Theymustbelocatedinthepremises(orliterally“acrosstheroad”fromEmONCfacilities.Sothattheparturienthasnotransportproblemwhencomesthetimetoreachthematernity;2)Theymustbemanagedinsuchawaythatthefamiliesfindthem sufficiently comfortable and appealing,with cooking place, cleaning equipment,andsecurity.ItissometimespreferabletogivethemanagementofMWHstolocalNGOs(althoughthisoptionmaynotbesustainable).

In Timor-Leste, a prenatal room installed near to the labour room in each facility isconsideredafeasibleoptionasthecostismanageable.

Equipment

TheessentialequipmentforeffectivedeliveryofEmONCserviceswillberevisedattheearlystagefortheImprovementPlan,withafocusonnewequipmentjudgedessentialor just usefulby theTechnicalCommitteeof theMoH.Special attentionwill begiventoequipment foradvancednewbornresuscitation inComprehensiveEmONCfacilities.(laryngoscopes,positivepressuremachines(CPAP),oxymeters)

Mobile battery operated incubators are often necessary to transport newborns withcomplications.

8 Kayli Wild, Barclay B b, Paul Kelly P and Martins N 2012. The tyranny of distance: maternity waiting homes and access to birthing facilities in rural Timor-Leste. Bulletin of the World Health Organization 2012; 90:97-103.


Standards forsurgicalequipment, includingsterilizationandanesthesia,willbe revisedinorder to includeotheremergencysurgicalproceduressuchashysterectomy,uterinerupture,ruptureofovariancysts,etc.

TheroleofultrasonographyinEmONCwillbereassessedandadjustedtoneeds,suchas identification of multiple pregnancies, identification of abnormal presentations andidentificationofdangerousmalformations.TheuseoffoetalDopplermustbeencouragedto detect and measure the foetal heart rate at admission, identify the presentation,detecttwins,andfollowFHRduringlabour.Thepurchaseofcheaperversionswillallowdistributingagreaternumberofdevicessothateverydeliverywardcanuseone.

Municipalityhealthauthoritiesmustensurethatallequipmentprovidedis installedandoperating:Mobilemaintenanceteamsshouldbeorganizedwithappropriatetransport,tools, instruction manuals and spare parts to visit all facilities and assist in rendingequipmentoperational.

Essential drugs and supplies

ThelistofessentialdrugsandsupplieswillberevisedbytheNationalTechnicalCommitteeandadjustedifnecessary.SpecialattentionwillbegiventoavoidshortagesandstockoutsofEmONCdrugsandsuppliesbyinstallingsoftwarescapableofsendingwarningswhenexpirydatesapproach.

The policies concerning certain drugs (Parenteral antibiotics including metronidazole,oxytocicsincludingmisoprostol,anticonvulsantsincludingMagnesiumSulphate)willneedtoberevisedbythesameCommitteetoallowtheirprescriptionbymidwivesinEmONCfacilities.

3.3 Output 3 –Technical and managerial capacity strengthened to ensure high quality of care:Staffing and training

Teambuildingand teamworkare crucial componentsof theEmONCservicedelivery.Regularstaffmeetingsarerecommendedforteambuildingandforconstructivereviewofcomplicatedcases.

Staffingstandardswillberevisedtoensureavailabilityofstaff24/7forfulldeliveryofqualityservices.At least 4 midwives and 2 doctorsshouldstaffaBEmONCfacilityperforminglessthan300deliveriesperyear,anddoublethesenumbersformorethan300deliveriesperyear,andtriplebetween600and900deliveriesperyear,etc.Inthiscase,therearealwaystwocompetentprovidersworkinginteamsduringeachshiftofduty.


Box 1 Proposed Staffing Levels for EmONC Teams

Table 10 below provides the balance between the actual numbers of midwives anddoctors in thematernitiesof the36candidates forupgrade intoBEmONC facilities. Ifitwaspossible to reshuffle toa certainextent theactualmidwivesanddoctorswithintheir region, itwouldmeanthat35midwivesaremissingand27doctorsare inexcess(totheextentthatthequestionsaboutdoctors’availabilityhavebeenwellunderstoodduringtheassessment).Similarly,Table11showstheactualandrecommendedstaffinginthehospitalsofthecountry,indicatingadeficitof19doctorsbutanadequatenumberofmidwives.TheEmONCPlanofActioncontributes,butisnottheonlycontributor,toplanningpre-servicetrainingofhumanresourcesinthecomingyears.

1: BEmONC facilities with less than 300 deliveries per year

4midwivesand2doctorstotakeshiftsof12hoursinteamsPlus:CleanerandSecurityGuardandbackupstaff24hoursaday1or2driverstocoverfor24/7

2 BEmONC facilities with between 300 and 600 deliveries per year

8midwivesand4doctorstotakeshiftsof12hours(teamsoftwo)PlusauxiliariesinLabourroomPlus:InfectionControlOfficer,LabTechnicianandAssistants,PharmacistCleanerandSecurityGuardandbackupstaff24hoursaday1or2driverstocoverfor24/7

3: For facilities with more than 600 del per year :

Increaseto12midwivesand6doctors,etc

4: CEmONC facilities (presumably more than 600 deliveries per year, with many referred compllcations)

Atleast12midwivesand6doctorsworkingin12hourshiftsinteams,(oneextrateamifhighworkload)1Ob/Gynand1generalSurgeontocoverforOb/Gynabsences2TheatreNursesand1Assistant1CirculationNurse(extrapairofhandstogetthings),plus1extraforheavyworkload1Anaesthetistand1NurseAnaesthetist1LabtechniciantoensurebloodtestingandmatchingPlus:InfectionControlOfficer,LabTechniciansandAssistants,Pharmacist2driverstocoverfor24/71coach(seniororretired)whoisrespectedandexperiencedSeveralstudentstowatch,assist,becoachedatthebedsideandinthelabourward,andintheOperationTheatre


Table 10: Midwives and doctors actually present and needed in each candidate BEmONC facility (Type2-CSI;Type3-CHC)

Region Municipality Facility TypeN°

Births

Actual

MW

Actual

Dr

Norm

MW

Norm

Dr

Balance

MW

Balance

Dr

1 Baucau Quelicai 2 238 5 3 4 2 +1 +1

Baguia 3 215 1 1 4 2 -3 -1

Lautem LosPalos 2 586 10 7 8 4 +2 +3

Iliomar 3 48 1 2 4 2 -3 0

Luro 3 24 1 7 4 2 -3 +5

Viqueque Viqueque 2 383 7 4 8 4 -1 0

Uatulari 3 277 2 3 4 2 -2 +1

Lacluta 3 78 2 1 4 2 -2 -1

Uatucarbo 3 96 2 3 4 2 -2 +1

2 Aileu AileuVila 2 554 5 5 8 4 -3 +1

Remexio 3 177 4 3 4 2 0 +1

Ainaro AinarVila 2 199 7 6 4 2 +3 +4

Hautio 3 4 1 2 4 2 -3

Manufahi Same 2 370 8 2 8 4 0 -2

Fatuberlih 3 121 3 1 4 2 -1 -1

3 Dili Atauro 3 104 3 2 4 2 -1 0

Becora 3 557 17 9 8 4 +9 +5

VeraCruz 3 655 13 8 12 6 +1 +2

Centro 3 313 8 1 8 4 0 -3

Ermera Gleno 2 324 6 1 8 4 -2 -3

Atsabe 3 147 2 3 4 2 -2 +1

Hatolia 3 55 2 4 4 2 -2 +2

Liquica Liquica 2 304 4 1 8 4 -4 -3

Fatumasi 3 90 2 1 4 2 -2 -1

Maubara 3 176 5 1 4 2 +1 -1

Manatuto Manatuto 2 204 8 9 4 2 +4 +7

Laclubar 3 82 3 2 4 2 -1 0


Table 11: Midwives and doctors actually working in the maternities of the CEmONC facilities in Timor-Leste, and recommended numbers

CEmONC Facilities (Hospitals)


Births

Actual

MW

Actual

Dr

Norm

MW

Norm

Dr.Balance MW

Balance

Dr.

1 Baucau Baucau 1 1286 16 3 16 8 0 -5

2 Ainaro Maubisse 1 351 7 0 8 4 -1 -4

4 Bobonaro Maliana 1 655 12 1 12 6 0 -5

4 Covalima Suai 1 573 11 0 8 4 +3 -4

SpR Oecusse Oecusse 1 349 8 2 8 4 0 -2

3 Dili HNGV 1 4302 20 10 20 10 0 0

3 Dili Private 1 293 10 5 8 4 +2 +1

Total Hospitals 7809 84 21 80 40 +4 -19

Jobsatisfactionbeingacrucialfactorforretention,alleffortswillbemadetoimproveitatlowcost.“Takecareofyourstaff;theywilltakebettercareofyourpatients”.Studiesinallcountriesconcurtoshowtheimportanceoftheconditionsofworkandlifeonstaffretention.


Births

Actual

MW

Actual

Dr

Norm

MW

Norm

Dr

Balance

MW

Balance

Dr

Natarbora 3 23 2 3 4 2 -2 +1

4 Bobonaro Lolotoe 3 24 2 2 4 2 -2 0

Atabe 3 90 2 4 4 2 -2 +2

Bobonaro 3 60 2 3 4 2 -2 +1

Marco 3 76 3 3 4 2 -1 +1

Covalima Zumalai 3 154 3 6 4 2 -1 +4

Tilomar 3 150 1 3 4 2 -3 +1

Fohorem 3 48 1 1 4 2 -3 -1

SpR Oecusse Passabe 3 25 1 2 4 2 -3 0

Total 36 candidates BEmONC facilities

36 7031 149 119 184 92 -35 +27


ANationalTechnicalCommitteewillreviewtheNormsandStandardsforthemanagementofobstetricandNewborncomplications,adaptingtheinternationalstandardsprovidedbyWHOtothelocalspecificities.ThesameCommitteewillalsoreviewtheTrainingPackageforEmONCin-servicecurricula.TrainingneedsforEmONCwillberegularlyevaluatedbysupervisorsateachfacility,sothatallcadreswillbeappropriatelysenttotrainingsessions.Eachlargefacility(CEmONCfacilities)shouldhavemannequinsandanatomicalmodelsfor thepractical trainingof studentsandof the staffondutywhen idle.Coachingwillbedevelopedtoensurethatthebenefitsoftrainingareusefulinfurtherpractice,usingretiredseniorprofessionalswithupgradedcompetencies.

EmONC should become an essential part of pre-service education for midwifery andmedicine,sothatfreshlycertifiedmidwivesanddoctorshavebeenexposedtotheconceptbeforestartingtheirduties.

ItisessentialthatEmONCorientationandtrainingisalsodispensedtostaffotherthanmidwives,whoparticipateintheservicedelivery,suchasnurses,OTstaff,labtechnicians,managers,ambulancedrivers.

The participation of all concerned EmONC staff atMaternalDeathAudits andAuditsofNearMissedcases is stronglyencouragedandshouldbe formalized, inviewof thepowerfultrainingbenefitsoftheseprocedures.

TheEmONCtrainingand lifesavingskillscoachingshouldbeconducted inevery largematernitywithmannequinsandanatomicalmodels,inparalleltothedailyservice.

It is recommended to upgrade three (3) additional Clinical Training Sites, in 3 referralhospitals (Baucau, Suai and Maubisse) with training rooms and accommodationarrangementsfortraineesandcoaches.Theywillalsobeusedbystudents(medicalandmidwiferystudents)aswellasformidlevelprofessionalswhojustfinishedaspecializedtrainingsessionandneedcoaching.

Thisinservicetraining/coachingshouldbefocusedonlesspracticedsignalfunctionssuchasmanualvacuumextraction,manualremovalofplacenta,managementofpre-eclampsia,newbornresuscitation.


3.4 Output 4 - Increased Access and utilization of EmONC services: Strengthening service delivery –Quality

AllEmONCsignalfunctionsarelifesaving. Iftherearenotenoughpatientspresentingwitheachobstetriccomplications,supervisorsmustorganizesmallrefreshersessionstoremindstaffofthenecessaryprotocolsandpracticewithinstruments.

Allsignalfunctionsmustbeavailablewithoutdelay24hoursperdayand7daysperweek(24/7).Thecalendarofduties for thestaffmustbeavailable toall staffand frequentlysupervised.Measurestoreplaceinvalidorsickstaffmusthavebeenprepared.

TheMoHwillissueanddistributenationallyapprovednorms,protocolsandprocedurestomanageallpossiblecases:theseprotocolsaretaughtinclinicaltrainingsessions,buttheymustbeavailableinallunitsatalltimesforconsultation.

Accordingtoneeds,anumberofadditionalfunctionscanbeaddedinthelistoffunctionsreadytouseinEmONCfacilitiese.g.PMTCT,partograph,repairoftears,foetalmonitoringduring labor, dexamethasone and prematurity, antibiotics for premature rupture ofmembranes,KangarooMotherCare,NewbornCorners

Surgery

TheimprovementofEmONCandparticularlyCEmONCfacilitieswillleadtoanincreaseintheproportionofbirthsneedingaCesareansection(C-section).Thiswillneed:

1. Anincreaseinthenumberoftrainedsurgeons,andtrainedanesthetists,andtrainedinstrumentation.AllgeneralsurgeonsmustbecompetenttoperformC-section;

2. Improvementof the indications forC-section,especiallyonC-section for thesakeofthenewborn;

3. Improvementofthecapacityandauthorityofmidwivestodecidereferralandtoactuallyrefer;

4. Improvementofcommunicationsandreferralsystems;

5. Increasedattentiontoqualityoftheprocedure,infectioncontrol,andcareforadverseeffects.

TheincreaseinthenumberofCesareansectionsmustnotinduceanincreaseofthenumberof complications of C-section. Themore interventions themore risks, and the highertheneedforsupervising,checkingforquality,andpreventaccidents(sepsis,ruptureofarteries,haemorrhage,ruptureofscars,etc.)

Anotherareaforconsiderationisthepossibilityforobstetriciansandsurgeons,ifproperlytrained, toperformotheremergency surgicalprocedurese.g. hysterectomy for severePPH,explorationofhemoperitonium,uterinerupture,ruptureofovariancysts,repairoflargeperinealtears,andectopicpregnancy.


Blood transfusion

Asaprinciple,whenindicated,bloodshouldbetransfusedwithinonehourwithinCEmONCfacilitiesand2hourswhenrequestedbyBEmONCfacility.

TheNationalBloodBankStrategyshouldbeimplementedimmediately.Itisresponsibleforpoliciesandproceduresforcollectingblood,testing,grouping,crossmatchingandtransfusing.Blood shouldbe available24/7 at allCEmONC facilities, stored in specialfridgeskeepingsmallprovisionsofbagsofeachgroupforimmediateuse.

ThereshouldbeaLabTechnicianwith fullknowledgeofbloodtransfusionproceduresalwayspresentinCEmONCfacilities.

TrainingIssuesabouttestingandcrossmatching,qualitycontrol,testingforHIV,HepBandotherdiseasesareundertheresponsibilityofBloodBank, incoordinationwithhospitalmanagement.

Where is the “N” in EmONC?

The“N”inEmONChasbeentoooftenneglected,limitedtotheseventhsignalfunction“basicnewborncare”.Infactthissignalfunctionisonepartofacompleteseriesoflifesavinginterventions,collectivelyandjointlycalledEssentialNewbornCare(ENBC).Thisisapackageofinterventionsdeliveredtothemotherandthenewbornbetweendeliveryandthefirst3daysafterbirth.UNICEFhasalreadyinitiatedandwillcontinuetocontributetothissection.Box2andAnnex9detailtheinterventions.InthesamewayasMaternalDeathAudits,thereshouldbeNewbornDeathAudits,aswellasreviewsof“nearmisses”.

BOX - 2 Care for all mothers and newborns

Intrapartum and Immediate Newborn Care

(INC)

The First Embrace.Interventionsincludeimmediateandthoroughdrying;immediateskintoskincontact;appropriatelytimedcordclamping;andnonseparationofmotherandnewbornforearlyexclusivebreastfeeding.

Care for high risk mothers and newborns

Management of newborn infants who are not breathing despite thorough drying.Interventionsincludemanagementofasphyxiausingbagandmaskventilation.Carefullychecktherhythmandintensityofblowingviaobservationofthethoraxandabdomen.Checkforairleakagearoundface.

Expanded INC Prevention and management of prematurity–forpretermandlowbirthweight babies (7-8% of all newborns). Interventions include preventingunnecessaryinductionsandcaesariansections;antibioticsforprematurepre-laborruptureofmembranes;antenatalsteroids;tocolyticswhenindicated;andtheKangarooMotherCareapproach.

Care for Sick Newborns–forbabieswithbirthasphyxia,neonatalsepsisandcomplicationsofdelivery(10-15%ofallnewborns).Interventionsincludemanagement of asphyxia using bag and mask ventilation; identificationof babies at high risk, management of sepsis through antibiotics, andmanagement of other common problems i.e check for malformations,neurologicalexamination.


3.5 Output 5 – Referral system in place and operational in all parts of the country: Network of referral, communication and transport

Referralistheproductofthreefactorscommunication,roadsandvehicles.

InTimor-Lestemostmajorinter-municipalityroadsarenowbeingpavedandcanbeusedatallseasons.Alotofimprovementremainstobedoneinsecondaryroads.Thetelephonenetwork has also improved, now covering almost all villages and at least all locationswhereHealthPostsaresituated.Theambulancesandmultipurposevehiclesarenowmoreavailable,andthepopulationmayalsoinsomecasestakeadvantageofprivatevehicles,aswellaslocalsmallvehiclesinvillages.

Theminimumtraveltimeof2hoursfromanypointofthecountrytoahealthfacilityisrespectedinthegreatmajorityofvillages.Effortsshouldbemadetorespectiteverywhere.Theother“GoldenRule”specifiesthatallhealthfacilitiesshouldbelessthantwohoursfromahigherlevelreferralfacility.

Whatremainstobeconsiderablydeveloped,however,aretheconditionsofreferral,thecomfort of the patient, the competency of the accompanying personnel, the first aidtrainingofthedrivers,andthereceptionattheendpoint.

ThesepointsmustbesubjectedtoaseriesofauditsledbytheMunicipalityauthorities,andfollowedbyinstructionstominimizetherisksofdeathsduringtransport.

FirstaidtrainingofdriverscanbeperformedbytheRedCrossortheRoyalAustralianCollegeofSurgeons.MoreimportantistheobligationforeachreferralofemergencycasetobeaccompaniedbyanEmONCtrainedperson,equippedwithaminiemergencykitallowinghim/hertoprovidecomforttothepatient.

Many countries in theworld are nowequippedwith “CallCenters”, that is a toll freemobilephonenumberallowinganymidwifeorhealthpersonnelinaremotelocalityorinadifficultsituatione.g.facingaseverecomplication,toobtain24/7anadviceandasupporttohelpmakingthebestdecision.Acontractofhumanitariannaturewiththecellphonecompaniespresentinthecountrywouldprovidethefinancialsupportforsuchanetworkofcallcenters.


3.6 Output 6 –Municipality EmONC plans developed, fully operationalized and monitored by DSMs and MoH: Management, budgeting and financing

Managing an EmONC facility, particularly CEmONC, requires a strong backgroundof administrative processes, which is usually not present among medical doctors.Experience and specialized training are necessary, whichmay require the involvementofretiredmanagersandspecialistsinmanagementofhealthorganizations.It is indeedtheresponsibilityoftheMinistryofHealthandtheExecutiveDirectorstoensurepropermanagementoftheirEmONCfacilitiesandtoensuresupportivesupervision.

DSMsshouldalsoreceiveacertainamountofautonomytoraiseresourcesatmunicipalitylevelforimprovingEmONC.

Annualactivityplanswithcorrespondingbudgetsandannualreportsareessentialtoolsofagoodmanager

Quality control

ManagersareresponsibleforensuringthatqualityproceduresarefollowedforallEmONCservices. Infectioncontrol isoneof themost importantmeasures.AgoodexampleofastrategyforQualityImprovementisproposedinAnnex10.

Annex11alsoprovidesanexampleofamonitoringsheetthatDPHO-SMIofficersshouldapplytoallEmONCfacilitieseveryyeartomonitortheperformanceofsignalfunctions.

Maintenanceof teamspiritandconflictprevention/resolutionarealsoamongtheskillsneededfrommanagers.

3.7 Output 7 – Community participation strengthened for improved awareness and increased utilization of EmONC services

Thecommunityisthefirsttargetofaprogrammetoreducematernalandnewbornmortality.Itisthereforelogicaltoinvolveitsrepresentativesinawarenessraising,informationsharing,andqualitycontrol.

TheHealthPostsremainthemostimportantentitiestoensurecommunityparticipation,awareness,andallpreventiveandeducativeactivities. InthecontextofPrimaryHealthCare,doctorsandmidwivesperformantenatalandpostnatalhomevisits,duringwhichtheycanraiseawarenessofdangersigns,encourageinstitutionaldeliveryandfacilitatetransporttothenearestfacility.

VillagecommitteesaswellaslocalNGOsshouldalsoparticipateintheawarenessofthepopulationaboutEmONC.



4. EXECUTION, CALENDAR, AND IMPLEMENTATION RESPONSIBILITIES

The EmONC improvement Plan of Action covers four years, and not everything can be implemented at once or the first year. It will be the responsibility of DSMs and their DPHO-SMI to build Annual Plans at the beginning of each year and to prepare Annual Reports at the end of each year. As an example, it may not be possible to upgrade all desired BEmONC facilities in a municipality the first year. Priorities have to be fixed. The table on “candidates for upgrade” can be used to indicate priorities over the 4 years. Maps have been prepared to help planning the networks. Regional and municipality maps are presented in Annex 14.

The MCH Department remains the focal point for implementation and monitoring and evaluation of the EmONC Improvement Plan, as well as keeping an eye on finances. They will receive continuous support and technical assistance from international donor agencies.

To that effect, an attempt will be made to cost the management of each obstetric and newborn complication, and estimate the incidence of each complication.

Table 12 Indications of the order of priorities and calendar distribution of implementation

Items Year one Year two Year three Year four

Policy decisions

and Enabling Environment

- Name a National EmONC Coordinator

- Establish National EmONC Technical Committee to review Norms and Standards, including for staffing, training and management

- Enact Blood Transfusion Strategy and implement it with WHO technical Assistance

- Instructions to DSMs to start upgrading action

- Revise and introduce uniformized Registers to monitor EmONC, in coordination with HMIS

- Issue national norms and guidelines for Referral (Golden Rules) using the same Technical Committee

- Monitor implementation

- Disseminate quality improvement strategy

- Review general situation and adjust for pending priorities

- Calculate EmONC Process indicators

- End of Plan of Action Evaluation

- Plan a national assessment focusing on Signal Functions

Upgrading facilities to BEmONC :

infrastructure

- Finalize selection of Candidates for upgrade, prioritize.

- DSMs to initiate infrastructural work in priority facilities

Continue infrastructural work in second priority facilities

Continue infrastructural work in third priority facilities

Continue infrastructural work in fourth priority facilities



Strengthening CEmONC facilities

- Initiate infrastructural improvements in all CEmoNC

- Review surgical conditions

Human Resources Staffing/Training

- Review essential staffing of selected BEmONC facilities and reshuffle staff if /when/where necessary

- The National Technical Committee for EmONC will standardize BEmONC inservice Training Package

- Recruit trainers and tutors for clinical training from among senior midwives from all municipality

- Start BEmONC training - Review Pre-service Training to

include BEmONC for Doctors and Midwives, with University of Timor-Leste and Directors of Schools

- Review staffing in view of increased activity of facilities and react accordingly

- Supervise staff performance and provide coaching where necessary

- Continue BEmONC Training



- Continue BEmONC Training



Equipment and Supplies

- Collect and review lists of missing equipment/supplies provided by candidates facilities and start procurement

- Send maintenance units to facilities

- Supervise distribution and utilization of old and new equipment and supplies

- Review missing and non-functioning equipment and supplies: respond.

- Review missing and non-functioning equipment and supplies: respond

Procurement and

distribution of EmONC medicines

- Collect and review lists of missing medicines provided by candidate EmONC facilities and start procurement

- Set up monitoring and warning systems to prevent stock outs

- Supervise distribution and utilization of medicines

- Check Emergency Trolleys in labour rooms





Referral - DSMs Review human and material resources for referral

- Order missing vehicles and spare parts

- Initiate First Aid training for drivers

- DSMs Review human and material resources for referral

- Implement First Aid training for drivers



Quality Improvement

- Start planning supervision teams to review quality at all levels of EmONC management. Involve Medical Association and Midwives Association

- Respond to needs identified by supervision visits





Partograph - Review deficiencies and plan remedial action at National and municipality levels

- Implement remedial actions



Maternal/newborn

Death Reviews

- Review deficiencies and plan remedial action at National and municipality levels




Community Involvement

- MoH to link with Ministry of Local Administration to involve Suco and Aldeia Chiefs in awareness and promotion of EmONC in their communities

- MoH issue circulars and instructions to Health Posts to raise awareness and utilization of EmONC facilities

- Liaise with local leaders and local civil society organizations to raise awareness and utilization of EmONC

- Implement community involvement around EmONC facilities








5. COSTING, MONITORING AND EVALUATION

5.1 Executive summary of the Costing Report In order to be implemented and supported by development partners, the EmONC Improvement Plan of Action (IPA) was costed.The costing of the following components were considered;

1. Costing of additional infrastructure, to build, including pre-natal rooms

2. Cost of upgrading the BEmONC candidate facilities (rehabilitation)

3. Cost of remunerating newly recruited health workers

4. Cost of purchasing and distribution (logistics) of drugs and supplies required by the additional patients (pregnant mothers and newborns) presented to BEmONC and CEmONC facilities resulting from improvement plans of actions;

5. Costing of Programme Management functions (including developing norms, standards and other guidelines development, capacity building, system reorientations, community awareness/advocacy, M & E activities, and supply logistics), presented at national level and not by municipality.

WHO One Health Tool (OHT) was used for the cost estimates. Unit costs were obtained from relevant Directorates of Ministry of Health, values presented in the IPA, the cost assumptions used in the RMNCAH strategy 2015-2019 cost assessment report, UNICEF and UNFPA product catalogues, and OHT default data base. For few items, for which the unit cost was not available from any of the above sources, respective costs were obtained by perusing the commercial costs quoted in the internet.

Findings are summarized by 13 Municipalities, with the exception of the program management cost, which is estimated at national level.

The total estimated cost for implementing the Improvement Plan of Action (IPA) over 4 years will be around 7,983,081 US $ (Table 13). The expenditure will be highest during the first 2 years, which will be around 2.6 and 2.2 million US$ respectively (Table 13). This is because investments related to priority one and two BEmONC institutions, will be made during these 2 years. Year 3 and 4 require around 1.98 and 0.9 million US$ respectively.

At Municipality levels, infrastructure construction, rehabilitation and utility costs together became the largest cost driver, which is around 2.4 million US$ (34%). Equipment supplies also amounted to 2.2 million US$ (31%). Human resource salaries amounted to 2 million US$ (28%) while the incremental cost of drugs and supplies required for IPA will be around 0.5 million US$ (7.4%) (Table 14)

Figure 6 shows how different cost elements drive total cost over time.


Figure 6 Distribution of costs over time

Municipality Cost dimensions Year 1 Year 2 Year 3 Year 4 Total

Aileu

Drugs & Supplies 4,815 5,045 5,257 5,445 20,562

Human resource costs 24,000 24,000 24,000 24,000 96,000

Equipment cost 14,249 22,297 - - 36,546

Infrastructure construction cost (pre-natal rooms)

33,000 33,000 - - 66,000

Infrastructure rehabilitation cost

6,784 20,086.00 - - 26,870

Infrastructure utility cost (Pre -natal rooms)

1,650 3,300 3,300 3,300 11,550

Total for the Municipality 84,498 107,728 32,557 32,745 257,528

Table 13 Summary of the estimated costs over four years by Municipality

Sub-Total 2,675,443 2,258,694 1,950,806 1,098,138TOTAL 7,983,081

Year1 Year2 Year3 Year4Drugs&supplies 105,368 126,390 146,583 165,643

Humanresourcecosts 347,856 500,233 615,073 615,073

Equipmentcost 727,889 826,591 612,931 67,197

Infrastructureconstructioncost(Pre-natalrooms) 951,000 390,000 291,000 33,000

Infrastructurerehabilitationcost 313,590 95,421 82,774 12,362

Infrastructureutilitycost(Pre-natalrooms) 47,850 67,650 84,150 80,850

Programmemanagementcost 181,890 252,409 118,295 124,013

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000



Ainaro

Drugs & Supplies 5,546 7,005 8,571 10,242 31,364

Human resource costs 51120 69480 69480 69480 259560

Equipment cost 91,112 90,943 - - 182,055


66,000 33,000 - - 99,000


34,659 3,500 - - 38,159


3,300 4,950 4,950 4,950 18,150


Baucau

Drugs & Supplies 10,072 10,852 11,594 12,287 44,805


Equipment cost 13,135 109,320 - - 122,455

Infrastructure construction cost (pre-natal rooms) 148,500 33,000 - - 181,500

Infrastructure rehabilitation cost 3,734 3,734 - - 7,468

Infrastructure utility cost (Pre -natal rooms) 7,425 9,075 9,075 9,075 34,650




Bobonaro

Drugs & Supplies 8,067 10,100 12,073 13,961 44,201


Equipment cost 8,453 63,806 105,456 - 177,715

Infrastructure construction cost (pre-natal rooms) 148,500 33,000 66,000 - 247,500

Infrastructure rehabilitation cost - 24,137 34,748 - 58,885



Covalima

Drugs & Supplies 6,841 7,332 7,792 8,214 30,179


Equipment cost 87,228 95,717 93,899 - 276,844


148500 33000 33000 - 214,500


1650 6355 13475 - 21,480


7,425 9,075 10,725 10,725 37,950




Dilli

Drugs & Supplies 35,099 39,603 43,929 47,999 166,630


Equipment cost 111,172 73,363 86,200 67,197 337,932

Infrastructure construction cost (pre-natal rooms) 33000 33000 33000 33000 132,000

Infrastructure rehabilitation cost 3,860 5,775 3,980 12362 25,977



Ermera

Drugs & Supplies 7,565 11,223 14,484 17,271 50,543


Equipment cost 47,583 97,413 22,903 - 167,899


Infrastructure rehabilitation cost 6,835 7,026 4,294 - 18,155





Lautem

Drugs & Supplies 5,479 6,483 7,454 8,378 27,794


Equipment cost 65,559 62,373 88,706 - 216,638


Infrastructure rehabilitation cost 127,500 3,664 - - 131,164



Liquica

Drugs & Supplies 5,427 7,184 8,894 10,537 32,042


Equipment cost 30,946 36,377 99,082 - 166,405



Infrastructure utility cost (Pre -natal rooms) 1,650 3,300 4,950 - 9,900




Manatuto

Drugs & Supplies 2,975 3,962 4,924 5,847 17,708

Human resource costs - 6,120 18,360 18,360 42,840

Equipment cost 12,386 42,937 42,334 - 97,657





Manufahi

Drugs & Supplies 1,883 2,281 2,667 3,035 9,866


Equipment cost 77,620 73559 - - 151,179

Infrastructure construction cost (pre-natal rooms) 33000 33,000 - - 66,000

Infrastructure rehabilitation cost 32,899 7299 - - 40,198

Infrastructure utility cost (Pre -natal rooms) 1650 3,300 3,300 3,300 11,550




Oecusse

Drugs & Supplies 5,059 7,420 9,727 11,953 34,159


Equipment cost 31,359 - - - 31,359

Infrastructure construction cost (pre-natal rooms) 148500 - - - 148,500

Infrastructure rehabilitation cost* NA NA NA NA NA

Infrastructure utility cost (Pre -natal rooms) 7425 7,425 7,425 7,425 29,700


Viqueque

Drugs & Supplies 6,540 7,900 9,217 10,474 34,131

Human resource costs 24000 36,240 48,480 48480 157,200

Equipment cost 137,087 58,486 74,351 - 269,924

Infrastructure construction cost (pre-natal rooms) 66000 33,000 33,000 - 132,000


Infrastructure utility cost (Pre -natal rooms ) 3300 4,950 6,600 6,600 21,450


All 13 Municipalities

Total cost from all cost elements

2,493,553 2,006,285 1,832,511 974,125 7,306,475

Overall program management cost -

As national estimate181,890 252,409 118,295 124,013 676,607

Grand Total for IPA implementation 2,675,443 2,258,694 1,950,806 1,098,138 7,983,081 Engineering unit was unable to to visit Oeucusse to callect this data


The following radar chart (Figure 7) and Table 14 describes the cost of proposed improvement plans of actions according to their relative sizes of expenditures by different cost elements. It shows that infrastructure construction costs in Bacau, Bobonaro, Covalima and OeCusse Municipalities. The reasons for these high estimates are the building of new training sites in these institutions. The equipment costs of Municipalities that have relatively larger number of EmONC institutions seemed to be relatively high. (E.g. in Dili, Viqueque)

Figure 7 Radar chart showing relative costs related to different cost elements by Municipality


Tabl

e 14

Est

imat

ed c

ost o

f IPA

in th

e M

unic

ipal

ities

by

cost

com

pone

nts

Mun

icip

ality

D

rugs

&

Supp

lies

Hum

an

reso

urce

co

sts

Equi

pmen

t co

st

Infr

astr

uctu

re

cons

truc

tion

cost

(pre

-na

tal r

oom

s)

Infr

astr

uctu

re

reha

bilit

atio

n co

stIn

fras

truc

ture

util

ity

cost

(Pre

-nat

al ro

oms)

Tota

l

Aili

eu20

,562

96

,000

36,5

4666

,000

26,8

7011

,550

257,

528

Ain

aro

31,3

64

2595

6018

2,05

599

,000

38,1

5918

,150

628,

288

Bauc

au44

,805

96

,000

122,

455

181,

500

7,46

834

,650

486,

878

Bobo

naro

44,2

0117

8,56

017

7,71

524

7,50

058

,885

41,2

5074

8,11

1

Cova

lima

30,1

7929

0,16

027

6,84

421

4,50

021

,480

37,9

5087

1,11

3

Dili

166,

630

24,4

8033

7,93

413

2,00

025

,977

19,8

0070

6,82

1

Erm

era

50,5

4328

2,60

016

7,89

999

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18,1

5514

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633,

047

Laut

em27

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140,

760

216,

637

90,0

0013

1,16

414

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621,

205

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ica

32,0

4220

9,16

016

6,40

599

,000

31,4

609,

900

547,

967

Man

atut

o17

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42,8

4097

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90,0

0011

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14,8

5027

4,80

9

Man

ufah

i9,

866

71,9

5515

1,17

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40,1

9811

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350,

748

Oec

usse

34,1

5922

8,96

031

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148,

500

029

,700

472,

678

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uequ

e34

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157,

200

269,

924

132,

000

92,5

7721

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707,

282

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l 5

43,9

84

2,0

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35

2,2

34,6

09

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00

504

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80,5

00

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Perc

enta

ge7.

428

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93.

810

0.0


5.2 Monitoring and evaluationMonitoring is an on going activity, while evaluation is periodic and intermittent. Both must be integrated in the annual plans, and funds must be set apart for these activities.

It is the responsibility of the DSMs to monitor and evaluate the implementation of the EmONC program, and monitor it in coordination with HMIS and DHIS 2.

It is recommended to conduct a mini survey of signal functions performed at each BEmONC facility every year to follow progress and identify training needs. A sample of a monitoring form is provided in Annex 11. The AMDD has proposed a methodology for a mini EmONC assessment that might be worth considering.

Monitoring quality is also part of the responsibility of managers: A Quality improvement initiative is presented in Annex 10.

A midterm Review is proposed at the end of second year of implementation, with a focus on availability, access and utilization of EmONC in each municipality. Remaining gaps and challenges will need to be addressed in the following two years.

Indicators and Log frame are presented in Annexes 1 and 5, respectively



6. ANNEXES

Annex 1 - Process Indicators

Annex 1 Table 1: Summary of the EmONC Process Indicators (PI) and calculation

PI Indicator Description Numerator Denominator Acceptable Levels

1 & 2 Availability of EmONC facilities and geographic distribution (national or Municipality)

Ratio of facilities providing EmONC to population and geographical distribution of EmONC facilities

No. of facilities providing Basic or Comprehensive EmONC

Population of area divided by 500,000

≥ 5 EmONC facilities per 500 000 population

No. of facilities providing Comprehensive EmONC

Population of area divided by 500,000

≥ 1 Comprehensive per 500 000 population

3 Proportion of all births in EmONC facilities

Proportion of all expected births in EmONC facilities In catchementarea

No. of women giving birth in EmONC facilities in specified time period (1 year)

Expected no. of births in the same catchment area in same time period

15% to 100% (if ALL births should take place in EmONC facilities)

4 Met Need for EmONC

Proportion of women with direct obstetric complications treated at EmONC facilities

No. of women with major direct obstetric complications treated in EmONC facilities in specified time period

Expected no. of women with major direct obstetric complications in area in same time period (expected)

100%

5 Caesarean sections as a proportion of all births

Proportion of all births by Caesarean section taking place in EmONC facilities

No. of Caesarean sections in EmONC facilities in specified time period

Expected no. of births in area in same time period

5% – 15%

6 Direct obstetric case fatality rate (DOCFR)

Proportion of women with major direct obstetric complications who die in an EmONC facility

No. of maternal deaths due to direct obstetric causes admitted in EmONC facilitiy in specified time period

No. of women admitted and treated for direct obstetric complications in EmONC facilitiy in same time period

< 1%


PI Indicator Description Numerator Denominator Acceptable Levels

7 Intrapartum and very early neonatal death rate

Proportion of births that result in an intrapartum death or a very early neonatal death occurring within the first 24 hours in EmONC facilities

No. of intrapartum deaths (fresh stillbirths; > 2.5 kg) and very early neonatal deaths (≤ 24 hours; > 2.5 kg) in EmONC facilities in specified time period

No. of women giving birth in EmONC facilities in same time period

To be decided but normally < 1%

8 Proportion of maternal deaths due to indirect causes

Out of all maternal deaths in EmONC facilities, what % are due to indirect causes

No. of maternal deaths due to indirect causes in EmONC facilities in specified time period

All maternal deaths (from direct and indirect causes) in EmONC facilities in same time period

None set (depends on the local epidemiology)

Annex 2 – Summary findings of the EmONC NA in 2015

Indicator Finding UN standard/Comments

Current availability

of functional EmONC facilities

3.4 EmONC facilities per 500,000 population ≥ 5 EmONC facilities per 500,000 population

2.6 CEmONC facilities per 500,000 population Of which ≥ 1 Comprehensive per 500,000 population

Geographical distribution of functional

EmONC facilities

EmONC coverage is poor at the sub-national level. Coverage for CEmONC facilities is

sufficient but BEmONC coverage is largely insufficient

Seven Municipalities have no functional EmONC facilities

BEmONC is clustered around urban areas

27 (37%) of facilities assessed are more than two hours travel time from higher level referral

facilities

100% of sub-national areas have the minimum acceptable numbers of

basic and comprehensive EmONC facilities

Proportion of all births in EmONC

facilities

All facilities assessed

47.8% of all expected live births

Functional EmONC facilities

24.6% of all expected live births

Minimum should be 15% but the optimum should be close to 100%

Annex 2 Table 1: Indicators for all facilities assessed and for functional* EmONC facilities Timor-Leste 2015


Indicator Finding UN standard/Comments

Met need for EmONC

services


54.7 % of the expected number of women who will develop complications

Functional EmONC Facilities

33.8% of the expected number of women who will develop complications

100% of the estimated complications which is 15% of all

births

Caesarean sections as a

percentage of all births


3.5% of all births were by caesarean section


3.4% of all births were by caesarean section (1.6% if Dili was excluded)

Minimum 5% Maximum 15%

Direct Obstetric Case Fatality Rate

(DOCFR)


0.8 % of women treated with obstetric complications


0.9% of women treated with obstetric complications

Standard set at less than 1%

Note: This indicator is not reliable as maternal mortality data is

incomplete.

Intrapartum and very early

newborn death rate


0.7% of intrapartum and very early and late newborn deaths


1.0% of intrapartum and very early and late newborn deaths

Standard set at less than 1%

Note: The reliability of this data is questionable due to under reporting

Proportion of maternal

deaths due to indirect causes

All Facilities assessed

21.9% of total deaths from all indirect causes


26.9% of total deaths from all indirect causes

No standard set –depends on local epidemiology

Note: Data is questionable due to under reporting.


Annex 3 - Direct Obstetric Complications (DOC, to be used for process indicators 4, 6, and 8); Operational definitions and Signal Functions to manage themIt is highly recommended to enter the cause of admission to the maternity in a separate column in the Admission Register, using the below definitions.

Operational definitions of major direct obstetric complications

1. Antepartum Haemorrhage

• severe bleeding before and during labour: placenta praevia, placental abruption

2. Postpartum Haemorrhage (any of the following)

• bleeding that requires treatment (e.g. provision of intravenous fluids, uterotonic drugs or blood)

• retained placenta

• severe bleeding from lacerations (vaginal or cervical)

• vaginal bleeding in excess of 500 ml after childbirth

• more than one pad soaked in blood in 5 minutes

3. Prolonged or obstructed labour (dystocia, abnormal labour) (any of the following)

• prolonged established first stage of labour (> 12 h)

• prolonged second stage of labour (> 1 h)

• cephalopelvic disproportion, including scarred uterus

• malpresentation: transverse, brow or face presentation

4. Postpartum sepsis

• A temperature of 38 °C or higher more than 24 h after delivery (with at least two readings, as labour alone can cause some fever) and any one of the following signs and symptoms: lower abdominal pain, purulent, offensive vaginal discharge (lochia), tender uterus, uterus not well contracted, history of heavy vaginal bleeding. (Rule out malaria)


5. Complications of abortion (spontaneous or induced)

• haemorrhage due to abortion which requires resuscitation with intravenous fluids, blood transfusion or uterotonics

• sepsis due to abortion (including perforation and pelvic abscess)

6. Severe pre-eclampsia and eclampsia

• Severe pre-eclampsia: Diastolic blood pressure ≥ 110 mm Hg or proteinuria ≥ 3 after 20 weeks’ gestation.

Various signs and symptoms: headache, hyperflexia, blurred vision, oliguria, epigastric pain,

• Eclampsia: Convulsions; diastolic blood pressure ≥ 90 mm Hg after 20 weeks’ gestation or proteinuria ≥ 2. Signs and symptoms of severe pre-eclampsia may be present

7. Ectopic pregnancy

• Internal bleeding from a pregnancy outside the uterus; lower abdominal pain and shock possible from internal bleeding; delayed menses or positive pregnancy test

8. Ruptured uterus

• Uterine rupture with a history of prolonged or obstructed labour when uterine contractions suddenly stopped. Painful abdomen (pain may decrease after rupture of uterus). Patient may be in shock from internal or vaginal bleeding

Major complications Signal Functions or Life Saving Skills to manage them

Haemorrhage

If Antepartum: Cesarean section for placenta praevia – Blood transfusionIf Postpartum: Uterotonics

Manual removal of placentaRemoval of retained productsBlood transfusionEmergency surgery (Hysterectomy)

Annex 3 Table 1: Signal Functions used to manage the major Obstetric and Newborn complications


Major complications Signal Functions or Life Saving Skills to manage them

Prolonged or obstructed labor

Assisted vaginal delivery

Cesarean section

Uterotonics

Newborn resuscitation

Postpartum sepsis

Parenteral antibiotics

Removal of retained products

Surgery for pelvic collection drainage

Complication of abortion

Removal of retained products

Blood transfusion if hemorrhage

Parenteral Antibiotics

Pre-eclampsia and Eclampsia

Parenteral anticonvulsants (MgSO4)

Cesarean section

Newborn resuscitation

Ectopic pregnancy

Emergency surgery (laparotomy)

Blood transfusion


Ruptured uterus

Emergency surgery (laparotomy)

Blood transfusion


Newborn distress at birth

Newborn resuscitation (basic and advanced)

Cesarean section

Parenteral antibiotics on newborn

Intrapartum stillbirth Induction of labor (if not spontaneous)


Annex 4 - List of Municipalities with population (in 2014)

Municipality RegionPopulation (in 2014, before

Census)Expected.

Births per yearExpected

complications per year

Expected complications

per day

Baucau

1

122152 4214 632 2

Lautem 67690 2335 350 1

Viqueque 74907 2584 388 1

Aileu

2

51733 1785 268 1

Ainaro 67357 2324 349 1

Manufahi 55735 1923 288 1

Dili

3

312700 10788 1618 4

Ermera 133457 4604 691 2

Liquica 73131 2523 378 1

Manatuto 47521 1639 246 1

Bobonaro4

99954 3448 517 1

Covalima 65032 2244 337 1

Oecussi SpR 73716 2543 381 1

ALL TIMOR LESTE 1245085 42955 6443 18

Place of birth N %

Total Institutional births 21192 52.3

in Health Posts 1831 4.5

in 8 CSIs 2924 7.2

in 59 CHCs 7719 19.1

in 5 Referral Hospitals 3214 7.9

in National Hospital 4302 10.6

in 2 private facilities 1202 3.0

Estimated Home births 19294 47.7

Total estimativa nacidos 40486 100.0

Annex 4 Table 1: expected births and expected obstetric complications

Annex 4 Table 2: Summary of Births during one year as reported by the 2015 EmONC Assessment


Anne

x 5 -

Logf

ram

e – M

onito

ring

and

evalu

atio

n fra

mew

ork f

or o

utpu

ts

Out

puts

Obj

ectiv

ely

Verifi

able

In

dica

tors

Mea

ns o

f ve

rifica

tion

Targ

et 2

019

Act

iviti

esRe

spon

sibl

eTi

min

g

Out

put 1

Polic

ies

in p

lace

fo

r a s

uppo

rtiv

e

and

enab

ling

envi

ronm

ent f

or

EmO

NC

EmO

NC

Impr

ovem

ent

Plan

of A

ctio

n pu

blish

ed,

dist

ribut

ed, t

o al

l st

akeh

olde

rs in

clud

ing

in

13 M

unic

ipal

ities

Endo

rsem

ent l

ette

rsAl

l st

akeh

olde

rs

info

rmed

Advo

cacy

for i

ncre

ased

visi

bilit

y an

d fin

anci

al c

ontri

butio

n fo

r Em

ON

C ac

tiviti

es

Diss

emin

atio

n of

Em

ON

C Im

prov

emen

t Pla

n to

all

stak

ehol

ders

MdS

DSM

s

2016

Hig

h le

vel c

omm

itmen

t ex

pres

sed

in sp

eech

es,

artic

les,

TV e

vent

s

Med

ia,

Nat

iona

l Day

Advo

cacy

MoH

2016

- 20

19

Partn

ersh

ips e

stab

lishe

d,

MoU

sCo

ntra

cts a

nd

colla

bora

tive

agre

emen

ts

Advo

cacy

Reso

urce

mob

iliza

tion

MoH

2016

- 20

19

Mun

icip

ality

lead

ersh

ip

for E

mO

NC

Impr

oved

Min

utes

of m

eetin

gsfu

llAn

nual

Wor

kpla

ns, a

nnua

l Rep

orts

, su

perv

isory

visi

ts, s

uppo

rtive

ac

tiviti

es

DSM

s

% o

f Em

ON

C fa

cilit

ies

follo

win

g na

tiona

l st

anda

rds a

nd p

roce

dure

s

Mun

icip

ality

repo

rts10

0%Iss

uanc

e an

d di

strib

utio

n to

all

EmO

NC

faci

litie

s of s

tand

ards

and

pr

otoc

ols f

or st

affin

g, e

quip

men

t, an

d ca

se m

anag

emen

t

DSM

s20

16 -

2019

N° S

tock

outs

of e

ssen

tial

med

icin

es a

nd su

pplie

sEl

ectro

nic

data

base

s0

Vigi

lanc

e sy

stem

s put

in p

lace

Ce

ntra

l and

M

unic

ipal

ity

2016

- 20

19

Bloo

d av

aila

bilit

y 36

5/7/

24Re

cord

s of B

lood

tra

nsfu

sion

100%

Expa

nsio

n of

ope

ratio

nal B

lood

D

epot

s in

ALL

CEm

ON

C fa

cilit

ies

Bloo

d Ba

nk/

MO

H

2016

- 20

19


Out

puts

Obj

ectiv

ely

Verifi

able

In

dica

tors

Mea

ns o

f ve

rifica

tion

Targ

et 2

019

Act

iviti

esRe

spon

sibl

eTi

min

g

Out

put 2

Ava

ilabi

lity

and

acce

ssib

ility

of

EmO

NC

faci

litie

s an

d se

rvic

es, i

n al

l par

ts o

f the

co

untr

y

CEm

ON

C fa

cilit

ies

Mun

icip

ality

reco

rds

At le

ast 6

Hos

pita

l adm

inist

ratio

n /D

G to

re

view

stat

us a

nd n

eeds

Hos

pita

l H

eads

/MoH

20

16 -

2019

BEM

ON

C fa

cilit

ies

Mun

icip

ality

reco

rds

At le

ast 3

6 at

the

end

of

IPA

DSM

s to

sel

ect

for

upg

rad

ing

DSM

s20

16 -

2019

Out

put 3

Tech

nica

l and

m

anag

eria

l ca

paci

ty

stre

ngth

ened

to

ens

ure

high

qu

ality

of c

are

% o

f BEm

ON

C fa

cilit

ies

with

at l

east

4 m

idw

ives

an

d 2

doct

ors

DSM

reco

rds

100

%D

SMs t

o re

view

and

adj

ust

DSM

s20

16 -

2019

% o

f mid

wiv

es a

nd

doct

ors t

rain

ed o

n BE

mO

NC

INS

/ MoH

/ D

SM

reco

rds

100%

INS/

MoH

/DSM

s to

revi

ew a

nd

adju

stIN

S/H

ospi

tal

Hea

ds/D

SMs

2016

- 20

19

% o

f mat

erna

l and

ne

wbo

rn d

eath

s rev

iew

ed

thro

ugh

Audi

ts

MoH

/Hos

pita

l /D

SM

reco

rds

50%

MoH

/Hos

pita

l/DSM

s to

revi

ew a

nd

adju

stM

oH/

Hos

pita

l H

eads

/DSM

s

2016

- 20

19

Dire

ct O

bste

tric

Case

Fa

talit

y Ra

teFa

cilit

y re

cord

s, D

SM

reco

rds

< 1%

Impr

oved

iden

tifica

tion

and

reco

rdin

g of

DO

CFa

cilit

y m

anag

ers,

Hea

ds o

f ob

stet

ric

depa

rtmen

ts

2016

- 20

19

% o

f Em

ON

C fa

cilit

ies

with

an

infe

ctio

n pr

even

tion

prog

ram

in

plac

e an

d op

erat

iona

l

Faci

lity

reco

rds

100%

Impr

oved

follo

w u

p of

refe

rred

case

sD

SMs

2016

- 20

19


Out

puts

Obj

ectiv

ely

Verifi

able

In

dica

tors

Mea

ns o

f ve

rifica

tion

Targ

et 2

019

Act

iviti

esRe

spon

sibl

eTi

min

g

Out

put 4

Util

izat

ion

of

EmO

NC

serv

ices

by

all

in n

eed

% o

f birt

hs in

Em

ON

C fa

cilit

ies

Faci

lity

reco

rds

60%

Advo

cacy

and

boo

king

dur

ing

ANC,

Ref

erra

l sys

tem

ope

ratio

nal

DSM

s/ fa

cilit

y he

ads

2016

- 20

19

% o

f del

iver

ies b

y Ce

sare

an se

ctio

n Fa

cilit

y re

cord

s10

%Re

ferra

l sys

tem

ope

ratio

nal,

OTs

in

ord

er, S

urge

ons i

n pl

ace

24/7

An

esth

etist

s

DSM

s/

Hos

pita

l H

eads

2016

- 20

19

% o

f fac

ilitie

s im

plem

entin

g Es

sent

ial

New

born

Car

e

Faci

lity

reco

rds

100%

Tech

nica

l tra

inin

g in

New

born

car

eD

SMs/

H

ospi

tal

Hea

ds

2016

- 20

19

UN E

mO

NC

Proc

ess

indi

cato

r N° 4

: Met

nee

d fo

r Dire

ct O

bste

tric

Com

plic

atio

ns

DSM

s rec

ords

Faci

lity

reco

rds,

100%

Impr

oved

iden

tifica

tion

of D

irect

O

bste

tric

Com

plic

atio

ns

Impr

oved

refe

rral s

yste

m

Refe

rred

patie

nts a

re a

ccom

pani

ed

by a

trai

ned

mid

wife

DSM

s

Faci

lity

man

ager

s

2016

- 20

19

Out

put 5

Refe

rral

sys

tem

in

pla

ce a

nd

oper

atio

nal i

n al

l par

ts o

f the

co

untr

y

% o

f Em

ON

C fa

cilit

ies

with

insit

u am

bula

nce

read

y 36

5/7/

24 w

ith

train

ed d

river

s

DSM

reco

rds

Faci

lity

reco

rds

100%

Avai

labi

lity

and

mai

nten

ance

of

ambu

lanc

es, a

nd a

vaila

bilit

y of

tra

ined

driv

ers a

roun

d th

e cl

ock

DSM

s Fac

ility

m

anag

emen

t20

16 -

2019

Out

put 6

Mun

icip

ality

Em

ON

C pl

ans

deve

lope

d, fu

lly

oper

atio

naliz

ed

and

mon

itore

d by

DSM

s

% o

f DSM

s with

ann

ual

EmO

NC

Impr

ovem

ent

Plan

and

ann

ual r

epor

ts

DSM

reco

rds

100%

Trai

ning

and

tech

nica

l ass

istan

ce

for D

SMs t

o im

prov

e Em

ON

C m

anag

emen

t, re

cord

kee

ping

, an

alys

is of

cha

lleng

es a

nd re

porti

ng

DSM

s20

16 -

2019

Out

put 7

Com

mun

ity

part

icip

atio

n st

reng

then

ed

for o

ptim

al

utili

zatio

n

% o

f Hea

lth P

osts

with

aw

aren

ess o

f Em

ON

C an

d pr

omot

ion

of

inst

itutio

nal d

eliv

ery

DSM

reco

rds

100%

DSM

s to

enco

urag

e H

CMC

and

Com

mun

e Co

mm

ittee

to m

eet a

nd

disc

uss i

mpr

ovem

ents

of E

mO

NC

DSM

s20

16 -

2019


Anne

x 6 –

Tim

e lin

e fo

r the

impl

emen

tatio

n of

the

EmO

NC Im

prov

emen

t Plan

of A

ctio

n 20

16-2

019

Item

sYe

ar o

neYe

ar tw

oYe

ar th

ree

Year

four

Polic

y de

cisi

ons

and

Enab

ling

Envi

ronm

ent

• N

ame

a N

atio

nal E

mO

NC

Coor

dina

tor

• Es

tabl

ish N

atio

nal E

mO

NC

Tech

nica

l Com

mitt

ee to

re

view

Nor

ms a

nd S

tand

ards

, inc

ludi

ng fo

r sta

ffing

, tra

inin

g an

d m

anag

emen

t

• En

act B

lood

Tra

nsfu

sion

Stra

tegy

and

impl

emen

t it

with

WH

O te

chni

cal A

ssist

ance

• In

stru

ctio

ns to

DSM

s to

star

t upg

radi

ng a

ctio

n

• Re

vise

and

intro

duce

uni

form

ized

Regi

ster

s to

mon

itor E

mO

NC,

in c

oord

inat

ion

with

HM

IS

• Iss

ue n

atio

nal n

orm

s and

gui

delin

es fo

r Ref

erra

l (G

olde

n Ru

les)

usin

g th

e sa

me

Tech

nica

l Com

mitt

ee

• M

onito

r im

plem

enta

tion

• D

issem

inat

e qu

ality

im

prov

emen

t stra

tegy

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view

gen

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sit

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d ad

just

fo

r pen

ding

prio

ritie

s

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lcul

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NC

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ess i

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d of

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n of

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ion

Eval

uatio

n

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an a

nat

iona

l as

sess

men

t foc

usin

g on

Sig

nal F

unct

ions

Upg

radi

ng

faci

litie

s to

BE

mO

NC

: in

fras

truc

ture

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naliz

e se

lect

ion

of C

andi

date

s for

upg

rade

, pr

iorit

ize.

• D

SMs t

o in

itiat

e in

frast

ruct

ural

wor

k in

prio

rity

faci

litie

s

Cont

inue

infra

stru

ctur

al

wor

k in

seco

nd p

riorit

y fa

cilit

ies

Cont

inue

infra

stru

ctur

al

wor

k in

third

prio

rity

faci

litie

s

Cont

inue

infra

stru

ctur

al

wor

k in

four

th p

riorit

y fa

cilit

ies

Stre

ngth

enin

g CE

mO

NC

faci

litie

s•

Initi

ate

infra

stru

ctur

al im

prov

emen

ts in

all

CEm

oNC

• Re

view

surg

ical

con

ditio

ns

Mon

itor i

mpl

emen

tatio

n M

onito

r im

plem

enta

tion

End

of

Plan

of

Ac

tion

Eval

uatio

n


Item

sYe

ar o

neYe

ar tw

oYe

ar th

ree

Year

four

Hum

an R

esou

rces

St

affin

g/Tr

aini

ng•

Revi

ew e

ssen

tial s

taffi

ng o

f sel

ecte

d BE

mO

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faci

litie

s and

resh

uffle

staf

f if /

whe

n/w

here

nec

essa

ry

• Th

e N

atio

nal T

echn

ical

Com

mitt

ee fp

r Em

ON

C w

ill

stan

dard

ize B

EmO

NC

inse

rvic

e Tr

aini

ng P

acka

ge

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crui

t tra

iner

s and

tuto

rs fo

r clin

ical

trai

ning

from

am

ong

seni

or m

idw

ives

from

all

Mun

icip

aliti

es

• St

art B

EmO

NC

train

ing

• Re

view

Pre

serv

ice

Trai

ning

to in

clud

e BE

mO

NC

for

Doc

tors

and

Mid

wiv

es, w

ith U

nive

rsity

of T

imor

-Le

ste

and

Dire

ctor

s of S

choo

ls

• Re

view

staf

fing

in v

iew

of

incr

ease

d ac

tivity

of

faci

litie

s and

reac

t ac

cord

ingl

y

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perv

ise st

aff

perfo

rman

ce a

nd

prov

ide

coac

hing

whe

re

nece

ssar

y

• Co

ntin

ue B

EmO

NC

Trai

ning

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view

staf

fing

in v

iew

of

incr

ease

d ac

tivity

of

faci

litie

s and

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t ac

cord

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y

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aff

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rman

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nd

prov

ide

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hing

w

here

nec

essa

ry

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ntin

ue B

EmO

NC

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ning

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view

staf

fing

in v

iew

of

incr

ease

d ac

tivity

of

faci

litie

s and

reac

t ac

cord

ingl

y

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perv

ise st

aff

perfo

rman

ce a

nd

prov

ide

coac

hing

w

here

nec

essa

ry

• Co

ntin

ue B

EmO

NC

Trai

ning

Clin

ical

trai

ning

Ce

ntre

s•

Plan

and

impl

emen

t inf

rast

ruct

ural

wor

k to

tra

nsfo

rm 3

hos

pita

ls in

to C

linic

al tr

aini

ng C

entre

s (B

auca

u, M

aubi

sse,

Sua

i).

• Pr

ocur

e tra

inin

g eq

uipm

ent (

com

pute

rs, p

roje

ctor

s, m

anne

quin

s, an

atom

ical

mod

els,

etc)

• Im

plem

ent a

nd im

prov

e cl

inic

al tr

aini

ng in

thes

e 3

hosp

itals

and

in D

ili

HN

GV

• Im

plem

ent a

nd

impr

ove

clin

ical

tra

inin

g in

thes

e 3

hosp

itals

and

in D

ili

HN

GV

• Im

plem

ent a

nd

impr

ove

clin

ical

tra

inin

g in

thes

e 3

hosp

itals

and

in D

ili

HN

GV

Proc

urem

ent a

nd

dist

ribut

ion

of

equi

pmen

t and

su

pplie

s

• Co

llect

and

revi

ew li

sts o

f miss

ing

equi

pmen

t/su

pplie

s pro

vide

d by

can

dida

tes f

acili

ties a

nd st

art

proc

urem

ent

• Se

nd m

aint

enan

ce u

nits

to fa

cilit

ies

• Su

perv

ise d

istrib

utio

n an

d ut

iliza

tion

of o

ld

and

new

equ

ipm

ent a

nd

supp

lies

• Re

view

miss

ing

and

nonf

unct

ioni

ng

equi

pmen

t and

su

pplie

s: re

spon

d.

• Re

view

miss

ing

and

non-

func

tioni

ng

equi

pmen

t and

su

pplie

s: re

spon

d

Proc

urem

ent

and

dist

ribut

ion

of E

mO

NC

med

icin

es

• Co

llect

and

revi

ew li

sts o

f miss

ing

med

icin

es

prov

ided

by

cand

idat

e Em

ON

C fa

cilit

ies a

nd st

art

proc

urem

ent

• se

t up

mon

itorin

g an

d w

arni

ng sy

stem

s to

prev

ent

stoc

kout

s

• Su

perv

ise d

istrib

utio

n an

d ut

iliza

tion

of

med

icin

es

• Ch

eck

Emer

genc

y Tr

olle

ys in

labo

ur ro

oms

• Su

perv

ise d

istrib

utio

n an

d ut

iliza

tion

of

med

icin

es

• Ch

eck

Emer

genc

y Tr

olle

ys in

labo

ur

room

s

• Su

perv

ise d

istrib

utio

n an

d ut

iliza

tion

of

med

icin

es

• Ch

eck

Emer

genc

y Tr

olle

ys in

labo

ur

room

s


Item

sYe

ar o

neYe

ar tw

oYe

ar th

ree

Year

four

Refe

rral

• D

SMs R

evie

w h

uman

and

mat

eria

l res

ourc

es fo

r re

ferra

l

• O

rder

miss

ing

vehi

cles

and

spar

e pa

rts

• In

itiat

e Fi

rst A

id tr

aini

ng fo

r driv

ers

• D

SMs R

evie

w h

uman

an

d m

ater

ial r

esou

rces

fo

r ref

erra

l

• Im

plem

ent F

irst A

id

train

ing

for d

river

s

• D

SMs R

evie

w h

uman

an

d m

ater

ial r

esou

rces

fo

r ref

erra

l

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ntin

ue F

irst A

id

train

ing

for d

river

s

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SMs R

evie

w h

uman

an

d m

ater

ial r

esou

rces

fo

r ref

erra

l

• Co

ntin

ue F

irst A

id

train

ing

for d

river

s

Qua

lity

Impr

ovem

ent

• St

art p

lann

ing

supe

rvisi

on te

ams t

o re

view

qua

lity

at

all l

evel

s of E

mO

NC

man

agem

ent.

Invo

lve

Med

ical

As

soci

atio

n an

d M

idw

ives

Ass

ocia

tion

• Re

spon

d to

nee

ds

iden

tified

by

supe

rvisi

on

visit

s

• Re

spon

d to

nee

ds

iden

tified

by

supe

rvisi

on v

isits

• Re

spon

d to

nee

ds

iden

tified

by

supe

rvisi

on v

isits

Part

ogra

ph•

Revi

ew d

efici

enci

es a

nd p

lan

rem

edia

l act

ion

at

Nat

iona

l and

Mun

icip

ality

leve

ls•

Impl

emen

t rem

edia

l ac

tions

• Im

plem

ent r

emed

ial

actio

ns•

Impl

emen

t rem

edia

l ac

tions

Revé

Mor

atlid

ade

mat

erna

/Beb

e fo

in m

oris

• Re

view

defi

cien

cies

and

pla

n re

med

ial a

ctio

n at

N

atio

nal a

nd M

unic

ipal

ity le

vels

• Im

plem

ent r

emed

ial

actio

ns•

Impl

emen

t rem

edia

l ac

tions

• Im

plem

ent r

emed

ial

actio

ns

Com

mun

ity

Invo

lvem

ent

• M

oH to

link

with

Mo

Loca

l Dev

elop

men

t to

invo

lve

Suco

and

Ald

eia

Chie

fs in

aw

aren

ess a

nd p

rom

otio

n of

Em

ON

C in

thei

r com

mun

ities

• M

oH Is

sue

circ

ular

s and

inst

ruct

ions

to H

ealth

Po

sts t

o ra

ise a

war

enes

s and

util

izatio

n of

Em

ON

C fa

cilit

ies

• Li

aise

with

loca

l lea

ders

and

loca

l civ

il so

ciet

y or

gani

zatio

ns to

raise

aw

aren

ess a

nd u

tiliza

tion

of

EmO

NC

• Im

plem

ent c

omm

unity

in

volv

emen

t aro

und

EmO

NC

faci

litie

s

• Li

aise

with

loca

l lea

ders

an

d lo

cal c

ivil

soci

ety

orga

niza

tions

to

raise

aw

aren

ess a

nd

utili

zatio

n of

Em

ON

C

• Im

plem

ent c

omm

unity

in

volv

emen

t aro

und

EmO

NC

faci

litie

s

• Li

aise

with

loca

l le

ader

s and

loca

l civ

il so

ciet

y or

gani

zatio

ns

to ra

ise a

war

enes

s and

ut

iliza

tion

of E

mO

NC

• Im

plem

ent c

omm

unity

in

volv

emen

t aro

und

EmO

NC

faci

litie

s

• Li

aise

with

loca

l le

ader

s and

loca

l civ

il so

ciet

y or

gani

zatio

ns

to ra

ise a

war

enes

s and

ut

iliza

tion

of E

mO

NC


Annex 7 – Norms and Standards for Minimum Enabling Environment to Support EmONC

Minimum Requirement Basic EmONC Comprehensive EmONC

Clinical hours At least one midwife and one doctor with EmONC competencies present 24/7, working as Team

Same as for BEmONC PLUS OB/GYN, Emergency surgical team, OT, and blood transfusion Lab Tech present 24/7

Infrastructure • Separate Rooms for essential services (labour, sterilization, surgery, postop)

• Rooms and beds for prelabour and postpartum, incl kitchen for serving meals

• Running water

• Electricity (alternative backup)

• Sewage system

• Waste disposal (placenta pit) and sharp objects disposal

• Secure staff quarters

• Shower and Latrines for patients

• Curtains and partitions for patients

• Basic laboratory, including blood screening

• Pharmacy

Personnel for the Maternity

• Doctor

• Midwife, nurse

• Auxiliaries and cleaners

• Lab and pharmacy staff

• Administrative staff

• Security staff

• OB/GYN and another surgeon Backup

• Anesthetists

• Midwives, nurses and supporting staff

• Lab and pharmacy staff

• Administrative staff

• Security staff

Infection control • Safe water, soap

• Disinfectants

• Boiler/autoclave

• Universal precautions to prevent the spread of HIV and other infections

• Laundry facilities

• Staff’s attitudes (hand washing, etc)

Referral • Reliable referral system 24/7 with trained drivers (incl back up)

• If vacuumassisted vaginal delivery is carried out, Cesarean section backup within 30 minutes is recommended, in case of failure

• Communication facilities: cellphone or landline


Minimum Requirement Basic EmONC Comprehensive EmONC

Registers and records

• ANC register

• ADMISSION REGISTER (including information on obstetric/newborn complications)

• Delivery/maternity (including information on obstetric/newborn complications)

• OT register (for comprehensive EmONC facility)

• Blood Transfusion register (for comprehensive EmONC facility)

• Referral register In and Out

• Monthly summary

• ANC card

• Individual patient records

• Partographs

• Others; example Maternal death reviews

Annex 8 - Lists of Equipment, Supplies and Medicines for EmONC with unit cost

No Items Name Dosage Form Unit Price (USD)

ESSENTIAL DRUGS

1 Ampicilin 1gr Injection -

2 Metronidazole 500mg Injection 0.0143

3 Gentamicin 80mg Injection -

4 Magnesium Sulphate 50% Injection -

5 Hydralazine 20mg Injection 0.4744

6 Methyldopa 250 mg Tablet 0.0879

7 Oxytocin Injection 0.3325

8 Ergometrin Injection -

9 Misoprostol Tablet 0.0214

10 Adrenaline Injection 0.2244

11 Atropine Injection 0.1625

12 Calcium Gluconate Injection 0.2308

13 Furosemide Injection -

14 Hydrocortisone Injection -

15 Vitamin K 1mg/mL Injection 0.9000

16 Tetarcycline 1% Eye Ointment 0.3100



17 Amoxicillin 500mg Tablet 0.0385

18 Paracetamol 500mg Tablet 0.0060

19 Multivitamin Tablet 0.0100

20 Ferrous Sulphate Tablet 0.0031

21 Folic Acid Tablet 0.0080

22 Tetanus Toxoid - 226.8255

23 Erythromycin 500mg Tablet 0.0641

24 Mebendazole Tablet -

25 Sterile Water for Injection - -

26 Metoclopramide Injection 0.2500

27 Metroclopramide Tablet 0.0090

IV FLUID

1 Normal Saline 0.9%, 1L 0.6452

2 Ringer Lactate 500mL 1.6353

3 Dextran 10.1816

4 Glucose 5% 1.1875

MEDICAL SUPPLIES

1 Syringe (disposable) 2.5mL 0.1042

2 Syringe (disposable) 5mL 0.1046

3 Syringe (disposable) 10mL 0.1582

4 Infusion Set adult - -

5 Infusion Set for newborn (Burete) - -

6 IV Cannula 16 G Not Qouted

7 IV Cannula 18 G 0.5020



10 Vicryl 2/0 (36 ‘’ Needle) - 2.8514

11 Tubing for Oxygen (adult) - -

12 Tubing for Oxygen (newborn) - -

13 Suction Catheter 8Fr 0.3800




17 Endotracheal Tube 6 Fr 2.7959



18 Endotracheal Tube 6.5 Fr 2.7959

19 Endotracheal Tube 7 Fr 2.7992

20 Endotracheal Tube 7.5 Fr 2.7959

21 Endotracheal Tube for newborn (uncuffed) - 1.8304

22 Measuring Tape - -

23 Wall Clock - -

24 Foley Catheter 16 Fr 1.1000

25 Ambu Bag (Adult) - 36.0000

26 Mouth Guard - -

27 Urine dipstick - -

28 Bed Linens - -

29 Blankets - -

30 Baby Towel (100cm x 50 cm) - -

31 Delivery drapes (120cm x 75 cm) - -

32 Cord Clamps - 0.2800

33 Infant Face Mask (Size 0.1) - -

34 Plaster - -

35 Urine Bag - 0.3100

36 Face Mask - 0.0400

37 Apron (plastic) - -

38 Draw Sheet, Plastic 90 x 180 cm - -

39 Waterproof foot ware - -

40 OS (Roll) - -

41 Cotton (Roll) - 3.9884

42 Hand Towel - -

43 Plastic Bag - 0.0100

Medical equipment

I Item Packaging Description Unit Cost

1 Fetal doppller 1 Unit 100.00

2 Spygnomanometer 1 Unit 100.00

3 Stehethoscope 1 Unit 150.00

4 Clinical Thermometer 1 Unit 5.00

5 Infusion stand 1 Unit 30.00



6 Stretcher 1 Unit 150.00

7 Wheelchair 1 Unit 150.00

8 Laringoscope [adult] 1 Unit 250.00

9 Laringoscope [Pediatric & Nenat] 1 Unit 250.00

10 Suction Machine 1 Unit 250.00

II Delivery room

1 Delivery table 1 Unit 500.00

2 Hospital Bed 1 Unit 1,000.00

3 Mayo tray 1 Unit 100.00

4 Mayo Stand 1 Unit 50.00

5 Examination light 1 Unit 200.00

6 Instrument tray 1 Unit 20.00

7 Instrument trolley 1 Unit 200.00

8 Trash Bins 1 Unit 50.00

9 Stool with rollers 1 Unit 50.00

10 Bowl, round, stainless, 4 L 1 Unit 20.00

11 Bowl, round, stainless, 6 L 1 Unit 50.00

III Newborn

1 Weighing scale 1 Unit 50.00

2 Newborn resuscitation table 1 Unit 250.00

3 Radiant Warmer 1 Unit 17 000.00

4 Suction Mahine 1 Unit 250.00

5 Ambu Bag Newborn 1 Unit 150.00

6 Autoclave with temperatur and preasure gauza 1 Unit 20 000.00

7 Incinerator 1 Unit 50 000.00

IV Instruments

A Delivery Set

1 Artery Forceps 1 Unit 5.00

2 Sponge Forceps 1 Unit 5.00

3 Cord Cutting, Scissor Curved 1 Unit 10.00

4 Episiotomy Scissor, Curved 135 mm 1 Unit 10.00

5 Needle Holder 1 Unit 5.00

6 Dissecting Forceps with teeth 1 Unit 5.00



7 Suture Scissor 1 Unit 5.00

B Manual Vacuum Aspiration Set

1 Manual Vacuum aspiration with diferent sizes of flexible cannule 4 - 12 mm 1 Unit 150.00

2 Lubricant/oil O-Ring 1 Unit 5.00

3 Cuso Speculum [small, Medium, Large] 1 Unit 5.00

4 Volsullum Forceps 1 Unit 10.00

C Dressing Set

1 Gallipot bowl or Jar 1 Unit 10.00

2 Dissecting forceps with teeth 1 Unit 5.00

3 Scissor flat, curved 1 Unit 5.00

4 Scissor , sharp, straight 1 Unit 5.00

5 Artery forceps 1 Unit 5.00

6 Sponge forceps 1 Unit 5.00

7 Kidney basin 1 Unit 5.00

8 Bowl,round,stainless, 100 ml 1 Unit 50.00

9 Manual vacuum extractor with caps 1 Unit 50.00

Annex 9 - Special features for Newborn careAnnex 9 Table 1: Immediate Newborn Care

Intrapartum and Immediate Newborn Care (INC)

Care for all mothers and newborns

The First Embrace. Interventions include immediate and thorough drying; immediate skin to skin contact; appropriately timed cord clamping; and non-separation of mother and newborn for early exclusive breastfeeding.

Care for high risk mothers and newborns

Management of newborn infants who are not breathing despite thorough drying. Interventions include management of asphyxia using suction, bag and mask ventilation. Carefully check the rhythm and intensity of blowing via observation of the thorax and abdomen. Check for air leakage around face.

Expanded INC

Prevention and management of prematurity – for preterm and low birth weight babies (7-8% of all newborns). Interventions include preventing unnecessary inductions and caesarian sections; antibiotics for premature prelabor rupture of membranes; antenatal steroids; tocolytics when indicated; and the Kangaroo Mother Care approach.

Care for Sick Newborns – for babies with birth asphyxia, neonatal sepsis and complications of delivery (10-15% of all newborns). Interventions include management of asphyxia using bag and mask ventilation; identification of babies at high risk, management of sepsis through antibiotics, and management of other common problems i.e check for malformations, neurological examination.

source UNICEF


Designation of a Newborn Care Corner in a Labour Ward

Adapted from: Toolkit for Setting Up Special Care Newborn Units, Stabilisation Units and Newborn Care Corners UNICEF 2009

Labour rooms in every facility at every level are required to have appropriate facility for providing essential care to newborns and for resuscitating those who might require it. Newborn care corner in this document refers to the space within the labour room for providing immediate newborn care to all newborns.

Services at the corner

Newborn care corner provides an acceptable environment for all infants at birth. Services provided in the Newborn care corner include;

Essential Care at birth: breath, warm, move, first examination for detection of birth problems Resuscitation.

• Provision of warmth.

• Early initiation of breastfeeding.

• Weighing the newborn.

• Oxygen not essential

Configuration of the corner

• Clear floor area should be provided for in the room for newborn care corner. It should be within the labour room, 20-30 sq ft in size, where a radiant warmer is kept.

• Resuscitation kit should be placed under the radiant warmer. Availability of oxygen source is desirable but not essential.

• The area should be away from draughts of air and should have appropriate power connection for plugging in the radiant warmer or other devices.


Item No. Item Description Essential/Desirable Quantity

1 Open care system: radiant warmer, fixed height, with trolley, drawers, O2-bottles E 1

2 Newborn Ambu bag and Mask E 1

3 Weighing Scale, spring E 1

4 Pump suction, foot operated D 1

5 Room Thermometer E 1

6 Light examination, mobile, 220-12 V D 1

7 I/V Cannula 24 G, 26 G E 20

8 Extractor, mucus, 20ml, ster, disp Dee Lee E 1

9 Towels for drying and wrapping the baby E 50

10 Sterile equipment for cutting and tying the cord E 50

11 Tube, feeding, CH07, L40cm, ster, disp E 50

12 Oxygen cylinder 8 F D 1

13 Sterile Gloves E 200

Human resources for the Newborn Corner:

Staffing:

One staff (Doctor) is desirable in addition to the one conducting the delivery for providing appropriate care at birth.

Training:

All staff posted at the labour rooms should be trained in providing essential care at birth and basic resuscitation.

Annex 9 Table 2 Equipment and Renewables Required for the Newborn Corner


In Summary - General Guide for Newborn Care

This summary provides guidance for setting a newborn care.

All EmONC facilities must have skilled staff and facilities for care at birth to all newborns and to provide resuscitation of those who require it.

• In addition, CEmONC service should be equipped to provide initial care and stabilisation of sick newborns, and care of most low birth weight newborns that do not require intensive care.

• Hospitals that conducts more than 3000 deliveries should have a Special Care Newborn Unit that is equipped to provide special care to most sick newborns (except those requiring mechanical ventilation or surgical interventions).

• There should be agreed procedures for transport of sick newborns (using portable battery operated incubators when necessary.

• Newborn care in EmONC facilities must have continuous availability of qualified medical and nursing staff, and resources to meet the needs of all sick babies.

• Technical specification standards for the expected levels of equipment should be established and should be adhered to. Local systems for procurement, maintenance and replacement of equipment will be necessary.

Newborn care should comply fully with:

• Clinical guidelines • Quality assurance • Follow up of high survivors• Monitoring service provision and access• Training and continuing education

Mothers should be encouraged to be involved in care of their sick newborns at every level.

One time establishment cost

Equipment and furniture $ 1,700.00

Capacity building $ 130.00

Sub Total $ 1,830.00

Recurrent or running cost per year

Consumables $ 130.00

Maintenance cost $ 490.00

Sub Total $ 620.00

Annex 9 Table 3 Indicative Cost of Setting up a Newborn Care Corner


Annex 10 - Quality Improvement Strategy and ProcessesBased on examples of other countries, the Quality Improvement strategy is designed to:

• Enhance service provider self confidence and performance

• Institute a team approach to support better quality EmONC

• Involve communities in quality improvements, and

• Maintain quality through a system of certification and reward at all levels of the health system

Rationale: The quality of EmONC needs improvement. EmONC in Municipalities continue to be underutilized. Typically, low utilization occurs when service quality is poor and trust has not been established.

The Strategy: The strategy is through a system of certification and/or public recognition. The strategy involves 6 steps:

1. Improve quality of services:

The EmONC improvement Plan of Action (IPA) will support:

• Renovation and maintenance of facilities

• Provision of essential supplies and equipment

• Facility setup to meet standards and guidelines

• Improving record keeping, data collection and analysis

• Provide training

• Staff facilities

• Encourage teambuilding

2. Set EmONC standards of Quality

The Ministry of Health will develop EmONC standards which will include a small number of essential standards that all health facilities must meet. These standards will include quality indicators from the client’s perspective as well as the provider’s perspective. For example, in Brazil the Proquali Project developed a set of 61 “accreditation criteria” that could be monitored regularly. These criteria included 18 on service delivery; 9 on infection prevention; 12 on interpersonal communication; 14 on physical plant and supplies; and 8 on management systems. One can choose to have less.


3. Communicate EmONC standards throughout the Health Care System

Once a set of “EmONC standards” has been agreed upon, posters and handouts describing the program and listing the “EmONC standards” will be developed. These materials will be distributed during briefing meetings with Municipality managers, health facility managers, community leaders, and development partners and incorporated into existing supportive supervision tools and mechanisms. Posters and materials will be developed for clients and community members in the local language, which can be posted on health facility walls and distributed to clients attending the health facilities. The intention is to familiarize all members of the health care system with the “EmONC standards” and gain commitment to the strategy.

4. Monitor and reward facilities that meet and maintain “EmONC standards”

Initially standards will be monitored by health facilities themselves using a team approach. When a facility meets the standards the team will invite the local governor to inspect their facility.

Attainment of the “EmONC standards” will be monitored during routine integrated supervision visits, using checklists. A database of all facilities will be established to track which standards each health facility has attained during each supervisory visit. Once a health facility has met all the “EmONC standards” on two consecutive quarters, Municipality health management will verify that the health facility is meeting all the criteria, and award the facility with a “Seal of Quality” during a public ceremony. Municipality management will also award certificates to each health provider working at the health facility. In order to retain the “Seal of Quality”, health facilities will have to continue to maintain the “EmONC standards.” If the standards are not met during a supervisory visit, the seal will be removed.

5. Promote Facilities with “Seal of Quality” as Sites with Good Quality Services

Health facilities that meet the “EmONC standards” on two consecutive quarters will receive the “Seal of Quality” during highly publicized ceremonies in the communities. During the ceremonies, community members will learn about the standard of care they should expect and demand at the health facility. Mass media messages will be employed to inform the public about the quality of care activities and the meaning of the “Seal of Quality.” This is a bit similar to the Mother Baby Friendly Hospital.

6. Evaluate Impact of the Strategy

Baseline and final evaluation surveys will be conducted by the MoH.

The comparison will look at facilities which have implemented all elements of the strategy with those that have not yet completed elements 3, 4, and 5. In other words, the surveys will evaluate the impact of the entire strategy and compare facilities which have instituted the certification and reward system with those which have not.


Quality Cesarean Delivery

Source: Dujardin B, Delvaux T. Céariennes de qualité de déterminants. Communication to the 5th Congress of the Société Africaine de Gynécologie et d’Obstétrique (SAGO). Senegal: Dakar; 1998.

Functioning referral system

Financial Access

Acceptability of health services

Geographic access

Temporal Access

Quality admission examination

Correct supervision of labor

Respect of operating indications

Necessary resources available

Staff available and team complete

Respect of operating protocol

Quality of anesthesia

Quality of training

Protocol respected

Quality of postop supervision

Absence of treatment delays

Quality of nursing

Access of the mother to the

referral maternity is made easy

The correct diagnosis is

reached without delay

The procedure is performed correctly and without delay

Postsurgical care is performed

correctly

Teamwork, Commitment, Compliance, and Client Orientation

In order for this strategy to succeed in improving the quality of services, the entire health system must work as a team. Each level in the system must be committed to attaining and maintaining the “EmONC standards” and must know its role in supporting the health facilities. In addition, all members of the team must comply with the strategy. Only those facilities that attain and maintain the standards should receive the “Seal of Quality”, otherwise the public will lose trust in the health system as a whole. Finally, we have to learn to measure our performance in the eyes of our clients—the women, children, and men who we serve. We have to value their input and find ways to respond.

7. Criteria of quality C-Sections


Annex 11: Monitoring sheet for assessing the functionality of EmONC facilities Every year the MoH/ DSM (DPHO-SMI) must conduct an assessment of all its EmONC facilities in order to accredit them into BEmONC, CEmONC or No EmONC category according to the number of Signal Functions performed in the past one year, as reported in the facility service records.

The following control sheet can be used for each facility visited:

Signal function performance report for the year …………………….

Municipality:

Name of facility:

Designated category (Basic or Comprehensive)

Name of agent:

Signal Function Yes/No If Yes, number of cases last 12 mths

1 Parenteral Antibiotics

2 Parenteral Oxytocics

3 Parenteral anticonvulsants

4 Manual removal of placenta

5 Removal of retained products (MVA)

6 Assisted vaginal delivery (v. extractor)

7 Newborn resuscitation

8 Cesarean section

9 Blood transfusion

Reasons why one or more signal function could not be performed (e.g. lack of skills, lack of equipment, lack of drugs, lack of cases, absence of agent, etc: ……………

Conclusion: EmONC functionality: BASIC or COMPREHENSIVE (Circle one)

Recommendations e.g. procure missing equipment, offer BEmONC training, improve practice,

…………..

Submitted by (Name) :………………………..Date: ………….

Signature of supervisor:……….............................


Annex 12 – Estimates for CostingThe budget of the MCH Department of the MoH and its partners covers the major part of the needs. What needs to be costed and mobilized is the additional part to improve EmONC in the selected facilities for the 4 years of the Plan of Action, including:

1. Costing of additional infrastructure, equipment, supplies for to upgrading the EmONC facilities

2. Costing of additional staff to be posted in EmONC facilities

3. Costing of upgrading competencies, through inservice training in BEmONC and supervision with coaching

4. Costing of the management of common obstetric complications to be expected in EmONC facilities

5. The annual budgets to be envisaged during the 4 years of the Plan of Action

The following few tables provide background information for the costing exercise.

Below Table was constructed with data provided by the Municipality health authorities. It helps determining the number of each type of professional staff needed in each candidate EmoNC facility starting in 2016.

Region Municipality facility Type N° Births Actual MW

Actual Dr

Norm MW

Norm Dr

Balance MW

Balance Dr

1

BaucauQuelicai 2 238 5 3 4 2 +1 +1

Baguia 3 215 1 1 4 2 -3 -1

Lautem

LosPalos 2 586 10 7 8 4 +2 +3

Iliomar 3 48 1 2 4 2 -3 0

Luro 3 24 1 7 4 2 -3 +5

Viqueque

Viqueque 2 383 7 4 8 4 -1 0

Uatulari 3 277 2 3 4 2 -2 +1

Lacluta 3 78 2 1 4 2 -2 -1

Uatucarbo 3 96 2 3 4 2 -2 +1

2

AileuAileu Vila 2 554 5 5 8 4 -3 +1

Remexio 3 177 4 3 4 2 0 +1

AinaroAinaro Vila 2 199 7 6 4 2 +3 +4

Hautio 3 4 1 2 4 2 -3 0

ManufahiSame 2 370 8 2 8 4 0 -2

Fatuberlih 3 121 3 1 4 2 -1 -1

Annex 12 Table 1: Midwives and doctors actually present and needed in each EmONC facility


Region Municipality facility Type N° Births Actual MW

Actual Dr

Norm MW

Norm Dr

Balance MW

Balance Dr

3

Dili

Atauro 3 104 3 2 4 2 -1 0

Becora 3 557 17 9 8 4 +9 +5

Vera Cruz 3 655 13 8 12 6 +1 +2

Centro 3 313 8 1 8 4 0 -3

Ermera

Gleno 2 324 6 1 8 4 -2 -3

Atsabe 3 147 2 3 4 2 -2 +1

Hatolia 3 55 2 4 4 2 -2 +2

Liquica

Liquica 2 304 4 1 8 4 -4 -3

Fatumasi 3 90 2 1 4 2 -2 -1

Maubara 3 176 5 1 4 2 +1 -1

Manatuto

Manatuto 2 204 8 9 4 2 +4 +7

Laclubar 3 82 3 2 4 2 -1 0

Natarbora 3 23 2 3 4 2 -2 +1

4

Bobonaro

Lolotoe 3 24 2 2 4 2 -2 0

Atabe 3 90 2 4 4 2 -2 +2

Bobonaro 3 60 2 3 4 2 -2 +1

Marco 3 76 3 3 4 2 -1 +1

Covalima

Zumalai 3 154 3 6 4 2 -1 +4

Tilomar 3 150 1 3 4 2 -3 +1

Fohorem 3 48 1 1 4 2 -3 -1

SpR Oecusse Passabe 3 25 1 2 4 2 -3 0

Total 36 candidates BEmONC facilities 36 7031 149 119 184 92 -35 +27

CEMONC

2 Baucau Baucau 1 1286 16 3 16 8 0 -5

2 Ainaro Maubisse 1 351 7 0 8 4 -1 -4


4 Covalima Suai 1 573 11 0 8 4 +3 -4


3 Dili HNGV 1 4302 20 10 20 10 0 0

3 Dili Private 1 293 10 5 8 4 +2 +1

Total Hospitals 7809 84 21 80 40 +4 -19


The below table shows the training needs expressed by 160 provides; doctors (53) and midwives (107) during the Needs Assessment conducted in 2015 for different categories of procedures. It helps determining the volume of training needs for the duration of the Plan of Action.

TRAINING TOPICS Number expressing need

Bleeding in Pregnancy

Manage bleeding in early pregnancy 59% (95)

Manage bleeding in late pregnancy and in labor 60% (96)

Manage post partum bleeding 50% (80)

High Blood Pressure Problems

Manage pre-eclampsia 59% (95)

Manage eclampsia 61% (97)

Fever during Pregnancy and after delivery

Manage a fever before delivery (amnionitis) 57% (91)

Manage a fever after delivery (endometritis) 60% (96)

Procedures for Early Pregnancy Problems

Perform Manual Vacuum Aspiration 65 (104)

Annex 12 Table 2: Midwives and doctors actually present and needed in Hospitals (CEmONC Facilities)

Region Municipality Facility Type N° Births Actual MW

Actual Dr

Norm MW

Norm Dr

Balance MW

Balance Dr

2 Baucau Baucau 1 1286 16 3 16 8 0 -5

2 Ainaro Maubisse 1 351 7 0 8 4 -1 -4


4 Covalima Suai 1 573 11 0 8 4 +3 -4


3 Dili HNGV 1 4302 20 10 20 10 0 0

3 Dili Private 1 293 10 5 8 4 +2 +1

Total Hospitals 7809 84 21 80 40 +4 -19

Annex 12 Table 3: Training needs per topic expressed by 160 providers 53 Doctors and 103 Midwives in 13 Municipalities in 2015 (EmONC Needs Assessment)



Normal Labor and Labor Problems

Assess the fetal position 50% (80)

Assess progress of labor 43% (68)

Use a partograph correctly and completely until Fourth Stage 45% (72)

Manage normal labor 45% (72)

Manage abnormal early labor (latent phase) 54% (87)

Manage abnormal active labor (first stage) 53% (85)

Manage abnormal second stage 56% (89)

Manage abnormal third stage 58% (93)

Induce labor 58% (93)

Manage labor after prior cesarean section 84% (134)

Manage normal birth 39% (63)

Perform vacuum delivery 66% (106)

Abnormal Presentations

Recognize breech presentation 56% (90)

Manage a breech delivery 62% (99)

Manage a transverse presentation 71% (114)

Manage a prolapsed cord 64% (103)

Other Conditions Affecting Labor and Delivery

Manage malaria 64% (102)

Identify heart problem 75% (120)

Procedures for Labor and Delivery

Perform an amniotomy 58% (93)

Make and repair an episiotomy with absorbable sutures 51% (81)

Repair first degree tears 49% (79)

Repair second degree tears 52% (83)

Repair third degree tears 73% (117)



Repair a cervical tear 89% (143)

Complicated Delivery

Perform maneuvers for shoulder dystocia 60% (96)

Manage twin delivery 62% (99)

Perform manual removal of placenta 60% (96)

Perform curettage or MVA for retained products 63% (100)

Perform bimanual compression 58% (93)

Perform abdominal aortic compression 64% (102)

Post partum Care

Perform an IUD insertion after delivery or abortion 60% (96)

Pain Management

Perform local anesthesia of perineum 56% (89)

Procedures for Newborn Care

knowledge of 10 danger signs) 36% (58)

Perform newborn resuscitation 40% (64)

Other Emergencies

Conduct rapid initial assessment for emergencies 65% (104)

Manage shock from bleeding 51% (82)

Manage shock from sepsis 64% (102)

Perform adult resuscitation 78% (125)

Implement infection prevention measures 44% (70)

Maternal deaths review 88% (140)

The majority of these items can be included in the BEmoNC training curriculum

Additional short refesher courses can be added as needed.

The following table shows an estimate of the Costing of the management of obstetric complications, based on the estimated incidence and presumptive unit costs for each type of complication. The unit cost of C-section has been estimated at US$ 300 and the emergency referral at US$ 80.


Com

plic

atio

nIn

cide

nce

per 1

00

preg

nanc

ies

(%)

Num

ber

in T

imor

-Le

ste

in

one

year

Cont

ents

of c

urat

ive

proc

edur

eU

nit C

ost

of c

urat

ive

proc

edur

e(s)

(U

S$)

Cost

of

cura

tive

proc

edur

e(s)

(U

S$)

Cost

of

refe

rral

(U

S$)

Tota

l co

st

(US$

)

Pre-

part

um H

rg0.

520

0IV

flui

ds4

800

1600

016

800

Post

par

tum

Hrg

(not

sev

ere)

*1.

352

0AM

TSL,

IV fl

uids

631

2020

800

2392

0

Post

par

tum

Hrg

(sev

ere)

0.4

160

AMTS

L, IV

Flu

ids,

BT57

9120

1280

021

920

3rd-

4th

degr

ee p

erin

eal t

ears

0.4

160

Surg

ical

repa

ir15

2400

1280

015

200

Pre-

part

um S

epsi

s*0.

520

0An

tibio

tics

1020

0080

0010

000

Post

par

tum

Sep

sis*

280

0An

tibio

tics,

IV F

luid

s20

1600

032

000

4800

0

Post

abo

rtio

n ca

re*

140

0M

anua

l Vac

cum

Asp

iratio

n15

6000

1600

022

000

Prel

abou

r rup

ture

of m

embr

anes

*0.

624

0IV

Flu

ids,

Antib

iotic

s, st

eroi

ds15

3600

9600

1320

0

Pre-

Ecla

mps

ia0.

728

0M

ag/s

ulph

, IV

Flui

ds, n

ursin

g40

1120

022

400

3360

0

Ecla

mps

ia0.

280

IV F

luid

s, M

ag su

lpha

te, C

/S, n

ursin

g63

050

400

6400

5680

0

Prol

onge

d L

abou

r*2

800

Assis

t Vag

inal

Del

iver

y20

1600

032

000

4800

0

Obs

truc

ted

Labo

ur0.

624

0IV

Flu

ids,

C/S

630

1512

0019

200

1704

00

Ann

ex 1

2 Ta

ble

4: C

ost o

f man

agem

ent o

f obs

tetr

ic c

ompl

icat

ions

bas

ed o

n es

timat

ed in

cide

nce


Com

plic

atio

nIn

cide

nce

per 1

00

preg

nanc

ies

(%)

Num

ber

in T

imor

-Le

ste

in

one

year

Cont

ents

of c

urat

ive

proc

edur

eU

nit C

ost

of c

urat

ive

proc

edur

e(s)

(U

S$)

Cost

of

cura

tive

proc

edur

e(s)

(U

S$)

Cost

of

refe

rral

(U

S$)

Tota

l co

st

(US$

)

Plac

enta

Acc

reta

0.3

120

Man

ual R

emov

al o

f Pla

cent

a10

1200

9600

1080

0

Rupt

ured

ute

rus

0.2

80IV

Flu

ids,

Surg

ery,

Bloo

d Tr

ansf

usio

n65

552

400

6400

5880

0

Ecto

pic

preg

nanc

y0.

312

0IV

Flu

ids,S

urge

ry61

073

200

9600

8280

0

Ute

rine

Inve

rsio

n0.

140

IV F

luid

s, m

anua

l cor

rect

ion

2510

0032

0042

00

New

born

Asp

hyxi

a*2.

510

00Re

susc

itatio

n.25

2500

040

000

6500

0

Man

agem

ent o

f pre

mat

ure/

LBW

*2

800

New

born

car

e, K

angg

aroo

Mot

her C

are,

fe

edin

g13

010

4000

3200

013

6000

Pulm

onar

y Em

bolis

m0.

140

IV F

luid

s, An

ti Co

agul

ants

.30

1200

3200

4400

Oth

ers

0.2

80TB

S50

4000

6400

1040

0

Tota

l 15

.963

60

5338

4031

8400

8522

40

Not

e:*

Onl

y on

e ha

lf (%

=%) o

f the

se c

ompl

icat

ions

nee

d re

ferra

l


Finally, the following table shows the 4-year estimate of the cost of managing obstetric complications. It appears that the cost of managing up to 80% of all complications will amount to US$ 2.2 million for the 4-yr Plan of Action. Similar estimates can be done for each Municipality using the same rules and the findings of the EmONC Assessment.

Annex 12 Table 5: Estimation of the cost of managing incremental complications each year during the Plan of Action (in US$)

YearEstimated proportion

of all expected complications

Expected number of complications seen

Estimated cost of managing these

complications US$

Year One 50% 3180 426120

Year Two 60% 3816 511344

Year Three 70% 4452 596568

Year Four 80% 5088 681792

Total four years 16536 2215824

Annex 13 - Key Findings and Recommendations of the EmONC NA ReportA. Key Findings

• Performance of signal functions

While Timor-Leste has been successful in developing a network of functional CEmONC facilities which meets UN standards, only 2 functional BEmONC facilities have been identified. All BEmONC facilities are in Dili (CHC Comoro and Bairo-Pite Clinic). More facilities are needed at Municipality level

With the exception of the administration of uterotonic drugs, most signal functions were insufficiently performed, particularly at CHC level. The most poorly performed signal function was assisted vaginal delivery, with only 10% of CHCs performing, followed by administration of parenteral anticonvulsants for pre-eclampsia and eclampsia (<15%).

Seven Municipalities have no functional EmONC facilities

• Utilization of Services

In Timor-Leste during the one year preceding the survey 19361 (48%) of all expected births took place in all facilities assessed. Over half of these (9938 or 24.6%) were in functional EmONC facilities. At the same time 1831 births (4.5%) were reported in Health Posts and the rest were home births (19294 or 48%). The National Health Sector Development Plan 2011-2030 had identified a target of more than 40% deliveries to be in Health facilities


(not necessarily in EmONC facilities) to be achieved by 2015. In order to ensure that all women who develop complications have access to services, the MOH should consider raising this target, which should ultimately reach 100%.

• Obstretic complications treated in the health facilities

Over one half (3316 or 54.6%) of all women who were estimated as having obstetric complications (15% of all pregnancies) during the assessment were treated in the health facilities assessed; 2051 or 33.8% of these complications were treated in the functional EmONC facilities. This is far below the recommended level of 100%. This means the needs of women with obstetric complications of pregnancy are not being met.

• Performance of critical services: C-Sections

This indicator has been calculated by region and for the whole country, as hospitals providing C-sections service a region, made of 3 or 4 contiguous Municipalities. Only 3.4% of all expected births (1385) in all hospitals assessed and functional CEmONC facilities were by C-section. This is well below the globally recommended minimum level of 5% for all expected births in a country. If Dili is excluded from the analysis, the proportion of all births delivered by C-section falls from 3.4% to 1.6%. There are women who require C-sections, who are not receiving them.

• Availability of Blood for transfusion

The data also suggests there are issues with the availability of blood: None of the Referral Hospitals had any stored blood despite the availability of refrigerators and reagents.

• Access, referral and communications

Remote and isolated populations have little access, the “golden rule of two hours” is not respected in many Municipalities, 27 (37%) of all facilities were more than two hours from a higher level facility; 17 health posts were more than two hours from a CHC. Four CHCs were not providing obstetric and newborn services. Ambulances are in adequate numbers but second delay is still a constraint. Cellphone communication has greatly improved. There were no referrals recorded for newborn complications.

• Human Resources

Numbers have improved and meet current needs for midwives and doctors, but 24/7 availability is not guaranteed and competencies need to be reviewed in view of the increasing demand. Three CHCs and 2 hospitals have no doctor in the maternity. Midwives are the main providers of BEmONC signal functions.

• Knowledge, training and experience

Guidelines and protocols, although issued by the MoH, were not available nor consulted in one half of facilities, particularly in CHCs. Knowledge had serious gaps and training needs for EmONC were acknowledged for all categories of providers, including among the newly passed out midwives and doctors trained in Cuban education system.


• Availability of basic infrastructure

Considerable gaps in the physical availability of premises, the quality of buildings, the essential water, sanitation and electric supply, the beds for waiting patients, the post-partum observation beds, the newborn corners. One CHC had no electricity and 6 had no running water.

• Essential drugs supplies and equipment

There were many stock outs reported, with shared responsibility between the central store and the hospitals supply systems. Among the most missing essential drugs was magnesium sulphate and among equipment was neonatal resuscitation. Infection control had serious gaps.

• Case Reviews of Partographs

In the 75 facilities assessed, 180 partograph case studies were undertaken. Many gaps were observed in the use (in 20% of facilities) and in the interpretation, particularly in CSIs and CHCs

• Case Review of caesarean deliveries

Twenty one (21) C-section case studies were undertaken; 19 cases were emergencies and 2 were elective. Only 2 cases were managed with a partograph. Four cases only (20%) met the optimal time between decision and execution, and more than 50% were more than 2 hours. Newborn outcomes were seldom reported. The low use of partograph is a concern.

• Case Reviews: Maternal death Reviews

Ten maternal deaths, from 6 Referral hospitals were reviewed; nine of them were due to direct obstetric causes.

B. Key Recommendations

In considering how Timor-Leste should proceed, and how poor coverage, poor quality, and gaps in EmONC services should be addressed, three areas need to be considered:

1. Policy recommendations

2. Coverage, availability, geographic distribution of EmONC facilities and accessibility

3. Improving quality of care

4. Human resources


1. Policy recommendations

• First of all, the leadership of the MoH in MNH issues, including EmONC of course, should be strengthened, and all contributors to the National RMNCAH Strategy should support this leadership and conform to the guidelines issued by the Department.

• It is crucial to raise the visibility and public health importance of EmONC in Timor-Leste, but at the same time to highlight that EmONC is only a part of the overall strategy and programme of the country to reduce maternal and newborn mortality and morbidity. EmONC in particular does not cover the actions at village level, except for advocacy and awareness activities. Of the “Three Delays” approach, EmONC is mostly concerned with the third one, at facility level. It should be “integrated in the broader approach to improve MNH.

• It is recommended to name a National EmONC Coordinator at the MoH. The job of this coordinator will be to centralize the EmONC-related information, coordinate the implementation of the Plan of Action, and monitor the progress. A profile will be proposed.

• All BEmONC facilities (as well as CHCs before they are upgraded into BEmONC) should be authorized and encouraged to keep patients in their premises for a few days BEFORE and AFTER delivery, either in maternity waiting homes or in wards where patients can receive or prepare food, have a minimum of comfort and dignity (beds and linen, toilets, separation curtains, etc.)

• All registers related to EmONC should be uniformized and harmonized, and utilised in all EmONC facilities as well as maternity units in CHCs. This should be integrated and coordinated with HMIS and/or DHIS-2. The proper identification and recording of obstetric and newborn complications is key to the calculation of quality process indicators.

• Taking into consideration the specificities of Timor-Leste population and geography, it is recommended to use the 12 month benchmark for all further assignment of EmONC facilities, based on the performance of signal functions. Once the 12 month benchmark is met, then the 3 month period could be adopted in the future, but this is not feasible at the moment.

• In response to the critical shortage of BEmONC facilities at sub-national level (only 2 facilities have been designated as functional BEmONC facilities, both in Dili), there is a need for a policy to prioritise sub-national BEmONC facilities and strategically strengthen them one by one. Annexes provide a list of criteria, as well as a list of “candidate facilities” to be upgraded in priority in each district. The “Golden rules” specify that no health facility should be more than 2 hours from villages, and no health facility should be more than 2 hours travel time from a higher level referral facility.


• Norms and standards for EmONC, as well as guidelines and protocols will need to be revised and disseminated so they are available to all providers and their supervisors.

• The staffing of each category of EmONC facility will need to follow standards, and flexibility will be exercised to re-allocate staff when needed from one facility to another one.

• The policy about the proportion of all births that should take place in EmONC facilities must evolve over time, according to the progress of this indicator. The National RMNCAH Strategy recommends reaching a target of 75% skilled birth attendance by 2019 with 65% of deliveries in health facilities. The Plan of Action for improving EmONC should specify 65% of all deliveries in functional EmoNC facilities.

• There should be a renewed and strongly expressed focus on newborn health. The number of expected newborn deaths is far greater than the number of maternal deaths (500 Vs 100 each year). Equipment and skills for newborn care at birth are readily available and are potentially very effective: They need to be used.

• The Blood Transfusion Policy drafted in 2015 must come to approval and implementation. The strategic choices must be fixed so that all the CEmONC facilities have access to blood units within less than one hour of the decision to transfuse blood. A Lab technician must be available on-site 24/7.

2. Coverage, availability and geographic distribution of EmONC facilities

• According to UN standards, Timor-Leste should have 3 CEmONC and 12 BEmONC facilities. The survey reveals that there are 6 CEmONC and only 2 functional BEmONC facilities responding to the criteria (none in the districts). In response to this distortion, and taking into account the specificities of the population and geography of Timor -Leste, it is recommended that the 6 CEmONC facilities are maintained and strengthened, while all the 8 CSIs and as many as 36 among the CHCs are upgraded to become BEmONC facilities.

• The criteria to select which facilities need to be upgraded in priority, after discussions with DSM and DPHO-SMI officials, are technical and logistical. Priority should be given to the 8 or 9 CSIs and the 7 districts without any EmONC facility. The “Golden Rule” of less than 2 hours referral time must be one of the top criteria.

• “Upgrading” means raising the number and quality of EmONC services to standards. There are several components of the upgrading process, belonging to the physical/infrastructural category, equipment/drugs category, communication/transport category, staffing/training category, and quality of care category. Details will be in the Plan of Action for Improvement of EmONC Services.


3. Improving quality of care

• Several tables throughout this report show deficiencies in the care provided by different levels of health facilities. No lower level facilities (CHCs and CSIs outside of Dili) are functional BEmONC. Facilities at different levels must be upgraded, to provide a standardised package of EmONC along a continuum of care. The concepts of standardisation and facility readiness 24/7 should be introduced, and managers and clinical staff trained in a standard-based management approach.

• Lack of recognition, and under diagnosis of obstetric and newborn complications, is a key limiting factor for full functionality of EmONC facilities. Once conditions are recognised and diagnosed, good care is required. This may require immediate interventions and/or stabilisation and timely referral. Additional strategies are required to ensure correct diagnoses and timely interventions, which support EmONC improvement.

• Supportive supervision has been introduced in many programmes: it is particularly important when lives of mothers and newborns are at in the balance and stress is frequent. The MoH could consider undertaking observations of clinical skills as part of supervision.

• Facility management committees have been found a good management practice elsewhere. Involve the local community in evaluating the quality of care as they perceive it.

• Quality of care involves quality of data, both data recording and data management. Improve HMIS training, supervision and mentoring, especially in regard to the classification of obstetric complications, stillbirths and early newborn deaths, direct and indirect maternal deaths, as well as civil registration. In addition, routine maternal death and newborn death review/audits should help improve the correct classification of cause of death.

• For those facilities that are missing one or two EmONC signal functions, a plan should be made to ensure that staff have the skills and the enabling environment to perform the signal functions. Training is needed on manual removal of placenta, assisted vaginal delivery, removal of retained products, and provision of parenteral anticonvulsants to all birth attendants, in all the partially functioning health facilities with more than 10 deliveries per month.

• Continue to strengthen national guidelines for the clinical management protocols for obstetric and newborn complications. Where guidelines exist, training, and supervision for quality improvement should follow. Where they do not exist, they should be distributed. Every facility needs a complete set of these guidelines and accompanying posters, wall charts, or complication specific charts that designate the appropriate treatment at each level.


• Guidelines and protocols were available in less than 50% of the facilities. The biggest gap in guidelines and protocols was in CHCs. Clearly there is a need to review and ensure 100% of all guidelines and protocols are present and used in all facilities.

• Emergency patients should be accompanied by a qualified health professional. All drivers should have had“first aid” training and the vehicle used for transport should also have telecommunications available (cell phone or radio communication).

• All hospitals should record referrals in and out and collect information concerning each woman who is referred on. Where was she coming from? and going to? What was the purpose of the referral? What is the outcome for the patient?

• Maintain an emergency stock (trolley or box) of key drugs (in operating theatres, labour wards and maternity wards) in all facilities, even where pharmacies are always open. The emergency stock could then be refilled at re-order level.

• Whenever possible, maintain the practice of partograph reviews, C-section reviews, and Maternal/newborn deaths reviews with intention of raising competencies and prevent re-occurence of adverse events.

4. Human Resources

• Ensure availability of adequate qualified and competent staff at CHCs and hospitals providing BEmONC and CEmONC services respectively. In addition to midwives and doctors, essential staff should also include:

• Qualified/trained lab technicians

• Pharmacists

• At specific hospitals: paediatrician or pediatric nurse, at least one back-up surgeon to cover for the obstetrician’s absence, anaesthetists and OT technicians

• Health managers and administrators

• A lab technician should be available in all the CEmONC facilities 24/7 to group and match blood for urgent transfusion.

• Increase availability of national staff to support EmONC and essential maternal and newborn care. Provide opportunities, scholarships, for nationals to acquire missing competencies in specialized areas such as obstetrics, neonatology, anaesthesiology, emergency medicine.

• Recruit and train 2-3 senior medical doctors and/or midwifes per district, to support skills based clinical training and practice in the workplace, through facilitative supervision and/or clinical training; and/or consider a rotation system which allows staff to practice essential interventions to support EmONC and essential newborn care on a regular basis to avoid losing their skills.

• Consider increasing the number of Clinical Training Centres in the country (at least 3 additional) so that trainees have more opportunities to practice.


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Annex 14 – Maps Showing EmONC Facilities by Characteristics and Selected Candidates for BEmONC Upgrade


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Annex 15: Municipality Profiles Showing Existing Resources and Needs for The Implementation PlanA. Aileu Municipality

Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities

Population 48,554

Estimated number of births 2014-2015 (1 year) (Crude Birth Rate : 30/1000) 1,457

Reported number of births August 2014- July 2015 (in the assessed health facilities) 874

Reported number of births in Health Posts 105

Annex 15A Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCSI Aileu

Vila*CHC

NamolesoCHC

Remexio*CHC

Laulara

Number of births from August 2014-July 2015 554 55 177 88

Institution to which the patients with obstetric complications are referred

HR Maubisse

HR Maubisse

HNGV Dili HNGV Dili

Travel Time to higher level facility 1 hour30

minutes1 hour 30 minutes

30 minutes

Annex 15A Table 2: Performance of Signal Functions during preceding 12 months of the assessment


Vila*CHC

NamolesoCHC

Remexio*CHC

Laulara

Parenteral antibiotics (12months) Yes Yes Yes Yes

Parenteral Oxytocics (12months) Yes Yes Yes Yes

Parenteral Anticonvulsant (12months) Yes No Yes No

Manual Removal of Placenta (12months) Yes No Yes No

Removal of Retained product (12months) Yes No Yes No

Assisted Vaginal Delivery (12months) No No No No

Newborn resuscitation (12months) Yes Yes Yes Yes


Annex 15A Table 3: Availability of Human Resources


Vila*CHC

NamolesoCHC

Remexio*CHC

Laulara

Midwife (Currently employed) 5 0 4 3

Availability of midwives 24 hours Yes No No No

Medical Doctor (Currently employed) 5 2 3 3

Availability of medical doctor 24 hours Yes No No No

Nurse (Currently employed) 3 2 3 0

Availability of nurse 24 hours Yes No No No

Laboratory technician (Currently employed) 1 0 1 1

Availability of lab technician 24 hours No No No No

Nurse anesthetist (Currently employed)

Availability of Nurse anesthetist 24 hours

Obstetrician (Currently employed)

Availability of obstetrician 24 hours

Anesthesiologist (MD) (Currently employed)

Availability of anesthesiologist (MD) 24 hours

Annex 15A Table 4: Availability of general facilities for EmONC services


Vila*CHC

NamolesoCHC

Remexio*CHC

Laulara

Electricity Yes Yes Yes Yes

Back up generator No No No No

Running water Yes Yes Yes Yes

Functioning toilet Yes Yes Yes Yes

Total bed in the facility 10 5 5 6

Total bed for obstetric patient 4 3 3 3

Total delivery table 2 2 2 2

Delivery room Yes Yes Yes Yes

Postpartum room Yes Yes Yes Yes

Laboratory room Yes Yes Yes Yes

Operating Theater

Neonatal care room

Blood Bank



Vila*CHC

NamolesoCHC

Remexio*CHC

Laulara

Availability of stored blood for use in emergencies

General anesthesia

Spinal anesthesia

Functional fan/air conditioning No No No No

Curtains/means of providing patient privacy Yes No Yes Yes

Annex 15A Table 5: Availability facilities for accommodation and length of stay after normal delivery


Vila*CHC

NamolesoCHC

Remexio*CHC

Laulara

Length of stay for normal delivery (day) 1 1 1 0

Food for maternity patient Yes Yes Yes Yes

Food for family No Yes No No

Waiting area for visitors and family Yes Yes Yes Yes

Lodging for maternity patient Yes No Yes Yes

Lodging for family No No No No

Annex 15A Table 6: Availability of communication and transport facilities for referral


Vila*CHC

NamolesoCHC

Remexio*CHC

Laulara

Telephone at maternity ward No No No No

Telephone in the facility Yes No No No

Cell phone (own by facility) Yes Yes Yes Yes

Cell phone (own by staff) Yes Yes Yes Yes

Ambulance No No Yes No

Multi purpose vehicle Yes Yes Yes Yes

Other transport for referral No No No No


B. Ainaro Municipality

Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities - (KOICA has already undertaken the construction of CHC Hautio)

Population 66,397

Estimated number of births 2014-2015 (1 year) (Crude Birth Rate : 30/1000) 1,992

Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 613


Annex 15B Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCSI

Ainaro*CHC

Hautio*CHC

Maubisse CHC Hatu-

UdoHR

MaubisseNumber of birth from August 2014-July 2015 199 4 0 59 351


HR Maubisse

HR Maubisse

HR Maubisse CSI Same HNGV Dili

Travel Time to higher level facility 1 hour 30 minutes 1 hour 15 minutes 30 minutes 3 hours

Annex 15B Table 2: Performance of Signal Functions during preceding 12 months of the assessment

Description CSI Ainaro*CHC

Hautio*CHC

Maubisse CHC Hatu-

UdoHR

Maubisse

Parenteral antibiotics (12months) No No No Yes Yes

Parenteral Oxytocics (12months) Yes Yes No Yes Yes

Parenteral Anticonvulsant (12months) No No No No Yes

Manual Removal of Placenta (12months) Yes No No Yes Yes

Removal of Retained product (12months) Yes No No No Yes

Assisted Vaginal Delivery (12months) No No No No YesNewborn resuscitation (12months) Yes No No Yes Yes


Annex 15B Table 3: Availability of Human Resources

DescriptionCSI

Ainaro*CHC

Hautio*CHC

Maubisse CHC

Hatu-UdoHR

Maubisse

Midwife (Currently employed) 7 1 3 1 7

Availability of midwives 24 hours Yes No No No Yes

Medical Doctor (Currently employed) 6 2 1 2 0

Availability of medical doctor 24 hours Yes No No No No

Nurse (Currently employed) 0 0 2 0 0

Availability of nurse 24 hours No No No No No

Laboratory technician (Currently employed) 1 1 1 1 6

Availability of lab technician 24 hours No No No No Yes

Nurse anesthetist (Currently employed) 2

Availability of Nurse anesthetist 24 hours No

Obstetrician (Currently employed) 2

Availability of obstetrician 24 hours No

Anesthesiologist (MD) (Currently employed) 0

Availability of anesthesiologist (MD) 24 hours No

Annex 15B Table 4: Availability of general facilities for EmONC services


Hautio*CHC

Maubisse CHC Hatu-

UdoHR

Maubisse

Electricity Yes No Yes Yes Yes

Back up generator No No Yes Yes Yes

Running water Yes Yes Yes Yes Yes

Functioning toilet Yes Yes Yes Yes Yes

Total bed in the facility 15 2 0 6 40

Total bed for obstetric patient 2 1 0 2 10

Total delivery table 2 1 0 3 2

Delivery room Yes No No Yes Yes

Postpartum room Yes No No Yes Yes

Laboratory room Yes No Yes Yes Yes

Operating Theater Yes

Neonatal care room Yes



Hautio*CHC

Maubisse CHC Hatu-

UdoHR

Maubisse

Blood Bank Yes

Availability of stored blood for use in emergencies No

General anesthesia Yes

Spinal anesthesia Yes

Functional fan/air conditioning No No No No Yes

Curtains/means of providing patient privacy No Yes Yes Yes Yes

Annex 15B Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCSI

Ainaro*CHC

Hautio*CHC

Maubisse CHC

Hatu-UdoHR

Maubisse

Length of stay for normal delivery (day) 1 0 0 0 1

Food for maternity patient Yes No No No Yes

Food for family No No No No No

Waiting area for visitors and family Yes Yes Yes Yes Yes

Lodging for maternity patient Yes No No Yes Yes

Lodging for family No No No No Yes

Annex 15B Table 6: Availability of communication and transport facilities for referral

DescriptionCSI

Ainaro*CHC

Hautio*CHC

Maubisse CHC

Hatu-UdoHR

Maubisse

Telephone at maternity ward No No No No No

Telephone in the facility No No Yes No No

Cell phone (own by facility) No Yes Yes Yes Yes

Cell phone (own by staff) Yes Yes Yes Yes Yes

Ambulance Yes No No No Yes

Multi purpose vehicle Yes Yes No Yes No

Other transport for referral No No No No Yes


C. Baucau Municipality


Population 124,061

Estimated number of births 2014-2015 (1 year ) (Crude Birth Rate: 33/1000) 4,094

Reported number of births August 2014- July 2015 ( in the assessed health facilities ) 2,481


Annex 15C Table 1: Reported births during preceding 12 months of the assessment and referral information

Description

CHC

Uai

lili

CHC

Laga

CHC

Que

licai

*

CHC

Bagu

ia*

CHC

Vem

ase

CHC

Veni

lale

CHC

Ream

ari

HR B

auca

u

Number of birth from August 2014-July 2015

83 285 238 215 161 122 91 1286


HR Baucau

HR Baucau

HR Baucau

HR Baucau

HR Baucau

HR Baucau

HR Baucau

HNGV Dili

Travel Time to higher level facility

20 minutes

45 Minutes

1 hour 3 hours 1 hour 1 hour 5

minutes 2 hours

Annex 15C Table 2: Performance of Signal Functions during preceding 12 months of the assessment

Description

CHC

Uai

lili

CHC

Laga

CHC

Que

licai

*

CHC

Bagu

ia*

CHC

Vem

ase

CHC

Veni

lale

CHC

Ream

ari

HR B

auca

u

Parenteral antibiotics (12months) No No No Yes No Yes No Yes

Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes Yes Yes Yes

Parenteral Anticonvulsant (12months) No Yes No No No No No Yes

Manual Removal of Placenta (12months) Yes Yes Yes Yes No Yes Yes Yes

Removal of Retained product (12months) Yes Yes No Yes Yes No Yes Yes

Assisted Vaginal Delivery (12months) No No No No No No No Yes

Newborn resuscitation (12months) No No Yes Yes Yes Yes Yes Yes


Annex 15C Table 3: Availability of Human Resources

Description

CHC

Uai

lili

CHC

Laga

CHC

Que

licai

*

CHC

Bagu

ia*

CHC

Vem

ase

CHC

Veni

lale

CHC

Ream

ari

HR B

auca

u

Midwife (Currently employed) 3 3 5 1 4 5 4 16

Availability of midwives 24 hours No No No No Yes Yes No Yes

Medical Doctor (Currently employed) 0 0 3 1 0 7 9 3

Availability of medical doctor 24 hours No No No Yes No No No No

Nurse (Currently employed) 0 3 2 1 0 3 0 0

Availability of nurse 24 hours No No No Yes No No No No

Laboratory technician (Currently employed) 1 1 1 0 1 0 0 7

Availability of lab technician 24 hours No No No No No No No Yes







No

Annex 15C Table 4: Availability of general facilities for EmONC services

Description CHC

Uai

lili

CHC

Laga

CHC

Que

licai

*

CHC

Bagu

ia*

CHC

Vem

ase

CHC

Veni

lale

CHC

Ream

ari

HR

Bauc

au

Electricity Yes Yes Yes Yes Yes Yes Yes Yes

Back up generator Yes No No Yes No Yes No Yes

Running water Yes Yes No Yes Yes Yes Yes Yes

Functioning toilet Yes No Yes Yes Yes Yes Yes Yes

Total bed in the facility 1 6 5 7 9 9 10 114

Total bed for obstetric patient 1 5 3 6 8 7 8 20

Total delivery table 1 1 1 3 2 2 3 5

Delivery room Yes Yes Yes Yes Yes Yes Yes Yes

Postpartum room No Yes Yes Yes Yes Yes Yes Yes

Laboratory room Yes Yes Yes Yes Yes No No Yes



Description CHC

Uai

lili

CHC

Laga

CHC

Que

licai

*

CHC

Bagu

ia*

CHC

Vem

ase

CHC

Veni

lale

CHC

Ream

ari

HR

Bauc

au


Blood Bank No


No



Functional fan/air conditioning No Yes No No Yes Yes No No

Curtains/means of providing patient privacy

Yes Yes Yes Yes Yes Yes Yes Yes

Annex 15C Table 5: Availability facilities for accommodation and length of stay after normal delivery

Description

CHC

Uai

lili

CHC

Laga

CHC

Que

licai

*

CHC

Bagu

ia*

CHC

Vem

ase

CHC

Veni

lale

CHC

Ream

ari

HR B

auca

u

Length of stay for normal delivery (day) 0 1 1 1 1 1 1 1

Food for maternity patient No No No Yes No No No Yes

Food for family No No No Yes No No No Yes

Waiting area for visitors and family Yes Yes Yes Yes No No Yes Yes

Lodging for maternity patient Yes Yes Yes Yes Yes Yes Yes Yes

Lodging for family Yes Yes Yes Yes Yes Yes Yes Yes

Annex 15C Table 6: Availability of communication and transport facilities for referral

Description CHC

Uai

lili

CHC

Laga

CHC

Que

licai

*

CHC

Bagu

ia*

CHC

Vem

ase

CHC

Veni

lale

CHC

Ream

ari

HR

Bauc

au

Telephone at maternity ward No No No No No No No No

Telephone in the facility No No No No No No No Yes

Cell phone (own by facility) Yes Yes Yes Yes Yes No Yes Yes

Cell phone (own by staff) Yes Yes Yes Yes Yes Yes Yes Yes

Ambulance No No No No No No No Yes

Multi purpose vehicle Yes Yes Yes Yes Yes Yes Yes Yes

Other transport for referral No No No No No No No No


D. Bobonaro Municipality


Population 98,932

Estimated number of births 2014-2015 (1 year ) ( Crude Birth rate 36/1000) 3,562



Annex 15D Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCHC

Maliana Vila

CHC Cailaco*

CHC Balibo

CHC Atabae*

CHC Lolotoe*

CHC Bobonaro*

HR Maliana


0 76 120 90 24 60 655


HR Maliana

HR Maliana

HR Maliana

HR Maliana

HR Maliana

HR Maliana

HNGV Dili


15 minutes

45 minutes

40 minutes

2 hours 3 hours 1 hour 3 hours

Annex 15D Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCHC

Maliana Vila

CHC Cailaco*

CHC Balibo

CHC Atabae*

CHC Lolotoe*

CHC Bobonaro*

HR Maliana

Parenteral antibiotics (12months)

No No No Yes No Yes Yes

Parenteral Oxytocics (12months)

No Yes Yes Yes Yes Yes Yes

Parenteral Anticonvulsant (12months)

No No No No No No Yes

Manual Removal of Placenta (12months)

No No No No Yes No Yes

Removal of Retained product (12months)

No Yes Yes No No No Yes

Assisted Vaginal Delivery (12months)


Newborn resuscitation (12months)

No Yes Yes Yes No No Yes


Annex 15D Table 3: Availability of Human Resources

DescriptionCHC

Maliana Vila

CHC Cailaco*

CHC Balibo

CHC Atabae*

CHC Lolotoe*

CHC Bobonaro*

HR Maliana

Midwife (Currently employed)

5 3 2 2 2 2 12

Availability of midwives 24 hours


Medical Doctor (Currently employed)

4 3 3 4 2 3 1

Availability of medical doctor 24 hours

No No No No No No No

Nurse (Currently employed)

2 1 0 5 4 3 0

Availability of nurse 24 hours


Laboratory technician (Currently employed)

0 1 1 1 1 0 3

Availability of lab technician 24 hours



3


No


1


No


0


No


Annex 15D Table 4: Availability of general facilities for EmONC services

DescriptionCHC

Maliana Vila

CHC Cailaco*

CHC Balibo

CHC Atabae*

CHC Lolotoe*

CHC Bobonaro*

HR Maliana

Electricity Yes Yes Yes Yes Yes Yes Yes

Back up generator No No No Yes Yes Yes Yes

Running water Yes Yes Yes Yes Yes Yes Yes

Functioning toilet Yes Yes Yes Yes Yes Yes Yes

Total bed in the facility 3 4 9 6 4 2 34

Total bed for obstetric patient

3 2 7 1 4 4 12

Total delivery tables 0 2 2 2 1 2 3

Delivery room No Yes Yes Yes Yes Yes Yes

Postpartum room No Yes Yes Yes Yes Yes Yes

Laboratory room No Yes Yes Yes Yes No Yes


Neonatal care room No

Blood Bank Yes


No



Functional fan/air conditioning

No No Yes Yes Yes Yes Yes


Yes Yes Yes Yes Yes Yes Yes


Annex 15D Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCHC

Maliana Vila

CHC Cailaco*

CHC Balibo

CHC Atabae*

CHC Lolotoe*

CHC Bobonaro*

HR Maliana

Length of stay for normal delivery (day)

0 2 0 1 1 1 1

Food for maternity patient No No No No No No Yes

Food for family No No No No No No Yes

Waiting area for visitors and family


Lodging for maternity patient


Lodging for family No No Yes No No No No

Annex 15D Table 6: Availability of communication and transport facilities for referral

DescriptionCHC

Maliana Vila

CHC Cailaco*

CHC Balibo

CHC Atabae*

CHC Lolotoe*

CHC Bobonaro*

HR Maliana

Telephone at maternity ward


Telephone in the facility No No No No No No Yes

Cell phone (own by facility)

Yes Yes No Yes Yes Yes No

Cell phone (own by staff) No Yes Yes Yes No Yes Yes

Ambulance No No No No No No Yes

Multi purpose vehicle Yes Yes Yes Yes Yes Yes Yes

Other transport for referral

No No No No Yes No Yes


E. Covalima Municipality


Population 64,550

Estimated annual number of births ( Crude Birth Rate : 29/1000) 1,872


Reported number of births in Health Posts N/A

Annex 15E Table 1: Reported births during preceding 12 months of the assessment and referral information

Description CHC

Fatu

lulik

CHC

Fatu

Mea

CHC

Foho

rem

*

CHC

Mau

cata

r

CHC

Suai

Vila

CHC

Tilo

mar

*

CHC

Zum

alai

*

HR

Suai


1 43 48 5 0 150 154 573


HR Suai HR Suai HR Suai HR Suai HR Suai HR Suai HR SuaiHNGV

Dili


3 hours 2 hours 1 hour45

minutes10

minutes35

minutes

1 hour 30

minutes10 hours

Annex 15E Table 2: Performance of Signal Functions during preceding 12 months of the assessment

Description CHC

Fatu

lulik

CHC

Fatu

Mea

CHC

Foho

rem

*

CHC

Mau

cata

r

CHC

Suai

Vila

CHC

Tilo

mar

*

CHC

Zum

alai

*

HR

Suai


No No No No No No Yes Yes


Yes Yes Yes No No Yes Yes Yes


No No Yes No No No Yes Yes


No No Yes No No No Yes Yes


No No Yes No No Yes No Yes


No No No No No No No Yes

Newborn resuscitation (12months) No Yes Yes No No No Yes Yes


Annex 15E Table 3: Availability of Human Resources

Description CHC

Fatu

lulik

CHC

Fatu

Mea

CHC

Foho

rem

*

CHC

Mau

cata

r

CHC

Suai

Vila

CHC

Tilo

mar

*

CHC

Zum

alai

*

HR

Suai

Midwife (Currently employed) 1 1 1 1 3 1 3 11


No No No No No No Yes Yes


1 2 1 2 6 3 6 0


No No No No No No Yes No

Nurse (Currently employed) 0 2 0 0 0 0 0 0

Availability of nurse 24 hours No No No No No No No No


0 0 1 0 2 1 1 4


No No No No No No No No


3


No


0


No


0


No

Annex 15E Table 4: Availability of general facilities for EmONC services

Description CHC

Fatu

lulik

CHC

Fatu

Mea

CHC

Foho

rem

*

CHC

Mau

cata

r

CHC

Suai

Vila

CHC

Tilo

mar

*

CHC

Zum

alai

*

HR

Suai

Electricity Yes Yes Yes Yes Yes Yes Yes Yes

Back up generator Yes Yes No No Yes No No Yes

Running water Yes No No Yes Yes Yes Yes Yes

Functioning toilet Yes Yes Yes Yes Yes Yes Yes Yes

Total bed in the facility 7 8 11 3 6 6 9 46

Total bed for obstetric patient 2 4 5 1 2 1 4 12


Description CHC

Fatu

lulik

CHC

Fatu

Mea

CHC

Foho

rem

*

CHC

Mau

cata

r

CHC

Suai

Vila

CHC

Tilo

mar

*

CHC

Zum

alai

*

HR

Suai

Total delivery table 2 2 2 1 1 2 2 2

Delivery room Yes Yes Yes Yes Yes Yes Yes Yes

Postpartum room Yes Yes Yes Yes Yes Yes Yes Yes

Laboratory room Yes No Yes Yes Yes Yes Yes Yes


Neonatal care room No

Blood Bank No


No

General anesthesia No

Spinal anesthesia No


No No No No No No No Yes


No Yes No Yes Yes Yes Yes Yes

Annex 15E Table 5: Availability facilities for accommodation and length of stay after normal delivery

Description CHC

Fatu

lulik

CHC

Fatu

Mea

CHC

Foho

rem

*

CHC

Mau

cata

r

CHC

Suai

Vila

CHC

Tilo

mar

*

CHC

Zum

alai

*

HR

Suai


0 0 1 1 0 0 0 1

Food for maternity patient No No No No No No No Yes

Food for family No No No No No No No No


Yes Yes Yes Yes Yes Yes Yes No

Lodging for maternity patient

Yes Yes Yes Yes Yes Yes Yes Yes

Lodging for family No No No No No No No No


Annex 15E Table 6: Availability of communication and transport facilities for referral

Description CHC

Fatu

lulik

CHC

Fatu

Mea

CHC

Foho

rem

*

CHC

Mau

cata

r

CHC

Suai

Vila

CHC

Tilo

mar

*

CHC

Zum

alai

*

HR

Suai

Telephone in the facility Yes No No No Yes Yes No Yes

Cell phone (own by facility) No Yes Yes No No No No No

Cell phone (own by staff) Yes Yes Yes Yes Yes Yes Yes Yes

Ambulance No No No No No No No Yes

Multi-purpose vehicle Yes Yes Yes Yes Yes Yes Yes Yes

Other transport for referral No No No No No No No No


F. Dili Municipality

Note: Facilities with * are the facilities proposed for upgrading to EmONC facilities(Comoro CHC was found to be a functional BEmONC Facility and needs quality

improvement)

Population 252,884

Estimated number of births 2014-2015 (1 year ) ( Crude Birth Rate: 33/1000) 8,345



Annex 15F Table 1: Reported births during preceding 12 months of the assessment and re ferral information

DescriptionCHC

Centro*CHC

MetinaroCHC

Atauro*CHC

ComoroCHC

Becora*

CHC Vera Cruz*

NH HNGV


313 78 104 1513 557 655 4302


HNGV Dili HNGV Dili HNGV Dili HNGV Dili HNGV Dili HNGV Dili HNGV Dili


10 minutes

45 minutes

4 hours20

minutes10

minutes15

minutesN/A

Annex 15F Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCHC

Centro*CHC

MetinaroCHC

Atauro*CHC

ComoroCHC

Becora*

CHC Vera Cruz*

NH HNGV


Yes No Yes Yes Yes Yes Yes




Yes No Yes Yes No Yes Yes


Yes No Yes Yes Yes Yes Yes




Yes No No Yes No No Yes




Annex 15F Table 3: Availability of Human Resources

DescriptionCHC

Centro*CHC

MetinaroCHC

Atauro*CHC

ComoroCHC

Becora*

CHC Vera Cruz*

NH HNGV

Midwife (Currently employed) 8 3 3 20 17 13 20


Yes No No Yes Yes Yes Yes


1 5 2 22 9 8 10


Yes No No Yes Yes Yes Yes

Nurse (Currently employed) 0 2 2 0 4 0 0

Availability of nurse 24 hours No No No No Yes No No


1 1 2 2 1 3 18




3


No


6


No


4


Yes

Annex 15F Table 4: Availability of general facilities for EmONC services

DescriptionCHC

Centro*CHC

MetinaroCHC

Atauro*CHC

ComoroCHC

Becora*

CHC Vera Cruz*

NH HNGV

Electricity Yes Yes Yes Yes Yes Yes Yes

Back up generator Yes No Yes No No No Yes

Running water Yes Yes Yes Yes Yes Yes Yes

Functioning toilet Yes Yes Yes Yes Yes Yes Yes

Total bed in the facility 8 8 11 10 12 18 260

Total bed for obstetric patient 4 7 5 5 9 7 55

Total delivery table 2 2 1 2 3 2 12


DescriptionCHC

Centro*CHC

MetinaroCHC

Atauro*CHC

ComoroCHC

Becora*

CHC Vera Cruz*

NH HNGV

Delivery room Yes Yes Yes Yes Yes Yes Yes

Postpartum room Yes Yes Yes Yes Yes Yes Yes

Laboratory room Yes Yes Yes Yes Yes Yes Yes


Neonatal care room Yes Yes

Blood Bank Yes


100






Yes Yes No Yes Yes Yes Yes

Annex 15F Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCHC

Centro*CHC

MetinaroCHC

Atauro*CHC

ComoroCHC

Becora*

CHC Vera Cruz*

NH HNGV


1 0 0 0 1 1 0

Food for maternity patient Yes Yes Yes Yes Yes Yes Yes

Food for family No Yes No No No No No



Lodging for maternity patient Yes Yes Yes No Yes Yes Yes

Lodging for family No Yes No No No No No


Annex 15F Table 6: Availability of communication and transport facilities for referral

DescriptionCHC

Centro*CHC

MetinaroCHC

Atauro*CHC

ComoroCHC

Becora*

CHC Vera Cruz*

NH HNGV

Telephone at maternity ward No No No No No Yes Yes

Telephone in the facility Yes No Yes No No No Yes

Cell phone (own by facility) Yes No No No Yes No Yes

Cell phone (own by staff) Yes Yes Yes Yes Yes Yes Yes

Ambulance No No No No No No Yes

Multi purpose vehicle Yes Yes Yes Yes Yes Yes No

Other transport for referral No No Yes No Yes No No


G. Ermera Municipality


Population 127,283




Annex 15G Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCHC

RailacoCSI

Gleno*

CHC Ermera Lama

CHC Letefoho

CHC Atsabe*

CHC Hatolia*

Number of birth from August 2014-July 2015 79 324 97 87 147 55


CSI Gleno

CSI Gleno

CSI Gleno

CSI Gleno

CSI Gleno

CSI Gleno

Travel Time to higher level facility15

minutes1 hour

30 minutes

2 hours 4 hours 2 hours

Annex 15G Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCHC

RailacoCSI

Gleno*

CHC Ermera Lama

CHC Letefoho

CHC Atsabe*

CHC Hatolia*

Parenteral antibiotics (12months) No Yes Yes No Yes Yes

Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes Yes

Parenteral Anticonvulsant (12months) No Yes No No No No

Manual Removal of Placenta (12months) No Yes No Yes Yes Yes

Removal of Retained product (12months) No Yes Yes No Yes No

Assisted Vaginal Delivery (12months) No No No No No No

Newborn resuscitation (12months) No Yes Yes No Yes Yes


Annex 15G Table 3: Availability of Human Resources

DescriptionCHC

RailacoCSI

Gleno*

CHC Ermera Lama

CHC Letefoho

CHC Atsabe*

CHC Hatolia*

Midwife (Currently employed) 2 6 3 2 2 2

Availability of midwives 24 hours No Yes No No No No

Medical Doctor (Currently employed) 4 1 3 3 3 4

Availability of medical doctor 24 hours No Yes No No No No

Nurse (Currently employed) 4 0 2 1 5 1

Availability of nurse 24 hours No No No No No No

Laboratory technician (Currently employed) 1 1 1 0 0 1

Availability of lab technician 24 hours No No No No No No







Annex 15G Table 4: Availability of general facilities for EmONC services

DescriptionCHC

RailacoCSI

Gleno*

CHC Ermera Lama

CHC Letefoho

CHC Atsabe*

CHC Hatolia*

Electricity Yes Yes Yes Yes Yes Yes

Back up generator No No Yes No No No

Running water Yes Yes Yes No Yes Yes

Functioning toilet No Yes Yes Yes No Yes

Total bed in the facility 1 20 1 5 11 7

Total bed for obstetric patient 1 4 1 2 8 5

Total delivery table 1 2 1 2 2 2

Delivery room Yes Yes No Yes Yes Yes

Postpartum room Yes Yes No Yes Yes Yes

Laboratory room Yes Yes No No No Yes

Operating Theater

Neonatal care room Yes Yes Yes


DescriptionCHC

RailacoCSI

Gleno*

CHC Ermera Lama

CHC Letefoho

CHC Atsabe*

CHC Hatolia*

Blood Bank


General anesthesia

Spinal anesthesia

Functional fan/air conditioning No No No No No Yes

Curtains/means of providing patient privacy Yes Yes Yes Yes Yes Yes

Annex 15G Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCHC

RailacoCSI

Gleno*

CHC Ermera Lama

CHC Letefoho

CHC Atsabe*

CHC Hatolia*

Length of stay for normal delivery (day) 0 0 0 0 0 0

Food for maternity patient Yes Yes No No No Yes

Food for family No No No No No No

Waiting area for visitors and family Yes Yes Yes Yes Yes Yes

Lodging for maternity patient Yes Yes No Yes Yes Yes

Lodging for family Yes No No Yes Yes No

Annex 15G Table 6: Availability of communication and transport facilities for referral

DescriptionCHC

RailacoCSI

Gleno*

CHC Ermera Lama

CHC Letefoho

CHC Atsabe*

CHC Hatolia*

Telephone at maternity ward No No No No No No

Telephone in the facility Yes No No Yes No No

Cell phone (own by facility) Yes No Yes No Yes No

Cell phone (own by staff) Yes Yes Yes Yes Yes Yes

Ambulance No Yes No No No No

Multi purpose vehicle Yes Yes Yes Yes Yes Yes

Other transport for referral No No No No No No


H. Lautem Municipality


Population 64,135




Annex 15H Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCSI

Lospalos*CHC

LautemCHC

Iliomar*CHC

Luro*CHC

Tutuala

Number of birth from August 2014-July 2015 586 116 48 24 42


HR BaucauCSI

LospalosCSI

LospalosCSI

LospalosCSI

Lospalos

Travel Time to higher level facility 2 hours45

minutes2 hours 30

minutes1 hour 30 minutes

45 minutes

Annex 15H Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCSI

Lospalos*CHC

LautemCHC

Iliomar*CHC

Luro*CHC

Tutuala

Parenteral antibiotics (12months) Yes Yes Yes No No

Parenteral Oxytocics (12months) Yes Yes Yes Yes Yes

Parenteral Anticonvulsant (12months) No No No No No

Manual Removal of Placenta (12months) Yes Yes Yes No Yes

Removal of Retained product (12months) Yes Yes No No No

Assisted Vaginal Delivery (12months) No No No No No

Newborn resuscitation (12months) Yes Yes No No Yes


Annex 15H Table 3: Availability of Human Resources

DescriptionCSI

Lospalos*CHC

LautemCHC

Iliomar*CHC

Luro*CHC

Tutuala


Availability of midwives 24 hours Yes Yes Yes No No


Availability of medical doctor 24 hours Yes Yes No No Yes




Availability of lab technician 24 hours No No No No No







Annex 15H Table 4: Availability of general facilities for EmONC services

DescriptionCSI

Lospalos*CHC

LautemCHC

Iliomar*CHC

Luro*CHC

Tutuala

Electricity Yes Yes Yes Yes Yes

Back up generator Yes Yes Yes Yes Yes






Delivery room Yes Yes Yes Yes Yes

Postpartum room Yes Yes Yes Yes Yes

Laboratory room Yes Yes Yes Yes No

Operating Theater

Neonatal care room

Blood Bank


DescriptionCSI

Lospalos*CHC

LautemCHC

Iliomar*CHC

Luro*CHC

Tutuala


General anesthesia

Spinal anesthesia

Functional fan/air conditioning Yes No Yes No Yes

Curtains/means of providing patient privacy No Yes Yes Yes No

Annex 15H Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCSI

Lospalos*CHC

LautemCHC

Iliomar*CHC

Luro*CHC

Tutuala


Food for maternity patient Yes No No No No


Waiting area for visitors and family Yes No Yes Yes No

Lodging for maternity patient Yes Yes Yes Yes Yes

Lodging for family No No Yes No No

Annex 15H Table 6: Availability of communication and transport facilities for referral

DescriptionCSI

Lospalos*CHC

LautemCHC

Iliomar*CHC

Luro*CHC

Tutuala


Telephone in the facility Yes No No Yes Yes

Cell phone (own by facility) No Yes Yes No No


Ambulance Yes No No No No

Multi purpose vehicle Yes Yes Yes Yes Yes



I. Liquica Municipality


Population 73,027

Estimated number of births 2014-2015 (1 year) (Crude Birth Rate: 36/1000) 2,629

Reported number of births August 2014- July 2015 (in the assessed health facilities) 570


Annex 15I Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCHC

Fatumasi*CSI

Liquica*CHC

Maubara*

Number of birth from August 2014-July 2015 90 304 176

Institution to which the patients with obstetric complications are referred HNGV Dili HNGV Dili HNGV Dili

Travel Time to higher level facility 1 hour 1 hour 2 hours

Annex 15I Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCHC

Fatumasi*CSI

Liquica*CHC

Maubara*

Parenteral antibiotics (12months) No No Yes

Parenteral Oxytocics (12months) Yes Yes Yes

Parenteral Anticonvulsant (12months) Yes No No

Manual Removal of Placenta (12months) No Yes Yes

Removal of Retained product (12months) No No Yes

Assisted Vaginal Delivery (12months) No No No

Newborn resuscitation (12months) No Yes Yes

Annex 15I Table 3: Availability of Human Resources

DescriptionCHC

Fatumasi*CSI

Liquica*CHC

Maubara*

Midwife (Currently employed) 2 4 5

Availability of midwives 24 hours Yes Yes Yes

Medical Doctor (Currently employed) 1 1 1

Availability of medical doctor 24 hours No No Yes


DescriptionCHC

Fatumasi*CSI

Liquica*CHC

Maubara*

Nurse (Currently employed) 1 0 1

Availability of nurse 24 hours No No Yes

Laboratory technician (Currently employed) 0 1 1

Availability of lab technician 24 hours No No No







Annex 15I Table 4: Availability of general facilities for EmONC services

DescriptionCHC

Fatumasi*CSI

Liquica*CHC

Maubara*

Electricity Yes Yes Yes

Back up generator Yes Yes No

Running water Yes Yes Yes

Functioning toilet Yes Yes Yes

Total bed in the facility 4 12 3

Total bed for obstetric patient 4 4 2

Total delivery table 2 2 2

Delivery room Yes Yes Yes

Postpartum room Yes Yes Yes

Laboratory room Yes Yes Yes

Operating Theater


Blood Bank


General anesthesia

Spinal anesthesia

Functional fan/air conditioning No Yes No

Curtains/means of providing patient privacy Yes Yes Yes


Annex 15I Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCHC

Fatumasi*CSI

Liquica*CHC

Maubara*

Length of stay for normal delivery (day) 0 0 0

Food for maternity patient Yes Yes Yes

Food for family No No No

Waiting area for visitors and family Yes Yes Yes

Lodging for maternity patient Yes No Yes

Lodging for family No No No

Annex 15I Table 6: Availability of communication and transport facilities for referral

DescriptionCHC

Fatumasi*CSI

Liquica*CHC

Maubara*

Telephone at maternity ward No No No

Telephone in the facility No Yes No

Cell phone (own by facility) Yes Yes Yes

Cell phone (own by staff) Yes Yes Yes

Ambulance No Yes No

Multi purpose vehicle Yes Yes Yes

Other transport for referral No Yes Yes


J. Manatuto Municipality


Population 45,541




Annex 15J Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCSI

Manatuto*CHC

LaleiaCHC Laclo

CHC Soibada

CHC Natarbora*

CHC Laclubar*


204 40 13 21 23 82


HNGV DiliCSI

ManatutoCSI

ManatutoCSI

ManatutoCSI

ManatutoCSI

Manatuto


1 hour 30 minutes

30 minutes1 hour 30 minutes

4 hours 30 minutes

6 hours3 hours 30

minutes

Annex 15J Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCSI

Manatuto*CHC

LaleiaCHC Laclo

CHC Soibada

CHC Natarbora*

CHC Laclubar*


Yes No Yes Yes No Yes


Yes Yes Yes Yes Yes Yes


No No No No No No


Yes No Yes No No No


Yes Yes Yes Yes No Yes


No No No No No No


Yes No No Yes No No


Annex 15J Table 3: Availability of Human Resources

DescriptionCSI

Manatuto*CHC

LaleiaCHC Laclo

CHC Soibada

CHC Natarbora*

CHC Laclubar*

Midwife (Currently employed)

8 1 1 1 2 3


Yes No No No No No


9 3 3 4 3 2


Yes No No No No No

Nurse (Currently employed)

0 2 2 1 0 0

Availability of nurse 24 hours

No No No No No No


2 0 1 2 1 1


No No No No No No

Nurse anesthetist (Currently employed)Availability of Nurse anesthetist 24 hoursObstetrician (Currently employed)Availability of obstetrician 24 hoursAnesthesiologist (MD) (Currently employed)Availability of anesthesiologist (MD) 24 hours

Annex 15J Table 4: Availability of general facilities for EmONC services

DescriptionCSI

Manatuto*CHC

LaleiaCHC Laclo

CHC Soibada

CHC Natarbora*

CHC Laclubar*

Electricity Yes Yes Yes Yes Yes Yes

Back up generator Yes No No No No No

Running water Yes Yes Yes Yes Yes Yes

Functioning toilet Yes Yes No Yes Yes Yes

Total bed in the facility 18 7 5 10 9 10

Total bed for obstetric patient

6 4 2 8 7 7

Total delivery table 2 2 1 1 2 3


DescriptionCSI

Manatuto*CHC

LaleiaCHC Laclo

CHC Soibada

CHC Natarbora*

CHC Laclubar*

Delivery room Yes Yes Yes Yes Yes Yes

Postpartum room Yes Yes Yes Yes Yes Yes

Laboratory room Yes Yes Yes Yes Yes Yes

Operating Theater

Neonatal care room

Blood Bank


General anesthesia

Spinal anesthesia


Yes Yes Yes Yes No No


Yes Yes Yes Yes Yes Yes

Annex 15J Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCSI

Manatuto*CHC

LaleiaCHC Laclo

CHC Soibada

CHC Natarbora*

CHC Laclubar*

Length of stay for normal delivery (day) 1 0 0 1 0 1

Food for maternity patient Yes Yes Yes No No Yes

Food for family No No No No No Yes

Waiting area for visitors and family Yes Yes Yes Yes Yes Yes

Lodging for maternity patient Yes Yes Yes Yes Yes Yes

Lodging for family No No No No No No


Annex 15J Table 6: Availability of communication and transport facilities for referral

DescriptionCSI

Manatuto*CHC

LaleiaCHC Laclo

CHC Soibada

CHC Natarbora*

CHC Laclubar*

Telephone at maternity ward

Yes No No No No No

Telephone in the facility Yes No No No No No

Cell phone (own by facility)

No No No No No No

Cell phone (own by staff) Yes Yes Yes Yes Yes Yes

Ambulance Yes No No No No No

Multi purpose vehicle Yes Yes Yes Yes Yes Yes

Other transport for referral

No No No Yes No Yes


K. Manufahi Municipality


Population 52,246



Reported number of births in Health Posts N/A

Annex 15K Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCSI

Same*CHC Alas

CHC Fatuberlio*

CHC Turiscai

Number of birth from August 2014-July 2015 370 35 121 86


HR Maubisse CSI Same CSI Same HR Maubisse

Travel Time to higher level facility1 hour 20 minutes

1 hour 2 hours 1 hour

Annex 15K Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCSI

Same*CHC Alas

CHC Fatuberlio*

CHC Turiscai

Parenteral antibiotics (12months) Yes No No No

Parenteral Oxytocics (12months) Yes Yes Yes Yes

Parenteral Anticonvulsant (12months) Yes No No No

Manual Removal of Placenta (12months) Yes No No No

Removal of Retained product (12months) Yes No Yes No

Assisted Vaginal Delivery (12months) No No No No

Newborn resuscitation (12months) Yes No No No


Annex 15K Table 3: Availability of Human Resources

DescriptionCSI

Same*CHC Alas

CHC Fatuberlio*

CHC Turiscai

Midwife (Currently employed) 8 2 3 2

Availability of midwives 24 hours Yes No No No

Medical Doctor (Currently employed) 2 1 1 1

Availability of medical doctor 24 hours Yes No No No

Nurse (Currently employed) 0 1 1 0

Availability of nurse 24 hours No No No No

Laboratory technician (Currently employed) 1 1 0 0

Availability of lab technician 24 hours No No No No







Annex 15K Table 4: Availability of general facilities for EmONC services

DescriptionCSI

Same*CHC Alas

CHC Fatuberlio*

CHC Turiscai

Electricity Yes Yes Yes Yes

Back up generator Yes Yes No Yes

Running water Yes Yes Yes No

Functioning toilet Yes Yes Yes No

Total bed in the facility 29 5 5 3

Total bed for obstetric patient 5 4 4 1

Total delivery table 2 2 2 2

Delivery room Yes Yes Yes Yes

Postpartum room Yes Yes Yes Yes

Laboratory room Yes Yes Yes Yes

Operating Theater

Newborn care room Yes

Blood Bank


DescriptionCSI

Same*CHC Alas

CHC Fatuberlio*

CHC Turiscai


General anesthesia

Spinal anesthesia

Functional fan/air conditioning Yes Yes Yes No

Curtains/means of providing patient privacy Yes Yes Yes Yes

Annex 15K Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCSI

Same*CHC Alas

CHC Fatuberlio*

CHC Turiscai

Length of stay for normal delivery (day) 0 0 0 0

Food for maternity patient Yes Yes No No

Food for family Yes Yes No No

Waiting area for visitors and family Yes Yes Yes Yes

Lodging for maternity patient Yes Yes Yes No

Lodging for family Yes Yes Yes No

Annex 15K Table 6: Availability of communication and transport facilities for referral

DescriptionCSI

Same*CHC Alas

CHC Fatuberlio*

CHC Turiscai

Telephone at maternity ward Yes No Yes No

Telephone in the facility Yes No No No

Cell phone (own by facility) Yes Yes Yes Yes

Cell phone (own by staff) Yes Yes Yes Yes

Ambulance Yes No No No

Multi purpose vehicle Yes Yes Yes Yes

Other transport for referral No Yes No No


L. Special Region Oecusse


Population 72,230

Estimated number of births 2014-2015 (1 year) ( Crude Birth Rate: 40/1000) 2889



Annex 15L Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCHC

BaquiCHC

BaocnanaCHC

BobometoCHC

Passabe*HR

Oecusse



HR Oecusse

HR Oecusse

HR Oecusse

HR Oecusse HNGV Dili

Travel Time to higher level facility 30 minutes 1 hour 45 minutes 2 hours 12 hours

Annex 15L Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCHC

BaquiCHC

BaocnanaCHC

BobometoCHC

Passabe*HR

Oecusse

Parenteral antibiotics (12months) No No No Yes Yes


Parenteral Anticonvulsant (12months) No No No No Yes

Manual Removal of Placenta (12months) Yes No No No Yes

Removal of Retained product (12months) No No No No Yes

Assisted Vaginal Delivery (12months) No No No No Yes

Newborn resuscitation (12months) No Yes No Yes Yes

Annex 15L Table 3: Availability of Human Resources

DescriptionCHC

BaquiCHC

BaocnanaCHC

BobometoCHC

Passabe*HR

Oecusse


Availability of midwives 24 hours No No No No Yes


Availability of medical doctor 24 hours No No No No No



DescriptionCHC

BaquiCHC

BaocnanaCHC

BobometoCHC

Passabe*HR

Oecusse









Availability of anesthesiologist (MD) 24 hours No

Annex 15L Table 4: Availability of general facilities for EmONC services

DescriptionCHC

BaquiCHC

BaocnanaCHC

BobometoCHC

Passabe*HR

Oecusse


Back up generator Yes Yes Yes No Yes

Running water Yes Yes No Yes Yes







Laboratory room No Yes Yes Yes Yes



Blood Bank Yes


No



Functional fan/air conditioning No Yes Yes No Yes

Curtains/means of providing patient privacy Yes Yes Yes Yes Yes


Annex 15L Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCHC

BaquiCHC

BaocnanaCHC

BobometoCHC

Passabe*HR

Oecusse


Food for maternity patient No No No No Yes

Food for family No No No No Yes

Waiting area for visitors and family Yes Yes Yes No Yes

Lodging for maternity patient Yes Yes Yes Yes Yes

Lodging for family Yes Yes Yes Yes Yes

Annex 15L Table 6: Availability of communication and transport facilities for referral

DescriptionCHC

BaquiCHC

BaocnanaCHC

BobometoCHC

Passabe*HR

Oecusse


Telephone in the facility No No No No Yes

Cell phone (own by facility) Yes No No No Yes


Ambulance No No No No Yes

Multi purpose vehicle Yes Yes Yes Yes No



M. Viqueque Municipality


Population 77,402




Annex 15M Table 1: Reported births during preceding 12 months of the assessment and referral information

DescriptionCHC

Uatucarbau*CHC Ossu

CHC Uatolari*

CSI Viqueque*

CHC Lacluta*



HR Baucau HR Baucau HR Baucau HR Baucau HR Baucau

Travel Time to higher level facility 4 hours 1 hour 2 hours 30 minutes 3 hours 2 hours

Annex 15M Table 2: Performance of Signal Functions during preceding 12 months of the assessment

DescriptionCHC

Uatucarbau*CHC Ossu

CHC Uatolari*

CSI Viqueque*

CHC Lacluta*

Parenteral antibiotics (12months) Yes Yes No Yes Yes


Parenteral Anticonvulsant (12months) No No No No No

Manual Removal of Placenta (12months) No Yes No Yes No

Removal of Retained product (12months) No Yes No Yes No

Assisted Vaginal Delivery (12months) No No No Yes No

Newborn resuscitation (12months) Yes Yes Yes Yes Yes


Table 3: Availability of Human Resources

DescriptionCHC

Uatucarbau*CHC Ossu

CHC Uatolari*

CSI Viqueque*

CHC Lacluta*


Availability of midwives 24 hours No No No Yes No


Availability of medical doctor 24 hours No No No Yes No


Availability of nurse 24 hours No No No Yes No









Annex 15M Table 4: Availability of general facilities for EmONC services

DescriptionCHC

Uatucarbau*CHC Ossu

CHC Uatolari*

CSI Viqueque*

CHC Lacluta*


Back up generator No No No Yes Yes








Laboratory room Yes Yes Yes Yes Yes


DescriptionCHC

Uatucarbau*CHC Ossu

CHC Uatolari*

CSI Viqueque*

CHC Lacluta*

Operating Theater

Neonatal care room

Blood Bank


General anesthesia

Spinal anesthesia

Functional fan/air conditioning Yes No No No No

Curtains/means of providing patient privacy Yes Yes Yes Yes Yes

Annex 15M Table 5: Availability facilities for accommodation and length of stay after normal delivery

DescriptionCHC

Uatucarbau*CHC Ossu

CHC Uatolari*

CSI Viqueque*

CHC Lacluta*


Food for maternity patient No No No No No


Waiting area for visitors and family Yes Yes Yes Yes Yes

Lodging for maternity patient No No No No No

Lodging for family No No No No No

Annex 15M Table 6: Availability of communication and transport facilities for referral

DescriptionCHC

Uatucarbau*CHC Ossu

CHC Uatolari*

CSI Viqueque*

CHC Lacluta*


Telephone in the facility No No No No No

Cell phone (own by facility) No No No Yes No


Ambulance No No No Yes No

Multi purpose vehicle Yes Yes Yes Yes Yes

Other transport for referral No Yes Yes No Yes



7. BIBLIOGRAPHYNational Statistics Directorate, Ministry of Finance and ICF Macro. Timor-LesteDemographic and Health Survey 2009-10. Dili, Timor Leste: NSD [Timor Leste] and ICF Macro.2011.

https://www.mof.gov.tl/TimorLeste-the-millennium-development-goals-report-2014/?lang=en

Quoted from Timor-LesteChild Health Factsheet. WHO-SEARO. Unpublished. 2013.

UNICEF (2003) Multiple Indicator Cluster Survey 2002, Dili, UNICEF Timor Leste.

Democratic Republic of Timor Leste. Health Management Information on System (HMS) 2012 and Final Statistical Abstract

Abstract: Timor-Leste Survey Living Standar 2007

WHO et al. 2015.Trends in maternal mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division.

National Statistics Directorate and UNFPA 2011.Timor-Leste2010 Population and Housing Census.

National Statistics Directorate and UNFPA 2012.Analytical Report on Mortality.Volume 6.Timor-Leste2010 Population and Housing Census.

UNFPA, WHO and ICM State of the World’s Midwifery Report 2014

UNFPA and WHO (Dr Neil Thalagala). Estimated costs of the EmONC Improvement Plan of Action 2016-2019 in Timor-Leste(June 2016)

Ministry of Health of Timor Leste.HMIS 2015. Table 4 Data for January-September 2015.

Ministry of Health of Timor Leste.National strategy on Reproductive, Maternal, Newborn, Child and Adolescent Health, 2015-2019; MOH

General Directorate of Statistics. Population and Housing Census 2015: Preliminary Results. 2015.

Countdown to 2015 decade report: Taking stock of maternal newborn and child survival. Lancet 2010, 375: 2031-2044.

Wagstaff A, Claeson M: The Millennium Development Goals for Health: Rising to the challenges. World Bank, Washington; 2004

WHO, UNFPA, UNICEF and AMDD. Monitoring emergency obstetric care: A handbook, WHO, 2009



8. ACKNOWLEDGEMENTSThe preparation of this EmONC Improvement Plan of Action 2016-2019 is the product of several inputs that need to be acknowledged:

1. First and foremost H.E. Dr. Maria do Ceu Sarmento Pina da Costa, Minister of Health and Dr. Odete da Silva Viegas, Director General for Service Delivery for providing leadership.

2. UNFPA Representative Mr. John M. Pile, WHO Representative Dr Rajesh Pandav and Assistant UNFPA Representative Dr Domingas Bernardo for the excellent support in the successful completion of the EmONC Needs Assessment and in development of this plan.

3. UNICEF for the partnership.

4. Partner Organizations; Health Alliance International, USAID/JSI Hadiak project and USAID/JSI HAKBIT project for participating in the assessment and in the planning exercise.

5. Mr. Francisco Borges, National Director of Logistic, Procurement and Assets MoH for allocating the engineering teams to estimate the infrastructure rehabilitation costs in the CHCs that are identified for upgrading.

6. Mr. Marcelo Amaral, National Director of Finance, MoH for providing the unit cost for drugs, equipment and supplies.

7. Delegacia Saúde Municipio and District Public Health Officers (DPHO) MCH in 13 Municipalities who gave the orientation for the Plan.

8. All members of the Data collection team, who contributed in numerous ways to competently perform 2015 EmONC Needs Assessment and to develop the Plan of Action.

9. Members of the core team on EmONC Needs Assessment for providing their inputs from planning stage until the completion of this improvement plan.



9. CONTRIBUTORSTechnical Team

1. Dr Vincent Fauveau, UNFPA Consultant

2. Dr Mao Bunsot, UNFPA Consultant

3. Ms Jenny Middleton, UNFPA Consultant

4. Dr Neil Thalagala, WHO costing expert

5. Dr. Chandani Galwaduge, UNFPA Timor Leste

Core Team

1. Dr. Triana do Rosario, Head of MCH Department, MoH

2. Ms. Florencia Corte-Real Tilman, Safe Motherhood Officer, MoH

3. Ms. Norberta Belo, Advisor, MoH

4. Dr. Carla Jesuina do Carmo Quintão, Health Officer UNICEF

5. Dr. Arun Malik, WHO

6. Dr. Sudath Peiris, WHO

7. Ms. Nelinha do Santos, INS

8. Dr. Amita Pradhan Thapa, OBGyn-MoH/HNGV

9. Ms. Lurdes Vidigal-MoH/HNGV

10. Ms. Antonia Mesquita Fernandes, HADIAK

11. Ms. Teresinha Quevedo Sarmento, HAI

12. Dr. Domingas Ângela Sarmento-UNFPA

13. Dr. Chandani Galwaduge- UNFPA

Data Collection Team

1. Dr. Francis Saison, OBGyn-MoH/HR Maubisse – Team leader

2. Dr. Amita Pradhan Thapa, OBGyn-MoH/HNGV- Team leader

3. Dr. Jannatul Ferdous-MoH/ MCH Advisor – Team leader

4. Dr. Domingas Ângela Sarmento-UNFPA – Team leader

5. Ms. Florencia Corte-Real Tilman-MoH/ MCH Department

6. Ms. Fatima Isabel Gusmão-MoH/MCH Department


7. Ms. Emilia Ayati-MoH/CHC Comoro

8. Ms. Nelinha dos Santos-INS

9. Ms. Filomena Mendonca do Espirito Santo-MoH/Vera Cruz

10. Ms. Lurdes Vidigal-MoH/HNGV

11. Ms. Maria Lucia Godinho F. Soares-MoH/HNGV

12. Ms. Filomena de Carvalho-HADIAK

13. Ms. Antónia Maria R. M. Fernandes-HADIAK

14. Ms. Teresinha Quevedo Sarmento-HAI

15. Ms. Rara Deathicta A. S. S. Dethan-HAI

16. Ms. Maria Jacinta Araújo Chang-HAI

17. Ms. Paulina de A. Pereira de Neri-MoH/DPHO Maliana

18. Ms. Justa Pereira-MoH/ CSI Same Vila

The team that selected the health facilities for upgrading

(Consultations held on 22 and 24 February 2016 )

1. Antonio da Costa, Health Delegate Aileu

2. Alda Quintão Falcão, DPHO MCH Aileu

3. Agostinho da Costa, Health Delegate Ainaro

4. Jacinta Barros, DPHO MCH Ainaro

5. Leonel Guterres, Health Delegate Baucau

6. Maria Alice da Costa, DPHO MCH Baucau

7. Victor Soares Martins, Health Delegate Bobonaro

8. Paulina de A. P. Neri, DPHO MCH Bobonaro

9. Felipe Pereira Lemos, Deputy Health Delegate Covalima

10. Maria de Fatima Moniz, DPHO MCH Covalima

11. Agostinha da Costa Saldanha Segurado, Health Delegate Dili

12. Maria Bernardo, DPHO MCH Dili

13. Higinia Maria E. M. Carvalho, DPHO MCH Ermera

14. Bernardo Amaral Lopes, Health Delegate Lautem


15. Lolalina da C. Freitas, DPHO MCH Lautem

16. Apolonia dos Santos, Health Delegate Liquica

17. Beatriz Filomena, DPHO MCH Liquica

18. Mateus Vicente Correia, Health Delegate Manatuto

19. Otilia Joana A.M. Pereira, DPHO MCH Manatuto

20. Florencia Corte-Real Tilman, Health Delegate Manufahi

21. Francisco de Carvalho, Health Delegate of Viqueque

22. Adelaide Maria Tilman, DPHO MCH Viqueque

23. Dr. Vincent Fauveau- UNFPA consultant

24. Dr Mao Bunsoth – UNFPA Consultant

25. Dr. Chandani Galwdauge –UNFPA

26. Dr. Domingas Ângela Sarmento-UNFPA

Partcipants of the stakeholder workshop on 29th Feburay and 1st March 2016

1. Dr. Horacio Sarmento, Director of Hospital Services, MoH

2. Mr. António Bonito, Director of Training, INS

3. Dr. Triana de Oliveira, Head of MCH Department

4. Ms. Fatima Isabel Gusmão, Gnerela Reproductive Health (GRH-MCH) MoH

5. Mr. Manuel Mausiry, EPI officer MoH

6. Dr. Benedita M. de Araújo, Head of ….

7. Ms. Lucia Taeki, Regional Secretary for Health, RAEOA Oecusse

8. Ms. Batista Punef, Executive Director HR. Oecusse

9. Mr. Manuel da Costa, Executive Director Hospital Regional Oecusse

10. Mr. Herminia B. Seto, DPHO MCH Hospital Regional Oecusse

11. Dr. José António Gusmão Guterres, Executive Director HNGV

12. Ms. Maria Lucia de F.G.Soares, Midwife, HNGV

13. Ms. Lourdes Gonzaga Vidigal, Midwife, HNGV

14. Dr. Amita Pradhan Thapa, OBGyn, HNGV

15. Dr. Hermenigildo Pereiar, Executive Director HR. Suai


16. Dr. Alipio Gusmão Lopes, Health Delegate Covalima

17. Ms. Maria de Fatima Moniz, DPHO MCH Covalima

18. Dr. Elisabeth Leto Mau, Executive Director HR Baucau

19. Dr. Salesiano P. Fernandes, Executive Director HR. Baucau

20. Mr. Leonel Guterres, Health Delegate Baucau

21. Ms. Maria Alice da Costa, DPHO MCH Baucau

22. Dr. Gabriela da C. M. Pereira, Executive Director HR Maubisse

23. Dr. Virgilio M. Pereira, Clinical Director HR. Maubisse

24. Ms. Lolalina da Conceição Freitas, DPHO MCH Lautem

25. Mr. Bernardo Amaral Lopes, Health Delegate Lautem

26. Mr. Mateus Vicente Correia, Health Delegate Manatuto

27. Ms. Otilia G. de A.M. Pereira, DPHO MCH Manatuto

28. Mr. Agostinho da Costa, Health Delegate Ainaro

29. Ms. Jacinta Barros, DPHO MCH Ainaro

30. Mr. Francisco de Carvalho, Health Delegate Viqueque

31. Ms. Adelaide Maria Tilman, Deputy Health Delegate/ DPHO MCH Viqueque

32. Mr. Graciano da C. Cruz, Deputy Health Delegate Ermera

33. Ms. Higinia Maria E. M. Carvalho, DPHO MCH Ermera

34. Ms. Apolonia dos Santos, Health Delegate Liquica

35. Ms. Beatriz F. da Silva dos Santos, DPHO MCH Liquica

36. Ms. Agostinha da C. S. Segurado, Health Delegate Dili

37. Ms. Maria de F.A. Bernardo, DPHO MCH Dili

38. Ms. Filomena Mendonça E. Santo, Midwife, CHC Vera Cruz

39. Ms. Francisca Cardoso, Midwife, CHC Vera Cruz

40. Ms. Emilia Ayati de Sousa, Midwife, CHC Comoro

41. Ms. Florencia C.R. Tilman, Health Delegate Manufahi

42. Ms. Dulce C.R. Tilman, DPHO SMI Manufahi

43. Ms. Justa Pereira, Midwife, CSI Same


44. Dr. Adilia O.T. Moniz, Clinical Director HR Maliana

45. Mr. Victor Soares Martins, Health Delegate Bobonaro

46. Ms. Paulina de A. p. De Neri, DPHO MCH Bobonaro

47. Dr. Francis Saison, UNFPA

48. Mr. Alipio Cardoso Moniz, Mapping Analyst, GDS

49. Mr. João Soares Gusmão, Mapping Analyst, GDS

50. Mr. Dirce Sarmento, Child Fund

51. Mr. John M. Pile, Representative to UNFPA

52. Dr. Domingas Bernardo, Assistant Representative UNFPA

53. Dr. Chandani Galwaduge, RH Specialist, UNFPA

54. Dr. Vincent Fauveau, Consultant, UNFPA

55. Dr. Domingas Ângela Sarmento, RH Program Analyst, UNFPA

Mapping Team

1. Mr. João Soares Gusmão, Department of Census and Statistics

2. Mr. Alipio Cardoso Moniz, Department of Census and Statistcs

Documents

Emergency Obstetric and Newborn Care (EmONC) …timor-leste.unfpa.org/sites/default/files/pub-pdf/Emergency... · Table 9: Candidates for BEmONC upgrade in EmONC Plan of Action 2016-2019: