national safe motherhood and (nsmnh-ltp)

National Safe Motherhood and

Newborn Health-Long Term Plan

(NSMNH-LTP)



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ANC Ante Natal CareANM Auxiliary Nurse MidwifeBCC Behaviour Change CommunicationBEOC Basic Emergency Obstetric CareCAC Comprehensive Abortion CareCBO Community Based OrganisationCBS Centre Bureau of StatisticsCDP Community Drug ProgrammeCEDAW Convention for the Elimination of Discrimination Against

WomenCEOC Comprehensive Emergency Obstetric CareCHD Child Health DivisionCTEVT Council for Technical Education and Vocational TrainingDACC District AIDS Coordination CommitteeDDA Department of Drug AdministrationDDC District Development CommitteeDHMC District Health Management CommitteeDHS Demographic and Health SurveyDoHS Department of Health ServicesDUDBC Department of Urban Development and Building

ConstructionEDP External Development PartnerEHCS Essential Health Care ServicesENC Essential Newborn CareEOC Emergency Obstetric CareFCHV Female Community Health VolunteerFHD Family Health DivisionFMIS Financial Management Information SystemHEFU Health Economics and Financing UnitHMIS Health Management Information SystemHP Health PostHURDEC Human Resource Development CentreHURIC Human Resource Information CentreIEC Information Education CommunicationIMCI Integrated Management of Childhood IllnessIOM Institute of MedicineKAP Knowledge Attitudes and PracticeLMD Logistics Management DivisionLMIS Logistics Management Information SystemLSGA Local Self Governance Act

List of Acronyms



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LSI Livelihood and Social InclusionMBBS Bachelor of Medicine Bachelor of SurgeryMDG Millennium Development GoalMOF Ministry of FinanceMOGA Ministry of General AdministrationMoHP Ministry of Health and PopulationMOLD Ministry of Local DevelopmentMPPW Ministry of Planning and Physical WorksMRT Midwifery Refresher TrainingNAN Nursing Association of NepalNNC Nepal Nursing CouncilNEPAS Nepal Paediatric SocietyNESOG Nepal Society of Obstetricians and GynaecologistsNGO Non Government OrganisationNHEICC National Health Education Information Communication

CentreNHTC National Health Training CentreNHSP-IP Nepal Health Sector Programme-Implementation PlanNLSS National Living Standard SurveyNMC Nepal Medical CouncilNSMNH-LTP National Safe Motherhood Newborn Health -Long Term PlanPAC Post Abortion CarePCL Proficiency Certificate LevelPESON Perinatal Society of NepalPHCC Primary Health Care CentrePMTCT Prevention of Mother to Child TransmissionPNC Post Natal CarePPP Public Private PartnershipRH Reproductive HealthRHCC Reproductive Health Coordination CommitteeRHD Regional Health DirectorateRHTC Regional Health Training CentreSBA Skilled Birth AttendantSHP Sub Health PostSMNF Safe Motherhood Network FederationSMNH Safe Motherhood and Newborn HealthSMNSC Safe Motherhood and Neonatal Sub CommitteeSN Staff NurseSSMP Support to the Safe Motherhood ProgrammeTMIS Training Management Information SystemTT Tetanus ToxoidUNFPA United National Fund for Population ActivitiesUNICEF United Nations Children’s FundUSAID United States Agency for International DevelopmentVDC Village Development CommitteeWHO World Health Organisation



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This revised National Safe Motherhood and Newborn Health Long Term Plan(NSMNH-LTP) 2006-2017 has been developed to be in line with the Second LongTerm Plan Health Plan (1997-2017), the Nepal Health Sector ProgrammeImplementation Plan and Millennium Development Goals (MDG). The revisiontakes into account recent developments such as the increased specific emphasison neonatal health, recognition of the importance of skilled birth attendance inreducing maternal and neonatal mortalities, health sector reform initiatives,legalisation of abortion, recognition of the significant levels of mother to childtransmission of HIV/AIDS and increased emphasis on equity issues in safemotherhood services.

The overall goal of this plan is to improve maternal and neonatal health and survivalespecially among poor and socially excluded communities, with indicators drawnfrom the MDGs. These include a reduction in the maternal mortality ratio to 134per 100,000 live births by 2017 and a reduction in the neonatal mortality ratio to 15per 1,000 live births by 2017.

The purpose is increased healthy practices and utilisation of quality maternal andneonatal health services, especially by the poor and excluded, delivered by awell-managed health sector. The indicators are an increase in the number ofdeliveries assisted by Skilled Birth Attendants (SBA) to 60 percent by 2017 andincrease in the number of deliveries in a health facility to 40 percent by 2017. Metneed for Emergency Obstetric Complication will be increased by 3 percent eachyear and the met need for Caesarean Section by 4 percent each year.

Eight key outputs have been identified, with individual indicators and key activities:

1. Equity and AccessThe purpose is to ensure that individuals, groups and networks are sociallyempowered to practise desired Safe Motherhood and neonatal Health (SMNH)behaviours, leading to increased equity of and access to health services. The keyactivity areas are in advocacy, social mobilisation and behaviour changecommunication.

2. ServicesThe purpose is to enhance equitable provision of quality SMNH services. Theseinclude: focused antenatal care, delivery and newborn care by skilled birthattendant, postnatal care, emergency obstetric care, comprehensive abortion careand referral services. Activity areas include strengthening and expansion of SMNHservices, improvement in quality of services, reaching socially excluded groups,creating an enabling environment for services and developing appropriate linkages.

Executive Summary



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3. Public Private PartnershipThe purpose is to increase participation of the private sector, NGOs, communitybased organisations and professional/academic institutions in SMNH related publicservices to ensure consumers have equitable access to affordable services.

4. DecentralisationThe purpose is to enhance local government and partner capacity to plan andoversee SMNH services in line with the Local Self Governance Act (LSGA).

5. Human Resource Development: Skilled Birth Attendant StrategyThe purpose is to develop and implement a strategy and plan for human resourcedevelopment in safe motherhood and neonatal health, particularly skilled birthattendant training.

6. Information ManagementThe purpose is to develop a comprehensive sector wide SMNH information baseand to incorporate and utilise this within the Health Information System to supportpolicy, planning, monitoring, evaluation and advocacy at national and local levels.Key activity areas include information management, data collection and quality,access to information and monitoring.

7. Physical Assets and ProcurementThe purpose is to ensure adequate physical resources for SMNH services alongwith year round availability of SMNH related drugs and supplies. Key activity areasinclude construction and maintenance, planning and quality assurance anddistribution of drugs and commodities.

8. FinanceThe purpose is to ensure improved sustainable financing systems for SMNHservices. Key activity areas include mobilisation of resources, alternative financingsystems and formation of safety nets for the socially excluded.

Seven cross cutting issues and approaches were identified, which are commonto all the outputs. These are: social inclusion, gender, rights based approach,research and advocacy, enabling environment, public private partnership anddecentralisation.



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Preface

Acknowledgements

List of Acronyms

Executive Summary

1 Chapter: 1 Introduction and background 1

1.1 Introduction 1

1.2 Rationale for revision of the NSMNH-LTP 1

1.3 The revision process 2

1.4 Goal purpose and outputs 3

1.5 Definition of terms 4

1.6 Cross cutting issues and approaches 4

1.7 Risks and assumptions 6

2 Chapter: 2 Description of outputs 8

Output 1: Equity and access 8

Output 2: Services 9

Output 3: Public private partnerships 11

Output 4: Decentralisation 13

Output 5: Human resource development:

Skilled Birth Attendant Strategy 14

Output 6: Information management 15

Output 7: Physical assets and procurementOutput 8: Finance 16

3 Chapter: 3 The logframe 20

Annexes

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Introduction and Background

1.1 IntroductionThe overarching goal of development efforts in Nepal is to reduce poverty,as highlighted in the Tenth Plan (Poverty Reduction Strategy Paper) 2002-2007, and health sector development efforts are treated as an integral partof this strategy. The Ministry of Health and Population (MoHP, formerlyMinistry of Health) developed the Second Long Term Health Plan (1997-2017) as a sectoral perspective plan and the National Safe MotherhoodLong Term Plan (NSMLTP) (2002-2017) was based on this document as asub sector plan, in l ine with the Nepal Health Sector ProgrammeImplementation Plan (NHSP-IP) 2004-2009.

Within the health sector, safe motherhood has been a national priority programmefor the last decade, and is highlighted in all major health related policies andplans. The Tenth Plan, the Second Long Term Health Plan and the NSMLTP (2002-2017) all highlight the need to reduce the high levels of mortality among women,infants and children. The Millennium Development Goals (MDG) specify a twothirds reduction in the under-five mortality rate and 75 percent reduction in thematernal mortality ratio by the year 2015. The NHSP-IP draws on the MillenniumDevelopment Goals, with the stated purpose of improving the health status of theNepalese population through utilisation of essential health care services (EHCS),specifying maternal mortality and infant and child mortality reduction among otheressential health care indicators. Since safe motherhood and newborn health arenot purely health issues, they warrant a multi-sectoral approach, and the role ofother sectors is particularly important in enhancing access and promoting equity.This is acknowledged in the NSMLTP and outputs are related to programmes ineducation, information and communication, transport and local development, asappropriate.

The NSMLTP outlines strategic directions and defines the major outputs andgeneral areas of activity, but without a more specific set of activities, detailedcosting is beyond its scope. This will be included on a three-year rolling basis withimplementation planning.

1.2 Rationale for Revision of the National Safe Motherhood LongTerm Plan (NSMLTP 2002-2017)

In recent years many safe motherhood stakeholders, both government and non-government, at district, regional and national forums, have noted gaps in the originalNSMLTP and advocated for its revision and updating. In order to retain itseffectiveness as a guide to programming, the plan needs to be treated as a rollingdocument, and revised regularly, in line with the changing context of newdevelopments. A number of specific issues have been identified that highlight theurgent need for revision as follows:

Chapter 1:

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MDGs and Neonatal health: The NSMLTP (2002-2017) was developed beforethe Millennium Development Goal Country Report was prepared, and so wasunable to fully take into account the recommendations it contained. For example,prior to this little attention had been paid to neonatal health in its own right, but theMDG report highlighted the growing recognition that safe motherhood shouldspecifically incorporate newborn health. The infant mortality rate in Nepal isdeclining but only slowly - child mortality declined by 34 percent between 1996and 2001, but during the same period infant mortality declined by only 18 percent.Since two thirds of infant deaths occur in the neonatal period, significant reductionof infant mortality rates depends on a decrease in the neonatal mortality rate.While it is understood that safe motherhood interventions do contribute to areduction of perinatal and neonatal mortality, in order to achieve the substantialinfant and child mortality reductions encompassed by the MDGs, additional specificnewborn health interventions need to be integrated with safe motherhoodprogramming. The National Neonatal Health Strategy and National Neonatal HealthLong Term Plan formulated in 2004 and 2005 respectively to address neonatalhealth issues had also not been incorporated into the previous plan.

Skilled birth attendance: The original NSMLTP (2002-2017) placed littleemphasis on the importance of skilled birth attendance in the drive to reducematernal and neonatal mortalities. Global standards for what constitutes skilledbirth attendance and how a skilled birth attendant (SBA) is defined have alsochanged significantly in the last few years. The National SBA Policy has been onlyrecently formulated and endorsed, and key points from this need to be incorporatedinto the current plan.

Health sector reform: The NSMLTP (2002-2017) pre-dated the recent work onhealth sector reform and strategy development, and the outputs of Nepal HealthSector Strategy and Nepal Health Sector Programme Implementation Plan (2004-2009) need to be included.

Abortion: The legalisation of abortion under specified conditions in 2002 hasresulted in an intensive programme to establish comprehensive abortion care(CAC) services in public hospitals from 2004 and a commitment to integratingCAC into safe motherhood programming. This important step acknowledges thesignificant effect of complications due to unsafe abortions on the high maternalmortality ratio in Nepal and was not included in the original NSMLTP (2002-2017).

Mother to child transmission of HIV is an increasing problem. As HIV infectionrates grow, this is likely to become major issue in the near future for serviceprovision As it is a recently acknowledged phenomenon, prevention activities arenot mentioned in the original NSMLTP. Prevention of mother to child transmission(PMTCT) needs to be incorporated in the current plan.

Equity issues in access and utilisation of safe motherhood and neonatal health(SMNH) services are not mentioned in the original NSMLTP and are of criticalimportance if the most needy members of society are to be targeted and theMDGs achieved.

1.3 The Revision ProcessRevision of the plan was carried out in three stages, with the participation of multiplestakeholders, both government and external development partners (EDP). Thelist of participants is shown in the annex.

1. A preparatory meeting of potential participants was held in November 2005,to share the rationale for revision and the proposed methodology for the

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process. The meeting determined the parameters, boundaries and broadoutputs and assigned tasks. Working groups for different outputs were formedon the basis of professional expertise, and possible reviewers suggested.

2. In preparation for the first workshop, held in January 2006, consultantsreviewed existing national policies, strategies and plans, to identify the gaps,deficiencies and discrepancies, and prepared a background paper forpresentation at the workshop. Based on this review, an analysis of thestrengths, weaknesses, opportunities and threats of the existing plan wascarried out. The groups then worked to analyse and update the individualoutputs and associated activities for the plan, and presented their ideas in aplenary session for further discussion and refining. By the end of the workshopa first draft revision of the plan had been prepared.

3. Each group met at least twice before the second workshop, which was heldin March 2006. During this period they refined the output statements,developed a full set of activities under each output and agreed on indicatorsand their means of verification. Cross group sharing helped to avoid theduplication and ensure consistency in the plan, and groups consulted withother experts for technical inputs. At the second workshop groups presentedtheir work for comments and suggestions, on the basis of which the draftplan was refined and finalised. Risks and assumptions were developed andgroups drafted a brief narrative of their output.

1.4 Goal, Purpose and Outputs

Goal: Improved maternal and neonatal health and survival, especially of thepoor and excluded.

The key indicators for this NSMNH-LTP goal are:

1. A reduction in the maternal mortality ratio from 539 per 100,000 livebirths1 to 134 per 100,000 by 2017

2. A reduction in the neonatal mortality ratio from 39 per 1,0002 to 15per 1,000 by 2017.

Purpose: Increased healthy practices, and utilisation of quality maternaland neonatal health services, especially by the poor and excluded,delivered by a well-managed health sector.

Key indicators for this include:

1. Increase in the percentage of deliveries assisted by an SBA to 60% by 20172. The percentage of deliveries taking place in a health facility increased to

40% by 20173. Increase in met need for emergency obstetric care of 3% per year4. Increase in met need for caesarean section of 4% per year.

Outputs: Eight outputs are specified in the plan, each withindividual indicators.

1. Equity and access2. Services3. Public private partnership4. Decentralisation5. Human resource development: Skilled birth attendant

strategy6. Information management7. Physical assets and procurement8. Finance

1 Nepal Family HealthSurvey 1996

2 Demographic andHealth Survey 2002

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1.5 Definition of termsIn order to ensure consistency and clarity, technical terms used regularly amongsafe motherhood stakeholders are defined below, as used in this document.

Poor: Classification of poverty is based on the annual expenditure on food andnon-food items. The official poverty line developed for the year 2003/4 by the NepalCentral Bureau of Statistics is a total real per capita consumption of NRs.7,696(approximately US$102) per year3. The food poverty line is based on an energyintake of 2,144 Kcal per person, per day.

Social exclusion; A process and state that prevents individuals or groups fromfull participation in social, economic and political life and from asserting their rights.It derives from exclusionary relationships based on power and may relate to caste,ethnicity, religion or gender status.

Social Inclusion: The removal of institutional barriers and enhancement ofincentives to increase the access of diverse individuals and groups to developmentopportunities (World Bank).

Social empowerment: Improvements in knowledge, attitudes, behaviours,confidence, legal and social status and access to resources, including transportand finance schemes, among individuals, groups and networks. The World Bankdefines empowerment as: The enhancement of assets and capabilities of diverseindividuals and groups to function and to engage, influence and hold accountablethe institutions that affect them.

Enabling environment: The existence of support (physical and social/attitudinal)that promotes and enables desired behaviours or service provision.

Comprehensive abortion care (CAC): Legally available elective induced abortionservice that includes safe techniques (manual vacuum aspiration and effectivepain management), counselling and post procedure contraception services.

1.6 Cross cutting issues and approachesSocial inclusionSocial exclusion, due to caste, ethnicity, age, religion or gender, is a major causeof poverty, affecting access to and utilisation of essential health care services(EHCS). A number of institutional barriers have been identified related to accessand utilisation by these groups, and the Vulnerable Community Development Planwas developed as a part of the Nepal Health Sector Implementation Plan (2004-2009) to directly address these and ensure poor and excluded people haveequitable access to EHCS. This includes increasing the coverage and raising thequality of EHCS, with special emphasis on improved access for poor and excludedgroups. Thus social inclusion has emerged as a major social, economic and politicalpolicy issue, which is high on the agenda of policy makers and planners. SinceSMNH services are a major component of EHCS, the NSMNH-LTP mainstreams socialinclusion as a cross cutting issue in its goal, purpose and all outputs. Related annual planswill specifically address the needs of socially excluded groups, and progress in reachingthem will be monitored by means of disaggregated indicators. Priority will be given toinfrastructural and resource needs in areas serving socially excluded groups, andcommunities will be encouraged to identify and support the training of women from thesegroups as SBAs and create an enabling environment for them to serve their communities.Access activities will encourage self-confidence, voice and agency, especially amongwomen and other socially excluded and vulnerable groups and will engage them in aninclusive and empowering way.

3 Adjusted toNRs.11,057 forKathmandu,NRs.7,901 for otherurban areas,NRs.8,902 for ruralwestern hills,NRs.8,070 for ruraleastern hills,NRs.7,418 for ruralwestern terai,NRs.6,079 for ruraleastern terai.

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GenderAs an excluded group in themselves, and as the key beneficiary targeted by safemotherhood interventions, the needs of women are treated as paramountthroughout the NSMNH-LTP, not simply as individuals, but as members of familiesand communities functioning within complex relationships and social expectations.Gender issues are included as a cross cutting issue and an important part of allthe outputs, but particularly in human resource development and deployment,management approaches and access activities.

Rights based approachHuman rights standards relevant to maternal health include, but are not limited to:

• The right to life and survival• The right to the highest attainable standard of health• The right to decide freely the number and spacing of one’s children• The Convention for the Elimination of Discrimination Against Women

(CEDAW).

The right to life and health through access to essential health care services, andspecifically SMNH services, is thus a basic human right, and one that is denied tocountless women in Nepal. Behind every preventable maternal death lies a failureto assure women’s rights, linked to social issues such as the low status of women,their lack of decision-making power, poor access to information and care, restrictedmobility, early age of marriage, and the low priority and resources given to theirhealth. There are also marked disparities by social group in women’s access toskilled birth attendance and to essential obstetric care. Achieving improved andmore equitable maternal survival will thus require political, social, legal andeconomic actions as well as scaling up technical strategies. Traditional publichealth and health systems approaches must therefore be combined with a humanrights-based approach.

Rights based approaches are therefore included as fundamental and cross-cuttingto all outputs of the NSMNH-LTP, with the aim of increasing accountability formaternal and neonatal health, strengthening local capacity of duty-bearers to fulfilwomen’s rights, strengthening women’s voices and their ability to demand theirrights to maternal health and transforming the distribution of power and resourcesthat maintain inequalities across society, in families, communities and healthsystems.

Research and advocacyImproving the quality and utilisation of evidence in policy and practice can helpsave the lives of mothers and their newborns. Research provides the scientificevidence needed to improve the quality and safety of SMNH services, reducecosts and broaden access. It also informs advocacy, which at central level playsvital role in developing favourable policies and plans and at community level isimportant in raising public awareness of key health and social issues and creatingdemand for services Thus research and advocacy are incorporated as importantcross cutting issues in all outputs of the NSMNH-LTP.

Enabling environmentSimply providing training and facilities or undertaking access activities, are not enoughto ensure women receive high quality SMNH services. An enabling environment isimportant in supporting staff in facilities and motivating them to provide high qualityservices. This means that human resource development must go hand in hand withupgrading of infrastructure, provision of equipment and supplies. An enabling

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environment is also important at community level to support women in making healthyreproductive health choices and carrying them through. It encourages people toutilise health services within any given social context, using local knowledge,perceptions and values, relevant traditional practices, preferences and beliefs toenhance knowledge and awareness. Sensitivity to the effects of the armed conflict,which has already been reported to negatively impact women’s access to SMNHservices will also be important.

1.7 Risks and assumptions

Key assumptions on which the NSMNH-LTP is based include:1. Continuing political commitment to safe motherhood and neonatal care as a

high priority in both policy and programming, including allocation of resources2. Effective and timely execution of the Nepal Health Sector Programme

Implementation Plan3. Social, political and economic stability, enabling activities to be carried out as

planned and resources accessed as needed4. Resolution of the conflict and/or development of effective strategies for working

safely and effectively in conflict affected areas, such as using locally acceptablecommunity workers as bridging people and using rights based messagesand approaches

5. Elected leaders in place in functional district and village developmentcommittees, able to facilitate devolved decision-making, local ownership andaccountability

6. Commitment to local level capacity building and support, combined withdecentralisation, to ensure quality services.

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Chapter 2:

Description of the Outputs

The outputs are derived from NHSP-IP and so are closely linked with it. Thisplan however, elaborates the outputs with a focus on maternal and newbornhealth concerns.

Output 1: Equity and Access

Purpose: Individuals, groups and networks socially empowered to practisedesired SMNH behaviours, leading to increased equity of andaccess to health services.

Lead Agency: This output will be led by National Health Education, Informationand Communication Centre (NHEICC) mainly in collaborationand coordination with the Family Health Division (FHD) and ChildHealth Division (CHD) and other relevant Divisions within theDepartment of Health Services, development partners, NGOs,civil society, networks, federations, groups and individuals.

BackgroundIncreasing equity of and access to SMNH services requires changes in national,community and household level behaviours and expectations. This is not onlytrue for preventative and promotive services, but also for timely treatment ofcomplications in which dangerous delays are common. A combination of mutuallyreinforcing approaches - advocacy, social mobilisation and BCC - has provedsuccessful in addressing barriers to services in Nepal. These three approaches,combined with the provision of quality services, will be critical to improving thehealth of mothers and newborns and reducing the three delays responsible for somany maternal and neonatal deaths.

This output will seek to promote gender and social inclusion as cross cuttingissues, and to address equity issues in order to expand the reach of services tothe poor and socially excluded. Specific localised advocacy, social mobilisationand BCC activities, linked to increased availability of services, will address barriersto health services among poor and socially excluded groups. Access activities willwork to encourage self-confidence, voice and agency, especially among womenand other disadvantaged groups and to engage poor and socially excludedcommunities in inclusive and empowering way.

Equity and access outputs will seek to create an enabling environment thatencourages people to utilise health services within any given social context.Activities will advantageously use local knowledge, perceptions and values, relevanttraditional practices, preferences and beliefs to enhance knowledge and awarenessand will be sensitive to conflict issues. Access embraces financial, institutionaland infra-structural factors including, but not limited to, funding, transportation

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and education. It also relies upon positive and welcoming service provider attitudes,trust, honesty, responsiveness, accountability and quality service delivery both atestablished facilities and through outreach programmes.

Activity areas A. AdvocacyAdvocacy will be a key component for increasing equitable access to SMNHservices. In order to ensure coordinated, supported and sustained advocacyactivities, action forums (existing if possible) at national and district levels andcomprising a wide range of government and NGO partners, journalists andthe private sector will be mobilised to develop and implement specific actionplans. Activities will include lobbying for the formation or updating of appropriatepolicies for social empowerment, increased resources for SMNH programmesand provision of at least one telephone in each health facility. The actionforums will raise the profile of SMNH through a range of activities, such aspublishing articles and organising public events. Advocacy will focus at differentlevels through partnerships and collaboration with relevant stakeholders toincorporate the voices of users and providers. This output will be closely linkedwith Output 8, Finance.

B. Social MobilisationSocial mobilisation activities are important for ensuring the involvement of peopleat all levels and obtaining support for safe motherhood activities. Activities will becarried out at national, district and community levels, in collaboration with safemotherhood partners and stakeholders from other sectors (inter and intraministerial, divisional, NGO) and line agencies. The programme will useparticipatory approaches to encourage communities to take ownership of the driveto improve the health of the mothers and newborns. Safe motherhood programmeimplementers will support the strengthening of existing committees. The capacityof community groups and networks will be enhanced to create and utilisesustainable emergency funds and transportation schemes. Referral systems willbe supported at all levels (linking with Output 2, Services).

C. Behaviour Change Communication (BCC)BCC informs people about safe motherhood and neonatal health issues and theservices available and promotes positive behaviours. Mass media, local mediaand inter-personal communication will be used to disseminate and reinforcemessages. BCC strategies will ensure that consistency of messages is retainedthrough all channels used, so that people are able to understand messages withintheir own context and act on the information received. There will be a strong focuson using localised approaches to cater to the needs of different target audiences,particularly reaching out to poor and socially excluded communities. BCCinterventions will need to go hand in hand with service availability, and will thereforebe closely linked with Output 2, Services.

The Safe Motherhood Information Education Communication (IEC) strategy (2003-2008) will be updated to incorporate research-based and standardised messages.It will be implemented through focused communication interventions that reachout to poor and socially excluded groups. Rights-based approaches will be usedto promote service utilisation, especially skilled attendance at childbirth, and reduceviolence against women. There will be an increased emphasis on birthpreparedness and complication readiness as well as renewed attention toenhancing positive non-discriminatory interpersonal communication betweenproviders and clients. Cost sharing initiatives will be promoted as appropriate,linked with Output 8, Finance.

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Output 2: Services

Purpose: Enhanced and equitable provision of quality maternal andneonatal health services

Lead agency: This output will be led by FHD, with support from the LogisticsDivision, Management Division, National Health Training Centre(NHTC), NHEICC, CHD, hospitals and PHCCs, concerned lineministries, external development partners and relevantprofessional organisations.

BackgroundThe aim of Output 2 is to make quality essential SMNH services equitablyaccessible for all women and their newborns, through functioning and well-managed public health facilities that provide services at all levels (from tertiaryreferral hospitals to community based outreach services) and are linked througheffective referral services. Essential SMNH services include: focused antenatalcare; skilled attendance at birth; newborn care; post-natal care, including familyplanning services; Basic and Comprehensive Emergency Obstetric Care (B/CEOC), including post-abortion care; comprehensive abortion care; and effectivereferral services. Close linkages will be established with Output 1, Equity andAccess activities in order to meet the needs of poor and socially excludedpopulations. Decentralisation of responsibilities to district and community levelsand development of appropriate public/private partnerships will be key strategiesin planning and programming. Professional organisations, such as the NepalSociety for Obstetricians and Gynaecologists (NESOG), Nursing Association ofNepal (NAN), Nepal Medical Association and Nepal Medical Council (NMC), willbe important partners, and linkages with other reproductive health related initiativeswill be developed as appropriate.

Advocacy efforts, through community level health service providers, will focusparticularly on the importance of skilled birth attendance and healthy practices formothers and newborns. At policy level, evidence based lobbying techniques willbe used to influence decision-makers in addressing issues related to equitableaccess to quality SMNH services for all women, particularly those in remote anddisadvantaged areas.

Activity AreasA. Strengthening and expansion of quality SMNH servicesA strategy will be developed and implemented for the phased strengthening andexpansion of quality SMNH services at all levels (especially the number and qualityof B/CEOC sites and birthing centres), including monitoring of services with five-yearly reviews.

It is recognised that the majority of women still give birth at home and are not ableto travel to health facilities for delivery or other essential SMNH services, and thiswill continue to be the case for some time. It is therefore essential to ensure thatSMNH care is available at community level through home visits and outreachclinics, and appropriate health posts and sub health posts are developed aseffective local facilities, with support provided for community level initiatives.

B. Linkages and integration with other reproductive health initiativesTo ensure the provision of complete SMNH services for all women and theirnewborns, neonatal care, family planning services, CAC, PMTCT and malariatreatment will be integrated with safe motherhood services through the developmentof improved linkages between relevant government ministries, divisions andprogrammes (the Female Community Health Volunteer (FCHV), Family Planning,HIV/AIDS and Malaria programmes) and appropriate external developmentpartners. Close links will also be maintained with health related IEC/BCC activities

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under the NHEICC (Output 1, Equity and Access). Joint planning, implementationand monitoring of activities at all levels will be promoted.

C. Quality of servicesThe quality of care provided in health facilities (including private and NGO) and atcommunity level will be improved through a range of interventions that focus ondevelopment and implementation of national standards, training and capacitybuilding for staff and community workers, effective monitoring and support systemswith on site coaching and development of an enabling environment to supportstaff and community volunteers in their work. Institutionalisation of monitoring willbe addressed through local quality of care teams.

D. Enabling environmentThe development of an enabling environment that encourages health workers atall levels to strive for high standards and take responsibility for the services theyprovide will be promoted through: evidence-based lobbying for appropriate policiesand programmes; improving logistic support, infrastructure quality and humanresource deployment; supporting and capacity building local health managementcommittees; encouraging socially inclusive local participation in health facilitymanagement; and promoting the concepts of accountability and the pursuit ofexcellence. Links with the SBA policy and programme will be improved.

E. Poor and socially excluded groupsSocially and economically excluded groups are also the hardest to reach because,in addition to their poverty and low education levels, they often live in areas thatare geographically remote and/or severely affected by the armed conflict. Thesegroups will be identified through equity and access programmes and communitybased volunteers and organisations, and innovative approaches used to prioritisethem in planning appropriate SMNH activities, such as cost sharing and subsidysystems, which increase their access to services. The use of facilities by sociallyexcluded groups will be monitored and the results used in programme planning(linked with Output 1, Equity and Access).

F. Referral systemsWhen complications occur, an effective referral system is essential to enablewomen and their newborns to receive appropriate and high quality emergencycare as quickly as possible. At service level, efforts to improve the effectiveness ofthe system will focus on ensuring 24-hour availability of skilled staff with essentialdrugs and equipment, good community and inter-facility linkages and feedbacksystems to promote further improvements. Remote areas present an even greaterchallenge and require additional focused efforts, which will be covered by districtspecific strategies.

Output 3: Public Private Partnership

Purpose: Increased participation of the private sector, NGOs, communitybased organisations and professional/academic institutions inSMNH related public services to ensure consumers haveequitable access to affordable services.

Lead agency: This output in relation to SMNH will be led by Department ofHealth Services with the shared responsibilities of Family HealthDivision and Child Health Division (for SMNH services),Management Division (regulation, and information) and NationalHealth Training Centre (for trainings) Other support Agencieswill include: Federation of Nepal Chamber of Commerce andIndustries (FNCCI), the Organisation of Private Hospitals andNursing Homes, Universities and the NGO CoordinationCommittee (NGOCC).

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BackgroundIn recognition of the limitations posed by financial and human resource constraintswithin the public health sector, the government is actively promoting the formationof new partnerships between the public and private or NGO sectors andprofessional/academic institutions, in order to ensure the provision of the widestpossible choice of high quality health services and effective human resourcedevelopment. In this way a range of different skills and resources can be madeavailable to support government efforts to improve the health status of womenand their newborns across the country. Public private partnership is a cross cuttingapproach, which can contribute to all other outputs in this plan.

Activity areasDespite the stated policy promoting public private partnerships within the healthsector, the lack of appropriate legal regulatory frameworks and guidelines meansthere has been little discernable progress. This is particularly important to ensurepartnerships are able to contribute to increased SMNH service provision and accessfor poor and socially excluded groups, who will be a key target. Activities for thisoutput will therefore focus on mainstreaming public private partnership initiativesat both policy and implementation level through the establishment of arepresentative regulatory body at MoHP. Appropriate legal frameworks andprotocols will be developed and mechanisms for joint planning and monitoringestablished. District level institutions will be encouraged to identify and establishlocal partnerships.

Output 4: Decentralisation

Purpose: Enhanced local government and partner capacity to plan andoversee SMNH services in line with the Local Self GovernanceAct (LSGA).

Lead agency: This output will be led by the Policy, Planning and InternationalCooperation Division (PPICD) of MoHP. Other support agenciesinclude the Ministry of Local Development and the District andVillage Development Committee Federations.

BackgroundSince most people access health services at local level, devolution of decision-making and promotion of local accountability is the most effective way of ensuringthat high quality services are available and accessible when needed for all sectorsof society. This requires the active involvement of local communities and enhancedcapacity of responsible local institutions, combined with effective communicationand information sharing. Decentralisation is a cross cutting issue, with the potentialto positively contribute to all other outputs in this plan, but its achievement will relyheavily on the overall decentralisation of health services.

Activity areasThe current decentralisation policy is expected to enhance the participation oflocal stakeholders in SMNH service provision and monitoring and increaseequitable access to these services. The activities of this output will aim to clarifythe roles and responsibilities of stakeholders in local level SMNH service provision,raise public awareness of the devolution of services and facilitate informationsharing to promote public accountability and coordination at all levels. Capacitybuilding will be provided for local institutions and line agencies to ensure maximumefficiency. There will be a particular focus on issues relating to poor and sociallyexcluded groups.

12



(NSMNH-LTP)

Output 5: Human Resource Development: Skilled BirthAttendant Strategy

Purpose: Strategy/plan for human resource development in safemotherhood and neonatal health, particularly skilled birthattendant training, developed and implemented.

Lead agencies: This output will be lead by NHTC and MoHP. Support will beprovided by the Human Resource Development/Skilled BirthAttendant forum, which has representation from FHD, NepalNursing Council (NNC), NMC, NAN, NESOG, JHPIEGO,WHO, UNFPA, Support to the Safe Motherhood Programme(SSMP), Institute of Medicine (IoM), Council for TechnicalEducation and Vocational Training (CTEVT) and other keystakeholders involved in human resources development.

BackgroundGlobal evidence shows that skilled attendance during childbirth is a critical factorin saving the lives of mothers and their newborns. National human resourcedevelopment efforts in SMNH are therefore focusing on increasing the number ofhealth care providers competent to provide skilled birth attendance across Nepaland ensuring they possess the internationally defined set of skills required for askilled birth attendant. In order to promote service availability for poor and sociallyexcluded groups, efforts will be made to support the training of women from minoritygroups and remote areas and encourage them to serve their communities.Otherhealth workers, such as health assistants and auxiliary health workers, who alsoplay a key role at local level in saving the lives of mothers and newborns will betrained and encouraged to provide obstetric first aid. All training curricula willincorporate client friendly and gender sensitive approaches in order to promotean enabling environment for women to access SMNH services. Human resourcedevelopment needs to be combined with upgrading of Health infrastructure,provision of equipments and supplies to ensure quality service delivery, and forthis links will be made with Output 7, Physical Assets and Procurement. Publicprivate partnership approaches (link with Output 3) will also be explored forcontracting out of human resource development retention where appropriate.

Activity areas A. Human Resource Development PlanNHTC will take a lead role in developing an up coming Periodic Human ResourceDevelopment Plan to support National Periodic Plan. The aim of this plan will beto ensure 24-hour availability of SBAs, with required human resource mix for qualitySMNH services. The plan will also look at broader human resource managementrelated issues including geographical considerations for deployment, retentionand career advancement of staff. The plan will also encourage health facilitymanagement committees to recruit the required number of staff, including SBAs,to deal with the increased number of births and the demands for other reproductivehealth services and ensure continuum of care. Appropriate human resource foranaesthesia will be developed for CEOC services.

B. Skilled Birth Attendant Development StrategyThe SBA Development Strategy will identify, upgrade and accredit SBA trainingsites in order to produce the required number of SBAs as quickly as possible. Apublic-private-community partnership approach will be promoted to identify potentialSBAs, support their training, deploy and retain them through the creation of anenabling environment for them in the community. The Nepal Medical Council and

12



(NSMNH-LTP)

Nursing Council will approve an updated SBA training package (in-service andpre-service) in order to formalise the accreditation and licensing of SBAs. Specialconsideration will be given to recruiting and training health workers from the poorand socially excluded groups. Upgrading the skills of medical graduates (MBBS)for caesarean section will be done considering the importance and availability ofCEOC services at district level.

Output 6: Information Management

Purpose: A comprehensive sector wide SMNH information basedeveloped, incorporated and utilised within the HealthInformation System to support policy, planning, monitoring,evaluation and advocacy at national and local levels.

Lead agencies: This output will be led by the Health Management InformationSystem (HMIS) Section working with the Management Divisionand FHD of the DoHS and with support from the PPICD andMonitoring and Evaluation Division of the MoHP.

BackgroundThe HMIS provides an essential link in the work of all other divisions and sectionswithin the DoHS and MoHP and other stakeholders in the health sector. Theinformation stored underpins and supports all the other outputs within this plan, andforms basis for developing an understanding of cross cutting issues, such as ethnicity,caste, poverty and the effects of the armed conflict. In order to play this vital roleeffectively, the database needs to be comprehensive in its coverage, well managedand accessible, with reliable and accurate information collected from a range ofsources, such as facility based data, surveys and other research. It is also importantto ensure that this resource is known about so that it can be utilised to supportadvocacy efforts and ensure key issues and linkages are identified.

Activity areasA. Information Management StrategyAn Information Management Strategy for SMNH will be developed to improve thecollection of and access to reliable SMNH related data, and its use in evidence-based policy making, planning and advocacy work.

B. Data collection and qualityThrough the HMIS and/or surveys, health and service utilisation data will becollected and analysed in relation to ethnicity, cast and wealth. To supplementquantitative data, additional information will be collected through qualitative studiesusing a range of different tools, such as key informant monitoring. Exercises toverify data and increase its reliability will be designed and implemented. Informationwill be collected for maternal and newborn deaths from health institutions incollaboration with FCHVs.

C. Access to informationEfforts will be made to ensure that information is available to stakeholders at alllevels, including within communities, and orientation and capacity building will beprovided to increase their understanding of key SMNH issues. Public privatepartnerships and relationships will be explored to increase the flow of informationboth to and from HMIS.

D. MonitoringThe quality of monitoring will be improved through the provision of training in SMNHprogramme monitoring approaches. New and innovative monitoring tools, such askey informant monitoring, will be designed and implemented as appropriate.Strengthening of monitoring SMNH services at health institution level will be initiated.

13



(NSMNH-LTP)

Output 7: Physical Assets and Procurement

Purpose: Adequate physical resources for SMNH services with year roundavailability of MNH related drugs and supplies.

Lead agency: This output will be led by the Director General of the DoHS andRegional Health Directorates (RHD).

BackgroundAvailability of and access to high quality SMNH services is strongly dependent onthe provision of adequate physical resources and infrastructure, which also impactson staff morale and performance and on public perceptions of quality of service.Output 7 is therefore an important pillar on which other efforts rest. In the pastthere have been shortcomings in both infrastructural development/maintenanceand in the management of resources and essential supplies. This will be addressedthrough the establishment of improved systems for planning, monitoring and recordkeeping, and development of appropriate linkages with other relevant outputsand stakeholders.

Activity areasA. Inventory of MNH facilities and equipmentAn inventory of all government health facilities, by district, will be prepared, includingzonal, regional and district hospitals, Primary Health Care Centres (PHCC), HealthPosts and Sub Health Posts (SHP). Details of land ownership, age of buildings,type of construction and area, existing condition and available support serviceswill be recorded. A separate equipment inventory, stating the type, quantity andcondition of equipment, will be prepared for each facility.

B. Development, renovation and maintenance of physical resourcesSelection of sites for infrastructure development and upgrading will be need basedrather than resource based, taking into account equity and efficiency concernsand using agreed and approved criteria. Priority will be given to upgrading SHPsto birthing centres in order to promote community level service availability. Allphysical resources development work will be closely linked with Output 5, HumanResource Development.

A building and equipment maintenance policy will be developed, with coordinationbetween the DoHS and the Department of Urban Development and BuildingConstruction (DUDBC) and support from external development partners. This willguide the annual plan for infrastructure development and equipment.

C. Planning, implementation and quality assuranceNeed assessment, planning, design and implementation of health facilityimprovements will be carried out in consultation with users and other stakeholders,including inputs from expert advisers. Regular monitoring will be included in theprocess through a monitoring committee comprising representatives from relevantgovernment divisions, external development partners, users and otherstakeholders, chaired by the Director General, DoHS to assure quality ofconstruction and equipment.

Quality assurance procedures and compliance testing of drugs (through DDA,LMD and private laboratories) will be strengthened. Commodity distribution willbe improved through decentralised decision-making and strengthenedmanagement systems. Where possible, commodities will be delivered directly tosites, rather than through central stores.

14



(NSMNH-LTP)

A joint planning mechanism between FHD, LMD and CHD will be developed forequipment, drug and commodity procurement planning, implementation andmonitoring. A similar joint planning mechanism between MoHP, Ministry of Planningand Physical Works (MPPW) and MD will be developed for infrastructuredevelopment and maintenance work. Procurement mechanisms will be improvedby reforming MoHP procurement policies and capacity building at local and centrallevels.

D. Database, protocols and distribution channels for drugs and commoditiesA national level database of SMNH drug suppliers will be prepared, incorporatingdistribution channels such as means of transportation and storage facilities. Theauthority for purchasing commodities will be transferred to districts (where privatesuppliers can guarantee price and availability) while maintaining nationallynegotiated prices, both for government and sanctioned NGO and externaldevelopment partner facilities. This will gradually reduce the need for LMD todistribute drugs to districts.

In order to improve resource utilisation and information systems available todecision-makers, the Logistics Management Information System (LMIS) will bestrengthened through selective decentralisation of data processing to the districtlevel, inclusion of all SMNH commodities in the LMIS and a review of reportingmechanisms.

Rational use of drugs will be promoted through the use of the SMNH treatmentprotocol and drug financing schemes will be supported, linked with Outputs 2 and8 respectively.

Output 8: Finance

Purpose: Sustainable financing system improved for Safe Motherhood andNeonatal Health Services.

Lead agency: This output will be led by the Health Economics and FinancingUnit (HEFU), of the MoHP.

BackgroundThe emphasis of this output is on establishing a system to support a sustainablefinancing base for SMNH activities. This includes identifying and mobilising financialresources, ensuring their effective utilisation, looking at innovative approaches tofinancing, particularly at local level, and encouraging users and other partners todevelop supportive linkages that may include financing or other cost saving inputs.Where possible, initiatives promoting self sufficiency will be promoted, but specificsystems will be put in place to ensure the needs of poor and socially excludedgroups are catered for.

Activity areas A. Increasing and mobilising resources for SMNHWith assistance from the health sector support programme, financial resourcegaps will be identified, and the evidence used for lobbying and advocacy to increaseresource allocation for SMNH (linked with Outputs 1 and 6, Equity Access andInformation respectively). Resource allocation formula, capacity building/trainingand financial management information systems will be improved through thecollaborative efforts of HEFU the Finance Section DoHS, and HMIS. The privatesector (both for profit and not for profit) will be encouraged to increase inputs toMNH services (linked with Output 3, Public Private Partnerships), under appropriateregulation. The cost-sharing scheme will be implemented and promoted with theactive participation of local bodies, civil society, and NGOs.

15



(NSMNH-LTP)

B. Promoting alternative financing schemesThe community health insurance scheme developed under the health sectorsupport programme, which includes safe delivery and emergency obstetric andneonatal care services, will be expanded, and health cooperatives will be promotedwith the collaboration of HEFU, Management Division and FHD. Alternativefinancing schemes will be promoted, such as revolving community emergencyfunds to increase access to services for maternal and neonatal emergency cases(linked with Output 1, Equity Access). District based external development partnerprogrammes, community organisations and other local bodies will facilitate andmonitor emergency funds with the support of MoHP, Ministry of Local Development(MoLD), and Ministry of Women Children and Social Welfare.

C. Safety net for poor and socially excluded groupsSystems are necessary to protect poor and socially excluded groups and ensuretheir ability to access services. Mechanisms to achieve this will be furtherdeveloped and improved, working with the health sector support programme totest new mechanisms of financing (linked with Output 1, Equity Access). MoHPwill provide guidelines regarding user fees and safety net arrangements for poormothers and their newborns. The DoHS will monitor implementation, with supportfrom the Regional and District Health Offices (link with Output 2, Services).

Explanatory notesBasic Emergency Obstetric CareThis includes, administering parental antibiotics, oxytocic drugs andanticonvulsants, performing manual removal of placenta, use of manual vacuumaspiration and assist vaginal delivery with vacuum /forceps

Comprehensive Emergency Obstetric CareThis includes all the six components of BEOC and provision of surgery (caesareansection) and blood transfusion.

Essential SMNH servicesThese include: focused antenatal care; skilled attendance at birth; newborn care;post-natal care, including family planning services; Basic and ComprehensiveEmergency Obstetric Care (B/CEOC), including post-abortion care; comprehensiveabortion care; and effective referral services.

Definition of skilled birth attendant (SBA)“An accredited health professional-such as a midwife, doctor or nurse-who hasbeen educated and trained to proficiency in the skills needed to manage normal(uncomplicated) pregnancies, childbirth and the postnatal period and in theidentification, management and referral of complications in women and newborns(WHO)

16



(NSMNH-LTP)

Chapter 3: Logframe



(NSMNH-LTP)

Lo

gfr

ame:

Rev

isio

n o

f N

atio

nal

Saf

e M

oth

erh

oo

d a

nd

New

bo

rn H

ealt

h L

on

g T

erm

Hea

lth

Pla

n (

NS

MN

H-L

TP

200

6-20

17)

Go

al

Impr

oved

mat

erna

l and

neo

nata

l hea

lth a

nd s

urvi

val

espe

cial

ly o

f th

e po

or a

nd v

ulne

rabl

e

1.M

ater

nal

mor

talit

y ra

tio r

educ

ed:

2007

: 30

0 pe

r 10

0,00

020

12:

240

per

100,

000

2017

: 13

4 pe

r 10

0,00

02.

Neo

nata

l m

orta

lity

ratio

red

uced

:20

07:

32 p

er 1

,000

live

birt

hs20

12:

20 p

er 1

,000

live

birt

hs20

17:

15 p

er 1

,000

live

birt

hs

DH

SC

BS

Dat

aC

ensu

s

Pu

rpo

se

Incr

ease

d he

alth

y pr

actic

es a

nd u

tilis

atio

n of

qua

lity

mat

erna

l an

d ne

onat

al h

ealth

ser

vice

s, e

spec

ially

by

the

poor

and

vul

nera

ble,

del

iver

ed b

y a

wel

l man

aged

heal

th s

ecto

r

1.P

erce

ntag

e of

del

iver

ies

cond

ucte

d by

SB

As

2007

: 20

%20

12:

40%

2017

: 60

%2.

Per

cent

age

of d

eliv

erie

s in

a h

ealth

faci

lity

2007

: 20

%20

12:

30%

2017

: 40

%3.

Incr

ease

in m

et n

eed

for

EO

C o

f 3

%ea

ch y

ear

4.In

crea

se in

met

nee

d fo

r ca

esar

ean

sect

ion

of 4

% e

ach

year

(Ind

icat

ors

1-4

will

als

o be

dis

aggr

egat

ed b

ypo

or a

nd s

ocia

lly e

xclu

ded)

DH

SN

LSS

/Ann

ual

Rep

ort

ofD

oHS

NLS

S/A

nnua

l R

epor

t of

DH

SH

MIS

HM

IS/D

HS

EO

C M

onito

ring

Rep

ort

HM

ISE

OC

Mon

itorin

g R

epor

tB

asel

ine

disa

ggre

gate

dda

ta t

o be

dra

wn

from

DH

S

•P

oliti

cal

situ

atio

nre

mai

ns s

tabl

e an

dpe

acef

ul

•D

DC

s an

d V

DC

s ar

eel

ecte

d an

d fu

nctio

nal

•S

tron

g po

litic

alco

mm

itmen

t to

saf

em

othe

rhoo

d•

Ove

rall

envi

ronm

ent

(soc

ial,

polit

ical

and

econ

omic

) is

sta

ble

Ou

tpu

ts

1.

Eq

uit

y an

d A

cces

sIn

divi

dual

s, g

roup

s an

d ne

twor

ks s

ocia

lly

1.1

Kno

wle

dge

abou

t m

ater

nal

and

neon

atal

dang

er s

igns

am

ong

men

and

wom

en o

f•

DH

S•

SM

NH

con

tinue

s to

be

ahi

gh p

riorit

y in

an

Hie

rarc

hy

of

Ob

ject

ives

Ind

icat

ors

Mea

ns

of

Ver

ific

atio

n

Ass

um

pti

on

s/R

isks

18



(NSMNH-LTP)

empo

wer

ed t

o pr

actis

e de

sire

d S

MN

H b

ehav

iour

sle

adin

g to

incr

ease

d eq

uity

of,

and

acce

ss t

ohe

alth

ser

vice

s.

(Soc

ial

empo

wer

men

t in

clud

es i

mpr

ovin

g kn

owle

dge

attit

udes

, be

havi

ours

, co

nfid

ence

, le

gal

and

soci

alst

atus

and

acc

ess

to r

esou

rces

, in

clud

ing

tran

spor

tan

d fin

ance

sch

emes

, of

indi

vidu

als,

gro

ups

and

netw

orks

)

repr

oduc

tive

age,

inc

ludi

ng d

isad

vant

aged

grou

ps,

incr

ease

d to

80%

by

2017

.1.

2 M

en a

nd w

omen

of

repr

oduc

tive

age,

incl

udin

g di

sadv

anta

ged

grou

ps,

able

to

iden

tify

B/C

EO

C s

ites

and

SB

As

incr

ease

dto

80%

by

2017

1.3

Des

ired

chan

ge in

tar

gete

d K

AP

am

ong

men

and

wom

en o

f re

prod

uctiv

e ag

e(r

elat

ed t

o fo

cuse

d A

NC

, P

NC

EO

C,

EN

C,

PA

C a

nd C

AC

)1

1.4

Per

cent

age

of p

eopl

e pr

actis

ing

birt

hpr

epar

edne

ss a

nd c

ompl

icat

ion

read

ines

sin

crea

sed

to 7

0% b

y 20

171.

5 C

omm

uniti

es (

war

ds)

havi

ng s

usta

inab

leem

erge

ncy

fund

s an

d tr

ansp

orta

tion

sche

mes

incr

ease

d to

70%

by

2017

•P

erio

dic

surv

eys

both

qua

litat

ive

and

quan

titat

ive

•H

MIS

•D

HS

•D

oHS

ann

ual

repo

rt

Nat

iona

l KA

P S

urve

y2

emer

ging

sec

tor

wid

e fr

amew

ork

even

afte

r 20

09•

Har

mon

isat

ion

and

coor

dina

tion

amon

gS

MN

H s

take

hold

ers

2.S

ervi

ces

Enh

ance

d an

d eq

uita

ble

prov

isio

n of

qua

lity

SN

MH

serv

ices

(Ess

entia

l S

MN

H s

ervi

ces

incl

ude:

foc

used

AN

C,

deliv

ery

by s

kille

d bi

rth

atte

ndan

t w

ith n

ewbo

rn c

are,

PN

C,

EO

C,

CA

C s

ervi

ces

and

refe

rral

ser

vice

s)

2.1

Per

cent

age

of H

Ps

prov

idin

g no

rmal

deliv

ery

serv

ices

and

new

born

car

e in

line

with

nat

iona

l st

anda

rds

2007

: 10

%20

09:

15%

2012

: 3

0%20

17:

70%

2.2

Per

cent

age

of P

HC

Cs

prov

idin

g B

EO

C,

incl

udin

g ne

wbo

rn c

are

and

CA

Cse

rvic

es.

(Bas

elin

e: 9

% i

n 20

04/5

)20

07:

20%

2009

: 40

%20

12:

60%

2017

: 80

%

2.3

Num

ber

of d

istr

icts

pro

vidi

ng C

EO

C,

new

born

car

e an

d C

AC

ser

vice

s(in

clud

ing

priv

ate

sect

or)

(B

asel

ine:

26

in20

04/5

)20

07:

3120

09:

3720

12:

47

•Adm

inis

trative r

eco

rds

•Periodic

superv

isio

nre

port

s•

HM

IS•

DH

S•

DoH

S a

nnual re

port

s•

FH

D r

eco

rds

•Stu

dy/S

urv

ey r

eport

s

�Continuin

g p

olit

ical

com

mitm

ent

and

reso

urc

es

for

safe

moth

erh

ood a

s a

priority

�Com

mitm

ent

and

reso

urc

es

for

loca

lca

paci

ty b

uild

ing in

health m

anagem

ent

as

a p

art

of

dece

ntr

alis

ation e

ffort

s

�D

evelo

pm

ent

of

safe

and e

ffect

ive w

ays

of

work

ing in c

onflic

t-aff

ect

ed a

reas

1 S

pe

cifi

c in

dic

ato

rs r

ela

ted

to

th

e i

nd

ica

tors

are

: A

NC

- %

of

pre

gn

an

t w

om

en

wh

o r

ece

ive

4 f

ocu

sed

AN

C c

he

cku

ps

(wit

h T

T,

iro

n s

up

ple

me

nta

tio

n,

de

-wo

rmin

ga

nd

co

un

sell

ing

fo

r d

an

ge

r si

gn

s);

EO

C –

kn

ow

led

ge

of

da

ng

er

sig

ns,

id

en

tifi

cati

on

of

loca

l S

BA

an

d w

he

re t

o g

o i

n c

ase

of

em

erg

en

cy;

PN

C -

% o

f w

om

en

wh

ore

ceiv

e a

t le

ast

3 f

ocu

sed

PN

C c

he

cku

ps

(iro

n s

up

ple

me

nta

tio

n,

vita

min

A,

cou

nse

llin

g f

or

da

ng

er

sig

ns

an

d c

on

tra

cep

tive

se

rvic

es)

; E

NC

- %

of

po

stn

ata

l w

om

en

wh

o k

no

w t

o w

ait

fo

r a

t le

ast

24

ho

urs

to

ba

the

th

eir

ne

wb

orn

an

d t

o k

ee

p i

t w

rap

pe

d a

nd

wa

rm;

PA

C -

% a

cce

pta

nce

of

po

st p

roce

du

re c

on

tra

cep

tio

n;

CA

C-

% o

fw

omen

who

kno

w le

gal c

ondi

tions

for

saf

e ab

ortio

n an

d w

here

to

go f

or s

ervi

ces.

2 N

atio

nal K

AP

Sur

vey

2006

, N

HIE

CC

19



(NSMNH-LTP)

2017

: 60

2.4

CA

C s

ervi

ces

avai

labl

e in

all

dist

rict

hosp

itals

by

2009

3.P

ub

lic P

riva

te P

artn

ersh

ip

Incr

ease

d pa

rtic

ipat

ion

of p

rivat

e se

ctor

, N

GO

s, C

BO

san

d pr

ofes

sion

al /

aca

dem

ic i

nstit

utio

ns i

n pu

blic

serv

ices

(S

MN

H r

elat

ed)

whi

ch e

nsur

es c

onsu

mer

sha

ve e

quita

ble

acce

ss t

o af

ford

able

ser

vice

s.

3.1

Num

ber

of S

MN

H s

ervi

ces,

hum

anre

sour

ce d

evel

opm

ent

and

acce

ss r

elat

edco

ntra

cts

with

NG

Os,

CB

Os,

prof

essi

onal

/aca

dem

ic i

nstit

utio

ns a

ndpr

ivat

e se

ctor

inc

reas

ed3.

2S

trat

egic

pla

n an

d im

plem

enta

tion

guid

elin

es o

n P

PP

join

tly d

evel

oped

and

endo

rsed

by

the

MoH

P b

y th

e en

d of

200

73.

3P

rivat

e, N

GO

, C

BO

sec

tors

and

prof

essi

onal

/ a

cade

mic

ins

titut

ions

with

SM

NH

ser

vice

s in

crea

sed

by 2

0 pe

rcen

tby

the

yea

r 20

17.

•D

oHS

Ann

ual

Rep

ort

•P

lan

and

guid

elin

eson

PP

P•

DoH

S A

nnua

lR

epor

t

•C

ondu

cive

pol

icy

envi

ronm

ent

for

part

ners

hip

with

NG

O,

CB

O a

nd p

rivat

e se

ctor

cont

inue

s

4.D

ecen

tral

isat

ion

Enh

ance

d lo

cal

gove

rnm

ent

and

part

ner

capa

city

to

plan

and

ove

rsee

SM

NH

ser

vice

s in

line

with

Loc

alS

elf

Gov

erna

nce

Act

4.1

Ann

ual h

ealth

pla

ns d

evel

oped

by

DD

Cs

that

cov

er S

MN

H a

nd s

ocia

l inc

lusi

on,

and

invo

lve

loca

l st

akeh

olde

rs4.

2 In

crea

sed

shar

e of

SM

NH

fro

m 5

% t

o 8%

of d

istr

ict

annu

al b

udge

t

•A

nnua

l he

alth

pla

ns•

DD

C p

lan

•D

istr

ict

budg

et

•C

ondu

cive

pol

icy

envi

ronm

ent

onde

cent

ralis

atio

n•

Str

ong

polic

y an

dfin

anci

al c

omm

itmen

tsfr

om g

over

nmen

t, E

DP

s•

Prio

rity

give

n to

SM

NH

and

soci

al in

clus

ion

bylo

cal

bodi

es c

ontin

ues

•Lo

cal

bodi

es r

emai

nre

spon

sive

to

loca

lvo

ices

5.H

um

an R

eso

urc

e D

evel

op

men

t: S

kille

d B

irth

Att

end

ant

Str

ateg

y

Str

ateg

y/P

lan

for

Hum

an R

esou

rce

Dev

elop

men

t in

rela

tion

to S

MN

H a

nd f

or S

kille

d B

irth

Atte

ndan

tsde

velo

ped

and

impl

emen

ted

5.1

HR

D s

trat

egy/

plan

for

SM

NH

(20

07-2

012)

deve

lope

d, i

ncor

pora

ted

in n

ext

perio

dic

Hea

lth P

lan

and

impl

emen

ted

5.2

Hea

lth f

acili

ties

(Dis

tric

t an

d P

HC

C)

fully

staf

fed

by S

BA

s (w

ith s

kill

mix

, bo

thnu

mbe

r an

d ty

pes)

:20

07:

25%

2012

: 50

%20

17:

80%

•Tr

aini

ng r

epor

t fr

omac

cred

ited

trai

ning

site

s by

NN

C•

11th F

ive

year

Hea

lthP

lan

•H

UR

IC d

ata

•H

UR

IC,

TM

IS a

ndM

oHP

dat

a

•S

MN

H H

RD

str

ateg

y/p

lan

refle

cted

in t

he 1

1th

Fiv

e Y

ear

Pla

n

6.In

form

atio

n

Key

SM

NH

rel

ated

in

form

atio

n, in

clud

ing

6.1

95 p

erce

nt o

f pu

blic

and

25%

hea

lthin

stitu

tions

of

priv

ate

sect

ors

and

NG

Os

repo

rt t

heir

SM

NH

ser

vice

dat

a to

HM

IS b

y

•H

MIS

•D

HS

•D

oHS

ann

ual

repo

rt

20



(NSMNH-LTP)

200

8, 5

0% b

y 20

12,

and

100%

by

2017

6.2

Dis

aggr

egat

ed S

MN

H d

ata

gene

rate

d by

2008

6.3

Use

ND

HS

, N

LSS

sur

veys

info

rmat

ion

inpl

anni

ng a

nd p

olic

y fo

rmul

atio

n pr

oces

s.

7.P

hys

ical

Ass

ets

and

Pro

cure

men

t

Ade

quat

e ph

ysic

al r

esou

rces

for

SM

NH

ser

vice

s w

ithye

ar r

ound

ava

ilabi

lity

of S

MN

H r

elat

ed d

rugs

and

supp

lies

ensu

red

7.1

Num

ber

of d

istr

icts

with

at

leas

t on

e fu

llyeq

uipp

ed C

EO

C f

acili

ties

incr

ease

d fr

om28

to

31 b

y en

d of

200

7 an

d to

60

dist

ricts

by e

nd o

f 20

177.

2 P

erce

ntag

e of

PH

CC

s w

ith f

ully

equ

ippe

dB

EO

C f

acili

ties

incr

ease

d fr

om 9

% t

o 20

%20

07 a

nd 4

0 %

by

the

year

200

9, 6

0 %

by

the

year

201

2 an

d 80

% b

y 20

177.

3 H

Ps

with

birt

hing

cen

tres

2007

: 10

%20

09:

15%

2012

: 3

0%20

17:

70%

7.4

Year

rou

nd a

vaila

bilit

y of

SM

NH

dru

gs a

ndco

mm

oditi

es in

crea

sed

to 1

00%

by

2012

7.5

Dru

g fin

anci

ng s

chem

es i

mpl

emen

ted

asst

ated

in N

HS

P-I

P (

8)

•D

oHS

ann

ual

repo

rt•

LMIS

Rep

ort

•F

inan

cial

sup

port

fro

mE

DP

s co

ntin

ues

disa

ggre

gatio

n by

eth

nici

ty,

cast

e an

d w

ealth

,de

velo

ped,

inco

rpor

ated

with

in t

he H

MIS

, an

d o

ther

sour

ces

of in

form

atio

n (N

DH

S,

NLS

S e

tc)

used

at

natio

nal

and

loca

l le

vels

8.F

inan

ce

Sus

tain

able

fin

anci

ng s

yste

m f

or S

MN

H s

ervi

ces

impr

oved

8.1

At

leas

t 15

% o

f pu

bic

expe

nditu

re o

n he

alth

sp

ent f

or S

MN

H a

t the

end

of

2012

fro

m 1

0% a

nd 2

0% b

y 20

178.

2 A

t le

ast

45%

of

SM

NH

pub

lic e

xpen

ditu

rew

ill b

e sp

ent

for

the

bene

fit o

fdi

sadv

anta

ged

grou

ps3

by 2

012

and

50%

by t

he 2

017

8.3

At

leas

t 45

% o

f th

e w

omen

ben

efiti

ng f

rom

the

cost

sha

ring

sche

me

will

be

from

disa

dvan

tage

d gr

oups

(D

alit

and

Janj

ati)

by20

12 a

nd 5

0% b

y 20

178.

4 A

t le

ast

50%

of

villa

ges

will

hav

efu

nctio

nal r

evol

ving

SM

NH

em

erge

ncy

fund

s by

201

2 an

d 60

% b

y 20

17.

•S

urve

y re

port

•F

MIS

•LS

I M

onito

ring

/Ass

essm

ent

repo

rts

•N

LSS

•LS

I M

onito

ring

/Ass

essm

ent

repo

rts

•A

nnua

l rep

ort

DoH

S

•S

MN

H s

hare

of

heal

thbu

dget

inc

reas

ed a

spl

anne

d•

Loca

l bod

ies

are

func

tiona

l•

Leve

l of

reso

urce

sre

mai

ns t

he s

ame

aspl

anne

d

3 S

peci

fical

ly t

his

incl

udes

Dal

its (

low

cas

te o

r oc

cupa

tiona

l ca

ste)

and

Jan

jatis

(et

hnic

min

ority

gro

ups)

21



(NSMNH-LTP)

1.E

qu

ity

and

Acc

ess

A.

Ad

voca

cy1.

Lobb

y po

licy

mak

ers

and

influ

entia

l peo

ple

at n

atio

nal,

dist

rict

and

com

mun

ity le

vels

, in

corp

orat

ing

user

and

pro

vide

r vo

ice,

to

have

app

ropr

iate

pol

icie

s in

pla

ce f

or s

ocia

l em

pow

erm

ent

of w

omen

, fa

mili

es a

nd c

omm

uniti

es (

incl

udin

g pr

otec

tion,

sec

urity

,rig

hts,

end

ing

disc

rimin

atio

n, i

mpr

ovin

g st

atus

)2.

Lobb

y at

all

leve

ls f

or e

quita

ble

dist

ribut

ion

of s

ervi

ces

and

infr

astr

uctu

re,

incl

udin

g ro

ads,

brid

ges

and

one

func

tioni

ng t

elep

hone

in e

ach

faci

lity

B.

So

cial

Mo

bili

sati

on

1.In

volv

e co

mm

uniti

es i

n pa

rtic

ipat

ory

plan

ning

, in

clud

ing

cond

uctin

g so

cial

map

ping

, im

plem

entin

g, m

onito

ring

(incl

udin

g vo

ice)

of

SM

NH

pro

gram

mes

and

tak

ing

a co

mm

unity

-bas

ed lo

calis

ed a

ppro

ach.

Wom

en a

nd m

en s

houl

d be

invo

lved

esp

ecia

lly w

omen

of r

epro

duct

ive

age,

mot

hers

-in-la

w a

nd in

fluen

tial f

amily

mem

bers

, an

d di

spla

ced

wom

en a

nd t

heir

fam

ilies

incl

uded

2.M

obili

se h

ealth

wor

kers

, tr

aditi

onal

hea

lth c

are

prov

ider

s, l

ocal

med

ia,

yout

h gr

oups

, co

mm

unity

vol

unte

ers/

FC

HV

s, p

rivat

epr

actit

ione

rs,

mot

hers

’ gro

ups,

sch

ool t

each

ers,

loca

l rep

rese

ntat

ives

and

dut

y ho

lder

s (f

rom

sch

ools

, fo

rest

and

wat

er u

ser

and

savi

ngs

and

cred

it) g

roup

s to

pro

mot

e S

MN

H3.

Pro

vide

sup

port

to

stre

ngth

en c

oord

inat

ion

foru

ms

(RH

CC

/SM

NF

/SM

NS

C/

and

sub-

com

mitt

ees)

at

all l

evel

s to

impl

emen

t S

MN

Hpr

ogra

mm

es,

espe

cial

ly t

arge

ting

the

RH

IE

C t

echn

ical

com

mitt

ee4.

Bui

ld c

omm

uniti

es’ c

apac

ity t

o cr

eate

and

util

ise

sust

aina

ble

emer

genc

y fu

nds

and

tran

spor

tatio

n sc

hem

es (

link

with

Out

put

2,S

ervi

ces)

5.P

rom

ote

cros

s-se

ctor

al (

inte

r an

d in

tra-

min

iste

rial,

divi

sion

al,

NG

Os)

col

labo

ratio

n fo

r in

tegr

atin

g S

MN

H

Beh

avio

ur

Ch

ang

e C

om

mu

nic

atio

n (

BC

C)

1.C

ondu

ct n

atio

nal

base

line

rese

arch

2.U

pdat

e an

d im

plem

ent

inte

grat

ed s

afe

mot

herh

ood

and

new

born

hea

lth c

omm

unic

atio

ns s

trat

egy,

inc

ludi

ng s

tand

ardi

sing

mes

sage

s an

d m

akin

g th

em a

vaila

ble

at a

ll le

vels

3.D

evel

op a

nd i

mpl

emen

t fo

cuse

d re

sear

ch b

ased

com

mun

icat

ion

inte

rven

tions

(lin

ked

with

ser

vice

im

prov

emen

t) t

o re

ach

disa

dvan

tage

d an

d vu

lner

able

gro

ups

incl

udin

g di

spla

ced

peop

le4.

Pro

mot

e S

MN

H r

elat

ed h

ealth

y be

havi

ours

, in

clud

ing

birt

h pr

epar

edne

ss,

by c

ondu

ctin

g B

CC

act

iviti

es a

nd u

sing

rig

hts

base

dap

proa

ches

, sp

ecifi

cally

red

ucin

g al

l vi

olen

ce a

gain

st w

omen

5.P

rom

ote

posi

tive,

non

-dis

crim

inat

ory

inte

r-pe

rson

al c

omm

unic

atio

n be

twee

n pr

ovid

ers

and

clie

nts

•C

oord

inat

ed e

ffort

to

impl

emen

t th

ede

cent

ralis

atio

n ac

t•

Com

mun

ities

will

ingl

ypa

rtic

ipat

e in

SN

MH

prog

ram

mes

•C

onfli

ct d

oes

not

limit

the

mob

ility

and

gath

erin

g of

peo

ple

atdi

stric

t le

vel a

nd b

elow

•In

ter

Min

istr

yco

ordi

natio

n su

ppor

tses

tabl

ishm

ent

offu

nctio

ning

pho

ne l

ines

Maj

or

Act

ivit

y A

reas

Ass

um

pti

on

s

2. S

ervi

ces

1.S

tren

gthe

n an

d ex

pand

qua

lity

SM

NH

ser

vice

s at

all

leve

ls in

a p

hase

d m

anne

r, in

clud

ing

C/B

EO

C,

deliv

ery

and

CA

C s

ervi

ces,

2.Im

prov

e lin

kage

s an

d in

tegr

atio

n w

ith o

ther

rep

rodu

ctiv

e he

alth

and

chi

ld h

ealth

initi

ativ

es (

such

as

IMC

I, P

MT

CT,

Mal

aria

, C

AC

,F

CH

V p

rogr

amm

es)

�R

esou

rces

con

tinue

to

be a

vaila

ble

for

impr

ovin

g ph

ysic

alfa

cilit

ies,

mai

ntai

ning

adeq

uate

sta

ffing

and

22



(NSMNH-LTP)

3.Im

prov

e th

e qu

ality

of

serv

ices

thr

ough

dev

elop

men

t of

qua

lity

assu

ranc

e an

d m

onito

ring

syst

ems

with

on-

site

coa

chin

g an

dlo

gist

ic s

uppo

rt,

in c

oord

inat

ion

with

app

ropr

iate

div

isio

ns4.

Cre

ate

an e

nabl

ing

envi

ronm

ent

for

SM

NH

ser

vice

s th

roug

h ad

voca

cy a

t al

l lev

els,

cap

acity

bui

ldin

g of

loca

l man

agem

ent

bodi

esan

d in

volv

emen

t of

civ

il so

ciet

y an

d pr

ivat

e se

ctor

in c

oord

inat

ion

with

app

ropr

iate

div

isio

ns5.

Prio

ritis

e th

e ne

eds

of p

oor

and

vuln

erab

le g

roup

s, f

ocus

ing

on s

uppo

rtin

g co

mm

unity

car

e in

mar

gina

lized

are

as a

nd d

evel

opin

gst

rate

gies

for

red

ucin

g se

rvic

e co

sts

for

poor

wom

en6.

Impr

ove

the

func

tioni

ng o

f re

ferr

al s

yste

ms

by d

evel

opin

g si

mpl

e re

ferr

al p

roto

cols

, st

reng

then

ing

mec

hani

sms,

orie

ntin

gco

mm

unity

wor

kers

and

ens

urin

g 24

-hou

r av

aila

bilit

y of

ser

vice

s7.

Ava

il an

aest

hesi

a se

rvic

e(S

ee A

nnex

for

mor

e de

taile

d ac

tiviti

es)

prov

idin

g su

ppor

t�

Oth

er R

H in

itiat

ives

will

ing

to c

oope

rate

�C

onfli

ct d

oes

not

limit

activ

ities

�Lo

cal

Man

agem

ent

bodi

es a

re c

omm

itted

to

SM

NH

ser

vice

s

4.

Dec

entr

alis

atio

n1.

Ens

ure

clar

ity a

bout

rol

es a

nd r

espo

nsib

ilitie

s of

sta

keho

lder

s fo

r de

liver

ing

devo

lved

SM

NH

ser

vice

s2.

Rai

se p

ublic

aw

aren

ess

abou

t de

volu

tion

of S

MN

H s

ervi

ces

to c

omm

unity

leve

l3.

Fac

ilita

te q

uart

erly

pub

lic d

isse

min

atio

n of

SM

NH

bud

gets

and

am

ount

spe

nt4.

Str

engt

hen

man

agem

ent

capa

city

at

loca

l le

vel

5.S

uppo

rt d

istr

ict

and

faci

lity

leve

l pla

nnin

g an

d m

onito

ring

rela

ted

to S

MN

H,

with

foc

us o

n eq

uity

and

acc

ess

and

soci

al in

clus

ion

6.D

evel

op a

nd im

plem

ent

a st

anda

rd m

onito

ring

chec

klis

t fo

r S

MN

H s

ervi

ces,

incl

udin

g eq

uity

and

acc

ess

and

soci

al in

clus

ion

issu

es7.

Est

ablis

h a

syst

em o

f re

war

ds a

nd in

cent

ives

for

tho

se p

rovi

ding

ef

ficie

nt

non-

disc

rimin

ator

y S

MN

H s

ervi

ces

at lo

cal l

evel

8.Tr

ack

the

outc

ome

and

impa

ct o

f de

volu

tion

on lo

cal S

MN

H in

dica

tors

9.D

evel

op m

etho

ds f

or g

reat

er p

ublic

acc

ount

abili

ty o

f lo

cal h

ealth

ser

vice

s10

.Inc

reas

e tr

ansp

aren

cy a

nd p

ublic

acc

ess

to S

MN

H r

elat

ed i

nfor

mat

ion

on:

budg

et,

spen

ding

, hu

man

res

ourc

es,

logi

stic

s,su

pplie

s, s

ervi

ces

avai

labl

e an

d pr

ovid

ed a

nd i

ndic

ator

s11

.Enh

ance

coo

rdin

atio

n am

ong

key

bodi

es s

uch

as R

HC

C,

DH

MC

, D

AC

C,

CD

P a

nd I

SC

.

•Lo

cal

bodi

es r

emai

nre

spon

sive

to

loca

lvo

ices

•M

ater

nal

heal

th r

emai

nsa

prio

rity

for

the

loca

lbo

dies

•Lo

cal

gove

rnm

ent

isac

com

mod

ativ

e in

plan

ning

and

mon

itorin

g

3.

Pu

blic

Pri

vate

Par

tner

ship

1.E

stab

lish

an e

ffect

ive

regu

lato

ry b

ody

at M

oHP

with

rep

rese

ntat

ion

from

the

priv

ate

sect

or,

NG

Os

and

CB

Os

2.D

evel

op a

lega

l fra

mew

ork,

pro

toco

ls a

nd g

uide

lines

to

enco

urag

e an

d re

gula

te P

PP,

incl

udin

g tr

ansf

er o

f pu

blic

res

ourc

es t

oN

GO

s, C

BO

s an

d th

e pr

ivat

e se

ctor

3.E

stab

lish

and

stre

ngth

en jo

int

annu

al p

lann

ing

and

revi

ew m

echa

nism

s w

ith r

epre

sent

atio

n fr

om p

rivat

e se

ctor

, N

GO

s, C

BO

ssu

ppor

t fr

om e

xper

ts4.

Incl

ude

NG

O,

CB

O a

nd p

rivat

e se

ctor

SM

NH

pla

ns a

nd p

rogr

ess

in h

ealth

sec

tor

mon

itorin

g5.

Pro

vide

cap

acity

bui

ldin

g on

SM

NH

ser

vice

del

iver

y fo

r N

GO

s, C

BO

s an

d th

e pr

ivat

e se

ctor

6.H

arm

onis

e P

PP

pro

cedu

res

for

impl

emen

tatio

n to

ens

ure

cons

iste

ncy

with

tho

se o

f G

over

nmen

t an

d E

DP

s7.

Enh

ance

the

cap

acity

of

dist

rict

RH

CC

s to

add

ress

ser

vice

pro

visi

on,

equi

ty a

nd a

cces

s an

d so

cial

incl

usio

n is

sues

in S

MN

H8.

Trai

n do

ctor

s on

C/S

•S

tron

g po

licy

and

finan

cial

com

mitm

ent

from

Gov

ernm

ent,

ED

Ps

and

priv

ate

sect

or

23



(NSMNH-LTP)

5.

Hu

man

Res

ou

rce

Dev

elo

pm

ent:

Ski

lled

Bir

th A

tten

dan

ts’ S

trat

egy/

PL

an

A.

Hu

man

Res

ou

rce

Str

ateg

y1.

Dev

elop

a 5

-yea

r H

RD

str

ateg

y fo

r S

MN

H s

ervi

ces

2.D

evel

op a

nd m

aint

ain

a da

taba

se o

f hu

man

res

ourc

es a

nd s

kills

the

ir ut

ilisa

tion

3.D

evel

op t

ools

for

und

erta

king

pos

t tr

aini

ng o

nsite

sup

ervi

sion

and

mon

itorin

g4.

Dev

elop

mec

hani

sms

for

unde

rtak

ing

perf

orm

ance

ass

essm

ent

of t

rain

ed h

ealth

car

e pr

ovid

ers

5.E

stab

lish

a na

tiona

l aw

ard

syst

em f

or ‘

’saf

e m

othe

rhoo

d ch

ampi

on’’

in c

olla

bora

tion

with

pro

fess

iona

l or

gani

satio

ns

B.

Ski

lled

Bir

th A

tten

dan

ts’ S

trat

egy

1.D

evel

op a

5-y

ear

SB

A in

-ser

vice

tra

inin

g st

rate

gy/p

lan

2.D

evel

op g

ener

ic (

27 c

ore

skill

s) c

ompe

tenc

y ba

sed

SB

A t

rain

ing

pack

age

3.R

evie

w a

nd d

evel

op a

ccre

dita

tion

stan

dard

s fo

r tr

aini

ng in

stitu

tions

, sc

ope

of p

ract

ices

and

cer

tific

atio

n st

anda

rds

for

SB

As

4.Id

entif

y ga

ps in

the

exi

stin

g B

EO

C in

-ser

vice

cur

ricul

um a

nd a

dapt

for

in-s

ervi

ce S

BA

tra

inin

g (A

NM

s, S

N a

nd M

BB

S)

5.S

cree

n ex

istin

g he

alth

car

e pr

ovid

ers

(AN

Ms,

SN

s an

d do

ctor

s) w

ho h

ave

rece

ived

MR

T a

nd B

EO

C t

o as

sess

whe

ther

the

yre

quire

ref

resh

er t

rain

ing

6.U

pgra

de S

BA

tra

inin

g si

tes

7.C

ondu

ct p

lann

ing

mee

ting

with

5 R

HT

CS

s to

mak

e ar

rang

emen

ts f

or b

egin

ning

SB

A t

rain

ing

8.Tr

ain

serv

ice

prov

ider

s to

ens

ure

they

hav

e co

re S

BA

com

pete

ncie

s an

d ce

rtify

the

m9.

Ada

pt t

he g

ener

ic p

acka

ge f

or p

re-s

ervi

ce t

rain

ing

10.S

tren

gthe

n th

e ca

paci

ty o

f pr

e-se

rvic

e tr

aini

ng in

stitu

tions

(A

NM

, P

CL)

11.E

nsur

e al

l new

AN

M g

radu

ates

hav

e co

re S

BA

com

pete

ncie

s an

d ce

rtify

the

m

•11

th F

ive

year

Hea

lthP

lan

appr

oved

by

MoF

,M

oGA

, P

ublic

Ser

vice

Com

mis

sion

and

Nat

iona

l P

lann

ing

Com

mis

sion

•O

bste

tric

com

pone

nt o

fpr

e-se

rvic

e cu

rric

ulum

for

MB

BS

upd

ated

•S

uffic

ient

num

ber

ofA

NM

, P

CL

trai

ning

site

sac

cred

ited

by N

NC

•S

uffic

ient

num

ber

ofA

NM

gra

duat

es c

ertif

ied

as S

BA

s by

NN

C

6.In

form

atio

n M

anag

emen

t

A.

Info

rmat

ion

man

agem

ent

stra

teg

y1.

Dev

elop

a s

trat

egy

to in

corp

orat

e ke

y S

MN

H in

form

atio

n w

ithin

an

inte

grat

ed m

atrix

(di

sagg

rega

ted

by e

thni

city

, ca

ste,

and

wea

lth)

B.

Dat

a co

llect

ion

an

d q

ual

ity

2.Im

prov

e th

e qu

ality

of

data

col

lect

ed3.

Con

duct

dat

a ve

rific

atio

n ex

erci

ses

4.D

esig

n an

d im

plem

ent

rese

arch

and

stu

dies

for

gen

erat

ing

addi

tiona

l inf

orm

atio

n th

at is

not

inco

rpor

ated

in H

MIS

C.

Acc

ess

to I

nfo

rmat

ion

5.In

crea

se a

cces

s to

SM

NH

info

rmat

ion

at a

ll le

vels

(co

mm

unity

to

cent

re)

6.B

uild

rel

atio

nshi

ps w

ith p

ublic

, pr

ivat

e an

d N

GO

sec

tors

, an

d in

trod

uce

mec

hani

sms

for

regu

latin

g th

e flo

w o

f in

form

atio

n to

HM

IS7.

Pro

vide

orie

ntat

ion

to b

uild

cap

acity

of

SM

NH

sta

keho

lder

s to

gen

erat

e un

ders

tand

ing

on S

MN

H is

sues

at

all l

evel

s (c

omm

unity

to c

entr

e)

•C

ompr

ehen

sive

HM

IS i

sfe

asib

le•

A f

unct

iona

l bod

y is

inpl

ace

to r

egul

arly

rev

iew

and

reco

mm

end

chan

gein

HM

IS t

o re

spon

d to

prog

ram

me

need

s

24



(NSMNH-LTP)

D.

Mo

nit

ori

ng

8.P

rovi

de t

rain

ing

and

refr

eshe

r tr

aini

ng o

n S

MN

H p

rogr

amm

e m

onito

ring9

. D

esig

n an

d im

plem

ent

Key

Inf

orm

ant

Mon

itorin

gsy

stem

10.

Des

ign

and

impl

emen

t co

nflic

t m

onito

ring

syst

em

7.P

hys

ical

Ass

ets

and

Pro

cure

men

t

1.D

evel

op a

n in

vent

ory

of S

MN

H s

ervi

ce f

acili

ties,

equ

ipm

ent

and

inst

rum

ents

2.Im

plem

ent

a sy

stem

for

crit

eria

bas

ed d

istr

ict

sele

ctio

n fo

r ex

pans

ion/

exte

nsio

n/re

nova

tion

of p

hysi

cal

faci

litie

s3.

Dev

elop

and

im

plem

ent

need

bas

ed p

artic

ipat

ory

plan

ning

, m

onito

ring

and

impl

emen

tatio

n m

echa

nism

s4.

Dev

elop

and

im

plem

ent

a m

aint

enan

ce p

olic

y5.

Dev

elop

int

er-m

inis

teria

l an

d in

ter-

depa

rtm

enta

l co

ordi

natio

n m

echa

nism

s fo

r ph

ysic

al r

esou

rce

and

com

mod

ities

pla

nnin

g,m

onito

ring

and

impl

emen

tatio

n6.

Est

ablis

h a

data

base

of

supp

liers

and

dis

trib

utio

n ch

anne

ls f

or d

rugs

and

com

mod

ities

7.S

tren

gthe

n th

e qu

arte

rly L

MIS

rep

ortin

g sy

stem

for

con

sum

ptio

n of

SM

NH

rel

ated

dru

gs a

nd o

ther

com

mod

ities

8.Im

plem

ent

MN

C t

reat

men

t pr

otoc

ols

with

rat

iona

le u

se o

f dr

ugs

(ref

er t

o O

utpu

t 2,

Ser

vice

s)

•Tr

ansp

ort

bottl

enec

ksar

e no

t si

gnifi

cant

lyin

crea

sed

•E

DP

com

mitm

ent

offu

ndin

g su

ppor

t do

es n

otde

clin

e•

Situ

atio

n al

low

sm

onito

ring

of p

hysi

cal

faci

lity

cons

truc

tion

•C

onfli

ct s

ituat

ion

does

not

affe

ctim

plem

enta

tion

activ

ities

2.F

inan

ce

A.

In

crea

sin

g r

eso

urc

es f

or

SM

NH

1.C

ondu

ct e

vide

nce

base

d ad

voca

cy t

o in

crea

se a

vaila

bilit

y of

fin

anci

al r

esou

rces

for

SM

NH

ser

vice

s2.

Red

esig

n th

e re

sour

ce a

lloca

tion

form

ula

3.C

arry

out

cap

acity

bui

ldin

g/tr

aini

ng f

or t

imel

y sp

endi

ng o

f av

aila

ble

finan

cial

res

ourc

es4.

Impr

ove

Fin

anci

al M

anag

emen

t In

form

atio

n S

yste

m (

in li

ne w

ith t

he N

HS

P-I

P)

5.Im

plem

ent

and

refin

e th

e co

st s

harin

g sc

hem

e6.

Dev

elop

and

im

plem

ent

a su

stai

nabi

lity

plan

B.

Pro

mo

tin

g a

lter

nat

ive

fin

anci

ng

sch

emes

7.C

ondu

ct o

pera

tiona

l re

sear

ch o

n su

stai

nabl

e fin

anci

ng8.

Dev

elop

nat

iona

l gui

delin

es a

nd p

rovi

de c

omm

unity

mat

chin

g fo

r S

MN

H e

mer

genc

y fu

nds

C.

Saf

ety

net

fo

r p

oo

r an

d v

uln

erab

le g

rou

ps9.

Con

trib

ute

to t

he u

ser

char

ge p

olic

y, a

ddin

g ex

empt

ion

crite

ria f

or t

he m

ost

vuln

erab

le g

roup

s10

.Mon

itor

and

eval

uate

fin

anci

ng s

chem

es

•Le

vel o

f de

man

d fo

rhe

alth

res

ourc

es d

oes

not

grow

mas

sive

lybe

caus

e of

the

con

flict

•A

ll di

stric

ts h

ave

func

tioni

ng t

elep

hone

s•

Insu

ranc

e sc

hem

eex

pand

s as

pla

nned

•S

ituat

ion

allo

ws

regu

lar

mon

itorin

g an

dev

alua

tion

25



(NSMNH-LTP)

An

nex

1:

Det

aile

d a

ctiv

itie

s u

nd

er m

ajo

r ca

teg

ori

es f

or

serv

ices

(O

utp

ut

2)

2.1

S

tren

gth

en a

nd

exp

and

qu

alit

y S

MN

H s

ervi

ces

at a

ll le

vels

in a

ph

ased

man

ner

, in

clu

din

g B

/CE

OC

, del

iver

y an

d C

AC

ser

vice

s

a)D

evel

op a

ppro

pria

te s

elec

tion

crite

ria f

or B

/CE

OC

site

s an

d bi

rthi

ng c

entr

es.

b)D

evel

op a

nd i

mpl

emen

t a

need

bas

ed p

lann

ing

and

mon

itorin

g sy

stem

and

a p

hase

d ex

pans

ion

plan

for

B/C

EO

C s

ites

in d

istr

ict

hosp

itals

and

PH

CC

s, a

nd fo

r bi

rthi

ng c

entr

es in

app

ropr

iate

HP

s an

d S

HP

s, a

ccor

ding

to a

gree

d cr

iteria

. The

min

imum

req

uire

men

t for

CE

OC

and

BE

OC

site

s ac

cord

ing

to t

he U

N s

tand

ard

is f

our

BE

OC

site

s an

d on

e C

EO

C s

ite p

er 5

00,0

00 p

opul

atio

n. H

owev

er,

the

spar

se p

opul

atio

n di

strib

utio

n in

the

hill

and

mou

ntai

n ar

eas

and

asso

ciat

ed p

oor

tran

spor

t ava

ilabi

lity

mea

ns th

at N

epal

may

nee

d m

ore

C/B

EO

C s

ites

than

spe

cifie

d by

this

crit

erio

n, o

r a

stre

ngth

ened

ref

erra

l sys

tem

in th

ose

dist

ricts

whe

re C

EO

C s

ervi

ces

are

not f

easi

ble

or c

ost

effe

ctiv

e.c)

Enc

oura

ge t

he c

omm

unity

, E

DP

s an

d pr

ivat

e/N

GO

sec

tor

to d

evel

op d

eliv

ery

cent

res

and

EO

C s

ervi

ces

(incl

udin

g es

sent

ial n

ewbo

rnca

re)

to c

ompl

emen

t go

vern

men

t se

rvic

es a

nd c

onfo

rm w

ith n

atio

nal s

tand

ards

.d)

Ens

ure

skill

ed b

irth

atte

ndan

ts a

re a

vaila

ble

at H

Ps

and

SH

Ps

and

in c

omm

uniti

es. E

ncou

rage

wom

en to

use

an

SB

A fo

r ho

me

birt

hs if

they

are

not

abl

e to

go

to a

hea

lth f

acili

ty (

link

with

Out

puts

1,

Equ

ity a

nd A

cces

s, a

nd 5

, H

uman

Res

ourc

e D

evel

opm

ent)

.e)

Enc

oura

ge h

ealth

wor

kers

to

prov

ide

early

PN

C c

are

(with

in 7

2 hr

s of

the

birt

h) a

t ho

me

or in

the

hea

lth f

acili

ty.

Enc

oura

ge F

CH

Vs

topr

ovid

e po

stna

tal h

ome

visi

ts t

o ad

vise

new

mot

hers

and

the

ir fa

mili

es a

bout

car

ing

for

mot

her

and

baby

, an

d lin

k th

is w

ith t

he F

CH

Vpr

ogra

mm

e to

ens

ure

mot

hers

’ gro

ups

are

info

rmed

abo

ut t

he im

port

ance

of

PN

C.

f)S

tren

gthe

n ca

re f

or lo

w b

irth

wei

ght

and

sick

new

born

s in

hea

lth f

acili

ties

and

in c

omm

uniti

es/

fam

ilies

.g)

Str

engt

hen

post

part

um f

amily

pla

nnin

g co

unse

lling

and

ser

vice

s (li

nk w

ith f

amily

pla

nnin

g se

rvic

es).

h)D

evel

op C

AC

ser

vice

s in

all

dist

rict h

ospi

tals

and

app

ropr

iate

PH

CC

s, a

nd e

ncou

rage

priv

ate/

NG

O s

ecto

rs to

exp

and

CA

C s

ervi

ces

inlin

e w

ith th

e C

AC

pol

icy.

2.2

Im

pro

ve l

inka

ges

an

d i

nte

gra

tio

n w

ith

oth

er r

epro

du

ctiv

e h

ealt

h a

nd

ch

ild h

ealt

h i

nit

iati

ves

a)N

ewbo

rn c

are:

•In

tegr

ate

esse

ntia

l ne

wbo

rn c

are

in s

afe

mot

herh

ood

and

child

hea

lth c

are

prog

ram

mes

at

all

leve

ls i

n or

der

to c

reat

e sy

nerg

y an

dm

axim

ise

outp

uts.

•In

tegr

ate

neon

atal

car

e in

the

IM

CI

prog

ram

me.

•Li

nk w

ith C

hild

Hea

lth D

ivis

ion

to p

rovi

de m

icro

nutr

ient

sup

ply

and

TT

im

mun

isat

ion

for

preg

nant

wom

en a

s pa

rt o

f A

NC

and

PN

Cse

rvic

es.

•B

uild

link

ages

with

IE

C/B

CC

and

acc

ess

prog

ram

mes

to

ensu

re in

form

atio

n an

d se

rvic

es a

re m

atch

ed.

26



(NSMNH-LTP)

b)H

IV/A

IDS

: Li

nk w

ith N

CA

SC

to p

rovi

de P

MT

CT

and

car

e of

HIV

pos

itive

pre

gnan

t wom

en in

sel

ecte

d hi

gh r

isk

dist

ricts

acc

ordi

ng to

the

HIV

/A

IDS

pol

icy

and

prog

ram

me.

c)M

alar

ia:

Pro

vide

ant

i-mal

aria

l tr

eatm

ent

to p

regn

ant

wom

en i

n en

dem

ic a

reas

, ac

cord

ing

to n

atio

nal

stan

dard

s, t

hrou

gh l

inki

ng w

ith t

hem

alar

ia s

ectio

n of

the

Epi

dem

iolo

gy D

ivis

ion.

2.3

Im

pro

ve q

ual

ity

of

serv

ices

th

rou

gh

dev

elo

pm

ent

of

qu

alit

y as

sura

nce

an

d m

on

ito

rin

g s

yste

ms

wit

h o

n-s

ite

coac

hin

g a

nd

log

isti

csu

pp

ort

, in

co

ord

inat

ion

wit

h a

pp

rop

riat

e d

ivis

ion

s

a)C

oord

inat

e w

ith M

anag

emen

t D

ivis

ion

to d

evel

op a

nd i

mpl

emen

t a

com

preh

ensi

ve q

ualit

y as

sura

nce

syst

em f

or s

afe

mot

herh

ood

and

new

born

car

e, c

over

ing

all l

evel

s an

d in

clud

ing

priv

ate/

NG

O s

ecto

rs:

•D

evel

op/u

pdat

e an

d im

plem

ent

SM

NH

Sta

ndar

ds,

prot

ocol

s gu

idel

ines

and

too

ls f

or m

ater

nal a

nd n

ewbo

rn c

are

at a

ll le

vels

of

serv

ice.

•W

ork

with

Man

agem

ent

Div

isio

n to

dev

elop

qua

lity

of c

are

mon

itorin

g te

ams

at c

entr

al,

regi

onal

and

dis

tric

t le

vels

for

tec

hnic

al a

ndm

anag

emen

t su

perv

isio

n.•

Dev

elop

the

cap

acity

of

dist

rict

heal

th m

anag

emen

t co

mm

ittee

s, h

ealth

ser

vice

pro

vide

rs a

nd p

ublic

hea

lth n

urse

s an

d in

stitu

tiona

lise

qual

ity a

ssur

ance

, in

line

with

qua

lity

mon

itorin

g gu

idel

ines

.•

Sup

port

the

inc

lusi

on o

f th

e pr

ivat

e/N

GO

sec

tor

unde

r th

e na

tiona

l sy

stem

for

qua

lity

assu

ranc

e, t

o en

cour

age

them

to

adop

t na

tiona

lst

anda

rds

and

QO

C g

uide

lines

.•

Ens

ure

suffi

cien

t lo

gist

ic s

uppo

rt is

ava

ilabl

e (li

nk w

ith o

utpu

t 7,

pro

cure

men

t).

b)

Dev

elop

, pl

an a

nd im

plem

ent

regu

lar

mon

itorin

g an

d su

perv

isio

n sy

stem

s at

diff

eren

t le

vels

:•

Inst

itutio

nalis

e th

e E

OC

mon

itorin

g sy

stem

in H

MIS

and

in s

afe

mot

herh

ood

dist

ricts

incl

udin

g pr

ivat

e/N

GO

sec

tor

faci

litie

s.•

Incr

ease

the

cap

acity

of

publ

ic h

ealth

nur

ses/

dis

tric

t su

perv

isor

s to

pro

vide

effe

ctiv

e m

onito

ring

and

supe

rvis

ion

and

on-s

ite c

oach

ing.

•D

evel

op s

uper

visi

on c

heck

lists

and

gui

delin

es.

c)Im

plem

ent a

nd e

xpan

d m

ater

nal a

nd p

eri-n

atal

dea

th a

udits

in h

ospi

tals

in a

pha

sed

man

ner,

acco

rdin

g to

gui

delin

es a

nd in

volv

ing

prof

essi

onal

orga

nisa

tions

suc

h as

NE

SO

G,

NE

PA

S,

PE

SO

N a

nd N

AN

.d)

Car

ry o

ut p

erio

dic

asse

ssm

ent a

nd re

sear

ch in

the

field

of S

MN

H, i

nclu

ding

com

mun

ity p

erce

ptio

n of

qua

lity

of c

are

thro

ugh

use

of te

chni

ques

such

as

clie

nt e

xit

inte

rvie

ws

and

inte

ract

ion

with

com

mun

ities

, in

ord

er t

o im

prov

e po

licy

deve

lopm

ent

and

prog

ram

min

g.

2.4

C

reat

e an

en

ablin

g e

nvi

ron

men

t fo

r S

MN

H s

ervi

ces

thro

ug

h a

dvo

cacy

at

all l

evel

s, c

apac

ity

bu

ildin

g o

f lo

cal m

anag

emen

t b

od

ies

and

in

volv

emen

t o

f ci

vil

soci

ety

and

pri

vate

sec

tor

in c

oo

rdin

atio

n w

ith

ap

pro

pri

ate

div

isio

ns

a)A

dvoc

ate

and

lobb

y at

all

leve

ls fo

r ap

prop

riate

nee

d ba

sed

SM

NH

pol

icie

s, p

rogr

amm

es a

nd r

esou

rce

allo

catio

n, to

ens

ure

the

avai

labi

lity

ofqu

ality

SM

NH

ser

vice

s an

d re

spon

d to

loca

l rea

litie

s (li

nk w

ith O

utpu

t 1,

Equ

ity a

nd A

cces

s).

27



(NSMNH-LTP)

b)C

oord

inat

e w

ith M

anag

emen

t Div

isio

n to

str

engt

hen

the

capa

city

of l

ocal

hea

lth m

anag

emen

t com

mitt

ees,

coo

rdin

atio

n fo

rum

s an

d co

mm

uniti

esin

fluen

tial i

n th

e m

anag

emen

t of S

MN

H s

ervi

ces

at d

iffer

ent l

evel

s of

hea

lth fa

cilit

y, a

s pa

rt o

f the

dec

entr

alis

atio

n ef

fort

. Ens

ure

the

part

icip

atio

nof

civ

il so

ciet

y, N

GO

/ pr

ivat

e se

ctor

s an

d D

alit

and

Janj

ati g

roup

s in

the

pro

cess

.c)

Dev

elop

mec

hani

sms

to p

rom

ote

acco

unta

bilit

y an

d te

am s

pirit

in h

ealth

fac

ility

man

agem

ent

com

mitt

ees

and

staf

f fo

r th

e de

liver

y of

qua

lity

SM

NH

ser

vice

s, u

sing

app

reci

ativ

e an

d pa

rtic

ipat

ory

man

agem

ent

proc

esse

s an

d in

volv

ing

com

mun

ities

and

civ

il so

ciet

y.d)

Wor

k w

ith N

HT

C t

o en

sure

ade

quat

e hu

man

res

ourc

es a

re in

pla

ce n

urse

s ar

e le

gally

pro

tect

ed w

hen

deal

ing

with

em

erge

ncie

s in

out

lyin

gar

eas

(link

with

out

put

5, h

uman

res

ourc

e de

velo

pmen

t).

e)W

ork

with

Log

istic

s M

anag

emen

t D

ivis

ion

to d

evel

op e

ssen

tial S

MN

H r

elat

ed d

rugs

and

equ

ipm

ent

lists

and

mak

e th

em a

vaila

ble

(link

with

Out

put

7, P

hysi

cal A

sset

s an

d P

rocu

rem

ent)

.f)

Dev

elop

infr

astr

uctu

re s

tand

ards

for

SM

NH

ser

vice

s (li

nk w

ith O

utpu

t 7,

Phy

sica

l Ass

ets

and

Pro

cure

men

t).

g)E

mpo

wer

fem

ale

staf

f in

hea

lth in

stitu

tions

as

chan

ge a

gent

s, t

hrou

gh o

n-si

te s

uppo

rt,

lead

ersh

ip a

nd m

anag

emen

t tr

aini

ng.

Incr

ease

the

irpa

rtic

ipat

ion

in p

lann

ing

prog

ram

min

g, d

ecis

ion-

mak

ing

and

supe

rvis

ion.

2.5

Pri

ori

tise

th

e n

eed

s o

f p

oo

r an

d v

uln

erab

le g

rou

ps, f

ocu

sin

g o

n s

up

po

rtin

g c

om

mu

nit

y ca

re in

mar

gin

aliz

ed a

reas

an

d d

evel

op

ing

stra

teg

ies

for

red

uci

ng

ser

vice

co

sts

for

po

or

wo

men

a)

Prio

ritis

e an

d ta

rget

hea

lth f

acili

ties

whi

ch p

rovi

de S

MN

H s

ervi

ces

for

poor

and

vul

nera

ble

grou

ps.

b)D

evel

op a

str

ateg

y fo

r re

duci

ng t

he c

ost

of d

eliv

ery

and

EO

C t

hat

ensu

res

key

serv

ices

are

affo

rdab

le (

cost

s ar

e tr

ansp

aren

t, in

clud

ing

ratio

nal p

roto

cols

for

dru

gs),

and

sub

sidi

es a

re a

vaila

ble

for

poor

peo

ple.

c)E

nsur

e th

at th

e co

st-s

harin

g sc

hem

e, w

hich

aim

s to

enc

oura

ge a

ll w

omen

to u

se a

n S

BA

for

child

birt

h, is

kno

wn

abou

t and

acc

essi

ble

to p

oor

and

vuln

erab

le w

omen

(lin

k w

ith O

utpu

t 1,

Equ

ity a

nd A

cces

s).

d)M

onito

r util

isat

ion

of S

MN

H s

ervi

ces

by v

ulne

rabl

e gr

oups

to g

ain

a be

tter u

nder

stan

ding

of w

hat w

orks

, and

app

ly th

ese

less

ons

to p

rogr

amm

ing.

2.6

Im

pro

ve th

e fu

nct

ion

ing

of r

efer

ral s

yste

ms

by

dev

elo

pin

g s

imp

le re

ferr

al p

roto

cols

, str

eng

then

ing

mec

han

ism

s, o

rien

tin

g c

om

mu

nit

yw

ork

ers

and

en

suri

ng

24-

ho

ur

avai

lab

ility

of

serv

ices

a)

Str

engt

hen

the

resp

onsi

vene

ss o

f re

ferr

al m

echa

nism

s.b)

Est

ablis

h lin

kage

s be

twee

n he

alth

faci

litie

s, p

erip

hera

l hea

lth c

are

prov

ider

s an

d vo

lunt

eers

, tra

ditio

nal p

ract

ition

ers

and

NG

O/C

BO

coo

rdin

atio

nfo

rum

s.c)

Dev

elop

a r

efer

ral p

roto

col (

incl

udin

g co

nditi

ons

for

patie

nts

to b

e re

ferr

ed a

nd s

tabi

lisat

ion

with

obs

tetr

ic fi

rst a

id b

efor

e an

d du

ring

tran

spor

t)an

d sl

ip, w

ith m

echa

nism

s fo

r co

mm

unic

atin

g w

ith h

ighe

r ce

ntre

s an

d lin

ks w

ith e

mer

genc

y fu

nds

and

tran

spor

t sch

emes

to a

ssis

t in

refe

rral

of p

oor

wom

en (

link

with

Out

put

1, E

quity

and

Acc

ess)

.d)

Dev

elop

a s

peci

al s

trat

egy

for

rem

ote

dist

ricts

and

con

flict

affe

cted

are

as,

such

as

esta

blis

hmen

t of

mat

erni

ty w

aitin

g ho

mes

nea

r re

ferr

alho

spita

ls f

or p

regn

ant

wom

en w

ho a

re n

ear

term

.e)

D

evel

op a

nd p

ilot

mat

erni

ty w

aitin

g ho

me

oper

atio

nal g

uide

lines

.f)

D

evel

op a

saf

ety

net

and

subs

idy

syst

em f

or p

oor

wom

en (

link

with

Out

put

8, F

inan

ce).

28



(NSMNH-LTP)

Published byFamily Health DivisionDepartment of Health ServicesMinistry of Health & PopulationTeku, Kathmandu

Printed in Nepal bySagun Printing PressTeku, Kathmandu

Design and Layout byPrism Color ScanningKuleshwor, Kathmandu

national safe motherhood and (nsmnh-ltp)

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