SM2015 - BELIZE
SM2015 Initiative
Innovative Approaches
May 2012
Content
—Health profile
—Health System
SM2015
—Objective
—Components
—Methodology
Demographic transition
— A reduction in the fertility rate (3.3 to 2.7) and increase in life
expectancy (73 years) have resulted in population aging
— More than half of the population is below 25 years – 55.6%
Epidemiological transition
— Double burden – increasing non-communicable and
degenerative diseases related to lifestyle, behaviors and a
longer life-span, combined with the continued occurrence of
communicable diseases related to poverty, sanitation,
environmental conditions, malnutrition and sexual risk
behaviors
— NCD’s are among the main causes of morbidity and mortality
Maternal Mortality Ratio 1991-2011
05 Protocols
Training
161
147
139
134
134
113
09 Quality
improvement MNC
111
101
100
82
10 Protocols
Training
85
82
64
58
53.9
42
43
42
40
53.7
04-05 Surveillance
system
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
0
Source: MOH, Health Statistical abstracts
— Maternal and infant mortality are low compared to other
countries of the region and appear to be declining
Skilled birth attendance is high (96%)
Source: MICS, 2006
Quality improvement of maternal and neonatal care
since 2009
Process
— Planning and resource mobilization
— Standards and indicators
— Training
— Policy
— Framework
— Monitoring tools
Demonstration phase in 2 hospitals
— 70% reduction in neonatal death
— 65% reduction in birth asphyxia
Spread to rest of hospitals in 2011
Adapted from University Research Company LLC.,
maternal and neonatal care package [Nicaragua Office]
Monthly monitoring Quality of process of care in all hospitals
-Revisited monitoring tool
Refresher
training at SRH
New partograph form
- Post reminders
In-service training and
practical sessions
-Staff
sensitization
-peer coaching
Median =90
Audit sessions
with midwives
Strategy sample:
random selection and
convenience,
Partograph
modified
‘High season’
Midwife: patient
Source: MoH, Belize, May 2011
Source:
medical records
Under-5 mortality rate
Source: MoH, Belize, May 2011
Analysis of protected cohorts against Measles/Rubella by year of birth and Vaccination
Strategies 1962-2010
100
100
Rubella Mass
80
% Vaccinated
70
60
90
Campaign (males)
Rubella Mass
campaign
(2004)
Measles "Big
MMR vaccine
(females)
Coverage 97%
(1998)
80
Bang" (1991)
5-35 yrs
MMR vaccine
MMR vaccine
70
9mths-14 yrs
Coverage 82%
60
5-35 yrs
50
50
40
40
30
30
20
20
10
10
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
1970
1968
1966
0
1964
1962
0
% Vaccinated
90
Year of Birth
Source: MOH reports to EPI-CAREC
Routine MMR1 coverage
2nd dose MMR 2000 (1-4yrs)95%
Measles F/U 1995 (1-4yrs) 85%
MMR2 coverage
Measles vaccine 1986 (9mths-3yrs) 91%
Under nutrition (low height for
age) is persistent among certain
populations – MICS2006
Poorest/richest– three fold
Indigenous / Maya
12-23 months of age
Stunting in < 5 year old
LSMS 2001 – 17.9
MICS 2006 – 17.6
Stunting Standard I Class
1996 – 13.7
2009 - 12.2
Unmet need for
reproductive health
services, and teenage
pregnancy is a priority
concern
Contraceptive use
prevalence rate
MICS2006:
1999 – 56%
2006 – 34%
Adolescent birth rate
/ 1,000 females 15-19
1995 - 99
2010 - 73
Adolescent Health
• There were 1,356 live births to mothers in the 15-19 year age
group, which represents 18.1% of the total live births.
• There was an average of 24 live births to mothers under 15 years.
• From 2001-2005, there were 145 (41 males and 104 females) new
HIV Infections in adolescents 10-19 years
• 6.9% of total new HIV Infections (16 ) occurred in the 10-14 agegroup;
• Early initiation of sexual activity and the prevalence of STIs are
public health concerns in this age group.
• Fourteen suicides and self-inflicted injuries were reported in the
10-19 age group during 2001-2005.
Belize Health Agenda, 2007-2011
Objective
The SM2015 Operation in Belize seeks to:
Increase the coverage of quality
reproductive, maternal, neonatal and child
health care in the poorest geographic areas
and increase the use of information in
decision making to reduce neonatal death
and increase the use of family planning
among adolescents
Where?
National Poverty Assessment,
2009
•Living Standards
Measurements Survey
•% of poor and indigent
households per rural/urban
districts
Districts with highest
increase in poverty rates
[2001/2009]
— Corozal
— Orange Walk
— Cayo
Component 1: Strengthening use of data to improve
MCH service quality
• Expansion of the Collaborative Improvement Model to
reduce maternal and child mortality
• Expansion and Utilization of the Belize Health
Information System in decision making at the local
level
• System of facility based-incentives at the MoH Clinics
in the Northern and Western Regions for expanding
coverage and quality
• Cross-country exchange and training to improve
quality of care
Component 2: Improving Community Based Care
• Monitoring and Evaluation of Community Health
Workers (CHW)
• Currently rolling out community based nutrition initiatives
that include breast-feeding promotion, growth-monitoring,
and waiting for results to decide about rolling out sprinkles
• Incentives for Community Health Workers who reach
targets
• Currently receive $50 US, exploring incentives that would
improve working conditions such as Basic supplies and
equipment for CHW and developing a recognition system
• Improved coordination and training of CHW
(recognition of high-risk cases)
Component 3: Increasing the Coverage of Reproductive
Health Services
• Increased access to 5 modern family planning
methods
• Capacity-building in counseling for Patient/Users
• Differentiated services designed and used by
adolescents
Interventions
Making pregnancy safer : Prenatal, postnatal care, skilled birth
attendance, managing complicated pregnancy, childbirth and
patients in postnatal period, managing complications
Immediate and routine newborn care, Managing Complicated
neonates
Multiple micronutrient supplementation: females 15-49, children
Fortified food: pregnant women and children
Growth promotion and development: community, facilities
5/7 hospitals certified as baby Friendly
Contraceptive methods: public sector and NGO
Supplies procured thru UN Agencies [UNFPA, UNICEF] and IDA
Foundation.
Prevention mother to child transmission: HIV & syphilis…….
Technical assistance in Maternal and child
health including reproductive health services
Quality improvement of services utilizing collaborative model
— Updating of protocols, standards and indicators,
framework and tools for the monitoring of process of
care in all areas under the project
Integrated RH services for adolescents
Management of RH supplies
Data management [Belize Health Information System]
Community based care
Health System Structure
Ministry of Health
• Operates in six districts: Belize,
Corozal, Orange Walk , Cayo
Stann Creek and Toledo
• Employs Service Level
Agreements with District Level
• Limited planning function,
financing of health supply
• Interest in introducing incentives
National Health Insurance
• Started in 2001 and operates in
three areas: Toledo, Stann Creek
and South Side Belize
• Utilizes P4P through contracts
with PCP in private and public
health centers
• Provides free services to all
eligible (poorest) populations
• Focuses on pre-natal and
postnatal care and deliveries,
and primary care for chronic
illnesses such as diabetes,
hypertension, and asthma.
Health System Network
1 National
Referral
Hospital
3 Regional
Hospitals
Stann Creek,
Beloman,
Orange Walk
3 Community
Hospitals
Toledo, Corazol, y
San Ignacio
Poly-Clinic 2
Poly-Clinic 1
(primary care)
Mobile
Units
Health
Posts-no
permanent
staff
Community
Health
Workers
NHI Details (1)
• The NHI pays the clinics a monthly member capitation payment
•
Clinics have an incentive to register as many people as they can
• Each month, the NHI pays clinics 70 percent of the member capitation
payment upfront.
• The remaining 30 percent of the payment depends on how the clinic
performs on groups of indicators that lead to scores for efficiency
• 70 percent of the withheld amount
• quality (20 percent of the withheld amount)
• and administrative processes (10 percent of the withheld amount)
• If an indicator is not fully achieved, then the proportional weight is
deducted from the clinic’s total potential payment for that month
Source: Michelle Vanzie, Natasha Hsi, Alix Beith, and Rena Eichler (2010): Using Supply-side Pay for Performance to Strengthen
Health Prevention Activities and Improve Efficiency: The Case of Belize. USAID Health Systems 2020, P$P Case Studies.
NHI Details (2)
Source: Michelle Vanzie, Natasha Hsi, Alix Beith, and Rena Eichler (2010): Using Supply-side Pay for Performance to Strengthen
Health Prevention Activities and Improve Efficiency: The Case of Belize. USAID Health Systems 2020, P$P Case Studies.
NHI Details (3)
Source: Michelle Vanzie, Natasha Hsi, Alix Beith, and Rena Eichler (2010): Using Supply-side Pay for Performance to Strengthen
Health Prevention Activities and Improve Efficiency: The Case of Belize. USAID Health Systems 2020, P$P Case Studies.
Goals 18 months
Indicador
Target
Source of verification
Health facilities that have the necessary inputs for providing emergency obstetric and
neonatal care according to the norms
75%
Health Facility Survey
Health facilities that have the necessary inputs for providing pre- and post natal care
according to the norms
85%
Health Facility Survey
75%
Health Facility Survey
85%
Health Facility Survey
85%
Health Facility Survey
85%
Health Facility Survey
85%
Health Facility Survey
85%
Health Facility Survey
Norms for improving the quality of reproductive and child health and nutrition services
and for the establishment of a community platform of services adopted
Yes
Norm Approved
Community health workers (CHW) trained in the community platform
85%
Health Facility Survey
District HECOPAB Officers that are currently monitoring the CHWs
85%
Health Facility Survey
Health facilities with a mechanism in place for carrying out patient satisfaction surveys
85%
Health Facility Survey
Health facilities that have submitted a Quality Improvement Fund (QIF) proposal to the
national quality audit team
Health facilities that have the necessary inputs to provide child health care according to
the norms
Health facilities that have implemented Quality of Care job aid tools for reproductive
health
Health facilities that can submit and receive data from the Belize Health Information
System (BHIS)
Health facilities that have permanent availability of all 5 types of modern family
planning methods (injectable, barrier, oral, IUD, permanent) according to the norms
Health facilities that have sexual and reproductive health (SRH) educational materials
specifically targeted at adolescents
Goals 36/54 months
Indicator
Baseline
Target PP change
80%
15
Health Facility Survey
26%
14
Health Facility Survey
50%
40
Health Facility Survey
Neonatal complications (prematurity, low birth weight, asphyxia and sepsis) handled
according to norms in the last two years
15%
75
Health Facility Survey
Obstetric complications (sepsis, hemorrhage, severe pre-eclampsia and eclampsia) handled
according to the norms in the last two years
20%
70
Health Facility Survey
30%
-20
Health Facility Survey
Female health facility patients of reproductive age that are given family planning counseling
according to the norms in the last two years
25%
50
Health Facility Survey
Women of reproductive age (15-49 years) who were not using/unable to obtain
contraception during last year
31%
-5
Household-based survey
Infants 0–5 months of age who were fed exclusively with breast milk the previous day
23%
10
Household-based survey
Mothers with a child 0-23 months that that can recognize 3 out of 5 signs of danger
20%
40
Household-based survey
Percentage of children aged 6-23 months that consumed 60 sachets of micronutrients in the
last 6 months
0
30
Household-based survey
Mothers who gave their children (0-5 9 months) ORS and zinc supplements during the last
episode of diarrhea in the two weeks
0
40
Household-based survey
Institutional deliveries for which oxytocin was administered immediately following birth as
part of Active Management of the Third Stage of Labor (AMTSL) in the last two years for
the most recent delivery
Pregnancies for which the woman attended at least one antenatal care visit during the first
trimester that was carried out according to the norms for the most recent pregnancy in the
last two years
Institutional deliveries for which immediate neonatal care (within 24 hours) was provided to
the infant according to the norms in the last two years for the most recent pregnancy
C-sections as a proportion of childbirths in the last two years
Source of verification