Business Case and Intervention Summary
Intervention Summary
Title: Maternal and Neonatal Health Human Resource Capacity Building
What support will the UK provide?
The UK will provide up to £15.86 million over 4 years from January 2012 to December 2015 for a multicountry programme to train health professionals and expand the coverage and quality of Emergency
Obstetric and Neonatal Care (EmONC), thereby reducing maternal and newborn mortality and
morbidity in 12 countries in sub-Saharan Africa and South Asia.
Why is UK support required?
Worldwide, 358 000 women die each year from complications arising during pregnancy and childbirth,
over 99% occurring in developing countries1. An estimated 3 million newborns die in the first month
after birth, with up to one quarter occurring in the first 24 hours of life as a result of complications
arising during childbirth2, 3. Although both maternal mortality and neonatal mortality rates are declining
worldwide, progress is still insufficient to reach the Millennium Development Goal targets, particularly in
Sub-Saharan Africa and South Asia where mortality rates remain high, and in some cases are
increasing4.
The majority of maternal deaths and deaths of babies during and within 24 hours of birth can be
avoided if women and newborns receive the appropriate interventions from a skilled health worker, and
with adequate equipment, drugs and medicines. However, globally an estimated 45 million women
give birth each year without skilled care5. To address this gap, countries need to increase the number
of skilled birth attendants and should also build the capacity of existing health workers so that they
perform better.6 While many countries are taking action to increase the numbers of healthcare workers
(including doctors, nurses and midwives), less attention has been given to strengthening the
competence of existing health workers to maximise their contribution to reducing maternal and
newborn deaths.
WHO (2010). Trends in Maternal Mortality 1990 – 2008.
Enable the Continuum of Care. Knowledge Summary 2.Partnership for Maternal, Newborn and Child Health and
University of Aberdeen. 2010. Sharing Knowledge for Action on Maternal, Newborn and Child Health. PMNCH:
Geneva, Switzerland.
3 The Partnership for Maternal, Newborn and Child Health. 2011. Essential Interventions, Commodities and
Guidelines for Reproductive, Maternal, Newborn and Child Health. Geneva, Switzerland: PMNCH.
4 “The Millennium Development Goals Report 2010”. United Nations Department of Economic and Social Affairs.
June 2010.
5 Proportion of births attended by a skilled health worker – 2008 updates. Geneva, World Health Organization,
2008
6 Support the Workforce. Knowledge Summary 6. Sharing Knowledge for Action on Maternal, Newborn and Child
Health. Partnership for Maternal, Newborn and Child Health and University of Aberdeen. PMNCH: Geneva,
Switzerland.
1
2
DFID will support the training of approximately 17,000 healthcare workers in 12 countries to improve
their skills and competence to manage complications arising during pregnancy and childbirth and in the
critical hours following birth.
The programme will be delivered by the ‘Making it Happen’ Partnership between the Royal College of
Obstetricians and Gynaecologists (RCOG) and the Liverpool School of Tropical Medicine (LSTM). The
MiH partnership was supported by DFID from 2009 to 2011, and demonstrated success in the training
and support of health workers in 5 countries, and in saving mother and newborn lives.
If DFID did not fund this activity the opportunity to maximize the impact of health workers on saving
maternal and newborn lives would be lost. Counties would continue to invest resources in healthcare
workers who are not performing to their full potential. Although other groups, eg FIGO, have been
engaged in similar activities, such efforts have been small scale and have not had a co-ordinated,
multi-country reach. Through the MiH programme, in which evidence generation is embedded in
programme design, a critical mass of evidence will be gathered to demonstrate the value of capacity
building of health care workers. Dissemination of this evidence, in particular drawing on the expertise
and reach of the central advisory board, will ensure that lessons learned influence policy making at
national and global levels, beyond the immediate reach of the programme.
What are the expected results?
The support provided by DFID will lead to improved quality of maternal and newborn care with the
following results during the lifetime of the programme:




9,586 maternal lives will be saved
191,720 maternal disabilities will be avoided
10,490 newborn lives will be saved
12,690 stillbirths will be averted.
Facility based records will provide baseline numbers and data throughout the duration of the
programme on the number of women attending participating facilities for emergency maternal care and
childbirth and the number of maternal deaths and newborn deaths and stillbirths. This data will be used
to calculate the number of lives saved by the programme intervention.
Additionally, by building the capacity of over 17,000 healthcare workers to provide emergency
maternal and newborn care, including the training of a cadre of 1,025 national ‘Master Trainers’ in
participating countries, the benefits of the program will be sustained beyond the immediate funding
period.
Business Case
Strategic Case
A. Context and need for a DFID intervention
Worldwide, 358 000 women die each year from complications arising during pregnancy and
childbirth, over 99% occurring in developing countries7. Although the number of maternal deaths has
7
WHO (2010). Trends in Maternal Mortality 1990 – 2008.
declined, with a 34% decrease globally between 1990 and 2008, this reduction is insufficient to
achieve MDG 58. For every woman who dies during pregnancy or childbirth an additional 20 or 30
suffer complications such as such as severe anaemia, incontinence, damage to the reproductive
organs or nervous system, chronic pain, and infertility 9.
Globally, there are approximately 8 million deaths of children aged under five each year and although
mortality rates for under-fives dropped by 28% between 1990 and 2008, only 10 countries are on
track to achieve the MDG 4 target10. A large share of child mortality (41%) is attributable to deaths in
the neonatal period with approximately 3 million newborns dying in the first month of life11. Of these,
an estimated 23% die within 24 hours of birth as a result of complications arising during childbirth or
in the immediate post delivery period12, 13.
The UK Government is committed to save the lives of mothers and newborns. As described in
‘Choices for Women: planned pregnancies, safe births and healthy newborns. The UK’s Framework
for Results for improving reproductive, maternal and newborn health in the developing world’ (FfR),
the UK will support action to:
 Save the lives of at least 50,000 women in pregnancy and childbirth and 250,000 newborn
babies by 2015
 Support at least 2 million safe deliveries, ensuring long lasting improvements to maternity
services, particularly for the poorest 40%.
The FfR describes a continuum of care for reproductive, maternal and child health from prepregnancy to post pregnancy and childhood. The FfR recognizes the role of individual households,
community/outreach services and health facilities to improve maternal and child health while
emphasising that interventions for mothers and children should be integrated at each of these levels.
Within the continuum of care, in addition to interventions to save the lives of mothers, newborns and
children, there is an opportunity to reduce the deaths of babies both before birth and – critically in this
programme - during delivery through the provision of adequate antenatal and intrapartum care. The
prevention of stillbirths is not an explicit target set out in the FfR, nor is it an MDG goal. However,
under the continuum of care approach, the health of a baby before and during birth should be given
due consideration. Approximately 3.3 million stillbirths were reported for 2000 with around one third
of these occurring during childbirth as a result of poor quality of care and poor management of
maternal complications14.
The majority of maternal deaths and deaths of babies during delivery and within the first 24 hours
following delivery can be prevented if the woman and newborn receive the appropriate interventions
from a skilled health worker, and with adequate equipment, drugs and medicines15. Adequate access
“The Millennium Development Goals Report 2010”. United Nations Department of Economic and Social
Affairs. June 2010.
9 C Murray and A Lopez, eds. Health Dimensions of Sex and Reproduction, Vol. 3, Global Burden of Disease
and Injury Series. Boston: Harvard University Press, 2008.
10 “The Millennium Development Goals Report 2010”. United Nations Department of Economic and Social
Affairs. June 2010.
11 Understand the Burden. Knowledge Summary 1. Partnership for Maternal, Newborn and Child Health and
University of Aberdeen. 2010. Sharing Knowledge for Action on Maternal, Newborn and Child Health. PMNCH:
Geneva, Switzerland.
12 The Partnership for Maternal, Newborn and Child Health. 2011. Essential Interventions, Commodities and
Guidelines for Reproductive, Maternal, Newborn and Child Health. Geneva, Switzerland: PMNCH.
13 Enable the Continuum of Care. Knowledge Summary 2. Partnership for Maternal, Newborn and Child Health
and University of Aberdeen. 2010. Sharing Knowledge for Action on Maternal, Newborn and Child Health.
PMNCH: Geneva, Switzerland.
14 Lawn J E, et al (2005). 4 million neonatal deaths: when? Where? Why? Lancet 2005, 365:891-900.
15 Partnership for Maternal, Newborn and Child Health and University of Aberdeen. 2010. Sharing Knowledge
for Action on Maternal, Newborn and Child Health. PMNCH: Geneva, Switzerland.
8
to and provision of emergency obstetric and newborn care are crucial16. In recognition of this, the
WHO has set the target that for every 500,000 people there should be 4 facilities providing Basic
Emergency/Essential Obstetric and Newborn Care (BEmONC) and one facility providing
Comprehensive Emergency/Essential Obstetric and Newborn Care (CEmONC)17. However, in
developing countries, access to such care is often woefully inadequate. There are too few health
facilities providing maternal and newborn care, and those that do exist often do not provide the full
range of emergency services needed18. Hence, in addition to expanding the number of facilities,
there is a great need for interventions to build the capacity of existing health workers so that they
perform better19.
Between 2009 and 2011, DFID supported a partnership between the Royal College of Obstetricians
and Gynaecologists (RCOG) and the Liverpool School of Tropical Medicine (LSTM) to implement a
program to improve the competence of healthcare workers to provide emergency obstetric and
newborn care. The ‘Making it Happen’ (MiH) program operated in 5 countries (Kenya, Zimbabwe,
Sierra Leone, India and Bangladesh), working in close collaboration with the Ministries of Health to
build capacity of national trainers and researchers to ensure sustainability and results. The
programme applied evidence based training, using proven adult education techniques, together with
improved supervision and data management.
Under MiH (2009 – 2011)
 2006 health workers were trained and supported in the provision of emergency maternal and
newborn care;
 There was an observed 50% reduction in maternal case fatality and a 15% reduction in
stillbirths at participating facilities.
Following this success, all 5 participating countries have requested scale up to train more healthcare
workers, and an additional 7 countries (South Africa, Malawi, Pakistan, Ghana, Nigeria, Tanzania
and Nepal) have declared their interest in and commitment to develop the MiH programme in their
own countries.
B. Impact and Outcome that we expect to achieve
Scale up of the MiH Programme to a total of 12 countries between 2012 and 2015 is expected to
achieve the following results just within the lifetime of the programme:




Save 9,586 maternal lives
Save 10,490 newborns
Avert 12,690 stillbirths
Avert 191,720 maternal disabilities.
Sustainable capacity for the provision of quality emergency obstetric and newborn care within
participating countries will be developed by the training of 17,025 health workers, including 1,025
national ‘Master Trainers’. In addition, these benefits, achieved through knowledge, skills and
experience, will continue to be felt long after the end of the formal programme.
16
Paxton A, et al (2005). The evidence for emergency obstetric care. In J Ob Gyn, 88, 181-93.
BEmONC facilities provide the following 6 signal functions: parenteral administration of antibiotics, oxytocics
and anticonvulsants, manual removal of the placenta, manual vacuum aspiration, vacuum extraction, newborn
care (plus stabilisation of woman and newborn for referral). CEmONC facilities provide all basic signal functions
PLUS caesarean section and safe blood transfusion.
18 Singh S et al. Adding it Up:The costs and benefits of investing in family planning and maternal and newborn
health. New York: Guttmacher Institute and United Nations Population Fund, 2009.
19 Support the Workforce. Knowledge Summary 6. Sharing Knowledge for Action on Maternal, Newborn and
Child Health. Partnership for Maternal, Newborn and Child Health and University of Aberdeen. PMNCH:
Geneva, Switzerland.
17
Further details on the calculation of these estimates are presented in Annex 1.
Additionally, by ensuring that health workers are competent to provide EmONC signal functions, and
by ensuring that participating facilities have adequate equipment and supplies, backed up by
improved data collection and supervision, the MiH programme will contribute to increasing the
coverage of EmONC facilities in all participating countries.
The above outcomes will contribute to an overall reduction in Maternal and Newborn Mortality in each
participating country thereby assisting countries to make progress towards the attainment of MDGs 4
and 5.
Appraisal Case
A. What are the feasible options that address the need set out in the Strategic case?
Option 1: Scaling up the previous programme delivered by RCOG with LSTM support
Under this option the existing MiH partnership between RCOG and LSTM would be supported to
scale up in participating countries and expanded to an additional 7 countries.
Option 2: Contract to a UN Technical Agency (WHO, UNFPA, UNICEF)
Under this option one of the UN Technical Agencies for maternal, newborn and child health would be
contracted to deliver the MiH Programme.
Option 3: Tendering the project to competitive bidders
Under this option the implementing agency would be selected by open competition.
B. Assessing the strength of the evidence base for each feasible option
Theory of Change
As illustrated in Figure 1 below the theory of change assumes that the provision of additional
resources by DFID will enable the development and implementation of a training programme to
improve the capacity of health workers to provide quality emergency obstetric and newborn care. The
improved knowledge and strengthened technical skills of health workers, supported by ongoing
supervision and shared learning, will result in a critical mass of skilled health workers in each
participating country. As a result there will be more consistent delivery of high quality care leading to
a reduction in maternal and newborn deaths. Sustainability will be ensured by establishing a cohort of
Master Trainers in each country who are capable of continuing training beyond the lifespan of the
programme, and by establishing robust supervision and M & E systems. Multi-stakeholder steering
groups in each country will oversee in-country implementation and a central advisory board will
provide overview and co-ordination of the multi-country programme, ensuring that lessons learned
are disseminated to support advocacy and policy decisions beyond the immediate programme reach.
The Theory of Change is underpinned by the following assumptions:
-
in country ownership and support from Ministries of Health to implement programme as part
of national MNCH plans
sufficient expert trainers to conduct training programme
-
selection of appropriate health workers to participate in training within each country
capacity within participating country to establish a functioning steering group
capacity within each participating country to establish ongoing clinical supervision within the
national healthcare system
adequate infrastructure, equipment and supplies to provide EmONC
patient demand for and utilization of services
Figure 1 Theory of Change for Human Resource Capacity Building Programme
INPUT
Training resources
(manuals,
mannequins,
equipment)
Improved delivery
of quality maternal
and newborn
health services by
health
professionals in
target facilities
Programme
management;
Supervision; M &
E framework
Strengthened
accountability for
results at all levels
with increased
transparency
In country steering
group
Central advisory
board
Increased capacity
to sustain model
to improve
delivery of
Emergency
Obstetric and
Newborn Care by
health care
providers
IMPACT
Reduced maternal and newborn mortality
International
Expert EmONC
Trainers
Evidence based
EmONC
curriculum
adapted and
adopted in 12
countries
OUTCOME
Increased demand for and uptake of skilled birth attendance
and quality emergency obstetric and newborn care
EmONC Training
Curriculum
OUTPUT
Evidence base for each feasible option
In the table below the quality of evidence for each option is rated as either Strong, Medium or Limited
Option
1
2
3
Evidence rating
Strong
Moderate
Moderate
Option 1: Scaling up the previous programme delivered by RCOG with LSTM support
This option would enable rapid implementation and scale up of the programme building on an
existing partnership. The RCOG/LSTM programme incorporates a 3-4 day competency based
training for health workers that covers the 9 signal functions of EmONC and the 5 main causes of
maternal death (eclampsia, haemorrhage, obstructed labour, sepsis, complications of abortion and
complications of Caesarean Section). The training has two elements: the training of national ‘master
trainers’ by international volunteers, and the subsequent cascade of the training package to a larger
group of health workers by the master trainers and international volunteers. After the completion of
training, supportive supervision is initiated at each participating health facility to ensure that the skills
learned are put into practice and to support the ongoing review of maternal and newborn care within
the facility to ensure that high standards of care are maintained.
A DFID appraisal of Phase 1 MiH concluded that “the project approach was appropriate and
innovative, anticipated targets had been met, there was evidence to indicate improved technical
knowledge and skills among trainees, and positive effects in terms of effective medical and midwifery
team work that reduced delays in first-line management of emergencies and in improved care of
uncomplicated births have been effective”. The appraisal team concluded that the “tireless coordination and facilitation roles played by the LSTM team, and the mobilization of volunteer trainers
from the UK, were key drivers of the success of MiH”.
RCOG and LSTM are uniquely placed to scale up the MiH programme. The RCOG has strong
international credibility as a leading professional organization, setting standards and providing higher
specialist training for Obstetricians and Gynaecologists. Current membership of the RCOG is in
excess of 12,000, with members representing over 80 countries. LSTM currently has 250 research
projects in 70 countries and long experience of building capacity of health systems and health
professionals in both Asia and Africa. The RCOG has a substantial pool of specialist trainers who are
willing to volunteer their time to participate in the MiH programme. In addition to Obstetricians, the
MiH partnership can draw on a large number of volunteer midwives through the Royal College of
Midwives and can mobilize additional volunteers through in country Professional Associations.
Since 2009 the above MiH partnership has operated in Kenya, Zimbabwe, Sierra Leone, India and
Bangladesh. The DFID Country Offices in each of these countries have requested scale up of the
programme, and an additional 7 Country Offices, in consultation with in country stakeholders, have
requested commencement of the MiH programme.
This option would allow rapid implementation and scale up through a partnership that has a proven
track record of delivering MiH results, responding directly to the request of DFID Country Offices.
Option 2: Contracting to a UN Technical Agency (WHO, UNFPA, UNICEF)
WHO, UNICEF and UNFPA provide global technical leadership on reproductive, maternal, newborn
and child health by establishing policies, norms and standards, setting research and development
priorities and developing guidelines for policy implementation. Each Agency has experts and offices
in all countries. However it is unclear which of these Agencies would be best placed to deliver the
MiH programme.
WHO collaborated on the design of the training materials used for the MiH programme, however
WHO is not an implementing agency. In Sierra Leone the DFID bilateral programme channelled
funds through UNICEF for the government’s maternal health programme and MiH works with
UNICEF as their in-country partner.
However, the UK’s Multilateral Aid Review (2011)20, although identifying many positive findings in
each Agency, concluded that a common theme for all three was a lack of robustness in financial
management and cost efficiency. For UNFPA there was ‘no evidence that poor performing projects
are curtailed and savings recycled, weak transparency and insufficient programme information”.
None of the UN Agencies currently has the staff in place at global or country level to implement the
MiH Programme and hence there would be significant delay in scale up of the MiH Programme if a
UN Agency was chosen as the implementing partner. Although all Agencies are aware of the MiH
Programme, with the exception of UNICEF in Sierra Leone, none of the Agencies are currently
participating in Programme implementation and hence there would a lack of continuity in ‘in country’
relationships and a lack of institutional knowledge for scale up in the 5 countries that currently
participate in MiH.
Option 3: Tendering the project to competitive bidders
There are a few, mostly US based, technical agencies focused on reproductive, maternal and
newborn health. For example JHPIEGO, a non-profit health organization affiliated with John Hopkins
University, is well recognized for training health workers in developing countries with maternal and
newborn health programmes in more than 25 countries.
Competition can generate new ideas and approaches but can be costly and time consuming. With
the exception of RCOG and the LSTM, no organisation has the proven experience of delivering the
MiH program, and it is unlikely that another organisation could mobilize the extensive volunteer
participation that has been demonstrated through the RCOG/LSTM partnership at the same value for
money.
Additionally, the process to select an implementing partner, the employment of programme staff, the
development of in country relationships and establishment of MiH by the selected partner would take
some months to complete, with no guarantee that another implementing partner would carry the
same credibility as the RCOG/LSTM partnership. This would result in an implementation gap and
delayed scale up in the 5 countries that are already participating in MiH.
What is the likely impact (positive and negative) on climate change and environment for each
feasible option?
Categorise as A, high potential risk / opportunity; B, medium / manageable potential risk /
opportunity; C, low / no risk / opportunity; or D, core contribution to a multilateral organisation.
Option
Climate change and environment risks
and impacts, Category (A, B, C, D)
C: Unnecessary travel will be minimized.
Capacity will be built for future national
level interventions = Low risk of climate
and environmental impact
D: Overall low risks/impacts. Assess
safeguards/policies
of
multilateral
agency
C: Unnecessary travel will be minimized
although if implementing agency is US
based this might involve more air travel.
1
2
3
20
To be added
Climate
change
and
environment
opportunities, Category (A, B, C, D)
B: Improved quality of services results in
improved waste disposal and attention to
sanitation. Family planning uptake is likely to
increase after delivery = Positive impact
D: Strengthen safeguards or put measures to in place to
mitigate risks. Build measures into log-frame
B: Improved quality of services results in
improved waste disposal and attention to
sanitation. Family planning uptake is likely to
Capacity will be built for future national increase after delivery = Positive impact
level interventions = Low risk of climate
and environmental impact.
No direct environmental impact is anticipated from this programme. Both RCOG and LSTM support
a range of environmentally friendly measures that include among others:
 minimising flights to cover essential external travel and combining in country activities and visits
e.g. supportive supervision and M&E
 increased use of teleconferencing and video conferencing where possible
 reducing paper by reducing the number of meetings requiring hard copy paper; wide-scale
recycling of paper, glass, plastic bottles, printer cartridges
 consideration given to disposal costs before purchasing equipment or consumables
 drawing on the multi-country and national cadre of trainers, air travel will be minimised
increasingly over the life of the programme.
The different delivery options are expected to have roughly the same impact related to climate
change and environment. Option 1, arguably presents less environmental damage from flying than
an organisation based in the USA.
At the country level, the capacity building will include maintenance of clean environments outside and
within the health facilities and safe disposal of human and medical waste. This is integral to quality
assurance and safety standards. Local procurement, provided it meets required standards is
preferred. .
C. What are the costs and benefits of each feasible option?
Expected resource costs of the intervention
Costs can be considered in 4 categories:
A. Core costs
This includes central management, monitoring and research and dissemination of findings.
B. Implementation costs
This includes resource materials, equipment costs, supervision costs and the travel, expense and
consultant fees for trainers. It should be noted that RCOG and LSTM are able to draw upon an
extensive pool of volunteers who will provide training on an ‘expense only’ basis. In contrast, it is
likely that a UN Agency and any other implementing partner selected by competitive tender would
need to pay consultant fees for trainers. Approximately 5,952 ‘trainer days’ will be required to deliver
the training programme to 17,025 health workers. Assuming a consultant fee of £550 per day, this
would incur an additional ‘implementation cost’ of £3,273,600 for a UN agency or partner selected by
competitive tender when compared to the RCOG/LSTM partnership.
C. Overheads
RCOG/LSTM overhead costs are calculated at 13% of ‘core costs’; UN overhead costs are
calculated at 17% of both ‘core’ and ‘implementation’ costs; competitive tender overhead costs are
calculated at 20% of both ‘core’ and ‘implementation’ costs.
D. External evaluation
A budget of £400,000 will be set aside for two external evaluations of the programme. A mid term
and end of programme evaluation will be conducted. Both will be commissioned by DFID through
competitive tender.
An estimate of these costs for each option is presented in Table 1 below.
Table 1 Estimated budget
RCOG/LSTM
UN Agency
Competitive
tender
A. Core costs
Central management and coordination
M&E, research
Dissemination
Total core costs
700,000
1,400,000
800,000
2,900,000
700,000
1,400,000
800,000
2,900,000
700,000
1,400,000
800,000
2,900,000
B. Implementation costs
Implementation costs - 'in country delivery'
Implementation costs - UK based1
Total implementation costs
11,657,206
5,791,780
17,448,986
11,657,206
9,065,380
20,722,586
11,657,206
9,065,380
20,722,586
Overhead costs2
377,000
3,522,840
4,144,517
C. DFID external evaluation
400,000
400,000
400,000
21,125,986
27,545,426
28,167,103
Budget
Total budget
As indicated above, the implementation of training would be delayed under Options 2 and 3 when
compared to Option 1. This would result in a lower number of lives saved over the course of the
training programme. In Table 2 below, the number of lives saved and total cost for each Option are
presented, based on which the cost per life saved is calculated.
Table 2 Cost per life saved
RCOG/LSTM
UN Agency
Competitive
Tender
Maternal
lives saved
9,586
8,729
Newborn
lives saved
10,490
8,570
Total lives
saved
20,076
17,299
Cost
£21,125,986
£27,545,426
Cost
per life
saved
£1,052
£1,592
8,729
8,570
17,299
£28,167,103
£1,628
As shown in Table 2, the preferred option is Option 1: Contracting to RCOG/LSTM. This option offers
the best value for money and will result in the highest number of lives saved.
D. What measures can be used to assess Value for Money for the intervention?
Measures that will be used to assess Value for Money for the intervention include:


Number of health workers trained
Number of deliveries taking place in participating facilities and % increase against baseline,






measured annually
Number of facilities providing 24 hour BEmONC and CEmONC services, and % increase against
baseline, measured annually
Number of maternal deaths and institutional maternal mortality rate at participating facilities. %
reduction in institutional maternal mortality rate, measured annually
Number of maternal deaths avoided (calculated from number of deliveries and institutional
maternal mortality rates), calculated annually
Number of intrapartum stillbirths at participating facilities and % decrease against baseline,
measured annually
Number of deaths within 24 hours of birth, and % decrease against baseline, measured annually
Annual costs and cost per maternal or newborn life saved
E. Summary Value for Money Statement for the preferred option
The preferred option is to contract to RCOG/LSTM for delivery of the MiH Programme. This option
will result in the greatest number of lives saved, and offers the best value for money. Additionally,
RCOG has professional credibility and the LSTM has a proven record of success in implementing the
MiH Programme.
Commercial Case
Direct procurement
A. Clearly state the procurement/commercial requirements for intervention
n/a
B. How does the intervention design use competition to drive commercial advantage
for DFID?
n/a
C. How do we expect the market place will respond to this opportunity?
n/a
D. What are the key cost elements that affect overall price? How is value added and
how will we measure and improve this?
n/a
E. What is the intended Procurement Process to support contract award?
n/a
F. How will contract & supplier performance be managed through the life of the
intervention?
n/a
Indirect procurement
A. Why is the proposed funding mechanism/form of arrangement the right one for this
intervention, with this development partner?
The programme will be funded through an Accountability Grant to LSTM.
As demonstrated through the first phase of MiH, LSTM has a proven record of accountability and the
technical competence to deliver the MiH programme.
MiH is a multi-country programme that requires engagement with up to 12 countries. This would
place a high administrative burden on DFID if DFID were to procure the training directly in each
participating country. LSTM has already developed relationships with governments and relevant
stakeholders in all 12 countries and hence is well positioned to consolidate and expand the MiH
programme.
B. Value for money through procurement
LSTM’s technical and commercial capacities have been assessed to ensure that they can offer
sustainable quality which represents VFM throughout the life of the programme. Economies of scale
in training and in production of materials will also be achieved as the programme scales up. The
LSTM has already developed all necessary tools and materials needed for the training programme
which will be adapted for use at country level in partnership with the respective Ministry of Health.
Since DFID aims to scale up a successful intervention, direct engagement with the LSTM rather than
open competition is justified.
Financial Case
A. What are the costs, how are they profiled and how will you ensure accurate
forecasting?
As shown in Table 3 below, the estimated budget for the programme is £21,125,986. The main cost
drivers are:
a. Central management and coordination: This includes LSTM programme management and
administrative support, the establishment and support of a central management group with
representation from in-country partners, and the establishment and support of a technical
advisory group comprising technical experts in the field of maternal and newborn health including
LSTM, DFID and RCOG.
b. Monitoring and Evaluation and Research: This includes costs to provide robust monitoring and
evaluation data including training for data recording and reporting, data compilation, analysis and
interpretation. Costs associated with technical collaboration such as participation of professional
associations, joint appointments/PhD students are also included.
c. Dissemination: This includes costs associated with putting evidence into practice. For example,
embedding lessons learned within national and international policy, raising the profile of maternal
and newborn health within UN agencies, communications strategy, and annual end of programme
conferences.
d. Implementation costs – in county delivery: This includes the travel, meal and accommodation
costs of training participants and national ‘master trainers’. Costs for supportive supervision and
quality improvement activities are also included.
e. Implementation costs – UK based: includes international faculty flights and subsistence, incountry offices (where appropriate), equipment (where appropriate) and a small facility
improvement and equipment fund.
f. Indirect costs: LSTM applies a fixed overhead of 13%. This has been applied to the total ‘core
costs’ of the programme, as show in Table 3 below.
g. DFID external evaluation: At the mid-point and end point of the programme DFID will commission,
by competitive tender, an independent external evaluation of the programme.
Table 3: Total MiH budget, 2012 – 2015, in 12 countries
2012 2015
2012
2013
2014
2015
A. Core costs
Direct
Central management and coordination
M&E, research
Dissemination
Total direct
175,000
350,000
200,000
725,000
175,000
350,000
200,000
725,000
175,000
350,000
200,000
725,000
175,000
350,000
200,000
725,000
700,000
1,400,000
800,000
2,900,000
Indirect core costs (13%)
94,250
94,250
94,250
94,250
377,000
Total core costs
819,250
819,250
819,250
819,250
3,277,000
3,095,201
1,383,107
4,478,308
3,466,215
1,695,728
5,161,943
2,916,435
1,528,559
4,444,994
2,179,355
1,184,386
3,363,741
11,657,206
5,791,780
17,448,986
200,000
400,000
4,382,991
21,125,986
B. Implementation costs
Implementation costs - 'in country delivery'
Implementation costs - UK based
Total implementation costs
C. DFID external evaluation
Total budget
200,000
5,297,558
6,181,193
5,264,244
Forecasts of spend
The programme will be implemented in 12 countries, with the following anticipated start dates:
January 2012: Zimbabwe, Sierra Leone, India, South Africa, Malawi
June 2012: Kenya, Bangladesh Pakistan
Jan 2013: Ghana, Tanzania, Nepal, Nigeria
NB: In the 5 countries that are currently participating in MiH, healthcare worker training will begin
immediately after the above start date. However, for countries where this is a new programme, the
initial 6 months of the programme will be an ‘inception phase’ to engage with partners and conduct
more detailed country level planning with relevant stakeholders prior to the commencement of health
worker training.
The budget will be forecast annually taking into account any changes in the actual or anticipated start
date of any of the participating countries.
Additionally, programme funds are currently being sought from individual DFID Country Offices and
private companies. If funds are mobilized from these sources this will be reflected in the annual
forecast of funds required from the ARHT budget.
B. How will it be funded: capital/programme/admin?
As show in Table 3 above, the total programme budget is £21,125,986.
A number of agencies will contribute to these programme funds as shown in Table 4 below. To date,
approximately £3,220,000 (15% of total budget) has been committed by the Government of India (to
support implementation in India), Ark (to support implementation in Zimbabwe) and UNICEF (to
support implementation in Sierra Leone). Funds are also being sought from the private sector, but as
yet no private sector funds have been fully committed.
If no private or other donor funds are secured then the remaining costs of £17,905,986 will be met by
DFID, drawing from Country Office budgets and the programme budget of the Aids and Reproductive
Health Team (ARH) team.
Within DFID, a separate Business Case, to the sum of £2,043,256, has already been approved by
the DFID South Africa Country Office to support implementation of the programme in South Africa.
Therefore this Business Case seeks approval for up to the remaining £15,862,730 program costs to
be met by the programme budget of the ARH team +/- Country Office budgets. If funds are mobilized
from other donors and/or from DFID Country Offices then the sum of money required from the ARH
team budget will be reduced accordingly.
The ARH team will continue to work closely with countries as their programmes develop to ensure
that all possible additional funding options are explored.
Table 4: Funding source, by year
2012
2013
2014
2015
All
Other partners
Ark
UNICEF
Govt. India
Total other partners
£367,000
£520,000
£400,000
£1,287,000
£367,000
£400,000
£767,000
£366,000
£400,000
£766,000
£400,000
£400,000
£1,100,000
£520,000
£1,600,000
£3,220,000
DFID
DFID South Africa
DFID ARHT
Total DFID
£878,402
£3,132,156
£4,010,558
£579,114
£4,835,079
£5,414,193
£293,077
£4,205,167
£4,498,244
£292,663
£3,690,328
£3,982,991
£2,043,256
£15,862,730
£17,905,986
Total
£5,297,558
£6,181,193
£5,264,244
£4,382,991
£21,125,986
C. How will funds be paid out?
Funds will be disbursed to LSTM quarterly in arrears upon receipt of a detailed statement of
expenditure and consistent with Blue Book requirements.
D. What is the assessment of financial risk and fraud?
As demonstrated by the first phase of MiH (2009 – 2011), LSTM has a proven record of strong
financial management and probity. Regular financial and activity reports for Phase 1 were submitted
to DFID, showing the progress of the programme and how funds were expended.
LSTM has in place reasonable policies and procedures and systems for managing its finances and
procurement. It has a well established office in Liverpool staffed with professionals and will place an
appropriate number of representatives in each country to ensure well-functioning management,
financial and administrative expertise. LSTM has accounting software to ensure efficiency, enhance
timely reporting of financial activities, and further reduce administrative costs. Its accounts are
audited annually by independent auditors. The LSTM adheres to International Financial Reporting
Standards and engages in competitive tender for all goods and services valued over US$5,000, in
accordance with international policies and procedures. Sole-source procurement is only allowed
when there are no additional providers available in country but must include a written explanation.
E. How will expenditure be monitored, reported, and accounted for?
LSTM will maintain records of the disbursement of grant money and will report activities completed
and expenditure on a quarterly basis. LSTM will submit Annual Audited Accounts for each financial
year of the Accountability Grant.
DFID will:
 review annual work plans and budgets to monitor efficiency and identify cost savings
 track progress and budget execution through quarterly narrative and financial reports
Financial tracking and payments will be maintained in ARIES in accordance with Blue Book
requirements.
Management Case
A. What are the Management Arrangements for implementing the intervention?
Management within DFID
A Project Officer will be assigned within the ARHT for the day to day administration of the programme
including financial tracking, compliance and other administrative functions. The Maternal, Neonatal and
Child Health Health Advisor of ARHT will provide the lead technical role. The Asia and Africa Regional
Advisors will also provide technical advice to support implementation in their Regions. The Advisors will
also consult with DFID Country Offices to ensure their full engagement in the programme. Quarterly
meetings will be held between the Project Manager, MNCH Advisor and Regional Advisors.
Management within LSTM
The programme will be under the overall direction of a Program Director with the support of a full time
Operations Manager.
A Central MiH Board will be established to oversee the programme. The Board will be chaired by LSTM
and will include representation from all participating countries. The Board will conduct quarterly
meetings (by telephone/VC as necessary) and will meet in person at least once per year. The Board
will receive progress reports and will guide overall implementation of the programme.
A Steering Group will be established in each participating country. Each group will include
representatives from the Ministry of Health, Professional Associations, DFID Country Office and other
relevant stakeholders. A representative from each steering group will be a member of the Central MiH
Board.
B. What are the risks and how these will be managed?
The main risks, and strategies to mitigate these risks are presented in Table 5 below.
Table 5: Risks and strategies to mitigate the risks
Risk
Lack of interest and/or
ownership by national
government, professional
associations, development
partners or other
stakeholders
Insufficient equipment and
supplies to provide
EmONC services
Inadequate record
keeping and reporting at
facility level to monitor and
evaluate programme
Failure to build
sustainability and ensure
benefits beyond the
immediate lifespan of the
programme
Probability
(1 = low; 3 =
high)
Impact
(1 = low; 3
= high)
1
3
2
2
1
Risk mitigation strategies
Country ownership has been demonstrated
through Phase I in the 5 countries that are
currently implementing MiH. The remaining
7 countries were selected based on
expressions of interest shown by the
respective governments. In these new
countries, a 6 month inception phase is
planned during which time engagement will
be sought with all relevant bodies to
ensure country ownership. A steering
committee will be set up in each country to
ensure the full participation and
engagement of stakeholders.
2
A small part of the budget has been
assigned for the purchase of essential
equipment and supplies where these are
missing. The baseline assessment in each
facility will demonstrate where significant
items are required. The in country steering
group, with representatives from Ministries
of Health will take responsibility to ensure
that equipment and supplies are
maintained in the long term.
2
The design of Phase 2 MiH has been
modified to give greater attention to record
keeping and reporting as part of the
EmONC training package. Additionally,
greater emphasis is given to supportive
supervision in Phase 2 so that any
problems with the completeness and/or
accuracy of data can be identified and
addressed at an early stage.
3
A central element of MiH is to build the
capacity of local healthcare workers and a
cohort of ‘Master Trainers’ who will
continue to provide training to others after
MiH support is phased out. Additionally,
supportive supervision is strengthened
throughout the duration of the programme
with the expectation that this will continue,
working through government systems, after
the end of MiH support. The external mid
term evaluation will be tasked to
specifically consider the extent to which in
country capacity and sustainability have
been strengthened, so that any challenges
will be identified and addressed as
necessary.
Weak in-country financial
management and misuse
of programme funds
1
2
LSTM will appoint in-country staff to
manage the programme, including financial
management. Country staff will comply
with LSTM policies and will adopt standard
LSTM accounting and administrative
practices. In this way all expenditure will be
tracked from central to front line delivery
level thus minimizing the risk of corruption.
C. What conditions apply (for financial aid only)?
n/a
D. How will progress and results be monitored, measured and evaluated?
The programme will be monitored and evaluated within the context of the overarching monitoring and
evaluation framework of the UK’s “Framework for Results for improving reproductive, maternal and
newborn health in the developing world” (FfR). The MiH programme is one of several activities
supported by DFID towards attaining FfR goals.The FfR monitoring framework tracks country level
progress towards saving maternal and newborn lives and increasing the number of safe deliveries.
Through the MiH programme it is anticipated that 9,586 maternal lives and 10,490 newborn lives will be
saved, 19% and 4% respectively of FfR targets.
Success will be measured by a demonstrable reduction in maternal and newborn mortality at facilities
that participate in the programme, based upon which the number of lives saved will be calculated.
Additionally, programme success will be judged by the increased competence of healthcare providers
to provide quality intrapartum and early newborn care and by an increase in population coverage of
CEmONC and BEmONC facilities within participating countries.
Responsibility for routine monitoring of progress lies at all levels. Within each country, quarterly
progress reports will be prepared and reviewed by the in-country steering group. The country reports
will be submitted to LSTM where the reports will be compiled into a quarterly report of the overall MiH
Programme. This will be reviewed by the Central MiH Board on which DFID participates.
During MiH Phase 1, the LSTM used a monitoring and evaluation framework, agreed between LSTM,
RCOG and WHO based on the Kirkpatrick Model. This was used to assess the effect of the
interventions on health facility functioning, health care provider capacity and health outcomes for
women and their babies. The framework has four levels:
Level 1 Participants’ reaction to training (e.g. venue, time, participation, usefulness)
Level 2 Change in knowledge and skills in EOC/NC
Level 3 Behaviour change through focus group discussions, key informant interviews and log books
Level 4 Societal change. This uses UN process indicators and includes assessment of the availability
of the signal functions for EOC and early Newborn Care as well as the quality of care. Assessment of
effect on healthcare provider is via quantitative and qualitative research methodology and is applied at
3, 6 and 12 months after training.
In addition LSTM uses a ‘Level 5’ to document lessons learnt and implications for policy and practice.
This highlights the fact that the training package serves as a catalytic package with a focus on MNH to
generate multi-disciplinary dialogue and ideas, improve teamwork, improve confidence and challenge
norms and policies.
The above Framework will be applied during Phase 2 in order to monitor and evaluate the programme.
A logical framework will be finalized during the initial 6 month ‘inception phase’ of the programme. The
logical framework uses standard DFID indicators and targets specific to the intervention countries and
will form the basis of the quarterly reports from participating countries to LSTM and from LSTM to
DFID.
DFID will conduct annual reviews (output-to-purpose reviews) of the project to examine progress
against outputs and outcomes, risk and innovation, with field visits to a selection of the countries. In
addition, DFID will commission an external evaluation at the mid and end points of the programme.
Logframe
Quest No of logframe for this intervention: 3306469
Annex 1
Estimates of Outcomes
Table 1
Maternal lives saved per year of full implementation
Country
Kenya
Zimbabwe
Sierra Leone
Bangladesh
India
South Africa
Pakistan
Nigeria
Ghana
Nepal
Tanzania
Malawi
Total
Total
population
39,802,015
12,522,784
5,696,471
158,570,535
1,181,193,422
50,586,797
187,342,721
154,728,892
23,837,261
29,959,364
43,739,051
15,263,417
1,903,242,730
CBR
(births per
1000
population)
Estimated
livebirths per
annum
MMR
(maternal
deaths
per
100,000
livebirths)
Annual
number
of
maternal
deaths
Skilled
birth
attendance
rate (%)
34.8
31.0
31.5
24.7
23.1
19.5
30.7
40.6
30.8
28.4
38.1
42.4
1,385,110
388,206
179,439
3,916,692
27,285,568
986,443
5,751,422
6,281,993
734,188
850,846
1,666,458
647,169
50,073,533
530
790
970
340
230
410
260
840
350
380
790
510
7,341
3,067
1,741
13,317
62,757
4,044
14,954
52,769
2,570
3,233
13,165
3,301
182,257
44%
69%
43%
27%
47%
91%
39%
40%
59%
19%
51%
56%
Expected
maternal
deaths in
any
health
facility
% of
facilities
participating
in MiH
Expected
maternal
deaths in
MiH
facilities
3,230
2,116
748
3,596
29,496
3,680
5,832
21,107
1,516
614
6,714
1,848
80,497
50%
25%
50%
25%
10%
25%
10%
10%
25%
25%
25%
25%
1615
529
374
899
2949.6
920
583.2
2110.7
379
153.5
1678.5
462
12653.5
n/a
*Maternal
lives saved
per year
(25%
reduction in
case fatality
rate)
404
132
94
225
737
230
146
528
95
39
420
116
3166
Data sources
Total population: World Bank, 2010
Maternal Mortality Rate (MMR): WHO Health Statistics, 2011
Skilled birth attendance rate (SBA): WHO Health Statistics, 2011
*Based on the outcomes of the first phase of MiH a decrease in maternal mortality at participating facilities is estimated at 25%
Table 2
Country
Kenya
Zimbabwe
Sierra Leone
Bangladesh
India
South Africa
Pakistan
Nigeria
Ghana
Nepal
Tanzania
Malawi
Total
Maternal lives saved, by year
Start date
Jul-12
Jan-12
Jan-12
Jul-12
Jul-12
Jul-12
Jul-12
Jan-13
Jan-13
Jan-13
Jan-13
Jul-12
End date
Dec-15
Dec-14
Dec-14
Jun-15
Jun-15
Jun-15
Jun-15
Dec-15
Dec-15
Dec-15
Dec-15
Jun-15
2012
202
132
94
113
369
115
73
0
0
0
0
0
1,098
Maternal lives saved
2013
2014
2015
404
404
404
132
132
0
94
94
0
225
225
113
737
737
369
230
230
115
146
146
73
528
528
528
95
95
95
39
39
39
420
420
420
58
116
58
3,108
3,166
2,214
Total
1,414
396
282
676
2,212
690
438
1,584
285
117
1,260
232
9,586
Table 3
Country
Kenya
Zimbabwe
Sierra Leone
Bangladesh
India
South Africa
Pakistan
Nigeria
Ghana
Nepal
Tanzania
Malawi
Total per year
Neonatal lives saved, per year of full implementation
Number of
livebirths
1,385,110
388,206
179,439
3,916,692
27,285,568
986,443
5,751,422
6,281,993
734,188
850,846
1,666,458
647,169
50,073,533
NMR
(deaths
per 1000
livebirths)
27
49
27
30
34
19
42
39
27
27
33
30
n/a
Number of
neonatal
deaths
37,398
19,022
4,845
117,501
927,709
18,742
241,560
244,998
19,823
22,973
54,993
19,415
1,728,979
Number
of
neonatal
deaths
during
childbirth
(23%)#
8,602
4,375
1,114
27,025
213,373
4,311
55,559
56,349
4,559
5,284
12,648
4,465
397,665
SBA (%)
44
69
43
27
47
91
39
40
59
19
51
56
n/a
Expected
neonatal
deaths
during
childbirth
in
facilities
3,785
3,019
479
7,297
100,285
3,923
21,668
22,540
2,690
1,004
6,451
2,501
175,642
% of
facilities
participating
in MiH
50%
25%
50%
25%
10%
25%
10%
10%
25%
25%
25%
25%
n/a
Expected
NNDs in
MiH
facilities
1,893
755
240
1,824
10,029
981
2,167
2,254
673
251
1,613
625
23,303
*NN lives
saved,
15%
reduction
in case
fatality
284
113
36
274
1,504
147
325
338
101
38
242
94
3,496
Data sources
Total population: World Bank, 2010
Neonatal Mortality Rate (NMR): WHO Health Statistics, 2011
Skilled birth attendance rate (SBA): WHO Health Statistics, 2011
#Ref: Enable the Continuum of Care. Knowledge Summary 2.Partnership for Maternal, Newborn and Child Health and University of Aberdeen. 2010.
Sharing Knowledge for Action on Maternal, Newborn and Child Health. PMNCH: Geneva, Switzerland.
*Based on the reduction in stillbirth of the first phase of MiH a decrease in neonatal mortality at participating facilities is
estimated at 15%
Table 4
Neonatal lives saved, by year
Neonatal lives saved
Country
Kenya
Zimbabwe
Sierra Leone
Bangladesh
India
South Africa
Pakistan
Nigeria
Ghana
Nepal
Tanzania
Malawi
Total
Start
date
Jul-12
Jan-12
Jan-12
Jul-12
Jul-12
Jul-12
Jul-12
Jan-13
Jan-13
Jan-13
Jan-13
Jul-12
End date
Dec-15
Dec-14
Dec-14
Jun-15
Jun-15
Jun-15
Jun-15
Dec-15
Dec-15
Dec-15
Dec-15
Jun-15
2012
142
113
36
137
752
74
163
0
0
0
0
47
1,464
2013
284
113
36
274
1,504
147
325
338
101
38
242
94
3,496
2014
284
113
36
274
1,504
147
325
338
101
38
242
94
3,496
2015
142
0
0
137
752
74
163
338
101
38
242
47
2,034
Total
852
339
108
822
4,512
442
976
1,014
303
114
726
282
10,490
Table 5
Country
Kenya
Zimbabwe
Sierra
Leone
Bangladesh
India
South Africa
Pakistan
Nigeria
Ghana
Nepal
Tanzania
Malawi
Total
Stillbirths averted, per year of full implementation
Stillbirths
per 1000
births
Stillbirths
per
annum
1,385,110
388,206
22.0
20.0
30,472
7,764
Number
of
stillbirths
occuring
during
childbirth
(33%)
10,157
2,588
179,439
3,916,692
27,285,568
986,443
5,751,422
6,281,993
734,188
850,846
1,666,458
647,169
50,073,533
29.0
36.0
22.0
20.0
47.0
42.0
22.0
23.0
26.0
24.0
5,204
141,001
600,282
19,729
270,317
263,844
16,152
19,569
43,328
15,532
1,433,195
1,735
47,000
200,094
6,576
90,106
87,948
5,384
6,523
14,443
5,177
477,732
Total
population
(World Bank
2010)
CBR
Estimated
livebirths
per annum
39,802,015
12,522,784
34.8
31.0
5,696,471
158,570,535
1,181,193,422
50,586,797
187,342,721
154,728,892
23,837,261
29,959,364
43,739,051
15,263,417
1,903,242,730
31.5
24.7
23.1
19.5
30.7
40.6
30.8
28.4
38.1
42.4
SBA
rate
Expected
stillbirths
in any
healh
facility
% of
facilities
participating
in MiH
Expected
stillbirths
in target
facilities*
Number of
stillbirths
averted
(15%
reduction)
44%
69%
4,469
1,786
50%
25%
2,235
446
335
67
43%
27%
47%
91%
39%
40%
59%
19%
51%
56%
746
12,690
94,044
5,984
35,141
35,179
3,177
1,239
7,366
2,899
204,721
50%
25%
10%
25%
10%
10%
25%
25%
25%
25%
373
3,173
9,404
1,496
3,514
3,518
794
310
1,841
725
27,829
56
476
1,411
224
527
528
119
46
276
109
4,174
Data sources
Total population: World Bank, 2010
Stillbirth Rate: WHO Health Statistics, 2011
Skilled birth attendance rate (SBA): WHO Health Statistics, 2011
*Based on the outcomes of the first phase of MiH a decrease in stillbirths at participating facilities is estimated at 15%
Table 6
Country
Kenya
Zimbabwe
Sierra
Leone
Bangladesh
India
South Africa
Pakistan
Nigeria
Ghana
Nepal
Tanzania
Malawi
Total
Stillbirths averted, by year
Start date
Jul-12
Jan-12
End date
Dec-15
Dec-14
2012
168
67
2013
335
67
Jan-12
Jul-12
Jul-12
Jul-12
Jul-12
Jan-13
Jan-13
Jan-13
Jan-13
Jul-12
Dec-14
Jun-15
Jun-15
Jun-15
Jun-15
Dec-15
Dec-15
Dec-15
Dec-15
Jun-15
56
238
706
112
264
0
0
0
0
163
1,774
56
476
1,411
224
527
528
119
46
276
109
4,174
Stillbirths averted
2014
2015
335
168
67
0
56
476
1,411
224
527
528
119
46
276
109
4,174
56
238
706
112
264
528
119
46
276
55
2,568
Total
1,006
201
224
1,428
4,234
672
1,582
1,584
357
138
828
436
12,690
Table 7
Country
Kenya
Zimbabwe
Sierra Leone
Bangladesh
India
South Africa
Pakistan
Nigeria
Ghana
Nepal
Tanzania
Malawi
Total
Health workers trained, by country, 2012 - 2015
Number of
'Master
Trainers
Trained'
180
100
40
100
100
100
90
75
75
40
75
50
1,025
Total health
workers
trained
6,400
1,120
380
1,000
1,000
2,500
750
1,000
1,000
500
1,000
375
17,025