kingdom of cambodiacambodia.unfpa.org/sites/default/files/pub-pdf/emonc_ip_book_2016... · kingdom...

KINGDOM OF CAMBODIANATION -RELIGION-KING

MINISTRY OF HEALTH

3

June 2016

EMERGENCY OBSTETRIC&

NEWBORN CARE (EmONC)IMPROVEMENT PLAN

2016 – 2020

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នៅក្នុងការន្លើយតបនៅនឹងអត្រាស្ល ប ់និងអត្រាមានជំងឺរបស់មាតា យនិងទារកន�ើបនឹងនកើត កម្នុជាបាននរៀបចំ និងអននុវតតាផែន

ការផកលម្អនសវាសន្គ្រ ោះបន្ទា នផ់ែ្កសម្ភពនិងផែទាទំារកន�ើបនឹងនកើតនលើក�ីមយួ សត្មាប់្ ្ ាំ២០១០-២០១៥។ ការពិនិត្យ

ន�ើងវញិន្នពលែ្ីៗ នៅនលើផែនការននោះ (នមស្ ២០១៥)1 បានបគ្ហា ញពវីឌ្ឍនភាពគរួឱ្យ កតស់មារ ល់នៅក្នុងការនរៀបចឱំ្យមាន

ការ��ួល គនុណភាព និងការនត្បើត្បាស់នសវាសន្គ្រ ោះបន្ទា នផ់ែ្កសម្ភពនិងផែទាទំារកន�ើបនឹងនកើត នៅក្នុងត្បន�សកម្នុជា

កាលពីន�ើមឆ្្២ំ០១៥ ក�ូ៏ចជា បគ្ហា ញពីបញ្ហា ត្បឈមនៅក្នុងការ អននុវតតាផែនការននោះ។ ពីឆ្្២ំ០០៩ �ល់២០១៥ ចំនួនមូល

ដ្ឋា នសនុខាភបិាលផ�លមាននសវាសន្គ្រ ោះ បន្ទា នផ់ែ្កសម្ភព និងផែទាទំារកន�ើបនឹងនកើតកត្មតិនពញនលញ (CEmONC)

បាននកើនន�ើងពី ២៥ នៅ ៣៧ ន�ើយចំនួនមូលដ្ឋា នសនុខាភបិាលផ�លមាននសវាសន្គ្រ ោះបន្ទា នផ់ែ្កសម្ភពនិងផែទា ំ

ទារកន�ើប នឹង នកើតកត្មតិមូលដ្ឋា ន (BEmONC) បាននកើនន�ើងពី ១៩ នៅ ១១០។ វឌ្ឍនភាពនកើតន�ើងនត្ចើនបំែនុតទាក�់ង

នៅនឹងការពត្ងីកការត្គប�ណតា បន់សវាសន្គ្រ ោះបន្ទា នផ់ែ្កសម្ភពនិងផែទាទំារកន�ើបនឹងនកើតកត្មតិនពញនលញ ន�ើយគិត

ត្តមឹឆ្្២ំ០១៥ កម្នុជាបានសនត្មចនលើសសតាងដ់្រអនតារជាតិសត្មាបក់ារត្គប ់ �ណតា បន់សវាCEmONC។ នគសនងកេតន�ើញ

មានភាពត្បនសើរន�ើងែងផ�រ នៅក្នុងការពត្ងីកចនំនួមលូដ្ឋា នសនុខាភបិាលផ�លមាននសវាសន្គ្រ ោះបន្ទា ន ់ផែក្សម្ភពនិងផែទា ំ

ទារក ន�ើបនឹងនកើតកត្មតិមូលដ្ឋា នផ�លមាន�ំនណើ រការប៉នុផនតា វឌ្ឍន ភាពមានលក្ខណៈយឺតយ៉វជាង នៅក្នុងផែ្កននោះ។ មានផត

២៨ប៉នុន ណ្ ោះ ក្នុងចំន្មមូលដ្ឋា នសនុខាភបិាល BEmONC ចនំនួ ១១០ ផ�លបាន�ំន�ើងកត្មតិរចួ មាន�ំនណើ រការនពញនលញ

(ផ�លអននុវតតាជំន្ញសន្គ្រ ោះបន្ទា នន់ន BEmONC ទាងំ ៧ នៅក្នុងរយៈនពល៣ផែមនុននពល ពិនិត្យន�ើងវញិននោះ)។

មានភាពត្បនសើរន�ើង ែងផ�រនៅក្នុងសមាមាត្តននការសត្មាលកូនផ�លបាននកើតន�ើងនៅក្នុងមលូដ្ឋា នសនុខាភបិាល EmONC

ផ�លមាន�ំនណើ រការ ការកាតប់ន្ថយឧបសគរផែ្ក�ិរញ្ញ វត្ថនុចំនោោះការ��លួបានការផែទា ំEmONC ការកាតប់ន្ថយ អត្រាស្ល ប់

នដ្យស្រការសត្មាលកូនផ្ទា ល់ និងការអននុវតតាជំន្ញ សន្គ្រ ោះបន្ទា នជ់ាកល់ាក។់

នទាោះបីជាយ៉ង្កតាី កម្នុជានៅផតមានចំនួនមូលដ្ឋា នសនុខាភបិាលផ�លមាននសវា EmONC តិចជាងោក ់ ក ត្ា ល ននចំនួន

ផ�លបានផណន្សំត្មាបត់្បន�សននោះ ន�ើយមូលដ្ឋា នសនុខាភបិាល EmONC នៅផតត្បមូលែតានុ ំភាគនត្ចើននៅថ្្កម់នទាីរនព�្យ

ធំៗ និងនៅក្នុងតំបន�់ីត្បជនុំជន នដ្យក្នុងនន្ោះមាននែតតាមយួផ�លនៅផតែ្ោះមនិទានម់ានមូលដ្ឋា នសនុខាភបិាល EmONC

នៅន�ើយ។ តត្មរូវការជួយ��សន្គ្រ ោះទារកន�ើបនឹងនកើតផ�លមានែលវបិាក កម៏និត្តរូវបានបំនពញឱ្យបានត្គបត់្រានផ់�រ។

ន�ើម្នីដ្ោះត្ស្យបញ្ហា ត្បឈមននោះ ក�ូ៏ចជាបញ្ហា ត្បឈមផ�លនៅនសសសល់នែសេងន�ៀត ផែនការផកលម្អ EmONCែ្ីកំពនុង

ត្តរូវបាននធ្ើន�ើងសត្មាបឆ្់្២ំ០១៦-២០២០។

េសងខេប្បតិបត្ិ

Ministry of Health and MBS Research, Review of the Cambodian Emergency Obstetric and Newborn Care Improvement Plan 2010-2015, April 2015.

EmONC Improvement Plan 2016-2020

Preface

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២៨ប៉នុន ណ្ ោះ ក្នុងចំន្មមលូដ្ឋា នសនុខាភបិាល BEmONC ចនំនួ ១១០ ផ�លបាន�ំន�ើងកត្មតិរចួ មាន�ំនណើ រការនពញនលញ














Preface

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Table of contents

Executive Summary............................................................................................................................................1

1. Background and Context................................................................................................................. ..3 Maternal and Newborn Health in Cambodia......................................................................... ..3 Policy context...........................................................................................................................6 Progress since 2009..................................................................................................................6

2. Rationale for a new EmONC Improvement Plan 2016-2020............................................................9

3. EmONC Improvement Plan 2016-2020: Goal, objectives, targets and guiding principles.......... 11 Goal........................................................................................................................................ 12 Objectives and targets.............................................................................................................12 Guiding Principles................................................................................................................. 12

4. EmONC Improvement Plan 2016-2020: Outputs and key interventions..................................... 13 Output 1 – Policies and strategies in place for a supportive and enabling environment ...... 14 Output 2 – Adequate coverage of EmONC facilities (availability and accessibility, Including financial accessibility), assured throughout the country....................................... 15 Output 3 - Technical and managerial capacity strengthened to ensure high quality of care.. 17 Output 4 - Increased utilization of EmONC services to reduce unmet needs....................... 18 Output 5 - Referral systems in place and operational throughout the country ..................... 21 Output 6 – Provincial EmONC plans developed, operational and monitored...................... 21 Output 7 - Community participation strengthened to increase utilization ............................ 21

5. Execution, Calendar, and Implementation Responsibilities.......................................................... 22

6. Monitoring and Evaluation............................................................................................................ 22

Annex 1 - Monitoring & Evaluation framework.............................................................................. 22 Annex 2 - Major obstetric and newborn complications and signal functions for their management....................................................................................................................................... 28 Annex 3 – Recommended infrastructure, equipment, supplies & drugs for EmONC....................... 29 Annex 4 – EmONC Process Indicators.............................................................................................. 32 Annex 5 – Minimum requirements for EmONC facilities................................................................ 33 Annex 6 - Existing & proposed EmONC facilities by Province...................................................... 35

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Acronyms

AMDD Averting Maternal Death and Disability (Columbia University, New York)AMSTL Active Management of the Third Stage of LabourANC Antenatal CareBEmONC Basic Emergency Obstetric and Newborn CareCBR Crude Birth RateCDHS Cambodian Demographic and Health SurveyCEmONC Comprehensive Emergency Obstetric and Newborn CareCFR Case Fatality RateCMS Central Medical StoreCPA Complementary Package of ActivitiesCPR Contraceptive Prevalence RateCMA Cambodian Midwives AssociationEENC Early Essential Newborn CareEmONC Emergency Obstetric and Newborn CareFP Family PlanningFTIRM Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality HEF Health Equity FundHIV Human Immunodeficiency VirusHMIS Health Management Information SystemHRH Human Resources for HealthHSDP Health Sector Development PlanHSSP Health Sector Strategic PlanLBW Low Birth WeightMBS Mao Bunsoth ResearchMDG Millennium Development GoalsMNH Maternal and Newborn HealthMoH Ministry of HealthMPA Minimum Package of ActivitiesNGO Non-governmental organizationNMCHC National Maternal and Child Health CentreOD Operational DistrictPHD Provincial Health DepartmentRGoC Royal Government of CambodiaRH Referral HospitalRMNH Reproductive, Maternal and Neonatal HealthSBA Skilled Birth AttendantSDG Sustainable Development GoalsSMW Secondary MidwifeSDG Service Delivery GrantUN United NationsUNFPA United Nations Population FundUNICEF United Nations Children FundUSAID United States Agency for International DevelopmentWHO World Health OrganizationWRA Women of Reproductive Age

AMTSL

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Acronyms

AMDD Averting Maternal Death and Disability (Columbia University, New York)AMSTL Active Management of the Third Stage of LabourANC Antenatal CareBEmONC Basic Emergency Obstetric and Newborn CareCBR Crude Birth RateCDHS Cambodian Demographic and Health SurveyCEmONC Comprehensive Emergency Obstetric and Newborn CareCFR Case Fatality RateCMS Central Medical StoreCPA Complementary Package of ActivitiesCPR Contraceptive Prevalence RateCMA Cambodian Midwives AssociationEENC Early Essential Newborn CareEmONC Emergency Obstetric and Newborn CareFP Family PlanningFTIRM Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality HEF Health Equity FundHIV Human Immunodeficiency VirusHMIS Health Management Information SystemHRH Human Resources for HealthHSDP Health Sector Development PlanHSSP Health Sector Strategic PlanLBW Low Birth WeightMBS Mao Bunsoth ResearchMDG Millennium Development GoalsMNH Maternal and Newborn HealthMoH Ministry of HealthMPA Minimum Package of ActivitiesNGO Non-governmental organizationNMCHC National Maternal and Child Health CentreOD Operational DistrictPHD Provincial Health DepartmentRGoC Royal Government of CambodiaRH Referral HospitalRMNH Reproductive, Maternal and Neonatal HealthSBA Skilled Birth AttendantSDG Sustainable Development GoalsSMW Secondary MidwifeSDG Service Delivery GrantUN United NationsUNFPA United Nations Population FundUNICEF United Nations Children FundUSAID United States Agency for International DevelopmentWHO World Health OrganizationWRA Women of Reproductive Age

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Executive Summary

In response to high levels of maternal and newborn morbidity and mortality, Cambodia developed and implemented an Emergency Obstetric and Newborn Care (EmONC) Improvement Plan for the period 2010-2015. The recent review of the EmONC Improvement Plan (April 2015) revealed significant progress in the availability, accessibility, quality and utilization of EmONC services in Cambodia by early 2015, as well as challenges in implementation. Between 2009 and 2015, the number of CEmONC facilities increased from 25-37 and the number of BEmONC facilities increased from 19 to 110. Progress was strongest in terms of expanding coverage of Comprehensive EmONC care (CEmoNC), and by 2015, Cambodia had exceeded international standards for CEmONC coverage. Improvements were also made in expanding the number of functional Basic EmONC (BEmONC) facilities, but progress has been slower in this area. Only 28 of the 110 upgraded BEmONC facilities were found to be fully functional (performing all 7 BEmONC signal functions in the 3 months preceding the EmONC Review). Improvements were also found in the proportion of births taking place in functional EmONC facilities, reductions in financial barriers to EmONC care, reductions in the Direct Obstetric Case Fatality Rate, and performance of specific signal functions.

However, Cambodia still has fewer than half of the recommended number of EmONC facilities for the country and EmONC facilities are still largely concentrated at the hospital level and in urban areas, with one province still lacking any EmONC facilities. The needs of newborns with complications are also being insufficiently met. In order to address these and other remaining challenges, a new EmONC Improvement Plan is being proposed for the period 2016 - 2020.

The Goal of this new EmONC Improvement Plan 2016-2020 is to reduce maternal and newborn deaths and contribute to the Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality (FTIRM) 2016-2020. The main objectives and targets in EmONC for the year 2020 are to:

• Improve EmONC coverage and availability so that there are at least 5 EmONC (CEmONC and BEmONC) facilities per 500,000 population, including at least 1 functional CEmONC facility and at last 4 functional BEmONC facilities per 500,00 population (UN Process Indicator #1), • Ensure greater accessibility to EmONC through improved geographic distribution of EmONC facilities throughout the country and a more functional referral system, • Ensure effective utilization of EmONC services in order to meet at least 90% of need, through improved communications, effective referrals, delivery of quality services, continued reductions in financial barriers, and community participation, • Improve the quality of care by strengthening the competencies of staff in designated EmONC facilities to perform key signal functions. Cambodia should reach or exceed UN standards for EmONC process indicators on proportion of births in EmONC facilities, met need, cesarean delivery, and direct obstetric case fatality rate (UN Process Indicators 3-6). Specifically, Cesarean deliveries should be at 10 percent (10%) of expected births nationally by 2020, with no province below 3.5% and Phnom Penh not above 17%), • StrengthenthecapacityofPHDsandlowerleveladministrativestructurestoplan,manage, monitor,andsupportEmONCservicesandensurehighqualityofcare, • Reduceremainingfinancial barrierstoEmONCservices.Ensurethatallwomenin reproductiveagehaveaccesstofullpackageofkeyreproductivematernalandnewbornhealth serviceswithoutfinancialhardship,whenneeded.

TheapproachesandkeyinterventionsproposedinthisEmONCImprovementPlanareevidence-based,buildonestablishedinterventionsandprograms,andareintegratedintotheexistinghealthsystem.Theyrelyon

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cleardefinitionsofrolesandresponsibilities,transparencyandaccountabilityatalllevels,equitabletreatment,ongoingmonitoringandperiodicevaluation,andpartnershipwithcivilsocietyandinternationalpartners.

Key interventions include: upgrading facilities and staffing,GISmapping ofEmONC facilities to ensuregeographic coverage, reducing gaps in basic drugs and equipment, increasing staff competencies throughtraining and on-site coaching, enabling availability of 24/7 EmONC services, improving management coordination, monitoring and evaluation by the National Program and Provincial Health Departments,and improving the recording and reporting of obstetric and newborn complications and deaths at health facilities.Thesekey interventionswillbe implementedatbothnationalandprovincial levels,accordingtophasedannualplans.

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cleardefinitionsofrolesandresponsibilities,transparencyandaccountabilityatalllevels,equitabletreatment,ongoingmonitoringandperiodicevaluation,andpartnershipwithcivilsocietyandinternationalpartners.

Key interventions include: upgrading facilities and staffing,GISmapping ofEmONC facilities to ensuregeographic coverage, reducing gaps in basic drugs and equipment, increasing staff competencies throughtraining and on-site coaching, enabling availability of 24/7 EmONC services, improving management coordination, monitoring and evaluation by the National Program and Provincial Health Departments,and improving the recording and reporting of obstetric and newborn complications and deaths at health facilities.Thesekey interventionswillbe implementedatbothnationalandprovincial levels,accordingtophasedannualplans.

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1. Background and Context

Maternal and Newborn Health in Cambodia

Maternalandnewbornhealthhasbeenapriorityofthehealthsectorsincethemid1990’swhentheNMCHCwascreated.Acceleratedplansforimprovingmaternalandnewbornhealthwereagreedtoin2009withtheFastTrackInitiativeRoadMap forReducingMaternal andNewbornMortality 2010-2015 and theEmergencyObstetricandNewbornCare(EmONC)ImprovementPlan2010-2015.Theimplementationoftheseplansiscomingtoanend,andwithcontinuedcommitmentatthehighestlevelsoftheRoyalGovernmentofCambodia(RGoC),itistimetotakestock,preparefollowupplans,andtomobilizeresources.ThisisthepurposeofthenewEmONC Improvement Plan 2016-2020.

TheEmONCImprovementPlan2016-2020buildsonanApril2015ReviewoftheEmONCImprovementPlan2010-2015,aConsultativeWorkshoponEmONCorganizedinPhnomPenhon19-20October2015,asecondconsultativemeetinginDecember2015,andoninputsfromprogrammanagers,partneragencies,andexpertsinthefield,includingfromaconsultantvisitinOctober2015.AnewFasttrackInitiativeRoadMapforReducingMaternal and Newborn Mortality 2016-2020 was developed at the same time and in close coordination with this EmONC Improvement Plan.

Select MNH indicators for Cambodia and neighboring countries

Cambodiais inthegroupofcountrieswiththehighestMaternalMortalityRatios(MMR,maternaldeathsper100,000livebirths)inSouth-EastAsia.However,Cambodiaperformsbetterthanseveralothercountriesintheregion,includingIndonesia,Myanmar,LaoPDRandTimorLeste(seeTable1).

Table 1: Maternal Mortality in South-East Asian countriesCountry Maternal Mortality Ratio

(confidence interval)Number of Maternal Deaths (An-

nual)

TimorLeste 270(140-500) 110

LaoPDR 220(130-370) 400

Myanmar 200(120-350) 1900

Indonesia 190(120-300) 8800

Cambodia 170 (110-280) 670

Vietnam 49(29-84) 690

Thailand 26(18-38) 180

Intermsofneonatalmortality(NMR,newborndeathsper1,000livebirths),Table2(nextpage)showsthatCam-bodiaisperformingbetterthanLaoPDR,Myanmar,andTimorLeste,butremainsbehindIndonesia,VietnamandThailand.

1MinistryofHealth.RoyalGovernmentofCambodia,FastTrackInitiativeRoadMapforReducingMaternalandNewbornMortalityinCambodia2010-2015,2009.

2 MinistryofHealth,RoyalGovernmentofCambodia,EmergencyObstetric&NewbornCareImprovementPlan2010-2015,2009.

3 MinistryofHealth,RoyalGovernmentofCambodiaandMBSResearch,ReviewoftheCambodianEmergencyObstetricandNewbornCareImprovementPlan 2010-2015,April2015.

4MinistryofHealth.RoyalGovernmentofCambodia,FastTrackInitiativeRoadMapforReducingMaternalandNewbornMortalityinCambodia2016-2020,January2016.

5Source:WorldHealthOrganization,PartnershipforMaternal,NewbornandChildHealth.Countdownto2015,Geneva,2014.

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Number of Maternal Deaths(Annual)

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Table 2: Neonatal mortality and stillbirths in South East Asian countries Country Neonatal

Mortality Rate 1990

Number of Newborn

deaths in 1990

(thousands)

Neonatal Mortality Rate 2015

Number of Newborn

deaths in 2015

(thousands)

Stillbirth Rate 2000

Number of Stillbirths

in 2000(thousands)

Stillbirth Rate2015

Number of Stillbirths

in 2015(thou-sands)

LaoPDR 55 10 30 5 31.6 5 23.7 4

Myanmar 47 50 26 24 29.8 36 20 19

TimorLeste 56 2 22 1 26.3 1 17.8 0.9

Cambodia 41 14 15 5 20.8 7 11.9 4

Indonesia 30 138 14 74 17.7 78 13.2 73

Vietnam 24 46 11 18 15.0 18 10.1 16

Thailand 20 22 7 5 7.7 7 5 4 Maternal Mortality in Cambodia ThetrendsinmaternalmortalityreductionduringtheMilleniumDevelopmentGoal(MDG)period1990-2015areclear andencouraging (seeFigure1).To theextent that surveysandestimates canbe trusted in theabsenceof acomprehensiveandexpensiveseparatestudyofmaternaldeath in thecountry,MDGTarget5AhasbeenreachedinCambodia.Thisisarareachievementworldwide,andonethathasbeenwellrecognizedbyinternationalhealthauthorities.

Figure1belowshowstrendsinmaternalmortalityinCambodiafrom1990-2014andprojectedvaluesiftrendscontinuethrough2030,whentheSustainableDevelopmentGoals(SDG)aretobeachieved. Allvalueshavewideconfidenceintervals.TheFTIRMtargetforMMRis130per100,000livebirthsby2020.AlthoughnotexplicitintheSDGdocument,alldevelopingcountriesareencouragedtoreachaMaternalMortalityRatiooflessthan70maternaldeathsper100,000livebirthsby2030.Cambodiashouldaimatthisfigure.

Figure1:MaternalMortalityinCambodia1990-2030

0

200

400

600

800

1000

1200

1990* 1995* 2000 2005 2010 2014 2020 2025 2030

7Sources:LevelsandTrendsinChildMortality-Report2015andSupplementto:BlencoweetalH,CousensS,JassirFB,etal,forTheLancetStillbirthEpidemiologyInvestigatorGroup,2016)

8Sources:*1990and1995:TrendsinMMR1990to2015–WHO,UNICEF,UNFPA,theWBGroupandUnitedNationsPopulationDivision2015;2000,2005,2010,and2014:CDHS;2020,2025,and2030:estimates

basedonSDGtarget

4

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5


ThevaluesusedinFigure1aredrawnfromvariouspublications.Sincemostdataincludedarebuiltonindirectmeasuresofmaternaldeath,theyarelikelytobeanunderestimate,duetounderreporting,incompletenessandmisclassificationofdeathsinherentinalloftheindirectmethodsusedtocollectsuchdata.Forexample,theCDHSusestheSisterhoodMethod,whichgivesanestimateofpregnancyrelatedmortalityintheprevious5-6years,withlargeconfidenceintervals.TheAnnualHealthStatisticalReportoftheMoH(DPHI)reportedonly32maternaldeathsin2013,whiletheMaternalDeathAuditsystemoftheMOHreported113maternaldeathsin2014,mostoftheminstitutionaldeaths.Thesefiguresarelowcomparedtoexpectations,whichwouldbemoreintherangeof670maternaldeathsannually,assumingaMMRof170(CDHS2014).

Neonatal Mortality in Cambodia

Neonatal mortalityismucheasiertomeasurebecausenewborndeathsarebothmorefrequentandlesssensitivethanmaternaldeaths.Ideally,dataonearlynewbornmortality,whichiscloselylinkedwithmaternalmortality,wouldalsobeavailable.However,earlynewborndeaths(inthefirstdaysandweeks)arelessmeasuredandreportedthanlaternewborndeaths(upto28dayspostdelivery)inCambodia,asinmanydevelopingcountries.

Figure2:NeonatalMortalityinCambodia1990-2030

Figure 2 shows trends in neonatal mortality (newborn deaths in the first 28 days per 1,000 live births) between 1990 and 2015, and extends projected values until 2030, the end of the SDG era. Newborn deaths have not and are not expected to continue to decrease as fast as maternal deaths over time. These projected values are also approximate, probably underestimated, and subject to caution. However, they follow reasonable expectations. The main problem in the data is underreporting of Early Newborn Mortality (deaths during the first 6 days of life), Very Early Newborn Mortality (deaths during the first 24 hours), and Stillbirth Mortality, particularly late stillbirth or Intra-partum mortality, which is the most correlated with maternal mortality, sharing the same epidemiologic conditions and roughly the same case management, both of which are related to EmONC. It should be noted that very few developing countries report on Early, Very Early or Stillbirth Mortality, making the construction of UN EmONC Process Indicator N° 7 Intrapartum and Early Newborn Death Rate quite difficult.

9Sources:*1990and1995:TrendsinMMR1990to2015–WHO,UNICEF,UNFPA,theWBGroupandUnitedNations

PopulationDivision2015;2000,2005,2010,and2014:CDHS;2020,2025,and2030:estimatesbasedonSDGtarget

5

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6


Policy context

InCambodia,thepolicyenvironmentconcerningRMNHisveryenabling.TheMoHencouragesinstitu-

tional delivery,offersafinancialincentiveforeachlivebirthinapublichealthfacility,andproposesareasonable

midwiferystaffingstandardforfacilities(includingatleasttwosecondarymidwivesperhealthcenter).Resultsof

thesepoliciesareimpressiveintermsofinstitutionaldeliveriesand,withcontinuedsupportandattention,should

continuetoimprove(seeEmONCUNProcessindicatorsbelow).

Progress since 2009SincethepublicationoftheEmONCImprovementPlan2010-2015,significantprogresshasbeenobserved.Progress

andremainingchallengeswereanalyzedintheEmONCReviewpublishedinApril2015,whichcomparedthe

situationanddatacollectedin2008-2009tothatof2014-2015.

Table3summarizesthechangesinselectedindicatorsbetween2008andend2014.Italsoidentifiesgapsindata

collectionduetoinsufficientqualityofrecording,thereforerenderingsomeindicatorslessreliablethanexpected.

Table3:SummaryofthemainprogressinEmONCbetween2008and2014(inpink:veryreliabledata;ingreyanditalic:less-reliabledata)

Figure 2 shows trends in neonatal mortality (newborn deaths in the first 28 days per 1,000 live births) between 1990 and 2015, and extends projected values until 2030, the end of the SDG era. Newborn deaths have not and are not expected to continue to decrease as fast as maternal deaths over time. These projected values are also approximate, probably underestimated, and subject to caution. However, they follow reasonable expectations. The main problem in the data is underreporting of Early Newborn Mortality (deaths during the first 6 days of life), Very Early Newborn Mortality (deaths during the first 24 hours), and Stillbirth Mortality, particularly late stillbirth or Intra-partum mortality, which is the most correlated with maternal mortality, sharing the same epidemiologic conditions and roughly the same case management, both of which are related to EmONC. It should be noted that very few developing countries report on Early, Very Early or Stillbirth Mortality, making the construction of UN EmONC Process Indicator N° 7 Intrapartum and Early Newborn Death Rate quite difficult.

Domain/Indicator Baseline 2008 Progress 2014 RemarksNumberoffunctionalEmONC facilities (definedas3monthsperformance of all signal functions)NumberofEmONCfacilities recommended forupgrade

44,outof143recommendedEF,outofatotalof347as-sessed(incl40private)99recommendedforupgrad

63,outofatotal178as-sessed(noprivate)

115 recommended for upgrade

Applyingtheextendeddefinitionof7and9signalfunctionsperformedinthelast 12 months improves thefiguresandshowsmissingsignalfunctions

DensityoffunctionalEmONC facilities, per 500,000population

1.64 2.3511 Expectation:atleast5

DensityoffunctionalCEmONC facilities, per 500,000population

0.93 1.31 Expectation:1.0(metin2014)

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7


Geographicdistributionof

EmONC facilities

5 provinces had none 1 province had none

(Kep)

Dependingonsizeof

population.USEMAPS

Proportion of births in

functionalEmONCfacilitie

11.4% 23.5% Shouldbeminimum15%

butcangoupto100%

(optimal)Proportion of births in all EmONC facilities

17.8% 35.0% same

Met Need for obstetric complicationsinfunctionalEmONC facilities

12.7% 23.6% IndicatornotbuiltonreliabledefinitionsofDOC(DirectObstetricComplications)

Met Need for obstet-ric complications in all EmONC facilities

14.5% 30.0% same

Proportion of births by

Cesareansection(in

CEmONCfacilities)

1.3% 3.9%

(22.6%inPhnomPenh)

DirectObstetricCaseFatalityRatesinfunctionalEmONC facilities

0.75% 0.19% IndicatornotbuiltonreliabledefinitionsofDOC(DirectObstetricComplications)

DirectObstetricCaseFatalityRatesinallEmONC facilities

0.74% 0.16% same

IntraPartummortalityrates

1.2% 1.53% Indicatornotbuiltonreliabledefinitionsofintrapartumstillbirthsandvery early newborn death

Proportion of Indirect Obstetric complications

29.0% 16.7% IndicatornotbuiltonreliabledefinitionsofDirectandIndirectOCObstetric Complications

Numberofmaternal

complications referred

OUTofEmONCfacilities

to higher level in one year

2545 5512 Causes:hemorrhage,

obstructedlabour,Pre/

eclampsia, preterm,

anemia, othersNumberofmaternal


INTOEmONCfacilities

from lower level in one year

2135 5274 Missingthecausesof

referral

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8


Numberofnewborn


OUTofEmONCfacilities

to higher level

258 336 Causes:lowbirthweight,

prematurity,respiratory

problems,sepsis,jaundice,

othersNumberofnewborn


INTOEmONCfacilities

from lower level in one year

0 993

Missingthecausesof

referral

%offunctionalEmONCfacilities with 2 or more secondary midwives

84% 98%

%ofnon-functionalEmONC facilities with 2 or more secondary midwives

45% 74%

%ofmidwivestrainedinadministering MgSO4 for pre/Eclampsia

and performed this signal functioninlast3months

34%

(12%)

86%

(30%)

10MinistryofHealth,RoyalGovernmentofCambodiaandMBSResearch,ReviewoftheCambodianEmergencyObstetricandNewbornCareImprovementPlan2010-2015,April2015.

11CambodiahasmadesignificantprogressinthenumberofBEmONCdesignatedfacilitieswith4,5and6functioningsignalfunctionsincreasingfromnonein2009to98in2014(inthelast3months)and120(inthe

lasttwelvemonths)

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2. Rationale for a new EmONC Improvement Plan 2016-2020

TheReviewoftheEmONCImprovementPlan2010-2015(April,2015)includedanumberofobservationsand

initialrecommendations.Theyfocusedonachievements,aswellasdelaysinimplementation,insufficientprog-

ress,orbarrierstoavailability,accessibility,utilizationand/orqualityofEmONCservices.ProgressinEmONC

todatehasbeenstrongestintermsofexpandingcoverageofComprehensiveEmONCcare(CEmoNC).Byearly

2015,CambodiahadexceededinternationalstandardsforCEmONCcoverage.Improvementswerealsomade

byearly2015inexpandingthenumberoffunctionalBasicEmONC(BEmONC)facilities,butprogresshasbeen

slower in this area.

Between2009and2015,thenumberofCEmONCfacilitiesincreasedfrom25-37andthenumberofBEmONC

facilities increased from19 to110. Progresswasstrongest in termsofexpandingcoverageofComprehensive

EmONCcare(CEmoNC),andby2015,CambodiahadexceededinternationalstandardsforCEmONCcoverage.

ImprovementswerealsomadeinexpandingthenumberoffunctionalBasicEmONC(BEmONC)facilities,but

progresshasbeenslowerinthisarea.Only28ofthe110upgradedBEmONCfacilitieswerefoundtobefully

functional(performingall7BEmONCsignalfunctionsinthe3monthsprecedingtheEmONCReview).Byearly

2015,98ofthe138designatedBEmONCfacilities(thoseupgradedandothersthathadbeentargetedforupgrade)

hadperformedatleast4signalfunctionsinthe3monthsprecedingtheEmONCReviewand120hadperformed

atleast4signalfunctionsinthe12monthsprecedingtheEmONCReview.Improvementswerealsofoundinthe

proportionofbirthstakingplaceinfunctionalEmONCfacilities,reductionsinfinancialbarrierstoEmONCcare,

reductionsintheDirectObstetricCaseFatalityRate,andperformanceofspecificsignalfunctions.

However,CambodiastillhasfewerthanhalfoftherecommendednumberofEmONCfacilitiesforthecountry

(5/500,000population),andEmONCfacilitiesarestilllargelyconcentratedatthehospitallevelandinurbanareas,

withoneprovincestilllackinganyEmONCfacilities.Theneedsofnewbornswithcomplicationsarealsobeing

insufficientlymet,anddeserveadditionalattentioninthefuture.Thekeyremainingchallengesare:

• Notenoughfacilitiesprovideallthelife-savingEmONCfunctions.Only63facilitiesarefully

functionalasEmONC,withalargedeficitinBasicEmONCcomparedtoexpectednumbers

accordingtotheUNstandards.

• FacilitiesprovidingEmONCarenotequitablydistributedacrossthecountry.

• Althoughprogresshasbeenmade,EmONCservicesarestillunder-utilizedandthereisa

strongunmetneedfortheseservices.Specificsignalfunctions-suchasmanualvacuum

extraction,anticonvulsants,manualvacuumaspiration,andnewbornresuscitationwere

foundtobeunderusedcomparedtoexpectedcomplicationsneedingtheseinterventions.

• Theneedsofnewbornswithcomplicationsarebeinginsufficientlymetanddeserveparticular

attention moving forward.

• TheproportionofbirthsbyCesareansectionisimprovingbutremainsbelowinternational

standards(exceptinPhnomPenh)andavailabilityofbloodtransfusionisstillinsufficient.

12MinistryofHealth,RoyalGovernmentofCambodiaandMBSResearch,ReviewoftheCambodianEmergencyObstetricandNewbornCareImprovementPlan2010-2015,April2015.

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• ThequalityofEmONCservicesisstillpoorandrequiresmoretraining,coachingandskills

refreshingofstaff,aswellassignificantandcontinuedsupportivesupervision.

• StandardsforEmONCprocedures,althoughpublishedandavailable,arenotuniversallyfol

lowed.

• Thereferralsystemhasimproved,primarilyduetoimprovedinfrastructure,butmany

patientsinneedstillsufferdelaysinreferralandtreatment.

• Althoughimpressiveprogresshasbeenmade,somefinancialbarriersremain,particularlyfor

the“near-poor”,therecentpoorandmarginalizedgroups.

Table4:RecommendationsfromtheReviewoftheEmONCImprovementPlan2010-2015endorsedforthe EmONC Improvement Plan 2016-2020

Category Recommendations endorsed for EmONC 2016-2020

Policy level - Buildonachievements,andfocusonqualityimprovement,lowcost

interventionswhichhavebeenshowntowork

-PrioritizeHealthCenterstobecometrueBEmONCfacilities

-Selectandexpandlowcostlowtechinterventionswhichhaveanimpact

-Utilizethemassofcollecteddataforfurtherin-depthanalysisparticularlyat

provincial level

Qualityofcare - Addresslackofrecognitionofobstetricandnewborncomplicationsand

under-diagnosisbyfrontlineEmONCstaff,toreducemissedcases

-Addresstheleastpracticedsignalfunctions:newbornresuscitation,assisted

delivery,anticonvulsants,manualremovalofplacenta

-Augmenttheuseofcriterion-basedaudits,particularlyfornear-misses

-EnsurethatnationalguidelinesforthemanagementofEmONCconditions

aredistributed,consultedandusedinallfacilities,andthatwallchartsareposted

ineveryworkingroom.

-Linkqualityimprovementwithfinancialrewards(SDGs,othermethodsas

appropriate)

-Considerintroductionofcertification/accreditationprocessesforEmONC

facilities,potentiallyinvolvingcivilsocietyorganizations

Enabling environment

-Reviewandimproveperformanceofthesupplymanagementchaintoavoidshortagesorstockouts-EnsurethatallHealthCentershaveanemergencytrolleywithessentialsupplies-Ensurethateachlaborroomhasambubagandmaskfornewbornresuscitationandthateverystaffknowshowtousethemproperly-Exploittheimprovedroadnetworkforimproveduseofcommunication and referral-Ensurethatformalmechanismstoreduceuser-feesandout-of-pocketexpendituresforthepoorareeffectivelyusedinallnecessarycases,andexpandthemasnecessary

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UNindicators -MakeeffortstoincludelargeprivatesectorEmONCfacilitiesintheimprovementplan,inordertoobtainacompletepictureofneedsandservicesinthecountrye.g.forCesareansections.-Keepthe3-monthbenchmarkfordesignatingfunctionalEmONCfacilities.Consideralternativebenchmarkingsuchas“BEmONCminusone,twoorthreeSFs”foridentifyingprogresstobemade-Recalculateindicatorsbasedonthepopulationincreaseanddesignationof new provinces-ConsiderputtingatleastoneBEmONCfacilityinKep

Service delivery -IntegrateothervitalReproductiveandMNHservicesintheactivitiesofmidwivesforimprovedoutcome

Availability and qualityofbasicinfrastructure

-Reviewstandardsofinfrastructure:increasenumberofbeds,improvewaterhygieneandsanitation(esp.inlabourroom,preparebackuppowergenerator,procurenewborncribs,-EnsureaccesstoalaboratoryforallEmONCfacilities,includingcontracting private laboratories if necessary

Essentialdrugssuppliesandequipment

-Reviewlistsofstandardequipment,suppliesandessentialdrugsforEmONC(includingrefrigerator,chartsforexpirydatesandreplenishment,emergencystocks)

Cost of services -AbolitionofuserfeesupfrontatadmissioninpointofcareforallEmONCservices,includingsurgeryandtransport-StandardizationofuserfeesforotherthanEmONCservices-Ensurethatremainingout-of-pocketexpendituresarecoveredforthepoor

Emergency communicationand referral transport

-Emergencyreferredpatientsalwaysaccompaniedbyaqualifiedhealthprofessionalwithcommunicationequipment-Developprotocolsforsending,referringandreceivingpatients-Reinforcesupervision,monitoringandmisuseofambulances

Humanresources -EnsureavailabilityofadequateandtrainedstaffatRFandHC-VerifythatallEmONCstaffhavereceivedadequatein-servicetrainingtoperformtheirtasksproperly,givingprioritytounderstaffedfacilities-Improvetrainingbysupervisionandmentoring-Ensurethatnewborncarefunctionsaregivenenoughplaceinpre-andin-service training programs

Knowledge,training and experience

-SharpenknowledgeandskillsofallEmONCrelatedstaff-Undertakingobservationofclinicalskills - Review core pre-service training programs to integrate evidence-based EmONC-Extendevidence-basedEmONCrefresherin-servicetrainingprogramsforallcadresatEmONCfacilities,withafocusonmidwives,andwithinclusionofleastpracticedEmONCfunctions

3. EmONC Improvement Plan 2016-2020: Goal, objectives, targets and guiding principles

TheEmONCImprovementPlan2016-2020respondstotherecommendationsabove,aswellastofindingsoffieldvisits,anin-depthexaminationofchallenges,consultationswithnational,provincialandfacilitystakeholdersandinputsfromdevelopmentpartners.Thegoal,objectives,targetsandguidingprinciplesoftheEmONCImprovementPlan2016-2020areoutlinedbelow.Theexpectedoutputsandrelatedkeyinterventionsaredetailedinthenextsection.

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12


Goal

TheoverallgoaloftheEmONCImprovementPlan2016-2020istoreducematernalandnewborndeathsand

contributetotheFastTrackInitiativeRoadMapforReducingMaternalandNewbornMortality(FTIRM)

2016-2020.EmONCisakeycomponentofboththeFTIRMandtheSustainableDevelopmentGoalsfor

2030 for Cambodia.

Objectives and targets

ThemainobjectivesoftheEmONCImprovementPlanaretoimprovethecoverage,availability,accessibility,

utilizationandqualityofEmONCservices,andstrengthenthecapacityofadministrativestructuresto

supportEmONCservicesinCambodia.Thekeyobjectivesandtargetsfor2020aresummarizedbelow:

• ImproveEmONC coverage and availabilitysothatthereareatleast5EmONC(CEmONC

andBEmONC)facilitiesper500,000population,includingatleast1CEmONCandatleast4

BEmONCfacilitiesper500,000population(UNProcessIndicator#1).Thistranslatesinto

atargetofatleast160EmONCfacilities,includingatleast35CEmONC(>1per500,000

population)andatleast125BEmONCfacilities(>4per500,000population)by2020.

Toensurethatthistargetisreached,atotalof180facilitieshavebeenidentifiedforupgrading

ormaintenance,withthepriorityonexpandingcoverageofBasicEmergencyObstetricand

NewbornCare(BEmONC,145facilities),whilemaintainingprogressintheavailabilityof

ComprehensiveEmergencyObstetricandNewbornCare(CEmONC,35facilities),

• EnsuregreateraccessibilitytoEmONCthroughimprovedgeographicdistributionofEmONC

facilitiesthroughoutthecountryandamorefunctionalreferralsystem,

• EnsureeffectiveutilizationofEmONCservicesinordertomeetatleast90%ofneed,through

improvedcommunications,effectivereferrals,deliveryofqualityservices(the3delays),

continuedreductionsinfinancialbarriers,andcommunityparticipation,

• ImprovethequalityofcarebystrengtheningthecompetenciesofstaffindesignatedEmONC

facilitiestoperformkeysignalfunctions.CambodiashouldreachorexceedUNstandardsfor

EmONC process indicators on proportion of births in EmONC facilities, met need, cesarean

delivery,anddirectobstetriccasefatalityrate(UNProcessIndicators3-6).Specifically,

Cesareandeliveriesshouldbeat10percent(10%)ofexpectedbirthsnationallyby2020,

withnoprovincebelow3.5%andPhnomPenhnotabove17%),

• StrengthenthecapacityofPHDsandlowerleveladministrativestructurestoplan,manage,

monitor,andsupportEmONCservicesandensurehighqualityofcare,

• Reduceremainingfinancial barrierstoEmONCservices.Ensurethatallwomenin

reproductiveagehaveaccesstofullpackageofkeyreproductivematernalandnewbornhealth

serviceswithoutfinancialhardship,whenneeded.

Guiding PrinciplesEvidencebased:Allcomponentsshouldbebasedonproveninterventionsthathaveworkedinothercountriesandarethesubjectofinternationalconsensus.

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Goal

TheoverallgoaloftheEmONCImprovementPlan2016-2020istoreducematernalandnewborndeathsand

contributetotheFastTrackInitiativeRoadMapforReducingMaternalandNewbornMortality(FTIRM)

2016-2020.EmONCisakeycomponentofboththeFTIRMandtheSustainableDevelopmentGoalsfor

2030 for Cambodia.

Objectives and targets

ThemainobjectivesoftheEmONCImprovementPlanaretoimprovethecoverage,availability,accessibility,

utilizationandqualityofEmONCservices,andstrengthenthecapacityofadministrativestructuresto

supportEmONCservicesinCambodia.Thekeyobjectivesandtargetsfor2020aresummarizedbelow:

• ImproveEmONC coverage and availabilitysothatthereareatleast5EmONC(CEmONC

andBEmONC)facilitiesper500,000population,includingatleast1CEmONCandatleast4

BEmONCfacilitiesper500,000population(UNProcessIndicator#1).Thistranslatesinto

atargetofatleast160EmONCfacilities,includingatleast35CEmONC(>1per500,000

population)andatleast125BEmONCfacilities(>4per500,000population)by2020.

Toensurethatthistargetisreached,atotalof180facilitieshavebeenidentifiedforupgrading

ormaintenance,withthepriorityonexpandingcoverageofBasicEmergencyObstetricand

NewbornCare(BEmONC,145facilities),whilemaintainingprogressintheavailabilityof

ComprehensiveEmergencyObstetricandNewbornCare(CEmONC,35facilities),

• EnsuregreateraccessibilitytoEmONCthroughimprovedgeographicdistributionofEmONC

facilitiesthroughoutthecountryandamorefunctionalreferralsystem,

• EnsureeffectiveutilizationofEmONCservicesinordertomeetatleast90%ofneed,through

improvedcommunications,effectivereferrals,deliveryofqualityservices(the3delays),

continuedreductionsinfinancialbarriers,andcommunityparticipation,

• ImprovethequalityofcarebystrengtheningthecompetenciesofstaffindesignatedEmONC

facilitiestoperformkeysignalfunctions.CambodiashouldreachorexceedUNstandardsfor

EmONC process indicators on proportion of births in EmONC facilities, met need, cesarean

delivery,anddirectobstetriccasefatalityrate(UNProcessIndicators3-6).Specifically,

Cesareandeliveriesshouldbeat10percent(10%)ofexpectedbirthsnationallyby2020,

withnoprovincebelow3.5%andPhnomPenhnotabove17%),

• StrengthenthecapacityofPHDsandlowerleveladministrativestructurestoplan,manage,

monitor,andsupportEmONCservicesandensurehighqualityofcare,

• Reduceremainingfinancial barrierstoEmONCservices.Ensurethatallwomenin

reproductiveagehaveaccesstofullpackageofkeyreproductivematernalandnewbornhealth

serviceswithoutfinancialhardship,whenneeded.

Guiding PrinciplesEvidencebased:Allcomponentsshouldbebasedonproveninterventionsthathaveworkedinothercountriesandarethesubjectofinternationalconsensus.

12


Health system integration: TheImprovementPlanshouldbefullyconsistentwithandintegratedintotheN a t i o n a l

ReproductiveHealthStrategy,theFastTrackInitiativeRoadMapforReducingMaternalandNewbornMortality2016-

2020andotherkeyMOHstrategiesandguidelines.

Build on existing programs: TheEmONCImprovementPlanbuildsontheachievements,challengesandlessonslearned

fromtheearlierEmONCImprovementPlan(2010-2015)andtheReviewconductedin2014-2015.Itisalsobuildson

andisintegratedintoexistingnationalandprovincialentitiessuchasHumanResources,CentralMedicalStore,Labora-

tory,BloodBank,etc.

Partnership:TheEmONCImprovementPlanincludesstrongsupportfromlongstandingdevelopmentpartnersofthe

MinistryofHealth,butalsoseekstoengagenewpartners,frominternationaldonoragencies,non-governmental

organizations,theprivatesectorandcivilsociety.

Clear definition of roles and responsibilities: Nationalandprovincial levelfiveyear(2026-2020)andannualplans

shouldclarifyrolesandresponsibilitiesofstaff,supervisors,managersandleaders.Responsibilityandaccountabilityfor

successes(andchallenges)shouldbeclear.

Transparency and accountability:Followingonthepreviousprinciple,allstaffshouldactinfulltransparency,noting

downandrecordingalldecisionsandinterventions,sothattheycanbeaccountablefortheconsequencesofdecisions

andinterventions.EmONCistrulyaquestionoflifeanddeath.

Equity: Atallstepsofthechainofcasemanagement,attentionshouldbepaidtoequityintreatmentandaccess,without

discriminationorstigmatizationofthepoorormostvulnerable.

Ongoing monitoring and periodic evaluation: Managersanddepartmentheadsshouldputongoingmonitoring

proceduresinplaceandfollowuponthem,sothattheycankeepaneyeonactivities,progressandchallengesunder

theirresponsibility.Periodicevaluation,ideallyannually,isalsoimportantandshouldbeintegratedintotheplanat

eachlevel,sothatitdoesnotrequireanewsearchforresourceseachtime.

4. EmONC Improvement Plan 2016-2020: Outputs and key interventions

Outputs that canbe expected from full implementationof thisEmONC ImprovementPlan2016-2020 are included

below.ThekeyinterventionsrelatedtoeachoftheseoutputsarealsoincludedinthissectionoftheImprovementPlan.

Annex1includesalogicalframeworkwithaproposedmonitoringandevaluationframeworkarrangedundereachof

thesesevenproposedoutputs.

KeyinterventionsoftheEmONCImprovementPlan2016-202include:upgradingfacilitiesandstaffing,GISmapping

of,EmONCfacilitiestoensuregeographiccoverage,reducinggapsinbasicdrugsandequipment,increasingstaffcom-

petenciesthroughtrainingandon-sitecoaching,enablingavailabilityof24/7EmONCservices,improvingmanagement

coordination,monitoringandevaluationbytheNationalProgramandProvincialHealthDepartments,andimproving

the recording and reporting of obstetric and newborn

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complicationsanddeathsathealthfacilities.Thesekeyinterventionswillbeimplementedatbothnationaland

provinciallevels,accordingtophasedannualplans.Thekeyinterventionswillbeimplementedsynergistically

atnationalandprovinciallevels,andregularlymonitoredthroughnationalmeetingsandprovincialvisitstoassess

progressanddeterminenextstepsandlongertermplans,asneeded.

Thethree-delaymodel(delayinmakingadecisiontoseekcare,delayinaccesstoservices,anddelayinproviding

appropriateservices)wasalsousedtoinformthechoiceofoutputsandkeyinterventionsbelow.Theemphasisin

the EmONC Improvement Plan 2016-2020 is on the third delay once the patient has arrived at a facility. Additional

emphasisonthenewbornisalsoincludedinthisplanmovingforward,asthisaspecthasbeenrelativelyneglected

to date.

Output 1 – Policies and strategies in place for a supportive and enabling environment

Output1andcorrespondinginterventionsaimatcreatinganenablingenvironmenttofacilitatethedeliveryof

EmONCservices.Astrongenablingenvironmentincludessupportandactionfromthenationalgovernment,

nationalMinistryofHealth,anddecentralizedlevels,includingfacilitiesthemselves.Potentialinterventionsare

includedinTable5.

Level Proposed InterventionsNationallevel–RoyalGovernmentof

Cambodia

High level commitment and show of intereste.g.NationalDays,mediacoverage

Reviewoflegislationsupportiveofincentivesforretentionof

professionalstaffinremoteposts

NationalLevel-MinistryofHealth

High level commitment and show of interest with

International visibilityResourcemobilization–Budget-Donors

Financialsafetynetsextendedandimprovedtotrackandcoverthe“uncovered”Partnerships with other ministries and administrations, with internationalagencies,NGOsandprivatesector

EmONC Coordination and Steering Committee in place and meeting once a year to review achievements and constraintsStrategicguidanceandregulationfornewprocedures,newdrugsandnewequipmentProduction/revisionofStandardsandProtocolsforcasemanagement–MPA,CPA,SafeMotherhoodProtocolforRHsandHCs,etc(asneeded)Production/revisionofstandardsforstaffingandtrainingdifferentlevelsofhealth facilitiesOverallmonitoringandevaluationatnationallevel,annualreviewCentralmedicalstores–procurementanddistributionofequipment,drugsandsupplieswithwarningsystemsforstockouts

Pharmacyandlaboratories–StandardsandcontrolNationalBloodBank:expansionofnetworkofprovincialstructuresandblood depots in each designated CEmONC facility

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15


ProvincialLevel-PHD

ProvincialleadershipforEmONCatMCHdepartment–provincialsteeringcommit-

tee.AnnualplanningandreportingCertificationofEmONCfacilities,anddecisionsforupgradingaccordingtocriteria

ofpopulationcovered,resources,staffing,communicationforreferral

Relations with local administrations and provincial civil society

Resourcemobilizationandmanagementofresourcesatprovinciallevel

Postingofstaff,rotating,andmonitoringvacantposts

RegularmonitoringofEmONCservices:annualreportwithindicators

Organizationofthecommunicationandreferralsystem

PartnershipwithprivatesectorandNGOs

Protectionofstaffifandwhennecessary

Table5:SuggestedenablingactionsatvariouslevelsforoptimaldeliveryofEmONCservices

Output 2 – Adequate coverage of EmONC facilities (availability and accessibility, Including financial accessibility), assured throughout the country

Facilities and infrastructure – EmONC facilities

TheapplicationofUNStandard#1forthedensityoffunctionalEmONCfacilitiesleadstoarecommendationofa totalofatleast160EmONCfacilities(atleast35CEmONCandatleast125BEmONC)by2020.ThetotalnumberoffunctionalEmONCfacilitiesinCambodiainlate2014/early2015was63(35CEmONCand28BEmONC).WhileCambodiahadalreadyachievedtheUNStandardforavailabilityandfunctioningofCEmONCfacilities(atleast1per500,000population),thereremainedalargegap(of97)functionalBEmONCfacilities.Table6showsthestatusof EmONC, BEmONC and CEmONC coverage in 2009, at the time of the EmONC Review in late 2014/early 2015 andtargetsfor2020.Toensurethatthetargetof160EmONCfacilitiesismetby2020,180facilitieswillbeupgraded toEmONCstatus.

Table6:EmONCcoverageandtargetsforEmONCImprovementPlan2016-2020

2009 By late 2014/early 2015 2020

# EmONC facilities per

500,000 population

1.64 4.84(upgraded)

2.35(functional)

At least 5

(>160)

# of BEmONC facilities

per 500,000 population

0.71 3.62(upgraded)

1.04(functional)

At least 4

(>125)

# of CEmONC facilities

per 500,000 populat

0.93 1.22(upgraded)

1.31(functional)

At least 1

(>35)

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16


DesignatedCEmONCandBEmONCfacilitieswillbeupgradedormaintainedattheirpreviouslevel,sothatbytheend

of2020,between160and180facilitieswillbeabletoprovidethe9or7signalfunctionforCEmONCandBEmONC

respectively.Aphasedplanwillfocusforthefirst3years(2016-2018)onmaintenanceofEmONCstatusin63existing

EmONCfacilities(35CEmONCand28BEmONC)andupgradeanother78BEmONCfacilitiestoBEmONCstatus.In

thefinaltwoyears(2019-2020),progresswillbemaintainedandanother39BEmONCfacilitieswillbeupgradedtoBE-

mONCstatus.Amongthesefacilities,threeprovincialhospitalsandonenationalhospitalwillbemaintainedasEmONC

clinicaltrainingsites.Provincesthathaveachievedtheirtargetsearlywillbeeligibletomakeplanstoupgradeadditional

facilitiestoBEmONCorCEmONCbeforetheendof2020.Anadditional29faciliiteswereidentifiedbyprovincesin

December2015aspriorityfacilitiestoconsiderforfurtherupgradingbeforetheendof2020.

TheidentificationofspecificfacilitiestobemaintainedorupgradedtoCEmONCorBEmONCstatusistheresponsibil-

ityofPHDs,followingnationallydefinedcriteria.GISmappingof,EmONCfacilitieswillbeusedtoensuregeographic

coverage.Facilitybyfacilityplansshouldberevisitedandadjustedannually,takingintoaccountanycontextualchanges.

Someflexibilityinapplyingthestrictcriteria(3-monthperformanceofallsignalfunctions)maybeallowedbythe

nationalMOH,basedonlocalconditions(geographyandcommunications).However,flexibilitycanonlybeappliedfor

BasicEmONCfacilitiesandnotforComprehensiveEmONCfacilities.CEmONCfacilitiesmustalwaysmeetthe9signal

functionsinthelast3monthsbenchmarks.

Annex5includesminimalrequirementsforEmONCfacilitiesintermsofhoursoroperation,infrastructure,services,

personnel,infectioncontrol,referral,andrecordkeeping.

Equipment, Drugs and Supplies

Akeyinterventionunderthisoutputisensuringthatgapsinbasicdrugsandequipmentarefilledonanongoingbasis.Essentialequipment,drugsandsuppliesnecessaryforeffectivedeliveryofEmONCservicesinCambodiawillbedeter-minedattheearlyimplementationstageoftheImprovementPlan.Suggestedlistsofequipment,drugsandsuppliestoconsiderareincludedinAnnex3.Appropriatemedicalequipmentandsuppliesbasedonagreeduponfiveyear(2016-2020)andannualprovincialactionplanswillbeprovidedandinstalled.Aregularsupplyoflife-savingdrugsformothersandnewbornswillbeensured.PHDsandhospitalmanagementshouldensurethatallequipmentprovidedisinstalled,usedandwellmaintainedandthatsuppliesaremanagedeffectively.

Financial Access to EmONC services

FeesforserviceisnowroutineinCambodia.TheRGoCrequiresallpublicfacilitiestopostallfees,clearlydetailed,ateveryhealthfacility.Inaddition,therearenowsocialhealthprotectionschemesthroughoutthecountrythatprovidefreeaccessandfreeservicesforthepoor.CoverageofHealthEquityFunds(HEFs),theRGoC’smostxtensivesocialhealthprotectionschemethatcoversservicefees, transportforhospitalizationsandfordeliveriesatall facilities,andothercostsforthepoor,hasexpandedgreatlyinthepast5years.Bylate2014,HEFswereavailableinallbut2(98.6%)offunctionalEmONCfacilitiesand91.3%oftheremainingdesignatedEmONCfacilitiessurveyedaspartofthemostrecentEmONCReview(April2015).Bymid2015,HEFswereavailablein82%ofallhealthfacilities,includinghospitalsandhealthcenters,throughoutthecountry.TheEmONCImprovementPlanrecommendsthattheGoCensurethatallwomeninreproductiveagehaveaccesstofullpackageofkeyreproductivematernalandnewbornhealthserviceswith-outfinancialhardship,whenneeded.

13Ministry of Health and MBS Research, Review of the Cambodian Emergency Obstetric and Newborn Care Improvement Plan 2010-2015, April 2015.

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Output 3 - Technical and managerial capacity strengthened to ensure high quality of care

TheoverallstrategyoftheCambodianMoHthatallbirthsshouldbeattendedbyaskilledbirthattendantremainsa

priorityoftheEmONCImprovementPlan2016-2020.AskilledbirthattendantintheCambodiancontextmeans

the more modern concept of a competent and qualified midwife, whichentailsafullytrainedprofessionalwith

astate-recognizeddiplomaandappropriatein-servicetraining.Competencyisthesumofknowledge,skillsand

attitudes,andnotmerely thecapacity todeliverservicesandcare. TheEmONCImprovementPlan2016-2020

specifiesateamofcompetentmidwives(andatsomelevels,physiciansandothermidwiferystaff),sothattheycan

help each other and cover services 24/7. Investing in midwives is a “best bet” in modern EmONC strategic planning.

Team building and teamwork are crucial components of EmONC service delivery. Regular staffmeetings are

recommendedforteambuildingandconstructivereviewofcomplicatedcases.Staffingstandardswillberevisedto

ensureavailabilityofstaff24/7forfulldeliveryofqualityservices.Forexample,asuggestedminimalstaffinglevelfor

BEmONCfacilitiesthatperformfewerthan400deliveriesperyearmightbeforuptosixsecondarymidwiveson

staff,workinginshifts,sothatatleasttwocompetentmidwivesareworkingatanyonetime.BEmONCfacilitiesthat

performmorethan400deliveriesperyearwouldneedmoremidwives,atleast6secondarymidwives.CEmONC

facilitieswouldneedadditionalstaffastheytendtohavemorethan600deliveriesperyearandmanyreferredcom-

plications.AminimumforCEmONCfacilitiesmightincludeatleast10secondarymidwivesworkinginshifts,in

multipleteams(withanextrateambroughtinduringpeaktimesorifhigherworkload),onesurgicalteampershift

(accordingtoCPAguidelines).CEmONCfacilitiesatsubnationalandnationallevelwithevenhighernumbersof

deliveriesperyearwouldneedtoadditionalstaffingadjustedtotheirworkload.Ageneralrecommendationwould

betoaddanothermidwiferyteamforeveryadditional300deliveriesperyearandaddsurgicalteamsasneeded.

Lab, infectioncontrol,pharmacy,cleaners, securityandcoachingstaffshouldalsobe included in staffingplans.

In-service training and on-site coaching wlll be used to increase competencies of staff in designated EmONC

facilities to perform the core signal functions and Improve quality of care provided at EmONC facili-

ties. Medical staff, mainly midwives, surgeons and anaesthetists, should be trained to enable 24 hour/7 day

availabilityofqualityEmONCservices,includingCaesareansection,otheremergencysurgicalprocedures,andsafe

bloodtransfusioninCEmONCfacilities.

In-servicetrainingneedsforEmONCshouldberegularlyreviewedbymanagersateachfacilitysothatstaffcan

beappropriatelyidentifiedfortrainingsessions.Eachlargefacility(provincialhospitalsandCEmONCfacilities)

shouldhavemannequinsandmodelsforthepracticaltrainingofstudentsandondutystaff,inparalleltothedaily

service.Coachingandonsiteapproachesshouldbeusedtoensurethatthebenefitsoftrainingareusedinpractice,

usingexistingPHD,OD,andseniorRHstaff,aswellasnationalprogramstaffandretiredseniorprofessionalswith

highlevelsofcompetency.On-siteapproachesandskillspracticeareespeciallyimportantforstudents(medicaland

midwiferystudents)aswellasformid-levelprofessionalswhojustfinishedaspecializedtrainingsessionandneed

coachingandforlesspracticedsignalfunctionssuchasmanualvacuumextraction,manualremovalofplacenta,

managementofpre-eclampsia,andnewbornresuscitation.

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18


Soundmonitoringandevaluationrestonimprovedandreliabledatarecording.Inparticularrecordingofmaternaland

newborndeaths(includingstillbirths)andrecordingofobstetricandnewborncomplicationsandtheiroutcomeneed

tobeimprovedatallhealthfacilities.Facilitymanagersshouldbeencouragedandcoachedbyprovincialandnational

managerstoImproverecordingandreportingofobstetricandnewbornmplications.Theparticipationofallconcerned

EmONCstaffatMaternalDeathAuditsandAuditsofNear-Missedcasesisstronglyencouragedandshouldbe

formalized,inviewofthepowerfultrainingbenefitsoftheseprocedures.

EmONCshouldbecomeanessentialpartofpre-serviceeducationformidwiferyandmedicine,sothatfreshlycertified

midwivesandphysicianshavebeenexposedtotheconceptbeforestartingtheirduties.EmONCorientation,training

andon-sitesupportshouldalsobeencouragedforstaffotherthanmidwivesandbstetricianswhoparticipateinservice

delivery,suchasnurses,operatingtheatrestaff,labtechnicians,

managers,andambulancepersonnel.

Output 4 - Increased utilization of EmONC services to reduce unmet needs

AllEmONCsignalfunctionsarelifesaving.Table7summarizesthesevenBasicandtheadditionaltwoComprehensive

EmONCsignal functions. EmONCguidelinesspecify that inorder toqualify forBasicorComprehensiveEmONC

status,all thecorrespondingsignal functionsmusthavebeenperformedduring3monthsprior to thesurvey.Some

countrieshavefacilitatedaccesstoBEmONCstatusbyindicatingBEmONCminus1signalfunctionorBEmONCminus

2signalfunctionsifafacilityhasfulltechnicalpotentialandhasproperlydemonstratedskillsnecessarytoperform

missingsignalfunctions,butalackofpatientstohaveencounteredenoughcasesinthelast3monthstohaveemployed

thatsignalfunctions.TheliftingofthestrictrulecannotapplytoCEmONCfacilities–thesefacilitiesmusthaveper-

formedALL9signalfunctionsinthelast3months.Onecomprehensivesignalfunctionthatmaybeaddedinfacilities

wherethereisanewbornintensivecareunitis“advancednewbornresuscitation.”

Table7:EmONCSignalFunctions

Signal Functions to qualify as BEmONC Signal Functions to qualify as CEmONC

Antibiotics IM and IV ALL7BEmONCsignalfunctions(leftcolumn),plusthefollowing2additionalsignalfunctions:

OxytocicsIMandIV Cesarean section

AnticonvulsantsIMandIV(MgSO4) BloodTransfusion

ManualremovalofPlacenta

ManualVacuumAspiration,forPostAbortionCare

AssistedvaginaldeliverybyVacuumextraction(ven-touse

BasicNewbornResuscitationwithAmbubagandmask

18


Iftherearenotenoughpatientspresentingwitheachobstetriccomplicationduringthereferenceperiodof3months,

supervisorsshouldorganizesmallrefreshersessionstoremindstaffofthenecessaryprotocolsandpracticewithin-

struments.Allsignalfunctionsmustbeavailablewithoutdelay24hoursperdayand7daysperweek(24/7).The

calendarofdutiesforthestaffshouldbeavailabletoallstaffandfrequentlysupervised.Measurestoreplaceinvalid

orsickstaffareessential.

TheMoHhasissuedanddistributedprotocolsandstandardstomanageallpossiblecases:theseprotocolsaretaught

inclinicaltrainingsessions,buttheymustbeavailableinallunitsatalltimesforconsultation.Anumberofaddi-

tionalmidwiferyproceduresareessentiaalcomplementstotheEmONCsignalfunctionsandshouldbeperformed

accordingtostandarsinallEmONCfacilities–theseincludepartograph,repairoftears,foetalmonitoringduring

labor,dexamethasoneforprematurity,antibioticsforprematureruptureofmembranes, KangarooMotherCare,

NewbornCorners,PMTCT,etc.

Surgery

ExpansionofEmONCandparticularlyCEmONCfacilitieswillleadtoanincreaseintheproportionofbirths

needingCesareansection.Tomeetthisneedwillrequire:

1. Anincreaseinthenumberoftrainedsurgeons,trainedanesthetists,andtrained

instrumentalists.

2. ImprovementorclarificationoftheappropriateindicationsforCesareansection

3. Improvementinthecapacityandauthorityofmidwivestodecidewhentoreferandto

actuallyrefer

4. Improvementincommunicationsandreferralsystems

5. Increasedattentiontoqualityofprocedures,infectioncontrol,andpreventionandcare

of adverse events

TheincreaseinthenumberofCesareansectionsmustnotinduceanincreaseofthenumberofcomplications

ofCesareansection.Themoreinterventionsdone,thegreatertherisk,andthehighertheneedforsupervision,

qualitycontrol,andpreventionofadverseconsequences(sepsis,ruptureofarteries,hemorrhage,ruptureof

scars,etc.)

Anotherareaforconsiderationisthepossibilityforsurgeons(properlytrained)toperformotheremergency

surgicalactssuchashysterectomyforseverePPH,explorationofhemoperitoine,uterinerupture,ruptureof

ovarian cysts, repair of large perineal tears, and ectopic pregnancy.

14MinistryofHealth.RoyalGovernmentofCambodia,FiveYearActionPlanforNewbornCareinCambodia2016-2020,December2015.

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Iftherearenotenoughpatientspresentingwitheachobstetriccomplicationduringthereferenceperiodof3months,

supervisorsshouldorganizesmallrefreshersessionstoremindstaffofthenecessaryprotocolsandpracticewithin-

struments.Allsignalfunctionsmustbeavailablewithoutdelay24hoursperdayand7daysperweek(24/7).The

calendarofdutiesforthestaffshouldbeavailabletoallstaffandfrequentlysupervised.Measurestoreplaceinvalid

orsickstaffareessential.

TheMoHhasissuedanddistributedprotocolsandstandardstomanageallpossiblecases:theseprotocolsaretaught

inclinicaltrainingsessions,buttheymustbeavailableinallunitsatalltimesforconsultation.Anumberofaddi-

tionalmidwiferyproceduresareessentiaalcomplementstotheEmONCsignalfunctionsandshouldbeperformed

accordingtostandarsinallEmONCfacilities–theseincludepartograph,repairoftears,foetalmonitoringduring

labor,dexamethasoneforprematurity,antibioticsforprematureruptureofmembranes, KangarooMotherCare,

NewbornCorners,PMTCT,etc.

Surgery

ExpansionofEmONCandparticularlyCEmONCfacilitieswillleadtoanincreaseintheproportionofbirths

needingCesareansection.Tomeetthisneedwillrequire:

1. Anincreaseinthenumberoftrainedsurgeons,trainedanesthetists,andtrained

instrumentalists.

2. ImprovementorclarificationoftheappropriateindicationsforCesareansection

3. Improvementinthecapacityandauthorityofmidwivestodecidewhentoreferandto

actuallyrefer

4. Improvementincommunicationsandreferralsystems

5. Increasedattentiontoqualityofprocedures,infectioncontrol,andpreventionandcare

of adverse events

TheincreaseinthenumberofCesareansectionsmustnotinduceanincreaseofthenumberofcomplications

ofCesareansection.Themoreinterventionsdone,thegreatertherisk,andthehighertheneedforsupervision,

qualitycontrol,andpreventionofadverseconsequences(sepsis,ruptureofarteries,hemorrhage,ruptureof

scars,etc.)

Anotherareaforconsiderationisthepossibilityforsurgeons(properlytrained)toperformotheremergency

surgicalactssuchashysterectomyforseverePPH,explorationofhemoperitoine,uterinerupture,ruptureof

ovarian cysts, repair of large perineal tears, and ectopic pregnancy.

14MinistryofHealth.RoyalGovernmentofCambodia,FiveYearActionPlanforNewbornCareinCambodia2016-2020,December2015.

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Blood transfusion

Asaprincipleandwhenindicated,bloodshouldbetransfusedwithinonehourofarequestatCEmONC facilities

and2hoursofarequestatBEmONCfacility.TheNationalBloodBankisresponsibleforpoliciesandprocedures

forcollectingblood,testing,grouping,crossmatchingandtransfusing.Bloodshouldbeavailableatprovincial

hospitals(provincialbloodbanks)andinallCEmONCfacilitiesinBloodDepots,e.gfridgesthatcansafelykeep

asmallprovisionofbagsofeachbloodgroupforimmediateuse.MonitoringandreplenishmentofBloodDepots

andinter-facilitymobilityofsuppliesalsoneedtobeensured.

Where is the “N” in EmONC?

NewborncareisoftenaneglectedelementofEmONC.TheEmONCsignalfunctionofnewbornresusitation

isanessentialpartofEmONCaswellasakeypartofessentiallifesavinginterventionscalledImmediateNewborn

Care(INC)andmorerecently,EarlyEssentialNewbornCare(EENC).EENCisapackageofinterventionsdelivered

tothemotherandthenewbornbetweendeliveryandthefirst3daysafterbirth(seeTable8).Theseinterventions

arealsopartoftheFiveYearActionPlanforNewbornCareinCambodia2016-2020.Newborndeathauditsaswell

asreviewsof“nearmisses”shouldberoutinelyconducted,followingthestrategyusedformaternaldeathaudits.

Table8:EarlyEssentialNewbornCare(EENC)

Intrapartumand Immediate Newborn Care (INC)

Care for all mothers and newborns

TheFirstEmbrace.Interventionsincludeimmediateandthoroughdrying;immediateskin-to-

skincontact;appropriatelytimedcordclamping;non-separationofmotherandnewborn;and

early&exclusivebreastfeeding.CareforhighriskmothersandnewbornsManagementofnewborninfantswhoarenotbreathingdespitethoroughdrying.Interventions

includemanagementofasphyxiausingbagandmaskventilation.Carefullychecktherhythm

andintensityofblowingviaobservationofthethoraxandabdomen.Checkforairleakage

aroundface.

ExpandedINC

Preventionandmanagementofprematurity–forpretermandlowbirthweightbabies(7-8%ofall

newbornsinCambodia).Interventionsincludepreventingunnecessaryinductionsandcaesarian

sections;antibioticsforprematurepre-laborruptureofmembranes;antenatalsteroids;tocolytics

whenindicated;andtheKangarooMotherCareapproach.

CareforSickNewborns–forbabieswithbirthasphyxia,neonatalsepsisandcomplications

ofdelivery(10-15%ofallnewbornsinCambodia).Interventionsincludemanagementof

asphyxiausingbagandmaskventilation;identificationofbabiesathighrisk,management

ofsepsisthroughantibiotics,andmanagementofothercommonproblemsi.echeckfor

malformations,neurologicalexamination.

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Output 5 - Referral systems in place and operational throughout the country

Effective referrals are facilitated by three major factors: good communications, good roads and available and

appropriatemeansof transportation. In the last 5-10 years,mobile phonenetworkshas improved considerably,

nowcoveringalmostallvillagesandnearlyallHealthCentres.TheCambodianroadnetworkhasbeensignificantly

improved;majorroadsarenowpavedandcanbeusedduringallseasons.Ambulancesarefarmoreavailablethan

inthepast,withacombinationofpublicandprivatevehicles,aswellaslocalsmallervehiclesinvillagesandsmall

towns(three-wheelers).Theminimumtraveltimeof2hoursfromanypointinthecountrytoahealthfacilityhas

been assuredinthegreatmajorityofvillages.Effortsshouldbemadetoexpandthistoallpartsofthecounty.

Thereferralsystem,however,needsimprovement.Importantgapsremaininidentificationofcomplicationsnecessitat-

ingreferral,respectofreferralprocedures,competencyofaccompanyingpersonnel,availabilityofemergency kits

inambulances,patientcomfort,firstaidorstabilizationtrainingofambulancestaff,andreceptionandrapidaccessto

appropriatecareattheendpoint.The2014MDAfiguressuggestthat22%ofmaternaldeathstookplace“onthewaytoa

facility”,withoutspecifyingwhetherthedeathtookplaceonthewaybetweenthehomeandthefirstlevelofcare(facility),

betweenthefirstandsecondpointofcare(areferralfromahealthcenterordistricthospitaltoahigherlevelfacility),

orbetweenthefirstandsecondreferralfacility(incaseswherethefirstreceivingfacilitywasunabletoadequatelycare

forthepatient).Thislendsfurtherevidencetosupporttheneedforcomprehensivereferralsystemsimprovements.

Output 6 – Provincial EmONC plans developed, operational and monitored

ProvincialHealthDepartmentshaveanimportantroletoplayinplanning,developingpartnerships,mobilizing

resources,managing,monitoring,supportingandevaluatingtheEmONCImprovementPlan.Annualactivityplans

withcorrespondingbudgetsandannualreportsareessentialtoolsofagoodmanager. Monitoringshouldbeon-

going,evaluationperiodic.Bothactivitiesshouldbeintegratedintoannualplansandbudgeted.Thekeyinterventions

oftheEmONCImprovementPlanshouldbeimplementedatbothnationalandprovinciallevels,accordingtofive

yearandphasedannualplans.

Annex6includesalistofexistingandproposedEmONCfacilitiesforexpansionforeachprovince,developed

thoughaconsultativeprocesswithPHDsinOctober–December2015.Priorityneedsbyprovinceforspecific

signalfunctionsrequiringspecialattentionandimprovementarealsoincludedinAnnex6.

Output 7 - Community participation strengthened to increase utilization

CommunitiesarelikelytobestronglyinterestedintheperformanceofEmONCfacilities.Localentities(suchas

HealthCentreManagementCommittees)shouldbeencouragedtoparticipateinmeetingtheplanning,construc-

tion,rehabilitation,equipmentandreferralneedsofEmONCfacilities.Theymayalsobeencouragedtoparticipate

inqualityassessmentandmonitoring.

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5. Execution, Calendar, and Implementation Responsibilities

The EmONC improvement Plan covers a five year period from 2016-2020. Not everything can be implementedat once or in the first year, thus a phased plan has been proposed.The national program and PHDs should re-adjustcurrentplansonanannualbasis so that theyare informedbyprogressandchallenges, andare responsive tocontextual changes that occur over the course of implementation. An assessment should be undertaken at theend of the early implementation phase 2016-2018, before adjusting targets related to the second phase 2019-2020.

TheNMCHCanditsDirector,alsoactingasEmONCCoordinator,remainthefocalpointforimplementation,monitoringandevaluationoftheEmONCImprovementPlan.Theywillreceivecontinuoussupportandtechnicalassistancefrominternational donor agencies. An EmONC Steering Committee comprised ofmembers of theMCH Sub-TechnicalWorkingGroup,willassistinmonitoringandrespondingtochallengesthatoccurduringimplementationoftheEmONCImprovement Plan.

6. Monitoring and Evaluation

Monitoringisanon-going,permanent,activity,whileevaluationisaperiodicandintermittent.Bothmustbeintegrated

intheannualplans,andfundsmustbesetapartfortheseactivities.AnannualassessmentofEmONCfacilitiesshould

beundertakeninordertodeterminewhethertheymeetBEmONCorCEmONCfuntionalcriteria. Thisassessment

couldbecarriedoutbyPHDsoraspartofanaccreditationprocessforexamplebyintegratingitintotheLevel2Quality

Assessment.The3-monthbenchmarkmustbekeptwithexplanationsoffailuresorinsufficientinformation(forexemple

BEmONCminusonesignalfunction),sothatgapsandneedsfor improvement,oradditionaltraining,oradditional

equipmentareclearlyidentified.

Aproposedmonitoring&evaluationframeworkfortheEmONCImprovementPlan2016-2020isincludedinAnnex

1.TheUNEmONCProcessIndicatorsandtheirmodeofconstructionareincludedasAnnex4(Source:Handbook

for EmONC,2009,WHO,UNFPA,UNICEF,AMDD). Annex 1 - Monitoring & Evaluation framework

Hierarchy of aims Objectively Verifiable Indicators

Means of verification

Target 2020 Key interventions

Responsible

GoalReducematernaland neonatal deaths and contributetotheFastTrackInitiativeRoad Map for ReducingMater-nal and Newborn Mortality (FTIRM)2016-2020

Maternal Mortality Ratio

CDHS 140 All below All below

Neonatal Mortal-ity Rate

CDHS 14 All below All below

22

and newborn Mortality ( FTIRM) 2016-2020

Maternal

130

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23


Output 1

Policies and strategies in place for a support-ive and enabling environment

EmONC Im-

provement Plan

2016-2020final-

izedanddissemi-

nated

Document

signed by MoH

Complete - Advocacy for increased

financialallocationto

EmONC activities

-Disseminationof

EmONC Improvement

Plantoallstakeholders

MoH,

NMCHC,

PHDs

Coordination

mechanisms

operational

Minutesof

meetings

Complete -Regularmeetingsof

MCHSub-TWG

-AnnualEmONC

meeting

NMCH-

CPHDs

Provincial leader-

ship for EmONC

IP

Minutesof

meetings

90% -Annualworkplans,

annualreports,

supervisoryvisits,

supportiveactivities

-Pro-TWGH

PHDs

%ofEmONCfa-

cilitieswithguid-

ance on EmONC

standards and

procedures

Provincial

reports

90% -Standards&protocols

forstaffing,equipment

&casemanagement

distributedtoall

EmONC facilities

-Standards,guidelines

&protocolsupdated

as needed

NMCHC,

PHDs

Stockoutsofes-

sential medicine

andsupplies

MOH reports

and databases

<5% -Ensureregularsupply

ofbasicequipment,

supplies&drugs

-Logisticsystems

thatincludeessential

EmONC medicines

&suppliesinplace

andfunctional

Central&

Provincial

Medical

Stores

Blood availability

24/7 in CE-

mONC facilities

Records of

bloodtransfu-

sion

90% Expandoperationalblood

depots/banksinallCE-

mONC facilities

National&

Provincial

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24


Hierarchy of aims

Objectively Verifiable Indicators

Means of verification

Target 2020

Key interventions Responsible

Output 2Adequate coverage of EmONC facilities (availability and accessibility, including financial accessibility) assured throughout the country

#EmONC

facilities per 500,000

population

(UNEmONCPI

N°1)

Provincial

records

At least 5

(>160)

-Upgradefacilities

&provideequipment

according to phased

EmONC IP 2016-2020

-Reviewstatus&revise

plans for second phase

(2019-2020)asneeded

atendoffirstphase

MOH,

NMCHC,

PHDs

#ofBEmONCfa-

cilities per 500,000

population

(UNEmONC

PIN°1,sub-

indicator)

Provincial

records

At least 4

(>125)

- Same as above

-GISmappingof

EmONC facilities

MOH,

NMCHC,

PHDs

#ofCEmONC

facilities per 500,000

population

(UNEmONC

PIN°1,sub-

indicator)

Provincial

records

At least 1

(>35)

- Same as above

-GISmappingof

EmONC facilities

MOH,

NMCHC,

PHDs

Thefullpackage

ofreproductive,

maternal&

newborn health

services are

includedinbenefit

packagesofHealth

EquityFundsand

national health

insurance

MoH rports,

Specialsur-

veys

TBD -HEFexpansion,other

mechanisms as needed

to cover hard to reach

ormarginalized

populations

MOH,PHDs

Output3

Technical and managerial capacity strengthened to ensure high quality of care

%ofhealthcenters

with at least 2 sec-

ondary midwives

PHDrecords 50% - Pre-service training

-Ensureneededstaffing

at all health centers

-PHDstoreview&

proposeadjustments

MOH,PHDs

24

Special surveys

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25


%ofBEmONCfa-

cilities with at least

6SMWs

PHDrecords 50%of

BEmONC

facilities

with>400

deliveries

per year

-Ensureneededstaffing

at BEmONC facilities

- Pre-service training

-PHDstoreview&

proposeadjustments

(baseline2014–27%

ofBEmONCand50%

of EmONC

facilitieswith>400

deliveriesperyear)

MOH,PHDs

%BEmONCfacili-

tieswithallSMWs

trained on EmONC

PHDrecords 80% -Improvequalityofcare/

competencies to

perform core signal

functionsthrough

training&on-site

skillscoaching

-Annualplansforin-

service training

- Pre-service training

MOH,PHDs

%ofmaternal[and

newborn] deaths

reviewedthrough

audits

PHDrecords 80% -Improverecording&

reportingofobstetric&

newborn deaths

(includingstillbirths),

complications&their

outcomes

-Auditmaternal&

newborndeaths&near

missesonaroutine

basis

MOH,PHDs,

Facility

managers

DirectObstetricCaseFatalityRate(DOCFR)(UNEmONCPIN°6)

Facilityre-cords,PHDrecords

<1% -Improveidentification&recordingofDOCFRatEmONC facilities- Improve referral system

Facilitymanagers, Ob Ward

25

1



























26


26

Output 4

Increased utilization of EmONC services to reduce unmet needs

%ofbirthsinEmONC facilities(UNEmONCPIN°3)(UNEmONCPIN°3)

CDHS,Facilityre-cords

60% - Improveidentificationofobstetric&newborn complications- Improve referral system-Ensure24/7availabilityofqualityEmONC services at facilities

PHDs,Facilitymanagers

%ofdeliveriesbyCesarean section

(UNEmONCPIN°5)

CDHS,Facilityrecords

10% -Improveidentification

ofobstetric&newborn

complications

-Improvequalityofcare/

competencies to

perform core signal

functionsthrough

training&on-siteskills

coaching

- Improve referral system


%oftarget-ed facilities implementing ExpandedINC

PHDrecords,Facilityre-cords

90% -Improvequalityof

newborncarethrough

training and on-site

skillscoaching

NMCHC,PHDs,Facilitymanagers

%ofnewbornsreceiving early PNC (within2daysofdelivery)

PHD,Facilityrecords

95% -Improvequalityof

newborncarethrough

training&on-siteskills

coaching

NMCHC,PHDs,Facilitymanagers

MetneedforDirectObstetric Complica-tions

(UNEmONCPIN°4)

PHDsrecordsFacilityrecords,EmONC Survey

90% -Improveidentificationofobstetric&newborn complications-Improvequalityofcare/competencies to perform coresignalfunctionsthroughtraining&on-siteskillscoaching- Improve referral system


1



























27


27

Output 5

Referral sys-tems in place and operational throughout the country

%ofEmONCfacili-tieswithambulanceready 24/7with trained per-sonnel

PHDrecordsFacilityre-cords

80% -Ensureavailabilityandmaintenanceofambulancesand availability of trained personnel to accompany patientsaroundtheclock- Improve referral system


Output 6

Provincial EmONC plans developed, operational and monitored

%ofPHDswithannualEmONCImprovement Plan andannualreport

PHDrecordsand reports

90% -TrainingandtechnicalassistancetoPHDs&ODstoimproveEmONCmanagement, coordina-tion, monitoring, analysis ofchallenges,evaluation&reporting-Supportfacilitiestoim-proverecording&report-ingofobstetric&newborncomplications&deaths

PHDs,MOH, DevelopmentPartners

Output 7

Community

participation

strengthened to

increase utiliza-

tion

%EmONCfacili-

tieshavingannual

meeting with com-

munityrepresenta-

tives

PHDrecords

and reports

50% -Encouragecommunes,

HCMC&CommuneCoun-

cilstomeet&participatein

meeting needs of EmONC

PHDs

1



























28


Annex 2 – Major obstetric and newborn complications and signal functions for their management

Major complications Associated EmONC Signal Functions

Haemorrhage IfAntepartum:Cesareansectionforplacenta

praevia

Bloodtransfusion

IfPostpartum:Uterotonics

Manualremovalofplacenta

Removal of retained

Products

Bloodtransfusion

Emergencysurgery

(Hysterectomy)

Prolongedorobstructedlabor Assisted vaginal deliveryCesarean sectionUterotonicsNewbornresuscitation

Postpartumsepsis Parenteral antibioticsRemovalofretainedproductsSurgeryforpelviccollectiondrainage

Complication of abortion RemovalofretainedproductsBloodtransfusionifhemorrhageParenteral Antibiotics

Pre-eclampsia and Eclampsia Parenteralanticonvulsants(MgSO4)Cesarean sectionNewbornresuscitation

Ectopic pregnancy Emergencysurgery(laparotomy)BloodtransfusionParenteral antibiotics

Ruptureduterus Emergencysurgery(laparotomy)BloodtransfusionParenteral antibiotics

Newborn distress at birth Newbornresuscitation(basicandadvanced)Cesarean sectionParenteral antibiotics on newborn

Intrapartumstillbirth Inductionoflabor(ifnotspontaneous)

28


Annex 2 – Major obstetric and newborn complications and signal functions for their management

Major complications Associated EmONC Signal Functions

Haemorrhage IfAntepartum:Cesareansectionforplacenta

praevia

Bloodtransfusion

IfPostpartum:Uterotonics

Manualremovalofplacenta

Removal of retained

Products

Bloodtransfusion

Emergencysurgery

(Hysterectomy)

Prolongedorobstructedlabor Assisted vaginal deliveryCesarean sectionUterotonicsNewbornresuscitation

Postpartumsepsis Parenteral antibioticsRemovalofretainedproductsSurgeryforpelviccollectiondrainage

Complication of abortion RemovalofretainedproductsBloodtransfusionifhemorrhageParenteral Antibiotics

Pre-eclampsia and Eclampsia Parenteralanticonvulsants(MgSO4)Cesarean sectionNewbornresuscitation

Ectopic pregnancy Emergencysurgery(laparotomy)BloodtransfusionParenteral antibiotics

Ruptureduterus Emergencysurgery(laparotomy)BloodtransfusionParenteral antibiotics

Newborn distress at birth Newbornresuscitation(basicandadvanced)Cesarean sectionParenteral antibiotics on newborn

Intrapartumstillbirth Inductionoflabor(ifnotspontaneous)

28

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29


Annex 3 – Recommended infrastructure, equipment, supplies & drugs for EmONC

PhysicalInfrastructure Miscellaneous

• Electricityandbackupgenerator• Watersupply• Staffquarters• Telephone/radiocall/mobilephone• Ambulance

• Wallclock• Torchandextrabatteries• Refrigerator• Logbooks• Records• Registers

WarmandCleanRoom Waste

• Deliverybed(s)• Cleanbedlinen• Curtainsifmorethanonebed• Cleansurface(foralternativedeliveryposition)• Worksurfaceforresuscitationofnewbornneardeliverybed(s)ornewborncorner• Lightsource• Heatsource• Roomthermometer)

• Punctureresistantcontainerforsharps disposal• Receptacleforsoiledlinen• Bucketforsoiledpadsandswabs• Bowlandplasticbagforplacenta

HandWashing Sterilization

• Cleanwatersupply• Soap• Nailbrushorstick• Cleantowels

• Instrumentsterilizer• Jarforforceps

Equipment TestKits

• Bloodpressuremachineandstethoscope• Fetalstethoscope• Fetaldoppler• Thermometer• Babyscale• Selfinflatingbagandmasks(adult)• Self inflating bag and masks (newborn sizes0and1)• Mucousextractorwithsuctiontubes• Vacuumextractor• MVAsyringeandcannulae

• Syphilis(rapidtest)• HIV(rapidtest)• Haemoglobin• Oxymeter

DeliveryInstruments(Sterile)• Scissors• Needleholder• Arteryforcepsorclamp• Dissectingforceps• Spongeforceps• Vaginalspeculum

Supplies

• Gloves:-Utility - Sterile or high-level disinfected-Longsterileformanualremovalof placenta

• Antisepticsolution(iodophorsorchlorhexidine)• Spirit(70%alcohol)

29

1



























30


• Longplasticapron• Waterprooffootware• Plasticeyeshield• Urinarycatheters• Syringesandneedles• IVtubing• IVsolutions(Ringerslactate,normalsaline)• Suturematerialforrepairoftearsor episiotomy

• Swabs• Bleach(chlorine-basedcompound)• Cleanplasticsheettoplaceundermother• Sanitarypads• Cleantowels/clothsfordryingandwrapping the baby• Cordties/clamp• Impregnatedbednets• Urinedipstix

Drugs for pregnancy, childbirth, postpartum & newborn care

Drugs

• Amoxicillin• Ampicillin• Arthemeter• Benzathinepenicillin• Calciumgluconate• Ceftriaxone• Chloriquinetablets• Ciprofloxacin• Clotrimazolevaginalpessaries• Cloxicillin• Adrenaline• Diazepam• Dexamethazone• Erythromycin• Gentianvioletw• Gentamycin• Hydralazine• Iron/folicacidtablets• Lamivudine(3TC)• Lignocaine• Magnesiumsulphate• Mebendazole• Metoclopramide• Metronidazole• Nevirapine(adult,infant)• Oxytocin• Paracetamol• Quinine• Sulphadoxine-pyrimethamine• Tetracyclineordoxycycline• Tetracycline1%eyeointment• Trimethoprim+sulphamethoxazole• Zidovudine(AZT)(adult,infant)• Waterforinjection• VitamineK1

30

1



























31


Vaccines• Tetanustoxoid• BCG• OPV• HepatitisB

Contraceptives• Condoms• Progesterone-onlyoralcontraceptives• Progesterone-onlyinjectables• Implants• IUDs• Combinedoralcontraceptives• Combinedinjectables

Additional equipment & supplies for CEmONC

BasicEquipment• Sphygmomanometer(aneroid)andstethoscope(binaural)• Self-inflatingbagandfacemasks(adultsize)• Self-inflatingbagandfacemasks(newbornsizes0and1)• Adultandinfantlaryngoscopewithsparebulbandbatteries• Adultandinfantlaryngoscopetubes• Absorbable,nonreactivesutures(e.g.,polyglycolic,chromiccatgut)andsutureneedles• Urinarycathetersandclosedbagorcontainerforcatheterdrainage• Tourniquet• 16-to18-gaugeIVcannulas• Dextrosesolution(5%)• Ringer’slactateornormalsaline• IVadministrationsets• Adhesivetape• Oxygentubing,nasalcannulae,andfacemasks• Suctiontubingandcatheters• Surgicalscrubbrushes

ObstetricLaparotomyand/orCaesareanSection• Stainlesssteelinstrumenttraywithcover• Towelclips(5)• Spongeforceps,22.5cm(6)• Straightarteryforceps,16cm(4)• Uterineheamostasisforceps,20cm(8)• Hysterectomyforceps,straight,22.5cm(4)• Mosquitoforceps,12.5(6)• Tissueforceps,19cm(6)• Needleholder,straight,17.5cm(1)• Surgicalknifehandle,No.3(1),No.4(1)• Surgicalknifeblades(4)• Triangularpointsutureneedles,7.3cm,size6(2)• Round-bodiedneedlesNo.12,size6(2)• Abdominalretractors,double-ended(Richardson)(2)• Curvedoperatingscissors,bluntpointed(Mayo),17cm(1)• Straightoperatingscissors,bluntpointed(Mayo),17cm(1)

31

1



























32


Blood Transfusion Anaesthesia• 8.5g/lsodiumchloride

solution

• 20%Bovinealbumin

• Centrifuge

• 37ºCwasterbath

(orincubator)

• PipettesVolumetric(1ml,

2ml,3ml,5ml,10ml,20ml)

• Testtubes(smallandmedium

size)

• Sphygmomanometercuff

• Airwayneedleforcollecting

blood

• Arteryforcepsandscissors

• Pilotbottles(containing1ml

ACDsolution)

• Compoundmicroscopeand

slides

• Microscopeilluminator

• Bloodgivingsets

• Anaestheticfacemasks

• Oropharyngealairways

• Endotrachealtubeswithcuffs(8mmand10mm)

• Intubatingforceps(Magill)

• Endoctrachealtubeconnectors,15mmplastic(3foreach

tubesize)

• Spinalneedles(rangeofsizes,18-gaugeto25-gauge)

Annex 4 – EmONC Process Indicators

Indicator Description Numerator Denominator AcceptableLevels1&2.Availability of EmONC facilities and geographic distribution(nationalorprovincial)

Ratio of facilities providing EmONC topopulationand geographical distributionofEmONC facilities

No. of facilities pro-viding Basic or Com-prehensive EmONC

Populationofareadivided by 500,000

≥ 5 EmONC facilities per 500 000 population

No. of facilities providing Comprehensive EmONC

Populationofareadivided by 500,000

≥ 1 Comprehensive EmONC facility per 500000population

3. Proportion of all births in EmONC facilities

Proportion of all expectedbirthsinEmONC facilitiesin catchment area

No. of women giving birth in EmONC facilitiesinspecifiedtimeperiod(1year)

Expectedno.ofbirthsin the same catch-ment area in same time period

15%to100%(ifALLbirthsshouldtakeplace in EmONC facilities)

4. Met Need for EmONC...............

Proportion of women with direct obstetric complications treated at EmONC facilities

No. of women withmajordirectobstetric complications treated in EmONC facilities in specifiedtimeperiod

Expectedno.of women with majordirectobstetric complications in area in same time period (expected)

100%

32

1



























33


5. Caesarean sections as a proportion of all births

Proportion of all births by Caesarean sectiontakingplaceinEmONC facilities

No. of Caesarean sections in EmONC facilitiesinspecifiedtime period

Expectedno.ofbirthsin area in same time period

5%–15%

6.Directobstetriccase fatality rate (DOCFR)

Proportion of women with majordirectobstetriccomplications who die in an EmONC facility

No. of maternal deathsduetodirectobstetriccausesadmitted in EmONC facilitiesinspecifiedtime period

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

<1%

7.Intrapartumandvery early neonatal death rate

Proportion of births thatresultinanintrapartumdeathora very early neonatal deathoccurringwithinthefirst24hoursinEmONC facilities

No.ofintrapartumdeaths(freshstillbirths;>2.5kg)andveryearly neonatal deaths (≤24hours;>2.5kg)in EmONC facilities in specifiedtimeperiod

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

Tobedecidedbutnormally<1%

8. Proportion of maternaldeathsduetoindirectcauses

Outofallmaternaldeaths in EmONC facilities,what%areduetoindirectcauses

No. of maternal deaths duetoindirectcausesin EmONC facilities in specifiedtimeperiod

All maternal deaths (fromdirectandindirectcauses)inEmONC facilities in same time period

None set (dependson the local epidemiology)

Annex 5 – Minimum requirements for EmONC facilities

MinimumRe-quirement

Basic EmONC Comprehensive EmONC

Clinicalhours SBAwithEmONCskillspresentoroncall24hours

Emergencyteampresentoroncall24hours

Infrastructure • Roomsforessentialservices

• Runningwater

• Electricity(alternativebackup)

• Sewagesystem

• Wastedisposal(placentapit)

• Securestaffquarters

• Latrinesforpatients

• ShowerforpatientsFunctional Department and services (includ-ing equipment and supplies)

• Outpatientarea

• Ante-andpost-natalward/area

• Deliveryroomwithvisualand

audioprivacy

• Basiclaboratoryandpharmacy

• Outpatientarea

• Ante-andpost-natalward

• Deliveryroomandoperatingtheater

withvisualandaudioprivacy

• Essentialneonatalcare

• Laboratory,includingblood

screening and cross-matching

• Bloodbank

• Pharmacy

33

1



























34


Minimum

Requirement

Basic EmONC Comprehensive EmONC

Personnel • Midwife,nurseandsupporting

staffLabandpharmacystaff

• Administrativestaff

• Securitystaff

• OB/GYN

• Anesthetists

• Midwife,nurseandsupportingstaff

• Labandpharmacystaff

• Administrativestaff

• SecuritystaffInfection control

• Safewater,soap

• Disinfectants

• Boiler/autoclave

• UniversalprecautionstopreventthespreadofHIVandotherinfections

• Laundryfacilities

• Staff ’sattitudes

Referral • Reliablereferralsystem24hoursaday,7daysaweek

• Ifvacuum-assistedvaginaldeliveryiscarriedout,Cesareansectionbackup

within30minutesisrecommended,incaseoffailure

• Communicationfacilities:radiocallortelephone

Registers and records

• ANCregister

• Delivery/maternity(includinginformationonmajorobstetriccomplications)

• OTregister(forcomprehensiveEmONCfacility)

• Bloodbankregister(forcomprehensiveEmONCfacility)

• Referralregister

• Monthlysummary

• ANCcard

• Individualpatientrecord

• Partograph

• Others

34

1



























35


Ann

ex 6

- Ex

istin

g &

pro

pose

d Em

ON

C fa

cilit

ies b

y Pr

ovin

ce

Prov

ince

Prio

rity

Sig

nal

Func

tions

for

Impr

ovem

ent

Exis

ting

EmO

NC

faci

litie

s tar

gete

d

in

201

0-20

15Pr

opos

ed E

mO

NC

faci

litie

s

20

16-2

020

Add

ition

al fa

cilit

ies t

o up

grad

e if

2020

pla

ns in

the

prov

ince

are

achi

eved

ear

ly

BEm

ON

CC

EmO

NC

BEm

ON

CC

EmO

NC

BEm

ON

CC

EmO

NC

Bant

eay

Mea

nche

yACT,NNR,

AVD,R

RPBLT

3RH

s:Serey

Soph

orn,

Pre

ah N

et

Preah,P

hnom

Srok

(SrahChik)

3HCs:Malai,

SvayChek,Boeng

Trakuo

n

3RH

s:

Mon

gkulBorey-

PH,

O C

hrov

, Th

morPuo

k

3RH

s:Serey

Soph

orn,

Pre

ah N

et

Preah,P

hnom

Srok

(SrahChik)

3HCs:M

alai,

SvayChek,Boeng

Trakuo

n

3RH

s:M

ongkul

Bore

y-PH

, O

Chrov,Th

mor

Puok

2HCs:Kob,Poipet

1N

one

Batta

mba

ngABC

,ACT,NNR,

MRP

,AVD

1RH

:ThmarKou

l

11HCs:Chrey,Ta

Sanh

,Sdao,Kan

Toeu,P

rekNorin,

Bavel1,K

aos

Kralor,PreaekChik,

TaKrey,Trang,

Boeung

Prin

g

3RH

s:

Batta

mba

ng-P

H,

Mon

gRu

ssey,Sam

-po

vLu

on

1RH

:Th

marKol

11HCs:Chrey,Ta

Sanh

,Sdao,KanToeu,

PrekNorin,B

avel1,

KaosK

ralor,Preaek

Chik,TaKrey,Trang,

Boeung

Prin

g

3RH

s:

Batta

mba

ng-P

H,

Mon

gRu

ssey,

Sampo

vLu

on

Non

eN

one

Kam

pong

Cham

ACT,NNR,M

RP,

RRP

6RH

s:Srey

Sant

hor,

Bath

eay,

Steung

Trang

,Prey

Chh

or,C

heun

gPrey,

ChamkarL

eu

4HCs:Krouch,Ph’A

v,MesarChrey,P

rek

Rom

deng

1RH

:Kam

pong

C

ham

-PH

,4RH

s:Steung

Trang

,PreyChh

or,C

heun

gPrey,ChamkarL

eu

4HCs:Krouch,Ph’A

v,MesarChrey,P

rek

Rom

deng

3RH

s:Kam

pong

C

ham

-PH

, Sre

y Sa

ntho

r, Ba

thea

y,

Non

eN

one

15ABC

=Antibiotic

s;OXY

=Oxytocics;A

CT=

Anticon

vulsa

nts;MRP

=Manualrem

ovalofp

lacenta;RRP

=Re

movalofretainedprod

ucts;A

VD=Assistedvaginaldelivery;NNR=

Neonatalresuscitatio

n;BLT

=Blood

transfusion;C/S=Cesareansection.Seepages137-144oftheEmONCre

view

(April2015)fordetailson

missingsig

nalfun

ctionsbyfacility.

35

1



























36


Kam

pong

Chh

nang

ACT,NNR,

RRP,AVD,

ABC

, MRP

2RH

s:Kam

pong

Tralach,

Borib

o

4HCs:Kam

pong

Hav,

Cheap,SvayChu

k,

KraingLvea

1RH

:Kam

pong

C

hhna

ng-P

H2RH

s:Kam

pong

Tralach,Boribo

4HCs:Kam

pong

Hav,

Cheap,SvayChu

k,Kra

-ingLvea

1RH

:Kam

pong

C

hhna

ng-P

H1HC:P

reyKri

Non

e

Kam

pong

Speu

AVD,R

RP,

BLT,CS,ACT,

NN

R

2RH

s:Ko

ngPise

y,

Trapaing

Kraleun

g

4HCs:Cho

engRo

sSam

aki,

VealAng

Pop

el,K

akPreah

Khe,B

asetPom

real

2RH

s:

Kam

pong

Speu-PH

,Oud

ong

2RH

s:Ko

ngPise

y,Tra-

paingKraleun

g

4HCs:Cho

engRo

sSamaki,Ve

alAng

Pop

el,

KakPreahKhe,B

aset

Pom

real

2RH

s:

Kam

pong

Speu-

PH,O

udon

g

2HCs:PreyChu

m-

po M

ean

Ang

, Por

Ang

krang

Non

e

Kam

pong

Thom

ABC

,ACT,

RRP,AVD,

NNR,BLT

1RH

:Baray-Santuk

4HCs:Meanchey,

Pralay,Treal,Taing

Krasaing

2RH

s:Kam

pong

Th

om-PH,Stong

5HCs:Meanchey,Pra-

lay,Treal,TaingKrasa

-in

g, S

ambo

3RH

s:

Kam

pong

Thom

PH

, Sto

ng,

Baray-Santuk

Non

eN

one

Kam

pot

ABC

,ACT,

MRP

,AVD,

NN

R

4RH

s:Chh

ouk,Bun

Rany-

Hun

SenKoh

Sla,K

ampo

ng

Trach,Ang

korC

hey

2HCs:Trapaing

Rop

ov,

Touk

Meas

1RH

:

Kam

pot-PH

4RH

s:Chh

ouk,Bun

Ra

ny-H

unSenKoh

Sla,

Kam

pong

Trach,A

ng-

korC

hey

2HCs:Trapaing

Rop

ov,

Touk

Meas

1RH

:Kam

pot-PH

2HCs:Trapaing

Ra

ing,Dangton

gN

one

Kandal

ACT,RRP

,MRP

,AVD,

NNR,BLT

3RH

s:Saang,KeanSvay,

KsachKandal

9HCs:Anlon

gRo

meat,

KraingYo

v,Talun,Kok

iTh

om,D

eyEith

,PrekTon

-lorb,P

rekLu

ong,

3RH

s:CheyChu

m

Neah-PH

,Koh

Th

om,R

okarKorng

5RH

s:Saang,Kean

Svay,K

sachKandal,

RokarK

ong,SlveaEm

(TeukKlaing)

8HCs:Anlon

gRo

meat,

KraingYo

v,Talun,Kok

iTh

om,D

eyEith

,

2RH

s:Chey

Chu

mNeah-PH

,

KohTh

om,

Non

eN

one

36

1



























37


PrekAnh

chanh,TeukKlaing

PrekTon

lorb,P

rek

Luon

g,P

rekAn-

hcha

nh,

Kep

ABC

,ACT,

AVD,R

RP,

NN

R

1RH

:Kep

1HC:Pon

gTeuk

1RH

:Kep

1HC:Pon

gTeuk

Non

eN

one

KohKo

ngM

aint

ain

RH:SreAmbel

1RH

:Ko

hKo

ng-

PH1R

H:SreAmbel

1RH

:Koh

Kon

g-PH

1HC:KiriSakor

Non

e

Kratie

ABC

,ACT,

MRP

,AVD

1RH

:Snu

ol

2HCs:Sambo

ur,C

hambak

2RH

s:Kratie

-PH,

Chh

long

2RH

:Chh

long

,Snu

ol

2HCs:Sambo

ur,

Chambak

1RH

:Kratie

-PH,

2HCs:Ro

luos,P

rek

Pras

opN

one

Mon

dulkiri

ACT

2HCs:Koh

Nhek,KeoSeima

1RH

:Mon

dulkiri-

PH3HCs:Koh

Nhek,

KeoSeim

a,OÁm

1RH

:Mon

dulkiri-PH

Non

eN

one

Odd

ar M

eanc

hey

ABC

,ACT,

RRP,BLT,C

/S2HCs:Ko

kMorn,Trapaing

Pras

ath

2RH

s:Samrong

-PH

, Anl

ong

Veng

2HCs:Ko

kMorn,

Trapaing

Prasath

2RH

s:Samrong

-PH,

Anl

ong

Veng

1HC:C

hong

Kal

Non

e

Paili

nM

aint

ain

1RH

:Pailin

-PH

1RH

:Pailin

-PH

1HC:P

hnom

Preal

Non

e

Phno

m P

enh

ABC

,ACT,

NN

R, M

RP,

RRP,AVD

8RH

s:SamdachOv,Don

Penh

,ChamkarM

on,SenSok

(Anlon

gKgn

an),PrekPno

v,

PochenTon

g,M

eanchey,

Dangkor(C

hamkarD

ong)

7HCs:Teuk

Thla,Pon

gTo

euk,Tuo

lKork,Chak

Ang

rae,

Sten

g M

eanc

hey,

Psar

DoemTh

kov,ChroyChang

va

5NHs:Calmette-

NH

, MC

H-N

H,

PreahKo

ssam

ak-

NH,K

hmero-

Sovi

et-N

H,

Mun

icipal

Hos

pita

l

7RH

s:SamdachOv,

Don

Penh,SenSok

(Anlon

gKgn

an),

PrekPno

v,Po

chen

Tong

,Meanchey,

Dangkor(C

hamkar

Don

g)

6HCs:Teuk

Thla,

Pong

Toeuk

,Tuo

lKo

rk,C

hakAng

rae,

Sten

g M

eanc

hey,

Psar

DoemTh

kov

5NHs:Calmette-N

H,

MCH-N

H,PreahKos

-samak-N

H,K

hmero-

Soviet-N

H,Mun

icipal

Hos

pita

l

1HC:Samrong

Krom

Non

e

37

1



























38


PreahSihano

ukACT,NNR,

RRP

2HCs:Ve

alRinh,Steun

gHav

1RH

:Sihanou

kV

ille-

PH2HCs:Ve

alRinh,

Steung

Hav

1RH

:Sihanou

kVille-

PHN

one

Non

e

Prea

h V

ihea

rACT,NNR,

MRP

,AVD

3HCs:Ro

Vieng

,SraEm,

Cho

amKhsan

1RH

:PreahVihear-

PH3HCs:Ro

Vieng

,Sra

Em,C

hoam

Khsan

1RH

:PreahVihear-PH

2HCs:Ko

len,

Chh

ebN

one

Pursat

ACT,NNR,

MRP

,AVD

3RH

s:Ba

kan,Phn

omKra

-vanh

,KraKor

2HCs:Pram

oy,Talo

1RH

:Sam

pov

Mea

s-PH

3RH

s:Ba

kan,Phn

om

Kravanh

,KraKor

2HCs:Pram

oy,Talo

1RH

:Sam

povMeas-PH

3HCs:Metoek,

CheurTom

,Siya

Non

e

Prey

Ven

gACT,NNR,

MRP

,AVD,

BLT,ACT,

NN

R, M

RP,

AVD,B

LT

5RH

s:Peareang

,Preah

Sdach,Kam

chayM

ear,Me-

sang

, Sva

y A

ntho

r

3HCs:Cho

eung

Phn

om,

Kanchreach,PreyPo

n

3RH

s:PreyV

eng-

PH,N

eakLo

eung

,Kam

pong

Trabek

5RH

s:Preah

Sdach,Kam

chay

Mea

r,

M

esan

g,

Svay

An-

thor,Sith

orKandal

2HCs:Cho

eung

Ph

nom

,

Kanchreach,

4RH

s:PreyVeng-

PH,N

eakLo

eung

,

Kam

pong

Trabek,Pear-

eang

,

Non

eN

one

Ratanakiri

Mai

ntai

n1RH

:BorKeo

1RH

:Rattanakiri-

PH1RH

:BorKeo

1HC:OYadav

1RH

:Rattanakiri-

PH4HCs:Lu

mph

at,

Vensai,TaVe

ng,

And

ong

Mea

s

Non

e

Siem

Rea

pACT,NNR,

MRP

,AVD

3RH

s:Kralanh

,Ang

kor

Chu

m,P

uok

4HCs:Samrong

,An-

long

Sam

nar,

Srey

Sna

m,

Ba

ntea

y Sr

ey,

2RH

s:Siem

Reap

-PH

, Sot

h Nikum

3RH

s:Kralanh

,

Ang

korC

hum,P

uok

4HCs:Samrong

,A

nlon

g Sa

mna

r, Sr

ey

Snam

,Bakon

g

2RH

s:Siem

Reap-PH

,SothNikum

2HCs:SreNoy,

KokDon

gN

one

Stun

gTreng

ACT,M

RP,

RRP,AVD

2HCs:Siem

Pang,SreKror

Sain

g1RH

:Steun

gTreng-

PH2HCs:Siem

Pang,Sre

KrorS

aing

1RH

:Steun

gTreng-PH

1HC:C

hamkaleu

Non

e

38

1



























39


PreahSihano

ukACT,NNR,

RRP

2HCs:Ve

alRinh,Steun

gHav

1RH

:Sihanou

kV

ille-

PH2HCs:Ve

alRinh,

Steung

Hav

1RH

:Sihanou

kVille-

PHN

one

Non

e

Prea

h V

ihea

rACT,NNR,

MRP

,AVD

3HCs:Ro

Vieng

,SraEm,

Cho

amKhsan

1RH

:PreahVihear-

PH3HCs:Ro

Vieng

,Sra

Em,C

hoam

Khsan

1RH

:PreahVihear-PH

2HCs:Ko

len,

Chh

ebN

one

Pursat

ACT,NNR,

MRP

,AVD

3RH

s:Ba

kan,Phn

omKra

-vanh

,KraKor

2HCs:Pram

oy,Talo

1RH

:Sam

pov

Mea

s-PH

3RH

s:Ba

kan,Phn

om

Kravanh

,KraKor

2HCs:Pram

oy,Talo

1RH

:Sam

povMeas-PH

3HCs:Metoek,

CheurTom

,Siya

Non

e

Prey

Ven

gACT,NNR,

MRP

,AVD,

BLT,ACT,

NN

R, M

RP,

AVD,B

LT

5RH

s:Peareang

,Preah

Sdach,Kam

chayM

ear,Me-

sang

, Sva

y A

ntho

r

3HCs:Cho

eung

Phn

om,

Kanchreach,PreyPo

n

3RH

s:PreyV

eng-

PH,N

eakLo

eung

,Kam

pong

Trabek

5RH

s:Preah

Sdach,Kam

chay

Mea

r,

M

esan

g,

Svay

An-

thor,Sith

orKandal

2HCs:Cho

eung

Ph

nom

,

Kanchreach,

4RH

s:PreyVeng-

PH,N

eakLo

eung

,

Kam

pong

Trabek,Pear-

eang

,

Non

eN

one

Ratanakiri

Mai

ntai

n1RH

:BorKeo

1RH

:Rattanakiri-

PH1RH

:BorKeo

1HC:OYadav

1RH

:Rattanakiri-

PH4HCs:Lu

mph

at,

Vensai,TaVe

ng,

And

ong

Mea

s

Non

e

Siem

Rea

pACT,NNR,

MRP

,AVD

3RH

s:Kralanh

,Ang

kor

Chu

m,P

uok

4HCs:Samrong

,An-

long

Sam

nar,

Srey

Sna

m,

Ba

ntea

y Sr

ey,

2RH

s:Siem

Reap

-PH

, Sot

h Nikum

3RH

s:Kralanh

,

Ang

korC

hum,P

uok

4HCs:Samrong

,A

nlon

g Sa

mna

r, Sr

ey

Snam

,Bakon

g

2RH

s:Siem

Reap-PH

,SothNikum

2HCs:SreNoy,

KokDon

gN

one

Stun

gTreng

ACT,M

RP,

RRP,AVD

2HCs:Siem

Pang,SreKror

Sain

g1RH

:Steun

gTreng-

PH2HCs:Siem

Pang,Sre

KrorS

aing

1RH

:Steun

gTreng-PH

1HC:C

hamkaleu

Non

e

38


Svay

Rie

ngABC

,ACT,

RRP,

MRP

, AV

D,N

NR,

BLT

1RH

:ChiPhu

6HCs:Kruos,K

rasaing,

ChreyTh

om,M

esaTn

gork,

Nho

r, C

hant

rey

2RH

:SvayRieng

-PH

,Rom

easH

ek3RH

:ChiPhu

,Svay

Chrom

,SvayTeap

3HCs:Cho

rk,M

esa

Tngork,N

hor

2RH

:SvayRieng

-PH,

RomeasH

ekN

one

Non

e

Takeo

ABC

,ACT,

RRP,

MRP

, AV

D,N

NR

3RH

s:Ang

Rokar,P

reyKa-

bass

, Bat

i

4HCs:Ro

minh,Rovieng

,Trapaing

And

oeuk

,Ang

kor

Bore

y

2RH

s:Takeo-PH

,Kirivong

3RH

s:Ang

Rokar,

PreyKabass,Ba

ti

4HCs:Ro

minh,Rovi-

eng,TrapaingAn-

doeuk,Ang

korB

orey

2RH

s:Takeo-PH

,Ki-

rivon

g1HC:TramKna

Non

e

Tbon

gKhm

umABC

,ACT,

NN

R, M

RP,

AVD,R

RP,

BLT

3RH

s:Po

nheaKrek,Kroch

Chh

mar

, O R

eang

Ov

3HCs:Ro

karPo

rpram2,

Cho

ngCheach,Dar

2RH

s:Tb

ong

Khm

umRH,

Mem

ot

2RH

s:KrochChh

-m

ar, O

Rea

ng O

v

3HCs:Ro

karPo

rpr

am 2

, Cho

ng

Cheach,Dam

be

3RH

s:Tb

ongKhm

um

RH, M

emot

, Pon

hea

Krek

3HC:Sla,Toek

Chrov,K

rekI

Non

e

TOTA

L52

RH

s84

HC

s44

RH

s52

RH

s81

HC

s47

RH

s29

HC

sN

one

39

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