HEALTH FACILITY IN TOGO

67 designated referral facilities covering 81%

of the population within 1 hour travel time 109 designated referral facilities covering 81%

of the population within 1 hour travel time REFERRAL HEALTH FACILITIES IN 2017

(before prioritization with GIS/AccessMod) REFERRAL HEALTH FACILITIES IN 2018 (after prioritization with GIS/AccessMod)

Facilities Hydrography

Rivers Lakes

Regional boundaries National roads

Other roads Tracks/paths

Roads

< 1 hour 1–2 hours 2–3 hours 3–4 hours

> hours

Travel time N

Designated CEmONC [20]

Functional CEmONC [18]

Designated BEmONC [65]

Functional BEmONC [7]

This approach also contributes to highlight key multi-sectoral determinants of maternal and newborn health, such as the road infrastructure. Scenarios for improving the coverage of the population by the EmONC network can be driven by three key strategies - which could be combined:

▪ add an EmONC facility in an area densely populated and not yet covered;

▪ improve the travel time of population within the catchment areas of EmONC facilities by improving the road network;

▪ improve access of population to means of transport, particularly to public transport.

The population coverage maps and scenarios produced with AccessMod/GIS are important advocacy and planning tools (cf. Technical Sheet #3) as they model the theoretical coverage of the population by the EmONC network, taking into account the travel barriers (eg. road network, rivers, topography) and local transportation means (eg. pregnant woman carried by walk, motorized vehicle, or a combination of them). Stakeholders can then measure the impact of different improvement scenarios on the population covered by the national EmONC network.

4. Challenges

For health system managers who see each health facility in the health system as a potential EmONC facility, the paradigm shift proposed in this manual may not be easy to adopt. This issue needs to be managed by the high level authorities of the MoH using key elements of this manual. The ownership of the prioritization approach by these authorities should be the focus of the advocacy phase (cf. Chapter 1). In our experience, this approach resonates with the MoH’s authorities when they realize that the maternal health indicators are making limited progress and that the network of EmONC facilities is not developing as planned. They are then on the lookout for innovative solutions and are open to a change in strategy. The use of GIS and AccessMod helps this advocacy significantly, as it predicts the theoretical coverage of the population by the three networks of health facilities (all maternities, designated EmONC network, and functioning EmONC network). The suggestion of adopting a phased approach by focusing on a limited number of designated EmONC facilities to be made functional in the next programmatic cycle(s) and to keep other potential EmONC facilities for later programmatic cycle(s) has also been convincing for the ministry of health in several countries.

Experience also shows that an international expert capable of moderating the debates is an asset in these regional discussions, as national experts might be more likely to be criticized for being biased.

Another challenge for health system planners and managers is reconciling the map of EmONC facilities using GIS/AccessMod and catchment areas with administrative boundaries, given that these may not be aligned. The map of the network of EmONC facilities in Ngozy province in Burundi demonstrates this frequent pressing issue (Figure 11 in section 3 above).

Finally, as previously mentioned, the mapping of the national EmONC network is a robust tool for the Ministry of Health to advocate for intersectoral actions for improving access to quality EmONC services and improving maternal and newborn health. However, such essential actions are generally very difficult to effectively plan and implement.

Do all health facilities have the potential to become BEmONC facilities?

There is widespread confusion on this matter, which had a negative impact on the development of functional EmONC facilities. Not all health facilities with obstetric activity should become BEmONC facilities. BEmONC facilities are 24h/7d first line referral maternity facilities and centers of excellence. They attend to routine delivery but also handle basic obstetric and newborn and provide good-quality referrals to the CEmONC facilities. They require suitable infrastructure and facilities, and qualified human resources organized in teams, as well as a significant number of obstetric cases to maintain an adequate level of quality care. In many countries, considering each birthplace as a potential BEmONC facility has led to scarce resources being scattered around the country and has prevented genuine development of BEmONC facilities, and even CEmONC facilities. It has had the opposite of the desired effect: too few functioning EmONC health facilities. Deciding to carry out a prioritization work is therefore strategically very important for improving MNH by focusing efforts on making functioning a limited number of EmONC health facilities while keeping a good coverage of the population.

Do hard-to-reach areas need an EmONC facility?

This question arises almost systematically during the prioritization exercise and leads to long debates. As remote areas, by definition, pose problems for country planning, the answer is often found outside the health sector. The experience shows that it is extremely

difficult to maintain a hospital (a CEmONC health facility) or a BEmONC health facility in a remote area which has poor road network. Only Non-Governmental Organizations (NGOs) or bilateral cooperations manage it, through resource intensive interventions that are often not sustainable.

We recommend effective advocacy towards the government to implement alternative solutions to ensure access to EmONC by populations living in had-to-reach areas. Although sometimes controversial, the most promising solution is setting up “maternity waiting homes” close to a BEmONC or preferably a CEmONC facility, to welcome women nearing the end of their pregnancy. To be accepted, these maternity waiting homes must be linked to the community and be respectful of the local culture and the needs and desires of the pregnant woman and her entire family. The use of GIS/AccessMod could help conceptualize the various options for improving access to care in hard-to-reach areas.

Do private health facilities have to be taken into account when prioritizing EmONC facilities?

In some countries, the private sector makes a significant contribution to the provision of maternal and newborn health care. In any case, the private not-for-profit health facilities should not be omitted from the prioritization phase. Awareness-raising and, in particular, establishing or reinforcing communications with the management of private health facilities and highlighting the importance of sharing data for quality improvement (and not for other purposes), should enable private maternity facilities to participate in the network.

CHAPTER 4