Improving Immunisation and Newbo

							Improving Immunization and
Newborn Survival at the Aid-Post
Level in Papua New Guinea
Lester Bisibisera <lesterb_burnet@datec.net.pg>
Papua New Guinea


• Independent state since 1975
• 6 million people, 800 distinct languages
• Few roads and a capital isolated from the rest of the
  country except by air
• Challenging terrain including
   – scattered islands,
   – mountain ranges reaching above 4,000 metres
   – riverine jungle accessible only by water
• Urban drift and ethnic strife in some rural areas
A small health services delivery
study to assess the feasibility of:


• Using Uniject® in PNG in a real-world setting, including
  out-of-cold chain usage
• Early post-natal visits for home births in a remote district
• Integrated post-natal care package of
   – birth-dose hepatitis B vaccine,
   – vitamin A for mothers
   – education to promote maternal and newborn health
• Delivery by both Village Health Volunteers (VHV) and
  paid government Community Health Workers (CHWs)

• East Sepik Province, PNG - May 2008 to June 2010
Site: East Sepik Province, PNG
- a province that allowed testing under challenging
conditions, but with a strong cadre of village health
volunteers
Rationale for early post-natal visits in
homes as well as health centres

• Coverage of HepB birth dose is low:
   – National: 16% 2005 survey), 25% (2008 NHIS)
   – East Sepik: 27% Prov, 18% Angoram (2008 NHIS)
• Supervised (facility-based) delivery rates have not
  increased for 10 years - between 30 and 40%
• Maternal and newborn mortality is high
   – Maternal mortality rate 733/100,000 lb (2006 DHS)
   – Newborn mortality rate 29/1,000 lb (2006 DHS)
• Post-natal care is underused
Project Overview - May 2008 to Dec 2009
• Implementers:
   – Burnet Institute (PNG and Melbourne offices),
     with funding from WHO, UNICEF, AusAID and
     donations, working with:
   – National and provincial government health
     authorities
   – Local church health services: health centres and
     staff
   – NGO (Save International PNG): village health
     volunteer program
• Initial products:
   – Proposals for ethics and government approval
   – Baseline survey of perinatal care practices
   – Technical papers on rationale for early post-natal
     visits, use of Uniject, and post-natal vitamin A
   – Revision to national inservice training curriculum
     to include Uniject birth dose Hep B and early
     post-natal visit
   – Education materials on post-natal care
   – Supervision and and reporting tools
Project Activities
• Support Uniject® Hep B
  procurement and distribution
  through government systems
• Training of available health
  providers at four rural health
  centres from December 2008 to
  December 2009, including:
   – Nine paid health centre staff
     (CHWs and similar)
   – 176 Village Health Volunteers
     (164 female)
• Monitoring and supervision of
  health provider activity by a
  locally based project officer
• Liaison with partners
   – Government health office
   – Catholic Health services (who
     run health centres in this area
   – NGO supporting VHVs
Our minimal post-natal care package for
community or aid-post level included:
• Hepatitis B vaccine
   – within 24 hours of birth, using Uniject®
• Essential education and information on:
   – breast-feeding and nutrition for the mother and baby
   – signs of infection in mother and baby and how to
     respond (and cord care)
• Additional
   – weighing the baby and information on care of low-
     birth weight babies, especially for temperature
     control
   – routine postnatal care for mother and baby, including
     further routine immunisations
   – family planning
   – vitamin A for the mother
                    Trainers
                    Manual


                  IEC brochure
                      draft




Both translated
 into Tok Pisin
Monitoring tools
• For VHV or CHW:
   – birth record
     form
   – Out-of-cold-
     chain calendar
• For project officer
   – Supervision
     checklist to
     capture
     operational
     detail
   – Activity
     database

                        Extract from birth record form
Findings—Human Resources
• Paid health centre staff were not able to
  make home visits within 24 hours of
  birth at any site, although some were
  trained in Uniject
• Provision by health volunteers (VHVs)
  was what extended vaccination to
  newborns who would usually not receive
  services
• Only VHVs who were trained and who
  were already attending deliveries
  provided HepB for home births
• Use of VHVs extended coverage: there
  were approximately 10 VHVs for every
  paid staff member
• Uniject Hep B vaccine, given by
  volunteers, helps extend
• All VHVs who were active credited the
  level of support provided (see next
  slide)
Findings—Village Health Volunteers
•   VHVs serve as only source of health
    care in areas unable to access
    health facilities - which is about
    65% of births
•   VHV training is effective for delivery
    of wide variety services (delivery,
    nutrition, malaria, infant care, early
    immunization)
•   VHVs were well-supportedProject
    built on the existing strong VHV
    program
     – Basic training of 3 months (4-
        12 years ago)
     – Frequent refresher training,
        which can include attachments
        at the provincial hospital
        maternity unit
     – Some linkages between VHVs
        and supervising health centres
        (strengthened by this project)
  Findings—Out of Cold Chain

• Feasible, but requires continuing
  monitoring
• VHVs showed good capacity to
  read and respond to VVMs and
  adhere to 30 day rule, even
  with minimal literacy
• Implementation was disrupted
  by the "30-day rule" when VHVs
  returned vaccine even though
  VVMs were still satisfactory
• One episode of heat damage to
  vaccine, which was returned to
  the provincial store – but this
  occurred at district level prior to
  use by volunetters
Findings—Uniject® presentation of
Hepatitis B vaccine

• VHVs and other health staff
  felt very positively about
  using Uniject
• For VHVs the chance to use
  this tool acted as an extra
  motivator to attend births
• Some VHVs requested other
  drugs, such as oxytocin, to
  be made available in this
  form
• Health centre staff also prefer
  this presentation due to ease
  of use
HepB birthdose coverage in home births
and health centres for two catchments:
• Biwat Catchment Home Deliveries
   – coverage between 50% and 80%
   – Uniject returned after 25 days in village despite adequate
     VVM but immediately replaced by health sentre staff
• Kambot Catchment Home Deliveries
   – around 30%
   – Uniject returned after 25 days in village despite adequate
     VVM but not immediately replaced, resulting in stock-outs
• Biwat Health Centre
   – Coverage increased to 100%
• Kambot Health Centre
   – Relatively well performing facility saw significant increase
     coverage to 100% with Uniject given by VHV in HC
• Wewak Provincial Hospital
   – Coverage sustained over several years at >98%
   – Labour Sister provides HepB as routine with VitK and other
     interventions
Challenges   • Continuing problems with logistics
               and transport, typical of such a
               difficult location
             • One site not started because
               health centre fridge not working
             • Unable to stimulate home visits
               by health centre staff due to
               workload
             • VHVs who lacked birthing skills
               did not use Uniject in an early
               post-natal visit, even though this
               had been part of training and
               project plans
             • Educational brochure on postnatal
               care not yet rolled out, although
               most VHVs do counsel the mother
               when providing birth dose
Next steps and questions
• National Department of Health is
  examining possible expansion to
  high-priority districts
• Economic analysis, considering:
   – balance of Uniject cost against
   – increased coverage and decreased wastage
• Other questions to consider:
   – Function in districts with different mix of
     non-government health service providers
   – Issues common to volunteer programs:
     accreditation and incentives
   – How many services can volunteers be asked
     to provide?
   – What level of home births makes this cost-
     effective?
• Need to measure current virus prevalence,
  both in children and women of child-
  bearing age, to assist in planning
Acknowledgements
• Biwat and Kambot Villages
   – Village Health Volunteers
   – Health centre staff
   – Community leaders and members
• East Sepik Provincial Health
   – Provincial Health Office: Mr Bunat, Sr Ale,
   – Save the Children NZ and Austrialia,
   – Catholic Health Services
• PNG NDOH Family Health:
   – Dr. William Lagani
• PNG Paediatric Society
   – Dr. David Mokela
• WHO PNG and HQ:
   – Richard Duncan, Eigil Sorensen, Steve Wiersma
• Burnet Institute PNG:
   – Hedwig Winjong, Jim Benn
• Burnet Institute Melbourne:
   – Chris Morgan <cmorgan@burnet.edu.au>