In Bhutan, only 88 per cent of pregnant women receive antenatal care, and skilled health professionals attend only 51 per cent of births. While most pregnancy-related complications are difficult to predict, they are easily treatable by trained birth attendants but the chances of a mother dying at birth rise when deliveries are not performed in hospitals or when they are performed by low-skilled health-care workers. In Bhutan, 225 out of every 100,000 women die during pregnancy or childbirth. Poor access, low utilization of health services and inadequate numbers of health providers, especially women, are some of the main challenges.
Towards a Solution
Between 2011 and 2014, the Thailand International Cooperation Agency teamed up with UNFPA to implement a South-South cooperation initiative that enabled Thailand to share its maternal health successes with neighbouring countries. Early on, Bhutan, along with the Lao People’s Democratic Republic and Myanmar, were chosen as pilot countries. The aim was to share Thailands ‘knowledge, experience and good practices in safe motherhood in order to improve women’s and girls’ health and well-being and to reduce the maternal mortality rate. The project sought to do this by improving the capacity of the country’s health institutions and personnel in dealing with emergency obstetric care, referral services, and prenatal and postnatal care and services. This includes training of health managers and the health workforce tailored to the needs of Bhutan. As facilitator, UNFPA ensured quality, partnership and sustainability throughout the process.
The project approach focused on four key principles:
- UNFPA as one: The UNFPA Bhutan and Thailand country offices communicated closely and acted as moderators with local partners. UNFPA facilitated activities at the country level to ensure that needs and demands were met;
- Demand-driven: The UNFPA-Bhutan-Thailand team conducted the participatory needs and demands assessment of Bhutan’s institutional capacity for safe motherhood services. All identified needs and action plans were developed and a memorandum of understanding was signed by three partners;
- Partnership: Under the UNFPA role as facilitator, the three parties agreed on roles and responsibilities, including sharing of resources. All three partners fully participated in the entire process, including design, implementation, monitoring and review; and
- Key processes: The key processes included the needs assessment, the design of the capacity development plan, identification and selection of mentoring institutions, selection of focal points and key institutions in Bhutan, delivering skills and knowledge, monitoring the application of knowledge and skills effectiveness, and programme review. The project took one year to prepare, three years to deliver and adjust the knowledge, and a half year to monitor for quality.
As a demand-driven project, all stakeholders from policymakers to practitioners, trainers, trainees and UNFPA focal points were fully involved in all processes. Discussion and debates were regularly conducted to ensure that all needs were identified. From the needs assessment to the review phase, concerned stakeholders were given opportunities to become involved and engage (for example, via feedback on programme design, curriculum and teaching methodologies, and adjustment of technology to best fit the local context).
Thailand was able to adjust its international learning programme on midwifery and safe motherhood to fit with the needs and demands of partner countries. Its expertise in safe motherhood practices, which it had developed to share with other countries, fully met World Health Organization (WHO) and International Confederation of Midwives international standards, which were adopted in order to improve the quality of midwifery training programmes. Online consultations in turn took place between Thai trainers and Bhutanese trained health personnel.
After completing the project, the key institutions working to improve Bhutan’s in-service training programmes for health personnel and midwife students used the technology and knowledge transferred to improve health services and systems. The triangular partnership and demand-driven approach have been documented and replicated by UNFPA and Thailand for other countries, such as the Lao People’s Democratic Republic, and is recommended as a model to ensure the ongoing transfer of knowledge and skills.
Partners include health personnel such as doctors, nurses and midwives in the Bhutan Ministry of Health, teachers and trainers of midwives of the Royal Bhutan Health and Sciences University, and pregnant women in Bhutan. Key implementing partners include: the Ministry of Public Health of Bhutan and the Royal Bhutan Health and Sciences University; the UNFPA country offices in Bhutan and Thailand; and the Government of Thailand (the Ministry of Health, including its nursing colleges and Department of Health; the Institute for Health Workforce Development; and the Ministry of Foreign Affairs).