Countermeasure for Maternal andChild Health and Child Welfare

Country Reports

Japan International Corporation of Welfare Services (JICWELS)Contents
1. CAMBODIA
2. MYANMAR (1)3. MYANMAR (2)4. THAILAND (1)5. THAILAND (2)
6. TIMOR - LESTE
7. VIET NAM

Countermeasure for Maternal andChild Health and Child Welfare

CAMBODIA

1

Cambodia～Part (A)Indicators～

Please confirm data of following Indicators: Not only data of ‘country overall’ but also its“Changes” compared with previous data and “Disparities within the country”. The Latter ismuch important for the coming discussion.
(1) Crude birth rate (per 1000 population)
Country overall
43.6
27.1
22.5

1990
2000
2010
(2) Crude death rate (per 1000 population)

Country overall
12.3
9.6
8.0

1990
2000
2010

(3) Leading causes of death (1990) and (2009)1990:
1) Diseases (Bacteria, virus and micronutrient deficiency)
2) Hygiene and poverty
3) Environment and low knowledge
2010:1) Diseases (Bacteria, virus and micronutrient deficiency)
2) Hygiene
3) Environment and low knowledge(4) Infant mortality rate (per 1000 live birth)
Country overall
95
66
45

2000
2005
2010

(5) Leading causes of infants death (1990) and (2009)
2000:
1) Diseased
2) Infection
2010:1) Diseased

2) Infection(6) Under-5 mortality rate (per 1000 live birth)
Country overall
124
83
54

2000
2005
2010

2

3) Anemia
3) Anemia

Cambodia(7) Top 3 diseases and morbidity rate of the under-5 of (1990) and (2010)
2000:
Diseases:
1) Acute respiratory illness (ARI) 2) Fever
3) Diarrhea
Morbidity rate:1) ARI 6%2) Fever 28% 3) Diarrhea 15%
2010:2) Sever acuteDiseases:
1) Acute respiratory illness (ARI) and fever
malnutrition and anemia 3) Diarrhea
Morbidity rate:1) ARI 6% and fever 28% 2) sever acute malnutrition 2.5% and3) Diarrhea 15%
anemia 55%(8) Maternal mortality rate (per 100,000 live birth)

Country overall
2000
437
2005
472
2010
206
(9) Leading causes of maternal death (1990) and (2010)
2000:
1) Hemorrhage
2) Eclampsia
2010:1) Hemorrhage
2) Infectionabortion3) Infection3) unsafe(10)

Are there national standards for certifying disabilities in your country?
Yes /If yes, please explain briefly.
To certify the disabilities, the Royal Government of Cambodia has issued
Inter-Ministerial Declaration (Prakas) between Ministry of Social Affairs, Veterans andYouth Rehabilitation on Classification and Type of Disabilities. This Prakas aim to define
national definition for collecting statistic and data to implement laws, policies and programs
related to disability. Disabilities were classified 4 kinds as following:
1. Physical Disability
2. Intelligent Disability
3. Mental Disability
4. Other Disability.
(11)

Does your country perform any health check for infants and children?
Yes /If ‘Yes’,-When (at how many months)? Every month-How many times? One time per month-What kinds of contents includes in each? scalp, yellow card for children,
mother card…..

(12)
In the case any diseases or disabilities are confirmed, is there any support serviceson them? Describe the services, if any.]- Treatment through IMCI- For sever acute malnutrition refer to hospital for treatment- For pregnancy and post partum women we provided iron/folic acid andmebendazol

3

Cambodia～Part (B)Preliminary Analysis～※It is recommended to analyze those strengths/weaknesses through the discussion withthe authorities concerned (health and welfare) before coming to Japan in order tofacilitate to find the way for the collaboration between health and welfare for mothers andchildren. Preferably country report should be prepared in collaboration with authorities.
1. Please try to describe the followings on the surroundings mothers and children.

••① Three (3) Strengths in your country / region.
⇒Maternal and Child Welfare：（1.Family planning/birth spacing

2. Safeabortion and post-abortion contraceptive
3. Care for the Infants and young children.）⇒ Maternal and Child Health ： （ 1.ANC and PNC 2. Provided vaccine
3.Provided micronutrient (Iron/Folic Acid, Vitamin A, Multiple Micronutrient
Powders) and Mebendasol）② Three (3) Weaknesses/Challenges in your country / region.
⇒Maternal and Child Welfare：（1. Financial barriers to access health services.
2.Hygiene. 3. Environment and poverty）⇒Maternal and Child Health：（1. Limited capacity in Leadership and governanceamong provincial and district in planning of MNCH activities. 2. Insufficient skills andknowledge of service providers for MNCH activities. 3. Limited access to MNCH care）

2. In your country / region, who are the most vulnerable populations? Please list three(3)groups in order of priority.
ex) groups living rural areas? with low-income? with disabilities?
（1.People are living in rural areas 2. People are poverty 3. Pregnancy andpost partum women and children under five years）
3. What kinds of services are there for the above mentioned groups?
- Health center staff conducted outreach activities at villages far from healthcenter.
- To provide vaccine, vitamin A, Mebendazol, multiple micronutrient powders,
iron/folic acid.
- To conducted ANC and PNC at health center and community- We have to provide fund for people who have poverty- To provide services to orphan and vulnerable children (OVC) and poor children.
4. In implementing health/welfare policies and services by your organization：⇒to develop these strengths and improve these weaknesses,⇒to develop the services for the most vulnerable populations,4Cambodia①In your country/province, what are the priority issues/programmes in the area ofmaternal and child health/welfare? List five issues/programmes in order of priority.
（1.Emergency Obstetric and Newborn Care 2.Skilled Birth Attendance 3. Promote Child Care
Services in Orphanage and Community
4.Safe Abortion 5.To provide vaccine and micronutrient）②What are successful areas or programmes? List 3 areas or programmes.
（1.National Immunization Program 2.National Reproductive Health Program 3.
National Nutrition Program）②What are these challenges? List 3 challenges.
（1. Financial barriers to access health services. 2. Lack of human resources 3. Lackof good quality and adequately equipped health facilities to provide comprehensive healthservices.）③ Regarding the above-mentioned issues/challenges, explain background, current
situation and reason why those issues/challenges are difficult to solve.
- National policies and guidelines were not widely disseminated.
- Awareness of the limited special people in remote areas of praise.
- Funding for health service providers is limited.
- Guidelines and policies of providers of services outreach activities give priority
to villages far.
- HC times do not have enough staff for service providers, especially not enoughmidwifes.
④Describe your expectations to the training course.
- I will gain an understanding of the concept related to maternal and childhealth/welfare to improve and promote the social service to poor children andorphans and vulnerable children (OVC).
- I will understand how to write a good report related to maternal and childhealth/welfare sector.
- I will get the new experience from others countries, especially Japan from thistraining and I will share my experience to my coworkers.

5

Countermeasure for Maternal andChild Health and Child Welfare

MYANMAR(1)

6

Maternal and Child Health in Myanmar

Township Health Department
Taunggyi, Shan State
MyanmarMaternal and Child Health
Overview and Disparities

7

General Objective• To improve the health status of mother and children
including newborn by reducing maternal, neonatal andchild mortality and morbidity
Specific Objectives• To increase access to universal coverage of quality maternal
and newborn health services in Myanmar through ‐antenatal care
‐ deliveries by skill birth attendant‐ Emergency Obstetric Care
‐ Post abortion Care and Birth Spacing‐ Essential Newborn Care
3

Policy guidelines• National Health Policy– Guidelines of National Population Policy• National Population Policy– Awareness promotion on reproductive
responsibility and paternal involvement• Myanmar Reproductive Health Policy

48Strategic Approach for Reproductive Health
1. Setting enabling environment;
2. Improving information base for decision
making;3. Strengthening health systems and capacity
for delivery of quality reproductive healthservices;
4. Improving community and family practices.

5

Organization Set Up (Central level)
DG
Dy DG

Dy DG

(Disease Con)

Dy DG

(PH)

(Medical Care)

Dy DG(Admin)Director (PH)

DD
(MCH)

DD
(WCHD)AD (MCH)

AD (MCH)

MO (MCH)

MO (MCH)

DD
(BHS)

DD
(School H)

DD(Nutrition)

DD(BHS,
Training

DD(EH)

2 (DDs)(HE)

69Organization Set Up for Public Health( State/ Regional level)
S/D
Health Director

4 Senior Medical
Officers(MCH/SH)

TMO

MO(MCH/SH/UHC)

AS

LHV

SMO

HA (RHC)MWs

HA (RHC)THO

HA (RHC)

LHVs

LHVs

LHVs

MWs

MWs

AMWs(19974),TTBAs(10167)

MWs

MCH MOs – 52
MCH centers ‐ 348

Indicators
Health Index

1988

1999

2010

Crude Birth
Rate

Urban

28.6

24.5

15.4

Rural

30.5

27.1

16.6

Crude Death
Rate

Urban

8.9

6.0

5.2

Rural

9.9

7.8

6.1

Infant Mortality Urban
Rate
Rural

47.0

55.1

25.6

49.8

62.5

27.8

Urban

72.9

65.12

34.43

Rural

‐

85.16

35.11

Urban

1.0

1.8

1.12

Rural

1.9

2.8

1.54

Under fiveMortality Rate
Maternal
Mortality ratio

107Maternal Mortality Ratio in Myanmar
600

580

Per 100,000lb

500
470

400

360

300

260

200

200
145

100
0
1990

1995

2000

2005

2010

Source: UN interagency estimate, 2010

4.23% 1.41%

7.04%

35.21%

8

6

8.45%
9.86%

7

5

1

4
3

2

16.90%

16.90%

1. Haemorrhage
2. Hypertensive disease of pregnancy in cluding eclar
3. Abortion related
4. Prolonged/obstructed labour
5. Puerperal sepsis
6. Postpartum anaemia causes
7. Embolism
8. Indirect causes

Causes of Maternal Death (n=71)
11

2015

Maternal Mortality by Urban-Rural Residence

Urban -11 %Rural -89 %Maternal Deaths by Place of Delivery (%)

Hospital

Transit
2.5

10
87.5

Home

12

Infant and under 5 mortality
200

150

130
100

98

U5MR

82.4

IMR

50

77.77
66.1

55.4

46.1

55.1
45.7

43.3
32.7

37.5

0
1990

1995

1999

2000

2003

2005

2009

2010

2015

Source: MICS 2010

Causes of Death in children under five years age
CausesNeonates ( lessthan 28 days) in %Prematurity

30.9

Birth Asphyxia

24.5

Sepsis25.5(include pneumonia)

Above 28 days andless than 5 years
age (%)

5.8

Pneumonia

27.6

Diarrhoea

17.6

Brain Infection

17.1

Malaria

7.6

Beri Beri

7.1

Others17.2

13

Place of Death (U5MR)• Disproportionately higher in rural areas( 87% ) compared to that of urban areas(13%)

Place of Death
13 %‐ Urban Area

87%‐ Rural Area

Distribution of Under 5 Deaths By Age (Years)(n =778)
No of Deaths

600

570 (73%)

500
400
300
200
100
0

<111

83 (11%)58 (7%)

47 (6%)

2

3
Age (Years)4

20 (3%)

73 % of Death Occurs Under One Year

14

5

No Of Deaths

Distribution of Under 1Year Deaths by Age in Months(n=570)
200
180
160
140
120
100
80
60
40
20
0

192(34%}109(19%)93(16%)
64(11%)
24(4%)
18(3%) 14

<1

1

2

3

4

5

6

12

13

7

8

8

9

12

11

10

11

70 % of Death Occurs Under Three Months
34% Death Occurs Under One Month

Health Care Seeking pattern
60
40

49%

20
0

44%

Trained7%

Untrained Traditional

44 % treated with untrained
persons before death.

15Summary
Main causes of deaths for MMR were
• PPH
• Severe PET or Ecla
• Abortion complications
Main causes of deaths for U5MR were
• Neonatal Diseases• Infectious diseases which can be preventable and curable• Strongly related to key family practices
Most of the deaths occurred• In rural area
• Young infants and Neonate

MCH activities needed to be strengthened in order toachieve the MDG 4 and 5• Providing proper antenatal care
• Promoting skilled and institutional delivery and post natal
care• Expansion of post abortion care and quality birth spacing
services• Ensuring Emergency Obstetric Care
• Providing new born care
• Strengthening adolescent reproductive health• Promoting male involvement in RH• Focusing cervical cancer screening, early Dx and Tx• Promoting referral system and community volunteers

16Five year Strategic Plan for Child Health Development• The continuum of care for the mother and child (life cycle
approach)• The continuum of care across the health system (home andcommunity, first‐level health facilities and referral facilities)

Interventions most effective in improving child survival
Intervention

Reduction in under five
deaths (%)

Antenatal care

4

Skilled care at birth13

Postnatal care: routine care for newborns,additional care for
LBW, treatment of neonatal sepsis

13

Exclusive breast feeding

13

Appropriate complementary feeding, including
micronutrients

6

Immunization5

Insecticide‐ treated bednets

7

ORT and zinc for diarrhoea

19

Treatment of suspected pneumonia

6

Treatment of malaria

517Challenges/Weaknesses• Inadequate health workforce at different levels• Over workload of the BHS especially the midwives• Regular and systematic monitoring and supervision
mechanism• Reporting status• Harmonization of data and activities• Linkage of health service provision• Geographical and coverage gaps

Strengths• The financial allocation to health sector has been increased –free of charge services/ essential medicines supplies• Decentralization of the authority upon health expenditure ateach State/Region according to the bottom up plans• Integration and coordination with other programs bring
opportunities for child health development• Health volunteers were trained for community health careservices( by government as well as the NGOs/INGOs)

18

Countermeasure for Maternal andChild Health and Child Welfare

MYANMAR(2)

19

Overview of Maternal and Child
Health in Myanmar
Department of Food and Drug Administration
Member, MMCWA, Bago Region
MyanmarContents
2

Objectives
Policy Guidelines
Organization setup
Activities of MMCWA
Output and Indicators
Challenges
Future Plan

20

Objectives3

 To carry out operation to achieve its mission withfocus on mothers and children;
 To carry out education, health, economic andsocial activities down to grassroots level and keep
it as priority;
 To provide necessary assistance at various levels;
 To cooperate with related governmental and non-governmental organization.

Policy guidelines4 National Health Policy Guidelines of National Population Policy National Population Policy Awareness promotion on reproductive

responsibility and paternal involvement Myanmar Reproductive Health Policy

21

Myanmar Maternal and Child Welfare Association
Organizationl Structure
5

Central Council
Central Executive CommitteeState and Regional
Supervisory Committees
District Supervisory Committees
Township Associations
Branch Associations

6

22

Activities of MMCWA
7

A.

Health Activities

B.

Education Activities

C.

Economic Activities

D.

Social Acitivities

E.

International Relations

A. Health Activities
8

1. To carry out activities for health education
2. To carry out community based health activities incollaboration with Department of Health
3. To implement activities for reduction of maternalmortality ration and infant mortality rate throughMaternity Homes.
4. To promote capacity building, training ofauxiliary midwives and ten-household-in-chargevolunteers.

23

A. Health Activities
9

5. To carry out early detection of female
reproductive tract cancer and referral to thenearest health centres for further management.
6. To carry out nutrition promotion activities for"under 5" children.
7. To improve knowledge on indigenous medicine
among women and promote practising thereof.

B. Education Activities
10

1. To carry out early childhood development
programme by establishing community based daycare centres and pre-schools.
2. To ensure all children of school going age
complete their primary education.
3. To provide financial aid for formal education.
4. To participate in literacy campaign activities.
5. To promote evening classes and community
learning centres.

24

C. Economic Activities
11

1. To provide vocational training courses on sewing,
knitting, cooking, etc. appropriate to the respective
region in order to generate family income.
2. To carry out Micro credit and small loan scheme.
3. To assist in house-hold agriculture/ livestock
breeding.
4. To assist in small scale home industries.
5. To find appropriate job offers for the needy women
who want to work.

D. Social Acitivities
12

1. To provide assistance to mothers and children
with difficulties in health care and education.
2. To assist in activities for safeguarding cultural
heritage.
3. To assist in programme for "elderly care".

25

E. International Relations
13

1. Implementation of projects on Health in co-ordinationand collaboration with UN agencies and someInternational Non-government Organizations.
2. PMCT project and EBF Project with UNICEF.
3. RH, ARH and Maternity Waiting Home projects with
UNFPA.
4. 5 A' s with IPPF
Adolescent, AIDS, Abortion, Access, Advocacy
5. Community Based HIV/ AIDS care with NAP/ DOH.
6. Community Based TB care with NTP/DOH.

14

Output and Indicators

26

Antenatal Care Coverage (%)(2012)AN Coverage (%)≥ 80
71- <80≤ 70

Deliveries with Skilled Birth Attendants (%)(2012)

Deliveries with
Skilled Birth Attendants (%)
71 - 80
61- 70≤ 60

27Abortion Rate (%)(2010 ‐ 2012)Maternal Mortality Ratio (per 1000 LBs)
(2010 – 2012)28

Maternal Mortality Ratio in Myanmar
600

520

Per 100,000lb

500
380

400

300

300

230

200

200
130

100
0

1990

1995

2000

2005

2010

2015

Source: UN interagency estimate, 2010

Infant and under 5 mortality
20

200

150

130
100

98

U5MR

82.4

IMR

50

77.77
66.1

55.4

46.1

55.1
45.7

0

1990

1995

1999

2000

2003

Source: MICS 2010

29

43.3
32.7

37.5

2005

2009

2010

2015

4.23% 1.41%

7.04%
8.45%
9.86%

7

6

35.21%

8

5

1

4
3

2

16.90%

16.90%

1. Haemorrhage
2. Hypertensive disease of pregnancy in cluding eclar
3. Abortion related
4. Prolonged/obstructed labour
5. Puerperal sepsis
6. Postpartum anaemia causes
7. Embolism
8. Indirect causes

Figure3. Causes of Maternal Death (n=71)

Maternal Mortality by Urban-Rural
Residence
22

Urban -11 %Rural -89 %30

Maternal Deaths by Place of Delivery (%)
23

TransitHospital
2.5

10
87.5

Home

U5MR by Region
Region24

1. Hilly
2. Coastal
3. Delta
4. Central Plain
Union

U5MR
66.3
58.7
59.0
76.8
66.1

31

Place of Death (U5MR)
25

 Disproportionately higher in rural areas( 87% ) compared to that of urban areas(13%)

Place of Death
13 %- Urban Area

87%- Rural Area

No Of Deaths

Distribution of Under 1Year Deaths by Age in Months(n=570)
200
180
160
140
120
100
80
60
40
20
0

192(34%}109(19%)93(16%)
64(11%)
24(4%)
18(3%)14

<1

1

2

3

4

5

6

12

13

7

8

11

8

12

9

10 11

70 % of Death Occurs Under Three Months
34% Death Occurs Under One Month32

Leading Causes of Neonatal Deaths
30.9%

19.1%

25.5 %

24.5 %

SepsisPre-maturity
LBW

Asphyxia

Other

Leading Causes of Post Neonate Deaths
28 %
18 %

22%
17 %
8%

ARI

Diarrhoea

Brain
Infection

33

Malaria

7%

Beri
Beri

Other

Health Care Seeking pattern
60
40

49%
44%

20
0

Trained7%

Untrained Traditional

44 % treated with untrained
persons before death.

Main causes of deaths for MMR were
PPH
Severe PET or Eclampsia

Abortion complications
Main causes of deaths for U5MR were
Neonatal Diseases

Infectious diseases which can bepreventable and curable
Strongly related to key family practices
Most of the deaths occurredIn rural areaYoung infants and Neonate
30

34

Challenges
31

 Monitoring and supervision mechanism Volunteer work, no regular payment for staffs
 Reporting status
 Not well established infrastructure (Office,communication tools, facilities)
 Health expenditure depends on donor

Future Plan
32



Health promotion and health education up to
suburban and rural area.



Help for early referral of pregnant mothers, neonate,< 1 and < 5 children to reach hospitals and clinics.

Training and capacity building of local AMW, Tenhousehold leaders, MCH promoters and MMCWA
members

Infrastructure and facility promotion of labor room of
MMCWA.

35

Future Plan
33



Reproductive Health promotion.

Coordination with BHS and Health education
dissemination of vaccine preventable diseases.

Coordination and Cooperation of diseases control
activities of TB, Malaria and HIV, AIDS

Nutrition promotion activities

Coordination with related department in disastermanagementEnvironmental sanitation activities

Future Plan
34

Growing of Herbal medicine plants and giving
knowledge to family about traditional medicine

School health activities for healthy environment ofschool children

Health education to parents of pre school children

Helping every children for primary education



Micro financing activities

Social activities

Awarding of model MMCWA members

36

Countermeasure for Maternal andChild Health and Child Welfare

THAILAND
(1)

37

Thai

Country Report for JICA training course (2015)“Countermeasure for Maternal and Child Health and Child
Welfare”～Part (A)Indicators～(1) Crude birth rate (per 1000 population)
1990
2000
2010

Country overall
19
15
11

Source: http://data.worldbank.org/indicator/SP.DYN.CBRT.IN(2) Crude death rate (per 1000 population)
1990
2000
2010

Country overall
677Source: http://data.worldbank.org/indicator/SP.DYN.CDRT.IN/countries(3) Leading causes of death per 100,000 population (1999) and (2009)
1999: 1. NCD 89%
2009: 1. NCD 71.5%

2. CD 6.7%
3. Accident 3.5%
2. Accident 14.7% 3. CD 13.8%

In 2009, the leading causes of deaths by diseases
1) Cerebrovascular disease 28%,2) cardiovascular disease 16.6%,
3) Diabetes 13.4%, 4) accident 11%,5) CA liver 11%
Source: Burden of Disease Thailand, 2009 (http://thaibod.net/en/report.html)(4) Infant mortality rate (per 1000 live birth)
Country overall
1990
30
2000
19
2010
13
Source: http://data.worldbank.org/indicator/SP.DYN.IMRT.IN/countries

38

Thai

(5) Leading causes of infants death (2004)
2004: 1)

Death during labour

2)Prematurity

Source: Ministry of Public health Thailand, 2008

3) Birth asphyxia(6) Under-5 mortality rate (per 1000 live birth)

1990
2000
2010

Country overall (WB)
37
23
15

Country overall (MOPH)
12.8
11.9
9.5

Source: WB: http://data.worldbank.org/indicator/SH.DYN.MORT/countries
MOPH: Thailand Health Profile 2009, MOPH, Thailand(7) Top 3 diseases of the under-5 of (2000), (2005), and (2009)
2000:
Diseases: 1) neonatal causes 2) Infection (diarrhea/pneumonia) 3) HIV
Source: Ministry of Public Health Thailand, 2008
2005:
Diseases: 1) Birth asphyxia2) Obstetric condition
3) Drowning
Source: Thailand Health Profile, 2009, MOPH, Thailand
2010
Diseases: 1) Infection 2) Obstetric condition and Perinatal deaths 3) Malnutrition
Source: Burden of Disease Thailand, 2009 (http://thaibod.net/en/report.html)(8) Maternal mortality rate (per 100,000 live birth)
Country overall
42
40
28
26

1990
20001
20101
20132
1

Source: 1) http://data.worldbank.org/indicator/SH.STA.MMRT/countries2) http://apps.who.int/gho/data/node.country.country-THA?lang=en(9) Leading causes of maternal death (2002) and (2007)
2002: 1) Delivery cause2) maternal disorders predominantly edema, proteinuria,
and hypertension in pregnancy 3) Pregnancy with abortive outcomes
2007: 1) Delivery cause 2) other maternal disorders predominantly related topregnancy (except hypertensive disorders) 3) Pregnancy with abortive outcomes
Source: Health Information Unit, Bureau of Health Policy and Strategy, MOPH Thailand

39

Thai
(10)

Are there national standards for certifying disabilities in your country?
Yes / NoIf yes, please explain briefly.

There are 7 types of disabilities in Thailand
1.
2.
3.
4.
5.
6.
7.

Visual Impairment
Hearing Impairment
Physical Disabilities
Psychiatric Disabilities
Intellectual Disabilities
Learning Disabilities
Autism Disorder

Source:Notification of Ministry of Social Development and Human Security, Subject:Classification and measurement on disabilities (issue 2)(11)

Does your country perform any health check for infants and children?
If ‘Yes’, When (at how many months)? -How many times?
Yes / NoFor pregnancy woman  at least 5 times, adapted from WHO new ANC guideline
No.
1
2
3
4
5

Gestational age
Before 12 weeks
18 – 20 weeks
26 weeks
32 weeks
38 weeks

Contents (screening + treatment + parental school)
History taking+ PE+ initial lab test
History taking + PE + ultrasound for GA estimation
History taking + PE + routine lab
History taking + PE + routine lab + 2nd lab test
History taking + PE + routine lab + ultrasound

For infant and children
No.
1
2
3
4
5
6
7
8
9
10

Age
1 month (+-7 days)
2 months (+-7 days)
4 months (+-15 days)
6 months (+-15 days)
9 months (+-15 days)
12 months (+-15 days)
18 months (+-1 month)
2 years (+-1 month)
3 years (+-1 month)
4 years (+-1 month)

Thailand has MCH book that covers both records of mothers and children as shown picture.

(12)

In the case any diseases or disabilities are confirmed, is there any support

40

Thai
services on them? Describe the services, if any.]
1.
2.
3.
4.
5.

National health insurance.
Monthly allowance for disabilities 800 Baht/month (2015).
Temporary shelter for children and families.
Public Health Volunteer System.
Social welfare and services within local authority.

Source: Ministry of Public and Ministry of Social Development and Human Security

41

Thai

～Part (B)Preliminary Analysis～※It is recommended to analyze those strengths/weaknesses through the discussion
with the authorities concerned (health and welfare) before coming to Japan in order tofacilitate to find the way for the collaboration between health and welfare for mothers
and children. Preferably country report should be prepared in collaboration withauthorities.
(1) Please try to describe the followings on the surroundings mothers and children.
① Three (3) Strengths in your country / region.
⇒Maternal and Child Welfare：1) National framework/ agenda/ strategy focusing on MCH welfare
2) Family and Community Support.
3) Re-structure of Welfare Department.
⇒Maternal and Child Health：1) Benefit package in terms of health care for mothers and children
2) Certified MCH-standard in all public hospitals
3) High coverage of MCH health services② Three (3) Weaknesses/Challenges in your country / region.
⇒Maternal and Child Welfare：1) Nuclear family.

2) Single parents.
3) Teenage pregnancy.
⇒Maternal and Child Health：In terms of MCH issues

1. Low birth weight
2. Lowest rate of exclusive breastfeeding in ASEAN
3. Teenage pregnancy
In terms of Health system
1. Inaccuracy of health management and information system

42

Thai
2. Low public-private partnership and private hospital participated in national program(2) In your country / region, who are the most vulnerable populations? Please list three(3) groups in order of priority.
1. Low-income people
2. People with disabilities
3. Psychiatric disabilities(3) What kinds of services are there for the above mentioned groups?

-

In terms of health services, those above mentioned groups can access to healthcare for free under the universal health coverage schemes.
In terms of social welfare, those people with disabilities will receive monthly
allowance 800 bath/person(4) In implementing health/welfare policies and services by your organization：
By health sectors;⇒to develop these strengths and improve these weaknesses,
MOPH should work with multi-partner to raise the important of mothers and children
at top priority of national agenda. Then, all stakeholders review and implement
necessary benefit packages for MCH health as regular.
To improve the weakness, the national authority should review past and current
situation in order to find gaps of existing policies and determine the solutions to improve
weakness especially how to involve private hospitals to take part in national program.
⇒to develop the services for the most vulnerable populations,Thailand has universal health coverage scheme which covers all people who are
not covered by civil servant medical schemes and social security scheme. So, all lowincome people could access to health services for free especially maternal and childhealth care in public hospitals wherever they live.
What should be developed is the quality of health care. All people should receive
good care regardless of their abilities to pay and the type of health care facilities. The
MOPH tries to set standard and guidelines and also monitoring system to monitor healthservices delivered by health care facilities.

(5) In your country/province, what are the priority issues/programmes in the area

43

Thai

of maternal and child health/welfare? List five issues/programmes in order ofpriority.
1. Prevention and protection on teenage pregnancy.
2. Improve child rearing practices and increase child development
3. Surrogate mother issue.
4. Temporary shelter for children and families.
5. Child protection system.
(6) What are successful areas or programmes? List 3 areas or programmes.
In terms of health;
1. Prevention of Mother-to-Child HIV transmission
2. Certified MCH-standard in all public hospitals
3. MCH handbook(7) What are these challenges? List 3 challenges.
In terms of health;
1. Low birth weight
2. Low exclusive breastfeeding
3. Teenage pregnancy.
��8 Regarding the above-mentioned issues/challenges, explain background,current situation and reason why those issues/challenges are difficult tosolve.
For Low birth weight, LBW, (less than 2500 gram at birth), it is one of major publichealth problem which causes morbidity and mortality in infant and children in
Thailand. It also affects child development in early childhood. Currently, the rate of
LBW infant is around 10.9% in 2011 (National Health Security Office, 2011) andshow no signs to decreased. To solve the problem, it is necessary to 1) improvematernal nutritional status and 2) improve the quality of antenatal cares. As there
are many factors related to maternal nutritional status especially social determinantsof health and social welfare, that is why this problem is difficult to solve.
For breastfeeding issues, the MICS 4 surveyed in 2012 showed that only 12% of
mothers exclusively breastfed their children. This is the lowest rate of EBF among
ASEAN countries which is really need to be improved. From national research, themain reasons why mother discontinue breastfeeding are 1) returning to works, 2)
misunderstanding and improper attitudes towards breastfeeding and 3) lack ofsupports. The challenge for this problem is how to raise awareness of other sectors
on the important of breastfeeding and seek their cooperation in order to build
enabling environment for promoting breastfeeding practices, for example, how todeal with the labor sector to increase maternity leave to 6 months, how to deal withthe company to control their advertisement about infant formula.

44

Thai

(9) Describe your expectations to the training course.
1. To learn how to integrate Child welfare to maternal and child health
2. To learn the best practices and experiences from Japan and other countries
2.1 The Japanese health and welfare programmes for MCH on
2.1.1 The MCH book2.1.2 The promotion of breastfeeding in Japan
2.1.3 How to promote reading culture for children in Japan
2.1.4 MCH major health problems and how to solve it.
3. to share my experiences and views on maternal and child health in Thailand

45

Countermeasure for Maternal andChild Health and Child Welfare

THAILAND
(2)

46

Thai

Country Reportfor JICA training course (2015)“Countermeasure for Maternal and Child Health and Child
Welfare”～Part (A)Indicators～(1) Crude birth rate (per 1000 population)

Country overall
19
15
11

1990
2000
2010

Source: http://data.worldbank.org/indicator/SP.DYN.CBRT.IN(2) Crude death rate (per 1000 population)

Country overall
6
7
7

1990
2000
2010

Source: http://data.worldbank.org/indicator/SP.DYN.CDRT.IN/countries(3) Leading causes of death (1990) and (2009)
1990: 1.
2006: 1. Cancer 83.1
2010: 1. Cancer 91.2

2.
2. Accident 59.8
2. Accident 51.6

3.
3. Heart Disease 28.4
3. Hypertension 31.4

Leading Cause of Death per 100,000 Population
Source: Public Health Statistics 2010, Thailand(4) Infant mortality rate (per 1000 live birth)
1990
2000
2010

Country overall
30
19
13

Source: http://data.worldbank.org/indicator/SP.DYN.IMRT.IN/countries

47

Thai

(5) Leading causes of infants death (1990) and (2009)
1990:
1)
2)
3)
2010:
1)
2)
3)
Source:(6) Under-5 mortality rate (per 1000 live birth)

Country overall
37
23
15

1990
2000
2010

Source: http://data.worldbank.org/indicator/SH.DYN.MORT/countries(7) Top 3 diseases and morbidity rate of the under-5 of (1990) and (2010)
1990:
Diseases:
1)
2)
3)Morbidity rate:
1)
2)
3)
2010:
Diseases:Morbidity rate:

1)
1)

2)
2)

3)
3)

Source:(8) Maternal mortality rate (per 100,000 live birth)
Country overall
42
40
28

1990
2000
2010

Source: http://data.worldbank.org/indicator/SH.STA.MMRT/countries(9) Leading causes of maternal death (1990) and (2010)
1990:
1)
2)
3)
2010:
1)
2)
3)
Source:

48

Thai
(10)

Are there national standards for certifying disabilities in your country?
Yes / NoIf yes, please explain briefly.

There are 7 types of disabilities in Thailand
1.
2.
3.
4.
5.
6.
7.

Visual Impairment
Hearing Impairment
Physical Disabilities
Psychiatric Disabilities
Intellectual Disabilities
Learning Disabilities
Autism Disorder

Source: Notification of Ministry of Social Development and Human Security, Subject:Classification and measurement on disabilities (issue 2)(11)

Does your country perform any health check for infants and children?
Yes / No
If ‘Yes’,-When (at how many months)? -How many times?
No.
1
2
3
4
5

Gestational age
12 weeks
18 weeks
26 weeks
32 weeks
38 weeks

No.
1
2
3
4
5
6
7
8
9
10

Baby age
1 month (+-7 days)
2 months (+-7 days)
4 months (+-15 days)
6 months (+-15 days)
9 months (+-15 days)
12 months (+-15 days)
18 months (+-1 month)
2 years (+-1 month)
3 years (+-1 month)
4 years (+-1 month)

49

Thai
-What kinds of contents includes in each?
Part 1 a memo for mother.
Part 2 a memo for agent.
Part 3 the knowledge of pregnancy for husband to read and support.
Part 4 the knowledge of baby development for parent and care taker to read and follow the
instruction.
Source: Mother and Child Health Book
(12)
In the case any diseases or disabilities are confirmed, is there any support services onthem? Describe the services, if any.]
1.
2.
3.
4.
5.

National health insurance.
Monthly allowance for disabilities 800 Baht/month (2015).
Temporary shelter for children and families.
Public Health Volunteer System.
Social welfare and services within local authority.

Source: Ministry of Public and Ministry of Social Development and Human Security

50

Thai

～Part (B)Preliminary Analysis～※It is recommended to analyze those strengths/weaknesses through the discussion
with the authorities concerned (health and welfare) before coming to Japan in order tofacilitate to find the way for the collaboration between health and welfare for mothers
and children. Preferably country report should be prepared in collaboration withauthorities.
1.

Please try to describe the followings on the surroundings mothers and children.
① Three (3) Strengths in your country / region.
⇒Maternal and Child Welfare：

1. Family and Community Support.

2. Social network and Social media.
3. Re-structure of Welfare Department.
⇒Maternal and Child Health：

1. Public Health Volunteer System.

2. National Health Security Office (NHSO).
3. Mother and Baby Book.
② Three (3) Weaknesses/Challenges in your country / region.
⇒Maternal and Child Welfare：

1. Nuclear family.

2. Single parents.
3. Teenage pregnancy.
⇒Maternal and Child Health：

1. Minimum standard for health insurance (not appropriate).
2. Limitation of health services in rural areas.
3. Inadequate ratio of doctor and nurse.

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Thai
2.

In your country / region, who are the most vulnerable populations? Please list three(3)groups in order of priority.
ex) groups living rural areas? with low-income? with disabilities?
1. Mothers and children with HIV.
2. Terminal patient.
3. Psychiatric disabilities.

3.

What kinds of services are there for the above mentioned groups?

There are lack of shelter and variety of services for the above mentioned groups.
4. In implementing health/welfare policies and services by your organization：⇒to develop these strengths and improve these weaknesses,⇒to develop the services for the most vulnerable populations,①In your country/province, what are the priority issues/programmes in the area ofmaternal and child health/welfare? List five issues/programmes in order of priority.
1. Prevention and protection on teenage pregnancy.
2. Surrogate mother issue.
3. Temporary shelter for children and families.
4. Child protection system.
5. Maternal and child health insurance.

②What are successful areas or programmes? List 3 areas or programmes.
1. Public Health Volunteer System

2. National Health Security Office (NHSO).
3. Re-structure of Welfare Department.

②What are these challenges? List 3 challenges.
1. Teenage pregnancy.
2. Social worker license.
3. Educational system.
③Regarding the above-mentioned issues/challenges, explain background, current
situation and reason why those issues/challenges are difficult to solve.

According to my own experience, I found that there are limitation of shelter andservices for HIV mothers and children. Moreover, the government have not set up
the specific shelter or welfare service for this needy group.

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Thai

④Describe your expectations to the training course.

1. To understand more about Maternal and Child Health (MCH)
2. To share an experience with other participants
3. To improve our work on MCH in temporary shelter

53

Countermeasure for Maternal andChild Health and Child Welfare

TIMOR - LESTE

54

Country Report JICA Training Course on:“Countermeasure for Maternal Child Healthand Child Welfare‐2015”(Timor Leste Representative)

55

COUNTRY PROFILE
A. BACKGROUND
Timor‐Leste is a small country in Southeast Asia. It occupies primarily the eastern half of theisland of Timor, with
West Timor being partof the Republic ofIndonesia. Timor‐Leste
includes the nearby
islands of Ataúro andJaco, and also Oecussi,
anexclaveinIndonesian West Timor.
The first inhabitants
are thought to bedescendedfromAustraloid
andMelanesian
people.
Contact between the Portuguese and the island of Timor began in the early 16th century,with trade and eventual colonization occurring in the middle of the century. In 1859, thewestern portion of the island was ceded to the Dutch. During World War II, Japan occupied
Timor‐Leste from 1942
to
1945.
Portugal
resumedcolonial
authority
aftertheJapanese defeat in 1945.
The country declared
independence
fromPortuguese
ruleonNovember 28, 1975, butwasinvadedandoccupied by Indonesianforces just nine days
later on December 7, 1975. It was incorporated into Indonesia in July 1976 as a province
known as Timor‐Timur. Between 1974 and 1999, there were an estimated 102,800 conflict‐related deaths (approximately 18,600 killings and 84,200 “excess” deaths from hunger andillness), the majority of which occurred during the Indonesian occupation (UNESCO, 2009).
The local climate is tropical and generally hot and humid, characterized by distinct rainy anddry seasons. Timor‐Leste is divided into 13 administrative districts (now is known as
Municipio), 65 sub‐districts, and 442 Sucos and 2,225 aldeias. The 13 districts/municipio are

56

Ainaro, Alieu, Baucau, Bobonaro, Covalima, Dili, Ermera, Lautem, Liquiçá, Manatuto,
Manufahi, Oecussi,
andViqueque.
Thirty percent of
the population lives
in the urban areas,
and the rest live inrural areas (NSD,2010). Dili is thecapital. It is thelargest city and themain port. The
second‐largest cityis the eastern townof Baucau. Dili has
the only functioning
international
airport,thoughthere is also an airstrip in Baucau that is used for domestic flights. Several languages are
spoken in the country. Tetum is the most common language in Timor‐ Leste and is the first
official national language. Portuguese, spoken by fewer people, is the other official language.
English and Indonesian are working languages.
Despite having Natural oil and gases, agriculture and fishery are the backbone of the
Timorese economy, and coffee plantations have been of major significance. The 2007 Timor‐
Leste Survey of Living Standards reported that nearly 50 percent of the Timorese lived
below the national poverty line, estimated at $0.88 per capita per day. Based on a recent
survey‐to‐survey imputation calculation, the incidence of poverty in the country is predicted
to have declined by 9 percentage points between 2007 and 2009 (MOF, 2010). Timor‐Leste’s
Human Development Index for 2010 is 0.502—positioning the country at 120 out of 169
countries and areas (UNDP, 2010). This is an increase of 17 percent from 0.428 in 2005.
During the same period, Timor‐ Leste’s life expectancy at birth increased by over 2 years.
According to the 2004 Census, the population of Timor‐Leste is 923,198 and the annual
growth rate is 5.3 percent (NSD, 2006). The population increased by 24 percent over the last
15 years, growing from 747,547 in 1990 to 923,198 in 2004 (NSD, 2006). The population iscurrently estimated at 1,066,582 with an annual growth rate of 2.4 percent between the2004 Census and the 2010 Census (NSD, 2010). According to the 2004 Census, life
expectancy was estimated at 59 years, and increased to 62 years according to the 2010
Census.

57

B. HEALTH SYSTEM PROFILE
1. VISION
The Timor‐Leste MOH recognises that health is influenced by a variety of determinants ‐education, income, housing, food, water and sanitation being among the more significant ofthese. With this broad understanding of health, the Ministry’s vision is for a:“Healthy East Timorese people in a healthy East Timor”
The MOH envisages a Timorese community enjoying a level of health that allows people todevelop to their potential within a healthy environment. The vision is achievable only
through multi‐sectoral efforts. The vision also reflects a fundamental aim to reduce poverty
to a point where all Timorese are sufficiently endowed to cover basic needs. The Ministry
believes that only a healthy community is able to achieve poverty alleviation.
2. MISSION
Consistent with its vision statement, the MOH is committed to:• Ensuring available, accessible and affordable health services for all Timorese people• Regulating the health sector• Promoting community and broad‐based stakeholder participation
The table below shows recent Timor Leste key Health indicators that was compiled by
UNICEF in 2013 as follow:

INDICATORSVALUE

Population

INDICATORSVALUE

Nutrition Indicator

Population (thousands) 2011, total

1 154

Low birth weight (%), 2007‐2011

12

Population (thousands) 2011, under
18

616

Early initiation of breastfeeding (%),
2007‐201182

Population (thousands) 2011, under 5201

Exclusive breastfeeding (%), 2007‐
2011

52

Population annual growth rate (%),
1990‐20112

Underweight (%), 2007‐2011,
moderate

30

Population annual growth rate (%),
2011‐2030

3

Underweight (%), 2007‐2011, severe

15

Population live below the poverty line(%), 2007

50

Stunting (%), 2007‐2011, moderateand severe

58

0.495

Wasting (%), 2007‐2011, moderateand severe

19

Human development index, 201158

Population live in urban areas (%)

30

Number of districts

13 Immunization

Number of sub‐districts

66

Immunization coverage (%), 2011,
BCG

68

Number of villages (sucos)

442

Immunization coverage (%), 2011,
DPT1

69

Number of hamlets (aldeias)

2225

Immunization coverage (%), 2011,
DPT3

67

Immunization coverage (%), 2011,
Polio366

Basic Indicators

Vit A supplementation (%), 201159

Crude death rate, 20118

Immunization coverage (%), 2011,
HepB3

67

Crude birth rate, 201138

Immunization coverage (%), 2011,
newborns protected against tetanus

81

Life expectancy, 2011

62

Immunization coverage (%), 2011,
MCV

62

Total fertility rate, 2011

6 Treatment of common childhood illnesses

Under‐5 mortality rate, 2011(per1000 live births)

54

Pneumonia (%), 2007‐2012, antibiotic
treatment

45

Infant mortality rate, 2011(per 1000
live births)

46

Diarrhea (%), 2007‐2012, treatment
with ORS

71

Neonatal mortality rate, 2011(per1000 live births)

24

Malaria (%), 2007‐2012, anti‐malarial
treatment among febrile children

6

Annual number of births (thousands),
2011

44

Malaria (%), 2007‐2012, children
sleeping under ITNs

42

2730

Malaria (%), 2007‐2012, householdswith at least 1 ITN

42

GNI per capita (USD), 2011
Primary school net enrollment (%),
2008‐2011

83 Most populated districts – population
projection, 2012, MoH*)

CPR (%), 2007‐20012

22

Dili

266 236

ANC coverage at least one visit (%),
2007‐201284

Ermera124 687

ANC coverage at least four visits (%),

55

Baucau116 934

59

2007‐2012
Coverage of skilled care at birth (%),
2007‐201229

Bobonaro

96 271

Coverage of facility delivery (%),
2007‐201222

Viqueque

72 797

C‐section rate

2

Oecussi

68 655557

Liquica

67 831

MMR (per 100 000 live births), DHS
2009‐2010
Source: UNICEF. At a glance: Timor‐Leste, 2013.

CLINICAL REFERRAL SYSTEM

National Hospital

National Diagnostic
Services(radiology, laboratory)

Regional Referral
Hospitals Type A

Regional Referral
Hospitals Type B

CLINICAL SUPPORT & TRANSFER

R
E
F
E
R
R
A
L

Health Post – village
level, first point ofcontact

CHC with beds
(1 each Subdistrict)

Mobile Clinic –outreach from CHCs
(where there is no HP)

Integrated Community
Health Service(outreach to Suco basedon community
participation)

SERVICE SUPPORTCENTRAL SERVICES

DISTRICT HEALTH SERVICES

Of

CHC with beds
(1 each District)

Curre
nt
HealthSystemOrganization(2012‐
2013)

P
A
T
I
E
N
T
S

FutureHealthSystemby 2030

SUB-DISTRICT HEALTHSERVICES(Ambulance
Services)

ICT Network
conecting alllevelsCOMMUNITY HEALTHSERVICES

460

C. MATERNAL HEALTH
Traditional beliefs and practices around childbearing and child rearing are very strong inTimor‐Leste. A high number of maternal deaths have been documented. Furthermore, theabsence of a basic health service infrastructure, which was destroyed during the Indonesianwithdrawal in 1999, has compromised health services for women and children. Since then,
Timor‐Leste has set health as its national priority, yet gaps persist in the availability of strong
and sustained community‐ wide health promotion strategies (WHO Timor‐Leste, 2004). Dueto the above challenges, The National Strategic Development Plan 2011‐2030 was thendeveloped and clearly stated that the Government of Timor‐Leste’s (GoTL) commitment
towards improving maternal and child health programs by emphasizing the following: “Tofurther improve maternal health in Timor‐Leste, we will increase access to high quality pre‐natal, delivery, post‐natal and family planning health services so that by 2015, 70% ofpregnant women will receive antenatal care at least four times and 65% of women will havean assisted delivery. We will improve emergency obstetric care through the recognition,
early detection and management of obstetric complications at the community and referrallevel. We will strengthen adolescent reproductive health services and we will empower
individuals, families and the community to contribute to the improvement of maternal careand reproductive health services. We will also improve data collection and analysis inrelation to maternal health services.” This has further elaborated in the National Health
Sector Strategic Plan 2011‐2030 and the National Reproductive Health Strategy 2004‐2015.
The Reproductive Health Strategy promotes a rights‐based approach in all reproductive
health (RH) services with the following stated objectives.
 To substantially increase the level of knowledge in the general population on issues
related to RH.
 To promote family planning to stabilize population growth rate and reduce the incidenceof unintended, unwanted and mistimed pregnancies.
 To ensure that all women and men have access to basic RH services, health promotion
and information on issues related to reproduction.
 To reduce the level of maternal mortality and morbidity.
 To reduce the level of prenatal and neonatal mortality and morbidity.
 To reduce the burden of sexually transmitted infections and HIV.
 To meet changing RH needs over the life cycle and to improve the health status of
reproductive‐age people.
As further elaborated in 2010 a Declaration for Affirmative Action to Reduce Maternal andChild Death, Birth Rate and Teenage Pregnancy was adopted to affirm the right to every
Timorese to access sexual, maternal and Reproductive Health information and services thatare affordable, good quality, culturally sensitive and gender responsive. It pledged thefollowing visions:1
 No Timorese mother will die needlessly from pregnancy and childbirth.
 No Timorese baby will die needlessly before, during and after birth.
 No Timorese young woman will lose her place in school because of unplanned pregnancy.
 All Timorese people – men, women and young people – shall have access to correct andcomplete information and quality services to ensure their full maternal and SRH rights.
1

RDTL. CEDAW Specific Report on Education and Health Sectors – Timor‐Leste. SEPI, Dili, 2011.

61

The current Timor Leste Demographic and Health Survey indicates a stable reduction onmaternal mortality rate from 660/100.000 reported in 2003 to 557/100.000 in 2010. The
major complications of pregnancy reported are haemorrhage, eclampsia, obstructedlabour and sepsis. A complication of pregnancy on haemorrhage is reported by 50.2%.
There is also an increase proportion of women seeking ANC care from Skilled providers(doctors, midwifes, nurses) of 41% in which, from 61% in 2003 DHS to 86% in 2009‐2010
DHS. More than 90% of pregnant mothers were weighed and had their blood pressure
taken, while only 55.7% informed on danger signs. Almost 80% received tetanus toxoid
injections. The proportion of women who took iron supplements during pregnancy hasrisen from 43% in 2003 to 61% in 2009; however, only 16% took the recommended doseof iron supplements for at least 90 days. About 13% received deworming during
pregnancy, 31% received supplementary food while pregnant with their last birth, and
29% received supplementary food while breastfeeding their last‐born child. Just over
one in five births are delivered
in a health facility, with the vast
majority delivered in a public(21%) rather than in a private(1%) facility. The majority ofbirths (78%) are delivered athome. Delivery in a healthfacility is most common among
young mothers (25%), mothersof first‐order births (31%), andmothers who have had at least
four antenatal visits (31%). The
proportion of deliveries assisted
by skilled birth attendants has risen from 24% in 2002 to 30% in 2009, which is a slow
increase in seven years. About
30% of births are delivered by askilledprovider(doctor,midwife, nurse or assistantnurse), with a midwife or nurse
being the most common skilledprovider. Moreover, there is a
progressive increase in assisteddeliveries from 27/ in 2006 to62

an average of 49.3% reported in 2010. Doctors assisted 3% of deliveries, while nurses
assisted less than 1%. The risk of giving birth to a low birth‐weight baby is influenced by
the mother’s nutritional status. About 27% of women were malnourished (BMI less than
18.5 kg/m2), indicating that malnutrition among women is a serious public healthconcern.
Women age
15‐19
aremore likely tobeunder‐
nourished(33%) and also
those who livein rural areas(28%)
compared tothoseinurban areas(24% There are coverage of skilled care at birth by district with the highest coverage inDili (69%), and the lowest in Ermera (12%), Ainaro (11%) and Oecusse (10%),) as seen in
the side figure above.

D. CHILD HEALTH
There has been a slight progress on child health care with the recent reduction of indicators
showing a reduction of U5 mortality rates from 83/1000 to 45/1000 in 2003 to 64/1000 in2010 and an improvement
in infant mortality rate from
83/1000 to 45/1000 during
the same years. DHS 2009‐2010 also showed, NMR was
22 per 1000 live births,
which decreased from 33
per 1000 live births in 2003.
This is mostly due to thedecrease in infant mortality
rate, from 60 (2003) to 44
per 1000 live births (2009).
This decline shows that
Timor‐Leste is on track to reach the target for the MDG 4, which is, to reduce U‐5MR by
two‐thirds to 60 per 1000 live births by 2015. NMR among small/very small newborns is 34
per 1000 live births. The main causes of neonatal deaths are prematurity, asphyxia, birthtrauma and infections. U‐5MR in rural areas is consistently higher than in urban areas.
According to the 2009 DHS, IMR in rural areas was 61 compared to 42 per 1000 live births inurban areas, while U‐5MR was 87 in rural areas and 61 per 1000 live births in urban areas.

63

This may be because of poor access to health care, a weak communication system andfrequent use of harmful indigenous practices in rural areas. The majority of births in Timor‐
Leste take place at home and,
therefore, babies are seldom
weighed at birth. The mother’s
assessment of the size of the baby
at birth is used as a proxy for birthweight. The 2009 DHS results
indicate that among babies
assessed by their mother to besmall/very small, their mortality
rate is 1.5 times the level
observed for babies assessed as average or larger at birth. Under‐5 mortality for the mostrecent period (0‐4 years before the survey or, roughly, during the calendar years 2005‐2009) is 64 deaths per 1,000 live births. This means that 1 in 16 children born in Timor‐Leste
dies before the fifth birthday. Seventy percent of deaths among children under age 5 occur
during the first year of life: infant mortality is 45 deaths per 1,000 live births. During infancy,
the risk of neonatal deaths and post neonatal deaths is 22 and 23 per 1,000 live births,
respectively. The proportion of child deaths that occurs in the neonatal period (34%) in
Timor‐Leste is lower than the global estimation of 38 percent (Lawn et al., 2005). Childhood
mortality is higher for males than females for all mortality rates. Under‐5 mortality rates formale and female children are 85 and 76 deaths per 1,000 live births, respectively. The
excess mortality among male children is mostly due to their higher biological risk during the
first
month
of
life.
Exclusive
breastfeeding up to six months has
increased from 31% to 52% between
2003 and2010, while breastfeeding andconsumption of complementary foodduring 6‐9 months of age reachedaround 80% in 2010. Around 82% ofchildren are breastfed within the firsthour of birth (from 47% in 2003), while
13% are given prelacteal food(something other than breast milk)
during the first three days of life. The poor nutritional status of children has been a serious
problem for many years. About 58% of children under five are stunted and 33% are severely
stunted, while 19% are wasted and 7% are severely wasted according to DHS 2009‐2010.
Figure 6.3 shows that the overall nutritional status of children under five was not improved
from 2003 to 2009. The proportion of children under five with stunting increased from
54.8% in 2003 to 58.1% in 2009, underweight from 41.5% to 44.7% and wasting from 14.3%
to 18.6%. This deserves special and urgent attention. There is a need to understand thecontributing factors towards malnutrition in children, such as acute and chronic infections(e.g. malaria and tuberculosis) besides socio‐cultural factors.

64

E. CHILD WELFARE
Significant improvement has been made in reduction of Infant Mortality Rate from88 in 2002 to 45 in 2009 and U‐5MR from 125 in 2002 to 64 in 2009. However, 2010
Timor Leste MDG report indicated that several MDGs (poverty reduction,
malnutrition, maternal mortality, school completion and sanitation) are still off‐track.
Most disadvantaged children in Timor Leste are from poor, large families with lesseducated parents in disaster prone rural areas. Moreover, they have less access tobasic services and participation opportunities and are often left out in policy
decisions. They lack also to information and tend to continue harmful practices
against child survival, development and protection. These have resulted in lower
achievement of MDGs target (UNICEG Timor‐Leste Equity Tracker).

65

Timor Leste Representatives
PART A – INDICATORS

1. CRUDE BIRTH RATE‐CBR (per 1000 population)
CBR indicates the number of live birth occurring during the year, per 1000 population
estimated at midyear. CBR‐CDR provides the rate of natural increase, which is equal to rate
population change in the absence of migration.

Year

Country overall ( according toWorld Bank)
1990
43.0
2000
43.5
2010‐1138.45
NB: cited from www.tradingeconomics.com

2. CRUDE DEAT RATE‐CRD (per 1000 population)
CDR indicates the number of death occurring in the year, per 1000 population estimated at
midyear. CDR‐CBR provides the rate of natural increase, which is equal to rate population
change in the absence of migration.

Year

Country overall (according toWorld Bank)
1990
18.0
2000
11.3
2010‐11
8.14
NB: cited from www.tradingeconomics.com
3. Leading cause of Death (1990) and (2009)
Year
Leading cause of Death
1990
1. Lower respiratory infection (17%), 2. Diarrheal diseases (12.4%), Measles(7.8%), 4. Preterm Birth Complications (5.1%), 5. Congenital anomalies(5.3%)
2009
1. Lower Respiratory infections (13,5%), 2. Diarrheal diseases (8.2%), 3.
Preterm birth complications (7.8%), 4. Congenital anomalies (7.6%), 5.
Ischemic Heart Diseases (4,4%)
NB: cited from: www. healthdata.org on Global Burden Disease profile in Timor Leste

66

Timor Leste Representatives
4. INFANT MORTALITY RATE (IMR) (per 1000 live births)
Country
overallYear
1990

135.00

2000

85.70

2003
60
DHS
survey2010
46
DHS
SurveyNB: cited in www.indexmundi.com

5. Leading Causes of Infants Death‐ 1990 and 2009
Year

Leading cause of Death1990

2. Lower respiratory infection (17%), 2. Diarrheal diseases (12.4%),
Measles (7.8%), 4. Preterm Birth Complications (5.1%), 5. Congenital
anomalies (5.3%)

2009

2. Lower Respiratory infections (13,5%), 2. Diarrheal diseases (8.2%), 3.
Preterm birth complications (7.8%), 4. Congenital anomalies (7.6%),
5. Ischemic Heart Diseases (4,4%)

6. UNDER 5 MORTALITY RATE (per 1000 live birth)
Country
overall

Year
1990

169

2000

100

2003
83
DHS
Survey2010
64
DHS
survey67

Timor Leste Representatives
The decline in neonatal, infant and under‐5 mortality in the five years preceding the
TLDHS 2009‐10 indicates that Timor‐Leste is on track to reduce infant and under‐5mortality to reach the target for Millennium Development Goal (MDG) 4, that is, toreduce under‐5 mortality by two‐thirds by 2015. It is notable that the proportion of
neonatal deaths to under‐5 deaths (34 percent) is relatively lower in Timor‐Lestethan in the other neighboring countries of Indonesia, Philippines, Bangladesh, India,
and Nepal as measured in the latest DHS surveys in these countries. But on the other
hand it is to be noted that Neonatal mortality is stagnant, from 21(DHS 2003) to 22(DHS 2010) in Timor‐Leste which is the challenge for the country and urges
immediate attention.
Cited in

7. Top 3 diseases and morbidity rate of the under 5 of 1990 and 2010
In 1990:
Diseases: Prematurity and low birth weight, Pneumonia (lower respiratory tract infection),and Diarrhoea
Morbidity rate:
In 2010:
Diseases: Prematurity and low birth weight, Pneumonia (lower respiratory tract infection),and Diarrhoea
Morbidity:
8. Maternal Mortality Rate (per 100. 000 live birth)
Country overall
Year
1990

1200

2000

680

2010

300

9. Leading cause of Maternal deaths in 1990 and 2010
Mostly related to obstetric complications such as haemorrhage, eclampsia, obstructed laborand sepsis

10. Are there national standards for certifying disabilities in your country?
Yes there are.

68

Timor Leste Representatives

11. Do your country perform any health check for infants and children
Yes they do. As stated in “Livrinho Saude inan ho oan”‐

Vaccination/immunization

When: from 0 month‐11 months
How many times: at birth, 6th weeks, 10th weeks, 14h weeks and 9th monthContents: mostly related to EPI in Timor leste such as BCG, DPT, HEP B, Polio and Measles,
part for Vitamin A and Deworming‐Child growth and development graph

When: from birth‐5 year of age
how many times: 3rd‐6th months, 9th‐12th month, 12th‐18th month, 2‐3 year old, 3‐5 year old
and 4‐5 year old
Contents: the graph consists of date by weight, growth and developmentalste

12. In the case of any disabilities are confirmed, is there any support services on them ?

Yes there is.
1. Through collaboration of multi Ministerial approach to assist people with disabilities inTimor Leste as stated by TLDHS 2010 report that out of total population of 1.066.409,
approximately, 48.243 of people suffer from some type of disabilities such as 20.593 frommotor disability, 29488 from visual impairment, 17.672 from hearing impairment and13.308 from mental disability. These figures show that there are people who have morethan one type of disabilities and thus will have risk of not getting the opportunity to workand access to educational facilities. This report has made such an enormous impact on the
IV Constitutional government lead by PM Xanana to finally come up with the approval of
National Policy for Inclusion and Promotion of the Rights of People with Disabilities that wasapproved and signed by PM Xanana on April 2012. The policy stated that multi Ministerial
approach to assist and liaise with Disable persons in Timor Leste through subsidized
financial assistance.
2. Assistance of Non Governmental Organizations (NGOs) to respective disabilities group
3. There is also group exist so called “ National Association of Disable Persons In Timor Leste”

69Timor Leste Representatives
PART B‐ Preliminary Analysis
1. Describe the following on surrounding mothers and children:‐ Maternal and Child HealthThree strength:
1. Health system follows an integrated approach
2. Nearly 1000 new graduated doctors are in the system now
3. The donor and partner co‐ordination and support of MoH
Weakness:‐

1. Budget constraints/Limited budget ( 4.5% of total state budget)
2. Low capacity of the human resources ( both for managers and clinical staff)
3. Weak health system with less stewardship/leadership
4. Geographical inaccessibility
5. Less demand for health services/low utilisation of health service delivery
Maternal and Child welfare:Strength: there is law in place/exist to protect them, state support andWeakness: limited budget, isolation and discrimination
2.
‐
‐
‐
‐

Most vulnerable populations would be:Children
Women
Elderly
Disabled persons
1. Rural areas: mainly isolated in hilly areas and separated by rivers, enclaved
population, lack of access to information and facilities
2. Low income population: although treatment/service is free, but transportation is
not available and costly in the rural areas, MoH’s referral services is very weak,
3. Disabilities: unable to perform daily routines, isolation and discrimination

3. Services available are:
1. SISca/ mobile clinic
2. Plan for domiciliary visit by team of health professional ( guidelines are on the process ofthe development)
3. All services are free of cost
4. Free maternity packets
5. Social support/NGOs

4.

There are lots of strategies and Standards for improving quality of services. But
implementation of the strategies and guideline are not properly done yet, due to lack of
capacity of human resources and limited budget which is needed to be addressed.
Capacity building should be prioritised for MoH’s health staff.

70

Timor Leste Representatives

1.
2.
3.
4.

SMH program to combat high MMR, move towards facility delivery
Strengthening PNC by home visits
Maternal perinatal death reviews and response
Strengthening hospital for treating sick newborn and managing complications in five referral
hospital
5. Mobile message for increasing ANC, delivery and postnatal care

Successful program:
1. Establishment of maternity clinic at sub‐district level for increasing institutional delivery
2. Strengthening 5 referral hospital including national hospital for comprehensive EmOC
services

Challenges:
1.
2.
3.
4.

There are new doctors but they are not well skilled for safe and clean delivery
Shortage of midwives for 24/7 services
Stock out of essential medicine ( oxytocin) , equipment (logistic issues)
All midwives are not trained on EmOC, not able to manage complications‐under skilled

1. There is a training institute ( INS), but it itself lacks quality, no trainer, no standardised
practise site to train staff
2. Low commitment of health staff to provide quality of care
3. Delayed release of budget to implement activities

To learn:
I would like to learn more about Japan’s experience to address challenges
For indicators look at page 94 in NHSSP 2011 document71

Countermeasure for Maternal andChild Health and Child Welfare

Viet Nam

72

VietnamVietnam’s Report for JICA training course “Promotion of the Collaboration
between Child Welfare and MCH”

～Part (A)Indicators～(1) Crude birth rate (per 1000 population): The crude birth rate (CBR notation) is
one indicator of fertility of the population, and is one of two components ofnatural increase of population. CBR big or small can affect the size, structure
and rate of population growth. Crude birth rate indicates 1,000 people, there
are many children born alive in the year.
Country overall (%o)
27,4
1990
19,2
2000
17,1
2010
Crude death rate (per 1000 population) Crude death rate for every 1,000 residents
means how many people died during the period (usually a calendar year). Just as
crude birth rate, crude death rate is affected by many characteristics of the
population, especially in the age structure of the population. CDR is anindispensable component in calculating the rate of natural increase as well as thegrowth rate of the general population.
1990
2000
2010
2012

Country overall (%o)
5,6
6,8
7,0

(2) Leading causes of death (1990) and (2009)
1990:1) Infectious diseases
2010:1) The chronic non-communicable diseases
2) Accidents, injuries
3) Poisonings(3) Infant mortality rate (per 1000 live birth) [MICS 2010]
Country overall (%o)
1990
44,4
2000
31
2010
15,8 (rural: 18,2; urban: 9,2)

－ 531
73 －

Vietnam(4) Leading causes of infants death (1990) and (2009)1990:
1) Complications of prematurity
2) Pneumonia
3) Complications during labor and birth
2010:1) Sinh non2) Nhiễm trùng
3) Ngạt
(5) Under-5 mortality rate (per 1000 live birth) [MICS 2011]
1990
2000
2010

Country overall
53
24
16

(6) Top 3 diseases and morbidity rate of the under-5 of (1990) and (2010)
2010:
Diseases:
1) pneumonia
2) diarrhea 3) fever
Morbidity rate: 1) 17%
2) 15%
3) 11%(7) Maternal mortality rate (per 100,000 live birth)
Country overall
1990
233
2009
69
(8) Leading causes of maternal death (1990) and (2010)
1990:1)Haemorrhage2)Eclampsia3)Infection
2010:1)34,7-43,4%
2)10,7-18,4%3) 7,4-14,3%
According to the WHO, UN agencies and the World Bank published 10/2010, thematernal mortality ratio of Vietnam is the 4th in ten Southeast Asian Nations (after
Singapore, Malaysia and Thailand)(9) Are there national standards for certifying disabilities in your country?
Yes
Explain briefly:
Decree shall detail and guide the implementation of some articles of the Law on
Persons with Disabilities by the Government issued April 10, 2012 consists ofseven chapters and 35 articles, including Article 2, 3, 4, Chapter I contains
provisions on disability type and severity of disability and determine the degree of
disability
Article 2. Type of disability
1. Disability is the impaired motor or movement dysfunction head, neck, legs,
arms, body leading to restrictions in movement, movement.

74

Vietnam

2. Hearing disability, said that the impaired or lost function of listening, speaking,or both speaking and listening, pronunciation loud and clear sentences lead tolimitations in communication, exchange of information verbally.
3. Disability status view is reduced or lost the ability to see and feel the light,
colors, images, objects in low-light conditions and normal environment.
4. neurological disability, mental disorders of perception, memory, emotion,
behavior control, thought and expression with the words, act abnormally.
5. Intellectual Disability status is reduced or lost cognitive abilities, thinking
manifested by slow or unable to think, analyze the objects, phenomena, to resolve
this problem.
6. Other Disability status is reduced or loss of bodily functions for the operation oflabor, living, learning difficulty, but not in the cases specified in Clauses 1, 2, 3, 4
and 5 of this Article.
Article 3. The level of disability
1. People with disabilities are particularly severe disability leads to complete lossof function, no self-control or self-realization is the active movement, dressing,
personal hygiene, and other things serve the needs of individual daily living that
require the monitoring, assistance, care altogether.
2. People with severe disabilities who are disabled due to lead to partial loss or
impairment, no self-control or self-realization is a commuter operation, dressing,
personal hygiene, and the serve the needs of other personal activities that require
the daily monitoring, support and care.
3. Disability mild disability in cases specified in paragraph 1 and paragraph 2 ofthis Article.
Article 4. Determination of the degree of disability
1. The Board determines the degree of disability based on the provisions of Article
2, Article 3 of this Decree and direct observations of people with disabilities
through the implementation of simple operations serve the needs of individual
daily living using the questionnaire according to the criteria of health, social andother prescribed method to determine the degree of disability, unless otherwise
provided for in paragraph 2 and paragraph 3 of this Article.
2. Medical Examination Council identified disabilities and form conclusions about
the degree of disability for cases specified in Clause 2, Article 15 of the Law on
Persons with Disabilities.
3. Persons with Disabilities concluded by the Council of Medical Examination ofself-serving, the degree of reduction of working capacity before the effective dateof this Decree, the Board determines the degree of disability grounds Council
conclusions of the medical examination to determine the degree of disability as
follows.
a) Persons with disabilities are particularly severe when medical examiners
Council conclusions are no longer able to service or labor capacity reduced by
81% or more.

75

Vietnamb) People with severe disabilities when medical examiners Council conclusions
are able to serve people living if, aids in part or labor capacity decrease from 61%
to 80%.
c) Disability Council light when medical examiners concluded with self-service
capabilities living or working capacity decline below 61%.
4. If the text of the Council of the medical examination prior to the effective dateof this decree is not clear conclusion about the possibility of self-service, thedegree of reduction of working capacity, the Board determines the degree of
disability made is determining the degree of disability for people with disabilities
as defined in Paragraph 1 of this Article.
5. Budget secured funding for implementation of the determination of the degreeof disability and disability certificate under decentralized management of the statebudget.
6. Ministry of Finance, Ministry of Labour - Invalids and Social Affairs budget
guidelines specified in paragraph 5 of this Article.
Ministry of Justice Contact Us Feedback(10)

Does your country perform any health check for infants and children?
-Yes, it does
In Vietnam, All children from birthday to 6 years old are free
for treating in national hospitals,-What kinds of contents includes in each?
Maternal care during pregnancy and postpartum
Newborn Care
Breastfeeding and young child feedingMicro-nutrientsVaccination for mothers and children
Integrating care for sick children
Located chemical insecticide treated nets in malaria endemicareas(11) In the case any diseases or disabilities are confirmed, is there any support
services on them? Describe the services, if any- With normal children, when any diseases are confirmed, they are free intrue local hospital. Because they get Medical insurance at the same time
getting birth certificate. In the hospital, they get free examination, medicine,
sickbed,…ect.
- With disabilities children:
1. Every year, the state budget allocation for the implementation of policies on
disability.

76Vietnam

2. Prevention, reduce birth defects, defects caused by injury, disease, and otherrisk of disability.
3. Social protection; assist people with disabilities in health care, education,
vocational training, employment, culture, sports, recreation, access to public
facilities and information technology, in traffic; implementation of the policy
priorities of social protection and support disabled children, the elderly.
4. Integrate policies on disability policy in economic development - social.
5. Create conditions for people with disabilities orthopedic rehabilitation;
overcome difficulties, independent living and community integration.
6. Training and retraining of workers counseling, care for people withdisabilities.
7. Encourage activities to assist persons with disabilities.
8. To facilitate the organization of persons with disabilities, organizedactivities for people with disabilities.
9. Reward agencies, organizations and individuals with achievements andcontributions in helping people with disabilities.
10. Strictly handle agencies, organizations and individuals that commit acts ofviolating the provisions of this Act and other provisions of the relevant
legislation.

77

Vietnamj～Part (B)Preliminary Analysis～

I. Describe the surroundings mothers and children.
Poor maternal, newborn and child health remains a significant problem indeveloping countries. Health care for mothers and children are always identified as
one of the priority tasks of the care for people's health by Vietnam Government.
Over the years, the successful implementation of the national strategy on
reproductive health care, national strategy on nutrition and a series of national
action plans, such as the National Master Plan for motherhood safety, the National
Action Plan for the survival of children, the overall national plan of care, protect
and improve the health of young adolescents and Vietnam, national guidelines forthe care of reproductive health, ... has contributed to the implementation of theMillennium Development Goals (MDG) that Vietnam has committed to theinternational community in reducing maternal and infant mortality. On 14-11-2011,
the Prime Minister signed Decision No. 2013 / QD-TTg approving the Strategy for
Population and Reproductive Health Vietnam during the period from 2011 to 2020,
marked a new stage in taking reproductive health care with the strategic
perspective: "investing in population and reproductive health care is invested insustainable development, providing direct effects on economy, society andenvironment ".
Besides the system policy and political commitment, health Vietnam also
always interested in strengthening the primary health care, including the field ofreproductive health care and the health of mothers and children (RHC / MCH).
Currently, the index of reproductive health in general and the indicators ofmaternal mortality and infant mortality in particular in our country is relatively
good compared to other countries with the same level of economic development society. These indicators, such as antenatal care enough 3 times, giving birth inhealth facilities, mothers and infants after birth care, maternal mortality and infantmortality, ... are a clear improvement ; network providing reproductive healthservices from central to local levels have increasingly been expanded,
strengthened and developed, including the hospital system, hospital obstetric,
pediatric and obstetrics, pediatrics at the hospital level. Most midwives, obstetriccare, primary health care workers have the basic skills of RHC national guidelines.
In mountainous areas, ethnic minorities, where the proportion of women giving
birth at home is high, along with advocacy, encouraging women to give birth inhealth facilities, the Ministry of Health actual implementation of the type oftraining village midwives or training of village health workers have the knowledge
and skills to manage pregnancy and childbirth clean, safe delivery, including thedetection and timely referral high-risk cases, to reduce obstetric complications,maternal mortality and infant mortality.
Goal No. 4 and No. 5

78

VietnamAlong with the decline of maternal mortality, infant mortality under 1 year
and under 5 years of age decreased rapidly and sustainably. Mortality rate ofchildren under 5 years of age were more than halved from 58 ‰ to 23.2 ‰ in1990 to 2012. The mortality rate for children under 1 year of age has dropped bynearly two thirds, from 44.4 ‰ in 1990 to 15.4 ‰ in 2012. According to theinternational community, Vietnam can achieve Goal 4 of reducing deaths ofchildren under 5 years of age (down 19.3 ‰) and less than 1 year old (down
14.8 ‰) in 2015.
This is a result of the implementation of effective mass of the National
Target Program, such as expanded immunization; Prevention and acute respiratory
infections; Prevention and acute diarrhea; Prevention and malnourished children;
Care and treatment of common diseases in children; Reproductive health care ...
maternal mortality rate has fallen by more than 3 times from 233 / 100,000 births
in 1990 to 69 / 100,000 births in 2009. Compared with the objectives of theStrategy National Health Care reproductive period 2001 - 2010 the maternalmortality ratio is 70 / 100,000 births in 2010, the health sector has completed thisindicator before 1 year. According to the international community, Vietnam has
the ability to achieve goal number 5 on maternal mortality reduction (down to 58.3
/ 100,000 births in 2015) and is one of the countries' progress achieved level "(" ontrack ") in the implementation of the Millennium Development Goals.
However, there are still large differences in mortality among children underage 1 regions. Highlands is an area with mortality rate of children under 1 year ofage the highest in the country. This rate in rural areas is almost two times higher
than in urban areas, infant mortality is still quite high, around 70% of deaths ofchildren under 1 year of age and 50% of deaths of children under 5 age.
Strength in Maternal and child WelfareFirstly, the commitment of the political system.
Maternal and child always been considered a top priority in the care ofpeople's health in Vietnam. The Government of our country's commitment in theimplementation of the Millennium Development Goals are important factors
contributing to the success of health care for mothers and children. A series ofimportant documents have been issued to bring a positive impact on the health ofmothers and children. In 1989, the Law on Protection and Care of People's Healthlaunched, including the protection of women and children, the National Strategy
for care and protection of people's health the period 2011-2020, War National
Strategy for Population and Reproductive Health period 2011 - 2020, National
Strategy on Nutrition period 2011 - 2020, the National Action Plan on infant79

Vietnamfeeding ... Congress committee individual responsible for the social problems
including health problems of mothers and children.
Second, the economic growth of the country.
After nearly 30 years of implementation of the reform of the country, theeconomy of Vietnam to develop relatively fast and stable. In the period 2000 2008, GDP continued to increase, reaching 7.9% / year. Although affected by the
global economic crisis in 2008, but Vietnam has achieved a GDP growth of 6.31%
in 2008, 5.89% in 2011, 5.03% in 2012 and 5, 42% in 2013. Per capita income
was approximately $ 1,908 in 2013.
Industry and the alleviation of poverty to achieve good results. In two 2011 and2012, more than 70 trillion has been allocated for poverty reduction. The policy
package of health care, education, nutrition, legal services, culture, information,
support vocational training, job creation, investment in infrastructure construction
has been focused support for the poor and marginalized groups in society,including the 135 program had significant success in efforts to reduce poverty andimprove living standards for the poor. The poverty rate in the region was
supported by 10%; the income of poor households period 2007 - 2012 increased
by 20%.
Third, interventions in the health sector.
Working mothers' health care - children is done through a network ofservice providers throughout the central and local levels. At the commune level,
99% of commune health stations, nearly 94% of health centers with midwives orobstetric care, 66% of health centers have doctors, 84% of villages with village
health workers Version. In these villages are inaccessible to the clinic or ethnic
traditions survive birth at home, the health sector has trained village midwives
responsible health care for mothers and infants.
Total per capita expenditure on health has increased four-fold from 49 USD
to 233 USD 1995 in 2012. The improvement in the provision of health careservices for mothers and children through investment upgrading facilities for
hospitals and clinics, health centers, training health workers are important
contributing factor in improving the health of mothers and children.
The expanding access and improving the quality of health care for mothers
and children in all regions, objects, especially in remote, ethnic minority and thenumber of disadvantaged groups is an important factor to success in reducing
malnutrition, mortality among children under 5 and maternal mortality.

80Vietnam

Fourth, the active support of international organizations, the participation ofcivil society and the media.
There are significant achievements as above, not to mention the positive
support, both technical and financial organizations of the United Nations, thebilateral donors, multilateral. This support is not large compared to the investment
funds, however, support the advisory role is very important, it is essentiallyoriented, the source of the initiative, the effective intervention in health care formothers and children. The participation of non-governmental organizations arealso important, contributing to implement and demonstrate effective models of
health care for mothers and children, depending on local conditions. The
contribution of non-governmental organizations are also important in the remoteand for special populations such as adolescents, young, migrants, ethnic minorities
number. Finally, not to mention the positive role of mass media in thetransmission of messages about health care for mothers and children to large
masses, mobilizing people to work together with medical Overall economic andsocial participation of health care for themselves and their families.
Some weakness exist in Vietnam
Vietnam achieved important results in 2/3 of the way done the Millennium
Development Goals over and determination towards the completion of this goal in
2015. However, in addition to the already done, the work of health care formothers and children still face many challenges and difficulties to be addressed,
such as:- Vietnam has been included in the list of countries "middle income", so inthe coming years, our country is and will be faced with a huge challenge. It is the
reduction of financial aid of the international organizations and donors.
- Investment budget has not met the increasing demands of the people.
Although the project has national targets, but only partially meet and also only
have to invest mainly in mountainous provinces, provincial difficulties, in recent
years, funding projects of national goals Date for the content of reproductive
health are being cut.
- Maternal and infant mortality has declined but although the rate of decline
in recent years tended to slow down and there are still a large difference between
the regions (in the region Mount index to 3 times higher than in the lowlands).
Infant mortality is still high, accounting for 70% of deaths of children under 1 yearof age and 50% of deaths in children under 5 years of age. Malnutrition
underweight has improved markedly, however stunting still pretty high percentage,
almost 30% of children under 5 years of age.

81

Vietnam- Access and quality of MCH services before, during and after childbirth,
infant care is limited, having a baby without medical help is quite common in
mountainous areas, ethnic minority areas minorities.
- Network Systems provide reproductive health services was formed toconsolidate, but still exists. Facilities and equipment for obstetrics, pediatrics atmany district hospitals is poor, failing to meet the care needs emergency treatmentof women and children, infants. Due to limited funding, staff working in obstetrics,
neonatal and pediatric not been training regularly update their knowledge, leading
to limitations in skills, especially her survival skills mother and infant.
-The reporting system is limited and weak, the data collected was
inaccurate, not reflect the reality of the situation of maternal mortality, infantmortality, especially in the absence of data on mortality infants, not ensuring thetimeliness, failing to meet the requirements of policy formulation and planninginterventions.
Policy to promote the achievements and overcome the still exists,difficult problem
Firstly, the consolidation system network organization of reproductive
health care / health of mothers and children from the central to local levels.
Professional capacity, allocate sufficient staff for obstetric, pediatric hospitals of
the provincial, district and ensure the necessary equipment for resuscitation
obstetric and neonatal. Striving to all district hospitals which time access to theprovincial hospital in time over 60 minutes can perform caesarean sections andblood transfusions.
Secondly, the development of human resources. Enhanced training
specialist obstetrics, pediatrics, paying special attention to the form of specialist
training for rapid preliminary additional specialist staff force of over two majors
currently lack, even in the provincial health facility. This is one of the key
recommendations of the World Health Organization (WHO) "guarantee eachbirths are skilled birth attendants help ". The health sector strive to 2015, 80% of
the medical staff working in obstetrics at the provincial level, 70% at district levelstandards "skilled birth attendants", each have at CHS least one midwifery staff
qualified "person skilled birth attendants". Training improve emergency obstetricand neonatal care and emergency essential newborn oriented "hands-on" training
the crew, address, on demand. For remote areas, remote areas, ethnic minorities
need to strengthen training of village midwives or health officials said village
manager pregnancy, childbirth clean, safe delivery, detection, treatment -aid and82

Vietnamtimely referral of cases of pregnant women at risk.
Thirdly, interventions in the health sector.
Working mothers' health care - children is done through a network ofservice providers throughout the central and local levels. At the commune level,
99% of commune health stations, nearly 94% of health centers with midwives orobstetric care, 66% of health centers have doctors, 84% of villages with village
health workers Version. In these villages are inaccessible to the clinic or ethnic
traditions survive birth at home, the health sector has trained village midwives
responsible health care for mothers and infants.
Total per capita expenditure on health has increased four-fold from 49 USD
to 233 USD 1995 in 2012. The improvement in the provision of health careservices for mothers and children through investment upgrading facilities for
hospitals and clinics, health centers, training health workers are important
contributing factor in improving the health of mothers and children.
The expanding access and improving the quality of health care for mothers
and children in all regions, objects, especially in remote, ethnic minority and thenumber of disadvantaged groups is an important factor to success in reducing
malnutrition, mortality among children under 5 and maternal mortality
Forthly, increased investment, financial security and logistics. To ensure
the necessary budget for the activities of reproductive health / maternal health children. Recommend Parliament, the Government increased investment for the
reproductive health care through the national target program with a minimum of
100 billion / year and gradually increase over the years in order to better meet theneeds reproductive health care is increasingly diverse people, especially mothers children (project objective national reproductive health care from 2008 until now,the project national goals reproductive health care is only the average investmentof 35 billion / year. 2014, budget cuts only 20 billion).
Fifthly, strengthen the operational information - communication - healtheducation in order to increase knowledge, change attitudes and behaviors ofpeople, especially people in the mountainous areas, areas distance of prenatal care,
the risk of non-routine maternity care and not to give birth in health facilities or
self-birth, birth without medical staff trained support as well as the risk of thicktongue, prolific children, preterm birth (less than 20 years old) or late calving(over 35 years old).
Sixthly, replicate the model was evaluated to be effective, as the"Community-based Transit" (1); model "Caring mother - infant continuously from
communities and families to health facilities"; promote "the evaluation of maternal83

Vietnamdeath" experience to draw on expertise, on the basis of consideration and detailed
assessment of the diagnostic process, monitoring, emergency women, thereby
making judgments about the causes and factors affecting such deaths. This activity
will help physicians timely lessons learned expertise to improve the quality oftreatment, emergency management in order to avoid the occurrence of similarcases of complications.
Seventhly, strengthen supervision and professional support from higher
levels to lower levels; perform well Scheme rotating staff to support streaming on
the lower level (Project 1816), Scheme satellite clinics; improve the effectivenessand efficiency of the inspection and examination of the implementation of theprovisions of the Law on Examination and Treatment; hospital regulations,
technical procedures, technical guidance of the Ministry of Health for publichealth facilities as well as private. /.
2. In my country / region, the most vulnerable populations (list three groups
in order of priority)- Groups are living in rural areas- Groups with low-income- Groups with disabilities
3. What kinds of services are there for the above mentioned groups?
For the groups living in rural areas:
Set up and operate the neonatal care unit separately at the district hospital.
Training of health personnel directly engaged in obstetrics become "skilled
birth attendants" to limit and timely management of obstetric complications,ensuring the safety of every birth
Ensure policy regime to attract professional staff, especially qualified staff
to work permanently in the mountainous, remote and distant. Promulgate
regulations on social obligation for doctors to work in the remote, implement
specific policies to support her team to help villages of ethnic minorities such as
village health workers Version.
For the group with disabilities
1. A serious problem, such as the Annual State budget allocation for the
implementation of policies on disability.
2. Prevention, reduce birth defects, defects caused by injury, disease, and otherrisk of disability.
3. Social protection; assist people with disabilities in health care, education,
vocational training, employment, culture, sports, recreation, access to public
facilities and information technology, in traffic; implementation of the policy
priorities of social protection and support disabled children, the elderly.

84Vietnam

4. Integrate policies on disability policy in economic development - social.
5. Create conditions for people with disabilities orthopedic rehabilitation;
overcome difficulties, independent living and community integration.
6. Training and retraining of workers counseling, care for people with disabilities.
7. Encourage activities to assist persons with disabilities.
8. To facilitate the organization of persons with disabilities, organized activities
for people with disabilities.
9. Reward agencies, organizations and individuals with achievements andcontributions in helping people with disabilities.
10. Strictly handle agencies, organizations and individuals that commit acts ofviolating the provisions of this Act and other provisions of relevant laws
quan.chenh difference, namely the mortality rate of children in the mountains rural
areas and in poor families still 3 to 4 times higher than the plains and the more
affluent families

4. In implementing health/welfare policies and services by your organization：
�In your country/province, what are the priority issues/programmes in thearea of maternal and child health/welfare? List five issues/programmes
in order of priority.
1. There are large differences in the rates of maternal mortality between
regions that we need to address. Maternal mortality rate is still high in themountainous areas and ethnic minorities. The elements of geography,
education level of mothers and customs in the remote mothers often hinderaccess to health care services reproduction.
2. Ethnic minorities, young people and migrants still face manydifficulties in accessing information and services reproductive health care,including services for family planning
3. A large number of Vietnamese children die annually
According UNICEF, Every year there are 28,000 children under the ageof 5 have died, in it 16,000 are infants. Percentage of children under 5 years
old accounted for 6.5%, estimated 6,000,000 children and babies are borneach year where the 1.200.000- 1,500,000
4. The stark difference in the health and nutritional status of children
between cities urban and rural areas, between the wealthy and poorer
segments of the population in terms of physical obstacles and economic

85

Vietnamobstacles.
5. Perinatal mortality with a huge difference between areas / regions in
the country
�What are successful areas or programmes? List 3 areas or programmes.
1. Programs to combat child malnutrition
2. The EPI
3. Diarrhea prevention program
�What are these challenges? List 3 challenges.
（1. See “some weakness in Vietnam” ）�Describe your expectations to the training course.
Coming to this trainning course, I expect to gain knowledge about Japanesecurrent MCH and child welfare policies. Futhermore, I expect to gain anunderstanding of the features of Japanese MCH Handbook from the perspective ò
coodinnation between health and welfare

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