Maternal Health
Bangladesh is committed to achieving the Millennium Development Goal 5 (MDG5). The global community has selected the proportion of deliveries with a skilled birth attendant (SBA) as an indicator to monitor progress in the achievement of MDG5. As SSFP aims to support GoB to achieve health goals, it will ensure that the Smiling Sun Clinics increase antenatal and postnatal care services, improve safe delivery and newborn care practices, continue practicing Active Management of Third Stage of Labor, screen women for cervical and breast cancer, provide post-abortion care services and diagnose and refer fistula cases to appropriate centers.

Activities are:
· Antenatal care
· Delivery care (both normal delivery and caesarean section)
· Postnatal care
· Post-abortion care
· Awareness on fistula and referral of the cases

Antenatal and postnatal care services are being provided through 320 Smiling Sun clinics and service protocols developed are followed by all service providers in all clinics at all levels. To build on previous investment, SSFP is adopting job aides, such as flip charts. Additionally promotional materials such as brochures on ANC, PNC and male involvement in birth planning have been printed. To reinforce communication and favor behavior change, an EOC card has also been printed as a take away material for pregnant women.

Community Service Providers (CSPs) have been trained on basic messages on Essential Newborn Care (ENC), Birth Planning (BP), Post-abortion care (PAC), cervical & breast cancer and fistula. Monitoring Officers and Clinic Managers have been trained on male involvement in maternal health care and they will again train their clinic staff along with Service Promoters (SP) and CSPs on the same subject matter. A Community Support Group (CSG) has been established under each clinic to ensure male involvement in birth planning.

Since the early 1990s, the emphasis had been on improving the provision of Emergency Obstetric Care (EmOC). More recently, the Government determined that efforts to decentralize emergency obstetric care must continue but be complemented by a home-based Skilled Birth Attendant (SBA) strategy. Ultra clinics will continue to provide safe delivery services following protocols of emergency obstetric care; however, as part of its service expansion, SSFP will upgrade more clinics to comprehensive EmOC. Additionally, SSFP Home Delivery services have been evaluated to identify current implementation challenges. Based on the evaluation findings, SSFP will implement necessary changes.

Presently EmOC centers are providing PAC services, which include both curative and preventive care, along with three key elements. These are:

· Emergency management for complications of spontaneous or induced abortion
· Post abortion family planning counseling and services
· Coordination between emergency post abortion treatment and comprehensive reproductive health care services.

Child Health

During the last 15 years, Bangladesh has achieved a significant reduction in the child mortality rate, and now it seems that Bangladesh is on track to achieve millennium development goal (MDG) 4 on child survival. However, while children under five mortality is now at 65 per thousand live births, newborn and infant mortality rates remain stubbornly high. Newborn mortality rate is very crucial in reducing child mortality because it accounts approximately 70 percent of infant deaths and 55 percent of all under-five mortality. Again most newborn mortality occurs in first seven days of life-up to 50 percent in first 24 hours.

In line with the GoB policy, SSFP intends to address this particular problem by emphasizing essential newborn care through implementation of facility based as well as community based IMCI program. All 320 clinics have strengthened IMCI activities by skilled service provider of the clinic in the previous years. In particular, essential newborn care will be introduced in many clinics where normal delivery is performed. Likewise, community based IMCI activities have been strengthened Smiling Sun clinics. Community Service Providers (CSPs) have been trained on dissemination of key neonatal and child survival messages. In addition, SSFP has closely worked with ICCDR,B to introduce consistent use of Zinc tablets for diarrhea management. This activity will be a major focus of this year’s child health program. For this, SSFP developed a service protocol that is being followed by all service providers in the SS network. Promotional materials have been developed and distributed to reinforce this intervention.

Also, all clinics provide immunization and vitamin A capsule administration as per GoB directions. Pentavalent vaccine (combination of DPT, Hepatitis B and Hib) will be introduced gradually in all clinics in coordination with GoB. To the extent possible and practical, clinics will participate in national immunization days.

Promoting IMCI in Smiling Sun Clinics
Integrated Management of Childhood Illnesses (IMCI) is one of the main packages of services addressed to parents and caretakers of children. A particular Smiling Sun strength is the availability of child and maternal services under the same roof. The reputation that Smiling Sun clinics are good quality service providers for child health services is likely to contribute making successful proposed promotion efforts in this area. SSFP has strengthened child health services promotion at all network levels to generate demand for services.

Family Planning
High-quality voluntary family planning information and services are available to the customers through Smiling Sun clinics. So SSFP’s contraceptive mix faithfully reflects consumer reproductive preferences. Temporary methods including Injectables are currently offered in all static and satellite clinics. To ensure the availability of FP commodities, collaborative efforts have been taken to strengthen the relationship with DGFP and SMC.

Long Acting Permanent Method (LAPM) has been provided by trained service providers and for that matter, trainings have been organized on a regular basis. Quality of both clinical and non-clinical FP services have been considered a priority and ensured at all levels through clinic level quality circles and quality monitoring and supervision. Service providers and counselors have been trained on counseling to ensure good quality counseling and screening, as a way to reduce method discontinuation. In fact, the Family Planning Clinical Services Course (FPCSC) includes:
- Infection Prevention
- Counseling
- Pills including ECP
- Condom - Injectables
- IUD
- Counseling and screening for Implant, NSV and Tubectomy

Community Service Providers (CSPs) have been provided with refresher training in FP methods, side effects and rumors and misconceptions. CSPs have been made instrumental in disseminating counseling messages with a special emphasis on post-partum contraception.

The major Family Planning strategies are:
· Strengthen supply of and stimulate demand for long acting and permanent methods
· Strengthen counseling and proper screening to reduce discontinuation rates. Expand LAPM training for different providers with greater collaboration from DGFP. Essential Service Delivery (ESD) Flipchart that includes family planning messages will be adopted and re-printed to assist the Counselors in effective counseling.

Following trainings have been conducted so far for FP basic skills:
· Family Planning Clinical Services Course (FPCSC) for paramedics
· Implant both for medical officers and paramedics
· NSV both for medical officers and paramedics
· Tubectomy both for medical officers and paramedics
· Infection prevention both for medical officers and paramedics
 Counseling for counselors
· Contraceptive logistics and procurement to ensure method availability.

Communicable Diseases
STIs and RTIs contribute significantly to a woman’s ill-health by increasing her risk of infertility, ectopic pregnancy, cervical cancer, spontaneous abortion and HIV infection. Making a correct diagnosis of a sexually transmitted infection is essential for appropriate and effective treatment at early stage and its prevention.

Smiling Sun clinics emphasize on dissemination of STI/RTI prevention messages among women of reproductive age, adolescents and male partners. An effective response to STIs have been ensured through prevention by providing accurate and explicit information on safer sex, including correct and consistent use of condoms, as well as abstinence, delay in onset of sexual debut, keeping to one sexual partner or reducing the number of sexual partners. In addition to prevention, syndromic management of STI/RTI with as emphasis on 4Cs [Counseling, Condom demonstration, Compliance with treatment, Contact tracing] have been made available to provide early and effective treatment for STIs.

Additionally, SSFP has included cervical cancer screening using acetic visual inspection by acid solution (VIA). This screening procedure have been introduced in thirty-four Ultra clinics as a pilot. SSFP will use a syndromic approach by offering this service to all women between the age of 25 to 64+ years coming to SSFP clinics. SSFP has signed an agreement with FHI to provide family planning services to female sex workers in Integrated Health Centers.

Tuberculosis. Historically, tuberculosis (TB) has been a major public health problem in Bangladesh. The Government of Bangladesh, together with its many partners is committed to further strengthen the TB control program. SSFP is contributing to the National Tuberculosis Control Program by strengthening NGO capacity to deliver DOTS in urban areas. Nine SSFP NGOs provide DOTS through 56 Smiling Sun Clinics in city corporations in Dhaka, Chittagong, Rajshahi and Khulna. While all 56 clinics provide DOTS, 33 of them have microscopy centers to the diagnosis TB, and one with an External Quality Assurance (EQA) center to ensure quality of laboratory services.

Smiling Sun clinics will strengthen these efforts by ensuring the availability of equipment and reagents. SSFP will also comply with GFATM strategies to improve services in their catchments areas. Quality of microscopy services will be ensured through EQA system. SSFP will collaborate and contribute to all national endeavors along with NTP and BRAC. It will strengthen the case finding at the community level by utilizing Service Promoters, CSPs and TB volunteers. Defaulter cases will be reduced through an effective follow-up system.

Limited Curative Care (LCC)
LCC refers to the care of common illnesses and injuries (basic first-aid, treatment of medical emergencies, pain relief and advice, especially in Essential Service Package)

Diseases under LCC:
Diseases of respiratory tract
- Diseases of alimentary tract
- Disease due to micronutrient deficiency
- Skin diseases
- Infections in urinary system
- Disease of circulatory system
- Primary and emergency treatment
- Primary surgical treatment
- Few female diseases
- Ear, Nose and Throat (ENT) diseases
- Eye and dental care - Parasitic diseases
- And others

Steps for LCC treatment in SSFP:
· Identify the cause by taking history
· Look for respective sign
· Necessary physical examination
· Assess complication status
· Do necessary laboratory test
· Counsel for prevention, if any
· Provide appropriate treatment

Diagnostic Services
Most customers are looking for the convenience of one stop service from one service delivery point. Lab services are not available at all SSFP clinics at this moment, where and when they are, they represent a significant opportunity to generate substantial new revenue and offers high potential to further penetrate the market by attracting new customers and increased demand among existing customers. Lab/diagnostic services also help to create confidence among all customers –male and female. SSFP anticipates that diagnostic services will be one of the major revenue earners in many clinics as existing full-fledged lab owning clinics are doing very good in sustainability measure. The service will be promoted in cross-cutting steps with clinic promotional activities.

Ambulance Services
Grameenphone donated five ambulances to NGOs in the network to shorten response time to emergencies and transfer/refer patients to larger facilities when the need arises.