MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-388-LA-13-00004)

Quarterly Report April 01– June 30, 2017

Joint Efforts to Restore Confidence in Health Care Delivery System

Char Folcon Union Health & Family Welfare Center (UH&FWC) – the image of transformation

Submitted August 4 2017

Cover Story:

Char Folcon Union is a rural community in Komolnagar of district. The Union Health and Family Welfare Center (UH&FWC) was established in 1982 by DGFP of MoH&FW. Since the UH&FWC is the closest access point for health services for the community, its functionality is critical for saving lives and serving the community, particularly women and children who are under privileged and the most vulnerable. Previously, services at the facility were very poor due to scarce resources, limited availability of health workers, and poor quality of care. It was not unusual to find the facility locked and ill-equipped to provide services for maternal emergencies, including stock-outs of key consumables that are life-saving during such emergencies. To compound the situation, the center had very poor infrastructure, including a leaky roof, broken windows, and cracked walls and ceiling; there was also no access road, power, or water supply. This unsanitary situation in the clinic was worsened by the lack of a functional residence and toilet facility for service providers, making it difficult to ensure staff were available to attend maternal and newborn emergencies.

The MaMoni HSS program set out to transform this facility into a functional facility where the community could expect to receive quality care and services. As a first step and to ensure the initiative was locally driven and supported, the program conducted an assessment of the facility in collaboration with local government. Identified needs included facility upgrading, staff capacity development, and community engagement. MaMoni HSS has worked hard with local government, facility leadership and the community to address these needs, with the following achievements:

• Facility & Infrastructure Upgrades - The approach road and the infrastructure were reconstructed, and power and water supplies were ensured by installing solar panels. In support of this effort, the Char Folcon Union Parishad allocated a budget of 202,000 BDT (do you want to include approximate value in USD?) for the approach road, facility renovation, delivery bed and kits during the 2014-15 fiscal year; a budget of 122,000 BDT for the solar panel in the 2015-16 fiscal year; and 30,000 BDT for furniture in the 2016-17 fiscal year. Additional investments came from MaMoni HSS, with 2,700,000 BDT for dumping pits, a residence for service providers, and a deep tube well in year three of the program. • Effectively Engaging Existing Institutions – Sufficient quantities of relevant drugs and supplies were made available by bridging DGFP and LG, and MaMoni HSS helped to reinforce the UH&FWC Management Committee to engage with the community so that needs and quality issues can be raised and addressed. Under the leadership of UP Chairman, the committee meets bi-monthly at the facility to address high priority issues. As a result, significant improvements have been made in the ability of the facility to apply basic infection prevention practices and maternal, newborn, child health, and family planning (MNCH/FP) standards of care.

“Before the renovation of the facility, patients expressed their disgruntlement over the poor state of the facility infrastructure and the environment and the poor quality and absence of services arises from its condition,” she said. “But now, our clients are happy and there is up-trend in the demand of services” - Shumi Majumder, Sub-Assistant Community Medical Officer (SACMO), Char Folcon UH&FWC

The program’s initiatives and efforts towards the improvement of the UH&FWC have converged to manifest outcomes that are consistent with the initial goal of providing high quality services that are well-utilized. Prior to 2013, the services provided at the Char Folcon UH&FWC were very poor with low utilization levels. But since the improvement initiatives began, service utilization has increased dramatically from 1120 in 2013 to 2926 in 2017. Furthermore, when 24/7 services began at the facility in 2013, there were no normal deliveries recorded at the center, but usage since then has increased dramatically, with 251 normal deliveries in the first half of 2017 alone.

“We the people are happy because of 24-hours service, improved facility, and well trained & well-behaved smiling doctor apa are available for us,” says Mr. Abdul Khaleque, husband of Mosammat Selina Akhter, a mother who received delivery care and services from the facility.

“I really appreciate the cleanliness of the facility which is much far better from private clinics. I thank Allah and pray that they will do more.” - Mother-in-Law of Marium Begum (a mother who received services from the facility), Village Zazira, Char Folcon Union.

This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID -388 -LA -13-00004 through Maternal and Child Health Integrated Program (MCHIP) . The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government.

TABLE OF CONTENTS

MaMoni Health Systems Strengthening Activity ...... 1 TABLE OF CONTENTS ...... 3 ABBREVIATIONS ...... 4 EXECUTIVE SUMMARY ...... 7 Key accomplishments in this quarter include: ...... 7 Way Forward: ...... 9 Introduction ...... 9 DATA SOURCES ...... 9 Program Results for the Quarter ...... 10 IR 1. Improve Service Readiness through Critical Gap Management ...... 10 IR 2: Strengthened Health Systems at District Level and Below ...... 29 IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems ...... 40 IR4. Identify and Reduce Barriers to Accessing Health Services ...... 39 Challenges, Solutions, and Actions Taken ...... 45 Appendix 1: Scope and Geographical coverage of the Mamoni HSS program ...... 48 Appendix 2: DATA SOURCES ...... 50 Appendix 3: Program Performance Indicators (April 2017–June 2017) ...... 50 Appendix 4: Additional Indicators ...... 67 Appendix 5: QIS ACTIVITIES ...... 70 Appendix 6: News Clips Published During ……………………………………………………… 75 Appendix 7: Documentation and Dissemination of MaMoni Program Learning ... Error! Bookmark not defined.

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 3 ABBREVIATIONS

ACS Antenatal Corticosteroid ADCC Assistant Director, Clinical Contraceptive AUFPO Assistant Upazila Family Planning Officer AHI Assistant Health Inspector AMTSL Active Management of Third Stage of Labor ANC Antenatal Care APK Android package kit BCC Behaviour Change Communication BEmONC Basic Emergency Obstetric and Newborn Care BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CBT Competency Based Training CC Community Clinic CCSDP Clinical Contraceptive Service Delivery Program CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHW Community Health Worker CHX Chlorhexidine CIPRB Centre for Injury Prevention and Research, Bangladesh CMPM Community Micro Planning Meeting CS Civil Surgeon CSBA Community Skilled Birth Attendants CSI Clinical Severe Infection CV Community Volunteer DDFP Deputy Director Family Planning DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DH District Hospital DHIS2 District Health Information System-2 DN Death Notification DP Development Partner EH Engender Health ENC Essential Newborn Care EoP End of Project ETAT Emergency Triage and Treatment e-LMIS electronic-Logistics Management Information System e-MIS electronic- Management Information System FDR Facility Death Review FP Family Planning FPCS-QIT Family Planning Clinical Services – Quality Improvement Team FPI Family Planning Inspector FWA Family Welfare Assistant FWV Family Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HEU Health Economics Unit Hg HI Health Inspector HPNSP Health, Population and Nutrition Sector Program HR Human Resource HRIS Human Resource Information System HRM Human Resource Management HS Health Systems HSCS Health Systems Capacity Strengthening

4 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report HSS Health Systems Strengthening IDD Iodine Deficiency Diseases IEM Information, Education and Motivation IFB Isolated Fast Breathing IFA Iron Folic Acid IMCI Integrated Management of Childhood Illness IP Infection Prevension IPHN Institute of Public Health Nutrition IR Intermediate Result ISQUA International Society for Quality in Health Care IUCD Intra Uterine Contraceptive Device IUD Intra Uterine Death Jk Jhalokathi JSV Joint Supervisory Visit KMC Kangaroo Mother Care LAPM Long-acting and Permanent Method LARC Long-acting Reversible Contraceptive LG Local Government LMIS Logistics Management Information System LOC Letter of Collaboration Lp Lakshmipur MAM Moderate Acute Malnutrition MCWC Maternal and Child Welfare Center MEC Medical Eligibility Criteria MFSTC Mohammadpur Fertility Services and Training Centre MNCH/FP/N Maternal, Newborn and Child Health, Family Planning, and Nutrition MNH Maternal and Newborn Health MO Medical Officer MOCS Medical Officer – Civil Surgeon MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOMCH&FP Medical Officer-Maternal and Child Health & Family Planning MPDSR Maternal and Perinatal Death Surveillance and Response MSCS Marie Stopes Clinic Society MSH Management Sciences in Health MUAC Mid Upper Arm Circumference NGO Non-government Organization Nk Noakhali NNS National Nutrition Services NVD Normal Vaginal Delivery OBGYN Obstetrics and Gynecology OGSB Obstetrical and Gynecological Society of Bangladesh OP Operational Plan pCSBA Private Community Skilled Birth Attendants PDCA Plan-Do-Check-Act PE/E Pre-eclampsia/Eclampsia PHC Primary Health Care PHD Partners in Health and Development PIP Program Implementation Plan Pj Pirojpur PM Program Manager PMMU Planning, Monitoring and Management Unit PNC Post Natal Care PPFP Post-partum Family Planning PPH Postpartum Hemorrhage PPIUCD Post-partum Intra-uterine Contraceptive Device PRS Population Registration System PW Planning Wing

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 5 QI Quality Improvement QIS Quality Improvement Secretariat QoC Quality of Care RMO Residential Medical Officer RMNCH Reproductive, Maternal, Neonatal and Child Health RRQIT Regional Roaming Quality Improvement Team SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBCC Social & Behavioral Change Communication SBM-R Standards-Based Management and Recognition SCI Save the Children International SCANU Special Care Newborn Unit SCMP Supply Chain Management Portal SDP Service Delivery Point SIAPS Systems for Improved Access to Pharmaceuticals and Services SOP Standard Operating Procedure SSN Senior Staff Nurse TAB Tablet Computer TAG Technical Advisory Group TB Tuberculosis UFPO Upazila Family Planning Officer UHC Upazila Health Complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UP Union Parishad USAID United States Agency for International Development USC Union Sub-centers WISN Workload Indictors of Staffing Need WHO World Health Organization

6 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

EXECUTIVE SUMMARY During the third quarter of its fourth year, the MaMoni HSS program continued with on- going activities for health systems strengthening at the national and district level, with some activities expanding at the national level and others under consolidation at the district level. In addition, there has been a renewed focus on SBCC activities in specific areas to improve health behavior and practices of those communities.

Key accomplishments in this quarter include: . SBA delivery: Deliveries by skilled birth attendants has slightly increased than last quarter, total 28,568 deliveries were conducted by SBAs during the reporting period, of them, 12 percent are in upgraded 24/7 UH&FWCs. The number of deliveries by pCSBAs has also increased in this quarter (309 deliveries) than that of previous quarters.

. Specific newborn intervention revisits - In this quarter, phase two of the specific newborn intervention (essential newborn care including HBB and 7.1% CHX) revisits have been completed in 16 districts of , and Divisions. Phase 3 of the revisits were initiated in 16 districts of , Chittagong, and Dhaka divisions. Data collectors from partner organizations PHD and BSMMU conducted revisits in 868 facilities and gathered data using the standard checklist.

. 7.1% Chlorhexidine for newborn cord care - Five divisional dissemination meetings to share results of the post training follow-ups on application of 7.1% Chlorhexidine were organized in Chittagong, , Dhaka, Rajshahi and Rangpur divisions. The post training follow-ups were conducted by independent monitors in 64 districts during August and September 2016.

. Family planning orientations for health providers - Orientation of DGHS managers and providers from district hospitals and the upazila health complexes was held in all four MaMoni HSS districts on FP and PPFP service delivery. The objective of these orientations was to strengthen FP services at upazila and district level facilities and to intensify coordination between health & family planning departments.

. Initiation of Plan-Do-Check-Act cycle for quality improvement - A residential training on Plan-Do-Act-Check (PDCA) was held in Rajendrapur targeting 4 district hospitals (Hg, Nk, Lp, Jk). National level facilitators from the Quality Improvement Secretariat (QIS) and MaMoni HSS staff at national and district level who will facilitate the application of PDCA in their respective districts participated in the training. Participants were supported to develop a specific Quality Improvement (QI) project to work on in their respective facilities. This included the identification of specific improvement objectives, a root-cause analysis of the selected performance gaps, identification of counter measures, selection of indicators to measure progress, and the development of a workplan. Moving forward, divisional and district QI staff will monitor the progress of the PDCA process in the four facilities.

. Implementation of Human Resource Information System - MaMoni HSS is supporting the implementation of the central HRIS at Habiganj and Noakhali districts. A two-day training of trainers (ToT) on central HRIS was provided to 64 participants in collaboration with the MIS department of DGHS. One batch was organized at Habiganj and another at Noakhali. After the ToT, statisticians and HIS coordinators provided

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 7 training to 207 Community Health Care Providers (CHCPs) and Sub-assistant Community Medical Officers (SACMOs) from all eight of Habiganj.

. Introduction of e-LMIS in additional districts - In coordination with SIAPS, the project is supporting the MOHFW to introduce electronic logistics management information system (e-LMIS) in three additional districts (Hg, Nk, Jk) to improve recording, monitoring, and availability of essential drugs, particularly MNCH items. During the reporting quarter, the project conducted an orientation of district level stakeholders in Habiganj, Noakhali, and Jhalokathi districts on e-LMIS. Because the e- LMIS will be linked to the national DHIS2 data, the project hired a consultant to input health facility specific data into DHIS2 as an initial step for implementing e-LMIS.

. E-registers rolled out in Habiganj - In this quarter, maternal, newborn, and child health (MNCH), family planning (FP), and general patient and community e-registers were rolled out in all union facilities of Habiganj. Supervisors/managers of Madhabpur upazila have started using the e-MIS monitoring tool. The facility module of the e- Register has been launched in Lakshmipur and Jhalokathi.

Challenges and Mitigation Strategies:

As the project is approaching its end, the HR gaps filled by MaMoni HSS need to be absorbed within the MOHFW cadres, or replaced by MOHFW staff. For ensuring continuation of service the project has initiated dialogue with local health managers and local government for resolving this issue.

Every year, a good number of trainings are being conducted by different programs but there is no formal system of follow up after training and supportive supervision. MaMoni HSS strongly feels the need and hence conducted follow-up after ENC training. The project has now initiated dialogue with DGHS and DGFP for institutionalization of training follow-up and supportive supervision after critical technical trainings such as PPIUCD, EOC etc.

MaMoni HSS has been in continuous dialogue with DGHS, DGFP, QIS and other development partners for improving the quality of clinical care at a large scale. Innovative approaches need to be tested to encourage local ownership and leadership for quality improvement as well as expanding the involvement of the local government in problem solving and quality improvement.

Poor case admission and post discharge follow up of KMC as well as poor day-8 follow up of PSBI cases remain as key challenges for newborn health. In consultation with national and district health managers, the project has plans to orient and engage union level supervisors of public sector providers for the follow up of KMC and PSBI cases at community level.

In order to reap the benefit of Mobile Camps in boosting LARC& PM uptake, MaMoni HSS has initiated coordination with Mayer Hashi II project and DGFP in order to ensure skilled human resource, supplies, client referral etc.

Moreover, In this quarter pace of work was slow because of Ramadan and Eid festival in late May and entire June. Also GOB managers were busy with closing of financial year in June.

8 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

Way Forward: .

. Orient and engage union level supervisors in follow-up of KMC and day-8 follow-up of PSBI. . Support coordination between health and family planning directorates to ensure FP service provision by DGHS staff. . Coordinate with Mayer Hashi II project for effective utilization of mobile camps. . Monitor and document PDCA in 4 district hospitals. . Implement eMIS facility and community modules in Lakshmipur and Noakhali and only facility module in Jhalokathi. . Linking eLMIS to DHIS2.

INTRODUCTION The MaMoni Health Systems Strengthening (HSS) project is a five-year USAID-funded award1 aimed at improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services through a health systems strengthening approach. In quarter 2 of the fourth year, MaMoni HSS has continued to support the MOH&FW to strengthen health systems at the national level as well as at district level. During the reporting period, the program’s technical assistance at the national level has expanded, at the same time that implementation at the district level is under consolidation. However, during this quarter low performance have been observed for many indicators, most likely as a result of Ramadan and Eid festival in late May and through June. The project supports 40 upazilas in 6 districts, 23 of them are designated as high intensity (HI) areas and the remaining 17 as health systems capacity strengthening (HSCS) areas. The scope and geographical coverage of the MaMoni HSS Project has been summarized below. Program coverage is described in more detail in Appendix 1.

Table 1. Summary of MaMoni HSS geographic scope

No. of Health Facilities Population No. of Area No. of Upazilas (2015 Unions District projection) Hosp. & Upazila Union Community MCWC

High-Intensity 23 (Habiganj-8, Areas Noakhali-4, Lakshmipur-5, 226 7,355,822 5 20 208 619 Jhalokathi-4, Pirojpur-2)

1The MaMoni HSS program is an Associate Award under the Maternal and Child Health Integrated Program, with a period of performance from September 24, 2013 to September 23, 2018. MaMoni HSS is supported by Jhpiego—in partnership with Save the Children, John Snow, Inc., and The Johns Hopkins University Institute for International Programs. National partners include: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). Save the Children serves as the lead operational partner for the Award in Bangladesh.

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 9 Health Systems 17 (Bhola-7, Capacity Noakhali-5, 151 4,870,933 5 13 121 488 Strengthening Pirojpur-5) (HSCS) Area

Total 40 377 12,226,755 10 33 329 1,107

DATA SOURCES Program monitoring data for this report comes from different sources, including a population based tracer survey (in high intensity areas), a sentinel survey (selected facilities in MaMoni areas), service delivery point (SDP) assessments (select facilities in MaMoni areas), a revisit of specific newborn interventions (14 districts nation-wide), and routine MIS of DGHS. A list and detail on the scope of the surveys is attached as Appendix 2.

PROGRAM RESULTS FOR THE QUARTER

IR 1. Improve Service Readiness through Critical Gap Management

1.1 Introduction and Scale-up of MNCH/FP/N interventions

1.1.1 Maternal Health

The program’s major interventions in maternal health are pregnancy identification & registration through front line health workers, the provision of at least four antenatal care (ANC) contacts with Quality of Care (QoC), birth planning, promotion of, and increase availability and accessibility to quality skilled birth attendance including active management of the third stage of labor (AMTSL), distribution of misoprostol for home delivery, and ensuring four postnatal visits, including the promotion of post-partum family planning. There are also special interventions in selected areas, such as the management of severe pre-eclampsia & eclampsia through the administration of MgSO4.

1.1.1. a. Pre-eclampsia/Eclampsia (PE/E) management at union level facility: MaMoni HSS, in collaboration with the Obstetrical and Gynecological Society of Bangladesh (OGSB), has introduced severe pre-eclampsia and eclampsia management at the union level where a loading dose of injectable Magnesium Sulfate (MgSO4) is administered at the union level by Family Welfare Visitors (FWVs). This intervention has been rolled out at 140 union level facilities in 16 upazilas (5 upazilas in year 3 and rest in year 4) of 4 districts. In this quarter, need-based refresher trainings were organized for union level service providers (FWV, Paramedics) of Nabiganj, Companiganj, Ramganj, Raipur & Rajapur upazilas. The purpose of the training was to refresh the knowledge of the service providers on the identification and management of PE/E as per the algorithm.

10 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

Practical session of refresher training on PE/E at UHC

A total of 65 cases of severe PE/E patients (fig 1) were identified and managed in this quarter. Senior OBGYN professionals from OGSB continued their monitoring visits to provide on the job support to the service providers in case identification and management. Additionally, a meeting was organized with Population Council who is implementing a similar study in other locations. It has been decided that MaMoni HSS, Population Council and icddr,b will organize regular meetings to share experiences and identify areas for performance improvement.

Figure 1: No. of Severe PE/E cases identified and received pre referral loading dose of MgSO4 in 16 upazila of 4 districts (Aug 16 –June,17)

30 28 28 25 25 26 26 25 22 22 19 19 20 18 18 17 17 15 15 16 16 15 10

5 1 1 2 2 0 Aug'16 Sep'16 Oct'16 Nov'16 Dec'16 Jan'17 Feb'17 Mar'17 Apr'17 May'17 Jun'17

No. of SPE/Eclemsia identified by Service Provider No. of cases (SPE/E) received loading dose of MgSO4

Source: MIS-3, DGFP

1.1.1b. Misoprostol to prevent postpartum hemorrhage (PPH) at home births

MaMoni HSS is facilitating the distribution of misoprostol tablets to prevent PPH following home deliveries to pregnant women in their third trimester via FWAs and FWVs. A total of 27,914 tablets were distributed in this quarter (fig 2). The project also tracks consumption of the tablets by the mothers immediately after birth through tracer surveys every six months.

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 11

Monitoring field visit by Prof. Sabera Khatun from OGSB at Bamni & Sonapur UH&FWCs of

Figure 2: Trends in Misoprostol distribution in MaMoni HSS districts

30000 27918 27914 24750 25000

20000 16191

15000 11609

10000

5000

0 Q3-Y3 Q4-Y3 Q1-Y4 Q2-Y4 Q3-Y4

Source: MIS-4, DGFP

1.1.1. c. Increasing Skilled Birth Attendance (SBA) at the District Level

A total of 28,568 deliveries were conducted by skilled birth attendants (fig 3) during the reporting period. Of them 3,420 (12%) were in upgraded 24/7 UH&FWCs (fig 4).

Figure 3: Trends in SBA deliveries in MaMoni HSS districts

12 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

35000

30000 10470 25000 12938 8369 10991 20000 6771

Number 15000

22184 10000 18386 17665 17968 14882 5000

0 Y3-Q3 Y3-Q4 Y4-Q1 Y4-Q2 Y4-Q3

SBA delivery in HI area SBA delivery in HSCS area

Source: DGFP MIS 2 and 4, EmOC and CSBA report in DHIS-2, Project pCSBA report.

Figure 4: No of deliveries in 24/7 UH&FWCs in MaMoni HSS districts

90 4000 81 81 80 75 75 3467 3407 3439 3420 3500 65 65 70 3000 60 2418 2507 2500 50 2000 40 1500 30 20 1000 10 500 0 0 Q-2(FY-3) Q-3 (FY-3) Q-4 (Y-3) Q-1(FY-4) Q-2(FY-4) Q-3(FY-4)

No. of 24/7 UH&FWC No. of delivery

Source: MIS-3, DGFP

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 13

FWV of Jhalokathi MCWC is filling partograph A happy mother with her baby just immediate after delivery at 24/7 delivery centre, Harni of during a delivery in the facility

1.1.1. d. Private CSBAs (pCSBA) assisted deliveries The number of deliveries by pCSBAs has slightly increased in this quarter (309 deliveries) than that of previous quarters (fig 5).

Figure 5: Trends in deliveries by pCSBAs in MaMoni HSS districts

140 119 120 102 98 100 95 93 100 90 88 78 80

60

40

20

0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

Source: Project MIS.

In order to improve the quality of services and reporting, the project organized the following trainings during the reporting quarter:

14 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 1. Refresher training on reporting: To strengthen reporting mechanisms and to increase coordination of pCSBAs with GOB providers, MaMoni HSS organized a refresher training for 11 pCSBAs. 2. Refresher training on ANC, PNC and Infection Prevention: MaMoni HSS organized a refresher training on ANC, PNC and infection prevention for FWVs and nurses in Noakhali and Jhalokhati districts in May, 2017.

Refresher Training on Reporting Mechanism and refresher Refresher Training on ANC, PNC and Infection Prevention

1.1.2 Newborn Health National Scale Up Activities: National scale-up activities for newborn health are being supported by MaMoni HSS implementing partners - Bangabandhu Sheikh Mujib Medical University (BSMMU) and Partners in Health and Development (PHD) under the leadership of the IMCI section of DGHS. To follow up on support provided by MaMoni HSS for the national scale up of Helping Babies Breathe (HBB) and 7.1% Chx for newborn cord care, the program is supporting the MOHFW to conduct a revisit of these two interventions. This activity includes:

- Identification and training of two medical officers (MO’s) from each upazila as a newborn focal person - Divisional and district level advocacy and planning meetings to sensitize district/upazila managers about the importance of the program, explain activities and make upazila wise plans as per their directions. - Refresher training of skilled birth attendants (SBAs) on Essential Newborn Care including HBB and application of 7.1% Chlorhexidine for cord care - A revisit in all facilities in the district: this includes a quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, medicine and supply stocks (including 7.1% Chlorhexidine)and replacement or provision of supplies for newborn resuscitation equipment (bag, mask and sucker) in the facilities. The team also records the number of live births, still births, total delivery, C Sections, use of 7.1% CHX, number of preterm deliveries, number of LBW babies, number of AMTSL, use of oxytocin and number of newborns required resuscitation.

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 15 The national newborn and child health cell is providing management support for this activity and it will be completed in phases. The revisit in 16 districts (2nd phase) was initiated in February 2017 and completed by May 2017. Later in May, the revisit started in another 16 districts (3rd phase). Gradually, all 64 districts will be covered by this intervention with this phased approach.

1.1.2.a. Revisit of priority newborn interventions: In this quarter, phase two of the specific newborn intervention revisits were completed in 16 districts of Khulna, Chittagong and Dhaka divisions (phase two districts include: Khulna, Bagerhat, , Narail, Magura, Kustia, Chuadanga, Meherpur, Jhenaidah, Satkhira, Rangamati, Bandarban, Khagrachari, Sherpur, Narsingdi, ). Activities under phase three of the revisit have been initiated in 16 districts of Rajshahi, Chittagong, Sylhet and (phase three districts include: Rajshahi, , , Naogaon, Natore, Chapai Nawabganj, Joypurhat, Habiganj, Noakhali, Lakshmipur, Jhalakathi, Faridpur, Shariatpur, Gopalganj, Rajbari, Madaripur).

Data collectors from partner organizations PHD and BSMMU conducted revisits in 868 facilities in this quarter and gathered data using a standard checklist. Three district level advocacy meetings and 123 upazila level refresher trainings on a package of HBB & ENC interventions (including application of 7.1% Chlorhexidine) were organized for SBAs and CSBAs; a total of 2,427 providers received the refresher training.

Table 2: Percentage of service and logistics available by types of facility

Offer Facility types delivery HBB kit 7.1% CHX Gentamycin Amoxycillin MgSO4 N

DH 100 78 89 67 33 28 18 MCWC 100 76 67 14 90 10 21 UHC 89 79 82 50 34 7 96 UH&FWC-FP 91 89 66 6 86 2 638 UH&FWC-H 94 97 57 31 91 3 35 USC 55 45 36 27 36 0 11 RD 74 77 45 0 42 0 31 Others 50 50 50 17 50 6 18 Total 89 86 66 14 77 3 868

Training Types n n % 7.1% CHX trained 5304 3966 75 HBB trained 4604 2258 49 Source: Revisit Survey, February to May 2017

1.1.2.b.Divisional Dissemination of post training follow-up of application of 7.1% Chlorhexidine in newborn umbilical cord Five divisional dissemination meetings on post training follow up of 7.1% Chlorhexidine for cord care were organized in Chittagong, Barisal, Dhaka, Rajshahi and Rangpur divisions. The results of the

16 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

post-training follow up, conducted by 32 independent monitors in 64 districts during Aug- Sept 2016, were presented in these divisional dissemination meetings. The presentations included the status of human resources, skills and knowledge retention from trainings, availability and use of 7.1% Chlorhexidine in all level of facilities and pharmacies, and the availability, use, and cleanliness of HBB equipment in all tiers of facilities. Divisional and district level managers of health and family planning division attended the meetings.

The post-training follow-up revealed that 86% of the respondents (N=3400) who participated in the post-training follow-up received orientation on ENC including application of 7.1% CHX in the umbilical cord. At the time of the visit, 7.1% Chlorhexidine was available in 53% facilities. Eighty-four percent providers could demonstrate CHX use in right way and 47% of them reported applying 7.1% CHX in the newborn umbilical cord during the last week preceding the revisit. Eighty-six percent providers advocated pregnant mothers to use of CHX. It was also found that 7.1% CHX was available in 54% private pharmacies. Independent Monitors also found that bag- mask and sucker were available in 84% OT/ delivery rooms. Bag-mask and sucker was found to be clean in 86% facilities.

1.1.2.c. Mentoring workshop for Newborn Focal Persons in 21 Upazilas of MaMoni districts

Newborn focal persons were nominated by respective Civil Surgeons in 21 high intensity upazilas of 4 MaMoni districts (Habiganj, Noakhali, Lakshmipur, Jhalokathi). They were designated by the Program Manager-IMCI section on behalf of the Director, PHC. Doctors from DGHS who are interested to work on newborn and child health and have some newborn related training were selected as newborn focal persons. They were further oriented on new newborn interventions and will be mentored by DGHS and BSMMU. MCH/FP Medical Officers from DGFP in respective upazilas were also oriented so that they can work in coordination with the newborn focal persons. A total of 32 doctors attended, 7 of them had attended the previous workshop last year.

Participants were trained on Essential Newborn Care including HBB and 7.1% Chlorhexidine for cord care, quality improvement, program monitoring and record keeping & reporting. The newborn focal persons will support their managers in rolling out newborn health interventions in respective districts and upazilas including monitoring the quality of training sessions. They will also facilitate district and lower level training sessions as and when needed, visit facilities to monitor the supply and performance of health care providers, and provide on the job support for improving quality of service. They will highlight relevant issues in different meetings and forums and help support national level policy and advocacy.

1.1.2.d. Other national activities through National Newborn and Child Health Cell

MaMoni HSS provides regular and continuous technical support to the national newborn and child health cell in the MOH&FW to carry out its priority initiatives. During this quarter, the newborn and child health cell has supported the Line Director for MNC&AH to prepare the operational plan (January 2017- June 2022). As a part of its routine activity, the newborn and child health cell continuously supported the IMCI program manager (PM) to implement IMCI as well as the revisit activity for specific newborn interventions throughout the country. The national cell also supported the scale-up of kangaroo mother

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 17 care (KMC), emergency triage and treatment (ETAT), sick newborn care and newborn sepsis management.

The cell plays a leading role in the technical sub-committee that reviews and updates the IMCI-N case recording form and online reporting form. Along with the Challenge TB program of MSH, the newborn and child health cell plays a vital role in fostering inter- sectoral collaboration on childhood TB. The newborn and child health cell also worked with the ‘National Coordination Cell’ to arrange a consultative workshop on cervical cancer, fistula, and the national newborn health program.

The newborn and child health cell has analyzed and circulated Upazila specific ‘IMCI services and online reporting of 2016’ (IMCI service related performance analysis) to all the concerned Upazila Health and Family Planning managers.

1.1.2.e. Support for the development of the Child Health Strategy:

The IMCI section of DGHS has initiated the development of a national child health strategy. MaMoni HSS is participating in the development process through contributions in the technical sub-committees. District Level Newborn Interventions:

1.1.2.f. Use of 7.1% Chlorhexidine for cord care to prevent newborn infection As a part of the essential newborn care package, 7.1% chlorhexidine application for cord care of every newborn has been implemented as part of the national scale-up. MaMoni HSS has provided targeted support in project districts for the national roll-out. During the period of Apr- May 2017, a total of 15641 babies received 7.1% Chlorhexidine for newborn cord care. Of this number, a total of 4913 were from Habiganj, 5852 from Noakhali, 4245 from Lakshmipur, 1684 from Jhalokathi, 3627 from Bhola and 2350 from Pirojpur.

Figure 6: Use of 7.1% CHX in DGFP facilities or by DGFP providers by place of CHX application in MaMoni 4 districts (Oct'16 to Jun'17)

120 102 103 103 103 97 99 100 97 98 100 93 89 89 88 88 84 86 81 78 80

60 Percent 40

20

0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

CHX 7.1 used at facility delivery CHX 7.1 used at home delivery

Source: DGFP MIS

18 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

Snapshots from DHIS2 (Fig 7 and 8) also show increased use of CHX both in community and facility delivery. The map of Bangladesh presented in Figure 9 shows use of CHX is comparatively higher in 5 MaMoni HSS districts (46-68%), except in Noakhali where it is between 29-45%.

Figure 7: Percentage of newborns delivered by SBA in the community who received 7.1% chlorohexidine to the cord after birth

Figure 8: Percentage of newborns delivered by SBA at facility who received 7.1% chlorohexidine to the cord after birth

Fig 9: Map of Bangladesh showing rates of 7.1% CHX application

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 19

1.1.2.g. Management of sick children Sick young infant (<2 month of age) management following the national guidelines has been implemented out of 148 Union Health & Family Welfare Centers (UH&FWC) in 4 MaMoni HSS districts. The Sub-assistant Community Medical Officers (SACMOs) are the designated providers of this intervention, with the Family Welfare Visitors (FWV) enabled and authorized to provide a second dose of injectable Gentamycin for the management of Clinical Severe Infection (CSI) cases where referral has failed. MaMoni HSS has facilitated the training of all the SACMOs and FWVs in the facilities that provide this service.

To improve the 8-day follow up of PSBI cases by union level supervisors such as the Family Planning Inspectors (FPIs), MaMoni HSS supported the orientation of FPIs to conduct follow up visits at the household level. A training of trainers (TOT) for twenty master trainers (MTs) was completed in Lakshmipur and Jhalokathi districts. These MTs will conduct the orientations of supervisors at upazila level.

During the period from Apr-June 2017, a total of 1351 sick children were managed from UH&FWCs in Habiganj (614), Noakhali (236), Lakshmipur (268), Jhalokati (233) districts, the categories of illness were Critical Illness (CI)-3%, Clinical Severe Infection (CSI)- 6%, Isolated Fast Breathing (IFB)- 28%, Local Bacterial Infection (LBI)-26%, Other- 38%.

Figure 10: Number of sick infants (<2 month) managed at the union level in 21 upazilas of 5 districts during the Jan'16 - Jun'17 period.

20 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 800 700 719 600 640 532 534 523 544 500 474 496 498 494 486 497 465 454 447 430 400 396 376 300 200 100 0

CI CSI IFB LBI Other Total

Source: Project MIS

Figure 11: Classification of sick infants (<2 months) presented at the union level facilities in 21 upazilas of 4 districts during the Jan'16-Jun'17 period.

233, 3% 536, 6%

3411, 38% [VALUE], 28%

2341, 26%

CI CSI IFB LBI Other

Source: Project MIS

1.1.2.h. Kangaroo Mother Care (KMC) Kangaroo Mother Care (KMC) units were established at 15 facilities (4 district hospitals, 2 maternal and child welfare centers (MCWCss), and 9 upazila health complexes (UHC) of four MaMoni HSS implementation districts (Habiganj, Noakhali, Lakshmipur and Jhalokati).

During the period from April-Jun 2017 a total of 46 cases received KMC services in Hg(10), Nk(15), Lk(15),) from the KMC units. Short duration of hospital stays and poor post discharge follow up are the key challenges of this intervention. To address these challenges, the MaMoni HSS program organized sensitization and program review meetings with concerned personnel at 4 facilities. To improve post discharge follow up of cases, the project is supporting an orientation of union level supervisors (Assistant Health Inspectors) of respective upazilas who will conduct the follow up visits at the household level. A TOT of 22 master trainers (MT) was completed in Lakshmipur and Jhalokathi districts. These MTs will conduct orientation of supervisors at the upazila level.

1.1.2.i. Antenatal Corticosteroids (ACS) for threatened preterm labor

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 21 MaMoni HSS has been supporting the use of Antenatal Corticosteroids (ACS) in threatened preterm deliveries following national guideline in 3 District Hospitals (Habiganj, Noakhali and Lakshmipur). During the Q3 period of Apr-Jun 2017, a total of 114 eligible pregnant women received ACS from these hospitals (Habiganj 42, Noakhali 51 and Lakshmipur 21).

1.1.2.j. Facility based care for sick children Special Care Newborn Units (SCANU) in five MaMoni HSS supported district hospitals (Habiganj, Noakhali, Lakshmipur, Bhola & Pirojpur) have been providing services to the community. The availability of dedicated GOB manpower is the main challenge for service delivery in the SCANUs. MaMoni HSS is supporting the capacity building of GOB staff and has deployed trained staff nurses in Habiganj, Noakhali and hospitals. During the April-June ’17 period, a total of 15 doctors and 48 nurses received ETAT training in 3 batches. The project also supported training of 17 nurses Online Reporting Training in two batches of on-the-job training for standard operating procedures (SOPs), sick newborn management at the SCANUs, online reporting into DHIS-2 and hands-on practice for use of equipment. The trainings were conducted at BSMMU.

During the period April-June 2017 a total of 845 cases were managed at 5 SCANUs, of them 145 at Noakhali, 113 at Lakshmipur, 465 at Bhola, 102 at Habiganj and 20 at Pirojpur.

Fig 12: Number of cases managed at SCANU by district

200 172 146 147 150 123 87 100 69 69 75 73 72 42 49 42 4343 50 28 26 34 34 2528 10 0 9 0 0 0 0 5 5 0 0 8 7 0 2 6 0 0 4 6 0 5 2 0 4 6 7 0 7 0 Sep' 16 Oct' 16 Nov' 16 Dec' 16 Jan' 17 Feb' 17 Mar' 17 Apr' 17 May' 17 Jun' 17

Noakhali Habiganj Laksmipur Pirojpur Bhola

During the period, the project also supported maintenance services for SCANU equipment of in all project-supported SCANUs by a technical expert. It may be noted here that the MNCAH Operational Plan of MOHFW has kept a budget earmark for the maintenance of the SCANU, but that will not be functional before 2018.

22 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

Preventive maintenance and on the job coaching at Bhola SCANU

1.1.3 Family Planning 1.1.3.a. Use of modern methods of family planning The utilization of various methods of family planning remained almost the same since last year in all intervention districts (Figure 13).

Figure 13: FP method mix from June 2016 to June 2017

90 80 7 3 5 5 8 3 3 5 7 7 4 7 4 5 3 5 7 7 5 5 70 4 4 43 2 3 3 5 5 1 1 1 14 23 3 4 5 6 6 23 3 3 3 60 5 5 5 3 17 12 12 50 32 32 15 15 18 18 23 7 7 16 16 23 6 5 40 5 6 6 8 8

Percent 5 5 30 4 4 20 42 43 44 39 40 32 32 36 36 36 36 34 34 10 0 Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17 Standard Habiganj Bhola Pirojpur Jhalokati Noakhali Lakshmipur

Oral pill Condom Injectable IUD Implant NSV Tubectomy

Source: MIS-4, DGFP

In this year MaMoni HSS focused on increased coordination of DGHS and DGFP to intensify FP interventions, especially long acting and reversible contraceptives (LARCs), permanent methods (PMs), and post-partum family planning (PPFP) at all service facilities. Health managers are not oriented on FP or PPFP, and providers working under DGHS also don’t have adequate skills to provide FP methods to clients despite an estimated 44%

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 23 unmet need for PPFP. MaMoni HSS is contributing to the scaling up of FP services in general and PPFP in particular. The project is putting a special emphasis on strengthening the capacity of providers at health facilities managed by DGHS to ensure service readiness and provision of care.

In addition to strengthening DGFP activities, a number of activities & interventions in this quarter have been completed which are exclusive to DGHS. These are as follows:

A. Coordination meeting organized by the Clinical Contraceptive Service Delivery Program (CCSDP), DGFP, Dhaka: This is a regular meeting to develop action plans and prioritize areas to reduce gaps identified in the assessment findings for facility readiness on LARC & PM services. An action plan was developed and a team has been formed to work on the action plan.

B. Family Planning Counseling module: A national working group was formed during the quarter, and includes members from DGHS & DGFP, including representatives from MCH, CCSDP, Field Service Delivery, the IEM of DGFP and PHC, and Hospital Services of DGHS, as well as NGOs like Save the Children International, Marie Stopes Clinic Society (MSCS) and EngenderHealth (EH) Bangladesh.

C. Orientation of DGHS providers (DH & UHC) on FP service delivery including PPFP: An orientation of DGHS managers and providers from the district hospitals (DH) and upazila health complexes (UHCs) was held in all four MaMoni HSS districts on FP and PPFP service delivery. The objective of these meetings was to strengthen FP services at upazila and district level facilities and to intensify coordination between health and family planning departments, including the provision of basic information on FP services to the participants. The event was jointly organized by MaMoni HSS and DGFP. Participants included the Upazila Health and Family Planning Officer (UH&FPO),

CS speaking on FP & PPFP counselling in Orientation of DGHS providers on FP and Jhalokathi PPFP

Medical Officer – Civil Surgeons (MOCS), OBGYN Consultants, the Residential Medical Officers/UHC’s, Senior Staff Nurses (SSN’s) and were facilitated by the Medical Officers (MO) -Clinic, and the MOs MCH-FP of DGFP. Feedback from one health manager following the training included the statement that, “This orientation will change the perception, knowledge, and attitude of DGHS managers, as well as provider’s roles and responsibilities on FP & PPFP”. The managers will subsequently inform and build the capacity of other health service providers in their monthly meetings for effective counseling and skills building of providers to offer clients easy access to a wide range of affordable, reliable, and good quality FP & PPFP

24 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report contraceptive services with a special focus on promotion of methods like PPIUCD. A follow up meeting will be organized in each quarter for intense liaison and communication between DGHS and DGFP providers.

D. Training on FP policy changes & MEC wheel for Health & FP Managers: Training on FP Policy changes and medical eligibility criteria (MEC) wheels were organized in all four MaMoni HSS implementation districts with the objective of informing health and FP managers on recent updates of FP policy changes and Government Orders (from 2010 to 2017) and their implementation status. These updates aim to: - ensure that clients are able to make informed decisions on FP - fulfill the huge unmet need of PPFP - promote FP method acceptance - popularize LARCs & PMs - clarify the 2016 MEC wheel - refresh knowledge and skills on bottom up projection of FP The Deputy Director of Family Planning (DDFP) was the Chairperson and the Civil Surgeon (CS) was the Chief Guest in these events. Quality Assurance staff from CCSDP, DGFP, and the District Manager of the QIS of HEU were the key resource people. Partners from Engender Health facilitated the session on bottom-up projection of family planning. Participants included the CS, MOCS, the Assistant Director Clinical Contraceptives (ADCC), UH&FPO from Health department and Upazila Family Planning Officer (UFPO), MO Clinic, Assistant UFPO (AUFPO), and the MO-MCH in charge from the Family Planning department. The training ended with the formulation of an action plan for follow up and monitoring.

E. Interventions for increasing the coverage of LARC & PM in MaMoni HSS districts:

• Competency based training of newly appointed MO MCH-FP: Three batches of training on LARCs and PMs have been completed for the newly appointed MOs (MCH- FP) of DGFP in Sylhet, Barisal and Chittagong divisions under the direct supervision of CCSDP and with coordination from the FPCS QIT and MaMoni HSS. The 18 day training included lectures, dummy practice, and field camps designed to make the participants competent and skilled on placing implants and IUD’s, as well as tubal ligation and vasectomy. The training was organized outside of Dhaka where more cases are available for practice to further develop the participants confidence and skills. Supportive supervision to the trainees will be provided by CCSDP and the MaMoni HSS program and performance reviewed intermittently.

• Facility readiness of DH, MCWC & UHC: A facility readiness assessment of 4 DHs, 6 MCWCs and 22 UHCs was conducted to understand the current status and areas for improvement to address low utilization of LARC and PM services in MaMoni HSS areas. A structured checklist was used and the findings were shared with CCSDP, DGFP during this quarter to engage their support for infrastructure improvements, human resource strengthening, logistics and supply management, capacity development, infection prevention and improved QoC to increase utilization and patient satisfaction. An action plan has been developed for monitoring progress. CCSDP and MaMoni are jointly trying to improve the facility for quality service delivery of LARCs and PMs.

1.1.3.b. PPIUD performance

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 25 Two batches of basic training on IUCD and PPIUCD for Senior Staff Nurses have been completed at the Mohammadpur Fertility Services and Training Center (MFSTC), Dhaka during this quarter. All participants were provided with a training manual and other resources related to IUDs and PPIUCDs. Identifed challenges include the lack of strong coordination between the Health and FP departments regarding supply, reporting mechanisms, and fund mobilization. To mitigate these barriers, the project is coordinating between DGFP and DGHS at the national and district level to ensure the availability of essential FP supplies and funds needed to support services.

MaMoni HSS also organized a two-day refresher training on FP that included PPFP and PPIUCD for FWVs, Female SACMOs, and Paramedics, with the objective to increase the performances of FP and PPFP, and particularly PPIUCD in the UH&FWCs. They received the initial training earlier through the MaMoni HSS project with technical support from Engender Health, Bangladesh. Fig 14 shows an increasing trend in PPIUCD performance in Habiganj, Jhalokathi and Pirojpur districts.

Figure 14: Trends in PPIUD performance in MaMoni HSS districts

350 308 300 261 251 250 229

200 188 169

Number 150 131 119 123

100 92 77 63 42 44 50 32 28 14 18 14 3 6 5 5 6 8 0 Noakhali Lakshmipur Habiganj Jhalokathi Pirojpur

Apr-Jun,16 Jul-Sep'16 Oct-Dec,16 Jan-Mar,17 Apr-Jun,17

Source: MIS-4, DGFP

1.1.3.c. Contribution of CSBAs and CVs in family planning

The numbers for PPFP counselling have slightly decreased both in high intensity areas and health system strengthening areas (Fig 14) in this quarter. Also the total number of LAPMs

26 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report recipients has decreased in this quarter, possibly because of Ramadan and the Eid festival in late May and through June.

Figure 14: No. of women counseled on PPFP by CSBAs (Oct ’16 to Jun ’17)

2500

2000 485 482 485 462 420 332 1500 466 451 274

1000 1590 1672 1622 1542 1466 1413 1311 1198 1294 500

0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

No. of PPFP counselling (HI) No. of PPFP counselling (HSCS)

Source: MIS-4, DGFP

Though the total number of LAPM recipients has decreased in this quarter, the contribution of Community Volunteers (CV) has increased from 21 percent to 25 percent in this quarter. (Fig 15).

Figure 15: CV contribution in LAPM performance Jan'16-Jun'17 by quarter

7442 7525 7500 6884

6500 5969 6066

5500 4668 4500

3500

2500 1735 1594 1477 1342 1195 1500 970

500 Q-2(FY-3) Q-3 (FY-3) Q-4 (Y-3) Q-1(FY-4) Q-2(FY-4) Q-3(FY-4)

Total LAPM CV contribution

Source: Project MIS

1.1.4 Nutrition

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 27 Malnutrition is one of the most serious health problems affecting infants, children and women of reproductive age in Bangladesh, among others. Despite progress made, millions of children and women still suffer from different forms of under-nutrition, including low birth weight, stunting, underweight, wasting, vitamin A deficiency, iodine deficiency disorders, and anemia. The nutritional status of children is a proxy indicator of the state of health of a community or population. With this status in consideration, MaMoni HSS has been working in four districts (Noakhali, Lakshmipur, Jhalokathi and Habiganj) under the directive of the Institute of Public Health Nutrition (IPHN) and with the district and upazila level health and family planning authorities. MaMoni HSS has taken the initiative to develop skilled front line health workers on primary nutrition screening and counseling at household and outreach centers, which will help the program expand coverage through active case identification and lower the burden of malnutrition during the project life to strengthen the nutritional landscape and support related objectives in the HPNSDP (2011- 2016).

1.1.4.a. Logistic for Nutrition Screening:

MaMoni HSS facilitated the distribution of basic equipment and supplies (50 Spring Scales, 50 Height/Length Boards, 500 MUAC Tapes) for screening nutrition at Service Delivery Points 22% (SDPs) from IPHN. 28%

1.1.4.b Service Statistics: 19% Data from DGFP MIS, DHIS-2 and Project MIS 31% show the following outcomes in MaMoni Cured Discharged Stabilized supported districts during this quarter: Incomplete Rx Continuation Rx . 151,910 children and mothers (31,607 mothers & 120,303 children) were reached with nutrition interventions from different types of service delivery points (Community Clinics, UH&FWCs, UHCs and DHs from where IMCI services are being provided) . 37,490 caretakers received BCC interventions on essential infant and young feeding practices, hand washing, IDD, Vit-A etc. . 31,607 pregnant mothers were reached with Iron Folic Acid (IFA) supplementation during ANC visits . 1,726 children were identified who have been suffering from MAM . 314 children were identified as SAM patients and referred . Among the reached children about 14,670 (12.19%) children were identified as malnourished. Among them 4,943 were stunted (4.12%), 3,596 were wasted (2.99%) and 6,131 were under weight (4.77%).

1.1.4.c. Management of acute malnutrition:

As per the national protocol, acute malnutrition is categorized as Moderate Acute Malnutrition (MAM) where cases are traditionally treated in the home and Severe Acute Malnutrition where cases are referred for facility based management (SAM Unit/Corner at Upazila Health Complexes and District Hospitals). These children get therapeutic treatment as well as treatment for other co-morbidities (complicated SAM). In therapeutic treatment the F-75 is used for initial or ‘Stabilizing Phase’ and F-100 is used for ‘Catch-up’ phase. During the reporting period (Apr – Jun 2017), a total of 36 SAM patients were

28 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report admitted into 10 SAM units of MaMoni HSS supported project areas. At the end of the quarter 28 SAM patients were discharged. Among them 10 were cured (27.77%), 11 were discharged after stabilizing (30.55%), 7 (19.44%) left the facility without completing the treatment and the rest 8 (22.22%) remained in the facility for completion of treatment.

1.1.4.d. Monitoring visits and performance review meeting: Two monitoring visits and performance review meetings were organized and attended by the Line Director of NNS and the Director of IPHN at Representatives from IPHN visiting Nutrition activities at UHC, Ramganj, Lakhsmipur Noakhali and Lakshmipur districts. The visits were held in the Upazila Health Complexes, Union Health & Family Welfare Centers and Community Clinics. After the visits the Deputy Program Managers (DPMs) met with District and Upazila level managers and reviewed the district performance. During the visits and performance review meetings the DPMs discussed the nutrition activities in the respective districst and way forward for mitigating current bottle necks.

1.2 Management of critical human resource gaps of GOB service providers:

Table 3: Critical human resource gaps filled-in by MaMoni HSS

FWA FWV Nurses GYN/OBS

District GOB GOB GOB GOB MaMoni (Paramedic) Vacant Posts Vacant Posts Vacant Vacant Posts Vacant Vacant Posts Vacant MaMoni MaMoni (CHW) MaMoni (Nurse) Vacancy filled up up filled Vacancy up filled Vacancy Vacancy filled up up filled Vacancy Vacancy filled up up filled Vacancy Vacancy filled up by by up filled Vacancy by up filled Vacancy Vacancy filled up by by up filled Vacancy Vacancy filled up by by up filled Vacancy

Noakhali 165 0 0 18 0 2 67 0 0 6 0 0 Lakshmipur 71 0 0 10 0 0 48 0 0 4 0 0 Habiganj 92 0 12 27 2 24 54 0 13 5 0 0 Jhalokathi 74 0 0 7 0 2 0 0 0 0 1 0

Total 402 0 12 62 2 28 169 0 13 15 1 0

MaMoni HSS is currently supporting 12 FWAs, 28 FWVs, and 13 nurses to fill in the critical human resource gaps of GOB service providers. The decisions for filling such vacancies are made through local level discussions with district/upazila managers.

IR 2: Strengthened Health Systems at District Level and Below The MaMoni HSS program is implementing a comprehensive quality improvement strategy to support the MOHFW at the national and district levels to improve the quality of clinical care for MNCH/FP/N services. The project’s QI strategy comprises of three main components:

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 29 • National level support to QI efforts; • Improving service delivery of MNCH/FP/N services; and • Measurement of QI indicators and recognition of achievements for QI. The progress in improving the quality of clinical care during Year 4, Quarter 3 of the project is summarized below:

2.1.1. Supporting the national Quality Improvement Secretariat (QIS): During the reporting quarter, MaMoni HSS continued its support to the QIS in implementing the national QI strategy and aligning it with WHO MN QI Framework. The project’s seconded staff at the national and division level continue to provide vital assistance to the QIS in implementing the QI interventions nationwide. In addition, MaMoni HSS has provided assistance to the QIS in the following areas:

• Curriculum development and training on Plan-Do-Check-Act (PDCA): The residential training, held in Rajendrapur on May 7-9, 2017, targeted 4 district hospitals (Hg, Nk, Lp, Jk). National level facilitators from QIS and MaMoni HSS staff at national and district level that will facilitate the application of PDCA in their respective districts participated in the training. The outcome of the training was the development of a DH specific QI project to be implemented by DH members of the QIC in their respective hospitals. The performance gaps selected for participating district hospitals to address ranged from increasing service utilization for deliveries and KMC, to improving crowd management and sterilization of used instruments. Specific QI projects were developed including identification of the specific “aim” for the improvement, root cause analysis of the selected performance gap, identifying counter measures, indicators to measure progress, and developing a workplan.

• Developing National RMNCH QI indicators: The project contributed to the national effort led by the QIS and with participation of several international partners to develop RMNCH QI indicators based on the standards included in WHO MN QI Framework.

• Developing National Patient Safety Guidelines: Based on QIS request, the project has recruited a consultant to develop national patient safety guidelines. The guidelines include several domains such as: infection prevention, medication safety, patient identification and procedure matching, clinical handover, blood and blood product handling, and preventing pressure injuries.

• Developing QIS Communication Plan: the project is in the process of recruiting a consultant to work with the QIS to develop a communication plan to help advocate for QI at the national level, increase ownership and interest in quality of care by service providers, and engage community and other governmental and private entities in QI.

Please see Annex 5 for a detailed description of MaMoni HSS QIS supported activities.

2.1.2. Improving the quality of clinical care in stages: The project continues to provide support to the district health managers to improve the quality of clinical care provided by health facilities in stages as follows:

• Stage 1: to improve the cleanliness, infection prevention, and medical waste management; • Stage 2: to improve sterilization measures and compliance with antenatal care and newborn care services, and

30 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report • Stage 3: to improve compliance with all range of MNCH/FP/N standards. The following graph summarizes the progress in the number of facilities succeeded in passing the first stage of QI.

Figure 16: Number of Health Facilities in 4 Districts Meeting *Basic Infection Prevention Standards

Total Habiganj Noakhali Lakshmipur Jhalokathi

Total number of facilities 230 79 57 59 35

% with acceptable IP 33 42 21 37 26

*Basic Infection Prevention Standards=Cleanliness; Hand Washing; Use of Gloves; Decontamination by 0.5% Chlorine Solution; Basic Medical Waste Management.

2.1.3 Increasing local ownership of QI through establishing and supporting QI committees: MaMoni HSS continues to support the establishment and facilitation of QIC at district, upazila, and health facility levels. Project facilitation includes supporting QIC meetings, summarizing action points, and following up on implementation for improvement with the involvement of local government.

The table below includes an update on the status of the formation and activation of QI Committees by district.

Table 4: Status of Quality Improvement Committee Formation and Activation by District, May 2017

Number of QI Committees District

Habiganj Noakhali Lakshmipur Jhalokathi

Total to be formed 86 43 54 40

Actually formed 86 42 54 35

Active (had at least 1 meeting 86 41 49 25 in the last 3 months)

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 31 2.1.4 Strengthening routine supervision system and promoting supportive supervision:

The project supports districts in developing monthly visit plans and conducting joint supervisory visits (JSV) with district and upazila supervisors. Supervisory visits take place using structured supervisory checklists in the areas including: infection prevention measures, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI, normal vaginal delivery, and postnatal care. MaMoni HSS facilitation ensures that each supervisory visit identifies gaps, action plan for improvement, and follow up on results.

Table 5: Planned and Conducted Second JSVs by District (April - June, 2017)

District

Habiganj Noakhali Lakshmipur Jhalokathi

Number of JSV 49 62 06 24 Planned

Number of JSV 50 43 04 17 Conducted

Table 6: Example of Joint Supervisory Visit (JSV) Observations and Follow-Up Action Taken :

SL# Date of Observations during visits Recommendations/ Action Taken Facility Observat ion Noakhali 01 a. Facility is not net and a. Ensure regular preparation of chlorine Kadirpur 14th clean,0.5% chlorine solution.. UH&FWC, Jun’17 solution and autoclave b. Ensure Performance board update regularly. Begumganj are available b. Performance board is not updated. 02 a. Weight scale and To ensure Weight scale and IFA regular Satellite Aleyarpur 20th b. IFA was not available Clinic. UH&FWC, Jun’17 Begumganj 03 a. No use of height scale, FWV noticed to use Arjuntola 3rd b. Inadequate hand a. Height scale for ANC mother & children UH&FWC, May’17 washing facility and under 5 Senbagh c. Not maintaining privacy b. Arrange hand washing facility for interim for patients. period and the concerned persons will take care to solve the problem permanently and c. Maintain the patient privacy as per guideline. 04 Delivery room is not eligible Ensure supply of power, spot light and ceiling Dumuria 17th for conducting delivery due fan(s). UH&FWC, May’17 to lack of power supply, spot Senbagh light and electric ceiling fan. 05 No Infection Prevention Suggested to take some steps for maintaining Char Clark 7th Jun’17 management basic infection prevention including hand UH&FWC; washing. Follow up will be continued Subarnoch

32 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report SL# Date of Observations during visits Recommendations/ Action Taken Facility Observat ion ar Lakshmipur 06 a. Red coded bin is there a. The other two color coded waste bins (yellow Bhadur 9th for primary collection of & black) need to be provided UH&FWC; May’17 waste b. UFPO will sit with Union Parishad to Ramganj b. No waste management address the issue to create a permanent provision within the solution by constructing dumping pits. premise of the facility c. The concerned FWV, SACMO & FPI have c. Performance board is been instructed toupdate it immediately not up-to-date and to continue doing so. 07 a. Pregnancy and EDD list a. The responsible FWV was instructed by the Char 7th were not updated UFPO to update the list by getting Mohona May’17 information from FWA at Union Follow up UH&FWC; meeting Roypur 08 a. Color Coded bin was not a. The UHC store will be explored to see if bins Ichhapur 10th available (yellow and can be provided from there. UH&FWC, Apr’17 black) b. UFPO will sit with Union Parishad to Ramganj b. No dumping pit. address the issue to have permanent c. Display board was not solution by constructing dumping pits. updated. c. The concerned FWV, SACMO & FPI have been instructed to update it immediately and to continue doing so.

2.1.5 Supporting the implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR):

During the reporting period, MaMoni HSS continued to support the QIS in scaling up of facility level MPDSR in Hg, Nk, Lp, Jk districts. The capacity building initiative of Death Notification (DN) and Facility Death Review (FDR) has been designed in two steps. In the first step a TOT on DN and FDR were conducted with the technical assistance of CIPRB followed by cascading training of service providers at District Hospital, Upazila Health Complex and MCWC. During the reporting quarter, the following TOTs and trainings have been completed:

TOT on DN and FDR :

District Category of trainees Number trained

Noakhali MOCS, OBGYN & Pediatric 36 Consultant, Sr. Staff Nurse, Sr. Lakshmipur FWV, MO-Clinic, RMO/MO 26 Jhalokathi 26

Habiganj 49

2.1.6 Supporting CEmONC through Regional Roaming QI Teams (RRQIT):

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 33 The project has been supporting the RRQIT as an additional supervisory and mentoring team focused on monitoring and improving the quality of CEmONC provided at the district level in Hg, Nk, Lp, Jk. RRQIT includes OBGYN and neonatologist from medical colleges close to the project districts as well as district level supervisors. RRQIT visits are conducted using structured checklists to assess general CEmONC infection prevention measures, delivery services, readiness to provide CEmONC, and neonatal care including SCANU. During the reporting quarter, the 4th RRQIT visit has been conducted in Jk district hospital and MCWC. Based on the findings, an action plan has been developed in coordination with the district hospital service providers and quality improvement committee. The RRQIT’s 4th visit included follow up on progress of implementation of action points identified during previous visits. Table 6 below summarizes results:

RRQIT visits to Jahlokathi DH delivery room RRQIT debriefing MCWC staff

Table 6: Progress in implementing RRQIT action plan – Jhalokathi district:

Major findings from previous visits Improvement Dirty environment & hospital floor in DH Basic Cleanliness of DH improved Only one labor table was available in DH Two more labor tables supplied in DH OT lights with fused bulbs OT light arranged Autoclave of labor room was not functional Autoclave for labor room at DH arranged Inactive QI Committee at DH & MCWC Functional QI Committee at DH & MCWC Poor medical waste management at MCWC Dumping pit at MCWC is under process Only one MO-MCHFP in the district Posting of 4 new MO-MCHFP in the district Post for nurse was vacant in DH Posting of 35 SSN at DH, so a new maternal complex has been designed No use of partograph & practice of Use of partograph & practice of AMTSL for AMTSL for NVD at DH & MCWC NVD at DH & MCWC has been started Nonfunctioning digital X-Ray & USG Functional digital X-Ray & USG machine at machine at DH DH Cesarean section at MCWC could be Regular caesarian section in MCWC because performed only on Sundays with support of new MOMCH has anesthesia training in from DH sadar upazila

2.2 Support human resource for health

2.2.1 Workload and staffing needs assessment study

34 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report The study on “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities” is in the final stage. The objective of the study is to understand the existing workload of different cadres of health workers at health facilities and at the community level. The study has adapted WHO’s “Workload Indicators of Staffing Need” (WISN) methodology to the Bangladesh context. The study includes one medical college hospital (Rajshahi Medical College Hospital), two district hospitals (Kushtia and ), two MCWCs (Kushtia Sadar and Brahmanbaria Sadar), four selected Upazila Health Complexes (Daulatpur, Kumarkhali Nabinagar, Sarail), eight union level facilities, and four Community Clinics and corresponding community level workers of selected unions at Kushtia and Brahmanbaria districts. A Technical Advisory Group (TAG) formed by the MOHFW with representatives’ key departments of the ministry, professionals and key stakeholders provided guidance and advice on technical issues, methodology, and tools to expedite the study.

During the second phase of the study the workload components and activity standards obtained from analysis of the first phase data was shared with key persons at each facility for reconfirmation. These were further fine-tuned by matching with findings from direct observation of actual delivery of services. Relevant annual service data were also collected from respective facilities. Data analysis was done using WISN method. A draft report has been preparedand a summary of findings will be shared with the TAG in the next meeting and the report will be finalized incorporating comments from the TAG.

2.2.2 Support implementation of the HRIS The central Human Resource Information System (HRIS) is a web-based software developed by the MOHFW for capturing human resources information of all directorates/ agencies under the ministry at various levels across the country. MaMoni HSS is supporting implementation of the central HRIS at Habiganj and Noakhali districts. A two- day ToT on central HRIS was provided to 64 participants in collaboration with MIS department of DGHS. One batch was organized at Habigonj and another at Noakhali. Participants were UHFPOs, Statisticians, HIS coordinators and M&E Officers of MaMoni HSS project. Following the ToT, statisticians and HIS Coordinators provided training to 207 CHCPs and SACMOs from all eight upazilas of Habiganj.

2.2 Monitoring and improving the availability of essential MNCH/FP drugs: 2.2.1 Scaling up the implementation of electronic logistics management information system (eLMIS), in coordination with SIAPS:

In coordination with SIAPS, the project is supporting the MOHFW in introducing electronic logistics management information system (e-LMIS) in three additional districts (Hg, Nk, Jk) to improve recording, monitoring, and availability of essential drugs, particularly MNCH items. During the reporting quarter, the project conducted an orientation for district level stakeholders in Hg, Nk, and JK districts about the e-LMIS. Because the e-LMIS will be linked to the national DHIS2 data system, the project hired a consultant to input health facility specific data of the these districts into DHIS2 as an initial step for implementing e-LMIS. The project conducted district level orientation on e- LMIS for health managers in Jhalokathi, Noakhali and Habigonj districts. The

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 35 Jhalokathi district eLMIS orientation, Jhalokathi Civil Surgeon Conference Room purpose of this orientation was to refresh the district level GOB manager’s knowledge on basic logistics management system, their roles and responsibilities in improving LMIS status, the supply chain management portal (SCMP) of MOHFW and the LMIS activity done so far at each district. The MOCS facilitated the sessions and MaMoni staff shared the overall concept on the scale up of e-LMIS activity. The new e-LMIS is expected to improve essential drugs stock monitoring, procurement processes, and to reduce stock outs.

2.2.2 Supporting Sylhet Regional Warehouse, DGFP: The project LMIS advisor provided technical assistance to the Sylhet Regional Warehouse, of DGFP to review storage conditions, documentation processes, and the condemnation process of expired drugs. The QIS Sylhet team participated in the visit.

Reviewing temperature maintanence and storage conditions, Regional Warehouse, DGFP, Sylhet

2.2.3. Use of a color-coded system to monitor the availability of essential drugs:

The project continued to provide support to Hg, Nk, Lp, Jk districts to monitor availability of essential MNCH drugs and engage district managers in using stock information to take action to avoid stock-outs. This stock data monitoring is conducted by a color-coded chart to simplify data interpretation and use. The following is an example of the color-coded chart for tracking misoprostol stock in DGFP store in from October 2016 to May 2017.

Noakhali district from October 2016 to May 2017:

TAB. MISOPROSTOL 200 MCG (2 tab. = 1 dose) Sl Name of the Oct. Nov. Dec. Jan. Feb. Mar. Apr. May. No. store 16 16 16 17 17 17 17 17

1 Begumganj

2 Companiganj 3 Hatiya

4 Senbag

36 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 5 Subarnochar

Color-coded chart showing availability of Tab.Misoprostol 200 MCG at DFGP stores, Noakhali district.

Green= stock available; Yellow = stock avaible, yet expiring within 6 months; Red = stock-out

2.2.4. Monitoring availability of MNCH essential drugs at service delivery points: As part of the joint supervisor visits, the stock of essential MNCH drugs is checked and action is identified to avoid stock out. The following box summarizes some of the action taken during the reporting period to improve availability of essential drugs.

Examples of action taken to improve the availability of essential MNCH drugs:

• MaMoni HSS facilitated moving Inj. Oxytocin from CS Store to Rajapur and Kathalia UHC where NVD services are available. • Facilitated the process of redistribution of 750 bottles of 7.1% Chlorhexidine from Jk Health store to Barisal Medical College. The expiration date was on 30 May’17. But as a result of redistribution, the supplied amount of 7.1% Chlorhexidine were used up. • The food supplement (F-75 and F-100) was inadequate at SAM corners of district hospital and Rajapur UHC of Jhalokathi district early in the month of April, 17. After discussion with CS- Jhalokathi, it was revealed that had sufficient stock. Through coordination with Pirojpur CS office, Zianagar UHC, the DNSOs of unicef, 1 carton (90 sachet F-100) and 1 carton (120 sachet F-75) were distributed to the SAM corners of Jhalokathi DH and Rajapur UHC. • MaMoni facilitated the supply of 304 bottles of 7.1%Chlorhexidine and 304 packs of Tab. Misoprostol (2 tab. in a pack, total 608 Tab. Misoprostol) from DGFP to all Community Clinics of Sadar Upazila, Lakshmipur in April and May, 2017 as there were no supply of 7.1%Chlorhexidine and Tab. Misoprostol from DGHS. These were given to the mothers who did not receive those from the FWAs. • Facilitated the replacement of nonfunctional HBB kits from DGHS stores to different UH&FWC of Sadar upazila, and Roypur upazila of Lakshmipur district in April and May,2017. In Sadar upazila it was Khusakhali UH&FWC, Digholi UH&FWC, Dalal Bazar UH&FWC and Dattapara UH&FWC. In Kamalnagar upazila it was in Char Kadira UH&FWC, and Hajirhat UH&FWC. In Roypur upazila it was in Sonapur UH&FWC, Charpata UH&FWC and MCH-unit of Upazila Health Complex. • Mamoni facilitated the supply of ARI Timer from DGHS to DGFP UH&FWC level to roll out sepsis intervention after receiving the training of DGFP SACMOs in Lakshmipur district and also there were no supply from DGFP source. Total 28 pieces of ARI timer were supplied, at Sadar upazila14 pieces, at Kamalnagar upazila1 piece, at Roypur upazila6 pieces, at Ramgoti upazila 5 pieces and at Ramgang upazila 2 pieces in May 2017. • Facilitated the supply of IUD from DGFP to DGHS at district hospital & Upazila Health

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 37 Complex for PPIUD performance of nurses in May 2017 after the training. (District Hospital 13, Kamalnagar UHC 09, Roypur UHC 05, Ramgoti UHC 01, Ramgang UHC 02 total 30 pcs of IUD for PPIUD service) • Facilitated the supply of Implant from DGFP Roypur upazila store to DGFP store: 25 pcs in May, 2017 as there was stock out in Ramganj. • Facilitated the supply of one delivery table from DGFP Roypur upazila store to DGHS Ramgonj Upazila Health Complex as there was no delivery table available through DGHS supply. • Facilitated the supply of 1000 bottles of 7.1%CHX from DGHS store to cSBA (FP) and all UH&FWC, , Noakhali in April 2017 to overcome insufficient supply from DGFP. • Supplied HBB Kit from DGHS store to Harni UH&FWC of Hatiya Upazila in April’2017 after establishment of new DGFP facility. • Facilitated the supply of around 500 unit of Inj. Oxytocin to UH&FWC (24/7 Delivery Centers) from union parishad e.g. to Durgapur UH&FWC (24/7 Delivery Centers) under Begumangonj Upazila, Char Kakra UH&FWC under Companiganj Upazila, Jahajmara UH&FWC and Char King UH&FWC under Hatiya Upazila, Mohammadpur UH&FWC under Senbag Upazila. It was done in April& May 2017 and will continue in future.

2.3. Monitoring quality of care (QoC) indicators in sentinel sites:

During the reporting quarter, the project completed preparation for conducting the third round of the QoC sentinel survey. This included updating data entry tools, preparation of data entry platforms, and training of data collectors and project district staff. Four data collectors and 8 participants (Manager QA and FCQA) were trained on new tools and the web based data entry platform. Data collection started in Hg, Nk, Lp, Jk districts. In this round of data collection a new tool for exit interviews with a sample of postpartum women who delivered in the health facility will be conducted to assess the client’s experience of childbirth services. Data collection is ongoing in Noakhali, Lakshmipur, Habiganj and Jhalokathi.

2.4 Routine Health Information Systems (RHIS)/eMIS Initiative

This quarter activities focused on the integration between FWV and FWA modules of the e- register, enhancement of the monitoring tools, and addressing feedback from the field level GoB supervisors. Initiating the expansion of e-MIS to new districts is one of the major milestone achieved this quarter.

2.4.1 Implementation and Support

A ToT on the facility module e-register has been completed for Tangail and Lakshmipur districts. Following the ToT, the facility module e-register training has been completed for . The reference document and manual for the e-register were re-developed as per of icddr,b and MEASURE Evaluation’s requirement. The developed hypothetical scenarios are embedded in the manual are practiced during the training session.

The e-MIS design team is also helping to resolve implementation issues of the FWA e- register throughout Habiganj and Tangail. Team members are testing APK in TAB before

38 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report releasing to the field and are continuously monitoring e-MIS reports from unions using the monitoring tool.

In this quarter, the MNCH, FP, General Patient, and Community e-registers were rolled out in all union facilities of Habiganj. Supervisors/managers of Madhabpur upazila have already started using e-MIS monitoring tool and it will be replicated in the rest of the upazila by next quarter.

A total number of 37 FWAs were trained on the FWAs e-Register. A ToT on facility module e-register has been completed for Lakshmipur district, and the UFPO and MO (MCH-FP) from Lakshmipur, HIS Coordinators, IT Officers and M&E personnel from Lakshmipur and Noakhali were trained on the module. All the Health ID cards are printed for Madhabpur and almost 92% of the registered population has received Health ID cards. In Lakhai upazila 60% of the Health ID cards were printed and 40% of the registered population has received HID cards. The GOB field workers are distributing the HID cards during their HH visits and also counseling the community to bring the HID cards during facility visits.

2.4.2. Development Activities:

In this quarter, more MNH and FP indicators have been added into the monitoring tools. The team also incorporated GIS plotting for all of the Habiganj facilities and started work on facility plotting on the other five districts. A lot of feedback from the field and other stake holders have been incorporated. Some of the major changes include the ability to associate a single provider with multiple facilities as they fill gaps, , enhanced search facilities for faster performance and implant e-register. Facility Registry table with Geo- Location has been developed. The newly developed login tracking system with new screen allows tracking of health providers with geospatial coordinates.

The team has completed the development of the implant e-register and the permanent method register for family planning is near completion. A lot of feedback from GoB officials have been incorporated for the smooth flow of the system. Also lists of pregnant women collected by the CHWs are now automatically being reflected on the facility system.

2.4.3 Inauguration of e-MIS:

A district sensitization meeting on e-MIS has been completed in Lakshmipur and Jhalokathi districts in this quarter. In Lakshmipur, the Director General of DGFP graced the meeting as Chief Guest; the Director of MCH Services, the Line Director of MC-RAH, the Line Director of CCSDP, and DGFP were present at the meeting as special guests. Participants from MaMoni HSS, district and upazila level managers from DGHS and DGFP, local government members and officials, different NGO officials, and journalists were also present in the meeting. The DG highly appreciated the system and expressed his interest in seeing it in practice where the system is already being implemented ().

2.4.4. Visit of Government officials

Following his interest from the Lakshmipur Inauguration, the Director General of DGFP, an officer of DGFP, and the MaMoni HSS Chief of Party visited the Madhabpur upazila of Habiganj district to observe the e-MIS field level activities during this quarter. During his

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 39 visit, the FWV demonstrated the various advantages and features of the e-register as compared to the paper based register, such as continuum of care and embedded medical intelligence for risky categories.

2.4.5 Other activities:

1. The e-MIS team participated in the D4D Session in Hotel La Meridian. 2. The eMIS team is also extending support to other MaMoni activities. In conjunction with a consultant, the team supported the development of the Sentinel Survey forms during this quarter. 3. More indicators and improvements have been done for the eMIS monitoring tool and it has been demonstrated to the MaMoni HSS team and GoB officials. Their feedback is being incorporated for further enhancement.

IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems 3.1 National level technical Assistance The Program Management and Monitoring Unit of the Ministry of Health and Family Welfare (MOHFW) has been playing a significant role in providing technical support in management, monitoring and evaluation functions of the HPN Sector Program, which is being implemented by the MOHFW. The Program Management and Monitoring Unit (PMMU), Planning Wing (PW), of the MOHFW consists of GOB officials, TAST and an administrative support team consisting of 19 staff in different positions, who are working for the PMMU/PW of MOHFW. As an important partner to the Health, Population and Nutrition Sector in Bangladesh, the MaMoni HSS program is associated with supporting the MOHFW in matters related to policy formulation, health systems strengthening, and program implementation through an LOC signed between the MOHFW and MaMoni HSS to ensure the continued availability of administrative and operational support.

MaMoni HSS has provided regular salary support for 19 staff that are directly working with the PMMU. Internet, stationary and other relevant office supplies have also been provided. Moreover MaMoni HSS has provided significant support to conduct meetings, seminars, workshops, and policy dialogue programs, in addition to supporting regular requests from the PMMU of the MOHFW.

Policy Dialogue on APR 2016 (held on 09 March 2017): The Planning Wing conducted a policy dialogue session on the 2016 Annual Program Review (APR-2016) under the chairmanship of the Secretary of the MOHFW. It was held on March 9, 2017, with relevant GOB and DP representatives participating with high levels of interest.

OP Finalization Workshop: The Planning Wing of the MOHFW organized a series of workshops on the finalization of the 29 Operational Plans (OPs) of the 4th HPN Sector Program during April-May 2017, for which MaMoni HSS has provided all the necessary support.

Steering Committee Meeting: The Planning Wing of the MOHFW organized 5 Steering Committee meetings in order to approve the Operational Plans (OPs) of the 4th Health, Population and Nutrition Sector Program (HPNSP). The mentioned Steering Committee meetings were presided over by the respective secretary of MOHFW. The honorable Minister and State Minister were also present in these meetings. MaMoni-HSS has provided necessary support both financial and logistical as per requirement to make the events successful.

40 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 3.2 Observance of Safe Motherhood Day -2017

Safe Motherhood Day Observation

MaMoni HSS project observed the Safe Motherhood Day-2017 along with other stakeholders. Major objective to observe the day was to ensure facility delivery and that by qualified and skilled birth attendant. Counseling pregnant women on nutrition during pregnancy and improving antenatal care and thus to inspire the community to ensure safe and facility delivery and to inform women about family planning and safe methods was another objective.

Keeping in mind the above objectives, MaMoni HSS and its partners participated in the events at National and district level . The activities in project districts included: • Making death list of mother in this year (May-16 to April 17) • Sample maternal death review through social autopsy (10%-20%) • Conduct colorful Rally • Demonstration of Human Chain • Discussion session to address the importance of the day • Recognition of the "Local Government representatives and service providers in Noakhali" for their contribution in effectively functioning UH&FWCs

Effort at National Level

• The MaMoni HSS actively participated and collaborated with DGHS and DGFP to mark the Safe Motherhood Day, 2017 • MaMoni HSS Project designed and printed 60,000 posters which were distributed through DGHS to all 64 and assembled messages to circulate via social media. Effort at District level

District level Seminar

To mark the Safe Motherhood Day, MaMoni HSS deployed its volunteers and workers to go house to house and identify mothers who died in the last 12 months (May 2016-April 2017). The findings were then shared at district level meetings in Habiganj, Noakhali, Lakshmipur and Jhalokathi to sensitize the different stakeholders.

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 41 In the seminars the following suggestions and recommendations were made:

1. Every pregnancy/pregnant-mother needs to be considered as pregnancy at risk 2. All SBAs need to be more focus on counselling the mother and the family 3. Health and Family Planning staffs as well as MaMoni volunteers/staffs are asked to refer pregnant mothers with the complaint of swelling leg(s) to nearby Health Complex 4. Motivational programs for promoting institutional delivery need to be increased 5. 3 delays need to be considered as an emergency message for communication to reduce maternal death 6. Establishment of community managed functional referral system 7. Reporting of Maternal death needs to be bring under surveillance system 8. Institutional delivery needs to be increased 9. There needs an additional driver for ambulance service 10. The number of high risk pregnancy cases needs to be identified at its primary stage by the field staff 11. The death report and high risk pregnancy report must be prepared/ shared through prior sharing with UH&FPOs 12. Local facilities need to be utilized first and so to start working using available resources and supports

3.3 Journalist Engagement As a result of broader MaMoni HSS media advocacy, some 12 news/story were published by different media outlets such as Daily Observer, BDNews24.com etc. The news/story includes; issue specific current situation, case studies, technical information with call of actions for required health systems improvement.

The media engagement and capacity building program has resulted into significant increase in media coverage on MNCH/FP/N issues and increased stakeholders engagement. Representatives from the multiple government ministries/directorates, and non- governmental partners have been deeply involved in the program. This contributes immensely facilitating closer collaborations across organizations and resulted in both increased dialogue and news coverage. The Report links are listed in Appendix-6.

3.4 Program learning initiatives undertaken and disseminated MaMoni HSS submitted five abstracts at the 34th International conference for the International Society for Healthcare (ISQUA) to be held in London in October 2017. Three Abstracts have been accepted (one for oral, two for poster presentation) for. The topics include introduction of eMIS, quality of ANC at satellite clinics and quality improvement initiatives at the UH&FWC level in MaMoni HSS district interventions. IUNS 21st International Congress on Nutrition has also accepted an abstract on MaMoni experience on integrating nutrition in MNCH programs.

MaMoni HSS has received approval from DGFP to commence two separate study. The first program learning initiative, which aims to reduce early discontinuation of IUCD and implants, will be undertaken in Habiganj district. The second initiative aims to assess the skill of the FWV in detecting and managing severe pre-eclampsia and eclampsia during routine ANC services. Data collection has begun. MaMoni HSS has also completed data collection on the profile and earning ability of private CSBAs in Habiganj, Noakhali and Lakshmipur districts. The data analysis has commenced.

42 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report MaMoni HSS is also reviewing the decentralized planning process for the last three years to understand how the project support led to data driven decision making and action to increase facility readiness and utilization. Data collection is ongoing.

3.4.1 Process documentation of technical interventions:

To document the process of technical interventions as well as implementation experiences of MaMoni HSS, the team is capturing intervention processes based on frameworks that were agreed upon in the workplan. An updated matrix has been presented in Appendix 7.

IR4. Identify and Reduce Barriers to Accessing Health Services 4.1 Promote awareness of MNCH through innovative BCC approach

4.1.1 SBCC activities:

The activity ‘MaMoni HSS’s Media engagement initiative and Enhancing Community Behavior (SBCC) towards seeking appropriate MNCH/FP/N services are dedicated to creating enabling environment to strengthen district-level health systems and a sustainable appropriate community health seeking behavior practice that will result in declines in maternal, newborn and child mortality within the MaMoni HSS project districts in Bangladesh.

Enhancing Community Behavior (SBCC) towards seeking appropriate MNCH/FP/N services is an interactive process aimed at changing social circumstances and people’s behavior towards seeking appropriate MNCH/FP/N services.

In order to achieve the SBCC objectives, a multi-level communication approaches are adopted. The approach includes mutually supporting steps of local level advocacy, social/community mobilization, community participation and SBCC in a continuous process. MaMoni HSS framed a SBCC work plan with special focus on its intervention districts and patronized community volunteers along with Government frontline health workforce to visit households to provide appropriate health education, preventive and curative health services related to MNCH/FP/NMNCH/FP/N.

4.1.2 Community Video Show:

A recent study shows that more than a quarter of the rural population still does not have access to mass media which includes both electronic and print media. This limits our ability to reach a vulnerable segment of the population ( i.e. tea garden, Haor, char areas ) with important information to enhance their behavior towards seeking appropriate health services from available or within or near to their community. MaMoni HSS deployed a SBCC team aimed at reaching the media dark population through alternate strategy giving exposure to key messages through interactive community video show where the related TVCs and other materials (e.g. MNH TVCs, Meena film, job aids, stickers and posters) are shown, disseminated and discussed.

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 43

Popular Theatre in Sonadia, Hatiya Miking informing launching of 24/7 delivery centre at Char Romoni Mohan union, Sadar upazila

To maximize the benefit from such intensive activities, we carefully targeted locations where the largest numbers of mothers and other influential can be reached. The shows were held in the location/para of selected villages where no electricity or partial electricity is available. Each show targeted a minimum of 30 Households (HHs) of targeted audiences, community influential from that particular village and nearby areas like-a village doctor, religious leader, school teachers, union members, health workers, local opinion leaders, etc.

Over the month of April to June 2017, we organized 282 community video show in our different project locations (HG-94, JK-46, NK-34, LP-34 and Pirojpur-0) and reached 255,624 Community people in which 129,684 were male and 125,940 were female.

4.1.3 SBCC activities at the fast track areas :

Recently we hired a SBCC specialized communication agency to develop and implement a comprehensive area specific community behavior enhancement strategy (i.e. Habiganj, Lakshmipur, Noakhali/Hatiya) along with SBCC activity implementation plan to accelerate the change in behavior practice to seek appropriate MNCH/FP/N services and improve home-based care practices and also to create an enabling environment in families and communities that facilitate and support appropriate care-seeking behaviors. Messages on newborn danger signs and appropriate referral including care-seeking for very low birth weight babies are disseminated through the SBCC activities. By the end of June, the agency completed the following number activities.

Area wise Activity accomplishment chart

Community Sl. Area Advocacy Meeting Theatre Shows Meetings

44 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 1 Lakshmipur 5 58 116

2 Hatiya 11 24 48

3 Habiganj 8 77 154

Sub-total 24 159 318

Total activities conducted 501

4.1.4 Reaching the community through Aponjon services:

As of 14 June ’17 Aponjon had a cumulative subscriber base of 1,915,401 among which 6,081 acquisition happened in the last quarter. Prepaid model has been launched in this quarter which was designed to ensure timely revenue for Aponjon and for subscribers there will be no missing out of contents due to insufficient balance. Aponjon is exploring the ways of distributing the prepaid cards and partnerd with 3 dealers and trying out an outright commercial channel for making the card available to the subscribers. 7 ToT training was provided to stakeholders for bringing out efficiencies in providing refreshers training to field agents for online data entry and prepaid model.

Promoting Aponjon services and increasing the brand visibility has been the major focus through 3rd quarter. Digital channels like Facebook and Blog have been used for marketing and have reached around 1.4 million and 56,000 respectively. More than 6,500 user downloaded the mobile app during this quarter. The call center and counselling line met queries from around 3800 customers. Aponjon is continuing its effort to build partnership with Government and other development agencies and within the effort is participating in a consultative workshop to streamline Aponjon BCC activities with regular MNCH services. A high level team of Aponjon also participated in the ICT4D conference in Hyderabad, India to share Aponjon experience on impact and sustaiability issue and also to learn from other similar efforts throughout the world.

4.2 Enhance community engagement in addressing health needs

4.2.1 Monthly CMPM meetings:

Among the 4 MaMoni HSS HI districts monthly targets of CMPM is 2350. During April and May, 2017 a total of 88% CMPM held against plan in these 4 districts, in which Habiganj- 99%, Noakhali-76%, Lakshmipur-99% and Jhalokati 63%.

4.2.2 Engaging local government bodies and community action groups:

Local Government representatives and service providers were honored in Noakhali

On the eve of Safe Motherhood Day 2017, an advocacy meeting was held in the Sadar Upazila,

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 45 Noakhali engaging Local Government and MOHFW managers on May 24, 2017. Officials from health, family planning and local government department, Chairmen of Upazila Parishads and Union Parishads, electronic and print media reporters attended the meeting. Purpose of the meeting was to engage Local Government more for playing effective role in MNCH/FP/N in the facilities as well as at the community level. Expected output was to motivate all the Chairmen of the Upazila and Union Parishads to allocate more budget through DDLG in upcoming FY 2017-18. The event was also organized to recognize the successful Chairmen of Upazila and Union Parishads and Service Providers for their remarkable efforts and contribution in maternal

Chairman, Sundalpur union delivering speech Deputy Commissioner, Noakhali is awarding UP Chairman, Hatiya

and child health service delivery in their areas. A detail multimedia presentation consisting photographs and video clips on local government contribution in health services were shown. It was highly appreciated by the audiences. The Deputy Commissioner in his speech mentioned "Today's program will help a lot to enhance the potential role of Local Government in reducing Maternal and Newborn death.” "Union Parishad is such an organization where all ministrie’s activities are implemented. We can make an example in our union facilities like Durgapur with a bit support." said Union Chairman, Char Bata Union Parishad, Subornachar Upazila. "Only financial support is not enough to make a facility as a champion, it also needs strong monitoring and parental supervision and support" said Mr. Abdul Jalil Chowdhury, Ex- UP chairman, Durgapur Union Parishad, Begumgonj Upazila. Along with many of the UP Chairmen, Choiani UP Chairman committed to enhance their union level facility as a model 24/7 delivery center in the next financial year. Other Upazila Parishad Chairmen also expressed their feelings regarding the importance of health services which they have learnt from this advocacy meeting. Deputy Director-FP, Civil Surgeon, Superintendent (DH) gave special thanks to MaMoni-HSS for arranging this special program on the occasion of Safe Motherhood day. At the end of the program, 2 Upazila parishad Chairman, 2 Ex-Union Parishad Chairman and 18 current UP chairmen honored with crest for their remarkable efforts and contribution in health services. Twenty-one (21) Service Providers of Union and Upazila health facilities were also recognized for their excellent performance. The awardees shared their feelings and satisfaction that they are enjoying after ensuring proper health services for the people of their upazilas. They find it undoubtedly remarkable and a great achievement for them in their chairmanship tenure. The awardees also said they felt encouraged and motivated by this gesture and vowed to work harder for the improvement of maternal and child health situation of their areas.

CHALLENGES, SOLUTIONS, AND ACTIONS TAKEN Challenges and Mitigation Strategies:

46 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

• Ensuring continuity of services provided by paramedics: MaMoni HSS has been filling the HR gaps in selected health facilities by providing paramedics to provide MNCH/FP/N services. As the project is approaching its end, it is important to engage with the MOHFW to ensure that the paramedics will be absorbed within the MOHFW cadres, or replaced, to ensure continuation of services in the health facilities where paramedics are currently working. MaMoni has initiated dialogue with local health managers and local government bodies for ensuring this.

• Follow up of service delivery after training: A good number of trainings are being conducted by different programs but there is no formal system of follow up after training and supportive supervision. MaMoni HSS has supported post training follow up after ENC training (7.1% CHX and HBB). However, training follow-up and on-the- job support to ensure provision of quality services after training are required after each technical training. For example, nurses working in district hospitals and UHC who received training on IUD and PPIUCD need support in providing services. MaMoni HSS has initiated dialogue with DGHS and DGFP for institutionalization of training follow- up and supportive supervision after each technical training.

• Improving the quality of clinical care at a large scale: MaMoni HSS has been supporting the national QIS in developing and implementing a strategy for improving the quality of clinical care across the country. While there has been significant progress in updating standards, guidelines, and training, the implementation of interventions leading to improvement of the quality of clinical care at health facility level needs to be strengthened. Innovative approaches need to be tested to encourage local ownership and leadership for quality improvement as well as expanding the involvement of the local government in problem solving and quality improvement.

• Poor case admission and post discharge follow up of KMC and poor day-8 follow up of PSBI cases: Poor case admission and post discharge follow up of KMC as well as poor day-8 follow up of PSBI cases remain as key challenges for newborn health. To improve these interventions, MaMoni HSS has arranged sensitization meetings and mentoring visits in implementation districts by national level managers and representatives from professional organization for new newborn interventions including KMC & PSBI. In consultation with national and district health managers, the project has plans to orient and engage union level supervisors of public sector providers for the follow up of KMC and PSBI cases at community level. Orientation of Assistant Health Inspector (AHI) of DGHS and Family Planning Inspector (FPI) of DGFP have been planned for ensuring day-8 follow-up of PSBI and post discharge follow-up of KMC.

• Improve organization and quality of LARC & PM services provided by Mobile Camps: In order to reap the benefit of Mobile Camps in boosting LARC& PM uptake, there is a need to improve the preparation, organization, and utilization of Mobile Camps. MaMoni HSS will play an active role in coordinating Mobile Camps with national level and district level partners and health managers. This will include supporting the preparation of schedule for Mobile Camps within districts, coordinate with Mayer Hashi II project, DGFP to ensure availability of skilled service providers

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 47 and supplies, strengthen health facility readiness, and strengthen community utilization of services provided by the Mobile Camps.

. Slow pace of work: In this quarter pace of work was slow because of Ramadan and Eid festival in late May and entire June. Also GOB managers were busy with closing of financial year in June.

Way Forward: .

. Coordinate with Mayer Hashi II project for effective utilization of mobile camps. . Orient and engage union level supervisors in follow-up of KMC and day-8 follow-up of PSBI. . Support coordination between health and family planning directorates to ensure FP service provision by DGHS staff. . Monitor and document PDCA in 4 district hospitals. . Implement eMIS facility and community modules in Lakshmipur and Noakhali and only facility module in Jhalokathi. . Linking eLMIS to DHIS2.

APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF THE MAMONI HSS PROGRAM

48 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report The program’s objectives are well aligned with the GoB’s Health, Population, and Nutrition Sector Program (HPNSP) for 2016–2022; and also directly support the USAID/ Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh. MaMoni HSS designed a two- pronged approach in which districts and upazilas were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high- intensity areas is to demonstrate best-practice High models of MNCH/FP/N health care delivery through intensive Health System support to the Government of Bangladesh (GoB), and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi districts, while in the Noakhali and Pirojpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirojpur (refer to Figure 1 and Table 1). Whereas the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale up interventions such as 24/7 Union Health and Family Welfare Centers (UH&FWCs), chlorhexidine for cord care, and Helping Babies Breathe (HBB); instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 49 APPENDIX 2: DATA SOURCES Assessment Assessment Frequency Geographical Coverage Name Type

Population Independent 2 rounds in 23 High intensity upazilas of 5 Mamoni Districts (Hg, based tracer cross sectional a year. Lp, Nk, Pj, Jk). In addition, during the initial stages survey assessment by Each round of program – starting from October 2013 – this third party is for six population based assessment was also conducted for (ICDDR,B) months along with Noakhali and Lakshmipur. This included a baseline assessment and two rounds of the population-based survey. In October 2014, there was a major shift in the MaMoni HSS program strategy and the scale of program activities were reduced in Bhola. Accordingly, the project monitoring plan (PMP) was revised and the population based survey no longer covers Bhola, with the exception of conducting an end line survey in 2017.

Sentinel Selected Twice in a Selected District Hospital, MCWC, UHC, UH&FWC survey sentinel site year and satellite clinics in Habiganj, Jhalokati, Noakhali assessments and Lakshmipur district. using structured tool

Service Periodic facility Twice in a 21 High intensity upazilas of Habiganj, Jhalokati, delivery assessment by year Noakhali and Lakshmipur district. point using assessment structured tool

Newborn Nationwide Once in All over the country revisit assessment by project life upazila on HBB and 7.1% CHX using structured questionnaire

Routine MIS, Routine MIS Monthly All over the country MoH&FW forms of DGHS and DGFP

Project MIS Routine MIS Monthly Only in high intensity project areas reports

50 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report APPENDIX 3: PROGRAM PERFORMANCE INDICATORS (APRIL 2017–JUNE 2017)

Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Percent of women received at least one antenatal Tracer Survey care visit from a medically trained provider High intensity areas NA Lakshmipur 70 70

Noakhali* 67 67

Habiganj 70 70 Reporting quarter is Q2 and annual

Jhalokathi 73 73

Pirojpur* 70 70 HSCS areas Pirojpur 67 67

Bhola 56 56

Noakhali 63 63

Percent of births receiving at least four antenatal Tracer Survey care (ANC) visits during pregnancy

High intensity areas Lakshmipur 26 26 26 Noakhali* 26

Habiganj 26 26 Reporting quarter is Q2 and annual

Jhalokathi 50 50

Pirojpur* 36 36 HSCS areas Pirojpur 44 44

Bhola 23.5 23.5

Noakhali 21 21

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 51 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Percent of Births Attended by a Skilled Doctor, Nurse Tracer Survey or Midwife High intensity area Lakshmipur 45 45

Noakhali* 40 40

Habiganj 40 40 Reporting quarter is Q2 and annual

Jhalokathi 53 53

Pirojpur* 50 50

HSCS areas

Pirojpur 50 50

Bhola 30 30

Noakhali 38 38 Percent of women with home births who consumed Tracer Survey misoprostol to prevent postpartum hemorrhage High intensity areas Lakshmipur 30 30

Noakhali* 30 30

Habiganj 50 50 Reporting quarter is Q2 and annual

Jhalokathi 55 55

Pirojpur* 45 45

HSCS areas

Pirojpur 32 32

Bhola 25 25

Noakhali 20 20

Percent of newborns initiated breastfeeding within Tracer Survey one hour after birth

High intensity areas Lakshmipur 75 75 Reporting quarter is Q2 and annual Noakhali* 72 72

52 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Habiganj 85 85

Jhalokathi 70 70

Pirojpur* 63 63

HSCS areas

Pirojpur 58 58

Bhola 70 70

Noakhali 76 76 Percent of newborns received chlorhexidine application on their umbilical cord immediately Tracer Survey following birth High intensity areas Lakshmipur 60 60

Noakhali* 60 60

Habiganj 60 60 Reporting quarter is Q2 and annual

Jhalokathi 60 60

Pirojpur* 60 60

HSCS areas

Pirojpur 35 35

Bhola 35 35

Noakhali 35 35

Percent of newborns receiving postnatal health Tracer Survey check within two days of birth High intensity areas Lakshmipur: 20 20

Noakhali:* 20 20

Habiganj: 32 32 Reporting quarter is Q2 and annual

Jhalokathi: 33 33

Pirojpur:* 18 18 HSCS areas

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 53 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Pirojpur: 10 10

Bhola: 10 10

Noakhali: 20 20 Modern contraceptive method prevalence rate Tracer Survey High intensity areas Lakshmipur 55 55

Noakhali* 53 53

Habiganj 48 48 Reporting quarter is Q2 and annual

Jhalokathi 58 58

Pirojpur* 58 58

HSCS areas

Pirojpur 55 55

Bhola 58 58

Noakhali 51 51 Couple years of protection (CYP) in Source: DGFP MIS Form 4

USG-supported (accessed online) programs 1071044 High intensity areas 1071044

23458 163817 Lakshmipur 163817 17040 235128 Noakhali* 235128 21777 191852 Habiganj 191852 8771 77389 Jhalokathi 77389 5356 139063 Pirojpur* 139063 HSCS areas 13914 Pirojpur 37187 Bhola 263795 263795 17202 Noakhali

54 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Percent of targeted facilities that are ready to provide essential Source: SDP assessment newborn care

High intensity areas

Lakshmipur 90 90 Reporting quarter is Q2 and annual Noakhali* 90 90

Habiganj 90 90

Jhalokathi 90 90

Pirojpur* 90 90

HSCS areas

Pirojpur 70 70

Bhola 70 70

Noakhali 70 70 Percentage of public health facilities with functional bags and Source: SDP assessment (HI masks (two neonatal size mask) in the delivery room Upazilas only)

High intensity areas

Lakshmipur 50 50 Noakhali* 50 50 Habiganj 50 50 Reporting quarter is Q2 and annual Jhalokathi 50 50 Pirojpur* 50 50 HSCS areas Pirojpur Bhola Noakhali Percent of USG-assisted service delivery sites providing family Source: SDP assessment and planning (FP) counselling and/or services training data

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 55 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

High intensity areas

Lakshmipur 95 95 Noakhali* 95 95 Habiganj 99 99 Reporting quarter is Q2 and annual Jhalokathi 95 95 Pirojpur* 95 95 HSCS areas Pirojpur 17 17 Bhola NA NA Noakhali 25 25 Number of targeted facilities ready to provide delivery services Source: SDP assessment and 24 hours a day, seven days a week (includes DH, MCWC, UHC training data and UH&FWC)

Considering provider available , High intensity areas separate delivery room, CHX, Bag and Mask

Lakshmipur 25 25 Noakhali* 19 19 Habiganj 39 39 Reporting quarter is Q2 and annual Jhalokathi 21 21 Pirojpur* 4 4 HSCS areas Pirojpur 9 9 Bhola 32 32 Noakhali 7 7 Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by Source: Project MIS temporary non-GOB health workers High intensity areas 10 Lakshmipur 10 0 HG – FWA (CHW)-12 ,FWV-24 Noakhali* 15 02 15 Nurses-13.

56 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Habiganj 10 49 10 NK - FWV-02. 10 JK - FWV-02. Jhalokathi 10 02 Pirojpur* NA NA NA HSCS areas Pirojpur NA NA Bhola NA NA Noakhali NA NA

Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in maternal/newborn 2,149 NA health through USG- supported programs

High intensity areas

Lakshmipur Women Men Noakhali* Women Men Habiganj Women Men Jhalokathi 26 Women 15 Men 11 Pirojpur* Women

Men

National level

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 57 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

HSCS areas Pirojpur Women Men Bhola Women Men Noakhali Number of people trained in FP/RH 225 with USG funds

High intensity areas

Lakshmipur 43 Women 28

Men 15 Noakhali* Women

Men Habiganj Women Men Jhalokathi Women Men Pirojpur* Women Men National level HSCS areas Pirojpur Bhola Women Men Noakhali

58 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Number of people trained in child health and nutrition 200 through USG- supported programs High intensity areas 760 Lakshmipur Women Men Noakhali* Women Men Habiganj Women Men Jhalokathi Women Men Pirojpur* Women Men National level HSCS areas Pirojpur Bhola Noakhali

Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization

Number of union level public health facilities that are Source: SDP Assessment ready to provide normal delivery services 117 High intensity areas 75 75 35 Lakshmipur

22 Noakhali* 43 Habiganj

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 59 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

17 Jhalokathi NA Pirojpur*

HSCS areas

Pirojpur

Bhola

Noakhali

Intermediate Result 2: Strengthen health systems at district level and below

Number of district level quarterly performance review meeting Source: QPRM meeting minutes held for data-driven performance review and planning

High intensity areas 20 12

Lakshmipur 4 1 2 Noakhali* 4 1 2 Habiganj 4 1 2 Jhalokathi 4 1 2 Pirojpur* 4 - 2 Bhola NA 1 2

Data expected from QI sentinel

Intra partum still birth rate in project assisted facilities monitoring. The system is being established.

<5/1000 High intensity areas <5/1000

Lakshmipur <5/1000 <5/1000

Noakhali* <5/1000 <5/1000

Habiganj <5/1000 <5/1000

Jhalokathi <5/1000 <5/1000

Pirojpur* <5/1000 <5/1000

Sub-IR 2.1: Improve leadership and management at district level and below

60 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Number of GOB managers supported for leadership and management capacity development

Lakshmipur NA

Noakhali NA

Habiganj NA Source: Project MIS & District team

Jhalokathi NA

Pirojpur NA

Bhola NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated comprehensive Source: Project MIS annual MNCH/FP/N plan High intensity areas 23 23 Lakshmipur 5 5 Noakhali* 4 4 Habiganj 8 8 Jhalokathi 4 4 Pirojpur* 2 2 Bhola NA NA Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units Source: Project MIS conducting monthly meeting High intensity area Lakshmipur 100 99 100 Noakhali* 100 75 100 Habiganj 100 99 100 Jhalokathi 100 66 100 Pirojpur* 100 100

Sub-IR 2.4: Establish quality assurance system at district level and below

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 61 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Percent of planned supervision visit conducted where a supervision tool was Source: Project MIS used and findings shared with providers High intensity areas 90 70 90 Lakshmipur 90

110 90 Noakhali* 90 156 90 Habiganj 90 100 90 Jhalokathi 90 90 Pirojpur* 90

Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Percent of USG- assisted service delivery points (SDPs) that experience a stock out at any time Source: DGFP LMIS during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas <2 NA <3 <2 Lakshmipur 0.55 <3 <2 Noakhali* 0.75

<3 <2 Habiganj 0.8 <3 <2 Jhalokathi 0 <3 <2 Pirojpur* 0

Sub-IR 2.6: Strengthen local government planning and engagement in health service provision

62 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Percentage of unions that had at least 50 percent of the estimated births registered within 45 days of birth

High intensity areas Lakshmipur 60 22 60 60 It includes Three upazila ( Senbag, Noakhali* 60 5 Begumganj, Companigonj) Habiganj 60 100 60 Jhalokathi 60 66 60 Pirojpur* 60 NA 60

Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of union parishads (UP) that spent funds to Source: Project MIS support MNCH/FP/N activities High intensity areas Lakshmipur 58 16 58 Noakhali* 44 23 44

Habiganj 77 29 77 Jhalokathi 32 10 32 Pirojpur* 15 NA 15

Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GOB recruitment or Source: Project MIS redeployment in project areas High intensity areas 25 Lakshmipur 5 0 5 Noakhali* 5 0 5 Habiganj 5 02 5 FWV-02 Jhalokathi 5 01 5 Doctors-01 Pirojpur* 5 NA 5

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 63 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector Number of policies/ strategies/guidelines on MNH 4 0 developed/revised 4 with MaMoni HSS support Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program

1. Electronic health record of e-MIS links routine service data to decision making for improved quality of care in Bangladesh. 2. Service readiness and provision of quality antenatal care in satellite clinics: findings from remote areas of Number of program Bangladesh. learning initiatives 15 15 4 completed and 3. Implementation disseminated experience of MaMoni HSS project to improve quality of care (QOC) in public sector facilities in Bangladesh. 4. Integrating nutrition services into the maternal, newborn, child health and family planning services in rural Bangladesh.

Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA in USG- DGFP MIS, DHIS2, pCSBA assisted programs High intensity areas 5141 19687 Lakshmipur 19687

64 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

4231 12288 Noakhali* 12288 6141 25896 Habiganj 25896 1895 7054 Jhalokathi 7054 560 2658 Pirojpur* 2658

HSCS areas

2271 12148 Pirojpur 12148 4427 1982 Bhola 1982 6240 37848 Noakhali* 37848 Number of antenatal care (ANC) visits by skilled providers DGFP MIS, DHIS2, PCSBA from USG-assisted facilities High intensity areas 33024 53730 Lakshmipur 53730 30453 43414 Noakhali* 43414 45656 210611 Habiganj 210611 9365 16553 Jhalokathi 16553 3523 9914 Pirojpur* 9914

HSCS areas 7508 34698 Pirojpur 34698 18694 68546 Bhola 68546 26328 97682 Noakhali 97682

Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches

Number of people reached through Source: Project MIS project supported BCC activities High intensity areas

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 65 Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Lakshmipur 200000 31108 105000 NA

Women 19021

Men 12087

Noakhali* 145556 123629 75556 NA

Women 55575

Men 68054

Habiganj 205000 8760 110000 NA

Women 7548

Men 1272

Jhalokathi 115587 2572 60000 NA

Women 2216

Men 356

Pirojpur* NA Women Men Bhola Women Men

Sub-IR 4.2: Enhance community engagement in addressing health needs

Number of trained community volunteers Source: Project MIS promoting MNCH/FP/Nthrough project support High intensity areas Lakshmipur 6710 6424 6710 Noakhali* 5900 6522 5900 Habiganj 8379 8322 8379 Jhalokathi 2731 2305 2731 Pirojpur* 1205 1205

66 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Achievement Target Target (April 2017-May Remarks 2017 2018 2017)

Number of Community Action Groups with an emergency transport system for maternal and Source: Project MIS newborn health care through USG- supported programs High intensity areas Lakshmipur 6461 6287 6461 Noakhali 3876 3894 3876 Habiganj 4369 8079 4369 Jhalokathi 3746 1468 3746 Pirojpur* 1549 1549

APPENDIX 4: ADDITIONAL INDICATORS These Indicators were submitted to USAID separate from our workplan, and was approved in November 2016

Indicator Target FY Achievement Target Remarks 17 (April 2017– 2018 May 2017)

Percentage of newborns receiving CHX Source: DGFP application at birth in MoH&FW facilities MIS4

National 50 55 60

Barisal 50 67 60

Chittagong 50 68 60

Dhaka 50 53 60

Khulna 50 46 60

Rajshahi 50 51 60

Rangpur 50 38 60

Sylhet 50 69 60

Number of upazilas where a review of Source: Project Newborn interventions held report

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 67 Indicator Target FY Achievement Target Remarks 17 (April 2017– 2018 May 2017)

Total 326 86 165

Barisal 42

Chittagong 21 100

Dhaka 124 15

Khulna 53 50 7

Rajshahi 68

Rangpur 58

Sylhet 39

Number of Newborn for whom resuscitation Source: DGFP actions using bag and mask were initiated MIS-3

Total 14,817 8212 16272 (31% of annual target, within Barisal 640 7,03 range) 781 Chittagong 3,137 732 3,445

Dhaka 4,453 801 4,890

Khulna 1,952 1446 2,144

Rajshahi 1,995 2171 2,191

Rangpur 1,716 1319 1,885

Sylhet 924 962 1,015

Number of Union Health and Family Welfare Source: Project Centers (UH&FWCs) in the project area using report electronic MIS tools

Total 130 61 164 Noakhali implementation Lakshmipur 42 to begin in April, delayed Noakhali 69 0 because of Habiganj 61 61 Measure procurement Jhalokati 29

68 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Indicator Target FY Achievement Target Remarks 17 (April 2017– 2018 May 2017)

Pirojpur 46

Bhola 47

Number of districts having an active Quality Improvement (QI) committee

Total 32 41 64

Barisal 3 Data not 6 4 available

Chittagong 6 11 QI committees 9 were just Dhaka 9 17 8 formed in Khulna, Sylhet Khulna 5 10 6 and Chittagong Rajshahi 4 8 divisions 8 Rangpur 3 8 3 Sylhet 2 4 3

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 69

APPENDIX 5: QIS ACTIVITIES

1. Activities performed (April to June 2017) This report covers the activities performed from April to June 2017.

1.1. Recruitment and deployment of MaMoni HSS Project staff All staff seconded to QIS were on board. However, the Divisional Coordinator, Barisal has resigned and is not in job since 31 May. The position has already been advertised and selection process is going on. We expect to fill-up this position by the end of June.

1.2. Capacity development 1.2.1. MaMoni HSS Project staff:

All the project staff (divisional coordinators and district monitors) had received training on leadership, quality improvement and 5S earlier. In this quarter, the divisional coordinators and district monitors of Chittagong, Barisal and Sylhet divisions (n=7) have received a 3- day long training on PDCA cycle in Dhaka (7-9 May). This training was also attended by government staff from 4 district hospitals (Hobiganj, Noakhali, Laxmipur and Jhalokathi). The divisional coordinator of Sylhet (n=1) and the district monitors (n=2) of Sylhet and Barisal have attended a one day long TOT on MPDSR (Maternal and Perinatal Death Surveillance and Response) in Hobiganj (5 June) and Jhalokathi (31 May). The trained staff will train the targeted district hospital staff to implement PDCA and MPDSR phase by phase.

1.3. Implementation of 5S at district hospitals

In this quarter, 5S was introduced at 13 district hospitals in Chittagong, Sylhet and Khulna divisions.

To introduce 5S at the hospitals, a 1-day orientation was provided to the WIT members on 5S. The number of hospital staff trained include – 88 in Sunamganj (2 batches), 60 in Lakshmipur (1 batch), 120 in Bagerhat (2 batches), 154 in Kushtia (3 batches), 95 in Habiganj (3 batches), 56 in Chandpur (2 batches), 39 in Gopalganj (one batch), 76 in Cox’s Bazar (2 batches), 94 in Bhola (2 batches), 148 in Choadanga (2 batches), 50 in Joypurhat (one batch), 59 in Noakhali (2 batches) and 46 in Natore (one batch).

All these workshops were either chaired by the divisional director or Civil Surgeons/hospital superintendent. The overall objective of the workshop was to improve understanding of the participants on 5S and develop WIT wise action plans to implement 5S activities at the hospital for improvement of working environment, which is the gateway for quality improvement. All these workshops were facilitated by the divisional or district resource pool members. The divisional QIS staff played the role of overall facilitation, coordination and management.

70 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report Other 5S activities:

• Orientation on 5S was provided to 155 new staff (70 doctors and 85 nurses) at the Shaheed Shurawardi Medical College Hospital (2-4 April), which is a pilot hospital for 5S. • Refresher training on 5S was provided to the WIT team leaders and monitoring team members at Dhaka Medical College Hospital on 19, 20 and 23 April. The Director of the hospital inaugurated the session. Among others the orientation was attended by attended by the Deputy and Assistant Directors the hospital, professors of OG department, nurses and doctors. In total 122 staff members received the refresher training among those 108 were nurses. • 5S activities were monitored at Joypurhat, Natore and Sirajganj by QIS Advisor 1.4. Advocacy on QI and 5S at :

The advocacy workshop on 5S at Barisal division for the district managers and QIC members was organized on 3 May. The objective of the workshop was to advocate the managers and district resource pool members on QI and 5S. The workshop was attended (n=45) by the district manages (CS, DDFP), district QIC members, divisional resource pool, DPs and MaMoni project staff in Barsial division. The workshop was chaired by the divisional director, Barisal and was facilitated by Sr. Consultant and Consultant of QIS.

1.5. Safe surgery checklist introduced at Dhaka Medical College Hospital:

• Early in this quarter the safe surgery checklist was finalized. The checklist was formally introduced at all the surgical departments (departments who use Operation Theaters) of Dhaka Medical College Hospital (DMCH) on 9 May. The Director of DMCH inaugurated the occasion, while DG, HEU attended the event as Chief Guest. All the unit heads of the surgical departments were present along with other hospital staff. • Printing of safe surgery checklist is at final stage. The final and approved (by QIS) copy is submitted to SC for printing. It is expected that the printed checklist and guideline will be available at QIS within a few days.

1.6. Quality improvement committee and district resource pool In the meantime all the divisional and district QI committees have been formed and district resource pools developed. Continuous efforts are being given to activate (to have regular meeting) the divisional and district QICs. Table 2 shows the number of districts where QIC and district resource pools have been formed. The number of districts conducted the district and district hospital QI committee meetings are also shown in table 2 and fig 1 & 2.

Table 5.1. Information about quality improvement committees (QIC): January to June 2017

Division No. of Dist. QIC District District District districts formed* resource pool hospital QIC QIC meeting developed meeting held held (this

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 71 (cumulative) quarter)# (this quarter)#

Chittagong 11 11 11 9 10

Sylhet 4 4 4 3 4

Barisal 6 6 6 4 6

Khulna 10 10 10 6 6

Dhaka 13 13 12 7 7

Rajshahi 8 8 8 8 5

Rangpur 8 8 8 3 3

Mymensingh 4 1 0 1 2

Total: 64 60 59 41 43

*: Total no. of districts; NI: no information; #: No. of districts

1.7. Meetings:

1.7.1. Coordination meeting with QIS partners: A coordination meeting with the QIS partners were held on 7 April. The meeting was chaired by Dr. Aminul. The meeting was attended by representatives from WHO, UNFPA, UNICEF and other organizations (Marie Stopes, Engender Health). In the meeting coordination of QIS activities at divisional and district level was discussed. All the partners were requested to maintain coordination with the divisional QI coordinators for all QIS activities.

1.7.2. New initiative on MNH: A discussion meeting on new initiative on MNH was held on 9 April at QIS chaired by DG, HEU. The meeting was attended by representatives from MaMoni, WHO, UNICEF & USAID. In the meeting decision has been taken to conduct a facility readiness assessment (all DH and UHCs across the country) to understand the quality of services, especially for RMNCAH.

1.7.3. Meeting of the community participation districts: A review meeting of the community participation districts was held at BMA Conference room on 10 April. The meeting was attended by the district managers, facility managers, QI focal persons and representatives from the respective city corporations. The objective of the meeting was to review the plan of action of the CP districts. In the meeting, supports provided by different stakeholders including the city corporation was discussed. It was observed that city corporation are providing significant support (human resources and others) to some of the districts, such as Sirajganj, Jhenaidah, Khushtia.

72 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 1.7.4. Divisional DP coordination meeting: A coordination meeting with the development partners in was held on 17 April. The meeting was chaired by the Deputy Director of Health (Chittagong Division). The meeting was attended by representatives from UNICEF, UNFPA, MaMoni HSS Project districts, EngenderHealth and Marie Stopes. In the meeting there was a short presentation on 5S. In the meeting importance and ways of better coordination between the DP partners were discussed.

1.7.5. Quarterly staff coordination and review meeting: The third quarterly review meeting of MaMoni HSS project staff seconded to QIS was held on 24th May at HEU conference room. The meeting was chaired by DG, HEU. In addition to all the seconded staff, COP of MaMoni HSS Project attended the meeting. In the meeting all the divisional coordinators presented their achievements during last quarter. At the end of each presentation, there were discussions about the constraints and supports needed from QIS. The major constraint identified is ownership of the government staff for QI activities. Problems related to hierarchy (e.g., Divisional Director’s (Health) position is lower than the position of Divisional Director FP) seems to be a barrier for regular conduction of divisional QIC meeting. Moreover, some of the managers were also asking for meeting cost.

1.7.6. Joint DP (Development Partner) Coordination Meeting: A joint DP coordination meeting was held at BMA Bhaban conference room on 25 May organized by QIS. The meeting was chaired by the DG HEU. In total about 60 participants (national and field level) attended the meeting from EngenderHealth, UNICEF, UNFPA, Marry Stopes, MaMoni HSS project including the the QIS team, BRAC, and Plan International. In the meeting Dr. Aminul clarified the responsibility of the DP partners in implementing the QIS activities. He suggested all the partners to support/facilitate regular conduction of QIC meetings and follow up of the decisions taken in the meeting. He also proposed an implementation plan of QIS activities at the model districts and clarified responsibility of different DP partners. It was observed that MaMoni has the biggest contribution to the QIS for implementation of QI activities including staff, financial and technical supports.

1.7.7. National level DP coordination meeting: A national level DP coordination meeting was held at HEU on 4 June. The meeting was attended by representatives from MaMoni HSS Project, UNICEF, UNFPA, EngenderHealth and Marie Stopes. The meeting was chaired by DG HEU. Before the meeting, Dr. Aminul (QIS Focal Person) distributed a format to all the DPs to indicate the supports provided by them. In the meeting all the DPs made a presentation focusing the supports they are providing to QI activities. It was again observed that MaMoni has major share to QIS in terms of staff, financial and technical supports. It has been decided to have another meeting on 15 June to clarify the criteria and indicators for model hospitals. In the meeting, DPs supports will be also be explored district by district for better coordination and prevention of duplication.

1.7.8. RMNCAH framework review meeting: There was meeting to review and adapt the RMNCAH standards (adolescent health, child health, maternal and neonatal health) in Bangladesh context on 5 June at HEU. The meeting was attended by participants from UNICEF, UNFPA, WHO and representatives from DGHS, DGFP, BSMMU, and

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 73 professional bodies (OGSB, Pediatric Society). In the meeting standards were reviewed and suggestions were submitted to QIS for update. The MaMoni consultants at QIS also provided technical support in the document.

1.8. Development of technical materials:

1.8.1. Development of communication strategy: Consultant for development of communication strategy is identified. Official formalities are going on to offer him the formal contract for the job.

1.8.2. PDCA training manual: A consultant was assigned to develop the PDCA manual. The second draft of the manual was reviewed and feedback was provided to the consultant for further review.

1.8.3. Documentation of QI activities: The QIS has identified a suitable consultant for documentation of QI activities. A meeting with the consultant was held on 7 June to clarify the assignment and negotiate the budget. At the end the consultant agreed to take the assignment within the budget limit of MaMoni.

1.8.4. Development of patient safety manual: A consultant has been selected for this activity and process is going on to officially assign him the job.

1.8.5. Concept paper on Model Hospital: Government has selected 16 district hospitals from all the divisions to develop them as model hospitals. The concept paper on model hospital has been developed by the senior advisor (to QIS) indicating the objectives, interventions, indicators and management plan etc. This document has been shared with the focal person of the QIS for his comments and feedback, and was updated accordingly.

1.8.5. Printing of posters: Earlier QIS requested for printing support of 3 posters related to 5S and QI activities. MaMoni agreed to provide the printing support. The poster design has been finalized and approved by QIS. It is expected that the prineted posers will be available by the end of this quarter.

74 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

APPENDIX 6: NEWS CLIPS PUBLISHED DURING JANUARY- MARCH 2017

Appendix X: News articles published between April-June 2017

Media Date Article Title and Link Sylhettoday2 May 16, �������� �� ও ����� ��������� ����� পথ ���� 4.com 2017 ��������� Link: http://www.sylhettoday24.com/news/details/Sylhet/41474 BDnew24.co May 29, ‘MaMoni HSS’ brings local level solutions to ensure safe motherhood in m 2017 Bangladesh Link: http://bdnews24.com/health/2017/05/29/mamoni-hss-brings- local-level-solutions-to-ensure-safe-motherhood-in-bangladesh Currentnews. May 28, ����������� ������ ������� ���� ����� com.bd 2017 Link: http://www.currentnews.com.bd/bn/news/245107 Newsgalleryb May 28, �������� ����� ������ ������� ������ d24.com 2017 ������ ও ������ ��� Link: http://newsgallerybd24.com/%E0%A6%B9%E0%A6%AC%E0%A6%BF %E0%A6%97%E0%A6%9E%E0%A7%8D%E0%A6%9C%E0%A7%87- %E0%A6%AC%E0%A6%BF%E0%A6%B6%E0%A7%8D%E0%A6%AC- %E0%A6%A8%E0%A6%BF%E0%A6%B0%E0%A6%BE%E0%A6%AA%E0 %A6%A6-%E0%A6%AE%E0%A6%BE/ Sylhettoday2 May 28, ������ ������� ���� : ��������� ������� 4.com 2017 ��������� ��������� ����� ������ ����� Link: http://www.sylhettoday24.com/news/details/Sylhet/41884 Daily May 29, World Safe Motherhood Day observed in districts Observer 2017 Link: http://www.observerbd.com/details.php?id=76107 Daily May 29, ������������� ���������� ���� ����� Deshjamin 2017 ������ ����� Link: Offline only Daily May 29, �������� �� ���� ��������� ������ �� � Protidiner 2017 �������� ������: ����� ������ ���� Bani � ����������� ��� Link: Offline only Newsgalleryb May 30, �������� ������ ������� ���� ������ d24.com 2017 Link: http://newsgallerybd24.com/%e0%a6%ae%e0%a6%be%e0%a6%a7% e0%a6%ac%e0%a6%aa%e0%a7%81%e0%a6%b0%e0%a7%87- %e0%a6%a8%e0%a6%bf%e0%a6%b0%e0%a6%be%e0%a6%aa%e0% a6%a6- %e0%a6%ae%e0%a6%be%e0%a6%a4%e0%a7%83%e0%a6%a4%e0

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 75 %a7%8d%e0%a6%ac/

Daily June 02, 29 women die in Laxmipur in 12 months while giving birth Observer 2017 Link: http://www.observerbd.com/details.php?id=76794

76 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

APPENDIX 7: Documentation and Dissemination of MaMoni Program Learning

Updates on MaMoni HSS Program Learning and Documentation Plan Sl Study Final Product Status 1 Could providers use partographs to identify Journal Manuscript Drafted complications? Do partograph lead to Program Brief appropriate referral? Completed 2.a Are facilities ready to provide Quality Journal Manuscript NSV/Tubectomy services? What are the Drafted barriers to services? How was the experience of care? 2.b Why are eligible clients not utilizing Journal Manuscript Drafted permanent FP services? 2.c What policy changes are needed to ensure Journal Manuscript quality permanent contraceptive services? Delayed How does the service need to be reorganized? 3 How well can union level providers manage Journal Manuscript Data analysis ongoing in PSBI where referral is not feasible? collaboration with JHU 4 Was CHX national scale up achieved and Journal Manuscript Data collection ongoing, effective? Will it achieve sustainable Program Brief expected in Feb 2018 effective coverage at scale? 5 Is the income of private CSBAs sufficient to Journal Manuscript IRB approved, Data make them sustainable? How can the collection ongoing, program make them effective and expected in Jan 2018 sustainable? 6 Are providers able to provide quality ANC at Research Brief Completed satellite clinics? 7 Did UH&FWC strengthening lead to Program Brief Data collection ongoing, increased skilled attendance at birth? expected in Feb 2018 8 Did integrated distribution of Misoprostol Program Brief Data collection ongoing, and Chlorhexidine increase coverage in expected in Feb 2018 Lakshmipur district? 9 Did engaging local government lead to Program Brief strengthened health utilization in Habiganj Data collection ongoing district 10 What is the experience of introducing Program Brief simplified treatment of antibiotic at 10 sub- Draft report prepared districts? 11 Are facilities prepared to initiate facility KMC Poster presentation Completed, presented in care effectively? November, follow on documentation started on utilization of these facilities 12 Are providers able to correctly estimate Program Brief Data collected, analysis

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 77 Sl Study Final Product Status gestational age and manage threatened ongoing preterm labor? 13 Did integrated FP-MNCH lead to higher Program Brief Data collection ongoing, utilization of FP services? expected in Dec 2017. 14 Has MaMoni HSS inputs to PPFP led to Program Brief Data collection ongoing increased utilization? 15 Did training of CHCPs lead to improved Program Brief Data collection completed, growth monitoring and referral for SAM management ? analysis ongoing 16 Effect of introducing modified QI framework Program Brief Draft report being in health facilities prepared. Expected in August 2017 16. Did strengthening infection prevention and Program Brief Data collection ongoing. b waste management systems at UH&FWCs have a positive effect in Quality of Care? Expected in Sep 2017 17 Did MaMoni HSS interventions lead to more Program Brief Analysis framework equitable service utilization across drafted. Need to complete geographic areas and asset quintiles end-line survey in Mar 2018 18 Did MPDSR implementation in Begumganj Program Brief Implementation ended. sub-district of Noakhali lead to actions to Analysis of data ongoing. address preventable maternal and perinatal deaths? Expected Sep 2017. 19 Experience of introducing eMIS automated Program Brief data recording and reporting system in Data collection ongoing Madhabpur sub-district of Habiganj 20 Experience of introducing WISN workload Program Brief Data analysis ongoing. analysis tool in 2 districts Expected Sep 2017 21 Experience of supporting the national QI Program Brief Draft report being secretariat and introducing divisional QI prepared. Expected Sep committees 2017 22 Are providers able to correctly detect SPE/E Program Brief Sent for local IRB review. cases? Are they able to effectively manage Expected in April 2018. and refer these cases? 23 Can MaMoni reduce discontinuation of Research Brief Local IRB review ongoing. IUD/implants through targeted Expected in April 2018 interventions? 24 Did MaMoni's support in annual district Program Brief Data collection ongoing planning, monthly and quarterly reviews lead to better data driven decision making and pro-active management and supervision practices? 25 How sensitive are the survey tools to identify Program Brief in chronic maternal morbidities (obstetric partnership by Measure Validation ends April 06 fistula, pelvic uterine prolapse) (MMVS Evaluation 2016 study) 26 Can union level providers manage newborn Program Brief sepsis management cases in Ramganj sub- Endline data shared district? (JHU collaboration) 27 Changes in health facility readiness in Program Report Data collection expected MaMoni districts (HFS 2017) to begin in August 2017. Report expected in June 2018 28 Experience of introducing Special Care Program Brief Data analysis ongoing Newborn Unit in 3 districts

78 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report

MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 79