MCSP Annual Report

FY 2018 October 1, 2017– September 30, 2018

Submission Date: November 6th, 2018 Cooperative Agreement No. AID-OAA-A-14-00028 Activity Start Date and End Date: October 2016 – April 2019 Activity Manager: Pavani Ram AOR: Nahed Matta

Submitted by: Adhish Dhungana, Manager- Maternal & Child Survival Program Save the Children| Airport Gate Area, Shambhu Marg Kathmandu, Nepal GPO Box: 3394 Telephone: +977-1-4468130/4464803 Email: [email protected] This document was produced for review by the United States Agency for International Development (USAID).

Acronyms

BEmONC Basic Emergency Obstetric and Neonatal Care CHD Child Health Division CMA Community Medical Assistant CRS Contraceptive Retail Sales CSD Curative Service Division DDA Department of Drug Administration DHO District Health Office DoHS Department of Health Services DIP Detail Implementation Plan ENAP Every Newborn Action Plan FB IMNCI Facility Based Integrated Management of Neonatal and Childhood Illness FHD Family Health Division GoN Government of Nepal IMNCI Integrated Management of Neonatal and Childhood Illness MCSP Maternal and Child Survival Program M&E Monitoring and Evaluation MEL Monitoring, Evaluation, and Learning MNH Maternal and Newborn Health MNHI Maternal and Newborn Health Integration MoHP Ministry of Health and Population NCDA Nepal Chemist and Druggist Association NHRC Nepal Health Research Council NYI Newborns and Young Infants PI Principle Investigator PSBI Possible Severe Bacterial Infection PSD Partner for Social Development Nepal SBA Skilled Birth Attendant SCI Save the Children International SDG Sustainable Development Goal SNL Saving the Newborn Lives TAG Technical Advisory Group ToR Terms of Reference USAID United States Agency for International Development WHO World Health Organization WIRB Western Institutional Review Board

Contents Acronyms 2 FINANCIAL INFORMATION 4 INTRODUCTION 4 KEY ACHIEVEMENTS 4 SECTION 1: PSBI Survey and PSBI Pilot 6 I. Background 6 II. OBJECTIVES 6 III. Summary of Major Accomplishments 6 IV. Detail of Accomplishments 8 V. Monitoring, Evaluation, and Learning 13 VI. Challenges/ Lessons Learned and Recommendations 17 VII. Major Activities Planned for Next Quarter 17 VIII. Success Story 18 SECTION 2: Situation Analysis of Inpatient Care of Newborns and Young Infants 20 I. Background 20 II. Summary of Major Accomplishments 20 III. Detail of Accomplishments 20 IV. Challenges/ Lessons Learned and Recommendations 20 V. Major Activities Planned for Next Quarter 21 SECTION 3: Integrated Maternal and Newborn Health Training Study 22 I. Background 22 II. Summary of Major Accomplishments 22 III. Detail of Accomplishments 22 IV. Challenges/ Lessons Learned and Recommendations 23 V. Major Activities Planned for Next Quarter 23 Annex 1: Monitoring visits 24 Annex 2: Monitoring/Supervision Checklist 26 Annex 3: Interview Guideline for Client 28 Annex 4: MEL Plan 30 Annex 5: Report – National Dissemination of PSBI Survey Findings 33 Annex 6: Notes from CRS & Save the Children Nepal Meetings 38

FINANCIAL INFORMATION

INTRODUCTION The Maternal and Child Survival Program (MCSP) in Nepal implements through three separate activity streams: a field-funded pilot on management of possible severe bacterial infection (PSBI) among private providers, based on results from an MCSP-supported nationally representative survey; and two MCSP Core-funded newborn health activities that were added to the MCSP Nepal workplan in January 2018. To adequately reflect progress against all three activities, a brief summary of key achievements across the portfolio has been included at the beginning. The remainder of the annual progress report is divided into three sections, each one dedicated to one of the discrete activity streams included in the workplan. The annual progress report reflects a summary of key achievements on program activities during the reporting year as well as a summary of key updates during the fourth quarter of the reporting year.

KEY ACHIEVEMENTS From October 2017 through September 2018 (Project Year 4; PY4), MCSP Nepal accomplished several notable achievements:

Possible Severe Bacterial Infection (PSBI): In quarter 4 of project year 3, a nationally representative survey looking at the management of PSBI among private providers was completed in Nepal. The survey was conducted in June and July 2017 in 25 of the country’s 75 districts. In PY4, MCSP analyzed data from that survey, summarized the key findings, and then collaborated closely with in-country and global stakeholders to identify implications and agree on recommendations from that survey. In doing so, a full report of all findings and a technical brief of key findings were developed and disseminated in several events, including a vetting workshop in Kathmandu and a global webinar organized at MCSP in Washington, DC.

In addition, MCSP Nepal worked closely with representatives of the Ministry of Health and Population (MoHP) and USAID to distill key survey findings and used the evidence to design a pilot study aimed at improving the quality of care provided by private providers when managing PSBI symptoms among young infants. A Technical Advisory Group (TAG) was formed to adapt the national IMCNI protocols and develop a training curriculum for this intervention. Private outlets, including drug shops and pharmacies, were mapped in consultation with the district health office and the district chapter of NCDA, and Contraceptive Retails Sales Company (CRS) was contracted by MCSP to support with implementation in Kavre district. Meetings were also held with referral hospitals within the district to build referral networks and linkages with private providers.

As of the end of PY4, providers from 45 outlets had received training on PSBI management, and a total of 55 outlets had received a startup kit, which include a thermometer, respiratory timer and pan scale, as well as updated registers and referral slips. Training and implementation began in June, and is expected to continue for nine months, through March 2019. As of August, a total of 46 sick young infant cases had been registered, of which 24 cases were diagnosed with PSBI, the details of which are illustrated in below sections.

Situation Analysis of Inpatient Care of Newborns and Young Infants (Core funded): MCSP undertook all the preparatory work for supporting the MoHP to conduct a situation analysis of in-patient care for newborns and young infants (small and sick newborn assessment, or “SSNA”). This included drafting protocols and the implementation plan, receiving US IRB approval and submitting for in-country approval, forming an operations team and a Technical Advisory Group (TAG), and adapting all the necessary tools. Once approval is received from the Nepal Health Research Council, the project will begin data collection.

The Maternal and Newborn Health Training Study (MNHI) (Core funded) was completed in Nepal during project year 4. This two-phase study was intended to evaluate the effectiveness of integrated versus standalone training programs to improve knowledge, skills and practices for essential care during labor, childbirth and newborn care in Ethiopia and Nepal. The aim of the study was to generate evidence to inform MNH training programs and to assist the ministries of health to use the evidence to strengthen national training policies.

During the project year, the project team conducted six key informant interviews and three focus group discussions with trainers, doctors, and nurses, and then vetted all preliminary results in a validation workshop with stakeholders under the leadership of the MoHP. The key finding was that integrated training, while essential, has resulted in a diluted effect. The newborn components have suffered due to: time limits, which lead to decreased time spent on these components; and, a lack of clinical mentors who practice essential newborn care and newborn resuscitation. The study highlighted that integrated training is definitely the way forward, but more emphasis is needed now to strengthen training materials so as to ensure better attention to quality and time allocations for both the newborn and maternal components, including competent mentors.

Findings from this study should be shared and utilized for future provincial-level MNCH training programs. A draft report with recommendations was developed from this workshop and a manuscript will now be developed to capture and disseminate study findings.

SECTION 1: PSBI Survey and PSBI Pilot I. Background USAID requested the Maternal and Child Survival Program (MCSP) to build the knowledge base on care for small and sick newborns aged 0-2 months in the private sector in Nepal by conducting a large, nationally representative survey of PSBI care in medicine shops and private clinics. This survey was conducted from June to July 2017 in 25 purposefully selected districts throughout the country. It was designed to build on findings from an earlier study conducted by the Child Health Division (CHD) of the Department of Health Services (DoHS) with support from Save the Children’s Saving the Newborn Lives (SNL) program that illuminated key findings on the quality of PSBI care but had a limited sample. Findings from the survey informed a pilot in Kavre district where private medicine shops and clinics are engaged in delivering quality PSBI management service.

II. OBJECTIVES The goal of the MCSP Nepal program is to support the Government of Nepal to reduce newborn and young infant deaths from PSBI by documenting and disseminating key information on care practices in private sector drug shops and clinics and implementing a pilot to improve the quality of care for PSBI cases presenting to private medicine shops/clinics in Kavre district. Objective 1: To implement a comprehensive nationally representative survey designed to document the appropriateness of care provided by private drug shops and clinics for PSBI in young infants 0-2 months. [COMPLETED in PY3].

Objective 2: Disseminate survey findings to key stakeholders during a national workshop and initiate planning for next steps to improve quality of care for PSBI in the private sector. [COMPLETED in PY 4]

Objective 3: To develop an intervention for improving management of sick young infants and to test the intervention in a proof-of-concept approach within facilities belonging to the existing CRS network. [ONGOING]

Objective 4: Disseminate pilot findings and provide recommendations for improving care in the private sector, including recommendations for a national level strategy. [PLANNED]

Note: Objectives 1 was completed in PY3 and therefore this annual report focuses on activities related to objectives 2, 3, and 4.

III. Summary of Major Accomplishments During this program year, MCSP achieved the following key accomplishments (specific achievements in Q4 are indicated):

National Survey ● Preliminary findings from the survey were shared with key stakeholders nationally and globally, allowing for stronger in-country support of implications, cross-country sharing of experiences, and identification of considerations for the pilot. These included:

o With the IMNCI technical committee in October 2017; at a global Save the Children newborn health meeting in Indonesia in November 2017; and in a Save the Children International Asia regional webinar in December 2017. o In Q4, a national-level dissemination workshop was hosted by the CHD and USAID in July 2018 in Kathmandu, allowing for stakeholders to learn about the findings and discuss implications for the country. In addition, a global webinar was held in Washington, DC in August 2018 to share results and next steps with USAID, MCSP partners, and colleagues. o Additionally, in Q4, the MCSP Nepal team participated in a sharing exchange with the MCSP Nigeria child health team through a virtual Community of Practice networks. Both teams are working with private providers, and the program offered an opportunity for cross-country learning. ● The report for the national survey was brought to final stages, reflecting substantive feedback from USAID. The report summarizes data from New ERA and identifies implications and makes recommendations for the country. It will be finalized in early 2019. In addition, a technical brief summarizing key results and recommendations was developed and disseminated during the national-level stakeholder workshop. The brief and the report were also shared electronically with stakeholders who were unable to attend the event. Pilot Implementation

● Key program deliverables were developed and approved including a revised workplan that was submitted and approved in July 2018, and a Monitoring, Evaluation, and Learning Plan with monitoring tools that was submitted and finalized in Q4. ● Contracts were developed with Partner for Social Development (PSD) Nepal to finalize the clinical protocol and with Contraceptive Retail Sales (CRS) Company to support implementation of the Kavre pilot. As per the agreement, CRS will undertake pilot project activities in accordance with the design and report to MCSP. CRS is also responsible to enter project data, both qualitative and quantitative, and submit monthly reports to MCSP. ● Program implementation materials were finalized, including the service register, referral slip and monitoring tools, and a Facilitator’s Guide and Participants Manual for training of PSBI Management for Private Sector Service Providers. ● Implementation of the pilot was initiated, with formal orientation of 50 service providers from 45 private outlets. Of the total 45 outlets, 36 were medicine shops and 9 were clinics. Providers were trained in PSBI management for infants and initiation of monitoring visits by the MCSP team. A total of 4 monitoring visits were made during this program year, 3 of which were in Q4. ● Two district coordinators were hired, and offices were set up in the pilot district (Q4). Coordination work continued with District Health Office and district chapter of NCDA (Nepal Chemist and Druggist Association) to identify medicine shops and clinics (Q4) ● During the survey, 63 private outlets that included 54 medicine shops and 9 clinics, were mapped in the pilot district, Kavre. Of those 63 outlets, 45 (36 medicine shops and 9 clinics) participated in the formal orientation, 12 medicine shops received onsite coaching, and 2 were not under operation, hence were excluded. Four medicine shops are only mapped but had not received orientation/onsite coaching due to unsafe and inaccessible roads. All the 57 private

outlets, who either received orientation or onsite coaching, were provided with startup kits which contains an analog pan scale, a digital thermometer and an ARI Timer. Significant amount of time was required to map the outlets in remote area. Mapping exercise was conducted in consultation with local area stakeholders, communities, and nearest health facilities.

IV. Detail of Accomplishments The accomplishments by objective for Q4 are detailed below:

Objective 2: Disseminate survey findings to key stakeholders during a national workshop and initiate planning for next steps to improve quality of care for PSBI in the private sector.

Accomplishments / Progress Challenges/Barriers/Next Steps

Activity 2.1 Stakeholder Engagement Q4 Update In preparing for the stakeholder workshop in July, the program team engaged extensively with Child Health Division, the IMNCI Section, and USAID.

● The IMNCI section chief took the lead to refine presentations, finalize invitees list and invite the Director General (DG) of Department of Health Services (DoHS). Invitations to all participants were sent by CHD. ● The team also held multiple meetings with the IMNCI section chief to develop presentations and ensure logistical challenges are cleared before the workshop. ● USAID was consulted and engaged at every stage of planning. An event report was prepared after the workshop and sent to USAID for their record. ● For additional feedback and buy- in from stakeholders, the survey report and brief were shared by email to those who could not attend the workshop on that particular day. Activity 2.2 Dissemination of findings

Q4 Update ● A national stakeholder workshop was held on 16 July in Kathmandu to sharing findings from the survey and discuss the implications. A report is attached in Annex 1. ● A global-level webinar was organized in August. Participants included representatives from USAID Washington and global MCSP implementing partners. ● A technical brief summarizing key results from the survey was developed and disseminated during the stakeholder workshop. It is expected to be further shared in PY5 for information and advocacy to new stakeholders such as Municipality chiefs, provincial policy level stake holders and partners working for advocacy on newborn health. ● A consultant was hired, and a first draft was developed of a journal manuscript on the survey methods. It is expected to be submitted to a peer- reviewed journal early in PY5. ● A product plan was developed for a second journal manuscript on the main findings of the survey. This article is expected to be developed and submitted in PY5.

Objective 3: To develop an intervention for improving management of sick young infants and to test the intervention in a proof-of-concept approach within facilities belonging to the existing CRS network.

Accomplishments / Progress Challenges/Barriers/Next Steps

Activity 3.1 Undertake preparatory work at national level

Q4 Update ● The MEL plan was revised to reflect feedback from USAID and MCSP HQ colleagues and was submitted to USAID. It was considered final and accepted. Activity 3.2 Undertake preparatory work within Kavre district Q4 Update ● Two field coordinators were hired, based in the pilot Some of the sites identified in district the survey could not be tracked ● Coordination work continued with the district health due to a lack of contact office and district chapter of NCDA (Nepal Chemist and information or to being based in Druggist Association). NCDA district chapters were very remote locations where consulted to identify medicine shops and clinics in the field coordinators have not been area. The District Health Office, which regulates clinics,

and NCDA, which is an umbrella organization for able to reach. These sites did not medicine shops, are being consulted periodically to participate in the training either. understand how we can influence to change their While this does not pose any practice towards safer and appropriate one. significant implications for the pilot, it is a key lesson for scaling up implementation in the future. Activity 3.3 Implement pilot at district level Q4 update ● Altogether, 63 private outlets (54 medicine shops and 9 A key component of the pilot is clinics) were mapped in Kavre, of which 45 (36 medicine strong relationships with referral shops and 9 clinics) were identified in consultation with facilities. A coordination meeting DHO before the formal training and rest 18 were was attempted with Scheer identified from the list of outlets developed from the Memorial Hospital, but national survey. Of the 63, providers from 45 outlets unfortunately has been hard to received formal training and providers of additional 12 schedule. The program team will outlets received onsite orientation. Startup kits, which re-attempt to have a meeting contains an analog pan scale, a digital thermometer around mid-November 2018. and an ARI Timer, were distributed to all of these 57 Nevertheless, this has not had shops and clinics. There were 2 medicine shops that any negative implications on the were mapped but were not operational thus excluded pilot. from the list. Activity 3.4 Conduct routine monitoring and identify necessary course corrections Q4 update During the quarter, three monitoring visits took place: As part of the mapping exercise, ● In July, MCSP worked with the district coordinators to the district staff expressed monitor progress of the mapping exercise and the challenges with accessing the distributions of the start-up kits. Challenges with regards medicine shops in the remote to the mapping exercise were discussed, most parts of the district due to the prominently those related to access in the more remote rainy season. Furthermore, due parts of the district during the rainy season. Mentoring to procurement procedures and was provided to the district team in administering the difficulties with roads, the monitoring tools and maintaining the database. distribution of start-up kits was ● In August, a monitoring visit was undertaken by the not completed on time. The IMNCI/Immunization Chief, IMNCI/Immunization Officer implications of these challenges from MoHP, Project coordinator, MIS officer and District will be fully documented and coordinator from CRS, and Senior MEAR Coordinator factored into recommendations from SCI. The monitoring team visited several sites: for future implementation. Dolalghat, Mandan Deupur, Roshi, Bhimkhori, Bhakundebesi and a clinic in Banepa. Altogether, six medicine shops and a clinic in these sites were monitored. During the visit, the team observed the encouraging records of performance by the medicine shops but not by clinic. During the monitoring visit in

these six medicine shops, a total of 46 sick young infant cases had been registered thus far, of which 24 cases were assessed with PSBI. Several key issues were explored: o Most registers had not been thoroughly completed, with some date, weight, temperature, and other data missing. o Incomplete treatment practice was observed: Identified PSBI cases were treated only with oral amoxicillin without referral, and only one case had been properly referred. o Communication with the referral hospital was almost none, and in the few instances when the hospital was called, some providers reported that the phone call wasn't answered at the hospital. For these critical observations, several actions were taken by the monitoring and project teams: o Immediate coaching was provided on the importance of following procedure: on immediate referral of PSBI cases, appropriate follow up of cases, communication with the referral hospital, and complete recording of the cases. We also reinforced these messages to the project district coordinators to ensure they mentor the other providers accordingly. o The monitoring team met the hospital personnel/pediatrician and discussed the challenges experienced with communication. New phone numbers were identified, and that information was cascaded down to the medicine shops. ● In September, a monitoring visit was conducted by the CRS program staff, and MCSP staff accompanied the visit for two days. Three sites were visited (two sites in Mandan-Deupur Rural Municipality, and one site in KoshiDekha at Roshi Rural Municipality). Key findings of that visit included: o Medicine shops are increasingly entering data in the data registers. Providers continue to report being encouraged by our engagement and appreciate the work being undertaken to improve the wellbeing of infants. o One of the sites in Mandan-Deupur (near Indrawati River) sees around 25 patients in a day and is very

busy, especially in the evening time when there are large numbers of people in the market. Despite his busy schedule, the provider managed to enter data of four infants aged 0-2 months who sought treatment from his shop during 3 weeks before the day of the visit. However, he also mentioned that he forgot to enter data of another two due to lack of time. o The other site in Mandan-Deupur mentioned that he does not like treating infants because of a fear that villagers might be angry if something goes wrong. Instead, he refers them to the nearest health post or to the home of the health post staff if it is closed. We probed whether he has ever treated an emergency case, but he insists that while newborns and infants come for care, he does not assess them and quickly refers them elsewhere. o The third site visited was the shop of at health worker working at a (public) health post. He did enter data of those who came to his shop; there were some discrepancies with his records, but we counseled him on site. He was excited to be a part of the study and suggested that we may benefit if we engage more with the community. He claims he gives gentamicin regularly to sick children and says he has no issues with doing so, but that parents are hesitant to agree to their children receiving injectables. This means that compliance with the seven-day regimen is an issue, as parents rarely return for a subsequent dose once the child starts to recover.

Several actions were taken from this visit: o Reiterated the need to document all issues and data o Gave onsite coaching using the job-aid flip chart given to the medicine shops o Demonstrated how to weigh newborn and young infant in pan scale

In addition, the MCSP team regularly met with the CRS project team in Kathmandu. Notes from these meetings are included in the annex.

Objective 4: Disseminate pilot findings and provide recommendations for improving care in the private sector, including recommendations for a national level strategy.

Accomplishments / Progress Challenges/Barriers/Next Steps

Activity 4.1 Document key findings, lessons learned, and challenges, and disseminate to key stakeholders at national and global level

Q4 Update This activity will take place in PY5, once results from the pilot are available. However, during Q3 and Q4 of PY4, discussions were held with USAID on expectations for documentation of the pilot.

V. Monitoring, Evaluation, and Learning

The monitoring and evaluation (M&E) framework for the pilot study began in quarter one of project year four, with the Monitoring Evaluation and Learning Plan (MELP) developed to guide the overall M&E process. This draft plan underwent through several revisions including the feedback from USAID before being finalized in the second quarter. Along with design of MELP, monitoring tools were also developed. Tools were mainly focused around four sources of data; training records, service statistics, supervision records and program records. A monitoring checklist is developed that gathers information from client record register and service providers. A semi structured questionnaire has been developed to record the information of client. This will help to triangulate the information from medicine shops and clinics. These tools are detailed in Annexes (1-3). District-based staff will also maintain a field diary that will records their important observation beyond the tool.

Key performance indicators of the pilot are highlighted in the table below. As shown, none of the service providers adhered to the terms of commitment. This is the most comprehensive indicator of this pilot that demands to comply with other indicators i.e. adherence to treatment regime and/or referral as outlined in the IMNCI protocol, complete recording of all cases, following up of treated cases and facilitating referrals. Particularly, in adhering to the treatment algorithm as per IMNCI guideline and following up of the cases on at least third and fifth day were found to be important improving area to work on. Nevertheless, outlets are seen facilitating the referral process as per the protocol. Four out of five referred PSBI cases received support by outlet to facilitate the referral process as per the protocol.

Selected Performance Indicators for PY4 Target Achievement MCSP Global or Country PMP Indicators % (n) Number and percentage of eligible private sector outlets who 100% 100% (45/45) successfully complete the PSBI management improvement training Number and percentage of trained private sector outlets who sign 100% 100% (45/45) formal commitment letter

Number and percentage of participating sector outlets >50% 0% (0/15) * demonstrating adherence to the terms of commitment Percentage of private sector outlets adhere to at least 80% IMNCI 70% 0% (0/15)* guideline to treat all PSBI cases Percentage of private sector outlets who follow up at least once to ≥85% 33.3% (5/15)* the non-referred cases Percentage of private sector outlets who follow up all non-referred ≥65% 13.3 % (2/15)* cases on at least Day 3 & 5 Number and percentage of participating private sector outlets who >90% Will be reported in intend to continue in the PSBI management improvement initiative PY5 (renew their formal commitment) Percentage of the PSBI cases provided with gentamycin as pre- 80% 40% (2/5)** referral antibiotic Number and percentage of PSBI cases referred by participating >85% 100% (5/5)** private sector outlets who complete referral Number and percentage of PSBI cases referred by participating >90% 80% (4/5)** private sector outlets in which the referral is facilitated * The denominator 15 refers to the total number of outlets who have reported PSBI cases (please refer to the MEL plan attached in Annex) ** The denominator refers to total number of referred cases (please refer to the MEL plan attached in Annex)

Data management

District based staff collect information from the sources. For all the data generated from the service statistics are maintained in an excel database. Data is periodically cleaned and coded. Client data has not been obtained until September, however, from October it is expected that data from referral hospital and client will also start to come. Qualitative data will be coded and presented to complement or triangulate the quantitative information.

Key findings from service statistics (June- September 2018)

Table 1: Background characteristics of the sick young infants presenting at medicine shops

Frequency Percent Age Below 28 days 31 52.5

29-59 days 28 47.5

Missing 1 Sex Female 27 45.0 Male 33 55.0

Distance Proximal (<30 minutes from hospital) 2 3.3 Semi proximal (30-60 minutes from hospital) 35 58.3 Remote (>60 minutes from hospital) 23 38.3 Total 60 100.0

Of the total (N=60) sick young infants coming to the private sectors, 36 young infants (60%) were identified with at least one sign of PSBI. Most commonly reported sign was fever (48%) followed by grunting (28%). (Figure 1)

Figure 1: Percentage of PSBI signs reported among the sick young infants in selected private sector outlets(N=60)

Figure 2 shows the distribution of the PSBI cases according to the selected background characteristics. Out of twenty-eight 29-59 days old young infants reported, 71% were PSBI cases. 70% of all female sick young infants were PSBI. About 61% of all reported sick young infants from remote areas were PSBI.

Figure 2: Reported PSBI cases presenting at medicine shops by patient background characteristics

Of the total non-referred cases of PSBI at the piloted private sector outlets, around 9% (3 cases) were treated with gentamycin injection and 72% were treated with oral amoxicillin (Figure 3 & 4). Of the total 3 cases receiving gentamycin, completed full dose.

Figure 3: Non-referred PSBI cases treated with Figure 4: Non-referred PSBI cases treated with gentamycin (N=31) amoxicillin (N=31)

Fig 5: Non-referred PSBI cases receiving Gentamicin

3 3

Total number of Children Number of Children receiving Gentamicin receiving full dose of Gentamicin

VI. Challenges/ Lessons Learned and Recommendations

● A few of the outlets in Kavre that were identified in the survey could n not be tracked in the pilot. For some, there were no contact details available while others were too far without road access. The lesson learned from this experience has encouraged us to check if all contact details of the respondents are in the data sets. In addition, we may need to be extra careful to ensure all raw data including contact details are with us before we receive the final report and sign off. ● When rolling out our PSBI training in Kavre, we faced a challenge with getting some providers to attend our training due to a recent IMNCI training that had been delivered in district. While in this specific instance, this overlap could not have been avoided, our recommendation for the future is to work with IMNCI officials to coordinate that PSBI training is delivered before or immediately following IMNCI trainings to ensure the trainings are most effective. ● Early monitoring visits have revealed some challenges with providers properly filling out the registers. The program team is providing on-site coaching to address this when such problems are identified. In the future, the recommendation at this time is to revise the training curriculum so that future trainings place a heavier emphasis on register completion. However, we will continue to monitor data over the coming months to determine if there is another cause. ● Lack of access to roads was the main challenge faced while we were mapping service outlets. Moreover, badly damaged roads due to monsoon and heavy rains made a bigger impact in limiting the access. For future implementation, we recognize that we should have prioritized outreach so as to reach difficult places before the rains start and then moved to more easily accessible areas during the rains. Fortunately, our target outlets have remained accessible and implementation has not been impacted, but this is important information for future scaling up.

VII. Major Activities Planned for Next Quarter

● Continue implementation with the current list of 57 outlets (48 medicine shops and 9 clinics). As appropriate, add additional outlets from across the district whenever we are able to reach them, provide orientation, and distribute kits as needed. We will ensure that we are documenting accordingly to distinguish between those that are implementing for the full phase of the pilot and those that are added at later stages. ● Continue on-site mentoring and coaching to providers from district coordinators and during monitoring visits. ● Conduct a monitoring visit with representatives from USAID and implementing partner projects (such as SSBH). ● Finalize and disseminate the survey report.

VIII. Success Story Saved Life: Improving management practice of medicine shop

It was Thursday morning in Bhakundebeshi, when Sunita (name changed to protect privacy) rushed to the medicine shop with her 16-day-old daughter. Her daughter had presented with fever for two days, was having difficulty breastfeeding, and was constantly crying. With no sign of improvement, Sunita decided to seek care. She is a resident of Namobuddha Municipality, Kavre district, and Bhakundebeshi is a common site for careseeking for the community, although it’s about 30 minutes from her residence. Upon reaching the medicine shop, the provider, who had recently received orientation on PSBI management, assessed the baby, including the danger signs based on the protocol, and found the baby had fast breathing, fever, nasal flaring, and jaundice.Figure 1: OnService further register probing of medicine with shop Sunita, he noted that baby was not feeding well. In his opinion, this was a critical case, so he immediately provided the baby with a pre-referral antibiotic (gentamycin) and referred them to the nearest hospital, Scheer Memorial Hospital, along with a referral slip. He also recorded all necessary information in the service register.

“Baby had multiple signs of PSBI when she was brought here. I promptly referred her to the nearest hospital after Figure 2: Referral slip from medicine shop the assessment,” the provider at the medicine shop said. “I followed up with the mother if she took her child to the hospital or not. I am glad that she followed my advice.”

Once referred, Sunita had difficulty in managing the ambulance. Had she been able to secure one, the travel time would have been only 30-40 minutes, but unfortunately, she had to use public transportation due to unavailability of other means. It took two hours for her to reach the hospital, at which point her daughter was immediately admitted to the Newborn Intensive Care Unit (NICU). Fortunately, on the thirteenth day, the baby showed full recovery and was discharged from the hospital.

The medicine shop provider’s ability to diagnose the baby and to provide a pre-referral antibiotic, as well as to refer to the facility, may have saved her life.

SECTION 2: Situation Analysis of Inpatient Care of Newborns and Young Infants

I. Background

Improving the availability and quality of in-patient care for sick newborns and young infants (NYI) is critical to reducing neonatal and child mortality and disability. With this in mind, MCSP (with Core funds) is supporting the MoHP in conducting a situation analysis to understand the landscape of in-patient care currently provided for sick newborns and young infants in Nepal (age 0-59 days). This includes assessing components of national policy, implementation strategy, service readiness and systems to support quality services and clinical practices.

II. Summary of Major Accomplishments During Q4, MCSP: ● Received a formal letter of approval from MoHP to implement the assessment, ● Finalized the detailed implementation plans for the assessment, ● Received ethical clearance from the Western Institutional Review Board (WIRB) in the US, and ● Submitted adapted protocol and tools to in-country research board, Nepal Health Research Council (NHRC), which is currently being reviewed.

III. Detail of Accomplishments ● MoHP formally approved the conduct of the assessment and identified its Curative Division Director as the Principle Investigator (PI). ● The PI approved the formation of an operation team, under ministry’s leadership and comprising of Senior Advisor from USAID and MCSP team members. The first meeting of the operation team was held on July 3, and the detailed implementation plan was finalized. The meeting also worked on the Terms of Reference (ToR) of Technical Advisory Group (TAG) and recommended the members to the PI ● The PI approved the TOR for the TAG of the assessment. ● The global protocol and tools were adapted to the Nepali context. Adapted protocol and tools, including consent forms were submitted for ethical clearance to WIRB and since then have received approval. Adapted protocol and tools both in English and Nepali submitted to NHRC and is currently under review. ● The MCSP Nepal Manager with PI worked for the preparation for the first TAG meeting planned for October 4, 2018. Once the date was confirmed, members were informed. ● Finalized the TOR for a data collection firm to manage data collectors of the study. Firm to manage logistics and data collectors selected through a competitive process and hired.

IV. Challenges/ Lessons Learned and Recommendations ● The transition to federal structures and subsequent changes in the government systems delayed start up activities. We could have preempted and overcome these delays. However, the

assessment would have been less meaningful and useful, without allowing the provincial health system to get organized. The changes before the data collection meant that we now can better tailor implications and recommendations to reflect the new health system structure, particularly with regards to policies (which ones translate from central to provincial, who owns leadership, what new policies are needed) and budgetary recommendations ● The changes in government systems also influenced staff changes within the MoHP and the Department of Health Services. This resulted in MCSP team having to reintroduce the assessment concept to newly transferred officials and to support them fully until they were on board with key activities.

V. Major Activities Planned for Next Quarter

During the next quarter, selected key activities include:

● Revise the TOR for the TAG, reflecting the inputs received from members thus far, and convene the first TAG meeting ● Conduct First TAG meeting on October 4. Meetings with PI and operation team to finalize agenda ● Respond to NHRC comments that are received on the protocol and tools, as appropriate, and receive NHRC approval to conduct the assessment ● Undertake the preparatory work required for the data collectors’ training, data collection, and analysis. This includes finalizing the agenda and materials for the training, and the logistics for the data collection. These activities are then expected to occur early in quarter two.

SECTION 3: Integrated Maternal and Newborn Health Training Study I. Background

MCSP conducted a two-phase study to evaluate the effectiveness of integrated versus standalone training programs to improve knowledge, skills and practices for essential care during labor, childbirth and newborn care in Ethiopia and Nepal. The aim of the Core-funded study was to generate evidence to inform MNH training programs and to assist the ministries of health to use the evidence to strengthen national training policies. For Nepal, the study came at a crucial stage when the country transitioned to federal structures. The central government required evidence to support the guidance provided to the provincial and municipal levels. The workshop organized to review preliminary findings from the study, helped provide the platform for on-going debate regarding the value of integrated versus standalone MNH training with an evidence-based perspective. Both countries have completed data collection, data analysis and have drafted the recommendations from the study. MCSP will work with USAID Missions of both countries and ministries of health to draft a manuscript for submission to a peer review journal.

II. Summary of Major Accomplishments During the program year: ● Completed desk review and data extraction into data collection tool ● Key Informant interviews and Focus Group discussions were held among trainers, doctors, nurses and trainees ● Validation workshop conducted, and preliminary results vetted under the leadership of MoHP with support from MCSP ● A draft country specific report with recommendations from validation workshops group work was developed ● Authors identified from both countries to draft manuscript that captures study findings.

III. Detail of Accomplishments ● Following the collection of all relevant MNH curricula developed by MoHP and partners in country, an independent consultant undertook an in-depth analysis and extracted relevant information for analysis. MCSP entered the extracted information into a special data capture tool and analyzed the content. ● The independent consultant and the MCSP advisor jointly conducted key informants’ interviews with respondents identified from stakeholders’ analysis. An interview guide was used to capture opinions on integrated and non-integrated trainings. Doctors, nurses, trainers and trainees along with focal point in WHO, UNICEF and DoHS (CHD, FHD, and NHTC) were interviewed. The qualitative data were categorized based on themes that emerged from the information provided by the respondents. ● MoHP led a validation workshop that vetted the findings from the desk review. Workshop participants included directors and key focal persons from the Child Health Division, Family Health Division and the National Health Training Center. MNH advisors from partners, including USAID, WHO, and UNICEF, attended and contributed to the discussions. During group work, participants of the workshop reviewed the extracted data and confirmed or corrected where necessary. They

reviewed the findings of the key informant interviews and developed recommendations on key themes that emerged from the data analysis. Some of the key recommendations that emerged were: o Strengthen the neonatal component of the SBA/ASBA packages by increasing the time allocated to the newborn session and aligning each package to standard newborn training modules, e.g. HBB2. o All training programs led by the various program divisions should include follow-up plans as part of the training design. o Trained providers should take on the role of organizing continuing medical education (CME), which could be incentivized by the government to offer accreditation points. o Set up an online database to capture all health staff trainings undertaken by individuals using government ID numbers to avoid duplication and ensure that everyone has an equal chance to benefit from capacity building efforts. ● Following the validation workshop, MCSP developed the country specific comprehensive report that captured all of the findings along with recommendations from the validation workshop. ● The key deliverable from this study is a manuscript for submission to peer review journal. MCSP invited USAID Mission and other key contributors to join hands as co-authors for the manuscript that will developed in PY5Q1.

IV. Challenges/ Lessons Learned and Recommendations

MCSP developed the country-specific report for Nepal in response to a request from the Mission to have documentation of the Nepal phase of the study, and to help support the dissemination and implementation of study findings and recommendations. However, the country, particularly the health structures and entities including CHD and FHD, have now re-structured into a single entity under Family Welfare Division (FWD). It is not yet clear how the new leadership and the new re-structured group will receive the findings and how much would they and NHTC prioritize the implementation of the recommendations in light of the federal structures and evolving new organograms within the health ministry.

V. Major Activities Planned for Next Quarter

During the next quarter, main activities of the project are:

● MCSP will initiate work on a manuscript that will bring together the findings from the two countries included in the study ● MCSP will work closely with the USAID Nepal Mission and relevant Ministry counterparts in the development of the Nepal portions of the manuscript.

Annex 1: Monitoring visits Since the orientation to private sector outlet took place in June, 4 rounds of monitoring visit took place; each in June, July, August and September.

Monitoring visit of June

The first monitoring visit in Kavre was conducted along with the CRS team on June 27, 2018. The Senior Program Officer from MCSP HQ also participated. During the visit, the monitoring team interacted with providers from 2 medicine shops and 1 clinic in Banepa. It was learned from the visit that no PSBI cases had yet been reported within those two medicine shops after the training. However, they did receive some cases of diarrhea and acute respiratory infection. Further, the team also monitored the printed copy of the referral slip and recording sheet. The team observed that the trained service providers at the medicine shops were very keen to apply learnings from the training.

At the observed clinic, one PSBI case had been reported, but was neither referred nor treated. Discussions with staff revealed that doctors, who are the main service providers, were not available when the case arrived. The community medical assistant (CMA), who did receive our formal orientation, attended briefly to talk to the caretaker of the baby but was not referred because she said she was very busy dispensing drugs in the pharmacy during that time. The CMA acknowledged that she had forgotten the guideline of the referral process but showed commitment to follow the guideline in the future. The proposed job-aid would also be helpful in this regard.

Monitoring visit of July

MCSP team visited the pilot district and interacted with district coordinators on work activities. The team reviewed the monitoring process and got updates on the mapping exercise along with the start-up kit distribution status. Follow up was also done on the targeted activities that were set in the last monitoring visit in June. As a part of the mapping exercise, district team revealed the challenges in visiting the medicine shops in remote part of the district due to the rainy season. Furthermore, due to procurement procedure and difficulty in mapping the medicine shop, start-up kit distribution was also not completed. Mentoring was provided to the district team in administering the monitoring tools and maintaining the database. Strategic planning was done with the team to map the outlets.

Monitoring visit of August

Along with the CRS and SCI team members, this visit was also accompanied by the IMNCI Chief and IMNCI officer from Family Welfare Division

Monitored sites: Dolalghat, Mandan Deupur, Roshi, Bhimkhori, Bhakundebesi and Banepa. Altogether 7 medicine shops in these sites were monitored. During the visit, team observed the encouraging recording performance by the medicine shops. A total of 46 sick young infant cases were registered and of which 24 cases were assessed with PSBI.

Key issues explored:

● Some data were missing in the register such as date, weight, temperature. ● Incomplete treatment practice: Identified PSBI cases were treated only with oral amoxicillin without referral. Only one case was referred.

● Communication with the referral hospital was almost none. Some also reported that phone call wasn’t picked up at the hospital Actions taken:

● Mentored on immediate referral of PSBI cases and follow up of cases, and also encouraged communication with referral hospital. Coaching was also provided for complete recording of the cases. ● Met the hospital personnel/Pediatrician and discussed on the communication issue. Notified the changed phone numbers to the medicine shops Monitoring visit September

CRS team went to monitoring visits from September 25 to 28. MCSP team accompanied CRS on 25th and 26th. Sites visited two sites in Mandan-Deupur Rural Municipality, 1 site in Koshidekha at Roshi Rural Municipality. Below are some of the highlights from the visit:

Medicine shops are increasingly entering data in the data registers. Some shops despite their busy schedule, managed to enter data of 4 under-2 months old children who came to his medicine shop for treatment. Some cases were forgotten to enter in the register due to busy time. One of the visited shops reported that he referred sick infants including the emergency cases to the nearest public health facility. Another shop reported to provide the gentamicin to sick children. He did enter data of under2 months children who came to his shop; there were some confusion on recording, but we gave him advices for corrections. He reported people are more concerned when they are told their children needs injectables. Parents are hesitant to agree on injectables. Compliance of 7 days gentamicin was reported to be an issue: when child starts to recover, parents do not usually come for subsequent dosage

Actions taken:

● Re-iterated the need to document all issues and data ● Gave onsite coaching on some of the issues on PSBI management using the job-aid flip chart given to the medicine shops ● Showed them how to use job aid and use them in their practice ● Showed them how to weigh newborn and young infant in pan scale

Annex 2: Monitoring/Supervision Checklist

Monitoring/Supervisory Checklist

Period: ______to______

Date: ______Outlet ID: ______

Section I. Register Review and data quality assessment

# Area Response NOTES/SUMMARY A Recording completeness Recording forms are properly filled (all sections) Yes No

1 Referral slips completed properly (all sections) Yes No

2 Total Use the notes space to Assessment: number tally cases as needed 1 # of children 0-2 months assessed

2 # of PSBI cases 0-2 months identified

3 # of cases 0-2 months with signs of critical illness identified (not feeding, convulsion, unconscious/lack of movement)

Referral facilitation and completion 4 # of PSBI cases 0-2 months referred 5 # of referred PSBI cases 0-2 months given pre-referral dose of injectable antibiotic 6 # of referred PSBI cases 0-2 months in which the referral was facilitated (e.g. calling ahead, arranging transport, etc.) Treatment and follow-up of non-referred cases 7 # of PSBI cases 0-2 months given first dose of injectable gentamicin (treatment initiation) 8 # of PSBI cases 0-2 months completing all 7 doses of injectable gentamicin (treatment completion) 9 # of PSBI cases 0-2 months who return for follow-up on at least Day 3 & Day 5

Section II. Observation of medicines and supplies

Instructions: Ask provider to show you his or her supplies and medicines and record yes or no for all items below.

# Area Response NOTES/SUMMARY C Medicine and supply availability (all items must be functional Current In last 1 and non-expired as appropriate) month 1 Thermometer* Yes No Yes No

2 Stethoscope/timer* Yes No Yes No

3 Salter scale* Yes No Yes No

4 Amoxicillin* Yes No Yes No

5 Other (oral) Yes No Yes No ------6 Gentamycin* Yes No Yes No

7 Ampicillin Yes No Yes No

8 Other(injectable) Yes No Yes No ------9 Syringes appropriate for 0-2 months* Yes No Yes No

10 Recording forms available Yes No Yes No

11 Recording forms are in stock for a month* Yes No Yes No

C1 Necessary supplies and medicines available on day of YES NO YES NO interview (Criteria for yes: yes circled for #1-4, 6, 8, 9)

Annex 3: Interview Guideline for Client

Interview guideline for client

Date: ______ID: ______

Q.1 How is your child? What had happened to child …..days ago? Probe: signs recorded in the form

1) Improvement 2) Condition not improved Q.2 Where did you visit for the treatment service? Probe: for medical shop

1) Medicine shop 2) Clinic 3) Hospital 4) Others (…………………………………………………….) Q.3 How was your child assessed? Probe: on assessing the temperature, how the weight was measured,

1) Temperature 2) Weight 3) Respiratory rate 4) Convulsion 5) Sucks breastmilk 6) Bulging fontanelle 7) Assessed umbilical cord 8) Others (……………………………………………………………) Q.4 What was the treatment service provided? Probe: injectable, oral antibiotic. Try to observe the antibiotic strip if available

1) Oral antibiotic 2) Injectable antibiotic (if possible record the name of the antibiotic, look for medicine packet, prescription) Q.5 Did you comply with the recommended treatment? If no, why? If yes, how many days?

Q.6 What was the advice given by the provider? How comfortable were you to understand the advice? Probe: if clearly understood the treatment, follow up visits, danger signs

1) Use of medicine 2) Danger sign 3) Follow up visit 4) Others (…………………………………………………………….) Q.7 Did you have any difficulty to understand the advice provided by the medicine shop?

1) No

2) Yes Q.8 Were you referred to other health facility?

1) Yes 2) No Q.9 Were you provided referral slip after the check up?

1) Yes 2) No Q.10 Did you visit the referral hospital?

1) Yes 2) No Q.10_a If no, why?

…………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………..

Q.11 Did you go elsewhere beside medical shop? Where? Probe: if she visited due to referral or by her choice?

Q.12 How satisfied were you with the service provided at the medical shop? Probe: cost, behavior, time, effectiveness

Annex 4: MEL Plan

Performance Indicators and Targets

INDICATOR* DEFINITION** AND DATA Baseline FREQUEN T DISAGGREGATORS SOURCE (Source: CY OF A /COLLEC Baseline DATA R TION survey COLLECTI G METHOD through ON E intervie T ws of service provider s)

OBJECTIVE 3: To develop an intervention for improving quality of care for PSBI treatment of sick young infants and to test the intervention in a proof-of- concept approach within facilities belonging to the existing CRS network. 3. Number and N= Number of Training N/A One time, 100% 1 percentage of eligible private records/s June 2018 eligible sector outlets who elf- private sector pass post-test of the administ outlets who PSBI management ered tool successfully improvement training complete the D = Total number of PSBI eligible private management sector outlets improvement participating in the training training 3. Number and N= Number of Training N/A One time, 100% 2 percentage of eligible private records/ June 2018 trained sector outlets who commitm private sector sign formal ent letter outlets who commitment letter sign formal D = Total number of eligible private commitment sector outlets who letter participated in the training 3. Number and N= Number of Monitori N/A Quarterly ≥50% 3 percentage of eligible private ng visits participating sector outlets who & case- sector outlets adhere to the terms record demonstratin of commitment* review g adherence D = Total number of eligible private to the terms sector outlets who of sign formal commitment* commitment letter

3. Percentage of Numerator- Supervisi N/A Quarterly 70% 4 private sector Number of private on visit outlets adhere sector outlets to at least adhering to at least 80% IMNCI 80% IMNCI guideline to guideline to treat all PSBI cases treat all PSBI Denominator: Total cases** number of private sector outlets who provided PSBI treatment 3. Percentage of N= Number of PSBI Supervisi 7% Quarterly 80% 5 the PSBI cases cases 0-2 months on visit provided with referred by and gentamycin as participating sector baseline pre-referral outlets survey antibiotic administering one dose of gentamycin D= Total Number of PSBI cases 0-2 months referred by participating sector outlets that provide injectable treatment to sick young infants 3. Percentage of N= Number of non- Supervisi NA Quarterly ≥85% 6 private sector referred PSBI cases on visit outlets who 0-2 months follow up at followed up by least once to participating private the non- sector outlets within 7 days referred cases D= Number of non- referred PSBI cases 0-2 months presented to the participating private sector outlets 3. Percentage of N= Number of non- Supervisi 41% Quarterly ≥65% 7 private sector referred PSBI cases on visit outlets who 0-2 months and follow up all followed up by baseline non-referred participating private survey cases on at sector outlets at least on Day 3 & 5 least Day 3 & D= Number of non- 5 referred PSBI cases 0-2 months presented to the

participating private sector outlets 3. Number and N= Number of PSBI Supervisi N/A Quarterly >85% 8 percentage of cases 0-2 months on visits PSBI cases referred by & case- referred by participating sector record participating outlets who review, private sector complete referral Hospital D= Number of PSBI records outlets who cases 0-2 months complete referred by referral*** participating sector outlets 3. Number and N= Number of PSBI Supervisi N/A Quarterly >90% 9 percentage of cases 0-2 months on visits PSBI cases referred by & case- referred by participating sector record participating outlets in which the review private sector referral was facilitated (e.g. outlets in made call ahead, which the arranged transport, referral is etc.) facilitated D= Number of PSBI cases 0-2 months referred by participating sector outlets 3. Number and N= Number of Interview N/A Quarterly >90% 10 percentage of participating sector with (after at participating outlets who intend participat least 3 private sector to continue in the ing months of outlets who PSBI management private participati intend to improvement sector on) initiative (renew outlets continue in their formal (part of the PSBI commitment) supervisi management D = Total number of on) improvement participating sector initiative outlets (renew their formal commitment)

*Terms of commitment includes: Use of IMNCI protocol for assessment and treatment of PSBI, complete recording of all cases, following up of treated cases and facilitating caretakers when cases are referred ** IMNCI guideline to treat all PSBI cases: assess PSBI signs, dosage, duration and frequency for treatment of PSBI cases as mentioned in the IMNCI guideline, follow up of cases at least on day 3 and 5 ***Complete referral: PSBI cases who visit the referral hospital after the cases are referred from the private medicine shops/clinics. This will be verified using hospital records. Note: The shaded indicator reflects the key indicator for this pilot

Annex 5: Report – National Dissemination of PSBI Survey Findings

Summary Report on

Dissemination of Management of Sick Young Infants in Private Sectors of Nepal

The national survey titled ‘Management of Sick Young Infants in Private Sectors of Nepal’ was accomplished under the leadership of Child Health Division (CHD) with support from USAID, Save the Children and MCSP Nepal. New Era was the field implementing partner for this survey.

The dissemination meeting on the survey findings was held on 16th July 2018, at Hotel Annapurna, Kathmandu. The meeting was organized under the aegis of the CHD with support from USAID and Saving the Newborn Lives, Save the Children. CHD sent all the invitations including the stakeholders from government, development agencies, I/NGOs and associations who are involved in maternal, newborn and child health. Notably, some of the key stakeholders from Department of Drug Administration (DDA), UNICEF and WHO, could not come. The detail of the participants is provided in Annex 2.

The dissemination meeting had the following objectives:

● To disseminate findings of the survey on management of PSBI in private sector ● To discuss engagement of private sector to improve service delivery for newborn and young infant ● Incorporate feedback received in the discussion in the workshop The meeting started with the welcome remarks and objectives from Senior Public Health Officer, CHD. Then the IMNCI Chief presented the survey findings that included; the study context, survey objectives, methodology, key findings, recommendations and ongoing pilot work in Kavre. Key findings mainly included the practices of private sectors on assessment, treatment, follow-up and referral of sick young infants. This was followed by question and answer sessions where stakeholders from government and INGOs put some queries along with the suggestions. Both Senior PHO and IMNCI Chief responded the queries. Based on this discussion way forward points have been developed below.

Way forward from the dissemination meeting

● Revise the survey finding presentation, particularly, with addition of characteristics of clinics and service providers; ● Identify other platforms where this finding could be shared like; any technical group or steering committee under the Ministry of Health; ● Share the findings with DDA; ● Explore for a workshop involving key stakeholders to revise the recommendations reflecting the implications from the survey findings.

Annex 1: Dissemination Meeting Schedule

Time Activities Responsible Breakfast 8:30 - 8:40 am Welcome Remarks Senior Public Health Officer, CHD 8:40 - 9:00 am Objective and Outcome Director, CHD

9:00 - 9:50 am Findings / Results from the survey IMNCI Chief, CHD

9:50 – 10:20 am Questions/ Answers All

Country Director, Save the 10:20 – 10:30 am Remarks Children

10:30 – 10:40 am Remarks Senior MNCH Advisor, USAID

10:40 – 10:50 am Remarks DG, DoHS

10:50 – 11:00 am Remarks Director, CHD

Lunch

Annex 2: List of the participants

SN Name of participants Institution Designation

1 Dr. Gun Raj Lohani MoHP DG Dr. Bibek K. Lal DOHS DDG 2 Dr. Bikash Lamichane CHD/DOHS Director 3 Dr. Tara Pokharel FHD Director 4 5 Mr. Mahendra Shrestha MoHP Chief PHA 6 Mr. Shambhu Gyawali CHD IMNCI Chief 7 Mr. Parshu Ram Shrestha KTM DPHO Chief PH Administrator 8 Ms. Roshani Tuitui MoHP Chief Nursing Advisor 9 Mr. Shanker Pandey CHD Sr. AHWO 10 Dr. Punya Paudel FHD Reproductive Health Focal Person 11 Mr. Deepak Jha CHD Sr. PHO 12 Dr. Tara Nath Paudel MoHP CCM Gen 13 Dr. Surendra Chaurashia DHO, Kavre DHO 14 Mr. Kamelesh Kumar Mishra DHO, Kavre IMNCI Focal Person 15 Dr. Gambhir Shrestha CHD Medical Officer

16 Mr. Dinesh Rupakheti CHD M&E Officer 17 Mr. Tek Raj Ojha CHD HA 18 Ms. Sarada Adhikari CHD Computer Officer 19 Emee Awai Rai CHD Data Analyst Officer Dr. Shilu Adhikari USAID Sr. MNCH Advisor 20 Dr. K.P. Bista NEPAS President 21 22 Mr. Bishal Gyawali NEDS Program Manager 23 Mr. Dipak Raj Chaulagain - Freelance 24 Ms. Pranita Thapa Newera Deputy Director 25 Mr. Bharat Ban - Freelance 26 Mr. Uttam Neupane - Freelance 27 Mr. Ned Olney SCI Country Director Dr. Neena Khadka MCSP Team Lead 28 29 Dr. Deepak Paudel SSBH/SCI DCOP 30 Ms. Seema Baral SCI Director 31 Dr. Anjana KC Thapa SCI Manager-SNL Dr. Adhish Dhungana MCSP Manager-Maternal and Child 32 Survival 33 Ms. Sangita Khatri SCI Program Manager 34 Mr. Deepak Joshi SCI Sr. MEAR Coordinator 35 Mr. Umesh Bhusal SCI Sr. Program Coordinator 36 Mr. Rajan Bhandari SCI Program Coordinator 37 Ms. Honey Malla SCI M&E Coordinator 38 Ms. Pratikshya Deo SCI Support officer 39 Mr. Dhani Ram Chaudhary SCI Support staff

Annex 5: Some Glimpses from the meeting

Senior PHO, CHD welcoming the participants IMNCI Chief presenting the survey findings

Participants listening to the survey findings

Director, CHD presenting his remarks Senior MNCH Advisor, USAID presenting her remarks

Field visit to Kavre by MCSP HQ and Nepal team Field visit to Kavre by MCSP Nepal and CRS team

Annex 6: Notes from CRS & Save the Children Nepal Meetings

CRS & Save the Children Nepal | Meeting Notes | July 18, 2018

Agenda: 1. Discuss on the progress and delays of activities 2. Prepare action plan on next steps

Procurement: 1. Had said during the visit that the distribution will start from July 20 2. Challenges on vendor: CRS sent back the items from one of the vendors as the items were sent with stickers from another funded project (SUUAAHARA)

Action: By Friday, 20th July, the items will reach CRS By Monday, the startup kits will start going to district Job Aids and Flip chart will arrive on Monday 23 July Mapping of sites: 1. Had said during Elaine's visit the mapping will finish in a week’s time 2. Challenges were geography and finding the ones who did not come to training

Action points: 1. Coordination with DPHO IMNCI focal person in Kavre, NCDA district chapter, and medicine supplier 2. Neeti ji and Laxman ji to support field coordinators to coordinate and support in mapping

Office Setup: 1. Furniture procurement started

Report: 1. Detail MnE plan to be submitted by CRS by Wednesday next week 2. The report should incorporate coordination, challenges, learnings and more qualitative component 3. Next report to come on 6th of Aug, COB

Action points 1. Save the Children to send monthly report with comments tomorrow July 19 2. CRS to share days of involvement (LoE) of Program Manager (Neeti ji) on the project: By Wednesday next week

Visit: 1. Visit plan with MnE to be shared 2. Kavre visit to be held by end of July (2 days) with Program person of both SC and CRS 3. Visit to referral hospital within next two weeks - take points from monthly report on referral issues and talk with the hospital to mitigate them

Finance: 1. Finance to talk directly to Finance of SC for all trouble shooting

2. Plan to have inter Finance meeting next week

CRS & Save the Children Nepal | Meeting Notes | September 2018

● Updates from the field: o Difficult geographic area is now accessible to visit o 61 shops mapped till date; 45 outlets from the orientation and 16 from survey list who did not participate in the orientation o Mapping exercise revealed that 20 shops from the survey list were in the orientation o 55 shops are provided with start-up kit; 6 are yet to be distributed (only pan scale remaining) o Onsite orientation done with 14 outlet providers participants who had not received earlier o Out of 61, 7 shops were run by government

● Referred case going to Scheer memorial hospital, so if could be considered as referral point in our pilot ● CRS team will work on indicator matrix shared by SCI to incorporate into the monthly report ● As per the mandate of the SCI policy on accountability, a toll-free phone number will be provided to all outlet providers so that they can share their difficulties/dissatisfaction or any other opinion ● Dataset: Issues and improving area discussed; for e.g. making consistency in variable value; either numeric or string, addition of few variables ● Confusion remained on insurance of bike and reimbursement mechanism ● Challenges: o Some of the shops receiving the orientation were not run by the trained providers but by their relatives/spouse. However, all of them were paramedics Action Points ▪ Onsite coaching to other members who are running, and comparatively closer supervision o Not adhering to protocol; treating with amoxicillin not gentamycin Action points ▪ Need to identify whether its supply side or demand side barrier ▪ Referral of such cases if not getting treatment as per protocol ▪ Coaching/onsite mentoring to providers Next point

● Orientation/meeting with Scheer memorial ● Proposed M&E visit on 25th Sep ● Clarity on insurance between SCI logistic and CRS finance ● CRS will revise the phase-wise budget ● Qualitative information in monthly report; both from service providers and client ● Revision of dataset as per the discussion