MCHIP Leader with Associate Award GHS-A-

00-08-00002-00, Cooperative Agreement

No. 656-A-00-11 -00097-00

FY2014 3rd Year of the Project

Quarterly Report: April 1 to June 30, 2014

1. Project Duration: July 431, years 2014

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2. Starting Date: April 12, 2011

3. Life of project funding: $29,835,179; will increase to $32,835,179 once Modification 6 of the Cooperative Agreement is fully executed.

4. Geographic Focus: National

5. Program/Project Objectives

The goal of the MCHIP/ Associate Award is to reduce maternal, newborn and child mortality in Mozambique through the scale-up of high-impact interventions and increased use of MNCH, FP/RH, and HIV services. The project has eight objectives:

• Objective 1: Work with the MOH and all USG partners to create an enabling environment at national level to provide high-impact interventions for integrated MNCH / RH / FP services in the community and Health Facilities • Objective 2: Support efforts of the MOH to increase national coverage of high impact interventions for MNCH through the expansion of the MMI, in collaboration with USG partners in all provinces • Objective 3: Support the MOH to strengthen the development of human resources for the provision of basic health services and comprehensive Emergency Obstetric and Neonatal Care and RH • Objective 4: Support the expansion of activities for prevention of cervical and breast cancer using the single-visit approach and assisting in the implementation of "Action Plan for the Strengthening of and Expansion of Services for Control of Cervical and Breast Cancer" of the MOH • Objective 5: Assist in the development, implementation, and management of FP/RH services for selected health facilities • Objective 6: Promote and test the introduction of neonatal circumcision services in selected health units • Objective 7: Partnerships developed and strengthened (MOH and all USG partners) at the national level to promote high impact integrated MNCH services • Objective 8: Work with the MOH and all USG partners to define, implement and monitor standards of care at the point of service in essential areas

6. Summary of the reporting period

Objective 1: Work with the MOH and all USG partners to create an enabling environment at national level to provide high-impact interventions for integrated MNCH / RH / FP services in the community and Health Facilities

IR1.1 Strengthened policies and planning processes for MNCH/RH/FP

Flowcharts During Quarter 3, MCHIP received approval from the Ministry of Health to move forward with the printing of the package of flowcharts for reproductive health, maternal and neonatal health, post-partum and post-natal care, and organization of integrated care for women and children. USAID has requested to conduct a final revision of the flowcharts prior to printing. Once MCHIP receives this feedback, the project will conduct a public bid for printing of the package of flowcharts for all Model Maternity facilities, as well as printing of selected flowcharts as posters for display in health facilities.

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Family Planning During Quarter 3, MCHIP supported the MOH to finalize the Acceleration Plan to Increase the Utilization of FP Services and Modern Methods of Contraception. This plan was approved by the Ministry of Health during the reporting period.

Maternal and Newborn Health During Quarter 3, MCHIP worked in collaboration with the MOH and other partners to develop the framework and objectives for the Plan to Accelerate the Operationalization of the National Integrated Health Plan, with a focus on key, short-term activities to reduce maternal and newborn morbidity and mortality. MCHIP will provide technical assistance in Quarter 4 to write this plan, working closely with MOH counterparts and key SWAp members.

Women & Child Health Department During Quarter 3, MCHIP and the Ministry of Health conducted interviews for three key advisor positions for the Ministry of Health’s Women and Child Health Department (MOH – National Directorate of Public Health, including an MNH Advisor, Family Planning Advisor, and Logistics Advisor. Successful candidates were identified for all three positions, and the Family Planning Advisor and Logistics Advisor were contracted by MCHIP and seconded to the MOH. The MNH Advisor will be contracted and will begin in Quarter 4.

IR1.2 Implementation of consensus Community Mobilization strategy in support of MNCH/SRH/FP

During Quarter 3, MCHIP supported the creation of 29 new Community Health Committees (CHC) in Province (2), Sofala (3), Manica (1), Cabo Delgado (14), and Inhambane (9). Twenty-eight of these CHCs developed action plans based on identified priority health problems in their communities, which included the following issues:

• Poor quality care and long waiting time to receive care at health facilities due to the insufficient number of health care workers • Births outside of the health facility because women work in the fields far from their homes and some of them go into labor there. When they return home from the fields, their husband or mother-in-law may not be there and therefore they do not have permission to leave for the health facility and end up giving birth at home. • Malaria • Malnutrition • Snake bites • Thrombosis • Conjunctivitis and matequenha/tunguiasis(flea-related illness) • Anemia • Difficulty in continuing methods of family planning because of the long distances that women have to walk to collect more pills.

In order to respond to some of these identified problems, CHCs included the following priorities in their action plans:

• Construction of waiting homes for pregnant women • Home visits to distribute mosquito nets and to encourage their correct use • Nutritional education • Promotion of prevention methods for malaria, thrombosis, diarrhea, conjunctivitis, and matequenha

3 • In relation to family planning, the CHCs proposed to train TBAs and APEs in community-based distribution of FP methods (including pills), as well as a transportation plan for community members to arrive at health facilities.

During this quarter, focus was placed on consolidating existing Co-Management Committees. Only one new co-management committee was created during this quarter in Maciene Health Center (Gaza), a decision made by the Provincial Health Directorate.

In order to guarantee a successful consolidation in the implementation of the community mobilization strategy, MCHIP supported the implementation of the following coordination meetings between the District Health Services, Administrative Post Chiefs, health facilities, partners, community health committees, and co-management committees:

• Gaza: A total of 30 participants, including health technicians from all peripheral health facilities, program heads (MCH, Vaccinations, Oral Health, Adolescent Health, Pharmacy), the Director of the Rural Hospital, the head of community health, the administrative post chief, local chiefs, and partners (Pathfinder, World Relief and MCHIP), attended the coordination meeting. • Manica: One coordination meeting with 30 participants was held in Chimoio, and another was held in Manica with 13 participants • Tete: A coordination meeting was held in Tete City with 80 community members, 17 CHC members, the Medical Chief and Provincial Health Director, and members of the Tete Provinicial Hospital’s Humanization Committee. A coordination meeting was also held in Mutarara with community members from Tranquino, representatives from the Mutarara Rural Hospital, and MCHIP. • Cabo Delgado: A provincial community mobilization meeting was held with 34 participants, including SESP representatives from all districts in the province and one community member from the Co-Management Committee of each district. Also in Quarter 3, two meetings were convened by the district health services in Pemba City, in which 25 health technicians, health facility managers, MCH nurses, and partners were present. The objective of these meetings was to analyze district-level health indicators and coordination activities of partners working at district level in the province.

IR1.3 Strengthened Health Information System for MNCH/RH/FP

Data collection tools and registers In Quarter 3, MCHIP printed copies of the finalized registers and monthly summary forms for the MOH, which were then submitted to the Minister of Health for his review and approval. MCHIP is currently coordinating with the MOH on the specifications for the public procurement bid for mass printing of the new registers.

Also during the reporting period, MCHIP, in collaboration with other partners, provided support to the MOH to develop and harmonize the training packages for the each of the register books.

In addition, during the reporting period, MCHIP worked with the MOH, USAID, CDC, and other partners to define a guide for the monitoring of the implementation of the SRH/MNCH registers. The objectives of the monitoring of the implementation of these instruments are the following:

• To assess the level of health providers’ knowledge regarding the use/completion of information in the new SRH/MNCH registers; • To assess health providers’ attitudes regarding the use of the new registers;

4 • To assess the successes and challenges of reporting information by cohort; • To assess the consistency of aggregate data reported at various levels and to identify challenges, successes, and lessons learned in the implementation of the revised registers.

Technical Assistance to Strengthen Provincial-level M&E Capacity During Quarter 3, the MCHIP Monitoring and Evaluation Team conducted supervision/ technical assistance visits in 13 health facilities in five provinces, including the following: 1) (Nampula Central Hospital, 25 de Setembro Health Center, 1º de Maio Health Center, Nacala Porto District Hospital, Nacala Health Center, and Meconta Health Center); 2) Cabo Delgado (Pemba Provincial Hospital, Chiúre Rural Hospital, and Natite Health Center; 3) Niassa (Lichinga Provincial Hospital); 4) Sofala (Beira Central Hospital); and 5) Manica (1º de Maio Health Center and Chimoio Provincial Hospital).

The primary objective of these technical assistance visits was to train MNCH nurses in the correct use and completion of the SRH/MNCH registers, to interpret data for MMI indicators and use this information for decision-making, and to improve the quality of information collected and reported through the national health management information system.

During the supervision and technical assistance visits, the M&E team conducted the following activities:

• On-the-job training in Monitoring and Evaluation and the use of the SRH/MNCH register books. At least one (1) MNCH nurse was trained in each health facility that was visited during this quarter. • Review of the register books and monthly summary reports in the maternity and family planning services for quality (consistency and accuracy) and completeness Interpretation of the key indicators for MMI and CECAP programs, including SBM-R performance standards.

IR1.4 Strengthened capacity for program learning in MNCH/RH/FP

Community Study The objective of this study is to collect information about the knowledge, attitudes and practices related to pregnancy, childbirth, postpartum and care for newborns and children in selected MCHIP-supported communities. During Quarter 3, the consulting agency responsible for the implementation of the Community Study carried out field work in Gaza, Nampula and Tete provinces. The study report will be developed and finalized in Quarter 4. The results of the survey will be used to guide and prioritize MNCH social and behavioral change efforts in the future.

Integrated Packages Feasibility Study The goal of this study is to evaluate implementation of Integrated Service Packages linkage/referral model in order to identify opportunities, challenges, and lessons learned to inform the expansion integrated RMNCH services in Mozambique. During Quarter 3, MCHIP, in collaboration with the MOH, conducted a training of 10 data collectors (5 from Inhambane and 5 from Zambézia) from May 21 to 23 to support the endline field work. Following this training, endline data was collected in Inhambane and Zambézia, with the assistance of one supervisor in each province. Data entry commenced at the end of Quarter 3, and a preliminary report will be available by September 2014.

Post-Partum Family Planning Systematic Screening Study The Post-Partum Family Planning Systematic Screening Study focuses on increasing utilization of family planning of post-partum women and providing them facilitated access to

5 comprehensive MNCH services. During the quarter, MCHIP completed implementation of the first phase of the Post-Partum Family Planning Systematic Screening study at Xipamanine Health Center, Bagamoyo Health Center, and Polana Caniço Health Center. Recent preliminary data analyses show that 33% of new FP acceptors at the implementation health facilities have been referred through this screening and referral system. MCHIP conducted an endline evaluation of the initial intervention in April. During Quarter 3, MCHIP initiated the development of the study report. This report will be finalized during Quarter 4.

In Quarter 3, MCHIP initiated implementation of the second phase of the PPSS study in Nampula, which is examining whether the use of a simplified job aid (flowchart) increases the number of new contraceptive users being referred from other areas, as compared to the use of no tool or job aid to systematically screen clients for PPFP. During the reporting period, MCHIP trained four study assistants for data collection in the eight intervention and control health facilities. MCHIP also trained a total of 35 MCH nurses at the following intervention facilities in the simplified job aid and referral system:

• 25 de Setembro Health Center, Nampula City (Control: 1 de Maio Health Center, Nampula City) • Anchilo Health Center, Rapale District (Control: Rapale Health Center, Rapale District) • Namialo Health Center, (Control: Meconta Health Center, Meconta District) • Monapo Sede Health Center (Contro: Carapira Health Center)

The baseline data was completed and the intervention started during this quarter. Additionally, two supervision visits were conducted by MCHIP and the Provincial Health Directorate in May and June to monitor the implementation of the intervention. The implementation of this phase of the study will be completed in FY15 Quarter 1. The final report for this second phase of the study will be available by February 2015.

Objective 2: Support MOH efforts to expand national coverage of high-impact MNCH interventions, through the scaling-up of the MMI, in collaboration with USG partners in every province

IR 2.1 Selected Model Maternities equipped with minimal infrastructure and supplies for humanized and quality MNCH services

During FY14 Quarter 2, MCHIP submitted an application to the MVA Emergency Application Fund for 399 MVA kits and 798 accessory kits for Model Maternity facilities included in the expansion plan through 2013 (it was recommended that the application be limited in the quantity of MVA kits requested, and therefore MCHIP included a sufficient initial quantity for facilities with providers that have already been trained in Post-Abortion Care by MCHIP). The MVA kits were received from IPAS/Women Care Global in Quarter 3. MCHIP has developed a distribution plan for the MVA kits, and the materials will be distributed early in Quarter 4. The post training and quality improvement support for PAC service delivery will continue to be supported by the MOH and MCHIP.

For the re-supply of MVA kits, as well as the supply of kits included in the 2014 expansion plan, the MCHIP team is dedicated to working with the MOH, including the National Directorate of Public Health and the Women and Child Health Department, to provide direct budgetary support and/or request other donors to support the scale up of PAC services. The MCHIP team will continue to work at the policy level to ensure that district and provincial health directorates, as well as the central level MOH, plan for resource allocation to support

6 the future expansion of PAC services as well as the resupply of the facilities where the initial donations will be provided.

IR 2.2 Corps of maternity care workers and trainers up to date on key evidence-based practices

Helping Babies Breathe In Quarter 3, MCHIP supported an on-the-job training in HBB in , resulting in the training of 44 health professionals. The objectives of the training were the following:

• To prepare health professional to implement the HBB methodology in their areas of work; • To teach health professionals that provide newborn care in the health facilities the necessary skills to help babies breathe after birth; • To teach health professionals about neonatal resuscitation, using lectures, practical sessions, and tests.

MCHIP will provide follow-up and supportive supervision to monitor implementation of this intervention at the health facility level during standard TA visits to MMI facilities.

Table 1. Health workers trained in Helping Babies Breathe during Quarter 3 Categories Province MNCH Nurse Physician Midwife Anesthesia Others Total Technician Sofala 17 13 0 0 14 44

Kangaroo Mother Care During the reporting period, two training of trainers were conducted in Kangaroo Mother Care, resulting in the training of 69 health workers from all 11 provinces in Mozambique. The following table summarizes the number of health workers trained by province.

Table 2. Health workers trained as trainers in Kangaroo Mother Care during Quarter 3, by Province Categories Province MNCH Physician Midwife Anesthesia Others Total Nurse Technician Maputo City and Maputo 5 0 0 0 6 11 Province Gaza 8 0 0 0 0 8

Inhambane 4 2 0 0 0 6

Sofala 7 0 0 0 0 7

Manica 6 0 0 0 0 6 Tete 2 0 0 0 1 3 Zambezia 6 0 1 0 0 7 Nampula 5 0 1 0 1 7 Cabo Delgado 8 0 0 0 0 8 Niassa 6 0 0 0 0 6

7 TOTAL 57 2 2 0 8 69

After the training of trainers, some provinces initiated the reorganization of their Kangaroo Mother Care services in selected health facilities involved in the Model Maternity Initiative. The below table presents several indicators collected at the health facility level, which can serve as a baseline for evaluating the implementation of KMC at these health facilities.

Table 3. Baseline results for key KMC indicators at selected health facilities Province Health Number of Number of Number of Number of Facility newborns newborns newborns newborns with low with low with low with low birth weight birth birth weight birth weight during the weight that were referred to previous admitted released the quarter for KMC in based on Provincial or the health established General facility criteria Hospital (weight during the gain) past quarter Nº 4 HC 10 0 10 0 Nº 2 HC 25 0 17 0 Mutarara 26 0 14 0 Tete RH Macurungo 26 0 0 0 HC Ponta Gea 19 0 0 0 HC Munhava 56 0 0 0 HC Chingussura 61 0 0 0 HC Muxungue 12 0 0 0 Sofala RH Gurue DH 6 0 6 0 Quelimane 19 13 6 0 PH Coalane HC 4 0 4 0 17 de 6 0 6 0 Setembro Zambezia HC Marrere GH 26 26 24 0 25 63 63 50 9 Setembro HC Muhala 13 13 10 2 Expansão Nampula HC Mueda RH 17 4 17 0 Cabo Natite HC 12 0 0 12 Delgado

8 Pemba PH 53 40 65 0 Cuamba RH 7 7 7 0 Mandimba 8 8 8 0 Niassa HC TOTAL 469 174 244 23

Model Maternity Initiative In Quarter 3, MCHIP, in collaboration with the MOH, conducted three trainings in the Model Maternity Initiative, involving a total of 95 health workers. The objective of this training is to provide participants with the knowledge and skills to implement high-impact, evidence-based interventions in maternal and newborn health, with a focus on quality and humanization of care. MCHIP conducted a regional MMI training from March 31 – Abril 11, 2014 in Nampula for 25 MNCH nurses from 12 Model Maternity facilities in the northern region (Nampula, Niassa, and Cabo Delgado), and a regional training in Manica for the central region (Manica, Zambézia, Tete and Sofala) from May 26 – June 6, 2014 for 38 health professionals from 21 health facilities. Also in Quarter 3, in collaboration with EGPAF and the MOH, MCHIP trained 31 health professionals from 15 health facilities in Nampula in the Model Maternity Initiative in preparation for the implementation of the Performance-Based Financing model in the province. The objective of this model is to increase health worker motivation and the quality of MNH service provision by providing incentives based on the achievement of performance standards and targets for key indicators. This initiative will be rolled out over the remainder of the project in Gaza and Nampula provinces, in coordination with EGPAF.

PMTCT In June, MCHIP, in collaboration with the MOH and Niassa Provincial Health Directorate, conducted a provincial training in the management and treatment of HIV positive pregnant women (Option B+). Participants included 16 MCH nurses, two elementary nurses with more than 5 years of experience working in the maternity and two General Medicine Agents, and represented the following health facilities: Cuamba Rural Hospital, Mandimba Health Center, Lichinga City, Lichinga Provincial Hospital, Chimbonila District, Mecanhelas Health Center, and Majune Health Center.

IR2.3 MOH management and supervision of Model Maternities strengthened

MCHIP continued to support the MOH to implement the National Model Maternity Initiative in 119 health facilities in FY14 (see Annex 3 for a complete list of MMI facilities).

Provincial-level Supervision and Technical Assistance Visits During Quarter 3 of FY14, the Provincial-Level Mentoring Team (which includes DPS counterparts and MCHIP-supported provincial-level MCH nurses) worked with health facility staff to conduct a total of 91 technical assistance/supportive supervision visits to MMI facilities. During these visits, the following key activities were performed:

• Support to health facility staff to conduct internal SBM-R measurements • Identification of material, equipment, consumable, and human resource needs • Technical assistance to MNCH nurses at the health facilities in performing high- impact, evidence-based MNCH interventions • Review, analysis and discussion of registers and key indicators with key members of health facilities • Organization of the maternity to improve client flow and assistance in cleaning the maternity to standard • Review family planning services, with a focused review of post-partum IUD services

9 Table 4 provides a summary of the technical assistance visits and SBM-R measurements conducted with the support of MCHIP during FY14 Quarter 3, by facility.

Table 4. MMI facilities provided with technical assistance/supportive supervision in FY14 Quarter 3 Province Health Facility Focus of visit Supportive supervision and Mandimba Health Center technical assistance Chiuaula Health Center Supportive supervision and technical assistance Niassa Lichinga Provincial Hospital Supportive supervision and technical assistance Hospital Supportive supervision and technical assistance Natite Health Center Supportive supervision and technical assistance (2 supervision visits) Balama Health Center Supportive supervision and technical assistance; 3rd SBM-R internal measurement (61.4%) Pemba Provincial Hospital Supportive supervision and Cabo Delgado technical assistance; 7th SBM-R internal measurement (89.5%) (3 supervision visits) Supportive supervision and technical assistance; 6th SBM-R Chiúre District Hospital internal measurement (92.1%) (2 supervision visits) Monapo Rural Hospital Supportive supervision and technical assistance Supportive supervision and Muhala Expansão Health Center technical assistance Supportive supervision and Marrere General Hospital technical assistance

Supportive supervision and Nampula Nacala Porto District Hospital technical assistance

Supportive supervision and Anchilo Health Center technical assistance; Baseline SBM-R measurement (31.5%) Supportive supervision and 25 de Setembro Health Center technical assistance Supportive supervision and Mossuril Health Center technical assistance Gurué Rural Hospital Supportive supervision and technical assistance Mopeia Health Center Supportive supervision and technical assistance Zambézia Coalane Health Center Supportive supervision and technical assistance (3 supervision visits) Quelimane Provincial Hospital Supportive supervision and

10 technical assistance; 7th SBM-R internal measurement (56%) (3 supervision visits) Nicoadala Health Center Supportive supervision and technical assistance Supportive supervision and Tete Provincial Hospital technical assistance (2 supervision visits) Supportive supervision and Moatize Health Center technical assistance; 5th SBM-R internal measurement (51.4%) Supportive supervision and No. 2 (Matundo) Health Center technical assistance; 8th SBM-R internal measurement (53.4%) Supportive supervision and technical assistance; 4th SBM-R No. 4 (Muthemba) Health Center Tete internal measurement (62.1%) (2 supervision visits) Supportive supervision and Songo Rural Hospital technical assistance; 9th SBM-R internal measurement (75%) Supportive supervision and Chitima Health Center technical assistance; 3rd SBM-R internal measurement (57.9%) Supportive supervision and Changara Health Center technical assistance Supportive supervision and Ulongue Health Center technical assistance Supportive supervision and Gondola Health Center technical assistance; 6th SBM-R internal measurement (63.3%) Chimoio Provincial Hospital Supportive supervision and technical assistance; 9th SBM-R Manica internal measurement (77%) Hospital Supportive supervision and technical assistance; 9th SBM-R internal measurement (84.4%) Supportive supervision and 1º de Maio Health Center technical assistance Hospital Supportive supervision and technical assistance Muxungue Health Center Supportive supervision and technical assistance Hospital Supportive supervision and technical assistance (3 supervision visits) Sofala Chingussura Health Center Supportive supervision and technical assistance; 4th SBM-R internal measurement (75.5%) Supportive supervision and Buzi Rural Hospital technical assistance; 8th SBM-R internal measurement (75%) Hospital Supportive supervision and

11 technical assistance; 5th SBM-R internal measurement (75.5%) Macurungo Health Center Supportive supervision and technical assistance; 9th SBM-R internal measurement (77.6%) (3 supervision visits) Dondo Health Center Supportive supervision and technical assistance; 4th SBM-R internal measurement (81.5%) Homoine Health Center Supportive supervision and technical assistance; 9th SBM-R internal measurement (71.7%) Inhassoro Health Center Supportive supervision and technical assistance; 3rd SBM-R internal measurement (72.2%) Inhambane Provincial Hospital Supportive supervision and technical assistance; 10th SBM-R internal measurement (83.3%) Morrumbene Health Center Supportive supervision and technical assistance; 7th SBM-R Inhambane internal measurement (62.7%) Supportive supervision and technical assistance; 8th SBM-R Vilanculos Rural Hospital internal measurement (84.6%) (2 supervision visits) Supportive supervision and Quissico Health Center technical assistance; 8th SBM-R internal measurement (83.3%) Supportive supervision and Hospital technical assistance; 8th SBM-R internal measurement (75%) Supportive supervision and Xai-Xai Provincial Hospital technical assistance Supportive supervision and technical assistance; 11th SBM-R Manjacaze Rural Hospital internal measurement (76.3%) (2 supervision visits) Supportive supervision and technical assistance; 6th SBM-R Chibuto Rural Hospital internal measurement (49.4%) (3 supervision visits) Supportive supervision and Gaza Chokwe Rural Hospital technical assistance; 7th SBM-R internal measurement (63%) Supportive supervision and Macia Health Center technical assistance; 6th SBM-R internal measurement (65.2%) Supportive supervision and Massingir Health Center technical assistance; 3rd SBM-R internal measurement (61.6%) Supportive supervision and technical assistance; 10th and 11th Chicumbane Rural Hospital SBM-R internal measurements (70.8% and 75.6%) (3 supervision

12 visits) Supportive supervision and Boane Health Center technical assistance (3 supervision visits) Supportive supervision and Bedene Health Center technical assistance (2

supervision visits) Supportive supervision and Marracuene Health Center technical assistance Supportive supervision and Namaacha Health Center technical assistance Supportive supervision and Machava II Health Center technical assistance Supportive supervision and Matola II Health Center technical assistance Supportive supervision and Moamba Health Center technical assistance Supportive supervision and technical assistance; 4th internal Mavalane General Hospital SBM-R measurement (51.5%) (2 supervision visits) Supportive supervision and Chamanculo General Hospital technical assistance Maputo City José Macamo General Hospital Supportive supervision and technical assistance; 8th SBM-R internal measurement (83.6%) (3 supervision visits) 1º de Maio Health Center Supportive supervision and technical assistance

AlsoModel in Maternity Quarter Recognition 3, MCHIP supported Process the MOH to publically recognize Xai Xai Provincial Hospital, which achieved accreditation status in the previous quarter with external evaluations of over 80%. The Xai-Xai Provincial Hospital was recognized as a Model Maternity in a ceremony on June 16th. The ceremony was presided over by the Vice- Minister of Health, with representation of the Governor or Gaza, the USAID Mission Director, Ministry of Health Officials, Provincial Health Officials, hospital workers, MCHIP representatives, and representatives of other partners in the province. During the ceremony, the hard work and dedication of the individual health workers and custodians/cleaners was recognized. USAID/MCHIP donated several items to further improve the quality of MNH services at the hospital in recognition of their achievements, including a washing machine for the maternity, dishes for the staff kitchen, and a computer for improving data collection and registry. The recognition ceremony had ample press, including coverage in the following media outlets:

• 2 news spots in Televisão de Moçambique – “Bom Dia Moçambique” and the daily news at 8:00 p.m. • 6 articles were published in newspapers with national coverage • 2 radio spots were aired on the Xai-Xai community radio • 2 radio spots were aired on Rádio Moçambique in Gaza in three languages (Changana, Portuguese, and Chope) • 1 radio spot was aired on Rádio Moçambique at the central level (Maputo Province) • 2 radio spots were aired on the Mozambique Corredor Radio (English news) • MOH newsletter

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Also in Quarter 3, MCHIP provided technical assistance to selected health facilities during this quarter to conduct internal SBM-R measurements at 33 health facilities. During the week of May 19 -23, a team of external evaluators, composed of trained central MOH-level staff, provincial-level staff (from Niassa and Zambézia), health facility staff (from Beira Central Hospital and Machava II Health Center) and MCHIP staff, conducted an external evaluation at Pemba Provincial Hospital, which had reported internal evaluations of 80% or above in all applicable categories of the MMI standards for three consecutive measurements. Unfortunately, in the external evaluation, Pemba Provincial Hospital achieved a score of 75.7% and did not reach the necessary level to be accredited as a Model Maternity facility. The external evaluation team worked with health facility management and staff to develop an action plan to address the identified gaps. Once these issues have been successfully addressed, Pemba Provincial Hospital has been encouraged to request another external evaluation.

PMTCT (in addition to MMI activities) In May 2014, Stacie Stender, Jhpiego’s HIV/AIDS & TB Regional Technical Advisor, accompanied supportive supervision visits by MOH, Provincial Health Directorate, and MCHIP staff in two facilities in (Cuamba and Mandimba Hospitals). The objective of Ms. Stender’s visit was to assess on-the-ground implementation of PMTCT efforts in Niassa in order to enhance the quality of MCHIP leadership and implementation work in PMTCT. The MOH-approved supervision checklist, a 16 page document entitled “Guião de Supervisão Especifica de Prevenção da Transmissão Vertical”, was utilized by the team during the supervision visits. Based on her observations made during the supervision visits, Ms. Stender developed the following set of key recommendations for the PMTCT program:

1. Ensure standard operating procedure / protocol document for supervisory visits is available and relevant to integrated HIV and MNH care. Consider clinical consultation observations and ‘real time’ chart reviews of patient hand-held records as part of assessment to get better understanding of what and how care is actually being provided. Asking if equipment exists does not capture whether the equipment in place is functional or whether the task is performed correctly by the provider. 2. Minimum standards of clinical care should be consolidated and disseminated to provide succinct information regarding what tasks are required during maternal and newborn assessment in antenatal, maternity, post-natal and high risk infant care. Clinical environment standards should be included in these standards: job aids (including removing out-of-date materials), exam room equipment and supplies, and documentation. 3. Develop systems of implementation and mentorship to emphasize importance of the content of outpatient MNH visits (antenatal, postnatal, children of high risk, etc.)

14 rather than frequency. For women living with HIV, the content of each visit should meet a minimum standard of counseling and support. 4. A paradigm shift in the way data is recorded needs to happen to return the focus to the patient rather than the recording. Recording tools should be reviewed for completeness of current data entry and relevance to client care and reporting. It is suggested that innovative recording methods be piloted for consideration, i.e. having clinical documentation only done on the hand-held record and have an administrative staff copy this info into registers upon completion of consultation across the department. At minimum, a review of what is documented in the hand held record vs. facility clinical chart vs. registers should be completed. During the next scheduled revision they should be harmonized.

The MCHIP PMTCT and MMI staff will work with the MOH during the following quarter to identify priority action items based on these recommendations.

Also during this quarter, the MCHIP PMTCT Advisor worked with the MCHIP MMI staff and Provincial Health Directorate to conduct a supportive supervision of Option B+ services at Chibuto Rural Hospital and Manjacaze Rural Hospital. On-the-job training was conducted for four MCH nurses in Chibuto and two MCH nurses in Manjacaze based on identified gaps, with a focus on mobile files, registry of patients, and management of care for HIV+ women in ART.

IR2.4 Strengthened facility-community link in selected Model Maternities, leading to increased service utilization

Community Health Committees Since the beginning of the project, MCHIP has provided support to 289 Community Health Committees, of which 234 have action plans based on prioritized health issues and that include actions directed toward maternal and child health-related problems in their communities. During Quarter 3, 199 of these CHCs were able to implement activities listed in their plans on a consistent and regular basis. The main activities that were conducted by CHCs during the reporting period including home visits to pregnant women, group education sessions, nutritional education, and community-based pills and condoms distribution (in Pemba and Mueda of Cabo Delgado and Angoche and Nampula City of Nampula Province). In some provinces, committees analyzed deaths in their communities using the verbal autopsy methodology. The CHCs also conducted meetings during this quarter to discuss data and their use for decision-making.

The below table summarizes the key activities conducted by Health Committees during Quarter 3.

Table 5. Key activities conducted by Community Health Committees during Quarter 3 Activity April – June 2014 # pregnant women referred to ANC 4,312 # pregnant women referred for institutional delivery 2,553 # women of reproductive age referred for family planning 6,266 # newborns referred for post-natal care 575 # couples with birth plans 142 # cycles of pills (refills) distributed 141 # condoms distributed 4,192 # waiting homes functioning 10 # CHCs with community-based emergency transportation systems 80

15 # pregnant women referred to a health facility for delivery via community transportation systems 2,227 # CHCs that use data for decision-making 100 # maternal deaths that were analyzed at the community level using the verbal autopsy methodology 14 # neonatal deaths that were analyzed at the community level using the verbal autopsy methodology 39

In general, the community-based emergency transportation systems established during this quarter are based on monetary contributions from community members into an emergency transportation fund. MCHIP has also donated bicycle ambulances and handheld carts to communities, and in some cases, bicycles that have been donated by the project to CHCs for conducting home visits are used as an emergency transportation method. During the months of April and May, MCHIP handed over three motorcycle ambulances in order to contribute to the reduction of maternal and neonatal mortality. The handover of the motorcycle ambulances was conducted during a health fair (also supported by MCHIP) under the theme, “I use family planning. Do you?” The motorcycle ambulances are currently being used to transport sick or pregnant community members to referral health facilities in Nampula and Angoche.

Sixty health committees conducted community resource mobilization activities during the quarter, including monetary contribution for maintenance of community emergency transportation, construction of latrines, use of local resources for handwashing stations, provision of food and hygiene products for orphans, creation of a community garden, and construction of a meeting home for the health committee.

Co-Management Committees MCHIP has supported a total of 49 Co-Management Committees (CMC) since the beginning of the project, of which 46 have action plans developed through the Partnership Defined Quality (PDQ) methodology, and 42 of these implemented at least one activity in their plans during Quarter 3 in partnership with the target health facility. Activities implemented by Co- Management Committees in Quarter 3 include the following:

• Education sessions regarding family planning, newborn care, the importance of institutional births • Improvements to waiting homes for pregnant women • Analysis of key indicators regarding coverage of services, and subsequent development of plans to conduct community based sessions to hear from women on why they are not accessing services • Mobilization of communities to take part in National Health Week activities • Organization of waiting patients at health facilities • Cleaning events at health facilities involving community members • Investigation of illicit charges at health facilities

Table 6 shows the breakdown of activity plans implemented by CHCs and CMCs during Quarter 3.

16 Table 6. Implementation of Action Plans by Community Health Committees and Co- Management Committees During Q3 Province Total # # CHC # CHC that Total # # CMC # CMC that of with implemente CMCs with implemented CHCs action d at least action at least one plans for one activity plans for activity from Q3 from their Q3 their action action plan plan in Q3 in Q3 Nampula 23 23 19 4 4 4 Cabo Delgado 33 33 18 6 6 5 Niassa 30 30 30 2 2 2 Zambezia 18 6 6 4 4 4 Manica 33 24 24 15 15 15 Tete 27 8 8 3 2 1 Sofala 30 18 18 4 3 3 Gaza 38 35 19 4 3 2 Maputo Província 19 19 19 4 4 4 Inhambane 38 38 38 3 3 2 Total target districts 289 234 199 49 46 42

Supervision visits Also during this quarter, MCHIP, in partnership with the DPS/SDSMAS, conducted supervision visits of community agents, including 115 Community Health Committees, 202 community health agents (ACS), 112 traditional birth attendants, 49 polivalent agents, and 32 traditional healers. In general, it was observed that health committees and community health workers are using the standardized register books to document their activities, thereby permitting a regular monitoring of implemented activities and information for decision-making.

Of the 115 Health Committees that received supervision visits, 75 were evaluated against the standards set forth in the Terms of Reference for CHCs. Of these 75 evaluated, 57 achieved 80% or more of the standards. The standards that were not achieved included the following: • Documentation of the presentation and discussion of the plan with the community • Documentation of the process used to explore health problems with the community • Monitoring the CHC against the Terms of Reference (indicators) • Use of data for decision-making • Sharing of lessons learned with the community and partners • Mechanisms in place to ensure the sustainability of the committee

Also during this quarter, MCHIP supported supervision visits of 10 Co-Management Committees in Sofala, Tete, and Cabo Delgado to evaluate them against the standards set forth in the Terms of Reference for CMCs. Two of the 10 Co-Management Committees achieved 80% or more of the standards. Key challenges encountered included the following: • The composition of committees does not follow the standards set forth in the TORs • The standard that at least 75% of CMC members should be present in meetings has not been met

17 • Data is not used for decision-making • Satisfaction meters are not in place at health facilities

Training of Co-Management Committees and Community Health Committees During Quarter 3, the MCHIP team continued to provide training to community health committees and co-management committees in the PDQ methodology and the Community Action Cycle, as well as in key MNCH messages. A total of 5 Co-Management Committees (83 members) and 97 Community Health Committees (888 members) were trained during the reporting period.

Objective 3: Support MOH to strengthen the development of human resources for the provision of basic health services and comprehensive Emergency Obstetric and Neonatal Care and RH

IR3.1 Pre-service education strengthened in MNCH/RH/FP

During Quarter 3, MCHIP supported a training of trainers for 12 ISCISA clinical professors in competency-based training with a focus on MNCH/RH/FP. The 2-week course was designed to prepare the professors to improve their clinical teaching competencies in the area of MNCH/ RH/FP.

MCHIP also supported the training of 31 recent graduates from ISCISA and the School of Medicine (7 advanced-level MCH nurses and 24 physicians) in the Model Maternity Initiative (including aspects of PMTCT/Option B+ and Malaria in Pregnancy) and CECAP/FP

MCHIP continued to support ISCISA in the revision of the curriculum for graduate courses in Maternal Health and Hospital Administration. MCHIP also continued to provide technical support to ISCISA in the use of performance standards to monitor the quality of education.

IR3.2 In-service training strengthened through support of rollout of Integrated Training and Services Packages

It is MCHIP’s intention to conduct a retreat in Quarter 3 with a group of health professionals who have been working on the six packages to perform the final revision and harmonization of the Integrated Packages (date to be confirmed and adjusted according to the availability of the professionals involved). After the final revisions are conducted and approved, MCHIP will support the MOH to print and distribute the training packages.

Objective 4: Support the expansion of activities for prevention of cervical and breast cancer using the single-visit approach and assisting in the implementation of "Action Plan for the Strengthening of and Expansion of Services for Control of Cervical and Breast Cancer" of the MOH

IR4.1 Intensive focus CECAP facilities equipped

During Quarter 3, MCHIP supported the MOH to provide cervical and breast cancer prevention and control services at 129 facilities (see Annex 4 for a complete list of CECAP/FP facilities). During the reporting period, MCHIP provided technical support to the Nampula, Niassa, Zambézia, Tete, Manica, Maputo Province and Maputo City Provincial/City Health Directorates to ensure that health facilities initiating their participation in the National Cervical and Breast Cancer Prevention and Control Program were equipped with materials to provide VIA and cryotherapy services through the Integrated Reproductive Health Outpatient Visit. MCHIP supported the installation of cryotherapy units, as well as the provision of materials, including acetic acid, batteries for timers, replacement parts for cryotherapy units, CO2 gas tanks, and IEC materials, to 16 CECAP facilities. In addition,

18 MCHIP supported the installation of colposcopy and LEEP equipment at Nampula Central Hospital, Nacala Porto District Hospital, Lichinga Provincial Hospital, and Tete Provincial Hospital.

IR4.2 Trained corps of CECAP health workers and trainers in place

During Quarter 3, MCHIP supported provincial trainings in VIA and cryotherapy (and family planning, with a focus on implants and interval IUD) in Tete, Sofala, Manica, Zambézia, Nampula, and Maputo Province for a total of 113 MCH nurses / Provincial Health Directorate representatives and 8 representatives of implementation partners (FGH and ICAP) trained in CECAP/Family Planning. Table 7 below shows the breakdown of health professionals trained by province and health facility.

Table 7. Health professionals trained in CECAP/FP during FY14 Quarter 3 Province Number of health professionals trained by facility

Tete Total 16: Moatize (2), No. 4 Health Center (1), Chiuta Health Center (4), Changara Health Center (3), Chitima Health Center (1), No. 2 Health Center (1), Angonia Health Center (2), Tete Training Center (1), Tete City (1) Sofala Total 14: Macurrungo Health Center (3), Chingussura Health Center (2), Ponta Gea Health Center (1), Munhava Health Center (3), Gorongosa Health Center (2), Dondo Health Center (1), MCHIP (1), DPS (1) Manica Total 15: Nhamahonha Health Center (2), Guro Health Center (2), Mossurize Health Center (2), Eduardo Mondlane Health Center (2), Catandica Health Center (2), Manica Health Center (1), Vanduzi Health Center (2), 1 de Maio Health Center (1), DPS (1) Zambézia Total 25: Gilé Health Center (2), Alto-Molocué Health Center (1), Gurué Health Center (2), Nicoadala Health Center (3), Morrumbala Health Center (1), Milange Health Center (1), Inhassunge Health Center (1), Quelimane Provincial Hospital (1), Namacurra Health Center (1), Hospital (1), Mopeia Health Center (1), Coalane Health Center (1), 17 de Setembro Health Center (1), FGH (3), ICAP (3), Manica (2) Nampula Total 21: Namapa Rural Hospital (3), Hospital (3), Iapala Health Center (2), Ribaué Rural Hospital (1), Mossuril Health Center (1), Urbano Nacala Porto Health Center (1), Monapo Rural Hospital (1), Angoche Rural Hospital (1), 25 de Setembro Health Center (1), Muhala Expansão Health Center (1), 1 de Maio Health Center (1), Nampula Central Hospital (1), Ilha de Moçambique Rural Hospital (1), DPS (1), ICAP (2) Maputo Province Total 30: Machava II Health Center (2), Matola II Health Center (3), Moamba Health Center (2), Ressano Garcia Health Center (1), Manhiça Health Center (2), Xinavane Health Center (1), Boane Health Center (2), Ndlavela Health Center (2), Marracuene Health Center (2), Namaacha Health Center (3), Magude Health Center (3), Matutuíne Health Center (3), DPS (4),

19 IR4.3 Increased capacity for CECAP management

During this reporting period, MCHIP continued to provide support to Provincial Health Directorates and health facilities to carry out supportive supervision visits to address challenges in CECAP service delivery. In Quarter 3, a total of 19 visits were made to health facilities involved in the National CECAP Program (see Table 8 for a list of Quarter 3 Supportive Supervision/TA visits). During these TA visits, the following challenges in implementation of the CECAP program at the health facility level were observed:

• Health facility staff continue to have difficulty with completion of registers • Registers showed evidence of erasing/deleting information/ unreliable data • Acetic acid bottles were not marked with the first date of use • Several acetic acid bottles did not have expiration dates on the factory labels • Some MCH nurses continued to have difficulties with correct use of the cryotherapy units • Lack of health education sessions for waiting clients in the health facilities regarding the need for screening for breast and cervical cancer • Lack of information sharing amongst health facility staff working in different sectors regarding available CECAP services at their facility • The management of some health facilities has not assumed the replacement of carbon dioxide or acetic acid, as they agreed to when CECAP services were initiated at their facilities

Table 8. CECAP/FP Technical Assistance Visits Conducted in FY14 Quarter 3 Province Health Facility Focus of TA Visit Alto Maé Health Center Supportive supervision TA for VIA/Cryotherapy/FP 1⁰ de Maio Health Center Supportive supervision TA for Maputo Cidade VIA/Cryotherapy/FP Polana Caniço Health Center Supportive supervision TA for VIA/Cryotherapy/FP Machava II Health Center Supportive supervision TA for VIA/Cryotherapy/FP Marracuene Health Center Supportive supervision TA for Maputo Província VIA/Cryotherapy/FP Boane Health Center Supportive supervision TA for VIA/Cryotherapy/FP Chokwe Health Center Supportive supervision TA for Gaza VIA/Cryotherapy/FP Urbano Health Center Supportive supervision TA for VIA/Cryotherapy/FP; 2nd internal Inhambane SBM-R measurement (74.6%) Inhassoro Health Center Supportive supervision TA for VIA/Cryotherapy/FP Chimoio Provincial Hospital TA for needs assessment to Manica rehabilitate consultation room for Colposcopy and LEEP services No. 4 (Muthemba) Health Supportive supervision TA for Tete Center VIA/Cryotherapy/FP Quelimane Provincial Hospital Supportive supervision TA for Zambézia Colposcopy and LEEP

20 Pemba Provincial Hospital Supportive supervision TA for VIA/Cryotherapy/FP Natite Health Center Supportive supervision TA for Cabo Delgado VIA/Cryotherapy/FP Mopeia Health Center Supportive supervision TA for VIA/Cryotherapy/FP Lichinga Health Center Supportive supervision TA for Niassa VIA/Cryotherapy/FP Muhala Expansão Health Supportive supervision TA for Center VIA/Cryotherapy/FP Nacala Porto Health Center Supportive supervision TA for Nampula VIA/Cryotherapy/FP Monapo Rural Hospital Supportive supervision TA for VIA/Cryotherapy/FP

Objective 5: Assist in the development, implementation, and management of FP/RH services for selected health facilities

IR5.1 Strengthen national level capacity in FP

During FY14 Quarter 3, MCHIP continued to provide support as Co-Leader of the Family Planning Technical Working Group, actively supporting and participating in three technical meetings and one RH Commodity Security Task Force meeting. MCHIP, together with other partners, also supported the MOH in the development of the Guidelines for Integration of FP into HIV Services within the context of the implementation of the Acceleration Plan to Increase the Utilization of FP Services and Modern Contraceptive Methods that MCHIP provided full an active support for its development and has been approved by the Minister of Health at the beginning of the Quarter 3.

IR5.2 Improved FP service capacity in Model Maternity and CECAP facilities, focusing on LARM

Training in Family Planning As described in IR4.2, MCHIP supported provincial integrated trainings in VIA, Cryotherapy and Family Planning, with a focus on stock control, Implants and Interval IUD, in Tete, Sofala, Manica, Zambézia, Nampula, and Maputo Province, for a total of 113 MCH nurses and implementation partners trained in Family Planning.

Also in Quarter 3, MCHIP supported a regional training of trainers in family planning with an emphasis on post-partum and post-abortion IUD insertion. Fourteen (14) trainers from the northern region were trained, with participation from representatives of the following health facilities and training institutions: Cuamba Rural Hospital, Cuamba Training Center, Maúa Health Center, Eduardo Mondlane Health Center, Pemba Provincial Hospital, Natite Training Center, Lichinga Provincial Hospital, Carioca Health Center, Natite Health Center, Nacala Porto District Hospital, Nampula Health Sciences Institute, Nampula Central Hospital, 25 de Setembro Health Center, and the Nampula Provincial Health Directorate. Upon return to their health facilities, it is expected that these trainers will train their colleagues in the maternity on FP methods and counseling, with a focus on post-partum/post-abortion IUD, and that they will conduct health education sessions with clients waiting for ANC visits at the health facilities.

21 Supportive Supervision and Technical Assistance for Family Planning MCHIP continued to provide integrated supportive supervision and technical assistance to MMI and FP/CECAP facilities in FY14 Quarter 3 to strengthen the provision of FP services (see Table 9 below for supportive supervision/TA visits conducted during Quarter 3). In total, MCHIP supported 82 technical assistance/supportive supervision visits for family planning through the MMI and National CECAP/FP Program in a total of 143 facilities in FY14 Quarter 3.

Table 9. Health Facilities Provided with Integrated Supportive Supervision for Family Planning, FY14 Quarter 3 Province Health Facilities Focus of TA visit Niassa Mandimba Health Center Family Planning within the MMI Cuamba District Hospital Family Planning within the MMI Chiuaula Health Center Family Planning within the MMI Lichinga Provincial Hospital Family Planning within the MMI Lichinga Health Center Family Planning, with focus on integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) Cabo Delgado Natite Health Center Family Planning within the MMI; Family Planning, with focus on integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) Chiure District Hospital Family Planning within the MMI Pemba Provincial Hospital Family Planning within the MMI; Family Planning, with focus on integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) Balama Health Center Family Planning within the MMI Mopeia Health Center Family Planning, with focus on integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) Nampula Marrere General Hospital Family Planning within the MMI Family Planning within the MMI; Family Planning, with focus on Muhala Expansão Health integration with RH services Center (including Contraceptives Stock Control, implants, and interval IUD) Anchilo Health Center Family Planning within the MMI Family Planning within the MMI; Family Planning, with focus on Nacala Porto District integration with RH services Hospital (including Contraceptives Stock Control, implants, and interval IUD) 25 de Setembro Health Family Planning within the MMI

22 Center Monapo Rural Hospital Family Planning within the MMI Mossuril Health Center Family Planning within the MMI Family Planning, with focus on integration with RH services Monapo Rural Hospital (including Contraceptives Stock Control, implants, and interval IUD) Zambézia Gurué Rural Hospital Family Planning within the MMI Quelimane Provincial Family Planning within the MMI Hospital Mopeia Health Center Family Planning within the MMI Coalane Health Center Family Planning within the MMI Nicoadala Health Center Family Planning within the MMI Tete Tete Provincial Hospital Family Planning within the MMI Moatize Health Center Family Planning within the MMI No. 2 Health Center Family Planning within the MMI Songo Rural Hospital Family Planning within the MMI Family Planning within the MMI; Family Planning, with focus on integration with RH services No. 4 Health Center (including Contraceptives Stock Control, implants, and interval IUD) Changara Health Center Family Planning within the MMI Chitima Health Center Family Planning within the MMI Ulongue Health Center Family Planning within the MMI Manica Gondola Health Center Family Planning within the MMI Chimoio Provincial Hospital Family Planning within the MMI Manica District Hospital Family Planning within the MMI 1º de Maio Health Center Family Planning within the MMI Sofala Caia District Hospital Family Planning within the MMI Chingussura Health Center Family Planning within the MMI Nhamatanda District Family Planning within the MMI Hospital Búzi Rural Hospital Family Planning within the MMI Muxúngue Rural Hospital Family Planning within the MMI Gorongosa District Hospital Family Planning within the MMI Macurungo Health Center Family Planning within the MMI Dondo Health Center Family Planning within the MMI Inhambane Inhassoro Health Center Family Planning within the MMI; Family Planning, with focus on integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) Homoine Health Center Family Planning within the MMI Morrumbene Health Center Family Planning within the MMI Vilanculos Rural Hospital Family Planning within the MMI Quissico Health Center Family Planning within the MMI Massinga District Hospital Family Planning within the MMI Inhambane Provincial Family Planning within the MMI Hospital

23 Family Planning, with focus on integration with RH services Urbano Health Center (including Contraceptives Stock Control, implants, and interval IUD) Gaza Xai-Xai Provincial Hospital Family Planning within the MMI Manjacaze Rural Hospital Family Planning within the MMI Family Planning within the MMI; Family Planning, with focus on integration with RH services Chokwe Rural Hospital (including Contraceptives Stock Control, implants, and interval IUD) Macia Health Center Family Planning within the MMI Chicumbane Rural Hospital Family Planning within the MMI Chibuto Health Center Family Planning within the MMI Massingir Health Center Family Planning within the MMI Maputo City Mavalane General Hospital Family Planning within the MMI Chamanculo General Family Planning within the MMI Hospital José Macamo General Family Planning within the MMI Hospital Alto Maé Health Center Family Planning, with focus on integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) 1º de Maio Health Center Family Planning within the MMI; Family Planning, with focus on integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) Polana Caniço Health Family Planning, with focus on Center integration with RH services (including Contraceptives Stock Control, implants, and interval IUD) Maputo Province Family Planning within the MMI; Family Planning, with focus on integration with RH services Boane Health Center (including Contraceptives Stock Control, implants, and interval IUD) Family Planning within the MMI; Family Planning, with focus on integration with RH services Machava II Health Center (including Contraceptives Stock Control, implants, and interval IUD) Family Planning within the MMI; Family Planning, with focus on Marracuene Health Center integration with RH services (including Contraceptives Stock

24 Control, implants, and interval IUD) Namaacha Health Center Family Planning within the MMI Bedene Health Center Family Planning within the MMI Matola II Health Center Family Planning within the MMI Moamba Health Center Family Planning within the MMI

IR5.3 Increased demand for FP services in Model Maternities and CECAP facility catchment areas through community mobilization

Support Groups During Quarter 3, a total of 73 Community Health Committees establishing 123 support groups for pregnant women, mothers, mothers with malnourished children, and men. In these support groups, themes related to reproductive health and family planning were discussed (as well as other health topics related to maternal, newborn, and reproductive health).

Group Education Sessions During Quarter 3, MCHIP supported group education sessions at the community-level, reaching a total of 53,987 community members, of which 63.6% were women. The group education themes included family planning, nutrition for the pregnant woman, the importance of delivering in the facility, humanization of childbirth and the role of the birth companion, danger signs during pregnancy, the importance of prenatal and postnatal care, home care for the newborn, exclusive breastfeeding, community-based DOT for tuberculosis, PMTCT, vaccination, malaria prevention, diarrhea prevention, and nutrition.

Radio Programming During Quarter 3, MCHIP supported community radio programs to air 654 radio spots, including 471 in Cabo Delgado, 180 in Niassa, 2 in Gaza, and 1 in Zambézia. The radio spots were aired in Portuguese and the local language of each province. The principal messages of the radio spots included the importance of ANC, facility-based delivery, essential newborn care, vaccination, post-partum care, exclusive breastfeeding, complementary feeding, danger signs during pregnancy, danger signs during the post- partum period, danger signs for newborns, HIV/AIDS, vaccination, family planning, post- abortion care, prevention of cholera/diarrheal illnesses, and prevention of malaria.

In Gaza, in collaboration with Rádio Mozambique and their program, “O Médico em Sua Casa” (“Your Doctor at Home”), MCHIP conducted interactive radio programs with call-ins from community members. Participants on the radio program included administrative chiefs, community leaders, women of reproductive age, men, and MCH nurses in order to best respond to the community members health-related concerns. Several MNCH-related themes were selected for the programs, in including low coverage rates for service utilization, facility- based delivery, and family planning.

Objective 7: Partnerships developed and strengthened (MOH and all USG partners) at the national level to promote high impact integrated MNCH services

IR7.1 Partnerships strengthened with the MOH and USG implementing partners for key MNCH/SRH/FP activities, including quality improvement and community mobilization

During Quarter 3, MCHIP provided technical and financial support to the Provincial Health Directorates of Niassa, Manica, Gaza, Maputo City, Nampula and Cabo Delgado to conduct provincial training in the Standards-Based Management and Recognition (SBM-R) quality

25 improvement approach for district chief physicians, clinical directors of health facilities, district nursing supervisors, MCH district heads, and district and health facility statistical unit heads. Trainers included Provincial Medical Chiefs and Provincial Nursing Supervisors that were trained by MCHIP and the MOH in 2013, with support from MCHIP, Jhpiego and the MOH. A total of 187 participants (33 from Maputo City, 33 from Niassa, 29 from Manica, 27 from Gaza, 35 from Nampula, and 30 from Cabo Delgado) were trained to manage the process of quality improvement and humanization of care at the district and health facility level, emphasizing the following key responsibilities:

• Training and technical support of local teams; • Guaranteed availability and support for implementing the Performance Standards instrument in the areas of MMI, SRH-FP/CECAP, Model Wards, and Infection Prevention and Control, in order to comply with the established schedule for conducting internal measurements; • Identification of gaps in performance and possible causes based on the results of internal measurements, as well as selection/design of appropriate interventions and action plans, with a focus on management processes to support these changes; • Support for local teams in the development/updating and implementation of their action plans; • Reinforcing and supporting the supervision process and monitoring and evaluation of activities for quality improvement and humanization; • Promoting the creating and strengthening of local teams for the expansion of the quality improvement and humanization process; • Promoting a culture of documentation and sharing of best practices and lessons learned for the process of quality improvement and humanization; • Application of the practice of internal recognition of achievements made at the local level to strengthen health workers’ motivation, achieve established objectives, and further accelerate progress; • Facilitation of external recognition of health facilities that have achieved performance of 80% or more of standards.

Also during this quarter, MCHIP supported the MOH to develop the Terms of Reference (TOR) for the National Strategy for Quality and Humanization of Health Care, 2015 – 2019. These TORs were submitted to the MOH-DNAM in June for approval. MCHIP also provided technical support to the MOH to develop the QHC activities for the 2015 Economic and Social Plan (PES). In addition, MCHIP provided support to develop the program and materials for the second National Quality and Humanization of Care Meeting, which will be held in Quarter 4.

IR7.2 Strengthened partnerships with key national stakeholders to disseminate best practices in MNCH/RH/FP

MCHIP supported the Mozambican Association of Pediatricians (AMOPe), alongside other implementing partners, to conduct their first national congress from May 29 – 31. One- hundred and two (102) representatives from AMOPe, including representatives from all provinces, participated in this meeting.

In addition, MCHIP supported the revision and finalization of the provincial training plan for Quality Improvement and Humanization, HIV/AIDS, and Protection of Children’s Rights for the “Religious Leaders’ Guide” for staff of the Ministry of Health, Ministry of Finance, Ministry of the Interior (Immigration), Ministry of Justice, and community leaders. The plan is to be implemented by the Religious Counsel of Mozambique (COREM) as part of their participation in the quality improvement and humanization process.

26 Also during quarter 3, MCHIP provided support to DNAM to celebrate the International Midwives’ Day through the provision of MNCH materials and financing for refreshments for participants of the MOH-organized event.

Objective 8: Work with the MOH and all USG partners to define, implement and monitor standards of care at the point of service in essential areas

IR8.1 Performance standards produced and applied in all areas of integrated MNCH/RH/FP services

During Quarter 3, MCHIP supported the MOH to finalize and submit the Plan for Implementation of the SRH-FP/CECAP Performance Standards to DNSP. Based on this plan, MCHIP supported the Family Planning Program to plan for the first training in SBM-R Module 1 for the MCH nurses that will be responsible for the subsequent training and dissemination of the methodology in SRH-FP/CECAP services at health facilities.

7. Project Performance Indicators Below are specific results from selected indicators by thematic “result” areas, as well as discussions on progress/challenges.

The Performance Management Plan (PMP) is provided in Annex 1, reflecting cumulative results for indicators.

As of the end of Quarter 3 FY14 there were 124 maternities involved in the process of the Model Maternities Initiative. Annexes 1 (PMP) and 2 (Summary of Key Indicators) present data from 123 Maternities with complete data, out of 124. Maternities that provide normal ANC and post-partum services (central, provincial and general hospitals only provide ANC for high-risk pregnancies), including the following main results for Quarter 3 FY14:

• The percentage of pregnant women with 4 ANC visits at Q3 remains the same as the previous quarter: 36.9% in Q2 and 37.4% in Q3. MCHIP is supporting health facilities to improve the quality of ANC, including the reinforcement of counseling for pregnant women to attend at least 4 ANC visits. In 22 health facilities, MCHIP is also supporting interventions at the community level (in the catchment areas of these HF) to discuss the importance of ANC and to encourage women to start ANC as soon as they suspect that they are pregnant, as well as to be compliant with the ANC visit schedule. • The percentage of pregnant women tested for syphilis has increased from 24.8 in Q1,to 40.3% in Q2, and to 65.9% in Q3. Among the pregnant women tested, 4% were found to be positive for syphilis. Despite the increase in testing the percentage of pregnant women who received at least one dose of treatment decreased from 75.3% in Q2 to 59.7% in Q3. According to the Provinces Health Directorates, there are still frequent stock outs of Penicillin Benzatinic both at the provincial and health facilities levels. Even though the Women and Child Health Department (W&CHD) with assistance from AMOG defined alternative drugs for syphilis treatment, and a circular with these alternative drugs was sent to provinces, there are also stock outs of the alternative drugs. Since stock outs of several medicines remain a challenge for the National Health System, during the next quarter MCHIP will discuss with the W&CHD and the Reproductive Health Commodity Task-Force to see what more MCHIP can do to help, with a focus on on advocacy activities among other partners, as MCHIP cannot purchase drugs. • Key PMTCT results for Quarter 3 FY14 include: ✓ 94.6% of women presenting at their first ANC visit did not know their HIV Status; ✓ 97.3% of pregnant women with unknown HIV status presenting at their first ANC visit were tested for HIV;

27 ✓ 8.7% of women were HIV+; Regarding PMTCT, ANC data from FY14 Quarter 3 reflect the policy changes for the Option B+ regimen. Of the 3,216 women with known HIV+ status at ANC entrance, 2,286 (71%) were already in ARV treatment. Of all HIV+ pregnant women, 87.8% received ARV Treatment (ART), 10.4% received other regimens (AZT, NVP, other) and for 1.8% of women there is no information. • With regards to IPTp for Malaria, 60% of women received the first dose of IPTp, and 42.4% and 23.1% of women received the second and third doses, respectively. Bed nets were distributed to 84.4% of pregnant women during ANC. MCHIP has received information from the Women & Child Health Department and the Malaria Program that additional drugs requested by the Malaria Program for the implementation of the new IPTp Guidelines are expected to arrive in August 2014. As such, the Malaria Program requested MCHIP support to conduct intensive supervision visits that will start in July in provinces with low IPTp coverage to identify the constraints and to support provinces to solve them. As referenced in the previous quarter, the new IPTp guidelines have already been incorporated into the Flowcharts Book for Reproductive, Maternal and Newborn Care, and the MMI Training materials and the In-Service Training Package Nº 4 have already been updated according to the new guidelines for IPTp and Malaria Case Management/Treatment in Pregnancy.

From the 124 maternities involved in the MMI process, 123 maternities (99.2%) submitted complete data for FY14 Quarter 2, including the following key results: • 87.9% of births were normal deliveries, 11.1% were C-Sections and 0.7% were deliveries assisted with vacuum extraction; • 57.1% of women had a companion during delivery; • 19.9% of women delivered in vertical or semi-vertical positions, showing a decrease compared with previous quarters; • 68.1% of deliveries were reported as having a completed partograph, showing a decrease from the Quarter 1 (83.8%). However we think that it actually reflects the desired practice—the completion of the partograph during labour and delivery—due to increased efforts to improve data quality at the facility level. As mentioned in the previous quarterly report, as during last year’s supervision visits, MCHIP staff found that the number of deliveries reported to have a completed partograph reflected not only partographs completed during delivery but also completed AFTER delivery. Since this discovery, intensive work has been done with health facility staff to improve the registering and reporting of only those deliveries with the partograph completely filled in during labor and delivery. During recent supervision visits MCHIP staff, when reviewing the delivery process, has found an increase in the proportion of deliveries having a partograph that is actually completed during labor and delivery. Besides the intensive support provided to improve the register, MCHIP has also been working technically with MCH nurses, doctors and surgical technicians to use the partograph more effectively as a decision-making tool by improving the quality of the information registered on the partograph and making timely decisions based on the information. • Data reported shows that for all normal deliveries (99.8%), active management of the third stage of labor was performed, with a small increase compared to last quarter (97.4% in Q2); • In Q3, 52% of women with pre-eclampsia and eclampsia were treated with Magnesium Sulfate. This indicator has several problems, reported in previous quarterly reports, including the fact that monthly record forms combine reports of women with non-severe pre-eclampsia who do not need MgSO4 and severe pre-eclampsia who need MgSO4, thus inflating the denominator. When analyzing the number of women who received Magnesium Sulfate using only as denominator the number of women who had eclampsia, the percentage increases to 118.6%, which can demonstrate that all women who probably really needed to receive Magnesium Sulfate, actually received the

28 treatment, ie women with eclampsia and those women who had severe pre-eclampsia (from data reported only as pre-eclampsia) that actually needed Magnesium Sulfate. • 87.4% of newborn babies were put into direct skin-to-skin contact with their mother right after birth, and 86.6% were breastfed within the first hour of birth. These indicators have not shown much variation over the quarters. However one must consider that 11% of deliveries were C-Sections or assisted deliveries (0.7%) where the conditions of the mother or the baby were not conducive for performing these interventions; • 39 out of every 1000 live births had a delivery outcome of a stillbirth, and 6.8% of all stillbirths were fresh stillbirths (with a small decrease compared with the last quarter that was 7.3%); • During this Quarter, the Case Fatality Rate for direct obstetric complications shows a small decrease from 1.4% in the last quarter to 1.24% in Quarter 3. However the Institutional Maternal Mortality Ratio trends have been showing a decrease from the Quarter 1, respectively 247/100.00 LB in Quarter 1, to 245/100.000 LB in Quarter 2 to 178/100.000 in Quarter 3. . Figure 1 shows the evolution of selected MMI indicators from October 2013 to June 2014.

Figure 1: Trends of MMI Selected Indicators: January 2013 to June 2014

29 Table 9 and Figure 2 detail the main causes of Maternal Deaths and the Case Fatality Rate for Direct Obstetric Complications in FY14 Quarter 3 in the Maternities that are part of the MMI. Among the direct obstetric complications, post-partum hemorrhage, followed by sepsis, eclampsia and rupture of the uterus, are the major causes of maternal deaths in these maternities.

When comparing with the last quarter, the proportion of maternal deaths by rupture of the uterus decreased from 27.16% to 11.63%, and the Case Fatality Rate for this complication also decreased from 10.53% to 3.73%. It may demonstrate a better completion and increased utilization of the partograph leading to timely decision making both at peripheral HF with an early referral, and at the Referral HF with a timely intervention. In support of this, the proportion of deaths by prolonged delivery also decreased 7.41% in the last quarter to 3.49% in Quarter 3. One best practice that many HF are promoting is the discussion of partographs, during the shift change, from the deliveries occurred during the shift. During these discussions MCH Nurses who still have challenges filling in and using the partograph receive training and support from their colleagues.

On the other hand, the proportion of maternal deaths by sepsis increased from 14.81% in the previous quarter to 19.77% in Quarter 3, with also an increase in the CFR from 6.25% in Q2 to 8.10% in Quarter 3. The current situation of stock outs of antibiotics at HF may be the cause that is behind this increase.

Regarding post-partum hemorrhage, the proportion of maternal deaths also shows an increase from 17.28% in Quarter 2 to 20.90% in Quarter 3, while the CFR remains more or less the same (3.48% in Q2 and 3.50% in Q3). Despite that active management of the third stage of labor was performed in 99.8% of normal deliveries for preventing post-partum hemorrhage, as these maternities are mostly referral HF, the post-partum hemorrhage mortality figures may demonstrate cases of post-partum hemorrhage that were referred by peripheral HF and arrived quite late, and also the quality of Oxytocin that was used. The quality of this drug is an issue that has been discussed with the Women and Child Health Department and the Reproductive Health Commodity Security Task-Force. MCHIP proposed to the MOH and UNFPA (who is supporting the MOH performing quality tests of several drugs) to include samples of Oxytocin from several points on the logistics chain to analyze drug quality. According to the manufacturer, Oxytocin can only be out of cold conservation for 3 months at room temperature between its manufacturing and its application to women. We know that because of all the current constraints of the logistics and cold chains in Mozambique, the time Oxytocin is at room temperature likely exceeds 3 months.

Table 9. Maternal Deaths and Case Fatality Rate by Direct Obstetric Complications: April to June 2014 % of Total Number # of Case Maternal Direct Obstetric Complications of Maternal Fatality Deaths by Complications Deaths Rate Cause Ante-partum Hemorrhage 674 9 10.40% 1.34% Post-partum Hemorrhage 513 18 20.90% 3,51% Prolonged Delivery 2.306 3 3,49% 0,13% Pre-Eclampsia 1.725 5 5,81% 0,29% Eclampsia 725 16 18,60% 2,21% Uterine rupture 268 10 11,63% 3,73% Retained placenta 191 4 4,65% 2,09% Sepsis 210 17 19,77% 8,10% Ectopic Pregnancy 324 4 4,65% 1,23% Total of Direct Obstetric Complications 6.936 86 - 1,24%

30

In relation to indirect obstetric complications, HIV/AIDS and Malaria followed by anemia and traditional medicine intoxication are the main causes of maternal deaths.

Figure 2: Maternal Deaths by Type of Direct and Indirect Obstetric Complications in Quarter 3 FY14 (April to June 2014) Main Causes of Maternal Deaths by Direct Obstetric Complications Main Causes of Maternal Deaths by Indirect Obstetric Complications April to June 2014 April to June 2014

Ectopic Ante-partum Pregnancy; 4,7% Hemorrhage; 10,5% Malaria; 20,0% Sepsis; 19,8% Other Indirect Complications; Post-partum 34,3% Hemorrhage; 20,9%

Retained placenta; 4,7% Anemia; 14,3% Prolonged Delivery; 3,5% Uterine rupture; Toxicities by 11,6% Pre-Eclampsia; herbal 5,8% medicines; 8,6% HIV/SIDA; 20,0% Eclampsia; Tuberculosis; 18,6% 2,9%

FY14 Quarter 3 PMTCT Data from Maternities show the following main results: • 24.7% of pregnant women who arrived at maternity for delivery did not know their HIV status; • 14.1% of women at maternity entrance knew that their HIV Status was positive; • 105.5% of women were tested for HIV at maternity entrance (includes women with unknown HIV status at maternity entrance, as well as women who had the last test more than 3 months before); • Out of the women tested in the maternity, 2.4% were HIV+; • 14.74% of deliveries were in HIV + Women; • 91.7% of women with known HIV+ status at maternity entrance received ARV in ANC, showing an increase in relation to last quarters (80.5.3% in Q1 and 88.9% in Q2); • 95% of HIV+ women received ARVs at delivery for PMTCT (87.8% of women received ARV Treatment (ART) showing a small increase compared with last quarter (82.6%).

Regarding Postpartum Care (PPC), from the 124 HF involved in the MMI process, 101 are providing normal PPC, with a data completeness of rate of 100% (101 HF) in Quarter 3 FY14. Main results from PPC services during Quarter are the following: • A total of 60,581 women presented for the first postpartum (PP) visit during Quarter 3, an increase compared with Quarter 1 and Quarter 2 (47,468 in Q1 and 53,378 in Q2); • Of these women, 38.1% had their first PP visit 3 days after delivery; 29.6% had their first PP visit between the 4th and 7th days after delivery; 30.8% had their first PP visit between the 4th and 7st days after delivery, 26% had their first PP visit between the 8th and 21st days after delivery, and 15% had their first PP visit after 22 days after delivery. The percentage of women who attend to PPC visits by each visit has been increasing (see Table A4 in Annex 1); • 0.3% of women who presented at PP Care reported that their newborn died after delivery; • 0.9% of women had post-partum complications (568/60,581), and 0.2% of women had puerperal infection (136/60,581), a proportion of 23.9.2% of all postpartum complications

31 (136/568). The proportion of women with puerperal infection from the overall post-partum complications has decreased from 37.3% in Q1 to 34.6% in Q2 and 23.9% in Q3; • 19 women out of 60,581 presented at PPC Visit with an obstetric fistula; • 5,898 women presented at PPC knew their HIV status as positive (9.7%) and 3,931 women did not know their HIV status (6.5%). About 93.3% (3,931) of women with unknown HIV status were tested, and 205 (5.6%) of these women were found HIV+. Women who started ART were 436, which gives a percentage of 212.6% when using the HIV+ women found at PPC, however, the percentage above 100% means that more women that start PPC with a known HIV + status also started ART at PPC (the current HIS Monthly Resume Form for PPC does not report the number of women who started ART at PPC). Although the number of HIV+ women who started ART at ANC, Delivery and PPC shows in overall increase in the number of HIV+ women have started ART as recommended by Option B+, the question and issue of compliance and continuity of the treatment remain.

Family Planning Annex 1 (PMP) presents key indicators for Family Planning for FY14 Quarter 3. From the 143 HF providing FP Services (includes HF in the process of MMI and HF providing CECAP, as FP activities are included within these two programs), 100% submitted complete data for Q3. Figure 3 shows trends of Total Number of Family Planning First Visits, Total Number of Family Planning Visits, and Couple Years Protection for 143 Health Facilities.

It is also important to note that the current Health Information Register Book and Monthly Summary Reports do not include Implants, and monthly reports do not include the total number of Depo-Provera Doses administrated. Therefore, the CYP shown in Figure 3 was calculated without the CYP for Implants, and the CYP for Depo-Provera is a rough estimate using the information available regarding new and following clients for this family planning method.

Figure 3: Trends of Family Planning Indicators from October 2013 to June 2014

Trends of Family Planning Indicators January 2013 to June 2014 300.000

250.000

200.000

150.000 Number

100.000

50.000

0 July/Sept Jan/Mar 2013 Apr/Jun 2013 Oct/Dec 2013 Jan/Mar 2014 Apr/Jun 2014 2013

Family Planing First Visits 59.554 74.870 82.140 91.834 75.058 117.200 Total of Family Planing (First and 158.450 176.884 194.537 209.757 175.418 248.320 Following Visits) Cuple Year protection 33.473 46.404 51.699 65.851 49.286 79.389

32 Cervical Cancer Prevention and Treatment (CECAP) Annex 1 (PMP) and 2 (Summary of Key Indicators) present CECAP data. From the 126 HF included in the CECAP/FP Program, 118 health facilities submitted complete data for Quarter 3 (93.7% of data completeness). Data for last quarter was updated. Main results for the period of April 2014 to June 2014 are the following: • 61.8% of women who attended their first visit at reproductive health outpatient services did not know their HIV status; • 67.8% of women with unknown HIV Status were tested; • 4.9% of women tested were HIV+; • 6.3% of HIV+ Women initiated ARV Treatment at this service; • 46.3% of women ≥ 25 years old attending their first reproductive health outpatient services visit were screened with VIA for cervical precancerous lesions; • 7.9% of women screened were VIA positive; • % of HIV+ Women who are also VIA+: Data to construct this indicator is not included in the current HIS monthly summary. To date, MCHIP has been requesting Health Facilities and Provinces to report this indicator in a parallel system. For the FY14 Q3 MCHIP was not able to collect enough data to construct this indicator; • From the 1.432 eligible women for cryotherapy, 74.4% of VIA+ women were treated with cryotherapy in the same day of the screening (single visit approach) and 11.1% of VIA+ women were treated with cryotherapy after the day of screening, making a total of 85.5% of VIA + eligible Women treated with cryotherapy. The eligible women is equal to all VIA + Women minus the number of women referred for lesions more than 75% or with suspicion of cervical cancer, as the last group are not eligible for cryotherapy; • 25.7% of VIA+ women were referred for lesions more than 75% or with suspicion of cervical cancer; • For 14.5% of VIA+ women eligible for cryotherapy there is no information if cryotherapy was performed or if the woman was referred.

Frequent breakdowns of Cryotherapy machines continue to affect the single visit approach (see and treat). To mitigate this situation, MCHIP has strengthened aspects of operation and maintenance of Cryotherapy machines during the providers’ training courses and during supervision visits. The project has already programmed a training course for July 2014 to train more Provincial Maintenance Technicians, to increase the current number of these technicians, thus allowing and ensuring more adequate maintenance as well as more rapid repair of minor malfunctions. It is also programmed for the first week of August 2014, a meeting of the Central Level CECAP Technical Working Group (lead by the MOH’s Non Communicable Diseases Department, and co-led by MCHIP) to discuss several aspects of the CECAP Program, including a solution to mitigate the negative impact of Cryotherapy machines breakdowns on the single visit approach (see and treat), like the purchase of 4 extra Cryotherapy machines for each province, which can be lent out to HF while the broken machines need repairs.

8. Major Implementation Issues Nothing to report.

9. Collaboration with other donor projects

MCHIP continues to collaborate with other USG partners and other donor funded programs (USAID, CDC, WHO, UNFPA, ICAP, EGPAF, I-TECH, and FHI) to support the MOH to support the process of revising and implementing the MNCH registers for data collection. During this quarter, MCHIP collaborated with partners to develop the training plan and materials for the rollout of the revised registers. In addition, at the end of Quarter 3, MCHIP

33 developed a draft supervision guide for monitoring the implementation of the new registers, and shared with partners for inputs.

MCHIP continues to have great success in working with partners to achieve synergies in the area of CECAP/FP. During Quarter 3, MCHIP worked with other Implementing Partners to conduct provincial trainings in VIA/Cryotherapy and Family Planning. MCHIP provided technical assistance for training while the Implementing Partners supported the logistical costs of the trainings. Specifically, ICAP supported provincial trainings in Nampula and Zambézia, CCS supported training in Maputo City, and ARIEL supported training in Maputo Province.

10. Upcoming Plans:

Objective 1 • MCHIP will print flowcharts and selected posters for health facilities after receiving final feedback from the USAID AOR. • MCHIP will provide technical assistance to the MOH to develop and finalize the Plan to Accelerate the Operationalization of the National Integrated Health Plan, with a focus on key, short-term activities to reduce maternal and newborn morbidity and mortality. • MCHIP will support the finalization, printing, and distribution of IEC materials included in Integrated Package 1 • MCHIP will support the MOH to finalize the guide for monitoring the implementation of the newly revised registers and to finalize training materials for the rollout of the new registers. MCHIP will support the MOH to plan for a national training of trainers in the revised registers. • MCHIP will continue to provide intensive M&E technical assistance to intensive focus Model Maternity facilities in order to improve data quality, data completeness, analysis, and use of data. • MCHIP will hold a Results Symposium for USAID and USG partners to share the key results and lessons learned to date from the MCHIP project. • MCHIP, in collaboration with MCHIP, will write the study manuscript for Phase I of the PPSS study. MCHIP will continue to supervise implementation of Phase II of the study in Nampula Province alongside DPS counterparts. • MCHIP will work with the MOH to analyze data for the study of the Implementation of Integrated Service Packages for Reproductive, Maternal, Newborn, Child and Adolescent Health. The project will support the development of the draft manuscript for the study and will circulate for review and comments. • MCHIP will finalize the Community Study and the study report, in coordination with the contracted consulting agency.

Objective 2 • In June 2014, MCHIP received a Modification from USAID to increase the award ceiling by $3,000,000. The Modification will be fully executed in Quarter 4. The approved budget for this increase includes funds for rehabilitations of 13 maternities. In Quarter 4, MCHIP will initiate minor refurbishments on Tete Provincial Hospital and Jose Macamo General Hospital, and will launch public bids for Nacala Porto District Hospital, Chimoio Provincial Hospital, Matola II Health Center, Vilankulo Rural Hospital, and Pemba Provincial Hospital. • MCHIP will support the MOH to hold recognition ceremonies for Nacala Porto District Hospital and Tete Provincial Hospital to celebrate their accreditation as Model Maternity facilities. • MCHIP will complete the MMI regional training in the Southern Region, in collaboration with the MOH.

34 • MCHIP will conduct additional training in Helping Babies Breathe and Kangaroo Mother Care • MCHIP will provide support to the MOH to conduct regional trainings for MCH nurses from MMI facilities in the Northern and Central regions of Mozambique in Option B+. • The project will continue to provide intensive technical and financial support to the MOH to conduct supervision and technical assistance visits for Option B+ in Niassa. • MCHIP will continue to provide intensive supervision and technical assistance to health facilities involved in the Model Maternity Initiative. • MCHIP will provide technical support to conduct regional trainings of trainers for IMCI, in collaboration with the MOH and other partners. • The project will work with AMOG to develop a work plan and budget for the professional association to provide technical leadership for the implementation of the National Strategy for Preventing Post-Partum Hemorrhage. It is expected that AMOG will initiate preparatory activities in Quarter 4, including the revision of training and IEC materials and mapping of communities. • MCHIP will initiate planning with the MOH to conduct trainings in obstetric fistulas and adolescent health. • MCHIP will continue to provide incentives to health committees/ community health workers • MCHIP will support additional communities to develop community-based emergency transportation systems • MCHIP will continue to conduct community health workers in Integrated Package 1 • MCHIP will conduct training of community health workers in IMCI and Family Planning/ Reproductive Health

Objective 3 • MCHIP will support ISCISA to conduct a workshop to review and finalize the MNH curriculum. • MCHIP will support the MOH to incorporate final revisions to the In-Service Integrated Services Training Packages.

Objective 4 • MCHIP will support on-the-job training in LEEP and Colposcopy as well as supportive supervision visits in VIA/cryotherapy. • MCHIP will collaborate with the MOH and Medgyn to conduct a training of 15 maintenance technicians in the maintenance and repair of cryotherapy units. Participants will include representatives from each province as well as the central level.

Objective 5 • MCHIP will conduct two regional Post-Partum IUCD trainings. • MCHIP will continue to work with the DPS at the provincial level to strengthen supportive supervision of FP services at MMI and CECAP/FP facilities, with a focus on strengthening balanced family planning counseling. • MCHIP will continue to support radio programs to promote demand for family planning and MNH services. • MCHIP will receive a technical assistance visit from Jhpiego HQ staff (Rehana Gubin, Health Policy Technical Advisor, and Holly Blanchard, Senior Advisor for RHFP). During this visit, capacity-building sessions will be conducted with all relevant MCHIP Mozambique staff on topics including: 1) a contraceptive technology update, especially on PAC and PPFP services; 2) a global FP landscape update, including Family Planning 2020, Every Woman Every Child and its UN Commission on Life- saving Commodities, the Implants Access Program, A Promise Renewed and its USAID corollary, Ending Preventable Child and Maternal Deaths, and USAID High

35 Impact Practices; 3) applications of the newly-released WHO-USAID-MCHIP resource, Programming Strategies for Postpartum Family Planning; and 4) policy and advocacy strategy development (first internally and possibly later externally with stakeholders), using the Advance Family Planning (AFP) SMART approach, to strengthen MISAU’s commitment to FP and set goals for other FP advocacy objectives, such as scale up of LARC inclusive of commodity availability. Also during this TA visit, Gubin and Blanchard will conduct site visits to at least three different sites, such as: o Model Maternities, ideally both high functioning as well as those with challenges in PPFP and youth-friendly services (YFS); o Centers that provide PMTCT, to look for opportunities for PPFP integration; and o CECAP service delivery sites, to look for opportunities for FP integration.

Objective 7 • MCHIP will support the MOH to conduct the final provincial SBM-R trainings planned for FY14: Zambézia, Inhambane, Sofala, Maputo Province and Tete • MCHIP will support a benchmarking visit between the Lichinga Provincial Hospital and Xai-Xai Provincial Hospital, with the objective of exchanging best practices and lessons learned from the accreditation process of the Xai-Xai Maternity, as well as incentivizing Lichinga Provincial Hospital to make key changes in practices to further promote quality and humanization of care at this facility. • MCHIP will support the MOH to plan for the National Quality and Humanization of Care Meeting. • MCHIP will continue to coordinate meetings of the QHC Technical Secretariat.

Objective 8 • MCHIP will provide technical support to EGPAF and the MOH to conduct provincial MMI training in Gaza, in support of rolling out Performance-Based Financing in these provinces. • MCHIP will continue to work in collaboration with the MOH to incorporate MMI updates in MOH newsletters in order to disseminate program progress and achievements and lessons learned.

11. Evaluation/Assessment Update

Underway during the reporting period: Implementation of Integrated Service Estimated completion date November 2014 Packages for Reproductive, Maternal, Newborn, Child and Adolescent Health MCHIP is supporting the MOH to conduct formative research to monitor and evaluate implementation of Integrated Service Packages for Reproductive, Maternal, Newborn, Child and Adolescent Health, in order to identify opportunities, challenges, and lessons learned to inform the expansion of integrated services in the country. The overall program aim is to implement rapid quality improvement cycles (i.e., assess, identify, prioritize, plan, act, evaluate) over a six-month period to improve integration of Reproductive, Maternal, Newborn, Child and Adolescent (RMNCA) Health. The specific formative research objectives are to:

• Assess integration flows and scenarios, taking into consideration opinions of key informants and conditions at different levels of service provision. • Identify key issues, challenges, successes and lessons learned during the QI cycles to improve RMNCA integration and make recommendations for the consolidation and expansion of interventions defined in a care/service integration framework.

36 • Assess content of services delivered and the level of client satisfaction with the provision of integrated facility-based maternal child and reproductive health services.

During the first half of FY13, MCHIP provided technical assistance to the MOH to complete the draft report of the first round of the Integrated Services Package Feasibility Study that was conducted in Zambézia and Inhambane in 2012. The objective of the study was to evaluate the general conditions and level of readiness at selected health facilities for implementing integrated maternal and newborn health services. Based on the findings of this first round of the study and related recommendations, MCHIP worked with the MOH to draft the proposed intervention for the study, which is the implementation of an Integrated MCH Preventive Consultations Booking System. The study facilities in Zambézia and Inhambane initiated the implementation of the Integrated Maternal and Child Consultation Booking System, which was selected as the intervention for improved integration of services, in Quarter 4 of FY13.

In FY14 Quarters 1, MCHIP and the MOH conducted supervision visits to the study facilities in Zambézia to monitor the implementation of the Integrated Maternal and Child Consultation Booking System, which is the intervention that is being tested to determine its effect on improved integration of services. During these visits, it was observed that additional support is necessary in Zambézia to ensure fidelity to the implementation model. Because of the challenges encountered in the correct application of the model, the project is proposing to extend the data collection for at least two months in order to improve the quality of data gathered through the study.

During Quarter 2, MCHIP conducted the final supervision visits during the implementation phase. In Quarter 3, MCHIP conducted training of data collectors, followed by fieldwork for the endline. Data entry commenced in Quarter 3 and will be completed in Quarter 4. Data analysis and draft report writing is also expected to be completed by the end of FY14. The final report will be completed by November 2014.

Underway during the reporting period: Community Study Estimated completion date September 2014 MCHIP is supporting the MOH to conduct a community baseline study to determine the value of community mobilization on increased appropriate utilization of ANC and maternity services (use of antenatal care, skilled birth attendance, use of Malaria in Pregnancy services, use of PMTCT services, etc.) and increased community health behaviors. During the first quarter of FY14, the community study protocol was approved by the Johns Hopkins School of Public Health (JHSPH) IRB. During Quarter 2, MCHIP received the authorization from the Maputo City Health Directorate to undertake the field test of the questionnaire in Catembe District. The field test was completed by the contracted consulting agency and the questionnaires were adjusted based on the observations and results of the field test. Data collection was carried out in Quarter 3 in Gaza, Nampula and Tete provinces. Data analysis and reporting writing will be conducted in Quarter 4, with the final report to be completed by September 2014.

Underway during the reporting period: Post-Partum Systematic Screening Tool Estimated completion date February 2015 Study MCHIP is supporting the MOH to conduct a Post-Partum Family Planning Systematic Screening study, with MCHIP Core funds. As part of an effort to address unmet need for family planning, especially postpartum family planning, MCHIP in collaboration with the MOH, is piloting a postpartum systematic screening (PPSS) tool as part of ongoing effort to integrate services for maternal and child health. This PPSS checklist emphasizes screening for the following service(s):

37

1.1.1 Providing PPFP (including healthy timing and spacing of pregnancy (HTSP) and return to fertility (RTF) counseling) to women who have delivered within the last 12 months and are not using any FP method; 1.1.2 Providing Lactational Amenorrhea Method (LAM) and LAM transition counseling for women who meet the three LAM criteria; 1.1.3 Other services and referral for women who have additional service(s) needs, including postnatal care

MCHIP, in collaboration with the MOH, initiated implementation of the intervention in FY13 Quarter 4 at three health facilities in Maputo City: Xipamanine Health Center, Bagamoyo Health Center, and Polana Caniço Health Center. MCHIP completed implementation of the first phase of the study in FY14 Quarter 2. Preliminary data analyses show that 33% of new FP acceptors have been referred through this screening and referral system in the implementation health facilities. MCHIP conducted an endline evaluation of the initial intervention in April 2014. During Quarter 3, MCHIP and the MOH initiated the development of the study report for the first phase of the study. This report will be finalized in Quarter 4. MCHIP will also work with the MOH to prepare a manuscript for publication.

In FY14 Quarter 2, MCHIP received authorization from the local and JHSPH IRB to move forward with the second phase of the study in Nampula. This second phase will examine whether the use of a simplified job aid (flowchart) increases the number of new contraceptive users being referred from other areas, as compared to no use of any tool or job aid to systematically screen clients for PPFP. The implementation of this phase of the study initiated in Quarter 3 and will be completed in FY15 Quarter 1. The final report for this second phase of the study will be available by February 2015. The results of the second phase of this study will have implications for the scalability of the intervention.

38

12. Success Story and photos:

SUCCESS STORY: MOTHER SAVES THE LIVES OF GRANDSON & DAUGHTER-IN-LAW

By: Denise Alves

Boane, Mozambique - Dona Cacilda, mother of two, is the matriarch of her family at 43 years old. In Boane, Mozambique she has made her home with her eldest son, his wife, Elina Moises, and their two children, keeping a watchful eye on the family and providing guidance when due.

When Elina became pregnant with her third child, Dona Cacilda remained ever vigilant. Having worked previously in the Boane Health Center as an assistant for several years, Cacilda had learned a lot about maternal and child health and the complications that can occur during pregnancy. “I learned that people with high blood pressure should be careful when they are pregnant. While working at the hospital I saw many women with high blood pressure who died. It always scared me because it is something that happens at home and the women often do not realize that they are in danger.” Cacilda’s fears were not unwarranted, high blood pressure or hypertension, which can lead to eclampsia and pre-eclampsia—a common disease in women approaching labor—is one of the leading causes of maternal deaths, in Mozambique with 9.2% of total maternal deaths (Mozambique Maternal and Neonatal Needs Assessment Report, 2008). This knowledge would be of the utmost importance to Cacilda and her family in the coming months.

On A beautiful morning in Boane, Dona Cacilda and Elina began the day as they always did, completing household chores together. It was during this morning routine, that Cacilda began to notice that there was something wrong with Elina. Elina complained of a terrible headache and her body was beginning to swell. Recognizing the warning signs for pre-eclampsia/eclampsia, Cacilda insisted that they go the Boane Health Center to ensure that everything was okay.

At the Boane Health1 Center, Elina was assessed by the nurse on duty, who referred her to the Jose Macamo Hospital. Jose Macamo Hospital serves as the highest volume maternity ward in all of Mozambique, with an average of 1,144 deliveries per month (29% of these are C-Sections), and as an important facility for obstetric complications and referrals. Like Boane Health Center, Jose Macamo is a part of MCHIP Model Maternity Initiative (since 2009) and has received ongoing support from USAID/MCHIP to improve the quality of its emergency obstetric and neonatal care services.

Arriving at Jose Macamo, Elina was immediately hospitalized as her blood pressure was too high. After a few hours, she had a C-section and her baby was born, premature and underweight, but healthy. Happy to have her healthy baby boy, Elina and Cacilda were taught how to improve the health of the baby, including education on how to apply Kangaroo Mother-Care Method2.

1 Boane Health Center is part of the Model Maternity Initiative, that is being implemented by MOH with support from USAID/MCHIP, which focuses on high-impact interventions in Maternal and Newborn Health, including the identification and treatment of pre-eclampsia and eclampsia.

2 Kangaroo Mother-Care Method (KMC) is a 3 part neonatal care methodlogy which encourages, constant skin to skin contact between baby/mother, exclusive breast-feeding, and compliance with all medical appointments.

39 Back at home Cacilda helped her daughter-in-law on a daily basis, caring for her grandson and supporting Elina to breastfeed her baby while she recovered from her surgery. "Every day I thank God for my family’s health. My daughter-in-law is very young and as her elder I feel that I must always look out for her and pass on what wisdom I have whenever possible." The baby boy is doing well and gaining weight every day.

The KMC methodology originated in Colombia as a solution to the lack of incubators available for premature infants [MAYBE a statistic here about rates of improvement?]

40

13. Financial Information:

Expenditures for April through June 2014 were $2,757,197. Cumulative project expenditures through June 2014 were $24,288,357. Projected expenditures for next quarter (July - September 2014) are $2,311,234. These projections are based on the January – June 2014 6-month average burn rate.

41 ANNEX 1: MCHIP PMP Indicator Matrix

*Investing in People/Operational Plan Indicator;**WHO EmONC Indicator;***PEPFAR indicator, ****USAID Mission PMP indicator

Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) Objective 1: Work with the MOH and all USG partners to create an enabling environment to support quality nation-wide integrated community and facility-based delivery of high impact MNCH and FP/RH interventions. Support and lead national effort to update and disseminate key MNCH and associated FP/RH policies, strategies, guidelines and training materials [MCH, FP/RH] Number of (national) 10 1 10% (1/10) 2 20% (2/10) 2 20% (2/10) policies drafted with USG support* Percent of target 100% of 100% 100% 100% health facilities MMI and (102/102) (102/102) (123/123) 102 for MMI 102 for MMI 124 for MMI utilizing updated/ CECAP for MMI and for MMI and for MMI and and 95 for and 103 for and 126 for revised MOH forms facilities 100% 100% 100% CECAP CECAP CECAP and registers (95/95) for (103/103) (126/126) CECAP for CECAP for CECAP Percent of target 80% MCHIP will health facilities (99/124) focus efforts on analyzing and for MMI working with 22 displaying data and HF intensive focus and facilities in ------84/106 FY14 to ensure CECAP that HF staff are HFs) able to analyze and use their own data Number of community groups developed and implementing action 20.6% 36.6% 55.3% 150 31 55 83 plans addressing (31/150) (55/150) (83/150) MNCH issues with MCHIP support Percentage of communities using 51 34% 20.6% 100% data for decision 150 31 (51/150) 151 (31/150) (151/150) making to improve MNCH

42 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) Number of HC with action plans based on prioritized solutions to 20.6% 76.6% 95.3% addressing MNCH 150 31 115 143 (31/150) (115/150) (143/150) issues in these respective communities Objective 2: Support MOH efforts to expand national coverage of high impact MNCH interventions, through the scaling-up of the Model Maternity Initiative, in collaboration with USG partners in every province [MCH, PMTCT, PMI]. Direct Obstetric Case 1% 1.4% NA 1.5% NA 1.2% NA Fatality Rate** Number and Percentage of MCHIP- supported health 50% facilities (62/124) 59.8% 98.3% 55.9% 91.9% 45.5% 90.3% demonstrating of MMI (61/102) (61/62) (57/102) (57/62) (56/124) (56/62) improved compliance facilities with quality standards at least 50% compared to base line Number and 22 MMI percentage of health facilities 14.7% 68.2% 13.7% 63.6% 11.3% 63.6% facilities that reach (17% of (15/102) (15/22) (14/102) (14/22) (14/124) (14/22) 80% achievement of 124 all standards facilities) Number and percentage of pregnant women 47.1% 32.7% 45.8% 65.3% 44.6% 98.1% receiving at least two 87,528 (28,580/ (28,580/ (57,141/ (57,141/ (85,867/ (85,867/ doses of IPTp in USG- 60,718) 87,528) 124,716) 87,528) 192,496) 87,528) assisted health facilities***** Number of 5.9% 12.8% 21.0% postpartum/newborn 278,743 16,433 (16,433/ 35,701 (35,701/ 58,775 (58,775/ visits within 3 days of 278,743) 278,743) 278,743)

43 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) birth in USG-assisted programs*3 Number of antenatal (ANC) care visits by 22.9% 46.4% 72.3% skilled providers from 833,347 191,433 (191,433/ 386,959 (386,959/ 602,672 (602,672/ USG-assisted 833,347) 833,347) 833,347) facilities* Number of deliveries with a skilled birth 12.7% 26.2% 42.5% attendant (SBA) in 428,835 54,421 (54,421 112,546 (112,546 182,343 (182,343 USG-assisted /428,835) /428,835) /428,835) programs* Percentage of women receiving active management of the 96.8% 100% 96.7% 97.8% third stage of labor 80% 100% (94,176/ 100% (45,235/ (155,436/ (AMSTL) through 97,260) 46,768) 158,815) USG-supported programs Number and percentage of women with pre-eclampsia/ 80% 40.2% 50.3% 46.6% 58.2% 48.6% 60.7% eclampsia treated with (898/2,234) (40.2/80) (1,949/4,175) (46.6/80) (3,224/6,625) (48.6/80) MgSO4 per protocol Percentage of health facilities with at least 100% (all one provider trained 100% 100% 100% 124 MM and equipped for (102/102) 100% (102/102) 100% (123/124) 100% facilities) neonatal resuscitation**** Fresh Stillbirth Rate Fresh stillbirth proportion = 3.7% NA NA NA 7.7% 10.1% 6.8% 7.3%; fresh stillbirth rate =

3 The data submitted by facilities for this indicator is incomplete. MCHIP-contracted provincial nurses have been provided with a supplementary data collection form to collect this information from Model Maternity facilities and will begin reporting on this indicator in Q3. 44 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) 39 Percentage of 82.9% 74.6% 72.1% deliveries with 93.2% 90.1% 80% (45,235/ 100% (83,979/ (131,529/ partograph completely (74.6/80) (72.1/80) 54,521) 112,546) 182,343) filled Percentage of 84.1% 84.9% 85.9% newborns with skin-to- 80% (46,468/ (92,731/ (152,248/ skin contact 100% 100% 100% 53,323) 109,209) 177,270) immediately after birth Percentage of 86.8% 87.0% 86.8% newborns breastfed 80% (46,275/ (94,977/ (153,941/ within one hour of 100% 100% 100% 53,323) 109,209) 177,270) birth Percent of pregnant women and children 50% ------who slept under LLIN night before Percent of household with a pregnant woman and/or child 50% ------less than 5 years of age with at least one ITN Number of services outlet providing 118 (95% counseling and testing of 124 according to national 86.4% 86.4% 99.1% MMI 102 102 124 and international (102/118) (102/118) (123/124) facilities) standards (for pregnant women)*** Number and percentage of pregnant women who received HIV 416,673 97.1% 13.7% 94.2% 27.4% 97.4% 42.4% counseling and testing (55,765/ (57,142/ (114,365/ (114,365/ (176,742/ (176,742/ for PMTCT and 57,443) 416,673) 117,233) 416,673) 181,344) 416,673) received their test results*** 45 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) Number of HIV- positive pregnant women who received antiretroviral therapy 30,000 17.7% 36.9% 56.1% to reduce risk of 5,326 (5,326/ 11,065 (11,065/ 16,842 (16,842/ mother-to-child 30,000) 30,000) 30,000) transmission Number and percentage of KMC sites established/ 22 ------operational, by type of facility Proportion of babies who graduated from 30% ------KMC4 Number of Individuals reached through USG- funded community 16.7% 28.4% 40.7% health activities 441,600 74,188 (74,188/ 125,757 (125,757/ 179,744 (179,744/ (HIV/AIDS, Malaria, 441,600) 441,600) 441,600) FP/RH) Number of Community Health Agents trained in providing MCH/FP 85.8% 85.8% 100% including 190 163 163 260 (163/190 (163/190) (260/190) PPFP/CECAP prevention messages at community level Number of Co- management Committees 52.9% 67.6% 34 17 50% (17/34) 18 23 formed/strengthened (18/34) (23/34) with active participation of

4 The current HMIS registers do not collect this information; with MCHIP support, the new registers have been revised to collect this data. It is expected that the new registers will be rolled out in the next year. 46 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) community & health providers Number of Community support Groups 20.6% 50.0% 98.6% Developed and 150 31 75 148 (31/150) (75/150) (148/150) Supported with assistance from USG Objective 3: Support the MOH to strengthen the development of human resources for health service delivery in basic and comprehensive EmONC and Reproductive Health [MCH, FP/RH, PMTCT]. Number of health workers who 6.8% 28.8% 46.3% successfully complete 1,630 111 (111/1,680) 483 (483/1,680) 778 (778/1,680) an in-service training program Total number of health workers trained to deliver ART services, 26.6% according to national 75 0 0 0 0 20 (20/75) and/ or international standards (includes PMTCT+)* Number of people HBB: 325 HW trained in trained 12.9% 45.6% 45.6% maternal/newborn 860 111 392 544 KMC: 69 HW (111/860) (392/860) (540/860) health through USG- trained supported programs* Number of people trained in malaria 75 0 0 0 treatment or 0 0 0 prevention with USG funds* Number of people trained in child health and nutrition through 0 0 0 0 0 0 0 USG-supported health area programs* Number of people 8.2% 11.7% trained in strategic 0 0 7 10 (7/85) (10/85) information (includes 85 47 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) M&E, surveillance, and/ or HMIS)** Total number of individuals trained to provide cervical cancer prevention practices at primary 90 93.3% 100% 0 level (VIA & 0 84 (84/90) 197 (197/90) cryotherapy) and at the referral level (colposcopy, biopsy and LEEP)* Objective 4: Support the expansion of cervical cancer activities using the single visit approach (SVA) and assist in the implementation of the MOH “Action Plan to Strengthen and Scale-up Breast and Cervical Cancer Prevention and Control Services” [HTXS, PMTCT]. Number and The majority of percentage of MCHIP- CECAP supported health facilities are still facilities 50% completing their demonstrating (53/106 6.3% 11.3% 5.8% 11.3% 4.7% 11.3% baseline improvement of SBM- CECAP (6/95) (6/53) (6/103) (6/53) (6/126) (6/53) assessment R standards at least facilities) and do not yet 50% compared to have base line subsequent measurements Number and percentage of health 25% (26 5.3% 19.2% 6.8% 26.9% 5.5% 26.9% facilities that reach CECAP (5/95) (5/26) (7/103) (7/26) (7/126) (7/26) 80% achievement of facilities) all CECAP standards Total number of service outlets 106 95 89.6% 103 97.2% 126 100% providing HIV-related (95/106) (103/106) (122/106) palliative care5 Number of women 17.5% 34.5% 57.8% 104,490 who received VIA 18,334 (18,334/ 36,116 (36,116/ 60,387 (60,387/

5 Cervical cancer screening and treatment fall under PEPFAR’s definition of “HIV-related palliative care” 48 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) screening 104,490) 104,490) 104,490)

Total number of individuals provided with HIV-related palliative care 17.5% 34.5% 57.8% (PEPFAR), 104,490 (18,334/ (36,116/ (60,387/ disaggregated by HIV 18,334 36,116 60,387 104,490) 104,490) 104,490) status* (Alias: Number of women who received VIA screening) Number of women 18.1% 33.2% 33.2% with positive VIA result 8,119 1,467 (1,467/ 2,699 (2,699/ 2,699 (2,699/ 8,119) 8,119) 8,119) Percentage of women 8.0% 7.5% 7.7% 93.8% 96.5% screened with VIA 8% (1,467/ 100% (8/8) (2,727/ (4,655/ (7.5/8) (7.5/8) with a positive result 18,334 36,116) 60,387) Number of screened women with VIA positive results treated 840 12.9% 1,487 22.9% 2,552 39.3% 6,495 with cryotherapy on (840/ 6,495) (1,487/ (2,552/ the same day as 6,495) 6,495) screening Percentage of eligible cervical cancer screened women with 67.5% 84.3% 66.6% 83.2% 69.6% 87.0% 80% VIA positive results (840/1,243) (74.1/80) (1,487/ 2,230) (66.6/80) (2,552/ 3,662) (69.6/80) receiving immediate cryotherapy Number of VIA positive women receiving LEEP for 81 ------treatment of large lesions Percentage of VIA+ women receiving 1% ------LEEP or colposcopy for treatment of large 49 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) lesions

Objective 5: Assist in the development and implementation of preventive FP/RH services, management and referral to appropriate facilities in selected healthcare facilities

Number of MCHIP- supported service delivery points 84.7% 90.6% 95.3% 150 127 136 143 providing integrated (127/150) (136/150) (143/150) FP counseling or services** Couple Year Protection (CYP) in 44.5% 77.8% 100% 148,000 USG-supported 65,851 (65,851/ 115,137 (115,137/ 194,526 (194,526/ programs 148,000) 148,000) 148,000) Number and 28 (20% MCHIP is percentage of MCHIP- of 140 working with the supported health health MOH to develop facilities facilities ------a rollout plan for demonstrating offering the newly improved compliance FP approved FP with FP/RH standards services) standards Number of people trained in FP/RH, 333 0 0 84 25.2% 174 52.2% including PPFP (84/333) (174/333) Number of women who received integrated package of 33.2% 60.9% 100% 631,765 FP counseling and 209,757 (209,757/ 385,175 (385,175/ 633,495 (633,495/ cervical and breast 631,765) 631,765) 631,765) cancer screening Objective 6: Promote and test the introduction on neonatal male circumcision (MC) services in selected health facilities [MCH]. Number of males TBD circumcised as part of based on the minimum package planning ------of MC for HIV with the prevention services* MOH (NEWBORNS) Number of clients <2% ------circumcised who 50 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) experienced one or more moderate or severe adverse event(s) within the reporting period* Number of males circumcised within the TBD reporting period who based on return at least once for planning ------postoperative follow- with the up care (routine or MOH emergent) within 14 days of surgery* Number and percentage of target MCHIP-supported TBD health facilities based on demonstrating planning ------improved compliance with the from baseline with MOH neonatal MC standards Objective 7: Partnerships developed and strengthened to promote nation-wide integrated, quality, community and facility-based delivery of high impact MNCH interventions through MOH and all USG partners [MCH, FP/RH, PMTCT, PMI, HTXS]. Number of target Already partners staff trained achieved EOP in state-of-the-art target, no community 0 training planned mobilization for Y3. NA NA NA NA NA NA tools/methods/ approaches Number of target partners trained in modular integrated in- 40 0 0 0 0 0 0 service training package for MNCH and SRH Objective 8: Work with MOH and all USG partners to define, implement and monitor standards of care at the point of delivery in key service areas [MCH, FP/RH, PMTCT, PMI, HTXS] 51 Indicator Annual Q1 Results % Annual Q1 + Q2 % Annual Q1 +Q2 +Q3 % Annual Annual % Annual Comments Target Target Results Target Results Target (Q1 + Target Achieved - Achieved – Achieved – Q2 + Q3 Achieved Q1 Q1 +Q2 Q1+ Q2+ + Q4) - (Q1 + Q2 Q3 Results + Q3 + Q4) Number of target technical areas for which performance 3 1 33% 1 33% 1 33% standards have been developed and approved Number of staff Q2 training in trained in quality of SBM-R care standards and performance 10.9% 53.0% guidelines 275 0 0 30 146 standards for (30/275) (30/275) Care for Children Under 5

52 ANNEX 2: Summary of Key MNCH and RH/FP Selected Indicators

Table A1. Antenatal Care Selected Indicators from 123 Health Facilities (out of 124 HF that provide normal ANC) for Q3 FY14

October to April to January to Data/Indicator December June March 2014 2013 2014 Total # of First ANC Visits 60.718 63.998 67.780 # of Pregnant Women who had 4 ANC Visits 24.524 23.636 25.329 % of Pregnant Women who had 4 ANC Visits 40,4% 36,9% 37,4% # of Pregnant Women screened for Syphilis 15.076 25.815 44.635 % of Pregnant Women screened for Syphilis 24,8% 40,3% 65,9% # of Pregnant Women positive for Syphilis 771 1.005 1.772 % of Pregnant Women positive for Syphilis 5,1% 3,9% 4,0% # of Pregnant Women Syphilis positive who receive the first dose of treatment 563 761 1.058 % of Pregnant Women Syphilis positive who receive the first dose of treatment 73,0% 75,7% 59,7% Pregnant Women with HIV+ at entrance 2.714 3.192 3.216 Pregnant Women with HIV+ in ART at entrance 2.190 2.091 2.286 % of Pregnant Women HIV+ in ART at entrance 80,7% 65,5% 71,1% # of Pregnant Women with Unknown HIV Status at the First ANC Visit 57.443 59.790 64.111 % of Pregnant Women with Unknown HIV Status at the First ANC Visit 94,6% 93,4% 94,6% # of Pregnant Women tested for HIV at ANC (first test) 55.765 58.600 62.377 # of Pregnant Women tested for HIV at ANC (following tests) 7.681 8.120 11.691 % of Pregnant Women who did the first test HIV at ANC 97,1% 98,0% 97,3% # of Pregnant Women tested positive for HIV at ANC 5.186 5.888 5.419 % of Pregnant Women tested positive for HIV at ANC 9,3% 10,0% 8,7% Total # of HIV + Pregnant Women (Women with HIV+ at entrance plus Pregnant women tested HIV + 8.313 9.554 9.179 at ANC visit) # of Pregnant Women HIV+ who Started ARV Treatment at ANC 5.326 5.739 5.777 Total of Pregnant Women HIV+ in ARV Treatment 7.516 7.830 8.063 % of Pregnant Women HIV+ in ARV Treatment 90,4% 82,0% 87,8%

53 October to April to January to Data/Indicator December June March 2014 2013 2014 # Pregnant Women received other prophylaxis regime (option A plus others) 344 472 957 % Pregnant Women received other prophylaxis regime (option A plus others) 4,1% 4,9% 10,4% # of Pregnant Women who receive the first dose of IPTp Malaria 38.754 40.808 40.667 % of Pregnant Women who received the first dose of IPTp Malaria 63,8% 63,8% 60,0% # of Pregnant Women who received the second dose of IPTp Malaria 28.580 28.561 28.726 % of Pregnant Women who receive the second dose of IPTp Malaria 47,1% 44,6% 42,4% # of Pregnant Women who receive the third dose of IPTp Malaria 13.698 14.607 15.629 % of Pregnant Women who receive the third dose of IPTp Malaria 22,6% 22,8% 23,1% # of Pregnant Women who received a bed net in the first ANC visit 43.575 47.876 57.211 % of Pregnant Women who received a bed net in the first ANC visit 71,8% 74,8% 84,4% * PMTCT prophylaxis has changed according to new MoH treatment policy

Table A2. Delivery Care Selected Indicators from 123 Maternities out of 124 for Q3 FY14

October to April to January to Data/Indicator December June March 2014 2013 2014 Total # of Deliveries 54.421 58.125 69.797 # of Normal Deliveries 46.768 50.492 61.355 # of Instrumental assisted deliveries (Vacuum extraction) 504 402 502 % of Instrumental assisted deliveries (Vacuum extraction) 0,9% 0,7% 0,7% # of C-Section Deliveries 6.687 7.209 7.763 % of C-Section Deliveries 12,3% 12,4% 11,1% # of Deliveries in Vertical or semi-vertical positions 11.463 10.493 12.229 % of Deliveries in Vertical or semi-vertical positions (in relation to normal deliveries) 24,5% 20,8% 19,9% # of Women in Labour with companion 27.358 29.424 35.055 % of Women in Labour with companion (in relation to normal deliveries) 58,5% 58,3% 57,1% # of Deliveries with a partograph completed filled out 45.235 38.744 47.550 % of Deliveries with a partograph completed filled in (in relation to the total # of Deliveries) 83,1% 66,7% 68,1% # of deliveries with active management of the third stage of labour 45.235 48.941 61.260

54 October to April to January to Data/Indicator December June March 2014 2013 2014 % of deliveries with active management of the third stage of labour (in relation to normal deliveries) 96,7% 96,9% 99,8% # of Pre-Eclampsia & Eclampsia 2.234 1.941 2.450 # of Pre-Eclampsia & Eclampsia treated with Magnesium Sulfate 898 1.051 1.275 % of Pre-Eclampsia & Eclampsia treated with Magnesium Sulfate 40,2% 54,1% 52,0% # of Live Births 53.362 55.847 68.061 # of newborns with immediate skin-to-skin contact with the mother 44.901 47.830 59.517 % of newborns with immediate skin-to-skin contact with the mother 84,1% 85,6% 87,4% # of newborns breastfed within the first hour 46.275 48.702 58.964 % of newborns breastfed within the first hour 86,7% 87,2% 86,6% # of Stillbirths 2.217 2.345 2.742 Stillbirth Rate(X1000) 40 40 39 # of Fresh Stillbirths (with fetal heart beat at maternity entrance) 170 236 186 Proportion of Fresh Stillbirths to the Total # of Stillbirths 7,7% 10,1% 6,8% Total of Direct Obstetric Complications 6.450 5.945 6.936 # of Maternal Deaths by Direct Obstetric Complications 91 89 86 Case Fatality Rate for Direct Obstetric Complications 1,4% 1,5% 1,2% % of Direct Obstetric Complications (in relation to all deliveries) 11,9% 10,2% 9,9% Total # of Indirect Obstetric Complications 5.259 6.368 7.424 # of Maternal Deaths by Indirect Obstetric Complications 41 48 35 Case Fatality Rate for Direct Obstetric Complications 0,8% 0,8% 0,5% Total # of Maternal Deaths (Direct plus indirect) 132 137 121 Institutional Maternal Mortality Ratio (x100.000) 247 245 178

55

Table A3. PMTCT Selected Indicators from 123 Maternities for FY14Q3

October to April to January to Data/Indicator December June March 2014 2013 2014 # of Pregnant women with unknown HIV status at maternity entrance 14.256 13.906 17.267 # of Pregnant Women with HIV+ status at maternity entrance 6.834 7.650 9.848 Total # of Pregnant Women tested for HIV at the Maternity Entrance 15.541 13.960 18.222 % of Pregnant Women tested for HIV at the Maternity Entrance 109% 100% 106% Pregnant women HIV+ who started ARV Prophylaxis in ANC 5.499 6.800 9.028 # of HIV+ women identified in the maternity 389 583 439 % of Women tested HIV + in the Maternity 2,5% 4,2% 2,4% Total Pregnant Women with HIV+ (Status HIV+ at entrance plus tested HIV+ in the maternity) 7.223 8.233 10.287 # Pregnant Women received other prophylaxis regime (option A plus others) 1.800 1.202 741 % Pregnant Women received other prophylaxis regime (option A plus others) 24,9% 14,6% 7,2% % of HIV+ Pregnant women who received ARV in ANC 80,5% 88,9% 91,7% # of Pregnant Women in ART Treatment 5.612 6.800 9.028 # of Pregnant Women in ART Treatment 77,7% 82,6% 87,8% Total # of Pregnant Women who received ARV at delivery 7.412 8.002 9.769 % of Pregnant Women HIV + who received ARV at delivery 102,6% 97,2% 95,0%

Table A4. Post-Partum and Post-Natal Care data from 101 Health Facilities (out of 101 Health Facilities that provide normal PPC) for FY14Q3

October to January to April to June Data/Indicator December March 2014 2014 2013 Total first Postpartum visits 47.468 53.378 60.581 # of Women who have postpartum visit until the 3rd day 16.433 19.268 23.074 % of Women who have postpartum visit until the 3rd day 34,6% 36,1% 38,1% # of Women who have postpartum visit between 4º-7º day 14088 15.939 17.923 % of Women who have postpartum visit between 4º-7º day 29,7% 29,9% 29,6% # of Women who have postpartum between 8º-21º day 11254 12.552 16.012 % of Women who have postpartum between 8º-21º day 23,7% 24% 26% 56 # Women who have postpartum visit at 22 days and after 6004 6.828 9.062 % Women who have postpartum visit at 22 days and after 12,6% 12,8% 15,0% # of Deceased Newborn After Childbirth 179 255 186 Proportion of of deceased Newborn After Childbirth 0,4% 0,5% 0,3% Total # of women with postpartum complications 338 419 568 % of women with postpartum complications 0,7% 0,8% 0,9% # Women with anemia (<8 mg / dl) 87 138 92 % Women with anemia (<8 mg / dl) 0,2% 0,3% 0,2% # Women with Puerperal Infection 126 145 136 % of Women who attended the PP care with Puerperal Infection 0,3% 0,3% 0,2% Proportion of Women with Puerperal Infection from the total Women who presented PP 37,3% 34,6% 23,9% Totalcomplicactions # of Women with Obstetric Fistula 12 3 19 Proportion of Women withObstetric Fistula from the total Women who presented PP 0,03% 0,01% 0,03% %complicactions of Women with Obstetric Fistula (in relation to women with PP complication) 3,6% 0,7% 3,3% # of women tested for syphilis in CPP 29 1.252 883 % of women tested for syphilis in CPP 0,1% 2,3% 1,5% # of women tested positive for syphilis in CPP 0 24 30 % of women tested positive for syphilis in CPP - 1,9% 3,4% # of women with unknown HIV status at entrance 3.911 4.546 3.931 # of Women with HIV+ status at entrance 4.245 5.507 5.898 Total # of Women tested for HIV 3.946 4.565 3.668 % of Women tested for HIV 100,9% 100,4% 93,3% # of HIV+ women identified HIV+ in CPP visit 104 324 205 Total Number of HIV + Women 4.349 5.831 6.103 Total HIV-infected women who initiated ARV treatment 455 299 436 % HIV-infected women who initiated ARV treatment 437,5% 92,3% 212,7%

57

Table A5: Cervical Cancer Prevention (CECAP) data from 118 Health Facilities (out of 126 Health Facilities that provide CECAP) for Q3 FY14 October to January to April to Data/Indicator December 2013 March 2014 June 2014

Total # of women attending their first visit at the Reproductive Health Outpatient Services 73.417 60.262 102.011 Total # of Women with ≥ 25 years old attending their first visit at the Reproductive Health Outpatient 52.445 33.230 28.378 Services in CECAP Facilities Total # of women attended at Reproductive Health Outpatient Services (including first and following 220.912 169.866 145.462 visits) Total # of women with unknown HIV status 50.537 43.363 63.139 Nº Women with unknown status tested for HIV 32.937 30.237 42.784 % of Women with unknown status tested for HIV 65,2% 69,7% 67,8% # of Women Tested HIV+ at Reproductive Health Outpatients Services 1.785 1.611 2.111 % of Women tested HIV + 5,4% 5,3% 4,9% Total # of Women HIV + (women with previously known HIV + status plus women tested HIV+ in their 10.815 9.408 8.569 first RH outpatient services visit) # of Women HIV who initiated TARV 1299 1.020 680 % of HIV + Women sent for ARV Treatment 13,8% 11,9% 6,3% # of VIA performed 18334 17.782 24.271 % of VIA performed (of women presenting for their first visit) 55,2% 62,7% 46,3% # of Women with VIA positive 1467 1.260 1.928 % de VIA positives 8,0% 7,1% 7,9% # of Women referred for Lesions > 75% or due to cervical cancer suspicion 224 273 496 % of Women referred for Lesions > 75% or due to cervical cancer suspicion 15,3% 21,7% 25,7% # women Eligible for cryotherapy 1243 987 1.432 # of Women with VIA + who are also HIV + 141 137 - % of Women with VIA + who are also HIV + 9,6% 10,9% - # of Cryotherapy treatment performed in the same day of the screening 840 647 1.065 % of Cryotherapy treatment performed in the same day of the screening 67,6% 65,6% 74,4% # of VIA+ women treated with Cryotherapy after the day of the screening; 91 96 159 % of VIA+ women treated with Cryotherapy after the day of the screening; 7,3% 9,7% 11,1% 58 ANNEX 3: MCHIP Support for MoH Model Maternities Initiative Expansion Plan Basic Package of MCHIP Support: Clinical training in EMNC, BEmONC, ANC (including PMTCT and Malaria in Pregnancy), clinical supervision, basic materials and supplies for maternal and newborn care, support for implementation of QI system for MNCH/RH/FP, leadership of other USG health partners in support of MNCH/RH/FP activities. HEALTH FACILITIES CURRENTLY INCORPORATED IN THE PROCESS of MMI Intensive Package of MCHIP Support: Basic Package plus minor repairs for improving privacy and basic hygiene and intensive supportive supervision INTENSIVE COMMUNITY FOCUS: BASIC PACKAGE PLUS DIRECT SUPPORT FOR COMMUNITY MOBILIZATION (HEALTH AND CO-MANAGEMENT COMMITTEES) Province HF that entered in 2010 (34 HF that started in 2011 (22 HF for expansion in 2012 (July HF for expansion in 2013 (22 HF for expansion in 2014 (23 HF) HF) - Dec) (23 HF) HF) HF)

• HP Lichinga • CS Metangula • CS Mecanhelas • CS Maúa • CS Marrupa Niassa • HR CUAMBA • CS MANDIMBA • CS Metarica • CS Massangulo • CS Chiuaula • HP Pemba • HR Mocimboa da Praia • HR MUEDA • CS Balama • CS Palma Cabo Delgado • HR Montepuez • CS Chiure • CS Pemba Metuge • CS Namuno • CS NATITE • HC Nampula • HG Marere • HR ANGOCHE • CS Meconta • CS Anchilo Nampula • HG NACALA • HR Ribaue • HR Alua • CS Mossuril • CS Iapala • HR Monapo • CS 25 DE SETEMBRO • CS Ilha de Moçambique • CS Muhala Expansão • HP Quelimane • HR Alto Molócuè • HD Maganja da Costa • CS Coalane • CS Gilé • HR Mocuba • CS 17 DE SETEMBRO • HD MILANGE • CS Mopeia Zambézia • HD GURUE • HD Nicoadala • HR Morrumbala • CS Macuse • HP Tete • HR ULONGUE • HR Mutarara • CS Lifidzi • CS Changara Tete • HR Songo • CS Moatize • CS Nº 4 MUTHEMEBA • CS Chitima • CS Macanga • CS NO. 2 MATUNDO • HP Chimoio • HR Gondola • HD Espungabeira • CS Guro Sede • CS Nhamahonha Manica • HR Catandica • CS MANICA • CS Vanduzi • CS Sussundenga • CS Marera • CS 1º DE MAIO • CS Catandica • HC Beira • HR NHAMATANDA SEDE • HR Marromeu • CS Caia • CS Munhava Sofala • HR Buzi • HR MUXUNGUE • CS Chingussura • CS Dondo Sede • CS Mafambisse • CS Macurungo • CS Ponta Gêa • CS Gorongosa • CS Tica • HP Inhambane • HD Massinga • CS Maxixe • CS Inhassoro • CS Panda Inhambane • HR Chicuque • HR VILANCULO • CS Morrumbene. • CS Quissico • CS Inharrime • CS HOMOINE • HP Xai-Xai • HR Chókwè • HR Chibuto • CS Chigubo • CS Maciene Gaza • HR MANJACAZE • CS Macia • CS Massingir • HR CHICUMBANE • CS Manhiça • HR Xinavane • CS Marracuene • CS Bedene • CS Magude Maputo Province • CS BOANE • CS MACHAVA II • CS Namaacha • CS Moamba • CS Ressano Garcia • CS MATOLA II • HC Maputo • CS 1º de Junho • CS 1º de Maio • CS Catembe • CS Ndlavela • HG José Macamo • CS Bagamoio Maputo City • HG Chamanculo • HG Mavalane

59 ANNEX 4: MCHIP Support for MoH Cervical and Breast Cancer Prevention and Control Program BASIC PACKAGE OF MCHIP SUPPORT: Clinical training, supervision, equipment maintenance, SIS. All health facilities provide VIA and cryo services. Only “+LEEP” facilities provide treatment for serious lesions. INTENSIVE PACKAGE OF MCHIP SUPPORT: Basic Package plus equipment donation HEALTH FACILITIES CURRENTLY PROVIDING CECAP SERVICES Province HF entering in 2009/10 HF entering in 2011 (29 HF) Facilities for expansion in Facilities for expansion in Facilities for expansion in (17 HF) 2012 (31 HF) 2013 (20 HF) 2014 (32 HF) • HP Lichinga • HR Cuamba • CS Metarica • CS Mavago • CS Lichinga • CS Mecanhelas • CS Marrupa • CS Massangulo Niassa • CS Metangula • CS Mandimba

• HP Pemba • HR Montepuez • CS Balama • CS Palma • CS Natite • CS Mueda • Namuno Cabo Delgado • CS Chiúre • CS Mocímboa da Praia • Ancuabe

• HC Nampula (+LEEP) • HR Ribáue • HG Nacala Porto • CS Monapo • CS Moma • CS 25 de Setembro • CS Muhala Expansão • HR Angoche • CS 1º de Maio • CS Mossuril • CS Namapa Nampula • CS Ilha de Moçambique • CS Lapala

• HP Quelimane (+LEEP) • HR Mocuba • CS Milange • HR Alto Molocué • CS Gilé • CS 17 de Setembro • CS Mocuba • CS Gurué Zambézia • CS Coalane • CS Mopeia • CS Nicoadala • CS Namacurra • CS de Maganja da Costa • CS Inhassunge • CS Morrumbala • HP Tete • CS Lifidzi • CS Chitima • CS Changara • CS nº 2 - Bairro • CS Nº 4 - Bairro • CS Chiúta Tete Matundo Muthemba • CS Moatize • HP Chimoio • CS Manica • CS Guro Sede • CS Nhamahonha • HR Catandica • CS Vanduzi • CS Eduardo Mondlane • CS 1º de Maio • CS Espungabeira Manica • CS Gondola

• HC Beira (+LEEP) • CS Chingussura • CS Munhava • CS Caia Sofala • CS Ponta Gêa • CS Dondo • CS Búzi • CS Macurungo • CS Gorongosa • CS Nhamatanda

60 Province HF entering in 2009/10 HF entering in 2011 (29 HF) Facilities for expansion in Facilities for expansion in Facilities for expansion in (17 HF) 2012 (31 HF) 2013 (20 HF) 2014 (32 HF)

• HP Inhambane • HR Massinga • CS Inharrime • CS Panda • CS Maxixe • CS Inhassoro • CS Vilanculos • CS Zavala Inhambane • CS Homoine • CS Urbano • CS Chicuque • CS Morrumbene

• HP Xai-Xai • CS Guijá • HR Chibuto • CS Mabalane • CS Xai-Xai • CS Chokwe • CS Massingir Gaza • CS Manjacaze • CS Macia • CS Marien Nguaby • CS Chicumbane • CS Boane • HR Xinavane • HD Manhiça • CS Ndlavela • CS Magude • CS Matola II • CS Marracuene • CS Namaacha Maputo Province • CS Moamba • CS Matutuíne • CS Ressano Garcia • CS Machava II • HC Maputo (+LEEP) • CS Bagamoio • HG Chamanculo • CS Catembe • CS Malhazine • HG José Macamo* • CS Zimpeto • CS 1º de Maio • CS Inhaca • CS Albasine Maputo City (+LEEP) • CS Jose Macamo • CS 1º de Junho • CS Alto-Maé • CS Malhagalene • HG Mavalane * • CS Xipamanine • CS Polana Caniço • CS Mavalane *Not attending patients because of inadequate security conditions for equipment.

61 ANNEX 5: Model Maternity Facility SBM-R MeasurementsANNEX 5: Model Maternity Facility SBM-R Measurements

NIASSA Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Health Facility Lichinga 9.2.10 14.09.11 15.02.12 25.04.12 24.10.12 28.02.13 04.08.13 Provincial 35.5% 41.5% 53.1% 68.8% 71.1% 68.6% 68% Hospital Cuamba 11.2.10 16.09.11 17.02.12 26.10.12 24.02.13 25.01.14 Rural 38.7% 32.4% 49.2% 35.5% 72.4% 82.0% Hospital Chiuaula 10.2.10 15.09.11 16.02.12 14.09.12 22.03.13 29.01.14 Health 19.3% 18.8 42% 20% 43.7% 72.5% Center Mecanhela 4.7.12 9.11.12 05.04.13 24.08.13 s Health 31.8% 60.9% 81.3% 62.8% Center Mandimba 1.7.7.12 14.11.12 08.03.13 28.8.13 14.02.14 Health 35.7% 39.4% 84.9% 79% 68.4% Center Metangula 23.10.12 24.02.13 17.8.13 16.01.14 Health 22.9% 59.45% 55.8% 75.3% Center Maúa 17.05.13 14.9.13 Health Center 43.3% 52 % Metarica 21.05.13 20.9.13 Health 59.2% 71 % Center CABO Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th DELGADO Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Pemba 9.2.10 19.10.10 N/A 14.06.12 31.01.13 24.05.13 25.04.14 Provincial 23.2% 59.5% 85.7% 76.6% 84.1% 82.1% 89.6% Hospital Montepuez 16.10.10 18.10.10 N/A 3.11.12 06.03.13 23.07.13 Rural 24.2% 31.8% 44.2% 37.7% 36.4% 63.1% Hospital Natite 10.2.10 20.10.10 N/A 09.08.13 Health 13.9% 72.2% 51.9% 51.3% Center

62 Mueda 4.5.12 13.11.12 20.2.13 14.06.13 19.02.2014 Rural 47.3% 45.5% 64.2% 70.1% 68.4% Hospital Mocimboa 6.5.12 19.11.12 23.2.13 12.09.13 22.02.14 da Praia 41.3% 60.6% 55.3% 58.2% 79.2% Rural Hospital Chiure 7.11.12 5.3.13 29.06.13 20.09.13 28.04.14 Health 35.3% 61.2% 79.7% 82.2% 92.1% Center Balama 19.04.13 18.07.13 24.04.14 Health 41.3% 62.5% 61.3% Center Metuge 1.8.13 Health 40.6% Center NAMPULA Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Nampula 3.5.2010 21.10.10 16.8.11 29.4.12 1.10.12 10.5.13 20.9.13 Central 29% 52.4% 72.1% 60% 38% 42.9% 57.8% Hospital HD Nacala 7.10 23.10.10 8.11 4.4.12 20.8.12 7.12.12 14.3.13 11.7.13 15.11.13 District 41.9% 54.2% 78.3% 54.1% 60.9% 68.3% 81% 90% 90% Hospital Monapo 7.10 23.10.10 15.8.11 21.8.12 23.11.12 18.03.13 22.07.13 Rural 30% 76.3% 43.3% 20% 49.3% 70.2% 82.4% Hospital Marere 12.7.12 10.11.12 25.3.13 09.8.13 General 49.1% 50.7% 55.1% 73.9% Hospital 25 de 10.7.12 7.11.12 19.04.13 Setembro 34.8% 47.3% 71.7% Health Center Ribaué 25.8.12 16.11.12 15.2.13 16.8.13 Rural 11.5% 42.9% 32.4% 38% Hospital Ilha de 18.8.12 20.11.12 20.2.13 23.8.13 Moçambiqu 32.7% 45.3% 48.3% 44.7% Angocheee Health 23.8.12 14.12.12 04.04.13 Center

63 Rural 22.2% 48.1% 51.4% Hospital Alua Health 16.10.12 31.1.13 10.06.13 Center 31.4% 61.0% 63.8% Meconta 17.05.13 27.9.13 Health 25% 50% Center Mossuril 24.05.13 Health 24.6% Center Muhala- 03.05.13 12.9.13 Expansão 30.9% 58.9% Health CenterZAMBEZIA Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Quelimane 9.2.10 22.9.10 30.11.11 N/A 21.6.12 13.06.13 Provincial 53.8% 77.8% 49.2% 56.0% 61.5% 62% Hospital Mocuba 10.2.10 30.8.10 2.10.11 12.4.12 10.1.13 19.7.13 25.10.13 12.06.14 Rural 55.5% 64.6% 76.3% 64.6% 93.4% 60.6% 80.0% 82.1% Hospital Gurue 19.2.10 24.09.10 16.9.11 29.6.12 10.1.13 26.4.13 26.7.13 District 36% 43.0% 44.3% 73.4% 97.4% 81.9% 81.3% Hospital Alto 12.10.12 17.7.13 23.10.13 Molócuè 26.7% 67.1% 89.5% Rural Hospital Maganja da 14.10.12 11.4.13 31.07.13 Costa 66.7% 51.4% 89.6% District Hospital Milange 11.10.12 10.3.13 16.08.13 Rural 23.0% 41.1% 76.1% Hospital Nicoadala 9.11.12 5.4.13 6.09.13 Health 44.4% 62.3% 73.7% Center Coalane 09.05.13 06.09.13 Health 35.1% 61.2% Center 17 de 1.8.2012 10.05.13 4.09.13

64 Setembro 69.1% 64.7% 72.4% Health Center Tete Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Tete 6.6.10 29.4.11 8.9.11 22.8.12 19.12.12 20.3.13 12.7.13 11.10.13 22.01.14 Provinical 27% 60% 52.5% 80% 80.4% 81.4% 92.9% 93.4% 94.9% Hospital Songo Rural 20.01.10 17.06.10 12.5.11 14.9.11 7.8.12 21.12.12 3.5.2013 13.09.13 28.02.14 Hospital 30.6% 39% 88% 82% 72.1% 68.3% 69.4% 72.3% 73.4% Nº 2 2010 10.06.10 5.5.11 5.9.11 27.07.12 10.12.12 30.4.13 22.8.13 Matundo 35.5% 21% 82% 71% 40.4% 32.8% 38.3% 52.7% Health Center Ulongue 8.8.12 30.11.12 29.0313 16.8.13 Rural 52.1% 53.4% 42.3% 57.4% Hospital Moatize 25.7.12 17.12.12 10.05.13 23.8.13 Health 29.8% 32.8% 58.8% 57.1% Center Mutarara 13.8.12 14.12.12 26.4.13 26.7.13 Rural 50% 69.1% 55.6% 70.4% Hospital Muthemba 11.1.13 08.05.13 20.8.13 Health 12.2% 42.6% 40.7% Center Chitima 28.06.13 27.9.13 Health 28.8% 45.8% Center Lifidzi 21.04.13 25.10.13 Health 21.1% 38.5% Center Manica Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Chimoio 4.5.2010 31.3.11 N/A N/A 22.3.13 30.8.13 16.12.13 14.04.14 Provincial 31.7% 75.4% 70.9% 75.4% 61.2% 76.5% 86.2% 77.0% Hospital Catandica 4.5.10 31.3.11 N/A N/A 8.1.13 16.05.13 31.10.13 28.02.14 Rural 12.7% 70.7% 69.4% 56.9% 41.9% 53.8% 60.5% 64.9% Hospital 1º de Maio 4.5.10 31.3.11 N/A N/A 29.3.13 5.8.13 29.02.14 Health 17.7% 60.8% 68.5% 76.5% 74% 74.6% 79.7%

65 Center Gondola 23.12.11 7.12.12 19.4.13 9.8.13 19.12.13 08.05.14 Rural 44% 64% 54.8% 55.5% 72.4% 63.3% Hospital Manica 23.12.11 14.12.12 12.4.13 16.8.13 17.12.13 27.05.14 District 40% 41.1% 61.3% 69.4% 96.1% 84.4% Hospital Espunga- 23.12.11 21.12.12 13.6.13 21.9.13 24.02.14 beira 20% 36% 48.5% 60.2% 66.2% District Hospital Guro 27.4.2012 15.03.13 12.07.13 28.03.14 Health 43.1% 36.1% 56.3% 81.1% Center Sussun- 8.3.13 6.8.13 21.03.14 denga 20.6% 63% 56.9% Health Center Vanduzi 21.05.13 13.09.13 19.12.14 19.03.14 Health 39.1% 55.5% 61.8% 63.0% Center Sofala Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Beira 27.5.10 17.9.10 1.6.11 30.12.11 30.7.12 11.1.13 26.04.13 26.09.13 31.01.14 Central 20.7% 52.3% 67.7% 70.8% 67.7% 50.8% 59.5% 85% 70.1% Hospital Buzi Rural N/A 24.08.11 30.1.12 8.12 26.4.13 15.08.13 22.11.13 Hospital N/A 44.3% 39.2% 65.8% 51.3% 67.7% 82.5% Macurungo 27.05.10 2010 26.4.11 1.2.12 30.7.12 17.1.13 29.05.13 28.11313 Health 31.9% 57.0% 78.7% 62.5% 89.3% 52.6% 64.4% 75.0% Center Nhamatand 19.2.12 3.8.12 15.3.13 21.6.13 7.9.12 28.11.13 28.03.14 a Rural 49.3% 53.2% 36.4% 53.9% 53.1% 76.3% 70.4% Hospital Muxungue 13.3.12 20.6.12 7.2.13 19.06.13 15.06.13 Rural 56% 70.9% 51.9% 56.7% 77.5% Hospital Caia Health 28.02.13 29.06.13 12.10.13 Center 41.8% 68.4% 60.0% Gorongosa 18.05.13 Health 48.7% Center

66 Ponta gea 21.10.12 10.05.13 30.08.13 Health 49.4% 55.4% 69.6% Center Dondo 19.04.13 09.08.13 Health 42.7% 64.9% Center Chingussur 28.10.12 28.06.13 a Health 44.9% 60.5% Center Inhambane Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Inhambane NA NA 22.05.12 19.10.12 22.02.13 19.07.13 05.05.14 Provincial NA NA 29.5% 45.2% 72.1% 77.8% 83.3% Hospital Chicuque NA NA 12.10.12 15.02.13 17.05.13 15.11.13 14.03.14 Rural 27.3% 58.2% 68.8% 24.0% 51.3% 68.4% 65.4% 70.9% 77.5% Hospital Quissico 23.08.13 22.11.13 21.02.14 23.05.14 Health 50.7% 70.1% 66.7% 83.3% Center Vilanculos 24.05.12 21.09.12 25.01.13 26.04.13 22.07.13 18.10.13 14.02.14 16.05.14 Rural 42.1% 56.8% 60.8% 68.6% 88.2% 84.5% 80.0% 84.6% Hospital Inhassoro NA 29.11.13 25.04.13 Health NA 58.0% 72.2% Center Morrumbe 15.08.12 07.12.12 28.03.13 28.06.13 12.03.14 ne Health 36.8% 60.3% 40.3% 76.7% 72.7% Center Maxixe 17.08.12 14.12.12 22.03.13 NA 28.02.14 Health 30.3% 42.9% 70.4% 69.4% 71.2% Center Massinga 22.05.12 21.09.12 18.01.13 03.05.13 08.11.13 28.03.14 District 27.8% 31.6% 57.1% 65.3% 75.0% 60.5% Hospital Homoine 18.12.09 29.03.11 09.06.11 23.05.12 25.10.12 01.03.13 31.05.13 18.04.14 Health 37.7% 59.5% 73.8% 21.4% 43.7% 60.5% 67.1% 71.8% Center Maxixe Health Center Inharrime 25.08.12 15.11.12 13.02.13

67 Health 11.5% 42.9% 32.4% Center Gaza Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Manjacaze NA NA NA 28.11.11 11.07.12 24.10.12 08.02.13 13.06.13 17.01.14 NA NA NA 16.9% 33.8% 48.8% 57.9% 57.7% 79.2% Rural Hospital Chibuto 29.11.11 21.11.12 22.03.13 19.08.13 09.04.14 5.5.14 52.9% 50.7% 51.5% 55.8% 49.4% 86.4% Health Center Chicumban 24.01.14 e Rural 61.4% Hospital Chókwè 24.11.09 14.09.12 22.01.13 18.08.13 29.11.13 35.6% 53.4% 34.2% 64.5% 63.0% Rural Hospital Xai Xai 19.12.09 28.08.10 04.08.11 21.11.11 13.07.12 31.10.12 28.02.13 17.06.13 28.03.14 Provincial 24.1% 81.7% 72.9% 51.7% 68.3% 72.9% 82.0% 83.9% 93.8%

Hospital Macia 31.05.12 14.11.12 29.03.13 05.07.13 Health 25.4% 43.8% 43.4% 58.1% Center Maputo Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Province Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Namaacha 06.08.13 31.01.14 75.7% 75.7% Health Center Machava 11.10.13 31.01.14 Bedene 32.5% 81.6% Health Center Boane 30.4.10 30.8.13 45.5% 21.6% 17.7% 60.9 Health Center Manhiça 10.2.10 2.10.10 29.7.11 20.10.12 16.7.12 4.7.13 20.10.13

68 District 37.7% 55.8% 41.8 58.7 62.0% 40.0% 58.7% Hospital CS Matola II 28.4.10 6.2.13 16.10.13 27.3.14 Health 27.3% 15.5% 75.9% 85.9% 37.8% 46.10% Center Xinavane 31.01.14 10.10.13 5.2.14 19.4% 81.6% 43.7% 57.1% Health Center Marracuen 17.10.12 20.7.13 e Health 63.5% 37.7% Center Machava II 9.10.13 18.10.13 Health 56.9% 53.2% Center Moamba 14.2.14 Health 80% Center Maputo Baseline 2nd 3rd 4th 5th 6th 7th 8th 9th 10th City Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Measurement Maputo 1.11.9 9.4.10 Central 15.1% 47.7% Hospital José 18.3.10 27.4.12 25.3.13 11.12.13 5.5.14 Macamo 24.7% 21.6% 59.7% 78.8% 79.0% 86.4% General Hospital 1ºMaio 20.4.12 24.6.13 19.2.14 19.2% 39.7% 76.6% Health Center Chamancul 29.11.09 29.03.10 10.01.12 08.03.13 05.07.13 01.11.13 21.03.14 o General 33.3% 37.7% 54.8% 81.8% 87.7 75.3% 74.4% Hospital Mavalane 09.08.13 22.05.10 36.5% 51.5% Health Center 1 de Junho 19.10.12 09.08.13 Health 50.0% 69.3% Center

69 Bagamoio 15.03.13 05.09.13 Health 60.5% 80.5% Center Catembe 22.02.13 01.07.13 Health 47.8 62.8 Center

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