MATERNAL AND CHILD SURVIVAL PROGRAM

MCSP QUARTERLY REPORT JANUARY – MARCH 2017

SUBMITTED: APRIL 30th, 2017

SUBMITTED TO: UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT COOPERATIVE AGREEMENT NO. AID-OAA-A-14-00028 SUMMARY

Country: Tanzania Field Representative(s): John George, MCSP Project Director, [email protected]; Jérémie Zoungrana, Jhpiego Country Director, [email protected]

US-based Maternal and Child Survival Program Contact Person(s): Koki Agarwal, MCSP Director, [email protected]; Lauren Borsa, Program Officer, [email protected]

Maternal and Child Survival Program Organizations: Jhpiego (lead organization): maternal health, ANC/PNC, PPFP, CECAP, Community (CHW), Pre-service Education, Malaria In Pregnancy, HIV/RMNCH Integration JSI: Immunization, HIS Save the Children: Newborn health JHU IIP: evaluation, program learning R4D: HSS/MTUMA Approach In-Country Partners: MOHCDGEC divisions and units: RCHS, HRDD, HEPU, IVD, HSI&QAS, ICT, LMU; other Government agencies and institutions: MOHZ, PO-RALG, ZHRC, MSD; Professional associations: TAMA, AGOTA, MAT, PAT, PRINMAT; other international and national partner organizations: WHO, UNICEF, CHAI, PATH, WRATZ; other USAID projects: USAID | DELIVER/SCMS, Tanzania Capacity and Communications Project (TCCP); Health Systems Strengthening PS3, local CSOs, and others.

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INTRODUCTION

The MCSP Year 3 Quarter 2 progress report presents the major activities accomplished under MCSP Tanzania from January to March 2017. In collaboration with the Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) at all levels in the target regions, MCSP has remained focused on solidifying investments made on strengthening key health system components with intensive efforts put towards sustaining project gains. In this quarter and throughout the Project lifecycle, MCSP continued to support the MOHCDGEC in achieving the SDGs by implementing activities focused on international strategies and best practices to improve human resources for health for the provision of quality RMNCH services.

After transitioning selected MCSP interventions to the new USAID Boresha Afya Program in the last quarter, MCSP has continued to implement a few activities in maternal and newborn health (MNH), malaria in pregnancy (MiP), family planning (FP), but focused more efforts on the remaining 4 components of the Program, which includes pre-service education (PSE), cervical cancer prevention (CECAP), immunization, and health information systems (HIS). With this revised scope, MSCP continued to prioritize strengthening key heath system components at all levels in Mara, , Tabora, Simiyu, and Iringa Regions and extended CECAP in Region, while also prioritizing the documentation of achievements and sharing best practices with key stakeholders. MCSP has also continued to focus on the engagement of MOH partners in planning and service delivery with supportive supervision, clinical mentorship, quality improvement activities, and defaulters tracing for the immunization component.

Some of the key achievements from this quarter include: 1. Supported the MOHCDGEC to conduct regional-level recognition ceremonies in Mara and Kagera regions for Basic Emergency Obstetric and Newborn Care (BEmONC) services. In total, 14 facilities achieved level one and 9 achieved level 2. 2. MCSP facilitated MiP post-training follow up; commodities management supportive supervision and mentorship; and disseminated malaria guidelines, SOPs/job aids and IEC materials to 203 health facilities in Mara and Kagera. 3. Supported ZHRC and MOHCDGEC to conduct CQI follow-up assessments in the 7 unrecognized health training institutions (HTIs) of Kagera and Mara regions to strengthen the learning and training environment in order to produce qualified graduates delivering quality RMNCH services. 4. Conducted an assessment on student RMNCH clinical training and the linkage between schools and practicum sites so that MCSP, Ministry of Health and other stakeholders are able to develop a strategy to further strengthen and improve practical training. 5. Conducted a technical review meeting to update the National Cervical Cancer Prevention and Control Guidelines with WHO technical updates. 6. Facilitated national-level supportive supervision for rolling out CECAP quality improvement program and repair and maintenance system for cryotherapy machines. 7. Provided technical support during the 82nd Inter-agency Coordinating Committee (ICC) meeting convened by IVD. The ICC endorsed the IVD’s proposal to introduce the HPV vaccine and use a Performance Based Financing (PBF) budget to support warehouse expansion and rehabilitation of vaccine storage units. 8. Supported the MOHCDGEC to conduct a highly successful inception workshop hosted by the Permanent Secretary where the Health Information Mediator (HIM) implementation was officially launched. 9. Conducted clinical mentorship and supportive supervision to support service delivery component for MiP, CECAP, PSE and immunization services. 3 | P a g e

During supportive supervision and clinical mentorship visits, individual technical support on the use of mobile phones in RMNCH service provision to CHWs in the process of conducting counseling to clients during home visits was reinforced. MCSP’s health system strengthening component to deliver quality RMNCH services was also reinforced including management and utilization of RMNCH data through district health management information electronic system. In the HIS element in collaboration with the MOHCDGEC ICT unit, MCSP facilitated development of the Health Information Mediator (HIM) use cases and data matrix. In regards to the learning agenda, MCSP continued to support the implementation of the Facility Perinatal Mortality (FPM) study.

A. ACCOMPLISHMENTS

1. MATERNAL NEWBORN HEALTH (MNH)

Recognition Ceremonies MCSP in collaboration with MoHCDGEC, conducted recognition ceremonies in January 2017, for facilities scoring 70% and above in the external assessment conducted in Q1 using the nationally-approved standards for BEmONC and Kangaroo Mother Care (KMC). In total, 25 facilities qualified for recognition for achieving level 1 (80% and above) or 2 (70% and 79%). In Kagera, 8 facilities were awarded level 1 and 2 facilities were in level 2. While in Mara, 6 facilities achieved level 1 and the remaining 7 achieved level 2.

The recognition event was conducted onsite and all facility staff and community around the facility participated in the event. The guest of honor during recognition ceremony included the District Executive Directors (DED) and RAS, who applauded the achievements of respective health facilities. The RAS and DEDs were impressed with the QI approach supported by MCSP and requested providers to not only to maintain the performance, but improve and achieve higher scores in the coming assessments. Community representatives also promised to support facilities and work in collaboration with MCSP and the MoHCDGEC to address existing challenges in the facilities such as late booking for ANC, late reporting of women seeking delivery services, inadequate equipment and limited supplies to support MCH services. As part of the Nkwenda HC recognition event, the DED acknowledged MCSP support and promised to support Nkwenda HC by providing the extension of maternity ward and postnatal wing. Also Bishop Kilaini from Catholic Church promised to strengthen maternal and child health services by supporting all faith based facilities under Catholic Church in Kagera region to insure maternal and neonatal morbidity and mortality rate are reduced. Below are some of the quotes.

“Few people appreciates when thing goes well but blaming is simple and practical to everybody. Jhpiego have shown their strong commitments by appreciating efforts made to improve quality of care by our staff” Dr Grasmus Sebuyoya Biharamulo DDH MO I/C.

“I appreciate the support from MCSP for great improvement achieved in our hospital within a short time. We also appreciate the good approach hold the recognition ceremony at the hospital. Workers have been used to blames but now we are calling them to congratulate them and encourages them, this has real motivated me“ Dr. Juma Nyakina MOI/C Bukoba Regional Referral Hospital

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Table 1: Facilities which were recognized and the level of recognition for Mara and Kagera

Region Level 1 achievement Level 2 achievement 1. Musoma RRH 2. Murangi HC 1. Tegeruka Disp 3. Butiama DH 2. Bunda DDH 4. Kibara Hosp 3. Ikizu HC Mara 5. Kasahunga HC 4. Mtana Disp 6. Tarime DH 5. Kinesi HC 7. Masanga HC ` 6. Nyerere DDH 8. Shirati Hosp

1. Bukoba RRH 2. Mugana DDH 3. Kagera Sugar Hospital 1. Rulenge hospital 4. Nyakahanga CDH 2. Katoke dispensary Kagera 5. Biharamulo CDH 3. Nkwenda Health Center 6. Rubya CDH 4. Izimbya CDH 7. Nyamiaga Hospital 8. Igayaza dispensary

Picture 1: Local drama group entertaining during one of the recognition event

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Picture 2: Recognition ceremony event at one of the facility in Kagera Region

2. Malaria in pregnancy

MCSP in collaboration with the MOHCDGEC at both National, Regional and Council levels, conducted MiP post- training follow-up, commodities management supportive supervision and mentorship, and disseminated Malaria guidelines, SOPs/job aids and IEC materials to 105 health facilities in Mara and 98 health facilities in Kagera. A total of 176 health care providers (HCPs) in Mara and 135 in Kagera were mentored and coached on malaria testing, management (both uncomplicated and complicated), dilution and dose and administration of artesunate, and documentation. All HCPs were able to test and treat malaria cases and more than 90% of health facilities had maximum stock of ALU, Artesunate and mRTDs. Few health facilities had at least a minimum stock of SP, and health facility managers agreed to use their own resources to procure the missing stock. All health facilities were given malaria guidelines, SOPs/job aids, 26,000 leaflets and 500 posters with messages of MiP, and were oriented to the FANC SBM-R tool. These materials will enable HCPs to provide quality ANC service.

3. CECAP

National-level Technical Assistance

National CECAP and Control Service Delivery Guidelines Update In this quarter, MCSP worked in collaboration with the MOHCDGEC/RHCa to facilitate a 3 days’ subject matter experts’ review workshop for updating the National CECAP and Control Service Delivery guidelines in Morogoro from March 27-29, 2017. MCSP led the facilitation of the technical review process to incorporate new recommendations from WHO with 4 main objectives: 1) to inform key experts on the status of the national CECAP program implementation and regional-level CECAP program activities; 2) to review current CECAP and Control guidelines and existing technical information gaps to be incorporated; 3) to discuss, review and incorporate key technical information in the CECAP and Control Service Delivery guidelines for development of 6 | P a g e

an updated version; and 4) to discuss next steps for finalization of the draft of the national CECAP and Control Guidelines.

Sixteen subject experts and representatives from the MOHCDEGEC (RHCa, NCD, HPEU, M/E, RHMT, CHMT), IPs (EGPAF/THPS), national trainers and professional associations (AGOTA/MEWATA) were in attendance to facilitate local ownership of the revision process. Workshop methodology incorporated presentations, reviews of evidenced-based reference documents, group work and plenary discussions. Participants were divided into small groups and used evidenced-based reference documents to update and provide recommendations for the background, advocacy/communication and social mobilization, primary prevention, secondary prevention, tertiary care, infrastructure/equipments/supplies, monitoring and evaluation, training/competency qualifications sections and annexes. Next steps for finalization have been outlined and MCSP will facilitate the finalization of these national guidelines.

National Service Delivery Statistics Review MCSP supported the MOHCDGEC/RHCa unit to create awareness on the importance of strengthening data management through a review of the national service delivery statistics and designing a well-structured forum that engages regional managers to discuss data management issues. A 2-day workshop was conducted from March 30-31, 2017, in Morogoro for key MOHCDGEC stakeholders to review national-level indicators/benchmarks in order to strengthen capacity of data quality and use for decision making for program performance improvement. Twenty-five participants attended and included RRCHCO or their representative from 15 regions: Morogoro, DSM, Iringa, Pwani, Mbeya, Njombe, Manyara, Arusha, Kilimanjaro, Mtwara, Lindi, Kigoma, Kagera, Mtwara, Tabora and Mara as well as 4 representatives from the RHCa unit. This workshop aimed to reinforce five themes in data management: 1) understanding the tools for CECAP data collection; 2) understanding key program QI indicators and how to calculate them as well as existing WHO benchmarks; 3) data use for decision making; 4) data analysis; and 5) recognizing the need to meet the national targets.

From the national-level data it was observed fluctuating and very low VIA positivity rate in most regions especially Pwani, Ruvuma, Kigoma, Tabora, Manyara and Kilimanjaro. Participants used this forum to discuss the context of the problem, which included the lack of gas and understanding the recording and importance of the indicators. Program challenges and recommendations were also discussed among participants, such as the low number of women screened for CC, low positivity rate, low treatment rate, incomplete as well as incorrect data in DHIS2. At the end of the workshop, participants developed joint action plans to address key challenges in data management and documented lessons learned that were shared across participants.

Group-based Cryotherapy Machine Maintenance Training In coordination with the RHCa unit and Health Care Technical Unit, MCSP facilitated a 4-day skills and group- based training at Centre for Enhancement of Effective Malaria Interventions (CEEMI) in from February 15-18 2017, to equip 16 technicians from 8 regions on repair, maintenance and troublshooting skills of cryotherapy machines. Technical assistance was provided by Anudha Pharmaceuticals, who has been engaged to support the repair and maintenance system of medical equipment in Tanzania. In the first two days, participants developed checklists for maintenance and repair of cryotherapy machines that have two components 1.) checklist for servicing a cryotherapy machine; and 2) checklist for maintenance, repair and troubleshooting a cryotherapy machine. Ten experts were engaged to develop the tool, which will be used at the national level to facilitate effective supervision activities.

Technicians were also oriented on the parts of cryotherapy machines and maintenance tips. Those oriented all had an opportunity to dismantle the cryotherapy machine and return it back to the original position. After some practice, recommendations proposed from this process were: a) include repair and maintenance budget in the CCHP b.) Purchase repair and maintenance toolkit boxes to ensure equipment preventive7 maintenance| P a g e approach is taken with support from implementing partners; c.) Each technician should develop individual work plan to support CECAP facilities in their respective regions; d.) Engage health care service technical units from the MOHCDGEC in supportive supervision activities of technicians; f.) Orient HCPs in troubleshooting cryotherapy machines; and g.) Finalize checklists and share with key stakeholders. Participants were also equipped with knowledge on the basics of CECAP, the National Cervical Cancer Prevention Program, CECAP service delivery models, and discussed existing CECAP services in Tanzania.

Following the repair and maintenance training, MCSP supported the RHCa unit to conduct trouble shooting and supportive supervision activities in 9 selected regions. MCSP in collaboration with the MOHCDGEC conducted this activity to ensure regional-level technicians, trained with support from MCSP, practice their new skills acquired while at the same time roll out repair and maintenance systems and advocate the importance of maintence being included in the budget to R/CHMTs. Conducted from February 20-23, 2017, this activity was implemented in 2-4 facilities within 9 regions, including DSM, Iringa, Njombe, Lindi, Kilimanjaro, Tabora, Mbeya, Mwanza, and Kigoma. Through these visits, technicians assessed machines’ functionality, checked instruments and supplies, inspected machine parts, cleanliness and storage, and repaired or replaced damaged parts. Some of the key challenges identified included: 1) limited supplies items/spare parts of PM Kit to address the gaps; 2) malfunctioning cryotherapy machines created additional challenges in service delivery on site were spare parts were not available; 3) leakage of gas, worn out ring, worn exhaust filter, improper connection of machine and gas cylinder, lack of gas in ; and 4) lack of budget allocation to support machine maintanance. Action plans were developed in each site and R/CHMT were engaged in order to provide further support to this activity. MCSP will work in collaboration with the RHCa to adress some of these challenges and advocate for inclusion of maintenance in CCHPs.

Supportive Supervision and Clinical Mentoring MCSP worked with RHCa unit to conduct the first round of joint national-level CECAP clinical mentorship activities in 8 regions to improve program performance and build capacity of VIA/Cryotherapy trainers/mentors to conduct internal quality assessments. Supportive supervision (technical and programmatic) was also conducted to ensure the transfer of skills and encourage service providers to improve performance for providing quality CECAP services. Conducted from February 8-10, 2017, data from January-December 2016 was reviewed and MOHCDGEC tools were used to document program performance. RRCHCOs were responsible to select 2-3 facilities to be visited in each region based on the performance and conduct an internal assessment using the VIA QI tool in DSM, Morogoro, Pwani, Iringa, Mbeya, Mwanza, Kilimanjaro and Kigoma. Trainers used checklists to assess clinical skills of providers in VIA/Cryotherapy skills and provided immediate feedback, and also conducted mentorship of CECAP providers on data review and verification process. During this activity, trainers reviewed CECAP registers, records, and monthly summary forms, IPC and service providers’ skills, facility audit, coaching, interviews and discussions, and assessed facility-based program components that focused on services, staffing, infrastructure, procurement and supply chain, equipment and supplies, infection prevention, medicines and laboratory, data management, referral mechanisms, policies and guidelines and community sensitization.

Overall, facility readiness scores ranged from yellow (needs improvement) to green. Strengths included the availability of cryo machines in the majority of sites visited, availability of essential supplies, and participation of HCPs in writing monthly reports, and regular service and practice of IPC skills by providers. Some of the key challenges observed included the lack of regular supportive supervision and clinical mentorship in most regions; most providers could not mention the key indicators as well as the benchmarks; very low VIA positivity rate; some sites use expired acetic acid or inappropriate %, hence contributing to variability of very low VIA positivity rate; few clients are screened in most sites which yields low uptake; lack of ownership of programs in most regions and dependency on implementing partner support; data collection tools not accurately completed, 8 | P a g e

leading to an inconsistency of data between registers and monthly summaries; and non-use of latest data collection tools; data are not well utilized in most facilities. Through this activity, mentor’s mentorship skills strengthened, an internal assessment was conducted for the 1st time, and data validation accomplished. At the end of supervision, all sites developed action plans to address existing gaps identified, and MCSP will continue to work with the MOHCDGE to adress the challenges. This was a national level wake up call to focus on quality issues in CECAP programming.

Participation in PRRR Partner Coordination Meeting MCSP participated in the PRRR partner’s coordination meeting which was held on the RHCa unit on the February 3, 2017 and was attended by the CEO and Regional Program Manager of PRRR and PRRR partners such as: Tmarc, Jhpiego, MEWATA, AGPHAI, Mbeya HIV AIDS Network Group, DOD, TAYOA, NACOPHA, and HJFMRI. Partners gathered to share progress made against objectives, results achieved, lessons learned and best practices, and plans for 2017, including measures of success. The PRRR Secretariat shared updates regarding the transition of PRRR-supported CECAP program in 2017 and new partners, AGPAHI, NACOPHA, TNW+ (AGPAHI, NACOPHA and TNW+). Participants were also informed on the expansion of CECAP in Tanzania, utilizing GFF funds in 10 Regions, and new initiatives including mHealth to improve access to CECAP services in Mbeya, and Hostel design competition results. Last, PRRR reinforced the importance of setting targets to ensure effective program implementation in all regions, as well as advised to use best practices within the Country to improve CECAP program performance.

Clinical Competence, Readiness, and Service Delivery Improvements

CECAP Outreach Services MCSP supported RHMTs in Iringa and Njombe Regions to conduct CECAP outreach services for 3 days to improve access for CECAP services. This was led and coordinated by the RHMTs in both regions. During the outreaches, providers gained experience in implementing outreach services and strengthened their capacity to plan and implement community based interventions. This was underpinned with additional experience of trainers to support providers in the same component especially in Njombe Region since thsi was their 1st outreach. A total of 529 new clients were screened in Iringa and 7.2% fond to have pre cancer lesions and all were treated on the same day(37) while in Njombe out of 300 new clients screened, 29 (10%) were found to have pre cancer lesions and all treated on the same day. This activity contributed to improve proviedrs skills in cryotherapy treatment and improved awareness of the program in the respective Regions. The team worked very closely with Iringa and Njombe TC /CHMT to ensure effective coordination and implementation of this activity. The program will continue to work very closely with R/CHMT to strengthen community mobilization component through tailored engagement of community leaders and influential people in the next quarter so as to improve uptake of the program during outreach services. There was improved commitment from the regional MOH for the implementation process which helped to enhance future sustainability of the program beyond MCSP support.

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2000 1876

1500

1000 755 694 631 631 500 427

0 0 0 January February March Total Iringa Njombe

Number of women screened for cervical cancer using VI in Iringa and Njombe regions between January and March, 2017

10 9 8 6 6 4 3 2 2 0 Iringa Njombe Number (%) of new clients referred for large lesions (LL)¹ Number (%) of new clients referred for suspect cancer

Number of women referred for screening and treatment between January and March, 2017

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120% 100% 100% 100%

80%

60%

40%

20% 7% 11% 0% Iringa Njombe % of new women screened with a VIA positive result % of clients VIA+ results treated with cryo on the same day (SVA)

Proportion of women screened & VIA positive results treated on the same date

Capacity Building Under PRRR funding through USAID, MCSP provided technical guidance and supported the strengthening of 3 PRRR CECAP sites in which have recently received new cryotherapy machines donated from PRRR. This activity strengthened the capacity of trained service providers on VIA and Cryotherapy in those sites namely Kidabaga HC, Mdabula HC and Kiponzelo HC and improve uptake of CECAP services. Under this portfolio, MCSP supported capacity building of Iringa CECAP Regional trainers who were assigned to support on site mentorship for 4 days. The program supported the team to develop on site mentorship guidance and ensure providers are mentored in 4 different components: VIA, Cryotherapy, Counselling, IPC and data reporting/compilation and use. This activity was undertaken for four days from the 8th to 11th of March 2017.Trainers used checklist, conducted internal assessmnet in all three sites and stayed on site to support the team in all 4 days. They all scored yellow which shows some improvement were needed to adress specific challenge. Action plans were developed in ech site to adress the gaps identified. At the end of the clinical mentorship; providers capacity improved and they were well oriented in all components of CECAP service delivery. Linked with this activity, Jhpiego supported essential CECAP supplies that includes consumables and non-consumables as start up package to support smooth service delivery in all three sites. To promote sustainability of the program, this activity was led, coordinated and conducted by RHMT/RRCHCO with technical and financial support from Jhpiego/MCSP. CHMTs in all 3 DCs purchased 2 carbondioxide gas which shows committement to support the CECAP program. MCSP will continue to work with RHMT to ensure these sites are supported on a regular basis through supportve supervision/clinical mentorship.

Introduction of CECAP in Njombe In this quarter, MCSP introducted CECAP in Njombe Region, and supported the orientation/inception meeting for RHMT, Njombe TC CHMT, Kibena HMT to MCSP/ CECAP program scope and key national technical documents and conducted a site assessment to identify gaps for strengthening. The inception meeting, conducted February 24-25, was very successful and support for the Program was received very positively. Three major outputs were achieved from this activity: 1) RHMT/selected CHMT members and Kibena11 | P RRH a g e HMT awareness on CECAP program needs, scope and PRR/USAID/Jhpiego support as well as knowledge on the CECAP program docs improved; 2) facility based site assessment conducted, gaps identified and key recommendations made to improve CECAP program performance; and 3) site strengthening that incorporated procurement and purchase of all necessary supplies/equipments accomplished to ensure smooth running of CECAP service delivery at Njombe RRH. At the moment, Njombe RRH is operational and RHMT has been oriented to CECAP program components and shown great ownership and support as well as the HMT and RHCa unit.

To enhance ability of Njombe RRH for delivery of quality CECAP services, MCSP conducted a 6-day VIA/Cryotherapy training to build capacity of 14 service providers on VIA/Cryotherapy from March 13-18, 2017. Didactic sessions were held for 2 days at the MCSP/Jhpiego office and clinical practice sessions were conducted at Njombe RRH for the remaining 4 days. The objectives of this training were to strengthen participants ability to: (1) counsel women about cervical cancer prevention; (2) explain how cryotherapy treats precancerous cervical lesions; (3) demonstrate recommended infection prevention practices; (4) perform a pelvic examination; (5) perform VIA; (6) perform cryotherapy, if indicated; (7) provide follow-up instructions and counseling and (8) provide care and referral, as needed. Participants gained significant amount of knowledge and skills in VIA/Cryo and Counselling and they were able to practice in simulation in the classroom using VIA/Cryotherapy checklists. They were oriented on how to use CECAP program M/E tools (registers/monthly summary and client ID cards), critically reviewed how to properly complete VIA/Cryotherapy registers and monthly summary forms, and reviewed CECAP program indicators and benchmarks. At the end of the training, all trainees (14) were qualified to offer VIA services and 8 qualified to offer VIA/Cryo services, while 6 need on- going mentorship to become qualified in cryotherapy service delivery. In the clinical practice session, 303 women were screened in 4 days of using VIA --- 10% (33) were found to have pre- cancer lesions and all 31 eligible for cryotherapy were treated with cryotherapy on the same day. Out of 33, two were found to have large lesion and were referred to Iringa for LEEP.

CECAP Procurement MCSP purchased and donated CECAP supplies for Iringa and Njombe RRHs to support CECAP service delivery. Supplies includes consumables and non-consumables items for VIA/Cryotherapy and LEEP services including gas refilling during outreach services and for routine service delivery. Njombe RRH also received both consumable and non consumable items such as examination beds, trolleys, drums, etc. for site strengthening and to support smooth service delivery.

Supportive Supervision MCSP supported CECAP supportive supervision for service delivery at Iringa and Njombe RRHs where from the preliminary results: 2,507 new clients were screened with VIA in the period of January-March, 2017 and 215 (8.6 %) of the new clients screened had VIA positive lesions. 204 (99%) of women diagnosed with pre-cancer lesions eligible for cryotherapy treatment were treated on the same day. Nine (9) clients had large lesion and referred to Iringa for LEEP. 0.4 % clients had suspect cancer in the quarter and were managed accordingly.

4. PRE-SERVICE EDUCATION

Continuous Quality Improvement (CQI) MCSP supported the ZHRC and MOHCDGEC to conduct CQI follow-up assessments in the seven unrecognized HTIs of Kagera and Mara regions in order to strengthen the learning and training environment for production of qualified graduates for quality RMNCH service provision. The schools visited were Kisare, Shirati, Tarime Nursing and Midwifery Schools, RAO Health Training Institute and Musoma CATC, in Kagera, Kagemu and Murugwanza were visited. 12 | P a g e

The CQI was done after a benchmarking visit, whereby unrecognized HTIs had the opportunity to visit best performing HTIs in the Kagera region. A team of three assessors from Ministry of Health Headquarters, and a representative from the Lake ZHRC and MCSP conducted this assessment. The areas assessed included classroom and practical instructions, clinical instructions and practice, institutional infrastructure, learning and teaching materials and institutional governance and administration. Methods of assessment were physical observations, interviews and document reviews. During the assessment 60% of the HTIs in Mara reached required scores for recognition, and now are ready to request from the Ministry of Health to send a team of external verifies to be followed by recognition. Those institutions are Shirati and Kisare which are FBO owned and RAO a private HTI. Two schools owned by the Government – Musoma CATC and Tarime Nursing Schools equivalent to 40% of all HTIs of Mara are still struggling to improve. Among 2 schools assessed in Kagera, Murgwanza has showed a tremendous improvement and is now ready to apply for external verification. Kagemu School of environmental science was not fully assessed, as students and tutors were done with the semester during the assessment. Assessment of the infrastructure was not possible at Kagemu school of environmental science because, some of the classes and staff offices were closed and not in use due to multiple cracks caused by the earthquake. While the infrastructure was not scored the damage noted to these facilities indicated a need for infrastructure strengthening. The only standard assessed at this school was institutional governance and administration. The school scored poorly on this standard only meeting five of the 15 standards in this category.

CQI results for unrecognized schools in Mara and Kagera Regions between January and March 2017

From the above results 3 schools: Kisare, RAO for Mara and Murugwanza in Kagera are eligible to apply for external verification, while one school: Shirati had some minor issues which are within their capacity to rectify and, once done they should be able to apply for external verification. The remaining three schools13 | Pwhich a g e are

owned by the Government: - Musoma, Tarime of Mara and Kagemu of Kagera need more efforts to reach the desired standards. MCSP will continue working with the ZHRC to address chronic challenges in these two HTI in order to improve their performance.

Comprehensive Family Planning Training In collaboration with MOHCDGEC/RCHS, MCSP conducted a Comprehensive FP training to build capacity of 18 tutors and clinical instructors from nine HTIs in Kagera and Mara from February 13-25, 2017, at ZHRC Mwanza. The overall goal of the training was to prepare tutors and clinical instructors to be able to impart family planning knowledge and skills to pre-service students. The focus of the training was to develop their capacity to help students develop skills in FP demand creation, FP screening, client education and counseling on FP methods, provision of various FP methods and management of side effects and complications related to contraceptive use. Updates included informed choice counseling, infection prevention and control, interval IUCD insertion, PPIUCD, IUDCD removal, implant insertion and removal, combined oral contraceptives, depot Medroxy Progesterone, Depo provera, Progestin-Only Pills, emergency contraceptives, lactation amenorrhea and fertility awareness methods, standard days methods, and male and female condoms. At the beginning of the training, a pre-training knowledge test was administered to measure the entry level of knowledge of tutors and clinical Instructors before commencement of the training. The results of the pre-training knowledge test revealed a gap of knowledge among the tutors. While the cutoff point was 60%, the highest score was 55% while the lowest score was 20%. The average score was 33%. This indicates that Majority of participants scored below cut off points. The difference between highest and lowest score was 35% which shows a big variation among tutors.

The majority of participants were not well updated on knowledge and skills to teach students about modern methods of FP. One participants commented “I wasn’t aware of many modern methods, there are many changes even to what I used to know before; what I learnt during my nursing training was very little compared to what I have learned during this training” During practical training participants had an opportunity to practice using models in the classroom and later they spent four days in two Hospitals – Sekotoure and Nyamagana for practicum training. Each participant had an opportunity to provide a variety of family planning methods. At the conclusion of the training they agreed that each school should develop action plans for continued supportive supervision and mentorship in family planning skills after sharing their learning with colleagues at their respective schools.

Table 3: Indicates total number of clients served by participants with different methods in the two clinics used for practicum training during clinic practice Type of FP Method/ Procedure Total Number of Procedure / Clients Client Education 26 Informed Choice Counseling 271 Infection Prevention and Control 124 Interval IUCD insertion 34 PPIUCD 12 IUDCD removal 8 Implant Insertion 59 Implant removal 12 DMPA 21

Onsite Supportive Supervision Conducted MCSP supported the MOHCDGEC through the ZHRC to conduct onsite comprehensive supportive supervision and mentorship using SBM-R tool to tutors/clinical instructors and clinical staff who are working in RMNCH areas in Kisare, Shirati, Tarime Nursing and Midwifery Schools, RAO Health Training Institute and Musoma14 | P CATCa g e for

Mara region and Rubya, Murugwanza, St Magdalena and Ndolage in Kagera region. Supportive supervision focused on BEmONC, post-partum care (PPC), PPIUCD, Helping Babies Breathe (HBB), comprehensive FP, and FANC including PMTCT, Syphilis and MiP. The supervision focused on strengthening the linkage between knowledge attained and capacity building exercises with students to make sure it is transferred to students both in classrooms, skills labs and practicum sites. A total 14 tutors and clinical instructors from the nine schools were mentored in different RMNCH skills including post-natal care, normal labor management, management of 3rd stage of labor, HBB, vaginal examination, hand washing, abdominal examination, and new-born care. A common problem observed in all clinical sites was a shortage of equipment and supplies, which negatively impacts students’ clinical learning. After supervision, feedback meetings were held to discuss challenges and each school developed an action plan to address gaps identified.

Assessment of Linkages between HTI and Clinical Practice Sites In partnership with the MOH and ACNM, MCSP conducted an assessment on student RMNCH clinical training and the linkage between HTIs and practicum sites so that MCSP, MOH and other stakeholders are able to strategize on how best to strengthen and improve practical training. The assessment identified factors affecting the quality of practicum site training and produced recommended interventions to address the gaps identified. The MCSP PSE team worked closely with the MER team and ACNM to develop assessment tools based on existing CQI, supportive supervision, practicum sites checklists and SBM-R tools, the recommendations from the MOH situational analysis, drafts of the Clinical Instructors Policy for Nursing and Midwifery training, and the National Guideline for clinical instructors for nursing and midwifery. The team came up with 5 themes for assessment which included: 1) collaboration between the school and practicum site, 2) Student training in the practicum site, 3) Student monitoring for effective practical training, 4) Motivation of those who train students in the clinical area, 5) Support from Regional and district authority; and 6) cross-cutting issues. The assessment was then conducted by two teams, one in Kagera and one in Mara, comprised of MCSP, MOH, and ZHRC for two days at each HTI. The assessment was conducted at seven schools: Shirati, Tarime, Kisare, Murgwanza, Rubya, Ndolage, St. Magdalena and two allied health institutions in Mara, Musoma CATC and Rao. The groups assessed were tutors, preceptors and heads of schools, students and practicum site management (matron/patron) and staff. Data was collected with interviews, focused group discussion (FGDs) and observation.

As a result of this assessment, MCSP identified the following: 1) while there appears to be successful on-going collaboration between schools and practicum sites, especially faith-based HTIs, there is not a well-structured or defined relationship between HTIs and practicum sites. HTIs and practicum sites are lacking memorandums of understanding, separate budgets focused on student clinical training, and regular meetings to discuss issues around student practical training. This has resulted a weak commitment from both sides. 2) Great support was observed in practicum sites from HMTs/CHMT for student training. The Government has begun to develop guidelines for practicum training particularly focusing on clinical instructors, but a structured practical training guide is missing. 3) All schools reported having managed training in theory and acquisition of basic skills in the skills lab. The current curriculum was reported to have a lot of content to cover in a short time needing extra hours to assure coverage of the content. 4) Monitoring of students in practical training was observed through daily attendance, evaluation forms and the experience books which were found to be a good system for monitoring student clinical training. Unfortunately consistent utilization of these mechanisms was not clear. 5) Schools reported that little is being done by the district or regional authority to support student training.

The key recommendations include: 1) The MOH and MOE should reconsider the certificate education program length and structure since producing a competent clinician in 2 professions (i.e. nursing and midwifery) requires more than 2 years and a more clearly defined set of knowledge, skills and clinical application for each. 2) Create a structured system and process for assuring appropriate clinical learning experiences for students during their midwifery studies. 3) Provide assistance in developing and managing separate budgets for the schools and 15 | P a g e

practicum sites to support student learning. MCSP will work in collaboration with ZHRC and MOHCDGEC central level to address the recommendations.

5. COMMUNITY

Supportive Supervision for Community Health Workers In this quarter, MCSP in collaboration with technical staff, USAID Boresha Afya and D-tree International, conducted intensive follow-up visits to trained Community Health Workers (CHW) and CHW supervisors in Serengeti and Muleba District councils, who were previously trained on the use of innovative technology of mobile phones to improve RMNCAH. The main purpose of the supportive supervision was to strengthen the capacity and competency of CHWs and CHW supervisors in recording and reporting clients in registers and use of mobile phone application to foster community and facility linkages for tracking referrals to facilitate improved quality. In Mara (Serengeti), the team visited 9 back up health facilities; Kemugesi HC, Rungabure HC, Kebanchabancha HC, Musati Dispensary, Nyansurura Dispensary, Iramba HC, Machochwe HC, Nyakitono HC and Nata HC. In Kagera (Muleba), the team visited Kaigara HC, Kimeya HC, Kyebitembe Dispensary, Kamachumu HC and Mbunda HC where CHWs from villages around the respective health facilities gathered.

The process was guided by the use of RMNCAH CHW Supportive Supervision Checklist. The methods used included registration of CHWs and their villages, discussions, review of reports in line with client registers, review of clients in mobile phones, mentorship on how to fill clients in registers and in phones, troubleshooting the mango-logic application in mobile phone, documentation of health facility data and general discussions on observed challenges. Findings indicated an increased number of clients seeking services at the facility level; for example, an increased number of pregnant women with <12 weeks gestation age who booked early for ANC services at Iramba and Machochwe between December 2016 and January 2017. Similarly, the knowledge health facility delivery practices increased among community members, as an increase was seen in Mubunda HC in Muleba from 61 deliveries in December to 66 in January 2017.

The main challenge observed was slowing pace amongst some CHWs in conducting home visits, community health education group talks and gender dialogue meetings. Inadequate follow-up of CHWs in households followed the completion of CSO subagreements, as the immediate health facility supervisors could only meet CHWs during monthly meetings due to heavy workload at their facilities. The engagement of USAID Boresha Afya will support in addressing this challenge moving forward.

Close Out Meetings for Health Promotion Tanzania (HDT) Since 2015, Health Promotion Tanzania (HDT) supported MCSP to reduce maternal, newborn and child mortality by putting more emphasis on the improved health seeking behaviors and promotion of MCH services including family planning, ANC, male involvement, postnatal care, exclusive breastfeeding and safe delivery plan. Key areas addressed by MCSP community component included; creating demand for use of RMNCH services, Improve referral through creating linkages between health facilities and community, increase enrolment for community health fund, create transport mechanism at community level to facilitate access to health facilities and conducting health promotion activities with focus in addressing gender issues hindering access of RMNH services.

HDT supported 6 wards (19 villages) in Ngara district and 5 wards (17 villages) in Biharamulo district until December 2016. As part of the Subaward close-out process, a MCSP representative joined HDT in closeout meetings conducted in Ngara and Biharamulo districts to orient R/CHMT on the closeout progress, share the final program report, and advise on program sustainability. The R/CHMTs committed themselves to support community interventions in the district during the transition period to USAID Boresha Afya and/or other partnerships and to include community activities in CCHPs for sustainability. 16 | P a g e

6. IMMUNIZATION

82nd Inter-agency Coordinating Committee (ICC) Meeting MCSP provided technical support during the 82nd Inter-agency Coordinating Committee (ICC) meeting convened by IVD. The ICC endorsed the IVD’s proposal to introduce the HPV vaccine and use a Performance Based Financing (PBF) budget to support warehouse expansion and rehabilitation of vaccine storage units. The ICC endorsed both requests and agreed that the holistic supply chain review, conducted by Llamasoft through the USAID funded Global Health Supply Chain project, would prioritize immunization supply chain to inform the warehousing transition from Medical Stores Department (MSD) to the IVD warehouses. The results of the review are expected in late April 2017.

Participation in EPI Managers Meeting From March 20-24, 2017, MCSP and a Routine Immunization Officer from IVD participated in the WHO EPI Managers Meeting for Eastern and Sub-Saharan Africa (ESA) in Kampala, Uganda. The forum convened immunization stakeholders from ESA to meet and discuss challenges that affect immunization programs and develop plans to address the challenges. Due to production delays of Inactivated Polio Vaccine (IPV), WHO recommended that countries use two fractional doses when available. Tanzania expects to receive the IPV consignment in early 2018.

Workshop Updating Immunization PSE Education To ensure pre-service education (PSE) curricula for immunization is used nationally and by schools and health institutes providing immunization PSE education, MCSP facilitated a workshop to adapt the WHO Immunization Prototype Curricula. Six training institutions representing the medical, nursing, environmental health, public health faculties, schools and selected regional and district Immunizations vaccine officers were in attendance. Three immunization WHO prototype curricula for medical, public health, nursing and midwifery schools in Tanzania were updated with new information. The groups also developed lesson plans, course outlines and learner practicum packages for each cadre. MCSP will continue to provide technical assistance towards finalization and approval by the higher education curriculum development bodies before sharing with other schools in the country.

Immunization Field Visits In March 2017, the MCSP immunization team participated in two field visits. The first visit was with USAID to Simiyu and included visits to the Dodoma dispensary and Malampaka HC (Maswa district). Another team of MCSP immunization staff and the Immunization Technical Advisor from Washington visited Urambo and Bariadi districts in Tabora and Simiyu, respectively, to review the implementation of activities. The teams reviewed program aspects related to Reaching Every Child (REC) operationalization and supportive supervision. Both teams observed that district staff exhibited adequate technical skills for vaccine and cold chain management and REC operationalization. All health facilities were sufficiently stocked and schedules for outreach and fixed sessions, as well as dates for requesting new LP cylinders, were displayed as required. Challenges included lack of temperature monitoring devices in Bariadi DC District Vaccine Store (DVS) and Masiwa and Dutwa HFs in Simiyu, stock outs in regional stores in both Tabora and Simiyu due to delays in distribution and lack of microplans in some facilities. Upon subsequent follow-up, both stores have vaccines in stock.

VIMS In collaboration with IVD and partners, MCSP helped collect feedback from VIMS users on system ability, performance and usability to guide IVD with decisions to scale up the system countrywide. Users recommended areas to improve, but generally commended the system. The overall challenge many reported was that they were forced to enter data in multiple systems. They are still required to report in the District Vaccination Data 17 | P a g e

Management Tool (DVDMT) as well as required to use the two tally sheets and registers (DHIS2 and IVD) at health facility levels.

Technical Assistance With core polio support, MCSP provided technical writing inputs into the National Coordinating Committee (NCC) to African Region Coordination Committee (ARCC) polio situation report for Tanzania for 2016. NCC submitted the globally required report to WHO/AFRO for review.

To improve data quality, monitoring and use, MCSP helped the MOHCDGEC’s Integrated Diseases Surveillance Unit and the IVD’s Surveillance Unit to draft the Integrated Diseases Surveillance Report (IDSR. This report develops and defines strategies to ensure surveillance data for both programs are harmonized at all levels.

MCSP provided technical assistance during the IVD Annual Routine Immunization Program Review Meeting with RIVOs from all regions in the country. The meeting aimed to review, validate and harmonize 2016 routine immunization data. IVD, in collaboration with data sub-working groups which includes MCSP, facilitated the meeting and assisted RIVOs harmonize 2016 data from districts, regions and national levels. The final report was disseminated within the country and globally as a measurement of Tanzania’s IVD performance in 2016.

MCSP provided technical support and facilitated supportive supervision in Tabora and Mwanza, both regions where Vaccine Information Management System (VIMS) is being pretested. MCSP has continued to build capacity of RIVOs, DIVOs and assistant DIVOs on use of VIMS in the districts of Urambo, Kaliua Sikonge, Nyamagana, Kwimba and Ukerewe.

MCSP provided technical assistance to the IVD Logistics Technical Working Group with drafting the Gavi Cold Chain Equipment Optimization Platform (CCEOP) applications for procurement of cold chain equipment. The application will be submitted in May 2017. If successful, funds are expected to improve the immunization program cold chain management through provision of spare parts and storage equipment.

MCSP provided technical assistance in MCSP supported councils in Kagera with using the micro planning tool to reinforce immunization priorities during the 2017/2018 CCHP planning and budgeting process. The impact of the technical assistance has resulted in an increase in budget projected for immunization, subject to approval by President’s Office Regional Administration and Local Government (PORALG). The amount allocated to the councils will be known after the budget approvals in June 2018.

MCSP provided technical support to R/CHMTs in Kagera with supportive supervision in Missenyi, Kyerwa, Bukoba DC, Karagwe and Ngara councils. Forty-two health facilities, 126 HWs, 169 CHWs, 35 HFGC members and 49 community leaders (ward councilors, Ward Executive Officers (WEOs), Village Executive Officers (VEOs), village chairpersons, hamlet chairpersons) assessed key challenges in their communities and were oriented on their responsibilities to help strengthen routine immunization. Supervision findings revealed improved performance at health facility levels including no stock outs reported, use of SMT by districts to order vaccines, outreach and mobile services implemented, and improved defaulter tracking by CHWs. MCSP provided technical support to District Medical Officers (DMOs), DIVOs and DRCHCOs from Ushetu, Msalala and Shinyanga DC where they facilitated an Immunization in Practice (IIP) training for health facility workers (vaccinators) to build their capacity of providing immunization services in their respective health facilities. Eighty-eight health workers were trained from all immunization facilities in Ushetu, Shinyanga DC and Msalala DC in Shinyanga on the IIP modules to build their knowledge and practice of implementing day-to-day activities including vaccine preventable diseases, effective vaccine storage, injection safety, planning immunization sessions, holding an immunization session, monitoring and using data for action and building community support for immunization. Follow-up mentoring and supervision to the new districts is planned to reinforce 18 | P a g e

knowledge and skills acquired during the training.

7. Health Information System (HIS)

Health Information Mediator Inception and Launch In collaboration with the MOHCDGEC ICT unit, MCSP facilitated a working session that developed the Health Information Mediator (HIM) use cases and data matrix. Representatives from the MOHCDGEC, President’s Office Public Service Management (POPSM), e-Government Agency (eGA) and partners participated. MCSP shared progress on the HIM and the e-Government Agency shared progress on the Enterprise Service Bus (ESB) and how the HIM is related and expected to contribute. The main output of the session was a draft list of use cases and data matrix that will be supported by version one of the HIM during the development phase expected to start in May 2017.

MCSP provided technical assistance to the MOHCDGEC to conduct a highly successful inception workshop where the HIM implementation was officially launched. HIS experts from Washington, DC provided technical assistance with planning and facilitation of the workshop. Officials from the MOHCDGEC ICT unit, eGA, POPSM, PORALG, and implementing partners participated in the workshop. The MOHCDGEC Permanent Secretary (PS) provided opening remarks and expressed his support for the HIM and activities that promote use of data for decision making. The PS was particularly pleased at how the HIM is also in line with the investment recommendation roadmap for health information systems developed by the MOHCDGEC. Major achievements accomplished during the workshop included: o MOHCDGEC HIM technical team was oriented on the HIM solution (Universal HIE), Rapid registry (data warehouse) and Care Connector (e-referral), o The HIM project implementation process was reviewed and discussed, o The business process review for phase 01 use cases was conducted and documented.

Tanzanian MOHCDGEC Permanent Secretary Dr. Mpoki Ulisubisya providing opening remarks in Dodomo at the HIM inception workshop. 19 | P a g e

After developing use cases and data matrix, MCSP supported program-based subject matter experts (SMEs) review business processes to validate program-based cross cutting indicators.

 MCSP provided technical support to the MOHCDGEC to conduct an Enterprise Architecture Technical Working Group (EA TWG) meeting that reviewed progress of the EA task teams, and presented the revised the HIE conceptual framework for approval.

 MCSP provided technical assistance to the Care & Delivery EA task team workshop in Morogoro. MCSP shared updates on the HIM project, reviewed and updated requirement specifications for the Electronic Medical Record (EMR) and Client Registry. Once developed, the EMR is expected to share its records via the HIM with other registries, for example the Health Facility Registry (HFR).

 MCSP facilitated demonstrations of the Health-e-Link modules (Rapid Registry, Universal HIE, Care Connector) for the EA TWG and PMO. The PMO is the technical arm of the eHealth Steering Committee and their understanding of the system is important to keep the eHealth Steering Committee informed.

8. LEARNING AGENDA

Facility Perinatal Mortality Study As part of the learning agenda, the MCSP Tanzania team has continued to implement a study titled “Evaluating a Facility Perinatal Mortality (FPM) indicator in Tanzania: feasibility, acceptability and usefulness of the indicator and sensitivity in measuring neonatal birth outcomes”. This study seeks to establish the validity, feasibility and acceptability and perceived usefulness of introducing a new indicator, called the “facility perinatal mortality (FPM)” indicator, into the Tanzanian health management information system (HMIS). During this quarter, the team continued data collection from the 10 study sites in Kagera. Data collection will be completed in April 2017.

Family Planning and Immunization study- Planning for implementation of integration The formative study on Family Planning and Immunization was completed, and the report has been drafted and shared with USAID for review. On 3rd March, the study findings were presented to the Family Planning Technical Working Group, and the TWG members received the report positively and acknowledged the need to integrate the Family planning and Immunization services. The Family Planning TWG agreed that there is need to engage the immunization section of the Ministry of Health in order to decide on the integration approach. In March, the Tanzania team received Ms. Chelsea Cooper, who provided Technical Assistance from MCSP HQ aimed at facilitating planning for implementation on an approach to integration of FP and immunization. A follow up meeting with the Assistant Director for RCHS was held on 22nd March to discuss the formative assessment findings, implementation plans, and to solicit support for joint collaboration and ownership of the activity by the family planning and immunization teams within the Ministry.

Family Planning and Nutrition Study Final report for the phase I is completed and has been shared with stakeholders, including the Ministry of Health. The tools for the implementation of the Social and Behavior Change Communication strategy are being finalized. TA was received from MCSP HQ in March to finalize plans for implementation. The protocol for phase II was developed, which will be an evaluation of the strategy to be implemented. The phase II protocol was submitted to USAID for review in early April.

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MPDSR Assessment Tanzania is one of the 4 countries (Zimbabwe, Nigeria, Rwanda, and Tanzania) implementing an assessment titled “Regional Review of Facility Level Maternal and Perinatal Death Surveillance and Response (MPDSR) Systems in Four Sub- Saharan African countries”. The purpose of this activity is to conduct a regional situational review of facility-based MDSR, PDSR and/or combined MPDSR systems (when existent) in the Africa region to assess the status of implementation in select countries and to deepen understanding of operational barriers and generate recommendations for strengthening MPDSR systems at regional and country level. During this quarter, the study has received NIMR IRB ethical approval and data collection will begin in May 2017.

CCHP Analysis MCSP participated in the 2017/2018 CCHP process in all 6 MCSP focus councils in Kagera. MCSP will continue monitoring implementation of planned activities in the current, 2016-2017 financial year to identify bottlenecks and advise accordingly. The final report documenting learning and results is being edited and will be finalized in the next quarter.

B. CHALLENGES IN JANUARY –MARCH 2017 QUARTER  Government owned health training institutions are showing slow progression on CQI performance due to limited funding to support the infrastructure improvements and other standards that needs more resources to realize expected changes  There is no clear standardized clinical training guideline for students in HTIs in terms of the scope of work and roles of clinical instructors and or preceptors. The project is currently advocating with MoH to work on establishing the guidelines for this purpose.  For immunization, data discrepancies exist between data reported in the IVD monthly summary forms and data reported in the DHIS2. The project continues to address this through regular meetings with IVD and regional administrations.  Low engagement by community leaders and CHWs. They lack support for immunization planning, service delivery and particularly defaulter tracking. Immunization activities are not the community leaders’/workers’ primary responsibilities, which makes sensitization and explaining the importance of the program and benefits even more critical. The project constantly encourage the district authorities to engage community leaders and CHWs on vaccination activities  Districts have inadequate funds to operationalize REC activities in the community or to motivate CHWs to support infant monitoring and tracking of immunization statuses.  CHW involvement in Tabora and Simiyu is still a challenge. The lack of incentives is a major problem cited by facility and district personnel. TIMIZA, a new program managed by CARE International, includes strategies to further engage CHWs. MCSP plans to try collaborating with TIMIZA to engage CHWs more with immunization activities, particularly defaulter tracing.  Introduction of a new evaluation process by Programme Management Office (PMO) has caused some unexpected delays; however, MCSP will continue to fast track evaluation meetings and prioritize providing required documentation in a timely manner to avoid disruption of planned activities.

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ANNEX

1. Planned Quarter 3 Activities from April – June 2017

CECAP  Support the MOHCDGEC to conduct CECAP TWG meeting that ensures engagement of key implementing partners/technical experts to share best practices and address program implementation challenges  Conduct 2 days repair and maintanance training to build capacity of regional and district level technicians from 9 Regions to contribute to strengthen repair and maintanance system.  Support the MOHCDGEC to conduct desk review to finalize development of the the updated CECAP and Control Guideline  Support RHMT Njombe to conduct one day Regional Level Stakeholder’s meetings (R/CHMTs,Trainers, IPs,DEDs,DCs) led by RC/RAS to share best practices in program implementation, data use for decision making and provide opportunity to discuss CECAP program needs, challenges, transitioning and sustainability components including development of Regional sustainability strategies  Provide TA and support Iringa/Njombe RHMT to conduct mass screening campaigns to improve access of services in hard to reach population and provide opportunity for mentorship of trainers in mass screening campaigns planning/preparation/organization skills in Iringa and Njome Regions  Support RHCa to conduct LEEP training TOT training to build capacity of LEEP providers in Irinag and Njombe Regions  Support the MOHCDGEC to conduct VIA/Cryotherapy TOT training  Finalize develiopment of CECAP nad Control service delivery guidelines

Pre-service Education (PSE)  Provide technical inputs on monthly HRH TWG meeting at the MoHCDGEC  Conduct refresher course on BEmONC and orientation on CEmONC  Conduct Regional advocacy meetings to strengthen clinical practice trainings  Conduct Quarterly CQI assessment including external verification of well perfoming HTIs  Recognizing best performing health training institutions  Conduct supportive supervision and mentorship to address the clinical practice at the practicum sites in health training institutions in Mara and Kagera regions

Immunization  Provide technical assistance to IVD’s Advocacy, Communication and Social Mobilization sub-TWG to strengthen routine immunization activities, prepare for new vaccine introductions and finalize preparations for commemoration of AVW in Tanzania.  Provide ongoing technical support with coordination of the FP/immunization integration stakeholders meeting.  Facilitate training of RIVOs, DIVOs, assistant DIVOS and health facility workers from the next selected eight regions to begin using VIMS. Additionally, conduct supportive supervision and continue mentoring of users (RIVOs, DIVOs and assistant DIVOs) already using VIMS.  Provide technical support with the implementation research study to assess the effectiveness of a web- based VIMS on immunization related data functions. The aim of the study is to guide IVD and partners on decisions to effectively and efficiently scale up the system countrywide.  Continue to build capacity of R/CHMTs in MCSP focus councils, specifically by conducting22 | P a effective g e

supportive supervision visits including monitoring REC implementation, microplanning and conducting data quality self-assessments.  Participate in the ToT training and follow on activities for the Pneumococcal Conjugate Vaccine (PCV13) switch from single to four dose vial.  Conduct a stakeholders meeting to disseminate MCSP’s experience with REC microplanning to strengthen the CCHP process.

Health Information System (HIS)  Meet with subject matter experts from identified systems for integration (DHIS2, eLMIS, HFR, Hospital Systems) to explore requirements from system perspectives before customization.  Install Health e-Link testing environment for the Tanzania HIM project.  Furnish and equip the HIM project office at the MOHCDGEC to facilitate implementation and collaboration.  Recruit a senior software developer who will be seconded to the MOHCDGEC and work closely with both the MOHCDGEC and MCSP.  Analyze, design & develop/customize the Universal HIE, Rapid Registry (Data Repository) and Care Connector (e-referral) based on prioritized list of phase 01 use cases.

Learning Agenda  Facility Perinatal Mortality Study o Complete data collection and study close out - April o Data analysis and report writing- May- June  Family Planning and Immunization study- Implementation of integrated services o Stakeholders meeting - May o Districts and facility planning for integration – May o Start implementation of integration and data collection – June  Family Planning and Nutrition Study o Pretesting of study tools- April o Training of providers and Community Health Workers- May o Implementation and data collection- June  MPDSR Assessment. o Data collection - May

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