MOZAMBIQUE INTEGRATED MALARIA PROGRAM Quarterly Technical Progress Report: Year 2 (October 2018 to September 2019)
First Quarter Report: October to December 2018
January 31, 2019
This publication was produced for review by the United States Agency for International Development. It was prepared by Chemonics International Inc. for the Integrated Malaria Program, contract number 720-656-18C-00001.
MOZAMBIQUE INTEGRATED MALARIA PROGRAM
Quarterly Technical Progress Report: Year 1 (October 2018 to October 2019) First Quarter Report: September to December 2018
Contract No. 72065618C00001
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Contents
Acronyms ...... ii 1. Program Overview ...... 4 Program Purpose ...... 4 Goals and Objectives ...... 4 2. Summary of the Reporting Period ...... 5 Objective 1: Support the implementation of proven malaria interventions at community and facility levels, in alignment with MSP ...... 6 Objective 2: Strengthen management capacity of the provincial and district Ministry of Health personnel to provide oversight and supervision of malaria interventions ...... 22 Objective 3: Improve HMIS data reporting, analysis, and use at the provincial and district levels ...... 24 3. Monitoring and Evaluation of the Activity ...... 26 4. Challenges and Actions Taken to Meet Targets ...... 27 5. Key Activities Planned for Next Reporting Period ...... 27 Annex A. Measuring Performance ...... 31
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. i
Acronyms
ANC antenatal care ADR adverse drug reactions AL Artemether-Lumenfantrina APE APE elementary multipurpose agent (agente polivalente elementar) DDM district medical warehouse (depósito distrital de medicamentos) DDS district health directorate DFO director of finance and operations DIS health information department (Departamento de Informação para Saúde) DPS provincial health directorate DQA data quality assessment CBO community-based organization CSO civil society organization CMAM Central Medical Store (Central de Medicamentos e Artigos Médicos) GHSC-PSM Global Health Supply Chain-Procurement and Supply Management GP general practitioner GMA general medicine agent GMT general medicine technicians GUC grants under contract HMIS health management information system IEC information, education, and communication IMaP Integrated Malaria Program in Mozambique IPTp intermittent preventive treatment in pregnancy women IRS indoor residual spraying ITNs insecticide treated nets M&E monitoring and evaluation MEL monitoring, evaluation, and learning MiP malaria in pregnancy MISAU Ministry of Health NED nucleus of district statistics (núcleo de estatística distrital) NMCP National Malaria Control Program MSP Malaria Strategic Plan PIRS performance indicator reference sheets PMI President’s Malaria Initiative PNAPE National Program of APE (Programa Nacional de Agentes Polivalentes Elementares) RDT rapid diagnostic tests SBCC social and behavior change communication SDSMAS District Women's Health and Social Action Services SESP education for public health sector (sector de educação para a saúde) SIS-MA Health Information Systems for Monitoring and Evaluation SME surveillance, monitoring, and evaluation
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. ii
SMI maternal and child health nurse (enfermeira de saúde materno infantil) SP sulfadoxine-pyrimethamine ST senior technician STA senior technical advisor TMP traditional medicine practitioners TWG technical working group USAID United States Agency for International Development
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. iii
1. Program Overview Program Duration: October 2017 to October 2022 Start Date: October 31, 2017 Life of Project Funding: $23,797,392.34 Geographic Focus: Zambézia, Nampula, Cabo Delgado, and Tete Provinces
Program Purpose The United States Agency for International Development’s (USAID’s) five-year Integrated Malaria Program (IMaP) in Mozambique is led by Chemonics International with support from Family Health International 360 and Vanderbilt University Medical Center – Friends in Global Health (VUMC-FGH). IMaP aims to strengthen implementation of the Malaria Strategic Plan (MSP), as aligned with global and Mozambican President’s Malaria Initiative (PMI) strategies and the identified needs of the National Malaria Control Program (NMCP). IMaP builds on previous malaria investments and harnesses the potential of the Ministry of Health (acronym in Portuguese: MISAU), the National Malaria Control Program (NMCP), health directorates, communities, and other stakeholders to maximize its impact.
IMaP works side by side with the NCMP, provincial health directorate (DPS) and District Women's Health and Social Action Services (SDSMAS) staff members to strengthen capacity and facilitate systemic improvements for better decision-making, planning, and guidance. As part of this process, IMaP uses a systematic process for identifying ways to address challenges and opportunities for technical support. IMaP also supports civil society and community-based organizations (CSOs/CBOs) to improve individual health-seeking behaviors through social and behavior change communication (SBCC). IMaP has incorporated data collection into each objective, which feeds into our monitoring, evaluation, and learning (MEL) system and gives access to adequate, timely, and accurate information to monitor performance, evaluate progress, and make adjustments to generate continual improvements. We will promote sustainability by cultivating leadership skills and building ownership of malaria control efforts by health directorates and their partners.
Goals and Objectives IMaP’s overall goal is to contribute to reducing malaria-associated mortality, morbidity, and parasitemia in four high-malaria-burden provinces (Zambézia, Nampula, Cabo Delgado, and Tete). IMaP will achieve this goal through three objectives: 1. Support the implementation of proven malaria interventions at community and facility levels, in alignment with MSP 2. Strengthen management capacity of the provincial and district MISAU personnel to provide oversight and supervision of malaria interventions 3. Improve health management information system (HMIS) data reporting, analysis, and use at the provincial and district levels
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 4
2. Summary of the Reporting Period During this reporting period, IMaP began conducting Year 2 activities in Nampula and Zambézia based on its approved work plan and MEL plan. IMaP also opened its project office in Tete during the second half of December 2018 and prepared for the opening of its project office in Cabo Delgado in Quarter 2.
In Zambézia, IMaP worked alongside the DPS to train 36 doctors from the central and general hospitals on NMCP’s new malaria case management standards. Among those trained were medical specialists and general practitioners (GPs). In Nampula, IMaP conducted this training for 780 health-care providers, including general practitioners (GPs), senior technicians (STs), general medicine agents (GMAs), general medicine technicians (GMTs), general and basic nurses, maternal and child nurses (enfermeiras de saúde materno infantil, SMIs), and other DPS health staff.
In Nampula, IMaP conducted supervisory and mentoring training to 130 DPS (15) and SDSMAS (115) staff who were already part of supervisory teams. To improve the management capacity of the Malaria Program, IMaP included training on how to use the draft capacity maturity needs assessment tool as one of the components of the supervisory and mentoring visit training. Recently trained DPS staff conducted supervisory and mentoring site visits on malaria case management to three districts covering nine health facilities and provided on-the-job training to 301 health-care workers.
Alongside the Zambézia DPS, IMaP conducted supervisory and mentoring site visits to 41 health facilities in 12 districts, reaching 203 health professionals. During these supervisory and mentoring site visits, IMaP also provided on-the-job training to 147 health facility staff (74 males, 73 females) and to 115 APEs (78 males, 37 females), seven more than the 108 planned for Quarter 1. The supervisory teams also revitalized two health committees in Lugela district: Errumene and Pututin.
During this reporting period, IMaP also reviewed the applications submitted by 39 CSOs/CBOs (19 from Nampula and 20 from Zambézia) to implement community-based malaria SBCC activities. From these applications, IMaP selected nine and seven organizations, respectively, from the two provinces to participate in a two-day orientation in each province to present a clear explanation of the RFA’s associated terms of reference. A total of 15 of the 16 organizations that attended the provincial orientations submitted final proposals (eight from Nampula and seven from Zambézia).
IMaP also worked alongside the Zambézia DPS to develop a tool with standardized indicators to help with the review of data discrepancies with the districts and share program performance at the provincial level. IMaP also provided financial and logistic support to the Quelimane district to conduct a meeting to discuss the malaria data with all health facilities and to develop the matrix with the methodology to guide future data discussions for other districts. Lastly, under our MEL activities, at the central level, IMaP’s Nampula and Zambézia SME specialists and SME STA participated in the data quality assessment (DQA) tools training conducted by NMCP.
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 5
Challenges IMaP experienced a few challenges in implementation during the first quarter of Year 2. One such challenge was a delay in finalizing the capacity maturity model, which is an important tool to support the identification of gaps in the malaria program's capacity to implement activities in Year 2. This delay was due to the identified need to contract STTA to conduct a review and comparison of other existing tools to improve these tools, as well as the need to incorporate feedback and results from the use of the tool in one of IMaP’s targeted provinces. We anticipate the recruitment of this STTA will be completed by the end of Quarter 2.
Recruitment and finalization of the SBCC strategy were additional challenges that impacted project implementation. Delays in finalizing the SBCC approach/strategy affected the project’s ability to implement the GUCs and fund CSOs/CBOs to implement community-based malaria SBCC activities. To resolve this issue, the short-term SBCC technical advisor is working with the IMaP team to develop a framework and initial inputs for the SBCC strategy. IMaP expects to finalize the SBCC strategy in Quarter 2.
Lastly, identifying a candidate that is supported by the DPS and the NMCP has delayed completion of the provincial team in Cabo Delgado and affected the project’s ability to begin implementation at the provincial and district levels in that province. IMaP has re-advertised the job and expects to complete the recruitment process for all positions by the end of Quarter 2.
Objective 1: Support the implementation of proven malaria interventions at community and facility levels, in alignment with MSP Activity 1.1. Strengthen national malaria policies, strategies, and guidelines. IMaP Clinical STTA led the review of the supervisory checklists that are part of the Integrated Supervisory Manual (Activity 1.1.1). After completing the review, the checklists were tested during the practical sessions of the supervisory and mentoring training that took place in Nampula from November 7 to 17, 2018. These reviewed checklists will be incorporated into the Integrated Supervisory Manual, which is now under review and will be finalized by the case management short-term technical assistance (STTA), who will be identified and hired in Quarter 2. To support NMCP with its reporting requirements, based on discussions with NMCP counterparts, IMaP supported the NMCP in developing its quarterly newsletter covering the period from October to December. We expect that this newsletter will be published in Quarter 2 of this fiscal year.
Activity 1.2. Improve access to and quality of febrile case management at public health facilities and at the community level to ensure prompt and accurate diagnosis and appropriate treatment of malaria. In support of Activity 1.2.1, the Nampula district and community engagement specialist and clinical provincial specialist, alongside SDSMAS and DPS staff members from the education for public health sector (sector de educação para a saúde, SESP), conducted social and behavior change communications (SBCC) meetings in 12 districts in Quarter 1, exceeding the target of nine districts. IMaP invited community leaders, other key community members who influence behavior and social norms [e.g., matronas (old women), traditional birth attendants, traditional
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 6
healers, local administrators, and health committee members], and APEs to participate in these meetings. The aim of these meetings is to improve malaria care seeking behaviors in the health facilities in the target districts and enhance the SDSMAS and DPS’ capacity to coordinate and oversee SBCC activities. Discussion topics included how to prevent malaria and engage community members in actions that aim to improve their own health. IMaP will closely monitor the health facility-based data to determine if these meetings with a multidisciplinary group have helped to increase the number of individuals who seek care. These 12 districts are among the 15 that have benefited from supervisory and mentoring site visits conducted by IMaP alongside SDSMAS. There were 289 participants in these meetings, 104 (35.9%) of whom were female.
In support of Activity 1.2.2, IMaP trained 140 traditional medicine practitioners (TMP) in five districts in Zambézia (Exhibit 1). The training included topics on how to recognize the signs and symptoms suggestive of malaria; recognize the signs and symptoms of severe malaria; practice and communicate malaria prevention, testing, and treatment measures; perceive local myths and beliefs that interfere with the prevention and treatment of malaria; and complete the referral form for cases with symptoms suggestive of malaria.
Exhibit 1. TMPs Trained in Zambézia in Quarter 1, Year 2 Number of TMPs Projected to be Number of TMPs Actually Trained Districts Trained M F Total Milange 30 26 5 31 Gurué 30 14 23 37 Namarrói 30 2 23 25 Mocuba 30 8 13 21 Lugela 30 15 11 26 Total 150 65 75 140 Source: IMaP/DPS Zambézia
In Zambézia, IMaP continued training health providers on the new norms of malaria case management, an activity that began in 2017 (Activity 1.2.3). IMaP trained 36 doctors from the central and general hospitals and the Quelimane SDSMAS, falling short of the 50 projected for the quarter. Among those trained were medical specialists and GPs, as shown in Exhibit 2 below. The remaining 14 doctors who did not participate in the training were on annual leave or engaged in other activities outside of Quelimane. IMaP measured the knowledge of the 36 participants through pre- and post-tests, which showed a slight increase from 69% (pre-test) to 76% (post-test).
In Nampula, IMaP provided malaria case management training using the new malaria treatment standards to 780 health-care providers of various cadres, including GPs, ST, GMAs, GMTs, general and basic nurses, SMIs, and other DPS health staff (Exhibit 3). These trainings took place from December 10 to 21 in 16 of the 19 districts projected for the quarter. The staff of the remaining three districts, including staff from the Central Hospital of Nampula, will be trained in Quarter 2. In Cabo Delgado, training was led by MISAU after two delays that prevented IMaP from joining the MISAU team. In Tete, IMaP will conduct the training alongside NMCP counterparts during Quarter 2.
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 7
Exhibit 2. Central and General Hospital Doctors Trained in Malaria Case Management in Zambézia in Quarter 1, Year 2 Total Trained by Category Trained Projected T Coverag District to be o Obstetrici e rate Internal Trained t M F Pediatricians GPs ans/Gynec (%) Doctors a ologists l General 7 7 5 2 0 7 0 0 100 Hospital Central 2 38 14 10 2 17 2 3 63 Hospital 4 Quelimane 5 5 3 2 0 5 0 0 100 SDSMAS 3 Total 50 22 14 2 29 2 3 72 6 Source: IMaP/DPS Zambézia
Exhibit 3. Health Professionals Trained in Malaria Case Management in Nampula in Quarter 1, Year 2 Projec Total Trained Trained by Category ted to Coverag District be Tot GM GM Nur SM Oth e rate M F GPs STs Traine al Ts As ses Is ers (%) d Ilha de 43 41 22 19 1 7 3 17 13 0 0 95% Moçambique Erati 97 96 42 54 3 14 8 40 26 5 0 99% Nacarôa 47 42 16 26 2 7 1 14 18 0 0 89% Mecuburi 67 61 25 36 0 17 0 22 22 0 0 91% Malema 51 37 13 24 2 10 1 10 13 1 0 73% Liupo 29 25 8 17 1 9 0 8 7 0 0 86% Mogincual 39 30 11 19 2 6 0 14 8 0 0 77% Muecate 56 45 13 32 1 8 0 12 24 0 0 80% Moma 77 68 37 31 4 14 1 29 15 5 0 88% Larde 36 34 17 17 0 7 3 16 7 0 1 94% Ribaué 64 58 39 19 3 11 5 18 19 2 0 91% Lalaua 32 31 14 17 0 6 0 12 10 1 2 97% Memba 84 74 35 39 2 16 9 26 21 0 0 88% Mossuril 54 47 14 33 1 7 3 16 20 0 0 87% Meconta 71 59 21 38 2 11 5 24 15 0 2 83% Nacala-a- 39 32 9 23 1 5 0 13 13 0 0 82% velha 33 44 Total 886 780 25 155 39 291 251 14 5 88% 6 4 Source: IMaP/DPS Nampula
IMaP conducted a three-day supervisory and mentoring training alongside the Nampula DPS for 130 health professionals (Activity 1.2.5). . Lessons learned from the training included ensuring that the health facilities chosen for the practical sessions of the supervising training have an
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 8
adequate number of facilitators to accommodate all participants in the triage of pediatric, pharmacy, and laboratory. IMaP will continue to monitor participants after the first provincial- level supervision visits to identify lessons learned.
Exhibit 4. Participants of Supervisory and Mentoring Training in Nampula
Health Personnel Trained Cadre Total M F District Chief Medical Officer 19 4 23 General Practitioner 10 7 17 General Medicine Technician 23 8 31 General Medicine Agent 1 2 3 SESP/Preventive Medicine Technician and Maternal 21 7 28 and Child Nurse Nucleus of district statistics 25 0 25 Laboratory Technician 3 0 3 Total 102 28 130 Source: IMaP/DPS Nampula
The training was theoretical and practical and included the following topics: malaria case management and pharmacy and laboratory management based on NMCP standards; use of the supervisory checklists that IMaP used and revised during its first year of implementation in Zambézia and Nampula; scope of work of the health committees; main messages on use of mosquito nets disseminated in the health facility and community; main messages on malaria in pregnancy (MiP) disseminated in the health facility and community; malaria data sources, DQA tools, errors found in SIS-MA; NMCP cohort indicators (intermittent preventive treatment in pregnancy women - IPTp, mosquito nets); and supervisory tools used in the health facilities. The training also included a practical session in which the participants conducted supervisory site visits, guided by the training facilitators, which were followed by discussions of the visit findings and development of an action plan.
Among the 130 participants in the training of supervisors, 15 were DPS health professionals from the public health department, medical assistance department, planning and cooperation department, and the Nampula Central Hospital. Each of Nampula’s 23 districts were also represented by five health staff: chief medical officer, malaria officers, clinician (either GP, GMT, or GMA); SESP leader; and monitoring and evaluation (M&E) representative. The 130 participants were divided into five classes with a total of 13 training facilitators, seven of whom came from DPS and six were IMaP staff.The first round of trainings took place from November 7 to 17, 2018, and the second round occurred from December 3 to 8, 2018. Exhibit 4 below provides details on the training participants
Due to the unavailability of the Zambézia DPS, IMaP was unable to conduct the supervisory and mentoring trainings during the first quarter. IMaP has already confirmed that the training will take place in January and will be reported on in the Quarter 2 report.
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 9
IMaP, alongside the Zambézia DPS, conducted supervisory and mentoring site visits to 12 districts of the 18 districts projected for Quarter 1 (Activity 1.2.6). The IMaP-DPS teams visited 41 health facilities of the 54 projected, assessing 203 health professionals of the 486 targeted, as shown in Exhibit 5 (next page)1. Based on these supervisory and mentoring site visits, IMaP provided on-the-job training to 147 health facility staff (74 males, 73 females) who showed weakness in the following areas: malaria case management (including injectable artesunate dosage calculation); use of rapid diagnostic tests (RDTs) and/or microscopy; and treatment of MiP. Exhibit 6 (below) presents the main findings and recommendations for needed improvements during the supervisory and mentoring site visits. The main findings from the APE supervisory and mentoring site visits are summarized in Exhibit 7 (below).
IMaP also learned that some of the supervisory and mentoring visit team members in Zambézia had not been trained for such assignments. In order to avoid this in the future, IMaP has begun holding coordination meetings with supervisory and mentoring site visit team members in preparation for the supervision training in January 2019 to ensure maximum participation. Although supervision has started in this first quarter in Zambézia, there is still a need to train supervisors and to familiarize them with the tools currently being reviewed, such as the integrated supervision manual, supervisory checklists and the IMAP supervision approach.
In the respective sanitary units where APEs are attached, IMaP conducted on-the-job training to 115 APEs (78 males, 37 females) in Zambézia, seven more than the 108 planned for Quarter 1 (Activity 1.2.6). The training included the following topics: diagnosis of malaria; management of patients with fever; completion of health information system forms and the registry books; notification of malaria cases; and implantation of health promotion activities, such as lectures and home visits.
The supervisory team also revitalized two health committees in Lugela district: Errumene and Pututin. Exhibit 8 shows a photo of the health committee members linked to the Errumene Health Center. As part of the revitalization of these two health committees, IMaP trained members on the following topics: signs and symptoms of malaria, including MiP; major complications in malaria; ways to prevent malaria; and how to refer Exhibit 8. Health committee members of the Errumene Health Center in suspected malaria cases to the Zambezia, October 23, 2018. Source: IMaP.
1 There was a significant difference between the projected and actual number of health professionals reached during the supervisory and mentoring site visits for this quarter. There are a number of factors that resulted in this discrepancy, such as annual leave, leave without pay, and involvement in indoor residual spraying activities.
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 10
health facility. While this is not an activity that will be implemented across all districts, it was an additional benefit to the supervisory visit.
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 11
Exhibit 5. Health Facility Staff and Respective APEs Reached During Supervisory and Mentoring Site Visits in Zambézia during Quarter 1, Year 2 Number of Health Care Workers Trained, by Cadre and Sex Clinicians/ Laboratory Pharmacy M&E Officers APEs Districts Health Facility SMI Technician Technician M F M F M F M F M F CS Sede 3 4 1 0 1 0 1 0 2 0 Lugela CS Erurune 1 2 0 0 0 0 0 0 0 0 CS de Puthine 0 4 1 0 0 0 0 0 0 0 HD Gilé 1 6 1 0 1 0 1 0 3 4 Gilé CS de Maneia 1 2 1 0 1 0 0 0 2 2 HD Morrumbala 0 3 1 0 1 0 1 0 0 0 CS Morrumbala 0 3 0 0 0 0 0 0 4 0 Morrumbala CS de Boroma 1 2 0 0 0 0 0 0 3 1 CS de Pinda 1 2 0 0 0 0 0 0 2 0 CS Sede 2 3 2 0 1 1 1 0 0 0 CS Nabui 1 2 0 0 0 0 0 0 5 8 Pebane CS de Pele Pele 1 2 0 0 0 0 0 0 0 0 CS 7 de Abril 0 3 0 0 0 0 0 0 0 0 CS de Malema 0 1 0 0 0 0 0 0 0 0 CS de Guerissa 1 2 0 0 1 0 0 0 2 0 Derre CS Sede 2 4 1 0 1 1 1 0 10 3 CS de Machindo 0 1 0 0 1 0 0 0 1 0 CS Mopeia Sede 2 4 1 0 0 1 0 1 0 0 CS Gulamo 1 2 0 0 0 0 0 0 2 0 Mopeia CS Lua Lua 1 3 0 0 0 0 0 0 2 0 CS de Chimuara 1 4 0 0 0 1 0 0 0 0 CS Sede 2 4 1 1 1 1 2 0 7 4 Mulevala CS de Mabua 1 2 0 0 0 0 0 0 1 1
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 12
Number of Health Care Workers Trained, by Cadre and Sex Clinicians/ Laboratory Pharmacy M&E Officers APEs Districts Health Facility SMI Technician Technician M F M F M F M F M F CS de Chiraco 1 2 0 0 1 0 0 0 2 2 CS de Tebo 1 2 0 0 1 0 0 0 3 2 CS Sede 1 5 1 0 0 1 1 0 1 0 Namarrói CS Lipali 0 1 0 0 0 0 0 0 2 1 CS de Mutepua 1 1 0 0 0 0 0 0 2 0 CS Sede 2 4 1 0 0 1 1 0 4 3 CS Marcação 1 1 0 0 0 0 0 0 0 0 Luabo CS Chimbaza 1 2 0 0 0 0 0 0 0 0 CS Escovinho 1 2 0 0 0 0 0 0 0 0 HR Mocuba 4 5 1 0 1 1 1 0 0 0 Mocuba CS de Mugeba 1 3 0 0 0 0 0 0 2 2 CS S. Machel 0 3 0 0 0 0 0 0 2 2 CS Coromana 1 3 0 0 0 0 0 0 5 1 Molumbo CS Malua 1 3 0 0 0 0 0 0 2 0 CS Sede 5 3 1 0 1 0 1 0 0 0 CS Sede 1 2 0 1 0 1 1 1 2 0 Inhassunge CS Ngonhane 0 2 1 0 0 1 0 1 3 2 CS Palane Mocula 1 1 1 0 1 0 0 0 2 1 46 100 16 2 14 10 12 3 78 37 Total 146 18 24 15 115 Source: IMaP/DPS Zambézia
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 13
Exhibit 6. Health Facility Supervisory and Mentoring Site Visit Findings in 12 Districts in Zambézia in Quarter 1, Year 2 Positive Findings Areas to Improve Recommendations Made IMaP Next Steps During Outbrief Meeting Good availability of SP at Of 41 health facilities visited, 29 IMaP will distribute algorithms antenatal care (ANC) services health facilities do not have in Quarter 2 as described in the at the time the supervisory visit algorithms on preparation and Year 2 Work Plan occurred administration of artesunate injectable SP is provided following the Some health facilities do not have Charts with information on IMaP alongside DPS will follow established standards IPTp coverage charts and other IPTp coverage and trends of up on general visits in health malaria indicators on walls where other malaria indicators facilities (general visits are visits During the period under report, consultations take place should be easily accessible in that take place in the wards each of the health facilities health facility for health once a week with the entire visited has HTZ results workers to see and consult ward staff to discuss diagnosis expressed as parasite density whenever needed and treatment of patients)
Registry books are filled with The health facility team should illegible handwriting, making it analyze monthly summaries difficult to follow up and compile before sending them to district malaria-related data level The ANC registry book does not District malaria focal points have a column for collecting should distribute daily forms in malaria data all consultation rooms for counting malaria cases Health facilities do not regularly IMaP will continue to report and report adverse drug reactions advise clinicians, clinic directors, and medical chiefs Artesunate is not given at IMaP will continue to report and recommended intervals to advise clinicians, clinic directors, patients hospitalized with severe and medical chiefs malaria Health facilities do not regularly IMaP alongside DPS will conduct discussion of deaths due promote and schedule with the to malaria and clinical cases of chief medical officer, clinical severe malaria director, or health facility director monthly discussions on malaria-related deaths and severe malaria cases during supervisory and mentoring site
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 14
visits in the health facilities with inpatient care IMaP alongside DPS will coordinate with district medical officers to reactivate medical officers to reactivate general visits in health facilities
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 15
Exhibit 7. APE Supervisory and Mentoring Site Visit Findings in 12 Districts in Zambézia in Quarter 1, Year 2 Positive Findings Areas to Improve Recommendations made during IMap Next Steps out brief meeting Health information system The lack of log books and the APEs should receive on-the-job SDSMAS should monitor forms completed with legible use of adapted books lead to training on how to complete implementation of handwriting incomplete registration, which health information system forms recommended improvement makes it difficult to prepare the and registry books when they actions for APEs Most of the APEs are up to date monthly summary come to health facilities to with new malaria case deliver monthly summaries management standards but don’t provide pre-referral APEs supervisor does not Reactivate and intensify the treatment for severe malaria follow up on the community monthly supervisions from the cases before referring to health visits conducted by APEs APEs Supervisor, through the facilities use of APEs funds for supervision APEs have information, APEs do not have a lecture plan APEs should have a lecture plan education, and communication for dissemination of updated and conduct lectures in (IEC) materials, such as educational messages community based on this plan flipcharts, for use during lectures Of 115 APEs visited, 23 have The district medical not been receiving the warehouses, in coordination Artemether – Lumefantrine with the provincial medical (KIT AL) for more than three warehouse, should guarantee months availability of RDTs and antimalarial drugs for malaria testing and treatment at the community level There is data discrepancy between APEs’ summary and data found at health facilities APEs have not received subsidy for more than six months
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 16
In Nampula from October 22 to 26, an integrated team of IMaP and DPS staff divided into three groups to conduct supervisory and mentoring site visits on malaria case management to the districts of Mogovolas, Moma, and Mongicual, covering nine health facilities, as shown in Exhibit 9. During these supervisory and mentoring site visits, the teams provided on-the-job training to 301 health-care workers (182 male, 119 female) of the 486 projected in Quarter 1. In Nampula, only three districts received supervisory visits because the provincial director of health prioritized case management training of health professionals instead of supervisory visits. IMaP- DPS teams used these on-the-job trainings to develop technical skills and transfer malaria and febrile case management knowledge to these health facility-based professionals. The main findings can be found in Exhibit 10 (on the next page). At the community level, IMaP provided on-the-job training to 54 APEs (39 male, 15 female) of the 108 projected for Quarter 1. IMaP used these trainings to strengthen APEs’ implementation of health promotion activities, including group meetings and home visits.
Exhibit 9. Supervisory and Mentoring Site Visits Conducted in District Hospitals and Reference Health Facilities in Quarter 1, Year 2 in Nampula
Team Districts Period Health Facilities Visited Team Composition
Mogovolas October 25 to 26, Jael Ajana, DPS M&E Nametil Health Center 2018 Joselina Calavete, IMaP clinical provincial specialist Esmeralda Manuel, DPS 1 October 23, 2018 Nanhupo Health Center pharmacy Emilio Alfane, DPS October 24, 2018 Iuluti Health Center laboratory
Moma Regina Passe, DPS clinician October 23, 2018 Moma District Hospital Almera Fernando, DPS pharmacy Rachido Salimo, DPS 2 October 24, 2018 Chalaua Health Center laboratory Abdul Hamid, IMaP SME October 25, 2018 Micane Health Center specialist
Mongicual October 23, 2018 Quixaxe Health Center Azarias Gimo, DPS M&E Nere Luis, DPS clinician Isaura Cafuma, DPS 3 October 24, 2018 Xa-Selemane Health Center pharmacy Baptista Norgado, DPS October 25, 2018 Namige Health Center laboratory
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 17
Exhibit 10. Health Facility Supervisory and Mentoring Site Visit Findings in 3 Districts in Nampula in Quarter 1, Year 2 Positive Findings Areas to Improve Recommendations Next Steps made during our brief meeting Patients with suspected Poor clinical history: District medical IMaP, alongside DPS, malaria are tested and Providers do not ask if officer should provide will distribute then given the patient had malaria on-the-job-training algorithms and administration of ACT in the last 28 days before and mentoring flowcharts on when the test is testing and do not ANC/IPTp and positive conduct differential differential diagnosis of Women eligible for diagnosis fever to districts and sulfadoxine + their sanitary units to pyrimethamine (SP) be used by the receive malaria clinicians as reference prophylaxis through SP (at their desks or on during antenatal care the wall) during their visit and also receive patient consultations in bed net. the second quarter RDT are available in all sectors Anti-malaria drugs are available at emergency room even when pharmacy is closed Dosages of artesunate are well calculated and dosage respected; Artesunate is provided to patients following the malaria treatment Monthly statistical summaries were available at the health facilities units and districts During RDT testing the District medical IMaP, alongside DPS, providers do not write officer should provide will continue providing the time the test was on-the-job-training training on malaria case done and immediately and mentoring management standards read the result as foreseen throughout
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 18
Patients who have anti- District medical Year 2 of the Work malarial prescription do officer should provide Plan not receive any on-the-job-training explanation on how they and mentoring should take the medication
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 19
An integrated DPS and IMaP team participated in the discussion of the deaths that occurred in the Rural Hospital of Mocuba and in the Inhassunge Health Center in Zambézia, which included five reported deaths (four in Mocuba and one in Inhassunge) (Activity 1.2.10 and 1.2.11). Four of the reported deaths were from the pediatrics ward, and one was from the internal medicine ward. Of the deaths discussed, only one from the pediatrics ward was reported as being directly caused by malaria; the other three were due to other illnesses. The discussion of the death due to malaria was that the death was inevitable as the child came to the health facility in serious condition and with intoxication by traditional medicine. As a next step, the case will be presented to the community to raise awareness about the need to bring the children to the health facility before the disease becomes serious. In Nampula, deaths due to malaria in the three districts visited in October were not discussed because there were no deaths attributed to malaria recorded in the districts of Moma, Mongicual, and Mogovolas.
During supervisory and mentoring site visits to districts in Nampula and Zambézia, the joint IMaP and DPS team provided training to pharmacy technicians and SMIs on the quantification of malaria commodities (Activity 1.2.17). In general, it was observed that pharmacy technicians know how to quantify malaria drugs and supplies, but the SMIs still have some difficulty. Based on this observation, the IMaP-DPS team conducted on-the-job training to pharmacy technicians and SMIs on the quantification of malaria drugs and consumables during the site visits. Follow- up to SMIs who showed difficulty with this skill will be done on subsequent visits to see if their knowledge and practice have improved. The refresher training for laboratory technicians was postponed until Quarter 2 based on overlap with other DPS activities.
Activity 1.3. Increase delivery of the full course of IPTp using sulphadoxine- pyrimethamine as part of an integrated package of antenatal visits During this reporting period, the IMaP-DPS teams conducted supervisory and mentoring visits to 41 health facilities in 12 districts in Zambézia. During the supervision and mentoring visits, 100 SMI were trained on the job in provision of prophylaxis with sulfadoxine-pyrimethamine (SP) in pregnant woman. They were also trained in completion of the IPTp data collection system, including monthly summaries. During these visits, IMaP-DPS teams also found that all the health facilities had malaria medications and consumables, including SP.
As our SP activities are integrated into larger SP activities, the teams also found that these same facilities had the logistic management and information system (SIGLUS) installed, which has facilitated confirmation of existing drug and consumable stock levels. The team also identified gaps in the knowledge and skills of pharmacy technicians and SMIs on how to quantify medicines and consumables (Activity 1.3.1 to 1.3.4). They addressed these gaps by conducting on-the-job trainings that included how to complete the health information system forms and the registry books, collect registry book data, and complete monthly summaries.
In coordination with the DPS, IMaP will continue to provide on-the-job training to SMIs who have been identified as having difficulty in quantification. IMaP also provided logistical support in the transportation of antimalarial drugs from the district drug warehouse in Inhassunge district to the peripheral health facility in its catchment area.
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In Nampula, during the supervisory and mentoring visits, the IMaP-DPS teams found that there were no recorded drug or consumable stockouts in the target districts (Activity 1.3.1 to 1.3.4). However, they did identify gaps in the knowledge and skills of SMIs in the registry of pregnant women who received IPTp and mosquito nets during antenatal care and conducted these same types of on-the-job trainings. Seven SMIs in Mogovolas, along with one each in the Moma and Mongicual districts, received on-the-job training on how to count SP doses given to pregnant women during ANC visits. IMaP also provided logistical support by transporting antimalarial drugs from the provincial drug warehouse to districts of Malema, Mecuburi, and Ilha de Moçambique during the supervisory and mentoring visits. During these visits to the aforementioned districts, IMaP conducted case management training.
Activity 1.4. Strengthen SBCC implementation. During the first quarter, IMaP included SBCC as a component of the supervisory and mentoring trainings conducted in Nampula and as part of the supervisory and mentoring visits conducted in both provinces (see Activities 1.2.5 and 1.2.6 above) as a way to strengthen the SBCC skills of health-care providers. For example, IMaP integrated SBCC-focused thematic areas as part of the APE training, such as the importance of interpersonal communication (IPC) and use of IEC materials (e.g., APE flipchart). IMaP also used the supervisory and mentoring visits as an opportunity to strengthen the capacity of health committees. In Zambézia, the supervisory team revitalized two health committees in Lugela district—in Errumene and Pututin. The revitalization of these health committees allowed the two committees to reconnect with their respective health facilities and create openness in the communities to carry out their health promotion activities in coordination with the APEs. IMaP also provided on-the-job training in SBCC to 54 APEs (39 males and 15 females) supervised in 15 districts in Nampula and provided on-the-job training in IPC to 71 health-care providers (38 males and 33 females). Although planned, IMaP was unable to conduct community dialogues in Nampula and Zambézia during the first quarter (Activity 1.4.1). IMaP will conduct these dialogues once the project has a finalized SBCC model/strategy in late February. Similarly, the release of RFPs for community radios has been postponed to Quarter 2 to ensure they are aligned with the approved SBCC model/strategy.
Activity 1.5. Support CSOs/CBOs to implement malaria control activities. During this reporting period, the IMaP team reviewed the applications submitted by CSOs/CBOs to implement community-based malaria SBCC activities in two stages. In the first stage, IMaP reviewed concept notes submitted by 39 CSOs/CBOs (19 from Nampula and 20 from Zambézia). From these applications, IMaP selected nine and seven organizations, respectively, from the two provinces to move on to the next stage. The selections were based on the quality of approach and experience presented by each organization.
In the second stage, IMaP invited shortlisted CSOs/CBOs to participate in a two-day orientation in each province to present a clear explanation of the RFA’s associated terms of reference. The orientation also included a presentation outlining all the requirements and documents needed for the full grant application and considered under the grants program. A
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total of 15 of the 16 organizations that attended the provincial orientations submitted final proposals (eight from Nampula and seven from Zambézia).
IMaP also conducted a review of all applications submitted. From the submitted applications, the grants evaluation committee selected five organizations in Nampula and six in Zambézia to be awarded grants.
At this time, IMaP is waiting for the SBCC approach to be finalized before issuing the grant agreements to the selected organizations and training them (Activities 1.5.1 to 1.5.7). The SBCC approach will define in greater detail the framework for the activities of the CSOs/CBOs.
Also, IMaP’s provincial manager in Zambézia participated in the Ivan Nhampossa, provincial head of malaria program (Activity 1.5.8). The meeting was attended by Zambézia’s malaria program deputy chief and representatives of implementing partners (Johns Hopkins University, Abt Associates, and World Vision). The main meeting objectives were to revitalize the provincial malaria TWG; present each implementing partner’s scope of work, the main activities, and monthly work plan; andDuring the meeting, each implementing partner also presented the challenges they are facing in implementation. In Nampula, a similar meeting did not take place due to lack of availability of the DPS. Many DPS staff were involved in the indoor residual spraying (IRS) activities.
IMaP also updated the mapping, primarily focusing on the 13 districts in Zambézia where IMaP anticipates awarding GUCs to CSOs/CBOs in 2019 (Activity 1.5.9). In these districts, IMaP updated and identified 707 communities located in catchment areas of 52 health centers. Now that the name of each community located in the catchment area of each health center has been updated, the communities that registered the highest number of malaria cases in the last six months should be prioritized for IMaP during implementation of SBCC intervention. Tete started mapping CSOs/CBOS at the end of Quarter 1 (December), and Cabo Delgado started in January (Quarter 2). Mapping information will be reported in Quarter 2.
Activity 1.6. Conduct operations research.
This activity in Nampula and Zambézia will be reported beginning in Quarter 2. An operational research workshop will be held on Quarter 2 as decided in the last malaria case management – malaria in pregnancy TWG held on December 24, 2018.
Objective 2: Strengthen management capacity of the provincial and district Ministry of Health personnel to provide oversight and supervision of malaria interventions
Activity 2.1. Determine malaria-related health systems constraints and appropriate solutions IMaP included training on how to use the capacity maturity needs assessment tool as part of the supervisory and mentoring training in Nampula for DPS and SDSMAS staff members (Activity
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2.1.1). Through this training, IMaP instructed 130 supervisors (100 males, 30 females) how to carry out supervisory and mentoring site visits, as described in Activity 1.2.5 above; conduct the capacity maturity needs assessment; and develop action plans based on the assessment findings. For the capacity maturity needs assessment component, IMaP discussed the capacity maturity needs assessment concept, methodology, and domains to be evaluated as well as who will be responsible. The theoretical sessions were followed by practical sessions at the Nampula DPS, its related SDSMASs, and the Nampula City SDSMAS. Participants showed great enthusiasm for the tool, as they recognized that they could assess and improve their ability to manage the provincial malaria program by using the results of this type of needs assessment. They also suggested separating the pharmacy subdomain from the logistics subdomain to facilitate the rating of the subdomain elements. Participants also suggested that supervision teams visit peripheral health facilities and use the tool to assess and confirm the data collected at the district level. IMaP will work side by side with the DPS and SDSMAS to conduct capacity maturity needs assessments at the DPS level and later in the 23 districts in Nampula starting in the second month of Quarter 2. Visits to conduct the capacity maturity needs assessment tool in Nampula will begin in Quarter 2 because the DPS preferred to complete the case management training and the supervision training in the remaining districts before initiating these assessments (Activities 2.1.2 and 2.1.3).
IMaP will not include training on how to use the capacity maturity needs assessment tool as part of the supervisory and mentoring training in Zambézia. This session will be included only when the STTA completes the review and comparison of the capacity maturity needs assessment tool with other USAID-invested health systems strengthening tools between February and March. Once the DPS and SDSMAS teams are trained, IMaP will support visits to conduct the capacity maturity needs assessment tool in Zambézia, Cabo Delgado, and Tete throughout Year 2.
Activity 2.2. Increase management capacity of provincial and district health systems. In the context of improving the management capacity of the Malaria Program in Year 2, IMaP in Nampula included training on the use of the capacity maturity needs assessment tool, which is used to collect data to assess the capacity of districts to implement Malaria Program activities. The tool will be tested in Nampula in Quarter 2 as quarterly supervisory site visits are already underway in the districts.
Activity 2.3. Enhance quality of programmatic implementation through strengthened monitoring and mentorship at the district and facility level. In Nampula and Zambézia, the supervisory visits conducted by the IMaP team in coordination with the DPS were also an opportunity for coaching the district chief medical officer at several key moments: 1) at the beginning of each supervisory site visit during the presentation of the objectives of the visit and indication of health facilities and APEs to be visited, and 2) in the out- brief meeting led by the district chief medical officer, where discussions on the main findings and proposed next steps were presented and discussed (Activity 2.3.1).
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As the training to strengthen the management skills of district staff in Nampula and Zambézia is awaiting the results of capacity needs assessments, IMaP will report about these trainings in Quarter 2, as described in the Year 2 work plan.
Activity 2.4. Facilitate provincial-level coordination Since IMaP’s Year 2 Work Plan activities for each province were developed in coordination with the respective DPS and approved by the provincial health director before submission to PMI, IMaP’s COP determined that there was no need to resubmit and present the PMI- approved work plan to each DPS; the provincial health directors of each province agreed to conduct or to nominate their representative to conduct the meeting to present the IMaP Year 2 Work Plan to district chief medical officers, malaria focal points and maternal and child health nurses (Activity 2.4.2). Activities 2.41 and 2.4.3 will be reported in Quarter 2. relaunch of the provincial malaria TWG meeting conducted by Dr. schedule the next meeting.
Activity 2.5. Support coordination of provincial and district malaria activities This activity in Nampula, Zambézia, Cabo Delgado, and Tete will be reported beginning in Quarter 4, as described in the Year 2 work plan. Objective 3: Improve HMIS data reporting, analysis, and use at the provincial and district levels Activity 3.1. Strengthen quality of routine data. In preparation for the M&E training in Nampula and Zambézia, IMaP conducted an M&E needs assessment to collect data on training needs in each province by identifying existing strengths and gaps in M&E at the provincial and district levels. Assessment findings will guide the topics to be included in the M&E training, which will be conducted in Quarter 2 (Activity 3.1.1). The IMaP SME STA, HMIS specialist, and Zambézia SME specialist also participated in Zambézia’s M&E working session, where IMaP presented on NMCP’s malaria priority indicators to all M&E district representatives. The same presentation will be conducted in Nampula in Quarter 2.
In Zambézia, IMaP’s SME specialist alongside the DPS analyzed the SDSMAS data uploaded into SIS-MA. Based on this analysis, the SME specialist with the DPS reported to each SDSMAS the data discrepancies that needed to be corrected in the system before it closes each month; findings from Zambézia will be reported in Quarter 2. In Nampula, although the data for Quarter 1 was reported on time for all districts, IMaP and the DPS found discrepancies between malaria cases registered (RDT+ and HTZ+) versus those treated cases with Artemether-Lumefantrine. Discrepancies were more than 10 percent (NMCP consider discrepancies up to 10 percent as critical) in Larde, Malema, Meconta, Nacala a Velha, and Ribaue districts (Activity 3.1.2). Based on this, the DPS sent the feedback information to all districts, including those with discrepancies less than 10 percent to correct the data based on the primary sources (register book, weekly and monthly summary reports).
In Zambézia, IMaP and the DPS organized a meeting for all districts in Nicoadala from December 13 to 15 to discuss data and corrections. Districts with discrepancies received feedback and corrected the data in SIS-MA based on primary data sources, such as health
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 24
center monthly summaries and BES (Boletim Epidemiologico Semanal). During the meeting, IMaP and the DPS shared with the districts the discrepancies found in SIS-MA, reviewed and corrected data from the past 10 months in SIS-MA, and discussed how to prepare feedback to share with the health facilities regarding these discrepancies. During the meeting, IMaP and the DPS also conducted a SIS-MA data management refresher. All districts corrected the data in SIS-MA, prepared feedback information for health facilities, and were instructed to begin discussions in the districts to avoid data discrepancies in the future.
During this reporting period, IMaP’s Nampula and Zambézia SME specialists and SME STA also participated in the data quality assessment (DQA) tools training conducted by NMCP, in which IMaP led three of the training components: 1) how to develop an action plan; 2) how to disseminate results; and 3) how to conduct ongoing monitoring and follow-up. As a follow-up to this training, IMaP’s SME specialists, alongside the DPS and NMCP, will conduct trainings for the SDSMASs in the project’s target provinces. IMaP will also support the DPS to conduct the DQA at the health center level, including at least three APEs in each health center.
Activity 3.2. Support utilization of DHIS-2, in alignment with the Mozambican MISAU priorities. To facilitate the information and timely data flow at the DPS and SDSMAS, IMaP started to research tools compatible with electronic devices to collect data at the DPS, SDSMAS, and health facility levels and get feedback to avoid data errors. At the same time, IMaP conducted M&E needs assessments in Zambézia with the DPS to know how to implement those tools without changing the actual information and data flow, while incorporating the electronic system to health center level. IMaP plans to replicate this same process in Nampula during Quarter 2. The NMCP will distribute tablets to all SDSMASs in the country, and IMaP will use this opportunity to implement the electronic data management and analysis at the district level in its target provinces to improve the data quality inserted in the SIS-MA platform (Activity 3.2.1).
Activity 3.3. Strengthen data-informed decision-making, including management and supervision. IMaP worked alongside the Zambézia DPS to develop a tool called the retro information matrix, with standardized indicators to help with the review of data discrepancies with the districts and share program performance at provincial level A (Activity 3.3.1). IMaP is also supporting the DPS to send monthly discrepancies feedback through M&E TWGs and supervision activities. Additionally, as part of this support, during a supervisory and mentoring visit to Luabo district, the IMaP SME specialist worked with the district M&E technical team to identify the health centers with data discrepancies and verify performance program indicators at the health center level. The SME specialist also recommended that the technical team continue with this activity on a monthly basis and send feedback information to health centers.
IMaP and other partners worked with NMCP to select priority indicators to be reported for malaria activities and to have one platform that will be populated by all stakeholders throughout the country (Activity 3.3.2). This activity is still in discussion with different MISAU departments to gain consensus. Once there is consensus, the indicators will be incorporated into a platform
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that is under development. This platform development is led by NMCP with support of other malaria implementing partners and is expected to be finalized during Quarter 2. IMaP’s main activity in this process has been to support the selection of the indicators during the technical meeting with NMCP and other partners. During FY19 Quarter 2 and Quarter 3, IMaP will also develop a digital malaria indicator feedback template that will include the selected indicators for the district M&E teams. Teams will then use this template to clean and correct the data to be included in SIS-MA and other partners’ platforms used at health centers and the SDSMASs. The indicators table was shared with all partners, and IMaP is currently reviewing it to provide feedback to the NMCP.
In Zambézia, IMaP also provided financial and logistic support to the Quelimane district to conduct a meeting to discuss the malaria data with all health facilities and to develop the matrix with the methodology to guide future data discussions for other districts (Activity 3.3.3). The main discussion findings include: 1) low IPTp second dose coverage during the period under review; 2) low coverage of treated mosquito nets during the first ANC visit; 3) low quality of data reported from health facilities to the SDSMAS; and 4) high level of malaria death data discrepancies reported in BES and in the internment reports. Based on findings, it was decided that: 1) malaria health facility committees would be created to discuss the data at the facility level before sending it to the SDSMAS to help reduce data errors and discrepancies; 2) central and general hospital malaria program representatives would be included in future discussions; 3) all Quelimane city health facilities would report IPTp second dose data weekly; and 4) health facilities would conduct their own data discussions before sharing with the SDSMAS.
3. Monitoring and Evaluation of the Activity The IMaP team has been adjusting the targets and reviewing the indicators in the Year 2 MEL plan based on the activities proposed for life of project (LOP). Through STTA in Quarter 2, IMaP will revise the Year 2 MEL plan based on the comments received from USAID/PMI and the project’s LOP objectives. IMaP aims to complete this revision process during Quarter 2.
The IMaP SME team has also been developing and finalizing the data collection tools. For example, the SME team standardized the activities attendance form to be used in all IMaP activities. Based on the data collected from the attendance form, IMAP will populate other data collection tools, including its main database (IMaP DEvResults) every month to produce the MEL reports. The STTA also will conduct the DevResults management training for the SME team to ensure effective data collection and reporting based on the revised set of indicators and targets.
During this reporting period, IMaP’s HMIS specialist also reviewed different open source options to use as data flow management for IMaP internal tools and to recommend to the NMCP, DPSs, and SDSMASs based on their data management needs. Through STTA in Quarter 2, the IMaP SME team will determine which are the most appropriate data tools to be used and to recommend for use to the NMCP, based on availability and access.
Annex A provides an overview of IMaP’s performance.
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4. Challenges and Actions Taken to Meet Targets Staffing: During this quarter, the identification of the provincial manager for Cabo Delgado has been a challenge. IMaP conducted multiple rounds of recruitment for this position. During the first round, the top candidate selected was not accepted by the provincial health director. In the second round, the provincial health director supported the selected candidate, but she was not approved by USAID due to her high proposed salary. Considering requests from provincial health directorate (DPS) Cabo Delgado, it has been difficult to identify a candidate with the requested experience and a salary in line with our approved budget. IMaP has re-advertised the job on www.emprego.com. IMaP expects to complete the recruitment process for all these positions by the end of February. IMaP is also recruiting the district community engagement specialist and the SME specialist.
Delay in the development and implementation of the SBCC strategy: IMaP has experienced challenges and delays in developing its SBCC approach/strategy due to late onboarding of LT and ST staff for the development of the strategy. These delays have in turn affected the project’s ability to implement the GUCs and fund CSOs/CBOs to implement community-based malaria SBCC activities. During this quarter, IMaP has worked to identify additional short-term support to help with designing the SBCC strategy. Although identification of the support was quickly resolved, the short-term SBCC technical advisor was unavailable to fully support the project until recently. The short-term SBCC technical advisor is working with the IMaP team to develop a framework and initial inputs for the SBCC strategy. She will be traveling to Mozambique in the beginning of Quarter 2 to complete the process. IMaP expects to finalize the SBCC strategy by Quarter 2.
Maturity model: The delay in finalizing the capacity maturity model was due to the fact that when IMaP submitted to the PMI for review and approval, the comments received and the subsequent discussions with the PMI indicated the need to contract STTA to conduct a review and comparison of other existent tools to determine what additional modifications should be made to the submitted capacity maturity needs assessment tool. Additionally, there was agreement between PMI and IMaP that the consultant will consider feedback and results from the use of the tool in one of IMaP’s targeted provinces.
5. Key Activities Planned for Next Reporting Period Refinement and finalization of the Capacity Maturity Needs Assessment Tool: Through STTA, IMaP will work to refine and finalize the capacity maturity needs assessment tool based on tools developed by past USAID health systems strengthening investments. The STTA consultant will also use findings from the initial assessment to provide recommendations and lead revisions to the tool.
NMCP Integrated Supervision Manual: With support from the case management short-term consultant, IMaP will continue leading the review and update of the Integrated Supervision Manual (Activity 1.1.1). The case management STTA will revise the Integrated Supervisory Manual, including the supervision checklists, based on feedback collected from key stakeholders. Alongside IMaP senior staff, the consultant will also consider feedback and
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input from NMCP’s malaria case management TWG and PMI. At the end of the consultancy, IMaP will present a finalized, easy-to-use Integrated Supervisory Manual to the NMCP that can appropriately guide supervision visits at the provincial and district levels.
NMCP’s 2018 Annual Report: IMaP will work in close collaboration with the NMCP Surveillance, Monitoring and Evaluation focal point and her team to develop NMCP’s annual report. The report will include information and data on the activities conducted by the NMCP and its partners during 2018 (Activity 1.1.4 and 3.3.6).
NMCP Quarterly Report (Newsletter): IMaP will work in close collaboration with the NMCP technical team to develop NMCP’s Quarter 2 report. The report will include information and data on the activities conducted by the NMCP and partners from October to December 2018 (Activity 1.1.6 and 3.3.7).
SBCC Interventions: IMaP will continue conducting district SBCC meetings with the SDSMAS and community leaders, other key community members who can influence behavior and social norms, health committee members, and APEs in at least six districts in Cabo Delgado and Tete and in at least nine districts in Zambézia and Nampula (Activity 1.2.1).
Malaria Case Management Training: IMaP will finish conducting case management training for 920 health-care providers from three districts in Nampula and its central hospital (Activity 1.2.3).
Supervisory and Mentoring Visit Training: IMaP will conduct the supervisor and mentoring trainings to 20 DPS staff members, who are already part of the supervisory team, and 92 technicians from district-level participants in Zambézia (Activity 1.2.5).
Logistical Support for Supervisory and Mentoring Visits to Peripheral Areas: Beginning in Quarter 2, after the supervisory and mentoring training to SDSMAS health professionals eligible to be supervisors, IMaP will provide logistical support to the SDSMASs in each of the four provinces to conduct supervisory and mentoring visits to their catchment areas covering at least six peripheral health facilities and three APEs per quarter (Activity 1.2.9). The district chief medical officer will lead these supervisory and mentoring visits and will complement the visits conducted by IMaP alongside the DPS to referral health facilities and the two largest-volume health facilities in each district.
Laboratory refresher training: IMaP will be conducting the refresher trainings to laboratory technicians and microscopists on malaria diagnosis using RDTs and microscopy in Zambézia and Nampula by the end of February 2019 and in March 2019, respectively (Activity 1.2.13). These trainings were originally scheduled to take place in December 2018; however, IMaP experienced scheduling conflicts in both provinces. In Zambézia, IMaP attempted to organize the initial preparatory training meeting with the DPS, Mozambique’s National Institute of Health (Instituto Nacional de Saúde, INS), and NMCP to discuss technical aspects of the training; however, due to conflicting schedules, this meeting was postponed to January 7, 2019, delaying the team’s ability to conduct the actual training. In Nampula, the
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training did not take place because DPS staff were involved in IRS activities that lasted 60 days. The QI/QA laboratory assistant, along with the DPS laboratory supervisor, will conduct a pre-implementation assessment for the malaria external quality assessment (EQA) in Zambézia and Nampula. Findings from this assessment will guide the refresher training for laboratory technicians and microscopists. Following the training, the QI/QA laboratory assistant will carry out quarterly external blinded cross-checking of routinely taken slides (Activities 1.2.14 to 1.2.16).
GUCs for the selected CSOs/CBOs to implement community-based malaria SBCC activities: Once the SBCC approach/strategy has been finalized, IMaP will develop and execute grant agreements with the CSOs/CBOs selected to implement community- based malaria SBCC activities. IMaP will also train the CSOs/CBOs and work with them to conduct focus group discussions to update the community dialogue toolkit developed under previous projects and to guide the creation of the IMaP SBCC implementation kit (Activity 1.4.1). The postponement in finalizing the SBCC approach/strategy prevented this activity from taking place during Quarter 1.
Reproduction and distribution of materials in each province: Material to be used by the CSOs/CBOs (Activity 1.4.5) in Nampula and Zambézia will be reported in Quarter 2, as described in Year 2 Work for Nampula and Zambézia provinces.
Operations research (OR): In Quarter 2 in February, the OR technical advisor will conduct a review of past and ongoing MiP research activities in Mozambique to develop a research protocol addressing IPTp coverage that builds upon prior findings and is responsive to the NMCP’s goals for program improvement. During an STTA trip to Mozambique, the OR technical advisor will work with the IMaP technical team, the NMCP, PMI Mozambique, and the National Institute of Health (INS) to gather information relevant to designing a locally relevant protocol that is responsive to NMCP’s needs (Activity 1.6). Based on initial discussions with NMCP in February, the OR Technical Advisor will also develop NMCP’s and IMaP’s research agenda that highlights the research questions of interest. to DPS for M&E component: IMaP will support the DPS to conduct a two-day M&E training in Nampula and Zambézia Provide Logistics and Technical Support for the SDSMAS surveillance, monitoring, and evaluation staff. IMaP will use the M&E assessment findings that identified M&E weaknesses and strengths to guide the training content. IMaP will conduct the M&E assessment in Cabo Delgado and Tete to determine training needs (Activity 3.1.2). IMaP will support DPS to strengthen routine data collection (Activity 3.1.3 and 3.2.4).
Annual Meeting: IMaP will conduct an annual meeting to evaluate the project’s performance, review provincial and project trends, and identify gaps. The project will use this meeting to share experiences from the four provinces. IMaP expects participation from provincial chief medical officers, malaria focal points, SME specialists, and managers. IMaP will also invite three NMCP representatives and the PMI team (Activity 3.3.5).
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 29
Year 2 MEL Plan: During Quarter 2, IMaP, through STTA, will make further revisions to its indicators included in the Year 2 MEL Plan. In Quarter 2, an STTA will work together with the IMaP SME STA to develop indicators that reflect the direct influence/changes IMaP intends to effect. An immediate step is to provide a list of potential modifications to the indicator list to PMI once there is general agreement on indicators. The SME STA and SME team will begin working on revising PIRS, as necessary.
Modifications to the IMaP organizational chart: To ensure continued efficiency and effectiveness in provincial- and central-level implementation, such as logistics support for supervisory and mentoring visits and trainings, IMaP will be considering modifications to its structure. Once the modified structure is approved by USAID, IMaP will begin recruitment of the additional approved staff.
Central and provincial-level Memoranda of Understanding (MOUs): IMaP will be finalizing and executing MOUs with MISAU and the DPS of each target province to ensure smooth implementation of activities in the provinces.
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Annex A. Measuring Performance
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses 1. Percent of inpatient deaths in targeted provinces whose primary cause was 6% 8.5% 2% 8.5% 2% 100% malaria (Impact/Custom)
2. Incidence of malaria per 1,000 persons in 317.5 360 N/A 360 252 targeted provinces (Impact/Custom) Objective 1: Support implementation of proven malaria interventions in alignment with the NMSP IR 1.1: Strengthen national malaria policies, strategies, and guidelines 3. Number of strategic planning meetings held with NMCP staff to prioritize malaria 0 2 5 7 20 35% policies, strategies, and guidelines for review (Output/Custom) 4. Number of national malaria policies, strategies, and guidelines updated to meet international 0 0 0 0 10 0% standards in concurrence with focal people within NMCP and MOH (Output/Custom) 5. Number of malaria policies, strategies, 0 0 0 0 10 0% and guidelines distributed to DPS
Integrated Malaria Program, Annual Technical Progress Report - Project Year 1, pg. 31
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses and SDSMAS as result of national coordination activities (Outcome/ Custom) IR 1.2: Improve access to and quality of febrile case management at public health facilities and at the community level to ensure prompt and accurate diagnosis and appropriate treatment of malaria 6. Percent of APEs in targeted district who have stockouts of malaria commodities 0% 100% 0% 100% 0% 0% at least once in the last 12 months (Output/Custom) 7. Percent of health facilities in targeted district with staff trained in malaria laboratory diagnostics practices 0% 12.2% 28% 12.2% 95% 0% (rapid diagnostic tests or microscopy) with USG funds in the last 12 months (Output/Custom) 8. Percent of health facilities in targeted district with staff trained in established malaria case 0% 12.2% 28% 12.2% 95% 0% management practices with USG funds in the last 12 months (Output/Custom) 9. Percent of clinicians in targeted district who received on-the- 0% 40% 20% 20% 95% 21.1% job training or supervision in malaria case management in
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 32
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses the last three months (Outcome/ Custom) 10. Number of health workers in targeted districts trained in malaria laboratory diagnostics (rapid 0 226 816 226 16000 6.5% diagnostic tests or microscopy) with USG funds (Output/Contract) 11. Percentage of children under five with fever who were 47.5% 0 N/A 0 87.5% 0% tested for malaria (Outcome/Custom) 12. Percentage of malaria tests with positive results in targeted 59% 59.6% 54% 54% 33% 64% provinces (Outcome/ Custom) 13. Percentage of children under five years of age who were tested positive 97% 51% 98% 51% 100% 98% for malaria and who received treatment (Outcome/Custom) 14. Percentage of health facilities in targeted district who reported stockout of at least one consumables, ACTs, 0% 0% N/A 0% 0% 0% SP, RDTs, or mosquito nets in ANC for a period greater than or equal to seven days in the
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 33
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses last month (Outcome/Custom) 15. Percentage of children receiving an ACT among children under five years old with fever in the last 98.1% 0 N/A 0 100% 0% two weeks who received any antimalarial drugs (Outcome/Contract) 16. Percentage of children under five years old with fever in the last two weeks 47.5% 0 N/A 0 87.5% 0% who had a finger or heel stick (Outcome/ Contract) 17. Number of health workers in targeted district trained in case management with artemisinin- 0 513 816 1329 16250 8.2% based combination therapy (ACTs) with USG funds (Outcome/ Contract) IR 1.3: Increased delivery of the full course of IPTp using sulfadoxine-pyrimethamine as part of an integrated package of antenatal services 18. Percentage of health facilities in targeted districts with at least one staff member trained in preventive 0% 0% N/A 0% 100% 0% treatment in pregnancy (IPTp) with USG funds in the last 12 months (Output/Custom)
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 34
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses 19. Percentage of health workers in targeted districts trained in 0% 0% N/A 0% 100% 0% IPTp with USG funds in the last 12 months (Output/Contract) 20. Percentage of maternal and child health nurses in targeted districts who received on-the- 0% 0% 23% 23% 95% 24.2% job training or supervision on IPTp in the last three months (Output/Custom) 21. Percentage of women who received two or more doses of IPTp during their last 0% 0% N/A 0% 100% 0% pregnancy in the last 12 months (Outcome/ Contract) 22. Percentage of women who received three or more doses of IPTp 0% 0% N/A 0% 100% 0% during their last pregnancy in in the last 12 months (Outcome/Custom) IR 1.4: SBCC implementation strengthened 23. Number of SBCC community-based events held to promote malaria care 0 0 0 0 4279 0% seeking/treatment held at district, health facility,
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 35
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses community, and household levels in target provinces (Output/Custom) 24. Percentage of target population reached with malaria SBCC 0% 0% 0% 0% 100% 0% messaging (Output/Custom) 25. Percentage of children under five years old with fever in the last two weeks 0% 0% N/A 0% 100% 0% for whom advice or treatment was sought (Outcome/ Contract) 26. Percentage of children under five years old who slept 0% 0% N/A 0% 100% 0% under an ITN the previous night (Outcome/Contract) IR 1.5: Support to CSOs/CBOs to implement malaria control activities improved 27. Number of CSOs/CBOs receiving financial support to implement malaria 0 1 0 1 24 4.2% control activities and facilitate provincial and district coordination (Output/Contract) 28. Percentage of change in local organization capacity needs 0% 0% 0% 0% 80% 0% assessment score (Outcome/Custom) IR 1.6: Operations research conducted
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 36
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses 29. Number of studies conducted in collaboration with 0 0 0 0 10 0% NMCP and PMI (Outcome/Custom) 30. Number of policy briefs disseminated to government ministries and 0 0 0 0 10 0% national and international organizations (Outcome/ Custom) Objective 2: Strengthen management capacity of the provincial and district MOH personnel to provide oversight and supervision of malaria interventions IR 2.1: Malaria-related health system constraints and appropriate solutions determined 31. Percentage of capacity development plans for malaria 0% 0% 0% 0% 100% 0% program developed (Outcome/Custom) 32. Percentage of targeted districts that implement management capacity 0% 0% 0% 0% 100% 0% development plans for malaria programming (Output/Contract) IR 2.2: Increased management capacity of provincial and district health systems 33. Percentage of planned trainings on topics related to planning, budget, managing malaria 0% 0% 0% 0% 100% 0% program, and professional development conducted (Outcome/ Custom)
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 37
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses 34. Percentage of change in capacity maturity as a result of supervisory and 0% 0% 0% 0% 80% 0% mentoring visits and trainings conducted (Outcome/Custom) IR 2.3: Enhance quality of programmatic implementation (e.g., CM, MiP, IRS) enhanced through strengthened monitoring and mentorship at district and facility level enhanced 35. Percentage of planned case management mentoring visits that 0% 18.2% 39.5% 39.5% 98% 40.3% are conducted at health facilities in all targeted districts (Output/Contract) 36. Percent of follow-up actions determined during integrated mentoring visits of DPS to SDSMAS that 0% 0% 0% 0% 80% 0% are completed within 30 days of completion of visit (Outcome/ Contract) IR 2.4: Provincial-level coordination facilitated and increased 37. Number of report- out meetings conducted with U.S. government-funded 0 0 N/A 0 5 0% malaria partners and MOH/DPS/SDSMAS staff (Output/Custom) IR 2.5: Coordination of provincial and district malaria activities improved 38. Number of provincial and district 0 0 2 2 10 20% coordination meetings conducted
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 38
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses with IMaP support (Outcome/Custom) Objective 3: Strengthen the HMIS at the provincial and district levels to improve data reporting, analysis, and use IR 3.1: Quality of routine data strengthened 39. Percentage of targeted districts that have at least quarterly data-use 0% 3% 0% 3% 98% 3.1% and supervision planning meetings (Outcome/Contract) 40. Proportion of health facilities that benefitted from at least one round of 0% 0% 0% 0% 80% 0% DQA in the last 12 months (Outcome/Custom) 41. Percentage of health facilities in the targeted provinces 0% 23% 100% 23% 100% 23% that report complete data through DHIS2 (Outcome/Custom) 42. Percentage of health facilities in the targeted provinces that report HMIS 0% 23% 100% 23% 100% 23% data through DHIS2 on time (Outcome/Custom) 43. Percentage of health facilities in the targeted districts where more than 0% 0% N/A 0 0 0 0% 90% 0% 80% of the data in the given year matches (Outcome/Custom)
Integrated Malaria Program, Quarterly Technical Progress Report - Project Year 2, First Quarter, pg. 39
Project Goal: Reduce malaria-associated mortality, morbidity, and parasitemia in four targeted provinces of Mozambique Performance FY 2019 LOP LOP Annual LOP Baseline FY 2018 % LOP Indicators Q1 Q2 Q3 Q4 Total Target Progress Analyses IR 3.2: Utilization of DHIS-2 increased in alignment with the Mozambican MOH priorities 44. Percentage of target districts that have malaria indicator analysis in the DHIS- 0% 0% 0% 0% 100% 0% 2 (SIS-MA) dashboard (Outcome/Custom) IR 3.3: Data-informed decision-making strengthened, including management and supervision 45. Percentage of targeted districts that send feedback to the health facilities as a 0% 0% 0% 0% 100% 0% result of routinely collected HMIS data (Outcome/Custom) Crosscutting gender indicators 46. Proportion of female participants in IMaP 0% 26% 40% 40% 100% 40% training (Outcome/ Contract)
Integrated Malaria Program, Quarter Technical Progress Report - Project Year 2, First Quarter, pg. 40