MaMoni Health Systems Strengthening Activity
Quarterly Report January 1 – March 31, 2015
Submitted May 15, 2015
This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development, Bangladesh (USAID/Bangladesh) under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through MCHIP, managed by Jhpiego Corporation. The contents of this document are the responsibility of Jhpiego Corporation and do not necessarily reflect the views of USAID or the United States Government.
Cover Photo Credit: Using a computer tablet, MaMoni HSS data collectors enter population information into a national registry system in Madhabpur Upazila, where the Routine Health Information System (RHIS) project is being piloted. Directorate General Health Services and Directorate General Family Planning service providers will use this electronic information to track clients and ensure services to the families. Photo Credit: Shimantik/Save the Children.
MaMoni HSS – Year Two Second Quarterly Report April 2015 2 TABLE OF CONTENTS 1. Introduction ...... 7 2. Program Objectives and Key Activities ...... 8 3. Results for Year 1 ...... 11 3.1 Summary of Major Accomplishments ...... 12 3.2 Narrative Report of Major Accomplishments ...... 12 3.2.1 Improve service readiness through critical gap management ...... 12 3.2.2 Strengthen health systems at district level and below ...... 12 3.2.3 Promote an enabling environment to strengthen district-level health systems ...... 123 3.2.4 Identify and reduce barriers to accessing health services ...... 124 3.2.5 Challenges, Solutions and Action Taken ...... 125 4. The Way Forward ...... 26 5. Appendix ...... 26 Annex 1. Photos from key events ...... 27 Annex 2: Performance Indicators (October 2014-March 2015) ...... 28 Annex 3: Success Stories ...... 36 Annex 4: Key Achievements of Aponjon/MAMA initiative ...... 38 Annex 5: Media Stories Published this Quarter ...... 43 Annex 6: Quality Assurance Initiatives ...... 44 Annex 7: MaMoni HSS Project Training Activities, January 1 – March 31, 2015 ...... 46 Annex 8: National Newborn Scale-Up Initiatives ...... 51 Annex 9: Environmental Monitoring and Mitigation Plan...... 55 Annex 10: Summary of BCC materials produced during the quarter ...... 57
MaMoni HSS – Year Two Second Quarterly Report April 2015 3 Acronyms and Abbreviations
AO Agreement Officer AMTSL Active Management of Third Stage Labor BCC Behavior Change Communication BEmONC Basic Emergency Obstetric and Newborn Care BNF Bangladesh Neonatology Forum BPS Bangladesh Perinatal Society BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CEmONC Comprehensive Emergency Obstetric and Newborn Care CHX Chlorhexidine CIPRB Center for Injury Prevention and Research, Bangladesh cMPM Community Microplanning Meeting CNCP Comprehensive Newborn Care Package CS Civil Surgeon CSBA Community Skilled Birth Attendants CV Community Volunteer CVRS Civil Registration and Vital Statistical System CYP Couple Years of Protection DDFP Deputy Director Family Planning DGFP Directorate General Family Planning DGHS Directorate General Health Services ECEB Essential Care for Every Baby EM Environmental Manual FAOPS Federation of Asia and Oceania Perinatal Societies FWA Family Welfare Assistant FWV Female Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HMIS Health Management Information System HPNSDP Health, Population and Nutrition Sector Development Program HRCI Health Research Challenge for Impact HSS Health System Strengthening icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh IMNCS Improving Maternal, Neonatal, and Child Survival IR Intermediate Result J&J Johnson and Johnson JHU/IIP Johns Hopkins University, Institute for International Programs JSI John Snow, Inc.
MaMoni HSS – Year Two Second Quarterly Report April 2015 4 JSV Joint Supervisory Visit LAPM Long Acting and Permanent Method LMIS Logistics Management Information System MCHIP Maternal and Child Health Integrated Program MCRAH Maternal, Child, Reproductive and Adolescent Health MEO Mission Environmental Officer MNCAH Maternal, Newborn, Child and Adolescent Health MNCH/FP/N Maternal, Newborn and Child Health, Family Planning and Nutrition MNH Maternal and Newborn Health MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOU Memorandum of Understanding MPDR Maternal and Perinatal Death Review OGSB Obstetrics and Gynecology Society of Bangladesh OP Operational Plan OR Operations Research PFM Physical Facilities Management PNGO Partner nongovernmental organization PPH Postpartum Hemorrhage PPIUCD Postpartum Intra-uterine Contraceptive Device QA Quality Assurance QI Quality Improvement QPRM Quarterly Performance Review Meeting RCHCIB Revitalizing Community Health Care in Bangladesh RHIS Routine Health Information System RRQAT Regional Roaming Quality Assurance Team SACMO Sub-Assistant Community Medical Officer SBA Skilled Birth Attendant SBM-R Standards-based Management and Recognition SC Save the Children SCANU Special Care Newborn Unit SDP Service Delivery Point SIAPS Systems for Improved Access to Pharmaceuticals and Services SMC Social Marketing Company SOP Standard Operating Procedure SSN Senior Staff Nurse TBA Traditional Birth Assistant TIS Tracer Indicator Surveys TOT Training of Trainers UDCC Union Development Coordination Committee UEHFPSC Union Education Health and Family Planning Standing Committee UFPO Upazila Family Planning Officers
MaMoni HSS – Year Two Second Quarterly Report April 2015 5 UH&FPO Union Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UP Union Parishad USAID United States Agency for International Development
MaMoni HSS – Year Two Second Quarterly Report April 2015 6 1. Introduction
The MaMoni Health Systems Strengthening (HSS) project is a four-year Associate Award under the Maternal and Child Health Integrated Program (MCHIP), with a period of performance from September 24, 2013 to September 23, 2017. MaMoni HSS builds upon MaMoni’s previous work in Bangladesh and focuses on strengthening the systems and standards for maternal, newborn and child health, family planning and nutrition (MNCH/FP/N) that will result in declines in maternal, newborn and child mortality within seven districts in Bangladesh. The project supports the Ministry of Health and Family Welfare (MOH&FW) to introduce and leverage support for scale-up of evidence-based practices proven effective in Bangladesh.
MaMoni HSS is primed by Jhpiego in partnership with Save the Children (SC), John Snow, Inc. (JSI), and Johns Hopkins University, Institute for International Programs (JHU/IIP), with national partners International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dnet, and Bangabandhu Sheikh Mujib Medical University (BSMMU). SC serves as the functional operational lead partner for the Award in Bangladesh. MaMoni HSS engages with local government structures and non-governmental organizations (NGO) to improve delivery of health services and strategically partner at the national level to build consensus around policies and standards that positively drive evidence-based interventions at all levels.
Beginning the second year of implementation, Figure 1: Map of MaMoni HSS project areas the project is using a differential approach to implementation at the district level. Districts and upazilas are categorized into two groups based on the intensity of implementation support. This categorization will be maintained through the life of the project.
High-intensity areas: MaMoni HSS supports high-intensity interventions in a total of 23 upazilas. These areas include all upazilas of Habiganj, Lakhsmipur and Jhalokathi districts, four upazilas of Noakhali, and two upazilas of Pirozepur district.
Health system (HS) capacity strengthening areas: All remaining areas will receive support for implementing selected program components. These areas will also benefit from the district-level support for HS capacity strengthening. This covers a total of 17 upazilas – all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirozepur.
The map depicted in Figure 1 shows the geographic focus of the project from the second year of implementation. Table 1 below shows a
MaMoni HSS – Year Two Second Quarterly Report April 2015 7 summary of the geographic scope of the program.
Table 1: Summary profile of MaMoni HSS program areas
Population No. of Health Facilities No. of No. of Area (2015 District Upazilas Unions Upazila Union Community projection) (MCWC) High-Intensity 23 226 7,355,822 5 20 208 619 Areas Health Systems CB 17 151 4,870,933 5 13 121 488 Area Total 40 377 12,226,755 10 33 329 1,107
2. Program Objectives and Key Activities
The goal of MaMoni HSS is to improve utilization of integrated MNCH/FP/N services and will be achieved through the project objective to increase availability and quality of high-impact interventions through strengthening district-level local management of health systems. This objective is well-aligned with the Government of Bangladesh’s (GOB) Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016. MaMoni HSS will also directly support the USAID/Bangladesh Development Objective 3 (DO 3) “Health Status Improved” under the “Investing in People” Objective of the Country Development Cooperation Strategy (CDCS) Framework of USAID in Bangladesh.
MaMoni HSS has four intermediate results (IR). Shown below is a summary of the project’s IRs, sub-IRs, and the major activities included in the second year workplan.
IR1: Improve service readiness through critical gap management Sub-IR 1.1: Increase availability of health service providers • Support MOH&FW to develop a human resources information system (HRIS) for the country, including plans for recruitment and deployment of health workforce • Advocate GOB to expedite the recruitment of relevant staff and deploy them to fill all vacant positions, prioritizing positions in Union Health and Family Planning Welfare Centers (UH&FWC), Basic Emergency Obstetric and Newborn Care (BEmONC) and Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facilities • Support temporary gap management of critical service provider positions in strategically-located facilities in high-intensity areas
Sub-IR 1.2: Strengthen capacity of service providers to provide quality services • Adapt or develop training package for different providers for integrated MNCH/FP/N skill development • Establish mechanism for development of trainers pool to conduct training of trainers (TOT)/training on MNCH/FP/N packages • Support training of service providers on integrated package(s) of MNCH/FP/N clinical service delivery and quality improvement areas • Continue technical support for national scale-up of Helping Babies Survive (HBS)
MaMoni HSS – Year Two Second Quarterly Report April 2015 8 • Support MOH&FW to ensure availability of logistics, and supplies for the roll-out of new newborn care interventions
Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization • Support MOH&FW to maintain upgraded UH&FWCs to provide MNCH/FP/N services, including 24/7 delivery services • Support secondary and tertiary-level referral facilities of MOH&FW for integrated MNCH/FP/N services • Strengthen referral systems at the community level and at facilities • Upgrade facilities to be prepared for delivering the minimum essential package of MNCH/FP/N services • Support Directorate General Family Planning (DGFP) to scale up skilled birth attendant (SBA) deliveries by strengthening union level facilities
IR2: Strengthen health systems at district level and below Sub-IR 2.1: Improve leadership and management at district level and below • Build leadership and management capacity of MOH&FW managers at district and upazila levels through Strategic Leadership and Management Training Program (SLMTP) • Establish mentorship program for the district and upazila level managers
Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs • Facilitate MOH&FW decentralized MNCH/FPN planning and review systems • Facilitate regular review by MOH&FW of MNCH/FP/N performance against annual plans at upazila and district levels • Support the use of local data to track progress and make decisions on course corrections • Support MOH&FW to institutionalize community microplanning meetings (cMPMs) and union follow-up meetings
Sub-IR 2.3: Strengthen local management information systems • Support MOH&FW at the national level to design and pilot an automated comprehensive routine health information system (RHIS) • Support MOH&FW to roll out paper-based RHIS in high intensity areas until the automation is completed • Train managers and other key personnel on utilizing data for decision-making and for facilitative supervision
Sub-IR 2.4: Establish quality assurance (QA) system at district level and below • Support MOH&FW to strengthen national level QA initiatives • Support MOH&FW to strengthen supervision systems at all levels • Support improved infection prevention/ bio-waste management practices at health facilities • Support MOH&FW for the training of service providers on quality improvement and Standards- based Management and Recognition (SBM-R) • Support MOH&FW to activate and support Regional Roaming Quality Assurance Teams • Support MOH&FW to scale up Maternal and Perinatal Death Reviews (MPDR)
MaMoni HSS – Year Two Second Quarterly Report April 2015 9 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below • Scale up UIMS/ Service Delivery Point (SDP) dashboard module in high intensity areas • Support Directorate General Health Services (DGHS) to pilot and scale up a logistic management system for essential RMNCH commodities • National-level advocacy and support for the procurement of essential MNCH commodities for life-saving interventions
Sub-IR 2.6: Strengthen local government planning and engagement in health service provision • Build capacity of local government institutions to actively contribute to MNCH/FP/N • Strengthen the Vital Registration Systems (VRS) through improved coordination between MOH&FW and the Ministry of Local Government Rural Development & Cooperatives (MOLGRD&C) • Enhance the role of union parishads (UP) in MNCH/FP/N budgeting and problem-solving
Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N (in high intensity areas) • Facilitate activation of Union Education Health and Family Planning Standing Committees (UEHFPSC) in areas where they are not functional • Strengthen Ups’ bi-monthly Union Development Coordination Committee (UDCC) meetings
IR3: Promote enabling environment to strengthen district-level health systems Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector • National-level advocacy initiatives for policy reform • Provide national advocacy and technical support to MOH&FW to scale up SBA delivery by strengthening UH&FWCs to provide 24/7 services
Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidence-based learning in national policy and program • National-level advocacy to address barriers to utilization of budget allocated to MNCH/FP/N related Operational Plans (OP) • Promote program learning and documentation of lessons learned and accomplishments • Process documentation and program learning to learn from ongoing program implementation • Advocate for the scale-up of evidence-based maternal and newborn interventions in support of the Ending Preventable Child and Maternal Deaths (EPCMD) activities in Bangladesh
IR4: Identify and reduce barriers to accessing health services Sub-IR 4.1: Promote awareness of MNCH through innovative Behavior Change Communication (BCC) approaches • Develop and implement a mixed-methods communication campaign designed to catalyze behavior change in target groups • Contribute to the development of a national BCC campaign to support the scale-up of priority EPCMD interventions • Use technology from Aponjon, the local initiative of Mobile Alliance for Maternal Action (MAMA), to disseminate health messages to target populations
MaMoni HSS – Year Two Second Quarterly Report April 2015 10 Sub-IR 4.2: Enhance community engagement in addressing health needs • Recruit, train, and support community volunteers (CV) • Support CVs to provide FP counseling and referrals • Facilitate Community Action Group (CAG) meetings and establish emergency transport systems for referral transport
3. Results for Year 1 3.1 Summary of Major Accomplishments
This report focuses on the period January 1 to March 31, 2015. Key highlights for this reporting period include:
Programmatic Activities • The project facilitated decentralized district and sub-district level planning for MNCH/FP/N in four high intensity districts. Quarterly performance review meetings were held in four districts in January 2015 where both DGFP and DGHS staff jointly reviewed data and generated action plans. Examples of decisions include directive to ensure family welfare assistant (FWA) attendance in cMPM and changes in the reporting format for FWAs. • Developed a comprehensive human resources database for the project areas, based on the workforce needs assessment information. The project supported 78 temporary gap management positions in the high intensity subdistricts, which included paramedics, nurses and doctors. • A comprehensive, fully-automated routine health information system for the MOH&FW was introduced in Madhabpur upazila of Habiganj district. By the end of the quarter, information on 16,842 individuals and 3,138 households were entered into the national registry. • Facilitated referral of 1,030 maternal and 253 newborn cases in three districts to receive care at a higher level facility. • Established a Technical Assistance Cell in DGFP for strengthening the UH&FWCs with dedicated team members assigned from MaMoni HSS as well as from DGFP. Assessment of UH&FWCs started in two Divisions using a Tab-based assessment tool. • Commenced scale-up of 7.1% chlorhexidine (CHX) in one sub-district of Habiganj. The project has completed the procurement of CHX for scale-up in another 10 upazilas in the third quarter. A detailed implementation plan has also been developed for supporting the MOH&FW at national scale. • Aponjon service added 23,005 subscribers in the past quarter, reaching a total of 1,232,622 subscribers by the quarter’s end. • A total of 23,380 persons were reached with BCC through 238 video shows and 37 meetings with 2,195 pregnant women. In addition, 26 ANC campaigns reached 424 pregnant women and 12 “miking,”or megaphone campaigns reached an audience of 104,600. Trainings • Trained 30,508 GOB workers, CVs, implementing partner staff, and other community members on various MNCH/FP/N topics. A total of 19,982 CVs received training on FP counseling and compliance. • Selected and supported a total of 988 new CVs during the quarter. The total number of CVs in program areas are now 22,929. A total of 15,953 CAGs have established emergency transport
MaMoni HSS – Year Two Second Quarterly Report April 2015 11 plans. MaMoni HSS provided first and second step orientations (new CV orientations) to a total of 724 and 1,380 CVs during the quarter. • The roll-out of comprehensive newborn care package (CNCP) modules has started with national- level TOTs. Project-supported Results • Supported the GOB to ensure provision of round-the-clock services through 46 UH&FWCs in project areas, including 14 facilities where the project placed temporary staff. • A total of 196 joint supervisory visits (JSV) were initiated with local government staff at union and upazila levels in Habiganj, Lakshmipur, and Noakhali. • Achieved coverage for 14,759 deliveries conducted by SBAs in six districts, of which, 12,631 were conducted at health facilities. This total represents approximately 18 percent of all projected deliveries for the quarter for those six districts. • Generated 211,858 couple-years of protection (CYP), in six focus districts where the implementation started in the first year, including 9,118 who accepted Long Acting and Permanent Method (LAPM), which represents 29 percent of the total CYP in these districts. Phase-out of Habiganj district • MaMoni HSS has initiated phase-out in Habiganj. Thirty-nine Field Support Officers (FSO) have been withdrawn from the district at the end of March as part of the phase-out plan.
3.2 Narrative Report of Major Accomplishments
Initiation of Phase-out activities in Habiganj district: The phase-out strategy for Habiganj district was developed and the planned scale-down of project inputs was initiated. As a first step, the project withdrew 39 FSO at the end of the second quarter. The final phase-out strategy will be available after review by ministry counterparts at the district level, expected in June 2015.
Submission and approval of key project documents: The Environmental Manual (EM) for the project was approved by the Mission Environmental Officer (MEO) on February 16, 2015. The project organized orientation for key project personnel and partners on the EM and the monitoring and compliance requirements. Environmental compliance monitoring has been incorporated into the existing tools for field supervision visits. Structured monitoring visits will start from the next quarter and will be reported. MaMoni HSS submitted a revised PMP to USAID on March 15, 2015 for review and approval. Proposals for the renovation of four UH&FWCs and to establish a special care newborn unit (SCANU) in Lakhsmipur district hospital were submitted for USAID approval.
3.2.1 Improve service readiness through critical gap management
Management of critical human resource gaps of GOB service providers: During the quarter, the project supported the high-intensity areas with critical human resource gap management through temporary NGO service provider recruitment. MaMoni HSS continued to provide temporary staff to address the vacancies in nurses and Female Welfare Visitor (FWV) positions in selected facilities in Habiganj, Noakhali, and Lakhsmipur districts, while continuing to advocate for long-term solutions by filling the vacancies through GOB recruitment. In the six districts where implementation is in progress, the project is currently supporting 58 paramedics, and 19 nurses to fill critical human resource gaps.
MaMoni HSS – Year Two Second Quarterly Report April 2015 12 Table 2: Summary of critical health workforce gap management provided by MaMoni HSS in six districts, as of March 31, 2015
FWV Nurses Total District Paramedics Nurses Vacant Vacant Vacant MaMoni HSS deployed by deployed by Posts Posts Posts Support MaMoni HSS MaMoni HSS Habiganj 8 33 40 14 90 55 Noakhali 4 16 27 2 75 18 Lakshmipur 0 8 30 3 68 11 Jhalokathi 2 1 0 0 40 1 Total 14 58 97 19 273 85
The project recruits and deploys paramedics as a temporary gap management arrangement to address the gaps in the number of FWVs available in GOB facilities to provide essential services, especially at the peripheral levels. In some cases, the number of paramedics deployed exceeded the number of vacant FWV positions. According to DGFP planning, upgraded UH&FWCs should have two FWVs deployed. In keeping with this design, MaMoni HSS has deployed additional paramedics to maintain the delivery services and outreach services in hard-to-reach unions. The project also deployed additional paramedics in several union-level facilities to fill the gaps due to service providers’ absenteeism or responsibilities (deputation) at higher level facilities, even though the government does not count these positions as vacant.
The workforce needs assessment previously uncovered a significant gap in CEmONC in all four high- intensity districts. The obstetrician-anesthesiologist “pair” is not available round the clock at many of the designated upazila health complexes (UHC) in the project areas. During the quarter, MaMoni HSS recruited and deployed a project-supported surgeon to Hatiya upazila of Noakhali, where referral has been extremely difficult due to the isolated island context. The first C-section occurred in Hatiya UHC on April 6, 2015 as a result of this deployment.
Supported health facility preparedness for MNCH/FP/N services: In the project districts, MaMoni HSS facilitated a systematic process to identify health facilities that are strategically located and have the potential to provide a comprehensive package of services, including 24/7 delivery care, with some additional elements such as renovated physical infrastructure, filled vacant positions, deployment of additional paramedics, training of staff, and provision of essential equipment and supplies. The project is supporting the MOH&FW to identify and upgrade strategically-located UH&FWCs. As of March 2015, there are 41 of 193 UH&FWCs in the 21 high-intensity upazilas that are providing 24/7 delivery services, including 14 facilities where the project has provided additional paramedics and other inputs.
MaMoni HSS – Year Two Second Quarterly Report April 2015 13 Figure 2: Trend in Number of Deliveries at UH&FWC level, Habiganj District
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Figure 3: Trend in Number of Deliveries at UH&FWC level, Noakhali
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0 Durgapur Gopalpur Sirajpur Char King Sonadia
January'15 February'15 March'15
Because of seasonal trends, the number of normal deliveries varies from month to month. Based on the project’s data, December and January are months with higher numbers of live births compared to February and March.
MaMoni HSS – Year Two Second Quarterly Report April 2015 14 Figure 4: Trend in Number of Deliveries in 24/7 UH&FWC level, Lakshmipur
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Table 3: Total Number of UH&FWCs that are providing 24/7 delivery services with the support of MaMoni HSS
No. of UH&FWCs providing 24/7 delivery services with support of Program Area MaMoni HSS (March 2015) High-Intensity areas 41
Scale-up areas 5
All six districts combined 46
MaMoni HSS is supporting DGFP to assess all UH&FWCs managed by DGFP in the country, a total of roughly 3,860 centers, to provide integrated MNCH/FP/N services, including 24/7 delivery services. The DGFP has already budgeted additional funds in their revised operational plan to reflect this activity. Using data collection tools programmed into tablet computers, 14 data collectors working for the project have received training and begun visiting UH&FWCs to record the current status of basic amenities and physical infrastructure. The UH&FWCs in Sylhet and Barisal division will be included, except Barguna district.
National scale-up of newborn care interventions: In this quarter, MaMoni HSS revisited eight districts where the HBB initiative has been rolled out in the last year to review district performance data and provide supportive supervision, conduct refresher trainings, and train private sector providers. MaMoni HSS also monitored the ongoing need for HBB logistics and took steps to address any gaps identified.
MaMoni HSS – Year Two Second Quarterly Report April 2015 15 MaMoni HSS introduced 7.1% chlorhexidine (CHX) application for umbilical cord care at health facility and community levels in the Bahubal sub-district of Habiganj. CHX was procured by the project using non-USAID resources mobilized by Save the Children.
During this quarter, CHX was applied to 755 newborns, which represents 61 percent of projected live births in the upazila during this period. Among these, 13 percent (95) received CHX from health facilities while 87 percent (660) received treatment at home. A total of 177 newborns received CHX from GOB providers, which is 14 percent of projected live births during the period, while 578 newborns received CHX from traditional birth attendants (TBA), representing 47 percent of the projected live births during the period.
Figure 5: Contribution of Community Volunteers (CV) to LAPM referral (October 2014 – February 2015)
100% 52 78 90% 98 385 186 1171 88 116 80% 168 70% 60% 50% 749 430 40% 315 1485 566 4321 229 250 30% 297 20% 10% 0%
GOB CV
MaMoni HSS conducted a national-level sharing meeting involving all key stakeholders involved in supporting newborn care interventions to share the results and experiences from the pilot phase implementation.
Strengthened Family Planning services: MaMoni HSS trained 19,985 CVs in this quarter on FP counseling and compliance. These volunteers are completely unpaid, and work as an extension of the FWVs and FWAs in reaching the mothers with critical information. BDHS 2011 uncovered that contact with FWA among mothers surveyed was around 15 percent, which was insufficient for proper FP counseling. In BDHS 2014, this number is expected to decrease even further, due to FWA deployment to community clinics and larger population to health worker ratio. MaMoni HSS expects that the CVs National consultation meeting on early experience of introducing chlorhexidine for cord care will play a positive role in bridging this gap.
MaMoni HSS – Year Two Second Quarterly Report April 2015 16
Strengthened nutrition services: MaMoni HSS introduced postpartum iron-folic acid (IFA) supplementation through FWAs in Nabiganj upazila of Habiganj district. A pilot study was conducted in 2013 in Madhabpur upazila in collaboration with FANTA III project, reaching almost 70 percent distribution coverage among postpartum mothers in 2013-14, and the lessons were applied in Nabiganj upazila. In Madhabpur, the intervention is continuing, as well. A total of 27 master trainers were trained, who in turn trained 381 outreach workers in this quarter. FWAs will begin distributing IFA in April 2015. The additional required IFAs will have been supplied to the Nabiganj upazila office of DGFP from the central level by March 2015.
Competency-based training of GOB service providers: Adaptation of training modules and training of service providers and community-level volunteers was conducted on a number of packages on FP, MH, NH, nutrition, infection prevention and quality improvement during the quarter. The project also trained GOB staff on joint supervision, decentralized planning, routine information systems, and logistics management. The project teams supported competency-based training of GOB service providers, including QA related training; training to introduce JSVs; various modules of SBM-R training in phase 1 and phase 2 SBM-R facilities; training on maternal health training packages, which included Active Management of Third Stage Labor (AMTSL), partograph, and eclampsia management in high-intensity upazilas. During the quarter, the project implementing partners also completed a number of competency-based training activities for sub-district level GB workers and community level volunteers, such as: (i) orientation of CVS on FP counseling and referral in 23 high intensity upazilas; (ii) completion of basic training of CVs in Jhalokathi district; (iii) Training on management of malnutrition in Habiganj district; (iv) Training on post-partum IFA in Habiganj; (v) orientation on misoprostol in Habiganj; (vi) community microplanning in Jhalokathi district and union follow up training in four districts through externally contracted training agency.
MaMoni HSS facilitated and supported the competency-based training of GOB service providers. The details of the training program and the number of participants are presented in Annex 6. A summary list of the training activities supported by the project during the quarter are shown in Table 2 below:
Table 4: Competency-based training and orientations undertaken by MaMoni HSS in the second quarter of FY15
Training Type Training Duration Trainees AMTSL, partograph and PE/E three days (one day FWV, nurses, paramedics management (TOT and training), for each topic) all high-intensity areas Postpartum IFA (TOT and training) One Day AHI, FPI, FWA, HA, HI, SACMO, CHCP, MT- EPI, Statistician, UFPA, FWV, Nurse, MO Community Case Management of Three days CHCP Pneumonia (TOT and training) Malnutrition Management (TOT One day HI, AHI, HA, CHCP, FPI, FWA, UFPA and training), Madhabpur, Habiganj Misoprostol for preventing One day AHI, FPI, FWA, HA, HI, SACMO, CHCP,MT- postpartum hemorrhage (PPH) EPI, Statistician, UFPA, FWV (TOT and training), Jhalokathi and
MaMoni HSS – Year Two Second Quarterly Report April 2015 17 Habiganj districts
Postpartum Intra-uterine 15 days FWV, female SACMO, paramedics Contraceptive Device (PPIUCD) (training)
During the quarter, a total of 30,508 persons, including GOB workers, CVs and project staff were trained on various MNCH/FP/N topics.
3.2.2 Strengthen health systems at district level and below
Strategic Leadership and Management Training Program (SLMTP): In collaboration with the Health Research Challenge Initiative (HRCI), MaMoni HSS has been conducting leadership and management training programs for the public sector health managers. During the quarter, MaMoni HSS organized two batches of Strategic Leadership and Management Training Program (SLMTP) for district and upazila level managers from the project districts. As a follow up to the six days training, MaMoni HSS has designed a mentoring program, involving on-site and distance support to the managers to develop their leadership potential. The terms of reference for engaging the mentors have been developed.
District-level decentralized planning and performance reviews: MaMoni HSS has initiated a joint comprehensive data-driven MNCH/FP/N district planning meeting in MaMoni districts. Twenty-one upazilas of Habiganj, Noakhali, Lakhsmipur and Jhalokathi districts have completed district planning that includes separate plans for each upazila. Lakshmipur district managers have identified 10 low- peforming unions and developed union-specific plans for each union. Jhalokathi has completed union planning in three unions and the rest of the district will complete union QPRM in Noakhali district in February 2015 planning for low-performing unions during the next quarter. MaMoni HSS also continued to support quarterly performance review meetings in three districts: Habiganj, Noakhali and Lakshmipur.
Logistics Management Systems: The project continued its efforts at the national and district levels (Lakhsmipur) to improve Logistics Management Information Systems (LMIS) to improve the availability of essential drugs. At the national level, the project joined efforts with Systems for Improved Access to Pharmaceuticals and Services (SIAPS) in developing the uniform DGHS logistics management system. This national initiative aims to standardize the LMIS at the district and upazila levels. It has resulted in developing standardized stock ledgers, issue vouchers, and indent forms. The project played an important role in pursuing approval of the newly District planning session in Jhalokathi district developed Uniform Logistics Management System from the in progress
MaMoni HSS – Year Two Second Quarterly Report April 2015 18 DGHS. In addition, at the district level, the project completed the piloting of the paper-based reporting of availability of MNCH tracer drugs using the existing local registers. As a result, a dashboard type of information system has been created to help district-level managers monitor the availability of MNCH tracer drugs for all district stores and take action to avoid stock-outs. The graph below shows an example of the information generated from one store in the pilot district for selected MNCH tracer drugs.
Figure 5: Availability of Selected Tracer Drugs at Civil Surgeon Store, Lakshmipur
2014 2015 Item September October November December January February March Injectable
MgSO4 Injectable
Oxytocin Tab.
Misoprostol Injectable
Dexamethasone Oral Amoxicillin
Injectable
Gentamycin ORS
Zinc
= Stock-out = Available
As indicated, there were less stock-outs for tracer drugs in the month of March due to advocacy of SIAPS and MaMoni HSS.
Next steps related to these activities will include contributing to scaling up the Uniform DGHS Logistics Management System in MaMoni HSS project districts and scaling up the paper-based monitoring system, based on the Lakshmipur piloting experience in Habiganj, Noakhali, and Jhalokati.
Strengthening information systems at national level: MaMoni HSS is collaborating with several other USAID collaborating partners, such as Measure DHS, icddr,b, and SIAPS under the RHIS project to design, test and roll out a paperless reporting system in Madhabpur upazila of Habiganj. A population-based registration survey tool has been developed, revised and finalized with RHIS initiative. The tab-based program for this survey has been finalized and tested at Madhabpur. Data collectors commenced data collection on March 15 and in their first two weeks, they were able
RHIS sensitization meeting in Habiganj
MaMoni HSS – Year Two Second Quarterly Report April 2015 19 to visit 3,138 households, registering 16,842 members.
As part of the national RHIS initiative, MaMoni HSS has initiated the design of the automated tools to be used at the UH&FWCs. The other RHIS partners are designing the tools for the community level and for the upazila and district-level health facilities. MaMoni HSS, along with the other RHIS partners, participated in a national-level sharing meeting on the RHIS initiative before all other USAID-funded partners and senior officials from DGHS and DGFP.
MaMoni HSS has been supporting the pilot implementation of Mother and Newborn Care Register and Community Skilled Birth Attendant (CSBA) Registers in MaMoni HSS districts under the direction of the DGFP. As a part of the initiative, MaMoni HSS supported national-level TOT for the local level DGFP managers. All the MCH-FP and upazila family planning officers (UFPO) working in six MaMoni HSS intervention districts, 68 in total, received a day-long TOT in three batches, with national-level trainers from DGFP facilitating different sessions. The participants of the TOTs will in turn train the local-level service providers (FWV, SACMO and CSBA) on the use of these registers. Once trained, these service providers will start using these registers. The Mother and Newborn Care Register will replace the existing ANC, delivery, PNC and birth registers for the UH&FWC.
The new CSBA Register will be used by the CSBAs who provide maternal and newborn health (MNH) services at the community. These registers will reduce the record keeping load of the service providers and help to prepare timely and quality monthly reports.
Figure 5: The combined register from four, existing FWV registers
Strengthened planning and coordination through community microplanning and union follow-up meetings: By the end of the second quarter, the cMPM have been well-established in all high-intensity areas. In this quarter, 470 participants from Jhalokathi were trained on community microplanning in 22 batches. The participant categories were HI, AHI, HA, FPI, AUFPA, UFPO, MT EPI, Statistics, FWV, FWA and FSO.
In this quarter, a total of 2,828 cMPM units were conducting monthly meetings. The cMPMs are helping frontline health workers, i.e. FWAs and HAs, to enroll eligible couples and pregnant women into the program early on and to track and follow up for the provision of services. These meetings also help to improve the quality of information collected by the DGHS and DGFP. MaMoni HSS has also introduced a video-based training for union follow-up meetings that compiled the information from cMPM reports. 2,252 participants from the 23 high-intensity upazilas of Noakhali, Lakshmipur, Jhalokathi and Pirozepur
MaMoni HSS – Year Two Second Quarterly Report April 2015 20 received trainings on union follow-up meetings. During this quarter, a total of 5,081 union follow-up meetings were held in Habiganj, Noakhali and Lakhsmipur district.
Quality Improvement Initiative: The project is actively engaged in the MOH&FW initiative to develop a “National Strategic Plan on Quality of Care for Health Service Delivery” in Bangladesh. A workshop was held that reviewed the national quality improvement (QI) strategy, which calls for the formation of National Steering Committees (NSC), National Technical Committees (NTC), and QI committees at Divisional, District, and Upazila levels. The workshop identified the next steps needed to implement the QI strategy including developing terms of reference for each committee and soliciting partner support to operationalize the QI strategy. During the reporting quarter, the project extended the implementation of SBM-R to new health facilities in four districts as follows:
Table 5: Summary of SBM-R activities during the second quarter
New District Main Activities Facilities • SBM-R orientation of upazila-level health and family planning managers • Module 1 training for health providers in the eight new facilities to prepare Jhalokathi 8 for baseline assessment of MNCH/FP/ N standards application and develop an action plan to improve compliance with standards • Module 2 training for health providers in seven Phase II facilities. Habiganj 7 • Baseline assessment and first internal assessment completed (see graph below). • Module 2 training for health providers in eight facilities. Noakhali 8 • Baseline assessment and first internal assessment completed • Module 2 training for health providers in eight facilities. Lakshmipur 8 • Baseline assessment and first internal assessment completed
Figure 6: Compliance with Birth Spacing and Family Planning Standards in 5 Health Facilities, Habiganj
100 100 95
90 83 80
70 67 67 57 57 60 Baseline
50 43 1st internal 38 2nd internal 40 33 29 29 30 23 19 20 10 10
0 MCWC Shibpasha Murakuri Chunarughat Kakailso
MaMoni HSS – Year Two Second Quarterly Report April 2015 21
Joint Supervisory Visits and RRQAT: Last quarter, the project had conducted orientations for district- level supervisors and government managers in Habiganj, Lakshmipur, and Noakhali districts on the supervision tools and guidelines. During this reporting quarter, the project completed the orientation in Jhalokati and initiated joint supervisory visits in Habiganj, Lakshmipur, and Noakhali. In Habiganj’s eight upazilas, a total of 45 JSVs have been conducted during the reporting period, covering all upazilas. In Lakshmipur, 87 and 5 JSVs have been conducted at the Union level and upazila level, respectively. In Noakhali, JSVs started in February 2015. Thirty-seven and 21 JSVs have been conducted at union and upazila levels, respectively. The JSV is expected to contribute to effective supervision to health facilities in project Launch of Regional Roaming Quality Improvement Team in areas with particular emphasis in applying the Sylhet Division on March 30, 2015 supportive supervision approach to improve quality of MNCH/FP/N services.
Building on the national meeting conducted last quarter for approving the Regional Roaming Quality Improvement Teams (RRQIT)1 concepts and strategy, the project prepared for the establishment of RRQIT in three regions: Sylhet, Barisal, and Chittagong. The RRQITs are to complement the various QI interventions supported by the project. Particularly, RRQIT, consisting of specialists from regional medical colleges and professional associations, will visit selected referral sites, such as district hospitals, in MaMoni HSS Project-supported districts with the purpose of improving the quality of clinical MCH care and infection prevention measures. During the reporting quarter, the project initiated the first RRQIT in Sylhet Region. The launching event took place in Sylhet with participation of national-level MOH&FW officials representing DGHS and DGFP and professional associations, such as the Obstetrics and Gynecology Society of Bangladesh (OGSB), as well as the participation of Sylhet health division stakeholders and the local OGSB branch.
Maternal and Perinatal Death Review: The project initiated effective partnerships with the Center for Injury Prevention and Research, Bangladesh (CIPRB) and UNICEF for scaling up MPDR as a quality improvement approach. One upazila in Noakhali district has been selected and a contracting mechanism has been completed. The roll-out is expected to begin in the third quarter.
Expansion of strengthened birth registration system: MaMoni HSS has developed a model to link the cMPM, immunization clinics and the Civil Registration and Vital Statistical System (CVRS). The model involves facilitating close coordination between the HAs and the UPs’ birth registration systems so that the birth registrar is immediately notified of births. In addition to the three unions from the previous quarter, in this quarter, this model was introduced in 23 unions of two new upazilas of Lakshmipur and Noakhali districts. The Health, FP and UP staff were oriented on the initiative, and pilot areas have already started showing rapid increases in birth registrations within 45 days.
1 These earlier referred to as Regional Roaming Quality Assurance Teams (RRQAT). The change in nomenclature is in line with the focus of the MOH&FW on quality improvement vis-à-vis quality assurance
MaMoni HSS – Year Two Second Quarterly Report April 2015 22 MaMoni HSS shared the experience of piloting of CVRS with the senior officials of MOLGRD&C. It has been agreed to formalize the partnership between MOH&FW, MaMoni HSS and MOLGRD&C through a formal meeting to discuss the modalities of strengthening the CVRS with the involvement of frontline health workers and CVs.
3.2.3 Promote an enabling environment to strengthen district-level health systems
Capacity-building of media: In this quarter, MaMoni HSS conducted orientations for 24 local journalists in Jhalokathi district, with the support from the Civil Surgeon and the Deputy Director Family Planning (DDFP). In total, 151 journalists have been oriented in three districts. The orientations emphasized the role of journalists in reporting maternal health issues and informing their leaders. These efforts have resulted in coverage of maternal health stories, as well as five stories published on MaMoni HSS engagement of journalists. MaMoni HSS also connected national-level journalists with local counterparts to collect and produce stories. One such example is the op-ed piece published in the English language daily paper, Observer, about the achievements of Badalpur UH&FWC in Habiganj. MaMoni HSS also established linkages with Prothom Alo, Naya Diganta and Daily Star to support news stories for Safe Motherhood Day.
Aponjon One Million Celebration: Secretary of the MOH&FW, Mr. Sayed Monjurul Islam was the Chief Guest at the Aponjon One Million Celebration, held at
Spectra convention center with over 80 guests in attendance. As a result of his participation in the Secretary, MOH&FW at Aponjon One Million celebration, the Secretary requested that USAID to Celebration event on February 5, 2015 expand these types of programs so that more mothers can benefit.
Engagement of the Parliament: MaMoni HSS participated in the first meeting of the parliamentary caucus on Child Rights formed by Save the Children to orient 20 parliamentarians on MNCH/FP/N issues. The meeting, held in Cox’s Bazar on December 11-13, 2014, obtained commitment from the parliamentarians to support national initiatives on maternal and child health.
Program Learning Initiatives: The following learning initiatives are underway:
(i) Operations Research (OR): Under USAID’s TRAction research initiative, two research initiatives have completed the following:
• 24/7 delivery and EmONC services in public facilities through health systems strengthening in Bangladesh: This OR is conducted in two district-level facilities in Habiganj district. Areas covered in the analysis include availability of infrastructure, essential drugs and equipment for MNH services, availability of human resources based on sanctioned post, quality of care, and availability of different service providers for MNH care. During the quarter, MaMoni HSS and icddr,b worked with the district hospital to ensure nurses were present during night
MaMoni HSS – Year Two Second Quarterly Report April 2015 23 shifts. One observation is that the availability of round the clock C-Section continues to be a challenge. • Community-based prevention and treatment of severe pre-eclampsia and eclampsia in a low resource setting of Bangladesh: Analysis of baseline and program data collection has been completed by icddr,b and findings will be disseminated at the end of April 2015.
(ii) Performance analysis of Private CSBA of MaMoni HSS: Performance of private CSBA of MaMoni HSS in Habiganj has been analyzed using MIS data. The analysis included services of private CSBAs for both health and family planning from April 2013 to September 2014. Findings were shared internally in April 2014. A draft monograph was shared with USAID for review.
(iii) Documentation of the process of CHX introduction for clean cord care: Based on the documentation, a stakeholder meeting was organized in February 2015.
(iv) Development of OR concept papers: USAID has approved five OR proposals for the second year of implementation, which will investigate quality of service delivery for LAPM; use of partographs as a decision-making tool for identifying and referring complicated pregnancies; viability of private CSBAs; community behavior on application of CHX; and quality of ANC at satellite clinics and challenges.
MaMoni HSS received exemption on IRB approval for the proposed partograph study and completed it in this quarter. Among the 1,116 mothers who were admitted, around 91 percent had a partograph completed. According to the partographs, 33 percent of mothers had referral indications present. Among those, 2.7 percent were actually referred, identifying a lack of understanding among paramedics about danger signs. Of the 67 percent of mothers for whom referral was not indicated, 5 percent were referred to a higher level facility.
Key informant interviews revealed that understanding of partograph components varied from paramedic to paramedic, and referral decisions in several cases were based on practical considerations (distance to referral center, transportation availability, time of day), or circumstance of the birth (progress of labor). Challenges in completing partographs were highlighted, as well.
3.2.4 Identify and reduce barriers to accessing health services
Community mobilization: MaMoni HSS has selected, trained, and supported a cumulative total of 33,971 CVs to facilitate CAGs, promote MNCH/FP/N behaviors, and serve as interfaces between the communities and the frontline health service providers through cMPMs. In Habiganj district during the quarter, 29.9 percent of LAPM referrals were made by CVs. As mentioned earlier, MaMoni HSS trained 19,985 volunteers on FP counseling. These trainings are expected to have a positive impact on the acceptance and coverage of FP in Habiganj.
Behavior Change Communication: The implementing NGO partners of MaMoni HSS have established BCC units in each of the project districts, with the purpose of conducting focused BCC. A total of 23,380 people were reached through 238 video shows and 37 meetings with 2,195 pregnant women. In
MaMoni HSS – Year Two Second Quarterly Report April 2015 24 addition, 26 ANC campaigns reached 424 pregnant women and 12 “miking,”or megaphone campaigns reached an audience of 104,600. However, the levels of engagement differ from BCC channel to channel. MaMoni HSS participated and contributed to a national-level initiative to develop a BCC campaign for FP, to be implemented by USAID partners. The project will support the implementation of the FP BCC campaign plan in the project districts, through existing implementation mechanisms. During the quarter, MaMoni HSS also developed new or reproduced a number of existing BCC materials. Please refer to Annex 10 for a detailed listing of BCC materials developed or reproduced by the project during the last quarter.
Engagement of local government: MaMoni HSS organized a national-level meeting with the Additional Secretary of the LGD, MOLGRD&C and four other members of the ministry to update them on MaMoni HSS activities, including birth registration. A joint work plan between MOH&FW and MOLGRD&C was proposed to strengthen the birth and death registrations, as well as leverage support for introducing delivery service at union-level health facilities.
During the past quarter, MaMoni HSS continued the active engagement of local government institutions, especially the UPs, to improve MNCH/FP/N services in their communities. MaMoni HSS has also facilitated the bi-monthly meetings of UDCCs in Noakhali district, where MNCH/FP/N issues are discussed and progress reviewed.
MAMA: The locally branded initiative of MAMA, Aponjon, was integrated into the MaMoni HSS program starting July 1, 2014. By the end of the second quarter, Aponjon had 1,232,662 registered customers, including 23,006 new registrations during the quarter. Please refer to Annex 4 for a detailed description of the MAMA/Aponjon activities.
3.2.5 Challenges, Solutions and Action Taken
Challenges
Political disturbances: The country witnessed a series of violent political demonstrations and protests during the past quarter. The opposition parties had called for non-stop blockades and hartals, or complete shutdowns, during most of the last quarter. This unrest has seriously affected the ability of the project staff and partners to conduct the implementation of planned activities. The project followed the safety and security guidelines provided by the USAID Mission and Save the Children country office. However, the project teams made the best possible efforts to carry on with the activities that did not involve inter-district travel by a large number of participants. Also, the implementing teams rescheduled the activities in some of the areas, where the disturbances were more frequent.
Delay in implementation of renovation activities: There has been a number of back and forth communications with the USAID Mission regarding final approval of the proposals for renovation of a number of GOB health facilities. It is expected that the approvals will be granted very soon.
Opportunities
Chlorhexidine procurement: MaMoni HSS secured additional private funds from Save the Children US to procure a small quantity of CHX to support the implementation in Habiganj district. More proposals are in the pipeline to secure additional funds to support the procurement of CHX and small quantities of
MaMoni HSS – Year Two Second Quarterly Report April 2015 25 other essential drugs to introduce new interventions, such as simplified antibiotics treatment for newborn sepsis, in the project areas. MaMoni HSS is planning to undertake national-level training and sensitization campaigns to support the MOH&FW’s plan to roll out CHX nationally. MaMoni HSS is expecting USAID concurrence to begin these activities in May 2015.
4. The Way Forward
Below are the highlights of major activities planned for the third quarter:
• National roll-out of chlorhexidine and other newborn interventions • Intensive roll-out of all newborn care interventions in 10 upazilas • National technical support for human resource planning • Support of facility preparedness initiatives • Upgrade strategically-located facilities; facility preparedness in 30 more facilities • Develop a national master plan for strengthening of UH&FWCs based on the assessment • Establish SCANU in Lakhsmipur district and support the establishment of other SCANUs in three other districts • RHIS strengthening at national level • Pilot implementation of RHIS in Madhabpur sub-district of Habiganj district • Scale-up of quality improvement initiatives • Competency-based training • Strengthen post-training follow up and QI: SBM-R, JSV, MPDR
MaMoni HSS – Year Two Second Quarterly Report April 2015 26 5. Appendix
Annex 1. Photos from key events
Solar panel donated to Char King UH&FWC by Union Parishad District Planning Meeting in Jhalokathi district
Mothers wait for services in Char King UH&FWC, which now Upazila Chairman of Hatiya inaugurating Char King UH&FWC provides round-the-clock delivery services
MaMoni HSS – Year Two Second Quarterly Report April 2015 27 Annex 2: Performance Indicators (October 2014-March 2015)
Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014) The project PMP is being revised to Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services incorporate the programmatic changes made in second year Percent of births attended by a skilled doctor, Tracer nurse or midwife indicator District N/A2 survey (Bhola, Habiganj, report Jhalokati and Pirojpur Bhola DHSS 2013 21.7 25 24.6 Tracer survey report,
Habiganj MaMoni 2012 19.4 29 28.9 2015) (Noakhali and Jhalokathi BMMS 2010 28.1 31 44.2 Lakshmipur, Tracer Lakhsmipur DHSS 2013 34 37 35.1 survey report, 2014) Noakhali DHSS 2013 33.4 36 32.9
Pirozepur BMMS 2010 24.1 27 44.7
Percent of women with home births who Tracer consumed misoprostol to prevent post- indicator District partum hemorrhage survey report Bhola N/A N/A 13.2 (Bhola,Habiganj,
Tracer Jhalokati and Pirojpur Habiganj Indicator 2014 39.2 49 37 Tracer survey report,
survey 2015) Jhalokathi N/A 25 (Noakhali and
Tracer Lakshmipur, Tracer Lakhsmipur Indicator 2014 7.9 15 7.9 survey report, 2014)
survey Tracer Noakhali Indicator 2014 7.2 15 7.2
survey
2 Data from population-based Tracer Indicator Surveys (TIS) are currently not available. The data collection has been completed in Bhola, Pirozepur and Jhalokathi districts for baseline data. Data collection was collected in Habiganj, Noakhali and Lakhsmipur districts.
MaMoni HSS – Year Two Second Quarterly Report April 2015 28 Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014) Pirozepur N/A 15.6
Percent of newborns who initiated Tracer breastfeeding within one hour after birth indicator District survey report (Bhola, Habiganj, Jhalokati and Pirojpur Bhola DHSS 2013 70.7 75 62.3 Tracer survey report, MaMoni HSS Habiganj 64.7 67 76.9 2015) 2012 (Noakhali and
Jhalokathi BDHS 2011 43.6 58 57.5 Lakshmipur, Tracer
Lakhsmipur DHSS 2013 52.6 58 66.4 survey report, 2014)
Noakhali DHSS 2013 53.1 57 70.8
Pirozepur BDHS 2011 43.6 58 49.9
Percent of women attended at least once Tracer during pregnancy by skilled health personnel indicator District for reasons relating to pregnancy survey report (Bhola, Habiganj, Jhalokati and Pirojpur Bhola DHSS 2013 44.3 50 48.8 Tracer survey report, MaMoni HSS Habiganj 37.1 52 72.5 2015) 2012 (Noakhali and Jhalokathi BMMS 2010 53.9 58 65.7 Lakshmipur, Tracer
Lakhsmipur DHSS 2013 60.1 65 64.3 survey report, 2014)
Noakhali DHSS 2013 52.8 58 57.8
Pirozepur BMMS 2010 41.3 48 61.3
Percent of births receiving at least four ANC Tracer visits during pregnancy indicator District survey report (Bhola, Habiganj, Jhalokati and Pirojpur Bhola DHSS 2013 13.8 18 19.9 Tracer survey report, MaMoni HSS Habiganj 8.6 15 34.3 2015) 2012 (Noakhali and Jhalokathi BMMS 2010 20.3 24 43.8 Lakshmipur, Tracer
Lakhsmipur DHSS 2013 13.6 17 18.4 survey report, 2014)
Noakhali DHSS 2013 11.5 15 17.6
Pirozepur BMMS 2010 10.2 15 40.2
MaMoni HSS – Year Two Second Quarterly Report April 2015 29 Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014) Percent of newborns receiving postnatal Tracer check-up within two days of birth indicator District survey report (Bhola, Habiganj, Jhalokati and Pirojpur Bhola DHSS 2013 6.8 12 3.2 Tracer survey report, MaMoni HSS Habiganj 17.7 21 3.9 2015) 2012 (Noakhali and Jhalokathi BDHS 2011 26.3 30 26.6 Lakshmipur, Tracer
Lakhsmipur DHSS 2013 12.1 16 15.1 survey report, 2014)
Noakhali DHSS 2013 10.5 15 15.8
Pirozepur BDHS 2011 26.3 30 3.5
Percent of mothers receiving postnatal health Tracer check within first two days of birth indicator District survey report Bhola DHSS 2013 10.1 15 N/A Not measured in the
MaMoni HSS baseline surveys. Will Habiganj 17.7 22 2012 be reported in the subsequent surveys Jhalokathi BMMS2010 14 20
Lakhsmipur DHSS 2013 16.3 20
Noakhali DHSS 2013 12.9 20
Pirozepur BMMS2010 9.6 15
Prevalence of modern contraceptive methods Tracer use indicator District survey report (Bhola, Habiganj, Jhalokati and Pirojpur Bhola DHSS 2013 54.4 58 N/A Tracer survey report, MaMoni HSS Habiganj 40.6 44 42.1 2015) 2012 (Noakhali and Jhalokathi BMMS 2010 47.4 49 52.6 Lakshmipur, Tracer
Lakhsmipur DHSS 2013 48.2 50 N/A survey report, 2014)
Noakhali DHSS 2013 44.4 47 57.1
Pirozepur BMMS 2010 47.7 50 52.7
DGFP Couple years of protection (CYP) in USG- MIS 1,169,033 181,369 211,858 All 6 district supported programs Form-4 (118,768 in 23 High-
MaMoni HSS – Year Two Second Quarterly Report April 2015 30 Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014) intensity upazilas)
Intermediate Result 1: Improve service readiness through critical gap management Health Facility informati Percent of targeted facilities that provide on 2013 N/A 30 N/A Assessment ongoing essential newborn care collectio n checklist Health facility Percent of targeted facilities that provide informati 2013 N/A 70 N/A Assessment ongoing family planning services on checklist Health Percent of targeted facilities providing facility delivery services 24 hours a day, seven days a informati 2014 N/A 30 N/A Assessment ongoing week on checklist Number of vacant positions filled by Project 58 FWV,19 Nurses, 1 2013 81 281 172 78 temporary non-GOB health workers MIS doctor
Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in Project maternal/newborn health through USG- training 2013 N/A 5,500 1,760 1637 supported programs report Project Number of people trained in FP/RH with USG training 2013 N/A 615 19 21,449 funds report Project Number of people trained in child health and training 2013 N/A 2,750 0 540 nutrition through USG-supported programs report
Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization
MaMoni HSS – Year Two Second Quarterly Report April 2015 31 Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014) These facilities were upgraded to provide Number of facilities upgraded to provide Project 2013 7 6 14 15 MNCH/FP/N services, MNCH/FP/N services through USG support MIS without support for renovation of facilities
Intermediate Result 2: Strengthen health systems at district level and below
Percent of upazilas that used key Project MNCHP/FP/N performance data during 2014 Nil 80 65 report periodic review in the reporting period Targets for Percent of targeted facilities recognized for SBMR achievement of quality 2013 Nil 20 0 achieving set quality standards report standards is set for 2015 The data on stock- outs at SDP level is Percent of USG-assisted service delivery available through the points (SDP) that experience a stock-out at LMIS web-based LMIS of any time during the reporting period of a 2013 N/A <10 5.1 12 report DGFP. The application contraceptive method that the SDP is is currently rolled out expected to provide only in Lakhsmipur district.
Sub-IR 2.1: Improve leadership and management at district level and below
Percent of planned supervision visits JSV 21 High-intensity conducted where a supervision tool was used 2014 N/A 90 N/A checklist 56 upazilas and findings shared with providers
Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs
Number of districts with updated Project 21 High-intensity 2013 Nil 6 0 4 comprehensive annual MNCH/FP/N plan report upazilas
MaMoni HSS – Year Two Second Quarterly Report April 2015 32 Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014) Micro Number of CMPM Number of community microplanning units planning 2013 924 3,724 1,303 6,252 held in 21 High- conducting monthly meeting meeting intensity upazilas register
Sub-IR 2.3: Strengthen local management information systems
Health Facility informati Number of unions using automated system to 21 High-intensity on 2013 Nil 10 10 10 integrate facility and community MNH data upazilas collectio n checklist
Sub-IR 2.4: Establish quality assurance system at district level and below Project Percent of targeted facilities received visit by QA 2013 100 N/A a clinical quality assurance team report
Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below
Number of upazila implementing a LMIS 2013 Nil 21 5 5 comprehensive LMIS for MNCHFP report
Sub-IR 2.6: Strengthen local government planning and engagement in health service provision
Project Number Union Parishads (UP) in a district LG 21 High-intensity that allocated budget for MNCH/FP/N in the 2013 72 286 135 151 activity upazilas current year report
Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N
Meeting Number of UPs in a district that have active minutes 21 High-intensity Health and Family Planning Standing of 2013 72 286 92 163 upazilas Committees UEHFPS C
MaMoni HSS – Year Two Second Quarterly Report April 2015 33 Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014)
Intermediate Result 3: Promote enabling environment to strengthen district level health system
Number of critical vacancies filled by GOB Project 2013 N/A 31 19 recruitment in project areas report
Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector
Number of policies/strategies/guidelines on Policy MNH developed/revised with MaMoni HSS documen 2013 N/A 4 2 support t
Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program
Project FAOPS Conference; Number of MNCH/FP/N advocacy initiatives report 2013 N/A 4 2 World Prematurity held in reporting quarter on Day advocacy
Intermediate Result 4: Identify and reduce barriers to accessing health services
MOH&F All 6 districts Number of deliveries with a SBA in USG- W MIS 2013 54,444 78,542 18,102 14,759 (10,631 in 23 High- assisted programs report intensity upazilas) MOH&F All 6 districts Number of ANC visits by skilled providers W MIS 2013 259,041 398,198 149,655 148,343 (111,697 in 23 High- from USG-assisted facilities report intensity upazilas)
Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches
Project Number of people reached through project 21 High-intensity MIS 2013 NA 613,000 64,167 130,230 supported BCC activities upazilas report
Sub-IR 4.2: Enhance community engagement in addressing health needs
MaMoni HSS – Year Two Second Quarterly Report April 2015 34 Targets Achievement Achievement Remarks Data Baseline Baseline Indicator Disaggregation End of Q1 Source Year Value Jan–Mar 2015 (December 2015 2014) Number of trained community volunteers Project 21 High-intensity promoting MNCH/FP/N through project MIS 2013 14,000 34,929 33,961 22,929 upazilas support report
Number of Community Action Groups with Project an emergency transport system for maternal 21 High-intensity MIS 2013 2,126 30,967 14,726 15,953 and newborn health care through USG- upazilas report supported programs
MaMoni HSS – Year Two Second Quarterly Report April 2015 35 Annex 3: Success Stories
A. Sutapa Biswas reassured by Aponjon mobile messages during pregnancy After five years of her marriage, Sutapa Biswas and her husband decided to have their first child. After her pregnancy was confirmed, their days and nights were dedicated to thinking about their baby and planning its upbringing. In all those thoughts there was also a fear; fear of not knowing what it would be like during pregnancy. Sutapa found it difficult to accept that her body was starting to change as days went by; it was altering day by day. Everything started becoming so complicated. Sutapa Sutopa Biswas and her trusted mobile phone was not familiar with such experiences because for the first time in her life, she was becoming a mother. She had seen many relatives, friends and colleagues becoming pregnant but for the first time she was carrying a baby in her womb and the feeling made her happy as well as nervous all the time.
Initially Sutapa faced some minor problems, but she did not worry about it at all. Towards the end of her first trimester, she faced her first major pregnancy issue. She knew that during this period, the tendency to feel sick or even vomit might increase, and eating may become troublesome at times. For her, this entire experience became a feared one. She could not tolerate the smell of anything, and would start getting sick as soon as she smelled any food. Sutapa found it very difficult to get inside the kitchen, as she found it difficult to stop the feeling of queasiness as soon as she smelled certain spices, the vegetables, or fish. She faced a dilemma, and did not know what to do. Sutapa’s mother-in-law believed that she was being dramatic, as she had never experienced these kinds of feelings, and worked in her house up until her own delivery. Sutapa started feeling quite lonely. To bring her out of this helpless state, her friend Rukhsana came to her assistance. Rukhsana took Sutapa’s cell phone and got her registered for Aponjon service. Aponjon sent Sutapa two messages per week. Every week she received advice and suggestions to overcome any maternal complications that may arise. And the advice was not only for pregnant women, but also for the family members such as in-laws, husbands, brothers, and sisters so that they also become aware of the situation and can act when needed. Initially, the messages did not appear to be interesting to Sutapa. But during her twelfth week of pregnancy, she noticed that she felt restless for no reason and was always in a bad mood, for which she ended up in a quarrel with someone. She even fought twice with her mother-in-law. Sutapa could not understand what was happening; why it was happening. One day, a message from Aponjon came, saying: “You are now in your twelfth week of pregnancy. During this time you might feel restless and anxious, and you might feel low. Try to spend most of your time with your loved and close ones. Talk and always be in your jolly mood.” After seeing this message, Sutapa felt much better. She thought she was getting ill, going through some mental disorder. The message made her feel confident and relaxed. She showed it to her husband and her husband showed it to his mother. In a short span of time, the entire scenario changed; this message changed the entire environment of the house. Everyone in the house became quite caring about her from that point on. If Sutapa got angry during these times, her husband, in-laws and other members handled it considerately and they stayed calm about this as they were made aware that being anxious and restless are associated with pregnancy. A pregnant woman always needs love, support and friendly gestures from her home.
MaMoni HSS – Year Two Second Quarterly Report April 2015 36
B. Volunteers from Kaliargop village bring four women to receive antenatal care
Kaliargop is a locality surrounded by numbers of canals, which are branches of rivers named Sugandha, Dhansiri, Bamanda, and Biskhali. Kaliargop is a village of Binoykathi Union of Jhalahathi Sadar. The village is situated at the most far corner of the union which is 14 kilometers away from the Upazila Sadar. In this region, the roads are almost nonexistent during the rainy season. Local boats are the only Women from Kaliargop village at Binoykathi UH&FWC method of transportation during these times. During winter, people travel from one place to another by rickshaw vans. It can take 2-3 hours to reach District Sadar as people have to cross 13-14 shankos, bridges constructed of bamboo. However, the communication system becomes terrible during the interval time of winter and rainy season. Walking is the only way to travel, so seeking any kind of health care from outside one’s region is very rare. In the past, there was no knowledge about the overall healthcare issues among the villagers, especially those related to maternal and newborn health. Most deliveries were conducted at home by local unskilled birth attendants at the village of Kaliargop, which put both mothers’ and newborns’ lives at stake. The nearest healthcare center (UH&FWC) is 4 kilometers away. Willing pregnant mothers could visit the healthcare center by boat during rainy season, or look for rickshaw vans, which are rare and also risky due to the dangerous road conditions. Electricity was scarce in this region, so health services for pregnant mothers and basic education were uncommon. MaMoni HSS oriented three volunteers from the community. The volunteers learned about maternal and newborn health care, specifically, that the mothers and newborns lives can be saved by ensuring routine check-ups during pregnancy. Since receiving these orientation trainings, the three volunteers have already identified nine pregnant mothers through household visits in the village. The expecting mothers who received the visits were not aware of the importance of routine check-ups during pregnancy. The volunteers also provided information on pregnancy-related care and its importance to them and their family members. Many of their family members did not believe in the necessity of such check-ups, and were not willing to take mothers to health facilities for care. However, through the persistence of the MaMoni HSS project’s volunteers, they were successfully in bringing mothers into the union healthcare center. MaMoni HSS volunteer Mrs. Chaina Begum ensured four pregnant mothers visited health facilities. Family Welfare Visitor (FWV) Mrs. Marufa Begum provided antenatal care to them. Marufa Begum stressed that if MaMoni HSS volunteers continue to identify pregnant mothers and help them visit facilities, it would be easier for her to provide services. These kinds of efforts can ensure health services reach pregnant mothers from others villages, unions, and for all. In addition to Kaliargop village, MaMoni HSS volunteers from nearby villages Kandargati, Manpasha, and Balokdia are also referring pregnant mothers to health facilities for antenatal check-ups. One volunteer, Rawshan Ara Begum, said: “Since MaMoni HSS project started working here, volunteers are organizing meetings in the community and visiting households. Mothers’ willingness to receive pregnancy-related services is ever growing.” She added that this kind of support would help improve mothers’ and newborns’ health and to reduce their deaths. A pregnant mother from the village, Ria Begum, admitted: “I did not realize earlier that I was required to take routine health check-ups during pregnancy. I learned this from a MaMoni HSS worker. I have been immensely benefitted.”
MaMoni HSS – Year Two Second Quarterly Report April 2015 37 Annex 4: Key Achievements of Aponjon/MAMA initiative
The MAMA initiative, branded as Aponjon in Bangladesh, was fully integrated with MaMoni HSS from July 1, 2014. This annex presents a summary of key accomplishments of Aponjon during the period of January 2015 – March 2015.
Achieving improvements in health knowledge and practice as well as health seeking behavior of targeted women and gatekeepers. A total of eight units of a workshop were planned for the second quarter of the project’s second year. However, owing to the current state of political instability, only one workshop has been successfully held. Meanwhile, Aponjon team ventured out for new channels for subscriber acquisition and lay out a sustainable business model for the program. Orientation workshop on Aponjon has been held at the UHC Auditorium, Manirampur, Jessore on March 11, 2015. The workshop was aimed at explaining the operations of Aponjon program and was attended by govt. officials, Union Parishad Chairmen, ministerial secretaries and journalists. Manirampur Upazila Chairman Mr. Md. Amzad Hossain Lavlu attended as the chief guest was moderated by Mr. Sardar Bahadur Ali, Chairman of Durbadhanga Union. In addition, Upazila government officials, such as family planning officers, also spoke at the workshop. A total of 50 participants were present at the orientation workshop. Concrete plans have been put in place to ensure that the remaining seven orientation workshops can be held during the next quarter.
Orientation Workshop at the UHC Auditorium, Manirampur, Jessore on March 11, 2015
Selection Workshop on Aponjon Brand Promoters A total of 25 units were planned for this quarter, but progress was hampered due to political unrest. Meanwhile, the Aponjon team pursued quality assurance procedures, exploring new channels for subscriber acquisition and creating a sustainable business model. Aponjon introduced their own brand promoters in Manirampur Upazilla in Jessore District. For that reason, Dnet operated promotional activities in search of applications from December 2014 to February 2015.
Selection Workshop at the UHC Auditorium, Manirampur, Jessore on March 9-10, 2015
MaMoni HSS – Year Two Second Quarterly Report April 2015 38 A total of six training sessions on Aponjon were planned for this quarter. Of these six, only one was able to be held due to political unrest. A residential training has been arranged for the newly selected Aponjon brand promoters at the Jessore regional office. All 14 participants were present at the training. The participants were introduced to the Aponjon service, and learning about the registration process and the money transaction system, as well as the Aponjon Yard Meeting. Finally, the training included the marketing techniques needed to motivate new clients for subscriber acquisition.
Trainings of Aponjon brand promotors at the regional office of Jessore
Training of Community Agents (CA) and Static Agents (SA) A total of nine trainings for CAs and SAs were conducted during this quarter. A total of 173 CAs and SAs, 10 Upazila/Branch Managers, and 10 Program Organizers participated in 10 different batches of trainings from various areas of Gazipur district in the BRAC health program.
During this quarter, total of 23 local-level organizations contributed to Aponjon registrations across 22 districts. A total of 23,005 subscribers were enrolled with Aponjon services in this quarter. Among them, 10,392 were registered with BRAC health workers, 364 with MaMoni HSS, 1,815 with NHSDP and the remaining 83 were enrolled by TothyoKollyani. During this quarter, no brand promotors were engaged for Aponjon registration. The brand promoters usually collect data from different locations where a high number of pregnant women and new mothers are expected, mostly in urban areas.
MaMoni HSS – Year Two Second Quarterly Report April 2015 39 Table 7: Subscriber acquisitions, January to March 2015
Subscriber Type January February March Total Primary subscribers 8,937 8,711 4,158 21,806 Expecting mothers 3,823 3,666 1,613 9,102 New mothers 5,114 5,045 2,545 12,704 Secondary subscribers 421 514 265 1,200 (Gatekeepers) Husbands 83 64 23 170 Mothers-in-law 3 2 1 6 Mothers 1 0 0 1 Other Relatives 334 448 241 1,023 Total 9,358 9,225 4,423 23,005
Design of the new web template Aponjon has always considered developing a mother-friendly website, with eye-catching visuals and layout. Mothers-to-be and new mothers will be just a click away from very relevant and stage-specific information during and after the pregnancy period. In addition, they will be able to share their experiences and connect with fellow users. Aponjon solicited proposals for vendors to build an interactive and state-of-the-art website. The participants prepared mockups of the website, based on the communication team’s suggestions. Three crucial elements will be prioritized, namely interactive/ participatory features; the site’s functionality and user content, such as exercise tips during pregnancies, sleeping habits during pregnancy; and the overall visual appeal of the website’s layout. Website link: http://revinr.com/aponjon_final
Development of new content As per popular demand from the subscribers, as well as findings from formative research, a new service has been designed to be introduced for mothers with children aged one to five years. Accordingly, contents have been developed in IVR audio and text message format. Initially, messages have been designed for mothers only, while messages for gatekeepers will be introduced later. The service will follow the same frequency pattern as the existing Aponjon service for mothers with children below one year. The messages have been recorded and text messages developed. The service awaits strategic decision of deployment by Dnet management.
As part of continuous improvement of Aponjon contents, modifications are reflected through new versions of content. Based on a previously conducted content survey and following suggestions made by the Technical Committee on Content, changes had been made in the content and updated versions of the content, including a new recording, were created. The contents are due for deployment by the Technology team. Subsequent meetings of the Technical Committee on Content and the field study for the next version of content will be deferred.
Development of content for Aponjon mobile application To take Aponjon to the next level, and keeping in mind the constantly expanding market of smartphones, Aponjon has taken the initiative to develop a mobile application (app) for smartphone users. The app will be developed for the top three mobile platforms – Android, iOS and Windows Phone. A local firm has been selected to develop the app through a competitive bidding process. The firm will
MaMoni HSS – Year Two Second Quarterly Report April 2015 40 also develop the APIs and the backend framework for monitoring and reporting. The app is expected to be developed by the end of April 2015.
Management of call center and counseling lines As seen in the table below, the total number of registration calls for the quarter was 1,074, with 11,169 incoming calls and 53,457 outgoing calls. There were 169 DOB updates and 3,404 data entry calls.
Data Month Registration calls Incoming calls Outgoing calls DOB updates entry January 66 3,487 16,863 61 N/A
February 97 3,672 16,599 68 2276
March 911 4,010 19,995 40 1,128
Counseling line Management
Month Incoming calls Outgoing calls
January 1,637 12 February 1,438 9 March 1,342 6
Partnership with DGHS After several meetings with DGHS, both parties reached a consensus that the health workers of DGHS will work for Aponjon registration. An MOU with DGHS was signed on January 1, 2015. Dr. Ananya Raihan, CEO of Dnet and Prof. Dr. Abul Kalam Azad, Additional Director General (Planning & Development) & Line Director, MIS, DGHS signed the MOU. The health workers will fill up the information of the pregnant women with a harmonized and unified tab-based form. During their data entry, health workers will inquire about participants’ consent for providing information and data will be collected online for those who have provided consent to Aponjon.
Test financing/Business model for sustainability
Funder management program: Direct Sales and CSR Under this banner, a proposal is placed to the Business Social Responsibility (BSR) team, who are implementing the HER Project in Bangladesh. This project’s goal is to raise awareness among female workers on health and safety behavior and to improve their work environments, employees and employer’s relations by involving the buyers, factory owners, workers, NGOs, and related parties of the readymade garment industry of Bangladesh. The BSR team also builds the bridge between Aponjon potential consumers (female workers) and producers/suppliers of health and hygiene items.
In collaboration with the BSR team, a new Alternative Acquisition Channel for Aponjon will be explored with premium price arrangement and online-based real time Aponjon registration process. It is expected that these services will not only cater to the urban, low income target groups, but also be a device for
MaMoni HSS – Year Two Second Quarterly Report April 2015 41 factory authorities to stay connected with female workers on maternity leave. The MOU signing is process, and will be reviewed and finalized by each party’s legal representatives. Under this agreement, participating factories of the HER project will bear a 65 percent cost of the total subscription fees, with the remaining 35 percent paid for by the female subscribers/workers.
MaMoni HSS – Year Two Second Quarterly Report April 2015 42 Annex 5: Media Stories Published this Quarter
A listing of some of the media stories published this past quarter are as follows: http://www.eobserverbd.com/2015/03/18/7/details/7_r3_c1.jpg http://www.prothom-alo.com/bangladesh/article/444037/‘আপনজেন’-েমাবাইল-েসবা�হীতা-১০- লাখ#comments http://www.samakal.net/2015/02/05/116878/?version=beta http://www.kalerkantho.com/print-edition/news/2015/02/06/184497 http://bangla.bdnews24.com/health/article921002.bdnews http://www.banglatribune.com/েমাবাইল-�া�뷍েসবায়-১০ http://www.banglanews24.com/beta/fullnews/bn/364760.htmlhttp://www.dhakatribune.com/banglad esh/2015/feb/06/1m-expecting-and-lactating-mothers-benefit-mobile-health-service http://www.bizbdnews.com/general-news-116718 http://unb.com.bd/usaid-service http://redtimesbd24.com/2015/02/আপনজন-েমাবাইল-�া�뷍/ bnc24.com http://www.bnc24.com/index.php/নগর-মহানগর/24847-ইউএসএআইিড-আপনজন-েমাবাইল-�া�뷍-েসবার-দশ- ল�-�াহক-উদযাপন http://www.peoplesnews24.com/?p=6223 http://www.tourismnewsbd.com/?p=742 http://kansatnews24.com/আপনজন-েমাবাইল-�া�뷍/ http://physionews24.com/ http://ngonewsbd.com/usaid-aponjon-mobile-health-celebrates-million/ http://www.tourismnewsbd.com/?p=742http://www.newsagami24.com/index.php/details_news/index /54d3a1724435b#.VNbZmuHD_dM
MaMoni HSS – Year Two Second Quarterly Report April 2015 43 Annex 6: Quality Assurance Initiatives
National level Stakeholders’ meetings
No. of No. of SL # Name of Training Events Location Date Category of Participants Participants Total Batches Male Female Meeting with National Nutrition Services IPHN November Director, Deputy Director, AD, (NNS), IPHN for developing joint work Conference 27, 2014 Program Managers, DPMs, Jr. 1 1 18 4 22 plan to support implementation of room Clinicians and representatives from operational plan of HPNSDP MaMoni HSS Consultation meeting at DGFP along with MCH December Director MCH Services, LD CCSDP, professional bodies to develop Basic Conference 9, 2014 DD, AD, PM(QA), PM, Professor 2 MNCH/FP/N training package for non- room, DGFP (Gynae & Obs), Associate Professor 1 16 7 23 technical service providers (Pediatrics); MFSTC, representatives from MaMoni HSS Conduct national level orientation on MIS December Directors from DGHS & DGFP, BNF, RRQAT to share the concept, strategy conference 11, 2014 BPS, OGSB, representatives from 3 1 17 11 28 and develop next course of action to room, MaMoni HSS implement RRQAT concept DGHS
A) District level Orientation/Training/Workshops
B) Scaling up Quality Assurance interventions
1. Preparation for implementation and scaling up Maternal and Perinatal Death Review (MPDR): The project initiated effective partnerships with the Center for Injury Preventions and Research, Bangladesh (CIPRB) and UNICEF for scaling up MPDR as a quality improvement approach. The project organized a joint trip with UNICEF and CIPRB to Maulvibazar district, one of 10 districts currently implementing MPDR with support from UNICEF and CIPRB. During the trip, the project conducted a review of the process of MPDR implementation in the district and assessed the level of data collection and utilization. As a result, the project prepared for scaling up MPDR in MaMoni HSS project’s areas taking into consideration the UNICEF and CIPRB experience and challenges. During
MaMoni HSS – Year Two Second Quarterly Report April 2015 44 the reporting period, the project initiated the plan for introducing MPDR in one upazila in Noakhali district. In addition, the project has developed a scope of work to engage CIPRB as a lead organization in implementing MPDR in Bangladesh to collaborate with MaMoni HSS to scale up MPDR in Noakhali, Habiganj, and Lakshmipur Districts. The implementation of MPDR will improve maternal, perinatal, and neonatal mortality notification and will entail conducting reviews of each mortality case, focusing on the identification of gaps in health care seeking and in quality of services, and engaging district-level policy makers and community leaders in taking actions to avoid future maternal and newborn mortality.
2. Initiating a plan for developing Regional Roaming Quality Assurance Teams (RRQAT): The project has developed a plan for the development of RRQAT to contribute to improving the quality of clinical services in project areas. The teams are composed of selected staff from medical colleges and professional associations, such as OGSB and BPS, who will pay visits accompanied with district-level supervisors to selected health facilities at MaMoni HSS districts. RRQAT will use the supportive supervision approach to provide guidance to health providers in improving maternal and newborn care services. In addition, RRQAT will conduct clinical updates in selected topics based on the results of the supervisory visits. RRQAT will discuss results of the supervisory visits with district health officials and identify specific improvement actions. The project intends to start RRQAT in Habiganj district of Sylhet Region and will be followed by teams in Barisal and Chittagong to cover other project districts.
3. Support the implementation of Standards-Based Management and Recognition approach: During the reporting quarter, the project supported 31 health facilities in three districts (12 in Habiganj, 8 in Lakshmipur, and 11 in Noakhali) in implementing their quality improvement workplan.
4. Implementation of Joint Supervisory Visits (JSV): The project conducted orientation for district level supervisors and government managers in Habiganj, Lakshmipur, and Noakhali districts on the supervision tools and guidelines. Plans for conducting routine supervision using the developed tools will start next quarter. The JSV will contribute to conducting regular and effective supervisory visits to health facilities in project areas with particular emphasis in applying the supportive supervision approach to improve quality of MNCH/FP/N services.
MaMoni HSS – Year Two Second Quarterly Report April 2015 45 Annex 7: MaMoni HSS Project Training Activities, January 1 – March 31, 2015
Lakshmipur District
Number of SL # Name of Training Events Location Category of Participants Participants Total M F 1.A TOT CV orientation on FP counseling at MCWC, Lakshmipur CS, DDFP, UFPO, AUFPO, MO-MCH-FP, 14 3 17 district level for upazila level trainers MO-Clinic, FC-QA, TO 1.B TOT CV orientation on FP counseling at Lakshmipur FWV, FPI, FSO, AUFPO 111 79 190 upazila level for union level trainers 1.C CV orientation on FP counseling at Lakshmipur CV 596 5,971 6,567 union level 2.A Training on partographs, AMTSL and CS Office, MO (Gynae & EoC trained), RMO, MO- PE/E management (Doctor Batch) Lakshmipur MCH-FP, Jr. Consultant Gynae, FC-QA 7 9 16
2.B Training on partographs, AMTSL and Lakshmipur FWV, Nurse & Paramedic 0 56 56 PE/E management 3.A Training on SBM-R Module 2 CS Office, CS, DDFP, MO-CS, UH&FPO, UFPO, MO- Lakshmipur MCH-FP, MO, FWV, SACMO, Paramedic, 20 14 34 TO, DC 4.A PPIUCD Training MFSTC, Dhaka Female SACMO(1), FWV(6) & Paramedic (8) 0 15 15
5.A JSV upazila-level orientation for first Lakshmipur (Sadar, FWV, SACMO, FPI, AHI, HI, MT-EPI, TO, line supervisor Kamalnagar Raipur AUFPA 89 6 95 Ramgoti)
MaMoni HSS – Year Two Second Quarterly Report April 2015 46
Noakhali District
Number of SL # Name of Training Events Location Category of Participants Participants Total M F TOT CV orientation on FP counseling at DDFP, UFPO, MO-MCH, FC-QA, Sr TO, TO, 1.A CS Office, Noakhali 16 2 18 district level for upazila level trainers DC, DYC, M&E, BCCP, FC Shenbag TOT CV orientation on FP counseling at 1.B Companygonj FWV, SACMO, FPI, FSO, Paramedic 70 79 149 upazila level for union level trainers Begamgonj Htiya Shenbag CV orientation on FP counseling at 1.C Companygonj CV 888 4,282 5,170 union level Begamgonj Htiya Training on partographs, AMTSL and MO (Gynae & EoC trained), RMO, MO- 2.A CS Office, Noakhali 11 7 18 PE/E management (Doctor Batch) MCH-FP, Jr. Consultant Gynae, FC-QA Training on partographs, AMTSL and 2.B Noakhali FWV, Nurse & Paramedic 0 61 61 PE/E management CS, DDFP, MO-CS, UH&FPO, UFPO, MO- 3.A Training on SBM-R Module 2 CS Office, Noakhali MCH-FP, MO, FWV, SACMO, Paramedic, 19 20 39 TO, DC Shenbag JSV upazila-level orientation for first 4.A Companygonj Hi, AHI, FPI, MT-EPI, STATISTICIAN, TO 87 29 116 line supervisor Begamgonj Hatiya
MaMoni HSS – Year Two Second Quarterly Report April 2015 47
Habiganj District
Total Participants SL# Training Venue Category of Participants Male Female Total Conference Room, TOT on JSV at district level MaMoni HSS UH&FPO, UFPO, MO-MCH, MO-DC, DC, 1 14 4 18 District Office, UC, TO., FC-AQ) Habiganj Conference Room, MaMoni HSS MOMCH, MO (Clinic), UFPO, AUFPO, TOT orientation on FP counseling and 2 District Office, Manager-QA, DC, DDC, FC-QA,TO 23 6 29 referral for CV at district level Habiganj
Conference Room, TOT on Post-Partum Iron Folic Acid MaMoni HSS UH&FPO, UFPO, MO-MCH, MO-DC, DC, 3 4 23 27 (PPIFA) District Office, UC, TO., FC-AQ) Habiganj Conference Room, TOT on AMTSL, partographs and MaMoni HSS MO, MOMCH, Consultant(Gynae)’ 4 14 11 25 management of PE/E District Office, MO(Clinic), FC-QA Habiganj District Office, Training on AMTSL, partographs and 5 Habiganj, Sadar FWV, SSN, Paramedic 0 82 82 management of PE/E Hospital, Habiganj District Office, FWV, SACMO, Paramedic, UFPO, UHFPO, 6 Workshop on SBM-R Module 2 13 18 31 Habiganj MO, FC-QA, DC,TO, DDC, ME&DO JSV orientation for front line Upazila Health 7 Statistician, MT-EPI,UFPA, HI, AHI, FPI 196 10 206 supervisor Complex Misoprostol orientation for basic AHI, FPI,FWA,HA,HI,SACMO, CHCP,MT-EPI, 8 UHC 512 639 1,151 health workers Statistician, UFPA, FWV, Midwife Training on malnutrition management Upazila Health HI,AHI,HA,CHCP, FPI,FWA,UFPA, 9 74 85 159 of one upazila (Madhabpur) Complex Statistician
MaMoni HSS – Year Two Second Quarterly Report April 2015 48 TOT for union-level trainers on FP 10 UHC FPI, SACMO, FWV, FSO 143 99 242 counseling for CV UH&FWC, UP Orientation of CV/ SS on FP counseling 11 Poreshad, Primary CV 1,039 7,209 8,248 and referral of LAPM service School and CC AHI, FPI,FWA,HA,HI,SACMO, CHCP,MT-EPI, 12 PPIFA orientation UHC Statistician, UFPA, FWV,Midwife, Nurse, 185 197 382 MO
Jhalokathi District
Total Participants Sl # Training Venue Category of Participants Male Female Total Upazila Health 1 JSV Orientation HI,AHI,FPI 57 31 88 Complex Sharing Meeting On Misoprostol UHFPO, UFPO, MO-MCHFP, 2 Orientation with Upazila-Level Health CS Office 12 1 13 MO-DC & Family Planning Managers Misoprostol Orientation for Basic Upazila Health HI-,AHI-,HA-CHCP-FPI- 3 161 290 451 Health Workers Complex FWA-,FWV-,MTEPI-,SACMO-,UFPA- TOT on AMTSL, Partograph and Consultant (Gynae&Obs), MO-CS, MO- 4 CS Office 13 7 20 Management of PE/E MCHFP, MO Barisal Medical 5 TOT on CCM MO-MCHFP, MO 5 7 12 College Training on AMTSL, Partograph and 6 CS Office SSN, FWV N/A 43 43 Management of PE/E Upazila Health 7 Training on CCM for CHCP CHCP 39 46 85 Complex Orientation for District & Upazila 8 level Managers and Logistic CS Office MO-CS, UHFPO, UFPO, Store keepers 17 1 18 Management Staffs on LMIS Tools
MaMoni HSS – Year Two Second Quarterly Report April 2015 49 SBM-R Module 1 Orientation for 9 CS Office UHFPO,UFPO, MO-MCHFO, MO-Clinic 8 2 10 District & Upazila-level Managers Zila Parishad 10 Training on SBM-R Module 1 MO, SSN, FWV, SACMO (FP) 4 25 29 Auditorium MCWC, Zila Parishad Training on Mother & Newborn 11 Auditorium, FWV, SACMO (FP) 15 44 59 Register and CSBA Register MaMoni Office Conference Room
MaMoni HSS – Year Two Second Quarterly Report April 2015 50 Annex 8: National Newborn Scale-Up Initiatives
A. Comprehensive Newborn Care Package (CNCP)
CNCP is a comprehensive newborn care training package comprised of HBB and excerpts from the Essential Care for Every Baby (ECEB) curriculum that align with the national guidelines for four newborn health interventions (Chlorhexidine, ACS, Sepsis management at union level facility, and KMC) endorsed by MOH&FW, Bangladesh. CNCP will be implemented in three different levels with three different training modules: upazila and above-level providers, union-level facility providers and community-level health workers. In this quarter, we have prepared three different training modules, flip charts and other necessary training materials.
Summary of Results for the Quarter
Major accomplishments during this quarter included the introduction of the CNCP training, HBB training under the district revisit program, and newborn care surveillance dissemination at the district level. Components of the district revisit program include district review meetings, SBA trainings for private facility providers, strengthening of refresher trainings, and monitoring of logistics and logistics gap management. Master trainer workshops and TOT for CNCP training for upazila and above facilities were completed and thus a platform for roll-out of CNCP has been created. The project revisited six districts where HBB trainings had occurred (Dinajpur, Rangamati, Kishoreganj, Rangpur, Bogra, and Gazipur) and also responded to unmet needs of HBB trainings in a total of 11 districts. The project also carried out HBB trainings at the Dhaka City Corporation because approximately 3,000 doctors and nurses had been identified in the previous year who required HBB training in different private facilities within Dhaka. The project successfully completed newborn care surveillance data sharing meetings in eight surveillance districts (Barisal, Bagerhat, Bogra, Gaibandha, Habiganj, Narsingdi, Noakhali, and Laksmipur).
CNCP Master Trainers workshop A two-day long master trainers workshop was held from March 11-12, 2015. A total of 20 master trainers participated in the workshop. As many of the participants were previously involved with the development of the CNCP curriculum, the workshop was mainly focused on the training methodology.
MaMoni HSS – Year Two Second Quarterly Report April 2015 51 Master trainers workshop on CNCP: 1. Participants in a group photo; 2. Participants are conducting a session; 3. Prof. Mohammod Shahidullah is speaking to the participants regarding training process of CNCP.
TOT on CNCP Followed by a master trainers workshop, three batches of TOT on CNCP for upazila and above-level providers was provided. Participants included 64 doctors from Habiganj, Noakhali and Lakshmipur.
Prof. M A Mannan is conducting a session and participants are practicing a session in TOT for CNCP for upazila and above-level modules
B. Helping Babies Breathe HBB Training During this quarter, 1,060 SBAs have been trained in 53 batches on the HBB curriculum, including 216 private facility providers and 844 government providers. HBB trainings were organized in revisit districts (Dinajpur, Rangamati, Kishoreganj, Rangpur, Bogra and Gazipur) and other districts (Noakhali, Lakshmipur, Barisal, Bagerhat, Bogra, Kushtia and Habiganj) and Dhaka. The cumulative number of HBB trainings the project has conducted since inception is 28,131. Refresher Sessions Observed During this quarter, 294 SBAs were observed in 10 HBB refresher sessions in six districts. Most of the sessions were held on the same day as the regular monthly meeting. District Review Meeting At the onset of the district revisit program, meetings with health and family planning managers are organized for their awareness and commitment to different components of the revisits, including
MaMoni HSS – Year Two Second Quarterly Report April 2015 52 arranging refresher trainings for SBAs during routine monthly meetings. Six districts review meetings were held in Rangamati, Dinajpur, Kishoreganj, Rangpur, Bogra and Gazipur.
The Civil Surgeon of Gazipur is describing HBB performance of Gazipur district in DRM in Gazipur district. DD-FP, upazila managers and consultants also attended the meeting.
A total of 255 district and upazila-level health and family planning managers participated in six District Review Meetings. Facility Visits During this period, 265 facilities were visited out of 432 facilities in six revisit districts by HBB district coordinators. The facilities were Medical College Hospital, District Hospital, MCWC, Upazila Health Complex and UH&FWC. During facility visits, a logistics checklist is completed and bag and mask, sucker, and action plan posters in the operating theater and delivery room are checked and also replaced, if necessary. Distribution of Resuscitation Devices Under the district revisiting program, the project is replacing damaged equipment and also distributing some equipment as per requests from district health and family planning managers. A total of eight NeoNatalie complete sets, 14 resuscitators, and 14 penguin suckers have been distributed in this quarter. (See tables below) Replacement New distribution Cumulative distribution Item Total Item Total Item Total NeoNatalie NeoNatalie NeoNatalie complete set 8 complete set 0 complete set 1,410 Bag & Mask 10 Bag & Mask 4 Bag & Mask 13,859 Sucker 10 Sucker 4 Sucker 13,861
Distribution of HBB training video A total of 148 HBB training videos in Bengali were distributed in seven districts up to upazila-level facilities.
MaMoni HSS – Year Two Second Quarterly Report April 2015 53 Newborn Care Surveillance data sharing at district level The project has completed Newborn Care Surveillance in eight districts in December 2014. During March 2015, the project has organized data sharing meetings of newborn care surveillance data at respective districts with the participation of district and upazila-level health and family planning managers, designated Hospital Surveillance Officers and service providers of different levels who have participated in the surveillance data collection. A total of 371 participants of different categories have participated in the meetings.
CS, DDFP UH&FPO, UFPO and participants of different upazila of Barisal are participating in a Newborn Care surveillance data sharing meeting.
Way Forward The project has planned the roll-out of CNCP trainings in seven districts, including six MaMoni HSS districts as per action plans and in parallel with the HBB district revisit program. The project is planning for national-level dissemination of Newborn Care Surveillance data in the next quarter.
MaMoni HSS – Year Two Second Quarterly Report April 2015 54 Annex 9: Environmental Monitoring and Mitigation Plan
Developed Guidelines for Environmental Mitigation and Monitoring Plan (EMMP):
Based on the USAID-approved Environmental Manual, MaMoni HSS developed the guidelines for EMMP to serve as a reference for the district-level staff and for project trainers to conduct orientation for district-level staff. The guidelines are also meant to provide information to help project staff at headquarters in Dhaka and the district-level staff in developing plans to monitor environmental mitigation activities, including waste management.
The guidelines include the following sections: • The purpose of the EMMP • Project activities with potential harm to the environment and the mitigation and monitoring plan: o Procurement of equipment, commodities and materials o Renovation of health facilities o Waste management: General practice of waste management Management of sharps Management of placenta, blood, and blood-stained products. Management of chemicals Management of general hospital waste • Reporting requirements • Roles and responsibilities
Developed Environment Management Orientation Package: The package, developed for the orientation of district-level staff, includes a PowerPoint presentation and the guidelines. The presentation includes a simplified summary of the guidelines described above with specific instructions to the district staff on roles and responsibilities and reporting requirements.
Orientation of District staff: The project used the developed orientation package to conduct district-level orientations for all project staff, including partner NGOs, on EMMP. During the reporting quarter, all district staff in Jhalokati and Habiganj received the orientation.
Improving medical waste management procedures in selected health facilities through SBM-R: The project has assisted selected health facilities that are currently implementing SBM-R (30 health facilities in four districts) in complying with the medical waste management procedures. Through the SBM-R approach, health facilities conducted baseline assessments of their waste management procedures against the recommended standards and adopted changes to increase the compliance with the standards. Some of the changes included ensuring the introduction of
MaMoni HSS – Year Two Second Quarterly Report April 2015 55 color-coded waste collection containers and ensuring the availability of placenta pits within the premises of health facilities.
Improving medical waste management procedures in Habiganj district through SBM-R
Next steps: During the coming quarter, the project will complete the orientation of district staff in two more districts; Noakhali and Lakhsmipur. In addition, the project will develop a checklist for monitoring waste management procedures at the health facility level and integrate it in the Joint Supervisory Visits (JSV) tools. Such integration will make the process of monitoring waste management a regular and efficient task as it will be linked to the on-going supervision system. Selected counterparts at the district level, particularly supervisors, will be oriented on the overall EMMP, including management of medical waste.
MaMoni HSS – Year Two Second Quarterly Report April 2015 56 Annex 10: Summary of Behavior Change Communication materials produced during the quarter
Audience Total # of District BCC activities Audiences Messages Channel size/ materials name(s) coverage Community members, Leaflet on especially Newborn Distribution Habigonj, application of opinion danger signs during union All Noakhali, chlorhexidine leaders, and application 15,000 advocacy community Lakshmipur, for newborn union of CHX to meetings Jhalokathi cord care parishad umbilicus members, TBAs Preventing PPH by using misoprostol Pregnant Pregnant Flip chart on covering basics Display & women & 6,800 mothers & All districts misoprostol of use and Counselling Community community management after use, if needed
Awareness for Habiganj, Roman banner Pregnant Pregnant using tab Noakhali, on use of women & Display 500 mothers & misoprostol to Lakshmipur, misoprostol Community community prevent PPH Jhalokathi
Building awareness for Pregnant institutional Pregnant Misoprostol women & delivery and Display 5,000 mothers & All districts sticker Community collecting tab community misoprostol for home delivery Habiganj, 4 PNC visits All Noakhali, Poster on PNC Community with time Display 490 community Lakshmipur, schedule Jhalokathi Habiganj, Poster on Danger signs of All Noakhali, newborn danger Community Display 1,300 newborn community Lakshmipur, signs Jhalokathi
MaMoni HSS – Year Two Second Quarterly Report April 2015 57 Habigonj, Pregnant Pregnant Poster on 4 ANC 4 ANC visits Noakhali, women & Display 1,300 mothers & visits schedule Lakshmipur, Community community Jhalokathi Building Poster on 5 Habigonj, Pregnant awareness on 5 danger signs of All Noakhali, women & danger signs Poster display 1,300 pregnant community Lakshmipur, Community during mother Jhalokathi pregnancy Community Community Share volunteers Volunteer job information on (to be used All high- aid for Family Eligible FP choices and Job Aid 40,000 during one- intensity Planning couples refer to service to-one and areas Counseling and provider group Referral sessions)
MaMoni HSS – Year Two Second Quarterly Report April 2015 58