MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-388-LA-13-00004)

Annual Report October 01, 2017– September 30, 2018

Submitted

November 30, 2018

Cover Photo Story

A timely referral saved Kulsuma and her daughter

Bibi Kulsuma resides at 'Nasir Samaj' in a village of Harni union of Hatiya in . Her husband Omar Faruk is a day laborer with no education. After two boys a baby girl was born and the family was very happy to have a girl child. Within a year, the little girl was suffering from frequent illness and MaMoni HSS Community Volunteers referred her to the district hospital. Unfortunately, the little girl was infected by hepatitis B virus and passed away despite all possible effort. Kulsuma and her husband broke into the premature death of her daughter.

Kulsuma again became pregnant within a year. This time, Field Support Officer (FSO) of MaMoni-HSS referred her to Harni UHFWC for antenatal check-up. The family was poor and was reluctant to get ANCs, but the Paramedics convinced her for routine check-ups and blood tests. After testing Hepatitis-B virus was found in Kulasuma’s blood. Paramedic Asma Akter also counseled Kulsuma and her husband go to Noakhali General Hospital for checkup and relevant treatment as her previous baby died due hepatitis B infection and she might have the same. On September 17, 2017 a baby girls was born, the baby was vaccinated against hepatitis B virus immediately after birth. Kulsuma’s expressed that “me and my daughter are safe and healthy. We are grateful to the Community Volunteer Mahmuda Apa, FSO Salma Apa and finally Paramdic Asma Apa. I'm happy and grateful for their treatment, advice and also for referral services”.

Cover photo credits: MaMoni HSS project

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 (USAID), (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government. TABLE OF CONTENTS

Abbreviations ...... 4 Executive Summary ...... 8 Introduction ...... 10 Data Source ...... 11 Program Results of the Year ...... 11 IR 1. Improve service readiness through critical gap management ...... 11 IR 2: Strengthen health systems at the district level and below ...... 33 IR 3. Promote enabling environment to strengthen district level health systems . 54 IR 4. Identify and reduce barriers to accessing health services ...... 59 Challenges, Solutions and Actions Taken ...... 64 Appendix 1: Scope and Geographical coverage of the MaMoni HSS project ...... 66 Appendix 2: Data Sources ...... 67 Appendix 3: Program Performance Indicators ...... 68 Appendix 4: Additional National Level Indicators ...... 83 Appendix 5: List of union facilities upgraded to provide 24/7 normal delivery services85 Appendix 6: eLMIs color coded dashboard for local decision making ...... 90 Appendix 7: Forums where MaMoni HSS lessons were disseminated ...... 92 Appendix 8: List of MaMoni HSS Publications ...... 93 Appendix 9: List of video documentaries developed by MaMoni HSS project ...... 95

MaMoni Health System Strengthening Project Annual Report 2017-2018

ABBREVIATIONS

AAP American Academy of Pediatrics AHI Assistant Health Inspector AMTSL Active Management of Third Stage of Labor ANC Antenatal Care AUFPO Assistant Upazila Family Planning Officer BCC Behavior Change Communication BDT Bangladesh Taka BEmONC Basic Emergency Obstetric and Newborn Care Bh BICC Bangabandhu International Conference Center BIN Balance Identification Notes BMMS Bangladesh Maternal Mortality Survey BP Blood Pressure BPA Bangladesh Pediatric Association BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CC Community Clinic CCSDP Clinical Contraceptive Service Delivery Program CCTV Closed-Circuit Television CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHCP Community Health Care Provider CHW Community Health Worker CHX Chlorhexidine CI Critical Illness cMPM Community Micro Planning Meeting CNCP Comprehensive Newborn Care Package CS Civil Surgeon CSBA Community Skilled Birth Attendant CSA Community Sales Agent CSG Community Support Group CSI Clinical Severe Infection CV Community Volunteer CYP Couple Years of Protection DCS Deputy Civil Surgeon DDFP Deputy Director Family Planning DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DHSS District Health Service Strengthening DH District Hospital DHIS2 District Health Information System-2 DMCH Medical College Hospital DN Death Notification DO Development Objective DPM Deputy Program Manager DQA Data Quality Assessment DRS District Reserve Store DSS Decision Support System EmONC Emergency Obstetric and Newborn Care EMO Emergency Medical Officer ENC Essential Newborn Care EPCMD Ending Preventable Child and Maternal Deaths EPI Expanded Program on Immunization EPIQ Evidence-based Practices for Improvements in Quality EoP End of Project ESP Essential Services Package

4 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 eLMIS Electronic Logistics Management Information System eMIS Electronic Management Information System ETAT Emergency Triage Assessment and Treatment FDR Facility Death Review FP Family Planning FPI Family Planning Inspector FTC Field Training Center FWA Family Welfare Assistant FWC Family Welfare Center FWV Female Welfare Visitor FWVTI Female Welfare Visitor Training Institute GPS Global Positioning System GoB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HEU Health Economics Unit HI High Intensity/Health Inspector HIS Health Information System HPNSP Health, Population and Nutrition Sector Program HPNSDP Health, Population, and Nutrition Sector Development Program HRH Human Resource for Health HNN Healthy Newborn Network HQ Head Quarter HRD Human Resources and Development HRIS Human Resource Information System HS Health Systems HSCS Health Systems Capacity Strengthening HSM Hospital Services Management HSS Health Systems Strengthening icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh IT Information Technology ICMH Institute of Child and Mother Health IDD Iodine Deficiency Disorder IEC Information, Education and Communication IFA Iron Folic Acid IFB Isolated Fast Breathing IMCI Integrated Management of Childhood Illness IPC Inter Personal Communication IR Intermediate Result ISQUA International Society for Quality in Health Care IUCD Intra Uterine Contraceptive Device Jhpiego Johns Hopkins Program for International Education in Gynecology and Obstetrics JHU John Hopkins University JSV Joint Supervisory Visit KMC Kangaroo Mother Care KSH Shishu Hospital LARC Long-acting Reversible Contraceptive LBI Local Bacterial Infection LBW Low Birth Weight LG Local Government LMIS Logistics Management Information System LOC Letter of Collaboration MAM Moderate Acute Malnutrition MaMoni HSS MaMoni Health Systems Strengthening MCH Maternal Child Health MCRAH Maternal Child Reproductive and Adolescent Health MCHIP Maternal and Child Health Integrated Program MCHTI Maternal and Child Health Training Institute MCWC Maternal and Child Welfare Center

MaMoni Health System Strengthening Project Annual Report 2017-2018

ME&DO Monitoring, Evaluation and Documentation Officer MEC Medical Eligibility Criteria MFSTC Mohammadpur Fertility Services and Training Centre MgSO4 Magnesium Sulfate MIS Management Information System MIS-FP Management Information System Family Planning MNCH/FP/N Maternal, Newborn and Child Health, Family Planning, and Nutrition MNCAH Maternal, Neonatal, Child and Adolescent Health MNCH Maternal, Newborn and Child Health MaMoni-MNCSP MaMoni - Maternal and Newborn Care Strengthening Program MNH Maternal and Newborn Health MO Medical Officer MOHFW Ministry of Health and Family Welfare MO-MCH Medical Officer-Maternal and Child Health MP Member of Parliament MPDSR Maternal and Perinatal Death Surveillance and Response MSH Management Sciences for Health MSR Material and Services Requisition MT-EPI Medical Technologist – EPI NBCH Newborn Child Health NGO Non-government Organization NIPORT National Institute of Population Research and Training NIPSOM National Institute of Preventive & Social Medicine Nk Noakhali NNHP National Newborn Health Program NSU Newborn Stabilization Unit OBGYN Obstetrics and Gynecology OGSB Obstetrical and Gynecological Society of Bangladesh OP Operational Plan ORS Oral Rehydration Solution OT Operation Theatre PABX Private Automatic Branch Exchange pCSBA Private CSBA PDCA Plan-Do-Check-Act PE/E Pre-eclampsia/Eclampsia PHC Primary Health Care PHD Partners in Health and Development PIP Program Implementation Plan PM Program Manager/Permanent Method PMP Project Monitoring Plan PNC Post Natal Care PPFP Post-partum Family Planning PPH Postpartum Hemorrhage PPIUCD Post-partum Intra-Uterine Contraceptive Device PSBI Possible Serious Bacterial Infection QI Quality Improvement QIC Quality Improvement Committees QIS Quality Improvement Secretariat QoC Quality of Care QPRM Quarterly Performance Review Meetings RH Reproductive Health RMO Residential Medical Officer RMNCH Reproductive, Maternal, Newborn, Child and Adolescent health RP Residential Physician RRQIT Regional Roaming Quality Improvement Teams RS Resident Surgeon RTC Regional Training Center RWH Regional Ware House SACMO Sub-assistant Community Medical Officer

6 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBCC Social & Behavioral Change Communication SCI Save the Children International SCANU Special Care Newborn Unit SCMP Supply Chain Management Portal SDGs Sustainable Development Goals SDP Service Delivery Point SIAPS Systems for Improved Access to Pharmaceuticals and Services SIP Sector Improvement Plan SNL Saving Newborn Lives SOPs Standard Operating Procedures SPE/E Severe Pre-eclampsia and Eclampsia SSK Shasthyo Shuroksha Karmasuchi TAB Tablet Computer TAG Technical Advisory Group TIS Tracer Indicator Survey ToT Training of Trainers UzF-CM LG & BCC Upazila Facilitator-CM, LG & BCC UFPA Upazila Family Planning Assistant UFPO Upazila Family Planning Officer UHC Upazila Health Complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Center UN United Nations UNICEF United Nations Children’s Fund UP Union Parishad USAID United States Agency for International Development USC Union Sub-center USG United States Government Vit-A Vitamin A WISN Workload Indictors of Staffing Need WIT Work Improvement Teams WHO World Health Organization

MaMoni Health System Strengthening Project Annual Report 2017-2018

EXECUTIVE SUMMARY

The MaMoni Health Systems Strengthening (MaMoni HSS) project continued to support the Ministry of Health and Family Welfare (MOHFW) to strengthen health systems at the national and district levels. In year 5, the program’s technical assistance at the national level and implementation at the district level were under consolidation. The project supported 40 in 6 districts, 23 of which were designated high intensity (HI) areas and 17 of which were health systems capacity strengthening (HSCS) areas. At the district level, MaMoni HSS continued to support the scale-up of priority Ending Preventable Child and Maternal Deaths (EPCMD) interventions and to improve the quality of facility-based care.

Key accomplishments this year

. Revisit program of priority newborn intervention has been completed for all 64 . A brief on revisit program has been developed; . The project supported national Newborn Health Program (NNHP) establishing National Training Center for Newborn Health and Kangaroo Mother Care (KMC) corner at Dhaka Medical College Hospital (DMCH) in collaboration with Saving Newborn Lives (SNL) program of Save the Children; . Facilitated upgradation of six Union Health and Family Welfare Centers (UH&FWC) to provide 24/7 normal delivery services. The local government facilitated upgradation of two UH&FWCs to provide 24/7 normal delivery services. Union Parishads deployed 2 paramedics as the substitute of Family Welfare Visitor (FWV) at their respective unions; . Baseline assessment on WHO Quality of Care (QoC) Framework for MNC pilot project in has been completed and results have been shared with the stakeholders. Key interventions initiated and operational the District Hospital, MCWC and 2 UHCs in Narshingdi. . Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities study complete and disseminated in collaboration with WHO. Two research and policy briefs were published.

. Supported DGFP hosting a national dissemination event titled “improving institutional deliveries by strengthening public health facilities for 24/7 services”. Also launch of eMIS national scale up arranged by DGFP. . Implementation of operations research titled “Prevalence of severe pre-eclampsia/ eclampsia (PE/E) and skill of family welfare visitors in detecting and managing the cases of severe PE/E” is complete . A day-long Kangaroo Mother Care (KMC) Community of Practice meeting was held under the leadership of the MOHFW. The objectives of the meeting were to provide an update on the status

8 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 of KMC introduction and scale up and build consensus for KMC within the newborn health community in Bangladesh. The meeting came up with some recommendations for the successful implementation of KMC in facilities and it was decided that the NNHP will follow up with key recommendations from the meeting. . Two-day Client Fairs were organized in all MaMoni intervention districts under direct guidance from the Clinical Contraceptive Service Delivery Program (CCSDP), Directorate General of Family Planning (DGFP). The ‘Client Fair-2017’ was a big push for building awareness, creating demand, and increasing performance as well as disseminating proper messages on long acting reversible contraceptives and permanent methods (LARC & PM). . A good number of program briefs, research briefs, training manuals and videos developed in the reporting year. A coffee table book was published that showcases major interventions of MaMoni HSS.

Challenges, mitigation strategies and recommendations

. Distribution of tablet misoprostol to women who delivered at home was a major challenge observed in this project. The project continued advocacy at national level for recruitment in vacant position, address supply issues, engaging private providers, raising awareness etc. Exploration of alternate options/strategies for misoprostol distribution is also critical. . Though increased SBA delivery was observed in MaMoni districts, universal coverage of SBA is still a long way. GOB should work with development partners, private sectors for increasing skilled birth attendance across the country. . Identification and referral of PE/Eclampsia were major challenges of PE/E study. MaMoni HSS tried to boost up the study through training, monitoring and mentoring. MOH&FW, OGSB and other stakeholders need serious consultation, analysis and identify appropriate strategies as eclampsia is one of the major killers of pregnant women.

. Lack of coordination between the Quality Improvement Secretariat (QIS) and Hospital Services Management (HSM) unit of Directorate General of Health Services (DGHS) and maternal, child, reproductive and adolescent health (MCRAH) unit of DGFP has remained as a constant challenge for implementation of quality of care (QoC) in Bangladesh. MaMoni HSS has worked with HSM and MCRAH to ensure involvement of these units in QIS activities. However, intense follow-up is required. . A large investment was made of strengthening NIPORT. Some kind of support needs to be continued for sustainability of the investment made so far. Increasing visibility of NIPORT in DGHS & DGFP to increase coordination among NIPORT, DGHS & DGFP may be a key strategy to follow. . Implementation of National Newborn Health Program (NNHP) was slow and adhoc. A coordinated approach, led by government will be the key to success. Introduction of KMC, continuation of SCANU, CNCP are a few major initiatives for this sector program.

MaMoni Health System Strengthening Project Annual Report 2017-2018

. Coverage of PPFP is very low. MaMoni HSS supported DGFP in developing guidelines, strategies, organizing training and counselling, however, major efforts required for involving DGHS staff in this intervention.

. Sustainability of eMIS is a challenge as Measure and icddr,b decided not to stop expansion of HA module and other DGHS modules. Also DGFP is planning to develop DHIS-2 of their own. Strong coordination and collaboration with DGFP was the key for scaling up eMIS through family planning directorate.

Way Forward This was the last year of 5 year MaMoni HSS award. The lessons learned from this project will be shared in different forum, used for policy advocacy and planning of USAID’s follow-on project MaMoni Maternal, Newborn Care Strengthening Project (MaMoni MNCSP). The tested interventions need to scaled by the new project while testing new interventions for reducing maternal and newborn deaths in Bangladesh.

INTRODUCTION The MaMoni Health Systems Strengthening project, was a five-year USAID-funded award 1 aimed at improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services in Bangladesh. The project’s objective was to increase availability and quality of high-impact interventions through strengthening district- level local management and health systems. This objective is well-aligned with the Government of Bangladesh’s (GoB) Health, Population, and Nutrition Sector Program (HPNSP) 2017-2022 and its Sector Improvement Plan (SIP) 2016-2021. MaMoni HSS provided support and assistance to the Ministry of Health and Family Welfare (MOHFW) at national and district levels, and directly supported the “USAID/Bangladesh-Health Status Improved” activity under the Investing in People Objective, Health Project Area of the U.S. Foreign Assistance Framework.

The four Intermediate Results (IR) of the project were to: • Improve service readiness through critical gap management • Strengthen health systems at the district level and below • Promote an enabling environment to strengthen district-level health systems • Identify and address barriers to accessing health services

1MaMoni HSS is implemented through an Associate Award under the Maternal and Child Health Integrated Program, which is led by Jhpiego, with a period of performance from September 24, 2013 to September 23, 2018. MaMoni HSS is led by Save the Children in Bangladesh, in partnership with Jhpiego, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU).

10 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 The project expanded the technical assistance role at the national level, while consolidating the implementation at the district level. The scope and geographical coverage of the MaMoni HSS project has been summarized in Table 1. Detailed coverage has been included in Appendix 1. Table 1: Summary of the geographic scope of MaMoni HSS

Number Population Number of Health Facilities Area Number of Upazilas of (2017 Projection) UH&FWC/ Unions DH MCWC UHC CC USC

High Intensity 23 (-8, 226 6,662,456 4 7 20 213 619 Areas Noakhali-4, -5, Jhalokathi-4, Pirojpur-2)

Health Systems 17 (Bhola-7, 151 4,870,933 2 5 14 126 488 Capacity Noakhali-5, Strengthening Pirojpur-5) (HSCS) Areas

Total 40 377 10,718,274 6 12 34 339 1,107

DATA SOURCE This report uses data from various sources, including: the population-based Tracer Indicator Survey (TIS) in high intensity areas; sentinel surveys in selected facilities in MaMoni HSS districts; Service Delivery Point (SDP) assessments in selected facilities2; re-visitation of specific newborn interventions in 14 districts; and routine MIS from the DGHS and DGFP. The complete list and scope of the surveys are attached as Appendix 2.

PROGRAM RESULTS OF THE YEAR IR 1. Improve service readiness through critical gap management 1.1 Increase availability of health service providers 1.1.1 Management of critical human resource gaps of GOB service providers In Year 5 MaMoni HSS continued supporting the MOHFW in managing critical human resource gaps of service providers by providing eleven Community Health Workers (CHWs) in place of Family Welfare Assistants (FWA), eighteen paramedics in place of Family Welfare Visitors (FWVs), two nurses, and one obstetrics and gynecology consultant in program areas. The current gap management staff status is shown in Table 2.

2 DH, MCWC, UHC, UH&FWC and USC in 21 high intensity areas in 4 districts (Habiganj, Noakhali, Lakshmipur and Jhalokathi)

MaMoni Health System Strengthening Project Annual Report 2017-2018

Table 2: Critical human resource gaps filled-in by MaMoni HSS

FWA FWV/Paramedics Nurses OBGYN Consultant

District

filled MaMoni HSS MaMoni filled Vacant posts Vacancy filled by MOHFW Vacancy filled by MaMoni HSS Vacant posts Vacancy filled by MOHFW Vacancy filled by MaMoni HSS Vacant posts Vacancy filled by MOHFW Vacancy filled by MaMoni HSS Vacant posts Vacancy filled by MOHFW Vacancy

Habiganj 104 0 11 31 5 10 70 0 0 1 0 0 Jhalokati 82 0 0 6 4 1 11 0 0 2 0 0 Noakhali 179 0 0 20 2 7 102 29 2 2 0 1 Lakshmipur 86 0 0 10 10 0 62 0 0 2 0 0 Total 451 0 11 67 21 18 245 29 2 7 0 1

The project continued advocating with local government, parliamentarians, and local level stakeholders to take on the responsibility of filling vacancies and to develop long term local solutions when the project phases out. In Year 5, Union Parishads (UPs) deployed 11 paramedics and 2 CHWs at their respective unions in MaMoni HSS districts.

1.2 Strengthen capacity of service providers to provide quality services 1.2.1 Introduction and scale-up of MNCH/FP/N interventions 1.2.1.a. Maternal health The program’s major interventions in maternal health were pregnancy identification and registration through frontline health workers; the provision of at least four antenatal care (ANC) contacts with Quality of Care (QoC); birth planning; promotion of, and increased availability and accessibility to quality skilled birth attendants, including active management of the third stage of labor (AMTSL); distribution of misoprostol for home-based deliveries; and ensuring four postnatal visits, including the promotion of post-partum family planning. Special interventions in selected areas, such as the management of severe pre-eclampsia and eclampsia through the

administration of Magnesium Sulfate (MgSO4) were operational in selected areas.

i. ANC coverage ANC is the gateway intervention wherein a woman makes what might be the first contact in her life with a health facility or health care provider, as a result of her pregnancy. MaMoni HSS applied a multipronged approach to address the shortage of service providers, to ensure satellite clinics, and to confirm the availability of equipment and provide logistical support for providers.

12 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 The population based tracer indicator surveys (TIS) revealed a steady increase in ANC-1 and ANC-4 uptake for all the project supported high intensity districts, with most of the districts achieving the set End of Project (EoP) targets for ANC-1. For ANC-4, most of the districts were close to the targets (Figure 1 and Figure 2). Figure 1: Percentage of women who received at least one ANC check-up from a medically trained provider

100 85 85 90 83 77 80 86 84 83 80 80 81 70 77 79 77 77 75 73 68 69 60 66 65 62 50 60 51 40 Percentage 30 37 20 10 0 Habiganj Jhalokati Lakshmipur Noakhali

Baseline Year 2014 Year 2015 Year 2016 Year 2017 EoP Target

Source: Tracer Indicator Survey (TIS)

Figure 2: Percentage of women who received four or more ANC check-ups

100 90 80 70 60 46 50 45 45

Percentage 40 45 44 44 32 46 40 40 40 42 40 30 37 36 31 20 26 24 25 22 21 10 9 14 12 0 Habiganj Jhalokati Lakshmipur Noakhali

Baseline Year 2014 Year 2015 Year 2016 Year 2017 EoP Target

Source: Tracer Indicator Survey (TIS)

MaMoni Health System Strengthening Project Annual Report 2017-2018

ii. Severe pre-eclampsia/eclampsia (SPE/E) management at union level facilities Pre-eclampsia/eclampsia is the second leading cause of maternal death in Bangladesh, accounting for 24 percent of all maternal deaths (BMMS 2016 Preliminary Report). Injectable magnesium sulphate (MgSO4) is considered to be an appropriate and potentially affordable drug to prevent and manage severe preeclampsia/eclampsia (PE/E). In collaboration with the Obstetrics and Gynecological Society of Bangladesh (OGSB), MaMoni HSS continued supporting severe pre-eclampsia and eclampsia (SPE/E) management at union level facilities (UH&FWC), where a loading dose of injectable MgSO4 is administered by trained FWVs and the patients and their family members are counselled for referral care at higher level facilities. In some cases, the project staff facilitated and supported the process of arranging referral transports. This intervention has been rolled out at 197 UH&FWCs in 23 upazilas in 4 districts – Habiganj, Noakhali, Lakshmipur, and Jhalokati. Through the routine MIS of the Directorate General of Family Planning (DGFP) the project tracks the identification and management of PE/E cases. Figure 3 shows trends in PE/E case identification and management at UH&FWCs in MaMoni HSS districts. It is revealed from the figure that the PE/E case identification is quite far from the expected number3 in the districts and is gradually declining, only one percent of expected cases have been identified and managed from UH&FWCs during the last quarter of Y-5, which was 10 percent during the first quarter of the same year. Figure 3: Percentage of pregnant women with PE/E identified and managed at UH&FWCs in MaMoni HSS districts

12 10 10

8 7

6

Percentage 4 4

2 1

0 Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Source: MIS-3, DGFP

3 2.8% of live births

14 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 iii. Misoprostol to prevent postpartum hemorrhage (PPH) for home births MaMoni HSS facilitated the distribution of misoprostol tablets to pregnant women in their third trimester through FWAs and FWVs in order to prevent PPH at home deliveries. Figure 4 shows that distribution of misoprostol tablets remained the same for all MaMoni districts but it went down in Habiganj and increased in remaining 3 districts. Figure 4: Percentage of pregnant women who received misoprostol tablets in MaMoni HSS districts

100

80

60 50 39 39 42 40 26 29 25 27 28 Percentage 21 22 18 22 17 15 12 14 20 6 8 10 0 Habiganj Jhalokati Lakshmipur Noakhali MaMoni 4 Districts

Year 2014 Year 2015 Year 2016 Year 2017

Source: Tracer Indicator Survey (TIS)

Misoprostol tablets are distributed by the FWAs during their routine household visits, as well as by the FWVs during ANC 3 visits for pregnant women who did not get the tablets from the FWAs. Some of the primary contributors to the low distribution of misoprostol tablets were:

• Vacancies of FWAs (34%) and FWVs (23%) positions in MaMoni HI districts • Inadequate home visits by FWAs • Lack of a need based distribution system • Low coverage of ANC 3 visits • Stock out of misoprostol tablets. The project has taken several initiatives to address these issue. These are:

• Sharing the misoprostol distribution status with district and upazila mangers and subsequently reinforcing through quarterly performance review meeting at district level, • Working with the MOHFW to develop a need-based system of misoprostol distribution, including monitoring the stock and distribution status, as well as focusing on increasing the ANC3 coverage, • District for distribution of misoprostol and 7.1% CHX together in a zip lock bag both at community and facility level during third trimester of pregnancy, • Continue advocacy at national level for new recruitment of FWAs and FWVs against vacant positions, • Misoprostol has been made available to community sales agents, • Initiated discussion with local NGOs to explore the distribution of misoprostol through NGO community health workers. MaMoni Health System Strengthening Project Annual Report 2017-2018

The project also tracks misoprostol consumption through TIS. The TIS reveals a steady increase and high consumption in misoprostol in all the project supported high intensity districts, with all the districts (Figure 5). Figure 5: Percentage of women who consumed misoprostol tablets immediately after birth following home delivery (among those who received misoprostol)

98 98 98 94 97 100 91 91 94 91 92 86 88 87 86 88 90 85 84 84 84 86 80 70 60 50 40 30 20 10 0 Habiganj Jhalokati Lakshmipur Noakhali MaMoni 4 Districts Year 2014 Year 2015 Year 2016 Year 2017

Source: Tracer Indicator Survey (TIS)

iv. Deliveries assisted by skilled birth attendants (SBAs) The population based tracer indicator surveys (TIS) revealed a steady increase in deliveries assisted by skilled birth attendants (SBAs) in project supported high intensity districts, with all of the districts achieving the set End of Project (EoP) targets as shown in Figure 6. Remarkable increase has been seen in Habiganj and Noakhali, 22 percentage point and 26 percentage point respectively over baseline. Figure 6: Percentage of SBA deliveries in MaMoni HSS districts

100

80

55 60 45 45 40 55 55 52 54 40 47 45 Percentage 41 44 41 45 38 37 34 34 37 36 20 28 28 29 19 0 Habiganj Jhalokati Lakshmipur Noakhali

Baseline Year 2014 Year 2015 Year 2016 Year 2017 EoP Target

Source: Tracer Indicator Survey (TIS)

16 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Comprehensive social and behavior change communication (SBCC) with targeted groups focusing SBA delivery, community gathering, different quality improvement initiatives at District Hospital, UHC and UH&FWC and increased number of UH&FWCs (Figure 7) providing round the clock normal delivery services are the major contributing factors in increasing SBA deliveries in project areas.

The project continued its efforts to increase deliveries at union level facilities through ensuring round the clock normal delivery services from designated 24/7 UH&FWCs. Currently a total number of 106 UH&FWCs are providing 24/7 normal delivery services. In Y-5, around thirteen percent of the estimated number of deliveries were conducted at these 24/7 facilities, which was about 9 percent in Y-4 as shown in Figure 7.

Figure 7: Trends in deliveries at 24/7 UH&FWCs in MaMoni HSS high intensity districts

150 15 14 12 12 12 100 11 10 9 9 9 103 106 106 94 100 75 81 81

Number 50 5 Percentage

0 0 Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Number of 24/7 UH&FWC Percentage of delivery

Source: MIS-3, DGFP

v. Private Community Skilled Birth Attendants (pCSBA) assisted deliveries MaMoni HSS continued supporting 70 private CSBAs in three districts- Habiganj, Noakhali and Lakshmipur through facilitating supplies, and regular monitoring and supervision. pCSBAs are non-salaried community-based private skilled birth attendants, whose sole earnings come from charging for different services like ANC, deliveries, PNC and selling essential commodities. In Year-54 from quarter 1 through quarter 3, these pCSBAs assisted1193 deliveries at home in their catchment areas. On an average, each pCSBA assisted 17 deliveries, which is six percent of the estimated number of deliveries in their catchment areas as shown in Figure 8.

4 Quarter 4 data not available, since it comes from the project MIS and the project staff were withdrawn in July as part of project closeout. MaMoni Health System Strengthening Project Annual Report 2017-2018

Figure 8: Trends in deliveries by MaMoni HSS supported pCSBAs

100 8 90 80 6 6 70 5 5 5 4 4 60 4 4 50 3 3 4 40 2

Number of pCSBA 30

2 Percentage of delivery 20 10 52 52 91 89 64 71 68 68 69 70 70 0 0 Q1-Y3 Q2-Y3 Q3-Y3 Q4-Y3 Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Number of pCSBA Delivery assisted by pCSBA

Source: Project MIS

1.2.1.b Newborn health A. Newborn health national support

i. Scale-up of priority newborn health interventions

MaMoni HSS continued supporting the MOHFW in the national scale-up of newborn interventions and in improving the quality of facility based care. The project continued supported to the Newborn and Child Health Cell, under the leadership of National Newborn and Child Health Program (NNHP) and IMCI unit of DGHS which provides management support to the program and coordinates national scale-up, including monitoring the interventions through post- training follow-up led by DGHS. MaMoni HSS provides technical assistance to the MOHFW through this cell. A short term consultant was attached to the cell to monitor training quality and standard of care for facility care of selected newborn interventions. In Y-5, a face book group named ‘Revisit on Priority Newborn Interventions’ was introduced, where all the field coordinators posted their daily activities with photographs which helped NNHP to monitor the field level activities of revisit program. The ‘Cell’ also supported NNHP and IMCI to organize ‘National Newborn Health Program (NNHP) Implementation Design Workshop’ where more than 200 participants participated for finalizing NNHP implementation design. ii. Re-visitation of priority newborn interventions Revisit program of priority newborn interventions is completed for all 64 districts of Bangladesh. The three-pronged activity included: a) identification of newborn focal persons from each upazila, divisional and district to help local level managers in implementing priority newborn health intervention; b) refresher training of SBAs on ENC, including HBB and use of 7.1% CHX on the umbilical stump; and c) a quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, medicine and supply stocks

18 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 (including 7.1% CHX). The revisit also included the replacement/ or provision of supplies for newborn resuscitation equipment (bag, mask and sucker) in the facilities. The National Newborn and Child Health Cell supported by MaMoni HSS provided management support for this activity. Data collectors from partner organizations, Partners in Health and Development (PHD) and Bangabandhu Sheikh Mujib Medical University (BSMMU), conducted the revisits and gathered data using a standard checklist. A brief on revisit program findings and lessons learned has been developed. Following are the key recommendations based on the findings and observations from the revisit assessment:

• Institutionalizing Program Monitoring A structured reporting system has been established for the National Newborn Health Program. Emphasis needs to be given for completeness and use of data to improve service delivery and coverage. Relevant service providers are required to be trained on EmONC register including record keeping and use. Refresher trainings should emphasize the skill building in regular recording, reporting and data driven actions. Data should inform the performance review at divisional level for improving services at district, upazila, union and community levels. • Logistics and Supply Chain Supply chain needs to be monitored regularly at all level. National LMIS can be used to plan procurement and distribution, track commodities and address logistical issues. Essential medicines (e.g., Amoxicillin and Gentamicin) should be made available down to union level.

• Maintenance of Equipment Cleanliness of equipment (e.g., bag- mask and sucker) should be monitored at facility level.

• Coverage Surveys Since NNHP & IMCI is a new national scale program with a number of essential high-impact interventions, it is likely to benefit from regular surveys that will assess the reach of those interventions. iii. Situation analysis of inpatient care for newborn and young infant at district and upazila level facilities District hospitals and even few medical college hospitals in Bangladesh do not have adequate service provision for the management of sick newborn as per the Standard Operating Procedures (SOPs). Sick newborns are mostly managed in the pediatric ward without proper quality and safety procedures leading to high case fatality rates. There is also lack of compliance with standards for sick newborn care at hospitals largely due to non-availability of Special Care Newborn Unit (SCANU). The situation at Upazila Health Complex (UHC) is also very unsatisfactory. Save the Children along with icddr,b and UNICEF carried out a study entitled “Situation Analysis for Inpatient Care of Newborns and Young Infants in Selected District, Sub district and

MaMoni Health System Strengthening Project Annual Report 2017-2018

Private Health Facilities of Bangladesh”. The objective of the study was to inform and guide the policymakers regarding the best practices and bottlenecks for improving facility-based sick newborn and young infant care. The study was conducted under the guidance of MOHFW. iv. Establishment of SCANU National Newborn Health Strategy recommends establishment of SCANU in secondary and tertiary level hospitals while Newborn Stabilization Unit (NSU) at Upazila Health Complex (UHC) and Mother and Child Welfare Center (MCWC). MaMoni HSS project, UNICEF, and some other development partners have been supporting MOHFW for the establishment of SCANU. So far, 42 SCANUs have been established in 42 district hospitals. For the first time, the Directorate General of Family Planning (DGFP) has incorporated newborn health component in Maternal, Child, Reproductive and Adolescent Health (MCRAH) operation plan in current sector program with dedicated manpower for newborn health, medicine and commodity procurement, capacity building of providers etc. The Operational Plan for MCRAH has a target to establish 32 SCANUs at secondary and tertiary level health care facilities. MaMoni HSS supported DGFP in the establishment of a comprehensive newborn care unit at Mohammadpur Fertility Services and Training Centre (MFSTC) and Maternal and Child Health Training Institute (MCHTI) at Azimpur. The project also supported the establishment of a comprehensive newborn care unit in Khulna Shishu Hospital (KSH). The comprehensive newborn care unit consists of SCANU, Kangaroo Mother Care (KMC), provision of essential newborn care (ENC) including application of 7.1% chlorhexidine on to newborn umbilical cord and postnatal care (PNC). These comprehensive newborn care units are not only providing services to sick newborn, but also remains as a center of excellence for training of different level providers of DGFP on priority newborn interventions. v. Kangaroo Mother Care (KMC) Community of Practice A day-long KMC Community of Practice meeting was held under the leadership of MOHFW to celebrate the World Prematurity Day 2017. MaMoni HSS, Saving Newborn Lives (SNL) projects of Save the Children and UNICEF jointly supported the event. A broad group of stakeholders from MOHFW, DGHS, DGFP, professional bodies and development partners attended the meeting. Objectives of the meeting were to update the status of KMC introduction and scale up in Bangladesh, share implementation experiences, challenges and opportunities for KMC practice, exploring national and local models of best practices as per standard to inspire and increase motivation, utilizing unique platform at national level to mobilize KMC under NNHP and building a common consensus of KMC community in Bangladesh. Key note presentations were made by Director, PHC and Program Manager, NNHP and IMCI, DGHS and Deputy Director (Services) and Program Manager (NBCH), MCH Services unit, DGFP.

20 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Facility managers and service providers of 32 KMC implementing facilities shared their implementation experiences. A mother also shared her experience of providing KMC to her baby. Participants worked in groups on current experiences from KMC implementation at tertiary, district and upazila level facilities including addressing the barriers for ensuring quality of care while scaling up and the requirement or actions at policy and implementation level.

Key recommendations from the group work were:

• national guideline and standards has to be in place for successful implementation of KMC,

• all KMC facilities have to record KMC data by using national register,

• all KMC facilities have to submit KMC report through national reporting form

• online reporting system of DGHS and DGFP should have similarity for KMC reporting. It was decided in the meeting that National Newborn Health Program (NNHP) will follow up with the key recommendations of the meeting. vi. Design workshop on National Newborn Health Program (NNHP) MaMoni HSS, SNL and icddr,b jointly supported NNHP and IMCI units within MOHFW to convene a design workshop on National Newborn Health Program in October 2017. MOHFW, USAID, UN Agencies, development partners, professional organizations and NGOs participated in the workshop. Objective of the workshop was to share and review the program implementation plan (PIP) of NNHP and come up with recommendations. Program Manager- NNHP presented the NNHP program implementation package. The participants worked in groups worked on guideline and capacity building, procurement and supply, SBCC, communication and campaign, coordination, monitoring and supervision. Key recommendations from the group works were discussed. This will be utilized for NNHP implementation.

MaMoni Health System Strengthening Project Annual Report 2017-2018

vii. 20th National Conference and Scientific Session of Bangladesh Paediatric Association MaMoni HSS supported the 20th National Conference and Scientific Session organized by Bangladesh Pediatric Association (BPA). More than 700 participants consisting of pediatricians, researchers and public health workers from home and abroad joined the conference. Dr. Sabbir Ahmed, Program Director NB&CH, MaMoni HSS project presented a paper in the conference on introduction and scale up of management of infections among young infants at peripheral level facilities when referral is not possible. viii. Synthesizing learning from early implementation of new WHO guideline for management of Possible Serious Bacterial Infection (PSBI) among young infant when referral is not feasible Bangladesh and Ethiopia are the two leading countries implementing outpatient treatment for possible severe bacterial infections (PSBI) in newborns and young infants. Results from trials conducted in these countries had been instrumental for the development of the WHO guideline, managing possible severe bacterial infection in young infants when referral is not feasible. Bangladesh national guideline for the management of sick children (<2 month) from union level facilities has been developed through adaptation of WHO protocol. Since 2015, MOHFW has been implementing the PSBI national guideline in multiple districts, with support from partners like SNL/Save the Children, MaMoni HSS/USAID and Prohjohnnmo/JHU. Three implementation research studies were conducted concurrently in Kushtia, Lakhsmipur and districts with support from partners. The PSBI implementation is now at scale in four MaMoni HSS districts. Both Bangladesh and Ethiopia have strong policies and plans to continue implementation and scale up of newborn health interventions as part of five-year health systems plans, the Call to Action on Child Survival and Development, and movement towards SDGs. To deepen the cross-program learning on community based PSBI implementation, scale up, and sustainability and to put it in a long-term context, a global initiative has been undertaken and MaMoni HSS is a part of this global initiative. The aim of this global initiative is to contribute information on implementation of country-led transformation of newborn health within child health and other health systems more broadly.

22 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 By distilling, exploring, and synthesizing learning from these two countries through a mediated process and putting it into a 10-year context, it will structure initial descriptions of the environment, longer term aims for newborn health, and emerging implementation-related themes. MaMoni HSS supported an initiative of synthesizing lessons learnt from early implementation of the Bangladesh national guideline and management of infections among young infant when referral is not possible. A report on PSBI synthesis has been prepared. Based on the learning of PSBI implementation it was much needed to identify some themes that will influence/govern PSBI implementation in future in the broader health system context. ix. National Scale up of National Newborn Health Program (NNHP) Implementation Toolkit NNHP Implementation Toolkit is a practical guide to implement National Newborn Health Program (NNHP) in line with the MNCAH and MCRAH operation plan to provide a clear understanding to the district and upazila managers of DGHS and DGFP for implementing NNHP at the district and below level through the existing maternal and child health program. The toolkit is user-friendly and will help all managers at all levels of program implementation to understand the need of assuring quality of the high impact newborn health interventions through ensuring supportive supervision, monitoring and making necessary commodities available and thus overcoming the challenges of implementation gaps. Training of managers on NNHP toolkit is an activity of MOHFW Operation plan. During the reporting year, MaMoni HSS supported training on “NNHP toolkit” for managers of 7 districts- Habiganj, Noakhali, Lakshmipur, Jhalokathi, Bhola, Pirojpur and Kushtia). A core trainers group, consisting of 13 national level professionals, senior neonatologist and pediatricians, Program Mangers of DGHS and DGFP was formed in order to develop Master Trainers for NNHP Implementation Toolkit. The core trainers’ group organized two ToTs at the national level and developed 34 master trainers. The master trainers facilitated trainings on “NNHP Toolkit” for 194 district and upazila level managers and newborn focal persons of 7 districts in 10 batches.

MaMoni Health System Strengthening Project Annual Report 2017-2018

x. Workshop on Evidence-based Practices for Improvements in Quality (EPIQ) MaMoni HSS project supported a workshop on Evidence-based Practices for Improvements in Quality (EPIQ). The objective of the workshop was to sensitize the key managers from the National Newborn Health Program (NNHP), other technical and implementing partners of MOHFW, and representatives of professional bodies on the importance and process for integrating quality improvement initiatives in the implementation of newborn care interventions. Two eminent pediatricians from American Academy of Pediatric (AAP)- Dr. Douglas Donald McMillan, Head, Division of Neonatal-Perinatal Medicine, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada, and Professor Dr. Nalini Singhal, Professor of Pediatrics, University of Calgary, Calgary, Canada- facilitated the workshop. The workshop contents were adapted from the Evidence-based Practices for Improvements in Quality (EPIQ) model that demonstrated effective results in the Canadian neonatal network for improve newborn outcomes. The workshop has enabled participants to complete a quality improvement (QI) exercise. A group of facilitators was developed who understand principles of QI, how QI is taught and how QI is introduced in the workplace. Prof. Abul Kalam Azad, Director General, DGHS inaugurated the workshop and expressed his confidence for its implications in quality improvement of various health interventions of Bangladesh. xi. National Training Center and KMC Corner at Dhaka Medical College Hospital and Sir Salimullah Medical College and Mitford Hospital KMC is key evidence-based intervention to manage low birth weight babies. In collaboration with Saving Newborn Lives (SNL) program of Save the Children, the project supported NNHP in establishing national training center for newborn health and KMC corner at Dhaka Medical College Hospital (DMCH) and Sir Salimullah Medical College and Mitford Hospital.

Inauguration of national training center at DMCH Mother with newborn at DMCH KMC Corner

24 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 xii. Training events at national level a. Comprehensive Newborn Care Package (CNCP) In response to DGFP’s request the project supported orientation of 249 district and upazila level managers of DGFP from 22 districts (, , Chandpur, Chapai Nawabganj, Chattogram, Cumilla, Faridpur, Gaibandha, Gopalganj, Jamalpur, Jashore, Jhenidah, Kishoreganj, Manikganj, , Narsingdi, , Patuakhali, , Rangpur, Shariatpur, Sylhet) on CNCP. The orientation included background and content of CNCP, capacity building and skill retention, community awareness for newborn health service, supervision, monitoring, record keeping and reporting. The project also supported DGFP to organize ToT on CNCP for MO-MCH and district consultants of Barisal, Brahmanbaria, Chandpur, Chattogram, Cumilla, Faridpur, Gaibandha, Gopalganj, Jamalpur, Jashore, Kishoreganj, Manikganj, Mymensingh, Narsingdi, Pabna, Patuakhali, Rajshahi, Rangpur, and Sylhet. A total of 98 doctors received the ToT in 4 batches. The project also supported training on CNCP package for 20 doctors and 54 nurses from Dhaka Medical College Hospital, Sir Salimullah Medical College Hospital and Mugdha MCH.

b. Training on Emergency Triage Assessment and Treatment (ETAT) and sick newborn Care for Nurses and study Physicians The project supported training on Emergency Triage Assessment and Treatment (ETAT) and sick newborn Care for 19 nurses from 8 districts (Habiganj, Khulna Shishu Hospital, Kushtia, Lakshmipur, Narsingdi, Noakhali Pirojpur and Dhaka) and 26 study physician from BSMMU, MFSTC and icddr,b.

c. Training on Kangaroo Mother Care (KMC) for doctors: MaMoni HSS supported training on Kangaroo Mother Care (KMC) for 19 doctors from Dhaka Medical College Hospital, Sir Salimullah Medical College and Mitford Hospital and Mugdha MCH.

d. HBB training for post graduate students The project supported training on HBB for 28 students from BSMMU. xiii. Other national activities The project continued supporting Newborn and Child Health Cell, under the leadership of NNHP & IMCI unit of DGHS to publish quarterly National Newborn Health Bulletin. The purpose of this quarterly bulletin is to provide regular updates on the progress made by various initiatives by The Ministry of Health and Family Welfare, development partners, professional associations and other stakeholders to improve the survival and wellbeing of newborn in the country. The bulletin primarily focuses on the evidence based interventions prioritized by the Government of Bangladesh for accelerating the reduction of newborn mortality in the country. The 4th, 5th, 6th issues

MaMoni Health System Strengthening Project Annual Report 2017-2018

of the bulletin have been published in year-5. These bulletins are regularly posted in Healthy Newborn Network (HNN) web page.

B. Newborn health district interventions Project initiatives during the reporting period focused not only on increasing coverage, but also on improving the quality of service delivery through building capacity of service providers on priority newborn interventions, including record keeping and reporting, availability of logistics, job aids, and on-the-job coaching, as well as community awareness. i. Helping Babies Breathe (HBB) MaMoni HSS has been supporting the HBB intervention in all 64 districts under national scale- up activities. Resuscitation of newborns in health facilities using bag and musk ranges from 3%- 14% against estimated number of live births across divisions as shown in Figure 9. Figure 9: Percentage of newborns for whom resuscitation actions were initiated, using a bag and mask, in 7

20

15 14 12

10 8 7 7 7 7 6

Percentage 6 6 6 6 6 6 5 5 5 5 5 5 4 5 4 3 4 4 4 4 4

0 Barisal Dhaka Khulna Rajshahi Rangpur Sylhet

Y5-Q1 Y5-Q2 Y5-Q3 Y5-Q4

Source: MIS-3 and EmONC report of DHIS-2

26 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 ii. Application of 7.1% Chlorhexidine (CHX) for newborn cord care The application of 7.1% CHX to the umbilical cord stump is one of the major interventions to prevent newborn sepsis of all newborns, irrespective of their place of delivery. As a part of the essential newborn care (ENC) package, the project supports implementation of 7.1% CHX application in six project districts not only from public facilities but also from private facilities on a small scale. In addition to GOB supply chain, the project works with the manufacturing company to ensure availability of 7.1% CHX in local level pharmacies.

MOHFW’s routine MIS tracks the application of 7.1% CHX for all SBA assisted deliveries, both at the facility and in the community. Figure 10 shows the trends in application of 7.1% CHX onto newborn umbilical cords immediately after birth. Figure 10: Percentage of newborns who received 7.1% CHX onto umbilical cord immediately after birth by a SBA in MaMoni HSS districts

100 100 96 90 91 80

60

40 Percentage

20

0 Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Source: DGFP MIS 2 & 4, CSBA and EmONC report of DHIS-2

iii. Facility based care for sick children a. Management of sick children (<2 months of age) in union level facilities MaMoni HSS continued supporting the management of sick young infants (<2 months of age) in 148 UH&FWCs in 4 project districts. In Year 5, from quarter 1 through quarter 3, a total of 4,513 sick children were identified and managed by trained SACMOs. As shown in Figure 11, among these sick children, 69 were classified as critical illness (CI), 255 as clinical severe infection (CSI), 1,460 as fast breathing as a single sign of illness (IFB), 988 as local bacterial infection (LBI) and 1,741 as others.

MaMoni Health System Strengthening Project Annual Report 2017-2018

Figure 11: Sick children (<2 months of age) treated at 148 UH&FWCs in 4 MaMoni HSS districts

CI, 69, 1% CSI, 255, 6%

Other, 1741, 39% IFB, 1460, 32%

LBI, 988, 22%

Source: Project MIS (Quarter 4 data not available, due withdrawal of project staff as part of project closeout)

b. Management of sick children from Special Care Newborn Units (SCANUs) All the 5 SCANUs at district hospitals in project areas continued to provide services to critically sick newborns. SCANU data from the facilities is entered into DHIS-2. Figure 12 shows the trends in admissions of sick newborns in five project supported SCANUs. In Year 5, a total of 4759 newborns were admitted in these SCANUs for special care.

Figure 12: Trends in admissions of sick newborns at 5 project supported SCANUs

1300 1262 1265 1250

1200 1161 1150

1100 1071 Number

1050

1000

950 Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Source: DHIS-2

28 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018

iv. Kangaroo Mother Care (KMC) at district and upazila level facilities MaMoni HSS continued supporting thirty one facilities in 4 MaMoni HSS districts to provide KMC services to low birth weight babies. All these facilities have at least one doctor and two nurses trained, necessary logistics to manage at least five cases, and necessary job aids with record keeping and reporting tools for documentation. In Year 5, from quarter-1 through quarter-3, a total number of 295 low birth weight newborns received KMC services from these facilities.

1.2.1.c. Family Planning (FP) Major achievements in Year 5 are the following: i. Supported development of Postpartum Family Planning (PPFP) Counseling training modules for trainers and trainees, ii. Oriented district level managers of MOHFW in MaMoni HSS areas on newly developed Post-Partum Family Planning (PPFP) Counseling Training modules,

iii. Organized basic training on PPFP with special focus on PPIUCD for FWVs, SACMOs and Nurses at MFSTC, Dhaka where 16 FWVs, 2 SACMOs and 7 Nurses received training, iv. Facilitated celebration of client fair with CCSDP, DGFP: Two days long Client Fairs were organized by Family Planning (FP) department in all districts. With the support from USAID and MaMoni HSS and direct guidance from CCSDP, DGFP the client fairs were held in 4 MaMoni HSS districts (Habiganj, Lakshmipur, Jhalokati and Pirojpur). The ‘Client Fair-2017’ was a big push in building awareness, creating demand and increasing performances as well as disseminating proper messages on Long Acting Reversible Contraceptives (LARC) & Permanent Methods (PM). The Fair also created an enthusiasm among the FP field staff as well as in the community which can bring a positive impact in line with improving utilization and clear understanding on FP methods in near future, v. Developed brochure on FP methods and service related myths and misconception and printed and distributed Medical Eligibility Criteria (MEC) wheel to service providers in MaMoni HSS districts, vi. Supported finalization of PPFP counselling module and brochure on myths and misconception of FP and PPFP,

MaMoni Health System Strengthening Project Annual Report 2017-2018

vii. Supported orientation on FP policy changes and MEC wheel for FP service providers in MaMoni HSS districts, viii. Organized training on Protecting Life in Global Health Assistance (formerly referred to as the Mexico City Policy) for all categories of MaMoni HSS project and partner staff. Family planning performance in MaMoni HSS districts: i. Postpartum family planning (PPFP) Performance of postpartum IUCD (PPIUCD) is very low in MaMoni HSS districts. Figure 13 shows the quarterly trends in PPIUCD performance of public health facilities in MaMoni HSS districts. In year 5, the acceptance of PPIUCD as a method of family planning ranged between 5-9 as shown in the figure. Figure 13: Percentage of women who delivered at public health facilities in MaMoni HSS districts received postpartum IUCD

25

20

15

9 10 Percentage 6 5 5 5

0 Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Source: MIS-4, DGFP ii. Long acting and reversible contraceptive (LARC) and permanent (PM) method Figure 14 and Figure 15 show the trends in LARC and PM performances in MaMoni HSS districts. The acceptance of both LARC and PM has increased in both the areas in quarter 4 as shown in the figures.

30 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Figure 14: Trends in LARC performance in MaMoni HSS districts

7500 6601 5815 5175 4822 4970 5000 2846 2023 2257 Number 2500

0 HI area HSCS area

Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Source: MIS-4, DGFP

Figure 15: Trends in performance of permanent method (PM) in MaMoni HSS districts

1500 1177 1086 941 1000 803 659 714 588 486 Number 500

0 HI area HSCS area

Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Source: MIS-4, DGFP iii. Promotion of FP services through community volunteers In Year-5, there was a steady increase of the contribution of community volunteers (CVs) to LARC&PM performance in MaMoni HSS districts as shown in Figure 16. Figure 16: Contribution of community volunteers (CVs) to LARC&PM performance in MaMoni HSS districts

100 80 67 60 77 74 40 Percentage 20 33 23 26 0 Q1-Y5 Q2-Y5 Q3-Y5

Referred by community volunteers Referred by GoB staff

Source: MIS-4, DGFP and Project MIS Note: Quarter 4 data not available MaMoni Health System Strengthening Project Annual Report 2017-2018

1.2.1.d. Nutrition Data from DGFP MIS and DHIS-2 showed the following results in MaMoni implementation areas in the reporting year: . 1,271,474 (311,839 mothers and 959,635 children) were reached with nutrition interventions from different service delivery points from community to district (Community Clinics, UH&FWCs, UHCs and DHs from where IMCI and nutrition services are provided); . 281,123 caregivers received BCC interventions that promote essential infant and young feeding practices (hand washing, IDD, Vit-A etc.) ; . 311,839 pregnant mothers received iron and folic acid (IFA) supplementation including nutrition counseling; . 8,684 children were identified who had been suffering from MAM; . 3,839 children were identified as SAM patient and were referred; . Among the 959,635 children who were reached, 70,872 (7.4%) had been suffering from different forms of under nutrition- 23,423 (33%) were identified as stunted, 16,892 (24%) as wasted and 30,557 (43%) were identified as underweight (Figure 17). Figure 17: Nutritional status of children under 5 in MaMoni HSS districts

10000 8750

7,738 8000 7556 6917 7,086 6513

6000 5278 4769 4,809 4142 4125

Number 4000 3189

2000

0 Stunting (height-for-age) Wasting (weight-for-height) Underweight (weight-for-age)

Q1-Y5 Q2-Y5 Q3-Y5 Q4-Y5

Source: MIS-4, DGFP and DHIS-2

1.3 Strengthen infrastructure preparedness to improve MNCH service utilization 1.3.1 Upgrading UH&FWCs to provide 24/7 delivery services

Twelve UH&FWCs have been upgraded in MaMoni HI areas to provide 24/7 normal delivery services in Year 5. The local government had a significant contribution in upgrading two UH&FWCs in Noakhali to provide 24/7 normal delivery services. With this, a total of 106 UH&FWCs are now providing 24/7 normal delivery services in MaMoni HSS districts.

32 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 IR 2: Strengthen health systems at the district level and below 2.1 Improve leadership and management at district level and below 2.1.1 Quarterly performance review meetings (QPRM) The project facilitated quarterly performance review meetings (QPRM) jointly organized by DGHS and DGFP in all MaMoni HSS districts except Bhola. District and upazila level managers, other officials, NGO representatives and MaMoni HSS staff in the district attended the QPRMs. QPRMs reviewed MNCH/FP/N performances by upazilas. The meetings also discussed district action plans, joint supervisory visits (JSV) and data quality assessment (DQA) findings, local government engagement, challenges and up-coming priorities. Based on the participatory review and discussions, action points and decisions were taken to improve the coverage and quality of program activities.

2.2 Improve district level comprehensive planning (including human resources) to meet local needs 2.2.1 District and union level planning workshop MaMoni HSS supported the development of decentralized MNCH/FP/N action plans at district and upazila levels, using local level data from project’s Tracer Indicator Surveys (TIS) on priority MNCH/FP indicators, along with routine MIS of DGHS (DHIS 2), DGFP and project MIS. This process included analysis of current MNCH/FP/N service utilization and identifying bottlenecks of these services using available data, developing corrective action plans along with resources required and setting achievable targets with monitoring plan. Bottlenecks were categorized under four domains: service availability; accessibility; utilization; and quality index. A minimal set of interventions like ANC, SBA delivery, essential newborn care (ENC), PNC and FP which have the highest impact on reducing maternal and neonatal mortality and improving quality of life were assessed. Additional MNCH/FP/N interventions like EmONC, newborn care interventions (e.g., chlorhexidine, antenatal corticosteroids, Kangaroo Mother Care, sepsis management, HBB), IMCI, Management of maternal complications & newborn complications and advanced newborn care (e.g., SCANU, referral system) were also considered during the planning process. Facilitated by GOB health and FP managers and attended by various stakeholders, these workshops resulted in four district plans, four MCWC plans, 26 upazila plans and 52 union plans for four districts- Habiganj, Noakhali, Lakshmipur and Jhalokati. These plans were monitored during joint supervisory visits (JSV) and reviewed during monthly meetings at facilities and in QPRMs. This local level planning helped the managers from both the public and private sector in decision-making and resource mobilization. This was an ongoing process for improvement and availability of services with quality.

MaMoni Health System Strengthening Project Annual Report 2017-2018

2.2.2 Workload Indicators of Staffing Need (WISN) Study The project supported a study titled, “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities”. The objective of the study was to understand the existing workloads of different cadres of health workers at health facilities and at the community level. The study adapted WHO’s “Workload Indicators of Staffing Need” (WISN) methodology to the Bangladeshi context. The study was conducted at one medical college hospital (Rajshahi Medical College Hospital), two district hospitals (Kushtia and Brahmanbaria), two MCWCs (Kushtia Sadar and Brahmanbaria Sadar), four selected UHCs (Daulatpur, Kumarkhali Nabinagar, Sarail), eight union level facilities, four community clinics, and with corresponding community level workers at selected unions in Kushtia and Brahmanbaria districts. Key findings and recommendations was shared with TAG and a draft report has been submitted to Human Resource Branch of MOHFW for review.

Key findings from WISN study

• The workloads of health service providers such as physicians, nurses, FWVs, and FWAs were found to be very high at most facilities and community levels in the study area.

• A significant proportion of the available working time of major health care providers, namely physicians and nurses, are spent on supporting activities rather than activities related to health care delivery.

• There are inequalities in the workloads of similar categories of staff working at different facility levels (e.g. medical college hospital, DHs, UHCs), and at similar facility levels.

• Different types of support services staff, such as cleaning, laundry, attending, kitchen, and security staff, are also important for the optimum performance of facilities. The existing numbers of various support staff at different facility levels are inadequate to manage the workload. There are significant shortages in almost all categories of support staff.

• The existing record keeping system does not capture all health service related activities, particularly prevention and promotion activities. Additionally, the lack of discipline-specific data, even at the secondary and tertiary levels, makes it very difficult to accurately assess the workload.

34 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Key findings and recommendations of the study on “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities” were shared in the USAID implementing partners’ meeting in October 2017. Bangladesh’s experience of applying the Workload Indicators of Staffing Need (WISN) method was also presented in the 4th Global Forum on Human Resources for Health held in November 2017 in Dublin, Ireland. The WISN study conducted in two additional districts supported by WHO Bangladesh has also been recently completed. Both reports share similar findings and recommendations. WHO and MaMoni HSS collaborated with each other along with the HRD Unit, MOHFW for a joint dissemination of the key findings and recommendations of these two studies. A small group comprising of Principal Investigators of the two studies and technical persons from MaMoni HSS and WHO Bangladesh worked to develop policy briefs based on these studies. 2.2.3 Implementation of Central HRIS The MaMoni HSS project continued supporting the DGHS and DGFP in implementing a central Human Resource Information System (HRIS). During the reporting period, the focus was to facilitate initiation of HRIS implementation at DGFP where more than 55,000 staff are working in more than 5,000 service delivery facilities and administrative offices throughout the country. Several discussions were held with the Director and Program Manager of MIS unit of DGFP and Activation Ltd. for planning, conceptualizing and implementing HRIS in DGFP. In line with the MIS Operational Plan (OP), MaMoni HSS supported capacity building by providing a three-day Training of Trainers (ToT) to relevant central level DGFP staff who subsequently provided training to the relevant district and upazila level DGFP staff on HRIS. ToT was organized in collaboration with MIS unit and Activation Ltd. 38 central level staff including Deputy Directors, Program Managers, Deputy Program Managers, Statisticians, and Assistant Maintenance Engineers, etc. were trained in two batches. MaMoni HSS worked with the MIS unit, DGFP for initial inputs to HRIS’s facility and sanctioned post registries. MaMoni HSS project continued to provide support for capacity building of DGFP staff by rolling out the central Human Resource Information System (HRIS). Three batches of trainings were organized in collaboration with MIS unit of DGFP. A total of 74 staff were trained on HRIS in three batches. At the central level, Deputy Program Managers, Family Planning Officers, Computer Operators of different units /departments of DGFP who have been identified as HRIS MaMoni Health System Strengthening Project Annual Report 2017-2018

focal points of their respective departments were trained. In Habiganj and Noakhali districts Assistant Director-Family Planning, Statistician, Upazila Family Planning Officer (UFPO), Medical Officer-MCH, Upazila Family Planning Assistant (UFPA) were trained. With the initial capacity building support from MaMoni HSS project, MIS unit planned to provide training to relevant staff at division, district and upazila level throughout the country utilizing their Operational Plan (OP) budget for national roll out of HRIS. The project has also facilitated formation of a ‘HRIS core committee’ led by the Program Manager MIS Unit which consists of six members. This committee will work at the central level for further development of HRIS and address technical issues during implementation of HRIS.

2.3 Strengthen local management information systems 2.3.1 Implementation and Support

This year all TOTs and trainings related to eMIS activities at the community, facility and supervisory level have been completed for Jhalokati, Habiganj, Noakhali and Lakshmipur districts. This includes special training for capacity building of the eMIS focal persons from GoB counterpart.

In parallel, eMIS design team helped resolving implementation issues of the FWV, FWA, HA, AHI, HI, FPI eRegisters and assessment tools. Team members also developed new features and continuously monitored e-MIS reports from unions using the monitoring tool.

Major trainings conducted in this year are summarized below:

Table 3: Training information for eMIS for October, 2017 – September, 2018 No of Planned No of participants Participants Resources SL Event District Participa Attended Categories Persons nts ToT on FWA e- UFPO, Noakhali and Line Director 1 55 54 Register UFPA, MO Lakshmipur MIS, MCRAH

Training On FWA e- Noakhali and 2 400 394 FWA UFPO Register Lakshmipur Line Director- MNC&AH, ToT on HA e- UH&FPO, Noakhali and Director-PHC, 55 52 3 Register MO Lakshmipur Program Manager-MNH, DGHS

Training on HA Noakhali and 489 485 HA CS, UH&FPO 4 e-Register Lakshmipur

Line Director- ToT on AHI, HI UH&FPO, Noakhali and MNC&AH, 5 45 43 e-Register MO Lakshmipur Director-PHC, 6 Program

36 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 No of Planned No of participants Participants Resources SL Event District Participa Attended Categories Persons nts Manager-MNH, DGHS

Training on AHI, HI Noakhali and 231 231 AHI, HI CS, UH&FPO 6 e-Register Lakshmipur

Noakhali, ToT on FPI e- UFPO, MO 75 74 Lakshmipur, DD-FP 7 Register (MCH-FP) Habiganj

8 Training on FPI e- 44 42 FPI Lakshmipur DD, UFPO, Register MO(MCH-FP) HIS ToT on UH&FWC Coordinator assessment and District 9 12 12 s, ME&DO Noakhali Facility Module Coordinator and IT refresher Officer CS, DD-FP, Training on CSBA e- 10 193 189 FWA, HA Lakshmipur UH&FPO, Register MO(MCH-FP) Training on Facility 11 Module for SACMO 86 83 SACMO Noakhali UH&FPO,CS (Health) Training on Habiganj, UH&FWC FWV, Noakhali, DD-FP,UFPO, 12 assessment and 338 331 SACMO, Lakshmipur UH&FPO Facility Module Paramedic and Jhalokathi refresher UFPO, MO (MCH-FP), Habiganj, Training for eMIS 13 119 104 AUFPO, Noakhali and DD, CS focal persons Statistician, Lakshmipur UH&FPO

2.3.2 Development Activities: Developing and upgrading the eMIS system is a continuous process and major milestones were met during this PY. One such major milestone was stopping the duplication of recording in paper register in Madhabpur, Habiganj and Mirzapur, Tangail.

One major achievement of eMIS is the introduction of rules and protocol based decision support system (DSS). The system was designed following national protocol, standard operating procedure and guidelines with built-in medical intelligence that alerts and prompts providers on identification of women and newborns with greater risks of complications and guides appropriate case management decisions. The benefits of the protocol-based decision support system is

MaMoni Health System Strengthening Project Annual Report 2017-2018

demonstrated by increased identification and referral of pregnant women with eclampsia/pre- eclampsia (62% to 82%) and LBW babies as shown in Figure 18 and Figure 19.

Figure 18: Trends in PE/E case referrals from UH&FWCs using eMIS

82.35% 82.00% 77.78%

62.50%

40.86%

21.62%

Diastolic >= 90 PE(BP+Albumin)

Nov'16 - Jan'17 (N1=12549) Jun'17-Aug'17(N2=15392) Jun'18-Aug'18 (N3=15275)

Figure 19: Trends in referral of low birth weight babies from UH&FWCs using eMIS

26 26 24

14

7 6

LBW Cases Referred Cases KMC admission in secondary and above level facilities

Jun'2017 - Aug'2017 (Live Birth=1334) Jun'2018 - Aug'2018 (Live Birth=1617)

Major development activities under eMIS are shown in Table 4.

38 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Table 4: Major development activities during the reporting period:

Activity Description Status

Migration to There are number of problems reported for First phase is completed, the updated community module and some stage it needed to be second phase migration database stopped in Tangail and in Habiganj, Lakshmipur and completed for Tangail and new system Noakhali for data cleanup and upgradation of the structure is ready for Natore, database structure. Second phase of this migration is Jhenaidah, Moulavibazar still underway. The architecture is significantly (MEASURE districts). In MaMoni revised for better data validation at the community districts the migration started on part. The facility part architecture is revised along so Jhalokati then Habiganj, both system works seamlessly. Noakhali and Lakshmipur will follow.

Migration It is now possible to print service registers with The feature is incorporated into towards content from the supervisor level for record keeping monitoring tool and provider’s paperless purpose. This was an essential step before going TAB system paperless in targeted upazila (sub-division)

Moreover, provision is made to record data for sections in the MIS form that was not covered by the information collected from the e-register e.g. infertility service

Developed Submission and approval of satellite session planning Training is completed. Satellite is now automated within e-MIS system. Session Planning

Dashboard for In order to reduce dropout from LARC/PM method, it The feature is incorporated into service was proposed to DGFP that electronic notification for the providers system. statistics and follow-up services may be used. The team developed follow-up the dashboard at the provider end so that such client/patients are identified and provider can initiate necessary follow-up action. The implant and IUCD follow up is the primary focus but similar follow-up action is also useful for maternal health services. A common dashboard is developed for the provider where he/she can monitor all the client/patient due for follow up visit.

Dashboard for Dashboard for district level managers is added on Screen and Laptop are given to Managers monitoring tool that gives quick analytical overview district level managers with of the district performance by upazila (sub-division). dashboard system installed. Low birth weight, location and login, synchronization dashboard and server health check is added for monitoring the providers activity and better service availability.

MaMoni Health System Strengthening Project Annual Report 2017-2018

Activity Description Status

Added more Provider transfer mechanism added in the monitoring The feature is incorporated into functionality for tool. It is also now possible to assign additional monitoring tool. Provider responsibility for a provider management

Combined child DGHS and DGFP use two different format for the On hold - Child care register is care register child care register. The existing child care register for partially developed and waiting DGFP also do not have the provision of recording for final approval

data required to report IMCI activities under MIS3. The team is working to develop a combined child care register that meet requirement of the both the agencies and meet the IMCI guideline for 0-2 months and 2–59 months. The guideline is developed in consensus with the national/international stakeholders from GoB officials, ICDDRB and SNL.

The directorates (DGFP and DGHS) still do not have an agreement on the content of the updated child care register. Since the eMIS goal was to unify the content, development is currently paused until at least one of the directorate finalize the content.

GPS enabled Live GPS integration is introduced where every monitoring tool provider’s location can be traced. This will enable for better national and (sub) district level managers to view decision making service availability and identify the coverage gap. In the monitoring tool a number of new features are added for the managers and the M&E officers for effective monitoring.

Disease A longitudinal disease spread analysis tool is added The feature is incorporated into Monitoring in the dashboard. It uses the diagnosis from the monitoring tool. analysis add in general patient module used at union level facilities monitoring tool primarily by SACMOs.

Developed Synchronization of offline data is the most The feature is pilot tested in Automatic challenging part of the entire development. In Jhalokati first then it will be Database addition to the existing system a secondary system is rolled out in other district. upload developed for the providers whose synchronization is download blocked or slow due to network issue. system for Data Synchronization

Facility UH&FWC Assessment conducted in 2015/16 is now The training and implementation Assessment embedded in eMIS application and already receiving is completed and the feature is Tools updates from eMIS implementation areas. A incorporated into monitoring tool. Dashboard dashboard is developed to visualize change set between 2015 assessment and now

40 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 2.3.3 Launching Ceremony for Scale up of eMIS A launching Ceremony for National Scale-up of Electronic Management Information System (eMIS) was organized on 11th October’17. Hon’ble Minister for Health and Family Welfare Mr. Mohammed Nasim, MP was the Chief Guest of this event. Kazi Mustafa Sarwar, Director General, DGFP has chaired the program. Following the launch, eMIS scaled-up in 5 new districts which are Noakhali, Jhenaidah, Natore, and Madaripur.

Hon’ble Minister for Health and Family Welfare Mr. Mohammed Nupuri Das, FWV, Char Kakra UH&FWC Received TAB from Nasim, MP delivering his speech Honb'l Minister, Ministry of Health and Family Welfare

2.3.3 Others activities:

• Facilitated ToT, Training on UH&FWC assessment, and Facility Module refresher at Jhalokati, Habiganj and Noakhali and participated in national event representing eMIS. • Actively participated in Improving institutional deliveries by strengthening public facilities for 24/7 services dissemination.

eMIS showcasing in the “Improving Institutional eMIS showcasing in the “Improving Institutional Deliveries by Strengthening Public Facilities for 24/7 Deliveries by Strengthening Public Facilities for 24/7 Services” dissemination at Pan Pacific Sonargaon hotel Services” dissemination at Pan Pacific Sonargaon hotel

MaMoni Health System Strengthening Project Annual Report 2017-2018

2 2.4 Establish a quality assurance system for MNCH/FP/N services at the district level and below 2.4.1 Comprehensive strategy for improving the quality of clinical care The MaMoni HSS project implemented a comprehensive quality improvement strategy to support the MOHFW at the national and district levels to improve the quality of clinical care for MNCH/FP/N services. The QI strategy has evolved based on lessons learned, experience in applying different approaches, and results documenting actual improvement of QI indicators. The project’s QI strategy comprises of three main components: A. Building national capacity and updating national standards and guidelines; B. Improving delivery of MNCH/FP/N services in MaMoni HSS districts; and C. Measuring QI indicators and recognition of achievement. The project adopted the new WHO Framework for the quality of maternal and newborn health care as guiding principles for designing and implementing its QI interventions.

The project signed an LOC with Health Economics Unit (HEU) to provide technical, managerial and financial support to the Quality Improvement Secretariat (QIS) to implement the National Strategy for Quality Improvement (QI). Major areas of SCI’s support to QIS include: − Strengthen technical and managerial capacity of QI Secretariat; − Facilitate establishment and functioning of the decentralized QI management structures at divisional, district and sub-district levels; − Provide technical assistance to developing/updating national guidelines, protocols and tools to support implementation of the national QI strategy; and − Support development of a system for developing and monitoring QI indicators for clinical services. To implement the activities under the LOC and support implementation of activities directly executed by the QIS, MaMoni HSS Project seconded 19 staff to the QIS. They include- two consultants, one administrative and MIS officer, one divisional QI coordinator for each of the 8 divisions (sitting at divisional health office), two district QI monitors for Chattogram division and one district QI monitor for each of the Sylhet and Barisal divisions. In addition, to implement the RMNCAH pilot in Narsingdi district, one district QI coordinator, one district QI monitor and one MIS officer have been deployed under the QIS.

2.4.2 Building national capacity and updating national standards and guidelines

2.4.2.a Training on PDCA: In year-5, MaMoni HSS project supported the government to develop and publish the Plan-Do- Check-Act (PDCA) training manual. PDCA basic and refreshers trainings were organized for nearly450 staff across all divisions. The participants were mostly consultants (OBGYN), Resident Medical Officers, Medical Officers, Nursing Supervisors, and Nurses. The overall objective of the training was to enhance the understanding and skills of the participants to resolve day-to-day hospital problems using the PDCA approach.

42 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 The major areas identified by the participants to solve through PDCA approach were: a) Improve assessment of diarrhea patients for clinical management to prevent severe dehydration; b) Improve timely checking of capillary blood sugar to prevent neonatal convulsion; c) Improve hand washing in OT; d) Improve evening rounds by doctors/consultants; e) Reduce wound infection in surgical units; f) Improve infection control in delivery rooms; and g) Improve cleanliness of toilets. The trained divisional QI staff will follow up the implementation status through monitoring visits.

During this period orientation/coaching on PDCA was also provided to the managers of 4 MaMoni intervention districts (Lakshmipur, Noakhali, Jhalokati and Habiganj). All the district managers attended the orientation. The participants found this coaching session very useful and felt confident in implementing and monitoring PDCA at their respective hospitals.

2.4.2.b Training of trainers (TOT) on Infection Prevention and Control (IPC) During the reporting period, four (4) TOTs were conducted for the divisional and district resource pool members at Chattogram, Sylhet, Dhaka and Barishal divisions. The overall objective of the TOT was to prepare the resource pool members with necessary knowledge and skills to train the district hospital staff on IPC. The participants (resource pool members) were the consultants (OBGYN, Surgery, Pediatrics, and Anesthesia), DCS, RMO, UHFPO, MOs, and Nursing staff (including nursing supervisors). MaMoni HSS divisional QI team also supported QIS in training on IPC in hospital.

All capacity development activities of MaMoni HSS is summarized below:

Table 5: Capacity development activities in MaMoni HSS project Jan- Jul- Oct 17- Apri- Sl Event Division Participants Mar Aug Total Dec 18 Jun18 18 18

Save the Children MaMoni HSS Project 1 All divisions 16 0 0 0 16 organizational issues staff (all)

MaMoni HSS Project Training on leadership, staff (all) except 2 All divisions 12 1 0 0 13 QI & 5S administrative officer.

TOT on leadership, QI Divisional resource 3 and 5S for divisional All divisions 79 0 0 0 79 pool members resource pool

Chattogram, Refresher training on Rajshahi, Divisional resource 4 leadership, QI and 5S (for 31 0 0 0 31 Barisal, Sylhet, pool members divisional resource pool) Khulna divisions

MaMoni Health System Strengthening Project Annual Report 2017-2018

Jan- Jul- Oct 17- Apri- Sl Event Division Participants Mar Aug Total Dec 18 Jun18 18 18

TOT on leadership, QI Sylhet, Khulna & District resource 5 and 5S for district Chattogram 132 0 0 0 132 pool members resource pool divisions

Dhaka Medical Orientation to 5S 5S monitors, new College Hospital 6 monitors, new staff & staff & WIT team 300 0 0 0 300 & Shaheed WIT leaders on 5S leaders ShMCH

All divisions including WIT members (all 7 Orientation of WITs on 5S Chattogram, 3,213 338 101 0 3,551 category of staff) Sylhet, Barisal & Khulna divisions

Hospital staff Orientation to SSK & 8 (consultants, doctors 18 0 0 0 18 project facility staff on 5S its upazilas and nurses)

Orientation/advocacy with Sylhet, Khulna, District Managers 9 district managers and QI Chattogram & (CS, DDFP), QIC 177 0 0 0 177 committees on QI and 5S Barisal divisions members

DGHS, DGFP, Dhaka, Sylhet, NIPSOM, ICMH, Khulna, Consultant, Asstt. & Refresher training on Rajshahi, 10 Asso. Prof., RP, RS, 150 0 0 0 150 PDCA cycle Rangpur & CS, Superintendent Chattogram DH, RMO, Asstt. divisions Director, DPM

Hospital staff of 4 All divisions MaMoni targeted including districts; MaMoni 11 Training on PDCA Chattogram, 177 46 53 23 299 district managers, Barisal, and divisional QI Sylhet divisions coordinators etc.

UHFPO, MO, RMO, DCS, DP, MOMCH, 12 TOT on MPDSR All divisions DPM (MNH), Jr 78 0 0 0 78 Consultant (Paed), EMO

Sub-committee Rangpur, members, UHFPO, Training/ refresher on 13 Chattogram, & MO, RMO, DCS, 169 88 0 0 257 MPDSR Barisal divisions Consultants, Nurses (OG & Ped dept.)

TOT on Infection Chattogram, District and 14 Prevention and Control Sylhet & Barisal divisional resource NA 58 0 0 58 (IPC) divisions pool members

44 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Jan- Jul- Oct 17- Apri- Sl Event Division Participants Mar Aug Total Dec 18 Jun18 18 18

Doctor, Nurses and 15 DH staff training on IPC Bandarban others (cleaners, aya NA 42 0 18 42 etc.)

Training on Facilitation Narsingdi Doctor, Nurse, FWV NA NA NA 14 skill

Total: 4,552 573 154 55 5,334

2.4.3 Improving delivery of MNCH/FP/N services in MaMoni HSS districts 2.4.3.a Increasing local ownership of QI by establishing and supporting Quality Improvement Committees (QIC) and through the engagement of the local government

All divisional and district QI committees have been formed and district resource pools developed. Continual effort has been given to ensure regular meetings are occurring for the divisional and district QICs. The table below shows the number of districts where QIC and district resource pools have been formed. The number of districts conducted the district and district hospital QI committee meetings during the reporting period are also shown in the table below.

Table 6: Information about quality improvement committee (QIC) Division No. of Dist. QIC District resource District QIC District hospital districts formed # pool developed meetings held QIC meeting held (cumulative) (Apr-June 18) (Apr-June 18) (cumulative)

Chattogram 11 11 11 8 10

Sylhet 4 4 4 4 4

Barisal 6 6 6 3 6

Khulna 10 10 10 7 7

Dhaka 13 13 13 1 4

Rajshahi 8 8 8 NI NI

Rangpur 8 8 8 1 4

Mymensingh 4 4 4 3 3

Total: 64 64 64 27 38

#: No. of districts; NI: No information (because of lack of staff at the divisions);

MaMoni Health System Strengthening Project Annual Report 2017-2018

One key intervention that led to substantial improvements in the basic standards of infection prevention, including medical waste management, was the engagement of the local government. The local government contributed significant resources for health facility renovations, repairs, and construction of medical waste management dumping pits.

2.4.3.b Strengthening routine supervision system and promoting supportive supervision The project supported the districts in developing monthly visit plans and in the coordination of Joint Supervisory Visits (JSV) by district and upazila supervisors. The objectives of the supervisory visits are to identify gaps, develop action plans for improvement, and follow-up on results. The project introduced structured supervisory checklists and the supervisors conducted the JSVs using the checklists in areas including: infection prevention measures, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI and normal vaginal delivery. Based on the findings, the supervisors provided supportive supervision including mentoring, on- the-job training, and problem solving.

2.4.3.c Monitoring quality of care at sentinel facilities MaMoni HSS monitors the quality of care at selected facilities through sentinel surveys. The surveys were conducted by directly observing women attending ANC and FP services. Figures 20 and 21 display the findings of surveys on the QoC of ANC and FP services, conducted in 4 MaMoni HSS districts. The figures show that Habiganj and Jhalokati are doing better in terms of all quality indicators, however, Noakhali and Lakshmipur are lagging behind.

Figure 20: Quality of ANC services in MaMoni HSS districts

100100100100100 100100100100 100 100 100 100 99 96 99 100 93 94 92 95 86 90 84 81 80 76 70 64 60 50 40 30 20 10 0 HABIGANJ JHALOKATI LAKSHMIPUR NOAKHALI Total BP measured Weight measured Hemoglobin test conducted Urine albumin test conducted Iron folic acid prescribed or given

Source: Sentinel survey, 2017 (Q1-Y5)

46 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018

Figure 21: Quality of family planning counseling in MaMoni HSS districts

100999898 100989797 100 100 100 99 99 97 100 93 96 9693 94 90 86 77 80 707069 70 57 59 60 53 52 47 50 46 43 3939 40 36 30 20 14 10 0 HABIGANJ JHALOKATI LAKSHMIPUR NOAKHALI Total Audio/visual privacy Exploring client's experience Discussion on side effects Instructions to mitigate side effects Receiving client feedback Job aid using Fixing follow up visit

Source: Sentinel survey, 2017 (Q1-Y5)

2.4.3.d Supporting the implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR) MaMoni HSS provided technical support to the QIS in scaling up MPDSR at the district and upazila level health facilities. Steps for MPDSR included improving Death Notification (DN) for maternal, neonatal, and stillbirths, and Facility Death Review (FDR). 78 GOB staff received TOT and 178 staff received training on MPDSR in Y5. In addition, there were national and divisional level workshops for developing MPDSR action plan and reviewing the status.

2.4.3.e. Supporting CEmONC through Regional Roaming Quality Improvement Teams (RRQIT) The project continued supporting the RRQIT as an additional supervisory and mentoring team focusing on monitoring and improving the quality of CEmONC provided at the district level in Habiganj, Noakhali, Lakshmipur and Jhalokati districts. RRQITs include OBGYNs and neonatologists from medical colleges near project districts, as well as district level supervisors. RRQIT visits are conducted using structured checklists, which assess general CEmONC infection prevention measures, child birth services, CEmONC provision readiness, and neonatal care, including Special Care Newborn Unit (SCANUs).

2.5 Develop comprehensive logistic management systems for essential MNCH/FP/N commodities at the district level

MaMoni Health System Strengthening Project Annual Report 2017-2018

2.5.1 Scaling up the implementation of electronic logistics management information system (eLMIS), in coordination with Systems for Improved Access to Pharmaceuticals and Services (SIAPS)

In coordination with SIAPS, the project supported the MOHFW in introducing eLMIS in three additional districts- Habiganj, Noakhali and Jhalokati. eLMIS helps to improve recording, monitoring, and availably of essential drugs, particularly MNCH items. During the reporting quarter, the project oriented district level stakeholders in Habiganj, Noakhali, and Jhalokati districts on eLMIS. During the reporting quarter, the project conducted district level orientation on eLMIS for health managers. The purpose of this orientation was to refresh the district level GoB managers’ knowledge on basic logistics management system, their roles and responsibilities in improving LMIS status, SCMP of MOHFW and the LMIS activity conducted to date at each district. The new eLMIS is expected to improve monitoring the stock of essential drugs, the procurement process, and reduce stock outs. Total 635 providers were trained and reporting started from October 2017.

Screen shot from DGHS-eLMIS showing the monthly reporting status in September 2017

48 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 2.5.2 Monitoring and improving the availability of essential MNCH/FP/N drugs Post training follow up and trouble-shooting meetings were organized both for improving the reporting rate and for data quality of reported facilities. The daylong meetings were arranged at the upazila level with aims of reducing knowledge gaps; identifying the gaps in data entry of individual providers and hands on technical session for necessary correction. Local level GOB managers (UHFPO) and upazila statisticians were present in the meeting for future follow up. Trouble shooting meetings were completed during the first and second quarters.

The reporting rate increased gradually throughout the year except in January and February, 2018 due to strike of CHCP of the community clinic who are the bulk number of the DGHS- eLMIS participants reporting. Figure 22 shows an increasing trends in the monthly reporting rate in DHIS-2 in MaMoni HSS districts. Figure 22: Monthly reporting rate of eLMIS in DHIS-2 in MaMoni HSS districts

120% 100% 100% 100% 100% 100% 100% 100% 97% 97% 95% 100% 88% 89% 89% 89% 99% 86% 86% 85% 96% 83% 75% 90% 80% 68% 84% 83% 78% 63% 63% 60% 48%

40% 28% 30% 21% 20% 8% 10% 0% Oct.17 Nov.17 Dec.17 Jan.18 Feb.18 Mar.18 Apr.18 May.18 Jun.18 Jul.18 Aug.18 Sep.18

Habigonj Jhalokathi Noakhali

2.5.3 Meeting with statisticians and store keepers of MOH&FW on record keeping, reporting and data utilization:

Meeting with Statistician and Store Keepers of MOH&FW were arranged quarterly on record keeping, reporting and data utilization of DGHS eLMIS and Supply Chain Management portal(SCMP), MOH&FW at Lakshmipur, Noakhali, Habiganj and Jhalokathi districts.

MaMoni Health System Strengthening Project Annual Report 2017-2018

Meeting with Statisticians and Store Keepers of MOHFW in Habiganj and Jahlokathi

2.5.4 Monitoring availability of MNCH essential drugs through monthly color coded reports:

MaMoni HSS facilitated ensuring the availability of priority MNCH medicines at facilities in the project districts and works closely with local level managers and local government bodies to this end. The color coded findings from Supply Chain Management Portal (SCMP) were shared for improving the record keeping, reporting and data utilization for better distribution, utilization, stock out prevention and for reducing misuse of MNCH essential medicines in upazila stores and facilities.

Figure 23. Monthly availability of 7.1% chlorhexidine at DGHS store Sl Name of the Oct. Nov. Dec. Jan. Feb. Mar. Apr. May. Jun. Jul. No. store 17 17 17 18 18 18 18 18 18 18 1 CS store 2 Dis.Hospital 3 Nalchiti 4 Kathalia 5 Rajapur

Item is available Item is not available (Stock Out) Item is available but has a stock that will expires within 6 month

The dashboard above shows the availability of 7.1% Chlorhexidine at DGHS stores of Jhalokati district from October 2017 to July 2018. It was available in all DGHS upazila stores except Civil Surgeon store from August 17 to January 18. The yellow color is given from September 17 to January 18 as the expiry date of the medicine was February 2018. New lots were available from February 18 through local level procurement by Civil Surgeon facilitated by the project.

50 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Local Government contribution in management of essential medicine:

• Due to delay in procurement process by GOB, MaMoni facilitated the local level procurement by Hospital Superintendent and 2,250 bottles of 7.1% Chlorhexidine was procured in January 2018. • Ensured medicines at Union Health and Family Welfare Centers in absence of supply from national level. The medicines were Tab. Misoprostol in April, 2018 , 7.1% Chlorhexidine & Injection Oxytocin in May, 2018. Table 7 and 8 provide details of drugs procured by local government and re-distribution of drugs from one SDP to the other.

Table 7: Local level procurement by Upazila Parishad/UH&FWC committee Upazila & Which Amount When Why By whom Supplied to District medicine

Madhabpur, Tab. 10,000 tab Dec. 2017 Prevent stock Madhabpur Different Habigonj Misoprostol out Upazila UH&FWC, Parishad Madhabpur

Kathalia, 7.1% 60 units Feb. 2018 Prevent stock Char Char Jhalokathi Chx. out Shirampur Shirampur UH&FWC UH&FWC committee , 7.1% 30 units May. 2018 Prevent stock Kulkathi Kulkathi Jhalokathi Chx. out UH&FWC UH&FWC, management Nalchity. committee

Begumganj, 7.1% Chx. 2800 unit Apr.-May, 2018 Prevent stock Different Different Companigonj, Inj. Oxytocin 3950 unit out UH&FWC UH&FWC of Hatiya, ORS 5000 unit committee of Begumganj, Sonaimuri. Begumganj, Companigonj, Tab. 3000 unit Companigonj, Hatiya and Misoprostol Hatiya and Sonaimuri Sonaimuri.

Nabiganj & 7.1% Chx. 1575 unit Apr.-Jun. 2018 Prevent stock Different Different Ajmiriganj, Tab. 1850 unit out UH&FWC UH&FWC of Habiganj Misoprostol committee of Nabiganj & Nabiganj & Ajmiriganj Ajmiriganj upazila upazila

MaMoni Health System Strengthening Project Annual Report 2017-2018

Table 8: Local level re distribution for prevention of stock out: District Which Amount When Why From where Supplied medicine to

Habiganj Tab. 200 units Nov. Prevent Nabiganj store Ajmiriganj Misoprostol 2017 stock out store Habiganj 7.1% 840 units Nov. Use short dated Sadar Upazila District Chx. 2017 medicine store Hospital, Habigonj Habiganj Tab. 9600 units Dec. Prevent Sylhet Regional All upazila Misoprostol 2017 stock out ware of House(RWH) Habiganj Jhalokathi Tab. 2000 Dec. Prevent Patuakhali Nalcity Misoprostol units 2017 Stock out Regional Ware Upazila House(RWH) store, DGFP Jhalokathi SAM food 30 units Oct. Prevent Kawkhai UHC, Rajapur (F-100) 2017 Stock out Pirojpur UHC, Jhalokathi Jhalokathi Tab. 800 Apr. Prevent Faridpur RWH Sadar Misoprostol units 2018 Stock out upazila Store, Jhalokathi Jhalokathi 7.1% 300 Apr. - Prevent MCWC, sadar, Different Chx. units May, stock out Jhalokathi SDP of 2018 sadar upazila, Jhalokathi Lakshmi 7.1% 150 May. Prevent Raipur, & UH&FWC, Chx. units 2018 stock out kamalnagar UHC Raipur and Kamalnag ar upazila Noakhali Tab IFA. 1000 units May. Short dated Hatiya 2018 FP store UHC Noakhali Inj 200 units May- Short Begumganj UHC Durgapur Gentamycin Jun. dated UH & 2018 FWC, Begumganj . Noakhali HBB kit 4 units May,18 Replace DRS, Noakhali District nonfunctional one Hospita, Hatiya UHC and Chatkhil UHC

More examples of using eLMIS tools and color coded dashboards provided in Annex 6.

2.6 Improve local governance and oversight for MNCH/FP/N To allocate adequate budget for MNCH/FP/N services for respective union parishads (UPs), the MaMoni HSS project staff participated and facilitated ward meetings and budget meetings in all unions. Advocacy and planning meetings were arranged with all UPs in every district to engage them in the health service delivery of their unions. Some UPs are committed to deploying

52 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 service providers (paramedics) in the UH&FWCs of their unions with the support of their budget. The district teams worked to engage more UPs to motivate them to deploy service providers (paramedics) in the UH&FWCs of their unions. In Noakhali, the UP of Charbata union recruited paramedics in the UH&FWC using their own funds, while the UP in Rajganj union is in the process of recruiting another paramedic. A remarkable achievement was made by involving the UPs to take the lead and also to mobilize funds to upgrade and/or maintain the services at 24/7 UH&FWCs. Table 9 shows the fund allocation and utilization status by local government bodies for MNCH/FP/N activities for the period of July 2017 to June 2018 (GoB fiscal year). These funds were mainly used for the construction, repair, and maintenance of facilities; purchasing emergency medicine (especially during stock-outs); purchasing small medical and non-medical equipment and logistics; financial support to temporary support staff; and constructing approach roads to improve access to UH&FWCs .

Table 9: UP budget allocation and utilization, July 2017 to June 2018

No. of union No. of Parishad union allocated budget Allocated District Parishad for MNCHFP budget Spent budget % spent

Habiganj 77 77 10,594,850 7977504 75

Jhalokathi 32 31 4,054,000 1942110 48

Lakshmipur 58 58 15,556,975 5838787 38

Noakhali 91 90 9,610,000 6066200 63

Total 258 257 39,815,825 21,824,601 55

Total utilization in this year was 21,824,601 (55% of allocation). There are wide variation of allocation in the unions; selected UPs, especially those supporting 24/7 delivery services, allocated more resource than rest of the unions.

Usually UP increases allocation and utilization from January onwards. Utilization is less in Jhalokati and Lakshmipur. However, the funds will be utilized by June 2019. The remaining funds, when available will be utilized by the local government for MNCHFP projects in the area.

MaMoni Health System Strengthening Project Annual Report 2017-2018

IR 3. Promote enabling environment to strengthen district level health systems 3.1 Policy reforms in place to promote local planning and need-based human resource deployment in the public sector 3.1.1 Maternal health SOPs and Strategy

MaMoni HSS facilitated the development of Maternal Health SOPs and supported the development of the Maternal Health (MH) strategy. The SOPs were already been published and distributed to relevant stakeholders. MOHFW requested a translation of the strategy and MaMoni HSS is actively involved in the translation of the strategy which is currently in process.

3.1.2 Development of an Accreditation system for Health Service Developing an accreditation system in Bangladesh is one of the priorities identified in the Health, Nutrition, and Population Sector Program (HPNSP) 2017-2022 and is therefore included in the Operational Plans for Hospital Service Management. MaMoni HSS supported the Hospital Services Management (HSM) Operational Plan for developing the accreditation system, regulatory framework and a hospital accreditation act. This year, MaMoni HSS hired two consultants to facilitate the process and USAID Bangladesh hired two international consultants for providing technical assistance to the HSM. The consultant team reviewed the available documents and organized workshops and meetings with different stakeholders within government and private sectors. The consultants also proposed a “road map” designating the different activities required to bring about the establishment of an accreditation system. A draft act has been developed and submitted to the MOHFW for review.

3.2 Strengthen advocacy and coordination for adoption of evidence-based learning in national policy and program 3.2.1 Participate in national and district level campaign activities on various national days MaMoni HSS supported the MOHFW at the national as well as at the district level to observe the following national and international days related to MNCH/FP/N: • World Health Day 2018: theme- ‘Universal Health Coverage: ‘Health For All’ Every One Every Where’

World Population Day 2018: theme- ‘Family Planning is a Human Right’ Safe Motherhood Day: theme: Respectful Maternal Care World Prematurity Day

54 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018

MaMoni HSS supported the printing of Information, Education and Communication (IEC) materials to commemorate the events. MaMoni HSS also participated in rallies and roundtable discussions during the day celebrations.

3.3 Conduct and disseminate operations research and program learning/ documentation activities MaMoni HSS collaborated with various partners to document MaMoni HSS lessons on various issues. In Year 5, a number of program lessons learned were shared in national and international forums and select research and project briefs were published. A Coffee Table book was published that showcased major interventions of the project. A list of all research and project brief are provided in Appendix 7.

MaMoni Health System Strengthening Project Annual Report 2017-2018

3.4 Strengthening National Institute of Population, Research and Training (NIPORT) to deliver a capacity-building program for community level health workers to deliver community-based interventions of the essential services package

A LOC was signed between MaMoni HSS and NIPORT for strengthening the technical and managerial capacity of NIPORT to develop and implement a capacity development program for CHWs, their supervisors and first level managers for delivering community-based health interventions of the new ESP. Expected results of this initiative were:

• Equip NIPORT and its network of training institutions fully equipped to manage the implementation of CHW capacity-building program in an institutionalized way

• A harmonized package of job descriptions, skills, competencies matrix and capacity-building package for the various types of community health workers developed for national roll out

• A capacity-building package for health sector managers, first-line supervisors and CHWs developed and ready for roll out

3.4.1 Rapid assessment of the institutional and managerial capacity of NIPORT and its RTCs, FWVTIs & FTC An assessment on the capacity of NIPORT and its Regional Training Centers was conducted through a structured questionnaire. A short term technical expert assisted the process. Throughout the assessment, NIPORT officials were involved with the MaMoni HSS team in analyzing the data and suggesting recommendations for sustainable development of NIPORT and its RTCs. A directory with information for each RTC is attached with the assessment report. Key findings of the assessment are summarized below:

56 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018

A. Regional Training Center (RTC):

Infrastructure: Found to be overall good. The majority are functioning with two classrooms. One fourth need minor to major repair. RTC’s have separate hostel facilities for male and female. Forty percent of the hostels have adequate bedding and 50% have adequate reading tables and chairs.

Training Materials: The required training materials are not available as per standard, and mostly not in good condition.

Staffing: One-third of the sanctioned positions are vacant.

Status of TOT on Curriculum: The majority of the existing faculties do not have subject-specific TOT. All RTCs have a resource pool of trainers but lack TOT on the training curriculum for the trainings they facilitate.

Supportive Supervision: No structured provision for mentoring and supportive supervision were found. Occasional supervision and monitoring visits are done by NIPORT (HQ) faculty and sometimes by local government officials

Availability of Internet: Only two facilities out of twenty have Wi-Fi in the facility.

Training Calendars and Follow Up: Approximately 70% of the training calendars in the RTCs are not updated. Post-training follow up is absent in the majority (85%) of the RTC’s.

Paper Based Reporting Systems: Approximately 75% of RTCs have paper based HRIS, programmatic and financial reporting systems.

B. Family Welfare Visitor’s Training Institute (FWVTI): Maintaining harmonization; in terms of need for skilled and qualified trainers and vacancy of the trainer positions are major gaps identified in the assessment. Most of the centers have standard of hostel/ accommodation facility, equipped class rooms, uninterrupted power supply with backup support, internet connectivity with required number of multimedia projector, laptop and sound system, modernized skill lab/ demonstration facility etc.

C. Field Training Center (FTC): The FTC is fully functioning as a field support center of FWVTI but mostly underutilized and not well maintained. A lack of proper maintenance and involvement of administrative authority was found during the assessment. The existence of some FTCs are in threat in some places and being used for other purposes too.

MaMoni Health System Strengthening Project Annual Report 2017-2018

3.4.2. Mapping of potential collaborating institutions to manage large- scale training of CHWs NIPORT and MaMoni HSS developed a structured questionnaire to collect information of potential collaborating institutes in all 64 districts to manage large scale training of community health workers (CHWs), supervisors and managers. A total of 113 “collaborating institutions,” included those in the public, private and non-government sectors. Information was collected on capacity of providing training, information on faculty, status of training venue, focused area of expertise etc.

3.4.3 Digitalized information system of NIPORT: Based on the NIPORT and RTC assessment findings it was revealed that the management information system of NIPORT and its RTCs need upgrading. A web based Asset Management System and Training Management System (ams.niport.gov.bd) was developed which is now accessible from all RTCs and the NIPORT Head Office.

3.4.4 Capacity development through developmentDigital Asset of curriculum, Management System printing and training implementationDigital training calendar:

MaMoni HSS project provided support in development of Management and Leadership curriculum for upazila managers, upgraded training curriculum for first line supervisors and revised team training curriculum for CHWs including CHCP. All these modules were developed/adapted by stakeholders from different units of DGHS, DGFP and NIPORT, reviewed by technical committee and finally approved by the core committee formed for this particular task.

58 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018

IR 4. Identify and reduce barriers to accessing health services

4.1 Promote awareness of MNCH through innovative BCC approach

4.1.1 Intensive SBCC implementation plan development A communication agency specializing in SBCC was hired to develop and implement a comprehensive area-specific community behavior enhancement strategy (i.e. Habiganj, Lakshmipur, Noakhali/Hatiya) along with an SBCC activity implementation plan to accelerate a change with care-seeking for appropriate MNCH/FP/N services as well as improving home- based care practices. The SBCC activities are also aimed at creating an enabling environment in families and communities that facilitate and support appropriate care-seeking behaviors.

4.1.2 SBCC activities MaMoni HSS carried out comprehensive behavior change communication activities throughout Lakshmipur, Noakahli and Hatiya. Major activities were focused in the low performing areas based on crucial health indicators such as ANC, SBA delivery, and facility delivery. Key activities implemented this year are summarized in the table below:

MaMoni Health System Strengthening Project Annual Report 2017-2018

Table 10: SBCC activities in MaMoni HSS districts Activities No of Event Focused Target Forum Viewers/ Issue Audience Attendees Street Theaters 49 MNCH Women, men Below the line 10,000 and media camping adolescent Observe Safe Designed Maternal All Promotion of 80,000 motherhood day Poster Health safe motherhood posters day World Population Day Supplied Family All Promotion of 50,000 poster as per Planning safe motherhood posters template day provided by DGFP Prepared one 1 Health Clinical and Video show N/A documentary on staff’s non-clinical provider’s attitudes attitudes service for the quality providers Improvement Secretariat

4.1.3 Reaching the community through Aponjon services Aponjon continued to provide critical maternal, newborn, child health, nutrition and family planning messages to pregnant and lactating mothers during the pregnancy and postpartum period through the subscription based Shogorbha program. A total number of 72470 new acquisition was done during the program year of October 2017 to July 2018. With this, a cumulative total of 2,070,014 women have subscribed to the messaging service. Aponjon Facebook page remain active with feature posts and event news as a branding and marketing tool. Social media reach raised up to 10 million totaling all the quarter. On an average blog visit was 40000. Aponjon lunched three new audio-visuals for digital marketing campaign along with reuses of existing audio-visuals and dramas on Aponjon to engage people that resulted in marked responses from the users.

Screenshot of Aponjon digital commercial posted in social media

60 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Brand promotion and marketing also engaged pharmacies and door-to-door campaign with distribution of campaign materials. Thirty-five pharmacies were branded with Aponjon in select locations of Dhaka as part of the business model testing and branding of Aponjon. Road shows took place along with the branding where various activities like games, quizzes were arranged to engage people in the process. Through agencies, 9300 posters and 40000 door & car stickers were placed in hospitals, cars and CNGs. A 4-day campaign named ‘Aponjon Road Show’ was deployed in mostly populated and busiest areas of Dhaka city like, Dhanmondi, Mohammadpur, Mirpur & Nikunjo.

An amount of 593,690 BDT was disbursed among 2892 partner agents for 60591 acquisition as incentive. Cumulative count of Aponjon shogorbha app download was 30357 during this timeframe. A total of 363 participants were trained through 17 ToT during this period. Aponjon engaged in preparing audio-visual material and online training platform to reduce the cost and to ensure optimized use of resources during orienting, training and providing refreshers to field agents of Aponjon.

Quarter Training/Visit Partner/Location Participant

Oct-Dec 2017 6 ToT Mymensingh, , , , 131 Sylhet, Chuadanga

Jan-Mar 2018 5 ToT HDMBS, UPUS, Relation, AIMS & SJS 102

Apr-Jun 2018 2 ToT Ashar Alo Rural Development Sangstha 41 (AARDS) in Kurigram and Nari O Sisu Kollyan Society (NSKS) in Natore

July 2018 5 ToT NGO named ASS, Jashore; SEBA, 89 Mymensingh; ASPS, Netrakona; SMSS, Rajshahi and USK, Gaibandha

MaMoni Health System Strengthening Project Annual Report 2017-2018

Aponjon call center and counselling remained functional and a number of 13621 inbound call in the call center and 11705 inbound call in counselling line was attended during this timeframe. Sample Survey 3 was conducted during this timeframe, which showed user’s behavior and practice as well as feedback towards the service. A case story collection and compilation was done in this time from where 25 cases were documented and among them 10 video documentation was done. During this timeframe most important partnership was done with World Vision Bangladesh. Initiation of partnership started with OGSB and FHI360.

In terms of learning sharing Aponjon team participated in 3 National and International seminar, workshop and summits within and outside the country. To name a few, ‘Accelerating mobile internet adoption and usage in Bangladesh: Workshop on digital ecosystem solutions and insights’ arranged by GSMA, and SBCC & EE summit in Nusa Dua, Indonesia.

Dr. Partha Pratim Das presenting keynote at the GSMA workshop

As the first and largest mHealth initiative Aponjon has reached more than 2 million mothers in their cellphone and 60k users on their smartphone and had immense effect on outcomes of behavior generated through use of digital contents. As the program was ending, the learning from this journey was shared in an event in participation of USAID, Save the Children and all other stakeholders involved in the journey of Aponjon. This event marked the continuation of Aponjon as a new journey under LifeChord, a new venture and one of the sister concerns of Dnet.

62 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 4.2 Enhance community engagement in addressing health needs 4.2.1 Community mobilization in MaMoni HSS districts Frontline MOH&FW field workers - HAs and FWAs, facilitated Community Action Group (CAG) meetings and Community Microplanning Meetings (cMPM). Health Assistants took over the responsibility of cMPM facilitation and reporting. The cMPM report includes CAG meeting information of the area. There were 23,929 Community Volunteers (CV)/Community Action Groups (CAG) active in 4 MaMoni HSS districts. Community Mobilization related performances for the period Oct 2017-June 2018 are:

Sixty-five percent (65%) CAG meetings (highest 84% in Noakhali and lowest 34% in Jhalokati) held against 215361 planned; 90% cMPMs (highest 99% in Lakshmipur and lowest 71% in Jhalokati) held against 22804 planned and 98% Union Follow up meetings (highest 100% in Lakhmipur and lowest 95% in Jhalokati) held against 1740 planned in the 4 districts. Both HA and FWA attended in 70% of cMPMs. More than 55,299 new pregnancies were identified in the cMPMs and CVs referred about 24% (3,787 nos) of total LARC&PM performances of the districts. Figure 24 shows the community volunteers’ contribution to LARC&PM performance in MaMoni HSS districts. Figure 24: Contribution of community volunteers (CVs) to LARC&PM performance in MaMoni HSS districts:

100%

80%

60% 76% 77% 73% 76% 77% 74% 79%

40%

20% 24% 23% 27% 24% 23% 26% 21% 0% Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5 Q3-Y5 % referred by CVs % referred by GoB staff

Source: MIS-4, DGFP and Project MIS

4.2.2 Piloting cMPM through Community Support Group (CSG) MaMoni HSS piloted community microplanning meeting through the community mobilization structure of government, Community Support group (CSG) in 7 unions in 4 districts - Noakhali, Lakshmipur, Habiganj and Jhalokathi. During April-June 2018, 99% (187) CSG based cMPM held against 189 planned in these 7 unions where it has been rolled out. Total 617 pregnant women and 636 child birth notified in the cMPMs during the period. Comparison between outputs of the intervention unions and another similar unions shows that cMPMs of the

MaMoni Health System Strengthening Project Annual Report 2017-2018

intervention unions identified more pregnancies, notified more childbirth and referred more LARC-PM clients than that of comparison unions. Percent of cMPM and percent of CSG meeting held in the intervention unions were also more than that of comparison unions.

4.2.3 Transformation of MaMoni Community Volunteer (CV) to Community Sales Agent (CSA) Total 37 CSAs continued selling commodities in 9 unions of 3 districts; Habiganj, Noakhali and Lakshmipur. In addition to selling commodities, CSAs also sold total 156 Hexicord (7.1% CHX) and ensured application in newborns’ umbilical cord during April – June 2018. On average, each CSA sold an amount of BDT Tk. 6,249 in the quarter, making 25-30% profit, which was Tk. 3384 during Jan – March 2018 quarter.

Taking the learning of engaging MT-EPI in collecting cMPM resolution, project decided to functionally engage the first line supervisors. A meeting on sustainability of cMPM was arranged for first line supervisors and they were provided orientation to facilitate the CV refreshers orientation on cMPM and new born messages. In the refresher, emphasis was given to strengthen coordination between HAs, FWAs and CHCPs to make the cMP sustainable. Looking at the closing of the project, output of cMPM was also focused. After ToT, UzF-CM LG & BCC provided orientation to HI/AHI, FPI, MT-EPI, UFPA-MIS. Before this orientation, the issue was discussed and agreed in QPRM as next plan.

Challenges, Solutions and Actions Taken Challenges, Mitigation Strategies . Distribution of tablet misoprostol to women who delivered at home was a major challenge observed in this project. Misoprostol is distributed by FWAs through home visits and during 3rd ANC by FWVs. Some of the primary contributors to the low distribution coverage of misoprostol were: low coverage of ANC during the 3rd trimester, stock out of tablets, vacancies of FWAs and FWVs, inadequate home visits by FWAs, and the lack of a need based distribution system. The project continued advocacy at national level for recruitment in vacant position. The project also followed up supply issues of misoprostol at national as well as district level through LMIS. At the district level in quarterly performance review meeting the issues are shared with local level MOHFW managers. Another barrier is a large number of private sector providing maternal services but they have no supply and they are not providing misoprostol. Moreover private sector providers have also lack of skill/training on misoprostol. MaMoni HSS suggests to explore alternate options for misoprostol distribution i.e. through BRAC workers or other community based workers. . Proportion of women attended by a SBA during delivery is still low. Though increased SBA delivery was observed in MaMoni districts, universal coverage of SBA is still a long way. GOB should work with development partners, private sectors for increasing skilled birth attendance across the country.

64 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 . Identification and referral of PE/Eclampsia were major challenges of PE/E study. MaMoni HSS tried to boost up the study through training, monitoring and mentoring of the providers, however, nothing seemed to work. Improving quality of service delivery, adherence to protocol may bring positive change in this intervention. MOH&FW, OGSB and other stakeholders need serious consultation, analysis and identify appropriate strategies as eclampsia is one of the major killers of pregnant women. . Lack of coordination between the Quality Improvement Secretariat (QIS) and Hospital Services Management (HSM) unit of Directorate General of Health Services (DGHS) and maternal, child, reproductive and adolescent health (MCRAH) unit of DGFP has remained as a constant challenge for implementation of quality of care (QoC) in Bangladesh. MaMoni HSS has worked with HSM and MCRAH to ensure involvement of these units in QIS activities. However, intense follow-up is required. . Sustainability of the investment made for NIPORT improvement needs intense follow-up too. Increase visibility of NIPORT in DGHS & DGFP to increase coordination among NIPORT, DGHS & DGFP by involving representatives in most of the activities

. Though National Newborn Health Program (NNHP) was launched and operational, the progress is slow. MaMoni HSS along with partners supported different isolated components of NNHP but a coordinated approach, led by government will be the key to success. Introduction of KMC, continuation of SCANU, CNCP are a few major initiatives for this sector program. . Coverage of PPFP is very low. MaMoni HSS supported DGFP in developing guidelines, strategies, organizing training and counselling, however, major efforts required for involving DGHS staff in this intervention. . Sustainability of eMIS is a challenge as Measure and icddr,b decided not to stop expansion of HA module and other DGHS modules. Also DGFP is planning to develop DHIS-2 of their own. Strong coordination and collaboration with DGFP was the key for scaling up eMIS through family planning directorate.

Way Forward This was the last year of 5 year MaMoni HSS award. The lessons learned from this project will be shared in different forum, used for policy advocacy and planning of USAID’s follow-on project MaMoni Maternal, Newborn Care Strengthening Project (MaMoni MNCSP). The tested interventions need to scaled by the new project while testing new interventions for reducing maternal and newborn deaths in Bangladesh.

MaMoni Health System Strengthening Project Annual Report 2017-2018

APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF THE MAMONI HSS PROJECT

The program’s objectives are well aligned with the GoB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016; and also directly support the USAID/ Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh. MaMoni HSS designed a two- pronged approach in which districts and upazilas were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high- intensity areas is to demonstrate best-practice models of MNCH/FP/N health care delivery through intensive support to the High GoB, and if needed, direct implementation to maximize Health System learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi districts, while in the Noakhali and Pirojpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirojpur (refer to Figure 1 and Table 1). While the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale-up interventions such as 24/7 UH&FWCs, CHX for cord care, and HBB; instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.

66 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 APPENDIX 2: DATA SOURCES Assessment Assessment Frequency Geographical Coverage Name Type Population Independent 2 rounds in 23 high intensity upazilas of 5 MaMoni districts based tracer cross sectional a year. (Habiganj, Jhalokathi, Noakhali, Lakshmipur, survey assessment by Each round and Pirojpur). In addition, during the initial third party is for six stages of program – starting from October 2013 – (icddr,b) months this population based assessment was also conducted for along with Noakhali and Lakshmipur. This included a baseline assessment and two rounds of the population- based survey. In October 2014, there was a major shift in the MaMoni HSS program strategy and the scale of program activities were reduced in Bhola. Accordingly, the project monitoring plan (PMP) was revised and the population based survey no longer covers Bhola, with the exception of conducting an end line survey in 2017. Sentinel Selected Twice in a Selected DH, MCWC, UHC, UH&FWC and survey sentinel site year satellite clinics in Habiganj, Jhalokathi, assessments Noakhali and . using structured tool Service Periodic facility Twice in a 21 high intensity upazilas of Habiganj, delivery assessment by year Jhalokathi, Noakhali and Lakshmipur district. point using assessment structured tool Newborn Nationwide Once in All over the country revisit assessment by project life upazila on HBB and 7.1% CHX using structured questionnaire Routine MIS, Routine MIS Monthly All over the country MOHFW forms of DGHS and DGFP Project MIS Routine MIS Monthly Only in high intensity project areas reports

MaMoni Health System Strengthening Project Annual Report 2017-2018

APPENDIX 3: PROGRAM PERFORMANCE INDICATORS

Baseline End of Project Remarks Indicator Value Target Achievement Project Goal: Improve Coverage will be reported utilization of integrated on annual basis maternal, newborn, child health, family planning and nutrition services Percent of women received at least one antenatal care visit from a medically trained provider

High intensity areas

Baseline is DHSS and Lakhsmipur 60.1 77 77 Actual 2014 from TIS

Baseline is DHSS, re- analyzed for upazilas in Noakhali* 50.7 85 86 only high intensity area

Baseline is MaMoni Midline and Actual 2014 Habiganj 37.1 85 79 from Endline

Jhalokathi 65.7 83 80 Baseline is from TIS

TIS, only high intensity Pirojpur* 64.9 72 73 area

Percent of births receiving at least four antenatal care (ANC) visits during pregnancy

High intensity areas Baseline is from TIS 2014

Baseline from DHSS 2013 Lakhsmipur 13.6 32 24 and Actual 2014 from TIS

Baseline from DHSS 2013 and Actual 2014 from TIS Noakhali* 11.81 45 40 for HI areas

Baseline is MaMoni Midline and 2014 Actual Habiganj 8.6 45 40 is MaMoni Endline

68 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Baseline End of Project Remarks Indicator Value Target Achievement Jhalokathi 43.8 46 36 All data from TIS

All data from TIS, high Pirojpur* 30.4 36 31 intensity areas only

Percent of Births Attended by a Skilled Doctor, Nurse or Midwife

High intensity area

Baseline from DHSS survey 2013 and Actual Lakhsmipur 34.0 45 45 2014 from TIS

Baseline from DHSS; and Actual 2014 from TIS only Noakhali* 27.9 45 54 high intensity areas

Baseline from MaMoni Midline and Actual 2014 Habiganj 19.4 40 41 from MaMoni endline

Jhalokathi 44.2 55 55 All data from TIS

TIS, only high intensity Pirojpur* 42.7 50 44 areas

Percent of women with home births who consumed misoprostol to prevent post- partum haemorrhage

High intensity areas

Lakhsmipur 10.6 20 20 All data from TIS

All data from TIS, only Noakhali* 7.7 23 23 high intensity areas

Baseline and Actual 2014 from MaMoni Endline Habiganj 34.8 40 38 survey

Jhalokathi 41 25 29 All data from TIS

All data from TIS, only Pirojpur* 31.5 25 33 high intensity areas

MaMoni Health System Strengthening Project Annual Report 2017-2018

Baseline End of Project Remarks Indicator Value Target Achievement Percent of newborns initiated breastfeeding within one hour after birth

High intensity areas

Baseline from DHSS 2013 Lakhsmipur 52.6 65 76 and Actual 2014 from TIS

Baseline from DHSS2013 and Actual 2014 from TIS, Noakhali* 48 60 64 only high intensity areas

Baseline is from MaMoni midline and Actual 2014 Habiganj 64.7 80 84 from endline survey

Jhalokathi 57.5 55 70 TIS

TIS, only high intensity Pirojpur* 51.8 55 63 areas

Percent of newborns In 2014. 7.1% received chlorhexidine chlorhexidine is not application on their introduced in the country, umbilical cord immediately except in small scale following birth research settings. The baseline is assumed to be zero in all program areas

High intensity areas Yet to start

Lakhsmipur 0 25 38

Noakhali* 0 30 41

Habiganj 0 20 30

Jhalokathi 0 10 24

Pirojpur* 0 10 16

Percent of newborns receiving postnatal health check within two days of birth

High intensity areas

70 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Baseline End of Project Remarks Indicator Value Target Achievement Baseline from DHSS 2013 Lakhsmipur: 12.1 36 21 survey and Actual from TIS

Baseline from DHSS 2013 and Actual 2014 from TIS, only Noakhali:* 11.1 47 35 high intensity area

Baseline from MaMoni midline and Actual 2014 from MaMoni Habiganj: 26.8 32 29 Endline 2014

Jhalokathi: 26.6 48 40 TIS

Pirojpur:* 3.5 41 40 TIS, only high intensity area

Modern contraceptive method prevalence rate

High intensity areas

Lakhsmipur 48.2 55 50 Baseline from DHSS 2013

DHSS 2013 baseline and Actual 2014 from TIS, HI Noakhali* 47 53 58 areas only

Baseline from MaMoni Midline and Actual 2014 from MaMoni Endline Habiganj 40.6 48 46 2014

Jhalokathi 52.6 58 68 TIS

Pirojpur* 52.0 58 68 TIS, HI areas only

Couple years of protection (CYP) in USG-supported programs

Overall 966,143 901,298 853,018

Lakshmipur 158,305 138,942 112,096

Noakhali 214,571 217,475 193,279 From DGFP MIS

The 2014 achievement is Habiganj 166,771 149,475 205,621 for the whole district

Jhalokathi 73,814 51,762 46,084 From DGFP MIS

MaMoni Health System Strengthening Project Annual Report 2017-2018

Baseline End of Project Remarks Indicator Value Target Achievement Pirojpur 122,977 113,933 106,503 From DGFP MIS

The 2014 achievement is Bhola 229,705 229,711 189,434 for the whole district

Intermediate Result 1: Improve service readiness through critical gap management

Percent of targeted facilities that are ready to provide essential newborn care

High intensity areas

Lakhsmipur NA 90 81

Noakhali* NA 90 62

Habiganj NA 90 77

Jhalokathi NA 90 73

Percentage of public health facilities with functional bags and masks (two neonatal size mask) in the delivery room

High intensity areas

Lakhsmipur NA 70 81

Noakhali* NA 70 81

Habiganj NA 70 86

Jhalokathi NA 70 85

Percent of USG-assisted service delivery sites providing family planning (FP) counselling and/or services

High intensity areas

Lakhsmipur NA 95 78

72 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Baseline End of Project Remarks Indicator Value Target Achievement Noakhali* NA 95 88

Habiganj NA 99 90

Jhalokathi NA 95 76

Number of targeted Baseline and targets to be facilities ready to provide revised after first delivery services 24 hours a assessment day, seven days a week

High intensity areas

Lakhsmipur NA 32 33

Noakhali* NA 30 30

Habiganj NA 42 48

Jhalokathi NA 21 16

Sub-IR 1.1: Increase availability of health service providers

Number of vacant positions Only GOB service filled by temporary non- provider positions are GOB health workers included. As per the phase out plan, several temporary staff were phased out or handed over to GOB or local government in the final quarter.

High intensity areas

Lakhsmipur 10 2 FWV/Paramedics-2

FWV-10, Nurse-2, OBGYN Noakhali* 15 13 Consultant-1

Habiganj 10 9 FWV-9

Jhalokathi 10 0

Sub-IR 1.2: Strengthen All training targets will be capacity of service set during annual providers to provide workplans quality services

MaMoni Health System Strengthening Project Annual Report 2017-2018

Baseline End of Project Remarks Indicator Value Target Achievement Number of people trained in 16,519 maternal/newborn health (2604 for through USG-supported MaMoni 4 programs districts and 13,915 for national scale up initiatives) 16,287

Number of people trained in FP/RH with USG funds 70 44

Number of people trained in child health and nutrition through USG-supported programs 0 198

Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization

Number of union level public health facilities that are ready to provide normal delivery services 101 121

High intensity areas

Lakhsmipur 25 29

Noakhali* 23 34

Habiganj 35 57

Jhalokathi 15 15

Pirojpur* 3 NA

Intermediate Result 2: Strengthen health systems at district level and below

Number of district level quarterly performance review Nil 12 12 meeting held for data-driven

74 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Baseline End of Project Remarks Indicator Value Target Achievement performance review and planning

High intensity areas

Lakhsmipur 2 2

Noakhali* 2 2

Habiganj 2 2

Jhalokathi 2 2

Pirojpur* 1 NA

Bhola 1 NA

Intra partum still birth rate The indicator is dropped in project assisted facilities due to absence of reliable source

High intensity areas

Lakhsmipur NA NA

Noakhali* NA NA

Habiganj NA NA

Jhalokathi NA NA

Pirojpur* NA NA

Sub-IR 2.1: Improve leadership and management at district level and below

Number of GOB managers NA NA The indicator is dropped supported for leadership as the activity has been and management capacity completed by Year 4 development

Lakhsmipur NA NA

Noakhali NA NA

Habiganj NA NA

Jhalokathi NA NA

MaMoni Health System Strengthening Project Annual Report 2017-2018

Baseline End of Project Remarks Indicator Value Target Achievement Pirojpur NA NA

Bhola NA NA

Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs

Number of upazilas with This activity started in updated comprehensive 2015 annual MNCH/FP/N plan Nil 23 23

High intensity areas

Lakhsmipur 5 5

Noakhali* 9 9

Habiganj 8 8

Jhalokathi 4 4

Pirojpur* NA NA

Sub-IR 2.3: Strengthen local management information systems

Percentage of community micro planning units conducting monthly meeting

High intensity area

Lakhsmipur 90 99

Noakhali* 90 79

Habiganj 95 98

Jhalokathi 85 72

Pirojpur* NA NA

Sub-IR 2.4: Establish quality assurance system

76 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Baseline End of Project Remarks Indicator Value Target Achievement at district level and below

Percent of planned supervision visit conducted where a supervision tool was used and findings shared with providers

High intensity areas

Lakhsmipur 90 111

Noakhali* 90 22

Habiganj 90 100

Jhalokathi 90 172

Pirojpur* 90 NA

Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below

Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide

High intensity areas

Lakhsmipur <2 6

Noakhali* <2 3

Habiganj <2 3

Jhalokathi <2 0

Pirojpur* <2 0

Sub-IR 2.6: Strengthen local government planning and

MaMoni Health System Strengthening Project Annual Report 2017-2018

Baseline End of Project Remarks Indicator Value Target Achievement engagement in health service provision

Percentage of unions that The indicator is dropped had at least 50 percent of due to the unavailability the estimated births of data from LG sources registered within 45 days of birth

High intensity areas

Lakhsmipur NA NA

Noakhali* NA NA

Habiganj NA NA

Jhalokathi NA NA

Pirojpur* NA NA

Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N

Number of Union Parishads (UP) that spent funds to support MNCH/FP/N activities

High intensity areas

Lakhsmipur 58 29

Noakhali* 44 25

Habiganj 77 60

Jhalokathi 32 19

Pirojpur*

Intermediate Result 3: Promote enabling environment to strengthen district level health system

78 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Baseline End of Project Remarks Indicator Value Target Achievement Number of critical vacancies The targets will be revised filled by GoB recruitment or on annual basis, based on redeployment in project HR data areas

High intensity areas

Lakhsmipur 5 10 (FWV/Paramedics-10)

Noakhali* 5 31 (FWV-2, Nurses-29)

Habiganj 5 5 (FWV-5)

Jhalokathi 5 4 (FWV-4)

Pirojpur* 5 NA

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 MNH developed/revised with MaMoni HSS support 4 8

Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced- based learning in national policy and program

Number of program learning initiatives completed and disseminated 15 17

Intermediate Result 4: Identify and reduce barriers to accessing health services

Number of deliveries with a SBA in USG-assisted programs

MaMoni Health System Strengthening Project Annual Report 2017-2018

Baseline End of Project Remarks Indicator Value Target Achievement High intensity areas

Lakhsmipur 12,812 19,687 16,494

Noakhali* 23,204 12,288 12,511

Habiganj 18,428 25,896 19,405

Jhalokathi 7,054 6,374

Pirojpur* 2,658 1,743

HSCS areas

Pirojpur 12,148 8,355

Bhola 1,982 13,007

Noakhali 23,204 37,848 7,725

Number of antenatal care (ANC) visits by skilled providers from USG- assisted facilities

High intensity areas

Lakhsmipur 38,446 53,730 106,746

Noakhali* 69,895 43,414 82,015

Habiganj 150,700 210,611 138,621

Jhalokathi 16,553 32,114

Pirojpur* 9,914 11,783

HSCS areas

Pirojpur 34,698 15,860

Bhola 68,546 69,511

Noakhali 69,895 97,682 64,145

Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches

80 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Baseline End of Project Remarks Indicator Value Target Achievement Number of people reached through project supported BCC activities 999,215 1,396,477

High intensity areas

Lakhsmipur 300000 28,238

Women i16,035

Men 12,203

Noakhali* 218334 1,328,699

Women 626,290

Men 692,409

Habiganj 307500 32,925

Women 27,689

Men 5,236

Jhalokathi 173381 6,615

Women 4,680

Men 1,935

Sub-IR 4.2: Enhance community engagement in addressing health needs

Number of trained community volunteers promoting MNCHFPN through project support 28,371 22,304

High intensity areas

Lakhsmipur 6,710 6385

Noakhali* 5,900 5281

Habiganj 14,000 8,379 8333

Jhalokathi 2,731 2305

Pirojpur* 1,205 NA

MaMoni Health System Strengthening Project Annual Report 2017-2018

Baseline End of Project Remarks Indicator Value Target Achievement Number of Community Action Groups with an emergency transport system for maternal and newborn health care through USG- supported programs 2,126 24,355 20,299

High intensity areas

Lakhsmipur: 6,461 6,302

Noakhali: 3,876 4,331

Habiganj: 2,126 4,369 8,071

Jhalokathi: 3,746 1,595

Pirojpur* 1,549 NA

82 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 APPENDIX 4: ADDITIONAL NATIONAL LEVEL INDICATORS

End of Project Indicator Baseline Remarks Target Achievement Percentage of newborns Source: DGFP MIS-3 receiving CHX application at and EmONC report birth in MOHFW facilities of DHIS-2 National 39 60 90

Barisal 47.5 60 94

Chattogram 50 60 90

Dhaka 37 60 92

Khulna 38 60 93

Rajshahi 33 60 84

Rangpur 25.5 60 81

Sylhet 52 60 98 Number of upazilas where a Completed last review of Newborn interventions quarter held Total NA 165 165 Barisal NA 0 Chattogram NA 100 100 Dhaka NA 16 Khulna NA 7 7 Rajshahi NA 0 Rangpur NA 58 58 Sylhet NA Number of Newborn for whom Source: DGFP MIS-3, resuscitation actions using bag EmNOC and mask were initiated Total NA 16272 21,304 Barisal NA 7,03 1,508 Chattogram NA 3,445 4,617 Dhaka NA 4,890 5,013 Khulna NA 2,144 3,016 Rajshahi NA 2,191 2,946 Rangpur NA 1,885 2,478 Sylhet NA 1,015 1,726 Number of Union Health and Source: Project report Family Welfare Centers

MaMoni Health System Strengthening Project Annual Report 2017-2018

End of Project Indicator Baseline Remarks Target Achievement (UH&FWCs) in the project area using electronic MIS tools Total NA 237 237 NA 55 Lakshmipur 55 NA 83 Noakhali 83 NA 69 Habiganj 69 NA 30 Jhalokati 30 NA Pirojpur NA NA NA Bhola NA NA Number of districts having an active Quality Improvement (QI) committee 63 Total NA 64 6 Barisal NA 6 11 Chattogram NA 11 16 Dhaka NA 17 10 Khulna NA 10 8 Rajshahi NA 8 8 Rangpur NA 8 4 Sylhet NA 4

84 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 APPENDIX 5: LIST OF UNION FACILITIES UPGRADED TO PROVIDE 24/7 NORMAL DELIVERY SERVICES Sl No. District Name Upazila Name Union Name

1 Habiganj Ajmiriganj Badalpur

2 Habiganj Ajmiriganj Jalsuka

3 Habiganj Ajmiriganj Kakailseo

4 Habiganj Ajmiriganj Shibpasha

5 Habiganj Bahubal Mirpur

6 Habiganj Bahubal Putijuri

7 Habiganj Bahubal Snanghat

8 Habiganj Baniachong Daulatpur

9 Habiganj Baniachong Khagaura

10 Habiganj Baniachong Pukhra

11 Habiganj Baniachong Subidpur

12 Habiganj Baniachong Sujatpur

13 Habiganj Baniachong Uttar Purba Baniachang

14 Habiganj Chunarughat Ahmedabad

15 Habiganj Chunarughat Deorgachh

16 Habiganj Chunarughat Shatiajuri

17 Habiganj Habiganj Sadar Lukhra

18 Habiganj Habiganj Sadar Nizampur

19 Habiganj Habiganj Sadar Poil

20 Habiganj Habiganj Sadar Raziura

21 Habiganj Habiganj Sadar Richi

22 Habiganj Habiganj Sadar Saistaganj

23 Habiganj Habiganj Sadar Tegharia

24 Habiganj Lakhai Karab

25 Habiganj Lakhai Murakari

MaMoni Health System Strengthening Project Annual Report 2017-2018

Sl No. District Name Upazila Name Union Name

26 Habiganj Lakhai Muriauk

27 Habiganj Madhabpur Baghasura

28 Habiganj Madhabpur Bahara

29 Habiganj Madhabpur Chhatiain

30 Habiganj Madhabpur Dharmaghar

31 Habiganj Madhabpur Jagadishpur

32 Habiganj Madhabpur Noapara

33 Habiganj Nabiganj Bausha

34 Habiganj Nabiganj Debpara

35 Habiganj Nabiganj Dighalbak

36 Habiganj Nabiganj Paniunda

37 Habiganj Nabiganj Paschim Bara Bhakhair

38 Habiganj Nabiganj Purba Bara Bakhair

39 Jhalokati Jhalokati Sadar Basanda

40 Jhalokati Jhalokati Sadar Binoykati

41 Jhalokati Jhalokati Sadar Gabkhandhansiri

42 Jhalokati Jhalokati Sadar Kirtipasha

43 Jhalokati Jhalokati Sadar Ponabalia

44 Jhalokati Kanthalia Awrabunia

45 Jhalokati Kanthalia Chenchri Rampur

46 Jhalokati Kanthalia Kanthalia

47 Jhalokati Kanthalia Patikhalghata

48 Jhalokati Kanthalia Saulajalia

49 Jhalokati Nalchity Bhairabpasha

50 Jhalokati Nalchity Kulkati

51 Jhalokati Nalchity Kusanghal

86 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Sl No. District Name Upazila Name Union Name

52 Jhalokati Nalchity Magar

53 Jhalokati Nalchity Siddhakati

54 Jhalokati Rajapur Baramia

55 Jhalokati Rajapur Galua

56 Jhalokati Rajapur Mathbari

57 Jhalokati Rajapur Saturia

58 Lakshmipur Kamalnagar Char Falcon

59 Lakshmipur Kamalnagar Char Kadira

60 Lakshmipur Kamalnagar Hajirhat

61 Lakshmipur Lakshmipur Sadar Chandraganj

62 Lakshmipur Lakshmipur Sadar Dalal Bazar

63 Lakshmipur Lakshmipur Sadar Dakshin Hamchadi

64 Lakshmipur Lakshmipur Sadar Datta Para

65 Lakshmipur Lakshmipur Sadar Dighali

66 Lakshmipur Lakshmipur Sadar Hajir Para

67 Lakshmipur Lakshmipur Sadar Kushakhali

68 Lakshmipur Lakshmipur Sadar Mandari

69 Lakshmipur Lakshmipur Sadar Uttar Joypur

70 Lakshmipur Ramganj Bhadur

71 Lakshmipur Ramganj Darbeshpur

72 Lakshmipur Ramganj Bhatra

73 Lakshmipur Ramgati Bara Kheri

74 Lakshmipur Ramgati Char Algi

75 Lakshmipur Ramgati Char Alexandar

76 Lakshmipur Ramgati Char Gazi

77 Lakshmipur Ramgati Char Ramiz

MaMoni Health System Strengthening Project Annual Report 2017-2018

Sl No. District Name Upazila Name Union Name

78 Lakshmipur Roypur Bamni

79 Lakshmipur Roypur Char Mohana

80 Lakshmipur Roypur Char Pata

81 Lakshmipur Roypur Keroa

82 Lakshmipur Roypur Sonapur

83 Noakhali Begumganj Alyerapur

84 Noakhali Begumganj Durgapur

85 Noakhali Begumganj Gopalpur

86 Noakhali Begumganj Narottampur

87 Noakhali Begumganj Rajganj

88 Noakhali Companiganj Char Kakra

89 Noakhali Companiganj Char Parbti

90 Noakhali Companiganj Rampur

91 Noakhali Companiganj Sirajpur

92 Noakhali Hatiya Chandnandi

93 Noakhali Hatiya Char King

94 Noakhali Hatiya Harni

95 Noakhali Hatiya Jahajmara

96 Noakhali Hatiya Nijum Dip

97 Noakhali Hatiya Sonadia

98 Noakhali Senbagh Kabilpur

99 Noakhali Senbagh Mohamadpur

100 Noakhali Sonaimuri Sonapur

101 Noakhali Sonaimuri Jayag

102 Noakhali Subarnachar Char Bata

103 Noakhali Subarnachar Mohamadpur

88 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 Sl No. District Name Upazila Name Union Name

104 Noakhali Kabirhat Sundalpur

105 Noakhali Noakhali Sadar Dadpur

106 Noakhali Chatkhil Mohammadpur

MaMoni Health System Strengthening Project Annual Report 2017-2018

APPENDIX 6: eLMIS COLOR CODED DASHBOARD FOR LOCAL DECISION MAKING Examples of using of color coded reports for prevention of stock out:

Habiganj district: • It was identified that Ajmeriganj & were having a stock out of tab. Misoprostol from 3rd week of November. Regional Ware House, Sylhet was also having a stock out. So MaMoni HSS facilitated the process of distribution of 200 pcs of tab. Misoprostol to Ajmeriganj from Nabiganj. In Chunarughat upazila redistribution between unions were facilitated for smooth service delivery. • There was a stock of 840pcs of 7.1% Chlorhexidine at Habiganj sadar upazila store with expiry date on Feb, 2018 which sadar upazila would not be able to consume. Project facilitated the process of redistribution of 840 pcs from sadar to district hospital, Habiganj in November 2017. • DRS, Habiganj procured 140,000 pcs of tab Misoprostol in this financial year • parishad allocated budget for Tab. misoprostol (taka 126,000). • Due to fire accident in April 2017, there was less amount of tab. misoprostol available at all upazila stores as well as in Sylhet Regional Warehouse. Through project facilitation, tab Misoprostol was distributed from Central Warehouse, DGFP Dhaka to Sylhet Regional Ware houses and then ultimately to upazila stores of Ajmeriganj (1600 Pcs), Baniachang (1600), Chunarughat(1200), Nabiganj(1600 Pcs), Habiganj Sadar (800 pcs), Bahubal (800),Lakhai (800) and Madhabpur (1200) upazila stores, DGFP.

Jhalokati district : • District Reserve store (DGHS)-Jhalokati initiated the process of procurement of 7.1% Chx-1000 bottle from local market through tender. • 2000 pcs of Tab. Misoprostol were collected by Patuakhali RWH for Nalchity upazila. • Collected SAM food (F-100) 30 sachet from Kawkhali UHC for Rajapur SAM unit in Oct 2017. • Facilitated local redistribution of Chx-7.1% - 40 bottle from Shekherhat and Nobogram union to Kirtipasa union FWC in Oct 2017. • Civil Surgeon office, Jhalokati and Pirojpur districts procured 500 and 700 bottles of 7.1% Chlorhexidine through government MSR in 2018. This procurement was facilitated by MaMoni- HSS project following GOB circular from IMCI unit, DGHS. • As there was shortage of supply of 7.1% Chlorhexidine from DGFP ware-house, Chachirampur UH&FWC management Committee, Kathalia decided to procure 7.1% Chlorhexidine from Local Government budget and 60 bottles of 7.1% chlorhexidine were procured. • With the facilitation of MaMoni HSS, Jhalakathi Sadar Upazila store received 800 pcs of tab. Misoprostol from Faridpur Regional Ware House. • In April 2018, Chachirampur Union Parishad, Kanthalia upazila procured and supplied 50 bottles of 7.1% Chlorhexidine to Chachirampur UH&FWC from Local Government budget. • In April 2018, Jhalakati Sadar Upazila store received 800pcs tab. Misoprostol from Faridpur Regional Ware House. • 300 bottles of 7.1%Chlorhexidine were redistributed from Jhalokati MCWC to other SDP level for reduction of stock out and prevention of wastage. • In May 2018, Kulkathi UH&FWC management Committee, Nalcity upazila procured 30 bottles of 7.1% Chlorhexidine from Local Government budget in absence of GOB source.

90 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 • With the facilitation of MaMoni HSS, Civil Surgeon office, Jhalokati already procured 500pc Chx- 7.1% in June 2018.

Lakshmipur district: • Civil Surgeon, Lakshmipur district initiated local level procurement of 7.1% Chx in July 2017, and procurement of 6,000 bottles were completed in January 2018. 3000 pieces were distributed to district hospital, Raipur UHC, Ramganj UHC, Kamalnagar UHC, and Ramgati UHC. • 50 bottles of 7.1% Chlorhexidine were distributed from Char Mohana UH&FWC to Sonapur UH&FWC at in May, 2018 • 50 bottles of 7.1% Chlorhexidine was supplied from Health Complex to Char Falcon UH&FWC and 50 bottles from the same UHC to Hazirhat UH&FWC at Kamalnagar Upazila in May 2018.

Noakhali district: • Upazila Health Complex (UHC), Begumgonj, Noakhali supplied 100 units of 7.1% Chlorhexidin to Durgapur UH&FWC, Begumgonj, Noakhali district. • Senbag Family Planning (FP) store redistributed 100 units of 7.1% Chlorhexidin to Senbag Upazila Health Complex, Noakhali district. • Supply of 1000 Iron Folate tabled from Hatiya Family Planning Store to Hatiya Upazila Health Complex, Noakhali district. • 200 pcs Inj Gentamycin from Begumgonj UHC to Durgapur UH&FWC (100), to Kutubpur UH&FWC (50) and to Rajgonj UH&FWC (50), at Begumgonj upazila Noakhali district. • Four HBB kits were supplied from Civil Surgeon Store, 2 to District Hospital, one in Hatiya UHC and the last in Chatkhil UHC at Noakhali district. • Redistribution of 100 pcs tab. Misoprostol from Companigong FP store to Senbagh FP Store, Noakhali district. • Redistribution of 250 pcs Tab. Misoprostol from Senbag FP Store to Senbag UHC, Noakhali district • Supply of total 308 vial of 7.1% Chlorhexidin from Ramgonj UHC to Keroa UH&FWC (208) and Bamni UH&FWC (100) Under Raipur Upazila, Lakshmipur district. • Redistribution of 100 Pcs of 7.1% Chlorhexidin to Sonapur UH&FWC from Char Mohana UH&FWC Under Raipur Upazila, Lakshmipur district. • Redistribution of 200 vials of 7.1% Chlorhexidin from Kamalnagar UHC to Char Falcon UH&FWC (100) and Hazirhat UH&FWC (100) Under Kamalnagar Upazila, Lakshmipur district. • Redistribution of 300 vials of 7.1% Chlorhexidine from MCWC, Lakshmipur to Upazila and SDP level for reducing stock out and preventing wastage.

MaMoni Health System Strengthening Project Annual Report 2017-2018

APPENDIX 7: FORUMS WHERE MAMONI HSS LESSONS WERE DISSEMINATED

Title Forum Venue Month Type of Dissemination

Launch organized Pan Pacific National launch of Electronic by icddrb, Sonargaon Presentation, Oct 2017 Management Information System Measure and Hotel video, booth MaMoni HSS

Electronic Health Record of e-MIS , Links Routine Service Data to ISQUA United Oral Nov 2017 Decision Making for Improved Quality Conference Kingdom Presentation of Care in Bangladesh

Implementation Experience of London, MaMoni HSS Project to Improve ISQUA Poster United Nov 2017 Quality of Care (QoC) in Public Sector Conference Presentation Kingdom Facilities in Bangladesh

Service Readiness and Provision of London, Quality Antenatal Care in Satellite ISQUA Poster United Nov 2017 Clinics: Findings from Remote Areas Conference Presentation Kingdom of Bangladesh

Asia Pacific Regional Development of community skilled Conference on Ha Long Bay, Poster birth attendants in hard-to-reach Nov 2017 Reproductive & Viet Nam Presentation areas of Bangladesh Sexual Health and Rights

Ensuring Quality of Maternal Health Sylhet, Oral Care in three districts: Lessons from OGSB conference Dec 2017 Bangladesh Presentation MaMoni HSS Project

5th International Conference 2018 of Bangladesh Oral Bangladesh Neonatal Forum held on BICC, Dhaka Mar 2018 Neonatal Forum Presentation 3-4 March

Dissemination of progress in Hotel improving institutional deliveries by MaMoni June Presentations, Sonargaon, strengthening public health facilities dissemination 2018 Video Dhaka for 24/7 services

Presentations, MaMoni HSS MaMoni learning sharing event BICC, Dhaka Sep 2018 Video, Panel close-out event discussion

92 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 APPENDIX 8: LIST OF MAMONI HSS PUBLICATIONS 8.1 Project/Research Brief: i. Implementing National Guidelines on Use of Antenatal Corticosteroids to Prevent Complications of Prematurity ii. Supporting the scale-up of universal cord stump cleansing in Bangladesh: Successes and challenges iii. Community Mobilization and Local Government Engagement for improving health outcomes iv. Income viability of Private Community Skilled Birth Attendants in Habiganj v. Introducing Kangaroo Mother Care in Public Sector Health Facilities in Bangladesh vi. Evidence Based Human Resource for Health (HRH) Planning: Workload Indicators of Staffing Need (WISN) application at Public Sector Health Facilities vii. Implementing National Guidelines for Management of Young Infants (0-59 day) with Possible Serious Bacterial Infection (PSBI) at Primary Care Level Facilities in Select Districts of Bangladesh viii. Service Readiness and Provision of Quality Antenatal Care in Satellite Clinics: Findings from Operational Research in MaMoni HSS Intervention Areas ix. Quality of permanent methods of family planning services in three districts of Bangladesh x. Utilization of Partographs as a Referral Decision-Making Tool and Associated Factors in Union Level Health Facilities: Findings from Operational Research by MaMoni HSS xi. Improving community-based coverage of use misoprostol during home births to prevent PPH and 7.1% chlorhexidine for newborn cord care in Bangladesh xii. How Strategic Support to Union Health and Family Welfare Centers in Underserved Communities Has Improved Service Quality and Increased Facility Deliveries xiii. Addressing Eclampsia at the Primary Care Level in Bangladesh xiv. Managing Sick Newborns at Special Care Newborn Units in District Hospitals in Bangladesh xv. Integrating Management of Severe Acute Malnutrition (SAM) into the Bangladesh Public Health System xvi. Strengthening Newborn Health Interventions: An Overview xvii. Establishing an Electronic Health Management Information System (eMIS) to Improve Tracking of Clients Along the Continuum of Care

8.2 Manual/guideline/SOP: i. Management and Leadership Training, Facilitators and Participant’s Manual ii. Team Training, Facilitators and Participant’s Manual iii. First line supervisors Training, Facilitators and Participant’s Manual iv. Assets Management Systems manual for NIPORT v. Training Management Systems manual for NIPORT vi. Maternal Newborn Child Health Electronic Logistics Management Information System (eLMIS), User Manual vii. A booklet on Local Government's involvement in improving local level health facility viii. Maternal Health Standard Operating Procedures (Volume 1 & 2) ix. ANC and PNC training: Facilitator’s and Participant’s manual

MaMoni Health System Strengthening Project Annual Report 2017-2018

x. Labor Room Service Training Module for Facilitator’s and Participants xi. Eclampsia Prevention and Management in the community (Training Module) xii. PDCA Manual for Quality Improvement xiii. Infection Prevention Training Manual xiv. National Strategic Guideline on Patient Safety

8.3 Newsletter: i. MaMoni HSS quarterly newsletter, issue no 10 ii. MaMoni HSS quarterly newsletter, issue no 11 iii. MaMoni HSS quarterly newsletter, issue no 12 iv. National Newborn Health Bulletin, Volume 3, issue no 2 v. National Newborn Health Bulletin issue no 4 vi. National Newborn Health Bulletin issue no 5

8.4 Others: i. Myths on family planning- Factsheet ii. eMIS flyers iii. Report-Rapid Assessment of Regional Training Centers of NIPORT iv. Advocacy Booklet -- Local Government's involvement in improving local level health facility v. Report- Workload and Staffing Needs Assessment at Public Sector Health Care Facilities in Bangladesh

94 MaMoni Health Systems Strengthening Project: Annual Report 2017-2018 APPENDIX 9: LIST OF VIDEO DOCUMENTARIES DEVELOPED BY MAMONI HSS PROJECT i Video documentary on SCANU ii. Video documentary on Electronic Management Information Systems iii. Video on HBB intervention with Laerdal Global Health iv. Video documentary "Tale of Tayeeba" v. Video documentary titled "The Road to Change" vi. Video documentary titled "Protecting newborns from infection" vii. Video documentary titled "Strengthening Union Health Facilities to improve health outcome" viii. Video documentary titled "Engaging the community to increase use of health services"

MaMoni Health System Strengthening Project Annual Report 2017-2018