MaMoni Health Systems Strengthening Activity

Quarterly Report FY14 Q2: January 1-March 31, 2014

Submitted April 30, 2014 TABLE OF CONTENTS Acronyms and Abbreviations ...... 3 Project Summary ...... 5 1. Introduction ...... 6 2. Program Objectives and Key Activities ...... 7 3. Results for the Quarter ...... 10 3.1 Summary of Major Accomplishments ...... 10 3.2 Narrative Report of Major Accomplishments ...... 12 3.2.1 Project Start-up...... 12 3.2.2 Improve service readiness through critical gap management ...... 14 3.2.3 Strengthen health systems at district level and below ...... 19 3.2.4 Promote an enabling environment to strengthen district-level health systems ...... 25 3.2.5 Identify and reduce barriers to accessing health services ...... 27 3.2.6 Challenges, Solutions and Action Taken ...... 28 4. The Way Forward ...... 29 Annex 1. Materials Developed with MaMoni HSS Support ...... 31 Annex 2. Report of the Launch of Chlorhexidine in ...... 32 Annex 3. Report of Newborn Targeted Interventions in ...... 35 Annex 4. List of Government Orders and Circulars in Support of MaMoni HSS Activities ...... 37 Annex 5. Geographic Allocation of Implementing Partner NGOs ...... 38 Annex 6. MaMoni HSS Quality Assurance Framework ...... 39 Annex 7: Case Studies ...... 46 Annex 8: Performance Indicators (October 2013-March 2014) ...... 49

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/Bangladesh) under terms of Associate Cooperative Agreement No. 388-A-00-09-0104-00, through MCHIP, managed by Jhpiego Corporation. The contents are the responsibility of Jhpiego Corporation and do not necessarily reflect the views of USAID or the United States Government.

Cover Photo Credit: Sayed Salik Ahmed, Monitoring and Documentation Officer / Shimatik Dr. Mohammed Nasiruddin Bhuiyan, Civil Surgeon, applying 7.1% Chlorhexidine on the umbilical cord stump of a Newborn (name of newborn baby, if available) newborn baby born to Halima Begum (name of mother) from Ragupasha village, Lamatashi Union, of Bahubal Upazilla of Habiganj district. This was the first time that the Ministry of Health and Family Welfare in Bangladesh used7.1% Chlorhexidine for umbilical cord care in a program setting. The MOH&FW has included this intervention in its operational plans for national scale up.

MaMoni HSS Project – Quarterly Report FY14 Q2 2 Acronyms and Abbreviations

BCC Behavior Change Communication BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CSBA Community Skilled Birth Attendants CV Community Volunteer DCOP Deputy Chief of Party DGFP Directorate General Family Planning DGHS Directorate General Health Services DHSS District Health Systems Strengthening GOB Government of Bangladesh HBB Helping Babies Breathe HMIS Health Management Information System HPNSDP Health, Population and Nutrition Sector Development Program HRCI Health Research Challenge for Impact HSS Health System Strengthening IEE Initial Environment Examination IR Intermediate Result JHU/IIP Johns Hopkins University, Institute for International Programs JSI John Snow, Inc. JSV Joint Supervision Visit LAPM Long Acting and Permanent Method LLP Local Level Planning LMIS Logistics Management Information System MPDA Maternal and perinatal death audit MCHIP Maternal and Child Health Integrated Program M&E Monitoring and Evaluation MNCH/FP/N Maternal, Newborn and Child health, Family Planning and Nutrition MOH&FW Ministry of Health and Family Welfare MOU Memorandum of Understanding OR Operations Research PNGO Partner nongovernmental organization PPH Postpartum Hemorrhage PPIUCD Postpartum Intra-uterine Contraceptive Device QA Quality Assurance QPRM Quarterly Performance Review Meeting RRQAT Regional Roaming Quality Assurance Team SBM-R Standard-based Management and Recognition SC Save the Children SIAPS Systems for Improved Access to Pharmaceuticals and Services SOW Scope of Work

MaMoni HSS Project – Quarterly Report FY14 Q2 3 UH&FWC Union health and family welfare centers USAID U.S Agency for International Development

MaMoni HSS Project – Quarterly Report FY14 Q2 4 Project Summary Project Name: MaMoni Health Systems Strengthening (MaMoni HSS) Project Reporting Period: FY 2014- Quarter 2: January 1, 2014 – March 31, 2014 Obligated Funding Amount: $5,236,291USD Period of Performance: September 24, 2013 – September 23, 2017 Project Goal: Improved utilization of integrated maternal, newborn, child health, family planning and nutrition services Project Objective: Increased availability and quality of high impact interventions through strengthening district level local management and health systems Intermediate Results:  Improved service readiness through critical gap management  Strengthened health systems at district level and below  Enabling environment promoted to strengthen district-level health systems  Barriers to health service accessibility identified and reduced Geographic Focus: Sylhet, Habiganj, Noakhali, Lakhsmipur, , Jhalokathi, Pirozepur and districts

MaMoni HSS Project – Quarterly Report FY14 Q2 5 1. Introduction

MaMoni Health Systems Strengthening (MaMoni HSS) is a four-year Associate Award under the Maternal and Child Health Integrated Program (MCHIP), with a period of performance from September 24, 2013 to September 23, 2017. MaMoni HSS builds on MaMoni’s previous work and focus on strengthening the systems and standards for MNCH/FP/N that will result in declines in maternal, newborn and child mortality within seven districts in Bangladesh. The project supports the Ministry of Health and Family Welfare (MOH&FW) to introduce and leverage support for scale-up of evidence-based practices already acknowledged in Bangladesh. The project focuses on strengthening the systems and standards for maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) that will result in further declines in maternal, newborn and child mortality.

Jhpiego is the leader of the MaMoni HSS associate award and in Bangladesh it is implemented by Save the Children (SC) in partnership with John Snow, Inc. (JSI), and Johns Hopkins University (JHU)/Institute of International Programs (IIP), with national partners, icddr,b, Dnet, and Bangabandhu Sheikh Mujib Medical University (BSMMU). MaMoni HSS engages with local government structures and local NGOs to improve delivery of health services and strategically partner at the national level to build consensus around policies and standards that positively drive evidence-based interventions at all levels. MaMoni HSS implementation is supported by a group of local nongovernmental organizations (NGOs) that are strategically placed in local communities, and are channels for scale-up and sustainability.

MaMoni HSS supports the MOH&FW to strengthen the health systems in seven districts – Habiganj, Noakhali, Lakhsmipur, Bhola, Pirozepur, Jhalokathi and Brahmanbaria. In addition, receives support during the first year of implementation for targeted newborn care interventions. Implementation in

MaMoni HSS Project – Quarterly Report FY14 Q2 6 is planned to start in the second year. Habiganj, Noakhali and Lakhsmipur districts received substantial support under the previous MCHIP District Health System Strengthening (DHSS) program, and implementation will continue under MaMoni HSS.

2. Program Objectives and Key Activities The goal of MaMoni HSS is to improve utilization of integrated MNCH/FP/N services and will be achieved through the project objective to increase availability and quality of high-impact interventions through strengthening district-level local management and health systems. This objective is well aligned with the GOB’s Health, Population and Nutrition Sector Development Program (HPNSDP) 2011– 2016. MaMoni HSS will also directly support the “USAID/Bangladesh Development Objective 3 (DO 3) “Health Status Improved” under the Investing in People Objective, of the Country Development Cooperation Strategy (CDCS) Framework of USAID in Bangladesh.

MaMoni HSS has four intermediate results (IRs). Shown below is a summary of the project’s IRs, sub-intermediate results and the major activities included in the first year workplan.

IR1: Improve service readiness through critical gap management Sub-IR1.1 Increase availability of health service providers  Conduct an in depth assessment of service readiness to identify individual facility and community needs vis-à-vis human resources.  Develop human resource (HR) plan based on local needs and support institutional arrangement for HR development.  Hire and place project staff in facilities to meet service delivery gaps as a stop gap measure. Sub-IR1.2 Strengthen capacity of service providers to provide quality services  Train service providers on evidence-based interventions, including Helping Babies Breathe (HBB) guidelines.  Develop guidelines and train service providers on essential interventions for pre-term babies. Sub-IR1.3 Strengthen infrastructure preparedness to improve MNCH service utilization  Conduct facility assessment to identify strategically located facilities for providing essential maternal, child and neonatal services, especially at the Union level.  Upgrade facilities to be prepared for delivering the minimum essential package of MNCH/FP/N services.

IR2: Strengthen health systems at district level and below

MaMoni HSS Project – Quarterly Report FY14 Q2 7 Sub-IR 2.1 Improve leadership and management at district level and below  Provide in-service capacity development to district managers and subordinate supervisors through team training.  Establish a core of trainers with capacity to provide leadership and management training  Assist the GOB to develop district-wide plans to regularly monitor and review the performance of MNCH/FP/N indicators and services. Sub-IR 2 .2 Improve district-level comprehensive planning (including human resources) to meet local needs  Facilitate district level decentralized planning using locally generated data  Develop special strategies and service delivery approaches for hard-to-reach and under-served areas, including urban areas, choar areas and tea estates.

Sub-IR 2.3 Strengthen local management information systems  Identify and facilitate necessary changes in the field level data collection form to make data comparable between Director General of Family Planning (DGFP) and Director General of Health Services (DGHS) systems.  Train managers and other key personnel on utilizing data for decision- making and for facilitative supervision. Sub-IR 2.4 Establish quality assurance (QA) system at district level and below  Develop and implement QA models at each level of SDP to determine a model that yields the best results in the Bangladeshi context. Implement quality improvement models to build capacity and increase adherence to guidelines.  Scale up the standard-based management and recognition (SBM-R) approach in Habiganj, Noakhali and Lakhsmipur districts  Establish Regional Roaming Quality Assurance Teams (RRQAT) to support QAinitiatives in district and level facilities  Train personnel and support supervisors to undertake supportive supervision.  Through technical assistance, develop and/or strengthen the supervision system.

Sub-IR 2.5 Develop comprehensive logistic management systems at district level and below  Assess logistics management protocols in at various levels of supply chain management to identify barriers to ensuing uninterrupted availability of essential medicines and supplies at the facility and service delivery points  Develop practical guidelines for each element of the supply chain at the local level in concert with SIAPS  Integrate commodity security into the QA system.  Coordinate with SIAPS to ensure information flow from the local to national level and to inform national level procurement decisions according to need.

IR3: Promote enabling environment to strengthen district-level health systems

MaMoni HSS Project – Quarterly Report FY14 Q2 8 Sub-IR 3.1 Policy reforms in place to promote local planning and need-based human resource deployment in the public sector  Advocate to the ministry to generate a government order for local level planning and budgeting  Advocate for national level support for MIS improvements.  Support districts in the development of high quality operational plans and budgets related to health service delivery.  Develop a mechanism for districts to share the local level experience with MOH&FW Sub-IR 3.2 Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program  Identify learning opportunities and conduct operational research to support and advocate for successful planning models  Advocate for the scale-up of evidence-based maternal and newborn interventions, including the four new newborn interventions identified in the Promise Renewed Plan of Action for Bangladesh.  Engage Ambassadors and champions as important catalysts for change to stimulate policy-making and mobilize advocates.

IR4: Identify and reduce barriers to accessing health services Sub-IR 4.1 Promote awareness of MNCH through innovative BCC approaches  Conduct formative research to understand the unique characteristics driving decision-making in key populations  Develop and implement a mixed-method communication campaign designed to catalyze behavior change in target groups  Use Aponjon technology to disseminate health messages to target populations  Utilize mass media and traditional media innovatively to raise health awareness  Establish BCC units with implementing PNGOs and at the district level Sub-IR 4.2 Strengthen local government planning and engagement in health service provision  Orient Union Education Health and Family MNCH/FP/N and their roles  Facilitate the development and performance monitoring of plans by collecting and reviewing performance data alongside local government structures Sub-IR 4.3 Improve local governance and oversight for MNCH/FP/N  Facilitate activation of Union Parishad (UP) Education, Health and Family Planning Standing committees (UEHFPSCs) in areas where they are not functional.  Train UP members on their roles and responsibilities to address local level MNCH/FP/N issues.  Engage committee members in community microplanning meetings, CAG meetings and Community Groups of community clinics, and to visit service delivery points such as satellite clinics, EPI sessions, LAPM camps and union health and family welfare centers (UH&FWCs).

MaMoni HSS Project – Quarterly Report FY14 Q2 9  Collaborate with the USAID-funded Strengthening Democratic Local Governance (SDLG) project in the two districts where they overlap, Bhola and Lakhsmipur. Sub-IR 4.4 Enhance community engagement in addressing health needs  Form and support community action groups  Recruit, train and support community volunteers

3. Results for the Quarter

3.1 Summary of Major Accomplishments

Project Start-up

 Project operational guidelines developed to standardize the implementation processes and to build capacity of staff and partners who facilitate implementation. The operational guidelines will facilitate standardization of implementation processes across the seven districts and ensure a common understanding among staff and partners.  Completed the implementation of all previous MCHIP funded projects and transitioned those components into MaMoni HSS  Additional district-level implementing partners identified and their detailed scope of work and budget developed, setting the stage for starting implementation in the new districts from the third quarter.

IR1. Improve service readiness through critical gap management  District-level situational analysis completed to identify critical gaps in health workforce and physical infrastructure to provide integrated MNCH/FP/N services at all levels. This analysis has helped the MOH&FW and project staff to prioritize project inputs in the most strategic locations. In the three districts where implementation is in progress (Habiganj, Noakhali, and Lakhsmipur), the project is currently supporting 69 paramedics, 41 community health workers and 15 nurses to fill critical human resource gaps. The data available from the initial period shows consistently high levels of utilization of services in the areas where the project is supporting critical gap management.

 Capacity-building support provided for the MOH&FW to scale up evidence- based maternal and newborn care interventions at national scale. MaMoni

MaMoni HSS Project – Quarterly Report FY14 Q2 10 HSS supported the introduction of 7.1% Chlorhexidine application to reduce umbilical cord care in Bahubal upazila of Habiganj in March 2014. The project has also been supporting the national scale up of the provision of misoprostol to prevent post-partum hemorrhage for women delivering at home. Having completed the roll-out of HBB in all 64 districts under the MCHIP project, reaching a total of 23,579 skilled birth attendants (SBAs), MaMoni HSS is now focusing on provision of refresher training and the and the expansion of the package to include Essential Care for Every Baby (ECEB). These activities will ensure that these life-saving interventions are available to mothers and newborns beyond the MaMoni HSS direct support districts.

IR2. Strengthen health systems at district level and below

 QA framework developed and implementation started in Habiganj, Noakhali and Lakhsmipur districts. The initial analysis of data done this quarter from facilities implementing the SBM-R approach shows encouraging improvements in service quality standards. This will ensure pregnant women, mothers and their newborn infants utilizing the facilities receive appropriate preventive and curative interventions they need in a timely manner.  Draft tools and guidelines developed for district-level decentralized, data- driven planning for improved MNCH/FP/N. MaMoni HSS conducted population-based surveys on six tracer indicators1 in three districts, to generate union level estimates of current coverage. The preliminary data identifies critical unions where additional investments are needed to reach mothers and families and to set annual performance targets at union, upazila and district levels.

IR3. Promote an enabling environment to strengthen district-level health systems

 MaMoni HSS ensured procurement of calcium supplementation through routine DGHS MNCAH Annual Operational Plan for the 2014-15 fiscal year.  Priority areas for operations research identified (see additional information in section 1.2.4 below)  Carried out national-level advocacy and dissemination of new high-impact newborn interventions

1 the six tracer indicators were selected from the project M&E plan and include: ANC by medically trained professionals, SBAs, postnatal care for newborns within 48 hours, essential newborn care, use of misoprostol, and current use of modern contraceptive methods.

MaMoni HSS Project – Quarterly Report FY14 Q2 11 IR4. Identify and reduce barriers to accessing health services

 Community Volunteers (CV) selected and Community Action Groups (CAG) initiated in all Habiganj, Noakhali and Lakhsmipur districts. A total of 25,449 community volunteers have been trained and supported to mobilize communities and to disseminate key MNCH/FP/N messages in three districts.  Engagement of local government institutions, especially the Union Parishads to improve MNCH/FP/N in their communities

3.2 Narrative Report of Major Accomplishments

3.2.1 Project Start-up

MaMoni HSS completed most planned project start-up activities during the second quarter. These included the recruitment and orientation of staff, setting up of national and district level offices, orientation meetings with key government officials and partners, development of the project operational guidelines and tools, identification of implementing partners and developing the scope of work, development of the project monitoring systems, and conducting national and district-level situational analysis. The project has also engaged a consultant to conduct a detailed assessment of the environmental impact of project interventions, to develop mitigation plans and to build the capacity of project staff and partners to continuously monitor and mitigate any risks. This activity will be completed by mid- May 2014. Highlighted below are key accomplishments during the quarter:

(i) Development of project operational guidelines and tools. Drawing from experiences of the previous phases of MCHIP implementation, the project team developed detailed operational guidelines and tools to guide district- level MOH&FW counterparts as well as project staff and partners. The draft guidelines have been reviewed and refined through extensive internal consultations and discussions. The operational guidelines will facilitate standardization of implementation process across the various districts and ensure a common understanding among staff and partners. Draft operational guidelines have been developed for the following areas, which will be further refined after the initial phases of implementation:

MaMoni HSS Project – Quarterly Report FY14 Q2 12  Strategy for mobilizing and engaging communities, including mobilization and engagement of CVs, CAGs, and linkages with other existing community groups.  Guidelines for community microplanning and union follow up meetings.  Step by step processes for initiating program implementation in new districts including sensitization meetings and coordination efforts at district, upazila and union levels.  Guidelines for strengthening the role of local government institutions, including Union Parishads, Upazila Parishads and various standing committees that contribute to MNCH/FP/N improvements locally.  Draft guidelines strengthening the supervision systems of the MOH&FW at various levels.  Project framework for quality assurance and capacity-building of service providers including the use of SBM-R, RRQAT and Joint Supervision Visits (JSV).  Draft guidelines and tools for district-level, decentralized, data-driven planning.  Draft guidelines for conducting data-driven performance reviews at upazila, district and national levels.

(ii) Close-out and Transition of previous MCHIP-funded activities. During the reporting quarter, all the previously MCHIP funded project components completed implementation and transitioned into MaMoni HSS. The following project components transitioned into MaMoni HSS:

 MCHIP Associate Award - Integrated Safe Motherhood Newborn Care and Family Planning Project associate award (MaMoni). Project activities were completed by the end of December 2013 and transitioned into MaMoni HSS. Financial and program close-out activities were completed during the reporting quarter.  Field-support funded National Scale up of HBB. Program implementation completed on February 28, 2014 and the new phase of activities transitioned into MaMoni HSS from March 1, 2014, focusing on expansion of the HBB package and follow up on the SBAs who were trained during the earlier phase.  Field support-funded District Health Systems Strengthening (DHSS). All project activities were completed on January 31, 2014 and the two districts – Noakhali and Lakhsmipur – transitioned into MaMoni HSS on February 1, 2014. Program and financial close-out activities were completed during the reporting period.

(iii) District-level implementing partners identified in all districts MaMoni HSS completed the process for identification of local partner NGOs (PNGOs) in the new districts through a transparent and competitive process, following Save the Children’s established partnership guidelines and procedures. Five new PNGOs have been identified, in addition to the six PNGOs who have been supporting the implementation in Habiganj, Noakhali and Lakhsmipur districts.

MaMoni HSS Project – Quarterly Report FY14 Q2 13 The MaMoni HSS team worked closely with the new and the existing partner NGOs to develop detailed scopes of work (SOW), with clearly defined deliverables, and budgets. The six existing NGOs started implementation of MaMoni HSS activities from January 2014. The five new PNGOs are expected to begin implementation from April 16, 2014. Please refer to Annex 5 for the details of geographic allocation to PNGOs.

In addition to the partner sub-agreements with PNGOs, MaMoni HSS established an agreement of collaboration with BRAC to jointly implement the community level activities in Pirozepur district. Under this agreement, MaMoni HSS will build on BRAC’s existing initiatives under the Improving Maternal, Neonatal and Child Survival (IMNCS) project in the district. The cadre of Shwathyo Sebikas (SS) established by BRAC will lead the community mobilization initiatives of MaMoni HSS, similar to efforts made by CVs in other districts. The two projects will also work together to strengthen referral systems for MNCH/FP/N services. During the first six months, the collaboration will work in two - Nazirpur and Bhandari.

3.2.2 Improve service readiness through critical gap management

(i) District-level situational analysis completed to identify critical gaps in health workforce and physical infrastructure to provide integrated MNCH/FP/N services at various levels MaMoni HSS continued to strengthen delivery of MNCH/FP/N services through MOH&FW service delivery points, especially in facilities at strategic locations. These are mostly UH&FWCs that have the potential to provide essential MNCH/FP/N services to a large number of vulnerable communities, with minimal additional support. Some of the criteria used for selection include: size of the catchment area population, availability of basic infrastructure and staffing, distance to the nearest functioning referral point, geographic access to the facility, especially for under-served populations in the nearby communities. The project facilitated a district-level assessment of health workforce needs and gaps in Habiganj, Noakhali and Lakhsmipur districts. MaMoni HSS facilitated a comprehensive workforce needs assessment in three districts. Tools and guidelines were developed and shared with district-level MOH&FW staff and project staff to undertake a detailed analysis of the current status of staffing, vacancies and the projected needs to deliver the MNCH/FP/N services at various levels of service delivery. The preliminary data from this assessment is available, which will be analyzed and used for addressing the gaps during the district-level planning process and for national advocacy. The assessment shows that 25 positions of Family Welfare Visitors (FWVs), 102 positions of Family Welfare Assistants (FWAs) and 133 positions of senior staff

MaMoni HSS Project – Quarterly Report FY14 Q2 14 nurse are vacant in the three districts, which are critical gaps in the provision of MNCH/FP/N services. Additionally, several of the FWVs are not regularly available at the union level facilities due to their responsibilities at higher level facilities or due to absenteeism. In addition, six out of 26 district and upazila level facilities that are designated for provision of comprehensive emergency obstetric and newborn care (CEmONC) services are non-functional due to the unavailability of one or both of the pair of anesthesiologists, gynecologists or CEmONC-trained surgeons. These vacancies pose serious challenges in improving access to essential life-saving services for mothers and newborns, especially for those requiring emergency referral. The project will prioritize addressing the critical human resource gaps in these facilities for.

The project supported underserved populations with critical human resource gap management through temporary NGO service provider recruitment. During the quarter, the project addressed the vacancies in FWV and FWA positions in selected facilities in Habiganj, Noakhali and Lakhsmipur districts, while continuing to advocate for long-term solutions by filling the vacancies through GOB recruitment.

Table 1: Summary of Critical Health Workforce Gap Management Support Provided by MaMoni HSS in Three Districts Habiganj Noakhali Lakhsmipur Total Vacant MaMoni Vacant MaMoni Vacant MaMoni Vacant MaMoni Posts HSS Posts HSS Posts HSS Posts HSS support support support support FWV 12 412 13 15 0 13 25 69 FWA 30 37 45 41 27 0 102 78 Nurses 28 15 60 0 45 0 133 15 Total 70 93 118 56 72 13 260 162

In some cases the number of paramedics deployed exceeds the number of vacant FWV positions. These paramedics were deployed in several union level facilities to fill the gaps due to service providers’ absenteeism or responsibilities at higher level facilities as well as to meet the requirements for the provision of 24/7 services. By providing the above inputs, MaMoni HSS ensured the availability of key MNCH/FP/N services in 21 strategically located facilities, including eight that are now providing 24/7 delivery care.

2 Includes positions funded by leveraged funding from Save the Children Korea and Save the Children UK

MaMoni HSS Project – Quarterly Report FY14 Q2 15

As demonstrated in the graphs above, the facilities supported by MaMoni HSS for managing critical human resource gaps are showing early indications of improved utilization of services. With additional inputs for facility refurbishments and provision of essential equipment and supplies during the coming months, more facilities are expected to provide reliable and high quality MNCH/FP/N services, especially at the union level.

MaMoni HSS facilitated a systematic process to identify health facilities that are strategically located to provide an upgraded package of integrated MNCH/FP/N services. These facilities, mostly located at the union level, have the potential to provide a comprehensive package of services,

MaMoni HSS Project – Quarterly Report FY14 Q2 16 including 24/7 delivery care, with some additional inputs, such as renovation of physical infrastructure, filling vacant positions or deployment of additional paramedics, training of staff, provision and essential equipment and supplies.

As part of the plan for upgrading the services of these facilities, the project is conducting a detailed assessment of the physical infrastructure improvement needs for each of these facilities, along with the assessment of environmental impact and mitigation plans. As indicated in Table 2 below, the physical infrastructure improvement activities have already been completed during the previous phase of the project. In Noakhali and Lakhsmipur, the facilities identified below will be prioritized for infrastructure improvements.

Table 2: Summary of Facilities Identified for Infrastructure Improvements in Year One Type of Type Habiganj Noakhali Lakhsmipur facility of Number Current Number Current status Number Current status input status s UH&FWC Major 2 Environmental 2 Environmental assessment assessment and bill of and BOQ quantities development (BOQ) development Minor 8 Completed 4 Environmental 5 Environmental during assessment assessment MaMoni and BOQ and BOQ development development District Major - - 1 Environmental hospital assessment and BOQ development Minor - -

(ii) Capacity-building support for MOH&FW to scale up evidence-based maternal and newborn care interventions at a national scale: MaMoni HSS staff were actively involved in four national technical working groups that are developing training packages for various cadres of MOH&FW on new newborn interventions including management of preterm labor and use of antenatal corticosteroids (ACS), Kangaroo Mother Care (KMC), chlorhexidine application for umbilical cord care and management of newborn sepsis. One of the key milestones achieved by the project during the quarter was the launch of the use of chlorhexidine in a program setting for the first time in Bangladesh. The project

MaMoni HSS Project – Quarterly Report FY14 Q2 17 supported the training of 43 SBAs and 59 traditional birth attendants (TBAs) on chlorhexidine application. The initial supply of chlorhexidine was provided by the project, using resources leveraged by Save the Children from non-USAID sources. Since the launch of the initiative in two unions of Bahubal upazila in Habiganj on March 4, 2014, a total of 53 newborns have already benefited from the intervention as of March 31, 2014. Please refer to Annex 2 for a detailed report of this activity.

MaMoni HSS has been scaling up HBB nationwide since 2011. In this quarter, 1,990 SBAs from 332 health facilities of , Munshiganj, and Pirozepur districts were trained. The HBB training has now covered all 64 districts with 1961 trainers and 23,579 SBAs trained. During the last quarter, divisional level health and family planning managers, civil surgeons and the FP deputy directors, conducted 15 supervisory visits in four districts and completed 158 visits to SBA trainings at the district and upazila levels. Master trainers and trainers from BSMMU visited 21 SBA Newborn resuscitation practices recorded at training sessions at the surveillance sites district and upazila levels 400 Total number of Live births: 4427 during this quarter, 350 339 339100% improving the overall 300 27380% 270 quality of trainings. A total 80% 250 217 of 332 facilities were 64% 200 supplied with 107 154 150 45% 40% Neonatalies and 817 sets of 100 69 resuscitation equipment ; 20% 50 373 CSBAs and 279 0 UH&FWCs received bag- Not Breathing Dried Suctioned Stimulated B&M Breathing after Referred Ventilation Resuscitation valve-mask kits with penguin suction units immediately after training.

A total of 90 units in eight districts have been identified for newborn care surveillance. The districts are , Bagerhat, Bogra, Gaibandha, Habiganj, Narsingdi, Noakhali and Lakhsmipur. Facilities from the districts under surveillance include the medical college, district hospital, maternal child and welfare center (MCWC), two high-volume upazila health complexes (UHCs), two UH&FWCs, NGO clinics and private hospitals with high volumes of deliveries. Additionally, four CSBAs (two from each upazila) are included in the surveillance. In this quarter, a total of 27 doctors from the above district-level facilities have been trained as hospital surveillance officers (HSO). A total of 4,582 surveillance forms have been collected from the service providers. The surveillance data from 4,427 live births recorded at 32 surveillance sites show that 80 percent of newborns who did not breathe at birth were successfully resuscitated and 20 percent were referred to a

MaMoni HSS Project – Quarterly Report FY14 Q2 18 higher level facility for advanced care. No newborn deaths have been reported from the surveillance sites. A total of 65 fresh stillbirths and 90 macerated still births have been reported. The surveillance system uses self-reported checklists to be used by the SBAs, which helps them to prepare for the birth as well as to follow the resuscitation algorithm and document the steps followed. Thus, these checklists also serve as quality improvement tools for the SBAs.

During the quarter, MaMoni HSS collaborated with BSMMU, Saving Newborn Lives (SNL) and the American Academy of Pediatrics (AAP) to develop the national package of Essential Care for Every Baby (ECEB) and to organize a national level training of trainers on the package. A total of 18 participants from DGHS, DGFP, BSMMU and Save the Children received the training, which was facilitated by trainers from AAP. These trainers will lead the implementation of the package, as part of national scale up initiatives supported by MaMoni HSS.

In collaboration with the DGFP, MaMoni HSS organized a national level ToT for the roll out of misoprostol to prevent post-partum hemorrhage among women delivering at home. A total of 121 participants from 28 districts received this training; they will then lead the orientation of service providers from all DGFP facilities in their respective districts. DGFP has already procured and distributed misoprostol to all upazila and union level facilities for immediate roll out. Three of the MaMoni HSS districts – Habiganj, Noakhali and Lakhsmipur – have already started provision of misoprostol to pregnant women during their fourth antenatal visits. In Habiganj district, distribution of misoprostol began in all upazilas under the MaMoni project starting in February 2011 . The recent population-based survey (Tracer Indicator Survey, March 2014) has shown that 47.9 percent of women who delivered between August 1, 2013 and January 31, 2014 had received misoprostol and 39.2 percent received it just after delivery.

During the quarter, MaMoni HSS trained 22 FWVs from Habiganj district on Post- partum Intra-Uterine Contraceptive Devices (PPIUCD). The training allowed these service providers to provide PPIUCD services in 18 facilities at union and upazila level facilities.

3.2.3 Strengthen health systems at district level and below

(i) Health systems Gap Analysis: MaMoni HSS initiated a situation analysis to identify systems issues that affect rapid and effective scale up of essential MNCH/FP/N interventions. The analysis will identify issues which need to be addressed through longer term reforms and recommend doable solutions. This analysis will also provide the basis for MaMoni HSS’s system strengthening approach which includes workforce management and

MaMoni HSS Project – Quarterly Report FY14 Q2 19 quality implementation at the district level and below. Specific objectives of the situation analysis are to:

 Identify specific system causes of coverage, quality, management (and effectiveness) issues related to maternal, newborn, child, adolescent, family planning and nutrition interventions  Document feasible solutions for each of the system causes by levels of operation  Recommend a prioritization protocol for MaMoni HSS’s health systems interventions at national and district levels

In addition to review of literature and data from previous similar assessments, the methodology includes interviews of key government officials, development partners, program managers, service providers and other stakeholders at national, district, upazila, union and community levels and collection of relevant stories, anecdotes and reference documents. During the quarter, the assessment process was completed at the district level and a preliminary analysis of the findings completed. The findings from the initial district level analysis have been organized into various thematic areas such as: human resources, logistic management, management information systems, leadership and governance, service delivery, role of local government etc. In the next stage of the gap analysis, the team will organize consultations with senior GOB policy makers, such as retired secretaries, Director Generals, current directors, head of departments of relevant ministries and departments, head of NGOs who are working with health systems etc. with a focus on identifying policy level issues as well as to explore doable solutions options. A final report will be prepared and shared with relevant officials and stakeholders during the next quarter. The findings from the gap analysis will be used extensively to refine the program’s advocacy agenda as well as to refine health systems interventions.

(ii) Tools developed for district level decentralized, data-driven planning for improved MNCH/FP/N: MaMoni HSS team has developed the draft guidelines and tools to facilitate district level decentralized planning for improving MNCH/FP/N situation. The tools draw from the existing guidelines for Local Level Planning (LLP) used by the DGHS and DGFP, separately. The project has also drawn from similar tools developed by other development partners in Bangladesh and elsewhere, such as the Diagnose- Intervene-Verify-Adjust (DIVA), Marginal Budgeting for Bottlenecks (MBB) and the Reaching Every District (RED) approach used by EPI programs. The major shifts that MaMoni HSS strives to achieve in the planning process are:  Government owned and government led process at all levels. The project team has been closely working with the MOH&FW officials at national and district levels to ensure that the planning tools are accepted and owned by the GOB and the process is led by the government at all levels.

MaMoni HSS Project – Quarterly Report FY14 Q2 20

 Use of local level data for determining local priorities and performance targets. Since the unavailability of reliable coverage data has been a major limitation for decentralized planning process, MaMoni HSS has incorporated the collection of population-based surveys in preparation for the planning process. These surveys, entitled as Tracer Indicator Surveys (TIS), use a rapid survey methodology using simplified data collection instruments adapted from the MEASURE/DHS evaluations. The survey instruments are designed to collect very minimal set of information on six tracer indicators – antenatal care, SBAs, use of misoprostol, postnatal care, family planning, and essential newborn care practices. The surveys will be repeated once in every six month to enable regular tracking of progress made and to readjust performance targets and priorities. In preparation for the planning process in MaMoni HSS team supported the TIS in Habiganj, Noakhali and Lakhsmipur districts to conduct the first TIS in the month of February 2014. A total of 14,293 recently delivered women (between August 1, 2013 and January 31, 2014) and 27,531 women of reproductive age were interviewed. The survey was designed and implemented jointly by the project team, in close collaboration with the district level MOH&FW officials. Data was collected by the PNGO staff and the data quality assurance, data entry and analysis was done by icddr,b. The preliminary analysis of the data has been completed, which provides Union level estimates for the six tracer indicators. In addition to the data generated through the TIS, the information collected by through workforce needs assessments, service delivery preparedness assessments and the identification of strategically located facilities will also serve as valuable data inputs to inform the planning process.

 Emphasis on integrated comprehensive plans for improving maternal, newborn, child health, family planning and nutrition situation in each district, using a whole system approach. The plans not only integrate the roles of DGHS and DHFP service delivery systems, but will also actively engage the local government institutions, non-governmental organizations, private sector and other non-state providers.

 Extension of the planning process up to the union level, with close engagement of service providers, supervisors and managers from DGHS and DGFP, local government representatives, local NGOs, private sector and other relevant stakeholders.

The project conducted a field test of the tools and guidelines, which will inform further refinements. The revised tools will be shared with the relevant directorates of MOH&FW for their endorsement before use at the district level. The actual planning process will be completed in the three districts by the end of next quarter.

(iii) Development and Implementation of Quality Assurance Initiatives:

MaMoni HSS Project – Quarterly Report FY14 Q2 21 Based on a thorough review of the existing QA strategies and approaches used in the country, including field level assessments, the project developed its QA strategy to contribute to improving the effectiveness of MNCH/FP/N services in the project’s covered areas and beyond. The strategy describes a conceptual framework and the main project QA interventions at the national, district, health facility, and community levels. It provides guidance to the project in selecting priority QA interventions that contribute most to achieving its overall goal. It calls for applying multiple effective approaches, such as the SBM-R, RRQAT and JSVs to improve the quality of MNCH/FP/N service at different service delivery points. The developed strategy is summarized in a separate document entitled “MaMoni HSS Project Quality Assurance Framework: Applying QA to improve maternal, newborn, child care, family planning, and nutrition programs in project areas and beyond”. A synthesis of the document is included in Annex 6.

Strengthening Supervision System: MaMoni HSS project conducted review of existing supervision system in Habiganj and Noakhali to document strengths and weakness of the system and to guide the development of project’s intervention to improve the system. The review revealed that while the supervision system at the district level is well structured and while the roles and responsibilities at different levels are clearly delineated, the supervision visits conducted to different health facility levels are irregular and largely ineffective in improving quality of care. Supervisory visits are commonly conducted in a “traditional approach” where supervisors focus on mistake-finding and documentation. Based on the results of the review, the project identified a number of interventions to contribute to improving the regularity and effectiveness of the supervisory system to result in improving quality of MNCH/FP/N services. The main lines of interventions include:

 The introduction of supportive supervision to transform the supervisors to agents of problem solving and quality improvement.  Use of multiple opportunities to strengthen the quality of care by linking supervision visits and RRQAT to quality assurance initiatives, especially SBM-R  Linking supervision to in-services training so that the supervisory visits can serve as vehicle for enforcing clinical skills of service providers.  Develop/adapt existing supervisory checklists to ensure their effectiveness in identifying key problems with quality of care, suggesting solutions, and follow up on their implementation.  Conduct JSVs in the project’s areas where supervisors from the district level join selected MaMoni HSS staff in conducting supervisory visits to health facilities. Such approach, proved effective during the MaMoni Project, will contribute to improving the regularity of visits and will facilitate capacity building of district counterparts in conducting effective supervision.  Introduce effective and affordable mechanisms to recognize health facilities that succeed in improving different aspects of their MNCH/FP/N services.

MaMoni HSS Project – Quarterly Report FY14 Q2 22 Implementation of SBM-R and Preparation for scale up: MaMoni HSS Project continued the implementation of Standard Based Management and Recognition (SBM-R) in Habiganj district. In January 2014, a workshop to implement Module 1 included health and family planning service providers and managers who reviewed the progress of the implementation of the SBM-R approach in the district and discussed lessons learned. In addition, in 11-13 March, the project conducted Module 2 training to strengthen the implementation of the SBM-R approach and plan for next steps to expand the approach to other health facilities in Habiganj district and other districts. Thirty-five service providers participated in the training including doctors, FWVs, senior staff nurses, paramedics, and NGO partners. Participants shared the results of the internal assessment conducted to measure progress with implementing MNCH/FP/N standards. The Figure below summarizes the improvement documented in five health facilities in Habiganj district between the baseline assessment conducted in July-August 2013 and the first internal assessment conducted in January-February 2014.

Scaling Up SBM-R implementation: MaMoni HSS project has started the process of scaling up SBM-R in more health facilities in Habiganj, Noakhali, and Lakhsmipur districts. The project held a national level briefing and orientation meeting to develop a district core Proportion of MNCH/FP/N standards applied team from DGHS, DGFP, and in 5 health facilities in Habiganj district MaMoni HSS project. In addition, based on experience of 74% 59% applying SBM-R in Habiganj to 54% 44% date, the project realized that in 42% 38% 35% 33% 34% 21% order to scale up SBM-R efficiently, clinical standards must be reduced to focus on those that are critical to MNCH/FP/N services and that the assessment tools must be simplified. Hence, Baseline July-August 2013 1st internal assessment January-February 2014 the project engaged service delivery staff from Habiganj district in prioritizing the list of standards and the verification criteria assessment tools. As a result, the number of standards was reduced from 138 standards to a total of 83 critical standards. In preparation for the scale up, MaMoni HSS conducted a national level TOT, which was attended by 24 participants from Habiganj, Noakhali, and Lakhsmipur districts consisting of officials from DGHS, DGFP, and MaMoni HSS staff. Participants developed a list of facilities in the three districts to be included for the scaling up of the approach during the coming year. Furthermore, in preparation for scaling up SBM-R implementation, the project has started the process of translating the revised assessment tools to Bangla.

MaMoni HSS Project – Quarterly Report FY14 Q2 23 During the reporting quarter, MaMoni HSS project participated in a number of events discussing national QA strategies and approaches to gain better understanding of the QA approaches supported by other partners and stakeholders, such as the 5S-CQI-TQM approach supported by JICA and UNICEF. MaMoni HSS will continue to engage with other stakeholders to identify opportunities for leveraging on similar initiatives and to contribute to the national level discussions for coordination of QA initiatives in the country under a commonly agreed upon national framework and standards of care. The previous work under MCHIP to develop national Standard Operating Procedures (SOP) for maternal health provides a strong platform for the efforts for harmonization.

(iv) Other health systems strengthening initiatives: MaMoni HSS collaborated with the Health Research Challenges for Impact (HRCI) project of Johns Hopkins University and Department of Public Health Informatics of BSMMU to conduct a series of consultation to develop a strategic leadership training curriculum for Civil Surgeon and Deputy Director of Family Planning. MaMoni HSS is represented in the Technical Advisory Group (TAG) as well as in the pool of master trainers identified for this initiative. HRCI will develop the curriculum and train district level managers and selected upazila level managers from 64 districts starting in May 2014. MaMoni HSS will adapt this curriculum to also train upazila managers for the eight MaMoni HSS districts.

MaMoni HSS has been collaborating with the Routine Health Information System (RHIS project) of icddr,b to strengthen the local management information systems. In the Poil union of Habiganj Sadar upazila, MaMoni tested an integrated register for FWVs in order to reduce the reporting workload needed for ANC, delivery, and PNC and to facilitate tracking of mothers along the continuum. The Poil register and reporting forms were scaled up in of Habiganj in FY’13 and in two other districts by icddr,b’s Routine Health Information System (RHIS) project. The new national FWV register, expected to be rolled out in early 2015, was revised based on MaMoni HSS’ work in Poil Union. MaMoni HSS is also supporting the automation of the records for Chunarughat Upazila health Complex and Habiganj district hospital, using the DHIS2 server at DGHS MIS. The data can be viewed online at http://www.dghs.gov.bd using the username: view and password: DGHS1234

MaMoni HSS has initiated discussions with the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) project to work together to improve the logistics management of essential commodities in both DGHS and DGFP. The two projects are already working together in Lakhsmipur to support the pilot implementation of LMIS for DGFP up to the service delivery points, which was designed supported by SIAPS. Under the guidance of the Technical Working Group constituted under DGHS, Lakhsmipur district has been identified for the design and

MaMoni HSS Project – Quarterly Report FY14 Q2 24 testing of a logistics management system for DHGS. As an initial step, the two projects will jointly conduct an assessment of logistics management systems in the district during the next quarter, which will inform help to prioritize the logistics management interventions.

3.2.4 Promote an enabling environment to strengthen district-level health systems

(i) Successful advocacy for procurement of calcium for preventive of pre-eclampsia through DGHS procurement MaMoni HSS successfully advocated to DGHS to procure calcium for supplementation as a preventive measure for pre-eclampsia for pregnant mothers. In the sector plan, HPNSDP 2011-16, calcium supplementation was not included. However, because of broad advocacy of Mayer Hashi, MaMoni, OGSB and other partners, the National Technical Committee approved calcium supplementation in September 2013. Although DGFP Operation Plan revision included procurement of calcium, the procurement plan submitted to World Bank for NOC in early 2014 did not include procurement of calcium in the 2014-2015 fiscal year. MaMoni approached Director, Primary Health Care and Line Director, MNCAH of DGHS in February 2014, and provided scientific evidence (Cochrane Review and WHO recommendation) for inclusion of calcium supplementation. MaMoni HSS, with assistance from the Saving Newborn Lives project and Mayer Hashi Project of EngenderHealth ensured that the procurement plan of DGHS for the 2014-15 fiscal year includes calcium supplementation. MaMoni HSS will continue to work with DGFP to produce an estimate for nationwide requirement of calcium, and include the amount in the procurement plan of 2015-16.

(ii) Operations research (OR) areas identified: MaMoni HSS and the project partner, icddr,b, conducted several consultation meetings to identify areas of conducting OR to improve program implementation and to inform policy level discussions. A national stakeholders’ meeting was organized in January 2014 to seek inputs from experts and stakeholders. Based on the inputs received from various sources, MaMoni HSS has identified 21 possible research questions. Using the criteria of “Importance, Timeliness, Equity and Scalability”, a final list of three topics will be selected for implementation in the first year, from the six areas shortlisted below:

 Where are the barriers for mothers to receive misoprostol in third trimester? What strategies can help to improved access to the supply and adequate counseling?  What are the gaps in quality of NSV/Tubectomy services/infection prevention and client experience?

MaMoni HSS Project – Quarterly Report FY14 Q2 25  What is the minimum number of staff needed for effective 24/7 services at union level facilities? Which tasks cannot be performed by the existing UH&FWC staff structure? How task sifting can be introduced to minimize the gaps?  How the Simplified Antibiotic Therapy (SAT) for sick newborns can be introduced at home and community levels?  Can SBAs use partograph effectively to screen /detect complications?  Does the revised CAG strategy increase the likelihood of identifying increased number of complications and linking them with referral network?

MaMoni HSS’s partner, icddr,b, is leading the development of the design of these OR studies. The OR implementation will begin in the third quarter in selected sites.

(iii) National level advocacy and dissemination of new high-impact newborn interventions: As part of the “A Promise Renewed: A Call to Action” developed by Bangladesh, the MOH&FW has made firm policy level commitment to scale up the following newborn care interventions across the country:

 Introduction and scale-up of use of antenatal corticosteroid (Dexamethasone) during preterm labor by skilled providers to reduce complications of preterm birth, specifically respiratory distress syndrome (RDS);  Introduction and national scale-up of Kangaroo Mother Care (KMC) at the facility with its continuation to the community to manage preterm, low birth weight newborns;  Strengthening of union-level facilities for management of newborn sepsis with upward linkages with UHCs; and  Single early application of 7.1% chlorhexidine digluconate to all newborn umbilicus to prevent infection and newborn sepsis.

MaMoni HSS collaborated with the Bangladesh Perinatal Society (BPS), Obstetric and Gynecologic Society of Bangladesh (OGSB), Bangladesh Neonatal Forum (BNF) and Bangladesh Pediatric Association (BPA) and Saving Newborn Lives (SNL) to organize sensitization meetings across the country. During the sensitization meetings, the opinions, views and recommendations of the participants on implementation strategies of these newborn activities was collected through open discussions. A team of 73 facilitators from DGHS, DGFP, BPS, OGSB, BNF, BPA and other stakeholders were involved conducted sessions at the divisional and district levels. A total of 2,374 participants attended the sensitization meetings, which started in December 2013.

Seven divisional meetings were held in , , , , Rangpur, Sylhet and held during this quarter. A total of 409 participants from divisional and district level health and family planning managers, consultants, nurses, leaders of professional bodies and development partners attended the meetings. A total of 47 district meetings were held during this quarter,

MaMoni HSS Project – Quarterly Report FY14 Q2 26 which reached a total of 1,875 participants from district and upazila levels. District sensitization meeting in 17 districts of could not be completed during the quarter as planned. These meetings will be completed in the next quarter.

3.2.5 Identify and reduce barriers to accessing health services

(i) Community Volunteers and Community Action Groups initiated in all three districts: During the quarter, MaMoni HSS consolidated its efforts to engage community level volunteers and to form and support the community action groups. In all three districts, the CVs were selected and trained by the previous MCHIP components. In Habiganj, the 6,727 CVs already trained by MaMoni are regularly facilitating CAG meetings and are participating in the microplanning meetings with the FWAs and HAs as per the schedule. Additional CVs have been identified in Habiganj district to realign the population ratio of one CV per 250 people from the current ratio of 300 people, and also to fill the vacancies due to attrition. As the data indicates 99 percent of scheduled microplanning meetings took place during the reporting period. In Habiganj, MaMoni has followed up on existing 2,166 CAGs, who have been regularly meeting in the presence CVs.

In Noakhali and Lakhsmipur, the 19,130 CVs who were trained by the District Health Systems Strengthening (DHSS) project have started facilitating the formation and regular meetings of CAGs. During the reporting quarter, 6,271 CAGs have been formed by the CVs in Lakhsmipur district. The community microplanning meetings are yet to start in these two districts, which will be a priority for the project in the next quarter.

(ii) Engagement of the local government institutions, especially the Union Parishads in improving MNCH/FP/N in their communities: MaMoni HSS continue to engage with the local government institutions, especially the Union Parishads to enhance their role in improving MNCH/FP/N outcomes in their communities. During the quarter, the project staff and partners attended Ward level meetings, which are scheduled in preparation for the annual budget discussions at the UP level. The budget allocation will be finalized during the next quarter.

Table 3: Status of engagement of local government structures in MNCH/FP/N issues District Percent of Union Parishads Percent of Union allocated budget for Parishads with active MNCH/FP/N UEHFPSC Habiganj 90.5 100 Lakhsmipur 5.1 44.8

MaMoni HSS Project – Quarterly Report FY14 Q2 27 Noakhali 4.4 76.5 In the coming months, MaMoni HSS will collaborate with the USAID funded Supporting Democratic Local Governance (SDLG) project to leverage on their efforts, particularly to expand the roles and authorities of the local government; and to improve and expand the service delivery and resource mobilization of local government units. In the two overlapping districts of Bhola and Brahmanbaria, both projects will together train UEHFPSCs and facilitate their oversight role. SDLG lessons will also inform our work with the Union Parishads on budget allocations for local MNCH/FP/N. We will identify focal points in each district from both SDLG and MaMoni HSS to ensure coordination and collaboration between the two initiatives.

3.2.6 Challenges, Solutions and Action Taken

During the quarter, MaMoni HSS implementation progressed without any major hurdles. Following the completion of national elections in December last year and the formation of the new government at the beginning of the quarter, the political situation improved considerably, favoring smooth progression of activities at national and district levels. Some of the project start-up activities, which were planned for the first quarter, had to be completed during this quarter due to the unfavorable political situation in the country till early January.

A few of the planned activities could not be completed during the quarter owing to various internal and external factors. Some of those are summarized below:

 The national project launch, which was scheduled for the last week of March 2014 had to be rescheduled due to unavailability of dates convenient for senior MOH&FW staff as well as USAID mission. The project team is regularly following up with the mission and MOH&FW to schedule the event in May 2014.  Recruitment and retention of qualified and experienced staff to lead the district level implementation has been a challenge. Recruitment has been especially challenging for clinical and quality assurance roles, as most of the qualified candidates prefer not to work at the district level. The project has been focusing on targeted recruitment approaches through head-hunting. Some of the difficult to fill positions, such as the District Quality Assurance Manager, may be upgraded to attract more candidates.

MaMoni HSS Project – Quarterly Report FY14 Q2 28 4. The Way Forward

Key Activities Planned for the Next Quarter

General Project Start-up

 Project launch will be scheduled in May, in consultation with MOH&FW and USAID mission  Conduct gender analysis and incorporate in operational guidelines: A consultant has been identified to facilitate the process and scope of work has been finalized. The exercise will be completed in May  Complete EMMP and staff training on environmental compliance. A consultant has started working with the project team to develop environmental compliance plans, who will also train project staff and partners on environmental compliance procedures  Deployment of district level staff and PNGOs in three new districts – Bhola, Pirozepur and Jhalokathi by May 15  Develop and roll out the project MIS for community and facility level components, including data quality assurance (DQA) tools

Intermediate Result 1:

 Recruitment of all critical gap management staff identified through the workforce needs assessment in Noakhali and Lakhsmipur districts  Finalize the proposals for infrastructure improvements of strategically located facilities and obtain approvals  Develop special intervention strategies for urban and hard-to-reach locations, such as the island upazilas of Hatiya in Noakhali and Maunpura in Bhola

Intermediate Result 2:

 Complete district level planning in three districts: database developed with HMIS team for Union level plans and targets for key indicators  Support the HRCI training for district and upazila level managers on leadership and management skills  Formalize collaboration with SIAPS and NHSDP. A draft of the scope of collaboration with SIAPS has been developed, which will be finalized in April  Complete the HSS gap analysis and disseminate the findings with MOH&FW and stakeholders  Finalize district planning guidelines and obtain GOB endorsement, involvement at district level  Complete the district level decentralized planning in Habiganj, Noakhali and Lakhsmipur, using the new guidelines and using the data from tracer indicator surveys and district situational analysis

MaMoni HSS Project – Quarterly Report FY14 Q2 29  Conduct logistics management gap analysis in Lakhsmipur in collaboration with SIAPS  Train statisticians from DGHS and DGFP at district and upazila levels on use of MIS data and DQA  Phased expansion of SBM-R to additional facilities in Habiganj, Noakhali and Lakhsmipur  Develop guidelines for SBM-R recognition  Form RRQAT for all year one districts (three divisions)  Develop guidelines and tools for JSV and orient staff and partners  Review and adapt Maternal Perinatal Death Review (MPDR) guidelines and tools  Initiate a pilot test on use of MPDR in one district  HBB revisit program for the trained SBAs to follow up on resuscitation practices  Develop the expanded HBB package following the ECEB package and begin roll out  Organize the competency-based training for service providers on various MNCH/FP/N technical areas as per the training plan

Intermediate Result 3:

 Finalize national advocacy plan  Develop a capacity strengthening plan for professional bodies  Organize field visits for partners to observe MaMoni best practices in Habiganj  Develop project’s media strategy and ambassador strategy  Organize advocacy events on Safe Motherhood Day  Finalize the OR designs and begin implementation (with icddr,b)  Train district staff (and partners) on documentation  Develop a documentation and program learning plan

Intermediate Result 4:

 Develop guidelines for district level BCC planning and facilitate district level SBCC plan development  Establish BCC units with PNGOs in three districts  Complete community level training (video-based training on microplanning, union follow up) through in Noakhali and Lakshmipur  Initiate non-clinical training (basic facilitation skills, JD-based training, Union Parishads orientation, and complete the training in three districts  Finalize the training modules for Union Parishads and oversee the training of UP/ UEHFPSC. Develop the scope of collaboration with SDLG in Bhola and Brahmanbaria districts  Develop a model for strengthening vital registration system; test the model in four selected unions (one per district)

MaMoni HSS Project – Quarterly Report FY14 Q2 30 Annex 1. Materials Developed with MaMoni HSS Support Program area Document Title Produced by Draft/Final Language Tool Kit Health Systems Save the Draft Bangla Situation Analysis Children Tools Tool Kit Health Workforce Save the Draft Bangla Analysis Tools Children Tool Kit Local Level Planning Save the Draft Bangla Tools Children Program Tracer Indicators icddr,b Draft English Evaluation/Research Survey Findings for Habiganj, Lakhsmipur, Noakhali

MaMoni HSS Project – Quarterly Report FY14 Q2 31 Annex 2. Report of the Launch of Chlorhexidine in Habiganj

In Bangladesh, newborn deaths claim 60% of under-five mortality, most from preventable causes such as infections, prematurity and complications during birth. The National Core Committee on neonatal health has endorsed the national scale up of four new high impact newborn interventions for newborn survival. These are antenatal corticosteroids to prevent complication of preterm deliveries, Kangaroo Mother Care (KMC) to manage preterm and low birth weight newborns, simpler regimens of antibiotics at primary health care level to manage newborn sepsis, and 7.1% Chlorhexidine application to the newborn umbilicus to prevent umbilical sepsis. This was followed by a declaration of “A Promised Renewed on Child Survival” which was signed by the Honorable Minister of Health and Family Welfare.

MaMoni HSS team has been working closely with the Technical Support Group (TSG) to develop the national guidelines for the scale up of these new interventions. MaMoni HSS has also been taking initiatives to pilot these interventions in its focus districts to document implementation lessons, which will contribute towards development and finalization of the national guidelines and strategies. The IMCI Unit of DGHS organized a stakeholder meeting on October 07, 2013 where participants from DGHS, DGFP, professional bodies, UN agencies, donor, NGOs and others attended. The proposal to pilot the chlorhexidine intervention in two unions (Mirpur and Bahubal)) of Bahubal upazila of Habiganj district was discussed and endorsed at this meeting. DGHS and DGFP issued necessary directives to the Habiganj district MOH&FW managers for active support to roll out the activity.

Unions were the intervention took place Launch of 7.1% Chlorhexidine application for newborn cord care were selected based on some selection criteria such as: availability of round the clock delivery service in selected facility; presence of both DGHS and DGFP service providers; presence of CSBAs in the unions; sufficient volume of facility deliveries in last 6 months and availability of supervisors. The recommended formulation of Chlorhexidine (7.1%) is not available in the market and was procured through special arrangement with a local pharmaceutical company.

MaMoni HSS Project – Quarterly Report FY14 Q2 32 Launch of Chlorhexidine in MaMoni HSS Area: Under the leadership of DGHS and DGFP, the intervention was launched on March 04, 2014 in Bahubal upazila of Habiganj district. All senior district level officials and upazila managers of Bahubal attended along with representatives of DG Health and DGFP from national level. The Civil Surgeon and DDFP applied chlorhexidine to two newborn babies to mark the launch of the intervention.

DDFP, Habiganj applying 7.1% Chlorhexidine in Civil Surgeon Habiganj applying 7.1% newborn umbilical stump Chlorhexidine in newborn umbilical stump

Orientation of MOH&FW Providers: A half day orientation was organized for providers in the intervention area. Participants included doctors, nurses, FWVs, SACMO, CSBA and Paramedics. Orientation included strategy guidelines, hands-on demonstration and roll-out planning. The QA Manager of the project conducted the orientation session and a total of 43 MOH&FW as well as NGO providers were oriented. In addition, three batches of half-day orientation sessions were organized for 59 TBAsand Chlorhexidine kits were handed over to the TBAs after the orientation session.

UH&FPO, Bahubal, Dr Solaiman addressing union advocacy SSN Modhumita facilitating TBA orientation on Chlorhexidine cord

MaMoni HSS Project – Quarterly Report FY14 Q2 33 Advocacy Meeting on Chlorhexidine: In addition to the launch on March 4th, two advocacy meetings on Chlorhexidine were organized in two intervention unions. The participants included UP chairmen, UP members, teachers, village doctors, NGO workers, civil society members, local elites and service providers of respective unions. A total of 106 participants (Mirpur-53, Bahubal-53) attended the advocacy meetings.

Coverage status: As of March 31, 2014 Chlorhexidine has been applied on the umbilical cords of 53 newborns in the intervention areas.

MaMoni HSS Project – Quarterly Report FY14 Q2 34 Annex 3. Report of Newborn Targeted Interventions in Sylhet

MaMoni HSS is collaborating with the TRAction project to reduce newborn mortality in Jaintapur upazila of Sylhet. Overall, the targeted intervention/differential management approach holds two sets of activities - surveillance and targeting and management.

Inauguration of Special Care Newborn Unit at Jaintapur UHC by local MP Mr. Imran Ahmed

As part of the intervention, a Special Care Newborn Unit (SCANU) was established in Jaintapur Upazila Health Complex in March 2013. An additional room to care for newborns with sepsis has also been established. The entire upazila is divided into 21 units with each unit divided into 40 blocks. One CHW is assigned to each of the units and for each An admitted newborn being treated at Jaintapur UHC block one CV is selected. The average population of each block is 300 individuals.

The six unions of Jaintapur upazila are divided into four paramedic clusters and one paramedic is responsible for each of the clusters. CHWs of a cluster notify their paramedic of any maternal/newborn assessments and referrals. All the referred newborn cases receive essential services at the Jaintapur SCANU. A team of one medical officer and two nurses/paramedics provide services round the clock at the SCANU. The project has placed four MOs and six nurses (MATS certified Paramedics/Diploma nurses) under local supervision of UH&FPO. All of the service providers have received training on ETAT from BSMMU and hands-on in- service training from the Pediatrics Department of Sylhet Osmani Medical College Hospital. The project has supplied all necessary equipment, drugs and logistics required for the SCANU.

MaMoni HSS Project – Quarterly Report FY14 Q2 35 Total population of Jaintiapur upazila is 174, 449 and the number of married women of reproductive age (MWRA) who are registered into the program is 28,449. During March 2013 - March 2014, the CHWs tracked 5,272 deliveries. Of these, 4,220 (80%) deliveries occurred at home and 1,052 (20%) deliveries took place at health facilities.

Out of these deliveries:  5134 were live births and 189 were stillbirths.  CHWs visited and assessed risk level of newborn: 60% within 6 hours of birth, 79% on 3rd day, 85% on 7th day and 83% after 28 day.  550 sick newborn admitted in the SCANU at the Jaintiapur UHC.  The causes of the 550 admissions were: infection/sepsis – 219 (40%), birth asphyxia – 181 (33%), pre-term – 110 (20%), jaundice – 27, others -13  20 newborns died in the SCANU. Total neonatal deaths for Jaintiapur upazila during this period was 126 (neonatal mortality rate:24.5/1000 LB)

Figure 1: Coverage of newborn visits by CHWs (March 2013 – March 2014)

MaMoni HSS Project – Quarterly Report FY14 Q2 36 Annex 4. List of Government Orders and Circulars in Support of MaMoni HSS Activities

S Activity description Participants Date of Issue Place of Participants L /Organization 1 Training on Postpartum Paramedics Habiganj Iron folic acid and 27 Jan 2014 Postpartum Intrauterine Contraceptive Device (PPIUCD) 2 TOT on SBM-R Project Staff Noakhali, Lakhsmipur& 11 March 2014 Habiganj 3 TOT Misoprostol use to consultant Gynae& 17 districts prevent postpartum Obs, MO-Clinic 5 Dec 2013 hemorrhage 4 Training on Antenatal Consultant Gynae& Corticosteroid Obs, MO-Clinic 30 March 2014 5 Training of private PCSBA Habiganj community SBAs 22 Jan 2014 6 PPFP & PPIUCD training FWV Habiganj 28 Jan 2014 7 TOT on SBM-R Government staff Sylhet, Chittagong, 4 March 2014 Noakhali, Lakhsmipur & Habiganj 8 Meeting for updating Different level national strategy for participants from 20 Jan 2014 maternal health and GO-NGO finalizing maternal health SOP 9 Misoprostol handover and DGFP supply to Government 3 March 2014

MaMoni HSS Project – Quarterly Report FY14 Q2 37 Annex 5. Geographic Allocation of Implementing Partner NGOs

District Name of the PNGO Coverage Areas Habiganj Friends of Integrated Village Nabiganj, Ajmiriganj, Development Bangladesh (FIVDB) Baniachang, Chunarughat Shimantik Madhabpur, Sadar, Lakhai, Bahubol Noakhali Resource Integration Center Bangladesh Extension Education Begumganj, Services (BEES) Companiganj, Kobirhat, Senbag Development Organization for the Chatkhil, Sadar, Rural Poor (DORP) Sonaimuri, Subornachor Lakhsmipur Dustho Shwasthyo Kendra (DSK) Sadar, Ramganj, Raipur, Ramgoti, Komolnagar Bhola Eco-social Development Sadar, Borhanuddin, Organization (ESDO) Daulatkhan Sushilan Tazimuddin, Lalmohon, Charfasion COAST Maunpura upazila Pirozepur Eco-social Development Sadar, Najirpur Organization (ESDO) Nesarabad Light House Zianagar, Kaukhali, Vandaria, Mothbaria Jhalokathi Partners in Health Development All four upazilas

MaMoni HSS Project – Quarterly Report FY14 Q2 38

Annex 6. MaMoni HSS Quality Assurance Framework Applying QA to improve maternal, newborn, child care, family planning, and nutrition programs in project areas and beyond, March 2014

1. Objectives of MaMoni HSS’ Quality Assurance Component

The QA component of the MaMoni HSS Project is designed to contribute directly to the overall goal of the project to improve utilization of integrated MNCH/FP/N services. Specifically, the QA component aims to:  Improve the effectiveness of the critical MNCH/FP/N services provided at health facility and community levels in MaMoni HSS Project areas.  Advocate for the importance of QA for MNCH/FP/N programs at all levels.  Strengthen the capacity of national counterparts at all levels in QA and institutionalize effective QA approaches.

2. Role of QA in MNCH/FP/N Programs – Conceptual Framework

Despite the impressive reduction in the maternal and child mortality rates in Bangladesh, there are still unacceptable numbers of women, newborns, and children deaths every year. These deaths occur even though proven interventions are available to prevent or treat most causes of maternal, newborn and child mortality. Such interventions have contributed to reducing maternal and child mortality through health facility and community services. However, gaps in endorsing, scaling up, or implementing such life saving interventions continue to hamper the national effort to achieve further reduction in maternal, newborn, and child mortality. Hence, quality assurance interventions have an important role to play to identify and analyze the root causes of such gaps and implement intervention to close them. The gaps for achieving further reduction in maternal, newborn, and child mortality can be summarize into three main categories:

Gap 1: The evidence-based interventions proved to contribute to maternal, newborn, and child mortality reduction are not adopted in National health policies, standards, and guidelines (standards not up to date). Example: Standards for maternal care do not include calcium tablets as part of ANC to prevent pre- eclampsia. Gap 2: The evidence-based interventions are not implemented at a large scale (low coverage). Example: Misoprostol application for reducing post-partum hemorrhage for home deliveries is included in the national standard guidelines, but its implementation is limited.

Gap 3: The evidence-based interventions are not provided effectively and hence do not produce the desired impact in mortality reduction (low quality). Example: ANC coverage is high, yet blood pressure is not measured in every ANC visit.

MaMoni HSS Project – Quarterly Report FY14 Q2 39 The figure below summarizes the potential role of QA interventions in closing the three main gaps and consequently increasing MNCH/FP/N health outcomes. Conceptual Framework: The Contribution of QA Interventions to Increasing Health Outcomes

Evidence –based high National health Coverage of impact preventive & policies, standards evidence-based curative and guidelines interventions interventions in MNCH, FP, N

Gap 1: Evidence-based interventions Gap 2: Low coverage of evidence-based Gap 3: Implemented programs don’t

are not adopted in national health interventions have desired impact policies, standards & guidelines

Possible QA Response Possible QA Response Possible Causes Causes Causes

*Evidence not *Effective *Inadequate *Advocacy for more *Poor clinical well communication and financial resources; explore knowledge and communicated advocacy resources additional health skills financing schemes *Slow process of *Efficient process of *Poor monitoring adopting/ updating health *Inadequate *Advocate filling and evaluation updating health policies human resources vacant posts, task policies shifting; NGO & private sector *In effective *Updated national *Efficient process of engagement; supervision policies are not updating & sharing incentives reflected in standards & clinical standards guidelines *Inadequate *Improve drug & *Poor utilization & guidelines essential drugs supply procurement, of data and supplies distribution, *Health workers *Orientation/training management & *Weak are not familiar of health workers on promote rational use community with updated updated guidelines involvement guidelines

MaMoni HSS Project – Quarterly Report FY14 Q2 40

3. MaMoni HSS’ Main QA Interventions by Level

National Level 1. Develop and maintain an active communication channel with relevant “line directors” at the MoH&FW, particularly Director General Family Planning (DGFP) and Director General for Health Services (DGHS). 2. Provide technical assistance to the MOH&FW in developing a comprehensive national QA framework for MNCH/FP/N programs. 3. Contribute to harmonizing QA approaches. 4. Advocate for endorsing state-of-the art national health standards based on the latest scientific evidence and advocate for a higher profile for QA efforts for MNCH/FP/N programs. 5. Build the capacity of national counterparts at all levels to play a leadership role as QA agents in their corresponding institutions.

District Level 1. Build the capacity of relevant district staff in QA. 2. Develop and support RRQAT. 3. Support MoH&FW in conducting Maternal and Perinatal Death Audit (MPDA). 4. Conduct competency-based and focused in-service training program: The project will organize refresher training focused on key MNCH/FP/N services to service providers in the project’s covered districts. The training will be focused on improving the competency and skills of service providers in performing essential services.

Health Facility Level MaMoni HSS Project will apply a focused QA program at the health facility level aiming to improve crucial MNCH/FP/N services that, if provided with high quality, should contribute to reducing maternal, newborn, and mortality. In implementing the QA program at the health facility level, the project will apply the following guiding principles:  Focus on improving crucial MNCH/FP/N services.  Apply simple QA concepts and tools. The process of measuring gaps, applying interventions to closing them, and measuring results is a continuous process that should be institutionalized within the district health system to achieve improvement in key MNCH/FP/N indicators and beyond. The figure below presents a simplified core QA concept.

MaMoni HSS Project – Quarterly Report FY14 Q2 41

Core Quality Assurance Concept

4. Quality Assurance Approaches Applied at Health Facility and Community and their Links

MaMoni HSS will apply a combination of a simplified Standardbased Management and Recognition (SBM-R), modified Joint Supervisor Visits (JSV) approach, and selected concepts from the Partnership Defined Quality (PDQ) approach. While implementing different QA approaches, the project will ensure that all applied approached are focused on improving the same pre-selected key MNCH/FP/N indicators. In addition, the project will use the same content of tools, training approach, job aids, and improvement recognition schemes across all included health facilities. The graph below presents the main QA approaches that will be applied.

Critical Indicators

Health Facility Assessment tools

JSV Training & job aids SBM-R

Recognition schemes

Community

PDQ

MaMoni HSS Project – Quarterly Report FY14 Q2 42  Use existing structures.  Apply most suitable QA tools and approaches.  Focus on governmental health facilities particularly at the Upazila and Union levels.  Realize the special needs of district hospitals.  Focus on governmental health facilities while realizing the special needs of private hospitals/clinics.

Community level

 Support Union level facilities in conducting quality MNCH/FP/N community services.  Strengthen the link between health facilities and community.

5. Monitoring and Evaluation of QA Interventions

 Quality Indicators: As mentioned above, the MaMoni HSS Project will focus on improving crucial MNCH/FP/N services. To monitor achieving results, the project will develop a list of key quality indicators that will be measured regularly. The indicators will be selected within the overall Performance Monitoring Plan (PMP) of the project and in coordination with the Standard Operating Procedures (SOP) recently developed for maternal and newborn health.

 Drug Supplies and Commodity Management Indicators: The project will also monitor, mainly through the existing Logistics Management Information System (LMIS), the status of the availability of essential drugs and commodities and will partner with stakeholders at different levels to avoid stockouts.

 Sources of Data: Data needed for monitoring the improvement of the selected key quality indicators will be obtained within the overall MIS for the MaMoni HSS Project. Some of the data will be obtained through the existing MOH&FW sources. However, supplementary data collection will be needed to measure the quality indicators currently not measured by the existing sources.

 Capacity Building for Data Utilization: the process of collecting, interpreting and using data is an integral part of QA. The project will put special emphasis in building the capacity of counterparts at all levels to interpret data and use results for taking action to solve problem and achieve further quality improvement.

MaMoni HSS Project – Quarterly Report FY14 Q2 43  Data Validation: The project will take measures to verify the accuracy of data collected to measure the different performance indicators.

6. MaMoni HSS Project QA Counterparts

The main counterparts for the project in the area of QA include:

 National Level: The project will partner with MOH&FW DGFP and DGHS and provide support to existing QA structures such as the QA Steering Committee and the QA working groups formed at both DGFP and DGHS. In addition, the project will partner with international organizations active in the area of QA for MNCH/FP/N services such as WHO, JICA, and GIZ.

 Regional/District Level: The project will partner with Regional Roaming QA teams, the district leadership including Civil Surgeon, Deputy Director Family Planning (DDFP), district level supervisors, and district level trainers. The project will also include active NGOs and professional associations as deemed suitable in each district.

 Service Providers: Health facility staff such as doctors, nurses, midwives, and other paramedics are considered counterparts in the QA process. The project will build their interest and capacity in implementing and measuring QA approaches in their own health facility.

7. Operationalizing the Quality Assurance Framework

As mentioned above, MaMoni HSS Project will apply multiple QA approaches including SBM-R, JSV, and PDQ to improve the quality of crucial MNCH/FP/N services at the health facility and strengthen the health facility-community link. A specific implementation schedule will be developed in consultation with district leaders and MaMoni HSS district teams for scaling up the implementation of QA approaches. The key next steps for operationalizing the MaMoni HSS QA framework will include: 1. Establish contact with relevant national level “line directors” to seek their understanding, support, and involvement in MaMoni HSS QA activities. 2. Conduct orientation meetings with district level health leaders, managers, and service providers on QA approaches. 3. Initiate the implementation of SBM-R in selected health facilities in Habigani, Noakhali, and Lukipur. 4. Prepare tools and introduce supportive JSV in selected heath facilities in Habiganj, Noakhali, and Lukipur. 5. Assess current status of the implementation of the MPDA and facilitate its implementation in selected districts. MaMoni HSS will focus on utilizing the

MaMoni HSS Project – Quarterly Report FY14 Q2 44 results of the death audits to identify gaps in quality of care and support taking measures to close such gaps to avoid future mortality. 6. Prepare and initiate the implementation of competency-based training on key MNCH/FP/N areas.

The table below summarizes the project’s QA interventions by level and service delivery point. Level QA Intervention National Advocacy for QA, involvement and support of key “line managers” of MOH&FW. Advocate for endorsing state-of-the-art MNCH/FP/N standards. District Advocacy and capacity building of district level health managers on QA. Support implementation and utilization of results of MPDA. Conduct competency-based refresher training in key MNCH/FP/N. Develop and support RRQAT. Apply SBM-R in selected health facilities. Introduce and apply supportive JSV.

District Improve quality of selected services Hospital Upazila & Improve quality of key MNCH/FP/N services through SBM-R, Union Health JSV, and competency based refresher training. Facilities Community Improve the quality of key community MNCH/FP/N services through supporting union level facilities in conducting quality community services. Improve link between community and health facilities.

MaMoni HSS Project – Quarterly Report FY14 Q2 45 Annex 7: Case Studies

Union Parishad Chairman Sets Up Paramedics Workspace to Ensure Better Service Coverage Haim Char Village, Dhansiri Union, , , :

Dhanshiri is a newly declared union without a Union Health & Family Welfare Centre nor a Family Welfare Visitor to provide maternal health services. The people of the union either go to Companiganj or Upazila not less than 30 Pervez Alam, Union Parishad Chairman visits the paramedic’s kms away to receive room at the UP building. Rebena Khatun, paramedic working at her desk. health services. During the rainy season the Photo Credit: Wakarul Haque Nazvi, District Coordinator, MaMoni HSS Project roads become muddy and the commute to a health centre is extremely difficult for a pregnant or lactating mother. This previously deprived them from receiving the required antenatal, postnatal and newborn care services and deliveries were conducted at home in the hands of unskilled traditional birth attendants (TBAs).

Pervez Alam Buiyan, the Union Parishad Chairman is a kind man and dedicated to serve his community. On his own initiative in 2011 he had saved a mother with eclampsia befor labor by arranging her transport and travel to Maijdee General Hospital on a rainy night from his village. Previously the union had lacked a Union Parishad (UP) building but recently a tin shade building was rented on the UP premises. Paramedic Rebena Khatun was deployed by MaMoni Health Systems Strengthening Project3 to provide services in Dhansiri Union to mothers and their newborns. As the demand for her services in the community grew since December 2013, Pervez Alam considered the need for the quality services she was providing and was allocated a room for her in the UP building also donating required furniture such as a table, chair, bench and bed to serve the people who came to her.

3 USAID-supported MaMoni HSS collaborates with the government of Bangladesh to provide technical expertise and credibility in the field of MNCH/FP/N, It is led by Jhpiego, and managed in-country by Save the Children and MCHIP consortium partners John Snow Inc (JSI) and Johns Hopkins University, Institute for International programs (JHU/IIP). Local technical partners are ICDDR.B, BSMMU and DNet. The Project in Noakhali is implemented by local NGOs RIC, BEES and DORP.

MaMoni HSS Project – Quarterly Report FY14 Q2 46

Until the time the UP Chairman and members of the UP received orientation on maternal, newborn health, family planning and nutrition (MNHFP-N) services from MaMoni, they were not aware of the importance of antenatal and postnatal care nor aware of all essential newborn care related components. They had never seen a health service provider in their community till Rebena started her work there. Pervez considered Rebena as an asset for Dhansiri and took steps to provide her with work space. Currently the Union Parishad is negotiating with the Upazila Health and Family Planning Officers for MNHFP-N realted budget allocation for the Union. Since December 2013, Rebena has provided 692 general services, 367 child health, 573 antenatal care, 84 postnatal care service, 722 counseling sessions on family planning, and altogether conducted 29 satellite spots.

Community Health Worker Mishu Rani, Goes Above and Beyond Her Call of Duty to Save Newborns

Kalinji Village, Nijpat Union, Jaintapur Upazila, Sylhet District: Chandra Ban, 30 gave birth to twin babies, a girl and a boy, at home on 10 July, 2013. A Community Health Worker by the name of Mishu Rani Dhar visited Chandra twice to provide antenatal care. Mishu Rani was informed an hour later of the babies’ delivery by a TBA and rushed over with another health worker and a paramedic to provide postnatal counseling and assess the condition of the babies. After assessment it was found that the babies showed signs of birth asphyxia and weighed 1700 grams only, obvious danger signs that implied a high level of risk. The health workers urged Chandra Ban and her husband Abdul Jalil to take their newborns to the Jaintapur UHC where the Special Care Newborn Unit (SCANU) operated successfully. However a combination of cultural beliefs, superstitions and ignorance kept the couple from seeking services from the SCANU. Photo: Chandra Ban and her husband with their newborns before leaving the SCANU

Photo Credit: Muhibul

MaMoni HSS Project – Quarterly Report FY14 Q2 47 The MaMoni Project supported by USAID and implemented by Save the Chandra Ban was not able to tend to her family members after the birth of the Children in Bangladesh and local NGOs newborns. During the week that started from Shimantik and FIVDB, set up the the birth of the babies to the journey to the SCANU with special support from SCANU, Mishu Rani Dhar went far beyond in KOICA and Save the Children Korea, at her efforts and in her plight, to persuade the the Jaintapur UHC. This is a family and save the babies. government owned facility, and for the first time this intervention is available Mishu Rani expresses, ‘I wanted to save the at the sub-district level in Bangladesh. newborns. For a week we tried to convince the family to take them to the SCANU. I This was established with a full set of cooked for them, fed them and did all I equipment for effective management of could. My husband is also very supportive. pre-term babies, babies with low birth He told me not to worry about him and weight as well as birth asphyxia. The think about his meals, but instead go and pediatric department of Sylhet MAG do my job the best I could. After all this Osmani Medical College Hospital effort, if any newborn dies, there is a provides technical assistance to the feeling of tremendous loss’. doctors and nurses providing care in the SCANU. The purpose of this facility is to reduce neonatal mortality in an already low to moderate newborn mortality setting. Jaintapur is a low newborn mortality area where neonatal mortality rate is stagnant even after 3 years of intervention that focused mainly on behavior change.

When Mishu Rani and her colleagues attempt failed to convince the couple for referral, they spoke to MaMoni field staff, who spoke to community action group members and requested them to help. At one point, they all gave up but the head imam of the mosque and a community volunteer intervened and explained to Abdul Jalil once again the risk the newborns were exposed to. Jalil understood but he and his wife could not go to the SCANU leaving behind four other children alone at home. Therefore on the 17th of July, Mishu Rani took quick action and with the help of MaMoni staff, she took the babies to the pick-up point, and then by boat reached the upazila level SCANU. The babies were treated for five days in the facility before being released.

MaMoni HSS Project – Quarterly Report FY14 Q2 48 Annex 8: Performance Indicators (October 2013-March 2014) 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Modern contraceptive method use rate Percent Coverage will be reported on annual basis Lakhsmipur DHSS 2013 48.2 49.2 Noakhali DHSS 2013 44.4 45.4 Habiganj MaMoni 2012 40.6 42.6 Bhola DHSS 2013 54.4 55.4 Jhalokathi BMMS 2010 47.0 48.0 Baseline and targets will be revised in Q4 Pirozepur BMMS 2010 48.0 49.0 Baseline and targets will be revised in Q4 Brahmanbaria BMMS 2010 35.0 36.0 Baseline and targets will be revised in 2015 Couple-years of protection (CYP) in USG- Couple- supported programs years Lakhsmipur 2013 158,305 174,135 73,397 Noakhali 2013 214,571 236,028 106,059 Habiganj 2013 166,771 183,448 81,676 Bhola 2013 229,705 252,675 To start in Q3 Jhalokathi 2013 73,814 81,196 To start in Q3 Pirozepur 2013 122,977 135,274 To start in Q3 Brahmanbaria - - To start in 2015 Total 966,143 1,062,756 261,132

MaMoni HSS Project – Quarterly Report FY14 Q2 49 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) Percent of women attended at least once Percent Coverage will be reported on during pregnancy by skilled health annual basis personnel for reasons relating to pregnancy Lakhsmipur DHSS 2013 60.1 61.6 Noakhali DHSS 2013 52.1 53.6 Habiganj MaMoni 2012 41.1 45.1 Bhola DHSS 2013 44.3 45.3 Jhalokathi BMMS 2010 48.1 49.1 Baseline and targets will be revised in Q4 Pirozepur BMMS 2010 47.1 48.1 Baseline and targets will be revised in Q4 Brahmanbaria BMMS 2010 40.7 41.7 Baseline and targets will be revised in 2015 Percent of deliveries attended by an SBA Percent Coverage will be reported on annual basis Lakhsmipur DHSS 2013 34.0 35.5 Noakhali DHSS 2013 33.4 34.9 Habiganj MaMoni 2012 19.4 21.4 Bhola DHSS 2013 21.7 22.7 Jhalokathi BMMS 2010 28.1 29.1 Baseline and targets will be revised in Q4 Pirozepur BMMS 2010 24.1 25.1 Baseline and targets will be revised in Q4 Brahmanbaria BMMS 2010 22.8 23.8 Baseline and targets will be revised in 2015 Percent of newborns that received Percent Coverage will be reported on

MaMoni HSS Project – Quarterly Report FY14 Q2 50 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) essential newborn care annual basis Lakhsmipur DHSS 2013 0.4 5.0 Noakhali DHSS 2013 0.4 5.0 Habiganj MaMoni 3.9 5.0 20124 Bhola DHSS 2013 0.4 4.0 Jhalokathi BDHS 2011 3.2 4.0 Baseline and targets will be established in Q4 Pirozepur BDHS 2011 3.2 4.0 Baseline and targets will be established in Q4 Brahmanbaria BDHS 2011 3.2 4.0 Baseline and targets will be established in 2015 Percent of newborns initiated Percent This indicator is newly breastfeeding within one hour of birth included in the PMP. Coverage will be reported on annual basis Lakhsmipur DHSS 2013 52.6 55 Noakhali DHSS 2013 53.1 55 Habiganj MaMoni 2012 64.7 66 Bhola DHSS 2013 70.7 72 Jhalokathi BDHS 20115 43.6 55 Baseline and targets will be established in Q4 Pirozepur BDHS 2011 43.6 55 Baseline and targets will be established in Q4

4 Since data on all components of essential newborn care was not collected at baseline, immediate drying and wrapping is used as a proxy for essential newborn care 5 All data from BDHS are Divisional estimates

MaMoni HSS Project – Quarterly Report FY14 Q2 51 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) Brahmanbaria BDHS 2011 46.2 50 Baseline and targets will be established in 2015 Percent of newborns that received Percent Coverage will be reported on postnatal check-up within 48 hours of annual basis delivery from a medically trained provider Lakhsmipur DHSS 2013 12.1 13.6 Noakhali DHSS 2013 10.5 12.0 Habiganj MaMoni 2012 17.8 19.8 Bhola DHSS 2013 6.8 7.3 Jhalokathi BDHS 2011 21.0 22.0 Baseline and targets will be revised in Q4 Pirozepur BDHS 2011 21.0 22.0 Baseline and targets will be revised in Q4 Brahmanbaria BDHS 2011 23.9 24.9 Baseline and targets will be revised in 2015 Prevalence of exclusive breastfeeding of Percent BDHS 2011 36.3 - This indicator will be children under six months of age (among 4- measured only through 5 month olds) national surveys Percent of women with home births who Percent Baseline and targets for all consumed misoprostol to prevent PPH districts will be established in 2015 Lakhsmipur NA Noakhali NA Habiganj NA Bhola NA Jhalokathi NA Pirozepur NA

MaMoni HSS Project – Quarterly Report FY14 Q2 52 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) Brahmanbaria NA Intermediate Result 1: Improve service readiness through critical gap management Number of (USG-supported) MNCH Number 2013 690 1,595 923 service delivery points that have integrated at least one other type of service Number of USG-supported service delivery Number 2013 221 354 221 points providing both short acting and LA/PM services Sub-IR 1.1: Increase availability of health service providers Percent of vacant positions filled by non- Number 162 / 250 162 / 250 Positions of FWV, FWA, GOB health workers (64.8%) (64.8%) nurses and support staff Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in Number maternal/newborn health through USG- supported programs Female 5,889 321 Male 2,944 134 Total 8,834 455 Number of people trained in FP/RH with Number 526 Female: 22 USG funds Number of people trained in child health Number 424 - and nutrition through USG-supported programs Number of people trained in newborn Number Female: Female: 1,815 Total cumulative up to resuscitation through USG-supported 11,127 Male: 195 March 2014 is 23,579 programs Male: (including those trained 1,236 under MCHIP field support funded training)

MaMoni HSS Project – Quarterly Report FY14 Q2 53 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) Number of targeted facilities with Percent 354 The project did not support providers trained in IMCI through USG- any IMCI training in the supported programs quarter Percent of service providers trained on Percent 93 773 Female: 22 The target is based on total Standards-Based Management and Male: 25 number of service providers Recognition (SBM-R) methodology in 3 districts Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization Number of USG-supported facilities that Number provide appropriate lifesaving maternity care BEmONC 2013 15 41 15 CEmONC 2013 7 19 7 Number of targeted facilities that have Number 22 60 22 essential components to provide safe delivery services Number of targeted facilities that have Number 2013 22 60 22 essential components to provide essential newborn care Number of targeted facilities that have Number 2013 215 436 215 essential component to provide family planning services Intermediate Result 2: Strengthen health systems at district level and below Sub-IR 2.1: Improve leadership and management at district level and below Percent of targeted facilities that received Percent 31 (Plan: 48) Data for March not included. a supervision visit in the reporting quarter where an essential action was performed Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of districts with GOB and NGO Number 0 6 3

MaMoni HSS Project – Quarterly Report FY14 Q2 54 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) HR mapping updated yearly Percent of vacant positions filled through Percent NA NA NA reorganization and task shifting of HR within the public sector6 Sub-IR 2.3: Strengthen local management information systems Number of upazilas that used population- Number 0 40 22 level measures (estimates) for key MNCHP/FP/N indicators during periodic review Percent of targeted facilities using Percent 345 42 36 computers to process service data Percent of targeted facilities that scored at Percent NA 208/436 0 Not yet started least 80% on their RDQA (50%) Sub-IR 2.4: Establish quality assurance system at district level and below Percent of targeted facilities scoring at Percent 0 22 0 least 90% on SBM-R performance score Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Number of USG-assisted service delivery Number NA 0 NA DGFP/LMIS by SDP is being points (SDPs) experiencing stock-outs of piloted in five upazilas of specific tracer drugs (MNCH & FP) Lakhsmipur with support from USAID/SIAPS. Will report from Q3. Intermediate Result 3: Promote enabling environment to strengthen district level health system 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 Number 3 1 on MNH developed/revised with MaMoni HSS support

6 We propose to drop this indicator from the PMP while finalizing the M&E Plan

MaMoni HSS Project – Quarterly Report FY14 Q2 55 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program Number of MNCH/FP/N advocacy Number 4 1 initiatives held in reporting quarter Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA in USG- Number 2013 54,444 71,042 19,074 assisted programs Number of antenatal care (ANC) visits by Number 2013 259,041 361,998 186,570 skilled providers from USG-assisted facilities Number of newborns receiving essential Number 2013 54,444 71,042 19,074 newborn care through USG-supported programs Number of babies who received postnatal Number 2013 87,395 114,286 19,074 care within 2 days of childbirth in USG- assisted programs Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Percent of newborns with bath delayed at Percent Coverage will be reported on least 72 hours after birth annual basis Lakhsmipur DHSS 2013 31.6 35.0 Noakhali DHSS 2013 36.7 40.0 Habiganj MaMoni 2012 59.7 62.0 Bhola DHSS 2013 37.7 40.0 Jhalokathi BDHS 2011 37.3 40.0 Baseline and targets will be revised in Q4 Pirozepur BDHS 2011 37.3 40.0 Baseline and targets will be revised in Q4 Brahmanbaria BDHS 2011 23.3 - Baseline and targets will be

MaMoni HSS Project – Quarterly Report FY14 Q2 56 2014 Actual (Cumulative Unit of Baseline Baseline 2014 Indicator through Remarks Measure Year Value Target March 31, 2014) revised in 2015 Number of women reached with education Number 68,016 71,042 19,074 on exclusive breastfeeding Number of counseling visits for FP/RH as a Number result of USG assistance Female 6,185,545 2,370,874 Male 83,017 23,948 Total 6,268,562 2,394,822 Sub-IR 4.2: Strengthen local government planning and engagement in health service provision Percent of Union Parishads (UPs) in a Percent 477 68 / 226 district that allocated budget for (100%) (30.1%) MNCHP/FP/N in the current year Sub-IR 4.3: Improve local governance and oversight for MNCH/FP/N Percent of Union Parishads (UPs) in a Percent 72 477 25 / 226 district that have active Health and (100%) (11%) Family Planning Standing Committees Sub-IR 4.4: Enhance community engagement in addressing health needs Number of Community Action Groups with Number 2,126 5,212 2,215 an emergency transport system for maternal and newborn health care through USG-supported programs Number of Community Action Groups with Number 1,890 5,197 1,978 an emergency financing system for maternal and newborn health care through USG-supported programs

MaMoni HSS Project – Quarterly Report FY14 Q2 57