USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM Mahefa Miaraka
Cooperative Agreement No. AID-687-A-16-00001
FY2020 Quarter 2 Progress Report January 1 to March 30, 2020 Re-submitted: September 17, 2020
USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report ii
USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka
FY2020 Quarter 2 Progress Report January 1 to March 30, 2020 Re-submitted: September 17, 2020
Cooperative Agreement No. AID-687-A-16-00001
Submitted to: Dr. Andry Rahajarison, AOR USAID/Madagascar in Antananarivo, Madagascar
Prepared by: JSI Research & Training Institute, Inc. USAID Community Capacity for Health Program – Mahefa Miaraka Résidence Lavalley Près Lot IIK 50H Mahatony Alarobia, Antananarivo (101)
Tel: 20.22.425.78/ 79
Cover photo: Training of youth peer educators with their coaches, Maintirano Middle School, Melaky Region
Photo credit: Mahefa Miaraka Team, Melaky
DISCLAIMER: This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the responsibility of JSI Research & Training Institute, Inc. (JSI) and do not necessarily reflect the views of USAID or the United States Government.
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report iii Table of Contents
Executive Summary of Achievements in Q2 FY2020 ...... 7 Introduction………………………………… ...... 9 Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services…………………… ...... 10 Sub IA 1.1 Increasing CHV Skills and Competencies in Priority Interventions ...... 10 Sub IA 1.2 Sustainability of the CHV Model ...... 28 Sub IA 1.3 Strengthening of Community Structures to Improve Health and Sanitation Planning ...... 28 Sub IA 1.4 Promoting Universal Health Care Access and Coverage, Micro-finance Insurance, and Health Evacuation Activities ...... 29 Intervention Area 2 (IA2): Behavior Change and Health Promotion ...... 31 Sub IA 2.1. Community-level Health Promotion and Sensitization to Increase Healthy Behaviors and Uptake of Health Services and Products ...... 31 Sub IA 2.2 Community-level Health Promotion to Increase Health Behaviors, Update of Health Services and Products, and Advocate for Improved Services ...... 33 Sub IA 2.3 Innovations to Promote Adolescent and Youth Health ...... 37 Intervention Area 3 (IA3): Health Service Planning, Management, and Governance ...... 38 Sub IA 3.0 Strengthening of GOM Capacity ...... 38 Sub IA 3.2. Pharmaceutical and Commodity Forecasting ...... 40 Sub IA 3.3. Health Data Quality, Management, and Use ...... 40 Sub IA 3.4. Referral System Strengthening between CHVs and CSBs ...... 41 Intervention Area 4 (IA4): Monitoring and Evaluation, Learning Management, and Cross-Cutting Issues…………...... 42 Sub IA 4.1 Program Monitoring, Evaluation, and Performance System ...... 42 Sub IA 4.2 Learning Management ...... 45 Sub IA 4.3 Cross-Cutting Issues ...... 47 Intervention Area 5 (IA5): Reducing Child Marriage and related Reproductive Morbidity and Mortality among High-Risk and Married Girls in Sofia, Menabe and DIANA regions of Madagascar………………………...... 48 Recruitment and Staffing ...... 48 Introduction and Orientation with GOM and Community Partners ...... 49 Formative Research ...... 50 Challenges and Proposed Solutions for Q2 FY2020 ...... 52 Administrative and Financial Management ...... 53 Sub IA 0.2 Administration ...... 53 Sub IA 0.3 Financial Management ...... 54
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report iv List of Tables
TABLE 1– NUMBER OF PNSC MEMBERS TRAINED ON COMMUNITY HEALTH, Q2 FY2020 ...... 11 TABLE 2– READINESS OF CHVS IN THE PROGRAM REGIONS, Q2 FY2020 ...... 11 TABLE 3– CHV REFRESHER CLINICAL TRAINING BY THEME Q1& Q2 FY2020 ...... 13 TABLE 4– CHV REFRESHER TRAINING ON WASH, COMMUNICATION, COMMUNITY MOBILIZATION, AND COMMODITY AND INFORMATION MANAGEMENT, Q1& Q2 FY2020 ...... 14 TABLE 5– SUPERVISION OF CHVS BY TYPE OF SUPERVISOR, Q2 FY2020 ...... 15 TABLE 6 – REFERRAL OF WRA AND CU5 CASES FROM CHVS TO CSBS IN Q2 FY2020 ...... 18 TABLE 7– CHV MALARIA SERVICES BY REGIONS IN Q2 FY2020 ...... 22 TABLE 8 – AVERAGE RATE OF REPORTED STOCKOUTS OF CHILD HEALTH COMMODITIES BY CHVS, Q3 FY2019 – Q2 FY2020 BY PRODUCT TYPE (N = 3,939 FKT) ...... 24 TABLE 9 – AVERAGE RATE OF REPORTED FOKONTANY STOCKOUTS FOR MALARIA PRODUCTS BY REGION, Q2 FY2020 ...... 25 TABLE 10- PRESENCE OF FP METHODS POSTER AND CLIENT RIGHTS POSTER, Q2 FY2020 ...... 26 TABLE 11- OVERVIEW OF BICYCLE SALES PER EBOX COOPERATIVE Q2, FY2020...... 27 TABLE 12 – NUMBER OF PEOPLE REACHED ON KEY HEALTH AND WASH MESSAGES BY CHVS, Q2 FY2020 ...... 33 TABLE 13 – NUMBER OF PEOPLE REACHED ON KEY HEALTH AND WASH MESSAGES THROUGH RADIO BROADCASTS, Q2 FY2020 ..34 TABLE 14 – PROGRAM PARTICIPATION IN THE HEALTH AND WASH DAYS CELEBRATIONS, Q2 FY2020 ...... 34 TABLE 15 - TRAINING OF TRAINERS RECEIVED BY MOH OFFICIALS, Q2 FY2020 ...... 40 TABLE 16: NUMBER OF DQA CONDUCTED BY TYPE OF AUDITOR, Q1 AND Q2 FY2020 ...... 43 TABLE 17: TYPE OF CHV MONTHLY REPORT DATA ERRORS ...... 43 TABLE 18: TRIANGULATION OF CHV MONTHLY REPORT INDICATORS ...... 44 TABLE 19 – PROGRAM’S CUMULATIVE EXPENSES AS OF MARCH 31, 2020 ...... 54
List of Figures
FIGURE 1- MAHEFA MIARAKA’S REGIONS AND DISTRICTS ...... 9 FIGURE 2 - CHVS TRAINED IN CASE MANAGEMENT AND SERVICE DELIVERY TOPICS, Q2 FY2020 ...... 13 FIGURE 3 - CHVS TRAINED IN SBCC, WASH, COMMODITY AND DATA MANAGEMENT, Q2 FY2020 ...... 14 FIGURE 4- CU5 RECEIVING GROWTH MONITORING SERVICES FROM CHVS: Q1AND Q2 2020 (BY TYPE) ...... 16 FIGURE 5 - NUMBER OF CU5 CASES DIAGNOSED AND TREATED BY CHVS: Q4 2019 – Q2 FY2020 (BY DISEASE) ...... 17 FIGURE 6 - NUMBER OF GIRLS AND WOMEN USING FAMILY PLANNING SERVICES FROM PROGRAM CHVS, BY AGE GROUP, Q2 FY2020 ...... 19 FIGURE 7 - NEW FAMILY PLANNING USERS IN THE PROGRAM, BY AGE GROUP, Q2 FY2019 COMPARED TO Q2 FY2020 ...... 19 FIGURE 8 – TREND IN INJECTABLE CONTRACEPTIVES DISTRIBUTED FROM Q1 2019 TO Q2 2020 ...... 20 FIGURE 9 - COUPLE YEARS OF PROTECTION BY FAMILY PLANNING METHODS, Q2 FY2020 ...... 20 FIGURE 10- COMPARISON OF CHV MALARIA SERVICES, Q2 FY2019 AND Q2 FY2020...... 23 FIGURE 11- CHV-REPORTED STOCKOUT RATES OF FP TRACER PRODUCTS, Q2 FY2020 (N = 3,939 FKT) ...... 25 FIGURE 12 - CHV PERMANENT HEALTH HUTS BUILT AND IMPROVED, Q2 FY2020 (SINCE PROGRAM START) ...... 27 FIGURE 13 – CHAMPION COMMUNES GOAL SETTING Q1 & Q2 FY2020 ...... 29 FIGURE 14- PEOPLE WHO RECEIVED KEY HEALTH MESSAGES IN Q2 FY2020 BY CHANNEL OF COMMUNICATION ...... 31 FIGURE 15 - PHOTO COLLAGE OF HIGH VISIBILITY EVENTS, Q2 FY2020 ...... 35 FIGURE 16 - PHOTO COLLAGE OF HIGH VISIBILITY EVENTS, Q2 FY2020 ...... 35 FIGURE 17 - PHOTO COLLAGE OF HIGH VISIBILITY EVENTS, Q2 FY2020 ...... 36 FIGURE 19 – PERCENTAGE OF CSB REPORTS SUCCESSFULLY SUBMITTED IN DHIS2, Q2 FY2020 ...... 42
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report v Acronyms and Abbreviations
ACT Artemisinin-based Combination Therapy ANC Antenatal care ASOS Action Socio-sanitaire Organisation Secours CCDS Commission Communale de Développement de la Santé (Commune Health Development Committees) CCHP Community Capacity for Health Program CEFM Child, early and forced marriage CHV Community Health Volunteer CHX Chlorhexidine c-IMCI Community-based Integrated Management of Childhood Illnesses CoSan Comité de Santé (Health Committee) COVID-19 The disease caused by a new coronavirus that began infecting humans in 2019 CSB Centre de Santé de Base (Basic Health Center) CSC Community Score Card CU5 Children Under 5 DHIS2 District Health Information System 2 DPEV Direction du Programme Elargi de Vaccination (Directorate of Expanded Program on Immunization) DPLMT Directorate of Pharmacies, Laboratories and Traditional Medicine DRSP Direction régionale de la santé publique (Regional Public Health Directorate) DSFa Direction de la Santé Familiale (Directorate of Family Health) DQA Data Quality Audit DVSSER Direction of Health Monitoring, Disease Control and Response EMAR Equipe de management régionale (Regional Health Management Team) EMAD Equipe de management de district (District Health Management Team) EMMP Environmental Mitigation & Monitoring Plan EPI Expanded Program on Immunizations FHI 360 Family Health International 360 FKT fokontany (village or collection of hamlets, lowest administrative level) FP/RH Family Planning/Reproductive Health GAS-D District Supply Inventory Management Committee (Comité de Gestion des Approvisionnement et de Stock District) GBV Gender-Based Violence GOM Government of Madagascar HMIS Health Management Information System IA Intervention Area IEC Information, Education, and Communication IPTp-SP Intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine JSI JSI Research & Training Institute, Inc. KMSm Kaominina Mendrika Salamamiabo (Champion Communes for Health) LARC Long-Acting Reversible Contraceptives LLIN Long-Lasting Insecticide-Treated Net M&E Monitoring and evaluation MEAH Ministère de l’Eau, l’Assainissement et l’Hygiène (Ministry of Water, Sanitation and Hygiene) MOE Ministry of Education MOH Ministry of Health (Ministère de la santé publique) MPPSPF Ministry of Population, Social Protection and Women‟s Promotion (Ministère de la Population, de la Protection Sociale et de la Promotion de la Femme) MYS Ministry of Youth and Sports ODF Open Defecation Free PLGHA Protecting Life in Global Health Assistance PDSS Plan de Développement du Secteur Santé (Health Sector Development Plan) PhaGDis Pharmacie de gros district (District Pharmacy)
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report vi PhaGeCom Pharmacie à gestion communautaire (Community-managed Pharmacy) PMEP Performance Monitoring and Evaluation Plan PMI President‟s Malaria Initiative PNLP National Malaria Control Programme (Programme National de la Lutte contre le Paludisme) PNSC Politique Nationale de Santé Communautaire (National Community Health Policy) PSNRSC Plan Stratégique Nationale de Renforcement de la Sante Communautaire (National Strategic Plan on Strengthening Community Health) PSBI Possible severe bacterial infection RDT Rapid diagnostic test RED/REC Reaching Every District/Reaching Every Child RMA Rapport mensuel d’activités (Monthly Activity Report) RPGEM Réseau des Promoteurs de Groupes d’Épargne à Madagascar (Madagascar Savings and Loan Association Network) SBC Social Behavior Change SBCC Social Behavior Change Communication SDSP Service de District de la Santé Publique (District Health Office) SM Safe motherhood TOT Training of Trainers UNFPA United Nations Population Fund UNICEF United Nations Children‟s Fund USAID United States Agency for International Development VSLA Village Savings and Loan Association WASH Water, Sanitation, and Hygiene WHO World Health Organization WRA Women of Reproductive Age YPE Youth Peer Educator
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report 7
Executive Summary of Achievements in Q2 FY2020
In Q2 FY2020, the USAID Community Capacity for Health (CCHP) Program continued strengthening Madagascar‟s community health activities and services in the Analanjirofo, Boeny, DIANA, Melaky, Menabe, SAVA and Sofia regions. From January 1 to March 31, 2020, 9,111 community health volunteers (CHVs) provided services to a total of 453,703 children under five (CU5) and 369,169 women of reproductive age (WRA). Due to the National Health Emergency declared on March 20, 2020 in the wake of the first confirmed coronavirus (COVID-19) case in Madagascar, several CHV monthly meetings did not take place, particularly in the Analanjirofo region, due to limits on the size of group gatherings. This had a negative impact on CHV reporting rates for March in some regions. Where possible, Mahefa Miaraka worked with local authorities to conduct activities as planned and collect missing reports. On average, 82 percent of CHVs successfully submitted their monthly activity reports to the CSBs this quarter.
The following highlights summarize the Program‟s main achievements in the quarter:
CHVs provided growth monitoring services for 290,686 CU5, managed 106,280 sick CU5, and referred 56,737 CU5 for vaccinations. CHVs tested 67,509 of 75,349 CU5 fever cases (90 percent) using rapid diagnostic tests (RDT), with 31,162 CU5 malaria cases treated (92 percent) out of 33,744 RDT positive cases. In addition, CHVs provided pre-referral treatment for severe malaria to 281 CU51. CHVs provided family planning (FP) services to 311,620 regular users (of which 36,981 or 12 percent were new users) and referred 57,549 women for antenatal care (ANC), vaccination, delivery, and long-acting reversible contraception (LARC). Sixty-two percent (192,240) of total regular family planning (FP) users are youth (10-24 years of age). Stockouts were slightly reduced or unchanged from the moderate or high levels reported in Q1 FY2020 for child health and family planning commodities: RDT at 14 percent, ACT infant and child formulations at 29 and 25 percent respectively, amoxicillin and zinc both at 35 percent, and oral pills and injectables at 16 and 12 percent respectively. Health risk pooling mechanisms - community micro-insurance and village saving loan associations (VSLA) - covered 37,482 people (cumulative since the beginning of the Program) with 127 people accessing funds for care during this quarter. Program-supported communities conducted 5,579 emergency evacuations using locally available transport (1,189 pregnant women, 3,301 CU5, and 1,089 others); 91 percent (4,465) of all program fokontany (FKT) having an emergency evacuation plan. Health messages reached an estimated 2,068,144 people through various communication channels. CHVs distributed 34,380 women‟s and children‟s health cards to families. 68,199 family planning invitation cards to new and regular users, of which 32,824 (48 percent), were distributed to young people under age 25. The program expanded its youth approach to 244 schools and 125 community youth organizations with 5,026 youth participating in experiential learning about sexual and reproductive health (SRH) and life skills. The vast majority (82 percent) of CHVs submitted monthly activity reports during the monthly meetings at basic health centers (centres de santé de base or CSB). 5,563 CHVs received combined supervision by Regional Health Management Teams (Equipe de Management Régionale or EMAR), District Health Management Teams (Equipe de Management de District or EMAD), and/or their local CSB or FKT heads.
1 National reporting tools provide information on cases tested, results, and cases treated. In terms of referral information, the Program is unable to determine cause for referral beyond “danger signs” and “other” as the national referral and counter referral tools do not provide specific information on malaria referrals. For the eight percent of CU5 RDT+ cases that did not receive treatment, the Program assumes that these children were referred to the local CSB for treatment per c-IMCI protocols. However, the Program is unable to provide confirmation.
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report 8
Program staff participated in 63 GOM-led technical meetings and working groups at the national, regional, and district levels. Recruitment and orientation of Program team members for reduction of Child, Early, and Forced Marriage activities was completed for the Program Manager and three regional teams (Menabe, DIANA, and Sofia). Introduction of the Program‟s proposed CEFM objectives and activities were welcomed by the Ministry of Population, Social Protection and Women‟s Advancement and regional governors as well as civil society and community members in the selected communities.
The main Program achievements during the reporting period are presented in detail in the main report according to the intervention areas (IAs), with Annexes 1 and 2 detailing the activities conducted and the Performance Plan Report (PPR) respectively. In addition, selected success stories are presented in Annex 3.
CCHP continues to use appropriate management, accountability and financial control systems, meeting JSI and USAID requirements. Please see the section on Administrative and Financial Management for information about these systems.
While this report highlights the Program‟s achievements from January 1 to March 31, 2020, the declaration of a National Health Emergency on March 20, 2020 after confirmation of the first COVID-19 case did not affect overall Program activities this quarter. However, school closures took effect immediately and put a stop to in-school youth peer educator activities, and a few CSB did not perform supervision of CHVs in communities as planned. The Program has shared its contingency plan with the AOR and AO and the Program‟s staff in Antananarivo began to work from home on March 24. Program staff actively participate in MOH response coordination meetings at the national, regional and district levels on COVID-19 response. Work and travel restrictions between and within the 7 regions and 34 districts vary. Due to travel restrictions to Madagascar, all planned expert technical support provided through short-term technical assistance (STTA) to Madagascar was postponed. All of the Program‟s technical staff and subcontractors continue providing long-distance high quality technical support.
In terms of the national COVID-19 response, USAID requested Mahefa Miaraka to submit two proposals to USAID/Madagascar on proposed response activities. The first proposal assumes a scenario where the Program would redirect some of its current funding to COVID-19 response activities. The second proposes COVID-19 activities under the assumption that additional funding becomes available.
At this time, the Program has put plans in place to ensure staff safety, maintain a safe working environment, and provide the necessary resources for staff to work from home where it is required. The Program will continue to keep the AOR and the AO informed of any disruptions to the implementation of the USAID Community Capacity for Health Program.
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report 9
Introduction
USAID awarded the five-year Cooperative Agreement (No. AID-687-A-16-00001) for the USAID Community Capacity for Health Program, locally known as Mahefa Miaraka, to JSI Research & Training Institute, Inc. (JSI) on June 6, 2016. JSI collaborates with three partners for the implementation of the Program: Action Socio- sanitaire Organisation Secours (ASOS), Family Health International 360 (FHI 360), and Transaid. The Program has two objectives and three intervention areas (IAs):
Objective 1. Strengthen public sector capacity to plan, deliver, and manage community health services Objective 2. Strengthen community engagement in health
IA 1. Community engagement and ownership of health services IA 2. Behavior change and health promotion IA 3. Health service planning, management, and governance
The Program reflects USAID‟s commitment to providing high-quality community health services that integrate with the formal health system; addressing key drivers of maternal, newborn, and child mortality; and responding to client needs while promoting the importance of community health in contributing to the Government of Madagascar (GOM) efforts to reduce maternal, newborn, and child mortality. The Program contributes directly to the USAID/Madagascar Health Population and Nutrition‟s Intermediate Results (IRs) 1 and 2 health sector strategy, for which the development objective is “Sustainable Health Impacts Accelerated for the Malagasy People.”
Mahefa Miaraka operates in a total of 4,885 fokontany (FKT), 456 communes, and 34 districts in the Analanjirofo, Boeny, DIANA, Melaky, Menabe, SAVA, and Sofia regions. The Program has the potential to provide services to approximately 6.6 million people, or 28 percent of the country‟s total population.
Figure 1- Mahefa Miaraka’s Regions and Districts
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report 10
Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services
Key Achievements: 1. 9,111 functional CHVs provided services to 453,703 CU5, including 290,686 CU5 for nutrition and growth monitoring, and 106,280 sick CU5. In addition, CHVs referred 56,737 CU5 for vaccinations. 2. CHVs tested 67,509 of 75,349 CU5 fever cases, or 90 percent, using RDT, with 31,162 CU5 malaria cases treated (or 92 percent) out of 33,744 RDT positive cases. 3. CHVs provided pre-referral treatment for severe malaria to 281 CU5. 4. CHVs provided FP services to 311,620 regular users (of which 36,981 or 12 percent were new users) and referred 57,549 women for antenatal care (ANC), vaccination, delivery, and long-acting reversible contraceptive (LARC) services. 5. Sixty-two percent (192,240) of total regular family planning (FP) users are youth. Among all regular FP users, girls between 10–14 years represent 6 percent (19,165); women 15-19 years of age 25 percent (77,421), women between 20-24 years of age 31 percent (95,654), and women 25 and above 38 percent (119,380) of regular users. 6. Slight reduction of family planning commodities stockouts compared to Q1 FY2020: injectables from 13 to 12 percent; and oral pills from 17 to 16 percent. 7. Similar levels of malaria commodities stockouts compared to Q1 FY2020: RDT at 14 percent compared to 13 percent in Q1; infant ACT at 29 percent compared to 39 percent in Q1; and child ACT at 25 percent compared to 26 percent in Q1. 8. Health risk pooling mechanisms (mutuelle de santé and VSLA) expanded to cover 37,482 as compared to 24,745 people in Q1FY2020, an increase of 51 percent. 9. Program-supported communities conducted 5,579 emergency evacuations using locally available transport for 1,189 pregnant women, 3,301 CU5, and 1,089 others.
USAID Community Capacity for Health, locally known as Mahefa Miaraka, aims to increase local capacity to support CHVs in delivering priority interventions across the continuum of care, as well as introducing new innovative interventions in FP and newborn care. The Program works through the structures established under the Politique Nationale de Santé Communautaire (National Policy for Community Health or PNSC). This arrangement enables the MOH regional, district, and commune departments to train CHVs, community leaders, and local officials to oversee community health activities.
Sub IA 1.1 Increasing CHV Skills and Competencies in Priority Interventions
1.1.1 Strengthen the capacity of PNSC members at the commune and FKT levels on CHV priority interventions
PNSC Coordination Committees. An important element of the Program‟s strategy to increase involvement and ownership of community health programs involves strengthening the established PNSC coordination committees. In Q2, the Program continued to build the capacity of PNSC members on community health approaches, their role and responsibilities under the PNSC, and the importance of collaboration with CSB. During this quarter, the Program oriented 3,167 PNSC members (Table 1) on community health priorities including the following topics: malaria prevention, disease surveillance, importance of routine immunization, WASH, communication and community mobilization, and Champion Communes. Through the first two quarters of FY2020, the Program has oriented 13,532 PNSC members on community health approaches, attaining 55 percent of the FY2020 annual objective.
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report 11
Table 1– Number of PNSC Members Trained on Community Health, Q2 FY2020
Total FY2020 Members PNSC (% of FY2020 PNSC Coordination Structures Trained Committees objective) Q2
Coordination Committee for Community Health at the Regional Level (Comité de Coordination pour l’Approche 7 39 44 (21) Communautaire – Région, CCACR)
Coordination Committee for Community Health at the District Level (Comité de Coordination pour l’Approche 34 64 76 (8) Communautaire – District, CCACD) Commune Commission for Health Development (Commission Communale de Développement de la Santé, 456 767 1,019 (124) CCDS) Fokontany Health Committee (Comité de Santé FKT, 4,885 2,297 12,393 (69) CoSan) Total 5,382 3,167 13,532 (55)
1.1.2 In-Service Training, Continuing Learning, and Supervision of CHVs
CHVs. The Program continued to strengthen CHV capacity this quarter. As Table 2 shows, of the 9,881 CHVs nominated by their communities, 9,570 (97 percent) have completed the required training on c-IMCI or services for WRA and 9,111 (92 percent) have been certified by their local CSB to provide services in their communities. During Q2, 68 CHVs resigned bringing the total of CHV resignations to 145 during the first two quarters of FY2020, which accounts for 1.5 percent of nominated CHVs. If CHVs resign at a similar rate throughout the FY, it will represent roughly annual resignation rate among CHVs of three percent. As CHVs work on a voluntary basis, they decide to leave their posts for any number of reasons including the following: security concerns, other time commitments, economic activities, duration of service, and relocation to new areas, age and death.
Table 2– Readiness of CHVs in the Program Regions, Q2 FY2020
# of CHVs # of CHVs # of CHVs # of CHVs # CHVs # of female trained on certified on that resigned that nominated by CHVs (% of Regions services for services for in the resigned in FKT and regional CU5 and/or CU5 and/or quarter FY2020 Commune total) WRA WRA Analanjirofo 1,707 1,008 (59%) 1,692 1,648 15 21
Boeny 230 109 (47%) 228 195 2 3
DIANA 1,175 612 (52%) 1,124 1,139 17 26
Melaky 724 268 (37%) 710 523 1 11
Menabe 1,233 512 (42%) 1,135 1,140 3 20
SAVA 1,782 962 (54%) 1,698 1,637 28 59
Sofia 3,030 1,113 (37%) 2,983 2,829 2 5
Total 9,881 4,584 (46%) 9,570 9,111 68 145
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CHV Monthly Meetings at the CSB. In Q2, the Program continued to provide both technical and financial support for monthly meetings in its 34 districts. Monthly CHV meetings conducted at CSBs present an important opportunity to refresh technical, communication, and community mobilization skills in addition to monthly activity reviews, collecting and reviewing data, and resupplying needed health commodities. On average 82 percent (598 out of 732) of CSBs conducted a review meeting with CHVs each month during this quarter, with a CHV reporting rate of 82 percent, while 73 percent of CHVs attended monthly CSB meetings.2
Due to the restrictions on monthly meetings imposed after the declaration of the National State of Emergency for COVID19 in March, CSBs in several Program regions were unable to conduct monthly meetings and as a result CHV reporting rates fell in the month of March in these areas: Analanjirofo (51 percent), Boeny (65 percent), Melaky (55 percent), and Menabe (60 percent).
CHV Training. In Q2, the Program focused on the completion of training on community disease surveillance, community integrated management of childhood illness (c-IMCI) and pre- referral treatment for severe malaria in CU5 to address the preparation for peak malaria season. In addition, CHVs received refresher training on nutrition, reaching every child (routine immunization) and safe motherhood/family planning (SM/FP) and use of pregnancy tests. These trainings contributed to the Program‟s scaling up of the use of pregnancy tests for family SBC Training of MOH Facilitators- Nosy Be, DIANA region planning services and antenatal Photo Credit: Mahefa Miaraka DIANA referral for pregnant women. WASH training with a strong emphasis on hand-washing took precedence in March 2020 due to the declared state of emergency related to coronavirus (COVID-19). Mahefa Miaraka also continued strengthening CHV skills on social behaviour change (SBC) approaches, particularly the Model Families (ménage modèle/parrain) approach, and continued the reinforcement of reporting and commodities management.
Figure 2 presents information on the clinical skills strengthening conducted during monthly meetings (or added as additional days) in Q2 and includes the following topics: 1,982 CHVs received refresher training on SM and FP; childhood vaccination (reaching every district/child or RED/REC); 1,429 on c-IMCI; 1,394 on nutrition; 1,364 on the use of pregnancy tests; 922 on pre-referral treatment for CU5 severe malaria with rectal artesunate; and 900 community disease surveillance (malaria, vaccine preventable diseases).
2 CHVs in one FKT submit a common report. It is possible that the proportion of CHV who submit reports can be greater than the actual proportion of CHVs who attend meetings. This will be the case if only one CHV from a FKT attends the monthly meeting, but submits information for both CHVs in the FKT.
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report 13
Figure 2 - CHVs Trained in Case Management and Service Delivery Topics, Q2 FY2020
The Program is on track to meet its goals for clinical refresher training in FY2020 (Table 3). At the end of Q2, a total of 4,473 (95 percent of the total FY2020 objective) had received training on pre-referral treatment for CU5 severe malaria; 7,230 (81 percent) on nutrition; 7,202 CHVs (81 percent) on SM and FP; 7,085 (79 percent) on community surveillance; 6,550 (66 percent) on c-IMCI; and, 2,984 (48 percent) on use of pregnancy tests.
Table 3– CHV Refresher Clinical Training by Theme Q1& Q2 FY2020
Percentage of Male Female Total FY2020 Objective Pre-referral treatment for severe 2,729 1,744 4,473 95%3 malaria Nutrition 3,899 3,331 7,230 81%
SM/FP 3,804 3,398 7,202 81% Community 3,850 3,235 7,085 79% Surveillance c-IMCI 3,609 2,941 6,550 73%
Pregnancy test 1,876 1,108 2,984 48%4
In addition to clinical skills building, the Program aimed to strengthen its SBC activities, namely Model Family/Mentor Family approach, CHV home visits and radio listening groups. In light of the COVID-19 pandemic, the Program emphasized hand washing with soap through its WASH trainings that included construction and use of latrines, water treatment with “Sur Eau”, keeping a clean environment, and open- defecation free communities; also reinforcing the community emergency evacuation system; and improved commodity and data management by CHVs. As presented in Figure 3, 2,286 CHVs received refresher
3 FY2020 Objective is 4,690 CHVs trained, those CHVs in 19 high malaria burden Districts targeted for the rollout of pre- referral treatment of severe CU5 malaria cases. 4 FY2020 Objective is 6,168 CHVs trained. Those CHVs in six remaining regions (Sofia began in FY2019) for the rollout of pregnancy tests.
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2020 Quarter 2 Report 14
training on SBCC; 1,435 on WASH; 1,258 on emergency evacuation; 943 on commodity management; and 605 on data management (use of registers, individual client information and monthly reporting formats).
Figure 3 - CHVs Trained in SBCC, WASH, Commodity and Data Management, Q2 FY2020
Similar to clinical training, Mahefa Miaraka has set a good pace to meet its FY2020 training goals for communication, community engagement and mobilization (Table 4). At the end of Q2, a total of 8,983 CHVs (101 percent of the FY2020 objective) had received refresher training on WASH; 6,388 (72 percent) on SBCC; 4,124 (46 percent) on commodity management; 3,963 (44 percent) on emergency evacuation; and, 2,926 (33 percent) on data management. The majority of trainings planned for FY2020 have proceeded on track. The Program will make adjustments in Q3 and Q4 in order to ensure that the objective for data management trainings will be met.
Table 4– CHV Refresher Training on WASH, Communication, Community Mobilization, and Commodity and Information Management, Q1& Q2 FY2020
Percentage of Male Female Total FY2020 Objective WASH 4,753 4,230 8,983 101% SBCC 3,375 3,013 6,388 72% Commodity 1,922 2,202 4,124 46% management Emergency 2,242 1,721 3,963 44% evacuation Data management 1,271 1,655 2,926 33%
Supervision of CHVs. In addition to the skills reinforcement that CHVs receive during monthly meetings, the Program also supports supervision of CHVs at their sites. This supervision is both clinical and non-clinical in nature. In Q2, 5,563 CHVs (61 percent of functional CHVs) received supervision. For clinical care aspects of CHV responsibilities, monthly reporting, and management of commodities, Mahefa Miaraka supported EMAR and EMAD to supervise 220 CHVs, and CSB heads to supervise 1,259 CHVs (Table 5). In addition, Program staff supervised 1,362 CHVs to strengthen both clinical and non-clinical interventions. For non-clinical interventions (SBC, WASH, and community mobilization, client satisfaction), FKT heads supervised 2,611 CHVs during this period and commune community health committee members supervised 111 CHVs. Breaking down supervision by type of supervisor, out of the CHVs who received supervision, FKT heads supervised nearly half (47 percent), largely due to their proximity to CHVs; Mahefa Miaraka supervised 24 percent; CSB Heads 23 percent, EMAR/EMAD staff 4 percent, and CCDS members 2 percent.
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Table 5– Supervision of CHVs by type of supervisor, Q2 FY2020
Mahefa CCDS Chef FKT EMAR/EMAD CSB Total Miaraka # CHVs 111 2611 220 1,259 1,362 5,563 supervised in Q2 Proportion of 2% 47% 4% 23% 24% 100% total
1.1.3 CHV Service Provision in Q2 FY2020
This section presents CHV-reported results for integrated health services from the Program‟s seven regions during this quarter.
1.1.3.1 Maternal, Newborn, and Child Health Services
Prevention of Postpartum Hemorrhage (PPH) and Newborn Cord Infection (Using misoprostol and chlorhexidine (CHX) 7.1 percent). Throughout Madagascar, CHVs distribute misoprostol to prevent PPH and distribute CHX to prevent newborn infections via the umbilical stump.
Since Q1 FY2020, communities have had an increased but still limited availability of misoprostol and CHX after a long hiatus. The uptake of both misoprostol and CHX has been slow due to these products‟ long absence from the community. While both commodities are now available in all seven regions, reported stock outs remain high at 43 percent for CHX (all regions combined) and 81% for misoprostol. Re-establishing the supply processes for these two commodities will take time, and requires re-orienting CHVs on their use and distribution, re-introducing these commodities to communities, and communicating their availability in order to increase awareness and demand. In Q2, CHVs distributed 1,626 tubes of CHX gel with 1,636 tubes used5 and 1,351 doses of misoprostol distributed to pregnant women in their eighth month of pregnancy with 1,455 doses used.
Nutrition: CHVs regularly conduct routine growth monitoring activities and provide nutrition counseling during home visits and sick child visits at the health hut (Toby). In Q2, CHVs weighed 280,675 CU5 and measured the mid-upper arm circumference (MUAC) of 242,339 CU5. The total estimated number of CU5 who received growth monitoring services (weight and/or MUAC measurement) is 290,686 of which 178,382 (61 percent) represent children between 0-23 months. As presented in Figure Nicole, CHV Tsaramandroso, Befandriana Nord conducts a growth monitoring activity during a nutrition session 5 As CHX and miso is distributed in the 8thPhoto month Credit of pregnancy,: Mahefa Miaraka the numbers Sofia of doses distributed and used may not match exactly during a given period of time as the calculation of doses used also takes into account doses distributed prior to the period of distribution in question as well as doses distributed that will be used after the period in question.
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4, the number of CU5 who received growth monitoring services decreased slightly from 299,414 to 290,868 from Q1 to Q2 FY2020. This may be the result of reduced reporting of CHVs in March 2020 due to the cancellation of monthly meetings due to the COVID-19 pandemic in Analanjirofo, Melaky, and Menabe. Of the CU5 weighed in Q2 FY2020, less than one percent were underweight (0.89 percent) and/or suffering from moderate to severe acute malnutrition (MUAC measurement of less than 125mm, or 0.62 percent).
Figure 4- CU5 Receiving Growth Monitoring Services from CHVs: Q1and Q2 2020 (by type)
Community-based Integrated Management of Childhood Illnesses (c-IMCI) Services for CU5. As part of their routine activities, CHVs assess, treat, and (in severe cases) refer CU5 for three major illnesses: diarrhea, pneumonia, and malaria. Mahefa Miaraka addresses management of these illnesses through training and supervision, including prevention, diagnosis, treatment, counseling, and referral to CSBs as necessary. Starting in FY2020, CHVs have begun to provide pre-referral treatment for severe malaria in CU5 using rectal artesunate prior to referring cases to the CSB. During Q2, CHVs received 106,280 sick CU5, an increase from the 93,046 seen in Q1, as the disease burden increases during the rainy season. As shown in Figure 5, CHVs reported 33,744 cases of CU5 malaria, 13,150 cases of CU5 pneumonia, and 9,478 cases of CU5 diarrhea. Of the 33,744 cases of malaria, 92 percent (31,162) received treatment from CHVs. The same percentage of pneumonia cases were treated (92 percent) while CHVs treated a lesser percentage of diarrhea cases treated (67 percent). The continued high stockouts (35 percent) of oral rehydration salts (ORS) and zinc in Q2 explain the lower percentage of CU5 diarrhea cases treated and conversely the higher percentage of diarrhea cases referred for treatment at the CSB.
In general, the cases referred to the CSB and not treated by CHVs represent either complicated cases that would normally be referred, or referrals due to stockouts of health commodities that otherwise could have been treated by the CHV. The total number of referred and/or not-treated cases total 5,942. It is important to keep in mind that one child can be classified with several illnesses (e.g. pneumonia and diarrhea).
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Figure 5 - Number of CU5 Cases Diagnosed and Treated by CHVs: Q4 2019 – Q2 FY2020 (by disease)
Referral Services for Women and Children Under Five (CU5). In this quarter, CHVs referred 57,549 WRA and 62,788 CU5 to the health center for services (Table 6). The majority of referrals among WRA were for prenatal consultations (29,551), followed by tetanus vaccination (15,336), delivery (10,107), and long- acting contraception (2,555). In addition, CHVs referred 62,788 CU5: 56,737 for vaccination (representing 90 percent of all CU5 referrals); followed by 3,286 CU5 referrals for illnesses without danger signs, 2,037 CU5 referrals for danger signs, and CU5 728 referrals for malnutrition for a total of 6,051 sick CU5 referrals. CHV assessing the breathing of a sick child with a respiratory timer, Bealanana, Counter-referrals (from the CSB to Sofia Region. Photo Credit: Mahefa Miaraka Bealanana District Team CHV). Counter-referrals make CHVs aware that clients followed through on care and, in certain cases, signal the need for them to make home visits to follow up with patients after treatment at the CSB. In Q2, CHVs received counter-referrals for one- third (31 percent) of the WRA they had referred to the CSB. Of the total CU5 referrals, CHVs received counter-referrals for 47 percent of cases.
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Increasing the percentage of counter-referrals received by CHVs beyond current levels remains a challenge. Caretakers may not bring the referral slip with them to the vaccination sessions, or health workers may not be willing or may not remember to fill out the counter-referral information (e.g., when a large number of children need to be vaccinated at one time). Even if health workers correctly fill out the counter-referral information, caretakers may not return the completed referral slip to the CHV.
Table 6 – Referral of WRA and CU5 Cases from CHVs to CSBs in Q2 FY2020
Number of referrals in Referral services by CHVs Types of service Q2 FY2020
First prenatal consultation, including tetanus vaccination, IFA, IPTp-SP, Malaria, maternal care 14,961 and LLIN
Pregnant women for fourth ANC Malaria, maternal care 14,590 visit Maternal and newborn Pregnant women for delivery 10,107 care, assisted delivery Pregnant women for vaccination Maternal care 15,336
Long-acting contraception Family planning 2,555 Subtotal: number of women 57,549 referred to CSBs WRA with confirmed counter- 17,926
referral from CSB back to CHVs (31 percent) Cases of CU5 referred for Child health care 56,737 vaccination Cases of CU5 referred for Child health care 728 malnutrition Cases of sick CU5 with danger signs (malaria, acute respiratory infection, c-IMCI complicated cases 2,037 and diarrhea) Cases of sick CU5 from miscellaneous causes (newborn, Child health care 3,286 other CU5 illnesses)
Subtotal: number of CU5 referred 62,788 to CSBs
CU5 with confirmed counter- 29,469
referral from CSB back to CHVs (47 percent)
1.1.3.2 FP and Reproductive Health
Regular FP Users. During this quarter, CHVs provided FP services to 311,620 regular users (Figure 6). Sixty two percent (192,240) of the total regular users are youth and young women under 25 years of age with girls between 10–14 representing 6 percent (19,165) of all regular family planning users, women 15-19 years of age 25 percent (77,421), and women between 20-24 years of age 31 percent (95,654). Women 25 years and above represent 38 percent (119,380) of regular FP users. The discontinuation rate this quarter was 3.2 percent for all methods combined.
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Figure 6 - Number of Girls and Women Using Family Planning Services from Program CHVs, by Age Group, Q2 FY2020
New FP Users. This quarter, new FP users accounted for 12 percent (36,981) of regular users. As presented in Figure 7, the majority of new FP users are young women from 20-24 years old (11,395 or 31 percent), followed closely by women 25 and above (11,116 or 30 percent) and adolescents from 15-19 years (10,668 or 29 percent). One out of every ten new users (3,802) is a girl between ages 10-14. The Program had nearly 5,000 more new users in this quarter as compared to Q2 FY2019, reflecting the expanded number of CHVs currently providing FP services and the availability of FP commodities at the community level.
Figure 7 - New Family Planning Users in the Program, by Age Group, Q2 FY2019 compared to Q2 FY2020
Sayana Press. Over the past two quarters the use of Sayana Press has dropped by nearly 50 percent, from 50,569 regular users in Q4 FY19 to 25,820 regular users in Q2 FY2020 (Figure 8). For new users, 7,694 new users selected Sayana Press and 14,857 new users selected depo-IM, 34 and 66 percent respectively. During the same period the use of intramuscular DMPA increased from 124,104 users to 148,327 users. There has been a corresponding reduction in the proportion of new users choosing Sayana press, from 46 percent of new injectable users in Q1 to 33 percent in Q2. The large drop in Sayana Press use results from the lack of products in country. The procurement of DMPA-SC through UNFPA took quite a long time (more than 6 months) while the stock has gradually run out with no available supply from other sources. According to national level data (November 2019), the stock of DMPA-SC at the central level was 396 units with an
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average monthly consumption of 46,526 units, a stock covering only 0.01 months for USAID-supported regions. New supplies have been ordered and are expected to arrive in country in April 20206.
Figure 8 – Trend in Injectable Contraceptives Distributed from Q1 2019 to Q2 2020
Couple Years of Protection (CYP). During this quarter the Program recorded 50,770 CYP (Figure 9). Although the Program recorded an increase of 16,251 FP users from Q1 to Q2, the CYP results for Q2 are similar to Q1 results (50,720). The challenge is that CYP calculations depend on CHVs accurately recording product taken out of stock which continues to pose a challenge for some CHVs. Injectable methods continue to be the preferred method of contraception for regular FP users, representing 43,094 CYP, or 85 percent of the total CYP recorded this quarter. The Program is on track to meet its annual FY2020 CYP target of 170,000, having attained 101,488 (60 percent of the objective) by the end of Q2.
Figure 9 - Couple Years of Protection by Family Planning Methods, Q2 FY2020
1.1.3.3 CHV Malaria Activities
Mahefa Miaraka supports a common community approach to malaria interventions in our regions and districts, which includes the following major activities in alignment with national public health sector strategic plans and the PMI Malaria Operational Plan:
6 During the April 17, 2020 MOH/DSFa FP committee meeting, USAID IMPACT confirmed that 390,000 units supplied by UNFPA are now with them. Mahefa Miaraka is coordinating with IMPACT to ensure resupply to CHVs.
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Case management reporting in order to identify potential epidemics and to activate and support the district health team‟s response (investigation, screening and testing, and treatment of cases); CHV treatment of uncomplicated CU5 malaria cases (RDT+) and referrals with pre-referral treatment for complicated malaria cases; CHV training on pre-referral treatment for complicated malaria cases in 19 high malaria districts; CHV capacity building on managing CU5 illnesses through scheduled c-IMCI refresher trainings; CHV refresher trainings on data and health commodity management to ensure accurate case management reporting, as well as correct use and quantification of malaria commodities at health facilities; Expansion of the Model Family approach which includes malaria prevention and care-seeking behaviors (see page 31 for description of the approach); Promotion of long-lasting insecticide-treated nets (LLIN) use and care seeking for fever through CHV home visits and community health education sessions, local radio broadcasts, mother and child health week (SSME), the Champion Commune (KMSm) and model household approaches, and the use of mother and child health cards.
Support to District Health Offices (Service du District de Santé Publique or SDSP) and CSB for Prevention of Malaria Outbreaks. In Q2, Program supported-areas had 23 alerts of elevated levels of malaria cases. This compares to one alert in Q1, the difference being that Q2 is the height of malaria season in Melaky, Menabe, and Sofia, where a majority of the cases were located. The Program supported the SDSPs in these areas to conduct investigations, mass testing and treatment of communities. Districts with repeated alerts included the following: Maintirano in Melaky region and Befandriana, Mandritsara, and Mampikony in Sofia region.
CHV Activities for Malaria Prevention and Control. In Q2, Program-supported CHVs continued to promote key messages on malaria prevention, including the use of LLIN, mosquito habitat destruction, and the importance of seeking treatment for fever. In this quarter, CHVs counseled 438,186 people on malaria during home visits. CHVs also referred 14,961 pregnant women for their first ANC visit, which includes malaria prevention therapy with Sulfadoxine-pyrimethamin (IPTp- SP), and LLIN distribution. The Program continued its support of Rokia, a CHV, conducting a rapid diagnostic test for malaria at a school, Mahavanona, regional radio broadcasts of key DIANA region malaria prevention and control Photo Credit: Mahefa Miaraka DIANA messages, reaching 417,411 community members.
In February 2020, USAID IMPACT Malaria conducted the launch of its continuous distribution of insecticide treated nets (ITN) with the Ministries of Health, Education, and Population. Port-bergé district in Sofia has been selected for the implementation of continuous ITN distribution activities with first round trainings scheduled for Q3 FY2020. Mahefa Miaraka will support the orientation of CHVs on the intervention in this district.
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CHV Malaria Diagnosis and Treatment. CHVs are trained to test all CU5 fever cases using RDT and treat all RDT positive uncomplicated cases with artemisinin-based combination therapy (ACT). This quarter, the peak of malaria season, CHVs reported 75,349 cases of CU5 fever (Table 7). Of CU5 with fever, CHVs tested 90 percent (67,509) of fever cases using an RDT kit. Of those tested, 50 percent (33,744) tested positive for malaria. The greatest number of RDT+ cases was seen in Sofia (11,735) followed by Melaky (11,151) and Menabe (6,193). Of the positive malaria cases, 92 percent (31,162) received ACT treatment. Melaky and Boeny regions had the highest RDT positivity rates in the Program areas, at 71 and 56 percent respectively, followed by Sofia (51 percent), Analanjirofo (47 percent), and Menabe (42 percent). The low number of fever cases in Analanjirofo and SAVA reflect the challenges of the c-IMCI rollout in these regions, whereas the low number of fever cases in DIANA reflects the overall lower malaria burden in the region. In SAVA the challenge relates to the certification of CHVs by CSBs and a high level of stockout of malaria commodities compared to other regions (see section 1.1.3.4, Table 9), resulting in a lower than expected level of testing in SAVA and subsequent treatment of confirmed malaria cases. In Analanjirofo region, especially in Maroantsetra and Mananara Nord districts, the follow-up of CHVs post c-IMCI training remains a challenge. In November, the Program added additional commune level staff in these two districts to address these challenges and work with CSBs to provide the needed follow-up and training of CHVs.
Table 7– CHV Malaria Services by Regions in Q2 FY2020
Analanjirofo Boeny DIANA Melaky Menabe SAVA Sofia Total
CU5 fever cases 4,004 3,044 3,978 16,623 16,402 6,968 24,330 75,349 CU5 fever cases 2,380 2,828 3,508 15,706 14,885 5,083 23,119 67,509 tested (RDT) Percent of fever 59% 93% 88% 94% 91% 73% 95% 90% cases tested Number RDT+ 1,113 1,575 727 11,151 6,193 1,250 11,735 33,744 cases RDT Positivity 47% 56% 21% 71% 42% 25% 51% 50% Rate Number RDT+ 886 1,466 498 10,865 5,747 1,023 10,677 31,162 cases treated Percent of RDT+ cases 80% 93% 69% 97% 93% 82% 91% 92% treated
A comparison of results from Q2 FY2019 to Q2 FY2020 (Figure 10) shows an increase in the number of children who presented to CHVs with a fever, from 62,626 to 75,349, with a greater percentage of CU5 presenting with fever tested with RDT: 90 percent (67,509) of CU5 fever cases were tested by RDT this quarter compared to 80 percent (49,948) in Q2 FY2019, with a slightly higher positivity rate this quarter, 50 percent, versus 47 percent in Q2 FY2019. The greater proportion of cases tested this quarter as compared to one year ago reflects improved availability of RDTs. The same percentage of RDT positive cases were treated with ACT in both Q2 FY2019 and Q2 FY2020 (92 percent).
In terms of the increase itself, according to CSB and CHV data, 146,752 cases of fever were reported in Q2 FY2019 compared to 153,236 in Q2 FY2020. While the total number of fever cases increased slightly (4.4% increase), CHVs received a smaller proportion of overall fever cases than the CSB in Q2 FY2019 (43 versus 57%), while the opposite occurred in Q2 FY2020. The change in terms of where families sought treatment may be explained by the national measles epidemic that was in full swing in our regions during Q2 FY2019. This epidemic may have influenced where families sought care for their children, as treatment for measles is provided at CSB and CHVs were more likely to refer children with fever for treatment during the measles epidemic.
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Figure 10- Comparison of CHV Malaria Services, Q2 FY2019 and Q2 FY2020
Pre-referral treatment for severe CU5 malaria. As part of the Program‟s efforts to support the National Malaria Control Program‟s (NMCP) efforts to reduce malaria morbidity and mortality in districts with high malaria burden, Mahefa Miaraka initiated CHV trainings on pre-referral treatment of CU5 severe malaria. The 19 districts targeted by the Program in collaboration with NMCP are districts with some of the highest rates of malaria incidence in the Program. In Q2, EMAD and CSB trainers completed training of 922 CHVs on pre- referral treatment for CU5 severe malaria with ARC, bringing the total to 4,473 (95 percent of the FY2020 objective) by the end of this quarter.
1.1.3.4 Health Commodities
Health Commodities for CHVs. Stockouts of most child health commodities decreased from Q3 FY2019 to Q2 FY2020 (Table 8), with the exception of CHX and Misoprostol. The decrease in stockouts was due to several factors: 1) greater availability of CHX, amoxicillin and ORS at supply points, 2) greater regional health office support for supply of CHV in places like Analanjirofo, and 3) the Program‟s coordination with USAID IMPACT on the supply of a commodities kit for CHVs to resupply commodities like amoxicillin that had been out of stock for several months.
Despite partners‟ coordination efforts, the reported stockouts of CHX and ORS/Zinc remain high, 43 and 35 percent respectively. While Misoprostol and CHX have made their way to the level of many districts, their uptake has been slow due to these products‟ long absence from the community during FY2019. In addition, Zinc supplies have been limited and in short supply. The Program has targeted CHVs for SM and c- IMCI trainings over Q1 and Q2 as a means to reestablish the CHV, TSIMITEKY Eugène, from Sambolaza fokontany working at the health hut on International health workers day. Photo Credit: Mahefa Miaraka supply processes for these commodities but it will take time to re-orient CHVs on their use and distribution, their re-introduction in communities, and communication to increase awareness of availability and demand. The Program will continue to share stock data with USAID IMPACT and ACCESS for better coordination to address high levels of stockouts. This includes ensuring that representatives from the commune resupply points are supervised and resupply regularly at the regional supply points, and are invited to attend CHV monthly meetings in order to resupply the needed commodities. This also includes strengthening CHV and CSB calculation of commodity needs, and continuing to address issues that affect the resupply of CSBs by district
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pharmacies through monthly analysis of CHV stock-out data with the district health office and joint visits at the District Pharmacy (Pharmacie de Gros de District or PhaGDis) and community-managed pharmacies (Pharmacie à gestion communautaire or PhaGeCom).
Table 8 – Average Rate of Reported Stockouts of Child Health Commodities by CHVs, Q3 FY2019 – Q2 FY2020 by Product Type (n = 3,939 FKT)
FY2019 FY2020 Resupply Point Commodity Q3 Q4 Q1 Q2 CHX 7.1% 63% 51% 40% 43% PSI/PA Amoxicillin 54% 41% 34% 35% ORS-Zinc 45% 41% 38% 38% RDT 29% 21% 13% 14% CSB ACT Child 37% 30% 24% 25% ACT Infant 41% 33% 28% 29% Misoprostol 86% 90% 91% 81%
Malaria Commodities. The availability of RDT, and hence reduced stockout rates, has improved in the first two quarters of FY2020. In Q2, stockout of RDT was 14 percent for Program areas as a whole and stockouts of ACT infant and child formulations were 25 and 29 percent, respectively (Table 9). The Program averages obscure the wide variation in the levels of stockouts between regions. Results of regional analysis show stock- out of RDTs ranging from 2 percent in Sofia to 36 percent in SAVA, with most regions reporting < 18 percent stock-out of RDT. Similarly, the rate of stockouts of ACT infant and child formulations ranged from 3 to 5 percent in Sofia to 64 percent in SAVA, with higher stockouts for ACT child and infant formulations than for RDTs. In SAVA, the region with the highest level of stockouts, the team conducted refresher training for CSB heads and CHVs for the calculation of average monthly consumption for CHVs.
It also appears that some CSBs send separate orders for CHVs to the district pharmacies while others may include only CSB (or have CHV needs included with the CSB order). Analysis has shown that the calculation of monthly consumption, including CSBs, is less than required and it may be the case that some CSBs do not distribute to CHVs routinely as they may have stock issues at their own level. The Program‟s SAVA staff is following up with the district pharmacies to provide further information to the DRSP in order to take steps to resolve this issue. In contrast, the elevated stockouts in Menabe for Child ACT (29%) are related to the lack of stock in the national stores. The DRSP has contacted the central program and warehouse and they have agreed to send what is available, but it is not sufficient to meet the need. Most regions, such as Melaky and Sofia redistribute commodities from areas with surplus to those in need. However, the high case load in Melaky has also led to an overall shortage of supply in Child ACT.
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Table 9 – Average Rate of Reported Fokontany Stockouts for Malaria Products by Region, Q2 FY2020
Percentage of fokontany Analanjirofo Boeny DIANA Melaky Menabe SAVA Sofia Total with (n = 643) (n = 104) (n = 487) (n = 251) (n = 540) (n = 600) (n = 1,314) (n = 3,939) stockout
RDT 15% 15% 11% 18% 13% 36% 2% 14%
ACT/ASAQ 30% 39% 34% 24% 29% 64% 5% 25% Child
ACT/ASAQ 27% 23% 33% 15% 16% 64% 3% 29% Infant
Availability of FP Commodities. During this quarter, CHVs reported low rates of stockouts for FP injectables and oral contraceptives (Figure 11), 13 and 16 percent respectively. The high level of stockout for cycle beads and condoms remain a challenge (33 percent). Because condoms are not among the preferred products in Program-supported areas, compared to injectables and pills, CHVs may not always re-stock them. Cycle beads have not been available for some time at the level of the resupply points and are also not among the preferred FP products in Program communities. The higher levels of stockout for cycle beads and condoms reflect the lack of preference for these products in communities. Given CHVs have to buy their restock; they are not incentivized to keep products in stock that rarely sell.
Figure 11- CHV-Reported Stockout Rates of FP Tracer Products, Q2 FY2020 (n = 3,939 FKT)
1.1.4 Quality of CHV Services
FP Compliance. As part of their training from Mahefa Miaraka, CHVs receive orientation on the United States Government‟s FP compliance regulations. After the training, they are monitored on whether or not they respect the FP compliance during supervision visits. To do this, observations of CHVs are conducted during supervision visits to see that to see that all elements of compliance are respected during the counseling process namely: welcoming clients, presenting information on all methods (including potential side effects), determining eligibility criteria, allowing women to choose freely, registering clients, and setting a date for the return visit. In Q2, a high percentage (85%) of CHVs supervised demonstrated compliance with FP compliance regulations. More specifically, among CHVs supervised, 94 percent of the 2,473 health huts visited had a client‟s rights poster posted and 96 percent had a poster displaying the types of FP methods. In addition, CHVs supervised have available FP tools such as eligibility criteria and job aides that present all methods
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(Table 10). The program will ensure a supply of FP Methods and Clients rights posters at district level in order to supply to health huts that do not have them.
Table 10- Presence of FP Methods Poster and Client Rights Poster, Q2 FY2020
Client rights # Health huts FP Methods poster Both posted poster supervised REGION ANALANJIROFO 96% 91% 87% 321 BOENY 95% 91% 86% 142 DIANA 97% 94% 91% 516 MELAKY 98% 98% 95% 88 MENABE 97% 98% 95% 609 SAVA 93% 84% 77% 235 SOFIA 96% 95% 91% 562 Grand Total 96% 94% 90% 2,473
Commune Commission for Health Development or CCDS (Commission Communale de Développement de la Santé). Community members are able to use the Community Score Card (CSC) to gauge clients‟ satisfaction with services they receive from CHVs rated on a scale of 1 to 4, where 3 means “satisfied” and 4 “very satisfied” with services. During Q2, CCDS members conducted customer satisfaction surveys with 351 clients in 117 FKT. Clients interviewed included pregnant women, regular FP users and parents of CU5. Results from the CSCs show the following: 89 percent of FP users reported being satisfied with the availability and cost of FP commodities; 84 percent of all clients reported satisfaction with CHV counseling services; 70 percent of parents with sick CU5 reported being satisfied with the quality of services; and, 68 percent of clients interviewed reported being satisfied with the availability of services at the health hut (toby)
Community satisfaction with CHV services is near or exceeds the 70 percent objective for FY2020. However satisfaction dropped during Q2 as compared to Q1, from an average of 78 percent to 68 percent. The change in results from Q1 to Q2 is mainly due to a decrease in satisfaction in the districts of Sofia (Bealanana, Boriziny, Analalava, and Mandritsara) which represent nearly half of CSC conducted in Q2 and thereby brings the overall satisfaction rate lower. The lower satisfaction rate in these districts during Q2 is largely due to the season. Q2, being the height of the rainy season, farmers (including CHVs) spend their days tending fields and crops. As a result the CHVs have less time to conduct their regular duties and the health hut may not be open as frequently or for the same amount of hours as during other seasons.
1.1.5 Motivation Activities for CHVs
An important way that communities demonstrate support for community health work is by building and furnishing a health hut, or toby, where CHVs provide services. In Q1, the Program recorded 83 new community-built health huts for CHV use (Figure 12), bringing the total number of health huts built in Program regions to 3,625, or 82 percent of the FY2020 target (4,397). Of the 3,625 health huts, 96 percent (3,497) have community-provided tables, chairs and shelves, 91 percent (3,288) have hand washing stations, 76 percent (2,768) have waste pits, and 72 percent (2,628) have latrines. The Program continues to monitor and support CSBs and communities to ensure that all CHV health huts will eventually be equipped with essential hygiene and sanitation facilities. This includes the rebuilding of heath huts destroyed during storms and cyclones during the rainy season, such as the cyclones that hit Soalala district in Boeny Region this quarter.
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Figure 12 - CHV Permanent Health Huts Built and Improved, Q2 FY2020 (since Program Start)
Enterprise Box (EBox). Four bicycle sales and repair cooperatives, called Enterprise Box or EBox, located in Menabe (Bemanonga) and Sofia (Antsohihy, Bealanana) and DIANA (Anivorano) continued their activities during this quarter. As a group, the EBoxes received a total of 414 bicycles, sold 962 bicycles and have 778 bicycles in stock. In Q2, the four EBoxes, comprising 191 cooperative members of which 128 are CHVs, had revenue from bicycle sales that totaled roughly USD equivalent (Table 11). Each EBox provides 5% of their profit from bicycle sales to support the mutuelle in their geographic area.
Table 11- Overview of Bicycle Sales per EBox Cooperative Q2, FY2020.
Bealanana Antsohihy Bemanonga Anivorano* Total Bicycles Received Bicycles Sold Bicycles in Stock Receipts Expenses
*The fourth EBox in Anivorano has gone through its first cycle of sales and should receive a second container of bicycles in early May 2020. For this reason, its expense outlays (purchase of bicycles and shipment) exceed its receipts at this time. Typically after a second cycle of sales the EBox will be on a solid footing with greater receipts to expenses. Additional training will be needed in order for the EBox to master the activities related to the resupply including the preparation of documents, customs clearance, and bicycle sales. The EBox has recognized which bicycles are in highest demand, as well as which spare parts and tools are most needed and thus is better prepared to order from its international partner, Bikes for the World.
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Sub IA 1.2 Sustainability of the CHV Model
The Program supports CSB staff and CCDS members to take greater ownership of their responsibilities under the PNSC through management training for CCDS members and CSB staff (presented under IA3) and routine supervision of CHVs. Mahefa Miaraka assists these partners to ensure high CHV attendance and effective data reporting so that monthly meetings continue to provide opportunities for greater coordination and improved quality of activities among the CHVs and CSBs. Program activities related to FKT reporting and data review are presented in IA3 and IA4 sections of this report. Joint supervision of a health post in Ankirondro, Menabe Region. Photo Credit: Mahefa Miaraka Belo sur Tsiribihina
Sub IA 1.3 Strengthening of Community Structures to Improve Health and Sanitation Planning
1.3.1 Functionality and Reinforcement of Community Health Structure
The Program activities designed to strengthen the capacity of PNSC coordination structure members are reported under section 1.1.1.
1.3.2 Using a Champion Commune (KMSm) Approach to Manage Community Health
The KMSm approach is a cornerstone of community engagement, bringing together the FKT health committee, CCDS, and the CSB to set community health goals. In Q2, 371 communes continued to build on their initial successes with KMSm, with 160 conducting review meetings this quarter to monitor their set of goals for this year. A total of 99 communes (67 percent) elected to include indicators on preventing early marriage and pregnancy.
Of the 371 communes participating, 225 set goals at the “gold level,” 120 at the “silver level” and 26 at the “bronze level” during this fiscal year. There are 28 Essential Family Practices included as goals, spanning vaccination coverage for a CSB, the number of model families in a community, the number of latrines built, the achievement of open defecation free status, etc. Each level of actor has goals that pertain to their own activities: CHVs and FKT heads, CCDS members, and CSB heads. Based on the goals they set, KMSm members plan and act together to improve the uptake of essential family practices in their community. The breakdown for Gold, Silver and Bronze level goals are as follows: Gold, completion of all 28 Essential Family Practices Silver, completion of more than 23 of the 28 Essential Family Practices achieved Bronze, completion of more than 17 of the 28 Essential Family Practices achieved
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Communities who are new to the process typically begin setting goals at the bronze level and with additional experience move on to silver and/or gold levels. Figure 13 presents the goal setting of 371 communes participating in the activities.
Figure 13 – Champion Communes Goal Setting Q1 & Q2 FY2020
Sub IA 1.4 Promoting Universal Health Care Access and Coverage, Micro-finance Insurance, and Health Evacuation Activities
Madagascar‟s PNSC promotes the important role community structures play in health system planning and management. In particular, the CCDS is charged with identifying the needs of the community and addressing these needs through annual planning and health service implementation at the commune and facility levels, including micro-insurance (mutuelles de santé) or Village Savings and Loan Association (VLSA), as well as health evacuation and transport systems. The Program works with existing micro-insurance groups and VSLA to address financial barriers to access services linked to community emergency evacuation and health transport systems.
Mutuelle de santé and VLSA. Mahefa Miaraka has entered a collaboration with VSLA Platforme in SAVA region, the Aga Khan Foundation in Sofia region, L‟Association Longo Iaby in Menabe, and the Durell Wildlife Conservation Trust in Boeny to establish micro-health insurance schemes (caisse santé) within the structure of local VSLAs and mutuelles de santé to promote equity and to protect families against potential financial risks associated with accessing health services. In Q2, 37,842 community members participated in 127 micro-health insurance schemes (mutuelle de santé or VSLA). This represents a 53 percent increase from the 24,745 members reported in Q1. As one strategy to address financial barriers, the Program supports existing VSLA in order to establish group health accounts thereby expanding individuals‟ and their family‟s access to funds
for health services. This quarter, 127 members accessed funds to defray the cost of health care.
Emergency Evacuation and Transport Plans. An integral part of Mahefa Miaraka‟s work focuses on strengthening referral systems linking FKT and CSBs. Nearly half (45 percent) of Program-supported FKT are inaccessible by vehicle during at least four months of the year, with 20 percent of FKT inaccessible for half of the year. Therefore, establishing and strengthening community health transport systems in these areas is essential to ensure that community members have timely access to skilled care. Transport is especially essential to address complications during delivery, the neonatal period, and referral of CU5 and pregnant women with danger signs. The vast majority of Program-supported FKT (4,465 or 91 percent) have developed health and emergency evacuation plans. During Q2, Program-supported communities conducted 5,579 emergency evacuations (1,189 pregnant women, 3,301 CU5, and 1,089 others) using locally available transport.
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In an effort to expand transport options in communities, the Program undertook a training of more than 20 local transport associations in coordination with the Ministry of Transport on strengthening community transport plans and on the safe transport of patients using locally available bush taxis (taxi brousse) or Bajaj. Trainings have taken place in DIANA and Sofia regions in peri-urban settings.
The content of the training included: Review of the emergency evacuation (EVASAN) plan; Personal protection for drivers and patients being transported; Emergency communication between the community, health staff and drivers; And, the mobilization and displacement of patients.
In Q2, these transport cooperatives conducted 205 emergency evacuations, among which there were 40 pregnant women, 70 CU5, and 95 others.
Training of Bajaj drivers on emergency transport and safe transport of clients. Boriziny, Sofia Region. Photo Credit: Mahefa Miaraka Sofia
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Intervention Area 2 (IA2): Behavior Change and Health Promotion
Key Achievements: 1. Health messages reached 2,068,144 people through various communication channels: 1,372,746 people through CHV home visits, counseling, and group health education; 420,032 people through the Program-supported local radio broadcasts; and 275,366 people through high visibility events. 2. The Model Family (Ménage Modèle) and Mentor Families (Ménage Parrain) approach to engage families to undertake key health actions has taken off in communities with 26,644 model households and 12,888 mentor households reported this quarter. 3. CHVs distributed 34,380 health cards to families (of which 18,152, or 53 percent, are for CU5) in Program regions. 4. CHVs distributed 68,199 FP invitation cards to new and regular users, of which 32,824, or 48 percent, were distributed to young people under age 25. 5. The Program expanded its youth approach to 244 schools and 125 community youth organizations with 5,026 youth participating in experiential learning about SRH and life skills.
Sub IA 2.1. Community-level Health Promotion and Sensitization to Increase Healthy Behaviors and Uptake of Health Services and Products
The Program promotes health and WASH messages that are consistent, aligned with national strategies, and address the key causes of maternal, child, and neonatal mortality. To effectively expand community actors‟ reach in their communities, Mahefa Miaraka strengthens these actors‟ capacity. As part of these efforts, the Program works with CSBs, CCDS, FKT heads, and CHVs, and employs strategies, such as the Model and Mentor Household approaches, which empower community members.
2.1.1 People Reached by SBC Activities
The Program uses multiple communication channels to promote key health messages and essential family practices, including: 1) CHV counseling efforts (at health huts, home visits, and community-based education sessions); 2) radio broadcasts; and 3) high visibility events. Figure 14 presents data on exposure to key health messages through these complementary communication channels this quarter. In Q2 health messages reached 2,068,144 people through various communication channels. CHV SBC activities continue to be an important dissemination channel for key health messages. CHVs reached 1,372,746 people with health messages through home visits, health education talks, radio listening groups and individual counseling sessions at health huts. CHV messages are reinforced through radio broadcasts and community events organized around national health days. This quarter the Program reached 420,032 community members through radio broadcast and 275,366 people through high visibility events, primarily International Women‟s Day on March 8.
Figure 14- People Who Received Key Health Messages in Q2 FY2020 by Channel of Communication
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2.1.2 SBC Strategy, Approaches, Materials, and Tools
The Program‟s SBC interventions are linked to services that are available through CHVs or within public and private health facilities. All SBC activities are designed to support preventive health behaviors or increase demand for health services, consequently increasing referrals between CHVs and the formal health system. With this aim, the Program team coordinates messages and demand-creation activities with the Health Promotion Directorate, including other USAID or donor-funded projects.
Model/Mentor Family Approach (Ménages Modèles/ Ménages Parrains) to Create Sustainable SBC Activities in the Community. Along with the Champion Communes approach, the Model and Mentor Families approaches are the Program‟s means of multiplying the number of health actors. The Program recognizes this promising approach as a means to engage families in communities beyond what CHVs are able to do on their own and therefore plans to strengthen the implementation of the approach RAZAFINDRAKOTO Estella, CHV from Antsakoamileka Soalala, conducts a in its communities in the handwashing demonstration. Photo Credit: Mahefa Miaraka Soalala upcoming quarters. The Model Family/Mentor Family approach is based on families as community assets and aims to accelerate the adoption by households of essential family practices that correspond to the life cycle of a family: pregnant woman, child 0-11 months, 12-23 months, and 24-59 months. The Program has identified seven key actions for each of these life stages. Focusing on seven key life stage actions reduces the complexity of decision-making choices and helps parents stay on „action‟ and not „knowledge transfer‟. The tools are the four “fiche ménage” or fliers that depict the seven key actions depending on the life cycle of the woman and child in each family. The flier is posted to the wall of the family‟s home so that they can follow through with the seven key actions during the period in question. An important component of the Model Household approach is the opportunity to expand the promotion of improved health behaviors from household to household, allowing families to become important health leaders in the community as Mentor Households. After the community recognizes a household as a Model Household, that family begins to encourage their neighbors to become Model Households as well, and provides encouragement, guidance, and support based on their experience.
For FY2020 the Program has set the objective of nearly 120,000 Model Households and 42,000 Mentor Households as a means to boost community activities, improve adoption of essential family health actions, and increase demand for health services and products. This quarter, 26,644 households became Model Families with 12,888 recognized as Mentor Households, bringing the total number of Model Families this FY to 58,209 (49 percent of the FY objective) and Mentor Families this FY to 29,546 (70 percent of the FY objective).
Women‟s and Children‟s Health Cards. The Program also promotes essential family practices in communities through the use of the MOH‟s women‟s and children‟s health cards. These essential family practices outlined in the health card are the same used by Model and Mentor Households. In addition, the cards serve as the vaccination and growth record for infants, as well as the vaccination and ANC record for pregnant women. During this quarter, CHVs distributed 34,380 health cards to families in the Program regions, of which 18,152 (53 percent) were children‟s health cards and 16,228 (47 percent) were women‟s health cards. For FY2020, the CHVs have distributed a total of 32,562 (47 percent of the FY objective) children‟s health cards and 28,725 (52 percent of the FY objective) women‟s health cards.
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Sub IA 2.2 Community-level Health Promotion to Increase Health Behaviors, Update of Health Services and Products, and Advocate for Improved Services
SBC Activities at the Community Level
CHV Home Visits. As a key aspect of their work, CHVs promote key health messages through home visits, group education sessions, and community events. The possibility of community members adopting healthy behaviors increases when they receive the same message on multiple occasions. Table 12 shows the number of community members reached on various health topics by CHVs. This quarter, CHVs reached the greatest number of people (483,916) on vaccination messages, reflecting program efforts to strengthen routine vaccinations, followed by messages on malaria prevention and care seeking for child illness (438,186) and communicable diseases (384,516).
Table 12 – Number of People Reached on Key Health and WASH Messages by CHVs, Q2 FY2020
Key messages Women % Women Men Total Vaccination 262,415 54% 221,501 483,916 c-IMCI including malaria prevention 231,405 53% 206,781 438,186 Communicable diseases 201,353 52% 183,163 384,516 Family Planning 200,451 55% 162,535 362,986 Nutrition 154,546 54% 132,421 286,967 Exclusive breastfeeding 148,832 55% 122,739 271,571 Safe motherhood with malaria 145,374 54% 123,804 269,178 prevention Youth and adolescent health 115,538 52% 104,722 220,260
Community Radio Listening Groups (RLG) An innovative aspect of group education sessions is the use of CHV-led radio listening groups. As the basis of group education sessions, CHVs organize groups and tune into radio broadcasts at certain times of the week in order to listen to health-related information and dramas. In this quarter, CHVs in Program areas conducted 20,616 radio listening groups as part of their health education activities, reaching 106,530 people.
Sanitation and Hygiene in the Community. The Program promotes the construction and use of improved latrines in all Program areas. In this quarter, the Program recorded 5,773 new community-built improved latrines. As a result, 26,556 additional people gained access to basic sanitation during this quarter. During FY 2020, the Program has attained 65 percent of its annual target (11,465 out of 17,593) for latrine construction. As a result 52,739 people gained access to basic sanitation, 65 percent of the FY2020 objective of 80,929 people.
Local Radio Broadcasts. In addition to CHV and community events and activities, the Program has contracted with local regional radio stations to broadcast radio spots and dramas on themes of key health importance that reinforce the messages and dialogue that takes place within communities. In Q2 radio broadcasts on youth and gender themes (prevention of early and unwanted pregnancy, prevention of gender-based violence
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(GBV) including prevention of early marriage) reached 420,032 people (Table 13), 417,411 people were reached with messages on communicable disease (largely malaria), 385,712 people on nutrition, 382,908 people on family planning, 357,679 on safe motherhood, 237,907 on plague, and 197,487 on the signs and care seeking for childhood illness.
Table 13 – Number of People Reached on Key Health and WASH Messages through Radio Broadcasts, Q2 FY2020
Key Themes Total People Reached Youth/Gender 420,032 Communicable Disease 417,411 Nutrition 385,712 Family Planning 382,908
Safe Motherhood 357,679
Vaccination 344,969
Plague 237,907
Childhood Illness/Care Seeking (including malaria) 197,487 WASH 180,176 Breastfeeding 177,646 Measles 62,331
Participation in the GOM-organized Health and WASH Days. In Q2, CHVs, FKT heads, and Program staff participated in high-visibility government events organized in connection to community health and WASH. Table 14 presents the total number of community members who participated in these activities, including: 240,850 participants during International Women‟s Day, 30,324 during World Health Day, 1,499 for World Day of the Sick, 1,372 for World Water Day, and 354 for World Population Day.
Table 14 – Program Participation in the Health and WASH Days Celebrations, Q2 FY2020
Events Men Women People Reached
International Women‟s Day 64,088 176,762 240,850
World Health Day 10,060 20,264 30,324 World Day of the Sick 564 935 1 499 World Water Day 306 1,066 1,372 World Population Day 51 303 354
These national events included demonstration booths, posters, audiovisual presentations, parades, speeches, competitions, theater, musical presentations, education sessions and dance. Photo collages from these events are presented in Figure 15, 16 and 17.
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Figure 15 - Photo Collage of High Visibility Events, Q2 FY2020
Figure 16 - Photo Collage of High Visibility Events, Q2 FY2020
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Figure 17 - Photo Collage of High Visibility Events, Q2 FY2020
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Sub IA 2.3 Innovations to Promote Adolescent and Youth Health
2.3.1 Strengthening Local PNSC Committees to Promote Youth Health
The Program integrates youth and adolescent health approaches in trainings on FP, SBC, and KMSm with the expectation that community leaders will advocate for, support, and monitor youth activities in the Program regions. Trainings integrate youth health activities as part of community goal setting under the Champion Commune approach.
2.3.2 Youth SBC Activities
In coordination with the Ministry of Youth and Sports (MYS) the Program supports an experiential learning cycle on sexual and reproductive health and life skills. Learning cycles are group learning sessions of roughly 20 youth led by two peer youth educators that have been oriented by the program in coordination with the Ministry of Education (MOE) and MYS. The experiential learning approach is based on two adolescent reproductive health (ARH) courses, one for in-school and one for out-of-school youth ages 14 to 18 which include sessions on gender and ways to combat GBV among youth. The approach‟s learning sessions aim to strengthen five life skills: making good decisions, building self-confidence, setting realistic goals, resisting negative peer pressure, and actively seeking care and counseling at health and social service points. Student facilitators can easily replicate the youth peer educator (YPE) approach through a series of experiential learning sessions, with relevant content for each age group.
During Q2, the Program expanded its youth approach to 244 schools and 125 community youth organizations with 5,026 youth participating in experiential learning about SRH and life skills. In this quarter, 5,026 youth participated in experiential sessions led by YPE. In addition, Program-supported CHVs provided FP services to 192,240 regular FP clients under the age of 25 years, and distributed 68,199 FP invitation cards to new and regular users, of which 32,824 or 48 percent, were distributed to young people under age 25 to be shared with their peers. In addition, local radio stations broadcast messages on the prevention of child marriage and unwanted/early pregnancies, as well as the prevention of GBV (with a focus on physical violence), reaching individuals in communities 420,032 times.
Training of YPE on the experiential learning sessions, Miandrivazo High school, Menabe Region. Photo Credit: MM Miandrivazo
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Intervention Area 3 (IA3): Health Service Planning, Management, and Governance
Key Achievements: 1. Program staff participated in 63 GOM-led technical meetings and working groups at the national level. 2. The Program continued supporting the DHIS2 entry of CSB data in our seven regions 3. The Program in coordination with MOH completed the initial phase and evaluation of the piloting of community monthly reports by MOH in Menabe region. 4. 134 EMAR, EMAD, and CSB staff received refresher training on technical themes (community surveillance, data and commodity management, community disease surveillance, and Reaching Every Child). 5. EMAR and EMAD supervised 220 CHVs and CSB heads supervised 1,259 CHVs. 6. Eighty-six (82) percent of all 732 CSBs conducted monthly meetings. 7. Eighty (82) percent of CHVs submitted activity reports to CSB during monthly meetings.
Sub IA 3.0 Strengthening of GOM Capacity
3.0.1 Coordination with the MOH
Participation in Central GOM-Organized Technical Meetings and Workshops. During this quarter, Program staff at the central office attended 63 technical meetings and workshops organized by the MOH, the Ministry of Population, Social Protection, and Women‟s Promotion (MPPSPF), the MYS and other development partners at the national and regional levels. The program made its contributions in order to ensure strengthened community health services for the reduction of morbidity and mortality of mothers and children. This section highlights the Programs‟ main contributions in Q2.
Health Sector Development Plan (HSDP) 2020-2024, January 2020 Review of key program indicators on service delivery and essential family practices during the 2015-2019 HSDP Review Workshop held in April 2019 served as a basis for reflection on the future direction of the HSDP 2020-2024. The Program, in coordination with MOH and other stakeholders, contributed to the development of the HSDP 2020-2024, the technical component of which was finalized in January 2020 with stakeholders. This HSDP is grounded in the “Plan Emergence Madagascar (PEM 2019-2023)” developed under the political leadership of the current government, with the expectation that the HSDP will be finalized in Q3 FY2020.
Expanded Programme on Immunization (EPI), February 2020 Mahefa Miaraka contributed to the finalization of the EPI approach and reference documents under the lead of the MOH EPI in coordination with WHO, UNICEF and other key stakeholders. The strengthening of EPI activities remains an imperative and a basic performance indicator of the health system, hence the development and finalization of the EPI reference document. The work of revision took into account the New Global Vision and Strategies on Vaccination, the Global Action Plan for Vaccines 2011-2020, the Sustainable Development Goals (SDGS), the orientations of the WHO Regional Strategic Plan on Vaccination, and the 2018-2020 EPI Multi Annual Comprehensive Plan.
Guide on Reaching Every Child (Atteindre Chaque Cible), February 2020 The Reaching Every Child (REC) approach aims to revitalize immunization systems by improving planning, resource management, service delivery and monitoring in the context of community-based primary health care. When strengthened in this way, the systems should provide more equitable and sustainable access to vaccines in order to reduce the occurrence of vaccine-preventable diseases. The Program participated in completing the training package for ACC and its delivery as the basis for micro-planning in Madagascar‟s 22 regions. In addition, Mahefa Miaraka participated in the national training of trainers and supported regional
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health teams in our seven regions to do the same. The microplans for the 34 districts will be available in early Q3 and will be used as a basis for supporting vaccination centered outreach prioritized by CSBs.
National communication plan for the introduction of the second dose of measles vaccine (VAR2) in Madagascar, February 2020 Over the past few years, Madagascar has experienced two major epidemics of vaccine-preventable diseases: a polio epidemic in 2014-2015 and a measles epidemic in 2018-2019. During the national measles outbreak, nearly 240,520 cases were recorded and 1,039 deaths. While the first dose of measles has an efficacy of 85% in children after 9 months of age, a significant proportion of children, or 15%, may not produce antibodies in response to the administration of the vaccine. In an effort to maintain high population immunity, a second dose of measles vaccine (VAR 2) was recommended to be introduced into the routine immunization schedule. The Program therefore contributed to the development of the communication plan for VAR2, particularly to introduce the idea that a fully vaccinated child must receive VAR2, and that routine vaccinations extend to children in their second year of life.
COVID-19 Faced with the global outbreak of the coronavirus (causing the illness known as COVID-19) the MOH and the Presidency prepared for its arrival in Madagascar. JSI prepared two work plans as noted in the Executive Summary of this report, and while awaiting approval or denial from USAID, the Project has respected USAID‟s guidance not to extend any funds to coronavirus work. Under the lead of MOH/Direction of Health Monitoring, Disease Control and Response (DVSSER), Mahefa Miaraka contributed to the development of: The National Novel Coronavirus Contingency Plan; and The Communication Plan on the Risks of Coronavirus Disease, including the design of posters, flyers, and media spots.
On March 20, the President declared a National Health Emergency. Mahefa Miaraka‟s regional offices participated in the establishment of the COVID-19 coordination and monitoring structures established at regional and district levels during the initial 15-day containment in late March. In Analamanga region, schools and government offices were closed. In addition GOM severely restricted public transport within and to and from Antananarivo to and from the regions within the country. The Program supported regional and district health offices to emphasize WASH activities during CHV monthly meetings, with a particular focus on hand washing.
3.0.2 Capacity Reinforcement and Materials for GOM in Community Health at the Regional, District, and Commune levels
GOM Capacity Building. During this quarter, the Program conducted training workshops in coordination with the Directorate of Studies, Planning, and Information Systems (Direction des Etudes, Planification, et Système d’Information) for 111 MOH officials (18 at the regional level and 93 at the district level) and 205 CSB heads on community disease surveillance, pre-referral treatment for severe malaria (by CHVs), commodity and data management, and emergency evacuation (Figure 18).
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Table 15 - Training of Trainers Received by MOH Officials, Q2 FY2020
Topic EMAR EMAD CSB Total
SBC 6 51 348 405
Safe Motherhood/Family Planning 1 30 315 346
Emergency Transport 4 26 164 194
c-IMCI/Nutrition 0 7 111 118
Community disease surveillance/REC 51 303 354 134
Commodity Management 4 20 98 122
Data Management 2 17 56 75 Pre-referral severe malaria treatment 0 9 64 73 (rectal artesunate) At least one technical training in Q2 18 93 205 316
3.0.3 CHV Technical Supervision (Monthly Meetings and Supportive Supervision)
Information on monthly meetings and CHV supervision is presented in section 1.1.3.
Sub IA 3.2. Pharmaceutical and Commodity Forecasting
Health Commodity Quantification Workshops Led by the Pharmacy, Laboratory, and Traditional Medicine (DPLMT) Directorates for CSBs and CHVs. During this quarter, the Program participated in bi-weekly meetings with the DPLMT and will participate in two national workshops related to the supply of community health products (the Family Health Division, the National Malaria Control Program) scheduled in Q3. The Program continues to collaborate with USAID IMPACT, DPLMT and ministry programs to signal CHV commodity stockouts while working at the CSB level to advocate for resupply of CHVs. Mahefa Miaraka continues to collaborate with USAID IMPACT and ACCESS on the resupply of CHVs with child health and family planning commodities in each community site, as high levels of stock-out for certain commodities persist. Section 1.1.4 provides details on commodity availability in the Program areas.
Cascade Training for CHVs on Commodity Management, Including CHV Commodity Needs. In Q2, as a means to better manage commodities and reduce stockouts in communities, CSB heads supported by the Program conducted refresher trainings for 943 CHVs on commodity management and reporting commodity needs during monthly CSB meetings for improved decision-making and planning.
Sub IA 3.3. Health Data Quality, Management, and Use
3.3.1 CHV Monthly Reporting to CSB
When CHVs begin providing health services (either in c-IMCI or FP, or both), they are required to submit their monthly report to their local CSB. In Q1, 82 percent of a total 732 CSBs conducted monthly meetings, with 82 percent of CHVs reporting.
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3.3.2 Integration of CHV Data into MOH's Health Management Information System (HMIS)
Throughout FY2020, the Program has continued to support the District Data Managers in 34 districts to successfully enter and submit monthly CHV reports in the national health information reporting system. However, it appears that not all reports may be uploaded to the central database Gestion des Systèmes d’Information Sanitaire (GESIS) and that the central MOH team may have challenges pulling data from the system once received and shared with the health divisions. Mahefa Miaraka‟s central data team is aware of this problem and will track by district the information as it is sent from the districts and received at the central database. The team will also work with the central-level DVSSER team to ensure all data is received and shared with the relevant MOH program divisions. Mahefa Miaraka anticipates the situation will improve later this year when the MOH has switched over to community reporting through the DHIS2 system due to the availability of online dashboards that will alert central teams and partners to missing data earlier in the process; the Program, in collaboration with USAID‟s MEASURE/Evaluation work in Madagascar, led by JSI, provided support for the piloting and evaluation of the pilot in Menabe region.
3.3.3 Integrated Community-Based Surveillance of Preventable Diseases
During this quarter, 900 CHVs received refresher training on community disease health surveillance. In addition, the Program trained 134 EMAR, EMAD, and CSB staff and 1,139 PNSC members on community disease surveillance. See section 1.1.1 and 1.1.2 for further details.
3.3.4 Data Use for Performance Review
Mahefa Miaraka assists districts and CSBs in analyzing monthly CHV data to improve district and commune health performance on a regular basis. Mahefa Miaraka also supports quarterly and bi- annual joint reviews in its districts. This quarter the Program provided technical support to five regional bi-annual reviews and 23 district-level quarterly review meetings. In addition, the Program conducted 434 data quality assessments (DQA) this quarter with EMAR, EMAD, and CSBs. At this stage, the Program is targeting CHVs who have been identified by CSB heads as requiring further support in terms of data capture and reporting. As such, the results are not a global representation of the quality of CHV data management. For those CHVs who face challenges in terms of data management, the results of the DQAs identified the following areas for improvement: 1) management tools were not updated; 2) filling errors; 3) errors in transcription of registry data to monthly report formats; and, 4) sources of reported data not available; and, resulting in inconsistencies in reported data. Of the CHVs targeted for DQA, 13 percent had no issues Skill building of CHVs Ramoline and Sylvie during flagged in their reports and/or record keeping. supervision, ANKOFABE, Maroantsetra District, Analanjirofo Region.. Photo Credit: Mahefa Miaraka Analanjirofo. Sub IA 3.4. Referral System Strengthening between CHVs and CSBs
3.4.1 Referral System between CHVs and CSBs
Progress in this area was reported under IA1.
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Intervention Area 4 (IA4): Monitoring and Evaluation, Learning Management, and Cross-Cutting Issues
Sub IA 4.1 Program Monitoring, Evaluation, and Performance System
Key Achievements: 1. Supported MOH DHIS2 implementation in all districts 2. Completed piloting of community monthly reports in Menabe region and provided input to MOH and partners for the planned scale-up 3. Conducted 434 data quality assessments with EMAR, EMAD, and CSBs. 4. Provided technical support to five regional bi-annual reviews, and 23 district quarterly joint reviews. 5. Presentation of mid-term household survey results to USAID 6. Use of PowerBI software for detailed analysis of results in Program areas by technical and regional teams
4.1.1 Data Management
DHIS2: With the effective scale-up of DHIS2 in 2019 for CSB reports, the capture of monthly CSB reports effectively continues at district level in Mahefa Miaraka‟s seven intervention regions. In fact, during the last 6 months, the rate of completeness of the RMA CSB for the 7 Regions reached 96 to 100% except that of Melaky with a rate of 91-99% and that of Sofia in March 2020 which the data entry is in progress and will be closed on the 27th of this month of April. (Figure 18). To ensure network connectivity, the Program provides a monthly flat-rate internet connection to the 7 regional health directorates and the 34 district health offices for the operationalization of DHIS2. In Sofia however Befandriana district had problems with the Orange network and the district data manager has not been able to upload data to the system consistently. At the end of March only 46% of reports had been uploaded in this district whereas other districts had reporting rates near or greater than 90 percent,
Figure 18 – Percentage of CSB reports successfully submitted in DHIS2, Q2 FY2020
As planned by the Ministry of Health with its partners, both community and hospital monthly reports were integrated into this DHIS2 reporting platform in Q1 FY2020. Mahefa Miaraka actively participated in the various workshops and meetings organized by MOH this quarter to finalize the DHIS2 platform, indicators used, and the dashboards for each level of the system (Hospital, CSB and fokontany). The pilot supported by
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the Program in Menabe will make it possible to identify areas for improvement in the finalization of the configuration and data entry process. Although DRS and DSPS teams received training in Q1 FY2020, the region did not begin data entry until January 2020 due to confusing instructions on next steps sent by the central ministry. The evaluation will therefore be postponed until Q3.
Once the pilot is complete, Mahefa Miaraka will scale up the use of the community component of DHIS2 in Program areas, supporting the printing and distribution of the revised monthly meeting reporting formats and community registers. Our teams will also orient district teams and CSBs, and in turn CHVs, on the use of these updated tools. Mahefa Miaraka will also contribute to the DHIS2 user guidance on a community forum that has been developed by MOH and partners for the effective organization of district staff and the entry and transmission of community data to regional health directorates and central MOH teams.
Data Quality Audits: As stated in section 3.3.4., the Program has targeted for DQA CHVs who have been identified by CSB heads as requiring further support in terms of data management. As such, the results are not a global representation of the quality of CHV data management. During Q2 FY2020, Program and MOH staff conducted 434 Data quality audits (DQA) of CHV data (Table 16). Table 17 presents the results of these DQAs indicating the following areas for improvement for CHVs and for CSB focus during monthly data reviews: 1) tools unused or not kept up to date (38%) - particularly stock sheets, referral booklets, and FP individual client sheets; 2) filling errors (17%); 3) transcription errors (from register to monthly report) (13%), and 4/ recording tools not available (9%) (Table 2). In general, CHVs need further support to ensure that they use tools consistently when serving clients, especially for family planning clients and to successfully manage their stock of commodities.
Table 16: Number of DQA conducted by type of auditor, Q1 and Q2 FY2020
Grand Auditor Q1 Q2 Total CSB 110 236 346 EMAD/EMAR 63 55 118 Program Staff 124 143 267 Grand Total 297 434 731
Table 17: Type of CHV monthly report data errors
Total Errors Identified Q1 (n=297) Q2 (n=434) (n=731) •Recording tools not used or not kept up to date 39% 38% 38% •Filling error and/or calculation 18% 17% 17% •Incomplete or blank report and transcription error 10% 13% 12% •OG or sources not available 4% 9% 7% •Other 16% 12% 13% Without anomaly 14% 12% 13% Grand Total 100% 100% 100%
The percentage of monthly reports with deviations is low, ranging from two to nine percent on five key indicators reviewed (Table 18). Any deviations noted are small in nature, that is less than 10 percent deviation between the monthly report and program registers. This largely relates to the correct recording in the monthly CHV report that captures information on maternal child health services. Deviations noted included the following: < 24 month old children weighed (nine percent), CU5 fever cases tested with RDT and pneumonia cases treated (eight and five percent respectively), pregnant women referred to ANC (seven percent) and new FP users (two percent). The Program and MOH staff shared DQA results with CSB staff
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and CHVs in order to make corrections and avoid similar errors in the future. The Program will continue to address these issues through its support for ongoing skills building for CSB staff and CHVs during the consolidation of monthly reports at CSBs, supervision and refresher trainings.
Table 18: Triangulation of CHV monthly report indicators
Q1 Q2 Selected Indicator Deviation (n) Deviation (n) No. children < 24 months weighed 8% 223 9% 427 No. CU5 with pneumonia treated 7% 90 5% 284 No. CU5 with fever tested (RDT) 5% 214 8% 402 No. Pregnant women referred to ANC 10% 91 7% 292 No. new FP users 3% 74 2% 228
4.1.2 Data Use
Mahefa Miaraka assists districts and CSBs in analyzing monthly CHV data to improve district and commune health performance on a regular basis. Mahefa Miaraka also supports quarterly and bi-annual joint reviews in its districts. This quarter the Program provided technical support to five regional bi-annual reviews and 23 district level quarterly review meetings, and 2,268 data reviews with MOH staff at all levels (CSB, district and region).
Since Q4 FY2019, the MOH began using a new Performance Monitoring and Evaluation Framework to monitor key indicators and performance of the districts and regions, on which Mahefa Miaraka contributes through CHV results. However, with the change in the Minister of Health and the subsequent restructuring it will remain to be seen whether the tool will continue to be used, modified, or potentially discarded. Unfortunately, not enough time passed to evaluate the use of this tool and process with the regions.
4.1.3 Technology Use to Improve Health Services
In Q2, the Program continued to support online access to data at the regional level through a M2DATA web portal. Using this tool, the Program‟s regional teams can generate a monthly report of selected Program indicators as needed, ensuring data is available for decision making across the Program and at all levels of the MOH. While this is an internal tool, the Program routinely shares its analysis with the MOH. It is anticipated that DHIS2 will serve this purpose (with the possible exception of indicators not routinely collected by MOH on CCH Orientation with CCDS committee members, Nosy Be Urban Commune. Photo community activities). To this Credit : Mahefa Miaraka Nosy Be end, the Program, in coordination with the MOH, initiated and completed first phase of piloting of the DHIS2 monthly community reporting in Menabe region.
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Section 4.1.1. discussed Mahefa Miaraka‟s support to its 34 districts for use of DHIS2 for CSB monthly reports, and the piloting of community-level reports in DHIS for Menabe region.
Sub IA 4.2 Learning Management
4.2.1 Studies, Surveys, and Review Workshops for Improvement of Program Performance
In Q3 FY2019, the Program conducted its mid-term review and as part of this undertook a mid-term household survey through an independent consulting firm. Preliminary results from the household survey were presented to USAID this quarter. The results highlighted the challenges of strengthening the MOH system to effectively manage community health activities. Though Program strategies work to strengthen skill building and oversight for community actors, inadequate human resources at CSBs pose a fundamental challenge, particularly in the context of repeated annual epidemics (plague, measles, COVID-19). The findings raised important discussions with USAID and results will feed into USAIDs strategy development. The program will share the final report of the mid-term survey in May 2020.
4.2.2 Dissemination and Participation in High Visibility Events
International Women‟s Day Week. The Mahefa Miaraka program participated in activities led by the Ministry of Population, Social Protection, and Women‟s Advancement from March 01 to 08, 2020 in Toliara. Mahefa Miaraka, like other stakeholders involved in the activities to reduce early marriage, early and unwanted pregnancies, and ending child marriage, demonstrated its commitment to promoting these practices through the presentation and demonstration of its youth activities, inviting several YPEs to participate in discussions on youth involvement and present their work in communities (See success story #3 for further details). The Program facilitated the participation of four YPEs from Menabe and SAVA regions to attend several days of the week‟s events. The objectives of the week included:
Celebrate successes in women‟s struggle for gender equality; Highlight women‟s accomplishments, recognize women‟s achievements and shared experience; Engage in advocacy and promotion of the specific needs of women and protection of their rights; Bring together influential and civil society actors involved in the promotion of women‟s rights, development partners, and women and girls in a Discussion Framework to Assess Progress on Malagasy Women‟s Rights since the Beijing+25 Platform for Action and the Achievement of SDG 5.
Designating Mahefa Miaraka as a “Baby Friendly Workplace” and inauguration of the Breastfeeding Corner by the National Program Office: In order to promote optimal breastfeeding practices and support the ability of mothers to be provided the ability to breastfeed in the workplace, Mahefa Miaraka set up a nursing corner in its Antananarivo office, affording an opportunity for its working mothers to breastfeed their infants during
From left to Right: Inauguration of the Mahefa Miaraka Antananarivo Office as a “Baby Friendly Workplace” - Certification awarded to the Chief of Party by the Ministry of Labor.
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working hours. In being certified a “Baby Friendly Workplace” the Program allows mothers to breastfeed their babies exclusively during the first six months of life to two years and beyond. On 21 January 2020, the Ministry of Labor in the presence of the Ministry of Public Health, USAID Madagascar and implementing partners, recognized Mahefa Miaraka‟s successful efforts to create a Baby Friendly Workplace. The event was carried by two national television channels and the Program‟s Facebook post about the event achieved a record audience with 5,541 people reached with the information and 324 interactions.
Celebration of International Women‟s Day 2020: this year, the Ministry of Population, Social Protection and Women‟s advancement organized the national celebration of International Women‟s Day in Toliara, Atsimo Andrefana region, with a week‟s worth of activities. Mahefa Miaraka marked its contributions to the festivities through its community partners from Menabe region and by its regional team‟s participation in local celebrations. In Toliara, through testimonials and participation in conference debates, the Program- supported youth peer educators and The Menabe region delegation proudly marching under the banner of Mahefa their school-based coaches shared Miaraka during the festival parade of the celebration of International Women’s Day in Toliara, Atsimo Andrefana region. their experience the Program‟s youth experiential learning approach on sexual reproductive health, including the promotion of the five key life skills among young people and how they apply them in their daily lives. More than 5,500 participants visited the Mahefa Miaraka booth during the week and attended the various conferences. At the regional level, the Program-supported CHVs were key partners in the success of the festivals and conducting education and demonstrations on family planning benefits and methods during festival events.
Launch of IMPACT Malaria‟s continuous ITN distribution project. The Deputy Chief of Party and Regional Director of Sofia participated in IMPACT Malaria‟s program launch for the continuous ITN distribution in Foulpointe from February 13-15. The ceremony was attended by the newly appointed Minister of Health. The head of USAID Madagascar and USAID‟s implementing partners in health held a morning meeting to introduce the various projects to the Minister of Health and to better understand his priorities for health in the country. The Minister gratefully acknowledged the support of USAID and its implementing partners in the area of community health. The Minister focused on resiliency and response to the shocks that continually confront Madagascar, such as the recent cyclone that wrought havoc with the health infrastructure in the Soalala district of Boeny region and caused floods in Sofia and DIANA regions that severed the main highway between the two regions nearly two months. In addition, a major priority for the Minister is the development of the country‟s human resources for health, mentioning the potential of assigning doctors (generalists) who can help local populations. The Minister‟s background is in radiology and his newly assigned Secrétaire Général, although highly respected, also has a clinical focus, so there is some concern as to the understanding of the vital role community health plays in the country. Partners realized that there is work to do to further engage in discussions with the new MOH Minister and his management team around the continuum of care and key health system building blocks that assure primary care at the community level. As such Mahefa Miaraka will seek a meeting with the Minister and Secrétaire Général to present the work of the Program and its support to the PNSC and advocate for continued resources for community health as a cornerstone of the formal health system.
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Sub IA 4.3 Cross-Cutting Issues
Sustainability Mechanisms. As presented throughout this report, Mahefa Miaraka continued to promote a sense of ownership among stakeholders and develop the capacity of GOM officials and other community actors at the local level through technical and managerial trainings. Using the cascade training approach, the Program trained GOM officials at each level to conduct the training for their own staff members. In addition, the Program continued to strengthen the relationship between CHVs and the CSB by supporting monthly meetings and routine CHV supervision in the FKT. Finally, the Program also provides hands-on assistance to data quality assessments, uploading of data into MOH data portals, and identification of solutions to obstacles at the national, regional, and district levels to access and use data from the CHVs. As another mechanism, the Program invests in family capacity to improve and sustain improved health behaviors including through KMSm activities, and Model Family and Mentor Family approaches. Youth approaches, for both in- and out-of-school youth, also contribute to long-term sustainability of family and community behavior change.
Gender Equality and Female Empowerment. The Program took action to promote gender equality and female empowerment within the implementation team, as well as in Program-supported communities. Activities including those aimed at prevention of GBV are integrated into other work streams, including youth efforts and SBC activities. Program staff members continue to participate in national-level Gender and Youth Working Groups, contribute to national strategies, and participate in related national days in collaboration with the Ministries of Population, Youth and Health. In Q2, the Program has laid the groundwork for the new stream of work related to child, early and forced marriage (See section IA5).
Family Planning Compliance. By the end of Q2, nearly all (91 percent) of Program staff have completed the “U.S. Abortion and FP Requirements – 2020” and “Protecting Life in Global Health Assistance and Statutory Abortion Restrictions”. The Program aims to have remaining staff that have not completed these certifications, to do so in Q3. All sites supported by the Program are public sector sites, and routine monitoring activities reflect the “U.S. Abortion and FP Requirements”.
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Intervention Area 5 (IA5): Reducing Child Marriage and related Reproductive Morbidity and Mortality among High-Risk and Married Girls in Sofia, Menabe and DIANA regions of Madagascar
Key Achievements:
1. Recruitment of child, early and forced marriage (CEFM) team in the three targeted regions
(DIANA, Menabe, Sofia)
2. Introduction of CEFM objectives and activities to MPPSPF, regional government, local partners,
and communities
3. The approval of the Program‟s CEFM related research granted by the MOH Ethics Committee
for Biomedical Research
4. Orientation of 15 newly hired staff completed
5. Installation of commune level staff
On February 6, 2020, the Program received USAID‟s approval on the proposed objectives and activities in the child, early and forced marriage (CEFM) workplan, as re-submitted on January 16, 2020. The activities under IA5 aim to increase local capacity to scale up existing and new efforts at community and policy levels that aim to reduce CEFM, early and unwanted pregnancies, and birth rates – especially second births among teen wives – while increasing voluntary FP use and awareness of the negative effects of CEFM. In addition to the newly introduced CEFM activities, CCH will continue its work in communities to combat GBV and its physical, psycho-social, and sexual manifestations in communities based upon approaches and tools developed under the Ministries of Health, Youth and Population. Work under IA5 will contribute to improving the national policy environment for gender equity, with the Program continuing its active participation in the national-level Gender Working Group. All Program activities planned under IA5 are in line with the following HPN key priorities:
1. Expand access to evidence-based high-impact interventions and service delivery approaches. 2. Explore new innovations and innovative approaches for activity implementation.
In addition, the planned activities contribute to the attainment of the objectives outlined under the “National Strategy to Combat Child Marriage (2017-2024)” which aims to “protect children from union, marriage and early pregnancy,” the “National Reproductive Health and Family Planning Law” and the “National Strategic Plan for Sexual and Reproductive Health for Youth and Adolescents”.
In its final comments USAID requested that the Program consider three final recommendations: Since GBV rates are high in all three regions targeted for the work, it is likely that violence is normative in communities. Activities will need to take this into account and integrate sensitization and prevention at all levels (individual, community and among health system actors). Engagement of boys and men (e.g. in school-based and out-of-school youth; with husbands and other male community leaders) will be important. Positive Youth Development (PYD) approaches in the proposed youth work will be a plus.
Recruitment and Staffing
In order to ensure the required technical expertise and management experience required for the CEFM Program. CCHP recruit dedicated staff for the CEFM activities. By the end of Q2 the program has brought on board one CEFM Project Manager based in Antananarivo; three (3) Regional Technical Officers, and 11 community program officers, “Relais Communautaire" or "Accompagnateurs en Santé.” The Program‟s community program officers are based at the commune level and have responsibility for two to three
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communes. CCHP regional and district teams worked closely with the central team and an expert international youth and gender consultant to review of communication and training tools related to VBG and CEFM for Program adaptation, orient the field teams and the GOM staff from relevant ministries (particularly the Ministry of Population) as well as to introduce communities to the goals of the work.
The Program oriented the CEFM regional teams in two rounds, first bringing the teams from Menabe and Sofia together from March 9-16 in Morondava, and the DIANA team in a second round of orientation in Antsiranana from March 16-20, 2020. The objectives of the orientation included the following:
Orient and train new CEFM staff and other Program staff as required on the basic principles of the CEFM, our theory of change, approaches, and activities; Review the proposed activities for CEFM (such as community dialogue on gender-based violence, male and youth engagement) with partners, such as MPPSF, NGOs, the child protection network and associations in the Menabe region. Visit a community that has already undertaken initiatives (or that has an interest) in Mahabo District to learn more about what the community‟s experience and what it has learned. Review approaches and tools to identify gaps in program needs and adaptation planning and/or development of specific documents.
By the end of Q2, the regional teams had selected the communes of intervention in six districts (two in each region): Antsiranana II and Ambanja districts in DIANA, Mahabo and Miandrivazo in Menabe, and Antsohihy and Mandritsara in Sofia.
Introduction and Orientation with GOM and Community Partners
On January 22, 2020, the Program COP and DCOP met first the Secrétaire Général of MPPSPF to introduce the CEFM project and to better understand the Ministry and its partners‟ experiences related to strategies and efforts in country to end child marriage. Following this first meeting, the Secrétaire Général organized a meeting between Mahefa Miaraka and Community discussion on community traditions, customs and child marriage, the heads of the General Directorates Mahabo, Menabe Region. Photo Credit: Mahefa Miaraka Menabe of Women and Children on February 11 to agree on the process of collaboration at national, regional and community levels. A proposed national work planning scheduled for late February was postponed to Q3 due to the Belna cyclone disaster response.
On March 11, 2020 the Program team, composed of the Chief of Party, Deputy Chief of Party and Regional Directors from Mahefa Miaraka and CEFM technical staff from Antananarivo, Menabe and Sofia, met with local authorities including the Governor of the Menabe Region, the representative of the Regional Population Offices, Social Protection and Women‟s Promotion Office and other officials to present and discuss the objectives and proposed activities of the CEFM component of the Program.
This meeting was well received by local authorities and it served to inform the authorities at regional, district and commune levels of the outline of the CEFM project. The meeting allowed them to share their concerns and efforts to fight child marriage and early pregnancy in the region, and to gain their buy-in and support for the project. At the end of the meeting, the decision-makers present stated that they would gladly support the
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Program‟s efforts in implementing activities related to the prevention and reduction of child and early pregnancy and marriages in the region. A similar introductory meeting was held the following week in DIANA region that engaged the Representative of the Prefecture, the Regional Director of MPPSF, and the network for protection of children (which includes a number of CSO, local NGO, and is led by MPPSF).
In addition to meeting with local authorities, the Program in coordination with MPPSPF held community discussions in the Mahabo and Antsiranana I districts. The two meetings were attended by local authorities and key community figures, including the mayor of the commune, the Chief of Population Service of the district, a representative of the Ministry of Youth and Sport and the District Medical Inspector and representatives from each FKT. Among these participants were a CHV, the president of FKT, the president of an association of farmers of the region, the president of an association of cultivators of the commune, and YPEs.
While these were introductory discussions, some key elements arose from these discussions, including the challenges but also opportunities for implementing the CEFM prevention and reduction activities, as follows:
The traditional practices surrounding marriage (including child marriage) are deeply rooted among the different ethnic groups represented in these community discussions. These practices involve extremely complex parenting relationships. However, cultural practices vary in terms of practice and application among ethnic groups. Girls are married young by parents mainly due to poverty. In addition, they are married for the sake of “protection” considering that as soon as they reach puberty, they run the risk of becoming pregnant outside marriage. In DIANA the issue is complicated by young girls entering sex work in Diego. Those present were aware that child marriage and early pregnancy are a problem in their community which is widespread and largely accepted (or tolerated) within the community, with poverty of families cited as the main cause as the girl becomes a “burden” to her family; In addition, these discussions revealed generally poor communication between adults and youth in the communities (inter-generational conflict with a focus on access to information on the internet, clothing styles, etc.); there is a sense that parents are overwhelmed by changes in life or that their child‟s reality does not mirror their own experience (children‟s schooling, access to media and the internet) and struggle how to raise their children in this new context.
Nevertheless, there is a willingness to work on this issue and to support the interventions that will be carried out as part of the CEFM project. Strategies will need to be developed using community dialogue to work with all existing subgroups in the community, sometimes separately, sometimes jointly, to ensure representativeness in identifying needs, strategies and decision-making. Collaboration with existing resources and structures within communities will also be sought as there are associations and NGOs working on GBV that support at-risk girls; It will also be necessary to seek the support and buy-in of traditional leaders and elders, particularly through community decision-making processes, as their opinions and decisions carry a great deal weight and strongly influence families in the community.
Formative Research
The research protocol was submitted for ethical approval to the MOH Ethics Committee for Biomedical Research and approval was received on February 28, 2020. The Program recruited a local consultant to train and lead the qualitative data collection process. The orientation and training of the formative research team took place in Morondava from March 16 – 20. The research team field tested the interview and focus group discussion guides and made modifications based on use with community members. Unfortunately, just prior to the scheduled start of data collection the first cases of COVID-19 were confirmed in country. In fact,
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several members of the research team were held under COVID-19 quarantine as they stayed in the hotel with people who just returned from abroad when Madagascar‟s borders were closed.
With the declaration of a National Health Emergency, local authorities restricted all community activities and travel to and from regions to the capital were suspended. The team decided to put the formative research on hold while working with local authorities to reunite members of the research team with their families. As of the writing of this report, all members of the research team have been released from quarantine and repatriated to Antananarivo. The formative research is on hold until the country better understands the extent of COVID-19 spread in country and options for field research are clarified.
Work Planning
Despite the declaration of a national emergency, there are currently few reported cases of COVID-19 in country, and Program teams are following the guidance of local authorities in terms of any restrictions on travel or conduct of community meetings. Work planning therefore focused on what could be done through meetings with individuals and small groups to avoid having large gatherings and conduct meetings per social distancing guidance. However, commune and regional staff were able to successfully introduce the project and inventory community groups and their activities that support at-risk girls in their assigned districts and communes. The Program will conduct further orientation and work planning sessions with the CEFM in Q3 after the local teams have had a chance to better identify potential community resources, partners, and understand what local authorities and communities may have previously done to address child marriage.
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Challenges and Proposed Solutions for Q2 FY2020
CHALLENGES SOLUTIONS 1. Stock-out of child health products In regions with the highest rate of stockouts on remains high in certain regions misoprostol and malaria commodities, meet with the (SAVA in particular), particularly for Medical Inspectors and District Pharmacies to see if ACT for malaria case treatment. orders for CHVs are accepted, if monthly consumption The situation has improved as estimates are correct, and if CSB heads distribute to compared to Q4 2019; however, CHVs. arrival of child health commodities Coordination with USAID IMPACT on the distribution in the country has been delayed. of commodities kits to CHVs to ensure supply/re- supply in communities. For Family Planning commodities, Continue training of CSB Heads and CHVs on the unavailability of Sayana Press has commodities supply management. resulted in a 50% drop in use over Continued sharing of Program data on essential the past two quarters. The commodity stockouts in meetings with DPLMT, the continued lack of Misoprostol has National Malaria Control Program, the Family Health meant that stockouts remain near Division of MOH and relevant partners to inform 100 percent in Program areas. decision-making.
2. Change in MOH leadership in early Meet the new Minister of Health and Secrétaire Général February 2020 requiring orientation in order to introduce the Program in coordination with of the central management team on USAID and other implementing partners. community health as the team‟s Arrange for a joint supervision with the Minister and/or background is clinically focused. Secrétaire Général to Mahefa Miaraka sites.
3. Cyclones and floods in Analanjirofo, Regional teams modify activities based on accessibility Boeny, DIANA, Menabe, SAVA and to areas and ensure safety of staff and security of Sofia that destroyed infrastructure, vehicles. including latrines, roads, health huts Program inventoried losses and is working with resulting in loss of equipment, regional offices and procurement team to replace lost commodities and clinical, equipment and CHV materials. communication, and management Re-establishment of the health huts and latrines will tools of CHVs. Several CSBs were take some time as they are community-financed. also severely damaged. COVID-19 Pandemic. National Mahefa Miaraka teams actively participate in regional Emergency Declared on March 20, (7) and district (34) response committees in order to 2020. Antananarivo office closed, share and support the DRSP in its response in staff working from home until further coordination with stakeholders. notice by GOM. At national level, participate in GOM, USAID and Partners COVID-19 committees to be informed and support response efforts in country. Adhere to operational and personnel safety practices established for COVID-19. Submission to USAID on proposed COVID-19 response activities. Supported the transport (with returning Program teams) of tests of suspected cases from Morondava to Antananarivo, and the set up health control units. Repatriate CEFM formative research teams to Antananarivo during the period of the National Health Emergency related to COVID-19 prevention and response.
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Administrative and Financial Management
Key Achievements: 1. Ongoing recruitment to replace departing staff and for CEFM activities.
2. Response to the coronavirus covid-19 outbreak.
3. The FY2020 procurement process is ongoing.
4. Required reports submitted to USAID.
Sub IA 0.2 Administration
0.2.1 Human Resources The Program continued to fill the vacant positions due to staff departure. Recruitment was processed for new staff assigned to the CEFM (Child Early and Forced Marriage) activities in Antananarivo and in the three regions of Sofia, Menabe and Diana.
0.2.2 Response to COVID-19 In response to the covid-19 outbreak, the Program followed JSI policy and guidelines to protect staff, updated USAID guidance for the management of cooperative agreements in the time of covid-19, and the government instructions related to covid-19. The Program prepared a contingency plan and it was sent to USAID. In addition, the program began to prepare a formal written notification to the Agreement Officer to provide a formal readiness update in April.
JSI undertook measures regarding staffing and operations, communications, and staff education and wellness for the central and seven regional teams. CCH staff in Antananarivo started to work from home to ensure safety and continue project operations. Staff members were provided with telecom internet keys to maintain network connectivity. And a limited number of staff uses the office to ensure core functions, security and networking tasks. All staff working from home follow work plans and continue to document their work. Internal coordination is set up to effectively manage priority tasks and workloads using digital communications. Operations in the seven regions and 34 districts were affected in disparate ways depending upon whether there were confirmed covid-19 cases. JSI follows all local government requirements, which requires flexible working environments including tele-working, quarantining, social distancing and other covid- 19 related interruptions.
During this quarter, all international and domestic travels were disrupted. International technical assistance is no longer possible or advisable, and distance support is being provided by our sub-agreement holders as well as JSI headquarters staff. In addition, technical and administrative support and monitoring visits between program offices are no longer possible in many cases since travel between regions and districts is either not possible or requires complex approval from multiple jurisdictions.
0.2.3 Procurement and Distribution Management The Program continued the distribution and delivery of kits for CHVs in the seven regions. Such activity was stopped at the end of the quarter because of covid-19 limits on having daily workers at the office and due to lack of transport.
0.2.4 Reporting to USAID All required reports were submitted to USAID on time according to the Program‟s Cooperative Agreement.
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Sub IA 0.3 Financial Management
0.3.1 Financial Procedures The Program continues to work closely with the mobile banking operators to solve problems and improve the system.
To respond to USAID‟s follow-up on recommendations #1, 2, 3 and 4 included in the final Financial Review Report of 2019, CCH shared additional information and documentation with USAID on the corrective actions taken. All the solutions and documentation on three of the four issues were accepted, and the remaining discussion about VAT payments continues with the Agreement Officer.
0.3.2 Financial Reporting to USAID The Program submitted the required financial reports: FY2020 Q1, SF425 Q1, and FY2020 Q2 Accruals Report.
0.3.3 Expenditures The total cumulative expenditures as of March 31, 2020 is approximately excluding accruals and close-out cost (Table 19). The program has successfully recorded in cost share, which represents 71% of the required amount, reflecting the increased effort to meet the requirement.
Table 19 – Program’s Cumulative Expenses as of March 31, 2020
TOTAL TOTAL EXPENDITURES BY FUNDING TYPE EXPENDITURES GH - A049- A052- A053- A054- Emergency Budget line items AS OF CEFM March 31, 2020 Malaria MCH FP/RH Water Plague & (IN US$) Measles
SALARIES
CONSULTANTS
TRAVEL & PER DIEM
ALLOWANCES EQUIP, MATERIALS, SUPPLIES
OTHER DIRECT COSTS
PROGRAM COSTS
SUBRECIPIENTS
TOTAL DIRECT COSTS INDIRECT COSTS / OVERHEAD
TOTAL COST COST SHARE
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DISCLAIMER
This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the responsibility of JSI Research & Training Institute, Inc. (JSI) and do not necessarily reflect the views of USAID or the United States Government.
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