RESPOND TANZANIA PROJECT
Quarterly Report April 1, 2014 – June 30, 2014
SPOND TANZANIA PROJ
Submitted to: United States Agency for International Development/ Tanzania
Submitted by: The RESPOND Tanzania Project
Under: AID-621-LA-13-0000 Reference LWA No GPO-A-00-08-00007-00
Submitted on: 31, July, 2014 RESPOND Tanzania Project Quarterly Report: April 1, 2014-June 30, 2014
Our Mission EngenderHealth works to improve the health and well-being of people in the poorest communities of the world. We do this by sharing our expertise in sexual and reproductive health and transforming the quality of health care. We promote gender equity, advocate for sound practices and policies, and inspire people to assert their rights to better, healthier lives. Working in partnership with local organizations, we adapt our work in response to local needs. This report of the RESPOND Tanzania Project is made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents are the responsibility of EngenderHealth and do not necessarily reflect the views of USAID or the United States Government.
RESPOND Tanzania Project EngenderHealth/ Tanzania 1 RESPOND Tanzania Project Quarterly Report: April 1, 2014-June 30, 2014
The RESPOND Tanzania Project Associate Cooperative Agreement No. AID-621-LA-13-00001 Managing partner: EngenderHealth Associated partners: Meridian Group International, the Population Council Local partners: UMATI, Utu Mwanamke, WAMA Collaborating partners: NIMR, CCBRT
©2013 EngenderHealth. COPE®, Supply–Enabling Environment–Demand, and the SEED™ Model are trademarks of EngenderHealth. Photo credits: S. Lewis/ EngenderHealth, Staff/ EngenderHealth
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Acknowledgements
The RESPOND Tanzania Project continues to show good implementation results and did even better this quarter as compared to the last quarter. This achievement is a result of good cooperation received from many colleagues within the project, the Ministry of Health and Social Welfare (MOHSW) and the regions and districts that we supported.
RTP is sincerely grateful to the MOHSW, especially the Reproductive and Child Health Section, (RCHS) whose continued collaboration and cooperation was optimum, as well as MOHSW collaborators at the zonal, regional, district and facility levels. RTP acknowledges with deep appreciation the generosity of the American People for their support through the U.S. Agency for International Development (USAID). We are also grateful for the strong partnership that we have enjoyed with other FP, HIV, maternal and child health and GBV implementing partners.
We express our sincere gratitude to Michael Mushi, Alisa Cameron, Raz Stevenson, Patrick Swai and Jennifer Erie for their support and guidance. We also thank Jennifer Norling for her support from the USAID Agreements Office.
RTP is grateful for the technical support and inputs that we received from the colleagues at EngenderHealth in New York. We acknowledge and appreciate the valuable work of all the staff at RTP HQ, the Field Managers and staff at the Field Offices who worked tirelessly to ensure that we accomplish our objectives.
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Acronyms and Abbreviations ANC Antenatal Clinic ART Antiretroviral Therapy ARV Antiretroviral CHAMPION Channeling Men’s Positive Involvement in the National HIV/AIDS Response COPE Client Oriented Provider Efficient CCBRT Comprehensive Community Based Rehabilitation in Tanzania CCHP Comprehensive Council Health Plan CHBC Community Home Based Care CHMT Council Health Management Team cPAC Comprehensive Post Abortion Care DBS Dried Blood Sample DMO District Medical Officer DQA Data Quality Assessment DRCHCO District Reproductive and Child Health Coordinator EID Early Infant Diagnosis FO Field Office FP Family Planning GBV Gender Based Violence HIV Human Immuno-Deficiency Virus IEC Information Education Materials IUCD Intra–Uterine Contraceptive Device JHU/CCP Johns Hopkins University Center for Communication Programs JSI/DELIVER John Snow International/DELIVER LARC/PM Long Acting Reversible Contraception and Permanent Methods M & E Monitoring and Evaluation ML/LA Minilap (Minilaparotomy) under Local Anesthesia MNCH Maternal, Newborn and Child Health MOHSW Ministry of Health and Social Welfare MTUHA Kiswahili acronym for Health Management Information System MVA Manual Vacuum Aspiration NGO Non-Governmental Organization NSV Non-Scalpel Vasectomy OJT On-the-Job Training OVC Orphans and Vulnerable Children PE Peer Educator PMTCT Prevention of Mother to Child Transmission of HIV/AIDS PMO-RALG Prime Minister’s Office Regional Administration and Local Government PO Program Officer PSI Population Services International QMT Quality Management Tool R Result RCH Reproductive and Child Health RH Reproductive Health R & R Report and Request Form RRCHCO Regional Reproductive and Child Health Coordinator SP Service Provider SBCC Social and Behavior Change Communication SWOT Strengths, Weaknesses, Opportunities, Threats (analysis) RESPOND Tanzania Project EngenderHealth/ Tanzania 4 RESPOND Tanzania Project Quarterly Report: April 1, 2014-June 30, 2014
SWT Site Walk-through TOT Training of Trainers UMATI Uzazi na Malezi Bora Tanzania USAID United States Agency for International Development VAC Violence Against Children VCT Voluntary Counseling and Testing WAMA Wanawake na Maendaleo ZRCH Zonal Reproductive and Child Health ZRCHCO Zonal Reproductive and Child health Coordinator
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Contents Our Mission ...... 1 Acknowledgements ...... 3 Project monitoring record ...... 7 Acronyms and Abbreviations ...... 4 Executive Summary ...... 9 Introduction ...... 12 Result 1: Access to quality FP-LARC/PM and RH Services (HIV and AIDS and GBV/VAC) increased ...... 13 Result 2: Quality FP-LARCs/PMs and RH integrated services demonstrated, evaluated and scaled up...... 25 Result 3: Health systems management, monitoring and evaluation strengthened for integrated FP- LARC/PM and RH services...... 29 Result 4: Communities mobilized to increase use of FP-LARC/PMs and RH services ...... 35 ANNEX...... 38
List of Tables and Figures Table 1: Distribution of Modes of Service Delivery Events by Level of District, April to June, 2014 Table 2: RTP Performance January-March 2014 Table 3: LARC/PM Performance by Mode of Service Delivery, April – June 2014 Table 4: Training of service providers July 2013 to June 2014 Table 5: Clients served by UMATI disaggregated by Method Table 6: PMTCT performance, July 2013 to June 2014 Table 7: Individuals Offered Post GBV and VAC services, April - June 2014 Table 8: Number of clients served during Integration training Table 9: LARC/PM Client by Method, July 2013 –June 2014 Table 10: LARC/PM CYP by Method, July 2013 –June 2014 Table 11: Training by Type, July 2013 to June 2014 Table 12: cPAC Performance, July 2013 to June 2014 Table 13: GBV and VAC Performance by Type of Incidence, October 2013 –June 2014
Figure 1: LARC/PM Clients by Method, July 2013 to June 2014 Figure 2: Scale up of GBV and VAC facilities by month by district, October 2013 to June 2014 Figure 3: GBV and VAC Trend, October 2013 to June 2014 Figure 4: RTP Strategic Framework
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Project monitoring record Project name: RESPOND Tanzania Project Life of activity: 60 Months Value: US$ 42,357,285
Project To advance the use of Family purpose: Planning and Reproductive Health (FP/RH) services, with a focus on Amount US$ 18,800,000 the informed and voluntary use of obligated: long –acting and permanent methods of contraception (LA/PM)
Implementation EngenderHealth (prime), Meridian partners: International, Population Council; local partners include UMATI, Mortgage: US$ 23,557,285 WAMA and Utu Mwanamke, with NIMR and CCBRT as collaborating partners Award Associate Cooperative Agreement Accrued number: AID-621-LA-13-00001 expenditures: US$ 12,679,150
Period of 1st November 2012 – 31st October Pipeline: award: 2017 (Months) 8
CO/AO: Months of Charles Pope/ Jennifer Norling funding passed: 20
CTO: Michael Mushi Burn rate: US$ 713,930
Chief of Party: Richard Killian Months of funding 40 remaining: Linked to -Family planning long-acting Program Area: reversible contraception and Program permanent methods (FP- Element(s): LARC/PM), comprehensive post May 2014 for GBV; abortion care (cPAC), prevention September 2014 for of mother to child transmission of Next obligation FP and PMTCT HIV (PMTCT) and gender based due by: violence (GBV) and violence against children (VAC) service delivery. - Integrated FP-LARC/PM and reproductive health (RH) services - Health system management, monitoring and evaluation Comprehensive post abortion care RESPOND Tanzania Project EngenderHealth/ Tanzania 7 RESPOND Tanzania Project Quarterly Report: April 1, 2014-June 30, 2014
(cPAC)
- Community mobilization for priority FP/RH services Results in the R 1: Access to quality FP-LA/PM and RH services (HIV and AIDS and Results services for survivors of GBV increased. Framework: R 2: Quality FP-LA/PM and RH integrated services demonstrated, evaluated, and scaled up R 3: Health system management, monitoring and evaluation strengthened for integrated FP/LAPM and RH services R 4: Community mobilized to increase of FP-LARC/PM and RH services Major FP-LARC/PM, cPAC, PMTCT, Cost share customers/ GBV and VAC clients and considerations None beneficiaries communities where they live; the (if any): MOHSWs in Mainland Tanzania Site visits From 28th April to May 8th 2014, the HQ team comprising of the Senior conducted to Management and STAs conducted decentralization of midyear review to all date: the 4 FOs. The objectives were to review the implementation status of the Year 2 RTP work plan in order to understand progress and make any needed adjustments; provide staff with key updates and discuss priorities and the process for preparation of the Year 3 RTP Work plan. The exercise led to re- planning for the remaining period of Year 2 to maximize implementation.
Between 29th June and 18th July, the HQ team comprising of the Senior Management and STAs visited all the FOs to support them with Year 3 work planning. Each FO was supported to develop a draft work plan that are now undergoing further review at HQ before compilation, sharing with USAID and NY.
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Executive Summary This report presents accomplishments for the third quarter of the RTP Year 2 workplan (April 1, 2014 through June 30, 2014) and summarizes activities implemented under four key results that aim to increase use of FP/RH services, with a focus on LARC/PMs, to meet the reproductive interventions of Tanzanian women, men, and adolescents. During Year 2, RTP is providing direct project to 110 districts.
LARC/PM quarterly performance for clients served and CYP maintained an upward trend from 126,045 in July 2013 to 191,842 in June 2014 and with an increase of 55,673 clients (41 %) from last quarter.
Result 1: Access to quality FP-LARC/PM and RH Services (HIV and AIDS and GBV/VAC) increased
1.1 Improved capacity and performance of health service providers and facilities 145 FP service delivery events (27 FP weeks, 66 outreaches and 52 service days) were supported using a targeted district-based approach that focuses on improving access to and use of FP in low uptake districts. Consistent with RTP’s strategy to provide more support to low uptake districts, more service delivery events were implemented in level 1 districts, with 63 for level 1, 53 in level 2 and 29 in level 3. There was a good improvement of the overall performance quarter and the FOs did well in catching up with the challenges of heavy rains that had affected performance last quarter. The performance of FOs to achieve quarterly targets ranged from ranged 84% to 139% when compared to 79 to 86% last quarter. There was an increase of 55,673 (41%) from 136,169 clients served last quarter to 191, 842 this quarter.) During this quarter Mwanza FO participated in the National Green Star Re-launch organized by MOHSW in the five regions of the Lake Zone (Mwanza, Mara, Shinyanga, Geita, Simiyu) during May/June 2014. The FO supported FP services (outreach) in 13 districts (Magu, Kwimba, Misungwi, Tarime, Musoma DC, Serengeti, Meatu, Bariadi DC, Busega, Bukombe, Mbogwe, Shinyanga District Council and Kahama Town Council. A total of 14,095 LARC/PM clients were served (4,261 ML/LA, 6 NSV, 2,104 IUCD and 7,730 implants) and 304 clients were served with short-acting methods.
PMTCT Quality PMTCT and EID services in Manyara region increased; support the rolling out of Option B+ 12,852 women in Manyara region with unknown HIV status were tested and received their results and this represents 96% of the quarterly target. A total of 3,409 partners were tested and received their HIV results at ANC during this quarter. 149 (99%) out of 151 health facilities that provide RH services in Manyara Region are now providing PMTCT services and 143 (96%) of those providing PMTCT are now providing Option B+.
GBV and VAC services GBV and VAC clinical services were provided to 3,287 survivors in Iringa and Njombe regions at RTP supported sites. RESPOND Tanzania Project EngenderHealth/ Tanzania 9 RESPOND Tanzania Project Quarterly Report: April 1, 2014-June 30, 2014
59 service providers were trained to provide GBV and VAC services through central training
Result 2: Quality FP-LARCs/PMs and RH integrated services demonstrated, evaluated and scaled up RTP continued to support decentralization of cPAC and integration of FP into cPAC in 16 districts of Mwanza and Shinyanga regions. 708 clients received cPAC services during the quarter, all of them were counselled for FP and 434 (61%) were discharged with a FP method of their choice.
Other integration activities include: Integration of FP into Care & Treatment that is being implemented in 31 sites that are supported by AIDS Relief in Manyara Region, integration of HIV into FP through provider initiated testing and counselling (PITC) in all sites that are providing FP, and FP integrated into OPD and maternal and child health settings.
Result 3: Health systems management, monitoring and evaluation strengthened for integrated FP-LARC/PM and RH services Districts were finalizing their CCHPs for 2014/2015 during this quarter, and RTP shared its plans for district support with each district. Districts were encouraged to include budget for FP activities based on national guidelines and tracking of 59 district allocation of FP funds is in progress. EngenderHealth is the secretariat of the National Training Coordination Committee. A quarterly meeting was held on 18th June in which updates of training activities by partners were shared and the Clinton Foundation presented the status of the national training data base. EngenderHealth is leading the development of the updated mapping of FP partner activities in the Lake and Western zone regions that will likely be expanded to include the whole country. The tool was revised with input from partners during the quarter, data was collected, and the compilation is in progress.
RTP is conducting a rapid assessment of district coordination structures and status to ensure FP/RH activities supported or provided by different partners are well-coordinated and resources are efficiently utilized. This quarter data collection was done in eight districts - Mvomero DC and Morogoro Municipal, Kilolo, Rungwe, Arusha and Meru, Shinyanga and Uyui. Data collection of this assessment was completed and a draft report has been received from the consultant and is being reviewed.
RCHS Institutional Capacity Review An assessment is in progress that will inform development of a transition and sustainability plan for a shift to MOHSW/RCHS and district responsibility and capacity for mobilizing resources for, planning, managing and coordinating integrated FP-LA/PM, RCH and HIV services. The consultant has completed for the SWOT analysis with RCHS staff to identify structural, staffing and performance gaps and strategies to build the required skills and capacity to manage, support and coordinate activities.
District Health Information 2 (DHIS2) RTP continued to support MOHSW to strengthen the Health Management Information System (HMIS) web-based database, the DHIS2, by recharging modems with data bundles in 41 districts. Follow-up was conducted in 14 districts (Same, Rombo, Mwanga, Moshi district council, Moshi RESPOND Tanzania Project EngenderHealth/ Tanzania 10 RESPOND Tanzania Project Quarterly Report: April 1, 2014-June 30, 2014
urban, Siha, Bukoba Municipal, Bukoba District Council,Kilosa, Morogoro District Council, Kilombero, Ulanga, Morogoro Municipal, Mvomero and Gairo). Issues identified include that some district data managers do not know how to save the data after entering them in the system and how to run data validation prior to completing the data set. Managers were retrained and coached to help address these issues.
Result 4: Communities mobilized to increase use of FP-LARC/PM and RH services. RTP continues to use various approaches to mobilize clients for FP services such as community and religious leaders, VEOs and WEOs, posters on public places, house to house messages, announcements in local radios, announcements in public meeting and use of public address systems in public gatherings including markets.
In Mwanza, Six satisfied clients for ML/LA and NSV, IUCD and implants who were oriented last quarter, continued to give their testimonies during FP events to promote the use of LARC/PM in Nyamagana and Misungwi districts during FP services.
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Introduction This report presents accomplishments for the third quarter of the RTP Year 2 workplan (April 1, 2014 through June 30, 2014). The report summarizes activities implemented under four key results (described below) that aim to increase use of FP/RH services, with a focus on LARC/PMs, to meet the reproductive interventions of Tanzanian women, men, and adolescents. In Year 2, RTP provides direct project support to 110 districts.
RTP continued to support MOHSW and districts in FP-LARCs/PMs, decentralization of comprehensive post-abortion care (cPAC) down to lower level health facilities, scale-up of quality PMTCT services focusing on increased integration of family planning into other RH and HIV services and provision of HIV care and treatment services to eligible clients, and provision of care and support for survivors of gender-based violence (GBV) and violence against children (VAC).
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Result 1: Access to quality FP-LARC/PM and RH Services (HIV and AIDS and GBV/VAC) increased 1.1 Improved capacity and performance of health service providers and facilities in FP-LARC/PM, PMTCT and GBV/VAC Service Delivery
1.1.1 FP-LARC/PM Service Delivery A total of 145 FP service delivery events (27 FP weeks, 66 outreaches and 52 service days) were supported during the quarter using a targeted district-based approach that focuses on improving access to and use of FP in low uptake districts through a more intensive package of activities and resources. Through this approach more interventions were implemented in level one districts (63, events in level 1 as compared to 53 in level 2 and 29 in level 3), categorized as follows:
Table 1: Distribution of Modes of Service Delivery Events by Level of District, April to June, 2014 Field Office Type of Event Level 1 Level 2 Level 3 Total Arusha Outreach 0 3 2 5 FP weeks 2 1 5 8 Service days 2 1 2 5 Subtotal 4 5 9 18 Coastal Outreach 7 3 0 10 FP weeks 2 3 1 6 Service days 4 3 3 10 Subtotal 13 9 4 26 Iringa Outreach 3 0 3 6 FP weeks 2 0 1 3 Service days 1 2 2 5 Subtotal 6 2 6 14 Mwanza1 Outreach 20 17 8 45 FP weeks 4 4 2 10 Service days 16 16 0 32 Subtotal 40 37 10 87 Total events 63 53 29 145
A service provider counseling a ML/LA client during an outreach in Gairo District in Morogoro Region
1 Mwanza’s higher number of events this quarter is partly related to the Green Star re-launch in Lake and Western zone regions in which more funds were provided for FP events from UNFPA.
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A total of 191,842 clients were served with FP-LARC/PM services and 836, 183 CYP was generated, representing a 109 % achievement of the quarterly target for clients served and 108% of CYP generated this quarter.
Table 2: RTP Performance January-March 2014 ML NSV Implant IUCD Total
d office iel
F Indicator % % % % Target % Benchmark Achievements Benchmark Achievements Benchmark Achievements Benchmark Achievements Achievements
Clients 8,318 5,847 70 16 14 88 26,243 25,899 99 12,688 9,672 76 47,265 41,432 88
CYP 66,544 46,776 70 128 112 88 91,851 90,647 99 44,408 33,852 76 202,931 171,387 84 Arusha
Clients 5,546 4,477 81 8 47 588 22,205 22,482 101 7,091 6,371 90 34,850 33,377 96
CYP 44,368 35,816 81 64 376 588 77,718 78,687 101 24,819 22,299 90 146,968 137,178 93 Coast
Clients 6,558 5,318 81 11 18 164 19,177 21,288 111 8,583 6,893 80 34,329 33,517 98
CYP 52,464 42,544 81 88 144 164 67,120 74,508 111 30,041 24,126 80 149,712 141,322 94 Iringa
Clients 14,210 20,687 146 123 200 163 35,697 45,360 127 9,867 17,269 175 59,897 83,516 139
CYP 113,680 165,496 146 984 1,600 163 124,940 158,760 127 34,535 60,442 175 274,138 386,298 141 Mwanza
Clients 34,632 36,329 105 158 279 177 103,322 115,029 111 38,229 40,205 105 176,341 191,842 109
CYP 277,056 290,632 105 1,264 2,232 177 361,627 402,602 111 133,802 140,718 105 773,749 836,183 108 TOTAL
The service statistics obtained from MTUHA include services supported by other partners through outreach and through routine services, including those supported by EngenderHealth through other support mechanisms at public and private health facilities supported by the districts. Figure 1 below demonstrates LARC/PM performance by mode of service delivery.
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Table 3: LARC/PM Performance by Mode of Service Delivery, April – June 2014
Mode of service No. of Clients Served by FP Method Total delivery ML/LA NSV Implant IUCD Field Office Outreach 2,891 1 7,083 2,232 12,207 Service days 288 - 774 336 1,398 Routine services 2,668 13 18,042 7,104 27,827 SUB TOTAL 5,847 14 25,899 9,672 41,432 Arusha Outreach 2,885 9 4,520 939 8,353 Service days 140 2 155 43 340 Routine services 1,452 36 17,807 5,389 24,684 SUB TOTAL 4,477 47 22,482 6,371 33,377 Coastal Coastal Outreach 2,510 5 5,026 1,550 9,091 Service days 127 - 435 189 751 Routine services 2,681 13 15,827 5,154 23,675 SUB TOTAL 5,318 18 21,288 6,893 33,517 Iringa Outreach 8,441 31 14,867 4,766 28,105 Service days 131 - 98 40 269 Routine services 12,115 169 30,395 12,463 55,142 SUB TOTAL 20,687 200 45,360 17,269 83,516 Mwanza Mwanza TOTAL 36,329 279 115,029 40,205 191,842
As mentioned before, the overall performance of this quarter is higher than the past quarter and it is encouraging to note that the number of clients that are served through routine services is increasing. In the districts that are supported by the Arusha FO, 56% of the reported clients were served through routine services and approximately 45% of IUCD clients were served through routine services in Manyara region following the previous skills trainings. This is a result of based on the region’s decision to increase the number of skilled FP service providers through training, combined with supportive supervision and mentoring.
LARC/PM performance for clients served and CYP maintained an upward trend as shown in the tables below that compared performance over the past four quarters (July 2013 to June 2014).
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Figure 1: LARC/PM Clients by Method, July 2013 to June 2014 200,000 180,000 191,842
160,000 136,169 140,000 126,045 124,156
115,029 120,000 Jul-Sep 2013
100,000 Oct-Dec 2013 79,749
73,823 72,494
80,000 Jan-Mar 2014 60,000 40,205
36,329 Apr-June 2014
30,510
40,000 27,033 26,333 25,807 25,760
24,481
20,000 279 185 103 92
- ML NSV Impl IUCD Total
Coastal FO trained 42 service providers on COPE for CS in two districts of Mtwara, 22 from Nanyumbu and 20 from Mtwara Rural and involved 3 Health Centers and 6 dispensaries of Mtwara Rural and 4 Health centres and 4 dispensaries from Nayumbu District. The staff included medical officers, pharmacists, clinical officers and nurses in charge of the RCH units. The groups went for practical sessions in different units of the health facility-RCH, Pharmacy, Medical Records and OPD, with discussions following presentations of strengths, weaknesses noted in all the sites. All the trained staff were instructed to introduce COPE for CS and use their action plans to improve the quality of RH services in their sites, with follow up planned after 6 months.
In May, the Arusha FO conducted a CS meeting for Dodoma and Singida regions. Involving staff from selected districts and implementing FP partners, the meeting provided an opportunity to focus attention on factors contributing to stock-outs at the SDP level, particularly Jadelle. The discussion focused on challenges related to the timely submission of the R&R forms at the SDP level, and participants worked to develop joint action plans to address some of the underlying challenges, including weak communication, untimely delivery of FP commodities, shortages of train FP providers, inadequate knowledge of FP commodity ordering process as the SDP level, and the lack of regular CS meetings
Introduce COPE including for contraceptive security (CS) in targeted districts to improve quality of services in service delivery points (SDP) Mwanza FO introduced COPE for CS in two sites (Ngumo HC in Kwimba and Kiganamo in Kasulu). Active COPE committees were formed which will follow-up the implementation of developed plans. This was followed by orienting 12 CHMTs on the QI process who then identified their priority problems, developed possible solutions and developed action plans, e.g., how to reduce FP commodities stock outs at sites through improving R&R skills and proper stock management and forecasting.
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The members also agreed that Service providers should be educated on MSD codes for ordering different commodities as it is a challenge. EngenderHealth will address this issue through mentoring and coaching during facilitative supervision visits, facilitate monthly communication between districts/ DRCHCOs and District Pharmacist and MSD on available FP commodities. On the issue of staffing, it was suggested that MSD recruit sufficient staff knowledgeable in medicine and the medical supplies section.
Conduct COPE follow-up to strengthen services Mwanza FO conducted a two-day COPE follow-up in four health facilities (Kasulu DH, Maweni RH, Misungwi DH and Tarime DH). At all sites COPE committees were inactive, meetings were not being conducted, and many of committee members have either left for other studies, been transferred or retired, or have other commitments. Re-introduction to CHMTs was done to all sites followed by establishment of new COPE committees or filling the gaps where it was needed. All participants reviewed the action plans developed during the last follow-up meeting.
On the second day, they visited the hospital to observe what was achieved and identify new problems for action. For all hospitals it was observed that many identified problems in last follow-up meeting were solved and they developed a new action plan to work on the unimplemented /unsolved and newly identified problems; continuous follow-up will be conducted by the COPE committees and POs during their routine follow up.
Support CHMTs to conduct off-site training for LARC/PM In June 2014, 16 participants from 5 regions of the Lake Zone (Mwanza, Shinyanga, Mara, Geita and Simiyu) were trained on ML/LA and NSV by MOHSW national trainers in collaboration with the Mwanza FO. Nine participants were from level 1 districts, 4 from level 2 and 3 from level 3. A total of 636 clients (230 ML/LA, 371 implants, 29 IUCD and 59 short-acting) were served in 12 facilities during the practical period. Also through the Mwanza FO, RTP supported a two- week training to 41 LARC/PM TOTs from 2nd -14Th June 2014. Participants were from all eight regions of the Lake and Western zones. The Arusha FO supported training of 20 TOTs from Manyara, Arusha, Kilimanjaro, Dodoma, Tanga and Singida Regions. At the official opening MOHSW representative Mr. Maurice Hiza, the National FP Programme Coordinator, emphasized utilization and practice of skills acquired in their districts to train more service providers. The need to train more TOTs has been expressed by MOHSW and implementing partners following retirement of significant number of TOTs. Also during the quarter, a total of 578 service providers were trained in LARC/PM through the four FOs and 40 attended refresher training. From 7th to 18th April the Coastal FO supported Morogoro Urban district to train 20 service providers on Post-partum IUCD counseling and insertion, at Morogoro Municipal Hospital in which 57 clients were served with Postpartum IUCD.
During this quarter, a total of 541 service providers were trained shown in the table below. Majority of them (338) were trained on LARC/PM skills, which is a response to the MOHSW need for more LARC service providers especially at lower level health facilities.
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Table 4: Training of service providers July 2013 to June 2014 Training Type Jul-Sept Oct-Dec Jan-Mar April-Jun Total 2013 2013 2014 2014 LARC/PM Skills 64 82 94 338 578 LAPM refresher 0 13 0 40 53 Advocacy (Integration) 0 0 36 15 51 Monitoring and Evaluation 142 223 34 49 448 cPAC 0 0 0 30 30 PMTCT 0 0 425 15 440 GBV and VAC 58 28 21 54 161
Sub Agreement with UMATI RTP has sub granted UMATI to expand contraceptive options by increasing the availability of long- acting and permanent methods of contraception (LA/PMs) in UMATI clinics and improve access of FP services to youth in Dar es Salaam, Morogoro, Iringa, Mbeya, Mwanza and Shinyanga Regions. During the reporting quarter, UMATI renovated youth centers in Dar es Salaam and Shinyanga, trained 22 service providers in LARC, conducted FP outreaches and provided FP education to students at higher learning institution in Iringa Region. Service provision through this sub-award started in May 2014 and as at June 2014 1,120 clients were served as per the table below.
An UMATI service provider talking to university students in Iringa Municipality
Table 5: Clients served by UMATI disaggregated by Method Method NSV ML/LA IUCD IUCD Depo Pills Implant Implant Insertion Removal Insertion Removal Condom
Clients served 1 133 74 34 159 127 264 59 265 Total number of clients reached: 1,116
1.1.2 Quality PMTCT and EID services in Manyara region increased Increase access to PMTCT and EID services 12,852 women in Manyara region with unknown HIV status were tested and received their results, which is 96% of the quarterly target. A total of 3,409 partners were tested and received their HIV result at ANC during this quarter.
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149 out of 151 (99%) health facilities that provide RH services in Manyara Region are now providing PMTCT services and 143 (99%) of them are now providing Option B+.
Community engagement in supporting the roll out plan for option B+ EngenderHealth, in collaboration with Africare, conducted three orientation sessions on Home Based Care and Option B+ for community volunteers. The aim was to increase awareness, improve referrals and increase ARV adherence. A total of 90 Community Home Based Care Service Providers (CHBCPs) were oriented in three districts (Babati Town Council, Babati DC and Hanang DC).
Orientation to site staff on option B+ and integration services EngenderHealth in collaboration with the RHMT and CHMT in Hanang district conducted Orientation at Tumaini Hospital to sensitize the facility on advocating for the follow-up of HIV positive pregnant and lactating women who were on ARVs and for exposed infants. It also aimed at strengthening service integration in the facility across departments including integration of FP into mobile cervical cancer screening services. A total of 56 staff were oriented on Option B+. Tumaini is one of the sites of excellence in Manyara region that provides a full range of integrated services and all staff are motivated in recruiting clients and provision of different services based on clients’ needs.
Support procurement and distribution of PMTCT and EID commodities and equipment To address the issue of shortages of the HIV testing kits, RTP procured and distributed a total of 1,158 determine kits and 167 Unigold. RTP consistently monitors stock of DBS/HIV kits in collaboration with districts at the zonal Medical Stores department (MSD) and this is done on monthly basis and there is a budget to procure complimentary stock during critical shortage.
Recruitment of dedicated staff (retired nurses) for PMTCT services RTP continued supporting 14 dedicated retired nurses and voluntees who are working in the RCH section to improve the quality of RH services, including PMTCT in Manyara region. The engagement of these staff has improved data documentation, increased recruitment of new ANC and FP clients, and for HTC, cervical cancer screening, PITC, immunization , DBS collection and improved internal referrals.
Arusha FO and the RHMT organised a one-day meeting in Babati on 20th June to recognise the work of retired nurses and volunteers, review their contracts and update them in various services, including FANC, PMTCT Option B+, infection prevention and data management. Arusha FO continues to advocate to CHMTs to engage some of these staff in the formal employment.
Early Infant services The number of sites providing HIV EID increased from 127 to 143 sites. Increase in service provision was a result of refresher trainings, mentoring and on-the-job training. During this quarter, 121 HIV exposed infants were enrolled in EID and 101 (83%) were tested for HIV.
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Table 6: PMTCT performance, July 2013 to June 2014 Jul-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-Jun 2014
PMTCT Next Generation Indicators % % % % Actual Actual Actual Actual Benchmark Benchmark Benchmark Benchmark
Number of pregnant women with 45 126 36 53 135 39 86 135 64 220 135 163 known positive at entry Unknown Status at Entry (i.e. were tested for HIV and received 14,526 12,524 116 13,076 13,400 98 14,001 13,400 104 13,125 13,400 98 results.) Number of pregnant women with known HIV status (Including 14,571 12,650 115 13,129 13,535 97 14,087 13,535 104 13,345 13,535 99 women who were tested for HIV and received their results Number of new positive 98 125 78 146 306 48 144 306 47 219 306 72 identified Number of HIV positive women received ARVs to reduce risk of 178 226 79 142 328 43 185 328 56 128 328 39 mother to child transmission Number of health facilities providing ANC services that 141 145 97 143 145 99 146 151 97 146 151 97 provide both HIV testing and ARVs for PMTCT on site. Early infant diagnosis Number of infants enrolled in 105 103 130 203 EID Number of infants tested for HIV 91 84 125 161 Number of infants tested positive 1 4 5 10 PMTCT Programme performance Percent of new pregnant women enrolled At ANC who were 95% 95% 90% 90% 86% tested for HIV Percent of Pregnant women arrived at labour ward with 100% 100% 100% 100% 97% unknown HIV status who were tested for HIV
During this quarter, antenatal clinic (ANC) attendee was 15,433 and 13,309 (86%) were tested at first visit. 1,370 women had unknown status at labor and delivery (LD) and 1,328 (97%) of them were tested before discharge.
Achievement for maternal AZT seems low because of the high targets set [by CDC] for expected number of HIV-positive for Manyara region, where prevalence has been declining and overall prevalence is the lowest in Mainland Tanzania. During this quarter only 122 clients were newly identified to be HIV+ while the estimated number was 306. The projected number of HIV positives identified needs to closely match the HIV prevalence in the region.
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Basic Emergency Obstetric and Neonatal Care (BEmONC) EngenderHealth is supporting Manyara Region to provide BEmONC in 22 health facilities, including five hospitals and the rest being health centers and dispensaries. Arusha FO supported training of 25 service providers from Kiteto, Hanang, Mbulu, Babati and Simanjiro, including Medical Officers (3), Assistant Medical Officer (2), Enrolled Nurse (6), Registered Nurse (11), Clinical Officer (1) and 1 Medical Attendant (MCHA). Sixteen participants were from Hospital level, seven from health center and two from dispensary. During the practicum period 42 clients with different conditions were attended and discussed in the class room.
Strengthened supervision and quality improvement support for service delivery Supportive supervision was conducted in five districts, with districts using their own source of funds in Manyara region. EngenderHealth provided technical support and highlights on areas of supervision, especially in Option B+ and integration of services. Districts distributed HIV test kits provided by EngenderHealth to all facilities.
Trainee follow-up, coaching and mentorship for PMTCT Trainee follow-up, coaching and mentorship was performed in collaboration with the MOHSW PMTCT unit. In May 2014the team visited 32 PMTCT sites to observe quality of PMTCT and EID services, and reached 120 staff from Babati, Mbulu and Hanang districts. A total of 31 (96%) of sites were implementating option B+ toin accordance withstandards despite minor challenges that werewer observed. Almost 95% of service providers were trained on option B+ and services were going on in all facilities visited. All pregnant women , lactating mothers and those who were on other ARVs regimen were initiated with the new regimen of TLE (Tenofovir+Lamivudine+ Efavirez). All sites had ARV regimen meant for option B+, and cotrimoxazole tablets to prevent opportunistic infections. Lack of space for providing integrated services was still seen as a challenge, along with shortage of M&E tools for option B+. Shortage of MTUHA tools was observed in almost all facilities and districts did not have budget for printing these tools. The MOHSW is in the process of printing the tools and they will be distributed to the districts soon. Lack of laboratory investigations for women on ARVs is still a major challenge; only Dareda Hospital, Haydom and Manyara Regional Hospital have capacity of providing the full range of biochemistry investigations. Arusha FO is planning to meet with care and treatment partners and laboratory technologists to discuss modalities of sample transportation from facility levels, strenthening of district laboratories and quality control of samples.
1.1.3 Increase availability of GBV services Introduction of clinical GBV services in Iringa and Njombe In this quarter, EngenderHealth RESPOND Tanzania Project and the MOHSW conducted two core trainings on GBV and VAC from 28th April 2014-10th May 2014 and 12th May to 24th May 2014 covering five districts (Iringa DC, Njombe TC, Makambako TC, Ludewa and Mufindi DC). A total of 59 health care workers were trained in GBV and VAC using the Government of Tanzania’s national training curriculum for health care workers and social welfare officers. On return to their work stations, the trainees are followed up within one month and quarterly supportive supervision are done to ensure that they provide quality care.
Trainees were supplied with GBV MTUHA tools (registers, tally sheet and monthly summary forms and guidelines), National GBV and VAC Guidelines and MOHSW GBV and VAC Policy. Currently all trained health workers are providing GBV and VAC services in their respective facilities including provision of health education on GBV as per national standards. M&E was part of the training package hence participants are able to prepare a report, which is also filled in DHIS2. Following this training the
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coverage of GBV services has increased from 54 facilities to 64 facilities, which is 100% of the facilities audited.
The Program scaled up GBV and VAC services from 54 facilities to 64 facilities and achieved the goal of reaching 100% coverage by June 2014.
Health care worker trained on GBV and VAC providing group health education on GBV at the outpatient department during practicum sessions at Makambako dispensary.
Figure 2: Scale up of GBV and VAC facilities by month by district, October 2013 to June 2014 70 64
60 54 49 50
40 Oct-Dec 30 Jan-Marc April-June 20 14 14 1213 13 1113 1112 9 10 8 10 10 10 7
0 Ludewa Njombe Mak TC Iringa DC Mufindi TC
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Provision of routine GBV and VAC services Routine GBV and VAC services continued to be provided in integration with other services to all entry points i.e. OPD, RCH, CTC and in patients. At each entry point the following services are offered; Immediate medical management (history taking, physical exam), Treatment for all injuries that the facility can treat, HIV PEP, STI screening and treatment, Emergency contraception (EC) Basic psycho-social assessment and counseling Referral of survivors to higher level facilities for additional medical care (or collection of forensic evidence and provision of crisis counseling and psychosocial care and support)
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Figure 3: GBV and VAC Trend, October 2013 to June 2014
3,500 3,287
2,960
2,885 3,000
2,500 2,249
1,780
2,000 Oct-Dec 2013 1,559
1,500 Jan-Mar 2014 1,198
1,121
Apr-Jun 2014 1,000 613
500 181 146
128
83 59
15
- Sexual Phyisical Emotional Neglect Total Violence Violence Violence
Family Planning, HIV Integrated in GBV Services Other services continued to be integrated at the GBV and VAC room. GBV survivors received other services such as counseling for FP and screening for HIV in which 28 males and 213 females were counselled and 20 males took condoms while 117 females opted for pills, 63 injection and 14 took condoms.
A total of 3,287 GBV and VAC survivors were seen in this quarter, female being 78% of all survivors. Emotional violence has continued to be a leading cause of violence.
Table 7: Individuals Offered Post GBV and VAC services, April - June 2014 Type of Violence Age Group Total 0-4 5-9 10-14 15-17 18-24 25+ Total Female 28 76 148 202 668 1429 2551 Physical Violence FE 13 20 43 56 218 558 908 Sexual Violence FE 2 6 12 19 46 88 173 Emotional Violence FE 0 33 75 117 404 783 1412 Neglect FE 13 17 18 10 0 0 58 Total Male 21 65 77 69 104 400 736 Physical Violence ME 6 12 26 19 41 186 290 Sexual Violence ME 0 1 0 1 0 6 8 Emotional Violence ME 0 27 36 34 63 208 368 Neglect ME 15 25 15 15 15 0 70 Total Survivors 49 141 225 271 772 1829 3287
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Result 2: Quality FP-LARCs/PMs and RH integrated services demonstrated, evaluated and scaled up. 2.1 FP-LARC/PM integrated and HIV prevention, care and treatment services RTP continued to monitor integration of family planning and HIV services including:
Strengthening the FP component of PMTCT There has been an increase in number of women receiving FP services when they visit a facility for PMTCT services. A total of 3,797 women received FP counseling at postnatal visits and 478 of them received FP. This is due to continuous mentoring, training of service providers and supportive supervision.
Arusha FO and the MOHSW organized LARC training of 20 SPs from 13 facilities (Mrara Hospital, Magugu HC, Tumaini Hospital, Bonga HC, Bashnet HC, Dongobesh HC, Hydom Hospital, Gallapo HC, Kiteto Hospital, Mbulu District Hospital, Orkesmet Urban Health Centre, KKKT HC and Mererani HC).
The training was held at Babati from 22nd April- 2nd May 2014, with 114 clients served during this training, including 61 clients who received IUCD and 53 clients for implants. Lack of IUDC kits was a challenge; EngenderHealth has supplied 10 kits to Manyara this quarter and procurement of more kits is in progress.
Integration of FP into HIV Care & Treatment Centers (CTC) RTP collaborates with AIDS Relief to integrate FP into CTC in Manyara. During this quarter following scale up of CTC sites from 26 to 57 by Aids Relief; RTP also scaled up integration of FP into CTC from 26 to 31 sites. A total of 274 clients received FP methods this quarter compared to 113 in the last quarter. The Arusha FO is continuing to follow-up SPs who were trained in these sites and advocating to the CHMTs to provide necessary equipment and improved environment for provision of FP services. Through this advocacy effort the Hanang district has provided at least one IUCD kit and gas energy for sterilization to all facilities with trained SP. This is a very good start and the district will add more. This is also a lesson for other districts to ensure services are offered without donor dependence, although maintenance and reporting of data is a challenge due to lack of MTUHA registers. RTP is printing registers to fill the gap.
Integration of HIV Counseling & Testing into FP Clinic EngenderHealth supports districts in Manyara region to track FP clients counseled and tested for HIV at the FP unit. During this quarter a total of 11,618 clients received HIV counseling at FP units and 7,662 were tested and received their results. Among these who were tested for HIV, 24 were found to be HIV positive and were referred to CTC. CHMT members were trained on how to document HMIS book 12 with HIV counseling and testing, ensuring constant availability of HIV test kits and support districts in data collections and proper filling of data into the DHIS2 database.
Facilitate integrated outreach services in Manyara region EngenderHealth and the RHMT and CHMTs supported integrated outreach services conducted by Magugu Health Center, Manyara Regional and Babati District Hospitals from 12th -15th May 2014. During the integrated outreaches, FP, cervical cancer screening and immunization services were provided. A total of 488 clients received FP services (IUCD-123, implants-146, ML/LA-88, pills-35 and Depo-96). Shortage of implants was experienced during the outreach and the teams had to meet request
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for implants from other districts. The Arusha FO is looking at initiating CS meetings down to districts as an opportunity of ensuring availability of both HIV and FP commodities and supplies.
2.2 FP-LARC/PM integrated into maternal and child health settings (and other sites, such as outpatient departments)
2.2.1 Introduce integration in 15 new districts
Orientation of R/CHMT and other stakeholders on integration EngenderHealth continued to scale up integration of FP into broader MNCH and other setting such as antenatal clinics, under-five child health clinics, labor and delivery wards and within outpatient departments in 15 districts (4 districts in Mwanza zone, 4 in Iringa zone, 4 in Arusha zone and 3 in Coastal zone). This approach aims to maximize points of contact in which women and men may receive FP information and service. A first and important step was to introduce service integration to the district and region management and other stakeholders key to integration to get buy-in. This quarter on 22nd May 2014 an orientation meeting was done in Tanga for participants from Korogwe, Handeni, Kilindi and Muheza district. The meeting was also attended by development partners supporting RCH services, facility in-charges, RCH in-charge and in-charges of key units of service integration from 16 health facilities selected to provide integrated FP service. Other stakeholders who attend the meeting included Jhpiego, Africare, PSI, Marie Stopes and Tunajali.
Generally, a majority of stakeholders acknowledged the high unmet need for FP and the need for service integration as a key strategy to reach more women and men with FP information and services. However there was a concern of shortage of FP commodities, unavailability of FP registers (MTUHA books, monthly summary forms and RCH cards) to monitor the integrated services. To address the gaps, RTP is working with the MOHSW, through National and Zonal Contraceptive meetings to improve availability of commodities in integration sites. The project also is working with the MOHSW to secure more FP registers, FP, MCH and HIV related guidelines to distribute to these facilities.
Site orientation on service integration Considering that with service integration, more units at the facility will be providing FP services, it is important to make everyone at the facility aware of this new initiative. RTP is conducting orientation to all staff at the site where service integration is introduced in order to inform and sensitize all the facility staff about the initiative.
During this quarter, orientation was conducted to all 60 health facilities providing integration, and involved 1,200 participants. During these events every staff at the facility was invited to attend a half-day orientation meeting on service integration. Topics that are covered include description of services integration, the services that will be integrated at the particular facility and individual staff roles in the initiative. Most staff at integration sites are now aware of integrated services available in different units of the facility and this is likely to increase client FP uptake through better internal referrals.
Each facility identified units at their facilities that can provide integrated services. Facility assessments were conducted to assess the capacity of the selected unit to provide FP and provide recommendations on
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which services can be integrated, capacity building and other equipment needs. After the assessment, identified service providers were trained to provide family planning information, counseling and methods to patient/clients in the CTC, Immunization, RCH clinic and Labor and delivery services to clients who visit the facility for any reason, for example for immunization, malaria, dental service or simply to visit their sick relatives. Other units like OPD are expected to provide mostly short acting FP methods and implants and refer clients to the FP unit for IUD and permanent methods. In Manyara, where integration started about three years ago, providers from other units have been trained and are providing even IUD at CTC and other units.
As part of scaling up service integration, 159 SPs from CTC, immunization, gynecological/female wards, labor and delivery and outpatient departments were trained on FP, with the following numbers per FO (Mwanza 21, Arusha 45, Iringa 51, and Coastal 20). In Manyara the training of 30 SPs in other units also involved training on IUD and reports indicate that most units are now able to provide IUD services. After six days of theory, participants were able to practice for three days in different departments or during outreach organized during the training.
Trainers recommended that graduates practice immediately in RCH at least twice a week, and need immediate follow-up visits at work sites so as to provide them with technical support on especially Jadelle insertion accordingly so as to gain competence. They also recommended the integration curriculum be modified to suit participants from other units.
Table 8: Number of clients served during Integration training Zone No. of trainees No. of clients served during training Pills Injectable Implants Condom IUD Mwanza 21 321 100 49 56 - Arusha(Tanga) 25 74 79 126 19 - Iringa 51 69 51 75 17 - Coastal 41 28 39 179 20 0 Manyara 20 89 96 175 46 78 Total 158 581 365 604 158 78
Postpartum Family Planning (PPFP) From 7th to 18th April 2014, the Coastal FO, in collaboration with MOHSW trained 20 SPs from five facilities in Morogoro Municipal on PPIUD (6-Regional Hospital, 2-Mafiga HC, 2–Aga Khan HC, 2- Mwembesongo Dispensary, 2-Mzinga Hospital, 2-Sabasaba HC, 2-Uhuru HC, 2-Kingolwira HC). Fifty- seven clients were served during training and 16 were served in May.
2.2.2 Coordinate Monthly MNCH/HIV integration TWG meetings As a secretariat to the national MNCH/HIV Integration TWG, EngenderHealth continues to coordinate and support monthly meetings. Several activities have been implemented this quarter as part of this coordination including hosting visitors from the Kenya TWG on integration who came in Tanzania in April 2014 to learn about integration. Another key activity is preparations for the national stakeholders meeting which will also involve dissemination of the National Operational Guidelines on Integration of HIV and MNCH in Tanzania
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(NOGI). Through the National TWG we have also drafted job aids and IEC materials on integration and revised training materials on FP/HIV integration.
2.2.3 Review of Job aids and IEC materials on integration
EngenderHealth, with other members of the Integration TWG organized a five-day meeting to review job aids and IEC materials developed last quarter. Participants reviewed content of job aids (for providers), leaflets, posters (for clients) and key messages for public IEC materials such as T-shirts, Khanga, posters and banners. We also identified appropriate images, photo and graphics for different IEC materials.
Most IEC materials are designed to address pertinent issues that might limit uptake of integrated service in the intervention districts. These include: Inadequate knowledge on the availability of integrated services/inadequate signs directing clients to specific services. Low knowledge about FP among OPD, IPD, Male and Female, Ob/Gyn, Paediatric, PLHIV clients and care takers. Low uptake of FP among postpartum women, post abortion clients and PMTCT clients. Inadequate knowledge and attention on dual protection and dual method use. Persistent myths and misconceptions on FP methods among PLHIV, immediate post- delivery and post abortion. High incidence of GBV that contributes to low uptake of FP among women and low male involvement in FP/RH services.
Final edits will be done on the draft materials, the materials will be presented to the TWG for review and comments, and then they will be pilot tested before approval by MOHSW for printing.
2.3 Scale up of cervical cancer services in Manyara region In Manyara Region, cervical cancer screening services have been integrated into FP outreach services. During FP week in Hanang district, Manyara region five sites were visited and 104 clients received PITC at Bassodesh, Murumba, Gitting, Sirop and Getanuwas outreach sites. Out of these, 55 women of child bearing age and four post-menopausal underwent Visual Inspection with Acetic Acid (VIA). All were VIA Negative. Six had other gynecological problems for which they received medical advice and treatment.
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Result 3: Health systems management, monitoring and evaluation strengthened for integrated FP-LARC/PM and RH services.
3.1 Resource allocations for FP and reproductive health in CCHP services increased through advocacy and capacity building
3.1.1 Follow up Implementation and Support districts during annual planning sessions to ensure FP is included in CCHPs During this quarter most districts were finalizing their 2014/2015 CCHPs implementing planned activities for 2013/14. As part of continued advocacy, EngenderHealth has been visiting districts to monitor implementation of FP included in CCHPs, including reviewing the CCHP to determine FP activities planned for the quarter and provide any technical support needed.
3.1.2 Tracking of FP budget allocation for Council Comprehensive Health Plans (CCHP) Along with advocacy, EngenderHealth has been tracking resource allocation for FP to gauge the impact of its advocacy interventions on district-level budget allocations. The tracking included a review of budget estimates and expenditure reports from the districts (councils) to identify key FP activities included in the CCHP; what proportion of the budgeted funds are spent; the source of funds for FP interventions; and how funds are allocated based on five key result areas of the NFPCIP). Out of the 59 districts that were tracked, 45 had included FP funds and the amount ranged from Tsh 50,000,000 in Moshi Rural to Tsh 62,000,000 in Moshi Urban districts.
3.1.3 Improve Public – Private Partnerships in provision of FP Peer education (PE) training In April 2014 we conducted PE training at ChemiCotex and Shelys Pharmaceuticals in Dar Es Salaam, involving 44 PE (21 from ChemiCotex, and 23 from Shelys. The PEs were very active and the trainers were competent. Participants asked questions on FP and some shared their own experiences. The PEs have divided themselves into three groups and have planned to conduct two teaching sessions on FP and HIV per week. They have allocated two days per week, they have allocated Wednesday for an FP/RH session and Thursday for HIV/AIDS and sexual transmitted diseases (STDs). RTP will be following up the PE quarterly to provide technical assistance and address any of their concerns.
Follow-up of Workplace Initiatives in Arusha and Dar es Salaam RTP worked with the respective CHMTs to follow-up progress of PEs after training. In May 2014, RTP made follow-up visits to KiliFlora and SunFlag in Arusha to review workplace activities, assess progress of PEs, access to and use of services, and to collect monitoring forms. At SunFlag, PEs are active and well-coordinated. Based on monitoring forms, 11 of 20 PEs are active and conducted over 1,800 contacts with their co-workers. SunFlag management requested that employees be referred for services off-site (instead of on-site service days). RTP facilitated linkages with Themi dispensary, which is about 1.5 kilometers from their worksite. RTP is following up closely with the PE to ensure that they continue to perform their roles and provide support as required. Outreach services at KiliFlora are being conducted monthly and there is a good demand for FP services. At Chemicotex, in Dar es Salaam, educators have divided themselves into three groups and have planned two teaching sessions per week. They have allocated two days per week, Wednesday for an FP/RH session and Thursday for HIV/AIDS and STDs.
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3.1.4 Review the “National Package of Essential Family Planning Interventions for the Comprehensive Council Health Plan” In May 2014, EngenderHealth, in collaboration with the MOHSW, Pathfinder and Advance Family Planning Project (AFP), organized a technical meeting to review the above document. The need for review came out of discussion with CHMTs during dissemination of the documents in which it was noted that, FP is still not given priority by CHMT members. It was also noted that there was a directive from the national level about not to include trainings in the CCHPs. The meeting came up with 10 priority activities to be included in the CCHP. It was also agreed that the MOHSW and PMO-RALG will issue a circular to all districts informing about including these activities in the 2014/15 CCHP and that without inclusion, CCHPs will not be approved. The approved activities are: 1. To conduct 50 Family Planning outreaches that will provide short term, long- acting and permanent FP methods 2. To train 20 community based distributers and community health workers on Family Planning 3. To conduct on-job training and mentoring on IUD and Implants insertion and removal for 20 service providers 4. To conduct on job training and mentoring on vasectomy and mini-laparotomy for 10 service providers 5. To procure supplementary contraceptives and supplies on quarterly bases 6. To conduct on job training of 20 service providers on integrated logistic system at different levels 7. To conduct two days meeting for performance evaluation and feedback on Family Planning for health workers on quarterly bases 8. To orient 40 dispensary facility staff on updated healthcare management information system for 2 days 9. To conduct Family Planning stakeholders meeting involving 30 key decision makers ( councilors, heads of department, CHMT and Family Planning partners) to strengthen leadership, resource mobilization, attention and accountability, in planning and budgeting for Family planning involving 3 facilitators 10. To support 30 Family planning champions ( CHW, WEO/VEO, religious leaders, community influencers/opinion leaders) to raise awareness and providers accurate information, address, rumors, misconception and mobilize communities for FP services community
3.2 Improved district coordination and partner collaboration A three day Zonal Reproductive Child Health (ZRCH) partner coordination meeting involving 5 regions of the Lake Zone (Mwanza, Shinyanga, Geita, Simiyu and Mara) took place from 9th -11th April, 2014. EngenderHealth initiated the idea of coordinating all FP/RH implementing partners in the zone. The meeting was chaired by the ZRCH coordinator (ZRCHCO). The cost of the meeting was shared among partners including UNFPA, EngenderHealth, TANDABUHI, CSSO, AGPAHI, MST, UMATI, PSI and MSD. The meeting was attended by 237 participants who included DMOs, District Pharmacist, District Executive Directors (DEDs), Regional and District Reproductive and Child Health Coordinators from all districts of the 5 regions.
The main objectives of this meeting were; to share experience among stakeholders, involve district leaders for supporting FP/RH activities implemented in their districts, to review the status of FP/RCHS in the Lake Zone and explore opportunities for collaboration and coordination among stakeholders in order to improve FP/RH in the zone and thus reduce maternal and new born deaths. Participants developed action plans and RHMTs will follow-up on their implementation before the next meeting.
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The meeting was briefed about the national plans to re-launch the Green Star as one strategy to increase uptake of FP that was focusing primarily on low uptake regions and thus was to start with the Lake Zone in May. Through the presentations and discussions in that meeting there was a great realization of the need to improve the uptake of FP in the Zone as a way of reducing maternal mortality rates that are also high in the Zone.
Through Arusha FO RTP supported a partner coordination meeting in Babati,that has now shown the trickledown effect towards sustainability. The meeting aimed at reviewing partners’ implementation plans from July 2013 to June 2014. The district had allocated resources for and implemented HIV activities amounting to Tsh. 83,090,270. Interventions supported included nutritional support to people living with HIV/AIDS, sensitization of the community on HIV prevention s, campaigns towards stigma reduction that were conducted through WMACs (Ward Multi-sectoral AIDS Committees) and supporting 21 orphans and vulnerable children (OVCs) who were given school fees and educational materials. This indicates that districts are putting more money in HIV-related activities and effective coordination will increase impact at the community level. In May 2014, the Arusha FO supported the Manyara RC, RAS and RMO to participate in the official launch of the Sharpened One Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania (2014-2015). The meeting was held at Dar es Salaam and EngenderHealth supported regional authorities to participate as mentioned above. The President of Tanzania, Honorable Jakaya Mrisho Kikwete committed the said authority in supervising and supporting FP services in their respective Regions noting that FP contributes significantly to reducing maternal mortality and improving the quality of life for women, children and their families. . The Manyara RC (Honorable Elaston Mbwilu) with his delegates called a meeting of all districts from 27th June- 12th July 2014 to disseminate information from the Sharpened One Plan and hold districts responsible towards its implementation in Manyara region. The RC acknowledged activities done or supported by EngenderHealth and he requested Arusha FO to accompany his team to all districts. RTP attended 5 meetings out of 6 and used these forums effectively to promote strategies and interventions, note achievements and present gaps the region and districts need to address. Through Coastal FO EngenderHealth attended a meeting with other partners supporting Morogoro Municipal District, to prepare for the launch of Option B+. In relation to partners contribution to the activity, some opted to contribute funds to cover some items in the budget and others opted to support provision of services.
EngenderHealth supported the first Dar es Salaam FP strategic meeting, held in Regency Hotel and officiated by the RC. This was a follow up after the launch of the Sharpened One Plan by the President where the RCs were to be held accountable in the issues of maternal and child health. The RC visited one hospital and He thanked partners who are supporting the Region in RH issues, insisted the region will have an FP strategic plan and promised to support interventions to increase FP.
Collaboration with CCBRT Outside the CCBRT Disability Hospital building, on a strategic location near the entrance, a visually attractive structure (refurbished 20 foot sea freight container) has been established. The structure has been named “Tim’s Corner,” in honor of the late Tim Manchester, a dedicated FP champion, and hosts three types of activities:
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An FP clinic offering the services of a qualified nurse and the full range of short-acting and LARCs (with referrals for permanent methods). An information section offering free ‘take away’ reading materials on RH, FP and Disability, as well non-removable materials and audio/visual media (e.g Jiamini clips). A small shop selling a variety of merchandise as well as social marketing items (soap, clothes, Salama condoms, Waterguard, solar lamps etc) and offering financial (mobile Pesa) services.
PSI has been a key partner in development of the IEC corner and the small enterprise and provided start- up stock of social marketing merchandise (condoms, Waterguard) and promotional materials.
EngenderHealth has been the key partner in the FP service delivery and supported the registration of the clinic, supply of FP commodities from the DRCHCO and connected the clinic with MOSHW for service data-collection and quarterly supervision. EngenderHealth and CCBRT also provided a start-up kit of FP equipment and supplies and through a sub agreement with UMATI recruited an experienced family planning provider to provide the actual family planning services.
Family Planning services have been established at the CCBRT disability hospital premises and FP health education and information is being conducted at the outpatient departments of CCBRT’s Disability the hospital and at the Fistula ward.
Visitors at Tim’s Corner indicate that the approach offers good prospects for promoting FP and wider RH issues. In the first two weeks of the opening, over ten clients received counseling and FP methods of their choice.
The FP service provider in and outside CCBRT Tim’s Corner,
and inside the FP room.
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3.3 National, regional, and district level capacity built to support integrated services
3.3.1 Rapid assessment of district coordination structures Data collection for rapid assessment of district FP/RH coordination structures has been completed and a draft report has been submitted by the consultant. Preliminary report indicates that several FP/RH coordination structures exist at national, zonal, regional and district levels. The national level coordination of RH services including FP programs is done by the TWGs and Sector Task Forces under the leadership of RCHS. The principal national level coordination structure for FP is the National Family Planning Technical Working (NFPTWG). Under RCHS unit there are several TWGs organized by programs including MNCH/HIV integration TWG, Adolescent Sexual Reproductive health (ASRH) TWG and Maternal, Newborn and Child Heath (MNCH) TWG, among others. The report is being reviewed by RTP.
3.3.2 RCHS institutional Capacity Review Data collection for an RCHS institutional review is ongoing, and involves SWOT analysis with Zonal and Regional RCHS staff to identify structural, staffing and performance gaps and strategies to build the required capacities to manage and coordinate activities in general and specifically as relates to integrated FP/RH services in Tanzania, with a focus on LARC/PM. This assessment will help inform development of a transitional and sustainability plan that would emphasize a shift to MOHSW/RCHS and district responsibility and capacity for mobilizing resources for, planning, managing and coordinating integrated FP-LA/PM, RCH and HIV services. A report for this assessment will be shared next quarter.
3.3.3 Training of Governance and Leadership In collaboration with CEDHA, EngenderHealth through the Arusha FO organized a five-day training in May 2014, on governance and leadership that aimed at building capacities of district health managers and supervisors in order to strengthen coordination and management of health services, including FP services to meet the reproductive intentions of Tanzanian men and women. The 20 participants were managers representing five low FP uptake (level 1) districts, namely Arusha DC, Kilindi, Singida DC, Longido, Rombo DC, along with RRCHCOs form Arusha and Kilimanjaro regions. Managers were equipped with management skills that will help them improve FP services across their districts and revise implementation modalities, including improving availability of FP commodities and facilitative supervision.
It was observed that more than 70% of the managers were new in their current positions and hence they had insufficient knowledge on RH and specifically on FP services. Participants explored reasons for low FP uptake and CPR, including lack of community mobilization, shortages of equipment and lack of youth-friendly services in access to FP services. These factors were seen as contributed to by inadequate leadership and management. Improving leadership and strengthening of Public Private Partnerships was seen as a viable means of addressing health challenges. Therefore, this was a very important training that will be closely followed-up in order to document lessons and the impacts towards improving CPR
Support for the District Health Information System 2 (DHIS2) database RTP continued to support the MOHSW to strengthen the health management information system (HMIS) web-based database, with 41 districts benefitting from recharged data bundles for their modems. This was done in the seven regions for which ATP supported training for data managers, MTUHA focal person, DRCHCO and Assistant DRCHCOs on DHIS2 data entry and management in 2013; these
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regions are Kilimanjaro, Manyara, Mwanza, Geita, Iringa, Njombe and Morogoro. This has helped ensure timely uploading of monthly reports into the database. In April and May 2014, Engenderhealth in collaboration with the respective districts conducted a follow up DHIS 2 in the districts of Same, Rombo, Mwanga, Moshi DC, Moshi urban, Siha, Bukoba Municipal, Bukoba DC, Kilosa, Morogoro DC, Kilombero, Ulanga, Morogoro Municipal, Mvomero and Gairo. A number of issues were identified and addressed, including: Some district data managers did not know how to save the data after entering them in the system. This causes data to be captured in cache memory which does not allow users to see the data when running reports; this problem was fixed. Support was provided on running data validation prior to completing the dataset; this involved identifying and solving logical errors and two-way feedback mechanism between district and health facility Data backup: Once data entry is complete, districts were advised to print district report from DHIS2 for individual programs and store the hard copy in files. This will serve as a backup in absence of internet and when the system encounters security threats/attacks Districts were oriented in how to print and customize pivot table reports and received clarification on how online and offline data entry operates was elaborated.
Data Quality Assessment RTP continued to support MOHSW to ensure that data reported are of high quality and can be trusted for decision-making. This quarter, district level data quality assessments were conducted in 58 facilities in the districts of Same (2), Lushoto (2), Kasulu (10), Masasi District Council (12), Tandahimba (12), Sumbawanga DC (10) and Mpanda DC (10). The DQA teams were led by the RRCHCo, and the DQA team verified data reported in last six months and mentored SPs on completing new MTUHA forms; the main challenge for facility staff as observed by the team was completing both registers and tally sheet. The DQA team also noted SPs in some sites were completing MTUHA Book 8 register in a cross- sectional way instead of longitudinal tracking of the client for the whole year. Gaps observed were shared back to respective CHMTs.
RTP Review Meetings From 28th April to May 8th 2014RTP conducted mid-year program review meetings individually with each field office (Coastal, Arusha, Mwanza and Iringa). The HQ team visited each FO for two days and addressed respective FO challenges observed in implementation thus far for the year. In each FO Year 2 work plan was reviewed to determine whether the FO was moving according to the plan. It was noted implementation in all FOs had been affected by heavy rains between February and March 2014 which had led to reduced number of outreaches and FP weeks due to impassable roads. The FOs were guided on re -planning in order to catch up with the delayed number of events.
Training of service providers on completing integration data collection tools RTP introduced integration of FP into MNCH and other settings at the health facility level in 64 health facilities across the country. A total of 110 SPs were oriented on how to complete the FP data collection tool, and for each integration site one SP was selected to be integration focal person. These focal persons will be responsible to collect data from each integration service delivery point and assist to channel to district level where it will be transmitted to each respective RTP FO.
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Result 4: Communities mobilized to increase use of FP-LARC/PMs and RH services
4.1 Increased community mobilization for accessing tailored FP (LARC/PM) services
4.1.1 Community Mobilization to increase uptake of FP/LAPM during FP events Between April and May 2014 Mwanza FO in collaboration with CHMTs conducted a community mobilization meeting with village health workers and community leaders in Magu district one week before FP week services to sensitize them to mobilize clients. The activity involved 285 people, comprised of village health committee members, VHWs, CBDs, influential people, Clinical Officers, VEOs WEOs and village chairman from 10 villages, namely: Nyasato, Mahaha, Busalanga, Mwashepi, Kisesa B, Matale, Ihayabuyaga, Lutale, Kanyama AND Bujashi. The mobilization was done through public address system, announcements/posters, horns at public places such as markets and health facilities, as well as use of village leaders, religious leaders, school teachers and children for sending information to parents.
This activity was followed by FP week from 17th to 22nd June and, due to the effective mobilization strategy, 689 clients were served (ML/LA - 300, implant - 306, IUCD - 82, and NSV - 01).
4.1.2 Utilize and support satisfied clients Five satisfied clients on ML/LA, NSV and IUCD were utilized and supported during FP services to give their testimonies to promote the use of LARC/PM in Simiyu, Shinyanga, Mwanza and Mara during outreach, family planning weeks and service days. Clients at the clinics asked them several questions regarding rumors/myths and misconceptions related to different FP methods and the satisfied clients responded well. Testimonies will be continuously provided during services as one method of promoting the utilization of FP and addressing misconceptions among community members.
The Arusha FO also used satisfied clients in community mobilization. In Singida DC two satisfied NSV clients gave testimony and responded to questions during outreach. In Babati four implants and IUCD satisfied clients were supported to sensitize other clients during outreach services at Magugu and Magara HCs.
4.1.3 Educate communities through use of IEC/SBCC materials In this quarter the distribution of IEC materials was done during site walk-through and mobilization events and other community meetings. FP leaflets, FP posters, Tiahrt posters, and Green Star logos were distributed to the districts and more are being printed because demand is quite high. An estimated 2,667 community members heard messages concerning FP and cervical cancer screening services in Manyara region during integrated outreach services and during cervical cancer screening training. Posters were also used in directing clients where to get services.
4.1.4 Scale up of Site Walk-Through Strategy RTP organized a one-day event to implement a site walk-through at Misasi HC in Misungwi and Mlandizi HC The objective of SWT was to strengthen community partnership and relationships between health facility staff and communities. Participants visited the respective facilities and met facility staff. In Misungwi the event was officially inaugurated by the DED who was accompanied by the Misungwi DMO. A total number of 105 community members participated, including VEOs, TBAs, teachers, VHWs, WEOs, Health Governing committee members and Councilors.
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Some of the issues/comments and follow up actions or recommendations that came up during the event are: Water shortage at the facility - the Village chairman of Misasi committed to follow-up and make sure the facility is getting enough water. Delay in proper utilization of theater building renovated 4 years ago - the districts recruited additional staff, including the AMO who is already trained on ML/LA, however only a small number of procedures has been done so far. The Misungwi District Secretary promised to allocate a new AMO who is competent in ML to work with the existing AMO in order to improve services provided at site. . Low utilization of FP/RH services at sites due to negative attitudes of community - The WEO will conduct a follow-up meeting in August to strategize on how to address issues contributing to low FP uptake. Follow-up on action plan developed as a result of this site walk through will be done in August.
4.1.5 Use of community leaders and community’s own resource persons to mobilize clients Different mobilization methods are used for FP service delivery in order to increase access to clients in the remote areas. For example, in this reporting period under Coastal FO 34 Village Executive Officer (VEOs), 16 Ward Executive Officers (WEO)s, 28 home based care providers (HBCPs), 10 community based distributers (CBDs), 8 volunteers and 17 village health workers (VHWs )were involved in sending information to the households, and informing them when and where the services will be provided.
Community engagement in supporting the roll out plan for Option B+ EngenderHealth together with the Africare conducted three orientation sessions of to community volunteers or HBC SPs on option B+. The aim was to increase awareness, and improved referrals and adherence on ARV uptake. A total of 90 CHBCPs were oriented in three districts (Babati Town Council, Babati DC and Hanang DC).
WEO and VEO meetings A two-day meeting of WEOs and VEOs from Kondoa and Chemba districts was conducted whereby the community leaders were oriented on advocacy for FP use and acceptance. Participants asked many questions concerning fertility and HIV/AIDS, then the community leaders worked in groups to develop ward and village action plans to educate and sensitize their community members about FP use.
4.2 Improved sensitization and acceptability of FP services among targeted populations (e.g., youth, males, urban) in selected areas
4.2.1 Religious leaders meeting in Lindi urban In collaboration with the Lindi Urban CHMT, EngnderHealth conducted a sensitisation meeting for 27 religious leaders including sheikhs, Quran teachers, Imams and BAKWATA representatives, including five women religious leaders. The DMO emphasized the role and support needed from the religious leaders in educating and sensitizing their followers on FP utilization. He also mentioned youth are currently at risk for teen pregnancies and stressed on the need for more behavior change and family responsibility and support from religious leaders to curb this situation. Action plans were made, and participants were advised to collaborate with the District, especially regarding the need for TA during education programs so that they can be able to convey the right FP messages. All the participants were given a copy of the booklet “Uislam na Uzazi wa Mpangilio”.
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4.2.2 Follow-up of previously-trained religious leaders RTP and the Newala DRCHCO made follow-up to seven religious leaders in Newala who were oriented on FP in the March 2013. The trained leaders have formed youth groups who also share FP messages with the community. Most of the leaders are promoting FP services in mosques during Friday prayers. The DRCHCO involved some of them in community sensitizing during FP week and outreaches, and generally the CHMT has been providing technical support and guidance during implementation of their workplans.
A group of religious leaders in a follow up meeting with Engenderhealth Program Officer and DRCHCO in Newala.
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ANNEX
Table 9: LARC/PM Client by Method, July 2013 –June 2014
Method July-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-June 2014 Actual Target % Actual Target % Actual Target % Actual Target % ML 216,264 232,172 93 195,848 225,752 87 206,456 266,792 77 36,329 34,632 105 NSV 1,480 1,051 141 736 1,024 72 824 1,216 68 279 158 177 Impl 253,729 261,678 97 258,381 297,511 87 279,122 351,603 79 115,029 103,322 111 IUCD 92,166 93,174 99 90,160 109,022 83 106,785 128,842 83 40,205 38,229 105 Total 563,639 588,075 96 545,125 633,309 86 593,187 748,453 79 191,842 176,341 109
Table 10: LARC/PM CYP by Method, July 2013 –June 2014 July-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-June 2014 Method Actual Target % Actual Target % Actual Target % Actual Target % ML/LA 1,730,112 1,857,376 93 1,566,784 1,806,016 87 1,651,648 2,134,336 77 290,632 277,056 105 NSV 11,840 8,408 141 5,888 8,192 72 6,592 9,728 68 2,232 1,264 177 Impl 888,052 915,873 97 904,334 1,041,289 87 976,927 1,230,611 79 402,602 361,627 111 IUCD 322,581 326,109 99 315,560 381,577 83 373,748 450,947 83 140,718 133,802 105 Total 2,952,585 3,107,766 95 2,792,566 3,237,074 86 3,008,915 3,825,622 79 836,183 773,749 108
Table 11: cPAC Performance, July 2013 to June 2014 Indicator Jul-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-Jun 2014 Total Total cPAC 687 1,310 1,032 708 3,737 cPAC Clients Counseled 642 986 1,032 2,660 cPAC Clients Received FP Methods 590 850 722 434 2,596 Percent of PAC clients Counselled 93 75 71 Percent of PAC clients Received FP 92 86 70 61 98
Table 11: GBV and VAC Performance by Type of Incidence, October 2013 –June 2014 Quarter Sexual Violence Physical Violence Emotional Violence Neglect Total Oct-Dec 2013 83 2,249 613 15 2,960 Jan-Mar 2014 146 1,121 1,559 59 2,885 Apr-Jun 2014 181 1,198 1,780 128 3,287
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Figure 7: RTP Strategic Framework
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