IFPP - Integrated Family Planning Program Youth
Agreement No. #AID-656-A-16-00005
Quarterly Report:
April to June 2020 – Q3 FY4
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Table of Contents ACRONYM LIST...... 4 PROJECT SUMMARY ...... 7 SUMMARY OF THE REPORTING PERIOD (April to June 2020) ...... 8 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services ...... 12 Sub-IR 1.1: Increased access to modern contraceptive methods and quality, facility-based FP/RH services ...... 12 Sub-IR 1.2: Increased access to modern contraceptive methods and quality, community- based FP/RH services ...... 28 Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services ...... 39 Upcoming Plans for IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services ...... 40 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services...... 41 Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors ...... 41 Sub-IR 2.2: Improved community environment to support healthy FP behaviors ...... 42 Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions ...... 46 Upcoming Plans for IR 2: Increased demand for modern contraceptive methods and quality FP/RH services ...... 47 IR 3: Strengthened FP/RH health systems ...... 47 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution ...... 48 Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision-making ...... 56 Upcoming Plans for IR 3: Strengthened FP/RH health systems ...... 57 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services ...... 63 Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based 68 Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based ...... 69
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Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services ...... 70 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services...... 70 Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors ...... 70 Sub-IR 2.3: Improved systems to implement and evaluate SBCC interventions ...... 71 IR 3: Strengthened FP/RH health systems ...... 71 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution 72 Sub-IR 3.2: Improved management of commodities to ensure availability at local levels ..... 73 Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment ...... 73 Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers ...... 74 Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision- making ...... 74 Collaboration with other donor projects ...... 74 Evaluation/Assessment Update...... 75 Annexes ...... 75 Annex A - Success story ...... 76
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ACRONYM LIST Acronym Description AC Accommodation Center ANC Antenatal Care ART Antiretroviral Treatment AYSRH Adolescent and youth sexual and reproductive health APE Agente Polivalente Elementar – Ministry of Health Approved Community Health Worker BL Baseline BTL Bilateral Tubal Ligation CACUM Cancro de Colo de Útero e da Mama – Cervical Cancer of the uterus and breast cancer CBOs Community Based Organizations CDCS Country Development Coordination Strategy CDFMP Cenário de Despesas Fiscal de Médio Prazo (Midterm Fiscal Review) CECAP Cervical Cancer Prevention CF Community Facilitator CHW Community Health Worker (including APEs, PTs, other health activists) CIHO Communication for Improved Health Outcomes CL Community Leader CLC Community Leader Council (at village level) – “Conselho de Lideres Comunitarios” CLL Locality’s local council (covering an area of approximately 20 villages) – “Conselho Local da Localidade” CMAM Central de Medicamentos e Artigos Médicos (National Drugs, Commodities and Supplies Warehouse) CMM Consumo Medio Mensal – Monthly Average Consumption COVID-19 Coronavirus Disease 2019 CPR Contraceptive Prevalence Rate CR Community Radio CSC Community Score Card CYP Couple Years of Protection CwS “Connect with Sarah” app DDM Depósito Distrital de Medicamentos (District Medicines Depot) DMPA-IM Medroxyprogesterone acetate – Injectable contraceptive DMPA-SC Sayana Press DP District profile DPM Depósito Provincial de Medicamentos (Provincial Medicines Depot) DPS Provincial Health Directorate E2A Evidence to Action FP Family Planning EMMP Environmental mitigation and monitoring plan EPC Escola Primaria Completa – Primary School - 6th and 7th grade FP/RH Family planning/reproductive health FS Field Supervisors FTP First Time Parents FY Fiscal Year 4
GIS Geographic Information System GRM Government of the Republic of Mozambique HCN Central Hospital of Nampula HCW Health Care Worker HF Health Facility HMIS Health Management Information System HP Health Provider HR Human Resources HRIS Human Resources Information System HSS Health Systems Strengthening HTSP Health Timing and Spacing of Pregnancy IEC Information, Education and Communication IEE Initial Environmental Examination IFPP Integrated Family Planning Program IMASIDA National Malaria and HIV Indicator Survey IPC Interpersonal Communication Agent ISL Implementation Science and Learning IT Information Technology IUD Intrauterine Device LARC Long Acting Reversible Contraceptive LOE Level of Effort LOP Life of Project LTM Long Term Method M&E Monitoring and Evaluation MB Mobile Brigade MCH Maternal and Child Health mCPR Modern Contraceptive Prevalence Rate MCSP Mother and Child Survival Program MINEDH Ministry of Education and Human Development MISAU Mozambican Ministry of Health MMEMS Mozambique Monitoring. and Evaluation Mechanism Services MOU Memorandum of Understanding MSC Management Standards Compliance NED District Statistical Nucleus NEP Provincial Statistical Nucleus NGOs Non-governmental Organizations NHS National Health System OC Oral Contraceptives OVC Orphans and Vulnerable Children PDSA Plan, Do, Study, Act PES Social and Economic Plan PESOD District Operational Social and Economic Plan PHD Provincial Health Directorate PMP Performance Monitoring Plan POA Annual Operational Plan PPFP Post-Partum Family Planning PPIUD Post-Partum IUD 5
PSI Population Services International QI Quality Improvement RDQA Routine Data Quality Audit RH Reproductive Health SARA Service Availability, Readiness Assessment SAAJ Serviços Amigos dos Adolescentes e Jovens (Youth Friendly Services - YFS) SAPERS-CPF Sistema de Alerta Precoce para Evitar Roturas de Stock dos Consumíveis de Planeamento Familiar, or Early Warning System to Avoid Stock Outs of Family Planning Commodities SBCC Social and Behavioral Change Communication SDP Service Delivery Point SDSMAS District Health Welfare and Women Directorate SGBV Sexual and Gender-Based Violence SIFO Training Information System SIGLUS Sistema de Informação de Gestão Logística das Unidades Sanitárias (Logistics and Management Information System - LMIS) SISLOG Sistemas e Tecnologias - Gestão de Clientes (Local Digital Technology Company) SIS-MA Sistema de Informação em Saúde – Monitoria e Avaliação (HMIS) SMATG-CPF Sistema Móvel de Assistência Técnica para Gestão dos Consumíveis de Planeamento Familiar, or System for Mobile Management of Family Planning Commodities SOPs Standard Operating Procedures SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health Rights STM Short Term Method TA Technical Assistance TBA / “PT” Traditional Birth Attendant / “Parteira Tradicional” TEM+ “TEM mais” – Private clinic network ToR Terms of Reference TOT Training of Trainers TSO Technical Support Officers USAID United States Agency for International Development USAID AOR Agreement Officer’s Representative (USAID) USG United States Government VIA Visual Inspection using Acetic Acid WHO World Health Organization WRA Women of Reproductive Age YFHS Youth-Friendly Health Services
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PROJECT SUMMARY
Project Title: IFPP - Integrated Family Planning Program Duration: 5 years Start Date: June 2016 Life of project funding: $ 35,060,000 Geographic Focus: Nampula and Sofala provinces The Integrated Family Planning Program (IFPP) is a five-year USAID/Mozambique-funded initiative to increase use of modern contraceptive methods by target populations in all 36 districts in Nampula and Sofala provinces in Mozambique. IFPP responds to the United States Government (USG) strategy for development and foreign assistance in Mozambique through the Country Development Coordination Strategy (CDCS). USAID/Mozambique CDCS outlines an overarching development objective health goal to “Improve the Health Status of Target Populations” through three results: 1) Increased coverage of high impact health and nutrition services, 2) Increased adoption of positive health and nutrition behaviors, and 3) Strengthened systems to deliver health, nutrition and social services (CDCS, 2013).
In alignment with this goal and these results, IFPP aims to support the Government of the Republic of Mozambique (GRM) and Ministry of Health’s (MISAU) priorities and increase the use of modern contraceptive methods by target populations through three intermediate results (IRs): 1) Increased access to a wide range of modern contraceptive methods and quality family planning (FP)/reproductive health (RH) services, 2) Increased demand for modern contraceptive methods and quality FP/RH services and 3) Strengthened FP/RH health systems. Under IFPP, the three IRs are integrated and mutually reinforcing. Activities under IR1 increase the quality of service delivery at facility and community level, and activities under IR2 generate demand for those services and link the community with facilities. The health system strengthening activities proposed under IR3 are cross-cutting and support sustainability and institutionalization of service delivery improvement efforts (IR1) and demand generation interventions (IR2) and interact with IR2 activities to increase community involvement in health system accountability.
IFPP aims to reach women with a particularly high unmet need for FP, namely: postpartum women; women living with HIV; adolescents, including orphans and vulnerable children (OVC); medium- and high-parity women; and post-abortion women. Additionally, IFPP recognizes that increasing the uptake of contraception in Mozambique requires shifting inequitable gender norms. Therefore, men and boys, alongside other key influencers, are meaningfully and systematically engaged throughout all intervention areas and intervention packages.
The project is led by Pathfinder International with a team of global and local partners—N’weti, Population Services International (PSI) and Abt Associates.
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SUMMARY OF THE REPORTING PERIOD (April to June 2020)
During Q3FY4, COVID-19 had a significant impact on the demand for and availability of health services, largely as result of the government calling for an emergency state throughout the entire quarter. As a result, IFPP activities were impacted. For example, community service delivery, such as Mobile Brigades (MBs), were blocked during the first six weeks and progressively were re-authorized depending of negotiation with provincial and district authorities. However, the quarter was programmatically productive with IRs more synchronized and effectively reinforcing each another. Despite COVID-19 constraints, IFPP redoubled its efforts, clinical staff increased the number of visits to the health facilities (HFs), providing direct support to MISAU staff in this difficult time and focusing on ensuring, maintaining, and improving quality of services and abilities of health providers (HP). For example, the project saw an increase in joint supervision visits: 144 in Q1, 184 in Q2, and 213. Similarly, mentorship visits increased from 598 in Q1, 732 in Q2, and 777 in Q3. At the same time, 27 ‘five-day’ FP facility-based trainings were carried out involving 99 different HFs and reaching a total of 244 HPs in small groups below 10 participants and in full compliance with MISAU’s COVID-19 recommendations. Also, 130 additional staff benefited from on-the-job training (OJT) either to increase their abilities to insert Implanon or to perform cervical cancer prevention (CECAP) screening. Thirty HFs were trained and supported to strengthen their infection, prevention, and control (IPC) processes through the joint support of the Biosafety Project Officer and the provincial and district MISAU Supervisors. IPC materials and commodities were purchased for IFPP clinical and community- based staff as well as for the National Health System’s (NHS) HF staff. In parallel, during the first week of April, the urban and rural components developed plans to adapt demand creation activities to the COVID-19 context and revised the responsibilities of each team member. It should be noted that at the onset of the state of emergency, community leaders as well as some families understood that people should not work and should only stay at home, and the Interpersonal Communication Agents (IPCs) were prohibited from visiting their homes. Meetings were needed at multiple levels to adjust positions and clarify with community leaders the role IPCs and community assistants would play, specifically that they would sensitize the community not only on FP but also for COVID-19 prevention measures. At the same time, all IPCs and Community Facilitators (CFs) were trained on COVID-19 prevention messages and how to include them into their daily FP activities based on the national curricula. The dynamism of the demand creation component resulted in a considerable increase in confirmed referrals for FP from 29,735 in Q2 to 39,569 in Q3, which mitigated the existing limitation to access to HFs for primary health care. All these synchronized efforts resulted in a couple years of protection (CYP) of 211,337 nearly identical to Q2 CYP (223,930) Despite of the limitations imposed by COVID-19 where nationally the drop on this indicator was significant.
In additional to highlights above, the following accomplishments under IR1 should be considered: IFPP needs to multiply opportunities for FP service offerings as growing demand and unmet need had progressed faster than the capacity of NHS to respond. Therefore, specific attention this quarter was on mentoring HPs to improve the quality of FP services delivered and resulted in 3,905 different competency checklists being applied by mentors to assess and improve HPs’ skills in FP service
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provision, reaching 893 unique HPs this quarter. The focus was mainly on Maternal and Child Health (MCH) nurses for post-partum IUD (PPIUD) and IUD, and non-MCH nurses for implant counseling and insertion as these were areas noted as needing improvement from last quarter. Bilateral tubal ligation (BTL) activities continued to be offered in Nampula province (at the peripheral HF level) reaching 114 clients. Also, during this quarter, 58 additional HFs were fully compliant with the sexual and reproductive health and rights (SRHR) quality standards and 45 achieved a successful score for environmental compliance. Despite COVID-19 imposed limitations, 281 MBs were carried out in light of IFPP’s refined strategy to synchronize MBs and reduce vulnerable populations’ barriers to accessing services, especially for youth and those living far from health centers. Continuous support to APEs to increase FP services offered was provided resulting in 64,654 women of reproductive age (WRA) served compared to 62,219 last quarter. IFPP is currently in the process of identifying poor performing APEs to address barriers around a lack of commodities, persistent personal bias related to youth rights, FP myths, a lack of understanding of different types of FP methods, existing weaknesses in their ability to ensure improved male involvement, and accurate data registration.
For IR2.1, during Q3FY4, a total of 222,477 contacts with women were reported by Traditional Birth Attendants (TBAs), CFs, and IPCs compared to 196,966 in Q2FY4 and 145,277 in Q1FY4. With regards to the urban demand creation component, after changing the intervention strategy to a systematic mapping of all registered houses in preselected boroughs, the consistency and effectiveness of the component has dramatically increased as all houses are visited and either counseled for FP or identified to participated in small groups to further discuss constraints and barriers. IFPP achieved 77% of the predefined households in urban areas (93% in Nampula, 48% in Sofala) compared to 53% at end Q2FY4 and 39% at end Q1FY4. Without taking into account the 6,412 in-facility referrals, the total number of confirmed referrals by HPs in Q3FY4 was of 13,196 against 6,791 in Q2FY4 and 3,894 in Q1FY4 for the community-based urban component.
With regards to rural demand creation, this component is investing in reaching additional remote communities in order to provide FP information and knowledge, as well as FP services to the most remote populations. As activities were suspended between 3 to 6 weeks, 845 community dialogue groups attended six sessions in Q3FY4 compared to 1,212 in Q2FY4 and 781 in Q1FY4. CFs provide sessions with two groups per day; one with community leaders (CLs) and the other with young couples. They carried out activities six days per week, covering three different villages over three weeks and increasing their productivity. This is important so that IFPP can cover additional hard-to- reach areas and meet the life of project (LOP) target of 13,056 community dialogue groups. A total of 15,463 confirmed referrals at HFs were achieved against 12,104 in Q2FY4 and 10,621 in Q1FY4.
To improve the environment in communities that support healthy FP behaviors (IR2.2), the rural demand creation component is implementing a systematic community dialogue process. Half of the groups (423) are targeting key CLs and influencers to address social and gender norms and drivers behind the lack of modern FP use, and create a more enabling environment at the community level for adherence to modern FP methods. In order to strengthen CLs’ ownership and comfort of the 9
work CFs do through village-based CL groups, IFPP has sensitized upper administrative structures since FY2. During this quarter, IFPP organized 77 locality’s local council (CLL - Conselho Local da Localidade) one-day meetings focused on the FP program results in their localities and their important role as gatekeepers. In urban settings, 347 CLs were sensitized on FP through unique sessions, to ease roll-out of the household visits, supporting IFPP in gathering small groups of women and men (identified through the home-based mapping) with strong beliefs against the use of FP. During Q3FY4, 418 men and 1,185 women participated in men’s or women’s small groups, respectively, compared to 2,425 women and 1,346 men last quarter, highlighting efforts carried out in addressing FP sociocultural barriers despite challenges related to COVID-19. As an integrated component of IFPP, ten community radios have broadcasted 127 SRH/FP programs, discussions, and interviews related to the implementation of the Community Score Cards (CSC) events, community dialogues, and synchronized MBs.
Regarding IR3, the IFPP-Health System Strengthening (HSS) teams focused on integrating and ensuring compliance with MISAU’s COVID-19 prevention and control guidelines in ongoing IFPP managerial and technical interventions. The focus was on strengthening the capacity of the Provincial Health Directorate (DPS), the District Health Welfare and Women Directorate (SDSMAS), and HFs to improve coordination, implementation, and monitoring of 2020 activities under the Social and Economic Plan (PES), the District Operational Social and Economic Plan (PESOD), and the Annual Operational Plan (POA). Seventeen semi-annual Management Standards Compliance (MSC) assessments were conducted and achieved satisfactory scores of 80% or greater. During the Y4 IFPP planning workshop, the weak managerial preparation of the HF heads to support the implementation of health programs generally, and consequently the national FP program, was highlighted as a notable constraint to increase FP services and underscored the limits of training and mentorship activities if HF management does not monitor and emphasize the recommendations provided during support visits. Therefore, IFPP planned a five-module-based management training for HF heads implemented at district level and led by the SDSMAS management teams. This provided continuity from the first FY4Q2 training of trainers (TOT) focusing on human resource management. The IFPP team conducted five additional TOT involving 46 SDSMAS Directors and HR District Responsible who rolled out 39 cascade in-service trainings to 367 HF directors. The second training module for HF Directors prioritized the management of IPC at HF level, emphasizing IPC management elements, strategies, and approaches including IPC basic standards and MISAU’s guidelines on preventing COVID-19. This module was jointly developed with MISAU-DNAM and later revised with the DPS of Nampula and Sofala. The first regional competency-based TOT on HF IPC management was conducted in Nacala Porto involving 6 District Medical Chief Officers and SDSMAS Nursing head as future trainers for the roll-out of the cascade trainings at district level which will take place in Q4. Also, comprehensive competence-based technical assistance (TA), directed to Provincial Health Directorate (DPS) and SDSMAS management team of FP/MCH, human resources (HR), planning, monitoring and evaluation (M&E), Depósito Provincial de Medicamentos (DPM; Provincial Medicines Depot)/Depósito Distrital de Medicamentos (DDM; District Medicines Depot)-Logistics program
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areas, covered the 2 DPS and 36 districts, resulting in 125 Health Managers and Technicians (69 in Nampula and 56 in Sofala) receiving TA.
Overall, 274 out of the 406 existing HFs were assessed for stockouts. Following data verification and cleaning, one HF out of the 274 assessed (0.4%) reported stockouts. This low stock-out percentage resulted from the high-level attention given to monitoring HF’s stock levels on one side and, on the other side, due to a 30-50% diminution of commodity consumption related to COVID-19. In general, many HFs were confronted with eminent stock-outs and in-district coping redistribution mechanisms were frequently used. Furthermore, it’s important to point out that false stock-out-reporting decreased from 36% in Q2 to 16% in Q3, highlighting IFPP efforts in strengthening the daily use of the SIGLUS app through the 13 DDM Managers trained as first-line Help Desk (L1 help desk) in Q2. IFPP TA recruited in FY4Q1 continue ensuring the second-line help desk function, the maintenance and repairs of tablets, and the operation of SIGLUS software. IFPP is also striking to get the FP/MCH commodity taskforces at DPS and SDSMAS levels operational on a monthly basis. During Q3, only 36% monthly taskforce meetings were carried out (41/114) compared to Q2 where 45% (51/114) of the monthly taskforce meetings were carried out.
To strengthen governance and civil society engagement around FP and contribute to stronger systems (IR3.3), IFPP is carrying out CSC activities - a participatory, community-based tool for assessing the quality of health services. Twenty-nine HFs are enrolled to carry out the CSC process in FY4. Out of these, eight HFs completed the public meeting to share outcomes (the last step of the CSC process) last quarter and 20 completed them this Q3FY4.
Regarding M&E, IFPP has boosted the number of activities to improve data quality such as routine data quality audits (RDQAs), joint SDSMAS – IFPP supervision visits, and HP trainings on register logbooks. This Q3FY4, 48 additional HFs have moved into the sub-group of HFs having completed acceptable or medium RDQA results totaling 209 HFs compared to the 151 HFs of Q2FY4.
Major Implementation Issues Q3FY4 implementation issues include:
• In Sofala’s main corridors (National Highway Number 1 – Muxúngue, Inchope, Gorongosa and Nhamatanda) attacks on civilians hampered MBs, community dialogues, CSC activities. and resulted in closure of three HFs in Nhamatanda (Chiadeia, Macocorocho and Mbimbir). • The COVID-19 pandemic created anxiety among communities and reduced access to healthcare services overall, thus impacting FP/SRH services even though the first case in Mozambique was reported by end of Q2FY4 (March 23rd 2020) as state of emergency was started on first of April; consequently, all community related activities have been stopped; progressively, negotiating the conditions, community activities have been restarted even if not in full. • Keeping DPS/SDMAS staff compliant with their managerial duties while implementing COVID-19 prevention activities has been a very challenging process. Some managers see COVID-19 as a standalone issue with high priority especially compared to the original 11
planned PES/PESOD activities. In FY4Q4, IFPP will ensure a more integrated implementation of both activities.
Goal: Increase use of modern contraceptive methods
IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services Sub-IR 1.1: Increased access to modern contraceptive methods and quality, facility-based FP/RH services
Table 1. Project supported trainings at end of June 2020
FY1 FY2 FY3 FY4 Provinces TOTAL TOTAL TOTAL To date Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
# of Facility based trainings per quarter and province
Nampula 27 27 17 20 91 11 5 12 4 32 6 7 4 9 26 2 7 13 171 Sofala 0 30 24 8 62 6 12 8 4 30 3 2 1 2 8 5 1 14 120 TOTAL 27 57 41 28 153 17 17 20 8 62 9 9 5 11 34 7 8 27 291
# of unique Health Providers reached thru FP training per quarter and province
565 414 205 240 1424 132 72 183 121 508 132 115 55 169 471 30 82 108 2623 Nampula 26 **
463 347 81 891 107 213 139 65 524 57 34 16 26 133 72 15 136 1771 Sofala 64** 3 ** 26 **
TOTAL 565 877 552 321 2315 239 285 322 186 1032 189 149 71 195 604 102 97 244 4394
# of unique Health facilities reached thru FP training along quarters by province
Nampula 147/226 204/228 232/237 233/237 43 36 * 34 * 34 * 23 * 4 * 16 * 14 * 12 * 9 * 1 6 0 1 0 (cumulative %) (65%) (89%) (98%) (98%)
Sofala 112/157 150/157 157/162 166/172 55 43 * 14 * 24 * 13 * 1 * 0 0 3 * 4 *** 0 0 2 7 (cumulative %) (71%) (95%) (97%) (98%)
TOTAL 43 134 211 259 68% 47 64 81 95 92% 12 24 29 35 97% 0 3 7 98% (cumulative) * Additional HF ** Students of Training Institutions of Nhamatanda (Sofala) & Alua (Nampula) *** HF with at least one trained HP per HP's transfers
Cascade in-service training
During Q3FY4, a total of 27 five-day FP facility-based trainings were carried out (13 in Nampula and 14 in Sofala). Trainings involved 99 HFs, 54 in Sofala distributed among 11 different districts - Beira City (8), Nhamatanda (8), Chibabava (2), Machanga (1), Búzi (5), Gorongosa (1), Marromeu (5), Maringué (3), Dondo (10), Caia (5) and Cheringoma (6) and 45 HFs in Nampula province, distributed among 12 different districts – Angoche (6), Monapo (4), Mossuril (2), Cidade de Nampula (2), Mecuburi (4), Lalaua (5), Memba (2), Eráti (2), Meconta (4), Nacaroa (4), Nacala Porto (5), Nacala a Velha (5).
In Q3FY4, the trainings reached a total of 244 health providers (108 in Nampula and 136 in Sofala) and MISAU FP district’s trainers were actively involved in HP’s trainings in all performing districts. As summarized in Table 1, since the launch of the project, a total of 4,394 HPs has been trained (2,623 in Nampula and 1,771 in Sofala).
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In Q3FY4, 231 HF needs assessments were conducted for 205 HFs in Nampula – Angoche (11), Liupo (3), Mogincual (6), Eráti (12), Memba (13), Nampula (21), Meconta (5), Muecate (10), Nacaroa (5), Monapo (17), Mossuril (12), Ilha de Moçambique (5), Mecubúri (7), Murrupula (4), Rapale (5), Ribáue (9), Lalaua (7), Malema (10), Moma (10), Mogovolas (7), Larde (7), Nacala Porto (13) e Nacala Velha (6) and 26 HFs in Sofala in the districts of Beira City (1), Dondo (11), Table 2: Number of project-supported Health Facilities enrolled in Nhamatanda (4), Buzi (7), Chemba (3). FP trainings, by district to date Most of the HFs in Nampula and Sofala # of HF % of HF # of HF % of HF # of HF with at already with all with all HP repeated their assessment to DISTRICT per least 1 HP involved thru HP trained trained in district trained in training per in FP to strengthen the basic equipment FP to date FP to date district date needed to ensure FP service quality. Beira 17 17 100% 3 18% The assessments focused on Dondo 15 15 100% 7 47% commodity management, infection Nhamatanda 20 16 80% 12 60% Buzi 17 17 100% 8 47% prevention, client flow, adolescent and Chibabava 16 16 100% 4 25% youth friendliness. Although IFPP Machanga 11 10 91% 6 55% Caia 13 13 100% 13 100% regularly distribute goods to the HFs, Marromeu 10 10 100% 8 80% there is a lot of need and IFFP is Chemba 10 10 100% 10 100% Gorongosa 14 14 100% 9 64% planning to refurbish both surgical Cheringoma 8 8 100% 8 100% material – BTL, IUD, PPIUD and implant Maringue 10 10 100% 7 70% Muanza 11 10 91% 10 91% (insertion and removal) kits, medical SOFALA 172 166 97% 105 61% supplies such as gloves and furniture to PROVINCE the HFs (tables, chairs, information Angoche 20 20 100% 14 70% Mogincual 6 6 100% 2 33% boards, curtains and fans). Liupo 4 4 100% 1 25% Npla Cid 25 23 92% 4 16% Table 2 summarizes the number of Erati 11 11 100% 8 73% Memba 14 14 100% 10 71% project-supported HFs enrolled in FP Meconta 8 8 100% 3 38% trainings with at least one HP trained, Nacaroa 7 7 100% 4 57% Muecate 11 11 100% 2 18% by district and province. In Sofala, at Mogovolas 8 8 100% 2 25% end of Q3FY4, 97% (166/172) of the Moma 11 11 100% 4 36% Lardes 7 7 100% 5 71% HFs had at least one HP trained in FP Monapo 17 17 100% 10 59% and 98% (233/237) in Nampula Mossuril 10 10 100% 1 10% Ilha Moç. 5 5 100% 1 20% province. In Q3FY4, seven HFs without N.Porto 14 12 86% 5 36% a trained HP were included in the N.Velha 6 6 100% 3 50% Murrupula 6 6 100% 4 67% trainings being in Sofala: Ndeja in Rapale 7 7 100% 4 57% Nhamatanda district, Km37 and Mecuburi 13 13 100% 11 85% Ribaue 10 10 100% 4 40% Chicuecue in Buzi district, Ngase in Malema 10 10 100% 2 20% Marromeu, Malongue in Cheringoma Lalaua 7 7 100% 6 86% NAMPULA 237 233 98% 110 46% and Mussapassua and Nhamassizira in PROVINCE Muanza. Chicuecue HF opened in Both provinces 409 399 98% 215 53% Q2FY3 and started reporting data this quarter. In Sofala, in Nhamatanda
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district, the HP of 4 HFs (Nhamatanda district: Chiadeia, Mbimbir and Macarococho; Muanza district: Mussapassua) were transferred due to prevalent insecurity (unrest related to the dissident branch of Renamo) and two HFs still need to be provided with trained HPs ( Isapol HC in Nhamatanda and Zimuala in Machanga district). In Nampula, IFPP still has four remaining HFs without a HP trained in FP, two of them are located in Nampula city. One is the male penitentiary HP who will be trained to comprehensive counseling to enable partner support including male sensitization and the other is the Mental Health Center, which refers the WRA to the CS anexo psiquiatrico located within the center and offers FP services. Note that Mental HC and CAMINA HC are led by Catholic Church and on several occasions, they have declined the opportunity to integrate FP services within their HF. However, since Q1FY4, in order to diminish the lost opportunities at CAMINA HC (which focuses on preventative and curative care for children under five and attends to 800 children per month), an IFPP activist started mobilizing the mothers at the exit door of the CAMINA HC to counsel and establish a one stop referral pathway for the women with FP unmet needs to FP services in the neighboring Akumi HC which located 300 meters away. Comparatively, Table 2 illustrates the number of HFs with all HPs trained in FP. In Q3FY4, IFPP continued with HPs trainings to improve the total number of HFs with all HPs trained in FP; in Sofala, this number increased from 70 out of 164 (43%) in Q2FY4 to 105 out of 172 (61%) inQ3FY4 and in Nampula province, from 95 out of 237 (40%) in Q2FY4 to 110 out of 237 (46%) in Q3FY4, totaling for both provinces 53% (214/409). The main reason for not increasing as fast as planned is the incoming of MCH recently graduated volunteers and newly contracted staff through HIV partners (ICAP and ECHO) and the Direct Delivery Staff (DSD). Additional HP trainings are planned next quarter, but most of them will be on the-job-training and will follow the adapted five day training curriculum, carried out HF by HF, with maximum of 10 participants to comply with COVID-19 recommendations. In FY4, IFPP reduced the range of eligible HP to HPs in MCH, EPI and healthy child consultation, at risk child consultation, HIV integrated consultation and, adult and child first-line curative consultations.
During Q3FY4, the percentage of HPs in both provinces who completed the training on modern methods of contraception with passing scores on the written post-test remained high - 98% (238/244). Table 3: Number of other trainings, by topic to date Other FP related # of unique Health Providers reached thru other trainings Additional FY2 FY3 FY4 (Q1) FY4 (Q2) FY4 (Q3) trainings technical Nampula Sofala Nampula Sofala Nampula Sofala Nampula Sofala Nampula Sofala In Q3FY4, as illustrated Implanon 58 143 28 0 44 0 76 BTL 22 0 6 0 0 0 0 in Tables 3 and 4, a total ISL 83 0 36 0 0 0 0 of 130 HPs participated FP 86 41 0 0 3 days in additional on-the-job advanced 112 78 123 9 technical trainings, 121 FP updates CECAP 83 49 82 0 23 45 in Sofala and 9 in FP TOT 50 15 0 0 0 0 163 143 367 118 78 103 123 67 9 121 Nampula. 76 were TOTAL 306 485 181 190 130 trained on Implanon insertion while 45 in CECAP techniques and 9 in the 3-day advanced FP updates.
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In Sofala these trainings reached providers from Table 4: distribution of on-the-job trainings carried different peripheral HFs distributed in 9 districts. out in Sofala per district and topic
MISAU district’s FP trainers continue to support Implanon CECAP
IFPP activities at the district level and their # HPs # HFs # HPs # HFs participation and commitment are important to Dondo 12 10 support the HP at different HFs. They are involved Nhamtanda 21 9 7 4 in mentoring HPs at the HF level, supervising Buzi 10 6 10 8 FP/RH consultations, integrating FP Gorongosa 2 1 2 2 Maringue 2 1 consultations, FP offering at maternity level and Chibabava 12 7 12 7 Post-Partum consultations; additionally, they Machanga 5 4 5 4 support the MBs, data collection and Marromeu 12 4 6 4 Caia 3 2 aggregation, stock management, verification of Total 76 42 45 31 environmental and FP compliance at HFs, APEs supervision and TBAs training, and application of FP and CECAP Quality Standard tool.
Additionally, as IFPP has trained the main hospitals’ MCH nurses Photo 1 PPIUD insertion during Nacala Porto training; photos 2 and 3: HP’s FP training in and Medical Doctors Chemba district
Table 5: Number of other trainings, by topic to date % of PPIUD % of intra- % IUDPP or BTL # of Total # of # of intra- # intra- % of intra- # of inserted cesarian offered on Deliveries C- cesarian cesarian cesarian PPIUD (denominator = # tubal deliveries attended sections BTL IUD IUD inserted deliveries less C- ligation attended sections ) HCN 1848 838 38 5% 65 7.8% 15 1% 6.4% HD Moma 386 66 8 12% 0 0.0% 12 4% 5.2% HD Monapo 244 135 13 10% 1 0.7% 1 1% 6.1% HD Nacala Porto 680 238 20 8% 54 22.7% 243 55% 46.6% HG Marrere 393 14 5 36% 3 21.4% 0 0% 2.0% HR Angoche 566 136 33 24% 14 10.3% 7 2% 9.5% HR Namapa 706 96 3 3% 0 0.0% 4 1% 1.0% HR Ribaue 477 102 12 12% 9 8.8% 20 5% 8.6% TOTAL Nampula 5300 1625 132 8% 146 9.0% 302 8% 10.9% HCB 1543 648 19 3% 2 0.3% 0 0% 1.4% HR Marromeu 695 53 9 17% 2 3.8% 51 8% 8.9% HD Caia 691 78 8 10% 4 5.1% 18 3% 4.3% HR Búzi 307 44 2 5% 12 27.3% 4 2% 5.9% HR Nhamatanda 896 122 2 2% 10 8.2% 76 10% 9.8% HR Muxúngue 266 43 0 0% 0 0.0% 20 9% 7.5% Total Sofala 4398 988 40 4% 30 3.0% 169 5% 5.4%
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(MD) to improve the offering of PPFP methods, a comparative data analysis for further evidence- based taking decision is summarized in Table 5. Of cesarean section cases, 8% (132/1625) in Nampula and 4% (40/988) in Sofala were offered intra-cesarean BTL, and 9% (146/1625) in Nampula and 3% (30/988) in Sofala were offered intra-cesarean IUD. For the remaining attended deliveries, 8% (302/3,675) in Nampula and 5% (169/4229) in Sofala clients chose PPIUD as their FP method of choice. In total 11% of parturient benefitted of IUD or BTL in Nampula and 5.4% in Sofala. Further support should be given to Marrere General hospital, Namapa Rural hospital and to the Central Hospital of Beira to improve their counseling abilities while a supervision visit will be carried out to Nacala Porto General Hospital to verify that all FP compliance norms are well applied and to capitalize lessons learned.
Bilateral Tubal Ligation (Mini-Laparotomy) Trainings in Nampula province & Sofala
While 225 mini- Figure 1. Number of mini-laparotomy carried over, by HF's levels, provinces laparotomy BTL were and quarter – IFPP performed in FY2 (only at 250 hospital level), in FY3, 668 197 mini-laparotomy BTL were 200 carried out, of which 365 at 150 138 peripheral HF level in 13 119 118 114 100 84 81 different Health Centers, 68 74 50 57 making the mini- 50 40 37 22 18 8 laparotomy procedure 1 0 0 0 more available as an Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 option for contraception. FY2 FY3 FY4 In Q3FY4, there were 114 Nampula Hospital's level Nampula Health Center's level Sofala Hospital's level
BTL clients at peripheral HFs – Chalaua, Micane, Natiri, and Nakakana. At end of Q3FY4, out of 333 women who did Tubal Ligation, 169 were performed at peripheral HFs. At Hospital level, elective surgeries were cancelled due to COVID-19, consequently reducing the access to this service, therefore referring clients to FP/SRH consultation for the existing range of contraceptives.
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Joint supervision MISAU-IFPP
At the end of Q3FY4, IFPP team in Sofala did a supervision visit with MISAU head responsible of FP – Alda Mahumane, M&E responsible – Table 6: # of joint MISAU-IFPP supervision at district level Benilde Homo and logistic responsible – by province – Q3FY4 Bonfilho Sargento. DPS also took part with the participation of the FP focal HF receiving integrated District Health Facility point – Almija Pulseira. They had the supervision opportunity to visit Dondo, Nhamatanda, Existing Trained Q1 Q2 Q3 Buzi, and Muanza districts and they Angoche 20 20 0 7 10 Mogincual 6 6 6 4 6 analyzed the level of FP implementation Liupo 4 4 4 2 2 at these districts. They value that FP is Npla Cid 25 23 0 5 4 Erati 11 11 0 6 8 implemented regularly in all HFs and it Memba 14 14 0 4 8 continues even with COVID-19 context; Meconta 8 8 0 0 8 there is availability of FP consumables Nacaroa 7 7 7 7 7 Muecate 11 11 11 9 12 either at provincial warehouse and HFs; Mogovolas 8 8 8 0 5 HPs with high performance are involved Moma 11 11 11 0 5 Lardes 7 7 7 0 5 in FP activities in another HF. And they Monapo 17 17 17 16 11 recommended that it’s important to Mossuril 10 10 10 3 12 Ilha Moç. 5 5 5 5 5 reinforce LARC counselling at all N.Porto 14 12 0 0 5 consultation doors and with special N.Velha 6 6 0 0 0 attention to maternity ward; to Murrupula 6 6 0 5 6 Rapale 7 7 0 4 5 distribute to pill’s users three packs at Mecuburi 13 13 0 4 5 once; to maximize APEs activities to Ribaue 10 10 0 5 10 Malema 10 10 0 10 0 prevent discontinuation of FP among the Lalaua 7 7 7 0 0 clients; to strengthen the use FP data NAMPULA 237 233 93 96 139 daily summary sheet to guarantee high Beira 17 17 0 0 6 quality of data. Dondo 15 15 0 1 5 Nhamatanda 20 16 5 10 8 Buzi 17 17 7 10 4 Chibabava 16 16 5 14 8 The IFPP technical team and Machanga 11 10 5 9 6 SDSMAS/DPS staff carried out technical Caia 13 13 4 6 7 Marromeu 10 10 7 5 7 support and joint supervision visits to Chemba 10 10 2 6 6 HFs as described in Table 6. This quarter, Gorongosa 14 14 2 6 5 Cheringoma 8 8 4 6 1 213 (joint supervisions were carried out Maringue 10 10 8 8 6 (74 in Sofala and 139 in Nampula) in Muanza 11 10 2 7 5 SOFALA 172 166 51 88 74
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comparison with 184 in Q2FY4 Table 7: Mentoring visits received by HFs during Q3FY4 and 144 in Q1FY4. Joint supervision serves to strengthen HFs categorized according to the # of mentoring visits received - FY4Q3 understanding and coordination, HF with at # HF # Mentorship % of HF District Existing HFs least one mentored visits carried mentored to boost the quality of the SRH trained HP in Q3FY4 out in Q3FY4 in FY4Q3 services, as well as to lay Beira 17 17 9 27 53% foundations for self-reliance and Dondo 15 15 9 9 60% Nhamatanda 20 16 12 42 75% sustainability of quality Buzi 17 17 13 38 76% improvement initiatives. Chibabava 16 16 14 27 88% Machanga 11 10 6 13 60% Supervision includes the FP Caia 13 13 6 15 46% integration data aggregation tool, Marromeu 10 10 7 24 70% assessment of the quality of Chemba 10 10 7 16 70% Gorongosa 14 14 11 18 79% counseling, techniques for Cheringoma 8 8 9 17 113% method insertion, cleanliness, ICP Maringue 10 10 4 6 40% Muanza 11 10 5 6 50% and organization of HF services, Total Sofala 172 166 112 258 67% FP commodities and Angoche 20 20 12 38 60% management. Integrated Mogincual 6 6 6 16 100% Liupo 4 4 3 11 75% supervision visits are important, Npla Cid 25 23 18 50 78% as they boost adoption of new Erati 11 11 7 14 64% Memba 14 14 8 13 57% components and increase Meconta 8 8 8 42 100% ownership of the MISAU’s FP Nacaroa 7 7 7 39 100% strategy and consequently the Muecate 11 11 7 26 64% Mogovolas 8 8 2 4 25% sustainability of the FP program. Moma 11 11 8 17 73% In complementarity, IFPP Lardes 7 7 4 7 57% Monapo 17 17 12 25 71% supported mentoring visits which Mossuril 10 10 8 21 80% are summarized in Table 7 by Ilha Moç. 5 5 5 30 100% province and district highlighting N.Porto 14 12 11 24 92% N.Velha 6 6 5 10 83% the number of HF mentoring Murrupula 6 6 5 8 83% visits carried out during Q3FY4, Rapale 7 7 5 15 71% and the percent of HFs with at Mecuburi 13 13 6 11 46% Ribaue 10 10 9 32 90% least one HP trained that received Malema 10 10 10 42 100% a mentorship visit. 74% of the HF Lalaua 7 7 6 24 86% Total Nampula 237 233 172 519 74% (172/233) in Nampula and 67% Total Both 409 399 284 777 71% (112/166) were visited at least provinces once for HP mentorship in Q3FY4. Some HF received more than one visit as 258 visits were carried out in Sofala and 519 in Nampula in Q3FY4 totaling 777 visits while 732 were carried out in Q2FY4 and 598 in Q1FY4. Although there was a restriction of work during this quarter, there is a slight increase of the visits to the HFs to mentor providers. During Q3FY4, IFPP continues to target HPs that were never mentored. During the visits to the HFs (including assessments and joint supervisions), different needs were identified. IFPP will
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purchase next quarter a list of medical equipment item and furniture to diminish the gaps and complement the NHS efforts to ensure service’s quality.
COVID-19 support to DPS and SDSMAS COVID-19 pandemic highlighted Table 8: IPC materials distributed in COVID-19 context weaknesses of health services. At end of March, lockdown started and Nampula Sofala Item IFPP IFPP lasted through the entire Q3. NHS Preventive services were the most (staff and CHW) (staff and CHW) Alcohol Sanitizers 400 50 120 affected and the continuity of short- buckets with tap 5 74 45 term acting contraceptives reduced Soap 700 240 426 dramatically during the month of Chlorine 100 Gloves 5,500 April 2020. IFPP supported MISAU at Cloth-based masks 17,123 10,677 different levels in drafting guidelines N95 Masks 1,000 400 500 Protective Glasses 600 to prevent disruption of FP services. IFPP also supported DPS to share and train SDSMAS MCH responsible to follow the recommendations. Additionally, IFPP supported both Sofala and Nampula with posters, flyers, and IPC materials (Table 8), to guarantee that both providers and beneficiaries are safe during activities. Quality Improvement and Mentoring Quality improvement (QI) is key to project success in terms of achieving and maintaining high quality service provision garnering institutional support and buy-in to address systemic challenges and to support the sustainability of FP integration efforts. Mentorship drives the QI cycle through regular visits by project MCH nurses and District Coordinators. The objective of mentoring is primarily to guarantee that HPs trained by the project are engaged on a regular basis and are supported to achieve and maintain clinical proficiency and service quality. Mentoring includes direct observation of quality service provision coupled with supplementary on-the-job training. A secondary objective of the mentoring visits is to cultivate institutional engagement and ownership among HF management and staff to remove barriers to successful integration and greater uptake of FP services. The first mentoring visit is scheduled approximately 10 days after the end of the initial training. Subsequent mentoring visits are scheduled depending on the findings of the first visit, but the goal is to reach each HF with trained HPs, if possible, once per quarter.
Mentorship App
To ensure the consistency of mentorship and facilitate follow-up on action plans developed during mentoring visits, IFPP uses a mentorship digital app. It provides HP-specific electronic notetaking and follow-up action plans, which are discussed and shared before leaving the HF. The app provides prompts for mentors to guide them through each step of the mentorship process and sends reminders to mentors for the next mentoring visit to ensure providers who require additional 19
support are mentored at appropriate intervals. Out of a total of 4,394 reported as trained through IFPP at end Q3FY4, 3,982 (91%) HPs against 3,783 at end Q2FY4, are active and registered in the mentorship App; out of these, 3,558 (89%) – against 3,190 (84%) in Q2FY4 – were already mentored at least once after the initial training and 11% (against 16% at end Q2FY4 and 21% at end Q1FY4), that still need to be mentored for the first time. Meanwhile out of the 11% of providers not yet mentored, 23% (97/424) of them fall into the “other provider” cadre which includes health professionals in fields not traditionally associated with MCH or SRH services such as pharmacists, laboratorians, and more specialized health technicians including physiotherapists, ophthalmologists, radiologists, and anesthesiologists. These providers were trained to enable the environment by providing in-facility referrals, therefore clinical mentorship is being conducted to prioritize those providing FP methods. As seen in Figure 2, 3,982 HPs are still active and registered in the App and are distributed, per province, between MCH nurses, General nurses, Consultation officers, other categories, Preventative officers, Medical doctors and MCH bachelor nurses.
Figure 2: # of active HPs registered per category for each province at end Q3FY4
a: MCH Nurse 849 Nampula Sofala b: General Nurse c: Consultation officers d: Other Categories f: Preventative officers 526 g: Medical Doctor 451 h: MCH licensed Nurse 403 376 296 272 243 203 175
77 57 29 25
a b c d f g h
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As seen per provinces in Figures 3a and 3b, at end of Q3FY4, out of 3,982 HPs still active and registered in the App, 3,558 (against 3,190 at end Q2FY4 and 3,083 at end Q1FY4) unique health
Figure 3a and 3b: Comparison of the # of unique HP trained, registered, still active at end Q3FY4 and Q2FY4, who received a mentoring visit(s), per topic and province
3000 NAMPULA 2428 2500 2296 Q3FY4 Q2FY4 2099 2000 1813 1842 1553 1500 1248 1088 1000 674 627 470 530 500
0 Total of HP still Counselling Implant Injectavel IUD IUPP active and registered in the App
SOFALA 3000 Q3FY4 Q2FY4 2500
2000 1554 1487 1358 1500 1211 1100 1003 958 1000 762 494 391 500 324 269
0 Total of HP still Counselling Implant Injectavel IUD IUPP active and registered in the App
providers (2,187 in Nampula and 1,371 in Sofala) were already mentored at least once. Out of the 2,187 HPs in Nampula, 2,099 were mentored for counseling, 1,842 for implant, 1,248 for injectables, 674 for interval IUD and 627 for PPIUD. In Sofala, out of the 1,371 HPs already mentored at least once, 1,358 were mentored for counseling, 1,211 for implant, 958 for injectables, 494 for interval IUD and 391 for PPIUD. The difference between the blue bars and the orange ones are the specific accomplishment of Q3FY4. During the Q3FY4, IFPP staff prioritized mentorship at the HF level to support HPs during this difficult COVID-19 era. The project will continue to increase mentorship visits 21
during the daily shift changeover meetings at maternity ward level which provides an opportunity to give parturient women counselling and immediate PPFP, including PPIUD insertions, and, IFPP can catch night-shift workers who are otherwise missed for mentorship. This effort will be coupled with MISAU district trainers based at district level.
IFPP is focusing the implant insertion mentorship activities for MCH nurses, consultation officers and preventative officers who are Figure 4a: In-depth analysis per prior HP categories for Implant offering FP services at the insertion mentorship in Sofala frontline (out-patient consultations at HF and MB). In-depth analysis has been carried out since Q1FY4 to measure the existing gaps for these categories and print the related listings of HPs not yet mentored by category. As illustrated in Figure 4a, in Sofala province, at end Q3FY4, 25% of the consultation officers have not yet been mentored (against 35% at end Q2FY4), 26% of the preventative officers Figure 4b: In-depth analysis per prior HP categories for Implant (against 33% at end Q2FY4) insertion mentorship in Nampula and 12% of MCH nurses (against 17% at end Q2FY4) illustrating the efforts carried out to diminish the existing gaps in mentorship. Also, as illustrated in Figure 4b, at end Q3FY4, in Nampula province, 24% of the consultation officers have not yet been mentored (against 32% at end Q2FY4), 26% of the preventative officers (against 33% at end Q2FY4) and 10% of MCH nurses (against 18% at end Q2FY4).
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In-depth analysis, per province, per district and per HP category, were carried out to support management and district teams Figure 5a: % of Consultation Officers by mentoring status for Implant per district in Sofala province at end Q2FY4 improving planning and targeting for TA. As an example, figure 5a and 5b compare, in 100% % NOT YET mentored 80% 81% 81% 71% 73% Sofala, the percentage per % Mentored 64% 64% 54% 47% 48% 42% 45% district of the consultation 50% 36% officers/Clinical Officers
0% (“agentes e tecnicos de medicina % of Mentored of Mentored % -20% -19% -19% -29% -27% curativa”) mentored and not yet -50% -36% -36% -46% -53% -52% -58% -55% -64% mentored for implant insertion -100% skills, at end March 2020 (Q2FY4) (figure 7a) and at end June 2020 Districts (Q3FY4) (Figure 7b); it highlight Figure 5b: % of Consultation Officers by mentoring status for progresses achieved per district: Implant per district in Sofala province at end Q3FY4 while six districts (Machanga,
100% Muanza, Gorongosa, Marromeu, 100% 88% 92% 78% 80% 81% 73% Chibabava and Buzi) had more 68% 69% 64%
45% 47% 50% 42% than 40% of the consultation officers already trained thru IFPP 0% 0% still not mentored for Implant at -12% -8% % of Mentored of Mentored % -22% -20% -19% end Q2FY4, in Q3FY4, only three -32% -31% -27% -50% -36% -53% % NOT YET mentored -58% -55% Sofala Q3FY4 districts (Muanza, Machanga, % Mentored
-100% Marromeu) had more than 40% of consultation officers already trained but yet not mentored for implant; specific attention will be given to these districts during next quarter. Similarly, Figures 6a and 6b, compare in Nampula, the percentage per district of the consultation officers mentored and not yet mentored for implant insertion skills, at end March 2020 (Q2FY4) (figure 8a) and at end June 2020 (Q3FY4) (Figure 8b); while seven districts (Moma, Mogovolas, Lardes, Mecuburi, Lalaua, Angoche and Erati) had more than 40% of the consultation officers already trained thru IFPP still not mentored for Implant at end Q2FY4, in Q3FY4, only one district (Meconta) has more than 40% of consultation officers already trained but yet not mentored for implant. It’s important to highlight that the same analysis is carried out for preventative officers (“agentes e tecnicos de medicina preventiva”).
For IUD and PPIUD, the analysis focused on the MCH nurses (basic, medium and bachelor levels) as well as for medical doctors. It highlighted the need to strengthen mentorship activities for the medical doctors and the bachelor MCH nurses. 23
Figure 6a: % of Consultation Officers by mentoring status for Implant per district in Nampula province at end Q2FY4
100% % NOT YET mentored 89% 85% 85% 86% 88% 80% 82% % Mentored 73% 69% 71% 72% 64% 67% 67% 67% 59% 63% 56% 57% 57% 58% 50% 50% 42%
0%
% of%Mentored -11% -15% -15% -14% -13% -20% -18% -27% -31% -29% -28% -36% -33% -33% -33% -41% -38% -50% -44% -43% -43% -42% -50% -58%
-100%
Districts
Figure 6b: % of Consultation Officers by mentoring status for Implant per district in Nampula province at end Q3FY4
96% 100% 88% 88% 88% 89% 90% 82% 83% 83% 83% 83% 84% 86% 75% 77% 77% 70% 70% 71% 73% 60% 62% 63%
50%
0% -4% -13%-12%-12%-11%-10% % of Mentored of % Mentored -18%-17%-17%-17%-17%-16%-14% -25%-23%-23% -30%-30%-29%-27% -50% -40%-38%-38% % NOT YET mentored Nampula - Q3FY4 % Mentored
-100%
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Finally, during this Q3FY4, the MISAU SRH quality standard tool was applied in 32 HFs in Nampula province and 39 in Sofala, compared to 21 and 29 in Q2FY4. Sofala started to apply the tool in Q1FY3 and focused on 32 different HFs while Nampula started in Q3FY3 and focused on 44 different HFs. In Q3FY4, both provinces expanded the tool’s application, reaching 95 different HFs – 54 in Nampula and 41 in Sofala. The tool requires on average four hours to be applied. Figures 7a and 7b illustrate the trend between the first and the last assessments per HF. Nampula province should double its efforts in order to improve global results as at end Q3FY4, 15% of the HFs with at least one measurement are reaching less than 60% of the standards, 30% are in the range ≥60% to <75% and 56% of the HF reach the minimum level required (75%) while in Sofala, only 5% of the HFs assessed are reaching less than 60% of the standards, 15% are in the range ≥60% to <75% and 80% are ≥75%.
Figure 7a and 7b: Results of the SRH quality standard tool application by HFs in Nampula and Sofala provinces up to end Q3FY4 NAMPULA
100% 1st Assessment Last Assessment minimum required
80%
60%
40%
20%
0%
SOFALA
1st Assessment Last Assesment minimum required
100%
80%
60%
40%
20%
0%
Summary of the main observations and recommendations of the mentoring and supervision visits: • Technical skills: Difficulties persist in immediate postpartum method provision, especially for LARCs. The PPIUD insertion technique is the most difficult for HPs and they need more mentorship 25
to improve their self-confidence. For low-volume HF providers, an internship approach is progressively being implemented so that HPs have practicum opportunities at the main district- level HF. • Offering of FP methods at maternity level: The PPFP counselling at antenatal care (ANC) still needs to be more consistent so missed opportunities are diminished, specifically during ANC visits attended by the couple for HIV screening. • FP integration: In most of the trained HFs, FP methods are offered, but non-maternal and child health (non-MCH) providers need more follow-up with respect to FP method provision in order to decrease the missed opportunities and increase access to FP methods at the HF level. When providers are transferred or on annual leave, the substitute tends to not follow up on the activity even though they were informed. It was recommended through integrated supervision and mentorship visits that FP focal points and HF directors increase their follow-up and support. The daily and weekly monitoring role of the HF’s director is particularly important and should be reinforced. In order to do that, IFPP started this Q2FY4 to implement a management training in FY4 (please see section IR3). • M&E logbooks: More SRH/FP logbook daily summaries are filled out correctly when compared with previous quarters, even if challenges remain. Problems arise when the regular MCH nurse in charge of the FP/SRH consultation is absent and there is a substitute nurse or student who is not familiar with the process. Data follow-up on a weekly basis during the HF clinical review meetings continues to be recommended. FP data are reported by each HF responsible and discussed during the quarterly review data meeting at SDSMAS level. The 50 HPs, in Nampula, trained as district trainers for FP during Q3&4FY3 and the 15 district FP trainers trained in Q1FY4 in Sofala were trained in the correct registration and aggregation of data in the different logbooks for use at national level and contribute to improve data quality.
Experience exchange (Learning) visits between MCH nurses with low LARC volume and those with high volume
Experience exchanges (learning) visits motivate HPs to do more and share their experience with other HPs improving abilities on both sides as bounds are built. In Gorongosa, Maríngue and Muanza districts in Sofala and Nacala Porto in Nampula, one week of experience exchange visits between 9 HFs in Sofala and 6 in Nampula were carried out in Q3FY4 involving 11 and 9 HPs in Sofala and Nampula respectively and resulting in insertion of 53 interval IUDs, 19 PPIUDs, 206 Implants, offering of 139 injectables, and 119 pills. As, they were movement restrictions due to the pandemic, it wasn’t possible to implement this activity in other districts.
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Strengthening Cervical Cancer Prevention (CECAP) through Integrated Prevention, Testing, and Treatment Leveraging the opportunity presented by IFPP, Pathfinder supported the CECAP activities during the Q3FY4 in close collaboration with HIV partners (ECHO, ICAP) as strengthening the screening and treatment of HIV positive woman continues to be a challenge. In Q3FY4, in Sofala province, 45 HPs received OJT, focusing on recently posted HPs: Nhamatanda (7), Búzi (10), Gorongosa (2), Chibabava
Figure 8a: % of CECAP standards achieved by HF assessed in Nampula province at end Q3FY4
1st Assessment Last Assessment minimum required 100%
80%
60%
40%
20%
0%
Figure 8b: % of CECAP standards achieved by HF assessed in Sofala province at end Q3FY4
1st Assessment Last Assesment minimum required 100% 80% 60% 40% 20% 0%
(12), Machanga (5), Caia (3), and Marromeu (6). Additionally, the MISAU CECAP quality standard tool was applied in 28 HFs in Nampula province and 37 in Sofala, compared to 20 and 36 in Q2FY4 respectively. Both provinces started to apply the tool in Q3FY3 and focused on 31 different HFs in 27
Nampula and 27 different HFs in Sofala. In Q3FY4 the tool application was expanded to 76 different HFs, 39 in Nampula and 37 in Sofala. Figures 8a and 8b illustrate the trend between the first and the last assessments per HF: Nampula reach the minimum level required (75%) in 62% of the HFs, 23% are in the range ≥60% to <75%, and 15% have less than 60% of the standards completed; in Sofala 70% are ≥75%, 22% are in the range ≥60% to <75%, and only 8% of the HFs assessed have completed less than 60% of the standards. These results, even if improving, highlight the needs for more intensive follow up and support from DPS and clinical partners; IFPP’s will continue to carry out the CECAP quality standard tool during the next quarters.
It’s important to note that this support was given in light of the previously CECAP funded activities, that no longer is part for IFPP CoAG from FY4. The transfer of this responsibility towards ECHO in Sofala is going on.
Sub-IR 1.2: Increased access to modern contraceptive methods and quality, community-based FP/RH services Agente Polivalente Elementar trainings (APEs) IFPP support to APEs is a key activity that will increase FP access for the hard to reach, rural populations. APEs are trained on FP through the initial MISAU training. However, the MISAU requested that IFPP strengthen APEs skills and increase support and supervision to effectively integrate FP into their daily tasks. APEs were invited to participate in the first two days of HF provider trainings to refresh their knowledge and to boost HF and APE coordination mechanisms, including FP commodities, supplies, referrals, and supportive supervision schedules during the FY1 to FY3. By end of FY3, 868 APEs were already trained (316 in Sofala and 552 in Nampula) with the support of IFPP. During Q1FY4, 17 additional APEs were trained in Sofala, totaling 885 APEs trained. During Q2 & Q3FY4 no training was held. The number of women served through APEs has the potential to Figure 9: Trends of the # of APEs reporting data, reporting FP data, % of APE reporting FP data, per month, in Nampula province – Oct. 2017 – Jun 2020 1200 100% 1130 1125 1133 1133 1083 1084 95% 96% 993 90% 81% 82% 93% 92% 1001 90% 89% 91% 91% 1000 89% 89% 88% 89% 86% 87% 86% 86%931 86% 1030 85% 85% 84%909 80% 82% 81% 82% 81% 1001 1030 78% 827 801 803 970 773 922 70% 800 742 745 918 858 720 700 703 705 844 800 764 60%
691 765 600 566 551 653 661 50% 526 522 625 522 627 691 578 441 621 419 420 603 40% # of # APEs 414 501 366 478 400 489 452 452 305 30% 275 274 379
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increase as detailed analysis per APE is being carried out to identify the ones struggling offering FP services. Figure 9 illustrates the growing trends in the number of APEs reporting FP data and the percent of them compared with the number of APE reporting, in general, activities, per month, in Nampula. Monthly data reporting has the tendency to be incomplete as APEs are community based and represent the most peripheral FP service delivered, therefore, it is directly related to the number of monthly peripheral HF meetings carried out and also the number of APEs traveling from their communities to their catchment HFs every month to attend this meeting. 1030 APEs reported FP data in June 2020 against 284 in October 2018; these 1030 APEs represented 91% of the APEs reporting data in general. Figure 10 illustrates the number of users served per month and per type of contraceptive method through the group of APE reporting FP data in Nampula. The quarterly average number of DMPA- users served per APE is around 41 while the average number of oral contraceptive pill users served per APE is around 10 per quarter, totaling 51 (68% of the benchmark fixed by MISAU) users served per quarter and per APE, the goal of the MISAU is to have at least 75 women served per quarter by APE. IFPP starts supporting specifically the poor performing APEs through regular meetings; as poor performing APEs were identified, a complementary curriculum of three- days-training focusing on FP value clarification and the importance of offering FP methods to adolescent to commence the demographic transition, youth usual provider and community’s bias, LARC myths and main side effects, MLD user’s rights in regards to removals at HF level and male engagement have been drafted and will be carried out, starting next quarter, through three small group sessions of six hours to be scheduled on a monthly base and experience’s sharing with championing APEs discussing each topic. Additionally, IFPP continues to support provincial and district-level APE supervision—including one-on-one mentorship visits between APEs and MCH nurses from catchment area health facilities and district FP trainers, to address individual performance and challenges, and quarterly administrative post-wide meetings among APEs, district supervisors, and HF focal points to analyze data, improve reporting and supplies.
Figure 10: # of users served per month and per type of contraceptive method for the group of APE reporting FP data in Nampula province 14000 30
27 27 12000 25 23 24 10000 21 20 20 20 19 19 18 18 19 18 8000 17 17 17 17 17 17 16 16 16 17 16 16 16 16 16 16 16 15 14 15 6000 14 10
4000 Total number of Total users served
2000 5 Average number number Average of users served per APE 0 - Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2018 2019 2020 # of Pills users served # of Depo users served Average # of user served per APE
In Nampula province, during Q3FY4, out of 1,265 APEs trained and reported as active, through the NHS, 1133 have reported data in general and 1030 have reported FP data.
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More mobility constraints are existing in Sofala province due to lower population density and huge distance between the communities and HFs. For Sofala province, the number of existing APEs has increased from 380 at end Q1FY3 to 472 at end Q3FY4. In June 2020, 397 APEs out of 472 (84%) are reporting FP data, against 351 out of 472 (74%) in Q2FY4 and against 241 out of 380 (63%) at end Q1FY3. Figure 11 illustrates the number of users served in average per month and per APE and the total number of users served per month and per type of contraceptive method through the group of APE reporting FP data in Sofala. The quarterly average number of DMPA users served per APE is around 29 while the quarterly average number of pill users served per APE is around 18 per month, totaling 47 users (62%) per quarter against the MISAU benchmark of 75. The May 2019 peak of reporting is related to the post-IDAI campaign in Sofala province, but this data should be viewed very cautiously as data over-reporting occurs during campaigns and the gain of users (continuation) is not reflected in the following months.
Figure 11: # of users served per quarter and per type of contraceptive method for the group of APE reporting FP data in Sofala
12,000 80 70 70 10,000 60 8,000 50
6,000 40 28 25 23 18 16 30 4,000 21 20 22 22 21 22 20 21 21 18 15 16 16 15 20 18 19 17 19 18 14 15 14 20 2,000 Total # of users served users# of Total 10
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During Q3FY4, IFPP teams participated in 22 APE district’s meetings against 39 in Q2FY4. Direct technical assistance was provided to 362 APEs, 158 in Sofala and 204 in Nampula from 111 HFs, 55 in Sofala, and 56 in Nampula. Additionally, IFPP trained APEs in COVID-19 topic, using MISAU package for community activists in Monapo, Mossuril, Ilha de Moçambique, Muecate and Nacaroa. Among the APEs, 14 in Nampula were identified as champions, as they have a high performance. IFPP, during next quarters, will strengthen its efforts to support APEs. Therefore, the following activities Photo 4: Support to APE in filling logbook - besides the complementary three- days-training for poor Saua Saua - Nampula performing APEs, will continue to be carried out: 1) increase supervision visits of the IFPP technical team as well as support to APE supervisors at SDSMAS and DPS level for integrated supervision, FP registration in the APE logbook, referrals to HFs for long acting FP methods and or planning of specific MBs and management of traditional birth attendants
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(TBAs) FP referrals that are directed to APEs; 2) improve the supply of SAMs available to APEs in both provinces supporting the dissemination of MISAU’s recommendations for the distribution of MCH commodities for APEs, as well as the one clarifying that DMPA-IM injection can be provided by APEs as a substitution when DMPA-SC (Sayana Press) stocks are insufficient; 3) print register books and references slips when necessary.
Traditional Birth Attendant (TBA) Trainings IFPP’s rural supply-side strategy involves identifying, training and supporting TBAs to conduct home visits and community-based FP counseling and referrals. It is expected that TBAs will generate demand by improving knowledge of FP, Table 9 – TBAs trained in FP methods and community countering prevailing misconceptions and sensitization biases, conveying the importance of healthy timing and spacing of pregnancy (HTSP), TBAs trained in FP methods and community increasing self-efficacy and promoting linkages sensitization To Grand with contraceptive service delivery points Province FY1 FY2 FY3 FY4 date Total (IR1). Nampula 762 79 152 283 1276 TBAs are trained and supervised by the HF 1694 Sofala 92 179 72 75 418 trainers, in partnership with the IFPP teams. TBAs are expected to reach all women and adolescents of reproductive age, specifically targeting first-time parents (FTPs) who are pregnant or postpartum and medium- and high-parity women (defined under IFPP as woman with three or more children). TBAs also engage household influencers and gatekeepers (for example, male partners and mothers-in- law). During Q3FY4, no training of TBAs was held Photo 5: Mask distribution to PTs before the monthly meeting - Marrere (Table 9), some additional trainings will be carried out in Q4FY4, to respond to the need of Mogovolas, Liupo, Angoche, and all districts of Sofala. In Nampula province, these efforts were crowned with success as quarterly confirmed referrals reported by TBAs has jumped from 537 (Q1FY2) to 9,208 confirmed referrals in Q2FY4 and to 11,858 in Q3FY4. During Q3FY4, in Nampula, an average of 102 out of the 149 HFs that have trained TBAs have reported TBAs confirmed referrals and 106 out of 118 in Sofala. When analyzing the confirmed referrals by specific subgroups in Nampula province, adolescents without children appear as a specific sub-group for referral: this number has steadily increased from 1,144 (Q2FY3) to 1522 (Q3FY3), 1,572 (Q4FY3), 1,862 in Q2FY4, and to 2,469 in Q3FY4, representing on average, 21% of all confirmed referrals carried out by TBAs – an outstanding result as it illustrates the impact that TBAs can have on adolescent yet without children. In Sofala, adolescent without children represents 19% of all referrals carried out by TBAs. In Sofala province, the 418 trained TBAs 31
are spread over 118 rural HF catchment areas and not all HFs have a focal point trained as a TBA trainer, therefore the monthly review meeting between the HF MCH nurse and the TBAs is more difficult to organize; during Q3FY4, 3,605 (81%) FP referrals were confirmed as arrived at HF out of 4,455 against 2,895 (74%) in Q2FY4 out of 3,911. Technical assistance was provided to 166 TBAs in 55 HFs in Sofala Province. Some have a great performance and are highly committed. IFPP promoted the sharing of experience with less performing TBAs. In both provinces, in Q3FY4, 522 TBA’s meetings (273 in Sofala and 249 in Nampula) were carried out in 208 different HFs (106 in Sofala and 102 in Nampula) out of a total of 267 HFs having TBAs trained, to analyze and share the data and receive technical assistance to improve they work at communities. Interpersonal Communication Agent (IPC) Training The project’s urban demand creation strategy builds on the “TEM mais” or private clinic network (TEM+) model already used by PSI, which seeks to create Table 10: # of IPC agents trained, by province informed demand for FP Total directly at the household and FY1 FY2 FY3 Q1FY4 Q2FY4 Q3FY4 to community level through date home visits and community NAMPULA 39 95 27 10 25 0 196 meetings. Table 10 describes SOFALA 45 48 86 0 0 20 199 the number of IPC agents trained since the starting of the IFPP intervention illustrating the high number of trainees for Sofala province in FY3 as, at the end of Q2 , the IPCs agents were oriented to include additional priority activities such as water and sanitation awareness and ended up in other post-emergency NGOs. This FY4Q3, 20 additional IPC agents were trained in Sofala. In addition to the initial trainings, monthly updates are carried out to increase IPCs’ abilities to use the updated version of the digital platform “Connect with Sarah” (CwS) which operates on a more advanced cell phone model – the VODAFONE SMART E9 – and allow IPC agents to follow-up with WRA and their families. Monthly technical updates are also provided with focus on the importance of FP compliance, client follow-up, reporting behavior change barriers met at each household visited and the involvement of community leadership to conduct male group sensitization.
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Impact of COVID-19 and how IFPP adapted its intervention this FY4Q3 In the first week of April, the urban component developed a plan to adapt the demand creation activities to the COVID-19 new context, revising the responsibilities of each team member. It should be noted that at the onset of the state of emergency, the community leaders as well as some families understood that people should not work and should only stay at home, and the IPC agents were prohibited from visiting their homes. Meetings were needed at various level to adjust the positions and clarify nearby the community leaders what will be the role of the IPC agents and community assistants would play in the field. At the same time, all IPCs agents were trained about COVID-19 prevention messages and how to include into their daily FP activities; protective material for IPCs agents (masks) and individual prevention measures (social distancing and hand washing) were promoted in their daily activities; messages underscore the importance of not interrupting FP, particularly during this time of uncertainties and cost- living increasing; the IPC agents shared their CwS number with their clients to Images illustrating different activities carried out in the district of Angoche (above), Nacala Porto (middle) and Nampula city (below), namely from left to right modular training sessions be more easily reachable for IPC and door-to-door sessions in the context of physical distancing due to COVID-19 and for further counselling, review of confirmed referrals with the HP, couple counseling, in Nampula city. accompanied referrals or short-term methods provision. In order to ensure continuity of short- term contraceptive methods, authorization to Images Illustrating the in-service training session for Dondo IPCs and door-to-door activities in the neighborhoods of Dondo and Mafambisse provide these methods were requested to the respective DPS: pills were immediately authorized while Sayana Press application was dependent upon IPC agents training. The use of alternative modes of communication such as Zoom, Microsoft Teams, Skype, and WhatsApp was expanded within the community team and used to share guidance about COVID-19 prevention and integration into their daily FP sensitization activities; therefore, PSI in partnership with MISAU produced a video about COVID-19 to be shared at the beginning of each counselling session; follow-up and support of IPC’s agents through community IPC assistants was strengthened during this quarter.
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“Connect with Sarah” App (CwS) The “Connect with Sarah” platform was introduced at the end of FY2 to strengthen client’s registration, the number of sessions, follow-up of references and identify family’s subgroups with similar barriers for family acceptance to design additional strategies for demand generation activities.
The IPCs register the client and document the different interactions carried out during the year which will strengthen the follow-up of clients, improve registration of clients’ FP needs, collect client feedback on the services provided and track the referrals. As this App works on smartphones equipped with an android system, geo-location of the households is required and eases IFPP’s internal audits and IPCs return visits. The App is being used by both IPCs and HPs. To improve the performance of the CWS App, updates were made to the App of the PSC and the nurses, accompanied by clarification sessions in the field.
Mapping of IPCs agents
Furthermore, the urban community mobilization and counselling strategy redesigned in Q4FY2 has been implemented since beginning of FY3. The IPCs were redistributed in pre-selected neighborhoods within the mission to progressively reach 100% of WRA for FP counseling and further follow-up. Working meetings were held and will continue to be carried out with the community leaders (CLs). In Nampula city, the IPC agents are distributed in six administrative posts and 14 boroughs: in Murrupula, in one administrative post and six boroughs; in Angoche city, in one administrative post and 15 boroughs; in Nacala Porto city, in one administrative post and in 10 boroughs; in Ilha de Moçambique, in two administrative post and 3 boroughs; in Beira city, in four administrative posts and 18 boroughs; in Dondo, in two administrative posts and six boroughs. Each IPC agent is covering a geographical area of about 10,000 inhabitants with the objective to cover all households with home-based visits and with the support of 15 community assistants and the community leadership, conduct male group sensitization for families presenting specific socio- cultural and religious barriers. The model is quite intensive but aims to create FP demand within the households presenting high level of barriers.
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As seen in Table 11, data demonstrate a significant improvement in the demand creation actions at the level of the two provinces and, in particular, Sofala province, which registered a 100% increase over sessions, MIF's reached, references issued and confirmed by the nurses at the HF, when compared to the previous quarter. In Nampula province, IFPP planned to visit and register 212,500 WRA in predefined areas till the end of the IFPP intervention. At end Q3FY4, 198,641 (93%) were already visited and registered in CwS against, 147,455 (69%) at end Q2FY4, 121,204 (57%) at end Q1FY4 and 102,211 (48% of coverage) at end FY3. Out of these 198,641 WRA already visited, 120,311 WRA were using a FP method at the end of Q3FY4 (60,6%) against 90,679 at the end of Q2FY4, 73,778 at the end Q1FY4 and 62,476 reported as FP users at the end of FY3. Out of these 198,641 WRA already visited at the end of Q3FY4, 18,034 (9.1%) were not a FP user at the time of the visit and
Table 11: Cumulative data at end of Q1FY4, for the urban demand creation component
% of WRA that # of % of WRA that % of WRA that % of WRA # of WRA became LARC users estimated Total # of # of WRA # of WRA # of WRA that became users became LARC users covered that after IPC's expected WRA to be unique registered registered became users after IPC's after IPC's thru IPC became a intervention # of IPC covered in WRA in CwS not in CwS after IPC's intervention intervention District agent and LARC users (denominator = agent predefined registered yet using already intervention (denominator (denominator = registered after IPC's WRA that became a Province active areas till end in CwS at FP at end using FP at during FY3 = WRA WRA registered in in CwS, at interventio FP user in CwS after of end Q2FY4 Q3FY4 end Q3FY4 and Q1-3FY4 registered in CwS using a FP end Q3FY4 n community intervention CwS) method) intervention) Nampula city 45 112,500 123,152 109% 42,710 80,442 10,524 8.5% 1,817 2.3% 12.2% Angoche city 12 30,000 30,840 103% 13,382 17,458 3,166 10.3% 475 2.7% 12.9% Nacala Porto 20 50,000 31,328 63% 16,944 14,384 1,698 5.4% 315 2.2% 15.3% Murrupula 4 10,000 7,690 77% 3,601 4,089 1,939 25.2% 217 5.3% 10.9%
Nampula Ilha Moc. 4 10,000 5,631 56% 1,693 3,938 707 12.6% 181 4.6% 21.9% Total 85 212,500 198,641 93% 78,330 120,311 18,034 9.1% 3,005 2.5% 12.8% Beira 40 100,000 45,076 45% 22,737 22,339 5,483 12.2% 1,998 8.9% 34.3% Dondo 10 25,000 15,193 61% 5,708 9,485 1,521 10.0% 546 5.8% 34.4%
Sofala Total 50 125,000 60,269 48% 28,445 31,824 7,004 11.6% 2,544 8.0% 34.3% Both provinces 135 337,500 258,910 77% 106,775 152,135 25,038 9.7% 5,549 3.6% 18.8% initiated or reinitiated a FP method through the community visits against 11,007 at end Q2FY4, 8,132 at end Q1FY4 and 6,772 at end FY3. Out of the number of current users at end Q3FY4 (120,311), cumulatively 3,005 initiated a LARC (2,314 among the WRA not yet users at the moment of the visit and 691 were switchers to LARCs); among the WRA that became a FP users after IPC’s intervention
12,8% (2,314/18,034) choose a LARC in Nampula province while in Sofala province 34.3% (2,402/7,004) choose a LARC.
In Sofala, due to IDAI and the post-emergency phase, systematic mapping had to be carried out again in Q4FY3. This included the recruitment and training of most of the currently active IPCs agents. The systematic mapping aimed to ensure coverage of WRA who, due to the cyclone, moved from one neighborhood to another and, the ones settling in new neighborhoods emerging after IDAI. Therefore, Table 10 reports only the data from on Q4FY3 encompassing a period of twelve months up to end Q3FY4. IFPP planned to visit and register 125,000 WRA in predefined areas and 60,269 (48% of IFPP LOP target) were cumulatively visited and registered in CwS against 30,407 (24%) at end Q2FY4, 10,706 at end Q1FY4 and 10,136 at end FY3, illustrating the turnaround operated by the urban component team in Beira and Dondo in Q2 and Q3FY4. Out of these 60,269, at the end of Q3FY4, 31,824 (52.8%) were reported as FP users against 14,411 at end Q2FY4, 5,051 at end Q1FY4
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and 4,841 at end FY3. Of these (60,269), 7,004 (11.6%) were not a FP user at the time of the visit and either initiated or reinitiated a FP method through the community visits. Of the number of current users (31,824) at end Q3FY4, 2,544 initiated a LARC (2,402 among the WRA not yet users at the time of the visit and 142 switched to LARCs). For both provinces, when reporting the number of cumulative WRA who were not FP user at the first visit but became a LARC user (4,716), to the number of WRA that became user after IPC's intervention during FY3 and Q1-3FY4 (25,038), IFPP urban demand creation component reached amazing results as 18.8% (4,716/25,038) of them initiated a LARC, highlighting the improvement in IPC’s counseling skills for LARC. The use of the data- to-action framework methodology by the community assistants in monitoring the IPC agents’ activities supports the daily planning sessions with the IPC’s agents. Based on the previous results, the IPCs focused on the community assistant's recommendations to prioritize activities according to the daily results expected such as (1) MB’s planning and implementation in close collaboration with CLs and targeting the blocks where counseling beneficiaries reported concerns to go to HFs, (2) IPCs follow-up visits Table 12: Results achieved per HF by IPC agents posted at HF level in Q2FY4 prioritizing beneficiaries % of Referrals Referrals # of MLD % of MLD District Type of WRA Referrals without delivered confirmed users users confirmed confirmed WRA not FP user 89 59 66% 25 42% referrals, (3) Beira WRA FP user 325 273 84% 25 9% support to HPs WRA not FP user 418 343 82% 121 35% Dondo for referral’s WRA FP user 723 595 82% 16 3% redeeming. WRA not FP user 417 373 89% 25 7% Nacala Porto WRA FP user 4089 3778 92% 110 3% Table 12 WRA not FP user 241 234 97% 99 42% Nampula City illustrates the WRA FP user 944 923 98% 7 1% WRA not FP user 191 166 87% 3 2% results Murrupula WRA FP user 4 3 75% 3 100% achieved per 7023 6412 91% 381 6% city, in Q3FY4, WRA not FP user 1356 1175 87% 273 23% by the ten IPCs Both provinces WRA FP user 6085 5572 92% 161 3% agents posted at targeted HF’s to sensitize users Figure 12: Trends of confirmed referrals at the HFs benefiting on FP and refer them to FP from IPC agents posted at HF level along Q1-3 FY4 services either at SRHR or outpatient consultations to boost the FP service offering. Figure 12 illustrated the trends of confirmed referrals per HFs and quarter in Nampula province; this quarter, three HFs of Sofala province - the military HC, the
HCs of Dondo and Mafambisse – 36
benefitted from IPC agents posted at HFs. The results of this complementary strategy are quite encouraging as a total of 7,023 referrals were confirmed at the HF level for FP services. This in-door HF FP strategy focusing the HF with high volume has the potential to reduce the missed opportunities and decrease the unmet needs; indeed, as illustrated in table 11, 1,356 WRA not yet FP users, were counseled and 1,175 accepted a FP method and out of these (1,175), 273 (23%) chose a LARC. Additionally, WRA already FP users are also counseled either to continue their current method or to shift to a LARC, strengthening like this, the FP continuation rate among users; this quarter, 161 (3%) out of 5,572 WRA choose to switch for a LARC.
This Q3FY4, IFPP carried out Table 13: Results achieved thru Urban MB in Nampula and Sofala specific mobile brigades (MBs) in the urban settings # de BM % of Average # # of users MLD highly-synchronized with Q3FY4 carried MLD of served users the IPC’s agents activities; out users participants indeed, as the referral’s Nampula 59 1,623 76 5% 28 beneficiaries reported Sofala 115 2,750 571 21% 24 difficulties to access the HFs due to COVID-19, specific MBs were organized targeting pre-registered beneficiaries contributing like this to increasing the efficiency of the urban demand generation component. As Table 13 illustrates, the results achieved were higher in Sofala due to more support from CLs to mobile activities. On average, 28 and 24 beneficiaries per MB are served. It’s expected that these MBs will be repeated as the IPCs agents are entering in new boroughs and blocks of houses. Furthermore, in Ilha de Moçambique, the community assistant guided and supported the PSCs to organize and accompany groups of WRA having received a community referral to HFs removing like this beneficiary’s apprehension and concerns and increasing access to FP services.
Community Facilitators (CF) training During Q3FY4, all 236 facilitators were trained on COVID- 19 prevention curriculum and allocated hygiene and protection material before continuing carrying community activities. Any other training of CF was planned.
Photo 6: Training of CF on COVID-19 prevention Targeted Mobile Brigades (MBs) for priority populations measures MBs continue to be key in increasing access to FP, particularly for rural and hard to reach areas but were heavily impacted by COVID-19 restrictions. During Q3FY4, IFPP supported 281 MB (37 in Nampula and 244 in Sofala) against 669 MB (383 in Nampula and 286 in Sofala) in Q2FY4 and 823 MB (280 in Nampula and 543 in Sofala) in Q1FY4. Out of these 281 MBs, 2 in Nampula (145 in Sofala and 22 in Nampula) took place in school’s surroundings to enhance full access to the method-mix and are
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directed to all WRA with a focus on out-of-school adolescent but also promoting the in-school participation through sensitization; 13 (12 in Sofala and 1 in Nampula) in Q2FY4 against 120 (30 in Sofala and 90 in Nampula) in Q2FY4 and 24 MB in Q1FY4, were synchronized with the community dialogues targeting more and more remote and disperse areas, in phase with the timing of the 4th, 5th or 6th community dialogue’s sessions; the communities are sensitized on the FP benefits, LARC and STM, and the community facilitator, in coordination and with the support of the respective Community Leader Councils (CLCs), is mobilizing the population, distributing FP referrals for the MBs event during which specific attention will be given to access of LARCs. Note that, the community dialogue’s settings occurring in Q3FY4 which weren’t carried out this quarter due to COVID-19 restrictions will be planned in Q4FY4 to respond to the demand created. Further, out of the 281 MBs, 12 were MBs in predefined locations along the main roads (Q3FY4) against 94 (51 in Sofala and 43 in Nampula) in Q2FY4 and 254 (34 in Nampula and 220 in Sofala) were MBs in predefined rural locations or urban settings synchronized with the IPC’s agents; these latest aimed to reach and mobilized adolescents out-of-school and in-school who were confronted to a lack of access due to school’s closing due to COVID-19 state of emergency. Available data on MB report that, on average, this quarter, each MB served 28 WRA in Nampula and 24 in Sofala. Furthermore, 5% of the clients choose a LARC in Nampula and 21% in Sofala. In remote communities where an APE is already delivering FP services, close collaboration is carried out for the programming, as well as the implementation of the proper MB day. During the MB day, in communities where there is an APE present the STM clients are served by the APE and registered in the APE’s logbook. This will help ensure STM users continue the use of their chosen STM. During all MB’s, FP consultations inform the clients about their rights as well as the potential side-effects and complications of the FP methods and what are the next steps that the users should carried out, including in case of LARC removal need.
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Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services Figure 13 and 14 describes the trends in the number of confirmed referrals by the type of CHWs, Quarter and FY and by province.
Figure 13 and 14 : # of confirmed referrals as 'attended at HF' by province, from Oct. 2016 to March 2020, by provinces
30,000 IPC TBA CF 8,210 25,000
9,527 8,698 7,328 20,000 6,132 8,962 11,910 7,748 6,278 6,737 5,417 15,000 917 11,655 1,192 11,858
10,000 735 8,065 9,209 5,847 9,786 6,113 7,407 8,169 13,960 537 7,997 5,000 9,805 425 7,188 6,657 6,782 6,435 5,740 4,892 4,224 4,773 3,829 3,764 2,620 3,315 - 791 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY1 FY2 FY3 FY4 Nampula
14,000
IPC TBA CF 1,726 12,000 2,700 336 3,346 10,000
8,000 3,605 1,255 2,745 6,000 632 1,732 2,142 10,589 2,692 1,643 2,155 1,199 1,887 4,000 88 380 2,180 1,367 425 150 620 6,008 5,207 2,895 2,000 3,827 4,160 2,851 3,149 3,659 2,452 2,880 2,622 3,057 1,958 662 579 1,051 - 27 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY1 FY2 FY3 FY4 Sofala
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These two graphs highlight how much the community component was involved in maintaining and even increasing the number of confirmed referrals at HF and MB levels during this COVID-19 state of emergency; both provinces succeeded to adapt their strategies in order to accompany their referrals until HFs, diminishing the anxiety and concerns of beneficiaries; it’s worthful to highlight the strong turn-over succeeded by Sofala urban component totalizing 6,008 confirmed referrals against 1,051 in Q2 and 579 in Q1.
At the end of Q3FY4, the TBAs surpassed their achievement of FY3 with 38,188 confirmed referrals against 37,745 in entire FY3. Due to COVID-19, it was not possible to continue the FP cascade training for TBAs this quarter. Through the IPC agents based at community level, IFPP has achieved in three quarters, at the end of Q3FY4, 23,881 (16,243 in Nampula and 7,638 in Sofala) confirmed referrals against 26,333 in entire FY3, reaching already 91% of the FY3 result; the percentage of confirmed referrals for the IPC’s community-based referrals increased from 51% (Q1FY4) to 56% (Q2FY4) and 58% in Q3FY4, highlighting the increased abilities of the IPC’s agents. Additionally, 6,412 in-facility confirmed referrals (see Table 11) were carried out but not aggregated to the 13,196 confirmed community-based referrals illustrated in the above graph. At the beginning of Y3, IFPP introduced the CwS digital platform focusing on door-to-door visits and requiring the geo-localization of the households, easing IFPP’s internal audits, IPCs return visits, and all referrals became electronic, most likely explaining the drop of confirmed referrals between FY2 and FY3; this increase in number of referrals delivered and referrals confirmed at HF’s level is the result of following activities: (i) the introduction of MBs in blocks where MIF's report barriers to access and waiting time for assistance at the Health Unit, (ii) the presence of mobilizers in some of the HFs guiding the WRA arriving with a community-based referral either at the FP consultation or at others consultations offering integrated FP service; (iii) the regular visits by the Community Assistant to support MCH nurses in App password validation; (iv) the reinforcement of digital messages to all women enrolled in the OES study who have received a community-based referral, reminding them to carry out their referrals. In Q3FY4, through the rural demand creation component led by the community facilitators, 10,910 referrals were confirmed at HF’s level out of 12,867 delivered referrals (85% of confirmed referrals) against 10,840 referrals confirmed at HF’s level out of 12,867 delivered referrals (85% of confirmed referrals) in Q2FY4.
Upcoming Plans for IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services Strategies established for remaining FY4 to continuously increase the uptake of FP services at HF level include: • Continue the innovative facility peer twinning strategy in Y4, enabling peer-to-peer learning and development as part of the quality improvement process; • Increase nightshift mentoring activities involving the recently trained district trainers; • Analyze each provider effort (either at SR consultation, maternity ward or Integration), to easily work with each of them to improve and provide mentoring;
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• Carry out, for low-volume HF providers, an internship approach so that they have practicum opportunities at the main district-level HF for implant, IUD and PPIUD, observing recommended measures in-light of COVID-19 scenario; • Organize additional specific in-service training for the providers, including addressing adolescent and youth issues, who have already been trained through IFPP but identified as poorly performing in post-training period through mentorship (3-days advanced FP updates); • Carry out on-the-job training for the recently posted eligible HP when they are volunteers or contracted by HIV partners (ECHO, ICAP) or recently recruited by the DPS in order to comply with government recommendations under COVID – 19; • Organize in compliance with the MISAU community implementation activities guideline and carry out with the support of the CLs, the synchronized MBs with the demand generation activities at individual and community level; • Implement with the respective DPS and strengthen the offering of pills and Sayana Press through the IPC’s agents in urban settings - where APE’s doesn’t exist - to mitigate the lack of accessibility to HFs due to the COVID-19 pandemic; • Refresh all community actors such as IPCs agents, CFs, TBAs and APEs in national community package for COVID-19 prevention and mitigation; and • Register 59,400 additional WRA in the CwS App, counsel 40% of them and follow up of referrals.
IR 2: Increased demand for modern contraceptive methods and quality FP/RH services IFPP prioritizes high impact demand generation activities at the individual (Sub IR 2.1) and social level (Sub IR 2.2) to be implemented in line with the phased roll-out of the project’s IR1.
Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors During Q3FY4, a total of 222,477 female contacts have been reported, a 13% increase when compared to Q2FY4 (196,966), totaling 564,720 at end Q3FY4 and surpassing already by 8% of the result achieved in entire FY3 (524,166 contacts).
Rural Community Facilitators (CF) During Q3FY4 a total of 61,612 contacts (30,739 in Sofala and 30,873 in Nampula) with women were carried out, a decrease of 33% when comparing with Q2FY4; this decrease is mainly related to Nampula province where the CF have been prevented to carry out community dialogue groups during the six first week of the quarter due to COVID-19 state of emergency; in Sofala province, community authorities were more flexible and 3 weeks after the declaration of the state of emergency, they were authorized to resume activities; nevertheless, as soon as government and community partners were reassured that the preventive measures would be respected, the CFs subdivided the groups of 24 participants in two-twelve participants sub-groups; so, they had to carry out two sessions instead of one for the 24 participant group to address each of the 6 community dialogue sessions, multiplying per two their time of implementation. CFs in Nampula carried out 415 groups (48% of the planned Q3 target) and Sofala 430 groups (78% of the target). Note that this 41
quarter the number of groups reported are still related to 24 participants each, but next quarter, M&E tool will be adjusted to report each of 12 participants group.
Traditional Birth Attendants (TBA) As mentioned above in Sub IR1.2, at end Q3FY4, 1,694 TBAs have been trained and most of them are implementing regular sensitization activities at the community level. Because TBAs do not report female contacts, IFPP only reported the number of women referred to HFs. This Q3FY4, 17,032 women received a referral and were reported as contacts, 16% increase when comparing with Q2FY4.
Interpersonal Communication Agent (IPC) During Q3FY4, IPC agents reported 143,833 WRA contacts, an increase of 57% when comparing with Q2FY4 and representing 64% of all women contacts reported by IFPP this Q3FY4.
Sub-IR 2.2: Improved community environment to support healthy FP behaviors To contribute to the IR2, IFPP through the rural community component (N’weti) is implementing a systematic community dialogue process which involves groups of key CLs and influencers. The rationale behind the community dialogues is to address the social and gender norms and drivers behind the lack of use of modern FP. Also, with the support of the urban community component (PSI), CLs in urban settings are trained and sensitized about the importance of the FP national program and, further involved to organize groups either of men or women expressing strong opinions against the national FP program. The rationale also is to create a more enabling environment at the community level for adherence to modern FP methods. CLs are important gate keepers and educators.
Fostering an enabling environment for demand creation In rural settings, to boost the local leadership involvement in the areas in which CFs are facing a deficit in community leadership involvement, IFPP in coordination with the head of the Locality (Chefe da Localidade) has supported a one-day meeting focused on gathering the members of the Conselho Local da Localidade (CLL, Locality’s local council). This Leaders Council is a body of consultation for the local administration authorities in search of solutions to fundamental questions that affect the lives of local communities, as well as their well-being and sustainable development. With the introduction of Table 14: Distribution of the CLL meetings by province, quarter and FY restrictive FY2 FY3 FY4 measures due to PROVINCES Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 the state of Nampula 26 5 8 18 8 12 29 48 39 30 emergency, CLs Sofala 14 6 5 6 10 6 16 40 19 47 supported IPCs Total per Q 40 11 13 24 18 18 45 88 58 77 agents and Total per FY 64 105 223
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community assistants in organizing their sessions by strengthening the COVID-19 prevention measures and mobilizing the community to join the IPC activities as they also addressed messages from prevention of COVID-19; that was particularly notable in Sofala province. As illustrated in Table 14, in Q3FY4, IFPP carried out 77 CLL one-day meetings (30 in Nampula and 47 in Sofala) against 58 in Q2FY4 and 88 in Q1FY4, totaling 223 CLL meetings at the end of Q3FY4, against 105 in FY3 and 64 in FY2, highlighting the importance that IFPP is giving to carry out these bi-annual meetings regularly, strengthen the follow-up culture among the CLL members, and holding them responsible for leading an enabling environment within their communities.
The main objective of these meetings is to strengthen the CLL abilities to lead an enabling environment for FP behavior change within their area where IFPP is carrying out the community dialogues sessions involving the CLs sitting in the Community Leadership village Councils (CLCs), promoting social norms favorable to RH and HTSP. These meetings strengthen the CLL leadership to
increase the community participation in community Photo 7: CLL meeting in Dondo district. dialogues, MBs, CSC. The HF Director, the MCH responsible, as well as the provider in charge of the community involvement are invited to be the main orators in the facilitation. The main points discussed are the activities carried out within the specific locality led by each CLL, the progresses achieved since the last bi-annual meeting based on community-based and HF-based data. The final exercise is the adjustment of the activities planned for the next semester, including community dialogues, MBs, CSC follow-up, CMC operationalization. Topics such as adolescent’s contraception, early forced marriage and post-partum contraception are discussed and progresses achieved are assessed; linkages between early pregnancy, girl’s level of education and poverty are highlighted.
The CLs expressed their satisfaction with regards to the meetings and the contents. Their understanding about the role of the CFs has dramatically increased and subsequently their support. Leaders committed themselves to more engagement in the program, to interact with the churches and mosques to spread the FP messages, and to disseminate FP messages in communities. Additionally, the involvement of men and women champions in the community dialogue sessions for CLCs and in the community radio program was instrumental; during Q3FY4, 845 against 1,212 community dialogue groups (Q2), attending six session each, has been completed (415 in Nampula and 430 in Sofala).
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In the urban Table 15: # of participants and groups organized to boost a FP enabling environment settings, the # of meetings # of # of meetings carried # of couple sessions carried out with meetings # of CLs out with women # of Women # of men with couples having Community Urban settings men having strong carried out participating having strong beliefs participating participating strong believes beliefs against the with CLs against the use of FP against the use of FP Assistants use of FP together with Angoche city 1 5 18 180 6 56 10 Nacala Porto 8 60 6 50 6 36 3 the CLs and Nampula City 12 70 12 88 0 0 9 Ilha 0 0 10 116 2 22 2 the IPC Beira 34 154 190 708 40 156 0 agents, Dondo 8 58 11 43 37 148 0 Total Q3FY4 63 347 247 1185 91 418 24 organized Total Q2FY4 122 968 307 2425 156 1346 0 different groups in order to create an enabling environment for demand creation as summarized in table 15. During Q3FY4, in addition to the 934 CLs participating in Q1FY4, and 968 CLs in Q2FY4, 569 CLs attended the sensitization sessions related to SRHR and FP. IFPP highlights the importance of FP and which families would most benefit from FP use, how FP is linked to the demographic dividend and the poverty reduction. The objective is to ease the acceptability of the IPCs agents within the boroughs and obtain the active support of the CLs in gathering small groups of women, men having strong beliefs against the use of FP and identified through the home-based visits carried out by IPCs and Community Assistants. In addition to the 577 women and 606 men reached in Q1FY4 and the 2,435 women and 1,346 men in Q2FY4, 1,185 women and 418 men participated either in men’s or women’s small groups during Q3FY4. Participants are identified through home visits. During these groups, male and female FP champions are invited to share their experience and the experience of their community. These small group talks are led by the urban community assistants.
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During the meetings, it was noted that they are not unfavorable to FP, as one might suppose. However, because they lack Photos 14: meeting gathering CLs and influential men to plan contraception MBs within their community in Nampula information about modern contraceptive methods, the benefits of FP, and the type of services offered at HF, some men persist with some distrust, discredit FP and have a deeply ingrained idea that FP is harmful to health, man’s sexual pleasure and a root of women’s infidelity or is a
Photos 15 Small women’s and men’s groups unfavorable to FP in Beira woman’s exclusive matter. Many of them think of the man's role as authorizing or deciding if their partner should or should not use FP. These meetings highlight how use of FP is shaped by social and gender norms, which limit women's autonomy and restrict communication and decision making between men and women. During the sessions, the myths and misconceptions regarding FP were addressed, and couples using FP shared their experience about open communication and joint decision making. Women described their partner support as an essential facilitator for FP use. It was also noted that initiation rites which are different in Sofala and Nampula also played an important role in their position regarding FP.
Leveraging community partnerships through CBOs Technical support visits continue to be carried out, targeting 88 community-based organizations (CBOs) to more qualitatively implement the agreement signed with IFPP by increasing their follow- up activities and including monitoring CF activities at the community and HF level. CBO representatives were involved in the community score card (CSC) process. The rural component continued their sensitization activities towards the expanded localities of forty-seven HF catchment areas added up in Q2FY4 and twenty in Q3FY4.
Use of community radio to amplify the community dialogues focused on HTSP, FP and benefits for healthy families and communities IFPP is building on the community dialogues and working with eight community radios (CRs) in Nampula and nine in Sofala to broadcasts dramas, interviews and radio programs to help to demystify and minimize barriers linked to FP at the community level. CR staff were prepared to broadcast 16 SRHR and FP programs. Within IFPP’s communication and sensitization approach, the CRs complement the messages transmitted during community dialogue sessions with CFs promoting
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SRHR, FP rights and the duty of citizens to raise public awareness around SRHR and the benefits of FP services.
Since Q2FY4, the Social Communication Institute (ICS) required that affiliated community radios should not establish direct partnerships with third parties without a MoU signed at the central level. This Q3FY4, two follow-up meetings were held with ICS to align details on the content of the contract between ICS and N’weti and it’s expected that proceedings will be completed next quarter; 8 out of the 17 CRs are completed through this MoE. As illustrated in Table 16, this Q3FY4, 127 (33 in Nampula and 94 in Sofala) radio programs were broadcasted; this quarter a special focus was given to the content of the CSC; 52 programs were broadcast live and 75 in repetition. The radio programs included talks about the CSC process and Table 16: Radio sessions by station the community Broadcasting Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 dialogue Province & district Radio name FY1 FY1 FY2 FY2 FY2 FY2 FY3 FY3 FY3 FY3 FY4 FY4 FY4 Mossuril CR Mossuril 4 9 4 5 20 6 10 10 0 0 synchronized MBs. Monapo CR Monapo 22 26 22 11 10 4 15 17 0 0 18 11 Meconta CRT Namialo 22 14 0 6 0 22 14 14 4 0 Furthermore, the CRs Memba CR Memba 12 16 0 0 0 10 22 0 0 0
Erati CR Namapa 10 16 0 0 26 8 32 5 0 8
process
MOU inMOU extended conducted 43 Nampula Ribaue CRT Ribaue 22 13 0 0 11 11 9 14 0 1
interviews involving Angoche CR Parapato 18 16 2 0 12 4 2 26 0 0 6 8 MOU inMOU process be to 21 CLL’s leaders, six Nampula Radio Haq 12 15 0 0 0 0 12 6 0 0 12 14 Sub-total 122 125 28 0 22 79 65 116 92 4 9 36 33 mothers, two APEs, Nhamatanda CR Acordos de Paz 0 16 11 4 10 21 14 4 6 4 0 14 5 Gorongoza CR Gorongoza 4 14 18 12 20 14 16 16 0 12 27 10 eight male Maringue CR Maringue 2 champions. These Caia CR Caia 8 8 9 4 12 17 16 15 10 2 2 22 24
Marromeu CR Marromeu 8 18 8 4 10 18 16 14 10 3 0 Sofala interviews also Cheringoma CR Cheringoma 6 10 MoU 2 encourage reticent Dondo CR Dondo 0 11 15
Chibabava CR Chibabava 0 this Q4FY3 leaders to take the Buzi CR Buzi Only trained 0 31 36 Sub-total 20 56 46 24 52 70 62 49 32 9 24 105 94 lead and support Total 142 181 74 24 74 149 127 165 124 13 33 141 127 activities for the benefit of their communities, motivates community facilitators, increase awareness about Community dialogues and CSC's interventions. All the radio programs had, during Q3FY4, the active participation of Field Supervisors and the SDSMAS appointed HP. IFPP district coordinators joined as frequently as possible. It’s notable that the Gorongosa CR continues to broadcast the programs “tua cena” while they had already completed the broadcasting at end February and continue interviewing communities’ members within the scope of the CDs. Since May 2020, the Nhamatanda CR is paralyzed as their transmitter is out-of-function.
Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions IFPP/PSI designed, in close collaboration with OES, an operational study “Increasing the Utilization of Family Planning Services in Mozambique through an SMS Intervention”, focusing specifically on 46
the beneficiaries of the IPC agents. The study is still ongoing, but its implementation was suspended during this COVID-19 quarter and consequently results will be delayed. After initial pilot testing in December and January, the full roll-out of the enrollment protocols went into effect on January 30. OES affiliate, Jessica Leight, visited Mozambique in February to participate in the study launch and presented the protocol to Pathfinder and USAID. Randomization is ongoing; as of April 1, we have enrolled a total of 2,589 FP beneficiaries who have received a voucher from an IFPP promoter, registered cell phone, and provided consent. Approximately 50% of these beneficiaries are then assigned to receive a series of follow-up text messages over the next month, encouraging them to visit the clinic and redeem the voucher. Preliminary reports suggest that approximately 80% of messages can be confirmed as delivered to these registered phone numbers. Overall, enrollment to date is about half of the originally proposed sample size and reflects a much higher enrollment rate than first anticipated. However, new enrollment was paused on April 1 in response to the COVID-19 global pandemic and has yet to resume.
Upcoming Plans for IR 2: Increased demand for modern contraceptive methods and quality FP/RH services Strategies established for remaining FY4 to continuously increase the demand generation for FP services at community level include: • Finalize the MOU com ICS in order to resume activities with ICS affiliated community radios; • Organize and carry out two capacity building sessions for community radios in SBCC for FP; • Increase the use of the CRs taking the opportunities related to champion identification such as TBAs, APEs, CLs, CLL members, satisfied users, interviewing them, and reporting part of community events such as CLL and CMC meetings, MBs, and community dialogues; • Strengthen IFPP’s partnerships with community leaders to facilitate the implementation of demand creation activities at the time of COVID-19 in rural and urban settings; • Continue to carry out small men’s and small women’s groups with either men or women unfavorable to FP; • As it’s more difficult to gather with small groups of men or women unfavorable to FP during COVID-19, IFPP will complement the small group activity by expanding the use of the couple sessions model to tackle the families who remain unfavorable to FP; and • Increase community dialogue groups, in compliance with MISAU guideline to implement community activities during COVID-19.
IR 3: Strengthened FP/RH health systems To contribute to sustainable and institutionalized FP system strengthening activities, during Q3FY4, the IFPP-HSS team continued to provide TA and competency-based on-the-job trainings to Nampula’s and Sofala’s DPS and SDSMAS staff, depots managers, and HF technicians and SRH- FP/MCH nurses on topics such as planning, management, HRH, commodity logistics, and data use for decision making. With the outbreak of COVID-19, IFPP and DPS/SDSMAS teams were challenged to explore and improve the use of alternative TA mechanisms previously under-utilized such as conference calls, video conferences, WhatsApp, and TeamViewer.
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Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution Activities within this sub-IR include capacity building and TA to the districts and DPS to appropriately apply the standard operating procedures (SOPs), using the MSC tool and budget for evidence-based FP strategies in the annual provincial plans (PES) and district plans (PESOD). The PES/PESOD yearly cycle includes monitoring and understanding the next cycle by May-July.
In FY4Q3, IFPP has worked with 2 DPS and 36 SDSMAS (23 in Nampula and 13 in Sofala) to integrate COVID-19 prevention activities into their quarterly operational plans. Adherence with COVID-19 prevention standard measures as defined by the MISAU guidelines and protocols was also ensured throughout the implementation of the FY4Q3 planned SR-FP/MCH HSS activities. Relevant activities that took place during the quarter include TA visits and on-the -job trainings to address persistent gaps in SDSMAS managers ability to consistently apply and comply with the district managerial SOPs particularly in logistics, HRH, monitoring and evaluation and FP/MCH program management as guided by the QI action plans, MSC and PD assessments, co-facilitation and provision of TA in the quarterly review PES/PESOD and monthly task force meetings. As part of the planning process for PES/PESOD 2021, IFPP co-facilitated with DPS-Department of planning and cooperation in Sofala, district planning meetings to disseminate government priorities for 2021, update district managers on the revised Medium-Term Fiscal Framework (CFMP), assess the necessary financial, human and health commodities resources, and agree on SDSMAS targets for 2021. In Nampula this process was carried out during Q1 and Q2 and currently DPS is mobilizing resources do conduct district meetings to jointly review and realign PES/PESOD with the district’s managers and local partners. IFPP has discussed and aligned with DPS and SDSMAS its FY5 SRH-FP/MCH priority activities. Overall, 2 DPSs and 26 SDSMAS were visited (13 in Nampula and 13 in Sofala) while 10 additional districts were covered virtually. Additionally, during the period under report, all 17 district’s MSC assessments planned for the quarter, 9 Nampula1 and 8 in Sofala2, were conducted and all of them achieved satisfactory score of 80% or greater. Table 17 illustrates the trends in MSC assessments carried out
1 three round 3 in Nacaroa, Rapale and Lardes, one round 4 in Ilha de Mocambique, three round 5 in Memba, Malema and Mossuril and two round 7 in Angoche and Erati. 2 three round 3 in Cheringoma, Maringue and Muanza, two round 5 in Buzi and Gorongosa, one round 6 in Caia and two round 7 in Beira and Dondo. 48
since the beginning of the IFPP intervention at SDSMAS level: two of them achieved satisfactory score for the first time - Table 17: MSC trends by district ? 60% MSC District Scores Over Time Cheringoma (74% to >60% ? 70% (Target: achieve satisfactory scores ?80%) >70% < 80% 80%) and Maringue ?80% ? 90% FY1 (Oct. 16 - FY2 FY3 FY4 (Oct 19 -Mar 20) (75% to 86%), and >90% ?100% Sept. 17) (Oct. 17 - Sept. 18) (Oct 18 - Sept 19) DISTRICT Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 four by re- Angoche 40% 92% 94% 85% 78% 75% 94% Mogincual 59% 89% qualification, Beira Liupo 60% 90% Nampula D. 39% 83% 90% 90% 90% 95% (79% to 89%), Caia Erati 37% 75% 84% 84% 84% 98% 97% Memba 55% 79% 84% 98% 98% (75% to 88%), Meconta 68% 70% 84% 75% 85% Nacaroa 65% 90% 91% Gorongosa (63% to Muecate 47% 85% Mogovolas 57% 56% 66% 88% 82%) and Angoche Moma 42% 85% 85% 88% 96% 84% Lardes 25% 93% 91% (75% to 94%). Five Monapo 50% 92% 91% 97% 96% 87% Mossuril 53% 86% 74% 80% 93% districts which Ilha Moç. 36% 86% 82% 90% N.Porto 41% 66% 90% 98% 93% 91% already achieved
NAMPULAPROVINCE N.Velha 56% 88% 84% 88% Murrupula 49% 83% 72% 74% satisfactory scores Rapale 60% 98% 97% Mecuburi 41% 81% 88% 86% 66% 86% of 80% or greater in Ribaue 41% 92% 96% 100% 98% 87% Malema 38% 84% 85% 89% 99% previous Lalaua 41% 86% 80% Beira 63% 86% 89% 90% 92% 79% 89% assessments, Dondo 60% 71% 82% 87% 84% 90% 88% Nhamatanda 65% 83% 82% 85% 83% 79% continued to Buzi 74% 82% 82% 83% 90% Chibabava 60% 73% 79% 82% 82% 70% progress in their Machanga 67% 85% 82% 60% Caia 54% 66% 83% 83% 75% 88% overall MSC Marromeu 70% 62% 78% Chemba 37% 96% performance – Gorongosa 66% 82% 83% 63% 82% Cheringoma 59% 74% 80% SOFALAPROVINCE Malema (89% to Maringue 62% 75% 86% Muanza 53% 82% 86% 99%), Mossuril (80%
Table 18: MSC detailed scoring per standard and district – Q2FY4 MSC per standard area and district - FY4Q1 MSC per standard area and district - FY4Q3
District
g g
HRH HRH
Scores Scores
Round Round
Logistics FP/MCH Logistics FP/MCH
Planning Planning
Monitorin Evaluation Monitorin Evaluation
Total Total MSC - Total MSC - Angoche R6 75% 85% 74% 100% 90% 80% 60% R7 94% 100% 96% 90% 100% 90% 91% Mossuril R4 80% 90% 86% 75% 40% 35% 77% R5 93% 75% 100% 97% 90% 70% 100%
Ilha Moç. R3 82% 90% 86% 65% 46% 45% 77% R4 90% 100% 96% 100% 75% 90% 84% Nampula Malema R4 89% 100% 100% 95% 45% 45% 100% R5 99% 100% 100% 100% 100% 90% 100% Beira R6 79% 90% 68% 90% 100% 70% 76% R7 89% 100% 90% 83% 100% 100% 81% Buzi R4 83% 100% 100% 100% 45% 45% 81% R5 90% 92% 88% 85% 98% 90% 89% Caia R5 75% 92% 78% 40% 86% 90% 71% R6 88% 85% 90% 80% 94% 90% 89%
Gorongosa R4 63% 50% 68% 50% 60% 50% 71% R5 82% 82% 90% 80% 80% 90% 74% Sofala Cheringoma R2 74% 90% 76% 85% 59% 50% 76% R3 80% 60% 78% 85% 100% 90% 77% Muanza R2 82% 100% 78% 60% 86% 90% 83% R3 86% 80% 86% 80% 85% 90% 89% Maringue R2 75% 92% 78% 40% 86% 90% 71% R3 86% 85% 86% 93% 85% 80% 86%
to 93%) and Ilha de Mocambique (82% to 90%), Buzi (83% to 90%), and Muanza (82% to 86%). As 49
illustrated in Table 18 which compared, per district, the MSC area’s scorings achieved in Q1 and Q3 assessments, HRH, Monitoring and Evaluation areas have the most progressed. Also, although 22% (26/119) of SDSMAS managers (15 in Sofala and 11 in Nampula), in the districts assessed during Q3, were recently affected, the SDSMAS have managed to keep satisfying score highlighting the beneficial effect of the MSC and DP workshops held in Q1 and Q2 and gathering 36 SDSMAS management teams3, strengthening their knowledge and skill’s practice to develop DPs and conduct MSC self-assessments favoring the intersectoral support.
Regardless of all these gains, IFPP will in FY4Q4 provide a more intense and revival TA/supervision visits and on-the-job competence-based trainings to address specific gaps beyond persistent low performance (< 80%) in some MSC areas per district and guided by Q2 and Q3 MSC results. Sub-IR 3.2: Improved management of commodities to ensure availability at local levels
The CommCare App, SIMAM, and Table 19: FP commodity stock-out assessment at HF level – SIGLUS tools were used as Q3FY4 sources of information to report N° of HFs that % of HFs with stock out Nr. HFs experienced stock out HF’s stock outs of the main five Source methods of contraception (IUD, evaluated Before data After data Before data After data cleaning cleaning cleaning cleaning implant, progesterone-only oral Nampula contraceptives, combined oral SIMAM 12 0 0 0% 0.00% contraceptives and DMPA- CommCare 25 2 0 8.00% 0.00% SIGLUS 114 16 1 14.00% 0.90% IM/SC). As illustrated in Table 19, Sub-total 151 18 1 11.90% 0.70% in Nampula, a total of 151 HF Sofala SIMAM 8 0 0 0.00% 0% were assessed which CommCare 21 6 0 28.60% 0% corresponds to 64% of the total SIGLUS 94 19 0 20.20% 0% HF (237 HF), distributed among Sub-total 123 25 0 20.30% 0% Total 274 43 1 15.70% 0.40% those implementing SIGLUS (114 HF) in 13 districts (Monapo, Angoche, City of Nampula , Moma, Rapale, Nacala Porto, Nacala-a-Velha, Memba, Erati, Meconta, Muecate, Nacaroa and Mogovolas), and those mentored through CommCare App (25 HF) in nine districts (Ilha de Mocambique, Lalaua, Lardes, Malema, Mecuburi, Mogincual, Mossuril, Murrupula and Ribaue); SIMAM (12 HF) focused on hospitals. Similarly, in Sofala 123 HF were assessed representing 73% of the total HF (169 HF), distributed among those implementing SIGLUS (94 HF) in eight districts (Beira city, Dondo, Nhamatanda, Buzi, Caia, Gorongosa, Marromeu and Chibabava), those mentored through CommCare App (21 HF) in five districts (Machanga, Chemba, Maringue, Cheringoma and Muanza) and those mentored through SIMAM (8 HF). Overall 15.3% (42/274 HF) assessed for stockouts in this quarter were reporting false stockouts of which (11.2% in Nampula and 20.3% in Sofala). This represents a reduction of 20.7 percentage points in HF reporting false stockouts
3 the district health director, district chief doctor, HR, DDM/Logistics, FP/MCH and NED-M&A managers 50
when compared to the last quarter (36% Q2 less 15.3% Q3). However, after IFPP conducted quality checks of the reported stock-out through SIGLUS and CommCare Apps reports, against HF paper- based stock cards records, the overall stockout rate for the quarter was brought down to 0.4% (1/274), representing 2.6 percentage points reduction when compared to FY4Q2 results of 3%. This low stock-out percentage resulted from the high-level attention given to monitor the HF’s stock level on one side and, on the other side, due to a 10 to 15% diminution of commodity consumption related to COVID-19 pandemic. But in general, many HF were confronted with eminent stock-out and in- district coping redistribution mechanism was frequently used. It’s important to highlight the positive effect of community sensitization minimizing the COVID-19 reduction trend for FP service’s consumption; indeed, confirmed community referrals trends continue to increase this quarter when compared with Q2. In this quarter, only one HF in Nampula, CS Namina Rio, in Muecate district, reported a true contraceptive stock out of IUD as the HF pharmacist missed to include IUD in the monthly requisition and did not issue an emergency requisition. Meanwhile, as illustrated in figures 15a to 15d, when comparing the Nampula DPM OC’s and Injectable’s stock levels at the first day of
Figure 15a to15d: Comparison of the Nampula DPM OC’s and Injectable’s stock levels at the first day of each month with the respective monthly quantities distributed to DDMs Q2-Q3FY4
Level of OC's stock at DPM level at the 1st of Level of Injectable's stock at DPM level at the each month Jan-Jun 2020 1st of each month Jan-Jun 2020 200,000 300,000 200,000 100,000 100,000 0 0 Jan Feb Mar Apr May Jun Jan Feb Mar Apr May Jun
Microgynon Microlut DEPO (injectavel) Sayana Press
Pills distributed thru Nampula DPM to DDMs Depo/SP per month during Jan-June 2020 distributed thru Nampula DPM to DDMs per 40,000 month during Jan-June 2020 100,000 20,000 50,000 0 0 Jan Feb Mar Apr May Jun Jan Feb Mar Apr May Jun
Microgynon Microlut DEPO (injectavel) Sayana Press
each month with the respective monthly quantities distributed to DDMs along Q2 and Q3FY4, it seems obvious that shortages of STM have occurred and have influenced the offer to the beneficiaries. It seems that the beneficiaries’ demand is exceeding the availability of the DPM. Fortunately, when analyzing LARC data the same scenario didn’t occur with LARC.
To leverage progresses in reducing the number of HF reporting stock outs, IFPP conducted on-the- job training, TA and supervision through on-site visits, conference and video calls and TeamViewer 51
Software to reinforce DPM, DDM, and DDM first level Help desk (HDL1) skills and ensure the availability of contraceptive stocks levels at DDM and HF pharmacies by:
• Working with each health facility’s Figure 16: Comparison of the number of HF reporting pharmacist reporting false stock outs data timeliness in SIGLUS before and after help desk through SIGLUS in Q2 (Nampula- 51 HF and Sofala - 44 HF) and Q3 intervention in Sofala province – Q1-Q3FY4
(Nampula-15 HF and Sofala - 19 HF) to 100 detect and correct errors in SIGLUS operation, add contraceptives in the 80 electronic commodity essential 60 list, update electronic stock cards and 40 75 78 support data synchronization. In 55 20 28 general, this activity was carried out, 19 25 20 14 11 0 with the support of IFPP TA, by 7 snapshot on the 6th of snapshot on the 1st of April Snapshot on the 30th of DDMs - HDL1 in Sofala (Beira, Dondo, January 2020 2020 June 2020 Nhamatanda, Chibabava, Buzi, # of HF having synchronized within the last 24h # of HF having synchronized within > 24h and ≤72 h Gorongosa and Caia) and 6 DDMs – # of HF having synchronized within > 72h HDL1 in Nampula (Nampula City, Monapo, Moma, Rapale, Memba, Erati). Figure 16 illustrates the number of HF reporting data timeliness in SIGLUS along the FY4 quarters in Sofala province. The number of HF having synchronized within 72h has increased from 31% (Q1) to 74% (Q2) and 90% in Q3. • Supporting appropriate quantification and requisition of contraceptives, and follow up on contraceptive requisition along the quarter targeting all levels of the supply chain and by co- facilitating DPS and SDSMAS provincial and district Task-Force meetings (57% (24/42) in Sofala and 24% (17/72) in Nampula) to analyze requisitions against contraceptive consumption data, and by strengthening coordination and communication between HF-DDM-DPM-CMAM. Furthermore, to address issues of stock outs and/or accumulation of commodities at HF level, IFPP has strengthened the HF’s teams to use properly internal requisitions and stock cards. • Provision of transport and fuel to support distribution of medical commodities from DPM-DDM to HF and stocks sharing between HF.
To further improve SIGLUS data flow Table 20: Identified reasons of false stockout in Q3FY4 between HF-DDM and DPM levels, IFPP Reasons for false stock-out Nampula Sofala included the DPS of Nampula and e-stock card not updated 12/15 3/19 Sofala in the annual Delayed synchronization 3/15 1/19 CMAM/Movitel/Vodacom subsidized Staff appointed without contract which is expected to be active previous handover NA 6/19 in the next quarter. Main reasons for Trained staff still resistant to false stock-outs in Q3FY4 are change NA 6/19 Additional tablets starting to illustrated in Table 20. dysfunction during the current Q NA 3/19 It’s important to highlight that a proportion of HFs in the district in which SIGLUS was previously operationalized are confronted with
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the necessity to invest regularly in the purchase of new tablets due to serious hardware or software damages; IFPP will support next quarter the replacement of theses.
Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment
To strengthen governance and civil society engagement around FP and contribute to stronger
Table 21: Illustration of the CSC’s stage achieved at end Q1FY4 by HF
Province Nampula Sofala
District Caia
Buzi
Erati
Moma
Bibaue
Memba
Monapo Malema Chemba
Angoche Muecate
Meconta
Mossuril
Mecuburi Maringue
Chibabava Machanga
Mogincual Velha Nac. Gorongosa Marromeu
Mogovolas Murrupula
Cheringoma Nhamatanda
Health Facility
Tica
Sena
Iuluti Netia Chite
Siluvo
Cudzo
Calipo Iapala
Cazuzu
Bandua
Micane
Chipene
Malema Quixaxe Murraça
Muecate Namialo
Carapira Mossuril Catulene
Namirroa Mecuburi Machanga Chupanga
Chibabava
Nac. Velha Nac.
Namaponda Senga-Senga Repeating HF X X X X X X X X 1st time Implementing HF X X X X X X X X X X X X X X X X X X X X X Community mobilization
Eight community groups scoring services
HF's Providers scoring services offered
Data aggregation of the different community groups
Interface Meeting (HP with representatives of community groups)
Drafting of priorities identified during interface meeting
Inclusion of CPC's priorities in the HF's annual plan
Public meeting to share the outcomes of the CPC Process Not yet completed Completed at end Q1 FY4 Completed at end Q2 FY4 Completed at end Q3 FY4 systems, IFPP is carrying out Quotes from some participants community score card (CSC) activity - a participatory, “With the CSC, I perceived the constraints that communities met at the HF and how we can improve our service to better respond to the beneficiary’s community-based tool for needs; we can think that we are right and the population say that we are assessing the quality of health wrong, through the CSC we can identify the mistakes we have made.” services. The community MCH nurses from the CS of Siluvu-Nhamatanda-Sofala facilitators (IR2.1) and field “This process sensitizes the communities to local initiatives that will supervisors facilitate the process support the HF in solving some of their difficulties. It allows the sharing of responsibilities between the community and the Health Unit.” Reporter at of community assessment of Monapo-Nampula Community Radio FP/RH services, provider “The community needs to be encouraged to be able to expose its concerns, assessment on the same criteria, since there is still a fear of reprisals.” Member of the CBO Kunene de and support dialogues between Barragem - Nacala-a-velha-Nampula. 53
community members and providers to agree on priorities for action and plan for improvement. The aggregated results from facilities is discussed with SDSMAS and DPS during one of the PHD quarterly review meetings and is used to inform district and provincial advocacy plans which are led by partner CSOs, with support from N’weti. They also inform IFPP capacity building and systems strengthening efforts at SDSMAS and DPS.
While CSC process implementation was a sensitive subject when carried out for the first time in FY2 due to limited openness from local leaderships at the administrative post, district and province, during this FY, the process was easier to perform as MISAU also committed itself to carry out CSC through the Global Financing Facility funding mechanism. As summarized in Table 21, this FY4, twenty- nine HFs have initiated the CSC of which eight are HF repeating the exercise and 21 implementing the CSC for the first time. In Q3FY4, 20 HFs have completed the public meeting to share the outcomes of the CPC process Photos 17: public meeting in Maringue (HF of Senga - Senga totalizing at end of Q3FY4 28 HFs out of 29 having completed the CSC process; Namialo HC in Meconta district will be carried out next quarter. The CSC this year involved 3,104 participants consisting of 1583 women and 1520 men. As a result of this activity, CMC were re- functionalized, and the punctuality of HP improved.
Additionally, crucial to sustain the HF-community Photos 18: public meeting in Memba (HF of relationship, at end Q3FY4, 106 HF’s co-management Chipenhe) committees (49 in Sofala and 57 in Nampula) had carried out at least one CMC in Q3FY4 and were supported to analyze and discuss HFs and communities’ issues; some of the HF held more than one meeting per quarter.
Photos 19: public meeting in Angoche (HF of Namaponda)
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Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers
Based on the system assessment, capacity building and systems strengthening action plans, IFPP supported DPS and district managers to more effectively Table 22: Comparative between trained HP and registered in SIFO at end Q3FY4 manage the supply, distribution Nampula FY1 FY2 FY3 Q1FY4 Q2FY4 Q3FY4 TOTAL and retention of skilled FP Health Providers trained 1424 508 471 30 82 108 2623 Health Providers registered 1327 429 477 69 67 50 2419 workers. in SIFO Health Providers still to be 97 79 -6 -39 15 58 204 During the Q3FY4, IFPP trained registered in SIFO Sofala FY1 FY2 FY3 Q1FY4 Q2FY4 Q3FY4 TOTAL 244 new health providers in Health Providers trained 891 524 133 72 15 136 1771 Health Providers registered integrated FP module, 108 in 584 430 521 85 15 114 1749 in SIFO Health Providers still to be Nampula and 136 in Sofala. Of 307 94 -388 -13 0 22 22 registered in SIFO these 67.2% (164/244), 50 HP in Nampula and 114 HP in Sofala were successfully registered in REMINDER SIFo. The remaining 80 HP The HR management curriculum developed during last quarter, is trained in IFP will be registered based on MoH HR management SOP and aim to strengthen the in the next quarter, in Nampula knowledge and skills of the HF’s heads to properly manage their (58) and Sofala (22). The main workforce and ultimately to improve FP/MCH services reason for the delays in performance. An electronic kit of HR legislation and norms on HF recording these trainings was human resources management was provided for the participating due to SIFo’s maintenance that SDSMAS. The trainings were jointly facilitated by DPS and IFPP and lasted 2 months, from April to emphasis was on understanding the key HR management May 2020. standards and legislation to correctly and consistently manage their staff – not only from an administrative point of view but also An additional 346 (262 in from a dynamic point of view including the Health Provider’s Nampula and 84 in Sofala) dimensions related to motivation, ethics, skills and abilities to were also effectively registered perform team building and coping with changes. in SIFo which represents 87% (346/399) of all 399 health managers, trained in HR management, planning and Infection Prevention and Control (274 in Nampula and 125 in Sofala). Table 22 illustrates the progress achieved along the years for integrated FP training in SiFO: in Nampula, the in-service training centers have gradually diminished the gap but still have a gap of 204 HP not yet registered, while Sofala, during the FY3, resorbed the registration deficit that had occurred during FY1 and FY2, but has 22 HP still to be registered. The SIFO indicator focus on the IFPP FP eight- day training, meanwhile support was given to the district training nucleus for registration of all types of trainings carried out at district level. While, in Q2 IFPP reported two trainings of trainers in Nampula targeting the health district directors and the SDSMA officers of human resource to roll out the cascade training at district level of HF’s
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heads on human resource‘s management, this quarter, five additional TOT (2 in Nampula and three in Sofala) were carried out; these trainers reach 367 HF directors (242 in Nampula and 125 in Sofala); 39 cascade in-service-district trainings (23 in Nampula and 13 in Sofala) on HR management were carried out. Plans to conduct HF supervision visits based on HR specific checklist assessing changes in HF’s directors HR management practices were also developed; they will take place next quarter. This quarter, in addition, IFPP also finalized the Training Module on Infection Prevention and Control (IPC) for HF directors. The module emphasizes the IPC management elements, strategies and approaches, including IPC basic standards and MISAU guideline on COVID-19 prevention. This module was jointly developed with MISAU-DNAM and later revised with DPS of Nampula and Sofala. The first regional competency-based TOT on HF IPC management was conducted this quarter, in Nacala Porto with the participation of 12 participants (MCD-6 and district chief Nurse-6) from 6 SDSMAS (Memba, Meconta, Nacaroa, Muecate, Nacala Porto and Nacala Velha). At end Q3FY4, 53% of the HFs (215/409) against 41% at end Q2FY4 (165/400) has all eligible health providers trained in a range of modern contraceptive methods of health facilities: 61% (105/172) of HFs in Sofala and 46% (110/237) of HF in Nampula.
Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision- making A district profile tool composed of 10 selected strategic FP program indicators was designed in FY1, tested and refined in FY2 and progressively introduced in all 36 districts in FY2 and FY3. The level of SDSMAS staff’s ability to feed the district profile is variable from one district to another, but overall all districts have started to Photo 20: DP discussion meeting in Ilha de Mocambique, interpret the dashboard and use the Nampula. data to define their next steps and quarterly activities, thus strengthening the SDSMAS to acquire strategic information and use it for evidenced-based decision making to improve FP program performance. In Q3Y4, 36 SDSMAS receiving IFPP support, developed their FP district profiles (DPs), 23 in Nampula and 13 in Sofala. From these 26 SDSMAS (13 in Nampula and all 13 in Sofala) held quarterly review meetings based on DPs results and updated their QI action plans. Besides these 26 districts, 10 conducted DPs discussions by sharing DP analysis results through email and conference calls in Nampula. Additional discussion points included (i) SISMA-FP/MCH data quality, delaying or failure in holding monthly Task Force meetings, (ii) quality of the commodity task force meeting agenda organization and the process of conducting the meeting as well as the follow-
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up of the decision taken, (iii) need to review/update ToR for the task forces meetings to include comparison of SISMA -FP/MCH data and commodity distribution data from DDMs.
Upcoming Plans for IR 3: Strengthened FP/RH health systems Under the COVID-19 circumstances, in FY4Q4, IFPP will continue to ensure staff compliance with level 34 prevention measures and promote their uptake by DPS, SDSMAS, and HF staff, while delivering the following planned activities:
• Pulling up district MSC areas with low-non-satisfactory scores to ensure a homogeneous performance improvement in and between them by providing TA and on-the-job trainings focused on specific individuals and management processes, for 2 DPS and 36 SDSMAS; • Assessing district performance against managerial SOPs using MSC tools in 14 SDSMAS in Nampula and 5 SDSMAS in Sofala; • Ensuring a steady availability of contraceptive stocks at HF, DDM and DPM through weekly monitoring of contraceptive stock levels, sharing data on contraceptives status and active communication and coordination with SR-FP stakeholders; TA to DPS/SDSMAS to ensure more compliance with task force schedule and TORs; provision of TA and monitoring of HF and DDM compliance with logistics SOPs including SIGLUS operation; Follow up on DPS/Movitel and Vodacom contracts; • Finalize outstanding IPC cascade trainings for HF managers; • Finalize two training modules on M&A and Logistics, and conduct related TOT targeted to SDSMAS managers (MCD and NED, MCD and DDM) as trainers of the HF directors; • Driving quality improvement on FP/MCH data during 36 DPs discussions meetings, task force meetings (72 in Nampula and 42 in Sofala) and trainings in M&A and Logistics; and • Support the HF directors’ supervision by the SDSMAS in the area of Human Resource Management.
4 1) Gathering < 10 people with social distancing 1.5m; 2) Severe restriction in commercial sector; 3) Rotation of staff in workplace; 4) Prohibited all public events (sport events, cult ..) 57
Monitoring, evaluation and implementation research During Q3FY4, the Table 23: Main M&E activities implemented in Q3FY4 M&E team continued implementing Total FY2 Total FY3 Q1 FY4 Q2 FY4 Q3 FY4 activities to strengthen Supervision visits 86 57 61 52 128 the quality of project RDQAs 55 229 56 63 115 data. The support Support to the monthly summary HF data
Nampula 33 31 36 27 77 focused on data quality aggregation and discussion activities, supervision Support monthly discussion of Data at district 7 4 6 8 5 and technical support Supervision 52 76 57 102 110 to HFs to analyze and RDQAs 83 167 57 77 78
Sofala Support to the monthly summary HF data 12 71 35 74 47 present monthly aggregation statistics, support the Support monthly discussion of Data at district 1 2 3 1 6
M&E component, draft an operational study to reduce data discrepancy between FP methods delivered through the HF’s warehouses and HMIS reported data. Table 23 illustrates the efforts carried out by the M&E team, each M&E officer covers an average of three districts. 225 RDQAs were carried out in Q3FY4 against 140 in Q2FY4. Data quality activities IFPP is not prioritizing health post for RDQA but focuses efforts on health centers (HC) and hospitals, therefore 216 HFs out of 237 in Nampula and Figure 17: Comparison of data quality 165 out of 170 HFs in Sofala represent our improvement among HFs with at least two target. In Nampula, at end of Q3FY4, out of the RDQAs carried out (1st assessment vs last 216 targeted HFs, 211 (98%) received at least assessment) at end Q3FY4 – Nampula one RDQA visit and 178 (82%) received at least two RDQA visits, while 117 (54%) received at least three RDQA visits and 41 HFs (19%) received at least four visits. Figure 17 is comparing, at end Q3FY4, RDQA results between the first RDQA performed and the last one within the cohort of HFs having already carried out at least two RDQAs (178 HFs); 89 HFs out of these 178 HFs scored with an acceptable RDQA result and 16 with a medium result. Furthermore, within this sub-group of 89 HFs, at end of Q3FY4, 20 consecutively scored with an acceptable RDQA results against only five at the end of Q1FY4, highlighting that awareness of HF’s teams is increasing about the importance to report qualitative data. These
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HFs with two Table 22: # of HFs and RDQA rounds completed at end Q3FY4 consecutive RDQAs will be assessed every 6 # of HF # of HFs having received only Province months instead of targeted NO RDQA 1 RDQA 2 RDQA 3 RDQA 4 RDQA 5 RDQA 6 RDQA 7 RDQA 216 5 33 61 76 32 7 1 1 quarterly in the next Nampula 100% 2% 15% 28% 35% 15% 3% 0.5% 0.5% quarters. As illustrated 165 14 11 25 49 39 20 7 0 Sofala in Table 22, in 100% 8% 7% 15% 30% 24% 12% 4.2% 0.0% Nampula, 2% of the
216 HFs have received no RDQA visit, 15% only one RDQA visit, 28% two RDQA visits, 35% three RDQA visits, 15% four RDQA visits, 3% five RDQA visit and 0.5% six visits and seven visits, at end Q3FY4.
In Sofala province, at end of Q3FY4, out of the 165 Figure 18: Comparison of data quality targeted HFs, 151 (92%) received at least one improvement among HFs with at least two RDQA visit and 140 (85%) received at least two RDQAs carried out (1st assessment vs last RDQA visits while 115 (70%) received at least assessment) at end Q3FY4 - Sofala three RDQA visits and 66HFs (40%) received at least four visits. Figure 18 is comparing, at end Q3FY4, RDQA results between the first RDQA performed and the last one within the cohort of HFs having already carried out at least two RDQAs (140 HFs); 84 HFs out of these 140 HFs scored with and acceptable RDQA result and 17 with a medium result. Furthermore, within this sub- group of 84 HFs, at end of Q3FY4, 36 consecutively scored with an acceptable RDQA results against only five at the end of Q1FY4, highlighting the progresses achieved.
The main problems faced during the RDQAs continue to be related to not using the daily tally sheet, the poor registration of the mobile brigade data or loss of MB registration logbooks, the incorrect aggregation of the FP integration monthly summary form and, some HF not aggregating APEs and MB data into the HF FP integration monthly summary form. Acceptable data quality, following MISAU scale, is ≤ 10% for data discrepancy between data observed in primary logbook and data inserted in the HMIS data base, medium data quality is between 10 and 20% and non-acceptable data quality is over 20% of discrepancy. In case that data logbooks aren’t available at HF’s level, RDQA for this HF is considered as “not acceptable”. Furthermore, as this problem is not
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solely the problem of Nampula and Sofala provinces, but exist also in several other provinces, the central SRH/FP TWG is committed to propose revision of the data logbooks to the MISAU, as data quality is hampering evidence-based decision for the National FP program.
Support to the community component The M&E team in both provinces continued to supported the community component along this Q2FY4 to ensure reliability of records and data reporting, better filing of the community referral forms, improve involvement of and coordination with APEs settled in the areas benefiting of community dialogues, focusing on APE’s and TBA’s participation to the community dialogue as well as increasing the number of community referrals towards Photos 20: M&E officer giving support to APEs. In Nampula, 27 technical support visits (against 17 APEs in Gorongosa district. in Q2FY4) were conducted to community supervisors and CF to accompany the community activities and included the correct filling of the forms.
Supervision and technical support During Q3FY4, 36 districts (23 in Nampula and 13 in Sofala) received supervision and technical assistance visits including RDQA and HFs’ monthly data review meetings, against 29 districts in Q2FY4. Verifying the registering of the FP commodities’ stock-cards and the correct use and regular updating of the SIGLUS platform are additional Photos 21: M&E officer sharing RDQA results tasks introduced this quarter to diminish the falsely in Ribaue district. reported stock-outs. Also, during these supervision visits, support is given in data analysis and updating of graphics and verification of the FP and environment compliance files.
Support to district monthly meetings and elaboration of HF monthly statistics During Q3FY4, 11 SDSMAS monthly data discussions meetings (5 in Nampula and 6 in Sofala) were prepared together with the respective NEDs against 26 in Q1FY4. Also, 124 HF (77 in Nampula and 47 in Sofala) were supported for the elaboration of their monthly statistics against 60 in Q2FY4.
Support to the introduction of the Integration registration form into SISMA During the month of October 2019, the MISAU launched into SISMA the introduction of an additional data summary form aggregating separably the FP data coming from the outpatient consultations while before these data were aggregated in the SRHR consultation form. With the introduction of this additional form, data are also separated in the SISMA, increasing the SDSMAS and HF’s 60
ownership of the FP integration into other services. The M&E teams during this Q3FY4 continued to support the districts to comply with this new directive.
Client perspectives on service quality provided by IPC agents (Computer Assisted Telephone Interview – May 2020)
House to house visits is a strategy of the IPC agents to reach WRA to promote the use of FP and data is recorded through the CwS. During this session the women is asked if she accepts to Figure 19: Visits by IPC (n=762) receive a phone call to evaluate the service 100% provided by the IPC agents in Sofala and 90% 80% Nampula province. The objective of this study 70% 57% 60% 55% through CATI interview was to assess the level 50% of satisfaction of the beneficiaries and the 40% 30% 19% 21% 20% 15% 15% impact of the messages conveyed by the IPC 9% 9% 10% agents in the urban areas of the provinces of 0% Sofala and Nampula. A sample of 762 women Sofala Nampula 1 visit 2 visits 3 visits >=3 Visits (382 in Nampula and 380 in Sofala) 18 to 49 years of age were selected to participate in this quality service evaluation which took place between the 22nd and the 29th of May 2020. Out of the 762 women participating in this survey, Figure 20: Knowledge & Importance of FP (n=356) 56% had received one IPC agent’s visit and 44% at least 2 visits with no difference Support the mother and under-five 6% between Nampula and Sofala. 47% (356) children health 10% remember having received a referral to Improve family health and wellbeing 6% 10% the HF (51% in Nampula and 42% in Avoid STI 10% Sofala) and of these 356, 45% went to the 11% HF (50 % in Nampula and 39% in Sofala). Help decide how many children to have 21% 26%
Out of these 356, when asked if they Space births 46% 38% believe that FP is important, 98% Avoid unwanted pregnancy 72% responded that yes, it is important and, 76% when asked why it is important, 74% 0% 20% 40% 60% 80% 100% mention to avoid unwanted pregnancy, Nampula Sofala
42% to space births and 23% to help decide how many children to have, 11% to avoid STI, 8% to improve family health and wellbeing and 8% to support the mother and under-five children health. Furthermore, 72% of these 356 women are still using a FP method at the time of the call (76% Nampula and 66% Sofala; 65% 18-24 years old and 76% 25 -49 years old); out of the 28% currently not using a FP method, when asked why, 42% answered they are not interested to use FP (46% in Nampula and 39% in Sofala; 54% 18-24 years old 61
and 31% 25 -49 years old), 11% were currently pregnant, 11% are trying to be pregnant, 9% have difficulties to become pregnant, 8% complain about contraceptive method’s side-effects, 3% mention that partner doesn’t accept and 16% other reasons.
Out of these 356 women, when asked to evaluate the performance of the IPC agent, overall, the women were satisfied with the way the IPC agent did the session (99%) and felt comfortable in talking with the IPC agent (99%). Out of the 149 women who received a referral and went to the HF, when asked to evaluate the service provided at the HF, 40% stated that it was good 35% said that they liked it because it is discrete, 17% because it is close to home and 3% didn’t like the service. Out of 161 women who received a referral and went to the HF, 46 went only once or twice, when asked why, 46% answer my next consultation is scheduled for later, 22% had no time, 17% claim not having been informed about the necessity to go back, 7% because the HF was closed, and 9% for other reasons.
FP and Environmental Compliance
During Q3FY4, out of 138 HFs assessed for FP compliance compared to 115 in Q2 (70 in Nampula and 60 in Sofala), 58 were fully compliant. For FP compliance, the non-fully compliant HFs are still not compliant because a few HPs did not yet participate in the eight-day FP training including the compliance module. Out of 130 HFs assessed for environmental compliance this quarter, 45 continue to be fully compliant.
IFPP is confronting poor collaboration regarding the USAID compliance App operational management, it’s difficult to add new IFPP staff as users, to manage and share the reports with IFPP staff and mentors; therefore, IFPP is migrating to another system – Kobocollect - to track FP and environmental compliance more easily in Q4FY4, which remains a challenge and needs more proactive management.
Non-environmental compliant HFs are facing difficulties to segregate the different types of waste (biological waste such as placenta, infectious waste such as used needles and syringes, and common waste) and to decontaminate the medical equipment such as temporarily immersing used medical equipment (e.g. speculums, forceps, trawlers) in basins with chlorine solution. There’s also no appropriate incinerator and no fence surrounding the sanitation area. Other common problems at HF’s level are related to poor incineration of the garbage at sanitary landfill, poor conservation of the medical and surgical tools, and incorrect use of hypochlorite. Buckets and basins are scarce and not identified, garbage is not deposited in plastics, HPs don’t properly use gloves and don’t do prior hand cleaning, absence of cleaning plan posted at HF’s services, shortage of cleaning personnel at HF level.
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During Q3FY4, the IFPP Table 23: HFs receiving IFPP Biosafety Project Officer Technical Assistance in Biosafety Project Officer Q3FY4 has trained the staff of 30 HFs with MISAU staff to Districts HFs supported Namiconha, Namicopo, 1o de Maio, Anexo ao Hospital Nampula City implement the correct Psiquiátrico and 25 de Setembro waste management and Mecubúri Namina and Mecubúri biosafety standards. Some Intuto, Mirrote, Samora Machel, Alua and Namapa Rural Eráti of the HFs received more Hospital Namahaca, Chipene, Simuco, Mazua, Nivale and Memba Memba than one visit during the Sede quarter strengthening like Rapale Namaíta this the follow up of the Muecate Muecate, Namina Rio and Napala recommendations. Table Ribaue Iapala Monapo, Namiconha and Rural Hospital 23 lists the district and HFs. Meconta Nacavala Additionally, IFPP did a Malema Mutuali and Nioce refreshment on correct Mogincual Namige and Quixaxe hand washing, how to use the masks correctly for SDSMAS directorates during the Human Resource management training. After the technical assistance, IFPP recommended to acquire Biosafety materials (vests) and distribute to the HF staff, train HF’s staff in biosafety procedures.
Goal: Increase use of modern contraceptive methods
IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services
Achieved Achieved FY4 Annual LOP Achieved Indicator FY1 FY2 Annual % Q1 Q2 Q3 Target FY3 Target Achieved 595,202 278,144 1,018,869 752,299 89,422 424% 126,646 133,047 119,169 Since April 2016, the MISAU “FP new user” indicator defined new users as “first time users in life.” For the 1.A. # new FY4, IFPP proposed the target of 89,422 defined taking in account the contraceptive prevalence rate (CPR) users of and the unmet need for FP (IFPP baseline). Categorizing a client as a first-time user in her life is dependent modern on information provided by the user. The reliability of this information depends on the HF provider ability contraceptive and time. Before April 2016, the concept of new user was “first time for the current year” and obviously, methods this indicator “first time user in life” doesn’t seems appropriate in Mozambican context. The revision of the registration books was planned to start during the FY4Q2 and hopefully piloted during the FY4, but because of the COVID-19 the revision was postponed 3,045,547 544,230 1,159,123 932,254 620,477 84% 181,212 175,932 166,391 # of women initiating a The IFPP suggested, at end of FY2, the inclusion of this new indicator, "Number of women initiating a contraceptive contraceptive method", disaggregated by type of method as more reliable to monitor the trend of FP method access. FY2 is probably overreported due to implementation of the MCH National health week and the SRH and CECAP “caravan” organized during July-August 2018. During the FY3, a total of 932,254 initiators were 63
reported against 698,036 planned, an annual percentage achieved of 134%, meanwhile the FP post-IDAI emergency campaign contribute to most probably overreporting, explaining why we are still above 120% of IFPP yearly target. At end Q3FY4, IFPP reached 84% of the FY4 annual target.
658,968 399,381 639,144 642,638 667,145 60% 121,346 142,918 133,280 1.B. # continuers Following MISAU definition, a “continuer” user is a woman who used a FP method already in her life and users of should be registered only once per year in the FP logbook. The FY2 results were influenced by the National modern Health Week (NHW) and the CECAP caravan. IFPP surpassed the annual target by 14%. The total for FY3 is contraceptive 642,638 continuers users reported against 565,067 planned, an annual percentage achieved of 114%. At methods end FY4 Q3, IFPP reached 60% of the annual target but there is a lot of discrepancies between the number of users using a refill (173,237) and the number of continuers registered (133,280) which should be similar. 5,344,145 591,722 1,233,514 1,042,710 1,316,310 51% 238,887 223,930 211,337 Data disaggregated by method are presented in the PMP in annex. The FY2 annual target was 615,391 CYP. At the end of FY2 the project had reached 200% of the annual target. This achievement was influenced by the NHW and the 2017 contraception week that occurred during Q1 as well as the SRH and CECAP “caravan” organized during the July-Sept 2018. The FY3 annual target proposed, based on FY2 achievement, was 1,282,855. At the end of FY3, 1,042,710 CYP were reported thru the HMIS corresponding to eighty one 1.C. Couple percent of the annual FY3 target. Meanwhile, the comparison between the number of commodities Years of supplied through DPM and the FP services registered through HMIS, shows significant discrepancies, Protection specifically for IUD and Implants which, in turn, over-estimated the FY2 CYP achieved. The magnitude of the discrepancy in FY3 has already diminished when comparing with FY2, explaining the 81% of achievement and illustrating the efforts carried out to improve data quality. At end Q3FY4, a total of 674,154 CYP are reported through HMIS corresponding to 51% of the Y4 project target which was set based on highly overreported results of Y2. Technical support to reliably register data continue to be intensified in Y4 and it is expected that Y4 CYP data reported will be below the one reported in Y3, still overreported. IFPP will ask to readjust the Y4 and LOP targets erroneously increased from 2,963,877 to 5,344,145 at end Y2, based on results reported the same year. FY4 Annual LOP Achieved Achieved Achieved Indicator Annual % Q1 Q2 Q3 Target FY1 FY2 FY3 Target Achieved 43,512 3,136 10,000 11,033 20,516 47% 2,479 2,873 4,212 During FY1, 3,136 WRA receiving contraceptive services in HIV services were reached, 10,000 in FY2 and 1.D. # 11,033 in FY3 illustrating still an increase trend over the years, but the planned FY3 target was too ambitious women as IFPP reaches 66% of the annual target. One reason for this lower achievement is related to the recent receiving introduction of ART follow up consultations passing from quarterly to bi-annually. The other reason is that contraceptive the WLHIV have the choice to access FP services in every outpatient consultation at HF level (Integration of services in FP services in all outpatient consultation). Furthermore, dedicated consultation room attending only ART HIV services patients is existing only in the biggest HFs while in smaller HF, the ART consultation is integrated in the common outpatient consultation room. Another reason is related to the increasing proportion of LARC users within the PLHIV subgroup who rarely need re-supply. At end Q3FY4, a total of 9,564 WLHIV has been reported corresponding to 47% of the Y4 target. IFPP will ask to readjust the Y4 target. FY4 Annual LOP Achieved Achieved Achieved Indicator Annual % Q1 Q2 Q3 Target FY1 FY2 FY3 Target Achieved 330,059 36,427 71,373 77,957 102,582 60% 20,437 20,073 20,948
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1.E. # During Q3FY4, 5,724 PPIUDs were inserted and 15,224 women accepted another modern contraceptive postpartum method, totaling 20,948 and representing 60% of IFPP FY4 annual target. Compared to the number of clients institutional deliveries registered in Q3FY4, 25% of the women who gave birth at an HF have accepted one accepting a of the eligible post-partum FP methods with 26% in Nampula and 24% in Sofala. At the end of Q3FY4, IFPP modern achieved 60% of its yearly target but 75% (247,215/330,059) of its LOP target and will continue to improve contraceptive the quality of the PPFP services at maternity level as well as the couple counselling at ANC. method prior to or at discharge 1.F. # users 338,751 47,072 125,941 215,241 87,832 207% 55,135 62,219 64,654 receiving modern The total reported for FY3 is 215,241 WRA served by APEs against 84,454 planned, an annual percentage contraceptive achieved of 255%. Meanwhile this number integrated the FP post-IDAI emergency campaign data allocated methods to APEs which are overreported as the pick of WRA served in May drop down in the following months (see from APEs at detailed explanation in APE chapter). During Q3FY4, 64,654 women were reported as served through the community APE’s network resulting in 207% of the IFPP annual target. The number of APEs trained and active has level considerably increased and are actively supported as they represent an opportunity to reach the furthers.
Comments: Cyclone Idai affected the data being reported during Q2FY3 in Sofala and this information was updated during Q3FY3.
In general, indicators show a sustained moderated expansion of IFPP for the number of postpartum clients accepting a contraceptive prior to or at discharge and for the number of users receiving contraceptive from APEs at community level; meanwhile for the number of WRA initiating a method and for the CYP, IFPP has a trend of slight diminution (CYP) or a plateau (FP initiators) while quality of data reported is being progressively improved since FY3; indeed, in beginning of FY3, IFPP noticed that important discrepancies were existing between LARC contraceptives supplied through the CMAM and reported through HMIS which was highlighted at the national MCH meeting; consequently, IFPP increased its M&E team to support the HNS to progressively correct inconsistencies. Note that in Q1FY2 and Q4FY2, data were strongly influenced by the MCH NHW and the contraception week conducting to overreports; even if It was expected that some of the new SAM users and continuers reached during these two events will have difficulty refilling their methods in future quarters, it was not expected that the drop will be so wide. Meanwhile, it’s important to highlight that LARC methods supplied thru CMAM are progressively and consistently increasing since Y1, showing that more WRA are being inserted with a LARC.
Figure 19 shows the trend in women initiating a contraceptive method. Q1FY2 received a huge pull with the NHW that was also repeated during Q4FY2 with the CECAP “caravan” organized during the June-July 2018. During Q1 and Q2 FY3 the NHW was canceled and the data represents only routine HMIS data, but during Q3 an emergency health week was held in Sofala representing 54% of Sofala results which seems to be unlikely. A first verification with the HP in charge of data aggregation confirm us that the FP data produced at the HF level during the emergency week were reported two times as the instruction received from the DPS was to report the emergency data in the daily summary of the emergency health week and the same data were also aggregated in the HF monthly summary instead of being not aggregated. Analyzing the method mix within the group of initiators – without including the maternity data, for Nampula, during Q3FY4, we have 3.7% for interval IUD, 65
14% for implant (a total of 18% of LARC), injectable are responsible for 61% and pills with 21%. For Sofala, interval IUD is responsible for 4.8%, implant 23% (a total of 28% of LARC), injectable represents 45% and pills 27%.
Figure 21. Trends in women initiating a contraceptive method by type of method in Nampula and Sofala provinces - October 2016 to June 2020 (w/o PPFP at Maternity and minilap)
300000 Pills Injectable Implant IUD
250000
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0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY1 FY2 FY3 FY4 FY1 FY2 FY3 FY4 Nampula Sofala
CYP data (Figure 20): first, data for Q1FY1 are not comparable to the other quarters, as IFPP reported data from only 17 districts in Nampula compared to the 23 in the following quarters. From Q2FY1, data reported on a quarterly base are comparable. Data from Q1FY2 and Q4FY2 were influenced by implementation of the MCH NHW and the SRH and CECAP “caravan” organized during the 2018 Russia football world championship and most probably overreported.
During Q2FY4 the CYP in Nampula decreased by 2.7% compared to Q1Y4, with LARC being 61% of the CYP. In Sofala, the CYP decreased 10.9%, mainly due to the rainy season. Quarter 3 was affected by COVID-19 and when comparing Q2FY4 with Q3FY4 the CYP in Nampula decreased 7.4% mainly due to a decreasing of short-term methods and in Sofala 13.7% mainly due to a decrease of LARC methods.
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Figure 22. Trends in CYP in Nampula and Sofala provinces - October 2016 to June 2020
250000
Pills Injectable Implant IUD Pos Partum IUD T. Ligation 200000
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0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY1 FY2 FY3 FY4 FY1 FY2 FY3 FY4 Nampula Sofala
IFPP is increasing access to immediate post-partum FP methods (IUD, implants and progestin pills). The percentage of the women who give birth at HFs and adopt PPIUD (Figure 21) is stabilizing along the FY2 and FY3 reaching in Q3FY4 7,4% in Nampula province and 5,9% in Sofala province. Figure 23. PP IUD and institutional deliveries by province from October 2016 to June 2020
PP IUD in IFPP district PP IUD in non IFPP district % of PPIUD
5000 15.0% 4500 13.0% 4000 11.0% 3500 7.7% 7.0%7.1% 7.6%7.3% 7.4% 9.0% 3000 6.4%6.9% 6.9% 6.8% 5.6% 5.6%5.9% 2500 5.2% 5.2%5.4% 5.0%5.0% 4.9%5.5% 7.0% 4.3% 4.7% 4.7%4.3% 4.8%4.8% 2000 2.6% 2.7% 5.0% 1500 1.3% 3.0% 1000 500 1.0% 0 -1.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY1 FY2 FY3 FY4 FY1 FY2 FY3 FY4 Nampula Sofala
When analyzing post-partum women accepting a modern contraceptive method at the maternity level (Figure 22 - PPIUD and other PP methods as captured and reported under HMIS-SISMA), Nampula province reached 26% and Sofala province 24%.
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Figure 24. % of women accepting Post-partum FP method at Maternity by quarter and province from October 2016 to June 2020
PP IUD Other methods % of women accepting a PPFP method
18000 100% 16000 90% 14000 80% 70% 12000 60% 10000 50% 8000 40% 26% 26%25%27%27%26%25%26% 6000 23% 23%23%23% 22%22%24% 19% 21%21% 30% 16% 15%16%18% 18%17%17%16% 4000 20% 7% 9% 2000 2% 10% 0 0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY1 FY2 FY3 FY4 FY1 FY2 FY3 FY4 Nampula Sofala
Sub - IR 1.1: Increased access to modern contraceptive methods and quality, facility-based
FY4 LOP Achieved Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Target FY1 FY2 FY3 Achieved Target 3,749 2,309 1,032 604 180 246% 102 97 244 1.1.1. # health providers trained An IFPP accelerated start-up supported the MISAU to reach its 2020 FP targets. During the FY1 and FY2 on modern the IFPP trained 3,341 HPs. During FY3, IFPP trained 604 HPs reaching 112% of the annual target of methods of training (540 HPs). As additional HPs were posted at key integrated FP consultations and in MCH services, contraception IFPP increases its FP trainings in order to fill the gap. During Q3FY4 IFPP trained 244 HP reaching 246% of the annual target. 1.1.2. % of health 80% 90% 93% 90% 80% 97% 96% 98% 98% providers who A total of 98% of the HPs trained during Q3FY4 completed the post test of trainings successfully. have completed the training on modern methods of contraceptive with positive score in the post test 1.1.3. % of 100% 68% 92% 98% 100% 98% 98% 98% 98% supported service delivery At end of Q3FY4, 399 out of 409 HFs (98%) had already at least one HP trained in FP through IFPP, 166 sites providing HFs in Sofala out of the 172 and 233 HFs out of the 237 in Nampula had a trained HP. family planning counseling and/or services
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Comments The level of participation in trainings and knowledge retention after trainings is high, above 80%, the IFPP benchmark.
Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based FY4 LOP Achieved Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Target FY1 FY2 FY3 Achieved Target 1.2.1. # of additional USG-assisted 3,735 1,763 723 543 706 61% 211 199 20 community health During FY3, 164 APE, 224 TBA, 113 IPC and 42 community facilitators were trained totaling 543, workers (CHWs) reaching 66% of the annual target, leaving a total of 257 extra CHW to be trained during FY4 and already providing family planning information included in FY4 target. During Q3FY4 20 IPC agents were trained in Sofala. IFPP will focus on poorly and/or services performant APEs for FP training in Q4FY4. 1.2.2. # mobile 12,594 1,639 3,383 3,303 3,160 56% 823 669 281 brigades conducted including During Q3FY4, IFPP supported 281 MBs (37 in Nampula and 244 in Sofala) reaching at the end of Q3FY4, contraceptive 51% of IFPP annual target. The MB activity was heavily affected during Q3 FY4 due to COVID 19 MISAU services orientations. IFPP will ask to readjust the Y4 target.
Comments IFPP has introduced this Q1FY4 a suite of synchronized mobile brigades to reduce barriers to access for vulnerable populations such as youth and consistent access for those living far from health centers. Four types of MBs - continuation MBs, school-based MBs, targeted rural MBs, and community dialogue MBs were defined and planned to reach a priority population with limited access and amplify the impact of other related activities to accelerate progress towards government of Mozambique goals and FP2020 commitments. An important aspect of this synchronization is increased engagement of CLLs in planning and mobilization activities to increase accountability on both sides, both ensuring that the brigades are held regularly by the MISAU and that community awareness and attendance of brigades is high. At end Q2FY4, considerable efforts were already carried out as 88 CLL in Q1FY4 and 58 in Q2FY4 were sensitized and participated to the MB planning for their area. Continuation MBs take place at strategic locations along population corridors where there is a large distance between HFs. The previous provision of injectables, implants and intrauterine devices (IUDs) is now restricted on school grounds so the school-based MBs offering an expanded method mix are now taking place in the surrounding area near secondary and technical schools, focusing mainly out-of-school adolescent but remaining accessible to in-school adolescent. The school-based brigades in urban context are mainly financed with cost-share funds managed by PSI. Targeted rural MBs in 195 additional selected rural fixed points has been launched this quarter to reduce the well-known accessibility barriers, especially for the poorest population quintile and populations with limited mobility such as youth. BM linked directly with the community dialogue intervention has also been launched since Q1FY4 to strengthen connections between demand generation activities and easy access to FP services.
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Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services
LOP Achieved Achieved Achieved FY4 Annual Annual % Indicator Q1 Q2 Q3 Target FY1 FY2 FY3 Target Achieved
44% 57% 68% 64% 35% 74% 72% 74% 75% 1.3.1. % confirmed With CwS platform, all IPC referrals are now electronic and are accountable. For clients receiving a paper slip referrals from from a triplicated referral copybook from CFs and for client referred by TBAs whose referrals are confirmed thru communities to the monthly HF-TBAs meetings. During Q3 FY4 out of 52,749 referrals made (paper and electronic), health facilities for FP providers based at HFs have confirmed 39,569 referrals corresponding to 75% of confirmation rate. The number services of referrals delivered increased by 31% when compared to Q2FY4, and the number of confirmed referrals increased by 33% from Q2 to Q3.
IR 2: Increased demand for modern contraceptive methods and quality FP/RH services Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors
FY4 Annual Achieved Achieved Achieved Indicator LOP Target Annual % Q1 Q2 Q3 FY1 FY2 FY3 Target Achieved 2.1.1. 1,147,520 174,531 322,583 532,843 295,680 191% 145,277 196,966 222,477 # contacts conducted During Q3FY4 222,477 contacts were conducted. The annual target of FY4 is 295,680 contacts, IFPP surpassed the by trained annual target in 91% TBAs/activis ts to women
Comments The number of women contacted in Nampula during Q3FY4 was about 222,477 (30,873 by CFs, 82,872 by IPC and 13,427 by TBAs) and 95,305 (30,739 by CF, 60,961 by IPC and 3,605 by TBAs) in Sofala, highlighting huge efforts carried out by the community component during this COVID-19 state of emergency quarter.
Sub-IR 2.2: Improved community environment to support healthy FP behaviors LOP Achieved Achieved Achieved FY4 Annual Annual % Indicator Q1 Q2 Q3 Target FY1 FY2 FY3 Target Achieved
2.2.1. # 13,056 0 3,226 3,887 5,110 56% 781 1,212 845 community dialogues During this Q3FY4 845 community dialogues were conducted, 415 in Nampula and 430 in Sofala, reaching conducted on FP 56% of the annual target since COVID-19 orientations banned the reorganization of the community dialogues (6 sessions groups during 6 weeks in Nampula and 3 in Sofala. completed) 2.2.2. # 1,475 323 321 429 384 83% 49 141 127 community radio sessions During Q3 FY4 127 radio sessions were broadcasted (33 in Nampula and 94 in Sofala). broadcasted on FP/HTSP 70
Sub-IR 2.3: Improved systems to implement and evaluate SBCC interventions FY4 LOP Achieved Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Target FY1 FY2 FY3 Achieved Target 2.3.1. # meetings held NA 2 1 1 0 0 0 0 0 with SBCC project to plan/coordinate SBCC No meetings were planned for this quarter approaches 2.3.2. # capacity 10 2 2 2 2 0 0 0 0 building sessions for community radios and No capacity building session was planned for this quarter. community groups in SBCC for FP
IR 3: Strengthened FP/RH health systems FY4 Achieved Achieved Achieved Annual % Indicator LOP Target Annual Q1 Q2 Q3 FY1 FY2 FY3 Achieved Target
2 2 2 2 100% 2 2 2 2
As part of the planning process for PES/PESOD 2021, IFPP co-facilitated with DPS- Department of planning and cooperation in Sofala, district planning meetings to disseminate 3.A. # DPS including FP government priorities for 2021, update district managers on the revised Medium-Term interventions in Fiscal Framework (CFMP), assess the necessary financial, human and health commodities annual PES and budget resources, and agree on SDSMAS targets for 2021. In Nampula this process was done during Q1 and Q2 periods and currently DPS is mobilizing resources do conduct district meetings to jointly review and realign PES/PESOD with the district managers and local partners. IFPP has discussed and aligned with DPS and SDSMAS its FY5 SR-FP/MCH priority activities in planning, M&A, HR, Logistics and SR/FP-SMI program management.
36 7 21 19 25 124% 11 14 17
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During the period under report, all 17 district MSC assessments planned for the quarter, 9 Nampula5 and 8 in Sofala6 were conducted and all (100%) achieved satisfactory score of 3.B. # SDSMAS/DPS 80% or greater. As MSC is measured once every six months, the percentage achieved at end achieving satisfactory FY4Q3 is 124% ((14+17)/25 scores in MSC assessment
FY4 Achieved Achieved Achieved Annual % Indicator LOP Target Annual Q1 Q2 Q3 FY1 FY2 FY3 Achieved Target 5% 14% 6% 3% 0,4% 2% 4% 3% 0,4% To report this indicator, the CommCare App, SIMAM, and SIGLUS tools are used as sources 3.C. % USG-assisted of information to report stockouts of the main five methods of contraception (IUD, implant, service delivery points progesterone-only oral contraceptives, combined oral contraceptives and DMPA-IM / SC). (SDPs) that experience in Nampula, a total of 151 HF were assessed which corresponds to 64% of the total HF (237 a stock out at any time HF), in Sofala 123 HF were assessed representing 73% of the total HF (169 HF). Overall 15.3% during the reporting (42/274 HF) assessed for stockouts in this quarter were reporting false stockouts of which period of a (11.2% in Nampula and 20.3% in Sofala). This represents a reduction of 20.7 percentage contraceptive method points in HF reporting false stockouts when compared to the last quarter (36% Q2 less 15.3% that the SDP is expected to provide Q3). However, after IFPP conducted quality checks of the reported stock-out through SIGLUS and CommCare Apps reports, against HF paper-based stock cards records, the overall stockout rate for the quarter was brought down to 0.4% (1/274), representing 2.6 percentage points reduction when compared to FY4Q2 results of 3%. 100% 32% 45% 46% 90% 90% 47% 41% 53% 3.D. % of supported At the end Q3FY4, 53% of all HFs in both provinces (61% or 104 out of 170 HFs in Sofala, and SDPs with all eligible 44% in Nampula or 105 out of 237 HFs in Nampula) had all eligible health providers trained health providers in a range of modern contraceptive methods. Q2FY4 was a backstep due to the income of trained in a range of recently posted HP, IFPP in Q3FY4 has increased the number of trainings in order to diminish modern contraceptive the existing gap, but with some limitation due to the COVID-19 emergency state. Further methods efforts will be carried out in Q4FY4, meanwhile IFPP will ask to readjust the Y4 and LOP targets.
Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution
FY4 Annual LOP Achieved Achieved Achieved Indicator Annual % Q1 Q2 Q3 Target FY1 FY2 FY3 Target Achieved 3.1.1. # DPS and 170 125 SDSMAS staff 147 (50 (81 new – (26 new: 15 in Sofala receiving 152 52 128 192 152 167% 44 in in Sofala + 97 in Nampula and 11 in TA/capacity-building Nampula) and 37 in Nampula) in FP planning, Sofala)
5 three round 3 in Nacaroa, Rapale and Lardes, one round 4 in Ilha de Mocambique, three round 5 in Memba, Malema and Mossuril and two round 7 in Angoche and Erati. 6 three round 3 in Cheringoma, Maringue and Muanza, two round 5 in Buzi and Gorongosa, one round 6 in Caia and two round 7 in Beira and Dondo. 72
budgeting and During this quarter and under COVID-19 circumstances, IFPP used a mix of TA and capacity implementation building mechanisms such as on-site, conference calls, video conference and TeamViewers sessions, to conduct capacity building trainings and provide TA for DPS/SDSMAS managers to appropriately plan, budget and implement related PES/PESOD FP/MCH interventions in the areas of HR, logistics, M&A, FP/MCH, and IPC. Overall, these contributed to progresses in consolidating knowledge and skills of 125 (26 new) DPS/SDSMAS managers, 69 (11 new) in Nampula and 56 (15 new) in Sofala during Q3FY4, totaling 254 unique managers since the beginning of FY4 which represents an achievement of 167% ((147+81+26)/152) of the annual target to train 152 unique individuals.
Sub-IR 3.2: Improved management of commodities to ensure availability at local levels
FY4 Achieved Achieved Achieved Annual % Indicator LOP Target Annual Q1 Q2 Q3 FY1 FY2 FY3 Achieved Target 38 28 36 36 36 100% 36 36 36 This indicator has already been reached at 100% during Year 2 of IFPP project 3.2.1. # of supported implementation and the managers of Provincial and district depots have mastered the use districts with a of routes plans and logistic maps to manage FP commodities deliveries at HF. IFPP provided documented FP TA and transport (pickups) and fuel to complement efforts DPM as necessary and supported logistics map to optimize commodity stock redistribution between HF in 13 DDMs in Sofala and 23 DDMs in Nampula. distribution, Under the National Pharmaceutical Logistics Strategic Plan (PELF), CMAM/DPM with Village requisition and Reach has started end June in Sofala to implement the Last Mile Supply Chain (LMSC) reporting covering the entire province, while in Nampula, they are covering part of the province. Village Reach used these logistic maps along with the truck GPS to confirm maps and distribution routes.
Comments Logistics maps serve as the primary reference material upon which each district develops its monthly distribution plan for commodities and weekly pick up and drop off plan for laboratory samples and results. It has also been particularly useful for rapidly developing contingency plans related to responding to inclement weather (such as heavy rains) and other emergencies that cut off access routes, enabling districts to more effectively ensure uninterrupted access to essential medicines, consumables and laboratory services.
Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment LOP Achieved Achieved Achieved FY4 Annual Annual % Indicator Q1 Q2 Q3 Target FY1 FY2 FY3 Target Achieved 3.3.1. # of HF that 42 0 13 11 18 111% 0 8 12 undergo CSC feedback During Q1 FY4 CSC process was initiated in 29 HFs of which 21 were first-time-involved HFs processes through (13 in Nampula and 8 in Sofala) and 8 repetition HFs (4 in Nampula and 4 in Sofala). During community discussions Q2FY4, 8 HFs – all for the first time involved - completed the CSC process (3 in Nampula at least once per year and 5 in Sofala) corresponding to 44% of the annual target. This Q3FY4, an additional 20 73
HFs completed the CSC process of which 12 HFs (9 HFs in Nampula and 3 in Sofala) completed the process for the first time and 8 HFs were HFs of repetition; as IFPP indicator accounts only the HFs which complete the CSC process for the first time, this Q3FY4, IFPP is reporting 12 units, achieving 111% (20/18) of the FY4 target.
Comments No comments for this quarter on this activity.
Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers FY4 Achieved Achieved Achieved Annual % Indicator LOP Target Annual Q1 Q2 Q3 FY1 FY2 FY3 Achieved Target 3,533 1,911 859 998 180 225% 159 82 164 3.4.1. # DPS, SDSMAS & HF staff During the Q3FY4, IFPP trained 244 new health providers in integrated FP module, 108 in trained in family Nampula and 136 in Sofala. Of these 67.2% (164/244), 50 HP in Nampula and 114 HP in Sofala planning that are were successfully registered in SIFo. The remaining 80 HP trained in IFP will be registered in registered in e-SIFo the next quarter, in Nampula (58) and Sofala (22). The main reason for the delays in recording (database) these trainings was due to SIFo’s maintenance that lasted 2 months, from April to May 2020.
Comments IFPP provided TA in the institutionalization of district in-service training nucleus, strengthening staff competencies in operating the MISAU’s HRIS or SIFO platform. The project also developed and distributed clear SOPs for the reporting and registration of in-service trainings using SIFO forms in the respective platform.
Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision-making
Indicator LOP Achieved Achieved Achieved FY4 Annual Annual % Q1 Q2 Q3 Target FY1 FY2 FY3 Target Achieved 36 16 16 23 36 100% 20 33 36 3.5.1. # of districts In Q3Y4, 36 SDSMAS receiving IFPP support, developed their FP district profiles (DPs), 23 in that hold quarterly Nampula and 13 in Sofala. From these 26 SDSMAS (13 in Nampula and all 13 in Sofala) held data review quarterly review meetings based on DPs results and updated their QI action plans. Besides meetings using district profiles these 26 districts, 10 conducted DPs discussions by sharing DP analysis results through email and conference calls in Nampula.
Collaboration with other donor projects
During this reporting quarter, coordination meetings took place with government partners (MISAU, PHDs, and District Directorates of Health) and other partners such as FP2020, PSM and UNFPA.
The main agenda items at the discussion with the MISAU, through six meetings across three national technical working groups (adolescent and youth, FP and SRH commodities taskforce) include:
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1) Review and finalize the FP/SRH messaging for HFs around COVID-19; 2) Preparation and roll-out of national MCH nurses cascade training package for continuum of care under COVID-19 scenario; 3) Review of FP commodities pipeline for calendar Q2 and needed adjustments based on consumption; and 4) FP2020 workshop with anglophone member countries.
At the provincial and district level, regular meetings were held to coordinate and plan activities each month such as trainings, mentorship visits, supervision visits, MBs, commodity redistribution, data review, and district profile meetings.
Evaluation/Assessment Update During Q3 IFPP had the protocol for the DPS operational research, supported by IFPP, approved by the bioethics committee in FP at the DPS Nampula: "Use of modern methods of contraception by Women of Fertile Age in nine districts of Nampula province" (Nampula City, Angoche, Erati, Ribaué, Moma, Mecuburi, Nacala Porto, Monapo, and Meconta).
IFPP and DPS team recruited and trained data inquirers in line with the training protocol, revised the data collection questionnaire and MagPi mobile android app was installed in the interviewer’s cellphones to deploy the updated questionnaires. Currently the team is finalizing logistical arrangements to proceed with field data collection visits.
In Sofala, the research protocol titled “Assessment of the knowledge, perceptions and influences of mothers, midwives and men on the use of family planning methods by women of childbearing age in Chibabava district”, submitted on Q3FY3 is still under DPS research nucleus scrutiny awaiting submission to the national bioethics committee for approval.
Evaluations, Assessments, Studies, and Audits Include any and all types of evaluations, financial or programmatic, internal or external. Planned: List evaluations, assessments, studies and/or audits planned o Endline Survey planned for second quarter of FY5
Annexes
• Annex A - Success story • Annex B - PMP • Annex II - Workplan • Annex III - Financial information
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Annex A - Success story
Users of Namaíta Health Centre call for the strengthening of Comité de cogestão e Humanização (CCGH)
In 2018, the Health Centre of Namaíta in the Rapale District of Nampula province, was selected to benefit from an evaluation process of Family Planning (FP) services provided to communities. Community Score Cards (CSC) were used to measure the satisfaction level of Namaíta HC’s users regarding Family Planning services provision. Different groups of users participated, with specific characteristics and different FP needs, particularly youth groups, leaders, and influential community members. During the evaluation process all groups considered the bad functioning of CCGH an issue to be solved.
Users of FP services demonstrated satisfaction with the CSC tool and the whole process, once it contributed to revitalize the CCGH and therefore, an improvement in the proximity between users and FP service providers.
The need to strengthen the CCGH was identified as a priority after users encountered many unfriendly situations, such as, providers not showing up on time, illegal maternity charges etc, with the scoring process we understood what a CCGH should work on. We recognized that we should reinforce the role of the CCGH to be able to handle our concerns. (Focus Group Discussion (FGD), men).
Women would deliver their babies in their houses, fearing illegal charges. Once the CCGH started working appropriately the problems were solved and women are now going to deliver babies in the HC (FGD, Women).
Through interviews and FGD it became clear that participants were aware of that a malfunctioning CCGH was detrimental if FP services were to improve. Right after the Interface meeting, the HC Administration, together with the District Committee Chairperson and the IFPP team, facilitated the CCGH strengthening process using a voting system and training which resulted in a very engaged committee, that is actively involved in solving the HC’s problems and in the continuous improvement of FP services quality of.
The committee is beneficial for all of us and its essential for the good functioning of our Photo 1: CCGH de Mutivaze (2020) Photo by: Rita Juma, NW012020_IFPPNP HC, as well as our community, once it’s a liaison between the HC and community 76
members. When, for example, a stock-out happens in the HC the committee informs the communities. Or once the opening of medications kits takes place we are invited to witness the process and report to our communities. (Namaíta HC Chairperson).
The committee is proving to be an added value because together we are able to improve a lot and, as members, when we notice weakness in one of the member’s, we support each other in order to strengthen the functioning and resolution of problems related to FP services in the HC. (FGD, men).
We work as a link between the community and HC and we have updated information so that there is always that connection, and now we have disseminated information on COVID-19 prevention measures. (FGD, men).
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Abacar Muatamuro, champion man from Mutivaze
Abacar Abacar Muatamuro, a community leader in the Administrative Post of Mutivaze in Nampula province, is 67 years, married to three women, and has 14 children.
Abacar’s community had limited information on family planning (FP) and long-acting reversible contraceptives (LARCs) until the Integrated Family Planning Program (IFPP). Abacar has been involved project activities and distinguished himself as a key contributor in reaching families from his community, raising men’s awareness, and participating in community dialogue sessions.
“One day an activist from the IFPP Project, approached our village and informed us about the project and how the project was going to be implemented. After that brief meeting, I held a meeting with other leaders from this neighbourhood to gather help to establish the community dialogues’ groups within the community so that the sessions about family planning would be carried out,” he said.
He got involved with the project because he saw how much it would help his community to know more about FP. Abacar noted, “I also got involved because I also saw in my community difficult situations such as girls who are still children who are already mothers, or dying at birth because they are too young, or the damage and suffering because of obstetric fistulae in these young girls. I saw children and women who did not develop well because they had children in a row.”
Before IFPP, Abacar thought that FP methods were meant to kill women who had too many children or that it caused women to get diseases. “With my participation in the community dialogues, I started to understand it in a different way, and before I started to mobilize in the houses and in the communities, in general, I had to join FP myself with my family to be an example to others,” he said.
Abacar recognized the important of FP and how it contributes to the health of his community and its members. His involvement has allowed IFPP to be successful in his community.
“Most of the men here are already informed about family planning and its benefits and accept that their wives adhere to the methods without problem. Others, who insist in not knowing the advantages of FP, their wives are very unhappy. When this is the case, I have asked other leaders to help identify these men, Photo: Abacar raising awareness to a resident of Mutivaze Photo by: Rita Juma, NW022020_IFPPNP for me to raise awareness to change their behaviour,” he said.
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Abacar said, “Other leaders and I will not stop here, we will continue to raise awareness at Local Leaders Council meetings and, personally, I will always stop by houses to mobilize families to join FP.” He will continue to be an advocate for FP and working through ancestral principles still in place.
Abacar’s story is an example of the importance of male involvement and male champions in carrying forward FP messages. His knowledge and acceptance will ensure that IFPP’s messages continue to be disseminated beyond the life of the project. Through IFPP’s community dialogue approach and engagement of male community leaders, the project can affect the quality of life of families and communities.
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