Strengthening Reporting for ’s National Condom Program POLICY Brief March 2020

Sandra Mapemba and Flora Khomeni

Introduction partners received reports on condom consumption varied widely across districts. Based on findings and The Malawi National Condom Strategy 2015- recommendations from the HP+ assessment, the 2020 establishes the importance of leadership and NCCC recommended the development of condom- coordination at national and district levels and specific reporting tools to ensure that public sector evidence generation to inform evidence-based policy, condom distribution data were adequately captured in implementation, and monitoring for comprehensive the DHIS2 system. condom programming. While several information systems and reporting tools already existed for Multi-Partner, Multi-Sector condom reporting, condom program stakeholders Engagement to Advocate for recognized that gaps in information inhibited the program’s efforts to boost efficiency and effectiveness Strengthened Condom Reporting and, as a result, hindered efforts to improve availability of and access to condoms. The development of the new condom reporting tools involved multi-partner, multi-sector participation In 2017, Malawi’s National Condom Coordination and engagement from the Ministry of Health and Committee (NCCC) requested that the U.S. Agency for Population (MOHP)’s Department of HIV/AIDS International Development (USAID)-funded Health (DHA), USAID, the U.S. President’s Emergency Plan Policy Plus (HP+) project assess Malawi’s public sector for AIDS Relief, the United Nations Population Fund, condom distribution and reporting. HP+’s Condom implementing partners, and regional and district-level Distribution and Reporting Assessment identified stakeholders. The timeline for development of the inconsistencies and gaps in condom reporting at condom reporting tools covered a period of more than facility and community levels for integration into the two and a half years with various iterations of testing District Health Information Software 2 (DHIS2).1 For and refinement and development of new condom example, some departments at the facility level did indicators with the ultimate goal of institutionalizing not capture condom distribution in their consolidated the reporting tools and integrating these new monthly reports, even though many were dispensing condom indicators into the DHIS2 (see Figure 1). The condoms. In addition, the process by which participatory process involved national, regional, and community-based organizations and implementing district-level buy-in from MOHP stakeholders, input

1 Cisek, C. and F. Khomani. 2018. Condom Distribution and Reporting Assessment: Strengthening Linkages at National, District, Facility, and Community Levels in Malawi. Washington, DC: Palladium, Health Policy Plus. 2 from USAID and other donors and their regions. This multi-partner, multi-sector implementing partners, and engagement of engagement was critical to developing community-level partners involved in day- consensus and buy-in to ensure acceptance to-day distribution of condoms and HIV and continued use of the reporting tools, prevention programs, as well as testing of which were required to systemize condom the tools in 38 facilities across four different reporting and allow the MOHP to better

Figure 1. Timeline for the Development of Condom Reporting Tools

Condom distribution and reporting NCCC consensus Taskforce meetings assessment findings on development of to develop tools shared with the draft tools NCCC

July 2017 March 2018 May 2018

Presentation of final tools to the NCCC Refining draft tools Testing draft and discussion with with the NCCC condom the HIV Prevention for rollout and reporting tools at Technical Working orientation district levels Group

October 2018 September to July to October 2018 September 2018

Rolling out the condom reporting tools Development Districts initiate • Orientation to districts of condom use of condom (Phase 1) indicators reporting tools • Review and updating tools (Phase 2)

March to June to September 2019 September 2019 May 2019

Condom indicators District supervision to be incorporated visits into the DHIS2

TBD January 2020 track where and how male and female condoms, and condom distribution by 3 condoms are being distributed. By March program or department. In addition, data 2018, there was NCCC consensus about are disaggregated by sex as they appear in the need for the development of additional the health management information system/ condom tools. DHIS2. The draft facility reporting tool also summarizes the number of male and female Design of the New Condom condoms distributed through each program Reporting Tools or department, including family planning, HIV testing, youth-friendly health services, With HP+ support, the NCCC conducted antiretroviral therapy, voluntary medical meetings at the national and district levels male circumcision, and sexually transmitted to take up the modification and development infection. The tool distinguishes between of two additional condom reporting tools. In clinic-based and outreach services. May 2018, the NCCC proposed a specialized task force to enhance condom reporting at Testing Draft Condom Reporting two levels: 1) departments and programs at Tools at the District Level the health facility level, and 2) implementing partners at the community level. The task HP+ supported the DHA’s testing of the force comprised a select team from the condom reporting tools in 12 health NCCC, zonal representatives, pharmacy facilities—three facilities each in the districts technicians, and health management of , Machinga, , and information systems officers from the Zomba. In addition, several community districts of Blantyre, Machinga, Mangochi, partners participated in testing the and Zomba. This task force agreed on what community reporting form (see Table 1). type of condom data should be captured The test was conducted in two phases from at the facility and community level and July to September 2018. In the first phase, recommended the development of two in July 2018, HP+ and the DHA used the tools: 1) a facility reporting tool to capture District Condom Coordination Committee condom distribution across departments, quarterly meetings supported by PSI/Malawi and 2) a partner condom reporting form to educate district stakeholders on the draft to be completed by all nongovernmental condom reporting tools. The orientation was organizations, civil society organizations, conducted at the district level, targeting the etc., that receive free condoms from participants listed in Table 1. As a result, the facility. districts provided initial feedback on the HP+ and the DHA created a draft based on tools, such as the need to include reporting guidance from the taskforce. In addition, categories for walk-ins and other distribution HP+ developed a Quarterly Monitoring models, e.g., condom dispensers. These and Supervision Tool for Comprehensive observations were incorporated into the Condom Programming to be used at the second test phase in which districts used the district level to assess condom programming forms for collecting condom data from July activities at health facilities, clinics, and to September 2018. HP+ facilitated review community-based organizations. The of the reporting tools, per the district’s and newly designed condom reporting forms community partner’s experiences, refined the capture a facility’s standard in- and out- tools, and then presented them to the NCCC stock, closing balance for male and female for final approval in October 2018. 4 Table 1. Facilities and Implementing Partners Participating in Indicator Testing

District Health Facilities Community Implementing Partners

Umunthu Foundation, Blantyre City Assembly, Centre for the Development of Chileka Health Centre, People, Pakachere Institute of Health and Blantyre Lirangwe Health Centre, and Development Communication, JHPIEGO, Mpemba Health Centre Malawi AIDS Counselling and Resource Center, One Community

Machinga District Hospital, One Community, Youth Net and Counselling, Machinga Mlomba Health Centre, and Family Planning Association of Malawi Ntaja Health Centre

One Community, Pakachere Institute of Hospital, Health and Development Communication, Monkey Bay Community Centre for the Development of People, Family Mangochi Hospital, and Koche Health Planning Association of Malawi, Baylor Centre University, Centre for Youth Empowerment and Civic Education, Mangochi Town Council

Youth Net and Counselling, Action Hope Matawale Health Centre, Malawi, Banja La Mtsogolo, Bwalo Initiative, Zomba Domasi Health Centre, and St. Project HOPE, Future Vision Ministries, Youth Luke’s Hospital for Development and Productivity, Zomba Action Project

Rolling Out the Condom and support for district action plans on Reporting Tools condom programming (see HP+’s brief on Setting Up District-Focused Comprehensive Condom Programming). Orientation HP+ then supported an initial rollout of sessions were attended by DHA staff, district the tools across various districts in Malawi, health management information systems while the United Nations Population Fund officers, facility focal persons, pharmacy (UNFPA), through the Family Planning technicians, and relevant coordinators Association of Malawi, funded rollout (working in the areas of antiretroviral in the remaining 14 districts from June therapy, HIV testing and screening, family to September 2019 (see Figure 2). At the planning, sexually transmitted infections, same time, the DHA and HP+ continued and voluntary medical male circumcision). to sensitize districts on the following: the These sessions were designed to ensure National Condom Strategy (districts often there was technical guidance and support expressed either little or no knowledge of the in planning, implementation, scale-up, and strategy), guidelines for identifying district monitoring and evaluation of comprehensive condom focal persons and establishing condom programming activities at District Condom Coordination Committees, community and district levels. Figure 2. Rollout of Condom Reporting Tools 5

CHITIPA

KARONGA

RUMPHI

NKHATA BAY

MZIMBA

LIKOMA (An island in Lake Malawi)

NKHOTAKOTA KASUNGU

NCHISI

DOWA MCHINJI SALIMA

LILONGWE

DEDZA

MANGOCHI

NTCHEU

MACHINGA BALAKA

MWANZA ZOMBA

BLANTYRE NENO PHALOMBE CHIRADZULU

MULANJE THYOLO CHIKWAWA

NSANJE

Phase 1: June–July 2019 (supported by HP+)

Phase 2: September 2019 (supported by UNFPA)

Phase 1 and Phase 2: June–September 2019 (supported by HP+ and UNFPA, respectively) 6 Incorporating Condom in collaboration with the DHA’s monitoring Indicators into the DHIS2 and evaluation officer, two officers from the Central Monitoring and Evaluation Division, district health management information The final step in the institutionalization systems officers, and condom focal persons. process was to develop proposed condom The supervision visits were designed to check indicators that would aggregate the condom the accuracy of data (using comparisons distribution data captured at the facility to facility-level registers), to review the and community levels for submission to source documents (ensuring that data are the DHIS2. HP+ supported the DHA in disaggregated by condom type, i.e., male developing proposed condom reporting or female) and distribution model (static or indicators as outlined in Table 2; these outreach), and to confirm data timeliness indicators were also vetted and approved and completeness. Most of the challenges by the HIV Prevention Technical Working identified during the supervision visits were Group and shared with the MOHP’s Central not related to the condom reporting tools Monitoring and Evaluation Division. or difficulty in collecting, entering, and Following the districts’ orientation and the cleaning the data. Instead, the challenges rollout of the condom reporting tools from stemmed from resource constraints and lack June to September 2019, HP+ facilitated of district-level buy-in. For example, some supervision visits in four districts (Blantyre, districts did not have an adequate number Mangochi, Phalombe, and Zomba) in of condom reporting forms or registers (e.g., January 2020. These visits were carried out for documenting walk-ins). As a last step,

Table 2. Proposed Indicators for Incorporation into the DHIS2

Indicator Name Definition

Facility condom distribution Number of male and female condoms distributed by the facility at by distribution channel and static and outreach clinics. condom type

Number of male and female condoms distributed by the facility through different programs or service delivery points for family Facility condom distribution by planning, HIV testing and screening, voluntary medical male program and condom type circumcision, sexually transmitted infection treatment, and antiretroviral therapy.

Facility condom consumption by Number of people who received condoms at the facility program disaggregated by service and program.

Number of male and female condoms distributed by implementing Community condom distribution partners in different programs such as family planning, HIV testing by program and condom type and screening, voluntary medical male circumcision, sexually transmitted infection treatment, and antiretroviral therapy.

Community condom Number of people who received condoms from implementing consumption by program partners disaggregated by service and program. the DHA will submit the supervision report engagement by various donor agencies, 7 to the Central Monitoring and Evaluation national and district MOHP representatives, Division with the recommendation to implementing partners, and local incorporate the indicators into the DHIS2. organizations. The MOHP’s stewardship was instrumental in organizing this engagement. Lessons Learned Although development and rollout of the condom reporting tools and DHIS2 Based on HP+’s support of the NCCC in indicators took more than two years, the strengthening overall condom reporting, buy-in achieved at the various levels will help the project identified the following strengthen Malawi’s condom program in the lessons learned regarding multi-sector long term as well as ensure that the tools engagement and coordination related to continue to be well utilized. condom reporting. Having an identified district condom Lack of standardization of condom focal person improves the overall reporting in national and district quality of condom reporting. monitoring and evaluation systems led to government and implementing While each district has its own unique partners collecting different sets of challenges and opportunities to address data at all levels. in improving condom programming—as do lower-level facilities in more difficult to This activity demonstrated the complexity reach areas—districts with a condom focal of collecting condom data across many person produced more accurate and timely different programs and sectors. Lack of reporting. The condom focal person is also standardization of national and district critical in ensuring that condom reporting reporting requirements creates additional tools are being used correctly. challenges, causing a major gap in the information required to support efficient District-level engagement during and effective condom programming. As a testing and orientation increased the result, the National Condom Program had perceived value and importance of little information on where or how condoms collecting accurate condom data. were being distributed through public sector channels. The new condom reporting tools The testing and orientation activities and integration into the DHIS2 will make it were conducted with the participation of easier for health management information facility-level health workers, community- systems officers and condom focal persons to based organizations, and implementing determine which facilities are not adequately partners. Local stakeholders demonstrated reporting condom distribution. an increased appreciation during this process for the importance of condom Multi-sectoral, multi-partner data and for the need for timely, accurate collaboration was key to achieving data. The perceived benefits were national-level orientation and improvement of district planning and planning sessions for all districts. implementation efforts—without significant Throughout this process, there was resource demands—and a strengthened important collaboration and multi-sector national program. 8 Conclusion facility- and community-based distribution of public sector condoms where data were The efforts to standardize condom reporting previously incomplete or non-existent. In across districts, facilities, and partners the future, it will be important to regularly represent an important milestone for analyze historical and geographic trends Malawi’s National Condom Program. These across districts, facilities, and distribution new reporting tools are being integrated points. The DHA’s continued oversight into the DHA’s existing departments so and leadership in helping districts address that resource requirements are minimal the ongoing challenges related to condom for sustained use. These tools will help reporting will be critical to the condom the DHA better understand trends in program’s long-term success.

Health Policy Plus (HP+) is a five-year cooperative agreement funded by the U.S. Agency for CONTACT US International Development under Agreement No. AID-OAA-A-15-00051, beginning August 28, 2015. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). HP+ is implemented by Palladium, in collaboration with Avenir Health, Futures Health Policy Plus Group Global Outreach, Plan International USA, Population Reference Bureau, RTI International, 1331 Pennsylvania Ave NW, Suite 600 ThinkWell, and the White Ribbon Alliance for Safe Motherhood. Washington, DC 20004 This publication was produced for review by the U.S. Agency for International Development. It www.healthpolicyplus.com was prepared by HP+. The information provided in this document is not official U.S. Government [email protected] information and does not necessarily reflect the views or positions of the U.S. Agency for International Development or the U.S. Government.