MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-388-LA-13-00004)

Quarterly Report January 01– March 31, 2017

Dr. Abdur Rahim, Civil Surgeon of Jhalokathi is pictured below discussing issues with women in the community in an MPDSR session. His leadership is instrumental in improving MCHN services in Jhalokathi. He has been recognized with an award of Best Civil Surgeon of the Year for his tremendous effort in increasing EPI coverage. He acknowledges the contributions of MaMoni HSS and is always supportive to the project activities.

Submitted May 05, 2017

Cover Photo Story:

A Change Maker in Dr. Abdur Rahim, Civil Surgeon of Jhalokathi District

Dr. Abdur Rahim is a physician, a hospital superintendent, and a dedicated health worker, who over the last two years has brought radical changes in the fields of maternal and child health and nutrition (MCHN) in Jhalokathi district. These efforts have brought him recognition as the biggest change maker in the district. Dr. Rahim is an exceptional leader who, rather than operating in conventional ways, has not been afraid to swim against the tide and overhaul the system in order to strengthen it and make it more effective.

Some of his most significant accomplishments include the regularization of EPI -based birth registration, death reporting, collection and entry of monthly reports of private clinics in DHIS2, and improving government and NGO collaboration. He was encouraged when he learned about the local government contributions in the MaMoni HSS supported areas of and replicated similar initiatives in his own district. For example, he arranged for an allocation of Taka 2 lakhs from the local government to construct a dumping pit and to hire cleaners for the Jhalokathi Sadar Hospital.

Logistics management has also been strengthened with facilitation and support from the MaMoni HSS program and Dr. Rahim now has clear and up-to-date information on the status of medical supplies and pharmaceuticals through the dash-board and can mobilize emergency supplies from adjacent districts when needed. Previously this could only be done with re-stocking by the national level authorities. Dr. Rahim routinely follows the dash- board, takes necessary actions and contacts national level authorities when needed.

When he was selected as the best performer for increasing fully vaccinated coverage among children under one year from 76.4 in 2014 to 90.0 in 2015, the man humbly said that it was the result of all the concerned staff and volunteers who worked sincerely and with tremendous dedication. He expressed gratitude as they all complied with his requests, worked so hard and upheld his honor and intentions. He specifically praised the role of the MaMoni HSS volunteers, as much of the rapid progress was made possible by the exchange of information with Health Assistants and Family Welfare Assistants in the community micro planning meetings (CMPM).

Photo Credit: Mr. Mohitul Azim, Save the Children/MaMoni Health Systems Strengthening Project

This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government. TABLE OF CONTENTS

Table of Contents ...... 3 Abbreviations ...... 4 Executive Summary ...... 6 Introduction ...... 9 Program Results for the Quarter ...... 10 IR 1. Improve Service Readiness through Critical Gap Management ...... 10 IR 2: Strengthened Health Systems at District Level and Below ...... 33 IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems ...... 44 IR 4. Identify and Reduce Barriers to Accessing Health Services ...... 47 Challenges, Solutions, and Action Taken ...... 50 Way Forward ...... 51 Appendix 1: Scope and Geographical coverage of Mamoni HSS project ...... 50 Appendix 2: Data Sources ...... 53 Appendix 3: Program Performance Indicators (January 2017–February 2017) ...... 52 Appendix 4: Additional Indicators ...... 66 Appendix 5: List of Union Facilities Upgraded ...... 69 Appendix 6: QIS Activities ...... 70 Appendix 7: MNCH Essential Drugs Monitoring Report ...... 72 Appendix 8: Documentation and Dissemination of MaMoni Program Learning ...... 75 Appendix 9: News Clips Published During January- March 2017 ...... 75

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 3 ABBREVIATIONS

ACS Antenatal Corticosteroid AHI Assistant Health Inspector AMTSL Active Management of Third Stage of Labor ANC Antenatal Care APK Android package kit BEmONC Basic Emergency Obstetric and Newborn Care BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CBT Competency Based Training CC Community Clinic CCSDP Clinical Contraceptive Service Delivery Program CEmONC Comprehensive Emergency Obstetric and Newborn Care CHW Community Health Worker CHX Chlorhexidine CMPM Community Micro Planning Meeting CS Civil Surgeon CSBA Community Skilled Birth Attendants CV Community Volunteer DDFP Deputy Director Family Planning DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DH District Hospital DHIS2 District Health Information System-2 ENC Essential Newborn Care EoP End of Project e-LMIS electronic-Logistics Management Information System e-MIS electronic- Management Information System FP Family Planning FPI Family Planning Inspector FWA Family Welfare Assistant FWV Female Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe Hg Habiganj HNPSP Health, Nutrition and Population Sector Program HR Human Resource HRIS Human Resource Information System HRM Human Resource Management HS Health Systems HSS Health Systems Strengthening IFA Iron Folic Acid IMCI Integrated Management of Childhood Illness IPHN Institute of Public Health Nutrition IR Intermediate Result IUCD Intra Uterine Contraceptive Device IUD Intra Uterine Death Jk Jhalokathi JSV Joint Supervisory Visit KMC Kangaroo Mother Care LAPM Long-acting and Permanent Method LARC Long-acting Reversible Contraceptive LMIS Logistics Management Information System Lp Lakhsmipur MCWC Maternal and Child Welfare Center

4 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report MEC Medical Eligibility Criteria MFSTC Mohammadpur Fertility Services and Training Centre MNCH/FP/N Maternal, Newborn and Child Health, Family Planning, and Nutrition MNH Maternal and Newborn Health MO Medical Officer MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOMCH&FP Medical Officer-Maternal and Child Health & Family Planning MPDSR Maternal and Perinatal Death Surveillance and Response NGO Non-government Organization Nk Noakhali NNS National Nutrition Services NVD Normal Vaginal Delivery OBGYN Obstetrics and Gynecology OGSB Obstetrical and Gynecological Society of Bangladesh OP Operational Plan PDCA Plan-Do-Check-Act PE/E Pre-eclampsia/Eclampsia PHD Partners in Health and Development PIP Program Implementation Plan Pj Pirojpur PM Program Manager PMMU Planning, Monitoring and Management Unit PNC Post Natal Care PPFP Post-partum Family Planning PPIUCD Post-partum Intra-uterine Contraceptive Device PRS Population Registration System QI Quality Improvement QIS Quality Improvement Secretariat QoC Quality of Care RMO Residential Medical Officer SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBCC Social & Behavioral Change Communication SBM-R Standards-Based Management and Recognition SC Save the Children SCANU Special Care Newborn Unit SCMP Supply Chain Management Portal SDP Service Delivery Point SIAPS Systems for Improved Access to Pharmaceuticals and Services SSN Senior Staff Nurse TAB Tablet Computer TAG Technical Advisory Group UFPO Family Planning Officer UHC Upazila Health Complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development USC Union Sub-centers WISN Workload Indictors of Staffing Need WHO World Health Organization

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 5 EXECUTIVE SUMMARY

In the second quarter of fourth year, MaMoni HSS continued to support MOH&FW in strengthening health systems at the national and district level, and to improve utilization and service delivery of integrated maternal, newborn and child health, family planning, and nutrition services at the district level. Key accomplishments in this quarter include: . Gradual upgradation of Union Health and Family Welfare Centres (UH&FWC’s) through multi-pronged interventions and designation as functional 24/7 facilities. In this quarter, 15 facilities have been upgraded from category B to category A and 2 facilities from category C to category B. UH&FWC upgradation has been identified as a priority activity in the health, nutrition and population sector plan (2017-2022). . The Quality Improvement Secretariat (QIS) in the MOH&FW was strengthened through recruitment, deployment and capacity building of national and divisional level quality improvement (QI) coordinators. The project is facilitating the formation of the QI committees at district, upazila and health facility levels as well as activating the existing committees. The project is also ensuring the engagement of local government in the QI initiatives for mobilizing the resources required for replenishing supplies, minor renovations and building waste management pits. In this quarter the project focused on improving the quality of care at different levels of service provision and also community- focused approaches at the household, community and families to create demand for quality care. . MaMoni HSS attended the global meeting held in Malawi in February to launch the WHO QoC network. Follow up discussions have been held with the QIS and other stakeholders, including UNICEF, WHO and UNFPA to start joint initiatives to strengthen the MNH QOC in the country. Under the leadership of QIS, some progress has been made to prepare a draft of the RMNCH framework and standards relevant to the country. . First phase of the ‘workload and staffing needs assessment at public sector healthcare facilities’ study, aimed at defining the major workload components of different category of staff and setting standard time required for each workload components, has been completed. Draft report of the first phase has been submitted for review by Technical Advisory Group (TAG). MaMoni HSS is also facilitating the use of Human Resource Information System (HRIS) software by local managers for efficient HR planning. An inception meeting was held in Habiganj.

. The project extended the Letter of Collaboration (LOC) with the Planning Wing to support the finalization of the Operational Plans (OP) and support dissemination and coordination of implementation of the fourth sector program. MaMoni HSS also coordinated with several OPs to incorporate the project supported activities into the OP activities.

. MaMoni HSS finalized the plans for training the newly recruited Medical Officer (MCH- FP) from the project districts on emergency obstetric care (EOC) and on long-acting, reversible contraceptives and permanent methods (LARC & PM). These long-term training activities will start in the third quarter.

. The project contributed to the national scale up of e-LMIS in coordination with SIAPS. e- LMIS has been implemented in as a part of DHIS2. A government order has been issued for introducing e-LMIS in all MaMoni districts.

. The eMIS intervention aims to automate the business process of the GoB's rural health system through digitization of the paper based registers to e-register. This e-register,

6 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report which records individual health data traceable via uniquely assigned health ID, has been rolled out in all union level facilities in Habiganj. The patient level health data is also available on the monitoring tool which allows tracking/referral of high risk indicators. One such tool developed in this quarter is "high blood pressure monitoring". Since all the ANC visit data are digitally available, the medically intelligent system can detect if a visiting mother requires immediate referral and starts to prompt the provider (FWV) when the provider does not. The alert is also visible to the next level supervisor/managers who can initiate necessary action. A major achievement in this quarter is GIS incorporation in the monitoring tool. It allows easy presentation of the ever increasing volume of live service data generated from the facilities plotted in the map linked with demographic and human resource information for the entire country at a glance. This information can also be segregated by administrative level and areas. This category based color coded plotting of facilities also demonstrates the geographical coverage gap and helps policy makers to identify the areas where to concentrate the infrastructural activities and resource mobilization. The tool’s functionality was demonstrated in a USAID organized GIS workshop and widely appreciated.

. The newborn health reviews have been completed in the first 14 districts of , and divisions. The review process is coordinated by a medical officer identified as focal person for newborn health interventions, with facilitation support from the National Newborn Health Cell. The review includes: Refresher of HBB (including reprocessing of equipment) and Essential Newborn care including 7.1% Chlorhexidine for all SBAs who received both the trainings at upazila level, rapid assessment of preparedness and functionality of newborn interventions and replacement or provision of HBB equipment (Bag-mask and sucker) in the facilities. The findings include: 57% SBAs were trained in HBB and 83% were trained in ENC with 7.1% CHX; 88% of all facilities provided delivery care services and 15% had supply of 7.1% CHX; and HBB equipment were available in 69% of facilities having delivery care services. . MaMoni HSS is facilitating local government’s engagement in different tiers of service delivery through activating multi-level committees. A remarkable achievement has been made in involving Union Parishads during the process of UH&FWC assessment and upgradation. In many areas Union Parishads have taken the lead and mobilized funds for upgrading and/or maintaining the services at 24/7 union facilities. About USD 246,908 have been allocated by the local government bodies and by end of this quarter USD 83,294 has been spent for construction, repair, procurement, and arranging temporary staff for making the 24/7 facilities functional. Expenditures against allocated budget was affected due to election of local government (union parishad) in this financial year.

Challenges and mitigation strategies: . Shortage of staff: The chronic shortage in human resources is posing an important challenge to all project activities especially in improving the quality of health care. The project is facilitating the process in better utilization of available human resources through district and upazila planning.

. Staff Turn-over: Several key positions in DGHS and DGFP as well as in district level experienced turn-over within a short period. Moreover, MOH&FW has been recently divided into 2 directorates - the Directorate of Clinical Services and Directorate of Family Planning and Medical Education. This division has created uncertainties because of lack of clear guidelines on operational mechanisms. MaMoni is closely observing the changes and will adapt strategies to respond accordingly.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 7 . Frequent stock-outs of essential MNCH drugs hinder efforts to improve health outcomes. As a response, the project is building the capacity of local managers in monitoring the availability of essential drugs and taking local measures to avoid stock- out through routine tracking of supply chain management portal. . Chlorhexidine availability: Currently the supply chain of government only reaches the public providers. As a result, CHX is mainly used in public facilities and a small proportion of deliveries conducted at home by CSBAs. A large proportion of newborns who are delivered at home by unskilled providers (58%) or delivered in private facilities (22.4%) may be excluded from the intervention. MaMoni HSS is piloting distribution of CHX along with misoprostol in third trimester of pregnancy in Lakhsmipur district. Moreover, demand creation through national campaign/SBCC and awareness development of private providers are essential for increasing the coverage of CHX application.

. Transferring the ownership of the QI process to the project’s counterparts at district, sub-district, and health facility levels is a continuous challenge. There are encouraging examples of QI committees that have been able to solve local problems, they still require significant facilitation by project staff.

Way Forward: . Consolidate learnings from Habiganj and roll out the complete package of eMIS in Noakhali. Only UH&FWC e-registers will be rolled out in Lakhsmipur and Jhalokathi. MaMoni will also pilot paper-less record keeping and reporting in few unions in Habiganj. Supervisor’s modules, to be initiated in Habiganj and MaMoni will provide necessary support to the supervisors for using this for monitoring purpose. . A costed phase-wise UH&FWC upgradation plan will be developed and MaMoni HSS will continue advocacy with health, family planning and local government bodies for implementation of the plan and upgrade more UH&FWCs to 24/7 facilities. MaMoni is ready to provide technical support to MOH&FW in this regard. . Train the newly deployed MO-MCH-FP in project districts in EOC and LARC&PM. A total of 12 MO-MCH-FP will start the one-year EOC training, which will equip them to provide comprehensive EmONC services at MCWCs in the six project districts. Another 19 MO-MCH-FP, who are currently posted at the UHCs in the project districts will receive 18 days training on LARC&PM during the next quarter. . For ensuring chlorhexidine and other essential commodities, MaMoni HSS is planning to collaborate with Social Marketing Company (SMC) to use Community Volunteers in social marketing in few unions. The project staff already visited SMC to learn their experiences. . Continue collaboration with WHO, UNICEF and UNFPA and support GOB in strengthening maternal and newborn health through implementing WHO MN QI framework. MaMoni is in discussions with the QIS and other stakeholders to engage the QI implementation structures to identify critical gaps in service provisions and allow strengthening MNH care services in every facility with an ambitious aim of halving all preventable neonatal deaths and stillbirth in the facilities by 2030. Divisional and district QI teams will be involved in the process. . There is an anticipated stock out of essential drugs and supplies. Under the new sector program, drug procurement can’t be initiated before June. Moreover, there was a recent fire in FP national store causing massive destruction of FP commodities, essential drugs, registers and other logistics. MaMoni HSS will continue to monitor the drug availability and identify potential stock-outs with the help of LMIS. In case of potential

8 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report stock-outs, MaMoni will advocate and support DGHS, DGFP and local managers in adopting early and necessary actions. INTRODUCTION The MaMoni Health Systems Strengthening (HSS) project, is a five-year USAID-funded award1 aimed at improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services by utilizing a health systems strengthening approach. In quarter 2 of Year 4, MaMoni HSS has continued to support the MOH&FW to strengthen health systems at the national level as well as at district level. The project has expanded the technical assistance role at the national level, while consolidating the implementation at the district level. The project supports 40 in 6 districts, 23 of them are designated as high intensity (HI) areas and remaining 17 as health systems capacity strengthening (HSCS) areas. The scope and geographical coverage of the MaMoni HSS Project has been summarized below. Detailed coverage included in Appendix 1.

Table 1. Summary of MaMoni HSS geographic scope

No. of Health Facilities Population No. of Area No. of Upazilas (2015 Unions District projection) Hosp. & Upazila Union Community MCWC

High-Intensity 23 (Habiganj-8, Areas Noakhali-4, Lakhsmipur-5, 26 7,355,822 5 20 208 619 Jhalokathi-4, Pirojpur-2)

Health Systems 17 (-7, Capacity Noakhali-5, 151 4,870,933 5 13 121 488 Strengthening Pirojpur-5) (HSCS) Area

Total 40 377 12,226,755 10 33 329 1,107

In response to mid-term evaluation recommendations, a few strategic shifts in human resource and program structures have been implemented in this quarter, such as, number of Field Service Officers (FSO) reduced to half in high intensity areas and withdrawn from other areas. Also the Technical Officer (TO) position has been abolished across all project areas. New positions such as Facilitator-Service Delivery (26) in all high intensity districts, Upazila Facilitator-HIS (13) in Habiganj & Noakhali and Upazila Facilitator-Community Based Service (CBS-13) in Noakhali and Jhalokathi are on board and received intensive job description based training.

DATA SOURCES

1MaMoni HSS is the result of an Associate Award under the Maternal and Child Health Integrated Program, with a period of performance from September 24, 2013 to September 23, 2018. MaMoni HSS is supported by Jhpiego—in partnership with Save the Children, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). Save the Children serves as the lead operational partner for the Award in Bangladesh.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 9 Data from different sources such as Population Based Tracer survey (in high intensity areas), Sentinel survey (selected facilities in MaMoni areas), Service Delivery Point (SDP) assessment (selected facilities in MaMoni areas), Revisit of Specific Newborn Interventions (14 districts nation-wide), routine MIS of DGHS and DGFP have been used in this report. List and scope of the surveys is attached as Appendix 2.

PROGRAM RESULTS FOR THE QUARTER

IR 1. Improve Service Readiness through Critical Gap Management

1.1 Introduction and Scale-up of MNCH/FP/N interventions

1.1.1 Maternal Health

1.1.1.a. Increasing Antenatal Care (ANC) coverage

The population based tracer survey reveals that EoP targets of ANC-1 coverage were achieved in all districts and a steady increase has been observed in most of the areas (Figure 1). A remarkable achievement in ANC 4+ was observed in Noakhali. All other districts met EoP targets, except Jhalokahti, where a higher target was set considering the high baseline coverage (Figure 2).. In addition to increasing ANC coverage, the project is implementing an integrated strategy to improve the quality of ANC. Interventions include supporting service providers to follow the standards, providing supportive supervision, monitoring the availability of ANC drugs and commodities, and measuring the quality of ANC in sentinel sites through direct observation. Figure 3 demonstrates the gaps in prevailing counselling practices on pregnancy complications, delivery with skilled attendants and importance of at least 4 ANC visits. To improve the situation, refresher training/clinical attachment has been provided to improve the counseling practice and technical capacity of the service providers to address these issues. Improving quality of ANC service will remain as a focus area of MaMoni HSS throughout the remaining project period.

Figure 1: Trends in ANC-1 coverage by a medically trained provider

10 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 100 2012 2013 2014 (Round-I) 2015 (Round-II)

90 2016 (Round-III) 2016(Round-IV) 2017(Round-V) EoP target 83 81 81 80 82 80 76 77 74 75 75 74 73 72 74 70 70 71 72 70 68 69 70 66 66 64 73 70 65 60 61 67 70 60 53 51 50

40 37

30

20

10

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

Source: Population Based Survey in high intensity areas Figure 2: Trends in ANC 4+ coverage by medically trained providers

60 2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) EoP Target 50 50 44 44 43 42 43 41 40 39 39 40 38 37 35 36 36 34 36 31 30 30 30 26 26 25 26 26 23 22 21 26 20 19 15 14 12 9 10

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

Source: Population Based Survey in high intensity areas

Figure3: Observation of Antenatal Care Service and Counselling

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 11 100 99 98 96 98 96 100 94 93 93 94 91 92 93 88 90 83 83 80 82 77 80 73 70 70 65 62 64 61 59 60 51 49 50 45 47 39 37 38 40 32 30 21 20

10

0 Blood pressure Hemoglobin test Nutrition diet Iron Folic Acid Counselling given Counselling given Instructions given measured conducted discussed during tablet given or on Complications on Importance of to conduct delivery pregnancy prescribed during pregnancy 4 ANC with a qualified health worker

Habiganj Jhalokathi Lakshmipur Noakhali Total

Source: Sentinel survey in selected facilities, 2016

1.1.1.b. Pre-eclampsia (PE)/eclampsia management at community level In this quarter, MaMoni HSS focused on capacity building of service providers on identification and management of PE/Eclampsia. A total of 114 service providers including Family Welfare Visitors (FWV), Sub-assistant Community Medical Officers (SACMO), Paramedics and Senior Staff Nurse (SSN) of five upazilas in Habiganj participated in the training. Each batch had inclusive practical sessions conducted at the Upazila Health Complex (UHC) on proper technique of MgSo4 administration. Moreover, district level orientations on referral protocol were completed in Lakshmipur and in Habiganj by the facilitation of Obstetrical and Gynecological Society of Bangladesh (OGSB). Total 33 service providers including Consultant Obstetrician/Gynecologist (OBGYN), Medical Officer (MO), Residential Medical Officer (RMO), MO-Clinic and Medical Officer-Maternal & Child Health – Family Planning (MO-MCH-FP) participated in the orientation.

12 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report

Practical sessions on PE/Eclampsia at UHC Follow-ups after training were conducted by senior professors of obstetrics and gynecology from OGSB who observed the gaps in patient identification and management and provided on the job support for performance improvement of the providers.

Prof. Firoza Begum, Secretary General-OGSB facilitating sessions Prof. Latifa Shamsuddin visited Auskandi UH&FWCs

All these efforts resulted in increased patient identification and referral. Total 72 patients from high intensity program areas were identified and received loading dose of MgSO4 in this quarter, which is 1.5 times more than that of previous quarter (Figure 4).

Figure 4: Number of PE/Eclampsia Cases Identified & Received Pre Referral Loading dose of MgSO4 in selected upazilas where PE/E intervention on-going (Aug’ 16 to Mar’ 17)

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 13 30 Training conducted between Nov-Feb 25

20

15

10

5

0

Source: MIS-3, DGFP report

1.1.1.c. Misoprostol to prevent postpartum hemorrhage in home births MaMoni HSS is supporting the MOH&FW in tracking the distribution of misoprostol from the central level to the service delivery points. Family Welfare Assistants (FWAs) and Family Welfare Visitors (FWVs) are collecting misoprostol from upazila store and distribute to the pregnant mothers who are in 3rd trimester. As a result, there is an increasing trend in misoprostol distribution by FWAs and FWVs (Figure 5). Population based surveys show mixed results regarding the consumption of misoprostol by women delivering at home (Figure 6). This may be because of the recall period of population based survey which was during 3rd quarter of year-3 while distribution was low due to stock outs. Figure 7 demonstrates that majority of women who received misoprostol during pregnancy consumed the drug and compliance was not a major issue. As MaMoni HSS is tracking and facilitating the distribution, a better consumption rate may be expected in following surveys. However, the challenges of misoprostol distribution are about one-third vacant positions, lack of home visits by FWAs and lack of a need based distribution system. All upazilas, irrespective of their population size receive same number of tablets from the district store. Also, distribution from upazila store is not need based, all FWAs receive same number of tablets (50 each) at a time. As a result, FWA who has more HHs can distribute quickly whereas the one who has less HHs take more time to complete the distribution. Upazila store doesn’t supply any misoprostol till both of them distribute all the tablets. So, one FWA has to wait till the other finishes distribution. MaMoni HSS started advocating for need based distribution of misoprostol tablets and for developing a system of regular tracking and distribution. Figure 5: Trend of misoprostol distribution by FWVs and FWAs by quarter in all 6 MaMoni HSS districts (Apr ’16-Mar ’17) 27918 30000 24750 25000 20000 16191 15000 11609 10000 5000 0 Q3-Y3 Q4-Y3 Q1-Y4 Q2-Y4 Sources: MIS-4, DGFP

Figure 6: Trend of misoprostol consumption among women who delivered at home

14 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 60 2012 2013 2014 (Round-I) 55 50 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 50 47 2017 (Round-V) EoP Target

42 43 42 45 40 36 35 34 33 34

30 30 28 30 27 23 22 22 21 19 20 18 14 14 11 10 9 10 8 8 7 8

3 3 2

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Source: Population Based Survey in high intensity areas

Figure 7: Status of misoprostol received and consumption in home delivery since Mar’16 to Aug’16

100 Misoprostol received Misoprostol consumption 90

80

70

60 54

50 42 37 36 40 36 34 29 30 27

20 10 9 10

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

Source: Population Based Survey

1.1.1.d. Increasing Skilled Birth Attendance (SBA) at the District Level There is an increasing trend in deliveries attended by SBAs in all districts (Figure 8). Progress is slow in Habiganj and Lakhmipur where more efforts are required to achieve program targets. There is 34 percent increase in total number of SBA deliveries conducted in this quarter compared to the same period last year (Figure 9).

Figure 8: Percent of births attended by a skilled attendant

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 15 70 2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) EoP target 60 58 53 51 52 51 51 50 50 51 50 47 45 45 43 40 39 40 40 39 37 40 36 36 36 37 34 35 35 32 32 30 29 30 28 28 26

19 20

10

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Source: Population Based Survey in high intensity areas

Figure 9: Number of SBA deliveries in Q2 of Y-3 and Y-4 shows 34 percent increase in SBA deliveries in a year

30000 27696

25000

20000 17697 18231

15000 12894 9999 10000 5337 5000

0 SBA delivery in HI area SBA delivery in HSCS area Total SBA delivery

Y3-Q2 Y4-Q2

Sources: MIS-2 and MIS-4 of DGFP, DHIS-2 and pCSBA report of Project MIS.

1.1.1.e. Private CSBAs (pCSBA) supported deliveries Deliveries by private community SBAs remained static since last quarter (Figure 10). To increase the coverage in areas where there is no health facility around, MaMoni has taken steps to review their geographical locations, promotion of their service through multiple channels and linking them with the health system and local government institutions.

16 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report

Figure 10: Number of deliveries by pCSBA inMaMoni HSS areas during Oct'16 and Mar'17

120 100 95 98 100 93 90 78 80

60

40

20

0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Source: Project MIS

1.1.1.f. Health Facility Preparedness for MNCH/FP/N Services Capacity building through clinical attachment of FWVs & Paramedics in District Hospital & Maternal and Child Welfare Centres (MCWC): FWVs & paramedics from selective UH&FWCs of MaMoni HSS areas had gone through 21 days clinical attachment in DHs & MCWCs in Noakhali (12) & Lakshmipur (5) with the aim of promoting facility delivery & improving quality of normal delivery (NVD) services at UH&FWCs. The purpose of these attachments was to provide health workers from the UH&FWC’s an opportunity to practice in a higher level facility with stronger technical capacity and a higher load of complicated cases, and to learn from counterparts in these facilities. They were placed in OB/GYN outpatient department and inpatient ward (female Ward), labor room, postnatal and antenatal wards. The clinical attachment sites were identified on the basis of readiness and equipped with instruments, supplies, information materials & logistics. Senior staff nurses were full time mentors & district level supervisors (Hospital Superintendent, Civil Surgeon, Deputy Director-FP, MO-Clinic) supervised & monitored the clinical attachment.

NK participants in a group Participants conducting Practicing ENC on study delivery Dummy

The trainees practiced the skills required to provide quality ANC, PNC & skilled attendance at birth which was specially focused on Active Management of Third Stage of Labor (AMTSL) & use of partograph. Self-assessment checklists on ANC, PNC & labor room protocol including PPFP and essential newborn care were used.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 17 ii) The DGFP, MOH&FW with the support of USAID’s MaMoni HSS Project conducted a nation-wide assessment of union level health facilities to determine the readiness of these facilities for conducting normal delivery. The study was conducted between February 2015 and February 2016. The facilities were grouped in three categories for synchronized upgradation based on coverage, delivery facility, HR, training, infrastructure, furniture, delivery services, human resource, residence etc. The categories are:

Category A: These facilities met most of the requirements to provide normal delivery services. However, some of these facilities will require additional renovation or physical improvements, such as renovation of the staff residence, running water etc. During the assessment 14 percent facilities were found in this category.

Category B: Majority of the UH&FWCs were in this category Additional inputs will be required to renovate the staff residence and to ensure water supply and electricity. Also, additional staff, equipment and basic furniture will be required in these facilities. 69 percent facilities were found as category B during the assessment.

Category C: These facilities Figure 11: Change in no of UH&FWCs from B to A and require major inputs for C to B since 2015-16 to 2017 in MaMoni Districts renovation and upgradation. 250 Seventeen percent facilities were 200 187 200 in this category. 150 But now after one year of the 100 64 79 71 69 assessment, many facilities have 50 already been upgraded through 0 Category A Category B Category C various interventions and the MOH&FW has included it in their 2015-16 2017 next sector plan as a priority intervention. Some of them are now providing 24/7 delivery service. The categorization scores of facilities in MaMoni HSS districts were revisited in this quarter through using SDP assessment and staging process of the project. It was found that a total of 17 facilities have been upgraded to higher category than before. Fifteen facilities have been upgraded from category B to category A and 2 facilities from category C to category B. For example: Bagasura UH&FWC in Habiganj and Norottompur Before Upgradation After Upgradation UH&FWC in Noakhali were B category facilities. With local government interventions and change in delivery services, now they are converted into A category facilities.

18 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report

Figure 12: No. of deliveries in 24/7 UH&FWCs in a year (Apr 2016-Mar 2017)

90 4000

80 3500 3439 3467 3407 70 3000 60 2500 50 2507 2000 40 81 75 75 1500 30 65 20 1000 10 500 0 0 Apr-Jnu'16 Jul-Sep'16 Oct-Dec'16 Jan-Mar'17

No. of 24/7 UH&FWC No. of delivery

Source: Project MIS and MIS-3, DGFP

Through rigorous advocacy, MaMoni has ensured inclusion of union level facility upgradation in the current national sector plan. However, the resources allocated are not sufficient for nationwide coverage. Activities in the upcoming quarter include developing a national costed operational plan for upgradation of UHFWCs that will allow MOH&FW to implement a phase-wise efficient expansion. MaMoni HSS will continue advocacy and provide technical support to DGHS, DGFP and local government bodies in rolling out the plan as well as leveraging resource from other development partners. Moreover, the current information available will be linked to a live dashboard and GIS information of each facility that will support MOH&FW in decision making process.

1.1.2 Newborn Health National activities: All the activities under the national scale-up initiative were led by the Integrated Management of Childhood Illness (IMCI) section of DGHS. In 2015, MaMoni HSS supported the establishment of National Newborn and Child Health Cell at IMCI section. This body played a pivotal role in implementing the nation-wide activities on Essential Newborn Care (ENC) including resuscitation and chlorhexidine application to the umbilical cord stump through Bangabandhu Sheikh Mujib Medical University (BSMMU) and Partners in Health and Development (PHD). The major newborn activity in this quarter was the revisit of priority newborn interventions in selected 30 districts (750 facilities) which is being implemented in phases. Revisit in 14 districts was initiated in November 2016 and completed in February 2017, while revisit initiated in remaining 16 districts in February 2017. This report mainly captures the findings of 1st phase districts (see footnote). Gradually, all 64 districts will be covered by this intervention.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 19

1.1.2.a. Revisit of priority newborn interventions: In this quarter, Phase 1 of the specific newborn intervention revisit have been completed in 14 districts2 of Sylhet, Barisal and Dhaka divisions. Activities under Phase 2 of the revisit have been initiated in 16 districts3 of , and .

National Newborn Health Cell has designed the following activities under “Revisit of Specific Newborn Interventions.”

- Identification of 2 Medical Officers from each upazila to act as Newborn Focal Person - Divisional and district level advocacy meetings - Training: Training of Newborn Focal Persons; refresher training of SBAs on Essential Newborn Care including HBB and 7.1% Chlorhexidine - Revisit in all facilities in the district : Quick assessment of preparedness and functionality of newborn interventions (HR and skill retention, facility readiness, medicine, supply, service utilization, stock status of 7.1% Chlorhexidine) in all facilities; replace/ supply of HBB equipment (Bag-mask and sucker) in the facilities

Data collectors from partner organizations PHD and BSMMU conducted revisits and used standard checklists and gathered information on HR and skill retention, facility readiness, medicine, supply, service utilization and stock status of 7.1% Chlorhexidine from each facility of 14 districts. A total of 216 Medical Officers received a 2 day course from BSMMU and designated as Newborn Focal Persons. Fourteen district level advocacy meetings and upazila level refresher trainings on a single package of HBB & ENC (including application of 7.1% Chlorhexidine) were organized for SBAs and CSBAs.

TOT of Newborn Focal Persons at BSMMU Advocacy and Planning Meeting on Specific Newborn Intervention Revisit

Preliminary findings of the revisit conducted in the Phase 1 districts are listed below:

. The average percentage of trained personnel available in facilities is 57% for HBB and 83% for 7.1% CHX.

2 1st Phase districts: Sylhet, Maulavibazar, Sunamganj, Barisal, Perojpur, Bhola, Barguna, Patuakhali, Perojpur, Dhaka, , , Manikganj,Tangail, Munshiganj

3 2nd Phase districts: Khulna, Bagerhat, , Narail, Magura, Kustia, Chuadanga, Meherpur, Jhenaidah, Satkhira, Rangamati, Bandarban, Khagrachari, Sherpur, Narsingdi,

20 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report

. The average percentage of facilities where service delivery capacity and 7.1% CHX product is available by division is 88% and 15% respectively. Only a few of the MCWCs and union level facilities had 7.1% CHX supply during the visit. As a result of advocacy, in most places 7.1% CHX was made available from the respective district/upazila stores soon after the visit.

. 69% facilities where newborn resuscitation capacity exists had HBB kits available

. The average percentage of facilities where MgSO4, Amoxicillin Pediatric drop and Inj. Gentamycin 20mg were available were 6%, 75% and 4% respectively.

. The table below shows the average percentage of DH, MCWC and UHC where MgSO4, Amoxicillin Pediatric drop and Inj. Gentamycin 20mg were available by facility.

Table 2: Availability of essential newborn care medicines in phase 1 revisited facilities

Percentage of facility has Inj. MgSO4, Paediatric Amoxycillin and Inj. Gentamycin 80 mg during the survey time by facility types DH MCWC UHC UH&FWC-FP UH&FWC-H

Inj. MgSO4 25 17 16 5 2 Amoxicillin Pediatric drop 17 100 37 81 79 Inj. Gentamycin 25 6 26 1 0 Percentage of facilities offering delivery services & percentage of facilities (by type) where CHX 7.1% and HBB are available

DH MCWC UHC UH&FWC-FP UH&FWC-H Delivery service 100 100 96 89 77 CHX (7.1%) 75 22 83 6 7 HBB Kit 58 94 72 71 54 Percentage of personnel trained on CHX and HBB against the number of personnel available in the facility during the day of visit CHX trained 83 HBB trained 57

1.1.2.b. Other national activities:

National Newborn and Child Health Cell is supporting IMCI section to implement IMCI and specific newborn activities in all the districts. Through this ‘Cell’, the project is facilitating national level planning, stakeholder coordination, monitoring and documentation of the scale-up of KMC and newborn sepsis management.

With the leadership of PM-IMCI, the National Newborn and Child Health Cell has circulated the second issue of the ‘National Newborn Newsletter’ which contains national level newborn related GO-NGO activities of last quarter. The ‘Cell’ has analyzed and categorized the districts and circulated a report titled, ‘IMCI services and report for 2016’ to all concerned Civil Surgeons. The ongoing revisit program and quarterly staff coordination meetings are also arranged by Post training follow-up attended by PM-IMCI, Divisional Director-health and Divisional Director-FP

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 21

the newborn cell. Following is the link of the national newborn newsletter:

http://www.healthynewbornnetwork.org/resource/bangladesh-newborn-bulletin/

District Level Newborn interventions:

1.1.2.c. Use of 7.1% Chlorhexidine to prevent newborn infection Soon after national roll out of orientation on Essential Newborn care including application of 7.1% Chlorhexidine (CHX) ended in June 2016, a post-training follow up was done in 64 districts by 32 Independent Monitors during August-September 2016. Independent Monitors have also facilitated distribution and use of 7.1% CHX in respective districts. To follow-on, the national stakeholders convene regularly in a forum to discuss the progress of national scale-up. Other progresses include budget allocation of MOH&FW in the next operation plan (2017-2022), incorporation of indicators in the sector plan to monitor the use of 7.1% CHX, incorporation of application of 7.1% CHX at facility level in the revised EOC registers, inclusion of indicator in EOC monthly report to capture 7.1% CHX application information in DHIS2. A newborn health dashboard has been developed in DHIS2 which shows real time data on use of 7.1% CHX at facility and community.

Screenshot of newborn dashboard of DHIS2.

Under national scale up activities, CHX application for newborn cord care is being implemented in project districts. During this period a total of 8,226 newborns received CHX in project districts (Habiganj - 2680, Noakhali - 2362, Lakshmipur - 1903 Jalokathi - 236, Bhola - 821 and Pirojpur - 224). However, population based surveys show found a small proportion of newborns received 7.1% CHX immediately after birth in MaMoni intervention areas. This is likely due to low recall of mothers who may not remember all events around the childbirth. Also, due to the inadequate supply availability as direct distribution of CHX to antenatal mothers has not started, which limits the coverage for home deliveries. Figure 13, derived from DGFP’s routine reporting system shows 80% of the newborns who were born in a DGFP facility (MCWC and UH&FWC) or delivered at home by CSBA received CHX during this reporting period. In few cases coverage exceeds more than 100% at facility due to few newborns got PNC at facility within 24-48 hours though the deliveries took place at the community. Following are the barriers related to CHX application and the project is keenly working with the MOH&FW to deal with the barriers with multipronged approaches.

a) Currently the supply chain of government only reaches the public providers. As a result, CHX is mainly used in public facilities and a small proportion of deliveries conducted at home by CSBAs. A large proportion of newborns who are delivered at home by unskilled providers (58%) or delivered in private facilities (22.4%) may be

22 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report excluded from the intervention. MaMoni HSS is piloting distribution of CHX to the mothers along with misoprostol in third trimester of pregnancy. Moreover, demand creation through national campaign/SBCC and awareness development of private providers are essential for increasing the coverage of CHX application.

b) Procurement by MOH was not sufficient to cover all the facilities and home deliveries. There is a possibility of stock out as previous supply of CHX will be exhausted before the next procurement. Also 19,000 bottles of CHX were damaged by a recent fire at DGFP central warehouse that poses further challenge of mitigating stock-outs. Director- Primary Health care has issued memo to district level managers to procure it locally unit the national procurement is completed.

c) As this is a relatively new indicator, data quality remains as a challenge both in population based surveys and in routine MIS. MaMoni is working with the MOH&FW for data quality assurance and monitoring the intervention.

Figure 13: Use of 7.1% CHX in DGFP facilities or by DGFP providers by place of CHX application in MaMoni 4 districts (Oct'16 to Mar'17)

120 102 97 99 100 97 98 100 89 89 88 86 84 81 80

60 Percent 40

20

0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

CHX 7.1 used at facility delivery CHX 7.1 used at home delivery

Source: MIS-4, DGFP

1.1.2.d. Newborn Sepsis Management MaMoni HSS supports 163 UH&FWC of 5 districts in management of sick children (<2month of age) following national guideline (Figure 15). Sub-assistant Community Medical Officer (SACMO) is the designated provider of this intervention while Family Welfare Visitor can provide 2nd dose of Inj. Gentamycin in case of referral failure. In this quarter, a total of 1477 sick children (0-2month) were managed at UH&FWC. Of them 761 cases from Habiganj, 227 cases from Noakhali, 120 from Jhalokathi, & 379 from Lakshmipur. Twenty-eight percent of them had Isolated Fast Breathing (IFB), 26% had Local Bacterial Infection (LBI), 6% had Clinical Severe Infection (CSI), 3% had Critical Illness (CI) and the rest came with other different causes. During this quarter refresher training for SACMOs along with basic training for FWV of 64 unions of Jhalokathi district was organized.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 23

Figure 14: Number of sick infants (<2 month) managed at union level in 21 upazilas of 5 districts during Jan'16-Mar'17

800 700 719 640 600 532 534 523 500 496 498 494 486 497 474 465 454 447 400 396 300 200 100 0 Jan'16 Feb'16 Mar'16 Apr'16 May'16June'16 July'16 Aug'16 Sep'16 Oct'16 Nov'16 Dec'16 Jan'17 Feb'17 Mar'17

CI CSI IFB LBI Other Total

Source: Project MIS

Figure 15: Classification of sick infants (<2 months) presented at the union level facilities in 21 upazilas of 4 districts during Jan'16-Mar'17

203, 3% 448, 6%

2833, 37% 2136, 28%

2035, 26%

CI CSI IFB LBI Other

Source: Project MIS

1.1.2.e. Kangaroo Mother Care (KMC) The project has been supporting the establishment of Kangaroo Mother Care (KMC) units in 15 facilities (4 district hospitals, 2 MCWCs, 9 UHCs) in 4 implementation districts (Habiganj, Noakhali, Lakshmipur and Jhalokathi). During the reporting period, a total of 17 cases were admitted at KMC unit of 6

24 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report KMC service at Jhalokathi district hospital facilities. Poor case reporting, short duration of stay, and limited post discharge follow up are some of the key challenges of this intervention. To address the challenges, the program is planning to organize a district review on KMC in the program districts in next quarter.

1.1.2.f Antenatal corticosteroids (ACS) for threatened preterm labor Bangladesh recommends the use of Antenatal Corticosteroids (ACS) in threatened preterm deliveries to reduce neonatal mortality and morbidities. The program is supporting introduction of this intervention - utilizing national guidelines - in three district hospitals (Habiganj, Noakhali, and Lakshmipur). During this reporting period, the intervention was on-going in Habiganj and Noakhali, and it will be initiated in Lakshmipur district from next quarter. During January and February 2017, a total of 30 eligible pregnant women received ACS. We have a plan for retrospective collection of outcome information from a sample of clients who received ACS and delivered in the hospital.

1.1.2.g Facility based care for sick children There are five Special Care Newborn Units (SCANU) in five project district hospitals (Habiganj, Noakhali, Lakshmipur, Bhola & Pirojpur). Of them, four are supported by SAARC development funding while the Lakshmipur SCANU has been established with exclusive project support. Availability of dedicated and trained manpower, supply of equipment and logistics, and regular maintenance of sophisticated equipment are some of the key challenges to operation that are faced by the SCANU’s. The program has been supporting the MOH&FW to overcome these challenge. As part of this support, a batch Emergency Training and Triage (ETAT) training was organized, and 23 nurses have been attached to the SCANU’s. During the period of January and February 2017, a total of 310 sick children were managed in all SCANU’s of project area (129 in Noakhali, 76 in Lakshmipur, 8 in Habiganj, 8 in Pirojpur and 89 in Bhola). All the SCANUs have started reporting online into DHIS 2. Primary cause of admission and outcome will be available from next quarter.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 25

Case study: Life saved by Special Care

Anowara Begum (25) is from Gangchil village, 30 kilometers away from Companiganj Upazila in Noakhali. Her previous pregnancies had been met with misfortune – she had one miscarriage and two premature babies who died within four days of birth. During those pregnancies, she had never received antenatal care.

This time Anowara moved to her parent’s house in Anowara with her 2.5kg baby Mohammadpur union during the first month of her after 1 month stay in SCANU pregnancy. Mohammadpur UH&FWC is very close to her parent’s house. She had two antenatal checkups at this center. During her thirtieth week of pregnancy she suddenly noticed slight bleeding. Right away, she went to the UH&FWC and Rahima Khatun – the facility’s paramedic - examined Anowara and referred her immediately to the Hospital. However, Anowara’s family decided to take her to a private hospital where she gave birth to a premature baby. The baby weighed only 1200 gm. The duty doctors immediately referred the baby to Noakhali district hospital where the baby was readily admitted into the Special Care Newborn Unit (SCANU). After one month of close observation, the baby became physically stable and gained some weight.

Timely referral and specialized care at the SCANU saved the baby.

The SCANU at Noakhali District Hospital was established with funding from SAARC Development Fund with installation support from MaMoni HSS project. The project also supports the operation of the SCANU.

1.1.2.h Promotion of Essential Newborn Care in the community Postnatal check-up of newborns within 48 hours of birth has been increased in most of the implementation districts while early initiation of breastfeeding has shown no regular pattern (Figure 16 and 17). With the exception of , the project has a significant distance to go to reach targets on early initiation of breastfeeding.

Figure 16: Percentage of newborns initiated with breastfeeding within one hour after birth

26 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 100 2012 2013 2014 (Round-I) 2015 (Round-II)

90 83 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) EoP Target 77 77 7985 77 77 80 75 70 65 70 6472 62 55 57 63 60 52 53 54 52 52 48 48 50 45 44 42 42 41 41 42 37 40 38 38 40 30 20 10 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Source: Population Based Survey in high intensity areas

Figure 17: Percentage of newborns receiving a check-up within 48 hours of birth

2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 60 2016 (Round-IV) 2017 (Round-V) EoP Target

48 50 42 39 41 40 38 34 34 3432 32 29 33 28 30 27 24 25 22 19 19 1920 20 20 20 15 18 12 11 11 10 7 7 6 4 3 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Source: Population Based Survey in high intensity areas

1.1.3 Family Planning 1.1.3.a. Use of modern methods of family planning The population based surveys reveal that in the last five years use of modern contraceptives has remained static in all implementation areas (Figure 18). Use of various contraceptive methods also remained the same (Figure 19).

Figure 18: Prevalence of current use of modern method of contraceptive

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 27 100 2012 2013 2014 (Round-I) 2015 (Round-II) 90 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) EoP Target 80

70 58 57 56 56 56 55 57 55 60 53 54 53 53 54 5358 51 52 50 52 48 48 5549 50 5349 50 45 47 47 42 41 41 40 42 40

30

20

10

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

Source: Population Based Survey in high intensity areas

Figure 19: Change in FP method mix from February 2016 to March 2017

90 80 7 3 5 7 3 3 5 7 7 7 2 5 7 5 70 4 4 4 3 4 3 5 5 7 1 4 4 3 2 3 5 1 31 1 4 32 3 4 5 6 32 3 3 3 60 4 5 5 5 3

17 12 12 15 18 18 50 32 32 15 16 16 23 23 6 7 7 40 5 5 8 8 Percent 6 6 5 4 4 5 30

20 42 43 43 39 40 31 32 36 36 36 36 33 34 10 0 Mar-16 Mar-17 Mar-16 Mar-17 Mar-16 Mar-17 Mar-16 Mar-17 Mar-16 Mar-17 Mar-16 Mar-17 Standard Habiganj Bhola Pirojpur Jhalokati Noakhali Lakshmipur

Oral pill Condom Injectable IUD Implant NSV Tubectomy

Source: MIS-4, DGFP

MaMoni HSS is working with Clinical Service Delivery Program (CCSDP) of DGFP for improving quality of family planning service delivery including strengthening long acting and reversible contraceptives (LARC) and permanent methods (PM) in MaMoni HSS project areas. Major strategies adopted include:

• Joint monitoring visits to monitor and improve the quality of LARC & PM service delivery provided at UHC, MCWC and DH.

28 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report • Ensure logistic supply for quality improvement of mobile camps of LARC and PM in coordination with the Mayer Hashi II Project.

• Training of newly recruited MOMCH on LARC & PM in Sylhet and Chittagong divisions.

• Facilitate endorsement of the counselling module for FP & PPFP developed by MaMoni HSS by the Line Director, CCSDP.

• Capacity building of providers on FP policy changes, medical eligibility criteria (MEC) setting & monitoring of its implementation – the latest version of the MEC wheel is in the final stage. After finalization, training will be organized in Sylhet and Chittagong divisions with MaMoni HSS support.

1.1.3.b PPIUD performance

There is an increasing trend of PPIUD performance in most of the districts (Figure 20). However, progress is very slow in Habiganj, Jhalokathi, and Pirojpur where more efforts are required.

Figure 20: PPIUD performance between the period of April 2016 to March 2017

350 308 300 261 250 229

188 200 169

150 119 123 92 100 63 42 50 32 28 14 14 3 6 5 5 6 8 0 Noakhali Lakshmipur Habiganj Jhalokathi Pirojpur

Apr-Jun,16 Jul-Sep'16 Oct-Dec,16 Jan-Mar,17

Source: MIS-4, DGFP

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 29 Project has initiated basic training on IUCD & PPIUCD for Senior Staff Nurses from MaMoni HSS project areas in February 2017. Total 4 batches of trainings will be conducted by Mohammadpur Fertility Services & Training Center (MFSTC). At the end of the training, Kelly’s forceps, IUD posters & certificates, will be given to all participants. Also competency based refresher training on FP including PPFP was organized in this quarter. Engender Health, Bangladesh has provided technical support to this event. Total 46 participants attended the training.

Hands on coaching & demonstration on FP including PPFP

The project has also developed a planning and monitoring tool for newly trained nurses and is facilitating joint meetings of DGHS and DGFP to highlight these issues. 1.1.3.c Contribution of CSBAs and CVs in family planning

The counselling on PPFP by CSBA’s has increased in this quarter in comparison with previous quarters. (Figure 21). CV referral of LAPM remained static (between 20-23%) for last one year (Figure 22).

Figure 21: No. of women counseled on PPFP by CSBAs (Oct ’16 to Feb ’17)

2500

2000 485 485 462 1500 466 451 274

1000 1542 1590 1672 1311 1198 1294 500

0 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

No. of PPFP counselling (HI) No. of PPFP counselling (HSCS)

Source: MIS-4, DGFP

30 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Figure 22: CV contribution in LAPM performance Jan'16-Mar'17 by quarter

7442 7525 7500 6884

6500 5969 6066

5500

4500

3500

2500 1594 1735 1342 1477 1500 970

500 Q-2(FY-3) Q-3 (FY-3) Q-4 (Y-3) Q-1(FY-4) Q-2(FY-4)

Total LAPM CV contribution

Source: Project MIS

1.1.4 Nutrition MaMoni HSS works closely with government health and nutrition workers to help build their capacity towards social mobilization, referrals, and provision of effective nutrition counseling. To support the strategy of National Nutrition Services (NNS), MaMoni HSS has taken the initiative to develop skilled community front line health workers on nutrition screening (basic nutrition) and counseling which will help the program in active-case- finding. While generating demand, MaMoni HSS also develops the supply side through effective facility based services at upazila and district level (SAM Corner) under the leadership of IPHN (under NNS).

1.1.4.a Service availability: facility readiness for nutrition services

. Capacity building: MaMoni HSS supported competency based training (CBT) on nutrition in four upazilas (Sadar, Raipur, Ramgoti & Komolnagar) of Lakshmipur. A total of 320 service providers and first-line supervisors received training on nutrition screening and supervision. Additionally, 20 second-line supervisors were trained on supportive supervision of nutrition activities.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 31

Competency Based Training on Nutrition for Competency Based Training on Nutrition

. Logistic for SAM Units:

MaMoni HSS coordinated with IPHN and ensured basic consumable logistics (F-75 and F- 100)4 for 10 SAM Units located in 10 UHCs of four districts (Noakhali - 4, Lakshmipur - 4, Habiganj - 1, and Jalokathi - 1).

1.1.4.b Service Statistics

Data from DGFP MIS, DHIS2 and Project MIS show that in MaMoni HSS-supported districts:

. 330,399 (74,109 mothers & 256,290 children) children and mothers were reached with nutrition interventions from different types of service delivery points . 44,894 caretakers received BCC interventions that promote essential infant and young child feeding practices . 74,109 pregnant mothers were reached with Iron Folic Acid (IFA) supplementation during ANC visits among 94,294 pregnant women . 2,414 children were identified who had been suffering from MAM . 599 children were identified as SAM patients and referred . Among all children who were reached, about 17.5% were identified as malnourished. Among them 5.87% were stunted, 4.43% wasted, and 7.18% were underweight. . 41 SAM patients were admitted and treated from 10 SAM units in different districts. Of them, 44% were cured, 22.6% were discharged after stabilization, and 33.5% left the hospital without completion of treatment. No death reported among these children.

1.1.4.c Monitoring visits & performance review meetings:

4 F-75 is the “starter” formula to use during initial management, beginning as soon as possible and continuing for 2 to 7 days until the child is stabilized. Severe acute malnourished children cannot tolerate usual amounts of protein and sodium at this stage, or high amounts of fat. They must be given a diet that is low in protein and sodium and high in carbohydrate. The F-75 is specially made to meet the child’s needs without overwhelming the body’s systems in the initial stage of treatment. Use of F-75 prevents deaths. As soon as the child is stabilized on F-75, the F-100 is used as a “catch-up” formula during the rehabilitation phase to rebuild wasted tissues. F-100 contains more calories and protein than F-75.

32 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Two monitoring visits and performance review meetings were organized and attended by the Line Director NNS and Director IPHN at Habiganj and Jhalokathi districts. The visits were held in UHCs, UH&FWCs and Community Clinics. During the visits and performance review meetings, the Line Director discussed with the participants and managers about the performance of respective districts and way forward for mitigating current bottlenecks.

1.2 Management of critical human resource gaps of GOB service providers:

Table 3: Critical human resource gaps filled-in by MaMoni HSS

District FWA FWV/Paramedics Nurses GN/OBS

(CHW) (Nurse) up GOB up GOB up GOB up GOB (Paramedic) Vacant Posts Vacant Posts Vacant Posts Vacant Posts Vacancy filled Vacancy filled Vacancy filled Vacancy filled Vacancy filled Vacancy filled Vacancy filled Vacancy filled up by MaMoni MaMoni up by MaMoni up by up by MaMoni MaMoni up by up by MaMoni MaMoni up by

Noakhali 126 0 0 10 0 3 107 29 0 7 0 1 Lakshmipur 53 0 0 10 0 12 45 0 7 3 0 0 Habiganj 90 0 12 22 0 23 57 0 13 8 0 0 Jhalokathi 74 0 0 7 0 3 0 46 0 1 1 0 Total 343 0 12 49 0 41 209 75 20 19 1 1

MaMoni HSS is currently supporting 12 FWAs, 41 FWVs, 20 nurses to fill-in the critical human resource gaps of GOB service providers. The decisions for filling such vacancies are made through local level discussions with district/upazila managers. The vacant FWA positions are filled by CHWs in Habiganj to initiate the population registration and roll out of community based eMIS. The Paramedics were deployed to substitute FWVs in strategically placed UH&FWCs to ensure 24/7 delivery. In few UH&FWCs where patient load is too high to be managed by a single provider round the clock, an additional Paramedics was posted to manage the case load. Several nurses were placed in Habiganj and Laksmipur district hospitals as patient load is high and additional staff were required for round the clock delivery service as well as for newborn care especially at the SCANU. One OBGYN Consultant is posted in Hatiya, which is an isolated island without any facility to handle obstetrical emergencies. Staff retention in this island is a challenge and this population is usually excluded from any service. However, MaMoni is continuously advocating for filling-up of these positions in district level quarterly monitoring meetings as well as at national level.

IR 2: Strengthened Health Systems at District Level and Below 2.1 Comprehensive strategy for improving the quality of clinical care:

A comprehensive quality improvement (QI) strategy has been developed to support the MOH&FW at the national and district levels for improving the quality of clinical care for MNCH/FP/N services. The QI strategy has evolved over the past three years of project implementation. It has been revised based on lessons learned, experience in applying different approaches, and results documenting actual improvement of QI indicators. The project’s QI activities are comprised of three main components:

. National level support to QI efforts;

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 33 . Improving service delivery of MNCH/FP/N services; and . Measurement of QI indicators, through direct observation of services and taking action to close the gaps, and recognition of achievement. The progress in improving the quality of clinical care during Year 4, during the reporting quarter is summarized below:

2.1.1 Supporting the national Quality Improvement Secretary (QIS): MaMoni HSS continues to provide support to the QIS based on the Letter of Collaboration (LOC) signed last year. The purpose of this support is to enhance the capacity of the QIS to develop and implement strategies to improve the quality of clinical care across the country and measure their impact. MaMoni HSS supports to the QIS focuses on improving the quality of MNCH services and it extends to providing selected support for the implementation of the overall national health sector QI plan. The project has recruited and seconded several technical and support staff in Dhaka and at the divisional level as follows: • National Level - Senior QI Advisor, National QI Coordinator, Administrative Officer, and IT Specialist • Divisional Level – One QI Coordinator to each of the divisions (8 in total), plus QI Monitors for Sylhet, Chittagong and Barisal Divisions.

The project provided TA to support the inclusion of QI into the PIP and OPs, including the new WHO MN QI Framework. In addition, the project is supporting the QIS-led efforts to update the RMNCH standards.

Major project supports during this quarter include training of service providers and managers at heath facility on the 5S quality improvement approach, initiating the development of the PDCA (Plan-Do-Check-Act) curriculum through the hiring of a consultant, and development of a communication strategy for QI Secretariat.

Detailed QIS activities supported by the MaMoni HSS Project are included as Appendix 6.

2.1.2 Supporting the national effort to implement the new WHO Maternal and Newborn QI Framework: WHO member states and partners are launching a WHO-led network to improve quality of care for mothers, newborns and children. The network aims at an ambitious goal of halving maternal and newborn deaths in health facilities participating in the network over a period of 5 years. The WHO “Standards for improving quality of maternal and newborn care in facilities”, evidence based interventions for quality improvement, and a step by step country implementation framework have been developed to support the country processes. Bangladesh has been selected among one of the first group of countries for the implementation of this initiative. The MaMoni HSS program is supporting the MOH&FW to participate in this initiative and participated in a launching meeting in Malawi, February 14-16, 2017.

2.1.3 Leading the coordination of USAID QI efforts through Quality Improvement Council (QIC):

MaMoni HSS is chairing the QIC, which was established to coordinate QI activities and streamline support of USAID funded programs that contribute to improving the quality of clinical care. During the reporting quarter, MaMoni HSS chaired the third meeting of the QIC, which included an orientation on the national QI strategy, presented by the national QIS. The meeting also reviewed the QI strategy of NHSDP project.

34 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 2.1.4 Improving the quality of clinical care in stages:

The project continues to provide support to the district health managers to improve the quality of clinical care in stages as follows: Stage 1: to improve the cleanliness, infection prevention, and medical waste management, Stage 2: to improve sterilization measures and compliance with antenatal care and newborn care services, and Stage 3: to improve compliance with all range of MNCH/FP/N standards.

The following graph (Figure 24) summarizes the progress in the number of facilities that have successfully passed the first stage of QI. While improvements are being documented, several health facilities are yet to succeed in implementing the basic cleanliness and infection prevention measures. The project is encouraging the quality improvement committees at different levels to engage the local government and community to contribute to the efforts of quality improvement. In addition, the project is initiating an additional training on Plan-Do-Check-Act (PDCA) to stimulate improvement activities, particularly at district and Upazila level facilities.

Figure 24: Number of Health Facilities in 4 Districts Meeting Basic Infection Prevention Standards 60 51 SBasic Infection Prevention 50 Standards=Cleanliness; Hand Washing; Use of Gloves; Decontamination by 0.5% Chlorine Solution; Basic Medical Waste Management 40 36 31 28 30

20 16 16 9 8 10 8 8 10 5 5 6 4 5 0 0 0 0 0 Total Habiganj Lakshmipur Noakhali Jhalokati 15-Jul 16-Jan 16-Jul 17-Jan

Source: Health facility assessment checklist

2.1.5 Increasing local ownership of QI through establishing QI committees:

In order to increase local ownership, the project is facilitating the formation of the QI committees, which are formed by the national QIS of the MOH&FW at district, upazila and

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 35 health facility levels; as well as activating the existing committees. The project is also ensuring the engagement of local government in the QI committee meetings to mobilize resources required for replenishing supplies, minor renovations and building waste management pits. The table below includes an update on the status of the formation and activation of QI committees by district.

Table 4-: Status of Quality Improvement Committee Formation and Activation by District, February 2017

Number of QI Committees District

Habiganj Noakhali Lakshmipur Jhalokathi

Total to be formed 86 43 54 40 Actually formed 86 42 54 35 Active (had at least 1 meeting in 86 41 49 25 the last 3 months)

2.1.6 Strengthening routine supervision system and supportive supervision:

MaMoni HSS is facilitating the establishment of a system of supervisory visits by first line supervisors from union level to the community level, as well as by second line supervisors from upazila level to the union level and below. This facilitation includes the development of monthly visit plans and supporting the conduction of joint supervisory visits. Supervisory visits are taking place by using structured supervisory checklists in areas including: infection prevention, service delivery management, ANC, nutrition, FP, newborn and child health care, IMCI, normal vaginal delivery and postnatal care. The project ensures that each supervisory visit identifies gaps, develops an action plan for improvement and follows up on results.

Table-5: Percent of planned supervision visit conducted where a supervision tool was used and findings shared with providers.

High intensity areas Target Achievement Lakshmipur 90 53 Noakhali 90 100 Habiganj 90 96 Jhalokathi 90 100 Source: project MIS

Changes in the senior MO&HFW staff in Lakshmipur resulted in fewer supervisory visits conducted. The project is supporting the newly appointed staff to plan and conduct supervisory visits.

2.1.7 Maternal and Perinatal Death Surveillance and Response (MPDSR):

MaMoni HSS is providing support to the MOH&FW in its effort to scale up MPDSR in four districts (Habiganj, Noakhali, Lakshmipur, and Jalokathi), with support for full implementation of MPDSR in Begumganj upazila of Noakhali district. The activities include staff training, supporting the notification of maternal death, newborn death and

36 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report stillbirth, community based verbal case autopsy, and social autopsy of all maternal mortality cases and a sample of 10% of newborn mortality cases.

The data is being used to map out the location of deaths by union as well as for developing action plans by district managers to avoid future mortalities. The process includes an in- depth discussion on cause and social factors associated with the maternal and newborn deaths. The operational guideline for implementing MPDSR has been finalized, based on the national guidelines, and the data collection excel file has been developed to enable the district level staff to record and map mortality data. The map (Figure 25) shows the distribution of notified mortality by union from Begumganj upazila, Noakhali from January 2016 to January 2017. In addition to the concentrated MPDSR support in Begumganj upazila, the project is supporting the QIS in scaling up MPDSR at the health facility level in Habiganj, Noakhali, Lakshmipur, and Jalokathi districts.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 37 Figure 25: Distribution of notified mortality by union from Begumganj upazila, Noakhali from January 2016 to January 2017

2.1.8 Increasing compliance with clinical standards through SBM-R:

MaMoni HSS uses SBM-R to increase the capacity of the health facility staff to assess their own performance with regard to the clinical standards for ANC, childbirth, family planning, infection prevention and general management. After an initial baseline assessment to identify gaps in performance, the staff in each clinic develops and implement an action plan to address the gaps with the purpose of improving compliance with the clinical standards. The staff conducts an internal assessment to measure progress and continue to implement their workplan after necessary modifications. A second internal assessment is conducted to measure impact and adjust the interventions. Finally, an external assessment is conducted by staff not working in the assessed facility. Facilities that succeed in achieving 70 percent or more of the assigned score are recognized for their achievement. The graph below

38 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report presents an example of the progress of improving compliance with clinical standards in eight health facilities in Lakshmipur district. Figure 24: Improving compliance with standards for ANC, child birth, FP, infection prevention and general management

100 90 85 80 75 75 80 73 71 71 72 70 66 64 60 57 60 54 53 5151 51 49 50 50 46 47 48 46 50 43 40 40 35 26 26 26 30 23 20 15 10 0 Komolnagar Ramgoti UHC Raipur UHC MCWC Uttar Joypur Char Folcon Dorbeshpur Kerwa UHC UH&FWC Uh&FWC UH&FWC UH&FWC

Baseline 1st Internal 2nd Internal External

Source: Project MIS

2.1. 9 Mo nit Examples of changes to improve compliance with clinical standards in Lakhsmipur ori ng quality of care (QoC) indicators in sentinel sites: The project completed an analysis of the second round of the QoC indicators sentinel survey in four districts (Habiganj, Noakhali, Lakshmipur, and Jalokathi). The survey included 10 sentinel sites in each district (1 DH, 1 UHC, 4 UH&FWC, and 4 Satellite Clinics). Data collection was performed by direct observation by trained surveyors. The analysis of the sentinel survey includes results by district and by level of health facility. The graphs below include a sample of results. More results are available in a separate report.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 39 120

100

80

60

40

20

0 Asked about Cough Asked about Fever Chest Examined Breathing counted Weight measured Plotting in GMP or breathing card difficulty

Habiganj Jhalokathi Lakshmipur Noakhali Total

Figure 26: Observation of Sick Child (under 5) Consultation

Source: Sentinel survey (number of clients observed: 1253, Hg: 206, Jk: 324, Lp: 315, Nk: 308

2.2 Support human resource for health

2.2.1 Workload and staffing needs assessment study The objective of the “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities” is to understand the existing workload of different cadres of health workers in health facilities and at the community level. The study has adapted WHO’s “Workload Indicators of Staffing Need” (WISN) methodology to the Bangladesh context. The study, conducted by the MOHFW at the national level includes one medical college hospital ( Medical College Hospital), two district hospitals (Kushtia and ), two MCWCs (Kushtia Sadar and Brahmanbaria Sadar), four selected Upazila Health Complexes (Daulatpur , Kumarkhali Nabinagar, Sarail), eight union level facilities, and four Community Clinics and corresponding community level workers of selected unions at Kushtia and Brahmanbaria districts.

The first phase of the study - aimed at defining the major workload components of different categories of staff and setting standard times required for each workload component - has been completed. This was done through consultation with resource persons and interviews of different categories of staff at different levels. A draft report of the first phase has been submitted for review by Technical Advisory Group (TAG). The second phase of the study has been slightly delayed as the TAG was reconstituted by the MOH&FW to respond to changes in the Human Resource Management Unit at the MOH&FW as well as in other Directorates.

2.2.2 Support implementation of the HRIS

The central Human Resource Information System (HRIS) is a web-based software developed by the MOH&FW for capturing human resources information of all directorates/agencies under the ministry at various levels across the country. In line with the Letter of Collaboration (LoC) with Human Resource Management (HRM) unit of the MOH&FW, MaMoni is supporting the pilot implementation of the central HRIS at Habiganj and Noakhali districts. An inception meeting on HRIS was held in Habiganj in

40 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report January. The objective was to sensitize district and upazila level health and family planning managers on the HRIS. The meeting was jointly organized by Directorate General of Family Planning (DGFP) and Directorate General of Health Services (DGHS) and supported by the MaMoni HSS Project. Health and family planning managers from eight upazilas of Habiganj, the district hospital, the Civil Surgeon Office and the DDFP Office attended the meeting.

2.3 Monitoring and improving the availability of essential MNCH/FP/N drugs: 2.3.1 National level coordination: i) Scaling up of e-LMIS for DGHS: The project contributed to the national scale up of e- LMIS in coordination with SIAPS. The e-LMIS has been implemented in Lakshmipur district, as a part of DHIS2. In the reporting quarter, a training plan on e-LMIS was developed in Noakhali, Habiganj and Jhalokathi and a government order has been issued by the Director, MIS of DGHS to introduce e-LMIS in all upazilas of these districts. The project is now preparing for the implementation of the new e-LMIS during the next quarter.

ii) National distribution of 7.1% chlorhexidine: MaMoni HSS continues to facilitate the distribution of 7.1% chlorhexidine from the central warehouse in Dhaka to all regional warehouses. The distribution was based on list of that was prepared in last quarter. iii) Supporting the use of Supply Chain Management Portal (SCMP) to monitor FP commodities: The project conducted a one-day orientation, in coordination with SIAPS, to strengthen the capacity of 34 district level staff from Habiganj, Noakhali, Jhalokathi, and Lakshmipur to make use of the SCMP portal to track the availability of FP commodities and use data to take action to avoid stock-out.

2.3.2 Improving availability of essential drugs at district level: MaMoni HSS continues to extract data on the availability of essential MNCH/FP/N drugs and share them, in a simplified color-coded system with district level store keepers and health managers for stimulating action to minimize stock-outs.

Figure 27: Tablet Misoprostol at DGFP store, Habiganj district, Jan 2016-Mar 2017

16 . 16 .17 Sl .

Name of the store y .16 No

Sep.16 Oct.16 Nov.16 Dec.16 Jan.17 Feb Aug Jan.16 Feb Mar . 1 6 Apr. 16 May. 16 Jun. 16 Jul Mar.1 7

1 Sadar 2 Lakhai 3 Bahubal 4 Madhabpur 5 Chunarughat 6 Nabiganj 7 Baniachang 8 Ajmeriganj

Figure 26 is an example of availability and stock-out of essential drugs that was discussed with the Civil Surgeon and DDFP in Habiganj. The stock outs were addressed by moving drugs between stores, initiating local procurement (by the Civil Surgeon), or by mobilizing local government funds. As a part of QI initiative, the joint supervisory visit (JSV) checklist now includes a section on supplies and stock status. Local level stock out status at the

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 41 service delivery point (SDP) can identified through these visits (JSV) resulting in immediate actions.

The following are some examples of actions taken by district level management to avoid stock-out of essential drugs:

Noakhali District:

 Ensured Inj. Oxytocin supply of 4500 from Companigonj UHC to seven 24/7 UH&FWC delivery centers for Active Management of Third Stage of Labor (AMTSL).The facilities are: Sirajpur UH&FWC: a stock of 150, Char Kakra UH&FWC: a stock of 1500, Char Parbati UH&FWC: a stock of 50 , Rampur UH&FWC: a stock of 150, Durgapur UH&FWC: a stock of 1500, Alayerpur UH&FWC: a stock of 1000, Mohammadpur UH&FWC: a stock of 150.  Facilitated supply of 7.1% CHX from DGHS stores to DGFP facilities (UH&FWC) and providers (cSBA, pCSBA) through a special arrangement  Facilitated re-distribution of tablet misoprostol from one union to the other, from one FWA to the other considering the case load and stock status especially in Begumgonj, Senbag and Companiganj upazila.

The Appendix 7 includes more information on MaMoni HSS LMIS activities.

2.4 Routine Health Information Systems (RHIS)/eMIS Initiative The eMIS intervention aims to automate the business process of the GoB's rural health system through digitization of the paper based registers to e-register. This e-register, which records individual health data traceable via uniquely assigned health ID, has been rolled out in all union level facilities in Habiganj. This quarter activities focused on enhancement of the monitoring tools and addressing feedback from the field level supervisors. Incorporation of GIS mapping into the monitoring tool is one of the major milestones achieved this quarter. Data from the UH&FWC facility assessment has been integrated with the service statistics allowing presentation of multiple information in a logically segregated way.

2.4.1 Implementation at district level: The CSBA module (e-register) has been rolled out in Madhabpur and Tangail. Training on General Patient, Family Planning and PAC e-registers were organized in all upazilas of Habiganj except Madhabpur, where all the service modules have already been rolled out. The reference document and manual for the e-registers have been developed and were practiced during the training sessions. The FWA e-register was introduced concurrently throughout Habiganj. Team members tested android package kit (APK) in android TAB before releasing to the field and also continuously monitored e-MIS reports from unions using monitoring tools.

A total number of 77 FWVs, 22 paramedics, 2 SACMOs (DGFP) and 1 Midwife were trained on the MNC, FP, GP and PAC e-register and started using it. All the DGFP CSBAs of Madhabpur - 13 in total - were trained on the MNC e-register and started working on it. A total of 396 HAs and FWAs were trained on the Population Registration System (PRS) application and started collecting population data. 86 FWAs were trained on the FWAs e- Register.

All the Health ID cards were printed for Madhabpur and almost 92% of the registered population have received HID cards. The GOB field workers distributed the HID cards during their HH visits and also counseled recipients to bring the cards during facility visits.

42 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Service statistics recorded electronically are now readily available in the monitoring tools (Figure 28). Performance of the whole district can be monitored at the national level. Several indicators have been developed for the purpose.

Figure 28:UH&FWC statistics by upazila by selected services in Habiganj (Jan-Mar 2017)

700 656

600

500 441

400 348 317 290 261 300 239 229 212 204 196 181 196 190 173 175 200 165 149 159 120 127 82 100 57 28 0 AJMIRIGANJ BAHUBAL BANIACHONG CHUNARUGHAT HABIGANJ SADAR LAKHAI MADHABPUR NABIGANJ

Normal Delivery AMTSL Chlorehexidin Applied

Source: UH&FWC eMIS

2.4.2 e-MIS software development activities: In this quarter, different indicator-based monitoring tools have been developed. One such tool is “high blood pressure monitoring”. During pregnancy high blood pressure along with presence of albumin in urine indicates pre-eclampsia. Since all ANC visit data is digitally available, the system can detect if the mother requires immediate referral. This information is readily available to upazila level managers who can immediately take necessary actions. Some data quality issues were also revealed during the process, which were communicated to service providers. Based on the feedback from Supervisors/Managers, e-MIS team created the option to review and edit the data entry errors. . A PAC (Post Abortion Care) e- register and some new features were also incorporated in the application.

Tablet version view of MNC e-register for FWV

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 43

The system will provide an alert to the user/provider if the high risk patient is not referred. For example, the providers will be notified instantly whenever he/she enters any abnormal value for any kind of physical/PV/laboratory exam. Moreover, this medical intelligence is incorporated at the ANC service entry level for hypertension or preeclampsia/eclampsia patients. Multiple language support has been added for better demonstration.

A major achievement in this quarter is GIS incorporation in the monitoring tool, which brings the added value of quick decision making from central level. This web GIS is basically now capable of showing real-time service data. This also allows for the incorporation of different geographic information as well as facility information from the UH&FWC assessment work. The tool was demonstrated in a USAID organized GIS workshop and widely appreciated.

GIS mapping of UH&FWC assessment and services

2.4.3 Visit of senior MOHFW officials to project sites

A group of senior officials visited Sadar, Chunarughat and Madhabpur upazilas of Habiganj district to observe the e-MIS activities during this quarter. Representation included the Director General, DGFP (Acting), Director-MIS along with 2 Deputy Directors and 1

44 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Officer, DGFP; Dr. Sukumer Sarkar - Deputy Director, USAID; Mark Pierce - Country Director, Save the Children in Bangladesh; Dr. Shamim Jahan- Director- Health, Nutrition & HIV/AIDS, Save the Children in Bangladesh and Mr. Muhammad Humayun Kabir- Sr. Advisor, MEASURE Evaluation.

Mr. Sheikh Md. Shamim Iqbal, Acting Director General (DGFP) is observing e-MIS activities in Madhabpur

Md. Saiful Hasan Badal, Director-MIS is observing the e-MIS activities in Madhabpur

2.4.4 Other activities:

The MIS and eMIS team also extends support for other MaMoni activities: in conjunction with a consultant, the sentinel survey tool for QoC activities is being developed by the eMIS team. Soon this tool will be introduced in selected areas for the survey and for analyzing data.

2.5 National newborn dashboard: MaMoni HSS intended to strengthen the HMIS of MOH&FW under health system strengthening initiatives. As a part of this, the project is closely working with both DGHS and DGFP to strengthen their existing HMIS. With the leadership of the IMCI unit of DGHS, the project facilitated the development of a national dashboard on newborn health indicators. Different technical partners provided suggestions and support in identifying the indicators. After consensus on the indicators, IMCI decided to show them in the DHIS-2 platform of DGHS. The technical areas of the indicators are mainly HBB, SCANU, 7.1% CHX, KMC and Essential Newborn Care. During the reporting period, the MaMoni HSS MIS team provided technical support for the monitoring of Chlorhexidine application at facility level, and it’s activation in the DHIS-2 data entry template, as well as adding this in the dashboard. Technical issues related to the availability of newly added facility based indicators in the system have also been resolved. The application of HBB logistics can also be monitored from the DHIS-2 report view. Currently, MaMoni HSS is working closely with the technical team of DHIS-2 from ICDDR,B to identify new ways of data visualization and integration to develop an efficient and useful monitoring process.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 45 Screenshot of newborn indicators in DHIS-2 of DGHS

IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems

3.1 National level technical Assistance The Program Implementation Plan (PIP) of the HPN Sector Program - the fourth sector program - has been approved and was circulated in March 2017. Since July 2016, MaMoni HSS has also been providing technical and operational support to the Planning Wing to facilitate the development of the PIP. This includes operations support staff seconded to the Planning, Monitoring, and Management Unit (PMMU), support for organizing meetings and consultations, and routine logistics support. With MaMoni HSS support, the PMMU has published the 10th issue of their quarterly newsletter. MaMoni HSS has been working closely with the Line Directors to ensure that the project activities are incorporated into the OPs. This also helped to ensure alignment of OP priorities with the priorities advocated by the project. Project inputs have been incorporated/ or are being discussed with nine OPs – Maternal Newborn Child and Adolescent Health (MNCAH); Maternal Child Reproductive and Adolescent Health (MCRAH); Clinical Contraceptive Delivery Program (CCSDP); Health Economics and Financing (HEF); Sector-wide Program Management and Monitoring (SWPMM); National Nutrition Services (NNS); Management Information System-FP (MIS-FP); Human Resources and Development (HRD); and family Planning Field Service Delivery (FP-FSD).

3.2 Journalist Engagement Since January 2017, MaMoni HSS organized two journalist visits to its project areas (one in Habiganj and another in Hatiya) with a special focus on optimum media coverage on MNCH/FP/N issues. As a result of broader MaMoni HSS media advocacy, 6 news/stories

46 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report were published by different media outlets. The news/stories included issue-specific coverage on the current situation for relevant health coverage and needs, case studies, and technical information with calls for action required for health systems improvement.

The media engagement and capacity building program has resulted in a significant increase in media coverage on MNCH/FP/N issues and increased stakeholders engagement. Representatives from the multiple government ministries/directorates, and non- governmental partners were closely involved in the program. This contributed to closer collaborations across organizations. List and links are included as appendix 9.

3.3 Program learning initiatives undertaken and disseminated MaMoni HSS shared four learnings through oral presentation at the First Community Health Worker Symposium organized in Uganda. Recruitment and retention of Community Volunteers, Community Volunteer’s contribution to family planning, community microplanning and experience of developing private CSBAs were presented in the Symposium.

Three abstracts have been submitted to the International Society for Quality of Health Care (ISQua)’s 34th International Conference in London, planned for October 2017. Quality of Care in ANC, FP and QI initiatives in Habiganj district were the topics submitted for consideration.

A concept note on “Early discontinuation of IUD and implants (LARC)” has been drafted and submitted to USAID for review. MaMoni HSS also plans to undertake a program learning activity to understand the ability of Family Welfare Visitors (FWVs) in detecting and managing the cases of severe pre-eclampsia/eclampsia (PE/E). The project is reviewing the existing system to utilize information that is already available in regular MIS to simplify the data collection methods.

Three manuscripts have been prepared from operational research completed last year. All of these are undergoing internal review.

3.3.1 Process documentation of technical interventions:

To document the process of technical interventions as well as implementation experiences of MaMoni HSS, the team is capturing intervention processes based on frameworks that were agreed upon in the workplan. An updated matrix has been presented in Appendix 8.

IR4. Identify and Reduce Barriers to Accessing Health Services 4.1 Promote awareness of MNCH through innovative BCC approach 4.1.1 SBCC strategy development: Recently a communication agency specializing in SBCC was hired to develop and implement a comprehensive area-specific community behavior enhancement strategy (i.e. Habiganj, Lakshmipur, Noakhali/Hatiya) along with an SBCC activity implementation plan to accelerate a change with care-seeking for appropriate MNCH/FP/N services as well as improving home-based care practices. The SBCC activities are also aimed at creating an enabling environment in families and communities that facilitate and support appropriate care-seeking behaviors. By the end of February, the strategy was drafted based on the outcome of formative research and stakeholder consultations.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 47

In order to fine-tune the strategy and ensure that it is comprehensive and culturally sensitive, two SBCC barrier analysis workshops (one in Hatiya and the other in Lakshmipur) were conducted. The participants of the workshops included community level health service providers, community representatives (local government representative, community volunteers etc), and MaMoni HSS field level officials who are mostly engaged in community level work. Through a rigorous participatory process, the workshop identified upazila specific SBCC barriers along with strategies/activities to address them in a more effective manner.

4.1.2 SBCC activities:

In this quarter, the MaMoni HSS project reached 289,640 community people (46% male and 54% female) through courtyard meetings, video shows and other BCC activities.

4.1.3 Reaching the community through Aponjon services:

. Aponjon continued its partnership with a number of organizations to enrol expectant mothers, new mothers, and gatekeepers in Aponjon services. 6,458 subscribers have been registered during this reporting period.

. A live chat feature has been added in to the Aponjon website, which allows for real time communication between subscribers and customer service agents.

. Facebook and blog platforms have been extensively used to reach out to semi-urban and urban consumers, and the Aponjon web presence is growing steadily with 21,000 unique visitors on its blog and over 750,000 reach through Facebook, among which 75,000 were engaged in activities.

. The Aponjon product and content teams are working continuously to monitor and identify the need for any revision or updating of the apps. During this quarter, “Aponjon Shogorbha” and “Aponjon Koishor” apps for android OS have been updated to provide a better user experience. As a result of a digital marketing campaign, downloads of the Shogorbha app are on the rise.

Table 3: Aponjon Shogorbha Month Android Windows iOS Total

January 729 185 3 917 February 1021 159 3 1183 March 1530 113 5 1648 Grand Total 3280 457 11 3748

. The Aponjon mobile app Shogorbha - which relates to pregnancy - has found resonance even beyond the geographic borders of Bangladesh, with 20 percent of downloads coming from the neighbouring country of India. A few downloads were also made in the UK, USA, and Qatar.

. The Aponjon counselling line continues to provide important first-level medical advice to subscribers. In the reporting quarter the counselling line received and addressed 2,793 queries.

. Aponjon is repackaging the core service into Shogorbha 1000, and gatekeeper content for 1 to 2 years as the Aponjon service previously only had this for up to one year of the child’s age. In this quarter, the required gatekeeper content was finalized after incorporating user feedback. It is now ready to be recorded.

48 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Table 4: Counselling Line Calls

Month New Pregnant Shoishob Koishor Non- Total mother (2 to 5 & registered non- registered) January 434 190 207 3 182 1016 February 417 135 222 4 132 910 March 256 157 224 6 119 762

Total 1107 482 653 13 433 2688

As the Aponjon program continues to grow, maintaining the quality and efficiency of the service are topmost priorities, and standard operating procedures have been developed to ensure smooth operations in many areas. The Aponjon M&E team routinely conducts phone surveys to measure client satisfaction as well as to measure partner organization’s performance in randomly selected samples. In this quarter, 98% clients were found to be satisfied while 29% of the total responses were found to be fake. Aponjon is now taking measure to control fake responses.

4.2 Enhance community engagement in addressing health needs

4.2.1 Monthly CMPM meetings:

MaMoni HSS facilitates monthly CMPM meetings involving community volunteers and frontline health and family planning workers (HA, FWA, CHCP) to update information on eligible couples, new pregnancies, and newborns, and to follow up with these groups for services. During this quarter a total of 3,909 meetings were held in all areas. A reduction in the number of field level staff has affected the number of meetings in Jhalokathi and Noakhali.

Table 5: Number of CMPM meetings held by district Community Micro-planning meeting Jan-Feb District CMPM target CMPM held Habiganj 1842 1838 Jhalokati 751 225 Lakshmipur 1362 1350 Noakhali 1015 496 Total 4970 3909

4.2.2 Engaging local government bodies and community action groups:

MaMoni HSS is facilitating local government engagement in different tiers of service delivery through activating different committees. A remarkable achievement has been made in involving Union Parishads during the process of UH&FWC assessment and upgradation. In many areas, the Union Parishad has taken the lead and also mobilized funds for upgrading and/or maintaining the services at 24/7 union facilities. Table 6 shows the funds allocated by local government bodies. Through the end of March 2017, USD $83,294 was used for the construction, repair, and maintenance of the facilities, purchasing emergency medicine (especially during stock-outs), purchasing small medical and non- medical equipment and logistics, financial support to temporary support staff, and work on approaching roads. Fund utilization was less due to local government (Union Parishad) election in the last year. Table 7 shows that over 18,616 Community Action Groups have an

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 49 emergency transport system. The target was to have at least half of the CAGs to have emergency transport system. In Habiganj, almost all the CAGs have emergency transport system, while in Lakhsmipur and Noakhali it’s close to 50 percent.

Table 6: Local government budget allocation and utilization till Mar 2017

Allocated budget Expenditure till March 2017 District BDT USD BDT Habiganj 6,819,880 87,434.36 3,071,563 39,379 Jhalokati 3,090,069 39,616.27 414,590 5,315 Lakshmipur 5,090,893 65,267.86 859,395 11,018 Noakhali 4,258,000 54,589.74 2,151,360 27,582 Total 19,258,842 246,908 6,496,908 83,294 1 USD= BDT 78.00

Table 7: Number of Community Action Groups with an emergency transport system for maternal and newborn health care through USG-supported programs High intensity areas Target Achievement Lakshmipur 6461 6328 Noakhali 3876 4209 Habiganj 4369 8079 Jhalokathi 3746 1459 Total 18,452 18,616

CHALLENGES, SOLUTIONS, AND ACTIONS TAKEN Challenges and Mitigation Strategies . Shortage of staff: The chronic shortage in human resources is posing an important challenge to all project activities especially in improving the quality of health care. The inadequate clinical and support staff in addition to the inadequate supervisory cadres, such as medical officers, continue to impede efforts to improve the quality of care. The project is facilitating the process of better utilization of available human resources through district and upazila planning.

. Staff Turn-over: Several key positions in DGHS and DGFP as well as at the district level experienced turn-over within a short period. A few of them include the Director, PHC and Line Director ESD/DGHS, Director General of Family Planning, and the Director-MIS/DGFP at the national level. Also the DDFP in Habiganj and the UFPO in Madhabpur were changed in this quarter. Moreover, the MOH&FW has been recently divided into 2 divisions: the Health Services Division and the Medical Education and Family Welfare division. Each of the divisions will have one Secretary. This division has created uncertainties because of lack of clear guideline on operational mechanisms. MaMoni is closely observing the changes and will adapt strategies accordingly.

. Frequent stock-out of essential MNCH drugs hinders efforts to improve health outcomes. As a response, the project is building the capacity of local managers to monitor

50 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report the availability of essential drugs, and is taking local measures to avoid stock-outs through routine tracking of the supply chain management portal. . Chlorhexidine availability: The GOB strategy for CHX roll-out in Bangladesh has been to make it available only through government facilities. Because a majority of babies in Bangladesh are born at home, this means that those babies do not get CHX on their umbilicus after birth. For any deliveries other than those in public sector facilities, CHX needs to be purchased from a local pharmacy. Under the SBCC strategy, MaMoni is planning for a nation-wide campaign to raise awareness as well as create demand for procuring CHX from local pharmacies. . Reduced community mobilization activities: Reduction of FSO in other districts has reduced community mobilization activities. Involving GOB field workers for CMPM meeting might be helpful in response.

. Ownership and capacity development of QI committees: Transferring the ownership of the QI process to the project’s counterparts at district, sub-district, and health facility levels is a continuous challenge. The established of QI committees has been a positive step in increasing the staff capacity in identifying gaps and implementing actions to address them. There are encouraging examples of QI committees that have been able to solve local problems and engage local government in resource mobilization. However, while the QI committees have made a difference, they still require significant facilitation by project staff. . The performance of pCSBA’s has not been satisfactory. Strategic re-distribution, motivation of CSBAs/pCSBAs, linking them with the formal health system, and central and district level monitoring should be increased. . Lack of counselling on PPFP, improper screening during IUD insertion, low male participation in FP methods, and lack of reporting on all PPFP methods in the MIS 3 (report is only on PPIUCD & BLTL) are a few issues related to family planning faced by the program.

. The service delivery section of DGFP and MIS/DGFP use 2 different methods for categorizing ANC 1, 2 and 3 which has created confusion among service providers as well as made reporting difficult. MaMoni is planning to organize a workshop involving both the departments in order to resolve this issue as well as a few other MIS related issues.

Way Forward: . Consolidate learnings from Habiganj and roll out the complete package of eMIS in Noakhali. Only UH&FWC e-registers will be rolled out by the program in Lakhsmipur and Jhalokathi. MaMoni will also pilot paper-less record keeping and reporting in a few unions of Habiganj. Supervisor’s modules will be initiated in Habiganj and MaMoni will provide necessary support to the supervisors for using this for monitoring purpose. . A costed phase-wise UH&FWC upgradation plan will be developed and MaMoni will continue advocacy with health, family planning and local government bodies for implementation of the plan and upgrade more UH&FWCs to 24/7 facilities. MaMoni is ready to provide technical support to MOH&FW in this regard. . Train the newly deployed MO-MCH-FP in project districts in EOC and LARC&PM. A total of 12 MO-MCH-FP will start the one-year EOC training, which will equip them to provide comprehensive EmONC services at MCWCs in the six project districts. Another 19 MO-MCH-FP, who are currently posted at the UHCs in the project districts will receive an 18-day training on LARC&PM during the next quarter.

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 51 . To ensure availability of chlorhexidine and other essential commodities, MaMoni HSS is planning to collaborate with the Social Marketing Company (SMC) to use Community Volunteers for social marketing in a few unions. The program has already visited with SMC to consult with them and learn about their experiences. . Continue collaboration with WHO, UNICEF and UNFPA to support the GOB improve maternal and newborn health through implementation of the WHO MN QI framework. MaMoni is in discussions with the QIS and stakeholders on how to engage the QI implementation structures to identify critical gaps for service provision and strengthen MNH care services in every facility. The aim of WHO’s QOC framework is to halve all preventable neonatal deaths and stillbirth in facilities by 2030. Divisional and district QI teams will be involved in the process. . There is an anticipated stock out of essential drugs and supplies. Under the new sector program, drug procurement can’t be initiated before June. Moreover, there was a recent fire in FP national store causing massive destruction of FP commodities, essential drugs, registers and other logistics. MaMoni HSS will continue to monitor the drug availability and identify potential stock-outs with the help of LMIS. In case of potential stock-outs, MaMoni will advocate and support DGHS, DGFP and local managers in adopting early and necessary actions.

APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF THE MAMONI HSS PROGRAM

The program’s objectives are well aligned with the GoB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011– 2016; and also directly support the USAID/ Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh. MaMoni HSS designed a two- pronged approach in which districts and upazilas were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high- intensity areas is to

High

52 Health System MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report demonstrate best-practice models of MNCH/FP/N health care delivery through intensive support to the Government of Bangladesh (GoB), and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi districts, while in the Noakhali and Pirojpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirojpur (refer to Figure 1 and Table 1). Whereas the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale up interventions such as 24/7 Union Health and Family Welfare Centers (UH&FWCs), chlorhexidine for cord care, and Helping Babies Breathe (HBB); instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.

APPENDIX 2: DATA SOURCES Assessment Assessment Frequency Geographical Coverage Name Type

Population Independent 2 rounds in 23 High intensity upazilas of 5 Mamoni Districts based tracer cross sectional a year. (Hg, Lp, Nk, Pj, Jk). In addition, during the survey assessment by Each round initial stages of program – starting from October third party is for six 2013 – this population based assessment was (ICDDR,B) months also conducted for Bhola District along with Noakhali and Lakshmipur. This included a baseline assessment and two rounds of the population-based survey. In October 2014, there was a major shift in the MaMoni HSS program strategy and the scale of program activities were reduced in Bhola. Accordingly, the project monitoring plan (PMP) was revised and the population based survey no longer covers Bhola, with the exception of conducting an end line survey in 2017.

Sentinel Selected Twice in a Selected District Hospital, MCWC, UHC, survey sentinel site year UH&FWC and satellite clinics in Habiganj, assessments Jhalokati, Noakhali and Lakshmipur district. using structured tool

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 53 Service Periodic facility Twice in a 21 High intensity upazilas of Habiganj, delivery assessment by year Jhalokati, Noakhali and Lakshmipur district. point using assessment structured tool

Newborn Nationwide Once in All over the country revisit assessment by project life upazila on HBB and 7.1% CHX using structured questionnaire

Routine MIS, Routine MIS Monthly All over the country MoH&FW forms of DGHS and DGFP

Project MIS Routine MIS Monthly Only in high intensity project areas reports

APPENDIX 3: PROGRAM PERFORMANCE INDICATORS (JAN ’17–FEB ’17)

Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Percent of women received at least one antenatal care visit

from a medically trained provider High intensity areas NA Lakshmipur 70 77 70 Noakhali* 67 74 67 Habiganj 70 83 70 Jhalokathi 73 82 73 Pirozpur* 70 72 70 HSCS areas Pirozpur 67 67 Bhola 56 56 Noakhali 63 63

54 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Percent of births receiving at least four antenatal care

(ANC) visits during pregnancy

High intensity areas Lakshmipur 26 31 26

Noakhali* 26 43 26

Habiganj 26 44 26 Jhalokathi 50 43 50 Pirozpur* 36 36 36 HSCS areas

Pirozpur 44 44 Bhola 23.5 23.5 Noakhali 21 21 Percent of Births Attended by a Skilled Doctor, Nurse or

Midwife High intensity area Lakshmipur 45 39 45 Noakhali* 40 40 40 Habiganj 40 36 40 Jhalokathi 53 58 53 Pirozpur* 50 51 50 HSCS areas Pirozpur 50 50 Bhola 30 30 Noakhali 38 38 Percent of women with home births who consumed misoprostol to prevent postpartum hemorrhage High intensity areas Lakshmipur 30 9 30 Noakhali* 30 27 30 Habiganj 50 42 50 Jhalokathi 55 36 55 Pirozpur* 45 34 45 HSCS areas

Pirozpur 32 32

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 55 Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Bhola 25 25 Noakhali 20 20

Percent of newborns initiated breastfeeding within one hour after birth

High intensity areas Lakshmipur 75 55 75 Noakhali* 72 57 72 Habiganj 85 77 85 Jhalokathi 70 45 70 Pirozpur* 63 52 63 HSCS areas

Pirozpur 58 58 Bhola 70 70 Noakhali 76 76 Percent of newborns received chlorhexidine application on their umbilical cord immediately following birth High intensity areas Lakshmipur 60 10 60 Noakhali* 60 13 60 Habiganj 60 10 60 Jhalokathi 60 2 60 Pirozpur* 60 4 60 HSCS areas

Pirozpur 35 35 Bhola 35 35 Noakhali 35 35 Percent of newborns receiving postnatal health check within two days of birth High intensity areas Lakshmipur: 20 34 20 Noakhali:* 20 32 20 Habiganj: 32 27 32 Jhalokathi: 33 48 33 Pirozpur:* 18 41 18 HSCS areas

Pirozpur: 10 10

56 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Bhola: 10 10 Noakhali: 20 20 Modern contraceptive method prevalence rate High intensity areas Lakshmipur 55 50 55 Noakhali* 53 53 53 Habiganj 48 47 48 Jhalokathi 58 56 58 Pirozpur* 58 55 58 HSCS areas

Pirozpur 55 55 Bhola 58 58 Noakhali 51 51 Couple years of protection Source: DGFP MIS Form 4 (CYP) in USG-supported (accessed online) programs 219733 High intensity areas 1071044 1071044

35746 Lakshmipur 163,817 163,817 51261 Noakhali 235128 235128 36882 Habiganj 191,852 191,852 12743 Jhalokathi 77,389 77,389 27048 Pirozpur 139063 139063 Bhola 263,795 56053 263,795

Percent of targeted facilities that are ready to provide essential newborn Source: SDP assessment care

High intensity areas

Lakshmipur 90 81 90 Noakhali* 90 46 90 Habiganj 90 68 90

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 57 Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Jhalokathi 90 65 90 Pirozpur* 90 NA 90 HSCS areas Pirozpur 70 70

Bhola 70 70 Noakhali 70 70 Percentage of public health facilities with functional bags and masks Source: SDP assessment (two neonatal size mask) in the delivery room (HI Upazilas only)

High intensity areas

Lakshmipur 50 73 50 Noakhali* 50 84 50 Habiganj 50 84 50 Source: SDP assessment Jhalokathi 50 70 50 Pirozpur* 50 NA 50

Percent of USG-assisted service delivery sites providing family planning Source: SDP assessment (FP) counselling and/or services and training data

High intensity areas

Lakshmipur 95 83 95 Noakhali* 95 90 95 Habiganj 99 88 99 Jhalokathi 95 80 95 Pirozpur* 95 NA 95 HSCS areas Pirozpur 17 17 Bhola NA NA Noakhali 25 25

58 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Number of targeted facilities ready to provide delivery services 24 hours Source: SDP assessment a day, seven days a week (includes DH, MCWC, UHC and UH&FWC) and training data

Considering provider

available , separate High intensity areas delivery room, CHX, Bag

and Mask

Lakshmipur 25 27 25 Noakhali* 19 21 19 Habiganj 39 47 39 Jhalokathi 21 17 21 Pirozpur* 4 NA 4 HSCS areas Pirozpur 9 9 Bhola 32 32 Noakhali 7 7 Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by temporary non-

GOB health workers High intensity areas Lakshmipur 10 19 10 Noakhali* 15 03 15 Habiganj 10 36 10 Jhalokathi 10 03 10 HG -FWV- 23,Nurses- 13. Pirozpur* NA NA NA Lax - FWV-12, Nurses-07. HSCS areas NK - FWV-03. JK - FWV-03 Pirozpur NA NA Bhola NA NA Noakhali NA NA

Sub-IR 1.2: Strengthen capacity of service providers to provide quality services

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 59 Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Number of people trained Source: Project MIS in maternal/newborn 2,149 221 NA health through USG- Jan-Mar,17 supported programs

High intensity areas

Lakshmipur 18 Women 10 Men 8 Noakhali* 17 Women 12 Men 5 Habiganj 120 Women 88 Men 32 Jhalokathi 66 Women 45 Men 21 Pirozpur* Women

Men

Jan-Mar,17

National level 3520 Dhaka-442 National-3078 HSCS areas Pirozpur 140 Women 125 Men 15 Bhola 71 Women 64 Men 7 Noakhali

60 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Number of people trained Jan-Mar,17 225 49 NA in FP/RH with USG funds Dhaka-26

High intensity areas

Lakshmipur Women

Men Noakhali* Women

Men Habiganj 12 Women 12 Men 0 Jhalokathi 37 Women 16 Men 21 Pirozpur* Women Men National level HSCS areas Pirozpur Bhola Women Men Noakhali Number of people trained in child health and nutrition NA 200 through USG-supported programs High intensity areas 760 310 Jan-Mar,17 Lakshmipur 310 Women 168 Men 142 Noakhali* Women Men

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 61 Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Habiganj Women Men Jhalokathi Women Men Pirozpur* Women Men National level HSCS areas Pirozpur Bhola Noakhali

Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization

Number of union level public health facilities that Source: SDP Assessment are ready to provide normal delivery services

71 High intensity areas 75 75 22 Lakshmipur 14 Noakhali*

26 Habiganj 09 Jhalokathi NA Pirozpur*

HSCS areas

Pirozpur

Bhola

Noakhali

Intermediate Result 2: Strengthen health systems at district level and below

62 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Number of district level quarterly performance review meeting held for Source: QPRM meeting data-driven performance review and planning minutes

High intensity areas 24 12

Lakshmipur 4 1 2 Noakhali* 4 1 2 Habiganj 4 1 2 Jhalokathi 4 1 2 Pirozpur* 4 - 2 Bhola 4 1 2 Data expected from QI sentinel monitoring. The Intra partum still birth rate in project assisted facilities system is being established.

High intensity areas <5/1000 <5/1000

Lakshmipur <5/1000 <5/1000

Noakhali* <5/1000 <5/1000

Habiganj <5/1000 <5/1000

Jhalokathi <5/1000 <5/1000

Pirozpur* <5/1000 <5/1000

Sub-IR 2.1: Improve leadership and management at district level and below

Number of GOB managers supported for leadership and management capacity development 0 Lakshmipur NA NA 0 Noakhali NA NA 0 Habiganj NA NA Source: Project MIS & 0 District team Jhalokathi NA NA 0 Pirozpur NA NA 0 Bhola NA NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 63 Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Number of upazilas with updated comprehensive Source: Project MIS annual MNCH/FP/N plan High intensity areas 23 21 23 Lakshmipur 5 5 5 Noakhali* 4 4 4 Habiganj 8 8 8 Jhalokathi 4 4 4 Pirozpur* 2 0 2 Bhola NA NA Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting Source: Project MIS monthly meeting High intensity area Lakshmipur 100 99 100 Noakhali* 100 82 100 Strategy of Pirozpur is Habiganj 100 100 100 different than others having no MIS data Jhalokathi 100 39 100 Pirozpur* 100 NA 100

Sub-IR 2.4: Establish quality assurance system at district level and below

Percent of planned supervision visit conducted where a supervision tool Source: Project MIS was used and findings shared with providers High intensity areas

60 Lakshmipur 90 90

120 Noakhali* 90 90 112 Habiganj 90 90 108 Jhalokathi 90 90 NA Pirozpur* 90 90 Data is not available

Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below

64 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas <3 <2 Lakshmipur <3 0.50 <2 <3 <2 Noakhali* 1.7

Habiganj <3 0.6 <2 Jhalokathi <3 0 <2 Pirozpur* <3 0 <2

Sub-IR 2.6: Strengthen local government planning and engagement in health service provision

Percentage of unions that had at least 50 percent of the estimated births registered within 45 days of birth

High intensity areas Lakshmipur 60 62 60 It includes Three upazila ( Noakhali* 60 6 60 Senbag, Begumganj, Companigonj) Habiganj 60 100 60 Jhalokathi 60 50 60 Pirozpur* 60 NA 60 Data not available Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of union parishads (UP) that spent funds to Source: Project MIS support MNCH/FP/N activities High intensity areas Lakshmipur 58 21 58 Data not available for Pirozpur Noakhali* 44 14 44

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 65 Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Habiganj 77 37 77 Jhalokathi 32 7 32 Pirozpur* 15 NA 15

Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GOB recruitment or Source: Project MIS redeployment in project areas High intensity areas Lakshmipur 5 0 5 Noakhali* 5 29 5 Nurses-29 Habiganj 5 0 5 Jhalokathi 5 47 5 Nurses-46,Doctors-1 Pirozpur* 5 0 5

Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector Number of policies/ strategies/guidelines on 4 0 MNH developed/revised 4 with MaMoni HSS support Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program

66 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

1. Community Mobilization as “Community Micro Planning (cMP) 2. Community Volunteers as “Recruiting, training and retaining of Community Volunteers 3. pCSBA as “Development of community skilled Number of program birth attendants in hard-to-reach areas of learning initiatives 15 10 4 Bangladesh” completed and 4. Referral for PM of disseminated Family planning “Making a difference: community volunteers contributing to increasing use of effective family planning in Bangladesh”

Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA in USG-assisted DGFP MIS, DHIS2, pCSBA programs High intensity areas 4647 Lakshmipur 19687 19687 4026 Noakhali* 12288 12288 6480 Habiganj 25896 25896 1904 Jhalokathi 7054 7054 640 Pirozpur* 2658 2658

HSCS areas

1767 Pirozpur 12148 12148

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 67 Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

4343 Bhola 1982 1982 3889 Noakhali* 37848 37848 Number of antenatal care

(ANC) visits by skilled DGFP MIS, DHIS2, PCSBA providers from USG- assisted facilities High intensity areas 29829 Lakshmipur 53730 53730 29720 Noakhali* 43414 43414 47985 Habiganj 210611 210611 8715 Jhalokathi 16553 16553 3411 Pirozpur* 9914 9914

HSCS areas

6997 Pirozpur 34698 34698 22197 Bhola 68546 68546 23663 Noakhali 97682 97682

Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches

Number of people reached through project supported 666143 350556 Source: Project MIS BCC activities High intensity areas Lakshmipur 200000 60442 105000

Women 34203

Men 26239

Noakhali* 145556 302973 75556

Women 145271

Men 157702

Habiganj 205000 14265 110000

68 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Achievement Target Target (January 2017- Remarks 2017 2018 March 2017)

Women 12183

Men 2082

Jhalokathi 115587 2912 60000

Women 2434

Men 478

Sub-IR 4.2: Enhance community engagement in addressing health needs

Number of trained community volunteers Source: Project MIS promoting MNCHFPN through project support High intensity areas Lakshmipur 6710 6452 6710 Noakhali* 5900 6903 5900 Habiganj 8379 8212 8379 Jhalokathi 2731 2305 2731 Pirozpur* 1205 NA 1205 Data not available Number of Community Action Groups with an emergency transport system for Source: Project MIS maternal and newborn health care through USG-supported programs High intensity areas Lakshmipur 6461 6328 6461 Noakhali 3876 4209 3876 Habiganj 4369 8079 4369 Jhalokathi 3746 1459 3746 Pirozpur* 1549 NA 1549

APPENDIX 4: ADDITIONAL INDICATORS These indicators were submitted to USAID separate from the program work plan, and were approved in November 2016.

Indicator Target FY Achievement Target Remarks 17 (January 2017– 2018 March 2017)

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 69 Indicator Target FY Achievement Target Remarks 17 (January 2017– 2018 March 2017)

Percentage of newborns receiving CHX Source: DGFP application at birth in MoH&FW facilities MIS4

National 50 47 60

Barisal 50 55 60

Chittagong 50 58 60

Dhaka 50 47 60

Khulna 50 39 60

Rajshahi 50 45 60

Rangpur 50 33 60

Sylhet 50 69 60

Number of upazilas where a review of Source: Project Newborn interventions held report

Total 326 81 165

Barisal 42 18

Chittagong 3 100

Dhaka 124 39

Khulna 53 7 7

Rajshahi 68

Rangpur 58

Sylhet 39 14

Number of Newborn for whom resuscitation Source: DGFP actions using bag and mask were initiated MIS-3

Total 14,817 10764 16272 (31% of annual target, within Barisal 640 781 7,03 range)

Chittagong 3,137 3095 3,445

Dhaka 4,453 2094 4,890

70 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report Indicator Target FY Achievement Target Remarks 17 (January 2017– 2018 March 2017)

Khulna 1,952 908 2,144

Rajshahi 1,995 1076 2,191

Rangpur 1,716 1037 1,885

Sylhet 924 1773 1,015

Number of Union Health and Family Welfare Source: Project Centers (UH&FWCs) in the project area using report electronic MIS tools

Total 130 61 164 Noakhali implementation Lakshmipur 42 to begin in April, delayed Noakhali 69 0 because of Habiganj 61 61 Measure procurement Jhalokati 29

Pirojpur 46

Bhola 47

Number of districts having an active Quality Improvement (QI) committee

Total 32 41 64

Barisal 3 Data not 5 6 available

Chittagong 6 8 11 QI committees were just Dhaka 9 10 17 formed in Khulna, Sylhet Khulna 5 5 10 and Chittagong divisions Rajshahi 4 7 8

Rangpur 3 2 8

Sylhet 2 4 4

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 71

APPENDIX 5: LIST OF UNION FACILITIES UPGRADED

Habiganj Bagasura UH&FWC B A

Badeshwar UH&FWC C B

Uttar Purba Baniachong C B

Noakhali Norottompur B A

Kabilpur B A

Gopalpur B A

Mohammadpur B A

Rampur B A

Lakshmipur Bhabaniganj B A

Dalal Bazar B A

Mandari B A

Shak Char B A

Bhadur B A

Hajirhat B A

Char Algi B A

Bamni B A

Char Pata B A

72 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report APPENDIX 6: QIS ACTIVITIES

1. Background The USAID-supported MaMoni HSS program, led by Save the Children in Bangladesh, has signed an LOC with the Health Economics Unit (HEU) to provide technical, managerial and financial support to the Quality Improvement Secretariat (QIS) to implement the National Strategy for Quality Improvement (QI). Major areas of the MaMoni HSS program’s support to QIS include: − Strengthen technical and managerial capacity of QI Secretariat; − Facilitate establishment and functioning of the decentralized QI management structures at divisional, district and sub-district levels; − Provide technical assistance to developing/updating national guidelines, protocols and tools to support implementation of the national QI strategy; and − Support development of a system for monitoring QI indicators for clinical services.

2. Activities performed: 2.1. Recruitment and deployment of MaMoni HSS Project staff: all the national level staff, 8 divisional coordinators and 4 district monitors were recruited and deployed. 2.2. Capacity development 2.2.1. Orientation of all staff on quality improvement and 5S including a field visit in Hospital to provide an exposure to 5S activities. 2.2.2. The third TOT on leadership, QI and 5S for the divisional resource pool was held and 29 participants attended the workshop. 2.2.3. A refresher training was organized for the divisional resource pool who attended an earlier TOT These resource pools will be used to train the district resource pool members in Chittagong and Khulna divisions. Newly recruited and seconded staff of MaMoni HSS to the QIS also attended the orientation. 2.2.4. Two TOTs were organized to improve the capacity of the district resource pool members on leadership, QI and 5S in Sylhet and Khulna divisions. 2.2.5. To introduce MPDSR in 22 district hospitals, the third TOT on MPDSR was organized. In total 27 participants from 8 districts including 3 MaMoni district managers attended the TOT.

2.3. Quality improvement committee and district resource pool The first job of the QIS team is to develop and activate the management structure of QIS; i.e., with the formation and activation of QI committees at divisional and district levels and formation of the district resource pool. The table below shows the number of districts where QIC and district resource pool have been formed. In the meantime, several districts conducted the district and district hospital QI committee meetings.

Table 8: Information about quality improvement committees (QIC): Jan-Feb 2017 Division No. of QIC formed* District resource District District hospital districts pool developed QIC meeting held# QIC meeting held# Chittagong 11 11 11 6 4 Sylhet 4 4 4 3 2 Barisal 6 5 1 0 0 Khulna 10 10 7 4 3 Dhaka 13 7 NI 2 2 Rajshahi 8 8 6 4 3

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 73 Rangpur 8 4 3 NI NI Mymensingh 4 NI NI NI NI Total: 64 49 32 19 14 *: Total districts; NI: no information; #: No. of districts

Before 5S: Dhaka Medical College Hospital After 5S: Dhaka Medical College Hospital

2.4 MPDSR tools finalized: All the tools (community-based and facility-based death reviews forms for maternal and neonatal deaths) for MPDSR have been finalized through several meetings organized by QIS. The meetings were attended by representatives from UNFPA, UNICEF, CIPRB and QIS including the MaMoni HSS Project Consultants.

2.5. Safe surgery checklist and user guide developed: The initiative was taken to develop a safe surgery checklist that adopts the WHO guideline. A series of meetings were held at DMCH and QIS office involving the concerned stakeholders (teaching staff of medical college hospitals from the departments of general surgery, obstetrics and gynecology, plastic surgery, orthopedic, pediatrics, ENT, anesthesiology and others). The checklist is finalized and is on the desk of the Health Minister for approval. A user guide was also developed for the service providers. MaMoni HSS Project agreed to provide printing support for the checklist and user guide. The checklist will soon be introduced at the tertiary and district level hospitals. To monitor the use of checklist at facility level, a monitoring format was also developed. It is planned to integrate the format with DHIS2 database in the future.

2.6. Development of technical materials 2.6.1. PDCA cycle training manual: This activity has already been contracted out to a local consultant through competitive bidding. A draft manual was developed and is being pre-tested.

2.6.2. RMNCAH quality standards: The initiative has been taken by the QIS to adopt the WHO quality standards on RMNCAH for Bangladesh. In order to do this, 3 teams (maternal and child health, reproductive health and adolescent health), have been formed to review the relevant sections of the document.

2.6.3. Leadership and management training module: The Health Economics Unit has taken the initiative to develop a training manual on leadership and management training for medical officers, and upazila and district managers. The manual will be developed in in collaboration with ICDDR,B. The meetings were also attended by representatives from UNICEF and UNFPA.

2.6.4. Development of communication strategy for QI: After re-advertisement, a consultant has been selected to develop the communication strategy. As the proposed budget was much higher than the estimated/allocated budget, a negotiation meeting to minimize the cost was held and the consultant

74 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report is requested to submit a revised budget. If the budget is found to be within the limit, the contract may be awarded to him.

APPENDIX 7: MNCH ESSENTIAL DRUGS MONITORING REPORT

Fig 28: Reporting status of e LMIS at Lakshmipur district in February 2017

Reporting status of e LMIS at Lakshmipur district in February 2017

250 200 150 100 50 0 Komolnogor Laxsmipur Sadar Ramgoti Upazila Total Upazila Upazila

Total Center Reported Non reported

Monthly color coded reporting of MNCH essential drugs from DGHS & DGFP upazila stores:

Color coded reports of 25 MNCH essential drugs are prepared every month that reflects the stock status and drugs which are going to expire within six months. These information helps to take immediate steps for management of stock out situation and overstock of drugs which are going to expire within six months. Fig 2: Color coded report on the stock status trend of Inj. Gentamycin from January 2016 to March 2017 at DGHS store of Lakshmipur district

Sl Name of the No store

. Jan.16 16 Feb. Mar.16 16 Apr. May. 16 16 Jun. 16 Jul. Aug.16 Sep.16 Oct.16 Nov.16 Dec.16 Jan.17 Feb. 17 Mar.17

1 CS store 2 Dist.Hospital 3 Kamalangar 4 Raagonj 5 Raipur 6 Ramgoti

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 75

Fig 3: Color coded report on the stock status trend of 7.1% chlorhexidine di gluconate from January 2016 to March 2017 at DGHS store of Lakshmipur district.

Name of . 16 the store .17 Jan.16 Feb.16 Mar.16 Apr May.16 Jun.16 Jul.16 Aug.16 Sep.16 Oct.16 Nov.16 Dec.16 Jan.17 Feb March.17

Sadar Kamalangar Ramgonj Raipur Ramgoti Ramgoti

Tracking of FP commodities through Supply Chain Management Portal of DGFP:

Every month the availability of FP commodities is obtained by extracting information from SCMP and trends are observed. The table below shows the Injectable stock out situation at Jhalokathi district from October 2015 to February 2017 (data source: Supply Chain Management Portal of DGFP).

Sl Name of the Upazilla Jan Feb Mar Apr Ma Jun Jul. Aug Sep. Oct. Nov Dec. Jan. Feb. N 16 16 16 16 y16 .16 16 .16 16 16 .16 16 17 17 o.

1 Sadar 0 0 1.5 0 0 0 0 0 0 0 0 0 0 0

2 Kathalia 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3 Nalchiti 3.6 0 0 1.8 3.6 1.8 5.4 1.8 0 0 0 0 0 0

0 4 Rajapur 0 0 0 0 0 0 0 0 0 0 0

76 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report

APPENDIX 8: DOCUMENTATION AND DISSEMINATION OF MAMONI PROGRAM LEARNING

Table 9: Forums where MaMoni HSS lessons were disseminated

Type of Title Forum Place Month Dissemination Community Micro Planning (cMPM) - an innovative approach of MaMoni Health Systems Strengthening (HSS) Kampala, CHW Symposium Feb 2017 Oral Presentation project to strengthen public Uganda sector Community Health Workers (CHW) service delivery in Bangladesh Recruiting, training and retaining of Community Kampala, CHW Symposium Feb 2017 Oral Presentation Volunteers: Experience from Uganda rural Bangladesh Making a difference: community volunteers Kampala, contributing to increasing use CHW Symposium Feb 2017 Oral Presentation Uganda of effective family planning in Bangladesh Development of community skilled birth attendants in Kampala, CHW Symposium Feb 2017 Oral Presentation hard-to-reach areas of Uganda Bangladesh

Table 10: Updates on MaMoni HSS Program Learning and Documentation Plan

Study Final Product Status 1 Could providers use partographs to identify Journal Drafted complications? Do partograph lead to appropriate Manuscript referral? Program Brief Completed 2.a Are facilities ready to provide Quality NSV/Tubectomy Journal services? What are the barriers to services? How was the Manuscript Drafted experience of care? 2.b Why are eligible clients not utilizing permanent FP Journal Outline and results services? Manuscript drafted 2.c What policy changes are needed to ensure quality Journal permanent contraceptive services? How does the service Manuscript Not ready need to be reorganized? 3 How well can union level providers manage PSBI where Journal Study Design to be referral is not feasible? Manuscript prepared by Apr 15 4 Was CHX national scale up achieved and effective? Will Journal Study protocol it achieve sustainable effective coverage at scale? Manuscript finalized 5 Is the income of private CSBAs sufficient to make them Journal IRB approved, Data sustainable? How can the program make them effective Manuscript collection ongoing and sustainable?

MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report 77 Study Final Product Status 6 Are providers able to provide quality ANC at satellite Research Brief Completed clinics? 7 Did UH&FWC strengthening lead to increased skilled Program Brief Data collection attendance at birth? ongoing 8 Did integrated distribution of Misoprostol and Program Brief Data collection Chlorhexidine increase coverage in Lakshmipur district? ongoing 9 Experience of introducing CHX through community Program Brief Data collection distribution in Habiganj district ongoing 10 What is the experience of introducing simplified Program Brief

treatment of antibiotic at 10 sub-districts? 11 Are facilities prepared to initiate facility KMC care Poster Data collection effectively? presentation ongoing 12 Are providers able to correctly estimate gestational age Program Brief At discussion level and manage threatened preterm labor? 13 Did integrated FP-MNCH lead to higher utilization of FP Program Brief Concept note services? drafted 14 Has MaMoni HSS inputs to PPFP led to increased Program Brief

utilization? 15 Did training of CHCPs lead to improved growth Program Brief

monitoring and referral for SAM management ? 16 Effect of introducing modified QI framework in health Program Brief

facilities Did strengthening infection prevention and waste Program Brief management systems at UH&FWCs have a positive effect in Quality of Care? 17 Did MaMoni HSS interventions lead to more equitable Program Brief Need to complete service utilization across geographic areas and asset end-line survey in quintiles Mar 2018 18 Did MPDSR implementation in Begumganj sub-district Program Brief of Noakhali lead to actions to address preventable maternal and perinatal deaths? 19 Experience of introducing eMIS automated data Program Brief recording and reporting system in Madhabpur sub- district of Habiganj 20 Experience of introducing WISN workload analysis tool Program Brief

in 2 districts 21 Experience of supporting the national QI secretariat and Program Brief

introducing divisional QI committees 22 Are providers able to correctly detect SPE/E cases? Are Program Brief they able to effectively manage and refer these cases? 23 Can MaMoni reduce discontinuation of IUD/implants Undecided Concept note through targeted interventions? submitted to USAID for approval 24 Did MaMoni's support in annual district planning, Program Brief Concept note being monthly and quarterly reviews lead to better data driven drafted decision making and pro-active management and supervision practices? 25 How sensitive are the survey tools to identify chronic Program Brief Validation ends maternal morbidities (obstetric fistula, pelvic uterine April 06 prolapse) (MMVS 2016 study) 26 Can union level providers manage newborn sepsis Program Brief management cases in Ramganj sub-district? (JHU Endline data shared collaboration) 27 Changes in health facility readiness in MaMoni districts Program Report Pending USAID (HFS 2017) approval

78 MaMoni Health Systems Strengthening Activity: FY’17 Q2 Quarterly Report APPENDIX 9: NEWS CLIPS PUBLISHED DURING JANUARY- MARCH 2017 Media Date Article Title and Link Daily March 2, Prothom Alo Prothom Alo 2017 News Title: নবজাতেকরনািভরযত্ন Link: http://www.prothom-alo.com/life- style/article/1094761/%E0%A6%A8%E0%A6%AC%E0%A6%9C%E0%A 6%BE%E0%A6%A4%E0%A6%95%E0%A7%87%E0%A6%B0- %E0%A6%A8%E0%A6%BE%E0%A6%AD%E0%A6%BF%E0%A6%B0- %E0%A6%AF%E0%A6%A4%E0%A7%8D%E0%A6%A8 Daily February Prothom Alo Prothom Alo 12, 2017 News Title: �া�뷍েসবােথেকবহ‍দূেরচরও�ীেপরমানুষ Link: http://www.prothom- alo.com/bangladesh/article/1079687/%E0%A6% Daily February Daily Prothom Alo Prothom Alo 26, 2017 News Title: ২৩শতাংশিশশ‍জ�াে�কমওজনিনেয় Link: http://m.prothom- alo.com/bangladesh/article/1090540/%E0%A7%A8%E0%A7%A9- %E0%A6%B6%E0%A6%A4%E0%A6%BE%E0%A6%82%E0%A6%B6- %E0%A6%B6%E0%A6%BF%E0%A6%B6%E0%A7%81- %E0%A6%9C%E0%A6%A8%E0%A7%8D%E0%A6%AE%E0%A6%BE%E0%A6%9A% E0%A7%8D%E0%A6%9B%E0%A7%87-%E0%A6%95%E0%A6%AE- %E0%A6%93%E0%A6%9C%E0%A6%A8- %E0%A6%A8%E0%A6%BF%E0%A7%9F%E0%A7%87 Daily Ittefaq February Daily Ittefaq 28, 2017 Published Date: February 28, 2017 News Title: �েয়াজনঅপুি�িবেরাধীসমি�তঅিভযান Link: http://www.ittefaq.com.bd/print- edition/editorial/2017/02/28/179065.html Daily Kaler Published Daily Kaler Kantho Kantho Date: News Title: ব�েহাকঅ�েয়াজনীয়িসজািরয়ানঅপােরশন March 4, 2017 Link: http://www.kalerkantho.com/online/prescription/2017/03/04/470638

Daily March 6, Prothom Alo Prothom Alo 2017 Published Date: March 6, 2017 News Title: সব쇍জনীন�া�뷍সুর�ায়সমি�তউেদ뷍াগদরকার Link: http://www.prothom- alo.com/bangladesh/article/1098991/%E0%A6%B8%E0%A6%B0%E0%A7%8D% E0%A6%AC%E0%A6%9C%E0%A6%A8%E0%A7%80%E0%A6%A8- %E0%A6%B8%E0%A7%8D%E0%A6%AC%E0%A6%BE%E0%A6%B8%E0%A7%8 D%E0%A6%A5%E0%A7%8D%E0%A6%AF- %E0%A6%B8%E0%A7%81%E0%A6%B0%E0%A6%95%E0%A7%8D%E0%A6%B 7%E0%A6%BE%E0%A7%9F- %E0%A6%B8%E0%A6%AE%E0%A6%A8%E0%A7%8D%E0%A6%AC%E0%A6% BF%E0%A6%A4- %E0%A6%89%E0%A6%A6%E0%A7%8D%E0%A6%AF%E0%A7%8B%E0%A6%9 7-%E0%A6%A6%E0%A6%B0%E0%A6%95%E0%A6%BE%E0%A6%B0

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