USAID|Mikolo Quarterly Progress Report Period

USAID|Mikolo Quarterly Progress Report

Period: October 2017-December 2017

John Yanulis

January 30, 2018

USAID|MIKOLO is a five-year project (2013-2018), funded by USAID and implemented by Management Sciences for Health (MSH) with Catholic Relief Services (CRS), Overseas Strategic Consulting (OSC), and local partners. The project will increase community-based primary health care service uptake and the adoption of healthy behaviors among women of reproductive age, young children, and newborns under 5 years old.

[Primary health care – USAID – Community health services]

This report was made possible through support provided by the US Agency for International Development and the USAID Madagascar, under the terms of Contract Number AID-687-C-13-00001 and Andry Rahajarison. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the US Agency for International Development.

USAID|MIKOLO Management Sciences for Health 200 Rivers Edge Drive Medford, MA 02155 Telephone: (617) 250-9500 http://www.msh.org

USAID|Mikolo Quarterly Progress Report

Period: October-December, 2016

John Yanulis

March 13th, 2017

[Primary health care – USAID – Community health services]

USAID|MIKOLO Management Sciences for Health 200 Rivers Edge Drive Medford, MA 02155 Telephone: (617) 250-9500 http://www.msh.org

The USAID Mikolo Project

QUARTERLY REPORT Fiscal Year 2017 OCTOBER 2016 – DECEMBER 2016

Prepared by John Yanulis, Chief of Party Contact : [email protected] ______Submitted to USAID by Management Sciences for Health FITARATRA Building, 3rd Floor to the right – Ankorondrano Antananarivo - Madagascar

DATE : January 30th, 2017; REVISED March 13, 2017

This document was prepared with the generous support of the US Agency for International Development (USAID) under Contract No. AID-687-C-13-00001. Its contents are the responsibility of the USAID Mikolo Project and do not necessarily reflect the views of USAID or the US Government. FY 17 FIRST QUARTERLY REPORT The USAID Mikolo Project Page | 1

Table of ContentsTABLE OF CONTENT

LIST OF ACRONYMS 3

EXECUTIVE SUMMARY 5

RESULTS FRAMEWORK 7

IMPLEMENTATION AND RESULTS 8

SUB-PURPOSE 1: SUSTAINABLY DEVELOP SYSTEMS, CAPACITY AND OWNERSHIP OF LOCAL PARTNERS 9

SUB-PURPOSE 2 : INCREASE THE AVAILABILITY OF AND ACCESS TO BASIC HEALTH CARE SERVICES IN THE PROJECT’S TARGETED COMMUNES 14

REPRODUCTIVE HEALTH/FAMILY PLANNING 15 MATERNAL, NEWBORN, AND CHILD HEALTH 18 MALARIA 26 SUPPLY CHAIN/LOGISTICAL MANAGEMENT OF HEALTHCARE PRODUCTS 30

SUB-PURPOSE 3 : IMPROVE THE QUALITY OF PRIMARY HEALTHCARE SERVICES AT THE COMMUNITY LEVEL 33

SUB-PURPOSE 4 : INCREASE THE ADOPTION OF HEALTHY BEHAVIORS AND PRACTICES 36

M-HEALTH 40

MONITORING & EVALUATION 41

PROJECT MANAGEMENT 43

FINANCE AND OPERATIONS 45

SUCCESS STORY 47

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LIST OF ACRONYMS List of Acronyms

ACT Artemisinin-based Combination Therapy AMS Ankohonana Mendrika Salama (Household Champion of Health) ANC Antenatal Care ARH Adolescent Reproductive Health ASOS Action Socio-sanitaire Organisation Secours BCC Behavior Change Communication BR Bureau Régional (Regional Office) CCDS Commission Communale de Développement Social CHV Community Health Volunteer COSAN Comité de Santé (CHV Association) CRS Catholic Relief Services CSB Centre de Santé de Base (Health Center) CSLF COSAN Savings and Loans Fund CYP Couple Years Protection DDS Health Districts Directorate DHIS District Health Information System DHS District Health Service DLP Direction de la Lutte contre le Paludisme (Directorate to Combat Malaria) DQA Data Quality Assurance EMAD Équipe de Management de District (District Management Team) EMAR Équipe de Management de Région (Regional Management Team) ETL Education Through Listening FL Female Leader FMS Fokontany Mendrika Salama (Fokontany Champion of Health) FP Family Planning GMP Growth Monitoring and Promotion ITEM Institut de Technologie de l'Éducation et du Management KMS Kaominina Mendrika Salama (Commune Champion of Health) LAPM Long-Acting and Permanent Methods LLIN Long-Lasting Insecticide-treated Nets LQAS Lot Quality Assurance Sampling M&E Monitoring and Evaluation ML Male Leader MNCH Maternal, Newborn, and Child Health MOPH Ministry of Public Health MSM Marie Stopes Madagascar NCHP National Community Health Policy NGO Nongovernmental Organization ODF Open Defecation Free ORT Oral Rehydration Therapy OSC Overseas Strategic Consulting Processus d'Auto-évaluation de la Capacité Organisationnelle (Self- PACO Evaluation Process for Organizational Capacity) RDQA Routine Data Quality Assessment RDT Rapid Diagnostic Test RH Reproductive Health SAJ Séances d’Animation Jeunes (Youth Awareness Sessions)

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SDSP Services de District de Santé Publique (District Public Health Services) SILC Saving and Internal Lending Community STTA Short Term Travel Assistance SQA Service Quality Assurance SSF Sanitation Support Fund ST Support Technician STS Support Technician Supervisor TM Technical Manager TOT Training of Trainers T-SILC Saving and Internal Lending Community Technician TWG Technical Working Group VPD Vaccine-Preventable Diseases WASH Water, Sanitation, and Hygiene YPE Youth Peer Educators

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Executive Summary

ABOUT THE PROJECT uring the first quarter (Q1) of fiscal year 2017 (FY 2017), the USAID Mikolo project The USAID Mikolo Project is a five-year D strengthened its partnership with the project (2013-2018) implemented by Ministry of Public Health (MoPH) at the central and Management Sciences for Health (MSH), district levels in the eight target areas, as well as with international partners, Catholic focused on the implementation and scale-up of its Relief Services (CRS) and Overseas core program to reduce maternal, child and infant Strategic Consulting (OSC) together with mortality. their local Malagasy partners, Action Socio-Sanitaire Organisation Secours The results of the first quarter are as follows: (ASOS) and the Institut de Technologie de l'Éducation et du Management (ITEM). The Project aims to contribute to the reduction in maternal, child and infant mortality by increasing the use of primary healthcare services at the community level and by promoting the adoption of healthy behaviors in women of childbearing age, children under five and infants.

Sub-Objective 1: Sustainably develop systems, capacity and ownership of local partners

● 237 STs and ST supervisors were trained on Leadership and Management knowledge and skills, which surpassed the FY 2017 target of 234 people. ● 10 local NGOs were subcontracted to manage activity implementation in the 14 zones across the eight regions. ● 60 SILC groups were established at the community level, which is 9 % of the FY 2017 target. However, these data only cover three NGOs; seven have yet to provide data on the number of SILCS. Therefore, this number is expected to rise in Q2.

Sub-objective 2: Increase the availability of and access to basic health care services in the project's targeted communes ● The project reached 27,965 new users (NUs) of FP services and 92,221 regular users (RUs). This brings the current rate of success relative to the set objective for FY 2017 to 21% for NUs and 68% for RUs, respectively. With the results obtained to date, 21% of the couple-years of protection (CYP) objective for FY 2017 has been reached. ● 10,026 new users (37% of the total NUs) were adolescents (ages 15-19). ● 6% of CHVs report a stock-out of oral contraception products and 7% experience a stock-out of DMPA products at any point throughout Q1. Both of these indicators fully meet the FY 2017 targets.

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● A total of 8,915 ANC clients were referred by CHVs, which is 28% of the annual target. ● 1,154 newborns received umbilical care, which is almost 500% more than the number treated in Q1 of FY 2016. ● 18,315 children under five received treatment for pneumonia, which meets 17% of the annual goal, and represents a 95% treatment rate. ● 11,026 children under five suffering from diarrhea received ORT by CHVs, reaching 20% of the FY 2017 target. ● 120 health workers were trained in ACT case-management, and 120 were trained in malaria laboratory diagnostics, both meeting 19% of the respective annual objectives. ● CHVs provided ACT to 80% of children with a positive malaria RDT, which meets 100% of the FY 2017 target. ● CHVs have surpassed the annual goals for the level of stock-outs (i.e. achieving below the targeted percentage of stock-outs) of ORS/Zinc and of Pneumostop, achieving 142% and 162% of the targets, respectively.

Sub-Objective 3: Improve the quality of basic healthcare services at the community level ● 62% of CHVs achieve the minimum quality score for community case management of childhood illnesses, and 59% reach the minimum quality score for family planning counselling, which meets 91% and 87% of the FY 2017 targets, respectively. ● 87% of CHV monthly activity reports are timely and complete (97% of the annual objective). ● 87% of CHVs attend monthly COSAN meetings (97% of the annual objective).

Sub-Objective 4: Increase the adoption of healthy behaviors and practices ● 200 communes received the status of “Commune Champion,” and 42,609 households were certified “Household Champions,” meeting 47 % and 35 % of the respective annual objectives. ● 132 interactive radio spots were broadcasts, reaching 5% of the annual goal. ● 3,750 people were reached with health and WASH messages (4% of the FY 2017 target). ● 21,612 women were educated on exclusive breastfeeding (EBF), representing 31% if the annual objective.

The USAID Mikolo Project submitted its workplan on the 30th of October, 2016 and received final approval of its 2017 Annual Implementation Plan and Budget on November 29th, 2016 after responding to comments from the USAID Management Team for the Project. Multiple CLT field visits and STTA trips were also conducted, enabling several recommendations to be developed and implemented. Additionally, the Project participated in a joint review that gathered MOPH central and regional directors and other health partners, in order to facilitate the Project’s strategic partnerships. Finally, the Project organized an Alignment Workshop with all Project staff to ensure that the staff moves forward into the Project’s fourth year in a cohesive manner.

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Results Framework

PROJECT GOAL

TO REDUCE MATERNAL, CHILD AND INFANT MORTALITY AND MORBIDITY

PROJECT PURPOSE

To increase community-based primary health care services uptake and the adoption of healthy behaviors

SUB -PURPOSE 1 SUB-PURPOSE 2 SUB-PURPOSE 3 SUB-PURPOSE 4

To increase To sustainably To improve the availability of To increase the develop quality of and access to adoption of systems, community- primary health healthy capacity and based primary care services in behaviors and ownership of health care project target practices local partners services communities

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IMPLEMENTATION AND RESULTS

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SUB-PURPOSE 1: Sustainably Develop Systems, Capacity and Ownership of Local Partners

Sustainably Develop Systems, Capacity and SP1

Ownership of Local Partners

The USAID Mikolo Project works to strengthen the systems, capacity, and ownership of local partners in order for them to implement quality health programs. The main activities include capacity building for NGOs and health district managers, training of MoPH staff, and promotion of SILC and CSLF groups.

In Q1, the USAID Mikolo Project trained 237 STs and ST supervisors on Leadership and Management knowledge and skills, which surpassed the FY 2017 target of 234 people. Moreover, 10 local NGOs were subcontracted to manage activity implementation in the 14 zones across the eight regions. So far, data on SILC groups are available from three NGOs, therefore the number of SILC groups established at the community level is expected to rise in Q2 when more data become available.

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TRAININGTRAINING

Table 1: Training indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicator Annual Result ACHIEVED Target

Number of people (TA and supervisor) trained with increased 1.3.2 234 237 101% Leadership and Management knowledge and skills

In November 2016, the USAID Mikolo project held all planned regional trainings for 237 STs and ST supervisors from 10 local NGOs, representing 101% of the annual target. The training focused on (1) carrying out effective supervision and (2) leading group facilitation.

The training was structured to prepare STs for a planned increase in CHV mentoring support. Per project strategy, formal CHV training is phasing out as the project progresses. During FY 2017, the focus of ST support will be predominantly on supervision, mentoring and monthly review meetings with CSB heads. The project will continue to provide formal training for new CHVs and for those transitioning to polyvalent status.

In addition, during Q1, the project collaborated with the USAID “Mahefa Miaraka” project to initiate the development the protocol for a CSB non-clinical, health facility needs assessment. The results of this needs assessment will be used to develop a CSB support strategy for non- clinical aspects of quality of care that will be implemented starting in Q3.

Support technicians supervise CHVs on a monthly basis, ensuring the quality of services and data reporting.

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GRANTS GRANTS

Table 2: Grants indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicator Annual Result ACHIEVED Target

1.8 Number of local NGO grants 11 10 91%* awarded

*Please note that the target set in the USAID-approved FY 2017 Workplan is 11. However, this target was set prior to the launch of the NGO application process. After reviewing the applications, 10 NGOs were chosen to cover all 14 zones.

Following the FY 2017 contract modification signed with USAID on November 7, 2016, the project signed grants with 10 local NGOs to manage activity implementation across the 14 zones in the eight regions. The 10 NGOs were selected after a competitive and open application process. Seven of the NGOs were re-selected from FY 2016 to cover the same zones, two were re-selected from FY 2016 and each given an additional lot to manage, and the 10th NGO was a partner NGO in FY 2015. Consequently, all partner NGOs have rich experience with the USAID Mikolo Project’s approaches and implementation strategies.

In November and December 2016, the project led orientation sessions for the selected NGOs. The first session covered project norms, procedures, policies, and compliance. The second session was held in each region and focused on regional operations and logistics for activity implementation.

MICROFINANCEMICROFINANCE

Table 3: Microfinance indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

1.4 Number of COSAN savings and 28 NA loans funds (CSLF) established

1.5 Number of Saving and Internal 686 60 9 % Lending Community (SILC) established at the community level

USAID IR Number of households using 11662 1020 0% 1.2.1 savings and loans mechanisms

Sixty SILC groups were created during Q1, representing 1020 households. During the quarter, the project collected data from three NGOs in Atsimo Andrefana, Atsinanana, and Vakinankaratra, for whom USAID approval and hence contracts were obtained in early November. During this quarter, very few NGOs were able to mobilize the SILC technicians (SILC-T) and Field Agents because their notification and contracting following the call for tenders could only be launched after the approval at the end of November 2016. (See Table 4 below).

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Table 4: Number of SILC groups created Region of reported lot Number of SILCs created in Q1

Atsimo Andrefana 36

Atsinanana 18

Vakinankaratra 6

Total 60

In Q2, the project will collect data from the remaining seven NGOs, which began activities later, following USAID approval in late November.

During the Q1 NGO orientations, the project reviewed the challenges related to the SILCs and CSLFs identified in FY 2016 and identified strategies and focus areas for FY 2017.

Saving and Internal Lending Community (SILCs) challenges and strategies

Building on the successes of FY 2016 - when the project achieved 103% of the FY 2016 target for the number of SILC groups created, and achieved regular and active membership, the project will focus its FY 2017 efforts on increasing credit usage among SILC members.

As discussed in the FY 2016 annual report, some SILC members contribute financially to the SILC without taking out loans, in part related to concerns that they may not be able to pay back the loan with interest and the risks associated with new revenue-generating activities (RGAs). This challenge was discussed during the Project field orientations and will be addressed by improving financial education of SILC members, which will begin in Q2, first for SILC-Trainers who will then provide this training to the PSPs who will be able to provide greater financial education to the SILC members.

In addition, the project began to prepare for an internal study on the reasons why some SILC members do not utilize credit funds. Data collection is planned for Q2 and data analysis for Q3. The results of this research study will be used to inform the project strategy for increasing credit utilization in the SILCs.

SILC groups give to members the opportunity to regularly save money and to have access to credits from their own collective savings.

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Another challenge identified in FY 2016 was the resistance by some SILCs to pay Private Service Providers (PSPs) for their services. These relatively small payments are made to PSPs to cover training on the first nine SILC modules. After this, the groups should be fully functional and may pay for additional PSP training on financial management, if they are interested. The PSP service fees were covered by the project in its first year, but as part of the project sustainability strategy, the PSP payments were subsequently transitioned to the SILCs themselves. Many SILCs, e.g. one in Atsimo- Andrefana, value the PSP services and have paid for the services. However, in other areas, SILC members are more skeptical, and this is particularly the case where SILCs are relatively new. During the field orientations conducted during this quarter, project staff emphasized the importance of SILC- Ts reinforcing the rationale and importance of PSP services to SILC members during FY 2017.

The project also reviewed the data collection process for the new USAID indicator for USAID IR1.2.1: number of households using savings and loans mechanisms. The project began collecting data for this indicator in December 2016 and will provide an update in Q2.

COSAN Savings and Loans Fund (CSLF) challenges and strategies

During this quarter, the project did not plan to create new CSLFs, as this activity will start in Q2. The NGO SILC-Ts implement this activity and due to the delay in signing the NGO contracts, the project adjusted its plans for this activity which will now begin in Q2.

During Q1, the project conducted an internal review of CSLF-related challenges and strategies and found that CSLF members actively use credit and take out loans. However, these loans are often not used for one of the project’s intended purposes (the purchase of medical supplies/medications by CHVs; the establishment of emergency evacuation systems; and/or the construction of CHV health huts). Anecdotal reports from CHVs showed that many CHVs doubt that the profit on the sale of these goods will cover the interest on the loan. In addition, they are not always sure of the rate that they will be able to sell medical inputs and they feel that it is hence too risky to take out a loan. Instead, CHVs more often take out loans for other RGAs..

To overcome this challenge, the project will encourage CSLFs to set up a separate account for group RGAs that can be used for group projects without the payment of interest. This type of account could be used to purchase health inputs and remove the individual risk associated with purchasing these products. This model has been utilized successfully by CSLFs in Atsimo Andrefana.

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SUB-PURPOSE 2 : Increase the availability of and access to basic health care services in the project’s targeted communes

Increase the availability of and access to basic health SP2

care services in the project’s targeted communes

The USAID Mikolo Project supports community health volunteers and health centers to ensure a continuum of care. The key activities include family planning and reproductive health, maternal, newborn and child health, including vaccination promotion and follow- up and growth monitoring, as well as integrated management of childhood illness, malaria, and supply chain management.

In the first quarter of FY 2017, the USAID Mikolo Project reached 27,965 new users (NUs) of FP services and 92,221 regular users (RUs), resulting in the achievement of 21% of the couple-years of protection (CYP) objective for FY 2017. 10,026 of those NUs (37%) were youth aged 15-19. Furthermore, oral contraceptive and DMPA product stock-outs were within the range of the annual goals of 6% and 7%, respectively.

In regards to maternal and child health, a total of 8,915 ANC clients were referred by CHVs, which is 28% of the annual target. Moreover, 1,154 newborns received umbilical care (Chlorhexidine, which is almost 500% more than the number treated in Q1 of FY 2016. In addition, results regarding treatment rates are positive, as 18,315 children under-five received treatment for pneumonia, which represents a 95% treatment rate, and 11,026 children under-five received ORT, which is 30% more than the amount treated in Q1 of FY 2016. Finally, CHVs continued to provide quality malaria care, as 80% of children with a positive malaria RDT received ACT, which is almost 20% more than in Q1 of FY 2016.

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REPRODUCTIVE REPRODUCTIVE HEALTH/FAMILY HEALTH ANDPLANNING FAMILY PLANNING

Table 5: RHFP indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

2.2 - USAID IR Couple Years Protection (CYP) in 116 838 39051 33% 2.9 USG supported programs

2.3 - USAID IR 2.11 Number of new users of FP method 130 817 27 065 21% PPR USAID

2.4 - USAID IR Number of regular users of FP 2.10 135 572 113 114 68% method PPR USAID

During Q1, CHVs continued to provide regular family planning counseling throughout the eight regions. CHVs provided protection from unintended pregnancy to 24,668 couples and enrolled 27,065 new family planning users, reflecting 21% of the annual target. These Q1 results suggest that project is on track to achieving its annual target. In both cases, CHVs increased enrollment compared to Q1 of FY 2016. For new users, an increase of 18% was observed compared to Q1 FY16. This is mainly due to a lower number of CHVs having experienced a stockout of FP products (over 20% reduction compared to Q1 FY16). During Q1, 92,221 women continued to use an existing family planning method, representing 68% of the annual target.

As the NGO contracts were not signed until late November 2016, no family planning CHV trainings were held during the quarter. Moreover, due to the restrictions on training for DepoCom by the Ministry of Health, cross-training for child health CHVs or new CHVs was not conducted (see section on Family Planning Compliance below for more information on this restriction). The trainings will resume when the Ministry of Public Health finalizes the National Community Health Policy and the Package of Activities for CHVs, which will address the DepoCom issue.

Below are graphs that show the breakdown of CYP and new users by region. For both services, Haute Matsiatra is the highest performing region, most likely because of its relatively high number of FP CHVs. With 802 FP CHVs, Haute Matsiatra has the largest number of CHVs providing FP services. The three regions that reported the lowest number of CYP and new users (Alaotra Mangoro, Amoron’i Mania, and Analamanga) have the fewest FP CHVs, with a combined total of 656 across the three regions.

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Figure 1 : Couple Years of Protection by region, PY4, Q1 16000 14265 14000 12000 10000 8000 6140 6000 5006 3747 4000 2827 2633 2315 2118 2000 0

Ratio Couple Years of Protection/CHVs by region Q1 FY17 Alaotra Atsimo Vatovavy mangor Amoron' Analamang andrefan Atsinanan Haute Vakinankaratr fitovinan o i mania a a a matsiatra a y

163 336 193 495 443 758 250 572 #CHVs Ratio CYP/#CHV 14,2 8,4 11,0 5,3 11,3 18,8 15,0 10,7 s

Figure 3: Breakdown of New Users by region

Vatovavy Alaotra mangoro fitovinany 8% 22% Amoron'i mania 10%

Analamanga 3% Vakinankaratra 6% Atsimo andrefana 10%

Haute matsiatra 24% Atsinanana 17%

During Q1, CHVs were successful at targeting and enrolling youth in new family planning methods (Figure 3). Amongst new users, 37% were aged 15-19, up from 30% from the preceding quarter. This is perhaps due to the work of youth peer educators who have provided targeted family planning education to youth.

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Figure 3: New FP users by age group (Q1 FY15, FY16 and FY17) 12,000

10,000 10,026 9,221 8,000 7,814 7,824 7,818 7,355 6,000 6,671 6,284 6,161

4,000

2,000

- FY15 FY16 FY17

15-19 20-24 >25

Participation in the National Family Planning Committee

During Q1, the USAID Mikolo project contributed to updating the MoPH’s family planning norms and procedures, as a member of the National Family Planning Committee. The Project actively participated in drafting these documents, which included updates on three family planning innovations: 1. The administration of pregnancy tests by CHVs 2. The administration of Sayana Press contraceptive injections by CHVs 3. The use of Misoprostol to prevent hemorrhaging after childbirth

During Q1, the USAID Mikolo Project also engaged in government-led advocacy efforts to promote the adoption of Madagascar’s first family planning/reproductive health law. The new proposed law would protect the right of women in Madagascar to access family planning. As a key SRPF committee member, the project provided draft text of the law, documents to justify and explain the law, and a concept note on the law that was presented to government ministries. During the quarter, the Ministry of Health approved the law and it is now being reviewed by the President and other ministries. Once approved by these bodies, the law will pass to the National Assembly for adoption, currently anticipated by May 2017.

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MATERNAL, NEWBORN, AND CHILD HEALTH MATERNAL, NEWBORN AND CHILD HEALTH

Table 6: MNCH indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

Percent of children between 12-23 months USAID IR 2.5 of age who received their 3rd dose of DPT 81% 70% 86% by 12 months of age

Number of children reached by USG- 2.16 supported nutrition programs (Number of PPR 3.1.9.1- children under five years old registered 814 138 271 328 33% 15 by CHVs for Growth Monitoring and Promotion (GMP) activities)

Number of mothers/caregivers of children 0-23 months who received direct maternal USAID IR infant and young child nutrition 440 284 129 015 29% 2.19 counseling at least once during last quarter through USG supported programs

Number of newborns who received 2.17 - USAID umbilical care through the use of 27 436 1554 6% IR 2.6 chlorhexidine

2.18 Number of ANC clients referred by CHVs 32405 8915 28%

Percent of women with live births who USAID IR 1.4 completed at least 4 ANC visits during TBD 9% - their pregnancy

Number of clients referred by CHVs for 2.19 50 734 3 484 7% severe illness episodes (CU 5 years)

GROWTH MONITORING AND PROMOTION

During Q1, 271,328 children benefited from growth monitoring. This number is 33% of the FY 2017 target and 27% higher than the total number of children reached in Q4 of FY 2016 (214,473) figure 5). Thanks to regular on-site supervisions and Routine Data Quality Assurance, CHVs were able to: ● directly report growth monitoring and promotion results ● build trust with parents who gradually recognize CHV’s skills on GMP ● foster contact with parents, following an MNCH campaign conducted in October 2016 with the MoPH

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Figure 4: Number of children reached on GMP by quarter (FY15, FY16, FY17) 300,000 271,328 250,000

200,000

150,000 119,007

100,000

50,000

- FY15 FY15 FY15 FY15 FY16 FY16 FY16 FY16 FY17 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

Below is the regional breakdown of growth monitoring and promotion. Most regions showed strong performance in growth monitoring this quarter. CHVs in Haute Matsiatra and Atsinanana completed the largest number of growth monitoring activities. One explanation for this is the large number of CHVs, all of which conduct growth monitoring activities, in each of these regions. With 1,246 CHVs, Atsinanana has the highest numbers. Haute Matsiatra is not far behind with 999 CHVs. Alaotra Mangoro falls behind the other regions, but this is due to the fact that a growth monitoring training for the CHVs has been rescheduled for Q2 of FY 2017. The other regions received this training in FY 2016. Due to DRS scheduling and coordination conflicts, the training was rescheduled for Q2 of FY 2017 in Alaotra Mangoro. Once the regional CHVs receive this training, the project is confident that the results will increase to be more in line with the other regions.

Figure 5 : Number of people reached with GMP

60,000 54,434 50,799 50,000 42,731 40,000 37,351 29,484 29,960 30,000 21,355 20,000

10,000 5,214

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CHLORHEXIDINE

In Q1, 1,554 newborns received umbilical care. An increase of 7% was observed compared to Q4 FY 2016. The number of newborns (1,554) is 500% higher than the number (271) treated in Q1 of FY 2016. CHVs have significantly increased their distribution of and awareness raising regarding CHX.

Figure 6: Number of newborns receiving umbilical care (FY16 and FY17) 1,800 1,554 1,600

1,400 1,200

1,000 800 600

400 271 200 - FY16Q1 FY16Q2 FY16Q3 FY16Q4 FY17Q1

During the quarter, the CHVs supported by the USAID Mikolo project continued to promote CHX for umbilical cord care on newborns. PSI had previously distributed the gel based version of the product to CHVs, but the government received its first shipment of the gel in November 2016. The product will now be distributed to CSBs throughout the country. Since CHVs will now be able to obtain CHX from CSBs, this will increase their ability to have stocks of the product and distribute it accordingly. In addition, the skepticism regarding CHX amongst pregnant women should dissipate as the product becomes available from the public sector in addition to the private sector. The distribution of CHX and with Misoprostol will reinforce CHX usage as trainings and education regarding Misoprostol will provide an opportunity for women to also be exposed to CHX, given that the two products should be used concurrently.

The project expects that the use of CHX for umbilical care will continue to increase in the coming quarters as the USAID Mikolo project prepares for the joint scale up of CHX and misoprostol.

MISOPROSTOL Misoprostol is a medication that can be administered to women directly after childbirth in order to prevent hemorrhaging, one of the principal causes of maternal mortality in Madagascar. The first shipment of the product was delivered to the Ministry of Health in November 2016. In December, the project began planning for the scale up of Misoprostol across seven of its eight target regions (the Ministry of Health has determined that the Atsimo Andrefana region will be part of the second phase of distribution in 2018). In order to accelerate distribution and ensure that the product is utilized before its expiration date of December 2017, the Ministry of Health is requesting assistance from technical and financial partners, including the USAID Mikolo project, to distribute the product to CSBs. The project is currently working to update the instructional materials and tools related to Misoprostol usage and will train CHVs on misoprostol use in the upcoming quarter.

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DIARRHEA AND PNEUMONIA

Table 7: Diarrhea and pneumonia indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

Number of children under five years old 2.14 - USAID with diarrhea treated with Oral 54 666 11 026 20% IR 2.7 Rehydration Therapy (ORT)

2.15 - USAID Number of children with pneumonia 104 817 18 315 17% IR 2.4 taken for appropriate care

During the quarter, CHVs treated 11,026 children under five years old with Oral Rehydration Therapy (ORT). During FY 2017, the target for diarrhea treatment is more than double the FY 2016 target based on CHVs achievement in FY16. Note that diarrheal disease is seasonal and hence, it is expected that the number treated with ORT in Q2 will be higher than 25% of the target.

As shown in the graphs below, the number of diarrhea cases began to increase slightly in October and then much more in November 2016. This follows the expected seasonal diarrhea pattern, which predicts an increase in diarrheal disease during the rainy season (October- March), with a peak in Dec-Jan-Feb. CHVs successfully addressed the increased diarrhea caseload as reflected in the treatment rate, which reached 82% by the end of November 2016. The improved rate reflects a substantial improvement in the quality of case management by CHVs compared to Q1 of both FY 2015 and FY 2016, during which only 20% of cases were treated. The Q1 results also showed improvement compared to Q4 of FY 2016, during which the rate of treatment was 76%.

Figure 7: Diarrhea treated by CHVs by quarter (FY15, FY16, FY17 Q1) 25,000 21,518

20,000

15,000

11,026 10,000

5,634

5,000

- FY15 FY15 FY15 FY15 FY16 FY16 FY16 FY16 FY17 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

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Figure 8: Breakdown of pneumonia cases by region (PY4, Q1) Alaotra mangoro 4% Amoron'i mania 8% Vatovavy fitovinany Analamanga 26% 4%

Atsimo andrefana 20%

Vakinankaratra 8%

Haute matsiatra 12% Atsinanana 18%

In Q1, CHVs treated 18,315 children with pneumonia, which is 17% of the annual target, reflecting the expected seasonality. The project is therefore still on track to achieve the target. The treatment rate was 95% (i.e. the percentage of cases of simple pneumonia correctly diagnosed and treated with amoxicillin) for the quarter. As shown in the figure below, the percentage of treated cases increased each month and by November 2016, CHVs treated 100% of identified cases, a 13 percentage point increase from the preceding quarter. In addition, as with diarrhea treatment, Q1 FY 2017 results show a significant improvement in treatment levels for pneumonia compared to Q1 of FY 2015 and FY 2016. In both years, the rate of treatment was around 25%.

Figure 9: Pneumonia treated by CHVs by quarter (FY15, FY16, FY17 Q1) 30,000 26,521 25,070 25,000

20,000 18,315

15,000

9,923 10,000

5,000

- FY15 FY15 FY15 FY15 FY16 FY16 FY16 FY16 FY17 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

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From November 21-22, 2016, the project held an event to promote pneumonia and diarrhea prevention and treatment in the rural commune of Antsenavolo in the Vatovavy Fitovinany region. The event was carried out jointly with the Ministry of Health, PSI, CRS, the Office Nationale de la Nutrition, Peace Corps, the Ministry of Water, and local authorities. The region was chosen because of its high rate of pneumonia (in Q1 of FY 2017, Vatovavy Fitovinany had the highest number of pneumonia cases [26% of reported cases] in the project areas). The region also reports the second highest number of diarrheal cases among the project regions (19% of total cases).

During the event, the project helped convene residents and organize presentations and performances to highlight prevention and treatment for the two conditions. Diarrhea awareness was included alongside pneumonia as the prevention strategies are similar (exclusive breastfeeding, vaccination against disease, handwashing with soap, consumption of treated water) and both conditions are a leading cause of death among children in Madagascar. In The Regional Director of the MoPH certified Health addition, there is a high rate of co- Champion Households with USAID Mikolo and infection with malaria for both diseases. partners during the event in Antsenavolo.

Figure 10: Breakdown of diarrhea cases by region (PY4, Q1) Vatovavy Alaotra mangoro 5% fitovinany Amoron'i mania 19% 9%

Analamanga 7%

Vakinankaratra 12%

Atsimo andrefana 21%

Haute matsiatra 13% Atsinanana 14%

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PARTICIPATION IN NATIONAL MEASLES, POLIO AND MNCH CAMPAIGNS INCLUDING VACCINATION

During the quarter, the USAID Mikolo project assisted with the preparation, organization, and implementation of three national health campaigns: the annual measles vaccination campaign; the annual maternal and child health week; and the campaign for the fight against polio.

The annual measles vaccination campaign took place in October 2016. During the campaign, all children were vaccinated in the government identified priority regions of Atsinanana, Amoron’i Mania, and Atsimo Andrefana (prioritized based on weak performance on measles indicators). Project staff served on organizing committees with staff from the Direction de la Programme Elargi de Vaccination (PEV) and the Equipe de la Direction de la Sante de Famille to orient the CSB and DDS staff about the campaign. The orientation was used to provide information on the preparation and planning for the vaccination campaign (the number of teams, how to do supervision, data collection, etc.) to ensure that the campaign was carried out properly.

During October 2016, the project also assisted with organizing the maternal and child health week, during which children are vaccinated and their vaccination records are updated, and Vitamin A and deworming medication are administered to children and pregnant women. All in all, 2,063,644 children have been reached for the distribution of vitamin A and 1,832,373 received a deworming medicine in the 8 regions supported by the Project. The distribution of these medications was done concurrently with the administration of measles vaccines. This vaccination campaign reached 1,353,503 children in USAID Mikolo’s intervention zones, which represents 91.5% of the objective. The project’s contribution was well received as it was cited as a good example by the MoPH when they shared the results of the campaign.

In November 2016, USAID Mikolo also helped with the implementation of the national campaign for the fight against polio. The project participated in the technical preparatory meetings to organize the campaign, the regional launching ceremonies, as well as in daily supervision of the campaigns at community level . For each of the above initiatives, the USAID Mikolo project supported the CHVs to play a critical role in ensuring that all children and pregnant women were reached. CHVs were responsible for marking houses to count the total number of Supported CHVs contributed as vaccinators, social intended recipients, administering the mobilizers or registrars. USAID Mikolo followed up vaccines and medications, and providing field activites and helped with vaccine transportation reports on the distribution. The WHO issues in some regions. managed the CHV training for the campaigns, while the USAID Mikolo project ensured its implementation. The project followed up with CHVs in each region to verify that they were trained and fully understood their role and responsibilities.

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MNCH AND THE CONTINUUM OF CARE

During Q1, the project emphasized on the MNCH Continuum of Care areas of focus and vigilance for FY 2017. The following items were emphasized: ● CHVs need to maintain a list of pregnant women and newborns in their areas in order to effectively monitor and ensure that the pregnant women and newborns are receiving the necessary information and care, including pre- and postnatal care visits. ● CHVs need to master the management of the health card effectively and ensure that it is being completed accurately in their area. Project staff together with CSBs need to supervise this and reinforce this capacity. ● CHVs should continue to actively monitor vaccinations and track children to ensure that they are completing their vaccination schedules. ● In FY 2017, USAID introduced new indicators that necessitate the use of cross-referencing to verify that clients referred by CHVs to CSBs receive a service at the CSB. These include USAID IR 2.2.2 (Percent of CHV referrals that complete their referral with the receiving service) and 2.2.3 (Percent of clients referred to health clinics who were counter-referred to CHV). To track these indicators, Project staff will help improve and reinforce communication and support between the CHVs and CSBs. The Project developed new tools to help collect this data and will monitor their correct use closely. ● The targets for these indicators will be set in Q2 in collaboration with USAID. ● Data collection for these indicators will begin in Q2.

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MALARIA MALARIA

Table 8: Malaria indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

2.8 - USAID Number of health workers trained in IR 2.1.6 case management with artemisinin- 661 120 18 % PPR USAID based combination therapy (ACTs) with 3.1.3.1-1 USG funds

2.9 - USAID Number of health workers trained in IR 2.1.7 malaria laboratory diagnostics (rapid 661 120 18 % PPR USAID diagnostic tests (RDTs) or microscopy) 3.1.3.1-5 with USG funds

Number of children with fever in project 2.10 168 844 18 914 11% areas receiving an RDT

Percent of children with a positive RDT 2.11 80% 80% 100% who received ACT

In October 2016, the USAID Mikolo project trained 120 community health volunteers on case management with ACTs and on malaria laboratory diagnostics with RDTs (indicators 2.8 and 2.9). The majority of CHV trainings are planned for Q2 and the beginning of Q3. The CHVs continued to provide RDTs to children with fever and to provide ACT care for those diagnosed with malaria. CHVs administered RDTs to 18,914 children with fever in the project areas. While the total number tested is only 11% of the annual target, CHVs tested 92% of fever cases. The result likely reflects the seasonality that is associated with malaria (it typically peaks from October to April). However, and most importantly, CHVs provided ACT to 80% of the cases of RDT+ presented to them. This represents a significant improvement in quality case management by CHVs, as 62% of RDT+ were treated with ACTs in Q1 of FY 2016.

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Fever cases tested with RDT & RDT+ treated by ACT (FY15, FY16, and FY17)

41764 39294 38197 35513

30402 28272 26618 25468 25833

20656 18,914

13826 13049 13481 11409 8859 9576 6,754

FY15 Q1 FY15 Q2 FY15 Q3 FY15 Q4 FY16 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY17 Q1 Tested with RDT Treated by ACT

Figure 11: Malaria cases treated by CHVs in FY15, FY16 and FY17

20495 18914 FY17 Q1 8430 6754

29910 28272 FY16 Q1 14110 8859

27679 26618 FY15 Q1 15032 13826

0 5000 10000 15000 20000 25000 30000 35000

Number of fever cases Number of fever cases tested with RDT Number of uncomplicated malaria cases (RDT +) Number of uncomplicated malaria cases treated with ACT

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Figure 12: Malaria case management by region (Q1 FY16) Malaria cases management results by region 120% 102% 98% 100% 90% 84% 77% 79% 83% 82% 80% 69% 80% 66% 63% 60% 52% 60% 43% 44% 43% 42% 40% 31% 16% 13% 17% 18% 20% 11% 0%

% of fever tested with RDT % of fever tested with RDT with positif response (RDT +: malaria confirmed) % of malaria cases treated with ACT

As an illustration of the contribution to health system strengthening, for indicator 2.11 (% of children with positive RDT receiving ACT), the project is achieving its annual target. This is likely due in part to the fact that CHVs are now able to get the supplies of RDT and ACT that they need from the CSBs. In the past, the CSBs often did not have enough RDTs and ACTs to meet the needs of the CHVs and, as a result, the results for indicator 2.11 were below target (i.e. 75% of the target achieved in FY 2016). However, since August 2016, the project has shared its data on the CHV average monthly consumption rate with the CSBs. With this data, the CSBs have been able to stock an appropriate amount of ACTs and RDTs, which has allowed CHVs to improve their administration of these tests and drugs in their communities. This hypothesis is further confirmed by the data for indicator 2.12 (cf. table 9 below on supply chain indicators) that shows a stockout rate of 7%, which already achieves the annual target. This is a marked improvement over the FY2016 stockout rate, which averaged 12% during the year.

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ANTSIANANANA

Number of Number of Number of fever Number of uncomplicated uncomplicated cases tested with fever cases malaria cases (RDT malaria cases RDT +) treated with ACT Antanambao 224 215 82 57 Manampotsy Brickaville 1 273 1 253 456 298

Mahanoro 2 778 2 703 1 415 1 212

Marolambo 250 264 109 62

Toamasina II 1 370 1 388 645 488

Vatomandry 1 504 1 341 317 218

Total 7 399 7 164 3 024 2 335

ATSIMO ANDREFANA

Number of Number of Number of fever Number of uncomplicated uncomplicated cases tested with fever cases malaria cases (RDT malaria cases RDT +) treated with ACT

Ampanihy 1 155 914 474 402

Ankazoabo 159 149 108 54

Benenitra 21 62 42 39

Beroroha 35 45 23 25

Betioky 957 503 314 273

Morombe 220 239 134 69

Sakaraha 1 062 1 069 749 708

Toliara II 895 733 376 255

Total 4 504 3 714 2 220 1 825

VATOVAVY FITOVINANY

Number of Number of Number of fever Number of uncomplicated uncomplicated cases tested with fever cases malaria cases (RDT malaria cases RDT +) treated with ACT

Ifanadiana 658 530 226 210

Ikongo 1 573 1 593 808 592

Manakara 1 565 1 244 858 789

Mananjary 2 164 2 542 1 289 1 097

Vohipeno 591 498 150 116

Total 6 551 6 407 3 331 2 804

PARTICIPATION IN NATIONAL MALARIA EVENTS

From October 25-27, 2016, the USAID Mikolo project participated in the annual review of the national malaria program. The objective of the review was to evaluate the national malaria program performance and the contributions from all partners to reach program objectives. The project contributed technically and financially to this activity by paying for the transportation for 2 regional teams (Atsimo Andrefana and Vatovavy Fitovinany) and the provision of technical expertise. By the

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end of the review, the 2017 annual malaria program plan was developed.

On November 22-25, 2016, the USAID Mikolo project participated in the International Scientific Discussion on the Fight Against Malaria. This event was organized by the Ministry of Health and included participation by international malaria experts. The objective was to evaluate the performance of the 2013-2017 strategic plan for the fight against malaria. Project staff participated in the discussions and helped identify opportunities, challenges, and lessons learned to apply and address in the 2018-2022 plan.

SUPPLYSUPPLY CHAIN/LOGISTICAL CHAIN / LOGISTICAL MANAGEMENT MANAGEMENT OF HEALTHCARE PRODUCTSOF HEALTHCARE PRODUCT

Table 9: Supply chain indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

Percent of service delivery points (CHVs) 2.5 - USAID that experience a stock-out of Oral 6% 6% 100% IR 2.4.1 contraception products at any time during the quarter

Percent of service delivery points (CHVs) 2.6 - USAID that experience a stock-out of DMPA 7% 7% 100% IR 2.4.1 products at any time during the quarter

Percent of service delivery points (CHVs) 2.23 - USAID that experience a stock-out of ORS/Zinc 7% 4% 142% IR 2.4.1 at any time during the quarter

Percent of service delivery points (CHVs) 2.24 - USAID that experience a stock-out of 8% 3% 162% IR 2.4.1 Pneumostop© at any time during the quarter

2.12 Percent of service delivery points (CHVs) USAID IR that experience a stock-out of ACT at any 8% 7% 89% 2.4.1 time at any time during the quarter

In Q1, 4% of CHV service delivery points experienced stock-outs of ORS/Zinc and 3% experienced stock-outs of Pneumostop. Both results are significantly better than the annual targets, reflecting the project’s recent efforts to improve and assure a functional supply chain for CHV health products. These efforts included routine support as well as special supervision visits. Also, only 6% of service delivery points experienced a stockout of oral contraception products and 7% of Depo-Provera (DMPA) products, achieving the annual target.

SUPERVISION VISIT TO ADDRESS RDT/ACT STOCKOUTS

In November 2016, the USAID Mikolo project held an integrated supervision visit with the

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Direction de la Lutte Contre le Paludisme in Atsimo Andrefana. This supervision was carried out at the CHV, CSB, DDS, and DRS levels to monitor the management of RDT and ACT supplies. During the visit, project staff observed two main challenges.

The malaria control department addresses supply chain issues with partners to limit epidemiological risks.

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First, some CHVs were not going to the CSB to obtain the RDTs and ACTs, in part due to previous habits of procuring these products from social marketing distributors and in part, because some CHVs were not aware of the new process for obtaining RDTs and ACTs at the CSBs. The project will intensify efforts to inform and support CHVs to use the new CSB distribution process.

Second, the CSB chiefs sometimes do not have enough stock to provide ACTs and RDTs to the CHVs. CHVs provide reports to CSBs on the quantity of ACTs and RDTs used each month, but these data are often not uploaded and shared with SDSP or the DRSP. As a result, the DRSP is unable to accurately quantify and forecast the stock of ACTs and RDTs needed by each CSB. The CHV data are not shared because there are no dedicated personnel at the CSB or DDS to upload the CHV reports. In addition, some CSB chiefs were not aware of the need to provide these products to CHVs and there were cases in which CSB chiefs has refused to supply CHVs over the past year.

Following the supervision mission, the supervision team presented its findings to the Ministry of Health. The Ministry has created a committee to address CHV data management as the lack of up to date CHV data is affecting the availability of a wide range of products and medicines. The Ministry is also aware of the need to better communicate with CSBs regarding their obligation to provide ACTs and RDTs to the CHVs.

Figure 13: Percentage of CHVs who reported a stockout in health care products (Q1FY17)

8% 7% 7% 7% 6% 6% 5% 4% 4% 3% 3%

2% 1% 0%

In the interim, the USAID Mikolo project will share its CHV DHIS2 data with the SDSPs staff in order for them to effectively quantify, report and plan for health commodity supplies of CHVs. As mentioned in the malaria section above, since August 2016, the project has shared its data regarding average CHV RDT and ACT consumption with the CSBs. However, the project will now share the raw CHV consumption and service delivery data (by commune, fokontany, and district) with the DRS in each region. While this is a temporary solution, it will allow the CSBs to be more adequately stocked and able to provide CHVs with the needed quantities of ACTs and RDTs.

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SUB-PURPOSE 3 : Improve the quality of primary healthcare services at the community level

Improve the quality of primary healthcare services at SP3

the community level

The USAID Mikolo Project seeks to improve CHV’s performance with respect of national norms, standards and procedures during service delivery. Thus, Project staff conduct monthly group meetings, on-site supervision, individual CHV performance assessment, and gradual certification in collaboration with CSB heads.

In Q1, 62% of CHVs achieved the minimum quality score for community case management of childhood illnesses, and 59% reach the minimum quality score for family planning counselling, which meets 91% and 87% of the FY 2017 targets, respectively. Moreover, 87% of CHV monthly activity reports are timely and complete (97% of the annual objective), and 87% of CHVs attend monthly COSAN meetings (97% of the annual objective).

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Table 10: Service quality indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

Percent of CHVs achieving the 3.1 - USAID minimum quality score for community 68% 62% 91% IR 2.1.4 case management of childhood illnesses

Percent of CHVs achieving the 3.2 - USAID minimum quality score for family 68% 59% 87% IR 2.1.4 planning counselling at the community level

Percent of monthly activity reports 3.3 received that are timely and complete 90% 87% 97% (CHV)

Percent of CHVs in project areas 3.6 90% 87% 97% attending monthly COSAN meetings

This quarter, 62% of functional CHVs reached the minimum score of quality for community level management of childhood illness, i.e., 91% of the annual target. Furthermore, 59% had a minimum quality score in FP counseling at the community level, i.e., 87% of the annual target.

In Q3 and Q4 of each year, the project trains both new CHVs in either MNCH or FP and existing highly performing CHVs to become polyvalent. The Q1 quality score includes the results from the first assessment of newly trained CHVs. As shown in the table below, this year, a higher percentage of CHVs achieved a minimum quality score compared to Q1 of PY15 and PY16.

Figure 14: Evolution of Q1 results for USAID Sub-objective 3.1 and 3.2 (FY15 - FY17)

The stronger performance is most likely due to three factors.

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First, during FY16, the project introduced CHV supervision by CSB chiefs in three out of the eight regions. Prior to this, all CHV supervision was conducted by the Project STs. The project observed that the CHVs needed supervision from individuals with greater clinical experience and, to address this, decided to pilot supervision by CSB chiefs. This new approach will be formally evaluated during an external evaluation scheduled for Q2 of FY17.

Second, ST capacity to utilize monitoring and evaluation tools has improved over the course of the project due to project interventions and support. For example, data tables and completed CHV performance evaluation tools submitted by the Project STs need increasingly fewer corrections.

Lastly, the new CHVs added in Q3 and Q4 made up a smaller percentage of the total CHVs in FY 2016 compared to FY 2015 and FY 2014.

Furthermore, the Q1 results show that 87% of CHVs in project areas attended monthly COSAN meetings which suggests that CHVs have internalized and understand the process as well as benefits of holding regular monthly meetings. USAID Mikolo’s NGO partners played a reduced role in organizing these meetings as the CHVs themselves are increasingly taking the initiative to convene them along with the CSB head. In FY17, the project will focus on improving the quality of these meetings. While the meetings are held regularly, CHVs often do not follow the prescribed SOW, which should be utilized to assure that the meetings are effective. To ensure that the SOWs are followed more regularly, the CSB chiefs and the Project STs will focus on reinforcing this practice during the meetings and following up on the quality of the meetings during supervision visits.

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SUB-PURPOSE 4 : Increase the adoption of healthy behaviors and practices

Increase the adoption of healthy behaviors and SP4

practices

The USAID Mikolo Project ensures a high level of uptake of healthy behaviours with the certification of Champion Households, Champion Fokontany and Champion Communes. Women leaders, men leaders, youth peer educators and CHVs sensitize individuals and local communities on key health topics based on a continuum of care - in parallel to ongoing radio broadcasting.

In this quarter, 200 communes received the status of “Commune Champion,” and 42.609 households were certified “Household Champions,” meeting 47% and 35% of the respective annual objectives. Meanwhile, 3.750 people were reached with health and WASH messages (4% of the FY 2017 target), and 21,612 women were educated on exclusive breastfeeding (EBF), representing 31% of the annual objective. Several mHealth activities were also conducted in Q1 FY 2017, including piloting activities and stakeholder engagements.

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Table 11: Behaviour change indicators and results

FY 2017 FY 2017 Q1 % TARGET # Indicators Annual Result ACHIEVED Target

4.1 Number of Communes with the status 430 51* 10,08% of Commune Champion

USAID IR Number of communities with an 1 954 0 0% 1.2.3 established emergency transport system from the household to facility

% of communities with an established 50% 0 0 emergency transport system from the household to facility

4.2 Number of certified Household 120 465 42 609 35% Champions

4.3 Number of interactive radio spots 2 880 132 5% broadcast

USAID IR 1.7 Percent of households with soap and 17% 0 0% water at a handwashing station commonly used by family members

USAID IR 1.8 Percent of households in target areas 17% 0 0% practicing correct use of recommended household water treatment technologies

USAID IR Number of people reached with USG 877 592 3 750 0.4% 1.1.1 supported health and WASH messages

4.6 Number of people reached with 70 171 21 612 31 PPR USAID education on exclusive breastfeeding

* 184 champion Communes have been reported in FY16, 35 of which have been certified (level 3). 16 others were identified on Q1, resulting into 51 Champion communes in total. For FY17, 302 other communes (now at level 1 and 2) will be graduated.

During Q1, CHVs, female leaders, male leaders and CHVs educated 21,612 people on exclusive breastfeeding. In order to improve the quality of this education, the project staff began updating tools for CHVs, female leader, and male leaders to use when educating community members. These tools include an illustrated guide to exclusive breastfeeding best practices.

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Figure 15: Number of women who attended training sessions on exclusive breastfeeding (FY15, FY16, FY17Q1) 25,000 21,612

20,000

15,000

10,000

5,437 5,000

- FY15 Q4 FY16 Q1 FY16 Q2 FY16 Q3 FY16 Q4 FY17 Q1

BEHAVIOR CHANGE EVENT

During the quarter, the USAID Mikolo project collaborated with PSI and the Madagascar Ministry of Health to organize two integrated community mobilization events to promote handwashing, latrine usage, and exclusive breastfeeding. One event was held in October 2016 in the Ampasimbe Onibe District de Toamasina II, Atsinanana Region. The second event was held in November 2016 in Antsenavolo, Mananjary District, Vatovavy Fitovinany Region. During these two events, which reached 3,750 individuals (making up the Q1 result for USAID IR 1.1.1), local artists performed skits to promote healthy practices. In addition, a total of 92 Ankohonana Mendrika Salama (AMS) were recognized and presented with certificates (45 in Ampasimbe and 47 in Antsenavolo). In addition, 50 new CHVs (25 in each region) were given certificates of recognition.

AMS, FMS, and KMS criteria

During the quarter, the USAID Mikolo project also updated the Ankohonana Mendrika Salama (AMS), Fokontany Mendrika Salama (FMS) and Kaominina Mendrika Salama (KMS) criteria. The AMS criteria changes were made in order to collect data for new project indicators (USAID IR 1.7; USAID IR 1.8; and USAID IR 1.1.1). Data collection for these indicators will be launched in Q2. The fokontany and commune level updates were made to simplify the FMS and KMS criteria (existing KMS and FMS will retain status based on the old criteria). The updated criteria include the following changes:

Changes to AMS criteria: 1. Addition of a requirement for water treatment/purification 2. Specification that all household members must use a latrine 3. Addition of a requirement for the use of the hand washing device (a dedicated area with soap and water)

Please note that the data on latrine use and the use of hand washing devices will be self reported.

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Changes to FMS criteria: Three levels combined into one set of criteria: a. >50% of households meet AMS criteria b. Existence of a health hut built by the community c. Existence of an established health evacuation system

Changes to KMS criteria: Three levels combined into one set of criteria: a. Functional CCDS/COSAN b. Existence of a community action plan c. Community action plan is reviewed at least twice per year with at least 50% of activities achieved by the second review d. CCDS-COSANs conduct a self-evaluation of the KMS criteria e. More than 50% of the fokontany in the commune are FMS f. More than 50% of the commune has functional women’s groups (i.e. the group conducts monthly sensitization activities, completes monthly reports, and assists with AMS verification) g. More than 50% of the commune has functional men’s groups (i.e. the group conducts monthly sensitization activities, completes monthly reports, and and assists with AMS verification) h. More than 50% of the commune has functional youth groups (i.e. the group conducts monthly sensitization activities, completes monthly reports, assists with AMS verification, and refers youth to CHVs and CSBs)

Now that the new criteria are in place, the project will begin data collection for USAID IR 1.2.3 and sub-objective 4.2 in Q2. The project will also increase KMS identification under the new criteria, which will allow the project to get on track for sub-objective 4.1.

The USAID Mikolo project continues to work with the Fonds d’Appui à l’Assainissement (FAA) to revise its Memorandum of Understanding (MOU). The project collaborates with the FAA project to implement community led total sanitation in the USAID Mikolo project’s eight regions of implementation. Due to the delay in signing the MOU, the project has not yet determined the 2016-2017 target for sub-objective 4.5 (number of people who have gained access to an improved sanitation facility). Once this target is set in Q2, the project will begin USAID Mikolo provides ongoing supports to community collecting data for this indicator. However, the leaders to promote the AMS approach, which fosters the CHVs continue to promote latrine usage, uptake of healthy behaviours by each household. hand-washing, and water purification/treatment (the three pillars of community led total sanitation) in each of the eight regions.

In November 2016, the USAID Mikolo project also organized 132 radio broadcasts regarding polio prevention, which contributed to the national polio campaign.

FY 17 FIRST QUARTERLY REPORT The USAID Mikolo Project Page | 39 mHEALTH

The mHealth initiative, implemented by the USAID Mikolo Project, proposes to set up a mobile application which will be used by community health volunteers in their reporting activities and healthcare services. It has a two-fold objective:  Improve health services delivery to beneficiaries  Improve the quality of and access to data.

The following activities were carried out in Q1 FY2017:

(1) Identification of pilot zones and users (October 2016): The pilot phase, testing the mobile application with Project CHVs when they deliver services to beneficiaries, will be implemented in the regions of Analamanga and Atsinanana, where 50 first users were pre-selected. Each participant and site in Analamanga were visited in order to share initial information around the mHealth initiative and its pilot phase, as well as to do to an onsite testing of the mobile / internet network coverage. The same exercise will be carried out for Atsinanana. (2) Stakeholder engagement (November 2016, and ongoing): A workshop for representatives from the Ministry of Health was conducted in the beginning of November 2016. The objective was to inform them about the initiative and collect recommendations around its implementation. Visits to some technical partners (WHO, UNICEF, other USAID projects) were conducted in order to search for potential synergies. (3) Prototype built to specifications (Mid-December 2016): The technical specifications that will constitute the basis of the application (i.e service delivery flowcharts, modules to be developed, and reporting framework) have been validated by USAID Mikolo project. The service provider then delivered a prototype of the application that was built according to the project’s specifications. (4) A monitoring and evaluation system for the pilot has been set up (December 2016) The M&E system comprises a logical framework and methodologies of data collection. Related questionnaires will be developed and tested.

Next activities for the Q2 FY17 will include: - Finalization of the partnership with a mobile phone operator and acquisition of the mobile phone equipment for the pilot phase; - Participation in MOPH workshop on harmonizing the HMIS data collection system with other partners - Finalization of questionnaires for the monitoring and evaluation of the pilot - Launching of the Pilot phase - Preparation and implementation of the training sessions during the pilot phase.

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MONITORING & EVALUATION

Quarter 1 was marked with three major activities, namely (1) improving the performance of the project’s database (DHIS2); (2) improving the data quality assurance strategy to address the challenges identified by the data quality assessment carried out by USAID Madagascar in April 2016; and (3) orienting NGOs and members of the Regional Steering Committee (RSC) on the elements of the project’s M&E system.

DHIS2

In order to improve the performance of the DHIS2 platform, the project called upon the services of two international consultants tasked with the mission to (1) improve access to the server so as to make it easier for all users at all levels to access it whether in the Android or the Web version (2) develop several modules in DHIS2, including dashboards per indicator.

The DHIS2 platform is now operational and accessible to all users without problem. Several dashboards have been developed so far and this work will continue during the Quarter 2.

RDQA During Quarter 1, activities focused on improving the RDQA strategy based on the recommendations made by USAID further to the data quality assessment conducted in April 2016. A general recovery plan was developed based on USAID’s findings and recommendations, specifying activities to be conducted, people in charge, and implementation deadlines. A meeting convening all USAID Mikolo technical staff was organized to present the findings and to discuss the recovery plan. The plan was shared with USAID.

During the orientation of the NGOs awarded grants for FY17 in November 2016, the findings and recommendations were again presented and regional recovery plans were developed. Similarly, a specific operational plan for every NGO was prepared during the orientation of the NGOs’ field staff in December,. The project is currently monitoring the implementation of the activities specified in these plans at every contact with the NGOs’ field staff and CHVs.

The tools used for RDQA were revised to make them easier to use. Similarly, a tool for collecting information to ensure quality of the data feeding into key indicators was developed. These tools were validated by the project’s RSC members.

ORIENTATION ON THE MONITORING AND EVALUATION SYSTEM

To build the skills of the members of the CPR (made up of USAID|Mikolo central and regional staff) on the monitoring and evaluation system, a two-day orientation was organized. In all, 34 staff members took part in the orientation that focused on quality assurance, understanding of project indicators, data analysis through the use of DHIS2, and data for effective decision making.

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ENVIRONMENTAL COMPLIANCE

For this quarter, follow-up of the implementation of the actions defined in the Environmental Compliance Plan for environmental compliance activities was strengthened during on-site supervisory visits conducted by the STs and during field visits by project members (see results in Appendix 4)

FAMILY PLANNING COMPLIANCE

Monitoring of FP compliance is one of the activities carried out by the STs of the NGOs during the on-site supervision visits of CHVs. All CHVs who are trained to offer FP services are trained in FP compliance, included in their training curriculum. These CHVs are also equipped with the tools to be able to assure this compliance methodically, with the TIAHRT poster.

In Q1, FP compliance monitoring in FP was carried out during on-site supervision. The project identified focal points from central to regional levels.There is a focal point at the central level, 5 CPR / BR focal points and one focal point per NGO. The focal points will assist with FP compliance monitoring moving forward.

Next steps include the orientation of CPRs on the FP compliance monitoring grid, online training for all project staff and NGO staff, and continued orientation of the CHVs on FP compliance.

In addition, since April 2016, the Ministry of Health has issued a temporary ban on CHVs administering injections, which affects training on and administration of Depo-Provera and Sayana Press. This ban was issued after the Ministry of Health learned of CHVs administering injections (i.e. antibiotic injections) that they were not trained or authorized to give. In addition, there were rumors of Depo-Provera being misused on pigs in order to promote growth. The MOH is currently updating guidance on CHVs and hormonal injections. Until the ban is lifted, the project is not permitted to train CHVs on either Depo-Provera or Sayana Press. Please see Appendix 2 for a copy of this letter.

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PROJECT MANAGEMENT

Workplan and Operational Plans The USAID Mikolo Project submitted its workplan on the 30th of October, 2016 and received final approval of its 2017 Annual Implementation Plan and Budget on November 29th, 2016 after responding to comments from the USAID Management Team for the Project. Following this approval, the Project organized both central level and regional operationalization meetings to flesh out the details and timing of the workplan with its key stakeholders - NGO partners and the Ministry of Public Health. USAID’s COR and the Director of Health Districts (DDS) also participated in the central level orientation at Mantasoa.

CLT Field Visits The Project’s COP, the Director of USAID’s Health, Population and Nutrition (HPN) Office, and the Project’s COR conducted a week long site visit to Alaotra Mangoro and Atsinanana regions in mid- October, 2016. The team was able to visit two regions, three health districts, four CSBs, five CHVs as well as some women leaders and two SILC groups, thereby providing an ample opportunity to visit the project’s field activities. Key recommendations included: accelerating the extent to which CHVs become polyvalent; developing more success stories and publishing and promoting them especially illustrating the links between CSBs and CHVs; and ensuring that District Health Offices have access to the data coming from CHVs.

Joint Review - MOPH and Technical and Financial Partners The USAID Mikolo Project participated in the annual Joint Review conducted in Diego Suarez in December, 2017. The meeting brought together all MOPH Directors at the central level, Regional Directors from all 22 regions, as well as all partners working in health. Strategy papers were presented, policy updates were shared and partners were able to share their experiences in the field. A mapping exercise was presented and the Project is working closely with the Director of Partnerships at the MOPH to ensure accurate representation of the Project on the Ministry Map of partners.

Alignment Workshop In mid-December, the Project organized an Alignment Workshop for all project staff. Given the fact that there are many new staff working alongside more experienced staff, there is a need to review the Project’s vision, strategic approaches, and its style of working and management. The two and a half day meeting provided an opportunity for all project staff to prepare for the fourth year of the project in a unified and more cohesive manner.

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STTA

Name Date Location SOW

Meet with MSH home office experts on Lalah technical strategies and best practices in areas 9/24/16- Boston, DC, Rambeloson, applicable to Mikolo, share project experiences 10/7/16 New York MSH to date, and gain familiarity with the range of technical support available to Mikolo.

RECOMMENDATIONS: We need to work on the intensification of publication and documentation of project's best practices, as well as advocacy on PF law

Monita Baba 10/7/16- Conduct monitoring and evaluation activities Antananarivo Djara, MSH 10/28/16 and provide support for technical briefs.

RECOMMENDATIONS: . Hire an additional staff person at the BR level whose sole responsibility is to assure that M&E functions are completed in a quality and timely manner . Systematically follow up on identified data quality issues to make sure that solutions implemented are improving data quality . Complete the updated PIRS as quickly as possible and make sure that all technical leads, TAs, and CHVs clearly understand indicator definitions and data collection instruments . Complete testing of simplified RDQA tool (Fascicule 2) and monitor roll-out to make sure that it contributes to improving data quality. . Follow up on Key Indicator DQA efforts to improve the quality of data for indicators that we specifically know have issues. . Improve CHV participation in monthly meetings and ensure that the meetings focus on improving technical and data quality. . Use data to identify CHVs that have lower scores on data quality and provide targeted supervision with follow-up to make sure that the problems are resolved. . Reinforce the STA function at the NGO level

Antananarivo, Manjakandriana , Moramanga, Dr. Lynn 11/4/16- Vatomandry, Review Sub-Purpose 4 project performance in Lawry, OSC 11/25/16 Brickville, the field and at the Mikolo project office. Ranomafana, Antsenavolo, Mananjary

RECOMMENDATIONS: Training of NGOs on the new Champion Community approach using web- based communication (Webex, Skype etc.).

Provide home leave coverage to the Director of Larousse 11/7/16- Antananarivo Finance and Operations for the five regional Ceus, MSH 12/7/16 offices and headquarters office in Antananarivo.

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FINANCE AND OPERATIONS

Human Resources During the quarter, the project continued efforts to reinforce its regional focus. Dr Fanja Raelison was hired during the quarter to serve as Manager of Regional Steering Committees. Dr. Riana Ramanantsoa had been covering the dual roles of Senior Technical Advisor and Regional Field Manager but has now assumed the role of Senior Technical Advisor on the project. Further support to the regional focus will come with assignment of regional M&E positions that will reinforce quality of data transmission from the field. Recruitment for the positions began in the quarter and they are expected to be filled in the second quarter of FY 2017. A Finance and Administration Assistant position in Toamasina was recruited to fill a vacancy following a resignation in September 2016.

Information Systems M-Health USAID Mikolo moved forward with establishing an M-Health component that comprises three aspects – a Coordinator for the project, a subcontract with Dimagi for technical support and a partnership with a local telecommunications company. Following negotiations during the quarter with the local telecommunications company Telma, equipment was provided for a pilot effort with 50 community agents. A Memorandum of Understanding was developed for signature early in the next quarter. The project’s IT Specialist resigned during the quarter and a new candidate for the position of IT Specialist was identified and is scheduled to begin on February 1, 2017.

Grants Management New grants with local NGOs were started during the quarter for all regions. Of the 14 grants, 11 went to continuing NGOS and 3 were changed from previous NGOs. Of the continuing NGOs, 4 were identified as potentially capable of receiving funds directly from USAID and were evaluated to be certified using USAID methodologies. One NGO, AIM, succeeded in achieving the USAID qualification. The current grants include a Performance Based Financing component intended to raise the level of performance in and complete reporting.

Logistics The project completed procurement and pursued distribution of 3200 scales during the quarter. The effort included shepherding the scales through local requirements for certification using a freight forwarder. At the end of the quarter arrangements were underway for publicizing delivery of the scales with the support of USAID funding. An extensive process of formalizing and transferring vehicles and motorcycles to NGO partners continued with completion expected in the next quarter.

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Financial Management The project’s burn rate dropped slightly during the quarter as the new workplan and budget took effect. The fourth year of the project reflects emphasis on capitalizing gains thus far through an emphasis on reinforcing supervision and data quality.

Financial Highlights Budget: - Total billable expenses for the quarter: $1,348,225. - Percent total PY4 budget spent: 24% through December 31, 2016 (25% of the year) - PY4 average burn rate over the past 3 months: $449,448 - The target monthly burn rate to finish out PY43 budget is: $470,736

Obligations: Total obligations available at the end of the quarter amounted to $4,722,410.

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SUCCESS STORY A successful approach to monitoring and promoting growth

The people of Madagascar face many challenges to achieving good health, especially rural residents who have to travel long distances to health centers and often can’t afford care. Many rely on community health volunteers like Baondalana Marinette for guidance on health issues. Baondalana, 60, has been serving her community of Tsivangiana in eastern Vatomandry District for at least a dozen years. Trained by the USAID Mikolo Project on management of childhood illnesses, family planning, and promotion of healthy behaviors, Baondalana serves 614 village households. Through the support of the project, Baondalana was certified in the provision of both maternal and child health and family planning services in 2015. Today, she provides a continuum of care to the residents of Tsivangiana, with an emphasis on monitoring and promoting child growth. USAID Mikolo works with the Ministry of Public Health to improve maternal and child health in Madagascar through the adoption of healthy behaviors, which can lead to improved child nutrition. Half of children under the age of five in Madagascar suffer from chronic malnutrition, according the country’s 2013 Demographic and Health Survey. "From experience, I know that a well-nourished child has more vigor and rarely falls ill," Baondalana said. Every first Thursday of the month, she organizes a weighing session for all children under the age of five, accompanied by their mothers. During these sessions she takes the opportunity to raise awareness about breastfeeding, child nutrition, hygiene, and other health topics. Baondalana weighs more than 220 children per month to make sure their weight for height ratios are in line with standards for being well nourished. She is now using a brand new baby scale donated by the USAID Mikolo project in November 2016, since the old one was broken and became very difficult to use. Community health volunteers like Baondalana form the base of the health care pyramid in rural Madagascar, as they intervene directly at the community level by preventing diseases and managing simple cases. Dr. Lorris Delphin, head of the surrounding commune’s community health center, affirmed the contribution of community health volunteers to child health. "Just doing the weighing at the community level greatly reduces our workload,” he said. “Monitoring growth is vital and not everyone can travel miles per month to health centers for this activity."

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SUCCESS STORY Promoting exclusive breastfeeding by example

Half of children under the age of five in Madagascar suffer from chronic malnutrition, 24 percent from moderate malnutrition, and 26 percent from severe malnutrition, according to the country’s 2013 Demographic and Health Survey. Children in rural areas suffer disproportionately because they are often cut off from resources and health centers that help foster good health. Community health volunteers like Grancie Cicie help close the health education gap. Cicie serves the village of Ambodilahoaty, located 21 kilometers from the nearest health center, in eastern Vatomandry District. She has a four-month-old boy and is known in the community for her perseverance in promoting good health as a volunteer supported by the USAID Mikolo Project. USAID Mikolo works with the Ministry of Public Health to improve maternal and child health in Madagascar through the adoption of healthy behaviors, which can lead to improved child nutrition. It is clinically proven that breastmilk is the best nutrition for an infant during the first six months of life, and it helps fortify a child’s immune system in the long-term. Rates of exclusive breastfeeding for children six months of age and under have dropped steadily over the past 10 years to about 41 percent (2016), according to the Ministry of Public Health. Leading by example has proven to be an effective strategy in rural communities like Ambodilahoaty. Since the birth of her child, Cicie has breastfed outside her home as well as during health awareness-raising meetings with mothers. Her baby has not fallen sick, and is visibly growing fast. New mothers have started to understand the importance of exclusive breastfeeding, largely by word of mouth, which is very effective in rural areas. However, Cicie said it can be difficult to convince mothers about the importance of breastfeeding because of long-standing practices. “Mothers are stubborn,” she said. “Whatever I tell them about proper nutrition for their children, they persist in giving them rice, cassava, or soup, which they claim is more satisfying.” However, Cicie perseveres and said more women are breastfeeding longer and she anticipates the trend will grow. Among the roughly 20 women who participate in her awareness- raising meetings, they will in turn spread the message of exclusive breastfeeding to other women. Cicie said she plans to work more with community leaders to achieve broader and more sustainable impact in the community.

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APPENDIX 2: LETTER FROM THE DSFa ON INJECTABLE FP METHODS

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APPENDIX 4: REPORT ON ENVIRONMENTAL COMPLIANCE

Activity Potential Impact Mitigation Measure(s) Monitoring Indicators Monitoring and Q3– FY 2016 Reporting outcomes Frequency

Training/ After receiving - Incorporate environmental impact awareness into - Environmental Project quarterly No training Supervision training, CHVs handle training curricula and all job aids used by community protection component and annual reports courses were held on waste equipment and actors (NGO/TA) to sensitize on the importance of relating to CHV will include during this first management consumer goods that environmental impact mitigation. activities incorporated information on quarter. Training can generate waste. - Ensure monitoring of compliance with environmental in training curricula and trainings held, will planned for As a result, it is impact mitigation during activity implementation. working tools of topics addressed Q2 and the essential to train/ - Trainers will ensure that all waste generated during the NGO/TA during these beginning of Q3. inform all community training event is disposed of according to project protocol - Training report and trainings, as well as It should be noted actors involved in following WHO guidelines and Madagascar National list of participants the number of that activity Policy on Medical Waste Management. available, i.e. number participants. environmental implementation to of participants per compliance is minimize/ avoid the category (NGO/TA) included as a environmental - Supervision/ module in the impacts of this waste. monitoring report training curriculum available ie number of of all community agents supervised per actors. category (NGO/TA)

CHV waste Pollution The project will manage health care according to - Topics relating to Project quarterly The aim is to management Infection due to soiled international best practices in WHO guidance and the environmental and annual reports supervise all and disposal dirty objects Madagascar National Policy on Medical Waste compliance and safe will include functional CHVs Contamination of Management. Healthcare waste procedures will be posted injections integrated information on the at least once each drinking water at the work site. USAID’s Environmental Guidelines for into training curricula availability and use two months. sources Small-Scale Activities in Africa, Chapters 8 and 15. and CHV working tools of sharps boxes. Due to the delay CHVs will be trained on and equipped for proper waste - CHVs trained on the Mitigation in signing the management and safe injections. Trainings will cover risk topic of environmental measures will be NGO contracts, assessment, safe injections, medical waste management compliance, equipped monitored during no on-site (i.e. the use and disposal of sharps boxes), and CHV with sharps boxes and supervision visits supervision has sensitization. supervised for conducted every 2 been conducted compliance with months and this quarter. The Each CHV will receive sharps boxes at the end of the prescribed safe supervision reports project adjusted training and instructions for disposal and replacement. injection, management will form the its plans for this CHVs will be instructed to bring sharps boxes to BHCs of used pregnancy information base for activity which will once they are 2/3 full, and resupply at the BHC or the tests and Sayana assessing the now begin in Q2.

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Activity Potential Impact Mitigation Measure(s) Monitoring Indicators Monitoring and Q3– FY 2016 Reporting outcomes Frequency

Supply Point. Otherwise, they may dig a covered safety press and sharps box mitigation pit of 1.5-2m deep and 1.5m wide (Source: National use and disposal measures’ Waste Management Policy) to incinerate all sharp practices. effectiveness. materials and other products after use. Demonstration that During fiscal year 2015, the project will introduce the use staff is following the Review of training of pregnancy test at the CHV level. The target of this project procedures for records at least activity is to inform the women in their status in term of health care waste annually. pregnancy. Likewise, in FY16, Sayana press (DMPA sub management. cutaneous) was introduced at CHV level. Note that use of these pregnancy tests and Sayana press will be managed along with other project medical waste So, in order to reduce this risk, used pregnancy tests and Sayana press will be thrown into the safety box. CHVs will be oriented on this procedure during their training. CHV’s training curriculum will integrate this component.

Activities As the prime is - The project will ensure the training of grantees on their The signed letter of The project will Training for NGOs implemented responsible for environmental protection and waste management agreement is included include information on the by grantees implementing project responsibilities when conducting activities. in the contract on the results of environmental activities, including - The project will develop a letter of agreement which document of grantees. environmental compliance plan community-based grantees shall sign and attach to their contract. This Grantees reporting on activities in project was conducted in activities, it is letter demonstrates the beneficiaries’ commitment to environmental quarterly and mid of November important to train, comply with the plan developed by the project when mitigation measures, in annual progress 2016, during their inform and supervise implementing any activity. accordance with the reports. orientation prior to grantees on EMMP, in their Compliance with the environmental quarterly reports. the EMMP will be implementation of compliance during monitored on a activities for the activities quarterly basis. new grant. In implementation to Review records of total, 38 members enable them to ensure trainings and of NGOs the relating EMMP attendees. consisting of plan’s implementation central staff and when performing their field agents tasks. attended this orientation.

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