USAID Boresha Afya Lake and Western Zone Quarter Three Report April 1st – June 30st 2018
Submission Date: July 31th 2018
Submitted to: United States Agency for International Development SUMMARYCooperative Agreement No. AID-621-A-16-00003 Country: Tanzania Submitted by: Jhpiego in collaboration with PATH EngenderHealth USAID Boresha Afya Lake & Western Zone Quarter One Report PY2 2018 1
Project’s Contacts: Dr. Dunstan Bishanga, USAID Boresha Afya Chief of Party, [email protected]; Dr. Lusekelo Njonge, USAID Boresha Afya M&E Director, [email protected]; Jeremie Zoungrana, Jhpiego Country Director, [email protected]
US-based Contact Person(s): Lauren Borsa, Program Officer, [email protected] Financial Summary: Project Quarter Three (April 1, 2018 – June 30, 2018) Financial information MCH Malaria FP Total Total PY01 & PY02 Budget $11,284,481.00 $7,500,000.00 $5,067,213.00 $23,851,694.00 Funds Obligated to date $14,784,481.00 $7,500,000.00 $6,334,999.67 $28,619,480.67 Additional funds expected this 0 0 0 0 quarter
USAID Boresha Afya Lake and Western Zone Program Organizations:
Jhpiego (lead partner): maternal and newborn health (MNH), child health (CH) for febrile illnesses and nutrition, antenatal care (ANC), postnatal care (PNC) including postpartum family planning (PPFP), malaria in pregnancy (MiP), and community engagement activities; PATH: malaria case management; EngenderHealth: family planning (FP). In-Country Partners: MOHCDGEC divisions and units: Reproductive and Child Health Section (RCHS), Human Resources Development Department (HRDD), Health Education and Promotion Unit (HEPU), Health Services Inspectorate and Quality Assurance Section (HSI&QAS), Information, Communication Technology (ICT), Logistics Management Unit (LMU); Other government institutions: President’s Office – Regional Administration and Local Government (PO-RALG), Zonal Health Resource Centres (ZHRCs), Medical Stores Department (MSD);
Other USAID Boresha Afya awards (Central and Northern Zones, and Southern Zone); MCSP; Professional associations: Tanzania Midwives Association (TAMA), Association of Gynaecologists and Obstetricians (AGOTA), Paediatric Association of Tanzania (PAT); Other international and national partner organizations: World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Pathfinder, White Ribbon Alliance of Tanzania (WRATZ); Other USAID Projects: USAID | Global Health Supply Chain Technical Assistance; Tanzania Training Centre for international Health (TTCIH); PS3 – Public Systems Strengthening bilateral program and USAID Tulonge Afya
Report details Cooperative Agreement No: AID-621-A-16-00003 Reporting period: PY2, Q3 (April 1, 2018 – June 30, 2018)
Report contact person: Dunstan Bishanga, Chief of Party USAID Boresha Afya Contact details: [email protected]
Alternate contact: Lusekelo Njonge, M&E Director USAID Boresha Afya Contact details: lusekelo,[email protected] Due date of report: July 31, 2018 Date of report submission: July 31, 2018
TABLE OF CONTENTS
ACRONYMS ...... 5 EXECUTIVE SUMMARY...... 7 INTRODUCTION ...... 9 PROJECT COVERAGE ...... 9
1.0 PROJECT MANAGEMENT HIGHLIGHTS IN QUARTER 2 of PY2018 ...... 10 1.1. Staffing and HR administration ...... 10 1.2. Short-Term Technical Assistance (STTA) ...... 10 1.3. Project Coordination and Management ...... 11
2.0 MATERNAL AND NEWBORN HEALTH (MNH) ...... 14 2.1 Result 1: Improved Enabling Environment for Health Service Provision 14 2.2. Result 2. Improved availability of quality, integrated health services...... 16
3.0 CHILD HEALTH (CH) ...... 35 3.1. Result 2. Improved availability of quality, integrated health services...... 35
4.0 MALARIA CASE MANAGEMENT (MCM) AND MALARIA IN PREGNANCY (MiP) ...... 40 4.1 Improved Enabling Environment for Health Service Provision ...... 40 4.2. Result 2. Improved availability of quality, integrated health services...... 47
5.0 FAMILY PLANNING (FP) SERVICES ...... 55 5.1 Result 1. Improved Enabling Environment for Health Service Provision 55 5.2. Result 2. Improved availability of quality, integrated health services...... 56 5.3 Result 3. Increased access to health services at the community level, including vastly improved linkages with the health system...... 67
6.0 COMMUNITY ENGAGEMENT, SBCC AND GENDER ...... 68 6.1. Result 2. Improved availability of quality, integrated health services at facility level ...... 68 6.2. Result 3. Increased access to health services at the community level, including vastly improved linkages with the health system ...... 68
7.0 ZANZIBAR ...... 73 7.1. Result 1: Improved Enabling Environment for health services provision .. 73 7.2. Result 2: Improved availability of Quality, Integrated health services at facility level ...... 76
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8.0 CROSS CUTTING INTERVENTIONS ...... 80 8.1 Health System Strengthening (HSS) ...... 80 8.2 Digital Health ...... 86
9.0 EMMP Implementation Monitoring and Reporting ...... 87 10.0 CHALLENGES AND MITIGATION MEASURES ...... 87
ANNEX 1: SUCCESS STORY ...... 88 ANNEX 2: PROGRESS TOWARD ANNUAL TARGETS ...... 88 ANNEX 3: Q3 IMPLEMENTATION STATUS ...... 88
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ACRONYMS
GOT Government of Tanzania ACS Antenatal Corticosteroids HBB Helping Babies Breathe ACT Artemisinin Combined Therapy HC Health Centre ADDO Accredited Drug Dispensing HCW Health Care Worker Outlets HF Health Facility AGOTA Association of Gynecologists HMT Health Management Team and Obstetricians HII High Impact Interventions ANC Antenatal Care HIM Health Information ASRH Adolescent Sexual and Management Reproductive Health HIS Health Information System BEmONC Basic Emergency Obstetric and HIV Human Immunodeficiency Virus Neonatal Care HMIS Health Management BCC Behavior Change Information System Communication HRH Human Resources for Health CCHP Comprehensive Council Health HSI&QAS Health Services Inspectorate CEmONC Comprehensive Emergency and Quality Assurance System Obstetric and Neonatal care HSS Health Systems Strengthening CHAI Clinton Health Access Initiative ICT Information, Communication CHF Community Health Fund and Technology CHMT Council Health Management IEC Information Education CHW Community Health Worker Communication CPICI Comprehensive Platform for ILS Integrated Logistic System Integrated Communication IMCI Integrated Management of Initiative Childhood Illness CQI Continuous Quality IP Implementing Partner Improvement IPC Infection Prevention Control CUG Closed User Group IPD Inpatient Department CYP Couples Year Protection IPTp Intermittent Preventive D&A Disrespect and Abuse Treatment Prophylaxis DHIS District Health Information IRCHP Integrated Reproductive and System Child Health Program DHMT District Health Management ISS Integrated Supportive Team Supervision DQA Data Quality Audit ITN Insecticide-treated Bed Net EDS Electronic Data System IUCD Intrauterine Contraceptive eLMIS Electronic Logistics Information Device System IVR Interactive Voice Response EmONC Emergency Obstetric and KMC Kangaroo Mother Care Neonatal Care L&D Labor & Delivery EMR Electronic Medical Records LARC Long Acting and Reversible ENC Emergency Newborn Care Contraceptives EPCMD Ending preventable Child and LDHF Low Dose, High Frequency Maternal Mortality LGA Local Government Authority FP Family Planning LRP Learning Resource Package GIS Geographic Information System M&E Monitoring & Evaluation G&RMC Gender and Respectful MCM-QoC Malaria Case Management – Maternity Care Quality of Care GBV Gender-based violence
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MCSP Maternal and Child Survival QI Quality Improvement Program QIT Quality Improvement Team MiP Malaria in Pregnancy QOC Quality of Care MNCH Maternal, Newborn and Child RBF Results Based Funding Health RCH Reproductive and Child Health MNH Maternal and Newborn Health RCHS Reproductive and Child Health MOHCDGEC Ministry of Health, Community Section Development, Gender, Elderly RDQA Routine Data Quality and Children Assessments MOHZ Ministry of Health Zanzibar RH Reproductive Health MPDSR Maternal and Perinatal Death RHMT Regional Health Management Surveillance and Response Team MRDT Malaria Rapid Diagnostic Test RLT Regional Laboratory MSD Medical Stores Department Technologist MSDQI Malaria Services Data Quality RMC Respectful Maternity Care Improvement RMNCH Reproductive, Maternal, MTUMA Mbinu Timilifu Kwa Usimamizi Newborn and Child Health MVA Manual Vacuum Extraction RM2NCH Reproductive, Malaria, MYICAN Maternal Youth Infant Child Maternal, Newborn and Child Adolescent Nutrition Health NGO Non-Governmental RMO Regional Medical Officer Organization RRH Regional Referral Hospital NIMR National Institute for Medical RTP RESPONSE Tanzania Project Research SBA Skilled Birth Attendant NMCP National Malaria Control SBCC Social and Behavior Change NSV Non-Scalpel Vasectomy Communication OJT On-the-job Training SBM-R- Standards-Based Management OPD Outpatient Department and Recognition OpenSRP Open Smart Register Platform SM Safe Motherhood ORT Oral Rehydration Salt SOP Standard Operating Procedure OTSS Onsite Training and Supportive STTA Short-term Technical Supervision Assistance PAT Pediatric Association of TA Technical Assistance Tanzania WIT Work Improvement Team PATH Program for Appropriate PE/E Pre-Eclampsia/Eclampsia PO-RALG President’s Office-Regional and Administrative Local Governments PNC Postnatal Care PPC Postpartum Care PPFP Postpartum Family Planning PPH Postpartum Hemorrhage PPIUCD Postpartum Intrauterine PPLARC Postpartum Long Acting and Reversible Contraceptives PQIT Pediatric Quality Improvement PY Project Year QA Quality Assurance QC Quality Control
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EXECUTIVE SUMMARY
USAID Boresha Afya-Lake/Western zone aims to improve the health status of all Tanzanians, with a focus on women, youth and children, by improving the availability of, and access to, quality, respectful and integrated health services in Lake and Western Zone. This report covers the third quarter of project year two (PY2) of implementation, April 1 - June 30, 2018, and describes the progress, achievements, challenges and lessons learned during this period.
In this first quarter under the first result area, improved enabling environment for health service provision, USAID Boresha Afya continued to provide technical assistance (TA) to the Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) and the President's Office, Regional Administration and Local Government (PORALG). The Project conducted an orientation on the new version of the reproductive, maternal, newborn and child health (RMNCH) scorecard; reviewed the maternal and perinatal death surveillance and response (MPDSR) guideline to incorporate ICD – 10 classification of perinatal deaths; improved partners’ coordination; facilitated sharing best practices among midwives; and chaired the Respectful Maternity Care (RMC) symposium. USAID Boresha Afya also supported nationa technical working groups and/or task force meetings both in Mainland and Zanzibar. The project continued its collaboration with the Ministries including the support to capacity building in Governance and accountability to health management teams at various levels. USAID Boresha Afya has aligned its work to other national initiatives including; Jazia Prime Vendor System (JPV), Improved Community Health Fund (iCHF), Direct Health Facility Financing (DHFF), and RBF, which work as a catalyst to realizing quality services in RMNCH and Malaria. As the project works smarter, this quarter we established and operationalized a Digital Health System to streamline next steps for the implementation of Malaria Service and Data Quality Improvement (MSDQI) and Malaria Surveillance & Response (MSR). Vendors for closer user group (CUG) and e-Learning were engaged to facilitate capacity building of HCWs, and effective referral.
Under the second result area, improved availability of quality, integrated health services at facility level, the Project collaborated with health facilities (HFs) and providers to improve service delivery in each of the key technical areas. The Project strengthened providers’ competencies in providing quality reproductive, maternal, newborn, child and adolescent health (RMNCAH) and Malaria services through structured trainings mostly on job, clinical mentorship, integrated supportive supervision, quality improvement (QI) assessments. Besides, USAID Boresha Afya continued to strengthen quality improvement initiatives by strengthening quality improvement teams, conducting regular QI assessments at health facilities and empowering R/CHMTs in governance and oversight. In health systems, the project worked with PO-RALG and R/CHMTs on initiatives for improving availability of human resources and supplies/commodities for RMNCH and Malaria services, for instance through standardizing Supply Chain key performance indicators (KPI). Through use of quality data, USAID Boresha Afya was able to implement targeted interventions in addressing identified challenges. For example, special attention was given to Nyarusugu Health Center after learning that it contributed to most cases of malaria in Kigoma.
Under the final result area, increased access to health services at community level, the Project built the capacity of community health workers (CHWs), with 674 being active in community mobilization in RMNCAH, including FP, Malaria and nutrition services. In collaboration with Tulonge Afya, the project disseminated a number of IEC/BCC materials in project sites aiming at increasing knowledge on health care seeking behaviors. In collaboration with R/CHMTs, USAID Boresha Afya continued to conduct comprehensive supportive supervision and mentorship to CHWs and their supervisors, which has contributed to increased trend in services utilization in project supported sites. This quarter the project also completed
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the selection of local CSOs, and received the approval from USAID for their engagement. These CSOs will be engaged from next quarter in implementing community-based interventions in all project districts.
During the quarter, USAID Boresha Afya was also involved in high-level events including the national commemoration of the world Malaria Day in Kigoma, which was which was officiated by the Minister of Health, Hon. Ummy Mwalimu, and attended by USAID's mission Director and other Malaria stakeholders. The project supported provision of Malaria services in both health facilities and communities across project regions. USAID Boresha Afya was also able to host the Mission Director in Kagera where he could visit to learn successes and challenges with health of mothers, adolescents and children in the region. During the visit, the Mission Director was able to visit program activities supported through USAID Boresha Afya and MCSP, and hear directly from the beneficiaries of USAID investment in maternal, newborn and child health services including FP and Malaria.
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INTRODUCTION
USAID Boresha Afya Lake and Western Zone is a five-year project implemented in seven regions of Tanzania Mainland and Zanzibar. The goal of the Project is to improve the health status of all Tanzanians – with a focus on women, youth and children – by improving the availability of, and access to, quality, gender sensitive, respectful and integrated health services. A consortium of three partners, led by Jhpiego, an affiliate of Johns Hopkins University, with partners EngenderHealth and PATH implements the Project. The purpose of this Cooperative Agreement is to support the Government of Tanzania (GOT) to increase access to high quality, comprehensive and integrated health services, with a focus on maternal, newborn, child and reproductive health (RMNCH) outcomes in Mara, Kagera, Kigoma, Shinyanga, Geita, Simiyu and Mwanza and five districts in Zanzibar. To support this goal and purpose, USAID Boresha Afya will ensure the achievement of the following three intermediate results (IRs):
. IR 1: Improved enabling environment for health service provision primarily based on progress translating policy into meaningful action;
. IR2: Improved availability of quality, respectful, client-centered and gender-sensitive integrated services for children, adolescents and adults of reproductive age and beyond at target health facilities (HFs) whose outcomes generate momentum for further scale-up;
. IR 3: Increased access to health services at the community level, including vastly improved linkages with the health system.
USAID Boresha Afya seeks to achieve these results through strengthening existing platforms and building on a base of assets across the continuum of care to improve quality and support comprehensive services with bold, smart, and targeted initiatives that concentrate on geographic areas with the highest need and largest potential to achieve wide coverage and increased outcomes. As districts are the primary functional unit in Tanzania, the Project’s strategy focuses on district ownership to enable accelerated access to high quality, comprehensive integrated services at all points of care. The Project is implementing expanded services packages in high need areas, and essential service packages to all areas, to maximize outcomes and value for money, and ensure sustainability. The Project utilizes effective information and communication technology for development (also referred to as ICT4D or Digital Health) to increase demand, improve health care worker to health care worker, and health care worker to client communication, reinforce continuous learning, improve referrals, and strengthen data quality and use for decision-making.
PROJECT COVERAGE
USAID Boresha Afya is implemented in seven regions of Kagera, Mara, Geita, Kigoma, Shinyanga, Simiyu and Mwanza in Tanzania mainland, covering 51 councils. In addition, the Project supports five (5) districts in Zanzibar Island. In total USAID Boresha Afya interventions reach 1,822 HFs (HFs), of these HFs, 808 are classified as project “expanded sites”, receiving a high-intensity intervention package, while 1,014 are “essential sites”, receiving the same package of interventions through the RHMTs and CHMTs. Table 1 summarises the project coverage by region, HFs and technical areas.
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Table 1: USAID Boresha Afya Lake and Western Zone project coverage
Region Technical areas HFs coverage Total Expanded HFs Essential HFs Hosp HC Disp Hosp HC Disp Mara RMNCAH, Malaria, FP 9 38 35 0 0 196 278 and Community Kagera RMNCAH, Malaria, FP 14 31 55 0 0 208 308 and Community Geita RMNCAH, Malaria, FP 4 17 118 0 3 17 159 and Community (limited MNH) Mwanza CH, Malaria, FP and 16 21 205 0 29 103 374 Community Shinyanga CH, Malaria, FP and 5 6 42 0 14 151 218 Community Simiyu CH, Malaria,FP and 4 7 103 0 8 86 208 Community Kigoma CH, Malaria,FP and 6 11 56 0 18 181 272 Community Zanzibar RMNCAH, Malaria, FP 5 0 0 0 0 0 5 Total 63 131 614 0 72 942 1,822
This report documents the progress made up to quarter three of project year 2 (Q3, PY2) towards strategic project outcomes and the realization of the project and national goals. The report is presented by technical area (maternal and newborn health [MNH], child health [CH], malaria, family planning [FP], community engagement, social and behaviour change communication [SBCC], gender, and other crosscutting issues). The technical areas are further organized by result area and Intermediate Result (IR). Regional achievements are organized based on the package of interventions in that particular region (see Table 1). Key project indicators have been carefully analysed to measure implementation status towards the achievement of the PY2 targets. 1.0 PROJECT MANAGEMENT HIGHLIGHTS IN QUARTER 2 OF PY2018
1.1. Staffing and HR administration
This is the period of finalizing staff performance appraisal for cycle 2017/2018, support was provided to supervisors and supervisees to ensure that, they finalize their performance reviews and also input new performance objectives in line with the project deliverables for the coming cycle of 2018/2019. The Project is in the final stages of engaging two candidates to replace the Regional Program Manager for Kagera and the Senior Technical Advisor, Community Engagement and Outreach respectively.
1.2. Short-Term Technical Assistance (STTA)
In the period under review, the project received short-term technical assistance from various experts with the purpose of strengthening project approaches and strategies as follows:
Senior Technical Advisor, MER (Lolade Oseni): The purpose of the 4-day visit was to work with the USAID Boresha Afya team to review and strengthen malaria technical approaches under the Project and support the application of Jhpiego's data visualization toolkit to better demonstrate the Project’s success. The visit also aimed at learning from Boresha Afya’s experiences to share knowledge and best
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practices with other Jhpiego malaria programs. In this visit Boresha Afya were also able to map out the malaria indicator cascade against the MEL plan and also compared to what is available in the national HMIS. Some indicators were refined; however, the full cascade has not been incorporated. The malaria cascade starts with number people coming with a fever, and this is not currently part of the routine HMIS. Its inclusion in the national HMIS has been proposed and discussed with the National Malaria Control Program (NMCP) and HMIS units at the MOH. The MOH's perspective has been that fever is not an illness, it is a condition, and the HMIS does not report on conditions. We believe it is important to include this in the routine reports and will continue to advocate and provide TA in this area. As a result of this visit, Project staff were mentored on the use of Jhpiego data visualization tools and use of the toolkit to package the data and reporting of malaria interventions.
QI Advisor Jhpiego Baltimore (Edgar Necochea): The purpose of this visit was to increase staff understanding and application of key concepts, tools and current approaches around quality improvement, including approaches that will eliminate wasteful practices at the facility-level, with a particular focus on targeting the lean methodology/5S.
1.3. Project Coordination and Management
USAID Boresha Afya maintained timely and consistent submission of quarterly progress reports to USAID. The same reports were shared with MOHCDGEC and PO-RALG, and region-specific quarterly reports were shared with respective regional medical officers (RMOs)/RHMTs. The Project continued to provide oversight through structured joint supportive supervision across the seven regions. In April 2018, the Project conducted a joint field visit with the MOHCDGEC – Reproductive and Child Health Section (RCHS) and the Tanzania Food and Nutrition Centre (TFNC) to monitor implementation progress. The supervisory visit focused on 4 key areas: providers technical competency, client safety, privacy and confidentiality, and continuity of care. Forty-one best and poor performing HFs were visited in all the regions. Identified gaps and areas for improvement were shared with respective R/CHMTs for follow-up and further action. Key findings include:
1. Technical Competency Skilled providers – most of the HFs had at least one skilled provider; Most of the HCWs were trained in IMCI, Malaria, PF, nutrition, BEmONC; Protocols and guidelines were available – but not often used; Triage of patients was not practiced in the majority of HFs; In Shinyanga and Simiyu, essential HFs need comprehensive support on service provision (i.e. D- IMCI mentorship, regular MSDQI visits and IMCI compliance). However, they showed some improvement when compared with the previous assessment undertaken by CHMT; Inadequate knowledge on nutrition in most of the facilities visited; The majority of facilities do not track any key QI indicators, apart from HIV/AIDS-related services, and do not hold regular meetings.
2. Client Safety HFs have referral forms – but are not standardized. Most HFs do not have mechanisms for counter referral and there were no referral guidelines; Medical history is taken but is not comprehensive in some HFs; Almost all HFs have essential medicines, supplies and commodities except FEFO, RCH card 5, (Mara); intrauterine contraceptive device IUCD kits, and postpartum family planning (PPFP) kits;
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Infection prevention and control (IPC) measures are practiced but some HFs are doing better than the others; decontamination procedure is not followed in most HFs; Most HFs are aware of the procedures for handling and reporting adverse events; however, documentation is still a challenge in most of the facilities visited.
3. Privacy and Confidentiality The majority of the HFs had inadequate privacy at reproductive child health (RCH) clinics and maternity wards; Privacy at the outpatient departments (OPDs) was better in comparison; Confidentiality – in some HFs, patient files were not stored safely and not organized (ie. kept in shelves, not locked and therefore easily accessible).
4. Informed Choice (FP services only) Clients had access to a range of contraceptive methods, and information, including where to access; All commodities were available in all the HFs; All the HFs had Tiarht charts but not in all FP areas.
5. Continuity of Care Most HFs reported providing information to clients on how to identify danger signs and when to come back to the HF or referral to hospitals. However, a few of the facilities do not provide enough information to clients; Clients are informed where to go in case of emergency; important contact numbers are displayed but some were not reachable; Feedback mechanisms – suggestion boxes exist in most HFs but are not actively used; some feedback received through community meetings and discussed in HFGC meetings but not adequately documented
In addition, the Project participated in the USAID-coordinated technical meeting to discuss technical issues related to key thematic areas and was attended by technical experts from USAID, and the Joint Project Planning Meeting (JPPM), which deliberated on high level results of the project and some cross-cutting themes, including Health System Strengthening (HSS), community engagement and gender.
To improve efficiency and effectiveness in project implementation, regular meetings and field monitoring visits were held with project staff and key stakeholders, including the MOHCDGEC and R/CHMTs. Regional project reviews and planning meetings were conducted in all project supported regions, as well as monthly technical leads’ meetings, Senior Management Team (SMT) meetings, and regional project management and coordination meetings.
In addition, USAID Boresha Afya hosted two USAID visits in Kagera and Mwanza. The Mwanza field visit involved Dr. Troy Jacobs, a USAID Senior Medical Advisor from Washington, D.C. The aim of the visit was to review and provide input on newborn and child health programs supported by USAID Boresha Afya-Lake and Western Zone. The Senior Medical Advisor visited two health facilities in Nyamagana and Magu to observe supported child health services and provided feedback on case management of childhood illnesses. The following are selected recommendations from the visit: There is a need to systematically focus on process of care with case management (IMCI), especially for health centers and hospitals;
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Reinforcement and consistent use of low-cost interventions (such as vitals) at all levels of care would be beneficial before taking on more expensive interventions;
Triage and intervention (including care seeking referrals) needs continued work to better address greater acuity. This includes updating Emergency Triage Assessment and Treatment (ETAT) and incorporating quality of care (QoC) standards. The second field visit to Kagera involved the USAID Mission Director. The objective of the visit was to observe and learn more about MCH challenges that USAID investments aim to address in the region. The Mission Director visited 3 health facilities in Misenyi and Karagwe District councils. The following were key observations during the visit: There has been tremendous improvement in RMNCH indicators in Kagera over a period of USAID support under both MCSP and USAID Boresha Afya;
Leaders and managers at various levels (from region, district and facility) appreciate the impact of USAID-funded support in the region;
There is increased utilization of RMNCH services, as this was also acknowledged by community members reached through community health workers;
The availability of essential drugs has increased at health care facilities. This can be one basis for attracting clients to services;
Community health fund coverage is still low. The Project will continue working with councils and communities to raise awareness and increase enrollment into CHF.
Despite the observed trend in PPFP uptake, this is still low. The Project will collaborate with R/CHMTs to ensure that most women are counseled on PPFP and services are easy to access;
It was evident that revenue from the Results-Based Financing (RBF) program could improve facility infrastructure for quality services if used well. The Project will continue engaging with leadership at health facilities for proper use of resources from RBF.
Teenage pregnancies are still a challenge in Kagera. Appropriate interventions to reach adolescents for pregnancy preventions are necessary, and young mothers need the appropriate support for safe deliveries as well as accessing PPFP. Finally, the Project conducted a Semi-Annual Program Review meeting and team building session with all Project staff. The meeting provided a platform to review the project’s achievements for the first half of the fiscal year, share best practices and lessons across project regions, and discuss strategies for improving project effectiveness and efficiency. During the meeting, the team jointly identified strategies for accelerating implementation in the last 2 quarters of PY2 and identified priorities for PY3 programming.
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2.0 MATERNAL AND NEWBORN HEALTH (MNH) 2.1 Result 1: Improved Enabling Environment for Health Service Provision
2.1.1. Result 1.1: Development/Improvement of policies, guidelines and protocols
2.1.1.1. Orientation on new version of RMNCH Scorecard to RMNCH TWG and PORALG During this quarter, USAID Boresha Afya project supported the orientation of RMNCH TWG, PORALG and other stakeholders on the new/updated version of RMNCH Scorecard. The updated version of the scorecard included the following newborn indicators: Kangaroo Mother Care (KMC) and newborn resuscitation. During the orientation, it was suggested that the indicator for the number of babies successfully resuscitated also include the outcome of resuscitation. These indicators will be finalized under the coordination of child health unit, in collaboration with USAID Boresha Afya and UNICEF. The project will continue to advocate for the most meaningful indicators aligned with national and global recommendations and roll them out in project sites and beyond.
2.1.1.2. Revision of national MPDSR guideline and tools to incorporate ICD – 10 classification of perinatal deaths. Through the project support, the MPDSR consultant continued with the review of the the MPDSR guideline and shared the progress to the stakeholders for inputs. Major observations from the consultant and stakeholders were: o Maternal and perinatal death is notifiable event and should be notified within 24 hours at the district level using National Integrated Diseases Surveillance and Response (IDSR) o New ICD 10 will be used (ICD 10MM and ICD 10PM) o Community maternal and perinatal death will be reviewed after verbal autopsy
2.1.2 Result 1.2: Technical assistance (TA) provided to GOT to develop, communicate, and implement national plans. This quarter USAID Boresha Afya continued to provide TA to the MOHCDGEC, the President’s Office – Regional Administration and Local Government (PO-RALG) and the Ministry of Health Zanzibar (MOHZ) with strategic national level activities. The Project provided TA in the following activities in the reporting period:
2.1.2.1. Malaria in Pregnancy (MiP) Task Force meeting The project co-convened the Malaria in Pregnancy (MiP) Task Force meeting to share experience and updates on Malaria in Pregnancy implementation. This meeting involved both RCHS and NMCP, and other stakeholders in Malaria, with USAID Boresha Afya serving as a secretariat. The key issues that were discussed are summarized below: o Availability of new HMIS tools which capture IPTp3: NMCP has finalized the revision of the tool, the preparation for dissemination is underway internally; updates will be shared in the next quarterly meeting. o A need for NMCP to collaborate with Health Promotion Unit (HPU) of the MoHCDGEC to develop IEC materials and job aids to reinforce Artesunate injection use among health care providers instead of quinine. NMCP team agreed to contact HPU for development of these materials.
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o The NMCP emphasized on the use of Artesunate injection for treatment of severe malaria regardless of the gestational age, including the first trimester, which has already been included in the Malaria National Standard Treatment Guideline – 2017. o NMCP team presented data on Malaria in Pregnancy MSDQI updates indicating an increase in the ANC Malaria annual test rate from 60% in 2015 to 89% in 2017 for the first ANC visit as a good trend. Furthermore, the proportion of pregnant women receiving IPTp2 increased from 57% (2015) to 65% in 2017. The task force emphasized intensifying supportive supervision and mentorship to advocate for early ANC booking, as well as data quality support, and supply chain management support to ensure availability of commodities.
2.1.2.2. Nursing and Midwifery conference During the quarter, USAID Boresha Afya supported and participated in the Nursing and Midwifery Scientific Conference in Dodoma, and supported the participation of midwives from project supported health facilities in Geita, Mwanza, Simiyu, Shinyanga and Mara. USAID Boresha Afya coordinated and chaired the Respectful Maternity Care (RMC) symposium, which aimed at raising awareness among nurses, midwives, and other participants on respectful care, client experiences of facility-based disrespect and abuse, and community views on the experience of care as a support to ensuring quality of care.
2.1.2.3. National RMNCH Technical Working Group. USAID Boresha Afya participated in the quarterly RMNCH meeting. Key issues discussed included improving stewardship and coordination of RMNCAH implementation in Tanzania – a concept note has been drafted by the Ag. Assistant Director, RCHS which is being finalized before being shared with stakeholders for implementation.
During the meeting, it was noted that staff at RCHS are appointed without prior training on management; partners were therefore requested to support a capacity need assessment and capacity building for RCHS staff. RCHS will lead the development of RMNCAH Operational plan for the period of July 2018 – June 2019, and partners will align their activities according to the plan.
Finally, the meeting reviewed One Plan II, and it was agreed that USAID Boresha Afya will continue supporting the review of the plan to incorporate data from the recent TDHS 2015/16 and the respectful care component.
2.1.3.4. Safe Motherhood quarterly Technical Working Group; USAID Boresha Afya supported and participated in the Safe Motherhood technical working group was jointly conducted with the Family Planning TWG. The main aim of the meeting was to inform and guide each unit within RCHS to develop its annual operational plan for FY 2018/19 in alignment with One Plan II and FP CIP II by the end of the quarter 4. USAID Boresha Afya was requested to support and provided TA in the process.
2.1.2.5. Consultative meeting with MoHCDGEC-RCH section In this quarter, the Project team conducted project implementation progress review meeting for PY2 and PY3 pre-planning session with MoHCDGEC-RCH section. This served as an opportunity for the RCHS to understand and appreciate the project’s contribution to the overall performance of RMNCH indicators
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in the Lake and Western zone. Furthermore, national level priorities for RMNCAH were highlighted for consideration in the project year 3 work-plan development process.
2.2. Result 2. Improved availability of quality, integrated health services.
2.2.1. Result 2.1: Increased provision of quality, integrated health services
2.2.1.1: Strengthened provider’s competencies in managing pregnant and newborn complications
Capacity building on PPH prevention and management To improve the provider’s competencies on prevention and management of PPH, the project trained 54 BEmONC/CEmONC clinical mentors on PPH prevention and management for five days using bleeding after birth (BAB) modular training materials in Kagera and Mara. The HCWs were specifically trained on active management of third stage of labor, management of shock and specific management of PPH including use of uterotonic, bi-manual compression of the uterus, uterine balloon tamponade, and manual removal of retained placenta. Providers' knowledge increased post training, from 68% before training to 83% after training in Kagera and 70% to 84% in Mara. Correct performance of key skills (assessed using Objective Structured Clinical Evaluation (OSCE)) was went from 59% to 90% in Kagera and 62% to 84% in Mara. These mentors were also oriented on facilitation skills and they were given OJT training materials for them to continue training other providers within their health facilities. To improve their learning these mentors were also oriented on proper documentation and tracking information on AMTSL, PPH incidence and deaths due to PPH. The project will monitor this training through assessing provider’s performance, tracking quality of care indicator including proportion of women who received immediate uterotonic for PPH prevention, PPH incidence and PPH case fatality rate.
Strengthening mentorship program To strengthen and sustain mentorship process within the councils, the project trained 68 mentors including skilled providers from Kagera (6 HCWs per council in all 8 councils) and Geita (3 HCWs per councils in all 6 councils) on clinical mentorship skills for six days using the national curriculum for clinical mentorship. These are providers who were already trained in BEmONC and/or CEmONC clinical skills and are working in labor and postnatal wards. The clinical mentorship training aimed at equipping them with mentorship skills for them to continue mentoring service providers within their health facilities and also in essentials health facilities within their respective councils. During this training, the knowledge change was from 52% (pre-test) to 71% (post-test) in Kagera and 43% to 70% in Geita. The trained mentors will be followed up four weeks after the training and will be assessed using standard mentorship assessment tools (RMNCAH clinical mentor performance standards & clinical mentor’s assessment checklist) to understand their performance in mentorship skills.
It is anticipated that these trained mentors will cascade their skills to other HFs in the respective councils. The project will monitor the mentors' performance and document the number of providers who received mentorship on specific competencies using standard tool. The information will be captured in the clinical mentoring activity reports and the project will cross-check it during supportive supervision and
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mentorship visits by re-assessing the providers who received mentorship using SBM-R on specific competencies and the action plan will be set for the identified gaps to improve the mentorship process.
2.2.1.2 integrated supportive supervision, QI assessments and Clinical mentorship The project continued to strengthen capacity of service providers in provision of quality RMNCAH services through supportive supervision, quality improvement assessments and clinical mentorship. Based on previous performance, the project visited a total of 54 expanded health facilities in Kagera and Mara and 26 essential health facilities in Kagera reaching 217 service providers working at ANC, labor and delivery, and PNC wards. Areas for mentorship were prioritized using pre-visit summary checklist.
Table 2: Areas supported during Mentorship Technical area Service area Areas of Mentorship
Maternal Health ANC Proper history taking & physical examination and take appropriate action Preventive measures including malaria, syphilis, HIV, Anemia Counseling on PPFP, nutrition & birth preparedness Proper documentation on HIMS register no. 6
L & D Use of partograph to monitor labor and take appropriate action PPH management including management of shock Prevention and Management of sepsis Proper documentation on HIMS register no. 12
PNC History taking and physical examination for mother and newborn as well as take appropriate action Counselling and provision of methods for PPFP Proper documentation on HIMS register no.13
Newborn Health Newborn resuscitation Immediate newborn care including early initiation of BF within one hour after delivery, thermal care(drying & wrapping , skin to skin within one hour) and clean cord care
During these mentorship visits, we observed some improvement in practices including use of vaginal swab during vaginal examination and pre-operative antibiotics for sepsis prevention, checking blood pressure for pregnant women at ANC and during admission in maternity wards, and use of dexamethasone injection for prevention of complications of prematurity among women who had preterm births. We also observed proper allocation of RBF funds in some health facilities to address gaps in infrastructure and medical
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supplies, and over 95% of health facilities conducted maternal and perinatal deaths audits. However, some health facilities are still facing a shortage of human resources and a lack of infrastructure (such as bathrooms and toilet in the labor rooms), basic amenities (such as running water), and basic equipment (resuscitation kits, vacuum extractor, syphilis test kits and Hb test kits). Action plans were set to address these challenges, including the efficient use of RBF funds to address critical gaps on infrastructure, supplies and equipment.
2.2.1.3 BEmONC performance standards QI assessment USAID Boresha Afya continue to conduct assessments on BEmONC in Mara and Kagera using the Standards-Based Management and Recognition (SBM-R) tool which now also includes standards on gender, RMC, YFS and male engagement. Assessment included management of labor and delivery and antenatal, intrapartum and postpartum complications; postpartum, immediate, and subsequent newborn care. There is some improvement of overall BEmONC standards and improvement in clinical skills; however, progress is slow. The main reasons for slow progress are around staffing: a large number of providers who have been trained on BeMONC have been rotated to other departments, while other trained staff were terminated due to fake certificates. Other factors include the inadequate support of infrastructural and basic equipment by the local government. The project provided feedback to R/CHMTs and Health Facility management teams to address the identified gaps using available sources of funds (Basket fund, RBF, CHF). Figure 1 below shows overall BEmONC standard performance (clinical performance); Figure 2 shows trends in clinical skills and key system supports.
Figure 1: Trends in BEmONC performance standards
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Kagera & Mara 100%
80%
60% Clinical Skills 40% Support Systems Infrastructure and Human Resources 20%
0% Kagera Mara Kagera Mara Kagera Mara 2018 2017 2016
Figure 2: Trends in clinical skills and support system performance in Kagera and Mara
2.2.1.4 Strengthening Quality Improvement implementation In this quarter, the project conducted data management linked to QI mentorship in Mwanza and Geita. The project had introduced specific tools for addressing quality Improvement gaps for the RMNCAH services. As part of Quality Improvement strategies, the project identified poorly performed quality indicators and provided mentorship on how to increase performance of those indicators. Quality improvement mentorship included setting objectives for improvement. HCPs were able to identify barriers for improvement; propose strategies change including indicators to be tracked. More than 200 providers from more than 50 healthcare facilities from Mwanza and Geita were mentored on quality improvement. The QI mentorship was done alongside data and management support which aimed at assisting providers to generate high quality data for decision making. The project will scale up data/QI management mentorship to more healthcare facilities across other USAID Boresha Afya region.
2.2.1.4.1 The project continued collaboration with other partners implementing quality Improvement through joint meeting in Shinyanga region and will continue strengthen this collaboration semiannually. The project participated in partners meeting with AGPAI, Touch foundation, Pathfinder, World Vision, Red Cross where each partner presented activities that they are doing and identified areas to collaborate in both quality improvement and specific technical areas (i.e. Family planning, malaria and MNH). The project will identify extent or deficit on net distribution to facilities and inform JHU a partner working for net distribution. Similarly, we will continue working with Touch Foundation in supporting MPDSR meetings. Touch Foundation is charged with following up of the implementation of the MPDSR action plans while the project will continue supporting the Regional meetings. AGPAHI will support healthcare facilities in tracking RMNCAH indicators. 2.2.1.4.2 In the period under review, the project continued with its efforts to assess and revitalize QITs at healthcare facilities. This activity is been integrated with other HFs support such as IMCI, MSDQI, and HFs DQA and data management activities. Three regions were covered (Kagera, Kigoma and Mara). The Project identified both material and financial support that health facilities management team sees as barrier for QITs to carry out quality improvement activities. The project will continue advocating for the formation and support for the QITs at all levels and present these findings to R/CHMTs for follow up. We will reward best
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performing HFs in terms of certificate and trophy to motivate health care providers in QI efforts in the subsequent quarters. 2.2.1.4.3 Status of QIT/WIT in Kagera, Kigoma and Mara: More than 70% of visited HFs in Kagera and Mara reported to have established QITs while in Kigoma it was less than 40% (see Figure 3 below). The project will work collaboratively with Kigoma R/CHMTs in effort to establish and revitalize QIT.
Figure 3: Status of QIT in visited HFs in Kagera, Kigoma and Mara
Conducting QIT Meetings: Less than 45% of HFs are conducting QIT meeting in Kagera and Mara and it is less in Kigoma were only 6% reported conducting QIT meetings. In this HFs, the team were able to find the documentation and minutes for the meeting. Implementation of agreed action plan were 60%, 65% and 0% in Mara, Kagera and Kigoma respectively. USAID Boresha Afya will strengthen this area through data management linked to quality Improvement mentorship initiatives. The project developed a system to track the quality of key indicators for the RMNCAH. Facilities have started using the SES (standard Evaluation system) tools as problem solving tools for quality Improvement, where they plot graphs of key selected indicators.
45% 42% 40% 35% 35% 30% 25% 20% 15% 10% 6% 5% 0% Kagera Kigoma Mara
Figure 4: Status of QIT Meeting in visited HFs in Kagera, Kigoma and Mara
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Status of Availability of both Financial and material support from Health facilities management team (HMT): Figure 5 and 6 below depicts status of both financial and material support to enable QITs operations which is still a challenge. More facilities in Kigoma (89%) do not receive financial support whereas Mara and Kagera are better off as the graphs portrays. QITs in Kigoma, apart from not receiving financial support, they equally do not receive material support too. During revitalization of QIT, this is another potential that need to be strengthened.
100% 100% 94% 89% 90% 90% 81% 80% 80% 69% 70% 70%
60% 60% 52% 50% 45% 50% 34% 40% 31% 40% 33% 30% 30% 21% 19% 20% 20% 16% 10% 6% 6% 10% 6% 0% 0% 0% 0% 0% Kagera (n=26) Kigoma (n=18) Mara (n=135) Kagera (n=26) Kigoma (n=18) Mara (n=135)
Periodical Support Occasional Support Periodical Support Occasional Support No Financial Support No Material Support
Figure 5: HFs receiving Financial support Figure 6: HFs receiving Material support from HMT for QIT implementation from HMT for QIT implementation
2.2.1.5. Follow up of referral emergency preparedness for obstetric complications in Geita Following the initial assessment of emergency preparedness in Geita hospital that was done in quarter two, which was followed up with onsite mentorship and setting up action plan to rectify observed bottleneck, the project conducted follow up assessment in this quarter (Q3). We have observed improvement in implementation of emergency preparedness and referral feedbacks in Geita as shown in Table 3 below:
Table 3: Trend in emergency preparedness in Geita Regional Referral Hospital Selected Pre-referral components Jan-March April June 2018 2018 Late referrals from lower HFs 30% 6% Clients referred without referral letter 15% 2% Clients referred without being checked their blood group prior 13% 2% to the referral Clients referred without being catheterized prior to the referral 39% 5% Clients referred without an I.V line prior to the referral 33% 4%
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Strengthening KMC services In scaling up implementation of high impact interventions for newborn health, the project conducted a one day site readiness assessment in 5 CEmONC sites in Kagera and established the readiness including identification of gaps for provision of KMC services. The following were observed during this assessment: All 5 Heath Centers (100%) demonstrated readiness to establish new Kangaroo Mother Care services Four facilities except one (St. Therese HC) have beds, bed sheets and some of the basic supplies to support establishment of Kangaroo Mother Care services e.g. thermometer, graduated feeding cups. All five health facilities had gaps on the following basic supplies: digital weighing scales (5); Low reading body thermometers (15); Graduated feeding cups (50) and Feeding tubes (sizes 4, 5, & 6 total (250) In all 5 sites it was observed that, health care providers do lack knowledge and skills on KMC. Actions were set to address the gaps so that the service providers can be trained on KMC and start provision of KMC services.
Following this assessment in Kagera, and the one done in Mara during quarter two the sites were able to address most of the important gaps and were ready to start provision of KMC services. Following this feedback from the assessed sites, the project scaled up KMC services to 10 CEmONC sites (5HFs in Kagera & 5 HFs in Mara) through 2 day on-the-job training on KMC services using national KMC trainers. A total of 82 service providers working at Labor & delivery and PNC wards received the training. The service providers were also oriented on how to fill in the national KMC register and track the implementation of KMC interventions. The health Figure 7: One of the clients who facilities were supplied with National guideline for KMC, benefited from KMC services at SOPs and reporting tools and these sites started to Nyakahura HC, Biharamulo DC, provide KMC services. Kagera after the initiation of the services
To strengthen KMC services in pre-existing KMC sites, the project conducted clinical mentorship in eight districts of Kagera region on KMC reaching 8 health facilities out of 12 pre-existing sites. A total of 20 service providers received mentorship using district clinical mentors with technical assistance from the project. During this mentorship visit the following were identified :
Inadequate availability of equipment and supplies, like digital weighing scales in 6 out of 8 visited sites, feeding cups and resuscitation kits in 7 sites Some gaps were observed in documenting low birth weight babies in KMC registers. Only very low birth weight babies from 1500g birth weight and below were documented. All these providers were mentored on criterial for admission, discharge, and graduation of KMC babies.
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In all 8 facilities visited, feeding of low birth weight babies was noted to be a problem where babies were fed without calculation of feeding as per standards. Mentorship was done on proper calculation for feeding. Turnover and relocation of skilled staff trained in KMC e.g. in each facility it was found that only one to two staff have skills for KMC services despite training more numbers. Hence, observed gaps in making follow up for low birth weight babies was reported to be contributed by shortage of staff. The project will continue strengthening the KMC services through clinical mentorship and provision of equipment (digital weigh scale and KMC wrappers) budgeted in this project year.
2.2.1.6. Strengthening administration of Antenatal Corticosteroids (ACS) During the quarter under review, the project trained 90 service providers working at ANC, L & D and PNC wards on management of pre-term births including administration of antenatal corticosteroids at 7 CEmONC sites in Geita region. This was one day OJT training using modular training materials for the management of pre-term births. The average knowledge change was from 46% in pre-knowledge check to 70% during post-knowledge check. The providers were also oriented on proper documentation in HIMS register no. 12 and KMC registers. All facilities were supplied with job aids (e.g. medication chart, flow/action chart) and guideline on management of PTB.
Following the training, the sites started to provide services on management of pre-term births, making a total of 45 CEmONC sites for Kagera (19 sites), Mara (19 sites) and Geita (7 sites) which are implementing ACS intervention for preventing prematurity complications.
During the same quarter, USAID Boresha Afya conducted antenatal corticosteroid post training follow- up to 19 health facilities providing antenatal corticosteroid in Mara region. These facilities were trained in quarter two. A total of 68 health care providers were mentored, which is about 50% of all trained on ACS. During the follow up, the following were observed: Dexamethasone injection (one of the ACSs) was readily available in all sites except one health facility. No any reported adverse reaction to clients who received ACSs Newborn whose mothers received ACS had better outcomes Documentation on the register no. 12 was still a challenge especially on recording gestation age and preterm birth associated conditions like PPROM, Placenta Previa, Severe PE and Premature Labor. To address this the project instituted a form that will be included in patient’s files to easily capture information for tracking ACS intervention.
2.2.1.7. Implementation of Maternal Infant and Young Child Nutrition (MIYCAN) in USAID Boresha Afya supported HFs To improve the quality of maternal infant and young child nutrition services at health facilities, USAID Boresha Afya conducted on-the-job training for 179 providers from 40 health facilities in Geita Region. The training will enable health care workers to improve the quality of MIYCAN services provided in health facilities and address areas that require improvement to meet MIYCAN standards. The following are the areas/topics covered during MIYCAN OJT (Importance of Breastfeeding, Common problems/ difficulties during Breastfeeding, Complementary Feeding, Maternal Nutrition, Adolescent Nutrition, Early child hood development including growth monitoring, Protection, Support and Promotion of Breastfeeding in health
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Systems (Ten steps to successful breastfeeding, National Regulations on Breastmilk Substitutes, and Maternity protection law).
In addition to the on-the- job training the Project took inventory of existing nutrition anthropometric equipment, IEC material, job aids, supplies (Micronutrient powder and Plumpy’nut). Below were the challenges observed during on-the-job training: o Most health facilities have no length boards o Most health facility have no weighing scales for children above two years o No posters which promote breastfeeding o No timetable/ schedule for nutrition education at RCH section o Health care provider do not give feedback to mothers/ care givers on nutrition status of their children o Inadequate skill and knowledge of HCWs on providing quality nutrition services in some areas such as growth monitoring especially on the use of anthropometric equipment (weighing scales, height/length boards and MUAC tapes) o Some health facilities have Ready to use therapeutic foods (RUTFs) but have no knowledge on how to use them o Inadequate knowledge and skills on identification of malnourished children at the health facility and Community levels
In quarter 4 the project will continue to support MIYCAN OJT for phase II in 101Geita, 106 HF Mara and 115 HF Kagera.
2.2.1.8. Progress in Routine MNH health services Antenatal Care (ANC) Services At least one ANC visit is almost universal in all 7 supported project regions; however, the challenge is in ANC1 attendance below 12 weeks’ gestation. ANC visit below 12-week gestation has improved in Kigoma; Mara; Mwanza and Simiyu compared to previous quarters, with a bit of a drop in Kagera and Shinyanga while Geita maintained the same level. ANC1 below 12-week gestation is one of the payable indicators in RBF scheme, hence this could be a factor for improved documentation. CHWs and HCWs are encouraged to sensitize the community on early booking and this results into positive trend on proportion of pregnant women attending ANC1 below 12 weeks.
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Figure 8: Quarterly trends on ANC1 coverage below 12 weeks of gestation in Project supported Regions
ANC syphilis testing and treatment cascade Generally, there has been improvement in syphilis testing coverage in all three Regions compared to Q2. The reported reason for the improvement in Q3 (April-June 2018) is due to improvement in data documentation and availability of syphilis test kits. Syphilis positivity rate was 3% in Geita and Kagera and 2% in Mara. Despite the improvement, there is still a need to strengthen syphilis testing at ANC1 to reduce missed opportunity.
Figure 9: Quarterly trends on syphilis testing in Mara, Kagera and Geita
ANC syphilis treatment In Q3, almost all clients who tested positive were treated. This is a good progress compared to previous quarters.
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Figure 10: Quarterly trends on syphilis treatment in Mara, Kagera and Geita Labor and delivery services In this reporting period, the project continued to support comprehensive MNH interventions in 797 HFs: 180 in Geita, 319 in Kagera and 298 in Mara. There is positive trend in the proportion of facility-based deliveries in Geita from 76% in Q2 Up to 89% in Q3 with a decline in Kagera and Mara. USAID Boresha Afya, in collaboration with R/CHMTs, will continue to strengthen this component through engagement of CHWs to promote facility-based deliveries.
95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% % of pregnant women dellivering at HFs 0% Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun 2016 2017 2017 2017 2017 2018 2018 Mara 76% 76% 76% 78% 69% 87% 70% Kagera 63% 66% 67% 67% 65% 85% 75% Geita 74% 69% 71% 88% 89% 76% 89%
Mara Kagera Geita
Figure 11: Trends in proportion of facility-based deliveries in Mara, Kagera, and Geita
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Uterotonic coverage Uterotonics coverage continues to be universal across the three regions. USAID Boresha Afya will continue to strengthen HCWs skill and capacity in active management of third stage of labor (AMSTL) through supportive supervision, mentorship, and OJT, including correct administration of uterotonics within one minute of delivery of a fetus.
Figure 12: Quarterly trends in uterotonic use in HFs in Geita, Mara, and Kagera Obstetric Complications Like the previous reporting quarters, obstructed labor is the leading cause of maternal complications, and accounts for 58% of the total complications a drop of 2% from the previous quarter. PPH is the second, accounts for 23% of the total obstetric complications an increase of 3% from the previous quarter. The Project, in collaboration with R/CHMTs continues to address EmONC skills gaps through available and innovative interventions; OJT and mentorship prioritizes skills gaps for better obstetric outcomes.
Number of maternal complications in Kagera, Geita and Mara April-June 2018 600 503 500 Obstructed Labour Postpartum Haemorhage 400 357 Retained Placenta 300 Pre Eclampsia 200 Eclampsia 115 107 117 82 100 52 39 31 28 34 Sepsis 18 8 5 6 6 0 1620 6 8 16 15 1 Number of Maternal Complications 0 Ruptured Uterus Geita Region Kagera Region Mara Region Third Degree Tear Comprehesive MNH intervention supported Region
Figure 13: Number of Obstetric complications by region in April – June 2018
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PPH case fatality The project also, collected data from 46 CEmONC sentinel sites in Mara, Kagera and Geita to assess PPH case fatality rate. In the period under review, the number of HF deliveries was 21,412 of which 222 (1%) had PPH (Figure 14 and 15 below). This is lower than WHO benchmark of PPH occurring in 5% of the women who received AMTSL. Of 222 women who developed PPH 21 (9.4%) died, being highest in Geita at 16%. The project continues to address the preventable maternal deaths through strengthening EmONC services and working close with R/CHMT to address the identified gaps, especially on PPH management in Geita.
Number of PPH cases among HFs Deliveries in Selected CEmONC site in Mara, Kagera and Geita
7443 April to June 2018 90 (1.2%) 6966 Jan to March 2018 127 (1.8%) 7898 April to June 2018 75 (1%) 8472 Jan to March 2018 120 (1.4%) 6071 April to June 2018 57 (1%)
Geita Kagera Mara 6987 Jan to March 2018 57 (1%)
0 1000 2000 3000 4000 5000 6000 7000 8000 9000
Number of HFs Deliveries Haemorrhage complication
Figure 14: Number of PPH cases among HF-based deliveries in CEmONC sites in Mara, Kagera and Geita
Figure 15: PPH case fatality rate in CEmONC site in Mara, Kagera and Geita
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Newborn Care
Newborn Resuscitation Globally, about one quarter of all neonatal deaths are caused by birth asphyxia. Effective resuscitation at birth can prevent a large proportion of these deaths. USAID Boresha Afya continued to equip HCWs with skills in monitoring of labor and resuscitation to save lives of newborns. As shown in the figure 16 below, all three regions still report more than 10% bag and mask use. This is an area that needs continued support to improve intrapartum care to have 10% of newborns or less who reach the level of bag and mask for better newborn outcomes. Proportion of newborn resucistation by method in Mara, Geita and Kagera 80% 70% 60% 50% 40% 30% 20% Suction 10% 0% Stimulation Bag and Mask Jul-Sept'17 Jul-Sept'17 Jul-Sept'17 Jan-Mar'17 Jan-Mar'18 Jan-Mar'17 Jan-Mar'18 Jan-Mar'17 Jan-Mar'18 Oct-Dec'16 Oct-Dec'16 Oct-Dec'16 Apr-June'17 Apr-June'18 Apr-June'17 Apr-June'18 Apr-June'17 Apr-June'18 Oct-Dec '17 Oct-Dec Oct-Dec '17 Oct-Dec Oct-Dec '17 Oct-Dec Geita (n=180) Kagera (n=319) Mara (n=298) Figure 16: Proportion of newborn resuscitation by method Breastfeeding within 1 hour of birth Breastfeeding has many health benefits for both the mother and infant. Breast milk contains all the nutrients an infant needs in the first six months of life. Breastfeeding protects against diarrhea and common childhood illnesses such as pneumonia, and may also have longer-term health benefits, such as reducing the risk of overweight and obesity in childhood and adolescence. Breastfeeding within 1hour remains high over 95% in all regions (see Figure 17 below). The performance for this indicator is crucial as it helps to measure other proxy indicators of essential newborn care (clean cord care and skin-to-skin in the first hour).
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Figure 17: Proportion breastfeeding within 1hr of birth in Geita, Kagera and Mara Postnatal Care (PNC) within 48 Hours of Birth Postnatal care (PNC) for the mother should respond to her special needs, starting within an hour after the delivery of the placenta and extending through the following six weeks. The care includes prevention, early detection and treatment of complications, and the provision of counselling on breastfeeding, birth spacing, immunization and maternal nutrition. Over 90% women giving birth at HFs are reported to receive postnatal care within the first 48 hours after birth in Kagera, Mara and Geita. Although this is higher than the national target, USAID Boresha Afya aims at getting every woman giving birth at a facility to receive timely and quality postnatal care including for the baby. Documentation of PNC services has been improving and the project continues to strengthen the quality of PNC through mentorship.
Figure 18: Quarterly performance of PNC within 48hrs in Geita, Kagera and Mara
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Neonatal sepsis Neonatal sepsis is one of the major causes of newborn deaths and is a point of discussion in MPDSR meetings. Accordingly, USAID Boresha Afya has prioritized capacity building of HCWs in IPC as well as timely diagnosis and management of infection in newborns. To understand and monitor the problem, in PY2 the project started to collect data on number of neonates treated for neonatal sepsis in Kagera, Mara and Geita. In Q3, the reported cases have continued to increase by 29 cases from 416 in the last quarter to 445 in this reporting period of April to June 2018. The increase could be due to improved diagnosing and documentation of cases. The project will continue to track the trends in cases and scale up interventions for prevention and management of infection during labor, delivery, and postnatal period.
Figure 19: Quarterly trends on the number of neonatal sepsis among total deliveries in Mara, Kagera and Geita
2.2.2. Result 2.2: Districts and regions supported for increased accountability and responsiveness in service delivery.
MPDSR implementation in project supported Regions During this quarter, the project continued to support R/CHMTs in implementing MPDSR at all levels.
Two regions conducted regional quarterly MPDSR meetings (Geita and Shinyanga) to discuss the previous quarter notified maternal and perinatal deaths and to track implementation of previous recommended actions Seventeen (17) councils 8 in Kagera and 9 in Mara were also supported to track the status and implementation of MPDSR recommended action plan agreed in the previous meetings. Thirty- eight (38) CEmONC site were visited and the followings were the major findings observed
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Council level: MPDSR committees were available, however monthly review meetings as per national guideline were conducted in only 70% of the visited councils. This was due to the interference with other regional priority activities such as RBF verification exercise. Maternal and perinatal deaths are tracked, and the information is used to plan for supportive supervision visits Community feedback is given in about 40% of visited councils. The low percentage was due to the fact that, the current MPDSR guideline lack community death review. Of the total number of maternal/perinatal deaths review recommendations, 45% of them were implemented. And this was attributed to shortage of funds to implement the recommended actions.
Health Facility level MPDSR committees are available National MPDSR guidelines are available Review meetings are only for maternal and perinatal deaths whereas few health facilities do review of near miss cases. The notes of the review meetings do not contain all the important information to understand the root causes and hence the actions set are inadequately addressing the real problems. The providers have inadequate competencies in dealing with obstetric and newborn complications to save lives. Implementation of recommended actions was about 52% in the visited health facilities Action plans were set and RHMTs, CHMTs and health facility in charges will continue to track the implementation on monthly basis and address the identified gaps.
Comprehensive MPDSR implementation in Kagera, Mara and Geita The project continued to support facility based maternal death review process and mentorship in all 46 CEmONC sites (19-Kagera, 19-Mara & 7-Geita). The support included correct, timely notification and review, correct documentation, proper identification of dysfunctions, and implementation of recommendations. There is a slight decline in trends of both maternal and perinatal deaths across these regions. The number of reviewed maternal and perinatal deaths have improved (see Figures 20 and 21 below)
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Figure 20: Trends in maternal death in Mara, Geita, and Kagera
Figure 21: Trends in perinatal death in Mara, Geita, and Kagera The major contribution of reported maternal death during MPDSR meetings was PPH accounting for 38% of all death. Eclampsia and Anemia was also among the top on the list (Figure 22 below). The percentage contribution of leading cause of perinatal deaths were almost the same across these regions and these were asphyxia, sepsis and complication of prematurity. The implementation of the recommended actions was 52% completed compared to 40% in the previous quarter (January-March 2018).
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Figure 22: Percentage contribution of causes of maternal death
2.3.1: Strengthen client-provider interactions to promote respectful and informed care.
Gender, Respectful Maternity Care (RMC), YFS and Male engagement mentorship follow- up: In ensuring gender, respectful care, youth services and male engagement are promoted, the project conducted 1 day follow up and mentorship on Gender, Respectful Maternity Care (RMC), YFS and Male engagement to 11 health facilities in Kagera. A total of 51 health providers were reached, among these were, 33 nurses, 5 clinical assistants, 2 health officers, 7 medical attendants and 4 medical doctors. Exit interviews were conducted to a total of 22 men to determine male partner’s experience of care and their level of service satisfaction as per gender and RMC concern. Most of interviewed clients and relatives declared to see positive changes in the quality of health service - the service was provided with respect, no abusive language, privacy and confidentiality were maintained in most of health facilities.
Client service charter implementation in project supported HFs: During the period under review, the project did follow-up on the implementation of client service charters that were signed and distributed. It was observed that most heath facilities have signed the client service charter, and the brochures and posters were displayed in health facilities. The challenges observed were, some health care providers had no information on gender, RMC, birth companion; alternative birthing positions were not allowed, and written verbal consent not observed at work place. These are the areas that the project will strengthen and make close follow collaboratively with R/CHMTs in the subsequent quarter.
BEmONC Mentors training on Gender, RMC, youth friendly service and leadership: Geita, Simiyu and Shinyanga were not reached in the previous training to capacitate BEmONC mentors on issues pertaining to Gender, RMC, youth friendly service and leadership. In the period under review, 17 BEmONC mentors were trained on gender, RMC, YFS and leadership. The Project used a tailored social and leadership package to improve health workers knowledge on the social aspects that lead to maternal, newborn and child deaths and also improve inter and intra staff leadership communication as a way to improve performance. Their understanding of these social aspects would help the participants to be
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empathetic to pregnant women during provision of care and provide `and respectful care to women while actively engaging men in reproductive health.
3.0 CHILD HEALTH (CH)
3.1. Result 2. Improved availability of quality, integrated health services.
3.1.1 Result 2.1: Increased provision of quality, integrated health services 3.1.1.1. Distance IMCI training USAID Boresha Afya, in collaboration with the MOHCDGEC, conducted distance IMCI training in Geita and Mara. 626 health care providers were trained on IMCI in Mara, with an additional 158 providers trained in Geita, with the aim of strengthening the quality of care (QoC) in the management of sick children under five and ensuring providers follow the IMCI algorithm, to ultimately improve case management for child health. During the same quarter, the project conducted phase one dIMCI training to 898 health care providers from Shinyanga and Simiyu regions. The course will be completed in quarter four, and this will also add to the pool of health care providers trained on the skills required to manage sick children under five. The project is working with the Council Health Management Teams and HFs in charges to make use of standard recording form across all supported HFs when treating a sick child. 3.1.1.2 IMCI compliance assessment and mentorship USAID Boresha Afya, in collaboration with IMCI facilitators and district malaria/IMCI focal persons, continued to implement IMCI compliance assessment and mentorship. The IMCI compliance tool is used to gauge the status of service provision, identify gaps, and assess how under-fives with fever are assessed, classified and treated. Cumulatively from October 2017 to June 2018 a total of 14,330 cases of fever among under-fives were assessed using the IMCI algorithm. The Q4 plan is to conduct IMCI assessment in Mwanza region and also to complete reassessment and mentorship in the facilities which did not perform well (HFs with less than 50% of clients correctly assessed using the IMCI algorithm). Table 4: Number of HFs assessed in the previous three quarters HF Assessed in Q1 HF Assessed in HF Assessed in Total Q2 Q3 Geita 50 118 168 Kagera 246 192 89 527 Shinyanga 188 44 53 215 Mara 201 0 129 330 Kigoma 230 0 150 380 Simiyu 173 0 0 173 Mwanza 0 0 0 0 Total 1088 354 421 1,793
As shown in Table 4 above, in quarter three, 421 HFs were covered and reached 1,146 children under five. Health care providers were also observed during provision of care and scored using the standard IMCI facility quality of care (QOC) assessment tool. To ensure the adherence to IMCI guideline is effective, the project also assessed the availability and stock outs of the essential medical supplies needed for management of under-fives illnesses. Various gaps were identified in provision of IMCI services, including poor documentation in under-five morbidity registers, weak triaging, few ORT corners established, stock
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outs of essential medicines for IMCI, and a lack of diagnostic equipment (thermometers, weighing scales, length boards) in some facilities. Generally there is little difference in the 354 HFs that were assessed in Q1 (January - March 2018) and HFs that were assessed in Q3 (see Figure23 and 24 below). Height recording is still a major challenge; the performance is below 2% in all assessed children in Q1 and Q2. Other areas that need improvement is assessment for pallor, nutrition, and measles. Providers were not able to identify all symptoms that sick children under five presented at HFs. With R/CHMT, the Project will continue to provide technical assistance, clinical mentorship, and OJT to strengthen the capacity of HCWs on IMCI in supported regions.
Age Recorded 92% Age Recorded 94%
Availability of Referal Forms 77% Availability of Referal Forms 70%
Weight Recorded 57% Weight Recorded 53%
Availability of Transport for… 56% Availability of Transport for… 51%
Correct Classification 54% Vital signs 45%
General Danger Signs 45% Correct Classification 44%
Vital signs 45% General Danger Signs 36%
All main Symptoms 42% Assessed for pallor 14%
Assessed for pallor 23% Immunization status 12%
Immunization status 18% All main Symptoms 10%
Asked and Assessed for Measles 15% Asked and Assessed for… 10%
Nutrition Assessment 9% Nutrition Assessment 10%
Height Recorded 1% Height Recorded 2%
0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%
Figure 23: Overall IMCI assessment result Figure 24: Overall IMCI assessment result January-March 2018 (n=354) April-June 2018 (n=421)
3.1.1.3. Essential medical supplies availability Effective case management using IMCI algorithm requires access to appropriate medicines every day in the first-level facilities. Although IMCI requires only a limited set of medicines, the complex and interrelated issues of procurement and distribution have proved to be a serious challenge in some of the regions where the mentorship was completed. Ensuring the availability of second-line treatments and pre- referral drugs has presented a special challenge in these regions, as shown by the availability of Ampicillin and Gentamicin and injectable phenorbarbitone for convulsing neonates. Temporary solutions can be found, such as the use of district or facility funds through RBF to purchase the needed medicines in limited quantities or the establishment of special distribution systems for IMCI medicines.
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Inj Phenobarbiton 14% Oxygen Concentrator 21% NG Tube 37% 10% dextrose 41% RBG Machine 41% Inj Ampicilin 42% Inj Hydrocotisone/Adrenaline 42% FeFo 49% Inj Gentamycin 53% Amoxicillin DT 62% Inj Adrenaline 63% Inj Diazepam 68% Ped Zinc 75% Drugs and supplies Ambu Bag & Masks of Different Sizes 83% Inj Artesunate 85% Ceftriaxone 86% ORS 88% Cannula & Giving set 89% Normal Saline/Ringer Lactate 91% MRDT 93% ALU 99%
0% 20% 40% 60% 80% 100% 120% % availability of essential drugs and supplies
Figure 25: Availability of essential medical supplies for IMCI in the six regions (n=421) 3.1.1.4. Fever management cascade In this reporting period, one fifth of all children assessed for IMCI were not screened for fever. This is one of the areas that the project is emphasizing during mentorship, to ensure that all health care providers assess all under five years for fever during OPD attendance. Baseless prescription of anti-malaria drugs was observed in some HFs, of which 3% of mRDT negative children were given antimalarial. The Project, through its MSDQI approach, will continue strengthening the providers' knowledge and skill for provision of quality malaria services across all the supported regions. 3.1.1.5. HIV and TB screening and linkage During the reporting period, the Project worked closely with the IMCI mentors and HCWs to integrate HIV and TB screening during IMCI assessment and mentorship activities. Health care providers were also mentored on the importance of HIV and TB screening as it appears in the algorithm and the modules. A total of 34,845 under five children were screened for HIV, out of which 388 (1.1%) were found to be HIV positive. Only 136 (35%) of the 388 children who tested positive were linked to care and treatment. This is an area that the Project will closely work on with CTC partners to strengthen linkage and referral to
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care and treatment. In the same period, 6,819 under five children were screened for TB, and 249 were identified as TB suspect, and were referred for further investigation. 3.1.1.6. Growth monitoring: In the quarter under review, USAID Boresha Afya conducted mentorship on the growth monitoring booklet that replaced RCH card no. 1 to 278 project supported health facilities. The methodology use during mentorship included theoretical and practical components. The mentorship was integrated into IMCI supportive supervision, and was done in collaboration with the R/CHMTs (RCHCO and Nutrition officers). A total of 450 providers were mentored on the following: Figure 26: growth monitoring mentorship
How to take anthropometric measurements (length/height) for under-five children How to plot and interpret anthropometric measurements based on Z-Score charts provided in the booklets; and Appropriate counselling skills for mothers/caretakers, as indicated in the booklets.
3.1.1.7. Diagnosis for Under 5 year’s illness at OPD and IPD In this period under review, the project also analyzed data reported into DHIS2 for the under 5 years treated pneumonia and diarrhea at OPD. Generally, there is seasonality to the trends of treated pneumonia, with peaks around April and May. The observed peaks for diarrhea were January and August, with some spurs across regions. Understanding these trends will be a good target for community sensitization and advocacy across the supported regions, and will help the supported councils better plan for medical supplies and other commodities.
Figure 27: Monthly trends on reported pneumonia cases for under 5 years
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Figure 28: Monthly trends on reported Diarrhea cases for under 5 years 3.1.1.8. Nutrition Integration with FP.
Nutrition assessment for under five years was integrated in FP community outreach services to gauge the status of under-five nutrition in the project-supported regions. The outreach services are built on district child health immunization schedules and also serves to offer other services such as vitamin supplementation and deworming. During this quarter, the outreach services coincided with vitamin A and deworming campaign in some of our regions. In addition, antenatal (Malaria testing) and family planning services were also offered, as well as acute treatment of sick children and adults.
The Table 5 and 6 below shows the number of children screened during the quarter under review in integrated outreach services. Severely malnourished children were identified and referred to the nearby facility for management. All under-fives in Shinyanga, Simiyu and Kagera were provided with Vitamin A and deworming except in Simiyu were given both Vitamin A and Micronutrient supplements during the outreach in all 12 villages.
A total 2439 children 0-59 months were assessed on their nutrition status in which 91 were under weight and 95 were stunted. USAID Boresha Afya provided nutrition education and counselling to the clients basing on locally available foods. Clients with special attention such as underweight and severe acute malnourished children (a total of 9 children had weight for height <-3SD for Shinyanga, Simiyu and Mara regions) received individual counselling to address undernutrition and referral was done for those who were severely malnourished (SAM) to Hospitals for SAM management.
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Table 5: number of children screened for nutrition during community outreach interpreted using Growth monitoring Chart booklet Region Nutrition Status Service offered Normal Underweight Stunted Wasted Vitamin Mebendazole Micronutrient A Powder Simiyu 177 23 95 7 327 371 327 Shinyanga 501 78 132 1 740 1201 0 Mara 342 8 7 2 0 0 0
Table 6: number of children screened for nutrition using MUAC during community outreach
Region Nutrition Status using MUAC Service offered
Green Yellow Red Vitamin Mebendazole Micronutrient Powder (Normal) (Moderate) (Severe) A
Kagera 1031 19 10 0 0 0
4.0 MALARIA CASE MANAGEMENT (MCM) AND MALARIA IN PREGNANCY (MiP) In this reporting quarter, the project continued with the implementation of Malaria Case Management and MiP activities in the seven regions (Geita, Kagera, Kigoma, Mara, Mwanza, Shinyanga and Simiyu) in the Mainland and provided TA to Zanzibar. This quarter’s main achievements were supporting commemoration of World Malaria day in Kigoma and MSDQI visits to the remaining facilities in the region which led to improvement in malaria performance indicators in Kigoma compared to the baseline assessment findings.
4.1 Improved Enabling Environment for Health Service Provision
4.1.1. Participated in a meeting to establish and operationalize Malaria Digital Health System in Close Collaboration with MOHCDGEC and PO-RALG
USAID Boresha Afya in collaboration with NMCP supported a four-day workshop in Bagamoyo to streamline next steps for the implementation of MSDQI and Malaria Surveillance & Response (MSR). The main motivation was to harmonize both the national implementation framework and available resources. The workshop aimed at developing standard protocol for follow up of MSDQI & MSR field activities, specifically reviewing the EDS and MSDQI indicators and incorporating the actions in the protocol, assessing available resources to implement MSDQI and SMR (regional meetings), and finalizing the plan for implementation.
USAID Boresha Afya Lake and Western Zone was given the task of developing SOPs for the EDS, reviewing the logistics indicators with NMCP, and compiling the technical components of the EDQ_MSDQI dashboard. The NMCP shared the budget for MSDQI in other regions not supported by PMI. They also shared the budget for the regional review meetings.
The Project will complete the action points relating to EDS and MSDQI review indicated in Table 7 below. On the same note, NMCP has started conducting MSDQI to oversee the regional performance in non-
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PMI supported regions. They are expected to also visit the project supported regions for supervison and oversight.
Table 7: Tentative timeline for EDS and MSDQI review finalization Expected Outcomes Main activity Activity Responsible Timeframe /Place ‐ Harmonize the indicator names between the JHPIEGO/UD 12th April EDS and paper checklist – refer to end user SM/NMCP ‐ Export only subscores to the composite meeting/FHI3 database but also have a system to view the raw 60 data entered ‐ Interface for uploading existing excel sheets ‐ Differentiate a blank section from a score of 0% in DHIS Proposed to add grey shade in the score card to indicate blank areas, not penalize overall score EDS ‐ Factor in number of observations when B 12th April calculating sub score to avoid penalizing no observations ‐ Module specific indicators are missing in EDS – refer to end user testing feedback ‐ When exporting data in excel – the indicator names appear as codes rather than names ‐ Ensure all indicators of sub scores are present ‐ Revise methodology of QIP plan in the EDS
MSDQI Logistic Supply NMCP – Next week – checklist ‐ The paper based checklist - ‘register review Anna Davids, 12th April sections’ to be revised and sub scores Sumaiyya, calculation to be amended Tesha, ‐ The EDS; also revise the ‘register review Fabrizio, section’ and automatically calculate sub scores Nabila, LMU ‐ The acceptable discrepancies in register review consistency check requires to be defined ‐ The outputs for this checklist needs finalization mRDT ‐ The readiness section to be reviewed and scored by service delivery sections
4.1.2. Result 1.2 Technical assistance (TA) provided to GOT to develop, communicate and implement national plans.
4.1.2.1. Supported the Commemoration of world malaria day (testing and treatment) USAID Boresha Afya Project in collaboration with the MOHCDGEC - NMCP, R/CMHTs and the community commemorated the World Malaria Day in Kigoma whose theme was "Ready to Beat Malaria”. The aim of the event was to create awareness on malaria prevention, early treatment seeking behavior and proper malaria case management. The event was attended by high level officials from the
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MOHCDGEC including the Minister for Health who presided as a guest of honor and USAID Mission Director.
Figure 29: One of USAID Boresha Afya staff explaining what the project does in Malaria programming to the Minister for Health and the USAID Mission Director.
.
Figure 30: Malaria testing in Mwandiga village Figure 31: RHMT team in Mwanza in Kigoma DC overseeing malaria testing for quality of care and recording
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As part of the commemoration of the WMD, the project also supported other regions in the Lake and Western Zone to offer malaria testing and treatment services. A total of 9,060 clients were tested for malaria using mRDT among them 835 (16%) tested positive for malaria which is more than two times the national level average (7.3%) according to the 2017 Malaria Indicator Survey. Mara presented with the highest prevalence (37.7%) whereas Simiyu had the lowest prevalence (1%) among those tested on that day. Table 8 below summaries the number of people tested for Malaria using mRDT and positivity rate in USAID Boresha Afya supported regions during the world malaria day. Table 8: Summary of the number of people tested for Malaria during the world malaria day. Region Clients tested tested positive for % of positive malaria cases Geita 3769 593 15.7% Kagera 210 28 13.3% Kigoma 2313 227 9.8% Mara 1143 432 37.7% Mwanza 521 21 4.% Shinyanga 509 121 23.7% Simiyu 595 6 1% Total 9060 1428 15.8%
4.1.2.2. Malaria strategic plan review (2015 – 2020) The Ministry of Health Community Development Gender, Elderly and Children in collaboration with stakeholders in health organized a workshop to review the current Malaria Strategic plan (MSP) 2015- 2020 to make it more comprehensive to guide implementation as well as for resource mobilization . Participants included representatives from WHO, MOHCDGEC, NMCP, USAID Boresha Afya, TAMISEMI, Measure Evaluation, JHU, CHAI, Swiss TPH, MOF, APHTA, and RHMT/CHMT. The review was necessary following several consultative meetings with different national and international experts who recommended revision of the current strategic plan to focus on effective and efficient approaches/strategies that will accelerate the reduction of malaria prevalence in Tanzania.
Other major aim was to realign MSP to current epidemiological data variation, implementation achievement, diversity (difference malaria prevalence with in regions), malaria trend, and intervention outcome. This would aid in identifying appropriate intervention package tailored to the needs and address recommendations from midterm review (MTR) and expert consultative forums. The major accomplishment from the workshop was, a draft supplementary Malaria Strategic Plan which was submitted to the workshop coordinator for review. The supplementary plan include all the technical areas (vector control, malaria case management, SBCC, program management and SME). Next step: All technical groups to submit their work to the workshop coordinator NMCP to review and finalize the document in consultation with technical teams NMCP to share the supplementary Strategic Plan to the steering committee NMCP to share the finalized MSP to all stakeholder before October 2018.
4.1.2.3. Custody of Electronic Data System (EDS) for Malaria Surveillance USAID Boresha Afya-LW has continued acting as custodian of the EDS MSDQI system on behalf of the National Malaria Control Program (NMCP). The EDS system enables malaria surveillance data quality improvement and serves as a frontend for DHIS2 in the collation of malaria data from the field. It is optimized for use on smart phones and tablet computers. It is planned for USAID Boresha Afya to handover the EDS MSDQI system to NMCP in August 2018, when it is envisioned that NMCP will have the requisite capacity to handle the task.
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4.1.2.4. Support the implementation of ALu Therapeutic Efficacy Study (TES) The project has continued to support and oversee the implementation of Artemisinin Therapeutic Efficacy Study (TES) as per WHO guidelines in four sentinel sites in Kibaha, Mkuzi, Mlimba and Ujiji. Currently, the training was conducted to improve good clinical practice in these sites and recruitment of the clients has been in good progress in all sites. USAID Boresha Afya is working to ensure that there is no delay in procurement process to avoid unnecessary delay of study initiation and ensure supplies are of right quality and quantity by involving laboratory personnel from the study team in the process. . Table 9: below summaries the timelines for TES activities Activity Mlimba Mkuzi Yombo Ujiji Training start date 14-Apr-18 25-Apr-18 12-May-18 24-May-18 Start of recruitment 23-Apr-18 2-May-18 21-May-18 31-May-18 Status of recruitment 48 (55%) 56 (64%) 30 (34%) 25 (28%) Expected end of recruitment 18-Jun-18 27-Jun-18 16-Jul-18 26-Jul-18 Expected closure of study 16-Jul-18 25-Jul-18 13-Aug-18 23-Aug-18
4.1.2.5. Joint field visit Quality Assurance (QA) internal monitoring in Kigoma. According to HMIS data for January – March, Kigoma was leading with high malaria cases in the country. More than one third of these cases in Kigoma were from two facilities named Nyarugusu HC and Nduta HC that are located near the refugee campsites. The malaria cases for Kigoma DC increased when Nyarugusu HC started to report on the national DHIS2 in February 2017. From the above scenario, the ministry through NMCP requested USAID Boresha Afya as implementing partner to collaborate with R/CHMT to physically visit Nyarugusu HC, use standardized tools to gather different information and provide immediate feedback for prompt mitigation. Kigoma region was also among the regions with high clinical malaria cases (unconfirmed/suspected) malaria cases in Q2. Almost all of these cases were reported from Kasulu and specifically from Nyarugusu HC. The clinical cases reported from Nyarugusu HC were from February 2018. In March, a good number of cases were diagnosed using Blood Slide (BS).
Key findings: Nyarugusu Camp site has ten health delivery points as follows: 1. One big facility named as Nyarugusu Health Centre (Main) 2. One big health facility named as ANNEX (equivalent to HC) 3. One big health facility named as Health Post 4 (equivalent to HC) 4. Seven health posts (equivalent to Dispensary) 5. Zone 10-one health delivery point providing RCH (ANC & MNH) services (not termed as health post/ clinic)
Table 10: summary of finding and recommendation from Kigoma monitoring visit Issue Observation Recommendation:
Health service All ten health service delivery points i. Each big facility to be registered delivery points (Three big facilities -Main, Annex and as health centers with three Health Post no.4; seven health posts) different accounts and DHIS2
reported as one HF (Nyarugusu HC) data entry system.
ii. Due to population served and availability of all essential services Seven health posts to be registered as dispensaries
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iii. Follow up on registration of HC & Dispensaries with the R & DMO
Health Care Supervision Team identified good Follow guideline: Staffing Levels for Providers (HCPs) number of staff in all posts mostly Ministry of Health Departments, Health being Clinical Officers and nurses. Service Facilities, Health training Institutions and Agencies 2014-2018 However, there is also a group
named “incentives” (refugees) with different knowledge and skills of whom it was not easy for the team to recognize their qualifications and training Institutions from their origin countries. Some declared to have been trained at the camp (short course), they conduct activities like BS, and other practical procedures of which is for the qualified staffs.
STAFF TRAINING Most newly employed health care Plan for OJT/ coaching, on site training (formal/OJT) providers have reported NOT being focusing on different technical area- this trained (formal/OJT) on different areas can be organised by CHMTs and IPs and i.e Malaria Case Management, HMIS, conducted at the camp to minimize costs. IMCI.
HMIS tools & Only one facility (Main center) had i. Immediate ordering from reference materials the recommended HMIS tools eg DMO’s office or using OPD, tally sheet. They also have standardized copies allocate electronic system where they funds for photocopy and binding report some of target indicators the tools. (malaria, Tuberculosis, HIV) etc. ii. Each consultation room to have Generally all visited health delivery its own register and tally sheets points were missing HIMS tools so that the compilation of data (MTUHA, Tally sheets, monthly can be done. summary forms), some departments (Laboratory) with few un utilized Tally sheets Missing referencing materials (guidelines (FANC, NMDTG, IMCI booklets, manuals, fever case management algorithm, artesunate job aids, mRDT SOPs)
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Table 11: Malaria MSDQI key findings across camps health departments Unit Strengths Challenge Possible solution OPD There are different Standards are not observed Red cross to conduct rooms for Children, eg proper history taken and internal supervision to women and Men. physical examination. No monitor the quality of recording of the clients into service using the national HMIS (only main and few), guidelines. no use of tally sheets at all (all posts). Internal OJT training will be organized by the health management team
Print / photocopy and distribute HIMS, Guidelines, manuals, SOPs and Job aids tools
IPD Almost 30% of malaria Stock out of Inje. R&R use and the MSDQI cases are admitted and Artesunate logistic module to be are treated. NO administered to determine malaria deaths that the cause. have been reported since the start reporting on DHIS2. LABORATORY Available good number Existence of none Adhere with national of staff, functional qualified staff guideline (ICAMA) microscope, conducive No Giemsa stain (Using Stopped to order environment Field stain) Giemsa stain No retained slides for DLT to follow this rechecking up mRDT Available mRDT kits, No patient counselling Mentorship and coaching gloves, SOP not observed done (no labeling, 10% blood Request/ Purchase using splatter, 18% red available funds coloration). Mentorship done No retained used To adhere with IPC mRDT cassettes. guideline No Timer, stop watch, Establish mRDT services wall thermometer, SOPs at OPD and job aids IPC-not observed mixed infectious and none infectious materials
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ANC Available SP, FEFO, Missing FANC all HFs, Operational Research mRDT, ANC cards, Fever case Management Advocacy/ Incentives etc. Mebendazole algorithm Establish stand-alone LLINs not provided reporting system (HIMS Family Planning methods FP to each facility) not utilized For high malaria Health Post No.4: transmission mitigations- mRDT, HB, RPR not consider different tested at ANC prevention approaches – LLINs, IRS, Biolarviciding LOGISTIC & Available qualified Stock out Artesunate, Regular update of Bin SUPPLY staff Pharmaceutical ALU 1X6; 2X6 card Technologist Data mismatch Bin card Conduct AC service Available good Vs Physical counting stock SP, ALU 3X6, Missing standard Ledger, ALU 4X6, Quinine. R & R Updated bin card Many items for Spacious Pharmacy treatment of other with AC, palates diseases missing. Leaking AC-water drained on the floor DQA No clinical malaria Incompleteness and Ordering/ photocopy of cases which have inconsistence of data HMIS tool been reported at entered in HMIS system the facility. HMIS tools not available Existence of electronic data system
4.2. Result 2. Improved availability of quality, integrated health services.
4.2.1. Result 2.1: Increased provision of quality, integrated health services
4.2.1.1 Malaria services data use to improve quality of care.
During this reporting period, the project continued to use data to guide the project approaches and supervisors to better support HFs based on the gaps that were identified in the previous quarters. From the analysis of Q2 data from Mwanza city, a good number of HFs were reporting higher number of microscopy malaria positivity rate which set some alert to the quality of BS microscopy testing.
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Figure 32: OPD malaria diagnosis by type in Ilemela
In this period under review, the project conducted MSDQI to identify main causes of high malaria positivity rate among suspected patients tested using microscopy (Blood Slide), identify all health facilities that were never covered by MSDQI, identify competent qualified Laboratory technologist to conduct External Quality Assessment and lastly document and share findings. General findings identified from the visited laboratories (microscopy) are as indicated below;
Of all supervised facilities no single institution had laboratory personnel(s) previously trained on malaria microscopy, none performed IQC and none had all required SOPs. Most of the facilities have no mRDT; with associated myths and misconceptions on the latter, most of the private facilities prefer BS over mRDT. None of the facilities performing blood slide for microscopy retains slides for crosschecking There are lots of Giemsa stain brands, every lab with its own Microscopes at some facilities do not function well and therefore not fit to hold microscopy undertakings yet results are released e.g. Tumaini H/C and Corner dispensary All the facilities performing malaria microscopy using Giemsa stain have no buffer tablets, pH meter, pH salt and other pertinent consumables/supplies abided to. Few facilities still use field stain in the diagnosis of malaria Most of the mRDT testers have no TA-QC training and malaria microscopy training as well Clinicians in some facilities tend to change microscopy results presented to them from the lab leading to inconsistence of data and few evidenced clinical malaria cases in the region
In the subsequent quarters, USAID Boresha Afya in collaboration with R/CHMTs will continue to strengthen both mRDT and Microscopy TA-QC to ensure the supported regions are offering high quality Malaria case managements including Malaria in pregnancy
4.2.1.2. Implementation of Malaria Services and Data Quality Improvement (MSDQI) supervision. In this quarter, we continued facility visits to assess the quality of care for malaria services in Mwanza, Simiyu and Kigoma to cover HFs that were not visited in the previous schedules. By the end of Quarter three, a total
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of 1,314 Supported HFs (cumulative) in 7 project supported regions had been visited and covered with MSDQI. The remaining 503 HFs will be covered in Quarter four (4) PY02. Five (5) HFs in Muleba, Kagera are at Island (hard to reach), The project is looking at how better to support the CHMTs to reach these Health facilities Table 12: Summary of MSDQI coverage October 2017 to June 2018 in USAID Boresha Afya supported Regions Region Total # of Remained Coverage Facility facilities facilities visited Geita 160 41 119 26% Kagera 304 297 7 98% Kigoma 278 217 61 78% Mara 297 210 87 71% Mwanza 362 305 57 84% Shinyanga 211 92 119 44% Simiyu 205 152 53 74% Total 1817 1314 503 72%
Improvement in MSDQI performances in Kigoma: In this reporting period, we also analyzed the performance of quality of care indicators in Kigoma to compare with the baseline assessment which was done in Q3 of PY01 Generally, there is an increase in performance of quality of care indicators compared to the baseline performances (see Figures 33 & 34 below).
120
100
80
60 OPD Observation 40 Score: <50% 20 OPD Observation Score: 50‐75% 0 OPD Observation Score: 75%+ Kasulu Town Council Kasulu District Council Uvinza District Council Kigoma District Council Kibondo District Council Buhigwe District Council Kakonko District Council Kigoma Municipal Council
Figure 33: OPD MSDQI findings during Figure 34: OPD MSDQI findings by district Baseline assessment (April-June 2017) (April-June 2018)
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4.2.1.3. Malaria Diagnosis In quarter 3 (April-June 2018), Kigoma region still leads with high reported malaria cases 191,688 (12%) out of 1,605,880 reported malaria cases in Tanzania mainland (source DHIS2). In Kigoma, almost half of the cases are coming from three facilities in refugee camp centers named Nyarugusu refugee camp center (40,237), RCS Mtendeli HC (33,017) and Nduta HC (17,258). In Q4, a team will visit these sites to investigate the status of these facilities.
Number of malaria cases disaggregated by type of diagnosis (April‐June 2018) 250000 200000 150000 100000 50000 Malaria cases 0 Kilimanjaro… Lindi Region Mara Region Geita Region Iringa Region Tanga Region Pwani Region Katavi Region Dar Es Salaam… Simiyu Region Rukwa Region Kagera Region Mbeya Region Tabora Region Arusha Region Singida Region Kigoma Region Songwe Region Mtwara Region Njombe Region Ruvuma Region Mwanza Region Dodoma Region Manyara Region Morogoro Region Shinyanga Region
Clinical malaria Malaria mRDT +Ve Cases Malaria BS +Ve Cases
Figure 35: Number of malaria cases disaggregated by region in Q2 of PY2 Trends in reported malaria cases in project supported region: Generally there is a downward trend in reported malaria cases in USAID Boresha Afya supported regions in Lake and Western Zone. The DHIS2 data shows 25 % decrease in reported malaria cases in April –June 2018 compared to April-June 2017. 250,000
200,000 Geita Region
150,000 Kagera Region Kigoma Region Mara Region 100,000 Mwanza Region Shinyanga Region 50,000 Simiyu Region
0 Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun 2016 2017 2017 2017 2017 2018 2018
Figure 36: Trends in Reported Malaria cases between October-December 2017 to April-June 2018
USAID Boresha Afya Lake & Western Zone, PY18 Q3 Report Page 50 of 88
Trends in reported malaria cases that were treated based on clinical diagnosis: USAID Boresha Afya supported regions in lake and western zone have recorded tremendous decrease of patients who are treated for malaria based on clinical diagnosis. Reported DHIS2 data shows 82% decrease of clinical malaria management when you compare April-June 2017 and April –June 2018.
10,000
9,000
8,000
7,000 Geita Region
6,000 Kagera Region Kigoma Region 5,000 Mara Region 4,000 Mwanza Region 3,000 Shinyanga Region 2,000 Simiyu Region 1,000
0 Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun 2016 2017 2017 2017 2017 2018 2019
Figure 37: Individual region trends in reduction of malaria management based on clinical diagnosis in USAID Boresha Afya supported regions
4.2.1.4. Malaria Treatment The use of ACTs has reduced in some of project’s supported regions like Kigoma when compared to last quarter with adult dose being the most used ACTs (See Figure 38 below). Shinyanga region seems to have used more ACTs compared to the number of malaria cases reported which has also been reflected in the ACT/Cases ratio. The reason given that there is more consumption of pediatric dose to treat adult cases. However, this is doubtful as it does not reflect in the ACTs used.
Figure 38: Reported Number of ALU treatment dispensed by product categories and by Region
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The problem in Shinyanga seems to come from only nine facilities in two councils of Ushetu DC and Shinyanga MC where the ratio of ALU dispensed was more than 6 times of the confirmed malaria cases (See figure 39 below). In Q4, the project and R/CHMT will visit the nine facilities to look deeper into the issue.
Figure 39: ALU dispensed against confirmed malaria cases in Ushetu DC Stock out of ACTs has been reported in Itilima DC in Simiyu region. The project will communicate with regional authorities to know the possible cause and advise on re-distribution of ACTs from the councils with high stock.
Severe Malaria cases: The trend of malaria admission due to severe malaria in the project-supported region has been reducing with overall 32% decrease when compared to the same quarter in 2017. Mara region is leading with admissions followed by Kagera and Mwanza. The project will work to track where these admissions occurred most in the councils and work with RHMT and CHMTs for action.
16,000
14,000
12,000 Geita
10,000 Kagera Kigoma 8,000 Mara 6,000 Mwanza 4,000 Shinyanga 2,000 Simiyu
0 Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun 2016 2017 2017 2017 2017 2018 2018
Figure 40: Trends of Malaria admissions in USAID Boresha Afya supported regions October 2016 to June 2018
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Malaria Deaths Proportion of malaria deaths out of all deaths has been decreasing with 44% decrease compared to the same quarter in 2017. Mwanza region is leading followed by Mara, Shinyanga and Kigoma at fourth place.
Trend of proportion of malaria deaths out of total deaths by region‐ Oct 2016 to 2018 60 Geita 50 Kagera 40 Kigoma 30 Mara 20 Mwanza 10 Shinyanga 0 Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun Simiyu 2016 2017 2017 2017 2017 2018 2018
Figure 41: Trends on the proportion of malaria death out of total death by region in USAID Boresha Afya supported regions October 2016 to June 2018
4.2.1.5. Malaria in Pregnancy (MiP)
ANC Malaria testing rate: Malaria testing for pregnant women on their first visit has improved exceeding the national target of 80% in all of our supported regions. Reported malaria testing rate at ANC 1 has increased from 87% in April-June 2017 to 96% April –June 2018 which is 9% change over the period of one year.
100 95 90 Geita 85 Kagera 80 75 Kigoma 70 Mara 65 Mwanza 60 Shinyanga 55 Simiyu 50 Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun 2016 2017 2017 2017 2017 2018 2018
Figure 42: Malaria testing rate at ANC in USAID Boresha Afya supported region Q3
ANC Malaria positivity rate: In this reporting period (April-June 2018), the overall malaria positivity rate for pregnant women tested at their first ANC visit was 8.8 %. This is 1.8% lower compared to the same quarter, April-June 2017 of which ANC malaria positivity was 10.6% (see figure 43) below. Pregnant women confirmed with malaria cases were escorted to OPD for treatment.
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16 14 12 Geita 10 Kagera 8 Kigoma 6 Mara 4 Mwanza 2 Shinyanga % of Malaria positivity at ANC1 visit 0 Simiyu Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun 2016 2017 2017 2017 2017 2018 2018 Period
Figure 43: Malaria positivity rate at ANC in USAID Boresha Afya supported regions Q3
IPTp2 and IPTp 3 coverage: In the period under review, the IPT2 coverage in the project-supported region was 72.4% with an increase of 7.2% from last quarter of 65.2%. The coverage for IPTp3 has also increased by 6.6% from the last quarter coverage of 37.4% to 44% in April- June 2018. All these are yet to reach the national target of 80% and 60% for IPTP2 and 3 respectively. Figure 45 below depicts trends in IPTp3 coverage in project-supported regions
Quartely trends in IPTp2 coverage 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Oct‐Dec'16 Jan‐March'17 April‐June'17 July‐Sept'17 Oct‐Dec'17 Jan‐March'18 April‐June'18
Kagera Kigoma Mara Mwanza Shinyanga Simiyu Geita
Figure 44: Trends on IPTp3 coverage in USAID Boresha Afya supported regions October 2016 to June 2018
USAID Boresha Afya Lake & Western Zone, PY18 Q3 Report Page 54 of 88
60
50
Geita 40 Kagera Kigoma 30 Mara
20 Mwanza Shinyanga
10 Simiyu
0 Oct to Dec Jan to Mar Apr to Jun Jul to Sep Oct to Dec Jan to Mar Apr to Jun 2016 2017 2017 2017 2017 2018 2018
Figure 45: Trends on IPTp3 coverage in USAID Boresha Afya supported regions October 2016 to June 2018
5.0 FAMILY PLANNING (FP) SERVICES In the period under review, the project continued with the implementation of FP services across all seven USAID Boresha Afya supported Regions in the Mainland (Geita, Kagera, Kigoma, Mara, Mwanza, Shinyanga and Simiyu) and supported HFs in Zanzibar. Below are the Q3 main achievements and general project progress to date. 5.1 Result 1. Improved Enabling Environment for Health Service Provision 5.1.1. Technical assistance (TA) provided to GOT to develop, communicate, and implement national plans. 5.1.1.1 Printing and distribution of FP materials: During this reporting period, 200,000 RCH card no 5 and 70,000 client record forms were distributed in all seven supported regions. The distribution plan was based on the number of districts per region in order to avoid shortage during service provision. The RCH 5 cards will be distributed to all health facilities providing FP services and client record forms to facilities providing permanent methods for routine services and during outreach services.
5.1.1.2 National Family Planning (FP) TWG The Project facilitated the National FP Technical working group and the meeting include both Family planning and Safe motherhood TWG members. The meeting was chaired by the Assistance Director of RCHS and below were the issues discussed during meeting: Under new MOH guideline regarding FP outreach emphasized that health facility that do not have a well-functioning operating theatre and do not routinely conduct Minilap, under local anesthesia, these facilities should provide only LARCs and clients seeking Minilap must be referred to higher-level facilities with functional operating theatre. Consultation is going on with the Ministry of Health to see the impact of this decision on CPR target of One plan II and find a better way of addressing challenges observed at lower level facilities.
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The Ministry of Health is planning to develop the Annual Operational Plan for RCHS for 2018/19 and partners were requested to share their activities, coverage and budgets to be part of the Annual Operational plan
5.2. Result 2. Improved availability of quality, integrated health services.
5.2.1. Increased provision of quality, integrated health services 5.2.1.1. Integration of Compliance issues during training, OJT and mentorship During this quarter, USAID Boresha Afya oriented 426 (182 CHMTs from 21 districts and 246 services providers from 41 HFs) of Family planning compliance issues. This was carried out as part of the trainings - OJT and mentorship in order to comply as required. Main issues discussed were how to strengthen counselling skills for informed choice to promote method mix and provision of quality services and adherence to standards. 5.2.1.2. Family Planning Capacity building to service providers During this period of April-June 2018, three trainings on LARC/PM were conducted to 89 HCPs from all 7 regions (13 No-scalpel Vasectomy surgeons, 22 LARC, and 54 FP mentors) using MOHCDG/ trainers. The Table 13 below shows the type of training and participants by region
Table 13: Summary of FP trainings carried out in Quarter 3 (April June 2018) Mara Geita Kagera Shinyanga Simiyu Mwanza NSV Training 0 2 4 2 2 3 Comprehensive 23 0 0 0 0 0 FP Training FP mentorship 12 0 11 15 16 0 Total 45 2 15 17 18 3
No-Scalpel Vasectomy training The NSV training was conducted from 18 to 28 June 2018, facilitated by MOHCDGE trainers at Kasulu Town council. The first week was dedicated for theory followed by practical session in the second week which was integrated into facility-based outreach services where 14 clients were served. Each trainee was able to observe, assist and practice however, clients were few to gain skills and confidence, trainees follow up will continue by involving them in service provision to further strengthen their skills. During Pretest, the lowest score was 54% and the highest was 83%, while in Posttest, the lowest score was 70% and the highest 97% indicating an average change of 27%. Additionally during the HF outreach service, 250 clients were served on LARC/PM (62 Minilaparatomy, 155 Implants, and 33 IUCD). The main challenge was the shortage of NSV sets which were not enough for practical session, the project will include budget in year three to cover sites with trained providers with at least two kits. Follow up will be conducted as per MOH guideline.
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Family planning Mentorship training
In this reporting Period, the Project conducted Family planning mentorship training from 24th - 29th June 2018, aiming at strengthening the capacity of service providers on FP-PAC services. FP mentors from 54 out of 60 planned Post abortion care services (PAC) sites of Kagera (12), Mara (17), Simiyu 15) and Shinyanga (16) were selected to attend the training. In addition, a total of 39 providers were trained from kagera, Mara, Simiyu and Shinyanga (11 HCPs Kagera from 11 sites, 12 Mara from 12 sites, 16 Simiyu from 16 sites and 16 Shinyanga from 16 sites-one HCP per site). Figure 46: The pictre shows ongoing FP mentorship training
The aim of the training was to impart knowledge and skills on mentorship to enable them to mentor their colleagues in their respective facilities on FP integration into maternal health specifically strengthening FP integration into PAC services. A pre-test to assess the knowledge gaps was conducted whereby the lowest score was 23% and the highest was 88% while in post-test the lowest score was 66% and the highest was 100% with knowledge gain of 34%.
Comprehensive family planning clinical skills training to service providers in Bunda DC Between 25 June and 7 July 2018, the project collaborated with Bunda DC to conduct comprehensive family planning clinical skill training to 23 service providers. The activity was co funded by Bunda CHMT- CCHP budget, which covered the MoHCDGEC trainers' costs whereas USAID Boresha Afya facilitated the training logistics. The main objective was to build the capacity of service providers on comprehensive FP clinical skills so as to improve that quality FP services in Bunda. Six health facilities (RCH clinics) were used as practicum site under the supervision and guidance of trainers and preceptors (clinical instructors). Figure 47: Returning demonstration on insertion of IUCD Done by a Trainee in Bunda
During the training 249 clients were counselled for informed choice whereby a total of 235 clients were served with different FP methods of their choice (92 implants, 51 IUCD were inserted and 6 implants and 7 IUCD removals, 13 Depo and 66 pills) . Pre and post-knowledge skills assessment test was performed. In the pre-test the highest score was 63% and the lowest score was 22%, while in the post-test the highest score was 98% and the lowest score was 74% .Hence the pretest average gain score was 41% and post training the average score was 24%. Trainees follow up will be conducted as per MOHCDGE guideline.
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5.2.1.3. Follow up of LARC/PM trainees
Kagera and Mara: The project conducted follow up to 6 trainees; 3 ML/LA surgeons, 2 in Kagera and 1 in Mara, and 3 PPFP mentors from three sites of Shinyanga (Kolandoto, Shinyanga RRH and Kambarage HC). This activity was integrated with FP outreach services with the aim to assess their practical skills in provision of quality services and provide mentorship and coaching on identified gaps to strengthen their skills and improve the quality of services. The main gaps identified were; IPC protocol was not adhered to and few PPFP clients were counselled at RCH clinic. Plans were developed to improve FP counselling at all levels to increase the uptake.
Mwanza and Geita: R/CHMTs in collaboration with MOHCDGEC trainers and USAID Boresha Afya Project conducted PPFP trainees follow up to 11 trainees (4 from Mwanza and 7 from Geita Region) who were trained in January 2018. The trainees were drawn from HCs conducting 100 deliveries per month. The main goal was to reinforce PPFP skills and help services providers transfer learned skills to clinical practice at their respective working sites in order to provide quality services according to standards and increase PPFP uptake. Areas of focused for the assessment were: PPFP health education, counselling for informed choice, screening of client for medical eligibility, clinical procedure, management of minor complication related to family planning methods and record review. Methodology used included interviews, simulation, observation and record review. Each trainee was given 3 clients to attend from health education to post procedure counselling. The following is the summary of the findings; Jadelle insertion the highest score was 39% and the -lowest was 33%, counselling skills, the highest scored 63% the lowest 47%, PPIUCD insertion highest scored 63% lowest scored 50% and NXT insertion highest score was 80% lowest score was 54%.
Many services providers had difficulty in Jadelle insertion compared to other methods and hence scored very low. Counselling scores was also low because the providers missed some counselling steps for informed choice. It was observed from records that few clients are counselled at ANC and other trained staff are transferred to other departments and therefore tend to lose their skills.
5.2.1.4. Quarterly mentorship and coaching on PPFP/PPLARC USAID Boresha Afya in collaboration with CHMTs and FP Clinical mentors conducted quarterly supportive supervision, coaching and mentorship to service providers providing PPFP in 25 HFs in 7 districts of Mara region (Rolya, Tarime TC and Tarime Dc, Musoma Municipal, Musoma DC) and 2 districts of Kagera region(Muleba, Biharamulo). In these visits 88 (Kagera 31, Mara 57) service providers were mentored on specific skills gap. The main areas covered include; providers’ competence and skills in conducting client education on PPFP, IPC practice, counseling for informed choice, PPIUD and Implant insertion. Other area included; record keeping and data tools review, availability of FP commodities and R&R skills to avoid unnecessary stock out. Each facility was found to have at least one PPIUCD trained staff and one PPIUD kit but some staff were not practicing. Mentorship to improve IPC and data recording was conducted. Private/FBOs facilities were advised to use MSD ordering format to avoid stock out of FP commodities. The following were the gaps observed; PPFP performance was low due to inadequate counselling skills of providers, only a few pregnant women are counselled at ANC, inadequate skills in offering PPFP and incomplete documentation in the registers.
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5.2.1.5. Establish and equip learning corners USAID Boresha Afya in collaboration with CHMTs facilitated and established 30 learning corners in Shinyanga, Mara, and Kagera region which included equipping them with learning materials (simulation models, standard guidelines, checklists, Medical Eligibility Criterial Wheel for contraceptive use, FP commodities, RCH no 5 and kits). The identified areas are easily accessible by the health care workers for learning/practicing clinical skills. The established learning corners will be used to practice competencies across RMNCH technical areas and they will be enriched with materials as needed.
Figure 48: A Learning Corner in Musoma RRH
5.2.1.6. Family planning integration into CTC services During this quarter a readiness assessment for integration of FP/ CTC services was conducted in 22 sites in Kagera (6) and Mara (16) as summarized below: a) Kagera: USAID Boresha Afya in collaboration with R/CHMTs and MDH (who is the CTC partner) conducted health facility readiness assessment in 6 health facilities providing CTC services (Bukoba RRH, Izimbya, Kanazi HC, Kaigara HC, Kashai and Nyaishozi dispensary). (2 Hospitals, 2 Health centers and 2 dispensaries)
b) Mara: The Project with support from the RMO office conducted a HF readiness assessment for integration of CTC/FP services in few selected high volume CTC sites. The assessment was conducted to assess the extent to which health facilities are providing integrated family planning (FP) and HIV services meet basic minimum standards for the provision of quality FP services. Moreover, the assessment aimed at identifying gaps in the provision of integrated services, hence serve as a starting point for improving FP service delivery in CTC. Table 14 below summarizes the findings and recommendations;
Table 14: summary of CTC/FP integration assessment findings and recommendations
Region Observations: Recommendations
Kagera . All six health facilities visited offer Conduct On Job Training for LARC/SA; family planning services and CTC but Provide FP posters, leaflets, job aids and no FP trained staff located at CTC guidelines to CTC; strengthen routine FP health education at CTC and ongoing
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. Sites have more than 400 client counseling for group and individual; registered for ART, but most of them ensure availability of FP data tools, are using condoms (male condom). CHMTs to re-allocateFP trained staff in CTCs. . No space for family planning established at all the CTC visited. . An average of 1-2 staff are llocated at CTC ,most of the HCWs are not trained on FP except Bukoba regional referral hospital has 2 providers. . The Hospitals and Health centers have space to establish room for FP except at Dispensary level.
Mara Main gaps identified were: staff have On Job Training for LARC/SA, not been oriented on integration of accessibility of enough FP posters, FP/HIV services, no any leaflets, job aids and guidelines at CTC, strengthen routine FP health education at documentation/clients referred to RCH CTC and ongoing counseling for group for FP services, no IEC materials, FP/HIV and individual, availability of data tools, guidelines/Protocols and no specific room CHMTs advised to re-allocated skiled or space for FP/HIV service, in all sites the staff in CTC. CTC in charge was requested to improve as needed .
5.2.1.7. Distribution of FP materials: During this quarter, the project distributed SBCC print materials, equipment and simulators in all the regions. The material distributed include Mama U-116, PPIUD kits-116,IUCD insert/Removal 116, RATA 116, Madam Zoe-10 and Lignocaine 11850 vials of 2% 50 mils each. In addition, a total of 156,642 SBCC materials on FP methods provided by Tulonge Afya Project were distributed in all the regions to increase FP awareness and create demand for quality services. The material distributed included brochures on all FP methods, PPFP, and Tiahrt charts. The table below indicates the type and number of materials distributed by region:
Table 15: Family planning materials distributed in May 2018 Materials Mwanza Kagera Geita Shinyanga Simiyu Kigoma Mara Grand Total Family Planning 1203 1010 600 920 982 1130 1155 7,000 Materials for Emergency Contraceptives Implants 1203 1010 600 920 982 1130 1155 7,000 (Brochure IUCD (Brochure 1203 1010 600 920 982 1030 1155 7,000
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Post-Partum 1203 1010 600 920 982 1030 1155 7,000 Family Planning All FP methods 25,602 21,124 10,812 14,872 14,182 18,592 19,816 125,000 (Brochure WHO MEC 325 133 133 181 205 257 270 1,642 Wheel Tiahrt FP Chart 460 310 160 220 210 280 360 2,000
5.2.1.8. Family planning integrated supportive supervision, QI assessment and clinical mentorship In the period under review, the USAID Boresha Afya Project in collaboration with R/CHMTs in Shinyanga region conducted supportive supervision, and mentorship to 32 HFs in Busega DC (10), Meatu DC (10),Msala(6) and Kishapu (6) reaching 52 health service providers. The supervision aimed at assessing performance standards of HCPs on technical competency, client safety, informed choice, privacy/confidentiality and continuity of care. All the visited HFs has at least 2 FP trained HCPs and FP commodities were available. Two among the visited HFs were also offering PPFP service (Nasa HC & Meatu DH). Generally the findings revealed good progress in the implementation of PPFP services. Progress will be shared in relevant section in this report. Some of challenges observed were HMIS register no 8 are not filled properly, and IUCD interval kits were not enough at least each site has one complete set.
The health care providers reached during supportive supervision were mentored on counselling for informed choice, proper data recording/management, implant insertion procedures & IPC, management of FP complications and quality provision of PPFP services. In addition the Project conducted FP compliance orientation to 45 CHMTs and service providers; oriented on cycle beads use, and proper data documentation in MTUHA books and data visualization. Some HFs were observed to have very small rooms for FP services (e.g. the RCH clinic at Meatu Hospital),
5.2.1.9. Service provision in undeserved population During this reporting quarter USAID Boresha Afya provided FP outreach services through three service modes; facility based, service days and FP integrated community outreach. In total 34 HFs based outreach/FP week, 36 service days and 35 FP community outreach integrated with immunization and others health services were conducted.
Facility-based/FP week services on LARC/ PM in underserved population. During this quarter, 34 districts were supported to conduct Facility based/FP week services 34 out of 24 events planned. A total of 680 low level health facilities reached in the underserved communities mainly health centers and dispensaries whereby 36,920 clients were served (ML 4046, NSV 25, Implants 19679, IUCD 4488 and short acting methods 8682).
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Figure 49: Health education before services during Facility based outreach
Figure 50: Summary of clients served through facility-based FP Outreach
Monthly FP Special Service Days The Project continued to support districts in FP service provision through special service days in hospitals, health centers and potential dispensaries. A total of 16 districts were supported whereby 36 events were conducted, covering health facilities with trained service providers whereby 3,518 (ML/LA 401 NSV 4, Implants 1694, IUCD 439 and SA 980) clients were served. The services were integrated with HIV testing whereby total of 171 clients counselled for HIV testing, two were identified to be positive and were linked with CTC clinic for proper management. The aim of service days is to strengthen routine services in facilities with trained service providers. The number of clients served with FP in Q3 (3,518) is much higher compared to Q2 (989).
Table 16: summary of clients served through FP Special Service Day Short District ML/LA NSV Implants IUCD Total methods Kishapu Dc 3 0 56 6 69 134 Musoma Mc 11 0 18 7 18 54
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Kigoma Dc 13 2 82 12 29 138 Shinyanga Mc 51 0 146 56 170 423 Bukoba Dc 22 0 51 21 26 120 Baridi Tc 11 0 53 20 44 128 Kahama Tc 66 0 173 79 138 456 Maswa Dc 6 0 61 4 23 94 Serengeti Dc 0 0 37 7 15 59 Uvinza Dc 25 0 108 19 26 178 Msalala Dc 32 0 112 24 72 240 Kigoma Dc 11 0 33 15 34 93 Kasulu Tc 21 0 67 20 32 140 Musoma Dc 10 0 17 17 3 47 Musoma Mc 10 0 27 11 19 67 Butiama Dc 5 0 40 3 6 54 Itilima Dc 22 0 88 15 38 163 Kasulu Dc 13 0 66 19 17 115 Busega Dc 7 0 29 12 3 51 Bunda Tc 10 2 25 14 9 60 Shinyanga Mc 0 0 96 2 19 117 Meatu Dc 0 0 40 0 63 103 Kigoma Dc 39 0 181 48 76 344 Missenyi Dc 7 0 27 4 8 46 Maswa Dc 6 0 61 4 23 94 Total 401 4 1694 439 980 3518
FP utilization through routine service delivery In PY2, USAID Boresha Afya is supporting FP services in all seven regions covering 1,639 HFs. The benchmark for PY2 was informed by number of women of reproductive age (WRA), and estimates and trends on routine service statistics obtained from previous years. For the period under review, the cumulative achievement for Q1, Q2 and Q3 is 855,283 which is 79% of the annual benchmark of 1,079,351 see Table 17.
Table 17: Quarterly progress of client served with FP services in USAID Boresha Afya supported Regions
Quarterly 1 Quarterly II Quarterly II Cumulative PY2 % PY 2018 PY 2018 PY 2018 achievement Benchmark achievement Achievement Achievement Achievement towards Q1 Q2 Q3 annual benchmark Kigoma 46,097 56,059 58,398 160,554 160,796 99% Shinyanga 34,955 35,801 42,861 113,617 117,464 97% Kagera 50,421 56,252 62,903 169,576 193,079 88% Mwanza 46,535 42,551 51,251 140,337 228,952 61%
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Mara 41,463 36,660 39,057 117,180 132,113 89% Simiyu 23,416 22,128 25,159 70,703 114,924 62% Geita 24,648 23,976 34,692 83,316 132,023 63% Total 267,535(25%) 273,427 (25%) 314,321(29%) 855,283 1,079,351 79%
FP Acceptors by methods and Age group This quarter, we have generally seen an increase a number of FP users in all project supported regions (Fig. 51). The number of youths (10-24 years) who have received family planning services was 102,725 that is 21,931 more compared to 80,794 in January –March 2018 period. This number 102, 725 is 32.6% coverage of youth accepting modern FP methods among the total of all acceptors 314,321. Table 18 below summarizes number of all FP acceptors in Q3 (April –June 2018) by methods and age groups
Table 18: Summary of FP Acceptors Methods and Age group in Q3 April-June 2018 Age FP Method Group Pills NSV NSV Total Total IUCD IUCD Grand ML/LA ML/LA Implant Implant Total SA Total SA Condoms Injectable Injectable LARC/PM LARC/PM 10_14 202 12 214 61 83 147 291 505 15-19 16793 2165 18958 3150 7140 5050 15340 34298 20-24 31503 5386 36889 5732 19226 6075 31033 67922 25+ 12303 142 55967 16680 85092 8532 30652 11320 50504 135596 Revisit 11885 57955 6160 76000 76000 TOTAL 12303 142 104465 24243 141153 29360 115056 28752 173168 314321
70,000
60,000 Quarterly 1 PY 2018 50,000 Achievement Q1 40,000 Quarterly II PY 2018 30,000 Achievement Q2 20,000 Quarterly II PY 2018 Achievement Q3 10,000 Number of client served 0 Kigoma Shinyanga Kagera Mwanza Mara Simiyu Geita
Figure 51: Regional Trends on client served with FP services in USAID Boresha Afya supported Regions
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FP uptake by methods ML/LA 4% Condoms 9% NSV 0%
Pills 9% Implants 33%
Injectables 37% IUD 8%
Figure 52: FP uptake among Youth by methods in Q3
10‐14 Yrs 15‐19 Yrs 20‐24 Yrs
505(0%)
34,298(33%)
67,922(66%)
Figure 53: FP uptake among youth in Q3 (April –June 2018)
5.2.1.10. Attribution of USAID Boresha Afya on LARC/ PM and short acting methods Figure 54 below shows the direct and indirect attribution of USAID Boresha Afya in LARC/ PM and short acting methods in Q2 and Q3 of Project Year two. Direct attribution is from those clients served through project supported activities including: facility-based outreach, service days and FP integrated community outreach. In this quarter, the project increased its contribution of clients served by various FP methods compared to the previous quarters. 36% ML/LA, 20% NSV, 22% Implant, 21% IUCD. The project is expected to increase the direct contribution in subsequent quarters through planned trainings and scale up of HFs support.
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120% 93% 94% 98% 98% 94% 100% 88% 89% 88% 91% 87% 75% 80% 78% 79% 80% 64% 60% 36% 40% 25% 18% 20% 22% 21% 20% 11% 12% 9% 13% 7% 6% 2% 2% 6% 0% Oct‐Dec 2017 Oct‐Dec 2017 Oct‐Dec 2017 Oct‐Dec 2017 Oct‐Dec 2017 April‐June 2018 April‐June 2018 April‐June 2018 April‐June 2018 April‐June 2018 Jan‐March 2018 Jan‐March 2018 Jan‐March 2018 Jan‐March 2018 Jan‐March 2018 ML/LA NSV Implants IUCD Short Term Methods
Direct Project contribution Indirect Project contribution
Figure 54: Proportion of Direct contribution of the project in LARC/PM and SA methods October 2017 to June 2018
5.2.1.11. Postpartum family planning services
Counselling for PPFP In the quarter of October-December 2017, the project printed and distributed PPFP registers, tally sheets and monthly summary forms to 82 PPFP sites. Orientation to service providers including how to document PPFP service was done in quarter one and Quarter two. In this period under review, these HFs have recorded tremendous performance in PPFP counselling during postpartum period mainly attributed to improved documentation, tool availability and mentorship to improve HCWs’ attitude toward offering PPFP services.
96% 100% 91% 86% 78% 71% 75%
Geita Kagera Kigoma Mara Mwanza Shinyanga Simiyu Region Region Region Region Region Region Region
Figure 55: Proportion of clients counselled for PPFP during postpartum period in 82 PPFP sites supported by USAID Boresha Afya in April-June 2018 (n=82)
Women provided with immediate postpartum FP services: In the reporting period, all regions with exception of Mwanza and Geita reported good progress compared to January –march 2018 period. However, this is still a challengign area. Since all PPFP sites have all the tools to implement PPFP, the project will do
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follow up through supportive supervision and mentorship to ensure more women are reached with PPFP service of their choice during postpartum period
Jan‐March 2018 April‐June 2018 20% 17% 15%15% 15% 13% 13% 12%
10% 8% 7% 7% 5% 5% 5% 5% 3% 2%
0% Kagera Mara Geita Simiyu Shinyanga Mwanza Kigoma
Figure 56: Proportion of women provided with immediate postpartum FP services (acceptors of FP methods)
5.3 Result 3. Increased access to health services at the community level, including vastly improved linkages with the health system.
5.3.1. Family planning Community outreach
In this reporting period , USAID Boresha Afya collaborated with CHMTs to conduct 35 community based outreach FP services which was integrated with under five immunization mobile outreach. In these outreach health education and comprehensive services were provided by teams of skilled providers. Other health services such as malaria case management, HIV testing, nutrition education and nutrition status assessment were also integrated in community outreach services. Community outreach served 2,976 FP clients with various methods of their choice (Table 19 below summaries client who were Figure 57: Health education during FP Community served during community outreach events) integrated outreach
Table 19: Summary of FP client served during community based outreach events integrated with under five immunizations Short District ML/LA NSV Implants IUCD Total methods Busega Dc 0 0 58 0 140 198 Meatu Dc 0 0 115 0 135 250
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Bukombe DC 0 0 63 0 13 76 Misenyi Dc 0 0 55 0 71 126 Kigoma Dc 0 0 103 0 172 275 Mbogwe DC 0 0 189 35 37 261 Tarime DC 5 0 61 2 47 115 Ushetu DC 0 0 106 16 125 247 Msalala DC 0 0 560 0 146 706 Kishapu DC 0 0 31 0 28 59 Ngara DC 6 0 43 6 24 79 Maswa DC 0 0 69 0 48 117 Rorya DC 0 0 43 4 190 237 Uvinza DC 0 0 101 0 129 230 Total 11 0 1597 63 1305 2976
The integrated community outreach services reached a total of 8553 people, 6088 females and 2465 males. Of the 8553, people served, 2273 were tested for HIV and 28 (1.2%) were found to be HIV positive and linked to nearby CTC clinics. About 5096 people were tested for malaria, among them 1318 (26%) were found to be malaria positive and were treated by the outreach team. In addition, nutrition status assessment was conducted to 2439 under-five children where by 9 children were severely malnourished and referred to the nearby facilities for proper management , parents/care giver were educated on proper nutrition to improve their health status and clinic attendance for regular monitoring.
6.0 COMMUNITY ENGAGEMENT, SBCC AND GENDER
6.1. Result 2. Improved availability of quality, integrated health services at facility level
6.1.2: Strengthen client-HCW interactions to promote respectful and informed care The Project conducted advocacy meetings in Mara and Kagera this quarter to improve gender norms, address socio-cultural practices and encourage respectful care. During the advocacy meetings, the Project shared the gender norms perceived as barriers to uptake of RMNCAH services and advocated for access to gender- sensitive services and YFS within a high quality and respectful settings. It was an opportunity for the project to help the participants understand the root causes of gender inequalities and respectful care challenges. The Project supported participants to develop action plans to include gender, RMC, YFS and male engagement in their routine activities. A total of 177 Kagera and 102 Mara participants were reached.
6.2. Result 3. Increased access to health services at the community level, including vastly improved linkages with the health system
6.2.1 Build capacity for the new CHWs in 20 expanded districts on integrated RM2NCH During this reporting period, the Project built capacity of 242 community health workers (CHWs) through a 3-week training on integrated RMNCH, as they will be actively involved in mobilizing communities to seek RMNCAH services, including Family Planning. The Project worked with CHWs and HCWs to promote RMNCAH, Malaria and FP services at both the community and the facility level. They were equipped with knowledge and skills to be able to identify danger signs during household visits and provide timely referral to the nearby facility. Below are the findings of the pre-test and post-test results:
Table 20: Pre-test and Post-test results during CHW Training Regions District Pre-test Post-test Highest Lowest Highest Lowest Kigoma Kasulu 64 5 97 51 Buhigwe 59 14 92 59
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Mara Butiama 83 8 93 54 Kagera Misenyi 71 43 92 62 Biharamulo 71 17 94 55 Shinyanga Msalala 62 18 96 54 Ushetu 63 18 98 56
6.2.1.1 Maternal Infant and Young Child Nutrition (MIYCAN) at Community Level
The Project also worked this quarter to strengthen delivery of MIYCAN services at the community level. 28 CHWs in Butiama were trained on the integrated Maternal Infant and Young Child Nutrition (MIYCAN) package, which covered the following topics: Healthy Family; Maternal Nutrition; Promotion of Antenatal Services and Care to Pregnant Woman; Family Planning Services in the Community; Exclusive Breastfeeding of Children 0-6 Months; Early Initiation of Breastfeeding; Breastfeeding techniques; Complementary Feeding (Feeding a Child 6 – 24 months); How to Care for a Child with Diarrhea; Water, Sanitation and Hygiene; Water Treatment and Storage at Family Level; Environmental Cleanliness; Early Childhood Development; and Responsive Feeding. The training also Figure 58: CHWs participating in involved a cooking demonstration for the CHWs of the practical session during MYCAN complementary foods. training in Tarime TC
The training involved a knowledge assessment using a pre and post-test. The average pre-test score was 56% while post-test was 88%; the average gain was 16%. USAID Boresha Afya will work with CHWs and HCWs to promote MIYCAN services at the community and facility levels and encourage screening for malnutrition and referrals to the nearest facility during household visits.
6.2.1.2. Follow up mentorship of CHWs trained on FP provision (short term) in Kagera region During this quarter, the Project collaborated with MOHCDGEC trainers and CHMTs to provide post-training follow-ups to 45 CHWs who had been trained on FP provision (short term) in Kagera region (4 in Muleba, 13 in Biharamlo, 12 in Misenyi) and Mara region (16 in Butiama). The post-training follow-ups aimed at assessing FP service provision at community level based on national standards, provide mentorship and coaching on identified gaps, provide guidance in completing M&E tools including daily register and monthly summary forms, and provide technical assistance in ordering FP commodities and referring clients to HFs.
The team used the MOHCDGEC post training follow-up checklist for CHWs to ensure services are provided according to MOHCDGEC standards, assess CHWs' technical performance, identify their strengths, and gaps, challenges faced, and reinforce their knowledge and skills including record keeping, reporting, and storage of commodities appropriately. During the assessment, the team also used different methodologies including review of community-based family planning records (daily register, monthly summary forms), FP commodity ordering forms, and referral forms. A total of 70 households (45 in Kagera, 25 in Mara) were reached through integrated supportive supervision and post training follow up. During the assessment the team observed CHWs performance on conducting health education, counseling for informed choices, using appropriate checklists for screening clients for FP methods, actual provision of FP methods (e.g. pills, condoms, and cycle beads), storing and distribution of FP commodities, record keeping, reporting, use of FP data, provision and follow up FP referrals, and questions and answers.
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The key findings of the supervision assessment were that there is inadequate reporting, and commodity ordering forms are used in such a way that CHWs do not keep copies of their submitted reports. Additionally, it was noted that no feedback is being provided to the CHWs on their referrals, and that supervisors are not aware of their roles and responsibilities and lack work plans. Other gaps identified included: CHWs are not provided with adequate supplies and some facilities supervisors were not trained on FP (e.g. at Minziro Dispensary and Gera Dispensary). Regular mentorship and ensure provision of supplies to CHWs.
A total of 55 CHWs assessed were performing well overall, but at different levels. 7 (2 Muleba, 3 Biharamulo and 2 Mara) were not assessed because they were engaged in other official duties during the exercise. Regional teams will plan another visit in the next quarter to cover them.
In addition, mentorship and coaching was provided to strengthen service provision. Individual action plans were developed, and the Project team recommended frequent supervision and supervisor mentorship on FP issues so that supervisors are better aware of their roles and better able to provide effective support to CHWs. From February to April 2018, the 55 CHWs conducted a total of 1678 (1397 Kagera, 281 Mara) home visits, serving 748 (597 Kagera,151 Mara) FP clients (297 pills, 436 condoms, 11 cycle beads, 4 ECP) and 67 clients were referred for other services not provided at community level.
Table 21: CHWs performance on FP provision by district in Kagera and Mara regions DC Pills Condo Cycle Home Referrals ECP ms beads visited Misenyi 78 114 0 534 1 1 Biharamulo 116 161 3 568 8 2 Muleba 36 80 3 295 54 1 Butiama 67 81 3 281 4 0 Total 297 436 11 1678 67 4
6.2.1.3 Dissemination of IEC/BCC materials to increase knowledge on health care seeking behavior among mothers/caregivers
During this quarter, the following relevant IEC materials on RMNCAH, Family Planning, Malaria and Nutrition targeting mothers/caregivers were reprinted by Tulonge Afya and disseminated by USAID Boresha Afya in Lake and Western Zone:
4,000 "Wazazi ni Pendeni" campaign breastfeeding posters 4,000 SP posters ("Onyesha Upendo wako meza angalau dozi tatu") 4,000 Emergency Contraceptive brochures 7,000 Implants brochures 7,000 IUCD brochures 7,000 PPFP brochures 125 All FP methods brochures 2,000 Tiahrt charts 4,000 "Tunakuthamini" Posters on PMTCT discordant couples 4,000 Couple support poster (for non-discordant couples) 4,000 "SioKila Homa ni Malaria Zama zimebadilika" posters 4,000 "Malaria haikubaliki" mother and son poster 4000 "Tokomeza maambukizi mapya ya VVU kwa mtoto" posters
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4,000 "Getting Zero e MTCT" posters 4,000 "Dawa za ARV zimemkinga mtoto wetu" posters.
A total of 209,701 copies (41,778 Mwanza, 33,035 Kagera, 18121 Geita, 27115 Shinyanga, 24467 Simiyu, 31,551 Kigoma and 33,634 Mara) of the IEC/BCC materials have been distributed to the project-supported health facilities to increase knowledge on healthcare-seeking behavior among clients, including mothers and caregivers.
6.2.1.4 Community intervention supportive supervision During this quarter, the Project collaborated with R/CHMT to conduct comprehensive supportive supervision and mentorship to 367 trained CHWs and 30 CHW supervisors from 10 districts. In addition, the Project provided technical support to CHWs and CHW supervisors in order to facilitate competency in provision of integrated services to clients, including on how to deliver key messages on RMNCAH, Malaria, Nutrition and FP during household visits and data reporting.
6.2.1.5 Community Score Card: During this reporting period the team managed to review 4 Community Score Cards (CSC) in 4villages from 3 Districts on the implementation of agreed actions plans. Among the 4, Nyanchabakeye village in Rorya DC sets a good example of achievement of CSC: the village has established an opinion box at the health facility; the village continued to encourage community members to enroll in CHF; their health facility is currently providing services 24 hours a day, including weekends; and there was reliable electricity available in the facility. Each of these achievements came from the implementation of the community score card
6.2.2. CHWs quarterly performance Figures 60 and 61, below, show CHWs' performance on fostering access to and utilization of RM2NCAH services, including referrals for those who need further management at the HF level. In this quarter , a total of 7,490 pregnant women were visited in Mara and Kagera, which is 132 more than those visited in Q2 (7,358, January - March 2018). Among the 7,490 pregnant women visited, 958 (12.8%) were referred for various advanced services at higher levels.
Figure 59: CHW visits to pregnant women in Mara and Kagera
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4200 4091 4028 3932 4000 3857 Apr to Jun '17 3800 3747 3633 3560 Jul to Sep '17 3600 3514 3430 3426 Oct to Dec '17 3400 Jan to Mar '18 3200 Apr to Jun'18 3000 Kagera Mara
Figure 60: The number of pregnant women visited, revisited and referred by CHWs by quarter in Kagera and Mara
In this quarter, a total of 26,495 children were visited by CHWs in Kagera and Mara. Among these, 282 (1%) were referred for further management at HF level.
Community Health Education Meetings: During this quarter, the Project held community health education meetings in Kagera and Mara. These meetings provided a forum to sensitize the community on issues around Family Planning, Maternal, Child, and Adolescent Health, Malaria and Nutrition and their role in promoting the uptake of the services for better health of the community. In Kagera, a total of 24,191 community members were reached through 1430 community engagement meetings or community health education meetings. Similarly, in Mara, 9,920 community members were reached through 423 meetings.
Institutional Deliveries: During this reporting period, institutional deliveries in health facilities in Kagera with CHWs was 87%, whereas those without CHWs was 68%. In Mara, the rate of institutional deliveries was 128% with CHWs, but 84% without. This shows that CHWs play a significant role in sensitizing community members to deliver at health facilities. We are expecting that involvement of local CSOs from next quarter will facilitate increased RMNCH awareness in communities with no CHWs.
Figure 61: Trend analysis on institutional deliveries between HFs with CHWs and with no CHWs in Mara and Kagera
Improved ANC1 below 12 weeks in HFs with CHW supports: Similarly, there have been positive trends on the percentage of ANC 1 attendance below 12 weeks in HFs that have CHWs compared to other
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HFs in the respective councils in Mara and Kagera region. This area along with others (including FP services and institutional deliveries) will be further strengthened through CSOs engagement.
Trend analysis on ANC 1 Below 12 weeks between HFs with and with no CHWs in in Mara and Kagera 60% 51% 51% 49% 50% 43% 42% 38% 38%40% 40% 33%33% 32%32% 30% 27% 22% 21% 18% 20% 15% 15% 14%16% 15% 16% 10% 12% 10% 0% Jan to Apr to Jul to Oct to Jan to Apr to Jan to Apr to Jul to Oct to Jan to Apr to Mar Jun 2017Sep 2017 Dec Mar Jun 2018 Mar Jun 2017Sep 2017 Dec Mar Jun 2018 2017 2017 2018 2017 2017 2018 Kagera Region Mara Region
Facilities with no Community Interventions Facilities with Community Interventions
Figure 62: Trend analysis on ANC1 below 12 in HFs with community intervention against non- community intervention HFs
7.0 ZANZIBAR This section highlights USAID Boresha Afya achievements in Zanzibar during Quarter 3 of PY2 implementation.
7.1. Result 1: Improved Enabling Environment for health services provision
7.1.1. Result 1.2 Technical assistance (TA) provided to GOT to develop, communicate, and implement national plans. 7.1.1.1. Supported six ZAMEP staff to participate in MSDQI visit in Mwanza A team of six ZAMEP staff visited public and private health facilities in Mwanza to learn about the MSDQI implementation and best practices. A team spent two days in Mwanza conducting site visits, using the electronic data tool on tablets to collect data at selected public and private health facilities. A team met with the RMO for a briefing on the purpose of the trip, and enabled them to use the tools for observation, assessment, interviews and records review. Team members gained hands-on experience with the tools and saw their use for collecting and analyzing data.
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Figure 63: PMI team together with ZAMEP and USAID Boresha staff during MSDQ1 visit debrief meeting
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Following the Mwanza visit, the team in Zanzibar will continue receiving support from USAID Boresha in: . Finalization of MSDQI checklist for Zanzibar . Adoption of the MSDQI Checklist depending on the program need . Integration of ANC services in MSDQI to involve RCH continuum of care . Plan for procurement of tables
7.1.1.2. Zanzibar Strategic plan for RMNCAH (One Plan II) (2018 – 2022), USAID Boresha Afya participated in a 5-day meeting for finalizing the Zanzibar Reproductive, Maternal, Newborn, Child and Adolescent Health Strategic Plan (2018 – 2022). This plan aims at aligning with other strategic initiatives such as the Sustainable Development Goals (2016 – 2030), Zanzibar Strategy for Growth and Reduction of Poverty II-MKUZA (2010 – 2015) and Zanzibar Health Sector Strategic Plan III. The major focus of the plan will be to strengthen the delivery of quality services along the continuum of care and in line with the WHO quality of care framework to achieve respectful maternity care, equity, and coverage of high impact RMNCAH interventions in an integrated manner. As well as advancing RMC to ensure improved experience of care for women, where there is effective and responsive communication, care provided with respect, dignity, and emotional support. Gender, youth friendliness, male engagement and integration in RMNCAH were also raised as strategic priorities.
7.1.1.3. MNCH Technical Working Group Meeting:
The project facilitated the quarterly MNCH Technical Working Group meeting on June 26, 2018. Key issues from this meeting included the update on the Zanzibar Family Planning Costed Implementation plan (ZCIP), which was signed and launched on May 19, 2018. Dissemination and resource mobilization is ongoing to facilitate the implementation of the plan.
It was highlighted during the meeting that the MOHZ has secured money from the World Bank to support the development of a standard data dictionary for RCHS indicators. The TWG also discussed the increasing trend of maternal deaths, there is a need for formation of National MPDSR committee. Terms of reference for the national committee have been drafted and will be finalized next quarter. The Zanzibar Guidelines for Post Abortion Care Service Delivery presented is also being finalized; the Zanzibar Strategic Plan for RMNCAH (One Plan II) is now in the final stages, and a two-day meeting will be organized in July to finalize the document for an August 2018 launch.
7.1.1.4. Joint Program Planning Meeting (JPPM) with ZAMEP During this quarter, the project also participated in the Joint Program Planning Meeting (JPPM) with ZAMEP, which also involved PMI and other implementing partners. The objective of the meeting was to review previous action points, share program accomplishments from January - May 2018, share planned activities June – September 2018, and outline challenges and solutions. Tables 22 and 23 below summarise the issues raised and action points
Table 22: summary of Issues discussed during Jointly Program Planning Meeting with ZAMEP S/n Issue Responses/Discussion
1. Number of Malaria Case Management Team need to follow up the details and emphasized made (MCM) is too high compared to Active on ACD Case Detection (ACD) 2. Increase of malaria cases in Tumbe More investigation needs to be done; timing of IRS to be combined with other effort to eliminate malaria
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3. Low utilization (57%) of LLINs despite Explore further and find other reasons for low utilization good ownership 4. Issue of quality checks for nets was Quality check were not done due to limited time raised 5. Low testing rate despite the availability This was due many factors: poor documentation; of mRDT stock mistrust of the testers. Advised to sensitize the implementers (SBCC)
6. No funds to print guidelines and Need to budget during the work plan training manual 7. Modality of tracking the stock Sit with LMU discuss the available information, data use, availability to the facility what works, what is the issues then streamline what is written in the papers if it is in sync with the system to avoid duplication 8. One track for distribution of nets Procurement to procure one motorbike by December, 2018 9. SBCC materials and IEC materials for Tulonge Afya to work on attractive messages for the travelers travelers 10. Overstock of commodities Facility to verify the order, quantification/pipelines and integrate the orders 11. Delay of LLINs This was due to no enough vehicle for transportation and bulk LLINs with no warehouse
Table 23: summary of action Points developed during JPPM with ZAMEP
S/n Action Item Responsible
1. Conduct slide bank sustainability meeting ZAMEP & USAID Boresha Afya 2. Involve all units during work plan development ZAMEP 3. Travel to mainland and learn more on MSDQI ZAMEP 4. Treatment guidelines to be shared to PMI by June,2018 ZAMEP 5. Use system to determine the facility stock status to avoid ZAMEP/LMU duplication 6. Dissemination of communication strategy USAID Tulonge Afya 7. Dissemination of report for possibility analysis findings MEASURE evaluation 8. Explore the reasons for low utilization of LLINs in Tumbe ZAMEP 9. HMIS team to meet with PMI ZAMEP 10. Develop work plan by July ZAMEP 11. ZAMEP will start soon development of the work plan and PMI the budget to shared 12. Conduct training to ensuring the ordering system ZAMEP maintained
7.2. Result 2: Improved availability of Quality, Integrated health services at facility level
7.2.1. Result 2.1: Increased provision of quality, integrated health services 7.2.1.1. Quality Improvement Assessment and Mentorship
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The project worked with IRCH to conduct quality improvement (QI) assessment to all 5 facilities supported by the project, with the aim of identifying strengths and challenges and develop action plans for improvement, including providing mentorship on the identified gaps. The challenges identified included: inadequate practice of IPC principles; inadequate monitoring of women during the 1st stage of labour; insufficient counselling on PPFP; low morale among staff in all facilities especially MMH staff.
Figure 64: Mentorship at Mnazi Mmoja Hospital Some overarching findings on the QI implementation included that incinerators are not adequately functioning, so there is poor handling of waste products, and there is inadequate care for women in the post-natal ward, contributed by over-crowding. It was noted that, about one third of the women in Mnazi Mnoja Hospital maternity ward are sleeping on the floor making nursing care difficult. An action plan was developed, mentorship was conducted, and feedback was given to the providers and management.
Among other recommendations, the management was advised to ensure incinerators are functioning and that the workload for the providers is reduced. OJT was given to the providers on management of a woman in the 1st stage of labor, including use of partograph; generally there is slight improvement shown in some of the facilities through SBM-R assessment tool.
The following were major recommendations: Mentors to support the HCWs in solving the gap identified, including improper documentation, inadequate IPC practices, syphilis screening and neonatal resuscitation; USAID Boresha Afya to work with IRCH to strengthen the QI teams to support the provider to perform internal QI assessment; USAID Boresha Afya to work with IRCH to put more effort in advocating for FP and integrated services, emphasising to the community that it is both for males and females. Orientation of the new WHO IPC guideline to the providers and emphasise on it's implementation through OJT
7.2.1.2. Integrated supportive supervision in Zanzibar: During this quarter, the Project in collaboration with Zanzibar district teams, conducted integrated supportive supervision in Zanzibar across Reproductive Maternal, Newborn and Child Health (RMNCH), Malaria and Family Planning in three out of five facilities supported by the Project: Mnazi Mmoja, Makunduchi, and Kivunge. Gaps identified were poor IPC measures, limited space, shortage of staff, inadequate information and health education on PPFP provided at ANC and L&D. Other gaps identified included lack of a proper system for requesting and monitoring FP commodities, inadequate counselling skills, poor documentation and data inconsistency. Mentorship was done to standardize health care providers’ practices and feedback were given to the facility authorities including section in charges to ensure on going follow up of the deliberations.
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Health Facilities delivery Mnazi Mmoja hospital continued to serve high percentage of deliveries accounting for 46% of all deliveries in high volume sites in Zanzibar. The project will continue to support improvement of quality of service through the MNH interventions in Zanzibar.
Figure 65: Number of HF deliveries is USAID supported HFs in Zanzibar
Percentage of clients received Uterotonics The proportion of women who received uterotonics immediate after birth was 100% in the 4 project supported HFs, and 85% for Mnazi Mmoja Hospital.
Figure 66: Uterotonic coverage in Zanzibar supported HFs Q1nad Q2 7.2.1.3. Maternal and Perinatal Death Review (MPDSR): This quarter, the Project worked with the IRCH department to conduct a Zonal level MPDSR, to continue working towards the goal of reducing Maternal and Neonatal Mortality. In this period, 15 (0.6%) maternal deaths occurred out of 2,597 deliveries at Mnazi Mmoja Hospital. All deaths were reviewed, with the
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leading cause of death being PPH and Eclampsia. In the same period, 79 perinatal deaths occurred of which 36 were FSB and 43 being MSB. In general, MPDSR reporting has improved, due to the use of ICD 10 classification for identifying the causes of death. The presence of Mnazi Mmoja leadership was appreciated, with the Director acknowledging their willingness to participate to strengthen their response to actions from MPDSR review at Mnazi Mmoja. A shortage of commodities was also reported; the IRCH requested that in each supportive supervision and mentorship conducted in Project-supported facilities (except MMH) to involve a District Materials Manager to resolve health commodity issues through the Central Medical Store. Clinical mentorship on PPH and Severe preeclampsia/ eclampsia was conducted by Project and ZMOH staff at all the hospitals supported by the Project.
Figure 67: The number of perinatal deaths in USAID Boresha Afya supported HFs in Zanzibar for Q2 and Q3. 7.2.1.4. Integrated FP Outreach services This quarter the Project conducted integrated FP outreach in Mnazi Mmoja, Makunduchi, and Kivunge Hospitals in Unguja and Wete, and Chakechake Hospital in Pemba. Each of these facilities, except for Chakechake Hospital, selected a lower-level facility for outreach: outreach for Mmnazi Mmoja was conducted at Mpendae Primary Health Care Unit (PHCU); for Makundichi, outreach was conducted at Jambiani PHCU; for Kivunge Hospital, Matemwe PHCU; for Wete Hospital, Junguni PHCU. Services provided included FP, particularly LARC/PM, HIV testing, and Figure 68: Clients waiting for services during screening for malaria and cervical cancer. outreach at Mpendae PHCU During this outreach we reached 144 clients in all FP methods, (18 Minilap and 53 LARC). 249 people were tested for HIV, with 1 testing positive and referred to CTC. 121 were screened for cervical cancer, with 2 having suspicious lesions and referred for further management. 269 were tested for malaria, with 0 positives.
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PPFP achievement in Zanzibar In the period under review, 1,434 (27%) of the total deliveries 5,374 in 5 HFs received PPFP counselling. However, only 104 (7.3%) of 1,434 who were counselled accepted modern FP method of their choice. The Project will continue strengthening HCWs’ skills on PPFP counselling through OJT and mentorship.
Total Deliveries Counselling for PPFP
6000 5498 5428 5374 5000 4000 3000 2000 1434 (27%) 1181 (21%) 1043 (19%) 1000 0 Oct‐Dec '17 Jan‐Mar '18 Apr‐ Jun '18
Figure 69: Trend on PPFP counseling in project supported HFs in Zanzibar
8.0 CROSS CUTTING INTERVENTIONS
8.1 Health System Strengthening (HSS)
8.1.1 Result 2: Improved availability of quality, integrated health services at facility level
8.1.1.1: Result 2.2: Districts and regions supported for increased accountability and responsiveness in service delivery
8.1.1.1.1 Finalization of supply chain key performance indicators (KPI) workshop: During this quarter, the Project and other partners worked with the MOHCDGEC and PO-RALG to discuss supply chain KPI standardization. The process commenced with understanding how the exercise was done, starting with the collection of KPIs from national and international organizations and from different sectors, followed by review, analysis, verification and standardization of the indicators.
During the KPI standardization workshop, the team discussed refining the KPI framework shared by MOHCDGEC before they share with RHMTs and CHMTs for use. The team came up with 13 out of 21 indicators that had previously been proposed, and suggested the development of dashboard for the indicators, as well as re-aligning KPIs based on comments provided during discussion. The participants also suggested to include laboratory and diagnostics KPIs in the standards and to finalize the indicator reference dictionary.
The task team worked on the recommendations and some are in the finalization stage. Participants had an opportunity to review the overview and use of the national health supply chain results framework,
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where priority objectives for the National Health Supply Chain of health commodities were aligned with the KPIs selected.
8.1.1.1.2. Facilitate implementation of direct facility financing policy and national rollout of improved CHF and Prime vendor system During this quarter, the Project supported PO-RALG training on Jazia Prime Vendor System (JPV), Improved Community Health Fund (iCHF), and Direct Health Facility Financing (DHFF) for 5 participants from each USAID-supported region: a Regional Accountant, Financial Management Officer (FMO), Regional Medical Officer (RMO), Regional Health Secretary (RHS), and Regional Community Health Fund (CHF) Coordinators from each region. The aim was to orient participants on the key aspects of iCHF, the prime vendor system, and new procedures for disbursement and management of funds through facility bank accounts. The training also oriented participants on M&E, supervision, and backstopping approaches and tools.
8.1.1.1.3 Training on Tendering process to Regional Secretariat members USAID Boresha Afya supported training of tendering process to Regional secretariat members. Following after training the Regional secretariat was able to know how to conduct the tendering process and 20 regions achieved to get Prime vendors.
During this training, the PO-RALG organized evaluation of tender documents from prime vendors in partnership with HPSS Tuimarishe Afya Project and take 2represenatives from each region including USAID Boresha Afya supported regions. A total of 262 documents were evaluated from 23 regions. The average score that was used to select bidder to buy a tender documents and finally enter in the competition was 75% and above. Based on the evaluation findings 20 out of 23 regions are expected to continue with the Bidding process except 3 regions that did not get qualified bidders i.e. Mara, Kagera and Tabora. If there is a need to re-advertise tender for unqualified regions will depend on decision of the relevant Regional Tender Board.
8.1.1.1.4 Strengthen financial systems for rational use of available health resources Community Health Fund advocacy and sensitization In this quarter, the Project supported regions to conduct a 1-day advocacy meeting with each council on iCHF benefits in Shinyanga, Simiyu and Mara, in collaboration with RHMTs. The advocacy meeting involved Council Health Management Teams (CHMT), Council Health Service Board (CHSB) and CHF Board members. A total of 252 participants were sensitized across all councils. There was good representation from key stakeholders, including the District Commissioner and District Administrative Secretary on behalf of District Commissioners. Table 24 below summarizes the major issues raised and proposed solutions that were discussed during the Community Health Fund advocacy and sensitization meeting.
Table 24: Major issues discussed and proposed solutions during Community Health Fund Advocacy and sensitization Major issues Discussed Proposed solutions The iCHF provides wide coverage All Councils to sensitize the community on for health service provision including CHF but also include key political actors at private HFs in providing services to the appropriate levels CHF members, expected to start on 1st July, 2018
The new premium (Tsh. 30,000/=) All Councils to propose new mechanism seems expensive to community and develop strategies according to the members; the Council needs to environment of specific area.
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develop a strategy to ensure wide All CHSB and CHF Board members to be coverage of community members enrolled into the CHF joining the iCHF scheme. They should also sensitize community to enroll before they get sick. CHF to be an agenda in RCC, DCC, Councilors meeting, WDC, VDC meetings Some bottlenecks observed on low enrolment rate were due to CHF CHF Coordinators and CHF Officers to be enrolment (IMIS) system issue for active and accountable insurers.
8.1.1.1.5 Support Results Based Financing (RBF) Verification in Project regions During Q3, the Project supported RBF verification process for Kagera, Kigoma and Simiyu. A total of 568 Health Facilities were reached with the verification exercise. Generally, there is increase in the overall performance of quality indicators in these regions when compared with Q1 and Q2 Verifications of PY2 (see Table 25 below). Verification of the remaining regions are scheduled to happen in subsequent quarters. The low performance in some regions was attributed to low enrolment of CHF and late entry of HMIS into DHIS2. USAID Boresha Afya has been working with R/CHMT to support HFs that are performing poorly to strengthen their performance through data quality and data management support, linking them to quality improvement initiatives.
Table 25: status of RBF verification in USAID Boresha Afya supported region in Q1 and Q2 PY02. Regions October-December 2017 January-March 2018 Kagera 66.3% 65.2% Kigoma 59.2% 72.2% Simiyu 70.1% 79.4% Shinyanga 87.2% Verification will be done in July-August 2018 Mwanza 77% Verification will be done in July-August 2018 Geita 41.7% Verification will be done in July-August 2018
Table 26: Summary of Key RBF strengths and challenges during RBF verification RBF Strengths Challenges Way forward
Health facilities Labour and delivery Data quality and use utilized Emergency, labour and delivery not HFs to ensure quality incentive funds prioritized and well arranged. data are submitted of RBF to timely. improve the Incompleteness of partograph filling, quality of care plotting and interpretation with delayed HFs to ensure decision making consistence of data in the Improved register, tally and report patient/client No existing HF plan for maternal and forms. service perinatal mortality and morbidity reduction satisfaction Health care workers to No data entry of Maternal and perinatal receive training on filling services from community level in DHIS2 MTUHA books and
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Most of prepare dash board essential HRH according to RBF medicines Minimum availability of trained/skilled staff indicators. were available in facilities assessed HF infrastructure and IPC in the facilities (i.e. in Kagera Medical supplies and commodities CHMTs to arrange by > 95%), Overstocking of medicine with month of renovations plan stock (MOS) above 6month Quarterly. Availability of maternal and Pharmacy ledgers and other forms are not IPC and 5s to be newborn timely updated. observed in their plans. services within the facilities, all To improve the type of Basic amenities availability of water in the vaccinations Most of the facilities lack source of water facilities within and supply Ensure cleanness of enrolment of IPC internal and external Family planning environment of the services within The facility environment internally and facilities the facilities. externally is not conducive for provision of clean services, no incinerator, no placenta HF Management pit CHMT to assist quarterly Data quality and use facilities work plan as per Inconsistence of information available in RBF indicators. DHIS2 and those available in registers. To ensure transparency Poor storage of old or completed MTUHA according to RBF books resulting into failure to capture some indicators. information. To ensure preparation Lack of validity, quality and consistency of and availability of data available in DHIS 2. quarterly reports. HF Financing Sensitization of the No technical audited finance and others community to join CHF. report within the facility. To ensure availability of Lack of transparency to the community on active and strong CHWs income and expenditure or availability of
services
Low CHF enrolment
All facilities failed to segregate TASAF clients and others who received Health Services from OPD.
8.1.1.1.6. Leadership, Governance and Accountability training to R/CHMT members in Simiyu During quarter 3, the project supported Simiyu through building capacity on leadership, Governance and accountability skills to be able to deliver quality health services at health facilities. The Rationale of the
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training was to address the observed Inadequate leadership, Governance and Accountability skills among RHMT and CHMTs. This has led to poor performance among various actors to deliver quality health care at health facilities and community. The training was organized to strengthen capacity of RHMT and CHMTs in Simiyu region to develop their knowledge and skills on Leadership, Governance and Accountability.
Achievements and lessons learnt: All sessions were facilitated as timetable or agreed teaching plan between organizers and facilitators Two topics which were not reflected in the time table were facilitated due to their importance namely: Management Theories, Organization, Organization strictures in relation to staff performance and Time Management. Attendance was good as most invitee attended the training. Each team RHMT and CHMTs prepared a work plan to address the identified gaps.
Challenges and constraints Some participants left earlier due to family or official issues. The time table did not provide room for pre- and post-tests. Not all RHMT and CHMT members attended the training. Staff Ethics, stress management, effective Public Speaking, and staff retention were not part of the training topics. That may be due to time limit. Recommendations There should be a post training follow up after the given time so as to assist participants on areas they face challenges as per training. Simiyu RHMT should look for a best way to conducting training to the remained RHMT and CHMTs members who were not involved in this training RHMT and CHMTs who attended the training should plan on the job training for the remained members in order to share the acquired knowledge and skills.
Impact of the training to the USAID Boresha Afya interventions: At the end of the training, participants were able to understand the concept of leadership, governance and accountability; and they apply the knowledge in their day to day duties. R/CHMT members are going to demonstrate leadership, governance and management on bringing about desired changes in RM2NCAH in the councils and regions; through doing planning that is need based and client – centred, prioritizing according to RM2NCAH needs and allocating enough resources and utilize them to improve reproductive, maternal, new born, child and adolescents health. The trainees are expected to exercise accountability and ensure their subordinates are accountable hence improve quality of service provision as far as the project is concerned
8.1.1.1.7. Strengthen commodity security for improved services delivery at health facilities In this quarter, USAID Boresha Afya collaborated with the Global Health Supply Chain partner (GHSC) to support Simiyu region in their review of logistics gaps based on previous assessments' findings. Mara region was also supported to conduct a supply chain management review, which included District Pharmacists and District Laboratory Technicians, coordinated by the Regional Pharmacist and Regional Laboratory Service Coordinator. The review resulted in the design of a modified tool for ILS commodities gap assessment, for use in all health facilities in Mara. The ILS commodities gap assessment tool was disseminated separately to the key players (district level staff dealing with commodities supplies) at each District Council in the region.
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.
Figure 70: A team of facilitators during review and design of ILS tool at USAID Boresha Afya Mara Office on 19th May 2018 The Project continues to work with GHSC, district pharmacists and lab techs to monitor improvement in the availability of essential commodities for MNH, FP, Malaria, ANC and Child Health, analysing essential medicines and commodities through the use of e-LMIS reports for decision-making. The figure below depicts the status of HFs reporting under-stock of selected essential medicines in Q3 (April-June 2018) across all seven regions.
Figure 71: Percentage of facilities reporting stock-out of essential medicines for malaria, FP, MCH
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8.2 Digital Health
USAID Boresha Afya is working to establish and operationalize a digital health system in collaboration with MOHCDGEC and PO-RALG. This system is aimed at aiding the accomplishment of the broader objective of the project – to improve health outcomes of women and children. The Digital Health component of the Project is comprised of the following: Implementation of an open smart register platform (OpenSRP) to strengthen linkages between health facilities, community health workers and clients. Establishment of Closed User Groups (CUGs) at selected facilities to facilitate communication, referral and emergency transport. Deployment of Digital Health to support self-directed learning and access to reference materials for health care providers Employ Geospatial Information Systems Mapping (GIS) to aid planning and monitoring of Boresha Afya interventions in the Lake and Western Zone. 8.2.1 Implementation of OpenSRP to Strengthen the Linkage between Health Facilities, Community Health workers and Clients In this quarter, USAID Boresha Afya completed the evaluation of bids to develop and implement OpenSRP. The Project is awaiting prior approval from USAID to proceed with contractual engagement. Other preparatory work for OpenSRP development and implementation have continued. These include definition of datasets, preparation of data dictionaries and refinement of functional requirements. It is envisioned that focused preparation will speed up implementation of the system once we have a contractor on board. 8.2.2. Establishment of Closed User Groups (CUGs) at selected facilities to facilitate Communication and Referral & Emergency Transport. In this quarter, Jhpiego entered into contract with Halotel, a telecommunications operator, for providing Closed User Group (CUG) services that will be used in the area served by USAID Boresha Afya. The CUG service will enable healthcare workers in different health facilities to communicate amongst themselves. The tariffs for calls made between members of the closed user group are lower than normal consumer tariffs. Boresha Afya will use CUG to facilitate the operationalization of emergency transport system and referral management. 8.2.3. Deployment of Digital health to support self-directed learning and access to reference materials for health care providers USAID Boresha Afya Project has also entered into a contract with the Tanzania Training Center for International Health (TTCIH) to deploy an e-Learning platform to serve the Lake and Western Zone Regions. Under the agreement, Boresha Afya will leverage the TTCIH e-Learning system, that has been designated by the MoHCDGEC as the national e-Learning platform for health workers, to provide e- Learning courses and reference materials to practicing doctors, medical officers, nurses and community health workers. Boresha Afya will enrich the TTCIH platform with additional content and embed it in the OJT framework it already uses to provide a blended learning model to health workers. USAID Boresha Afya has continued working with MoHCDGEC at each step of the process to ensure ownership of the initiative by the Ministry as well as to set the groundwork for future official recognition of the e-learning platform as a contributor to Continued Professional Development for healthcare workers.
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8.2.4. Employ GIS and other Visualization formats to efficiently and accurately collect, analyze and display data to inform constant improvement efforts In the period under review, significant work was conducted in Pemba and Unguja, with the objective of mainstreaming the use of GIS in visualization of complex datasets. Among other achievements, the Project provided a free QGIS tool; teams were oriented to the GIS tools; the Project agreed on a coordinated structure of implementing activities, especially outreach; and the team produced maps on disease burden and service delivery in Zanzibar 9.0 EMMP Implementation Monitoring and Reporting In this reporting period, the project continued to monitor and implement mitigation measures as stipulated in EMMP. During Joint supportive supervision the project identified gaps on adherence to IPC guideline in some facilities. However, the project team continued to address the gaps on proper waste segregation through integrated supportive supervision and mentorship including encouraging provider to adhere to the IPC protocols. 10.0 CHALLENGES AND MITIGATION MEASURES Maternal and Newborn Health During the implementation of project activities during this quarter, some of the challenges were observed and mitigation measure were identified as shown below:
Table 27: Summary of Challenges and Mitigation Measures Challenges Mitigation 1. Critical shortage of skilled staff in some of Advocating to CHMTs to re-allocate staff the HFs by prioritizing HFs with high client volumes Capacity building for providers to be able to perform multiple tasks including EmONC, ANC & PPFP 2. Shortage of syphilis test kit, Hb test kits Advocacy to use RBF, CHF funds to purchase the missed supplies to improve quality of services 3. Inadequate adherence to standards of care CHMTs to conduct frequent supportive and staff attitude towards respectful care supervision Providers to conduct Frequent peer assessments Establishment/strengthening of learning corners
Lessons Learnt Provider’s clinical performance also depends on addressing system challenges. This requires health leadership to promptly respond to the recommended actions. It includes proper allocation of resources including skilled staff, proper use of available funds (RBF, CHF) to purchase missed medicines, availability of supplies and basic equipment, and regular communication with service providers.
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ANNEX 1: SUCCESS STORY
ANNEX 2: PROGRESS TOWARDS ANNUAL TARGETS
ANNEX 3: Q3 IMPLEMENTATION STATUS
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