Guinea Ebola Response Plan I: End of Project Report November 17, 2014–August 16, 2015

Submitted to: United States Agency for International Development under Cooperative Agreement #AID-OAA-A-14-00028

Submitted by: Jhpiego Corporation in cooperation with Save the Children

The Maternal and Child Survival Program (MCSP) is a global United States Agency for International Development (USAID) Cooperative Agreement to introduce and support high- impact health interventions with a focus on 24 high-priority countries with the ultimate goal of ending preventable child and maternal deaths within a generation. The Program is focused on ensuring that all women, newborns and children most in need have equitable access to quality health care services to save lives. MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. Visit www.mcsprogram.org to learn more.

This report is made possible by the generous support of the American people through USAID under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of MCSP and do not necessarily reflect the views of USAID or the United States Government. Guinea Summary

Jacqueline Aribot/MCSP

Strategic Objectives Prevention at facilities: Support health care workers and facilities to offer safe and high-quality health services by strengthening infection prevention and control (IPC) practices through training, supportive supervision, and complementary monitoring and evaluation. Prevention within communities: Support communities and their local leaders to combat disease transmission through improved contact tracing and intensified social mobilization.

Program Dates November 17, 2014 to August 16, 2015 (approved December 15, 2014) PY1 Approved $3,482,000 Budget Geographic 5 communes of Conakry and 3 rural prefectures—Beyla, Kissidougou, and Forekariah Focus Area No. of facilities and/or No. of regions (%) No. of prefectures (%) Geographic communities (%) Presence 4/8 (50%) 8/38 (21%) 55/461 (12)

Technical Interventions PRIMARY: Community Health and Civil Society Engagement OTHER: Ebola Response—Infection Prevention and Control

Selected Programmatic Data Number/percentage of staff in health facility who 2,985 (100%) receive IPC training Number/proportion of health facilities that have 29/51 (57%) health facilities; appropriate (and sufficient quantity of) personal 41/66 (62%) services at 3 National Hospitals protective equipment for at least 1 month Number/proportion of health facilities that have 32/51 (63%) health facilities; access to disinfecting agents (and sufficient quantity for 15/66 (23%) services at 3 National Hospitals at least 1 month) Note: MCSP was requested to monitor the indicators on availability of supplies for IPC, but was not directly involved in their provision beyond an initial stock provided to focus facilities following training.

Guinea Ebola Response Plan I: End of Project Report iii Table of Contents

Guinea Summary ...... iii Table of Contents ...... iv List of Tables and Figures ...... v Abbreviations ...... vi Acknowledgments ...... vii Executive Summary ...... viii Introduction ...... 1 Goal and Objectives ...... 2 Major Accomplishments ...... 3 Objective 1: Prevention at Facilities ...... 3 1.1. Active Participation of MCSP in Coordination Nationale de Lutte contre la Maladie à Virus Ebola ...... 3 1.2. Train/Update Consultant Trainers ...... 4 1.3. Procure and Supply Necessary Sterilization and Sanitation/Waste Management Equipment for Trainings ...... 6 1.4. Conduct Site Selection, Rapid Assessment of Target Sites and Preparation for the IPC Trainings and Supervision ...... 6 1.5. Conduct Trainings for Facility Staff ...... 7 1.6. Conduct Routine Quality Assurance Visits and Provide Additional Follow-Up Support ...... 8 1.7. Monitoring and Evaluation ...... 11 Objective 2: Ebola Virus Disease (EVD) Prevention within Communities...... 19 2.1. Behavior Change Communication and Sensitization ...... 19 2.2. Sensitization for Civil Society Groups and Community Health Worker (CHW) Associations ...... 20 2.3. Contact Tracing and Surveillance in Affected Sub-Prefectures ...... 20 2.4. Coordination and Technical Support to the Direction Préfectorale de la Santé (DPS) ...... 21 Recommendations and Way Forward ...... 22 Appendix 1: Performance Monitoring Plan ...... 25 Appendix 2: Impact Story ...... 37 Appendix 3: Health Facilities Supported by the Ebola Response Project ...... 38 Appendix 4: Infection Prevention and Control Materials Provided to Facilities of Focus ... 40 Appendix 5: List of Presentations at International Conferences and Publications ...... 42 Appendix 6: Materials and Tools Developed or Adapted by the Ebola Response Project .. 43

iv Guinea Ebola Response Plan I: End of Project Report List of Tables and Figures Figure 1: Map of Guinea and type of Ebola Virus Disease interventions ...... 2

Table 1. Infection prevention and control (IPC) trainers by location and professional category ...... 5

Table 2. Number of health care providers trained in infection prevention and control (IPC), by profession and geographic location ...... 8

Table 3. Trained health care providers categorized by profession and location ...... 10

Table 4. Number of health care providers and support staff coached ...... 10

Table 5. Comparison of baseline, midterm, and end-of-project assessments of infection prevention and control (IPC) performance at Donka National Hospital (December 2014 to August 2015) ...... 11

Figure 2. Comparison of baseline, midterm, and end-of-project assessments of infection prevention and control (IPC) performance at Ignace Deen National Hospital (December 2014 to August 2015) ...... 12

Figure 3. Comparison of baseline, midterm, and end-of-project assessments of infection prevention and control (IPC) performance at Sino-Guinéen National Hospital (December 2014 to August 2015) ...... 13

Figure 4. Comparison of baseline, midterm, and end-of-project assessments of infection prevention and control (IPC) performance at health facilities in Conakry and Kissidougou (December 2014 to August 2015) ...... 14

Figure 5. Comparison of baseline, midterm, and end-of-project assessments of infection prevention and control (IPC) performance at health facilities in Forécariah and Beyla (December 2014 to August 2015) . 15

Figure 6. Evolution of infection prevention and control (IPC) performance in the 66 services of the three national hospitals in Conakry (December 2014 to August 2015) ...... 15

Figure 7. Evolution of infection prevention and control (IPC) performance in the seven medical centers and three prefectural hospitals in Beyla, Forécariah, and Kissidougou (December 2014 to August 2015) . 16

Figure 8. Evolution of infection prevention and control (IPC) performance in the 42 health centers of Beyla, Forécariah, and Kissidougou (December 2014 to August 2015) ...... 17

Figure 9. Evolution of the percent of health personnel infected with Ebola Virus Disease (EVD) by Region/ Prefecture (December 2014 to May 2015)...... 18

Guinea Ebola Response Plan I: End of Project Report v Abbreviations

CHW community health worker CMC centre médical communal (communal medical center) CMS centre médicosocial (sociomedical health center) Coordination Nationale de Lutte contre la Maladie à Virus Ebola (National CNLEB Coordination for the Fight against the Ebola Virus) CS centre de santé (health center) CSR centre de santé rurale (rural health center) CSR centre de santé urbain (urban health center) CVV comité de veille villageois (community surveillance committees) DART Disaster Assistance Response Team DCS Direction Communautaire de la Santé (Community Health Directorate) DPS Direction Préfectorale de la Santé (Prefectural Health Directorate) DRS Direction Regionale de la Santé (Regional Health Directorate) DSC Direction de la Santé Communautaire (Community Health Directorate) Direction Sanitaire de la ville de Conakry (Health Directorate of the City of DSVCo Conakry) EVD Ebola Viral Disease HP hôpital préfectorale (prefectural hospital) HR hôpital regionale (regional hospital) IP Infection Prevention IPC infection prevention and control MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MOH Ministry of Health OFDA Office of U.S. Foreign Disaster Assistance NGO Nongovernmental Organization PPE personal protective equipment SBM-R Standards-Based Management and Recognition WHO World Health Organization

vi Guinea Ebola Response Plan I: End of Project Report Acknowledgments Key Partners

• Maternal and Child Survival Program (MCSP) partners, Jhpiego, and Save the Children thank our collaborators and partners. • Ministry of Public Health and specifically, the Secretary General, the Coordination Nationale de Lutte contre la Maladie à virus Ebola, National Directorate of Family Health and Nutrition, National Directorate of Prevention and Community Health, National Malaria Control Program, and the National Program on Integrated Management of Childhood Illness • Regional health offices of Conakry, Kankan, Kindia, Faranah, and N’zérékoré, and the prefectural and communal health offices in these regions • Health care workers in MCSP-supported facilities and community health workers engaged in bringing health information and services to their communities • World Health Organization, United Nations Fund for Population Activities, and UNICEF • Implementing partners of United States Agency for International Development, Office of U.S. Foreign Disaster Assistance, and the Centers for Disease Control and Prevention • Médecins Sans Frontières—Belgium, Action Contre la Faim, Alliance for International Medical Action, Women and Health Alliance International, and other nongovernmental organizations (NGOs) engaged in the Ebola response and in particular, infection prevention and control • Local NGOs and civil society organizations that collaborated with MCSP • Local radio stations and theater groups that partnered with the Ebola Response Project

The MCSP Team

• In-country technical team: Professor Yolande Hyjazi, Dr. Gassim Cissé, Dr. Bokar Dem, Dr. Havanatou Camara, Dr. Suzanne Austin, Dr. Mamadou Malal Diallo, Bamba Mamady Camara, Jacqueline Aribot, Dr. Abdoulaye Diallo, Dr. Ibrahim Pita Bah, and Bakary Berete • In-country Save the Children team: Fatoumata Diakite, Adama Diop, and the many community organizers • Finance, administration, and operations team: Antoine Lamah, Mamadou Amadou Diallo, Sougoulé Ténin, Thierno Saidou Diallo, El Hadj Mamadou Saliou Bah, and Abbas Kourouma • Headquarters’ technical support team: Dr. Tsigue Pleah, Professor Blami Dao, Ruparelia Chandrakant, Willy Shasha • Headquarters’ program team: Rachel Waxman, Erin Fleming, Lauran Skolnik, Karine Nankam, Caroline Tran, Joan Peto, and Linda Benamor (for translation support)

Guinea Ebola Response Plan I: End of Project Report vii Executive Summary

The Maternal and Child Survival Program (MCSP) is a global cooperative agreement funded by the United States Agency for International Development (USAID) to introduce and support high-impact health interventions in 24 priority countries, and it has the ultimate goal of ending preventable maternal and child deaths within a generation. MCSP carries forward the momentum and lessons learned from the highly successful USAID-funded Maternal and Child Health Integrated Program (MCHIP), which made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America, and the Caribbean. MCSP interventions build on the development of local training capacity among health care providers in Guinea, focusing on competency-based training methods that work to improve both knowledge and skills. These efforts build from previous work specifically on infection prevention practices in health care facilities, and a focus on quality improvement and supportive mentoring and supervision to assist health care providers translate new skills into practice at their worksites.

In order to contribute to the response to the Ebola Virus Disease (EVD) epidemic in Guinea and the severe effects the epidemic had on the country’s health services, including increased risk for health care providers, USAID requested MCSP to develop a work plan to address infection prevention and control (IPC) practices in facilities and work with communities to prevent disease transmission. The Ebola Response Project was approved for a period of nine months from November 17, 2014 to August 16, 2015. The geographic areas of focus were determined in collaboration with the Coordination Nationale de Lutte contre la Maladie à Virus Ebola ([CNLEB], National Ebola Response Coordinating Committee), Centers for Disease Control and Prevention (CDC), Office of U.S. Foreign Disaster Assistance (OFDA) Disaster Assistance Response Team (DART), and US government-supported partners, including Catholic Relief Services and Save the Children. (Save the Children is leading the activities in Objective 2 of this project.)

The focus areas for this project are the capital city of Conakry and three rural prefectures: Beyla, Forécariah, and Kissidougou. MCSP is supporting 55 targeted facilities in these areas: three national hospitals (Donka, Ignace Deen, and Sino-Guinéen), three prefectural hospitals (Beyla, Forécariah, and Kissidougou), six centres médical communal ([CMCs], communal medical centers—five in Conakry and one in Beyla prefecture), one sociomedical center (Jean Paul II/ Conakry), and 42 health centers in the three prefectures.

The goal of the MCSP Ebola Response Project in Guinea was to scale up efforts to prevent and control the spread of EVD to protect and maintain quality reproductive, maternal, newborn, and child health services.

The key achievements for this nine-month project are presented by the two project objectives: 1) prevention at facilities and 2) prevention within communities.

Objective 1: Prevention at Facilities Objective 1 focused on supporting health care workers and facilities to continue to offer high quality health services in a safe environment by strengthening IPC practices through training, supportive supervision, and complementary monitoring and evaluation.

viii Guinea Ebola Response Plan I: End of Project Report 1.1. Active Participation of MCSP in National Level Coordination

• MCSP has provided technical support to CNLEB. As a member of this committee, MCSP has assisted in improving national protocols for EVD treatment centers, managing community transit centers, and promoting safe burial practices. • MCSP contributed to the creation of an IPC Technical Committee under the CNLEB in collaboration with USAID, OFDA/DART, CDC, and the World Health Organization (WHO). The committee comprises 15 national and international organizations, and it leads the standardization of IPC training documents and establishment of triage units across the country. • Jhpiego’s IPC training curriculum, introduced to the committee through MCSP, and MCSP’s IPC training strategy have been adopted as the national standard by both the IPC Technical Committee and CNLEB. • In November 2014, MCSP participated in the development of a set of community-focused educational materials (health education messages, posters, and visual aids) that have been validated by the Ministry of Health (MOH); 500,000 copies have been distributed with support from donors. • In February 2015, MCSP coordinated the establishment of a triage and isolation unit for medical and surgical emergencies at Donka National Hospital in collaboration with Médecins sans Frontières—Belgium, WHO, CDC, and the hospital administration. In the first two months of operation, the unit identified 51 suspected cases and 11 (22%) of these were confirmed positive for EVD. • In collaboration with the MOH and CNLEB, MCSP participated in the validation workshops for IPC reference documents and training curricula for basic training institutions. • With the goal of ending cross-border infections, MCSP provided technical support during the joint microplanning between the Forécariah prefecture and neighboring Kambia District in Sierra Leone. • MCSP provided technical assistance to partner organizations in need of IPC training, including 19 trainers from the African Union’s mission in Guinea and other organizations, such as the WHO, Action Contre La Faim, Première Urgence—Aide Médicale Internationale, International Medical Corps, and the CDC. • To improve the quality of trainings, MCSP supported the development of directives to define and certify trainers and master trainers. The IPC Technical Committee tasked the MCSP technical team with updating the trainers’ knowledge and evaluating the trainers for certification.

1.2. Train/Update Consultant Trainers

• In November 2014, MCSP participated in a regional EVD prevention and IPC training program in Accra, Ghana, led by Jhpiego, and attended by representatives of several West African countries. At this training, MCSP assisted in developing IPC training documents later used to train trainers in Guinea. • MCSP initiated the Ebola Response Project with an IPC update for 27 trainers who were previously trained under MCHIP. In February 2015, five additional MCHIP-trained trainers joined 18 new candidate trainers who were selected from a group of providers who had completed the IPC training and demonstrated initiative in improving IPC; this group was

Guinea Ebola Response Plan I: End of Project Report ix trained in Clinical Training Skills, resulting in 50 qualified IPC trainers to support the MOH and the CNLEB’s response to EVD. • 1.3. Procure and Supply Necessary Sterilization and Sanitation/Waste Management Equipment for Trainings

• Based on site assessment data and feedback from IPC trainings, MCSP developed a list of 23 crucial IPC products—including equipment, consumables, and waste management tools— necessary for the implementation of IPC measures and practices. MCSP provided a one- month supply of materials (unless the materials were available through other sources) following the training to each of the 55 facilities, including the 66 different services of the three national teaching hospitals. The IPC materials were also offered as incentives to sites with improved performance standard scores.

1.4. Conduct Site Selection, Rapid Assessment of Target Sites, and Preparation for the IPC Trainings and Supervision

• Starting in December 2014, MCSP conducted baseline assessment in the 55 targeted facilities to identify IPC performance and gaps to address with training and onsite coaching. The assessment also evaluated the availability of materials and consumables, including personal protective equipment. Standards used for the baseline assessment were also used during the training and for the midterm and end-of-project performance assessment.

1.5. Conduct Trainings for Facility Staff

• In collaboration with health facility administrators, MCSP trained 2,985 providers in 121 five-day training sessions that were held from December 2014 to March 2015. The training sessions targeted all health care personnel working in 55 health facilities located in some of the areas hardest hit by the EVD epidemic: Conakry, Forécariah, Kissidougou, and Beyla. The sessions were led by IPC consultant trainers and were also attended by members of the local Direction Préfectorale de la Santé ([DPS], Prefectural Health Directorate) and Direction Regionale de la Santé ([DRS], Regional Health Directorate). • MCSP conducted a special training session in March 2015 targeting 32 department heads of Donka and Ignace Deen National Hospitals. The session reviewed the IPC training content, oriented the department heads to national and international IPC guidelines, and elicited interest and commitment from department heads to integrate IPC measures and support staff in their respective departments.

1.6. Conduct Routine Quality Assurance Visits and Provide Additional Follow-Up Support

• Within a month after the training, consultant trainers conducted follow-up visits to review implementation of IPC practices and assist staff to address challenges. In each prefecture, six to eight coaches were identified among well performing providers, so that they could further support the implementation of high-quality IPC practices and strengthen hygiene and safety committees in targeted health facilities. The coaches were trained on coaching skills and use of IPC supervisory tools. Consultant trainers and MCSP technical advisors supported the coaching as well as prefectural and facility health managers. Coaching sessions were organized at least twice a month in Conakry and once a month in rural prefectures (due to travel time required). As a result, 91% (3132/3441) of trained health care x Guinea Ebola Response Plan I: End of Project Report providers and auxiliary staff at all 55 targeted facilities received supervisory support during the project period. • MCSP conducted a one-day IPC training for 447 support staff members (e.g., janitors and orderlies) at seven health facilities using materials developed by the MOH. The trainers taught a broad range of fundamental IPC skills, including preparation of chlorine solution and proper waste collection and disposal, and taught in the local language to ensure comprehension of the content delivered.

1.7. Monitoring and Evaluation

• In December 2014, April 2015, and August 2015, MCSP conducted performance evaluations using the Standard-based Management and Recognition process to assess the implementation of IPC performance standards at each of the 55 health facilities. See tables below for detailed results. An analysis of performance scores at baseline (December 2014), second (April 2015), and third evaluations (August 2015) reveals the following progress: • At the national hospitals of Donka, Ignace Deen, and Sino-Guinéen, 66 services were evaluated and the median performance score rose from 24% (baseline) to 50% (second evaluation) to 68% (third evaluation). • At seven CMCs in Conakry and Beyla, and three prefectural hospitals in Beyla, Forécariah, and Kissidougou, the median performance score rose from 20% (baseline) to 50% (second evaluation) to 62% (third evaluation). • At the remaining 42 health centers supported by the project, the median performance score rose from 19% (baseline) to 42% (second evaluation) to 67% (third evaluation). • From December 2014 to May 2015, MCSP’s monitoring and evaluation team recorded a marked decrease in the rate of EVD infection among health care providers in targeted project areas: • In Conakry, the infection rate dropped from 14% in December 2014 to 4% in May 2015. • In Forécariah, the infection rate dropped from 25% in December 2014 to 1% in May 2015. • In Kissidougou, the infection rate dropped from 5% in December 2014 to 0% in May 2015. • In Beyla, the infection rate dropped from 34% in December 2014 to 0% in May 2015.

Objective 2: Ebola Virus Disease (EVD) Prevention within Communities Objective 2 focused on supporting communities and their local leaders to combat disease transmission through improved contact tracing, intensified social mobilization, and improved technical assistance to district health teams.

2.1. Behavior Change Communication and Sensitization on Ebola Virus Disease (EVD) Prevention and Hygiene Promotion in Affected Sub-Prefectures through Public Health Committees and Radio Messages

• A local theater troupe was engaged to design participatory community theater. A play called “Le Proces d’Ebola” (Ebola on Trial) helped raise awareness and enabled public discussion

Guinea Ebola Response Plan I: End of Project Report xi through a question and answer format. Along with 300 participants in Forécariah and 200 in Coyah, approximately 3,075 people participated in the theater troupe’s performances in five urban communes of Conakry. • A soccer match for the fight against Ebola was organized in the prefecture of Kouroussa. The match was chaired by the prefectural coordinator and involved prefectural officials and field partners (Guinean Red Cross, WHO, CERADE, and CENAFOD). The match was between two teams composed of women who worked as vendors and teachers in Kouroussa. General Ebola awareness messages were conveyed by project staff during the event with an emphasis on the importance of safe burial practices, monitoring contacts, and referring patients to the health centers. This match brought together approximately 4,300 spectators. • 249 group talks and sensitization sessions were carried out in the prefectures of Kouroussa, Beyla, and Kankan, and in the communes of urban Conakry. These sessions focused on Ebola prevention measures and active surveillance for cases, acceptance of handwashing devices, use of “thermoflash” thermometers, and rumor management in schools. These awareness sessions were conducted in schools and communities by members of comité de veille villageois ([CVV], community surveillance committees) in Kouroussa and Beyla, and by the communication and social mobilization supervisors in the communes of Conakry. Approximately 30,000 people were reached through these educational sessions. • Radio broadcasts on local radio stations and in local languages were also used as a way to disseminate key information and messages. Round table radio discussions were organized with staff from prefectural health offices and project staff to present key topics related to Ebola and to discuss topics such as reluctance in the villages, safe burial practices, and the use of handwashing devices to prevent the disease. Seven round tables were recorded in Conakry, Kouroussa and Beyla, and were rebroadcast a total of 22 times. Eight interactive sessions were also held to query listeners who called. An estimated 53,000 were reached by the broadcasts.

2.2. Sensitization for Civil Society Groups and Community Health Worker (CHW) Associations

• Focus groups were conducted with 463 members of civil society of Dixinn-Conakry in order to support them to influence their communities to discard myths about EVD and better understand some of the constraints to behavior change. Participants included community leaders, religious leaders, and representatives of women's and youth associations. • EVD awareness training was provided to 233 members of 67 civil society associations, including community health worker (CHW) associations, and two police brigades. • To ensure participation from women, members of 300 women’s associations (Serés) in Conakry were sensitized to the importance of women’s involvement in the EVD response. Each Serés was represented by three people (president, vice-president, and councilor); 900 women were sensitized/trained, and 300 handwashing kits and 300 cartons of soap were given to each association. It is estimated that 6,000 to 9,000 women directly benefitted since each Serés is composed of 20 to 30 members.

2.3. Contact Tracing and Surveillance in Affected Sub-Prefectures

xii Guinea Ebola Response Plan I: End of Project Report • MCSP supported the orientation of 100 CVVs in Kouroussa and Beyla. This orientation included 200 CHWs and trained 28 new CHWs in Conakry to support contact tracing. The project provided the committees and CHWs with contact monitoring kits, and the project conducted regular supervision and provided monthly incentive payments as mandated by the CNLEB. 3,195 contacts were followed in the project intervention areas during the life of the project; of these contacts, 92% were successfully followed for the full 21-day period. • Another approach to improving surveillance was to provide training to pharmacists, health care workers, and traditional healers who work outside of the public health system. These trainings were particularly pertinent because the public had lost its confidence in the public health system and feared acquiring infections therein; as a result, many patients/sick people actively sought private healers or practitioners, many of whom are not registered to provide medical care and may not have clinical training. 1,463 people were trained on the case definition of EVD, personal protection, and referrals.

2.4. Coordination and Technical Support to the Direction Prefectorale de la Santé (DPS) to Help Manage the Ebola Virus Disease (EVD) Response at the Prefecture Level

• MCSP worked closely with the DPS offices in the targeted prefectures; its work included providing materials support, such as fuel for ambulances and generators, phone credit, and support in distributing materials to health centers. • Several thematic groups (communication, surveillance, safe burials, and logistics) were implemented to enable all partners to contribute to the development of action plans and coordinate resources. MCSP’s active participation in these groups helped to clarify who was providing what support to health worker groups, such as CHWs and CVVs, thereby avoiding duplication of efforts.

Recommendations and Way Forward The implementation activities of the MCSP Ebola Response Project have helped save the lives of service providers; strengthen IPC practices, standards, and protocols in health facilities; and provide a foundation for the restoration of maternal, newborn and child health services post- Ebola. MCSP’s work will continue through the Restoration of Health Services Project to support the efforts and results achieved in the Ebola Response Project, and to contribute to the institutionalization of IPC as the basis for providing quality health services in Guinea.

Key lessons from this project include: • Attention to IPC is an essential component of health systems strengthening and the initial response to an infectious disease outbreak. • Post-training follow-up is an integral aspect of ensuring continuing success in changing behaviors and improving IPC. • The MOH does not have an accurate census of the number of staff working in health facilities. • No goods, no services, or IPC. Lack of the materials for IPC put providers and patients at risk when they are unable to put into practice the existing guidelines

Guinea Ebola Response Plan I: End of Project Report xiii • Strong leadership is critical to sustain the systemic integration of IPC standards at all levels of the health system. • Local leadership is essential in an emergency response, and it starts in routine health services and systems. • Regulation of the private sector is needed.

xiv Guinea Ebola Response Plan I: End of Project Report Introduction

The Maternal and Child Survival Program (MCSP) is a global cooperative agreement funded by the United States Agency for International Development (USAID) to introduce and support high-impact health interventions in 24 priority countries, and has the ultimate goal of ending preventable maternal and child deaths within a generation. MCSP carries forward the momentum and lessons learned from the highly successful USAID-funded Maternal and Child Health Integrated Program (MCHIP), which has made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America, and the Caribbean. MCSP interventions build on the development of local training capacity among health care providers in Guinea with a focus on competency-based training methods that work to improve both knowledge and skills. These build from previous work, specifically on infection prevention practices in health care facilities, and a commitment to quality improvement and supportive mentoring and supervision to assist health care providers translate new skills into their ongoing practice.

To respond to the current Ebola Virus Disease (EVD) epidemic in Guinea and the disease’s severe effects on health services, including increased risks for health care providers, USAID requested MCSP to develop a work plan to address the infection prevention and control (IPC) practices in facilities and work with communities to prevent disease transmission. The Ebola Response Project was approved for a period of nine months from November 17, 2014 to August 16, 2015. The geographic areas targeted were determined in collaboration with the Coordination Nationale de Lutte contre la Maladie à Virus Ebola ([CNLEB], National Coordination for the Fight against the Ebola Virus), the Centers for Disease Control and Prevention (CDC), Office of U.S. Foreign Disaster Assistance (OFDA), and US-government supported partners, such as Catholic Relief Services and Save the Children. (Save the Children is leading the activities of Objective 2 in this project.)

The targeted areas for this project are the capital city of Conakry and three rural prefectures: Beyla, Forécariah, and Kissidougou. MCSP is supporting the 55 targeted facilities in these areas: three national hospitals (Donka, Ignace Deen, and Hôpital Sino-Guinéen), three prefectural hospitals (Beyla, Forécariah, and Kissidougou), six centre médical communal ([CMCs], communal medical centers; five in Conakry and one in Beyla prefecture), one sociomedical center (Jean Paul II/Conakry), and 42 health centers in the three prefectures. Refer to Figure 1 for a map of the focus areas.

Guinea Ebola Response Plan I: End of Project Report 1 Figure 1: Map of Guinea and type of Ebola Virus Disease interventions

Goal and Objectives The goal of the MCSP Ebola Response Project in Guinea is to scale up efforts to prevent and control the spread of EVD, in order to protect and maintain quality reproductive, maternal, newborn, and child health services.

The key objectives of the Ebola Response Project are: • Objective 1—Prevention at facilities: Support health care workers and facilities to continue to offer high quality health services in a safe environment by strengthening IPC practices through training, supportive supervision, and complementary monitoring and evaluation. • Objective 2—Ebola virus disease (EVD) prevention within communities: Support communities and their local leaders to combat disease transmission through improved contact tracing, intensified social mobilization, and improved technical assistance to district health teams.

The rapid implementation of this project led the OFDA to further fund MCSP to extend IPC training to five other prefectures (referred to as the IPC2 project and reported on separately). Jhpiego also successfully leveraged funding from the World Health Organization (WHO) and Alcoa Foundation to conduct IPC training in additional prefectures.

In additions to the project achievements listed in the following pages, MCSP staff highlighted project activities and success via international conference presentations and journal publications; additional details can be found in Appendix 5.

2 Guinea Ebola Response Plan I: End of Project Report Major Accomplishments

An official launch of the MCSP Guinea’s Ebola Response project was held on February 19, 2015 in a ceremony officiated by the Ministry of Health’s Chief of Staff, with the support of representatives from the Direction de la Santé Familiale (Family Health Directorate) and the Direction de la Santé Communautaire ([DSC], Community Health Directorate). The event was attended by sixty guests including the Ambassador of the United States, representatives of USAID, and the administrators of national hospitals and local health centers. The welcome address was given by the Director of Donka National Hospital. The U.S. ambassador followed with a speech, and the Ministry of Health’s representative concluded with a few words.

The key achievements for this nine-month project are presented by the two project objectives: 1) prevention at facilities and 2) prevention within communities.

1.1. Active Participation of MCSP in Coordination Nationale de Lutte contre la Maladie à Virus Ebola CNLEB was formed to lead the national, multi-sectoral EVD response and consists of several technical working groups, including IPC and community engagement. MCSP has been an active leader in several initiatives and working groups coordinating the national response to the EVD epidemic in Guinea.

Throughout the project period, MCSP provided technical support to CNLEB, particularly in the effort to improve national protocols for EVD treatment centers, manage community transit centers, and promote safe burial practices. MCSP also participated in the development of a set of community-focused EVD prevention educational materials (health education messages, posters, and visual aids) that have been validated by the Ministry of Health (MOH); 500,000 copies have been distributed with support from donors.

The MCSP team contributed to the creation of an IPC Technical Committee under the CNLEB in collaboration with USAID, OFDA Disaster Assistance Response Team (DART), CDC, and WHO. The Technical Committee, which has become an important source of technical support within the CNLEB, comprises 15 national and international organizations and leads the standardization of IPC training documents and establishment of triage units across the country. Jhpiego’s IPC training curriculum and MCSP’s IPC training strategy have been adopted by both the IPC Technical Committee and CNLEB as a national standard.

MCSP also worked closely with partners to develop triage protocols for routine health services in order to screen patients for EVD symptoms for prompt referral to Ebola Treatment Units (ETUs) and avoid admittance of EVD patients into the hospital. MCSP coordinated the establishment of a triage and isolation unit for medical and surgical emergencies at Donka National Hospital in collaboration with Médecins sans Frontières—Belgium, WHO, CDC, and the hospital administration. In the first two months after its opening in February 2015, the triage unit at the largest hospital in the country identified 51 suspected cases, 11 (22%) of which were confirmed positive for EVD.

Guinea Ebola Response Plan I: End of Project Report 3 To support efforts to improve the quality of IPC trainings throughout the country, MCSP, in collaboration with the MOH and the CNLEB, participated in workshops to validate IPC reference documents and training curricula for basic training institutions. The reference documents were also accompanied by the development of directives to define and certify trainers and master trainers. The IPC Technical Committee tasked the MCSP technical team with updating the trainers and evaluating them for certification.

The IPC reference documents validated by the CNLEB were also used by MCSP to provide IPC training to partner organizations, including WHO, Action Against Hunger, Première Urgence— Aide Médicale Internationale, International Medical Corps, CDC, and 19 trainers from the African Union’s mission in Guinea. Additional information reference documents and materials developed or adapted with MCSP’s support can be found in Appendix 6.

MCSP also responded to the EVD epidemic on a regional level by providing technical support during the joint microplanning between the Forécariah prefecture and neighboring Kambia District in Sierra Leone; both areas have been epicenters of the EVD epidemic in their respective countries. The intervention was two weeks in duration and had the goal of ending cross-border infections.

1.2. Train/Update Consultant Trainers In November 2014, MCSP participated in a regional EVD prevention and IPC training in Accra, Ghana, led by Jhpiego and attended by representatives of several West African countries. At this training, MCSP assisted in the development of IPC training documents that were later used to train trainers in Guinea.

The following month, MCSP initiated an IPC update for 27 trainers who were previously trained through MCHIP. This group became the trainers/coaches for future training groups and were referred to as consultant trainers. In Participants are in the first IPC training-of- February 2015, five additional MCHIP-trained trainers session in December 2015 trainers joined 18 new candidate trainers who were selected from providers who had completed the IPC training and demonstrated initiative in improving IPC; this group was trained in Clinical Training Skills, resulting in a total of 50 qualified IPC trainers to support the MOH and the CNLEB’s fight against EVD. As shown in Table 1, the trainers were selected with a conscious regard for recruiting the widest geographic representation possible and a variety of professional categories.

4 Guinea Ebola Response Plan I: End of Project Report Table 1. Infection prevention and control (IPC) trainers by location and professional category Prefecture or Commune/ Professional Category Total Health Facility N MW MD O/G Conakry Dixinn 3 6 7 14 CHU Donka 2 6 5 9 CMC Miniere 1 2 3 Ratoma 1 2 1 2 CMS Jean Paul II 1 CMC Ratoma 1 1 2 DSVCo 1 Kaloum 12 CHU Ignace Deen 1 1 3 4 12 Matam 6 CMC Coleah 1 1 1 3 CMC Matam 1 1 1 3 Dubréka 1 1 DPS Dubreka 1 1 Faranah 2 2 DPS Faranah 1 1 HR Faranah 1 1 Forécariah 1 1 3 DPS Forécariah 1 1 CS Farmoriah 1 2 Kankan 1 2 1 4 DRS Kankan 1 1 HR Kankan 1 1 1 3 Kissidougou 2 1 HP Kissidougou 2 1 Siguiri 1 1 HP Siguiri 1 1 Nzérékoré 1 HR Nzérékoré 1 1 Kindia 1 1 2 HR Kindia 1 1 CS Manquepas 1 1 Boké 1 1 CS Kassapo 1 1 Total 50

Notes: university hospitals [CHU]; centre médical communal ([CMC], communal medical center); centre médicosocial ([CMS], sociomedical health center); Centre de Sante ([CS], health centers; Direction Préfectorale de la Santé ([DPS],

Guinea Ebola Response Plan I: End of Project Report 5 Prefectural Health Directorate); Direction Regionale de la Santé ([DRS], Regional Health Directorate); Direction Sanitaire de la ville de Conakry ([DSVCo], Health Directorate of the City of Conakry); hôpital prefectorale [HP], prefectural hospital); hospital regionale ([HR], regional hospital); nurse (N); midwife (MW); medical doctor/general physician (MD); and obstetrician/gynecologist (OB)

1.3. Procure and Supply Necessary Sterilization and Sanitation/Waste Management Equipment for Trainings The availability of materials and supplies necessary for sterilization and waste management has been an essential component of breaking the chain of infection during the EVD outbreak. Due to the chronic stock out of materials necessary to adhere to IPC standards, MCSP developed a strategy to provide project-supported facilities with an initial stock of inputs after the training of health care personnel. Based on site assessment data and feedback from IPC trainings, MCSP developed a list of 23 crucial IPC products—including equipment, consumables, and waste management tools— necessary for the implementation of IPC measures and practices. Donations of handwashing stations at Donka [left] and IPC inputs at Following the training, MCSP Ignace Deen [right] in Dec 2014 provided a one-month supply of the materials (unless available through other sources) to each of the 55 facilities, including the 66 different services at the three national teaching hospitals. IPC materials were also offered as incentives to sites with improved performance standard scores.

Given the shortage of water in many health facilities, MCSP also donated 140 handwashing stations, which were obtained from a local supplier, to support all departments at national hospitals adhere to this fundamental element of IPC protocols.

The distribution of the handwashing stations, along with all other IPC inputs, were determined based on the services provided by each health facility. Health structures in the prefectures of Beyla, Kissidougou, and Forécariah did not receive the initial stock of donations from MCSP because they had already been receiving material support from Women and Health Alliance, Médecins Sans Frontières—Belgium, and Action Contre la Faim, respectively. However, MCSP regional coordinators assigned to these prefectures collaborated closely with the local Direction Préfectorale de la Santé ([DPS], Prefectural Health Directorate) teams to ensure the availability and effective distribution of IPC inputs in health facilities. Additional information on inputs is in Appendix 4.

1.4. Conduct Site Selection, Rapid Assessment of Target Sites and Preparation for the IPC Trainings and Supervision Starting in December 2014, MCSP conducted baseline assessment of the 55 targeted facilities to identify IPC performance and identify gaps to address through training and onsite coaching. Appendix 3 provides a complete list of the project’s targeted facilities. The assessment also evaluated the availability of materials and consumables including personal protective equipment (PPE). The standards used for the baseline assessment were developed by Jhpiego and the Ministry of Health (MOH) during the USAID-funded Access to Clinical and Community Maternal, Neonatal and Women's Health Service Program—Family Planning

6 Guinea Ebola Response Plan I: End of Project Report (ACCESS-FP) project and were used during the IPC trainings, midterm assessments conducted three months after the trainings, and end-of-project performance assessments.

1.5. Conduct Trainings for Facility Staff Training providers in IPC is a key intervention in MCSP Guinea’s Ebola Response Project, which is aimed at preventing the spread of EVD and protecting health personnel against this infection. The competency-based IPC trainings were further reinforced by onsite coaching visits, as well as by monitoring and evaluation activities that also served to strengthen the health system.

In collaboration with the management teams of hospitals, centres médical communal ([CMCs], communal medical centers), and DPS, MCSP developed a training plan that included a targeted number of providers and a list of inputs necessary to successfully implement the trainings. Following the initial planning period, MCSP trained 2,985 providers in IPC practices that focused on EVD at 121 five-day training sessions, which occurred from December 2014 to March 2015. The trainings were facilitated by IPC trainers trained and qualified by MCSP, and targeted health care personnel working in 55 health facilities located in some of the areas hardest hit by Health providers participate in a handwashing the EVD epidemic: the five communes of Conakry and activities using paint as part of IPC training. the prefectures of Forécariah, Kissidougou, and Beyla. Members of the local DPS and direction regionale de la santé ([DRS], regional health directorate) teams also attended the sessions. The location and clinical qualifications of the training participants are in Table 2.

Each five-day training session reached approximately 25 providers and due to the magnitude of the epidemic, several parallel sessions in different project-supported sites were implemented to reach as many providers as possible. The trainings included theoretical and practical sessions in simulated classroom situations and field visits to real situations at various departments of hospitals.

MCSP also conducted a special training session in March 2015 to target the 32 department heads of IPC training participants in Conakry practice putting Donka and Ignace Deen National Hospitals. The training session reviewed the IPC training content on and taking off Tyvek PPE suits. and gave the department heads an orientation to national and international IPC guidelines. This special session was also used to elicit the interest and commitment from department heads to integrate IPC measures and support staff in their respective departments.

Guinea Ebola Response Plan I: End of Project Report 7 Table 2. Number of health care providers trained in infection prevention and control (IPC), by profession and geographic location

Commune

Auxiliary Nurse Biologist Dentist Dermatologist Student Nurse Generalist Doctor, Pediatrician Pharmacist Professor Midwife Technician Health Public Supervisor Technician Lab Other Grand Total Prefecture/

Conakry Dixinn 61 57 18 13 45 295 409 18 22 6 70 2 9 9 1034 28 38 13 24 232 314 6 14 7 37 1 13 7 734 Kaloum 40 24 7 53 59 6 5 47 1 1 243 Matam 1 1 2 Matoto 36 19 3 4 82 71 3 7 33 5 2 265 Ratoma 91 6 15 7 1 3 1 124 Beyla 116 13 6 26 13 1 12 4 8 199 Forécariah 272 17 39 18 3 22 7 3 381 Kissidougou 1 1 Coyah 2 2 Faranah Grand 644 175 41 13 79 743 894 33 53 13 224 4 39 30 2985 Total Note: The “other” category includes radiology technician, civil administrator, engineer, nutritionist, pulmonologist, nurse supervisor for the leprosy program, and other health care professionals.

1.6. Conduct Routine Quality Assurance Visits and Provide Additional Follow-Up Support Within a month after the training, consultant trainers conducted follow-up visits to review implementation of IPC practices and assist staff to address challenges. In each prefecture, six to eight coaches were identified among well performing providers, so that they could further support the implementation of high-quality IPC practices and strengthen hygiene and safety committees in the targeted health facilities. The local coaches participated in the finalization of their terms of reference and received an orientation from the MCSP team on: • Coaching skills; • Use of IPC performance standards to improve the quality of services; • Strategic approach to ensure compliance with IPC protocols (e.g., waste management, laundry treatment, equipment management, handwashing, and use of gloves);

8 Guinea Ebola Response Plan I: End of Project Report • Supervision plan for each health care provider in each health district; and • Use of IPC supervisory tools (e.g., summary sheet for IPC standards and records of support staff orientations)

Coaches were trained to support newly-trained providers by: Observing staff to assess skill competency using a checklist; • Providing feedback and demonstrating the skill correctly and using the checklist; and • Encouraging the provider to practice the skill, under the coach’s observation, until it is mastered.

Consultant trainers and MCSP technical advisors supported the coaches in collaboration with prefecture and facility The lab chief at Beyla Prefecture health managers. The coaches focused on providers’ Hospital completes a handwashing execution of six main standards: exercise. 1. Handwashing with soap and/or use of hand sanitizer; 2. Competence in preparing 0.05%, 0.1%, and 0.5% chlorine solutions; 3. Proper use of PPE suits based on the disease’s mode of transmission; 4. Proper treatment of contaminated materials; 5. Proper management of waste disposal; and 6. Proper screening and triaging of EVD patients.

To further support newly-trained providers and promote compliance to IPC standards, MCSP conducted a one-day IPC training for 447 support staff members (e.g., janitors and orderlies) at A supervisor at CS seven health facilities. The training used materials developed Nionsorimoudou practices by the MOH, covered a broad range of fundamental IPC proper use of gloves under skills, including preparation of chlorine solution and proper supervision of a coach. waste collection and disposal, and delivered the content in the local language to ensure comprehension. A summary of the participants reached by this training is in Table 3.

Guinea Ebola Response Plan I: End of Project Report 9 Table 3. Trained health care providers categorized by profession and location

Commune/

Prefecture CHWs Agent Service Janitor Ambulance Driver Female Orderly Male Orderly Trained traditional birth attendant Supervisor Other Grand Total

Conakry 305 Dixinn 1 26 26 53 8 8 122 Kaloum 9 41 13 12 12 87 Matam 2 6 1 17 1 27 Ratoma 1 38 4 10 10 2 4 69 Beyla 1 1 6 3 13 24 Forécariah 7 3 3 14 27 Kissidougou 3 3 20 3 61 1 91 Grand Total 3 11 118 1 78 85 135 2 14 447

Coaching sessions were organized at least twice a month in Conakry and once a month in rural prefectures (due to travel time required to reach sites). As a result, 91% (3132/3441) of the trained health care providers and auxiliary staff at all 55 targeted facilities received supervisory support during the project period. Conakry experienced lower than average coverage due to the irregular presence of providers in its area and the constant movement of staff and trainees, many of whom were students. Table 4 has additional information.

Table 4. Number of health care providers and support staff coached Location Number of Sites Number of People Trained Percent Trained Who Coached (Providers and Support Staff) Received Coaching Conakry 9/9 2593 70% Kissidougou 18/18 473 99% Forécariah 11/11 226 97% Beyla 17/17 149 99% Total 55/55 3441 91%

As a result of the consistent support providers received from the coaches after the training, MCSP observed: • Steady commitment from the MOH to provide IPC inputs and consumables; • Establishment of long-term coaches, such as supervisors and influential providers, in several departments; • Synergistic collaboration between key stakeholders and programmatic partners in the implementation of IPC measures in health care settings; and • Development of a culture among health care providers to provide high-quality service by adhering to IPC standards.

10 Guinea Ebola Response Plan I: End of Project Report 1.7. Monitoring and Evaluation In December 2014, April 2015, and August 2015, MCSP conducted performance evaluations using the Standard-Based Management and Recognition (SBM-R®) process at each of the 55 health facilities to assess the implementation of IPC performance standards. The evaluation results follow.

At Donka National Hospital, 29 departments were evaluated, and improvements in performance scores were observed in all departments across the project period. • At the baseline assessment in December 2014, scores ranged from 0% to 65% with an average of 17%, and none of the 29 departments achieved the minimum score of 75% needed for the MOH’s superior performance designation. • At the second assessment in April 2015, scores ranged from 22% to 83% with an average of 43%, and two of the 29 departments achieved a superior score of 75% or more. • At the third assessment in August 2015, scores ranged from 19% to 96% with an average of 66%, and nine of the 29 departments achieved a superior score of 75% or more.

Table 5 contains additional information about the performance scores of the Donka National Hospital.

Table 5. Comparison of baseline, midterm, and end-of-project assessments of infection prevention and control (IPC) performance at Donka National Hospital (December 2014 to August 2015) HOPITAL NATIONAL DONKA

Services / Performance (%) Dermatology Endoscopy Infectious diseases Pediatrics Emergency Internal Medicine Diabetes Laundry INSE Morgue Maternity Thoracic Surgery Plastic Surgery Otolaryngology Pharmacy Baseline 0% 0% 0% 0% 3% 5% 6% 8% 9% 9% 10% 11% 14% 16% 17% Assessment 2nd evaluation 41% 66% 40% 55% 55% 33% 22% 35% 41% 70% 43% 55% 57% 48% 71% April 2015 3rd evaluation 40% 59% 70% 53% 76% 50% 56% 71% 94% 90% 80% 60% 62% 67% 75% August 2015

Services / Performance (%) Ophtalmology Trauma Psychiatry Hematology Neurosurgery Hemodialysis Cardiology Oncology Dental/Oral Surgery Pathologie Radiology Visceral Surgery Néphrology Laboratory Baseline Assessment 18% 21% 22% 24% 24% 24% 31% 33% 36% 39% 39% 40% 50% 65% December 2014 2nd evaluation 72% 34% 41% 36% 27% 83% 32% 43% 35% 52% 57% 82% 35% 65% April 2015 3rd evaluation 96% 73% 19% 56% 52% 74% 58% 65% 85% 82% 69% 86% 50% 62% August 2015

Guinea Ebola Response Plan I: End of Project Report 11 At the Ignace Deen National Hospital, 22 departments were evaluated, and improvements in performance scores were observed in all departments across the project period. • At the baseline assessment in December 2014, scores ranged from 0% to 53% with an average of 17%, and none of the 22 departments achieved the minimum score of 75% needed for the MOH’s superior performance designation. • At the second assessment in April 2015, scores ranged from 10% to 75% with an average of 41%, and one of the 22 departments achieved a superior score of 75% or more. • At the third assessment in August 2015, scores ranged from 32% to 95% with an average of 64%, and five of the 22 departments achieved a superior score of 75% or more.

Figure 2 contains additional information about the performance scores of the Ignace Deen National Hospital.

Services / Performance (%) Acupuncture Laboratory Hematology Dental Trauma Laundry Maintenance Morgue Medico-legal Surgery General Radiology Baseline 0% 0% 0% 4% 4% 6% 8% 9% 10% 11% 14% Assessment 2nd evaluation 44% 43% 70% 38% 15% 22% 59% 10% 53% 37% 50% April 2015 3rd evaluation 50% 73% 94% 32% 56% 47% 43% 63% 69% 52% 81% August 2015

Services / Performance (%) Emergency Rhumatology Urology Cardiology Otolaryngology Pulmonary Neurology Pediatrics Maternity Ophtalmology Pharmacy Baseline Assessment 15% 15% 17% 19% 23% 25% 26% 38% 40% 46% 53% December 2014 2nd evaluation 52% 32% 17% 32% 25% 56% 30% 50% 42% 55% 75% April 2015 3rd evaluation 95% 69% 58% 82% 59% 73% 41% 71% 61% 69% 77% August 2015

12 Guinea Ebola Response Plan I: End of Project Report At the Sino-Guinéen National Hospital, 14 services were evaluated, and improvements in performance scores were observed in most departments across the project period. • At the baseline assessment in December 2014, scores ranged from 22% to 75% with an average of 44%, and one of the 14 departments achieved the minimum score of 75% needed for the MOH’s superior performance designation. • At the second assessment in April 2015, scores ranged from 46% to 86% with an average of 59%, and two of the 14 departments achieved a superior score of 75% or more. • At the third assessment in August 2015, scores ranged from 33% to 80% with an average of 60%, and one of the 14 departments achieved a superior score of 75% or more. A decrease in performance scores at the final assessment can be attributed to a decrease in adherence to post-training capacity-building activities (i.e., self-training and coaching from supervisors) and lack of compliance to recommendations given by MCSP trainers and coaches.

Figure 3 contains additional information about the performance scores of the Sino-Guinéen National Hospital.

Services / Performance (%) Medical imaging Medical Cardiology Pathology Neurology Acupuncture- therapy Physical Laboratory Surgery Neuro Endoscopy Trauma Pharmacy Visceral Surgery Emergency Maintenance Thoracic Surgery Baseline Assessment 22% 30% 32% 32% 35% 32% 41% 42% 48% 54% 58% 58% 70% 75% December 2014 2nd evaluation 59% 77% 59% 50% 68% 50% 48% 59% 59% 86% 47% 59% 57% 46% April 2015 3rd evaluation 60% 73% 62% 53% 80% 63% 62% 68% 58% 70% 52% 54% 33% 58% August 2015

At the 24 health facilities targeted in Conakry and Kissidougou, services were evaluated, and improvements in performance scores were observed in a majority of health facilities across the project period. • At the baseline assessment in December 2014, scores ranged from 0% to 61% with an average of 29%, and none of the 24 health facilities achieved the minimum score of 75% needed for the MOH’s superior performance designation. • At the second assessment in April 2015, scores ranged from 8% to 72% with an average of 46%, and none of the 24 health facilities achieved a superior score of 75% or more. • At the third assessment in August 2015, scores ranged from 32% to 79% with an average of 63%, and six of the 24 health facilities achieved a superior score of 75% or more. • Figure 4 contains additional information about the performance scores of the 24 health facilities.

Guinea Ebola Response Plan I: End of Project Report 13

Facilities / Performance (%) CMC FLAMBOYANT CMC II PAUL JEAN CMS CMC RATOMA CMC MATAM CMC MINIERE CMC COLEAH CS Albadariah CS Manfran Gbangbadou CS CS Bardou Kondiadou CS Yendé CS Baesline Assessment 16% 19% 19% 20% 35% 37% 0% 5% 14% 19% 19% 23% December 2014 2nd evaluation 39% 26% 61% 64% 72% 36% 8% 12% 15% 50% 38% 38% April 2015 3rd evaluation 60% 32% 59% 64% 69% 76% 56% 40% 52% 60% 71% 71% August 2015 KISSIDOUGOU

Facilities / Performance (%) CS Sangardo CS Banama CS Fermessadou CS Yombiro CS Salam Dares Firawa CS Beindou CS CS Hermakono Madina CS Sogbè CS CSU Lymania Hôpital P. Kissidougou Baesline Assessment 24% 27% 27% 31% 35% 35% 38% 46% 46% 50% 50% 61% December 2014 2nd evaluation 23% 58% 42% 50% 69% 50% 58% 65% 42% 62% 69% 55% April 2015 3rd evaluation 72% 54% 58% 79% 79% 52% 46% 75% 67% 79% 79% 73% August 2015

At the 28 health facilities targeted in Forécariah and Beyla, services were evaluated, and improvements in performance scores were observed in the majority of the health facilities across the project period. • At the baseline assessment in December 2014, scores ranged from 0% to 91% with an average of 19%, and one of the 28 health facilities—Beyla Prefectural Hospital—achieved the minimum score of 75% needed for the MOH’s superior performance designation. Beyla Hospital’s high performance score was 91%, and this high score can be attributed to the fact that prior to the MCSP Ebola Response Project, the facility had been an SBM-R implementation site in the MCHIP project; thus, Beyla Hospital already had many providers trained on IPC and used performance standards to provide high-quality health services. • At the second assessment in April 2015, scores ranged from 12% to 73% with an average of 42%, and none of the 28 health facilities achieved a superior score of 75% or more. • At the third assessment in August 2015, scores ranged from 40% to 92% with an average of 67%, and seven of the 28 health facilities achieved a superior score of 75% or more.

14 Guinea Ebola Response Plan I: End of Project Report Figure 5 contains additional information about the performance scores of the 28 health facilities in Forécariah and Beyla.

MCSP was unable to obtain a baseline assessment score for CS Karala due to security issues preventing access to the facility, or a final assessment score for CS Bokaria as it was closed for renovations during the data collection period.

Facilities / Performance (%) CSR Bassia CSR CSR Farmoriya Kakossa CSR CSR Kaback CSU Forecariah CSR Maferinya Sikhourou CSR CSR Benty CSR Bokaria CSR Moussayah HP Forecariah Baseline Assessment 0% 0% 0% 4% 8% 8% 8% 24% 27% 31% 13% December 2014 2nd evaluation 50% 46% 73% 46% 65% 50% 50% 62% 31% 46% 58% April 2015 3rd evaluation 54% 68% 80% 40% 83% 76% 60% 92% NA 72% 82% August 2015 BEYLA

Facilities / Performance (%) CS Foualah CSU Gbackedou CS Karala Koumandou CS CS Diarraguerela CS Samana Sokourala CS Diasodou CS Nionsomoridou CS CSU Sobakono CS Gbessoba Moussadou CS Boola CS CSU Diakolidou Sinko CS HP BEYLA CMC Sinko Baseline Assessment 0% 0% NA 0% 4% 4% 4% 8% 15% 17% 19% 23% 27% 46% 56% 91% 71% December 2014 2nd evaluation 12% 23% 24% 35% 38% 28% 33% 28% 35% 31% 36% 50% 38% 42% 28% 73% 57% April 2015

3rd evaluation 54% 54% 50% 69% 54% 62% 65% 69% 73% 58% 50% 69% 62% 69% 69% 91% 76% August 2015

An analysis of successive performance scores from the baseline through the third evaluation, aggregated and grouped according to the different types of health structures, reveals the following progress: • At the national hospitals of Donka, Ignace Deen, and Sino-Guinéen, 66 services were evaluated, and the median performance score rose from 24% (baseline—December 2014) to 50% (second evaluation—April 2015) to 68% (third evaluation—August 2015). These results are illustrated in Figure 6.

Figure 6. Evolution of infection prevention and control (IPC) performance in the 66 services of the three national hospitals in Conakry (December 2014 to August 2015)

Guinea Ebola Response Plan I: End of Project Report 15 100% 95% 86% 90% 80% 75% 68% 70% 60% 50% 50% 40% 32% Perfomance 30% 24% 20% 10% 10% 0% 0% Evaluation de base 2e Evaluation (Avril 15) 3 Evaluation (Août 2015) (Décembre 14) Max Mediane Min

Notes: 2e (second); 3 (third); Aout (August); Avril (April); Decembre (December); evaluation de base (baseline evaluation); and mediane (median)

• At seven CMCs in Conakry and Beyla and three prefectural hospitals in Beyla, Forécariah, and Kissidougou, the median performance score rose from 20% (baseline—December 2014) to 50% (second evaluation—April 2015) to 62% (third evaluation—August 2015). These results are illustrated in Figure 7.

80% 76% 71% 70% 62% 60%

50% 50%

40% 37% 32% 28% 30% Performance 20% 20% 10% 16% 0% Evaluation de base (Décembre 2e Evaluation (Avril 15) 3 Evaluation (Août 2015) 14) Max Mediane Min

Notes: 2e (second); 3 (third); Aout (August); Avril (April); Decembre (December); evaluation de base (baseline evaluation); and mediane (median)

16 Guinea Ebola Response Plan I: End of Project Report • At the remaining 42 health centers supported by the project, the median performance score rose from 19% (baseline—December 2014) to 42% (second evaluation—April 2015) to 67% (third evaluation—August 2015). These results are illustrated in Figure 8.

Figure 8. Evolution of infection prevention and control (IPC) performance in the 42 health centers of Beyla, Forécariah, and Kissidougou (December 2014 to August 2015)

100% 92% 90% 80% 73% 67% 70% 60% 56% 42% 50% 40% 40% Performance 30% 20% 19% 8% 10% 0% 0% Evaluation de base 2e Evaluation (Avril 15) 3 Evaluation (Août 2015) (Décembre 14) Max Mediane Min

Notes: 2e (second); 3 (third); Aout (August); Avril (April); Decembre (December); evaluation de base (baseline evaluation); and mediane (median)

After each assessment, MCSP organized feedback sessions to provide an opportunity to present and discuss the results of each health facility and sensitize all stakeholders to the gaps that needed to be addressed. Additionally, the feedback sessions allowed stakeholders to renew their commitment to support one another in the implementation of IPC policies and procedures.

The supervisors and department heads of health facilities also received an orientation on the use of performance standards and were tasked with regular internal evaluation of staff’s compliance to IPC protocols. Currently, the department heads, in partnership with IPC focal points, oversee the application of performance standards and provide a monthly report to MCSP for technical assistance in identifying and resolving any IPC gaps.

MCSP’s rapid scale up of IPC trainings, which were supported by supervisory visits and onsite coaching, contributed to a marked decrease in the rate of EVD infection among health care providers in targeted project areas from December 2014 to May 2015; Figure 9 has more details. Additional information on achieved indicators of the Ebola Response project are summarized in the Performance Monitoring Plan found in Appendix 1.

Guinea Ebola Response Plan I: End of Project Report 17 Figure 9. Evolution of the percent of health personnel infected with Ebola Virus Disease (EVD) by Region/Prefecture (December 2014 to May 2015)

Notes: avant (before); apres (after)

The activities implemented under Objective 1 of the Ebola Response Project—targeting prevention of EVD at the health facilities level—have helped save the lives of service providers by contributing to a reduction in the number of infected health personnel. This Impact Story is in Appendix 2. MCSP’s activities have also helped to establish a foundation to strengthen IPC standards in health facilities, thus strengthening, in turn, the quality of reproductive, maternal, and newborn and child health services provided after the EVD epidemic subsides.

MCSP activities will continue through the USAID-funded Restoration of Health Services project to support achievements of the Ebola Response Project and contribute to the institutionalization of IPC as the basis for providing high-quality services in Guinea’s health facilities.

18 Guinea Ebola Response Plan I: End of Project Report Objective 2: Ebola Virus Disease (EVD) Prevention within Communities Objective 2 focused on supporting communities and their local leaders to combat disease transmission through improved contact tracing, intensified social mobilization, and improved technical assistance to district health teams.

2.1. Behavior Change Communication and Sensitization MCSP conducted numerous outreach activities in the project area to spread awareness of EVD with targeted messages concerning: prevention methods for those at risk, management of rumors in schools and communities, importance of safe burials, and importance of monitoring contacts.

In the project’s second quarter, MCSP reached 3,075 community members in Conakry through a participatory theatre Theater group is performing “Le Procès d’Ebola” (Ebola on piece titled “Le Procès d’Ebola” (Ebola on Trial) in Conakry. Trial) to raise awareness about EVD prevention and enable public discussion on the importance of the national Ebola efforts and surveillance measures. In response to the increase in positive EVD cases in Coyah and Forécariah, MCSP also supported the government’s campaign, “Ebola ça suffit!” (Ebola, that’s enough!), by implementing additional theater performances in those regions that reached an additional 900 community members.

MCSP also organized a soccer match between two teams composed of women who worked as vendors and teachers in the prefecture of Kouroussa. The match was attended by approximately 4,300 spectators and was chaired by the prefectural Coordinator with involvement from prefectural officials and field partners (Guinean Red Cross, WHO, CERADE, CENAFOD). General Ebola awareness messages were conveyed by project staff during the event, with an emphasis on the importance of safe burial practices, importance of monitoring contacts, and the importance of referring patients to health centers.

A key element of MCSP’s behavior change communication efforts included 249 group talks and sensitization sessions that were carried out in the prefectures of Kouroussa, Beyla, Kankan, and the communes of urban Conakry. These sessions reached approximately 30,000 people and focused on the EVD prevention measures and active surveillance for cases, acceptance of handwashing devices, use of “thermoflash” thermometers, and rumor management in schools. These awareness sessions were conducted in schools and communities by members of comité de veille villageois ([CVV], community surveillance committees) in Kouroussa and Beyla and by the communication and social mobilization supervisors in the communes of Conakry.

MCSP also delivered radio broadcasts on local radio stations and in local languages to disseminate key information and messages. Round table radio discussions were organized for staff from prefectural health offices and the project to present key topics related to Ebola to discuss topics such as reluctance in the villages, safe burial practices, and the use of handwashing devices to prevent the disease. Seven round table sessions were recorded in Conakry, Kouroussa, and Beyla and were rebroadcast 22 times. Eight interactive sessions were also held, allowing audience members to call into a question and answer session. An estimated 53,000 people were reached by the broadcasts.

Guinea Ebola Response Plan I: End of Project Report 19 2.2. Sensitization for Civil Society Groups and Community Health Worker (CHW) Associations To fully equip and empower decision makers to influence their communities to adopt EVD prevention practices, MCSP conducted focus groups involving 463 members of the civil society of Dixinn-Conakry. The focus groups also helped to better understand the constraints to behavior change in the community and brainstorm culturally appropriate responses and solutions to these barriers. Participants included community leaders, religious leaders, and representatives of women's and youth associations.

MCSP also conducted EVD prevention and hygiene promotion trainings to 233 members of 67 civil society associations, including community health worker (CHW) associations and two police brigades. To ensure the participation of women, members of 300 women’s associations in Conakry (Serés) were sensitized on the importance of women’s involvement in the Ebola response. Each SERES was represented by three people (president, vice-president, and councilor); thus, 900 women were sensitized and trained. Three Ebola Virus Disease training provided for street hundred handwashing kits and 300 cartons of drug vendors. soap were also distributed to each association. Since each SERES is composed of approximately 20-30 members, it is estimated that 6,000–9,000 women were reached through this outreach.

2.3. Contact Tracing and Surveillance in Affected Sub-Prefectures In order to support the MOH with the scale-up of contact tracing in the project areas, MCSP assisted in providing orientation to 100 CVVs in Kouroussa and Beyla. The orientation also included 200 CHWs and trained 28 new CHWs in Conakry. The project provided the committees and CHWs with contact monitoring kits, conducted regular supervision, and provided monthly incentive payments mandated by the CNLEB. Three thousand one hundred ninety-five contacts were followed in the project intervention areas during the life of the project and of these, 92% were successfully followed for the full 21-day period.

Another component of improving surveillance centered on the training provided to 1,463 pharmacists, health care workers (public and private), and traditional healers who work outside of the public health system. These trainings were designed as two-day sessions with 20-25 participants in each session, and the objectives were to provide information about: • Personal protection to prevent against infection; • The case definition of Ebola to permit active surveillance; and • The management of information for recommended secure referral (i.e., use of the Ebola emergency hotline number 115).

These trainings were particularly pertinent in addressing the public’s loss of confidence in the public health system and fears of acquiring infection in public health facilities, reasons that had driven many patients and sick people to seek assistance from private healers or practitioners, most of whom were practicing illegally, not registered to provide health care, or untrained clinically.

20 Guinea Ebola Response Plan I: End of Project Report 2.4. Coordination and Technical Support to the Direction Préfectorale de la Santé (DPS) MCSP worked closely with the DPS offices in the targeted prefectures to support the provision of material support—such as fuel for ambulances and generators, office supplies, and phone credit—and their distribution to health centers.

MCSP also worked with DPS teams to develop EVD response action plans and coordinate resources with partners on matters related to communication, surveillance, safe burial, and logistics. This helped to clarify the roles and responsibilities of each stakeholder in supporting CHWs and CVVs.

MCSP’s accomplishments under Objective 2 of the Ebola Response Project contributed to the promotion of safer behavior in targeted communities, thereby impacting the overall reduction in the number of contacts exposed to EVD. The focus on strengthening and supporting CHWs and CVVs empowered communities to be involved in contact tracing and surveillance, which also contributed to the reduction of new cases of infection and an increase in survival of existing EVD cases.

Guinea Ebola Response Plan I: End of Project Report 21 Recommendations and Way Forward

The activities during the implementation of this first phase of the MCSP Ebola Response Project have helped save the lives of service providers; strengthen IPC practices, standards, and protocols in health facilities; and provide a foundation for the restoration of maternal, newborn and child health services after the EVD epidemic has ended. MCSP’s work will continue through the Restoration of Health Services Project to support the efforts and results achieved in the Ebola Response Project and to contribute to the institutionalization of IPC as the basis of quality of health services provided in Guinea.

Several challenges and lessons that arose during this brief project and the efforts made to resolve them in the short term serve to highlight some needs for improved emergency response and for restoring health services after the Ebola epidemic has ended: • Attention to IPC is an essential component of the initial response to an infectious disease outbreak and is an essential component in health system strengthening. In terms of the initial response to the EVD epidemic, IPC and triage in routine health facilities were not addressed until well into the height of the epidemic. This resulted in increased risk for health care providers and the public’s loss of confidence in routine health care services. Establishing Ebola treatment centers, which are certainly needed to care for those infected, was the initial priority while little was done at the outset to prepare existing hospitals and health centers to screen for symptoms or improve provider and patient safety. This should serve as an important lesson in responding to a disease epidemic and working to create a balance between the needs for new or additional infrastructure and personnel and the reinforcement of what already exists in a country. In terms of health systems strengthening, correct and consistent performance of IPC relies on the availability of basic materials, knowledge and skills of those working in health care, and supervision and accountability to ensure that practices are maintained. Thus, supply systems, human resources education and training, and quality improvement systems need to function together to maintain these fundamental practices. IPC could certainly be seen as a fundamental indicator of health systems functioning, as it is focused on the safety and security of workers and patients. • Post-training follow-up is an integral aspect of ensuring continuing success. Coaching, post- training follow-up, and internal and external supportive supervision are key to ensuring behavior change that enables the correct and consistent application of IPC measures as well as the replenishment of IPC inputs. Simply providing training for a couple of days is not enough whether in classroom based sessions or onsite. MCSP used several different methods to provide coaching from both external and internal sources. The behavior change required to improve IPC practices and perform them consistently is challenging and requires ongoing support to make it a reality and a shared responsibility among health care providers and managers. Another challenge with supervision was the harmonization and standardization of coaching and supervision by the many partners in the Ebola response. For reasons of staff availability and skill, as well as costs, there was a lot of variation in what was being provided on the ground. As each partner was coming in with its own ideas, it was difficult to develop consensus on concepts, such as what tools to use, amount of time required, and frequency; this is where local leadership (discussed further below) was needed to set the standards that partners needed to follow. • The MOH does not have an accurate census of the number of staff working in facilities. There are many student interns and under-employed health care workers who can be found working in

22 Guinea Ebola Response Plan I: End of Project Report the services as volunteers, while those who have civil service positions are not always present. At the beginning of the project, MCSP was informed of approximately 2,100 staff at 37 of the targeted facilities. Just after startup, an additional prefecture, Kissidougou, was added to the project at the request of USAID and CNLEB, bringing an additional 380 providers from 18 facilities. Nevertheless, nearly 500 additional staff were found providing health care in the targeted facilities, particularly university hospitals. Attention to human resource management systems and improving human resource policies could help address this challenge in the recovery period after the Ebola epidemic has ended. • No goods, no services, or IPC. The availability of basic supplies for correct and consistent IPC performance in health facilities is an ongoing challenge. These materials were lacking prior to the EVD outbreak, and initial attention to supplies in the response to the epidemic was focused on Ebola treatment centers rather than routine health care services. This put both providers and patients at increased risk as seen in the elevated number of health care providers infected. This is particularly true in maternity services, where it can be difficult to differentiate certain signs of labor and delivery from those of Ebola infection. As MCSP started the IPC training, many partners committed to the provision of IPC materials, but these materials were not available in time for the training and initial implementation in the focus facilities. As a result, MCSP purchased and provided a package of materials estimated for one month of service provision, so that providers could immediately implement the practices presented at the training. MCSP staff and consultant trainers also used the coaching visits to advocate facility mangers to include IPC materials as part of their regular procurement of materials. A number of lessons can be taken from the procurement challenges of the Ebola response to help the MOH to improve its forecasting and distribution systems. • Strong leadership is critical to sustain the systemic integration of IPC standards at all levels of the health system. There is a need to strengthen national and local leadership to harmonize IPC strategies and approaches, facilitate synergistic interventions of all partners and stakeholders, and avoid potential anarchy resulting from an uncoordinated response to an emergency situation such as the EVD epidemic. A key prerequisite is the active engagement and commitment of department heads and managers at health facilities, especially in relation to the strengthening of health committees, to ensure sustainability of achievements and continuing activities. Facility managers or other champions are essential to create accountability for IPC practices among staff. MCSP observed variations in performance that could be linked to the level of engagement of managers. At the national hospitals, most department heads refused to participate in the IPC trainings with their staff and be led by trainers who are junior to them; thus, the department heads participated in special sessions organized and led by the MCSP Country Director. The sessions focused on what their staff were taught and how the department heads could support ongoing IPC practice and provide supportive supervision. This lesson about leadership in an emergency situation can also be applied to health systems strengthening and in developing skills of managers or senior clinicians to model practices and support others to perform duties correctly. Policies and systems for holding staff accountable for essential practices and defining both rewards and corrective or disciplinary action is also needed. • Local leadership is essential in an emergency response and it starts with routine health services and systems. During the response to Guinea’s Ebola epidemic, there was a lot of international staff coming and going out of the country, more than what usually occurs for other types of technical assistance in the health sector. The CNLEB was formed to help coordinate all of the inputs to the Ebola response, yet local staff were not empowered or particularly skilled to manage the response. As a result, some of the short-term international staff took over

Guinea Ebola Response Plan I: End of Project Report 23 certain responsibilities for as long as they were in the country rather than working to build the capacity of local staff. This resulted in a lot of confusion and new people coming in and suggesting, or initiating work, on something that had already been done. Specific to IPC, the request to prepare a new curriculum or new guidelines was brought up over and over, even after the MOH had seen the experience of several different models, adopted the curriculum used by MCSP, and had specifically requested that all partners use the MCSP curriculum going forward. MOHs need support to build this sort of leadership capacity, and the international community needs to better respect the country’s national leadership during an emergency. • Regulation of the private sector is needed. While the request to MCSP was to focus on public facilities, a general challenge in the Ebola response was the lack of information available about private health services and health care providers. The MOH or other Ministries do not have information on these businesses to help identify who might be in need of information or material support as part of the response to the epidemic. As people became wary of public healthcare services during the height of the epidemic, many sought care from private services, such as private health care providers, both registered and clandestine, or traditional healers. These private groups are not regulated or overseen by the MOH or accreditation body, and the care provided may have been sub-standard, thereby increasing the risk for Ebola to spread. Additionally, private sources of healthcare may place increased financial burden on families that already have very limited means and creating the potential for families to shy away from seeking care at all.

24 Guinea Ebola Response Plan I: End of Project Report Appendix 1: Performance Monitoring Plan

Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method OBJECTIVE 1—Prevention at Facilities: Support health care workers and facilities to offer safe and high quality health services by strengthening infection prevention and control practices through training and intensive supportive supervision IR 1.1: Delivery of quality health services improved IR 1.1.1: Availability of integrated quality maternal, newborn and child health services increase IR 1.1.3: Availability of prevention, care and treatment services increased IR 1.1.4: Access to health services improved Number of national Number of national tools Project Annual 2 2 Done Done Done tools and service and service provision records (IPC IPC previous provision guidelines guidelines related to Curricula, curriculum quarter for an IPC prevention improving access to and Standards/ updated;

1.1.1 and treatment using health services Directives) performance developed/adapted drafted with US standards and validated government support, by adapted program Number of tools, job Number of tools, job Project Annual TBD 1 Done Done Done aids, and IEC aids, and IEC materials records IPC previous

materials developed/adapted for performance quarter developed/adapted IPC prevention and standards for 1.12 for IPC prevention treatment with US assessment and treatment government support and monitoring Number of tools, job Number of tools, job Project Annual TBD N/A N/A 1,000 posters Done

aids, and IEC aids, and IEC materials records (handwashing) materials distributed distributed for IPC 1.13 for IPC prevention prevention and and treatment treatment Number of Number of consultant Training Quarterly 20 32 18 Done Done consultant trainers trainers who received database who received updated IPC Training

1.1.4 updated IPC training disaggregated by: sex, cadre 25 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Number/percentage Number/percentage of Training Quarterly 2,150 503 2,482 Done Done of staff in health staff in health facility who database previous (total facility who received received IPC training; male: 1,176 quarter cumulative= IPC training female: 1,306 2,985 providers

1.1.5 disaggregated by sex and see report trained) cadre narrative for number per cadre Number of trained Number of trained Supervision Quarterly 2,150 Focused on 1,426 700 412 staff who received providers who received records services at post-training follow- post-training follow-up at national female: 793 female: 392 (total up supervision at 6 their work site to hospitals: male: 633 male: 308 cumulative= weeks and 3 months support the Donka (27 of 2,582 providers implementation of new 29); period: bi- period: bi- (86%) receive skills and behaviors; Ignace Deen weekly in weekly in follow-up at disaggregated by sex, (17of 23) Conakry city Conakry city their work sites)

1.1.6 cadre, and period (6 and bi- and bi- weeks, 3 month) monthly in monthly in the period: bi- Beyla and 3 others weekly in Forécariah prefectures Conakry city prefectures and bi-monthly in Beyla and Forécariah prefectures Number of Number of trained Supervision Quarterly 444 (First visit is Supervision 184 192 supportive providers who received records (12 visits per considered will begin next

1.1.7 supervision visits supportive supervision at site during 6 post-training quarter conducted on site their work site months) follow-up)

26 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Number/proportion Number/proportion of Supervision Quarterly 55 20 health 55 health 54 health of targeted health targeted health care records facilities facilities facilities care facilities that facilities that have the evaluated evaluated evaluated during have the following following key during the during the the quarter key components components: quarter quarter • dedicated space for 0/54 patient isolation 0/20 0/55 • changing rooms for health care workers • separate area for cleaning/laundering

1.1.8 contaminated supplies • separate area for cleaning staff who have handled contaminated supplies but who do not have direct patient care activities

disaggregated by service type and facility type Number/proportion Numerator: number of Supervision Quarterly 55 20 health 55 health 54 health of health facilities health facilities that have records facilities facilities facilities that have appropriate appropriate (standard evaluated evaluated evaluated during (and sufficient and complementary; and during the during the the quarter quantity of) personal sufficient quantity of) PPE quarter quarter protective equipment 29/51 health (PPE) for at least one denominator: total 6/17 health 25/52 health facilities

1.1.9 month number of health facilities facilities facilities observed (Conakry, 41/66 services Forécariah) 17/67 services (3 national disaggregated by service (3 national hospitals) type and facility type 15/65 services hospitals) (3 national hospitals)

27 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Number/proportion Numerator: number of Supervision Quarterly 55 20 health 55 health 54 health of health facilities health facilities that have records facilities facilities facilities that have access to access to clean water at evaluated evaluated evaluated during clean water at each each SDP during the during the the quarter service delivery point quarter quarter

(SDP) denominator: total 30/51 health number of health 8/17 health 30/52 health facilities facilities observed facilities facilities 1.1.10 (Conakry, 44/66 services disaggregated by service Forécariah) 34/67 services (3 national type and facility type (3 national hospitals) 33/65 services hospitals) (3 national hospitals) Number/proportion Numerator: number of Supervision Quarterly 55 20 health 55 health 54 health of health facilities health facilities that have records facilities facilities facilities that have access to access to disinfecting evaluated evaluated evaluated during disinfecting agents agents during the during the the quarter. (and sufficient quarter quarter.

quantity for at least denominator: total 32/51 health one month) number of health 8/17 health 27/52 health facilities facilities observed facilities facilities 1.1.11 (Conakry, 15/66 services disaggregated by service Forécariah) 60/67 services (3 national type and facility type (3 national hospitals) 37/65 services hospitals) (3 national hospitals)

28 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Proportion of sites Numerator: number of Supervision Quarterly 55 20 health 55 health 54 health where triage is facilities conducting records facilities facilities facilities correctly triage of patients prior to evaluated evaluated evaluated during implemented entry during the during the the quarter quarter quarter

denominator: total 29/51 health number of supported 9/17 health 28/52 health facilities health facilities/observed facilities facilities 1.1.12 (Conakry, 3 national disaggregated by facility Forécariah) 24/67 services hospitals type (3 national 23/65 services hospitals) (3 national hospitals) Proportion of health Numerator: number of Supervision Quarterly 55 20 health 55 health 54 health facilities with facilities with established records facilities facilities facilities established isolation isolation area evaluated evaluated evaluated during area for suspect during the during the the quarter Ebola cases denominator: total quarter quarter

number of supported 27/51 health health facilities observed 2/17 health 13/52 health facilities facilities facilities 1.1.13 disaggregated by facility (Conakry, 3 national type Forécariah) 1/67 services hospitals (3 national 0/65 services hospitals) (3 national hospitals)

29 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Proportion of health Numerator: number of Supervision Quarterly 0 20 health 55 health 54 health facilities with health facilities with record facilities facilities facilities presence of waste in presence of waste in the evaluated evaluated evaluated during the surrounding surrounding areas during the during the the quarter areas quarter quarter

denominator: total 27/51 health number of health 13/17 health 44/52 health facilities facilities observed facilities facilities 1.1.14 (Conakry, 45/66 services disaggregated by facility Forécariah) 47/67 services (3 national type (3 national hospitals) 42/65 services hospitals) (3 national hospitals) Number/proportion Numerator: number of Supervision Annual TBD N/A N/A N/A 54 health of health facilities health facilities that have record facilities that have fully fully functioning evaluated during installed/renovated incinerators to be able to the quarter and functioning properly dispose the incinerators increased quantities of 26/51 health disposable and facilities

(MCSP will advocate potentially contaminated with donors currently materials 1/3 national 1.1.15 purchasing incinerators hospitals to place them at target denominator: total facilities.) number of health facilities

disaggregated by facility type

30 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Number/proportion Numerator: number of Supervision Annual 12–15 (to be N/A N/A N/A 54 health of health facilities health facilities that have record confirmed) facilities that have appropriate appropriate autoclave evaluated during autoclave provided provided, to ensure the quarter proper instrument processing, with US Note: this

1.1.16 government’s support project did not provide denominator: total autoclaves. number of health facilities Number and percent Numerator: number of Monthly Quarterly TBD ND 4,712 5,537 10,608 of women delivering women delivering with report with assistance from assistance from an SBA* a skilled birth (in health facilities with

attendant (SBA)* SBA) trained in IPC An SBA is a trained 1.1.17 nurse, midwife, or medical doctor.

denominator: number of birth at facilities Number of Number of consultations Baseline, end Monthly 5% over life 34,643 56,524 96,993 80,828 consultations at in supported health line of project health facilities facilities per month

1.1.18 disaggregated by type of service and type of structure

31 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method MCSP learning and Number of reports, N/A N/A N/A 1 poster on IPC results documented articles, etc., completed presented at and disseminated to to document Jhpiego regional best better inform and learning practices advance policy meeting dialogue (WAHO, Burkina Faso, 2015); 3 abstracts 2 (brief, Jhpiego Annual accepted for commentary) 1.1.19 oral and poster presentations at conferences in following quarter (impact of EVD on health services, implementation of IPC training) IR 1.3: Health Systems Strengthened IR 1.3.2: Human Resources for Health Strengthened Number and Numerator: number of Supervision Annual 55 3 N/A N/A 4 health percentage of health facilities achieving or record facilities; facilities achieving or compliant with at least compliant with at 80% of IP performance 2/66 services least 80% of standards through (3 national performance Standards-Based hospitals)

standards of infection Management and prevention (IP) Recognition process. 1.3.1 denominator: total number of health facilities observed

disaggregated by facility type

32 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Proportion of staff Numerator: number of Supervision Quarterly 100% Supervision No data (ND) 55 health 54 health observed wearing staff observed wearing record will begin facilities facilities gloves and gloves and appropriate next quarter evaluated evaluated during appropriate PPE PPE when exposed to during the the quarter when exposed to blood or bodily fluids quarter blood or bodily fluids 51/51 health

1.3.2 denominator: total 52/52 health facilities; number of staff observed facilities; 60/60 services disaggregated by sex, 61/67 services (3 national cadre, services type, (3 national hospital) facilities type hospitals) Proportion of rooms Numerator: number of Supervision Quarterly 100% Supervision ND ND ND appropriately rooms appropriately record will begin disinfected after disinfected after patients next quarter patients are were discharged or discharged or referred for suspected

referred for Ebola suspected Ebola 1.3.3 denominator: total number of rooms observed

disaggregated by facility type Average time Average time between a Monthly Quarterly TBD ND ND ND ND between a patient’s patient’s admission and report admission and isolation due to

isolation due to suspected Ebola and suspected Ebola and when the patient 1.3.4 when the patient improved improved disaggregated by service type and facility type

33 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Proportion of sites Numerator: sites where Supervision Quarterly 55–100% 20 health 55 health 54 health where cleaning and cleaning and processing record facilities facilities facilities processing of of instruments and other evaluated evaluated evaluated during instruments and articles is correctly during the during the the quarter other articles is completed according to quarter quarter correctly completed standard. 47/51 health according to standard 13/17 health 41/52 health facilities;

1.3.5 denominator: total facilities facilities number of sites observed (Conakry, 20/48 services Forécariah) 15/46 services (3 national (3 national hospitals) 31/48 services hospitals) (3 national hospitals) Proportion of staff Numerator: number of Supervision Quarterly 100% N/A Supervision ND ND trained on IPC who staff trained on IPC who record will begin next achieved a score of achieved a score of 85% quarter 85% or higher on or higher on knowledge knowledge tests tests during post-training during post-training, follow-up supervision follow-up supervision visits. visits

1.3.6 denominator: number of total staff trained in IPC evaluated

disaggregated by sex, cadre, service type, facility type, period (6 weeks, 3 months)

34 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Proportion of staff Numerator: number of Frontline Quarterly 100% ND ND ND ND trained on IPC who staff trained on IPC who SMS have a mobile phone have a mobile phone and database and who received all who received all SMS short message messages. service (SMS)

1.3.7 messages, within the denominator: number of phone’s network staff trained on IPC to zones whom text messages were sent (in the areas covered and who have mobile phones) OBJECTIVE 2: Ebola virus disease (EVD) prevention within communities: Support communities and their local leaders to combat disease transmission through improved contact tracing, intensified social mobilization, and improved technical assistance to district health teams. Number of contacts District Weekly ~2,000 314 2,223 476 Data for last six traced by MOH with health team (monthly for weeks of project

MCSP support data, per diem unavailable for 2.1 MCSP/SCI payments) this objective data Percentage of District Weekly >95% 100% 98% 89.5% contacts traced for health team

21 days data, 2.2 MCSP/SCI data Number of Training Monthly 100 men and 0 228 276 community health records, 100 women workers (CHWs) payment trained and records for supported (total and per diems,

per 10,000 monthly

2.3 population within reports, project area) by sex payment records for CHWs, and training reports

35 Guinea Ebola Response Plan I: End of Project Report Data Frequency Result Q1: Definition** and Source Result Q2: Result Q3: Result Q4: Indicator* of Data Target Nov 17–Dec Disaggregators Collection Jan–Mar 2015 Apr– Jun 2015 Jul–Aug 2015 Collection 31, 2014 Method Number of radio Radio Monthly 100 3 30 0 messages/ records and

sensitization payment 2.4 broadcast and/or slips to radio sponsored station Number of civil Training Monthly 60 6 69 300 (Serés-

society organizations records and (includes 2 women’s

2.5 trained attendance police groups) sheets brigades) Number of public Training and Monthly 25 70 100 100 ND health committees payment

supported records, and 2.6 monthly reports

36 Guinea Ebola Response Plan I: End of Project Report Appendix 2: Impact Story A Successful Approach to Infection IMPACT Prevention and Control (IPC) in a Guinea National Hospital in Guinea Moussa Koulibaly is the Professor of Anatomy-Pathology at the University of Conakry in Guinea’s capital city. At 60 years of age, the married father of four children is also the Deputy Director General of the national Ignace Deen Hospital in the district of Kaloum in Conakry. Professor Koulibaly also conducts awareness-raising activities in his community on Ebola Virus Disease (EVD), cancer prevention, and smoking. When asked to share his experiences and thoughts on the fight against EVD at the national Ignace Deen Hospital, he stated: "Before the outbreak of EVD, our problems centered on the lack of training and information on good hygiene practices, and because it was not perceived as a priority, we never viewed infection prevention and control as important. When the EVD epidemic began, the NGO Jhpiego implemented an approach to break the contamination chain in health facilities. This approach focuses on IPC assessments, five days of training sessions, coaching and donations of IPC materials and NAME inputs. Such IPC capacity-building has fostered awareness Moussa Koulibaly about the fact that: infection control is a fundamental thing, [the importance of] the involvement of all [hospital staff] to ROLE make them understand that the fight against infections is an Deputy Director General of Ignace Deen essential part of medicine, and also that [IPC] is cross-cutting. Hospital, Professor at University of In my family, I have placed garbage cans everywhere, the use of chlorine has become systematic without forgetting hand LOCATION washing, and cases of diarrheal diseases have decreased Conakry, Guinea considerably. Other institutions or partners under the leadership of the RESUME Ebola coordination also played a significant role in resolving At the onset of the Ebola virus disease (EVD) the IPC challenges in our facility: the WHO conducted epidemic, many health centers in Guinea, training and screening, Expertise France supported health and including the national Ignace Deen Hospital in safety committees, and WAHA supported triage officers. the capital of Conakry, suffered from a lack of Finally, I will say that Jhpiego in particular has impacted the training and information on good hygiene realization of the concept of hygiene and safety, the change in practices. MCSP’s IPC trainings have the daily behavior of providers, and [experiencing] tangible empowered health system leaders—such as results from the practice of IPC standards within my facility, my family, and my community.” Professor Moussa Koulibaly—to prioritize IPC within their facilities and integrate it as a MCSP in Guinea has trained 726 health providers and 87 fundamental aspect of health service delivery support staff at the national Ignace Deen Hospital. As a result of the IPC trainings, the number of health services that have and the fight against EVD. obtained an IPC assessment performance score of 50% or more at the hospital increased from 1 out of 23 (December

2014) to 19 out of 23 (August 2015 ), as a result of the IPC Notes: Maternal and Child Survival Program (MCSP); trainings. nongovernmental organization (NGO); Women and Health Alliance International (WAHA); World Health Organization (WHO)

Guinea Ebola Response Plan I: End of Project Report Appendix 3: Health Facilities Supported by the Ebola Response Project Conakry 1. Donka National Teaching Hospital 2. Igance Deen National Teaching Hospital 3. Sino-Guinéen National Hospital 4. Centre Médical Communal Matam 5. Centre Médical Communal Ratoma 6. Centre Médical Communal Miniere 7. Centre Médical Communal Coleah 8. Centre Médical Communal Flamboyant 9. Centre Médicosocial John-Paul II

Forécariah 10. HP Forécariah 11. CSR Bassia 12. CSR Farmoriya 13. CSR Kakossa 14. CSR Kaback 15. CSU Forecariah 16. CSR Maferinya 17. CSR Sikhourou 18. CSR Benty 19. CSR Bokaria 20. CSR Moussayah

Beyla 21. HP Beyla 22. CS Foualah 23. CSU Gbackedou 24. CS Karala 25. CS Koumandou 26. CS Diarraguerela 27. CS Samana

38 Guinea Ebola Response Plan 28. CS Sokourala 29. CS Diasodou 30. CS Nionsomoridou 31. CSU Sobakono 32. CS Gbessoba 33. CS Moussadou 34. CS Boola 35. CSU Diakolidou 36. CS Sinko 37. CMC Sinko

Kissidougou 38. HP Kissidougou 39. CS Albadariah 40. CS Manfran 41. CS Gbangbadou 42. CS Bardou 43. CS Kondiadou 44. CS Yendé 45. CS Sangardo 46. CS Banama 47. CS Fermessadou 48. CS Yombiro 49. CS Dares Salam 50. CS Firawa 51. CS Beindou 52. CS Hermakono 53. CS Madina 54. CS Sogbè 55. CSU Lymania

Guinea Ebola Response Plan I: End of Project Report Appendix 4: Infection Prevention and Control Materials Provided to Facilities of Focus

A list of the initial donation of infection prevention and control (IPC) inputs given to Donka Hospital and Ignace Deen Hospital is below.

IPC Inputs Total Quantity Waste bins 120L 9 Waste bins 30L 566 Basin with lid 572 Floor brush and handle 477 Madar bleach 1l 1,220 Madar liquid soap 1,188 Window cleaner and handle 477 Broom 265 Washcloths 475 Boots 189 Bibs/aprons N-75 1,956 Disposable gowns 3,028 Masks N-95 /aprons 2,457 Plastic trash bags 50L 150 Plastic trash bags30L 63 Plastic trash bags120L 7 Safety box 472 Bibs N75 354 Disposable aprons 24,062 Cleaning gloves 1,409 Glasses 213 Toothbrush 3,950 Diama soap 2,646 Noncontaminated waste bins 63 Thermoflash 72

40 Guinea Ebola Response Plan The following table details the IPC equipment and materials donated to Sino-Guinéen National Hospital.

Waste Management Materials Total Quantity Solid waste trash bins for activities that risk health care-associated infections (5L) 60 Safety box (or recovery bottle) 120 Trash bin for household waste of 20L (in offices and public spaces) 40 Trash bin for household waste of 5L (in offices and public spaces) 30 Solid waste packaging bags to reduce health care-associated infections 180 Packaging bags for household waste 60 Containers for needles and sharps 20 Liquid waste trash bins for activities that risk health care-associated infections 10 Materials for Waste Collection Total Quantity Initial waste storage containers for activities that risk health care-associated infections (50L) 3 Initial waste storage containers for activities that risk health care-associated infections (30L) 3 Initial storage containers for household waste 120L 3 Initial waste storage containers 30L 1 Packaging bags for household waste 6 Solid waste trash bins for activities that risk health care association infections 6 Containers for safety box or recovery bottle 3 Transport cart 3

The following table details items provided to the centres médical communal (communal medical centers).

Items Total Quantity Bleach (L) 21,140 Soap 24,290 Liquid soap (Madar 1L) 3,808 Trash bin 325 Trash bag 33,600 Disposable towel 91,920 Brooms 1,120 Window cleaner 2,400 Floor cloth 2,880 Floor brush 2,880 Toothbrush 11,200 Basin with cover 800 Disposable apron 1,920 Boot 1,493 Glasses 1,920 Pair of cleaning gloves 3,040

Guinea Ebola Response Plan I: End of Project Report Appendix 5: List of Presentations at International Conferences and Publications

Several abstracts were submitted and accepted for presentation at international conferences that were held after the project ended: 1. Hyjazi Y, Pleah T, Austin S, Aribot J, Diallo A, Waxman R. 2016. The impact of the Ebola Virus Disease epidemic on Family Planning services in Guinea. Presented at: International Conference on Family Planning; January 25-28, 2016; Nusa Dua, Indonesia. 2. Aribot J, Diallo A, Hyjazi Y, Waxman R, Pleah T. 2015. Baseline evaluation of infection prevention and control (IPC) in the context of Ebola Virus Disease (EVD) in nine health care facilities in the city of Conakry, Guinea. Poster presented at: International Federation of Gynecologists and Obstetricians Conference; October 4-9, 2015; Vancouver, Canada. 3. Hyjazi Y, Aribot J, Waxman R, Pleah T, Blami D. 2015. The impact of the Ebola Virus epidemic on reproductive and maternal health care services in Guinea. Presented at: International Federation of Gynecologists and Obstetricians Conference; October 4-9, 2015; Vancouver, Canada.

42 Guinea Ebola Response Plan Appendix 6: Materials and Tools Developed or Adapted by the Ebola Response Project

1. Training resource package for the prevention and control of infections, including Ebola virus disease This package is in French and includes a facilitator’s manual, learner’s guide, and reference manual. The package was adapted from Jhpiego’s infection prevention and control (IPC) training materials (2003) and an Ebola-specific IPC training package developed by Jhpiego with the Johns Hopkins Hospital in 2014. 2. Performance standards for infection prevention and control 3. Complementary tool for the baseline assessment 4. Guide for the orientation and training of support staff 5. Guide for orienting a member to a hospital’s hygiene and safety committee

Guinea Ebola Response Plan I: End of Project Report