USAID COMMUNITY CAPACITY for HEALTH PROGRAM Mahefa Miaraka
USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM Mahefa Miaraka
Cooperative Agreement No. AID-687-A-16-00001
FY2018 Quarter 3 Progress Report April 1 to June 30, 2018 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report i
USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM - Mahefa Miaraka
FY2018 Quarter 3 Progress Report April 1 to June 30, 2018
Cooperative Agreement No. AID-687-A-16-00001
Submitted to: Dr. Jocelyne ANDRIAMIADANA, AOR USAID/Madagascar in Antananarivo, Madagascar
Prepared by: JSI Research & Training Institute, Inc. USAID Community Capacity for Health Program – Mahefa Miaraka Résidence Lavalley Près Lot IIK 50H Mahatony Alarobia, Antananarivo (101)
Tel: 20.22.425.78/ 79
Cover photo: A Community Health Volunteer demonstrates a rapid diagnostic test (RDT) at a World Malaria Day celebration in Andranomavo (Boeny Region). Photo: Andriarinirina Felana
DISCLAIMER: This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the responsibility of JSI Research & Training Institute, Inc. (JSI) and do not necessarily reflect the views of USAID or the United States Government.
Page i USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report ii Table of Contents
Executive Summary of Achievements in Q3 FY2018 …………………………………….. 1 Introduction ……………………………………………………………………………………... 3 Intervention Area 1 (IA 1): Community Engagement and Ownership of Health 4 Services ………………………………………………………………………………………….. Sub IA 1.1 Increasing Skills and Competencies of CHV…………………………………………… 4 Sub IA 1.2 Sustainability of the CHV Model……………………………………………………….. 19 Sub IA 1.3 Strengthening of Community Structure to Improve Health and Sanitation Planning … 19 Sub IA 1.4 Promoting Universal Health Care Access and Coverage …………………………….. 20 Intervention Area 2 (IA2): Behavior Change and Health Promotion ………………… 21 Sub IA 2.1. Community-Level Health Promotion and Sensitization ……………………………… 21 Sub IA 2.2 SBCC Capacity of Community Stakeholders ………………………………………….. 23 Sub IA 2.3 Innovations to Promote Adolescent and Youth Health ………………………………. 25 Intervention Area 3: Health Service Planning, Management, and Governance ……... 27 Sub IA 3.0 Reinforcement of GOM Capacity …………………………………………………….. 27 Sub IA 3.1. Introduction and Promotion of CSB Improvement ………………………………….. 28 Sub IA 3.2. Pharmaceutical and Commodity Forecasting ………………………………………… 28 Sub IA 3.3. Health Data Quality, Management, and Use …………………………………………. 29 Sub IA 3.4. Referral System Strengthening between CHVs and CSBs …………………………… 29 Monitoring and Evaluation, Learning Management, and Cross-Cutting Issues ……… 30 Sub IA 4.1 Program Monitoring, Evaluation, and Performance System ………………………….. 30 Sub IA 4.2 Learning Management …………………………………..……………………………… 31 Sub IA 4.3 Cross-Cutting Issues …………………………………..……………………………… 32 Challenges and Proposed Solutions for Q1 FY2018 ……………………………………… 34 Administrative and Financial Management ……………………………………………….. 35 Sub IA 0.1 Operation (Administration, Finance, and Partnership) ………………………………. 35 Sub IA 0.2 Administration …………………………………..…………………………………….. 35 Sub IA 0.3 Financial Management …………………………………..……………………………… 36
Annex 1. Activity Table Q3, FY2018 Annex 2. Project Performance Review, PPR (Q3, FY2018) Annex 3. Environment Monitoring and Mitigation Report, EMMR (Q3, FY2018) Annex 4. Success Stories Annex 5. International Trips at the End of Q3 FY2018
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report iii List of Tables
TABLE 1– NUMBER OF LOCAL PNSC MEMBERS TRAINED ON COMMUNITY HEALTH IN THE PROGRAM REGIONS, Q3 FY2018 ...... 4
TABLE 2– CHV FUNCTIONAL IN THE PROGRAM REGIONS IN Q3 FY2018 ...... 6
TABLE 3– REFERRAL OF WRA AND CU5 CASES FROM CHVS TO CSBS IN Q3 ...... 11
TABLE 4– CHV MALARIA SERVICES BY REGIONS IN Q3 FY2018 ...... 15
TABLE 5 – AVERAGE RATE OF STOCKOUTS FOR MALARIA PRODUCTS IN Q3 FY2018 AS REPORTED BY CHVS ...... 18
TABLE 6 – NUMBER OF PEOPLE REACHED BY KEY HEALTH MESSAGES IN Q3 FY2018...... 22
TABLE 7 – PROGRAM PARTICIPATION IN THE HEALTH AND WASH DAYS CELEBRATIONS IN Q3 FY2018 ...... 23
TABLE 8 – NUMBER OF SUPPORTIVE SUPERVISIONS CONDUCTED IN Q3 FY2018 ...... 28
TABLE 5 – PROGRAM COST SHARE AS OF JUNE 30, 2018 ...... 37
TABLE 6 – PROGRAM’S CUMULATIVE EXPENSES AS OF JUNE 2018 ...... 38
List of Figures
FIGURE 1- MAHEFA MIARAKA’S REGIONS AND DISTRICTS ...... 3
FIGURE 2 - CHVS TRAINED BY TOPIC BY THE END OF Q3 FY2018 ...... 5
FIGURE 3- CU5 GROWTH MONITORING ACTIVITIES BY CHVS FROM Q2 FY2017 TO Q3 FY2018 ...... 8
FIGURE 4- RESULTS OF CHV CU5 GROWTH MONITORING ...... 9
FIGURE 5- NUMBER OF CASES DIAGNOSED AND TREATED BY CHVS FOR C-IMCI IN Q3 (BY DISEASE) ...... 10
FIGURE 6- NUMBER OF WOMEN USING FAMILY PLANNING SERVICES OF CHVS IN THE PROGRAM, BY AGE GROUP, Q3 FY2018 ...... 12
FIGURE 7- NEW FAMILY PLANNING USERS IN THE PROGRAM, BY AGE GROUP, Q3 FY2018 ...... 12
FIGURE 8 – TREND IN INJECTABLE CONTRACEPTIVES DISTRIBUTED FROM Q2 2017 TO Q3 2018 ...... 13
FIGURE 9- COUPLE YEARS OF PROTECTION BY FAMILY PLANNING METHODS, Q3 FY2018 ...... 13
FIGURE 10- CHV MALARIA SERVICES BY Q1 TO Q3 FY2018 ...... 15
FIGURE 11- REPORTED STOCKOUT RATES OF CHILD HEALTH TRACER PRODUCTS BY CHVS ACCORDING TO SOURCE
IN Q1, Q2 AND Q3 FY2018 ...... 17
FIGURE 12- REPORTED STOCKOUT RATES OF FAMILY PLANNING TRACER PRODUCTS BY CHVS FROM Q1 TO Q3 FY2018 ...... 17
FIGURE 13- SANITATION AND HYGIENE AT CHVS’ HEALTH HUTS AS OF MARCH 31, 2018 ...... 18
FIGURE 14- CHAMPION COMMUNE (KMSM) PARTICIPATORY PLANNING CONDUCTED BY REGION AND LEVEL OF
GOALS SET IN END OF Q3, FY2018 (N=332) ...... 19
FIGURE 15- PEOPLE WHO RECEIVED KEY HEALTH MESSAGES IN Q3 FY2018 BY CHANNEL OF COMMUNICATION ...... 21
FIGURE 16- PHOTO COLLAGE OF HIGH VISIBILITY EVENTS IN Q3 FY2018 ...... 24
Page iii USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report iv Acronyms and Abbreviations
ACT Artemisinin-based Combination Therapy ANC Antenatal Care CCAC Comité de Coordination de l’Approche Communautaire (PNSC coordination structure) CCDS Commission Communale de Développement de la Santé (Commune Commission for Health Development) CHV Community Health Volunteer CHX Chlorhexidine c-IMCI Community-based Integrated Management of Childhood Illnesses CoSan Comité de Santé CSB Centre de Santé de Base (basic health center) CU5 Children under 5 CYP Couple Years Protection DLP National Malaria Control Program DRSP Direction Régionale de la Santé Publique (Regional Health Directorate) EMAR Equipe de Management Régionale (Regional Health Management Team) EMAD Equipe de Management de District (District Health Management Team) EMMP Environmental Mitigation & Monitoring Plan EMMR Environmental Mitigation & Monitoring Report FKT fokantany (village or collection of hamlets, lowest administrative level) FP Family Planning FY Fiscal Year GBV Gender-based Violence GOM Government of Madagascar HMIS Health management information system IA Intervention area IEC Information, Education, and Communication IFA Iron folic acid IR Intermediate Result IPTp-SP Intermittent preventive treatment during pregnancy with sulfadoxin-pyrimethamine JSI JSI Research & Training Institute, Inc. KMSm Kaominina Mendrika Salama miabo (Champion Commune) LARCs Long acting and reversible contraceptives LLITN Long-lasting insecticide-treated bed net MOH Ministry of Health MOU Memorandum of Understanding MUAC Mid-upper arm circumference ORS Oral Rehydration Solution PHE Population, Health, and Environment PNSC Politique Nationale de Santé Communautaire (National Policy for Community Health) PSI/ISM Population Services International /Integrated Social Marketing Project PSM Procurement and Supply Management RLG Radio listening group RDT Rapid diagnostic test SBCC Social behavior change communication SDSP Service de District de la Santé Publique (District Health Office) SE/CNLS Secrétaire Exécutif du Comité National de la Lutte contre le sida (SE/CNLS) USAID United States Agency for International Development VAT Value Added Tax WRA Women of Reproductive Age WASH Water, Sanitation, and Hygiene
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USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 1 Executive Summary of Achievements in Q3 FY2018
USAID Community Capacity for Health (Mahefa Miaraka) Program activities in this period focused on ensuring the readiness of Community Health Volunteers (CHVs) in the Program’s new districts in Analanjirofo and Sofia regions, while continuing to strengthen the capacity and skills of CHVs and PNSC (Politique Nationale de Santé Communautaire) community committees in the other five regions. As a result of efforts this quarter, more than 97 percent of the CHVs in Analanjirofo and SAVA regions received training on community-based integrated management of childhood illness (c-IMCI) and family planning (FP) and then began to offer services.
Unfortunately, CHVs have encountered consistently high stock-out rates for FP and child health tracer products since Q1 FY2018. In the first nine months of FY2018, Rapid Diagnostic Tests (RDT) had an average reported stock-out of greater than 20 percent; ASAQ infant and child formulations greater than 25 percent; chlorhexidine and amoxicillin greater than 30 percent; Zinc-ORS greater than 35 percent; and oral and injectable contraceptives greater than 15 percent. As a result of these stock outs, CHVs have struggled to consistently deliver quality health services to women of reproductive age (WRA) and children under five (CU5) in their communities. The continued inability of both the public (Basic Health Center) and the private sectors (social marketing) to ensure the availability of essential health commodities has left the Program at great risk of not reaching targets for FY2018, specifically those objectives that depend upon the assured supply and availability of health commodities for the community health system. In addition, recent changes in reporting requirements by the MOH may be having the unintended consequence of reducing the amount of CHV data being compiled each month by half. The Program is currently collecting data on this issue.
In the face of repeatedly high stock-out rates, the Program has coordinated with the USAID logistics programs (PSM, ISM, and Shops Plus) to address bottlenecks at the national level, while also working closely with regional and district health offices to reallocate identified surpluses of stock to areas that are nearing or have reported product stockouts. Despite these efforts, the Program does not have the ability to directly influence the availability of sufficient product in country (e.g. misoprostol and 7.1% Chlorhexidine which expired in December 2017 and in May 2018 respectively, and are no longer available in country) or the current gaps in the existing public system, which frequently leaves district pharmacies (Pha-G-Dis) with insufficient levels of stock to meet CHVs’ needs.
Despite these challenges, Mahefa Miaraka has continued to build the skills of CHVs in all seven regions by strengthening Government of Madagascar (GOM) officials’ supervision of CHVs and redoubling efforts to complete FP trainings in Analanjirofo and SAVA regions. In addition, the Program has continued to collaborate with the GOM and key partners to improve the availability of health commodities for CHVs through public and private sector channels. The following highlights summarize the Program’s main achievements in Q3 FY 2018.
Routine community health activities and services. This quarter, the Program trained 676 CHVs on c- IMCI and 5,970 CHVs on FP, bringing the total of CHVs trained to 9,519 (97 percent of the total FY2018 objective of 9,850). From April 1 to June 30, 2018 the 8,640 CHVs who successfully completed their practicum at the health center (Centre de Santé de Base, CSB) provided services to a total of 200,422 children under five (CU5) and 198,806 women of reproductive age (WRA). These totals reflect the following CHV services:
• 80,385 CU5 cases seen (of which 41,819 girls or 52 percent) managed through c-IMCI, out of which 31,519 were malaria cases, 9,941 were pneumonia cases, and 5,996 were diarrhea cases. Of the 47,456 malaria, pneumonia and diarrhea cases, CHVs treated 41,379 (87 percent). • 120,037 CU5, of which 54 percent are girls (64, 489), screened for early signs of malnutrition through weighing and mid-upper arm circumference (MUAC) measurement (118,442).
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• 51,045 referrals to the CSB among CU5, out of which 46,322 (91 percent) are for vaccination. • 161,003 female regular FP users received contraceptives. • 10,106 pregnant women referred to the CSB for their first antenatal care (ANC 1) visit and 9,231 referred for ANC 4. • 5,644 pregnant women referred to the CSB for delivery. • 11,296 pregnant women referred to the CSB for vaccination. • 1,526 women referred to the CSB for long-acting reversible contraceptive and permanent FP methods.
CHV Readiness in Analanjirofo and SAVA Regions. By the end of Q3, 97 percent of CHVs (3,001 of 3,476) in the Program’s two new regions, received training on c-IMCI for CU5 service provision. In addition, 82 percent of CHVs (2,837) in the two regions have received training on FP and FP compliance. The Program remains committed to having all CHVs functional and providing services by the end of FY2018. As of June 30, 2018, the Program has trained 97 percent (9,519) of all CHVs in all seven regions. Of those CHVs trained, 91 percent (8,640) are functional and can provide health services to CU5 and/or women of reproductive age (WRA).
Community Micro-Insurance Schemes and Emergency Transport. In Q3, the Program established four new mutuelle de santé, more than doubling the number of members participating in community micro-health insurance schemes from from 3,427 to 5,260, covering a total of 5,260 family members. In addition, 3,457 fokontany (FKT) have developed emergency evacuation plans, representing 88 percent of the FY 2018 target. This quarter, communities in Program areas conducted 1,644 emergency evacuations, an average of one person per fokontany (including 558 pregnant women and 865 CU5) using locally available transport.
Piloting of MOH DHIS2 reporting system in seven districts. Following the DHIS2 Training of Trainers (ToT) conducted by the MOH in Q2, the Program technically and financially supported the MOH to pilot DHIS2 in seven districts of Sofia Region in June. With the participation of two central Program staff, 22 users were trained in Antsohihy (14 EMAD from the seven districts, 4 EMAR, and 4 Mahefa Miaraka regional staff). Six out of seven districts successfully entered CSB monthly data and analyzed data using the DHIS2 system. The Program will provide computer equipment to the seventh district for the entry of data early in FY2019.
June 2018 Program Dissemination Workshop. In June 2018, the Program hosted a dissemination workshop to share best practices, and lessons learned from the first two years of implementation. Through testimonials from community health volunteers and other community actors, Mahefa Miaraka highlighted its contributions towards universal health coverage in Madagascar and its progress in reaching 6.1 million people with quality health services in communities.
Page 2 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 3 Introduction
USAID awarded the five-year Cooperative Agreement (No. AID-687-A-16-00001) for the USAID Community Capacity for Health Program to JSI Research & Training Institute, Inc. (JSI) on June 6, 2016. JSI collaborates with three partners for the implementation of the Program: Action Socio- sanitaire Organisation Secours (ASOS), Family Health International 360 (FHI 360), and Transaid. The Program has two objectives and three intervention areas (IAs):
Objective 1. Strengthen public sector capacity to plan, deliver, and manage community health services Objective 2. Strengthen community engagement in health
IA 1. Community engagement and ownership of health services IA 2. Behavior change and health promotion IA 3. Health service planning, management, and governance
The Program reflects USAID’s commitment to providing high-quality community health services that integrate with the formal health system; addressing key drivers of maternal, newborn, and child mortality; and responding to client needs while promoting the importance of community health in contributing to the Government of Madagascar (GOM) efforts to reduce maternal, newborn, and child mortality. The Program contributes directly to the USAID/Madagascar Health Population and Nutrition’s Intermediate Results (IRs) 1 and 2 health sector strategy, for which the development objective is “Sustainable Health Impacts Accelerated for the Malagasy People.”
The USAID Community Capacity for Health Program, locally known as Mahefa Miaraka, operates in a total of 4,887 fokontany (FKT), 456 communes, and 34 districts in the Analanjirofo, Boeny, DIANA, Melaky, Menabe, SAVA, and Sofia regions. The Program has the potential to provide services to approximately 6.1 million people, or 23.3 percent of the country’s total population.
Figure 1- Mahefa Miaraka’s Regions and Districts
Page 3 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 4 Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services
Key Achievements: 1. In Q3 FY2018, 11,078 members of local health coordination committees received training on social behavior change communication (SBCC), including the Champion Commune approach (KMSm). 2. By the end of June 2018, 97 percent of CHVs (9,519 out of the 9,850 FY2018 target) have been trained on either c-IMCI or FP and of those trained 93 percent (8,640) are able to provide health service to CU5 and/or WRA. 3. CHVs provided c-IMCI and growth monitoring services for 200,422 CU5 and provided FP and referrals for 198,806 women in Q3. 4. The average CHV attendance rate at the monthly CSB meeting this quarter was 73 percent (6,975), with a reporting rate of 79 percent (7,536). 5. In Q3, the Program established four new mutuelle de santé, more than doubling the number of members participating in community micro-health insurance schemes from 3,427 to 5,260. 6. During Q3, Program-supported communities conducted 1,644 emergency evacuations (including 558 pregnant women and 865 CU5) using largely locally available transport.
Sub IA 1.1 Increasing Skills and Competencies of CHVs
1.1.1 Reinforcement of capacity of members of PNSC structures at commune and Fokontany level on CHVs' priority interventions
PNSC Coordination Committees. At the beginning of FY 2018, all seven regions, 34 districts, 456 communes, and 4,887 fokontany in the Program area had their PNSC coordination committees in place. During Q3, 11,078 members (of which 97 percent, or 10,774, were members of FKT health committees) received training on SBCC and KMSm to strengthen community ownership and promotion of health activities in order to support CHVs in coordination with the local health center (Centre de Santé de Base, CSB). Results of KMSm activities are discussed in section 2.2.2.
Table 1– Number of Local PNSC Members Trained on Community Health in the Program Regions, Q3 FY2018
PNSC Coordination PNSC Number Number Trained Structures Committees Members Trained Q3 - Cumulative Comité de Coordination pour l’Approche Communautaire – Région (Coordination Committee for Community Health at the Regional Level) 7 208 1 85 Comité de Coordination pour l’Approche Communautaire – District (Coordination Committee for Community Health at the District Level) 34 981 2 358 Commission Communale de Développement de la Santé (Commune Commission for Health Development) 456 5,216 301 2,105 Comité de Santé FKT (CoSan fokontany and FKT Heads) 4,887 14,737 10,774 14,700 Total 5,384 21,142 11,078 17,248
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1.1.2 Pre-Service Training, Continuing Learning, and Supervision of Community Health Volunteers (CHVs)
Community Health Volunteer (CHV) Training. CHV trainings in Q3 focused largely on FP and safe motherhood, disease surveillance, and the data recording and reporting related to each of these components. During the quarter, a total of 5,970 CHVs received training on FP and safe motherhood, 676 on c-IMCI, 622 on disease surveillance, and 1,757 on data management related to these activities. Training of CHVs in Analanjirofo and SAVA regions make up the majority of CHV trainings this quarter. Of the total 5,970 CHVs trained on FP this quarter, 1, 1,444 (27 percent) are from Analanjirofo and 1,594 (24 percent) from SAVA. Figure 2 summarizes the Program’s CHV cumulative training at the end of Q3. Currently, 9,468 CHVs, or 96 percent of the total 9,850 CHVs targeted for training in FY 2018, have received training on c-IMCI, 99 percent (9,789) have received training on nutrition, 97 percent (9,540) on disease surveillance, and 82 percent (8,098) on FP.
Figure 2 - CHVs Trained by Topic by the End of Q3 FY2018
CHV Readiness. In Q3 the Program continued to strengthen CHV capacity. As Table 2 shows, out of the total 9,850 CHVs nominated from 4,887 fokontany, the Program has trained 9,519 CHVs on services for children under five years of age (CU5) and/or WRA. Females account for 46 percent (4,388) of trained CHVs. Of the total CHVs trained, 8,886 or 93 percent have completed their practicum and received certification by the CSB in order to provide services in their communities. The Program is close to achieving its target of 9,850 CHVs fully trained and delivering integrated health services by the end of FY2018. A major challenge to meeting this target is the number of resignations by CHVs, 1, 724 (18 percent) since the beginning of Mahefa Miaraka.
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Table 2– CHV Functional in the Program Regions in Q3 FY2018
# of CHVs # of CHVs # of CHVs # CHVs # of CHVs trained on certified on who have Nominated who Regions services for services for resigned by FKT and reported in CU5 and/or CU5 and/or (cumulative) Commune Q3 WRA WRA Analanjirofo 1,721 1,672 1,473 598 206 Boeny 233 227 207 225 42 DIANA 1,202 1,134 1,080 1,136 133 Melaky 713 697 536 715 140 Menabe 1,213 1,088 1,136 1,170 185 SAVA 1,755 1,702 1,390 654 539 Sofia 3,013 2,999 2,818 3,038 579 Total 9,850 9,519 8,640 7,536 1,724
Because the majority of the new districts in the Program areas are within the Analanjirofo and SAVA regions, these areas are currently catching up to the other regions regarding CHV service provision. In Q3, the Program focused its efforts to increase the functionality of CHVs in these regions. Of the 1,672 CHVs trained in Analanjirofo and 1,702 in SAVA, 36 percent (598) and 38 percent (654) have reported on their activities this quarter. In Q4, the program expects an increase in the reporting on services provided by CHVs in these regions as routine monthly meetings with CHVs will begin at the CSB.
CHV Monthly Meeting at the CSB. The Program provides both technical and financial support for monthly meetings at each CSB, during which the CSB head provides in-service training and updated technical information to CHVs, and checks and approves the monthly CHV reports. New CHVs are not expected to attend the meetings until they have received one of the core trainings and started to provide services (c- IMCI or Family Planning). The availability of CSB staff ultimately determines whether monthly meetings are routinely conducted or not. CHVs at a family planning training in Mananara Nord.
In Q3, 80 percent (584 of 732) of all CSBs conducted monthly meetings as anticipated in the quarter. Of the 584 CSBs reporting, 459 (79 percent) held meetings three times in the quarter, 83 (14 percent) held meetings two times, and 42 (7 percent) held meetings one time during the quarter. The remaining 20 percent of CSBs who did not conduct monthly meetings is largely explained by the fact that an additional 142 CSBs have not yet begun conducting monthly meetings in Analanjirofo and
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SAVA, staff vacancies and closure of CSBs due to ongoing insecurity accounting for some. The monthly meetings in the CSBs in Analanjirofo and SAVA will begin in Q4.
CHV attendance at monthly meetings corresponds to the proportion of CSBs that conducted monthly meetings. On average, 73% percent, or 6,975 of 9,519 functional CHVs, attended monthly CSB meeting this quarter. Starting from Q2 FY2018, FKT heads began participating in two monthly meetings per quarter in order to strengthen the coordination between CHVs, the CSB, and community leaders including routine quarterly reporting on community activities and supervision of CHVs. In Q3, the participation of Fokontany Heads in monthly CSB meetings increased to 49 percent or 2,390 compared to the 45 percent or 2,173 in Q2. The Program will continue to strengthen the involvement of FKT heads during monthly meetings, through routine supervision and KMSm review activities.
Community Health Data. CHV reporting is presented in detail in IA3: section 3.3.1 on CHV Monthly Reporting to CSB; section 3.3.2 on Integration of Data from CHV Routine Reporting into MOH's HMIS; and section 4.1.2 on Data Reporting, Quality, and Use.
1.1.3 Quality of CHV Services
The Program and government officials continued to conduct supervision visits during Q3 to ensure CHV service provision met quality norms and adhered to national standards. In Q3, 4000 CHVs received supportive supervision by GOM and Program staff Commune Health Committee Members
The head of the Ambohimena CSB checks monthly activity reports for two CHVs (DIANA Region).
and FKT Heads. Of the CHVs who received supportive supervision visits this quarter, 60 percent (2,902) were supervised by GOM staff, using the supervision grid for CHV supervision. During this quarter, almost all functional CHVs were provided with additional supervision by the CSB during the Polio campaign and the Mother and Child Health Week.
More information on CHV supervision is presented under section IA 3.0 Strengthening of GOM’s Capacity to Provide Technical Training and Supportive Supervision to CHVs.
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CHV service provision in Q3 FY2018
This section presents the quarterly results for integrated health services as reported by the 7,536 CHVs (79 percent of the total 9,519 functional CHVs) in the Program regions during this quarter.
Maternal, Newborn, and Child Health Services
Prevention of Postpartum Hemorrhage and Newborn Cord Infection (Using misoprostol and chlorhexidine (CHX) 7.1%). The Program continues to record a decrease in distribution of these two health products based on CHV data in this quarter as compared to Q2. This decrease during Q3 may be due to the fact that the misoprostol in circulation expired in December 2017 and the rate of stockouts reported for CHX remains high (33%). In addition, the remaining CHX product in country expired in May 2018. From April 1 to June 30, 2018, CHVs reported distributing misoprostol to 946 pregnant women with reported use by 92 percent (868) of women, compared to CHVs reported distributing misoprostol to 1,053 pregnant women with reported use by 87 percent (920) of women in Q2. In addition, they reported distributing CHX to 1,330 women, with 101 percent use (1,338 newborns). In Q2 they distributed CHX to 1,650 women, with 93 percent use (1,527 newborns).
Nutrition. CHVs continued to provide growth monitoring services via routine monthly weighing and MUAC measurement. In Q3, CHVs weighed 120,037 CU5 and measured MUAC of 118,442 CU5. The number of children registered during the course of nutrition activities increased from roughly 138,000 in both Q1 and Q2 FY2018 to 186,459 CU5 in Q3. Overall, the number of CU5 receiving growth monitoring services in Q3 FY2018 represents a 31% increase over the 91,332 CU5 weighed in Q3 FY2017 and a 49% increase from the 79,382 CU5 screened using MUAC in Q3 FY2017 (Figure 3). The Program is currently at 81 percent of the planned CU5 nutritional screening, or 309,958 CU5 screened, and is on track to reach the target of 383,849 CU5 for FY2018.
Figure 3- CU5 Growth Monitoring Activities by CHVs from Q2 FY2017 to Q3 FY2018
Figure 4 shows the trends of the weight and MUAC measurement results, both of which indicate a significant and continued decrease in the CU5 malnutrition rate among those seeking CHV care since Q2 FY 2017: from 5% of children weighed reported as underweight in Q2 2017 to 1.5 % underweight in Q3 2018 and from 3% of children with a MUAC measurement of less than 125mm to 1.6%. These decreases in reported malnutrition may reflect the impact of Program activities, including the promotion of improved nutrition practices with parents through CHV routine growth monitoring activities, nutrition counseling during home visits, and radio broadcasts on optimal
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feeding practices. The number of people reached by nutrition messages this quarter, 295,526, is superior to those reached in Q1 and Q2 of 2018, 266,423 and 258,711, respectively.
Figure 4- Results of CHV CU5 Growth Monitoring
c-IMCI Services for Children Under Five (CU5). CHVs assess, treat, and in severe cases of illness, refer CU5 for three major illnesses: diarrhea, pneumonia, and malaria. The Program addresses management of these illnesses through training and supervision on c-IMCI services, including prevention, diagnosis, treatment, counseling, and referral to CSBs as necessary. During Q3, CHVs assessed a total of 200,422 CU5 during sick child visits (c- IMCI) and growth monitoring services (80,385 CU5 assessed for illness and 120,037 weighed). As shown in Figure 5 below, CHVs reported a total of 31,519 CU5 cases of malaria, 9,941 cases of pneumonia, and 5,996 cases of diarrhea during the quarter. Of the A CHV in Mananara Nord (Analanjirofo Region) weighs a child under 5 (CU5). 47,456 CU5 cases of malaria, pneumonia, or diarrhea, 87 percent (41,379) received CHV treatment, while 3,780 (8 percent) were referred by the CHV to the health center. The percentage of cases referred doubled compared with Q2 results (1,462 or 4 percent). The 5 percent of cases (2,297) that were not reported as treated or referred
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could be the result of reporting errors or CHV decisions to refer families to a local pharmacy for the purchase of drugs in the face of high stockouts. The total number of CU5 cases treated by CHVs in Q3 represents an increase of 77 percent from the number of cases treated in Q1 (26,773), and an increase of 1.2 times from the number cases of Q2 (33,579).
As presented in Figure 5, the Program saw an improvement in the treatment of Rapid Diagnostic Test (RDT) positive malaria cases (from 82 to 88 percent) and diarrhea cases (from 73 to 77 percent) for CU5 while the treatment rate for pneumonia remained unchanged (from 89 to 88 percent). Overall, treatment rates for diagnosed cases of malaria, pneumonia, and diarrhea has either slightly increased since Q1 FY 2018 or has remained unchanged, largely due to unacceptably high rates of reported stockouts in Program areas for CU5 tracer products, starting in Q1 2018. The inability of CHVs to maintain an adequate stock of tracer products continues to present a major barrier to the provision of critical child health services in communities. During Q3, reported rates of stockouts among CU5 tracer products include the following: 35 percent stockout for ORS and Zinc, 19 percent for RDT kits for malaria, 24 and 28 percent malaria treatment (ASAQ) for infants and children respectively, and 32 percent for pneumonia treatment (amoxicillin). Section1.1.6. of this report provides more detail on the availability of health commodities. An additional factor that may influence service reporting by CHV is the recent change in reporting mandated by the MOH. Previously, each CHV submitted an individual report to the CSB at the monthly meeting. The head of the CSB then compiled the reports of all CHV in a fokontany. The government policy recently changed so that each fokontany submits one report to the CSB Chief. This means that the CHVs in one fokontany have to compile their data themselves. In many cases, the CHVs don’t live near each other or don’t have an opportunity to meet and compile their data. In these cases, it’s possible that the fokontany report only represents data from one CHV rather than both (or all three) CHVs in the fokontany. The Program has taken steps to compare monthly reports to CHVs registers in order to better understand how CHVs have responded to this change and identify means to ensure complete reporting. Figure 5- Number of Cases Diagnosed and Treated by CHVs for c-IMCI in Q31 (by disease)
1 Further information on the Program’s malaria activities, including CHV services, is presented under section 1.1.4 Program’s Malaria Activities.
Page 10 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 11
Referral Services for Women and Children Under Five (CU5). Table 3 shows the number of and the types of CHV referrals during Q3 FY2018. In this quarter, CHVs referred 37,803 WRA (compared to 33,290 WRA in Q2) and 51,045 CU5 (compared to 41,901CU5 in Q2) to the health center for care. The majority of referrals among WRA were for prenatal consultations, including vaccination. Among CU5 referrals, 46,322 CU5 were referred for vaccination, representing 91 percent of all CU5 referrals. Counter referrals (from the CSB to CHV) ensure that CHVs make home visits to follow-up with patients after treatment at the CSB. In Q3, 29 percent (10,538) of WRA referred to the CSB were counter referred to the CHV. Among CU5 referrals, 41 percent, or 20,998 of 51,045 cases were counter-referred by the CSB for follow-up services with the CHVs.
Table 3– Referral of WRA and CU5 Cases from CHVs to CSBs in Q3
Number of referrals in Referral services by CHVs Types of service Q3 FY2018 First prenatal consultation, including Malaria, maternal and tetanus vaccination, IFA, IPTp-SP, 10,106 newborn care and LLITN Pregnant women for fourth ANC Malaria, maternal and 9,231 visit newborn care Maternal and newborn Pregnant women for delivery 5,644 care, assisted delivery Pregnant women for vaccination Maternal care 11,296 Long-acting contraception Family planning 1,526 Subtotal: number of women 37,803 referred to CSBs Pregnant women with confirmed 10,538 (29% of referred counter-referral from CSB back to cases) CHVs Cases of CU5 referred for Child health care 46,322 vaccination Cases of CU5 referred for Child health care 943 malnutrition Cases of sick CU5 with danger signs (malaria, acute respiratory infection, c- IMCI complicated cases 1,879 and diarrhea) Cases of sick CU5 from miscellaneous causes (newborn, Child health care 1,901 other CU5 illnesses) Subtotal: number of CU5 referred 51,045 to CSBs CU5 with confirmed counter- 20,998 (41% of referred referral from CSB back to CHVs cases)
Family Planning and Reproductive Health
Regular Users of Family Planning. In Q3, CHVs provided FP services to 161,003 regular users (Figure 6). Women between 10–19 years of age (44,659) represent more than a quarter (28 percent) of FP users, while women between 20-24 years of age account for nearly one-third (32 percent) of FP users. Among the total 161,003 women using FP at the end of Q3, 14,871 (9 percent) are new users.
Page 11 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 12
Figure 6- Number of Women Using Family Planning Services of CHVs in the Program, by Age Group, Q3 FY2018
New Users of Family Planning. Figure 7 shows that in Q3, the majority of the new FP users are young women under age 25 (72 percent or 10,775 out of 14,871). Nearly one out of ten (7 percent) new users are girls between 10-14 years old.
Figure 7- New Family Planning Users in the Program, by Age Group, Q3 FY2018
Sayana Press. During Q3, the use of Sayana Press in the Program regions has decreased compared to the Q2 results, according to CHV reports. Figure 8 shows a rapid increase in the use of Sayana Press among regular FP users from the time the Program introduced Sayana Press through CHVs, until Q1 FY2018. In Q3, while the use of sayana press decreased, the use of Intramuscular DMPA increased from the Q2.
Page 12 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 13
Figure 8 – Trend in Injectable Contraceptives Distributed from Q2 2017 to Q3 2018
93,193
76,222 76,269 72,319 67,146 67,008
25,390 21,155 23,727 21,253
4,484 1,266
Q2 Q3 Q4 Q1 Q2 Q3 2017 2018
IM Injectables distributed SAYANA PRESS distributed
Couple Years of Protection. Based on the CHV distribution reports of contraceptive methods in Q3, the Program recorded 27,139 couple years of protection (CYP). Injectable methods continue to be the preferred method of contraception in the Program areas, representing 23,865 CYP, or 87 percent of CYP recorded in Q3 (Figure 9). At the end of Q3, the cumulative CYP achievement recorded in Program areas stands at 43 percent (73,110) of the 2018 annual target (169,500). This level of achievement towards CYP annual target is below what the Program had expected to achieve by the end of Q3 and is primarily the result of the high level of FP product stockouts (section 1.1.7.), In part this is due by the fact that CHVs are not fully functional to provide FP services in Analanjirofo and SAVA regions representing the 35% of total CHVs in the program areas. Also, as mentioned earlier, the changes in reporting requirements by the MOH may have an impact on the completeness of CHV recording. In this case, while the number of regular users continues to increase, the CYP does not correspond accordingly. This may also have to do to incorrect recording of contraceptives dispensed by CHVs from which CYP is calculated. The Program is currently collecting data on this issue.
Figure 9- Couple Years of Protection by Family Planning Methods, Q3 FY2018
Page 13 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 14
CHV Services Related to Immunization
Immunization. This quarter, CHVs referred 46,322 CU5 for vaccination (91 percent of the total CU5 cases referred). Nearly half (42 percent or 19,432) of the referred children have confirmed receiving the vaccinations, according to the counter-referral from the CSB to CHVs. In total, CHVs have referred 150,746 infants for vaccination by the end of June 2018, with 69,575 children (46 percent) confirmed having received vaccinations according to counter referral information. The lack of counter referral information reflects the fact that caretakers may not bring the referral slip with them to the vaccination session, that CSB staff may not be willing or
A CHV distributes polio vaccinations at a school in Nosy Be (DIANA may not remember to fill out the Region). counter referral information, or that at the end of the chain of communication, caretakers may not return the completed referral slip to the CHV.
1.1.4 Malaria Activities in the Program
Support to SDSP and CSB for Prevention of Malaria Outbreaks. There was no malaria outbreak reported in this quarter, although a few CSB in Melaky reported briefly surpassing the threshold in terms of the number of normal case numbers during this period before returning to normal.
Community Health Volunteers’ Role in Malaria Prevention and Control. In Q3, CHVs in the Program regions continued to promote key messages on malaria prevention, long-lasting insecticide- treated bed net (LLITN) usage, mosquito habitat destruction, the importance of seeking treatment for fever, and referrals for ANC visits that include IPTp-SP. During the Q3 period, the Program continued to deliver key prevention and control messages through radio broadcasts (1,198,125) through 23 regional radio stations and CHVs (339,973 people). .
CHV Malaria Diagnosis and Treatment. CHVs are trained to test all CU5 fever cases via RDT and treat all uncomplicated cases with artemisinin-based combination therapy (ACT). In Q3, CHVs reported 58,532 CU5 cases (Table 4) presenting with fever, an increase of 54% from Q1 (37,885), with 88 percent (51,331) of those tested using a RDT kit. In large part, CHV deviation from testing and treatment protocols for CU5 is explained by continued high levels of stockouts for both RDT kits and ACTs. Of the 51,331 CU5 tested, 61 percent (31,519) tested positive for malaria. Of the positive malaria cases, 89 percent (28,081) received ACT. In this quarter, Boeny and Melaky had the highest RDT positivity rates in the Program areas, at 75 percent and 70 percent, respectively.
Page 14 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 15
Table 4– CHV Malaria Services by Regions in Q3 FY2018
Analanjirofo Boeny DIANA Melaky Menabe SAVA SOFIA Total CU5 fever case 134 2,883 1,988 13,821 16,898 1,177 22,131 58,532 CU5 with fever tested with RDT 69 1,750 1,347 12,601 14,547 719 20,278 51,3I1 by CHV CU5 with fever tested positive 22 1,309 371 8,803 8,372 202 12,440 31,519 with RDT CU5 with fever treated with ACT 9 1,234 241 8,116 7,305 144 11,032 28,081 by CHV
The comparison of Q1, Q2 and Q3 results shows an increase in the number of children who presented with fever, as well as the proportion of these cases that were tested with RDT and treated by ACT in Q3 (figure 10). As shown in Figure 10, CHV reports demonstrate an increase, quarter after quarter, in terms of the proportion of positive RDT results in 2018. Results showed a low of 49 percent in Q1, increasing to A CHV in Antsirabe Antsahabe (Sofia Region) educates community 55 percent in Q2, with a high members on the importance of sleeping under an insecticide-treated of 61 percent in Q3. In mosquito net. addition, CHVs report an improvement in the percentage of CU5 with a positive RDT result that received ACT during the period of Q1 to Q3, from 82 percent to 89 percent. This increase has occurred despite continued high levels of reported ACT stockouts throughout the same period (see section 1.1.7.)
Figure 10- CHV Malaria Services by Q1 to Q3 FY2018
Page 15 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 16
Referral of Pregnant Women for Malaria Prevention Therapy with Sulfadoxine-pyrimethamine (IPTp- SP). One of the CHVs’ main duties is to provide counseling and referrals for women to the CSB for ANC visits, follow-up, and delivery. These visits are opportunities for women to receive malaria- prevention therapy, including IPTp-SP, LLITN, IFA, and tetanus vaccinations. In Q3, CHVs referred a total of 10,106 pregnant women for their first ANC visit and 9,231 for their fourth ANC visit. CHVs referred a greater number of women (19,337) to ANC services in Q3 than in Q2 (17,007)
Pharmacovigilance. In this quarter, the 676 CHVs who received c-IMCI training also received pharmacovigilance training, which is included as part of their c-IMCI training.
Malaria Products at the Community Level. During Q3, the Program continued to advocate at the national, regional, district, and CSB levels that the quantification and order of malaria commodities by the CSB must include CHV needs. Additionally, the Program staff participated in regular Roll Back Malaria (RBM) and National Malaria Control Program meetings to identify needs for any increases in malaria case responses as they occur in the field. However, the amount of malaria commodities the District orders in Program areas is rarely received as expected; in fact, the received stock is often much less than required. As one example, findings from a joint supervisory visit by the Mahefa Miaraka team with the DHO of Soalala (Boeny) during Q3 revealed that the District Pharmacy received only one-third of the malaria commodities requested from the central depot. Prior to receiving the routine order of commodities, the District had placed an emergency order for malaria commodities (due to reported stockouts) that was not met by the central depot (Salama). Joint supervision during this same visit revealed that ACs had no remaining stock of RDT.
1.1.5 Women- and Youth-Friendly Environment and Services
Situation Analysis on Gender-Based Violence (GBV). During this quarter, the Program produced a report on a secondary analysis conducted on existing data related to gender-based violence (GBV). Findings from the secondary analysis will inform the second phase of the study, the qualitative assessment scheduled for Q4. The Program is moving forward on the selection of an experienced researcher in qualitative methods to conduct the second phase of the study.
1.1.6 Health Commodities
Health Commodities for CHVs. Figures 11 and 12 present the percentage of stockouts CHVs reported from Q1 until Q3 FY2018 for child health and FP commodities. Throughout FY 2018, CHVs have continuously experienced high levels of tracer commodity stockouts. While Mahefa Miaraka has attempted to address these unacceptably high rates, the overall results have been limited. Specifically, the Program has attempted to work with CSB heads to include CHV needs in the CSBs’ bi-monthly order (even for products that are no longer available through the social marketing points of distribution). However, these efforts have not helped to decrease stock-out rates, primarily because of the fact that there is often a complete lack or insufficient quantities of product in the country (for example, misoprostol and CHX, ORS and Zinc combinations, or amoxicillin syrup). In addition, the amount of product sent from the government’s central warehouse (Salama) to the district is frequently less than the amount requested, and is therefore insufficient to meet the district’s demand. Due to the persistence and pervasiveness of these stockouts, the Program will not be able to meet many of its FY2018 child and family planning objectives.
For child health products supplied by PSI's Social Marketing channel, namely Zinc-ORS (“ViaSur”), Amoxicillin dispersible, and CHX, the rate of stockouts have remained high, although rates declined from Q1 to Q3. Between the three quarters, stock-out of CHX ranged from 29 to 33 percent, stockout of amoxicillin r from 28 to 32percent, and Zinc-ORS from 42 to 35 percent. For malaria products2, which CHVs resupply from the CSB, the RDT stock-out rate remained high although it
2 Rapid diagnostic test (RDT), Actipal, and ASAQ [infant and child]
Page 16 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 17
decreased from 23 to 19 percent, while child and infant Actipal and ASAQ stockouts decreased from 36 to 24 percent and from 38 to 28 percent, respectively.
Figure 11- Reported Stockout Rates of Child Health Tracer Products by CHVs according to Source in Q1, Q2 and Q3 FY2018
42% 36% 38% 33% 35% 32% 32% 32% 33% 30% 29% 28% 27% 28% 23% 24% 19% 19%
CHX Amoxicilin Zinc-SRO RDT Actipal and Actipal and ASAQ Enfant ASAQ (Child) Nourrisson (Infant) RESUPPLY PSI/PA RESUPPLY AT CSB Q1 Q2 Q3
During this quarter, CHVs reported high levels of stockouts for FP tracer products. Stockouts of injectable contraceptive decreased slightly (from 16-13 percent) with stockouts for oral contraceptives increasing from 13 -16 percent - reflecting little or no change from Q1 to Q3. In addition, while stockouts of cycle beads and condoms also decreased somewhat from Q1 to Q3 (from 35 to 32 percent and 43 to 38 percent, respectively); overall, the stock-out rate remained unacceptably high, representing twice that of other tracer products.
Figure 12- Reported Stockout Rates of Family Planning Tracer Products by CHVs from Q1 to Q3 FY2018
Page 17 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 18
In Q3, CHVs reported stockouts for RDT at 19 percent for Program areas as a whole (Table 5). However, with the exception of Sofia (5 percent), the other regions reported stockouts ranging from 22 percent in Melaky to 59 percent in SAVA. Similarly, reported stockouts of both infant and child Actipal ASAQ were 24 percent. The rate of stockouts ranged from a low of 10 percent in Sofia to 82 percent in SAVA. Stockouts of ASAQ, both infant and child formulations, had higher reported stockout rates compared to RDTs, at 28 percent and 24 percent, respectively.
Table 5 – Average Rate of Stockouts for Malaria Products in Q3 FY2018 as reported by CHVs
Percentage of fokontany with Analanji Mahefa Boeny DIANA Melaky Menabe SAVA Sofia stockout in Q3 rofo Miaraka RDT N/A 46% 37% 22% 28% 59% 5% 19% Actipal ASAQ Infant N/A 71% 54% 32% 41% 82% 10% 28% Actipal ASAQ Child N/A 44% 54% 25% 27% 73% 7% 24%
1.1.8 Motivation Activities for CHVs and FKT Heads
Financial Motivation Activity. In Q3, the four cooperatives located in Menabe and Sofia regions, called eBox, continued their activities. At the end of June 2018, 82% of the bicycles received by these cooperatives had been sold, generating a total revenue of USD for the four cooperatives. During the quarter, the cooperatives paid USD for staff salaries and a dividend of USD was shared between 107 members of the four cooperatives (54 women and 53 men), or USD per person. In addition, the cooperatives invested 5 percent (or ) of profits from sales in seven community micro-insurance schemes (Mutuelle de Santé).
Non-Financial Motivation Activity for CHVs: Community Support. One way that communities demonstrate support for community health work is by building a health hut, or toby, where CHVs can provide services. In Q3, the Program recorded 210 newly-built community-built health huts for CHV use, bringing the total of health huts built in Program regions to 2,477 or 84 percent of the FY 2018 target (2,937). Figure 14 presents the number of sanitation and hygiene facilities that communities have built at the health huts: 98 percent (2,421) of health huts have waste pits, 85 percent (2,097) include latrines, and 74 percent (1,830) are equipped with chairs, tables, and shelves. Of the total number of health huts built, 40 percent (980) have the full complement of sanitation facilities and furnishings. The Program will continue to monitor and support CSBs and communities to ensure that all CHV health huts will eventually be equipped with hygiene and sanitation facilities.
Figure 13- Sanitation and Hygiene at CHVs’ Health Huts as of March 31, 2018
Page 18 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 19 Sub IA 1.2 Sustainability of the CHV Model
All Program activities are designed to make sure that CHVs are fully integrated in the public health system through supervision and monthly meetings and reporting, which are described in section 3.0.1.
Sub IA 1.3 Strengthening of Community Structures to Improve Health and Sanitation Planning
1.3.1 Functionality and Reinforcement of Community Health Structure
The Program activities designed to strengthen the capacity of PNSC coordination structure members were reported under section 1.1.1.
1.3.2 Using a Champion Commune (KMSm) Approach to Manage Community Health
This quarter, the Program trained 11,078 members of PNSC community committees on the Champion Commune approach, which integrates essential family household practices with community wide goals for the use of health services, linked to and reinforced by CHV activities. Under the KMSm approach, communities have the choice to select goals that address current needs and then progress to remedying more complicated challenges once initial goals are attained – a progression from bronze through gold goal categories. By the end of Q3, 332 communes (73 percent) out of a total 456 Program communes undertook participative planning to set community and health center goals for the year (Figure 14). A total of 209 (63 percent) communes selected bronze level goals, 98 (30 percent) silver level goals, and 25 (8 percent) gold level goals. Of the 332 communes that carried out their participative planning in Q2, 253 communes (or 76 percent) conducted their first activity review in June 2018.
The Program will continue to work closely with the community committees, as well as regional and district health teams to closely follow the progress of activities on the ground as communities work together with health centers to achieve their selected goals by the end of FY 2018.
Figure 14- Champion Commune (KMSm) Participatory Planning Conducted by Region and Level of Goals Set in end of Q3, FY2018 (n=332)
Page 19 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 20 Sub IA 1.4 Promoting Universal Health Care Access and Coverage
1.4.1 Increased Access to Health Care via Health Financing Scheme
From Q2 to Q3, the number of members participating in micro-health insurance schemes (mutuelle de santé) more than doubled, from 3,427 to 5,260. This quarter 26 members accessed funds for services at the CSB from the existing mutuelle de santé. In addition, the Program established four new community micro-insurance schemes (mutuelle de santé) in the Andapa and Vohémar districts of SAVA region, as well as in the Bealanana and Befandriana Nord Districts of Sofia region during this quarter. In Andapa, the Program finalized its collaboration with the National Cooperative Business Association (NCBA) CLUSA International and provided technical support to Avotra cooperative leaders to identify the ratio of prepaid contributions to health care costs, the amount for household contributions, as well as the package of services the CSB provides, and the package of services to be covered. The Program’s district team met with the cooperative leaders to discuss the development of internal rules and regulations, organizational statutes, and the necessary documents to formalize their structure with local government officials. The Avotra
mutuelle de santé reaches 750 Discussion among vanilla cooperative members on establishing a members of 3 communes. Mahefa mutuelle de santé in their community, Doany, SAVA Region. Miaraka will organize training for the Avotra leaders in Q4.
1.4.2 Increased Access to Health Care via Emergency Transport
Emergency Evacuation Plans. During Q3, the Program focused on adjusting its approach for establishing emergency evacuation plans in all FKT. As a result, by the end of June 2018, 3,457 FKT developed emergency evacuation plans. This number represents 88 percent of the FY 2018 target of 3,910 for FKT (80% of all FKT in Program areas) with health emergency evacuation plans posted in the community. The Program will continue to encourage all FKT to develop their health evacuation plan, monitor its use, and make adjustments as necessary.
Emergency Transport. In this quarter, Program-supported communities conducted emergency evacuations using largely local transport for a total of 1,644 people; 558 pregnant women (34%), 865 CU5 (53 percent). The data on emergency evacuations comes from FKT head reports, which are provided during monthly meetings at the CSB. As FKT Heads began using these reports in Q2, the data from Q3 reports provides an indication of the added value of the FKT evacuation plans in mobilizing the community to strengthen emergency transport with any available means.
Page 20 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 21 Intervention Area 2 (IA2): Behavior Change and Health Promotion
Key Achievements: 1. Health messages reached people 2,838,664 times through various communication channels (1,199,837 times through the CHV’s activities, 1,198,125 times through the Program’s radio broadcast activities, and 586,117 times through high visibility events). 2. CHVs distributed 19,936 health cards to families (of which 10,700, or 54 percent, are for CU5) in the Program regions. 3. CHVs distributed 31,999 FP invitation cards to regular users, of which 15,496, or 48 percent, were distributed to youth under 25 years-old.
Sub IA 2.1. Community-Level Health Promotion and Education Session
People Reached by Social Behavior Change Communication (SBCC) Activities
The Program uses multiple communication channels to promote key health messages and essential family practices: 1) CHV counseling efforts (at health huts, home visits, and community-based education sessions); 2) media activities; and 3) high visibility events. Figure 16 shows that people were exposed to key health messages 2,838,664 times this quarter. CHV SBCC activities continue to represent the greatest dissemination channel for key health messages, representing 1,199,837 instances out of the whole (871,341 people through group education sessions, 328,496 people through individual counseling sessions in health huts, and 221,393 people through home visits). The second dissemination mechanism the Program used in Q3 was community radio, with broadcasts reaching 1,198,125 people with key messages. In addition to these two dissemination channels, the Program also shared information to 586,117 people through GOM-organized national and international health (Polio campaign and Malaria Day, Mother and child health week, and World International day.
Figure 15- People Who Received Key Health Messages in Q3 FY2018 by Channel of Communication
Page 21 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 22
Key Health Messages
CHVs promote key health messages through home visits, group education sessions, and community events. The possibility of community members adopting healthy behaviors increases when the same message is received on multiple occasions. Table 6 shows the number of people reached in Q3 through different CHV SBCC activities.
Table 6 – Number of People Reached by Key Health Messages in Q3 FY2018
Key messages Women % Women Men Total Vaccination 291,302 54% 250,553 541,885 c-IMCI including malaria prevention 234,970 54% 206,226 441,236 Exclusive breastfeeding 230,779 64% 132,241 363,020 Family Planning 185,380 54% 159,700 345,080 Communicable diseases 174,480 53% 165,493 339,973 Youth and adolescent health 126,295 38% 210,518 336, 813 Nutrition 159,387 54% 136,139 295,526 Safe motherhood with malaria prevention 148,244 54% 125,717 273,961
2.1.1 SBCC Strategy, Approaches, Materials, and Tools
Review of the Radio Listening Group (RLG) Approach and Tool. In Q3, the Program distributed 1,000 crank radios from the National AIDS Control Program (Secrétariat Exécutif du Comité National de Lutte contre le SIDA) to selected CHVs in 7 regions to undertake radio listening groups as part of their health education activities. In Q3, CHVs held 11,112 radio listening sessions reaching 36,371people.
2.1.2 Repositioning the Women’s and Children’s Health Cards as the Cornerstone of SBCC Strategies
The Program promotes essential family practices in communities through use of the MOH women’s and children’s health cards. In addition, the Program reinforces these essential family practices by using the same key health messages from the women’s and children’s cards and the household cards developed for community level use. CHVs reported distributing 19, 936 health cards to families in the Program regions in this quarter, of which 9,236 (46 percent) were women’s health cards and 10,700 (54 percent) were children’s health cards.
2.1.3 Development and Dissemination of Information, Education, and Communication (IEC)
Development and Use of IEC Materials. In Q3, the Program produced 1,615 improved latrine construction guides intended for FKT Chiefs to improve the quality of latrines built in the communities.
Media Activities for Promotion of Key Health Actions. In this quarter, the Program continued its collaboration with 23 regional radio stations to broadcast radio programs developed by the MOH and the Program several times per week. Q3 FY2018 media broadcasts focused on communicable diseases, nutrition, family planning, vaccination, and youth and adolescent health. The messages were broadcast 1,104 times this quarter, reaching 1,198,125 people.
Page 22 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 23 Sub IA 2.2 SBCC Capacity of Community Stakeholders
2.2.1 SBCC Skill-Building for Community Leaders
In Q3 FY2018, the Program oriented 668 PNSC committee members (1 CCACD, 115 CCDS, 552 FKT heads, and 415 CHVs) on the Program’s social behavior change communication (SBCC) approaches, including Champion Communes (KMSm).
2.2.2 SBCC Activities at the Community Level
Use of Ménages Modèles and Ménages Parrains (Model and Care Group Households) Approaches to Create Sustainable SBCC Activities at the Community Level. As described above, the Program reinforces key messages from the MOH by using household cards at the community level through the ménages modèles (model households). The cards target four types of households: those with pregnant women, families with infants 0-11 months, families with children 12-24 months, and families with children older than 24 months of age. Each card contains seven key health actions that correspond to the needs of the pregnant women or children as they grow. After completing the seven key actions, the household is recognized as a “model household.” This quarter, CHVs distributed a total of 19,556 household cards and 5,130 households became models. Since Q2 FY2018, when the Program introduced the approach in communities, a total of 27,903 households have been enrolled, with 7,788 becoming model households.
Ménage Parrains: An important component of the model household approach is the means to expand the promotion of improved health behaviors from household to household, allowing families themselves to become important health actors in the community as a care group household. After the community recognizes a household as a ménage model, that family begins to encourage its neighbors to become model households as well, providing the needed encouragement, guidance and support based on the family’s own experience of becoming a model household. In Q3, 3398 households became Ménage Parrains, increasing the total number of Ménages Parrains to 5807.
Participation in the GOM-Organized Health and WASH Days. As in previous quarters, CHVs, FKT heads, and Program staff participated in high-visibility events organized by the government in Q3. Table 6 presents the total number of participants by each event. These events engaged participants on key health and WASH themes through community activities, including demonstration booths, posters, audio visual presentations, parades, speeches, competitions, theater, musical presentations, and dance.
Table 7 – Program Participation in the Health and WASH Days Celebrations in Q3 FY2018
Key messages Women Men Total African Vaccination Week/Mother and Child 149 228 95 931 245 159 Health Week/FAV Polio World Health Day 84 003 78 300 162 303
World Water Day 45 900 44 100 90 000
World Malaria Day 48 695 39 960 88 655
Total 327 826 258 291 586 117
Collages of photos from these events are presented in Figure 16.
Page 23 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 24
Figure 16- Photo Collage of High Visibility Events in Q3 FY2018
Page 24 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 25
2.2.3 Water, Sanitation, and Hygiene (WASH)
WASH Training for PNSC Members and CHVs. In the Program’s design, WASH is included as part of several trainings: plague prevention, c-IMCI, CHX/Misoprostol, FP, nutrition, and SBCC so that participants at these trainings receive WASH information at the same time. In this quarter, the following numbers of people received WASH training:
7,130 PNSC members through the training on KMSm 676 CHVs through training on community case management of childhood illness
SBCC Activities. The Program continued to disseminate WASH messages in Q3 through several communication channels, including: CHVs’ routine promotional activities and health campaigns, such as counseling for case management, reaching 339,973 people from the routine promotional activities; 90,000 people from high-visibility health events organized by regional, district, and commune-level health offices, including plague prevention campaign day and national water day event; and the weekly broadcasts of 23 local radio stations in seven regions, reaching 348,187 people.
Sanitation and Hygiene in the Community. The Program continued to promote the construction and use of improved latrines in all Program areas. In Q3, the Program recorded a total of 1,615 new community-built improved latrines, bringing the total to 5,579 for FY2018. As a result, a total of 7,429 additional people gained access to basic sanitation during this quarter, 25,663 for Q1 through Q3 combined. The Program anticipates ODF evaluation activities will be carried out in Q4. CHVs in Anivorano (DIANA Region) educate a mother about water treatment and hand-washing with soap.
Sub IA 2.3 Innovations to Promote Adolescent and Youth Health
2.3.1 Strengthening Local PNSC Committees to Promote Youth Health
The Program integrates youth and adolescent health approaches in its trainings on FP, SBCC, and KMSm with the expectation that community leaders will advocate for, support, and monitor youth activities in the Program regions. In Q3, the Program trained 35 PNSC community committee members and FKT leaders on youth health promotion approaches. Specifically, the Champion Commune approach trainings integrate youth health activities as part of community goal setting.
2.3.2 School-Based Youth SBCC Activities
In this quarter, the Program built upon its youth SBCC school-based activities conducted in Q2, expanding to 18 new schools in four regions. A total of 275 parents and 1,744 students received an orientation on the model youth approach in schools and on using household health cards as a tool to promote youth health in school. In addition, the Program provided training to 54 government officials, 193 teachers to initiate the model youth approach in their schools. After the training, the student leaders began working with 736 youth who demonstrated an interest in working towards “model student” status. In addition, student leaders conducted 78 peer-to-peer education sessions on reproductive health with 300 youth this quarter.
Page 25 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 26
2.3.3 SBCC Activities for Out-of-School Youth
The Program’s SBCC activities for out-of-school youth continued to provide accurate information on and referral services for adolescent reproductive health focused on the following:
Community-based promotional activities by the ménage modèle and ménage parrain; CHV promotional sessions and service provision on FP; Use of FP invitation cards distributed by CHVs to the regular FP users for further distribution to interested and potential new users including youth; and Media programs, such as radio spots, promoting the importance of FP.
In this quarter, CHVs distributed 31,999 FP invitation cards to regular FP users, of which 15,496 (48 percent) cards were distributed to youth under 25 years old.
Also of note during Q3, the Program contributed to the development of the national 2018-2020 youth reproductive health work plan in collaboration with the Ministry of Public Health’s Department of Family Health and other development partners.
Page 26 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 27 Intervention Area 3 (IA3): Health Service Planning, Management, and Governance
Key Achievements: 1. 584 CSBs (80 percent of the total CSBs in the Program regions) conducted monthly meetings for CHVs in their catchment areas. 2. On average, 6,975 (73 percent) of functional CHVs attended these monthly meetings. 3. The average rate of CHV monthly reporting remained high at 79 percent. 4. 2,112 CHV supervision visits were conducted during this quarter by GOM, Program staff and FKT heads. 5. Program staff participated in 52 GOM-led technical meetings and working groups at the national level.
Sub IA 3.0 Strengthening of GOM Capacity
3.0.1 Coordination with MOH
Participation in Central GOM-Organized Technical Meetings and Workshops. During Q3, Program staff at the central office attended 52 technical meetings and workshops organized by the MOH and other development partners at the national and regional levels. These workshops included the following: contribution to the development of a national protocol for the introduction of the treatment of possible serious bacterial infection in newborns in health centers (CSB); the Malagasy translation of the PNSC; national quantification of child health, malaria and reproductive health and family planning commodities; and the PMI Malaria Operational Plan FY 2019 in partnership with the National Malaria Program and national development partners. These meetings and workshops allowed Program staff to support planning and monitoring of national program priorities and to provide an opportunity to inform national strategies by sharing lessons learned from the Program. .
GOM Capacity Building. During this quarter, the Program conducted trainings of trainers (TOTs) for 336 MOH officials (4 at regional level, 35 at the district level, and 297 at the commune level) on integrated family planning, Protecting Life in Global Health Assistance, and US Abortion and FP Requirements. After each TOT, MOH officials will conduct cascade trainings to the regional and district health officers, who in turn will conduct the TOT for the CSB heads. The CSB heads will then conduct training for CHVs. Figure 17 shows the total TOT trainings conducted in Q3 FY2018.
Figure 17- Training of Trainers Received by MOH Officials in Q3 FY2018 (n=336)
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CHV Technical Supervision (monthly meetings and supportive supervision). As reported earlier in IA1, 78 percent of CHV attended monthly meetings at the CSB. The monthly meetings present an opportunity for CHVs to submit their monthly reports and receive updates and continued technical training. The CHVs also discuss work-related difficulties and challenges and identify potential solutions to address barriers with the support of the CSB.
During Q3, the GOM, Program staff, and FKT heads conducted a total of 2,112 supervisory visits (Table 8). FKT heads conducted 632 supervision visits or 41 percent of the total visits; while GOM and Program staff conducted 1,480 (59 percent). The number of supervisory visits in Analanjirofo is expected to increase in Q4 as CHVs are able to provide services to CU5 and WRA. In total, 4,000 CHVs received supervision visits this quarter.
Table 8 – Number of Supportive Supervisions Conducted in Q3 FY2018
Number of supervisions Number of supervisions Number total of Region by GOM and CCHP by Fokontany heads CHVs supervised
Analanjirofo 34 5 74 Boeny 48 65 217 DIANA 371 34 771 Melaky 131 47 316 Menabe 340 381 1362 SAVA 133 2 253 Sofia 423 98 1007 Total 1480 632 4000
Sub IA 3.1. Introduction and Promotion of CSB Improvement
3.1.1 CSB improvements
In order to identify challenges to the access and the availability of quality MNCH services, the Program undertook a service availability readiness assessment (SARA) of CSBs in all seven regions. By the end of Q4, the consultant team engaged for the study will have completed all data collection and analysis with preliminary results available in Q4. Based on the survey results, the Program will identify activities for FY2019 that address the gaps the study identifies.
Sub IA 3.2. Pharmaceutical and Commodity Forecasting
During this quarter, Program staff participated in ten meetings and workshops related to the national supply of community health products (the Family Health Division, the National Malaria Control Program, and the Pharmacy, Laboratory and Traditional Medicine Division). Additionally, the Program team conducted a joint field visit to Sofia region with USAID, PSI, and the PSM project teams to better understand the context and the challenges facing CHVs for the resupply of FP and child health tracer products. The joint team held discussions with several CHVs, met with CSB staff, and owners of community depots supported by PSI’s social marketing programs. The main takeaways from the visit included: 1) reports of frequent stock shortages of FP products (injectables) at community depots in 2017, and 2) while the situation has improved since March 2018, available stock at the community depots does not always meet CHV demand and that certain products, such as ORS formula with Zinc, are out of stock. The Program will continue to collaborate with partners to address the issue of high levels of stock out of commodities among CHVs. However, as
Page 28 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 29
mentioned previously in this report, the high level of stockouts has had a negative impact on the Program, which is at risk of not achieving FY 2018 objectives that rely on the availability of health commodities at the community level.
Sub IA 3.3. Health Data Quality, Management, and Use
3.3.1 CHV Monthly Reporting to CSB
When CHVs begin providing health services (either in c-IMCI or FP, or both), they are required to submit their monthly report to their local CSB. In this quarter, a total of 584 CSBs conducted monthly meetings for CHVs in their catchment area. Reporting rates for CHVs for Q3 is 79 percent.
3.3.2 Integration of CHV Data into MOH's Health Management Information System (HMIS)
In Q3, the Program supported the DHO in 29 districts for the successful entry and submission of monthly CHV reports in the national health information reporting system.
Data quality assessment at a monthly meeting in Betsioky (Menabe Region).
3.3.3 Integrated Community-Based Surveillance of Preventable Diseases
A total of 2,339 CHVs received refresher training on disease surveillance in Q3 during monthly meetings held at the CSB.
3.3.4 Data Use for Performance Review
As reported earlier in the Capacity Building of GOM Officials section, the Program started to use a dashboard of selected indicators generated by the Program database to monitor Program progress on a monthly basis and prepare improvement plans at the district level. The Program will share GOM officials’ experience using the newly introduced dashboard the next quarterly report.
Sub IA 3.4. Referral System Strengthening between CHVs and CSBs
3.4.1 Referral System between CHVs and CSBs
Progress in this area was previously reported under IA1.
Page 29 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 30
Monitoring and Evaluation, Learning Management, and Cross- Cutting Issues
Sub IA 4.1 Program Monitoring, Evaluation, and Performance System
Key Achievements: 1. Supported MOH DHIS2 pilot in seven districts in Sofia Region. 2. Participated in 2 regional joint bi-annual review meetings and 24 district level review meetings. 3. The Program conducted a dissemination workshop in order to share results, best practices, and lessons learned from the Program’s first two years of implementation
4.1.1 Data Management
Following the DHIS2 TOT conducted by the MOH in Q2, the pilot was launched in two regions (Sofia and Vakinakaratra) in June. The Program provided technical and financial support, including training and equipment for the MOH piloting of DHIS2 in 7 districts of Sofia region. From June 3 to June 8, two Program staff assisted in the training of 22 users in Antsohihy (14 EMAD members from the 7 districts, 4 EMAR, and 4 Mahefa Miaraka regional staff). Six districts out of seven successfully entered and analyzed CSB monthly data using the DHIS2 system. The seventh district did not use the DHIS2 system due to the lack of computers to run the software. The Program has agreed with the district and central MOH teams to provide the necessary equipment to the district in early FY2019.
4.1.2 Data Reporting, Quality, and Use
CSB heads continued to organize monthly meeting, as presented in IA3, during which CHVs submit reports and CSB heads check and approve the data. The average reporting rate among CHVs this quarter increased to 79 percent. The Program continued to support health district teams for data entry and the review of electronic dashboards on key performance indicators of district and commune level results. This quarter, the Program participated in two regional bi-annual, joint review meetings and 24 district quarterly review meetings with GOM officials in order to assess progress on key service delivery indicators, enhance understanding of quality issues, and address concerns with recommendations for follow-up at each level. Regarding the data quality, the regional and district team conducted routine data quality assessments (DQAs) in 77 sites. Findings for these assessments resulted in the following recommendations to avoid similar errors in the future: 1) supply of new integrated record books, including stock management sheet; and 2) strengthen systematic and consistent recording of services offered in the record books.
In addition, routine performance monitoring revealed contradictory data trends in the achievements of some key indicators. For example, despite the increase in the number of reported routine users of FP, CYP does not reflect the anticipated increase that would accompany a greater number of FP users. Therefore, the Program team conducted an in-depth analysis of the routine data to try and better understand these trends, to look for possible causes, to test hypotheses of the issue’s cause, and to identify appropriate strategies based on the findings. The Program suggested and tested the following initial hypotheses: The low level of case management and number of FP clients at the CHV level is likely to be associated, in part, with high levels of stockouts in tracer commodities, thereby negatively effecting CYP. Commodities distribution on stock cards may not be systematically recorded by CHVs. The management of commodities is recorded separately from client registers, so CHVs may forget to complete the card.
Page 30 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 31
The unexpectedly low levels of case management by CHV may be associated with a decrease of disease incidence after six years of Program intervention at the community level. The lower than expected number of FP clients CHVs report may be associated in part to the decrease in the performance of the CHVs during the time between the end of the former MAHEFA program and the current Program (Mahefa Miaraka) when program support was not available. As a result, clients may now be more likely to seek services from the CSB, as opposed to CHVs (i.e. there has been a shift of clients from CHVs to CSBs). The low level of case management and number of FP clients at the CHV level is likely to be associated, in part, with CHVs’ underreporting of achievements. This possibility may be related from moving from an individual reporting by CHVs under MAHEFA to a single FKT-based report under Mahefa Miaraka. The Program is currently conducting an internal review to determine the potential impact of this move on achievements recorded.
The team will further analyze data and involve the Program’s district teams in a data validation exercise in Q4. Moreover, the seasonality of diseases still needs to be analyzed closely, as well as the recording of the distribution of commodities by CHVs, a potential shift in where clients seek services (at the CSB rather than CHVs due to frequent stockout of commodities), and the magnitude of potential underreporting by CHVs.
4.1.3 Technology Use to Improve Health Services
In Q3, the Program continued to support online access to data at the regional level through a web portal. Via the web portal, the Program’s regional team is able to generate the monthly report of selected indicators, thereby ensuring the timely availability of data across both the Program and at all levels of the MOH. DHIS2, as described earlier, was the main focus of the team.
Sub IA 4.2 Learning Management
4.2.1 Studies, Surveys, and Review Workshops for Improvement of Program Performance
The two studies and surveys planned for this Program year, the CSB survey and GBV study were reported under IA1, IA2, and IA3. In Q3, the Program finalized the tools for the study related to the mutuelles de santé, which aims to assess the performance and sustainability of these mutuelles in order to identify the measures of improvement and lessons learned for scaling-up. The Program will carry out data collection in Q4.
4.2.2 Dissemination
In addition to participating in high-visibility events to share Program innovations and achievements as reported in IA2, the Program disseminated and shared experiences and results during the activities presented below: World Health Day Program Dissemination Workshop
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World Health Day The Program participated in World Health Day activities held in Fianarantsoa on April 6-7. The team highlighted Program activities related to the youth and gender approach, emergency transport, and mutuelles de santé.
Program Staff providing clarifications to young Mascot during the parade visitors of the booth
Program Dissemination Workshop On June 6, 2018, the Program hosted a dissemination workshop to share results, best practices, and lessons learned from the first two years of implementation. Through testimonials from CHVs and other community actors, Mahefa Miaraka highlighted its contributions towards universal health coverage in Madagascar and its progress in reaching 6.1 million people with quality health services at the community level. The workshop participants included 74 from MOH, USAID and other partner organizations and 10 members of the national press. The workshop emphasized community approaches, best practices, and lessons learned through the perspective of community actors, including DHO and CSB staff, CHVs, and students of a local middle school. At the event, a gallery walk and group discussions highlighted the Program's contribution towards ensuring access to quality health services and the strengthening the commitment of local actors to improve the health of families in their communities. National press coverage of the event further disseminated key moments and messages from the workshop, including four articles in national newspapers, one radio station, and five television stations.
Ribbon cutting ceremony Booth visit session
Page 32 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 33 Sub IA 4.3 Cross-Cutting Issues
Sustainability Mechanisms. As presented throughout this report, Mahefa Miaraka continued to promote a sense of ownership among and develop the capacity of GOM officials and other community actors at the local level through the technical trainings. Using the cascade training approach, the Program trained GOM officials at each level to conduct the training for their own staff members. In addition, the Program continues to strengthen the relationship between CHVs and the CSB through its support of monthly meetings and routine supervision of CHVs in the FKT with data from CHV reports contributing to national results.
Gender Equality and Female Empowerment. The Program took action to ensure and promote gender equality and female empowerment within the team, as well as in Program activities. Program staff continues to participate in national-level gender working group meetings, such as the the Program’s contributions to the development of the national 2018-2020 youth reproductive health work plan in collaboration with the Ministry of Public Health’s Department of Family Health.
Environmental Compliance. The Environmental Mitigation and Monitoring Report (EMMR) is presented in Annex 3. During this quarter, the Program continued to see increases in the number of waste disposal pits built at the CHV’s heath huts. Additionally, the Program printed and distributed a poster depicting waste management procedures to all CSBs and CHVs, according to the instructions from the Mission Environmental Officer (MEO).
Family Planning Compliance. Ninety-eight percent of program staff (256 out of 262) had completed and received certificates for the “US Abortion and FP Requirements – 2018” and “Protecting Life in Global Health Assistance and Statutory Abortion Restrictions” through online Family Planning courses at the end of Q3 FY2018. Mahefa looks to have all of its staff complete FP Compliance training in Q4.
Page 33 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 34 Challenges and Proposed Solutions for Q3 FY2019
CHALLENGES SOLUTIONS 1. Continuous, high level of stockouts Held coordination meetings with MOH (EMAR – of child health and FP tracer EMAD), PSI, and PSM, and conducted a joint-learning products visit to Sofia region to better understand factors related to availability of commodities. Negotiated availability of commodities at CSB for CHVs with CSB, SDSP, and Direction Régionale de la Santé Publique. Participated in ToT on supply management with DPLMT and PSM (Analanjirofo et Melaky districts). Participated in national quantification workshops conducted by MOH in Antsirabe for child health (c- IMCI) and FP products in Q3. Continued sharing Program data on stock-out of essential commodities in meetings with DLP, DPLMT, and DSFa to inform decision-making. 2. Delays in delivery of CHVs kits Prioritized delivery of kits to CHVs in new districts of Analanjirofo and SAVA regions. Improved tracking of vendor delivery schedules to ensure timely and complete delivery of kits to the Program’s district teams. 3. Secure transfer and tracking of funds Flagged individual CHV technical difficulties faced by transferred to thousands of CHVs small groups for technical troubleshooting by Telma to each month ensure smooth and timely transfer of payments. Negotiated with other TELCO operators to establish the means of electronic transfer in regions where Telema, the current provider, does not have sufficient network coverage. Identified means to register new CHVs in the system locally for ease of administration of electronic fund account. 4. Security for staff, particularly in Engaged the community to improve staff security. Melaky and Menabe regions Improved tracking of staff on mission and strict enforcement of existing policies on travel. Collaborated with local authorities to address security issues.
Page 34 USAID Community Capacity for Health Program – Mahefa Miaraka FY2018 Quarter 3 Report 35 Administrative and Financial Management
Key Achievements: 1. The Program has recruited and oriented 298 Program staff. 2. The Program has signed a memorandum of understanding (MOU) with eight organizations and projects and is finalizing discussions with three other organizations to sign MOUs as of the end of the current fiscal year 2018. 3. The Program has launched electronic payments through mobile banking in all Program zones.
Sub IA 0. 1 Operation (Administration, Finance, and Partnership)
0.1.1 Administrative and Financial System
During Q3 of FY2018, the administrative and financial teams in all offices continued activities according to the systems established.
Sub IA 0. 2 Administration
During this quarter, all Program offices, including those at the district level, were fully functioning. Central-level teams provided monitoring visits and on-the-job support to regional and district teams.
0.2.1 Human Resources
By the end of June 2018, the Program had 276 out of a total of 283 planned positions filled. This is primarily due to staff resignation for personal reasons, whether family-related or for career advancement.
To date, the project has recruited and trained a total number of 298 program staff and faced 29 departures representing 10 percent of total recruited, of which 80 percent were from regional and district offices. As in previous quarters, staff continued to receive a series of capacity building and professional development sessions throughout this quarter. These capacity building efforts are important for regional and district staff and help to ensure streamlined efforts moving forward.
0.2.2 Information and Technology Systems
Efforts in Information Technology (IT) continued to focus on equipping the Program team with necessary electronic equipment (laptops, printers, and cameras), the best use of such equipment throughout the Program’s intervention zones, and the challenges faced due to power shortages. Maintaining connectivity with satellite offices remains a challenge with the poor quality of internet service outside of Antananarivo. The Program is prioritizing the use of laptops over desktops to mitigate challenges faced by power shortages. With the closure of the European funded PASSOBA project, and the launch of the DHIS2 pilot project, the needs of IT assistance for the MoH branches is increasing, and the project is analyzing the best ways to provide this support in terms of internet capability as well equipment availability. All MoH districts office under the Project intervention zones have been supplied with USB internet access with WiFi capability to enable these offices to perform their daily communication as well quality data reporting.
0.2.3 Procurement and Distribution Management
The procurement and distribution team provides bi-monthly updates to the technical staff on the Program’s supply chain process. While the CHV-kit packaging system appears to be a good practice for the procurement and distribution of the CHV materials and kits, this is still a challenge for some regions and districts. In-kind contributions from CCDS members are encouraged in the distribution
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process of CHV materials. Additionally, the Program was involved in the procurement and distribution of malaria related drugs and supplies in support of the MOH.
0.2.4 GOM and Partner Management
The Program continued to collaborate with several GOM offices on labor law, taxes, and other operations to ensure that the Program’s operations are in line with the evolving national regulations. By the end of Q3 FY2018, as previously reported, 25 MOUs had been signed with Public Health District Offices for the use of office space by Program staff. In addition, the Program is working with the 34 SDSP to provide them with internet accessibility for data reporting and information sharing between region and district and the Program and the SDSP themselves.
During the current reporting period, one MOU was been signed with the Cooperative KAMPI Mandroso for the implementation of an income generating activity through the sale and repair of bicycles collected by Program partners bringing the total number of signed MOU to eight.
As previously reported, the Program is under preparation of MOUs respectively with:
1. MP from Andapa: The Program plans to collaborate with the Mr Jean Max Rakotomamonjy, a MP from Andapa district and current President of the National Assembly of Madagascar for the implementation of a framework for the utilization of six donated ambulances in the district of Andapa by the communities. This MOu will be signed also with the Managing Board set up by the communities for the use of these ambulances. 2. NCBA-CLUSA Madagascar: The Program plans to collaborate with NCBA-CLUSA Madagascar to implement community health activities within the vanilla cooperatives and producers working with NCBA in three communes of the Andapa district in the SAVA region. 3. Office National de Nutrition: The Program plans to collaborate with the Office National de Nutrition (ONN) to promote the community group of listeners for joint messages on nutrition and community health activities.
0.2.5 Reporting to USAID and GOM
In addition to the timely submission of all other progress reports throughout the life of the Program, staff submitted all progress reports (technical and financial) to USAID on time as stated in the Program’s cooperative agreement. After the approval by the Program’s agreement officer representative, Program staff uploaded the reports to the DEC. For the GOM, only the regular monthly reporting for staff income revenue was due and was submitted by the due date. The program has managed to renew the Implementation Agreement (Accord de Siège) between JSI R&T and the GoM with the new framework set by the GOM for a two-year period. The new expiry date is May 31, 2020.
Sub IA 0.3 Financial Management
0.3.1 Financial Procedures
SIM cards were distributed to some 8,500 Program CHVs. This came after initial testing of the MVola mobile money platform with CHVs in a limited number of districts and signing a contract with TELMA to implement the use of mobile money. As planned, the Program issued the first transactions paid through the MVola platform for activities occurring at the end of April 2018. A discussion is also taking place with Orange for the implementation of the Mobile banking payments through the OrangeMoney platform to complement the offers to CHVs especially in zones not well covered by MVola. Mobile Banking payments will be extended to all participants in activities funded by the Program including staff from MoH during the last quarter of the FY18.
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0.3.2 Financial Reporting to USAID
As reported above, in the quarter, the Program submitted the required financial reports (SF425 and accruals reports) to USAID.
0.3.3 VAT (Value Added Tax)
The Program continued to submit VAT reimbursement requests to the MOH in order to comply with the procedure discussed among USAID Implementing Partners. Follow-up is done on regular basis with the vendors and there is no claim yet received. At the end of June 2018, the MoH didn’t process any reimbursement to Vendors for the current calendar year.
0.3.4 Expenditures
The Program recorded a total of of cost share at the end of Q3 FY2018, an increase of . compared to the amount previously reported. The collection of the Cost Share is running as planned with an increase expected this coming quarter reflecting some cost share collected during Q3 but not yet reported and some cost share to be collected in Q4. The Program continues to seek cost share and will report to USAID on a quarterly basis. CCH expects a significant increase in cost share moving forward as the project will begin recording in-kind costs share by calculating CHV time spent on project activities.
Table 9 – Program Cost Share as of June 30, 2018
ORIGIN USD ASOS (for joint program activities) BLUE VENTURES (for joint program activities) WAHO – West Africa Health Organizations Ouest Africaine de la Santé (support a staff participation at the conference on CHX in Burkina Faso) Government of China (for ACT) Madagascar MOH (office space and minor rehabilitation)
TOTAL
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A summary of Program expenditures through June 30, 2018 is presented in Table 6 below. The Program continues to report its expenditures distributed by source of funding.
Table 10 – Program’s Cumulative Expenses as of June 2018
TOTAL EXPENDITURES BUDGET LINE ITEMS AS OF JUN 30, TOTAL EXPENDITURES BY FUNDING TYPE 2018 (IN US$) GH - A049-Malaria A052- MCH A053- FP/RH A054- Water emergency Plague
SALARIES CONSULTANTS TRAVEL, TRANSPORTATION, AND PER DIEM ALLOWANCES EQUIPEMENT, MATERIALS, AND SUPPLIES OTHER DIRECT COSTS PROGRAM COSTS SUBRECIPIENTS TOTAL DIRECT COSTS
INDIRECT COSTS / OVERHEAD
TOTAL COSTS
COST SHARE
GRAND TOTAL
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DISCLAIMER
This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the responsibility of JSI Research & Training Institute, Inc. (JSI) and do not necessarily reflect the views of USAID or the United States Government.
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