MCSP Guinea Restoration of Health Services, March 2017

MCSP/Rachel Waxman

Guinea–Selected Demographic and Health Indicators Indicator Data Indicator Data Indicator Data TFR (births per Population (1) 10,628,972 5.1 Pneumonia (2) 38% woman) (2) CPR (modern 36.5% / Live births/year (3) 368,558 5% ORS / Zinc (2) methods) (2) 0.5% Ebola infections MMR (per 100,000 724 ANC +4 (2) 56.6% during recent 3,804 live births) (2) epidemic (4) Ebola death rate NMR (per 1,000 live (percentage of 34 SBA (2) 45.3% 66% births) (2) infections ending in death)(4) U5MR (per 1,000 live 94 DTP3 (3) 51% births) (2) Sources: (1) 2014 National Census; (2) DHS 2012; (3) WHO UNICEF 2015 coverage estimate; (4) WHO Ebola Situation Report, December 2015.

Strategic Objectives: Restoration of Health Services Program  At least 80% of MCSP-supported hospitals and health centers (n=221) meet minimum IPC standards.  34 facilities supported to reinvigorate and maintain the SBM-R process, with at least 80% achieving and/or maintaining recognition of performance.  75% of target facilities in the 20 focus prefectures have increased capacity to offer RMNCH services (of 26 hospitals and 195 health centers).  96 health posts supported to improve IMNCI and contribute to the care of sick children in the catchment areas of 30 health centers (revised target).  700 community health workers (ASC) are supported to reinvigorate community health and mobilization to provide health information, accompaniment of pregnant women, and FP services, as well as key lifesaving interventions; and to increase community ownership and capacity to explore, plan, and act together for improved RMNCH outcomes in communities surrounding 20 MCSP-supported health centers.

Program Dates July 14, 2015–December 17, 2016 (18 months) Financial Total budget = _____ Summary Geographic National; Regions of Boké, Conakry, Forécariah, Kindia, N’Zérékoré (plus Kissidougou Scope prefecture) No. of No. of provinces (%) No. of districts (%) facilities/communities (%) Geographic 26 of 44 (68%) hospitals/CMCs Presence 4 of 8 regions (50%) 20 of 38 prefectures (53%) 195 of 404 (48%) health (7,647,281 population) centers

Technical

Interventions PRIMARY: Maternal Health, Newborn Health, Child Health, Reproductive Health, WASH, Ebola CROSS-CUTTING: Community Health, SBCC, PSE

Key Accomplishments The RHS program supported national and regional trainers who conducted coaching visits to facilities focused on IPC performance. This work followed IPC training provided under the earlier Ebola Response programs, which were also supported through MCSP. In addition, the RHS program supported the reinforcement and/or reestablishment of hygiene and safety committees that oversee internal supervision, stock management, and action planning for IPC. Performance scores improved in almost all facilities, with 45% of health facilities/services meeting the minimum desired performance of 75% of IPC standards. The behavior change required to maintain IPC performance, and the need to ensure adequate availability of commodities for IPC, are ongoing challenges in the effort to achieve consistent and correct performance of standard precautions, let alone more complex tasks needed to prevent and control potentially epidemic disease. MCSP observed some declines in IPC performance as prefectures were declared Ebola-free and the EVD epidemic was declared over in Guinea. The coaching visits worked to remediate some of this reduced performance, yet changing providers’ beliefs about the risks to themselves and their patients, as well as their habits in terms of IPC practices, remains a fundamental health systems challenge

Health Centers Hospital Services Baseline Endline Baseline Endline Performance Score Evaluation Evaluation Evaluation Evaluation 165 % 165 % 174 % 174 % Score of 75% or higher 7 1% 60 36% 11 6% 91 52% Score of 50–74% 38 12% 68 41% 36 21% 44 25% Score of 25–49% 70 46% 34 21% 41 24% 21 12% Score of 0–24% 42 41 3 2% 77 44% 4 2% Not assessed 8

MCSP supported the rehabilitation of water storage and supply in service provision areas and solar energy supply for backup electricity in the key service provision areas of three hospitals. Twenty-three autoclaves were distributed to facilities to support correct instrument processing. In many cases, hospitals previously had been provided with large-capacity autoclaves that they could not operate on the available power supply; thus, smaller-capacity units were provided to better suit available conditions. Non-electric autoclaves were provided to health centers that did not have electricity but could obtain propane tanks to heat the unit.

Before (left): Matrons have to collect water for the maternity. After: A bore hole with pump and filter have been installed with a new tank on a platform to distribute water into service provision areas. A large storage tank (right) and a reservoir were repaired to improve water availability even when the pump is not running.

All 34 facilities using SBM-R were supported in their ongoing implementation of the SBM-R quality improvement approach. Although these facilities had been implementing SBM-R for several years before the Ebola epidemic, assessments at the beginning of the RHS program showed major declines compared to previous assessments. Thus RHS started by working with the internal SBM-R teams and prefectural and regional supervisors to reinvigorate the process, including orientation of new staff where needed. At the most recent assessment, nine facilities were performing at the recognition level, and nine had improved their performance but had not yet reached the recognition level.

Of the 221 focus facilities, 84% received support to improve RMNCH (training, materials, supportive supervision), including the following clinical areas: BEmONC (171 HCs); CEmONC (26 hospitals); IMNCI (39 HCs and 114 health posts, 1 CMC and 1 pediatrics unit of the prefectural hospital); and PPFP integration (17 hospitals and HCs). This exceeds the target of 75% of facilities in focus areas. The inputs to these health facilities contributed to increases in the number of pregnant women who had an assisted delivery in a facility including those receiving active management of third stage labor for prevention of postpartum hemorrhage (see graphs below). The program had the flexibility to alter the objectives for IMNCI once it was determined that other health partners were supporting health centers and CHWs, yet a large number of sick child consultations were taking place at health posts that were largely unsupported. MCSP RHS extended training to health post staff in collaboration with the health centers they feed into, reaching mostly auxiliary health agents (ATSs) at 114 health posts. These inputs contributed to a 13% increase in health care seeking in three of the four regions and 29% increase in assisted deliveries in the two regions that experienced the largest numbers of EVD cases (see details by region in third graph below; Boké is excluded because MCSP did not cover the entire region).

Figure 1: Evolution of number of assisted deliveries in the regions of Conakry and N’Zérékoré

57,080 60,000 50,000 44,226 40,000 35,881 30,000 21,764 22,462 21,199 20,000 10,000 0 Conakry region N'Zérékoré region Total

Oct 14–Sept 15 Oct 15–Sept 16

Figure 2: Percentage of women delivering at a health facility who received active management of third stage of labor (AMTSL)

100% 96% 91% 91% 92% 80% 85% 60% 40% 20% 0% Oct - Dec 15 Jan - March 16 April - June 16 July - Sept 16 Oct- Dec 16

Figure 3: Evolution of patients seeking care at health facilities in the regions of Conakry, Kindia, and N’Zérékoré, 2015 and 2016

1,400,000 1,275,260 1,200,000 1,125,276

1,000,000

800,000

600,000 519,949 535,483 379,973 331,993 359,804 400,000 273,334 200,000

- Conakry Region Kindia Region N'Zerekore Region Total January - December 15 January - December 16

The program successfully introduced a new training methodology of onsite, individualized learning, which allowed more providers to acquire key skills in RMNCH. With the introduction of a module on PPFP/PPIUD integration into maternity and ANC services, 153 providers participated in training at 17 facilities, and to date 105 have completed training and skills qualification to date, 24 have completed the course and are awaiting qualification, and another 24 were continuing the individualized learning at the end of the program.

A total of 975 CHWs (140% of target) were supported with education and information on maternal, newborn and child health to reinforce their capacity to provide community health services (755 in RMNCH and 220 in IMNCI). Community mobilization teams were established in eight districts of Boké and Kindia. Community mobilization activities help to strengthen the link between communities and health services and promote health care seeking when needed. MCSP RHS also supported the revision of the community education logbook/register used by CHWs to document activities that align with the key messages of the integrated community health package.

Challenges After the Ebola outbreak was declared over, the program found that it was difficult to maintain good IPC practices such as hygiene, triage, and waste management. Coaching for IPC must be ongoing to bring about the required behavior change. Although the program has closed, support for IPC is still needed. MCSP RHS also dealt with a number of delays in planned activities when MOH staff were called to participate in various campaigns, such as vaccination days and LLIN distribution, which took all staff away from their other responsibilities, despite the program’s best efforts to support coordination of and preparation for these and routine activities. Way Forward Despite the challenges discussed above, MCSP RHS enjoyed strong MOH engagement in reinforcing IPC and revitalizing community health, as well as close collaboration with other partners and projects, including other USAID Ebola Recovery–funded projects such as HC3 and HFG. This allowed for successful realization of program objectives. This program closed in the first quarter of PY3.

Selected Performance Indicators as of December 2016 MCSP Global or Country PMP Indicators Achievement Percentage of MCSP-supported hospitals and health centers (n=221) that meet minimum IPC standards (target 45% 75%) Percentage of target facilities in the 20 focus prefectures that have increased capacity to offer RMNCH services 77% (target 75%) 88% (improved from 85% in first quarter to 92% Percentage of women delivering in health facilities who in last quarter of PY2 to 96% in the first quarter receive a uterotonic in the third phase of labor of PY3) Couple years of protection 145,925 (50% contributed by LARC methods) Number of community health workers (ASCs) supported to reinvigorate community health and mobilization 975 activities (target 700)

MCSP Guinea Gender-based Violence Program, March 2017

“When I change, the world changes”

MCSP/Jacqueline Aribot

Strategic Objectives: Gender-Based Violence Program  Integrate activities and services for the prevention and management of Gender-Based Violence (GBV) within RMNCH services at the facility and community levels in Conakry.

Program Dates January 2015–September 2016, plus 5-month extension to February 2017 Financial Summary Closed: Total budget = ____ _ Geographic Scope Region of Conakry No. of No. of provinces (%) No. of districts (%) Geographic facilities/communities Presence 1 of 8 regions (20%) 5 of 38 prefectures/ 7 hospitals and CMC Population: 2,159,265 communes (13%) Technical CROSS-CUTTING: Gender Interventions

Key Accomplishments In 2013, USAID Guinea obtained three years of incentive funding to support gender-based violence (GBV) interventions to improve prevention and management of GBV. The Maternal and Child Health Integrated Program (MCHIP) was asked to implement activities, in collaboration with the American Bar Association, in its last year. MCHIP-supported activities were designed to focus on the integration of GBV services, as well as health, legal, and community support services, into reproductive, maternal, newborn, and child health (RMNCH) services. MCHIP completed a baseline assessment and identified stakeholders from among several government ministries, civil society, and the health care facilities to be involved in the intervention. When MCHIP ended, MCSP was asked to continue the implementation of GBV interventions for the remaining two years of funding.

In 2015 (during MCSP’s PY1), the Ebola epidemic took center stage and priority was given to the Ebola Response, so only a few GBV activities were accomplished in what was supposed to be the second year of the program. MCSP completed the dissemination of the baseline assessment findings to key stakeholders in Conakry, including more than 400 community members from the five communes. The terms of reference for an intra-ministerial committee were drafted for approval by the participating ministries. The curricula for community and provider training were drafted for review by stakeholders.

In MCSP’s PY2, the clinical and community GBV curricula were refined in collaboration with government ministries (MOH, Ministry of Social Action and Protection and Women and Children, and Ministry of National Reconciliation and Citizenship) and partners engaged in gender issues, and validated by the MOH. GBV prevention and management were then integrated with the Reproductive Health Norms and Procedures, the key document guiding primary health care, and standard operating procedures for GBV management were revised.

Following the training of 42 health care providers, seven health care facilities started screening for GBV and providing clinical management. Ten paralegals were trained to support GBV cases and assist with referrals to a legal aid clinic run by the local non-governmental organization (NGO) Meme Droits pour Tous (Same Rights for All).

The program selected and trained 125 community and school GBV educators, who have conducted community awareness activities that reached 38,639 people (62% women and girls). Orientation sessions were organized for local government officials, community leaders, police and security forces, and 30 journalists from public and private media outlets, along with members of community theater troupes. Five community committees, one in each commune, also were formed to support GBV awareness and prevention activities, and a community education flip chart was developed, tested, validated, and reproduced to support community awareness events.

Through the end of the program, seven facilities had conducted 128 screenings for GBV, and 95 clients had received medical treatment. The majority of cases were reported by family members, and most cases involved sexual and/or physical violence, although instances of psychological, verbal, and economic violence also were reported. The age of GBV survivors ranged from 2 to 37 years, and 25 cases occurred among children 13 and younger. Sixty-seven GBV cases were referred for legal assistance (including one case of human trafficking), and 48 cases, including 23 cases of rape, were or are still being pursued.

Five radio spots and one TV segment were produced and 10 radio broadcasts and two television broadcasts were aired through the end of the program. MCSP’s GBV work was highlighted at a National Social Forum in July 2016, and national journalists produced 33 articles or communications on GBV (22 on radio and 11 televised). MCSP also established a network of mobile phones between community committees, the Office of the Protection of Gender, Children and Minors (OPROGEM), paralegals, and health facilities to facilitate communication and referral. This system was tied into an existing network of phones among health care providers and managers, with the cost of voice calls paid by MCSP.

MCSP conducted an assessment of stakeholder satisfaction with the program’s efforts to address GBV prevention and management at the end of the program in February 2017.

Challenges During most of 2015, the program was unable to operate as a result of the Ebola epidemic. Implementation was therefore largely compressed into PY2. Nonetheless, the program was able to achieve its objectives.

Way Forward The synergy between health services, communities, and legal services is strong and there is the potential to do much more than was possible through this modest program. Lessons from the implementation of the MCHIP/MCSP GBV prevention and response program will be shared with all stakeholders and will guide the scale-up of GBV integration with RMNCH services and community engagement under the new USAID bilateral program, Guinea Health Service Delivery Program (December 2015–December 2020).

Selected Performance Indicators as of March 2017 MCSP Global or Country PMP Indicators Level of Achievement Number of health facilities that integrate GBV screening and counseling into family planning and maternal and 7 of 7 neonatal health activities Number of prevention committees achieving at least 80% 4 of 5 (80%) of their activity plans Number of individuals reached by community-level intervention that explicitly addresses gender-based 38,639 violence and coercion Number of cases of GBV received and managed in the 128 target health facilities included in the program Number of referrals made to legal clinics 67

MCSP Guinea Health Systems Strengthening, March 2017

MCSP/Meredith Klein

Guinea–Selected Demographic and Health Indicators Indicator Data Indicator Data Indicator Data TFR (births per Population (1) 10,628,972 5.1 Pneumonia (2) 38% woman) (2) CPR (modern 36.5% / Live births/year (3) 368,558 5% ORS / Zinc (2) methods) (2) 0.5% Ebola infections MMR (per 100,000 724 ANC +4 (2) 56.6% during recent 3,804 live births) (2) epidemic (4) Ebola death rate NMR (per 1,000 live (percentage of 34 SBA (2) 45.3% 66% births) (2) infections ending in death)(4) U5MR (per 1,000 live 94 DTP3 (3) 51% births) (2) Sources: (1) 2014 National Census; (2) DHS 2012; (3) UNICEF 2012 data; (4) WHO Ebola Situation Report, December 2015.

Strategic Objectives: Health Systems Strengthening Program 1. Support the Ministry of Health in the development/revision of key policy and strategy documents, including Infection Prevention and Control (IPC), and their integration into RMNCH services. 2. Support the national, regional, and prefectural levels to support health facilities using the Standards-Based Management and Recognition (SBM-R) quality improvement approach. 3. Support current initiatives of the health management information system for the strengthening of data collection and analysis. 4. Implement the Comprehensive Approach for health systems strengthening at the prefecture and regional levels.

Program Dates April 2016–December 2017 Financial Expenditures thru Q1, PY3 = _____ ; Remaining budget (PY3 plus PY4,Qtr1) = _____; Summary Total approved thru December 2017 = _____ Geographic Regions of Conakry, Boké, Forécariah, N’zérékoré (plus Kissidougou prefecture), Kindia Scope No. of No. of provinces (%) No. of districts (%) Geographic facilities/communities (%) Presence 4 of 8 regions (50%) 20 of 38 prefectures (53%) NA 7,647,281 population

Technical Interventions PRIMARY: WASH, Ebola CROSS-CUTTING: Quality improvement, HSS (Policy, Management, HMIS), PSE

Key Accomplishments The Ebola outbreak of 2014–15 had a devastating effect on routine health services, especially those related to reproductive, maternal, newborn and child health (RMNCH). An already weak health system was at a near- standstill in Guinea due to a lack of regular monitoring and supervision, a devastating loss of health workers and fear by the community to seek services in health facilities. MCSP’s Guinea HSS program, which started in April 2016 with Ebola Response and Recovery funding, was designed to link the facility-level achievements of the earlier MCSP Guinea Restoration of Health Services (RHS) program with health systems-level efforts to sustain the management and coordination of improved RMNCH services. In the first nine months of implementation, the HSS program provided technical support for the development of national Infection Prevention and Control (IPC) policy and program documents. Additionally, MCSP engaged with the Ministry of Professional Education and the Faculty of Medicine to reinforce IPC training in the pre-service education of health care workers (doctors, nurses, midwives). The Program also supports the strengthening of hospital hygiene and safety committees to support IPC management and supervision.

A Rapid Health Systems Assessment (RHSA) was one of the first program activities. Carried out in the four regions that are the focus for the HSS program, this qualitative evaluation targeted health workers at health posts, health centers, district hospitals/communal medical centers (CMCs), regional and national hospitals, town halls, and COSAH (health care committees), as well as community health workers. The final RHSA report was shared with stakeholders, including various directions within the MOH, regional and prefectural health directorates, and partners. Findings from the RHSA have been used to design activities that will improve management capacity in Phase 2 of the Guinea HSS program (2017), at both the prefectural and regional health office level and were presented in the first quarter of FY2017 during regional workshops to launch the Comprehensive Approach to Health Systems Management in Guinea.

The Comprehensive Approach is an MCSP-developed process in which subnational managers (typically at the district level) leverage, mobilize and coordinate local health system resources towards increased coverage, utilization, quality, equity, and sustainability of health services. The application of the Comprehensive Approach in Guinea is providing ongoing technical support to district teams so that they can develop and implement integrated work plans that address local health system challenges in a holistic and proactive manner. At the end of the workshops held, each district team had: (1) identified health system problems that prevented them from achieving their objectives; (2) conducted a root cause analysis of one priority health system problem; (3) developed a list of local resources (both potential and available) that could contribute to their objectives; and (4) identified corrective actions with allocated resources to address each root cause. Participating districts have incorporated these corrective actions into consolidated district and regional work plans (a process facilitated by the Ministry of Health). Participants remained engaged throughout the workshops in both plenary discussions and group work sessions. In each region, there was also significant interest in adopting and using the Comprehensive Approach moving forward in their local planning activities. The Regional Director in Conakry stated that, “we are going to do it ourselves. We are not going to align with the partners, the partners will align and respond to our needs.” The MOH partners also noted their interest in scaling-up the incorporation of the Comprehensive Approach for Health Systems Management into their annual work planning process to ensure that annual workplans are locally driven and address priority challenges.

At the policy and coordination level, MCSP HSS supported the printing and distribution of the recently validated National IPC Strategy and Program document to health managers in the regions and prefectures. Due to RHS program funding constraints, final IPC assessments and data analysis are being supported by the MCSP HSS program to inform future systems-level support for IPC strengthening. In Phase 2 of the HSS program, a component on Waste Management has been added to follow-up on incinerators installed under the OFDA-funded, MCSP IPC2 program and to support ongoing operation and maintenance of waste management services. The assessment of the current functional status of all incinerators has just been completed in collaboration with MOH, WHO and World Bank, who led the selection of the models to be installed in Guinea, with the objective being to establish a consistent infrastructure and facilitate maintenance capacity.

Other key accomplishment of the HSS program to date include the validation of SBM-R performance of five health facilities conducted in collaboration with the national SBM-R committee and the USAID-funded HC3 project. Three of these facilities successfully achieved recognition--two urban health centers achieved their first recognition of high-quality performance, while the regional hospital in N’zérékoré received its second recognition based on additional performance standards.

Finally, technical assistance was provided to the Bureau of Strategy and Development (BSD), in collaboration with partners Measure Evaluation and CRS, for configuration of the new national HMIS, which is being developed on the DHIS2 platform. MCSP facilitated training workshops for DHIS2 users in Conakry, Boké, Kindia, and N’zérékoré, and monitored data entry in these areas. The program also participated in the technical working group on the management of human resources for health (HRH) as a means to link new HRH management tools introduced with USAID support in prefectures supported by MCSP that were most affected by Ebola.

Challenges It can be challenging to keep activities on schedule with health managers dealing with many competing priorities and last-minute demands from multiple sources. It has not been possible to organize the MNCH Bottleneck Analysis that was planned in time for the OIC follow-up meeting in 2017. As of this writing, this activity may be removed from the MCSP workplan.

Way Forward Phase 2 of MCSP’s Guinea HSS program began in February 2017 and will continue in the four focus regions and twenty prefectures through MCSP PY3. MCSP will continue integrating the RHSA and Comprehensive Approach results into their annual work planning processes and will work to build management capacity through training activities, supportive supervision and the coaching of health managers. BSD has also requested HSS support at the national level to develop its own capacity to integrate the Comprehensive Approach into the annual work planning process in Guinea’s remaining four regions. Guinea HSS will continue to support national level policy and coordination actions in support of the MOH, including in IPC, QI/SBM-R, HMIS, and RMNCH.

Selected Performance Indicators as of March 2017 MCSP Global or Country PMP Indicators Achievement Percentage of SBM-R facilities achieving the minimum standards of 9 of 35 (25%) performance as defined by the MOH Number of laws, policies, or procedures analyzed, consulted on, drafted or revised, approved, and implemented with USG support from the 1 program Number of health districts implementing the Comprehensive Approach 20 to Health Systems Management