Final Report of IMNCI Training Courses in Five Selected States and Regions 2016-2018

Home , Hopong Township, Ingapu Township, Taungdwingyi

Taungdwingyi Township, Magway Region Ingapu Township, Ayeyarwaddy Region Minbya Township, Rakhine State Tang Yang Township, Northern Shan State Mongyai Township, Northern Shan State Mong Kai Township, Southern Shan State

MCSP Child Health Team July 2018

Acknowledgements MCSP is a global USAID initiative to introduce and support high-impact health interventions in 25 priority countries to help prevent child and maternal deaths. MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health system strengthening, water/sanitation/hygiene, malaria control, prevention of mother to child transmission of HIV, and Paediatric HIV care and treatment. MCSP will tackle these issues through approaches that also focus on household and community mobilization, gender integration and digital health, among others. In Myanmar, under the leadership and direction of the Child Health Development Division (CHD), MCSP collaborated with the MOHS in updating IMNCI guidelines for Basic Health Staff. The CHD has provided guidance and oversight for all aspects of the training cascade, implementation and post-training supervision. State and Regional Child Health teams closely collaborated with MCSP in the township Multiplier training and post-training supervision to the trained BHS and health facilities. This report is make possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents of this report are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government. July 2018

Cover Photo: A midwife conducting patient examination during a post-training supervision visit, Maternal and Child Health center, Mong Kai township, Southern Shan State

Contents Page

Contents 1 Abbreviation 3 1. Introduction 5 2. Background 6 3. Activity 7 3.1 Developing Updated IMNCI guidelines (2017) 7 3.2 Launching ceremony of Updated IMNCI guidelines (2017) (2-59 months) 7 3.3 Township selection meetings, June and July 2017 7 3.4 Training 10 3.4.1 Central MToT updated IMNCI training, Nay Pyi Taw 10 3.4.2 Central MToT Follow-up training, Nay Pyi Taw 11 3.4.3 State and Regional ToT training 12 3.4.4 State and Regional ToT for follow-up training 12 3.4.5 Township-level multiplier training 12 3.5 CME session 12 3.6 Learning and Performance Improvement Centers (L&PICs) 13 3.7 Post-training supervision visits 13 4. Implementation activity in 5 selected States and Regions 14 4.1 Magway region 14 4.2 Ayeyarwaddy region 16 4.3 Rakhine state 18 4.4 Northern Shan state 19 4.5 Southern Shan state 23

5. Summary of Training and Post-training supervision visits 25 5.1 Training 25 5.2 Post training supervision visits 29 5.2.1 Assessment on clinical skills management 29 5.2.2 Infrastructure 29 5.2.3 Drug stock management 30 6. Key Recommendations 33 7. References 34 8. Annexes 35 Annex 1. Agenda of Central MToT on updated IMNCI guidelines (2017), Nov 2017 35 Annex 2. Agenda for Central MTOT on Follow-up training of updated IMNCI guidelines (2017), January 2018 39 Annex 3. Agenda for State level Follow-up training of updated IMNCI guidelines (2017), S Shan state 42

Annex 4. Agenda for Township level Multiplier training, Mong Kai township, S Shan state, February 2018 46 Annex 5. List of participants in training and supervision visits 50 Annex 6. Number and percentage of trained MOHS trainers in the state, regional and township training teams 52 Annex 7. BHS (LHV and Midwife) existing, trained and supervised 52 Annex 8. Health centers (UHC, MCH, RHC, sub-center) existing, trained and supervised 53 Annex 9. (a, b) Pre- and Post-test scores of participants in trainings 54 Annex 10. Case Scenarios (OSCE) for Pre- and Post-tests in updated IMNCI training 55 Annex 11. Follow-up activity after training – Supervision Tools (English translation) 57 Annex 12. IMNCI Materials placed at L&PICs (5 states/regions) 64 Annex 13.Success stories 66 – Magway Region 67 – S. Shan State 69 – N. Shan State 71 – Rakhine State 73

Tables Table 1. Geographical situation and 2017 health profile data of implementing townships 8

Figures Fig 1. Number of participants who attended ToT from States and Regions 23

Fig 2. Percentage of BHS, trained and supervised in six selected townships 24

Fig 3. Percentage of health centers, trained and supervised (Health centers: UHC, MCH, RHC,

sub-center) 24

Fig 4. Pre- and Post-test scores achievement 25

Map 1. Locations of six selected townships in five states and regions implementing IMNCI activity 9

Abbreviations

ART Antiretroviral Therapy BHS Basic Health Staff CHD Child Health Development Division CME Continuing Medical Education EPI Expanded Programme on Immunization IMCI Integrated Management of Childhood Illness IMNCI Integrated Management of Neonatal and Childhood Illness IMR Infant Mortality Rate L&PIC Learning and Performance Improvement Center LB Live Births LHV Lady Health Visitor MW Midwife NAP National AIDS Program NHP National Health Plan NMCP National Malaria Control Program NMR Neonatal Mortality Rate MCH Maternal and Child Health MCSP Maternal and Child Survival Program MDG Millennium Development Goal MR Mortality Rate MTOT Master Training of Trainers OPD Out-patient Department ORS Oral Rehydration Salt/Solution OSCE Objective Structured Clinical Examination RHC Rural Health Center RUTF Ready-to-Use Therapeutic Food SDG Sustainable Development Goals THN Township Health Nurse TOT Training of Trainers U5 MR Under 5 Mortality Rate

UHC Urban Health Center WHO World Health Organization UNICEF United Nations Children's Fund

1. Introduction

The Integrated Management of Childhood Illness (IMCI) is an integrated approach to child health that intends to reduce death, illness and disabilities and promote proper growth and development among under 5 children through both preventive and curative activities1. WHO and UNICEF developed this approach in 1992 and currently more than 100 countries use the IMCI guideline and approach globally. The IMCI approach is mainly focused on improving case management skills of health care providers, improving family and community health practices, and improving overall health systems2. Since 2007 neonatal health has been added to the IMCI approach, as one of the essential components to address overall mortality and morbidity of under 5 children. IMCI or IMNCI (with neonatal care added to IMCI) guidelines and approaches are mainly intended for child health care in the public health sector, especially in developing countries. The IMNCI strategy was introduced in Myanmar in 1999 and the neonatal component was formally incorporated as IMNCI in 2011. Since then, IMNCI training has been ongoing to achieve nationwide coverage. The IMNCI modules used in Myanmar training were updated in 2017, based on the updated WHO IMNCI guidelines. The IMNCI strategy is intended to give under 5 children a better quality of life by promoting both preventive and curative child care and is implemented by the Basic Health Staff (BHS), in partnership with the families and community. The IMNCI strategy also includes improvement of health infrastructure, such as drugs and commodity management, patient data recording, documentation and reporting systems. In the Myanmar National Demographic Health Survey (2015-16) the under-5 mortality rate was reported as 50/1000 live births (LBs), infant mortality rate was 40/1000 LBs and neonatal mortality rate was 25/1,000 live births3. The Millennium Development Goal No. 4, set by the Ministry of Health, aimed to reduce under-5 mortality to 37 per 1,000 live births and infant mortality to 28 per 1,000 live births by 2015 in Myanmar 4. However, in 2016, both U5MR and infant mortality rate (IMR) in Myanmar were higher than the global rates of 40.8 per 1,000 LBs for U5MR and 30.5 per 1000 LBs, although all three mortality rates (under-5, infant and neonatal) declined in Myanmar from 2011 to 2016. At the end of the MDG years, most countries in the world had not reached the MDG 4 target of reducing under-5 mortality by two-thirds. Following the MDG period, a new global development agenda has been established with new targets, referred to as Sustainable Development Goals (SDG) (2015-2030). The child survival targets in the SDG are intended to further reduce the deaths of children under 5 from preventable diseases. By 2030 in Myanmar, the target is to reduce neonatal mortality to 12 deaths per 1,000 live births and reduce under-5 mortality to 25 deaths per 1,000 live births5.

2. Background

IMNCI trainings are conducted under the leadership of the Child Health Development Division, Ministry of Health and Sports, in Myanmar, and primarily intended for the Basic Health Staff at the township level of States and Regions. The IMNCI guidelines were updated by the MOHS, with technical support from MCSP, in 2017, to ensure that the latest IMNCI information from WHO was incorporated, to be in line with the global IMNCI strategy. The updated IMNCI guidelines (2017) are designed to be user friendly and easily understandable, promoting easy access to updated knowledge, and effective use by the BHS and the community, as well as family members of the child patient. It is composed of five books: Provider Guide, Facilitator Guide, Exercise Book, Handbill or Chart Booklet, Photo Book, plus a DVD with learning video clips and a Power Point CD. The content of the books covers childhood illness and management of sick children from 2 to 59 months old (5 years). In the IMNCI training, the updated IMNCI guideline books (2-59 months) are used, together with the introduction book and the follow-up after training book, for instruction on correct utilization of forms and formats used in the post-training supervision visits. The updated IMNCI guidelines (2017) are published in Myanmar language in order to be easily understood by the users and the BHS. The provider Guide is the main textbook and contains all needed information. A trainer or facilitator uses the Power Point CD, which contains all the contents of updated IMNCI guidelines during the training. The exercise book contains questions for each chapter on physical examination, clinical management, and making a diagnosis. The answers to the questions are included in the Facilitator Guide to assist the trainers/facilitators in checking the answers of the training participants. The updated IMNCI guidelines (2017) are composed of five main chapters: (1)Assess and Classify the Patient, (2) Identify Treatment, (3) Treat, (4)Counsel the Mother and (5) Follow- Up the Child. The guidelines explain how to ask the mother about the child's problem, and check for the general danger signs of the common childhood illnesses. It includes how to assess the signs and symptoms and classify the common childhood illnesses, such as cough or difficult breathing, diarrhea, fever, ear problems, malnutrition and anemia, mouth and gum infection, HIV infection and immunization status. According to the classification of the disease, the BHS makes the decision for identifying the correct treatment, such as providing suitable antibiotics and care according to the drug dosages in the guidelines. The updated IMNCI guidelines (2017) are intended to support the BHS to develop counseling skills for talking with the mother about childcare, treatment and feeding of the child. At the end, the BHS will provide health education to the mother and make an appointment for a follow-up visit if necessary. The BHS will record the patient consultation by using the patient record form and file the document. The patient identification, diagnosis and treatment are noted down in the patient register book.

3. Activity

3.1 Developing updated IMNCI guidelines (2017)

The MCSP Child Health team, in close collaboration with the Director of Child Health Division, provided support to the Child Health Development Division, MOHS for updating the IMNCI guidelines (2017). The 2-59 months portion of the previous existing IMNCI guidelines was redesigned to be user-friendly, compact and concise with updated global IMNCI information, and completed with additional chapters on HIV infection, mouth and gum infection and growth and development. The updated guidelines were developed in Myanmar language, except for some medical terminology and drug selection and dosages. The content of the updated guidelines was mainly based on the WHO guidelines and prepared to be in line with the country context. Additional technical information was provided by the Program Managers of the National AIDS Program (NAP), National Malaria Control Program (NMCP), Expanded Program of Immunization (EPI) and the National Nutrition Program. The new IMNCI guidelines were developed for a 4-day training of Trainers (ToT) at central and state/regional level and a 5-day training for the BHS at the township level. After one month, there was a three-day follow-up training for the supervisors of 5 States and Regions, focusing on the utilization of supervision check lists, forms and formats and organization of follow-up plans. At the State and Regional level, the follow-up training is conducted for 3 days (sometimes modified to 2 days, by decision of the State Health Department), followed by one day of orientation on use of the Continuing Medical Education (CME) modules for Pneumonia and Diarrhea.

3.2 Launching ceremony of updated IMNCI guidelines (2017) (2-59 months)

The updated IMNCI guideline was included in the launching ceremony for "Early Essential Newborn Care (EENC), Care for Small Babies and Updated Integrated Management of Childhood Illness" which was organized by the Child Health Development Division, MOHS, on 30th May, 2017 in Nay Pyi Taw. There were about 150 participants from Departments of MOHS, local and International organizations working with CHD, WHO, UNICEF and donor agencies. MCSP staff from Child Health and Newborn teams participated. The opening speech was provided by Dr. Thet Khaing Win, Permanent Secretary of the MOHS, and Dr. Myint Myint Than, Director of the Child Health Development Division. The participants were introduced to the two guidelines developed on Early Essential Newborn Care and the updated IMNCI guideline (2-59 months) and were informed of the future plans, training cascade and follow-up activity of MCSP on Newborn and Child Health care.

3.3 Township selection meetings - June and July 2017

MCSP activities for improving the capacity of Public Health staff in maternal, newborn and child health are carried out in LPIC-linked States and Regions, that is Magway region, Ayeyarwaddy region, Rakhine state, Northern and Southern Shan state. In order to plan for trainings to strengthen the technical knowledge and skills of the BHS at the implementing level, township selection meetings were organized in June and July 2017, through coordination with States and Regional Health Departments and training teams. Township

7 selection criteria were based on (i) high under-5 mortality rate (ii) inclusion in the 151- township list (those that have completed a previous IMNCI training) and (iii) inclusion in the National Health Plan Year-1 townships list. The Child Health Development Division, MOHS has a plan to provide the updated IMNCI guideline training to the remainder of the 181 townships in 2018 and onward. According to the selection criteria, there were six townships selected for implementation of IMNCI (2-59 months) training and follow-up activities. They are: Taungdwingyi township (Magway region), Ingapu township (Ayeyarwaddy region), Minbya township (Rakhine state), Tang Yan and Mongyai townships (N Shan state) and Mong Kai township (S Shan state). Among the six townships selected for IMNCI implementation, Taungdwingyi township (Magway) had the largest total population and largest under-1 population. Minbya township (Rakhine) had the largest under-5 children population. Mongyai township (N. Shan) had the highest IMR and Mong Kai township (S. Shan) had the second highest IMR. Mong Kai township (S. Shan) had the highest U5 mortality rate and Mongyai township (N. Shan) had the second highest U5 MR. Table 1. Geographical situation and 2017 health profile data of implementing townships

Ref. Township Health Profile 2017 2017 2017 2016 2017 2016 State/ Region Magway Ayeyarwaddy Rakhine N Shan S Shan Township Taungdwingyi Ingapu Minbya Tang Yan Mongyai Mong Kai 2,120 sq. Area (Sq. Kilometer) 1968 1005 1,338 4,710 1,693 miles

Total Population 277,736 221,912 221,381 170,512 63,705 74,895

Under 1 population 4,349 3,587 4,244 3,693 1,368 1,640

Under 5 population 20,699 16,072 22,035 16,836 6,951 8,328 No. of existing total BHS (HA, LHV, midwife, PHS I, II) 146 178 92 48 39 28 Health Infrastructure i) Township hospital 1 1 1 1 1 1 ii) Station hospital 2 4 1 0 0 0 iii) UHC 1 1 0 0 0 1 iv) MCH unit 1 1 1 1 1 1 v) RHC 8 11 6 4 3 3 vi) sub-center 40 52 29 16 16 9 IMR per 1,000 LB 11.98 (2016) 6.1 (2017) 15 (2017) 13.4(2016) 22.1(2017) 19.1(2016) U5 MR per 1,000 LB 13.82 (2016) 8 (2017) 18 (2017) 16.6(2016) 26.37(2017) 34(2016)

Map 1. Locations of six selected townships in five states and regions implementing IMNCI activity

3.4 Training

3.4.1 Central MToT updated IMNCI training, Nay Pyi Taw

The Central MToT training on the updated IMNCI guidelines was conducted from 27th to 30th November 2017, in Man Myanmar Hotel, Nay Pyi Taw. Twelve medical doctors/team leaders, 8 nursing officers and 1 Health Assistant, from the five State and Regional Health Department training teams attended the training, for a total of 21 participants. There were 5 participants each from Magway, Ayeyarwaddy and N. Shan, 4 from S. Shan and 2 from Rakhine state. The training was held for four days and led by 8 trainers from the Child Health Development Division, MOHS, including two Deputy Directors, Dr. Theingi Aung and Dr. Thida Win. Five MCSP staff from the Child Health Team also participated in the training. Each trainer and participant was provided with a package of updated IMNCI guideline (10 books with 1 learning DVD and 1 power point CD). The training methodology used included lectures, two-way discussions, group work, presentations, role-plays and clinical skills assessments by performing Objective Structured Clinical Examination (OSCE). The knowledge of the participants was assessed by pre- and post training test questionnaires. Training aids were used by the trainers for demonstration to the participants. Based on their implementation experience in the field, the training participants provided feedback and suggestions on the updated guidelines. The two Deputy Directors and the CHD trainers reviewed the inputs and made some minor adjustments technically. The revised version of the updated guideline was used for all subsequent training sessions.

Photo 1: Updated IMNCI Central MToT Training, Naypyitaw, November 2017

3.4.2 Central MToT Follow-up training, Nay Pyi Taw

The follow-up training was organized about 6 weeks after the central MToT, from 10th to 12th January, 2018 in Nay Pyi Taw. The participants were primarily the same as those who attended the Central MToT. The follow-up training is the second part of IMNCI training and is intended to strengthen the clinical skills management of BHS, to address the challenges found in utilizing the IMNCI guideline, to understand the general situation on the ground and to collect the data and information from the supervision visits. The supervision team is composed of trainers from State and Regional training teams and township training teams. During the follow-up training, the trainers/supervisors focused on ways of assessing the BHS to enhance understanding of the importance of post-training supervision visits, how to use the supervision checklists and follow-up forms, to assess the health center infrastructure and drug stock management, how to conduct data recording and preparing the supervision report. Eighteen participants attended the training from the States and Regional training teams. It was a three-day training led by 5 trainers from the Child Health Development Division, MOHS, Nay Pyi Taw. On Day 1, the participants learned how to use the follow-up forms, supervision checklist, and formats. On Day 2, the participants had a field visit to a nearby RHC and sub-center to practice the supervision activity with BHS and caretakers of under-5 children. Ah Lyin Lo RHC was visited in the morning and Pauk Taw sub-center in the afternoon. Participants (supervisors from each state and region) were divided into four groups. Two groups observed the BHS conducting clinical care management and provided the assessment scores by using the supervision checklists, while the other two groups practiced the supervision Photo 2: Field visit to A Lyin Lo RHC, Central of the drug stock management. At the MToT Follow Up after Training, Naypyitaw, end of the visit, the supervisors January 2018 combined their findings and provided feedback to the BHS on their performance and practice. The supervision report, with comments and recommendations, was sent to the Child Health Development Division, MOHS, Nay Pyi Taw. Seven MCSP staff participated in the field visit of supervision activity and provided comments and suggestions. On Day 3, the participants presented their findings with recommendations for group discussion. Each state and regional team prepared their supervision visit plans with support

from the Child Health Development Division trainers. It was a good opportunity for the state and regional trainers to meet with the trainers of the Child Health Development Division for sharing experiences, constraints and challenges, which were useful inputs for planning future supervision visits.

3.4.3 State and Regional ToT training

State and Regional level ToT trainings were conducted in each of the five selected States and Regions after the central MToT training in Nay Pyi Taw in December 2017 and January 2018. The selected State and Regional training team members who attended the central MToT disseminated the training to the other training team members of the State/ Region and township training teams of NHP Year-1 townships. These trainings were usually conducted in the training hall of the State and Regional Health Department. Each participant was provided with the updated IMNCI guideline package. The training aid materials were used for demonstration and practice during the trainings. Details of the individual State and Regional-level trainings are included later in this report under Section 4.

3.4.4 State and Regional ToT for Follow-up training

The follow-up training was usually organized in state and regional health departments of the 5 states and regions at least one month after the State and Regional ToT training, with almost the same individual participants. Follow-up training was focused on utilization of forms and formats, supervision checklist, organizing supervision plans, and assessment of the clinical skills management of the trained BHS. The participants of the follow-up training were members of the State and Regional Training teams and Township Training teams. The follow-up guideline booklet was used, with some revised forms with additional checklists, and based on the updated IMNCI guideline. The training curriculum contained lectures in the training hall and field visits to nearby health centers for practice.

3.4.5 Township-level multiplier training

The trained State, Regional and Township training team trainers conducted the multiplier training to the Lady Health Visitors (LHV) and Midwives (MW) of the 6 selected townships from January to April 2018. It was the 5-day training with lectures, individual and group discussion, learning through video clips. The clinical skills management of the BHS was assessed through use of case scenarios in OSCE sessions.

3.5 Continuing Medical Education session

MCSP prepared two CME modules on Pneumonia and Diarrhea, based on the updated IMNCI guidelines. This was developed as a package, ready to be utilized in the monthly CME sessions at the township level to refresh the BHS knowledge on common childhood illness, management and treatment. The BHS will share their experience on case management, problems, challenges and finding solutions through group work and discussion. There was one CME module session conducted in Mong Kai township, S. Shan state on 30th March 2018, covering both diarrhoea and pneumonia for 49 BHS, utilizing the new modules.

3.6 Learning and Performance Improvement Centers

L&PICs were set up in each State and Regional Health Department of the five selected States and Regions; Magway, Pathein, Sittwe, Lashio and Taunggyi. They contain maternal, newborn and child health training materials and are meant to support the clinical practice of trained participants. Some MOHS staff, which were members of the state training teams, were trained as skill lab coordinators. The training and practical sessions were Photo 3: Learning and Performance Improvement Center conducted in the L&PIC for Opening Ceremony, Magway, February 2018 the BHS to practice their clinical skills for patient management. At the end of the implementation, training materials along with updated IMNCI guidelines and CME module handouts were handed over to the L&PICs.

3.7 Post-training supervision visits

Post-training supervision visits were usually conducted about one month after the IMNCI training to the BHS at the township level. These visits were intended to assess the clinical skills management of the trained BHS to ensure quality care and treatment of under-5 children according to the IMNCI guidelines. Additionally, the drug stock management and health infrastructure were assessed. The number of supervised BHS and health centers were selected by the state and township training teams, based on the availability of supervision teams and accessibility of the health centers and the BHS. All supervision visits were joint visits done by the MOHS staff and MCSP Program Officers. The supervisory team was divided into groups and assessed the BHS on their ability to follow the guidelines, proper use of handbills, use of the patient record form in screening diseases, and utilization of the materials in the health centers for diagnosis of the patients. Supervisors assessed every step of patient management using the standard checklists. At the end of the visit, the supervisors provided feedback to the supervised BHS, recognized their efforts, discussed about strong and weak points, and suggested solutions for better achievements in the future. The supervision reports prepared by the supervisory teams were submitted to the Child Health Development Division, MOHS, Nay Pyi Taw. There were post- training supervision checklist forms used by the supervisors to assess the ability of the BHS on clinical skill management according to the IMNCI guidelines. If the performance of BHS in case management was correct according to the supervisor checklist, it was recorded as "1" scores and if not, it was recorded as "0" score.

4. Implementation activity in 5 selected States and Regions

4.1 Magway region

Training The State and Regional ToT training was organized for four days from 27th to 30th December 2017, in Magway. There were 25 participants from the Regional and Township training teams of the National Health Plan (NHP) year-1 townships, namely Taungdwingyi, Saytottara, Myaing, Htilin and Minhla townships. The training was led by 5 trainers of the Regional training team in Magway, consisting of 3 medical doctors/Team leaders, 1 Nursing Officer and 1 Health Assistant. (Annex 5 and 6) The State and Regional ToT for follow-up training was organized from 1st to 3rd February 2018 for the same 25 participants. The training was conducted both in the training hall of Magway Regional Health Department and the Rural Health Centers during the field visit. On Day 1, Dr. Ohnmar Aye, Assistant Director of the Regional Public Health Department of Magway, and Dr. Khine Su Mar, Team Leader of the Child Health team in Magway, explained about the forms and formats used in the supervision visit. On Day 2, the participants were divided into two groups for the field visit to Daung Nay RHC and Kan Thar Gyi sub- center to practice supervision. In the morning session of Day 3, the supervision teams Photo 4: Field Visit, State Level Follow Up after Training, presented their findings and Magway, February 2018 comments in individual groups. In the CME session in the afternoon, under the guidance of the trainers, the participants became familiar with the diarrhea and pneumonia modules to be used at the township level in the monthly CME sessions. In Taungdwingyi township there were two batches of multiplier training conducted on 15th to 19th January and 15th to 19th February 2018. A total of 60 BHS (4 LHV and 56 Midwives) were trained out of existing 68 BHS, with 30 participants in each batch. There were 5 trainers (2 medical doctors, 2 HA and 1 LHV) in the first batch and 4 trainers (2 HA, 1 Township Health Nurse and 1 LHV) in the second batch of multiplier training (Annex 5 and 7). Post-training supervision visits/ Follow-up activity Post-training supervision visits were conducted in Taungdwingyi township from 8th to 12th March and 15th to 19th March 2018. The field visits were led by three supervisors/trainers from the Regional Training team and 1 trainer from the township training team, jointly with

Dr. Han Set Lu, MCSP Program Officer. During the visits, 4 trained LHVs and 22 midwives out of 56 trained were supervised. The supervision team reached 7 out of 8 RHCs and 14/36 sub-centers for the BHS supervision and drug stock and infrastructure management (Annex 5, 7 and 8). Findings (Taungdwingyi township, Magway region) Assessment of BHS Among supervised BHS, 95% checked the general danger signs and 100% checked the symptoms of four main diseases (cough, diarrhea, fever and ear problems). Only 73% of supervised BHS checked the HIV status, and 68% assessed growth and development. All supervised BHS (100%) correctly performed the case management on referral cases according to the supervisory checklist. Eighty-six percent of supervised BHS performed correctly while providing suggestions to mothers for patient care for diarrhoea at home and mentioned two danger signs for immediate return to the health center. More than 90% of BHS were able to assess the immunization status, assess the feeding practice of the child and provide counseling to mother on feeding and proper nutrition according to the checklist. Assessment of caretakers or mothers Twenty-two mothers or caretakers with child patients were interviewed as part of the assessment. More than 90% of interviewed mothers were able to describe the correct home treatment and ORS solution preparation. All of them (100%) were able to describe three home care methods for the child patients. All mothers (100%) said that they were satisfied with the performance of the BHS on case management of the patients, including duration of patient examination, treatment provision and communication with the mothers. Some of them (95%) mentioned that they received additional health knowledge from the BHS. Health infrastructure and drug stock management There were 21 health centers (7 RHC and 14 sub-centers) assessed by the supervision team. All the basic health infrastructure materials such as weighing machines, wall clock, IMNCI guidelines (2017) package, MCH booklet and patient registers were available in all health centers (100%). The general patient register, for use on a daily basis, and a specific patient register for the 0-59 month patients were both available in every RHC and sub-center. ORT corners were available in 38 % of the health centers only and ORT register books were present in 29% of health centers. However, most health centers (90%) had availability of drinking water and essential materials for establishing an ORT corner. All health centers (100%) had proper cold chain system, vaccine storage and availability of all types of vaccines. None of them had functioning sterilizers for disinfection purposes. All health centers (100%) had patient treatment records, but only 38% of them completed the patient record forms in the OPD. In the drug lists of all health centers, there was no stock of Injection Diazepam, inhaled bronchodilators, spacers, Injection Artesunate, Ready-To-Use Therapeutic Food (RUTF) and ART drugs.

Amoxicillin capsules, Paracetamol tablets, ORS sachets, Vitamin A capsules and Albendazole deworming agents were available in all health centers (100%). Nystatin syrup and nasal tubes were available only in 14% of health centers. Anti-malaria drugs such as Chloroquine and Primaquine tablets were available in only 10% of health centers.

4.2 Ayeyarwaddy region

Training The State and Regional ToT training was from 26th to 29th December 2017, and attended by 20 participants; 2 from the Regional training team and 18 from the NHP Year-1 township training teams of Pantanaw, Kanguidaunt, Ingapu, Kyan Khin, Lay Myat Hnar and Yay Kyi townships. The participants were 2 medical doctors, 13 LHV, 4 THN and 1 Midwife. The training was led by 6 trainers (4 medical doctors and 2 senior nurses). Four trainers were from the Ayeyarwaddy Regional Health Department and Dr. Thida Win, Deputy Director of CHD joined the training as technical support from Nay Pyi Taw. The Follow-up training was organized from 19th to 21st March 2018, and attended by 21 participants/trainers - 3 persons from State Training team and 18 persons from the NHP year- 1 township training team. On days 1 and 3, training was organized in the training hall of the Regional Public Health Department, Pathein, and there was a field visit on Day 2 to an RHC and sub-centers. The supervision team divided into four groups for practicing the activities. The training and supervision visits were led by four trainers from the Regional training team (2 medical doctors, 1 THN and 1 Nursing Officer). Dr. Aung Kyaw Htwe, the Regional Health Director, provided the closing remarks on the last day of the training. In Ingapu township, three batches of township-level multiplier training were conducted on 15th to 19th January, 3rd to 7th February and 5th to 9th March 2018 for 75 BHS (4 LHVs and 71 midwives from 1 MCH, 11 RHC and 51 sub-centers). The training was led by 6 trainers in Batch 1, 5 in Batch 2, and 4 in Batch 3, all from the Regional and Township training teams. Dr. Myo Swe, MCSP Program Officer, participated in all three batches as the facilitator, working in close collaboration with the MOHS training teams (Annex 5 and 8). Post-training supervision visits Out of 75 trained BHS in Ingapu township, post-training supervision visits were conducted to 25 midwives (33%) from 1 MCH, 6 RHCs and 13 sub-centers. There was some limitation of transport due to flooding in the area and only 32% of health centers were accessed during the supervision visits. The midwives from other RHCs and sub-centers came to these health centers for assessment of their knowledge and clinical skills. The supervisory team was composed of 1 Medical Doctor (Child Health team leader), 1THN, 2LHVs, and Dr. Myo Swe (Program Officer of MCSP) for the joint supervision visits. The field visits were conducted on 27th February, 20th March, and 26th to 30th March 2018 (Annex 5, 7 and 8).

Findings (Ingapu township, Ayeyarwaddy region) Assessment of BHS All supervised BHS (100%) checked the general danger signs and symptoms of four main diseases (cough, diarrhea, fever and ear problems). More than 90% of supervised BHS checked the child’s nutritional status, EPI and mouth and gum problems. Eighty-eight percent of BHS checked the HIV status and growth and development of child patient. All BHS (100%) had good knowledge about patient referral criteria and performed the referral service well, according to the supervisory checklist. All of them provided the oral antibiotics and anti-malaria drugs correctly according to the checklist. More than 80% of BHS knew the correct treatment for diarrhoea patients and stated two danger signs for emergency return, according to the supervisors' assessment. Almost all BHS (96%) were able to provide information and management on immunization as required for the child patient. Only 72% of BHS assessed the feeding practice and 84% conducted counseling to mothers. Half of the supervised BHS (48%) asked the mother about other health problems of the child. Assessment of caretakers or mothers Twenty-five mothers or caretakers were interviewed as part of the supervision activity. All interviewed mothers (100%) were able to describe the home treatment of diarrhea and ORS solution preparation for the child patient; 96% of them knew three home care methods. All interviewed mothers (100%) said that they were satisfied with the performance of the BHS on case management, patient examination, treatment and health education provision. Health infrastructure and drug stock management There were 20 health centers out of 63 trained (32%) assessed by the supervision team. Some health centers were not accessible due to limited transportation, damaged bridges and flooding. All the basic health infrastructure materials such as weighing machines, wall clock, IMNCI guidelines package, MCH booklet and patient register books were available in all health centers. Patient treatment records were completely filled up with treatment information (100%). There was an ORT corner in all health centers (100%) along with the essential materials and drinking water. None of health centers had an ORT register book. For the EPI activity, there was a proper cold chain system, and all types of vaccines were stored in the functioning storage system. But there was no specific sterilizer used in the health centers for EPI activity because disposable syringes were used. There was no stock of Injection Gentamycin in any of the health centers. ORS sachets were available in nearly half of health centers (45%). There was a shortage of some drugs and materials in health centers. It was found the availability of the drugs as Primaquine tables (35%), Ciprofloxacin capsules (25%), cannula (30%) and nasal tubes (25%). There was no use of Bin cards in some health centers, according to the comments of the supervision team. As Ingapu township is not a malaria-endemic area, only Rapid Diagnostic Test kits are provided to the BHS. If the patient is RDT positive, he or she will be referred to the Ingapu township hospital for anti-malaria drugs and further treatment. ART drugs were basically not available in the RHC and sub-centers, and the HIV positive patients can get drugs from the township NAP team, after proper counseling. Some drugs and commodities were in shortage

such as Nystatin syrup, disposable syringes and Gentian violet. Oral salbutamol tablets, inhaled bronchodilator and nasal tubes were requested from the Regional to the central level for procurement next year.

4.3 Rakhine state

Training The state and regional ToT on the updated IMNCI guideline was organized in Sittwe General Hospital Meeting hall, from 15th to 18th January 2018. There were 3 participants from each NHP year-1 township in Rakhine State (Pauktaw, Minbya, Ponnagyun and Gwa) and 5 participants from the state training team, for a total 20 participants. Myebon township was added by the MOHS for training. It was a four-day training, led by 4 trainers who Photo 5: Role-play Activity, IMNCI Updated Guideline had attended the Central MToT State Level Training, Sittwe, Rakhine state, January of IMNCI. Dr. Thida Win, 2018 Deputy Director of Child Health Development Division, also joined as a trainer (Annex and 6). The Township Multiplier training on the updated IMNCI guideline was conducted in Minbya township in two batches. The first batch was conducted from 23rd to 27th February and the second batch was from 25th to 29th March 2018 in Minbya General Hospital. A total of 45 BHS (7 LHVs and 38 midwifes) participated in two batches. Dr. Aung Than Oo, Program Officer of MCSP, participated in all trainings as a facilitator (Annex 5 and 7). Post-training supervision visit The visits were conducted in Minbya township from 5th to 18th May, 2018. The supervisors were 2 trainers from the State health training team and 3 from the township health training team, supported by Dr. Aung Than Oo, Program Officer of MCSP. Three LHVs (42% of those trained) and 20 midwives (53% of trained MWs) of 1 MCH, 6 RHCs and 13 sub- centers were supervised in the follow up visits (Annex 7 and 8). Findings (Minbya township, Rakhine state) Assessment of BHS There were 23 BHS (3 LHV and 20 midwives) supervised out of 45 trained (51%). All supervised BHS (100%) checked the general danger signs, signs and symptoms of four main diseases. All of them assessed the nutritional status of the patient and checked the signs and

symptoms of mouth and gum disease. Only 48% of supervised BHS checked the growth and development of the child patient. All supervised BHS (100%) knew the criteria for classification of diseases and followed the IMNCI guidelines for patient referral in required cases. All of them (100%) correctly performed the case management in providing oral antibiotics and treatment with ORS solution according the supervisory checklist. All supervised BHS (100%) assessed the immunization status of the child, checked other health problems and counseled the mother for proper feeding of the child until 2 years of age, according to the checklist used by the supervision team.

Assessment of caretakers or mothers Almost all (96%) of the interviewed persons knew the home treatment of the sick child and ORS solution preparation and three home care methods. All respondents (100%) said they were satisfied with the performance of the BHS on case management, examination, treatment and communication skills. All of caretakers (100%) discussed with the BHS about common child health problems.

Health infrastructure and drug stock managements One MCH (100%), 6 RHC (100%) and 13 sub-centers (45%) were supervised. Weighing machines, wall clocks, MNCI guidelines and MCH booklets were available in all supervised health centers (100%). Ninety-five percent of health centers had patient register books with complete treatment records. Only 30% of health centers had ORT corners. However, all of them had drinking water and essential materials for ORS preparation. None of them had an ORT register book. For EPI activities, all supervised health centers (100%) had cold chain facility, immunization records, and all types of vaccines under the proper storage system. All health centers did not have a specific sterilizer. The BHS used disposable syringes during EPI activities and for providing injectable drugs to patients. Injection Diazepam, injection Artesunate, inhaled bronchodilator, spacers, ART for HIV patients, iron syrup, Nystatin syrup and nasal tubes were not available in all supervised health centers. Antibiotics, such as injectable Ampicillin and injectable Gentamycin were available in some health centers only (26% - 30%). The majority of essential drugs and materials were available in most of the supervised health centers (83% and above).

4.4 Northern Shan state

Training The State and Regional ToT training was organized for four days from 27th to 30th December 2017, in Lashio. The training was attended by 14 participants from State and township training teams from the five NHP- year 1 townships (Tang Yan, Mongyai, Muse, Mabein, Moe Meik and Hopan townships). The State ToT of Follow-up training was organized from 5th to 7th March 2018 for the 13 participants who had already attended the IMNCI State ToT training. On Day 1, Dr. Aung Than Swe, Child health team leader, Dr. Nwe Nwe Win and Daw Nang Mwe Lin San led the lectures. On the second day, participants divided into 3 groups and went to Enai RHC for supervision practice on clinical case management and stock management. In the afternoon,

participants presented their findings and discussed the results. On Day 3, CME modules on diarrhoea and pneumonia were introduced. The CME handouts, handbill and power point presentations were distributed to each participant and module exercises were conducted. In Northern Shan State, Township level IMNCI Multiplier trainings were conducted in Mongyai and Tang Yan townships. In Mongyai Township, it was organized in the training hall of township health department from 27th to 30th March 2018. It was attended by 20 BHS (1 LHV and 19 midwives) out of the existing 26. The training was led by 4 trainers from the Township health training team. In Tang Yan Township, the township level multiplier Photo 6: OSCE Examination, IMNCI Updated IMNCI training was organized in the Guideline BHS Level Training, Tang Yan, N Shan state, township health department April 2018 training hall from 27th to 30th April 2018. It was attended by 30 BHS (1 LHV and 29 midwives). The training was led by 5 trainers from the Township Health training team. Trainings were facilitated by Dr. Thu Naing and Dr. Han Set Lu, Program Officers of MCSP (Annex 5 and 7).

Post-training supervision visits Mongyai Township Post-training supervision visits were conducted in Mongyai Township from 14th to 16th May. The field visits were led by three supervisors/trainers, one from the Regional training team and 2 trainers from the Township training team, jointly with Dr. Han Set Lu, MCSP Program Officer. During the visit, 7 midwives out of 20 trained BHS (35%) were supervised. The supervision team reached 1 out of 2 RHCs and 6 sub-centers out of 16 sub-centers for the BHS supervision and drug stock and infrastructure management (Annex 7and 8). Findings Assessment of BHS Out of 20 trained BHS, 7 BHS were supervised by the State and township training team and MCSP Program Officer. Eighty-six percent of supervised BHS checked the general danger signs and all of them (100%) checked the symptoms of four main diseases (cough, diarrhoea, fever and ear problems). The HIV, EPI status, and growth and development of the child were assessed by 71% of supervised BHS, while 57% checked on nutritional status and mouth and gum problems of the child patients.

All supervised BHS (100%) knew the criteria for referral cases and provided the pre-referral services as required for the patients, according to the supervisory checklist. All BHS (100%) correctly performed provision of oral antibiotics including anti-malaria drugs according to the checklist. Most BHS (86%) correctly performed treatment for diarrhoea patients and explained about two danger signs for emergency return. Immunization status of child patients was checked by 86% of supervised BHS. All BHS (100%) assessed the feeding of children less than 2 years and 86% conducted counseling to the mothers for proper feeding practice. Assessment of caretakers or mothers Seven mothers or caretakers of sick children were interviewed during the assessment. All mothers (100%) were able to describe the home treatment and ORS solution preparation and 86% knew about the home care methods. All interviewed mothers (100%) said that they were satisfied with the performance of the BHS on case management and 86% highlighted that they received health information and knowledge from the BHS. Health infrastructure and drug stock management There were 7 Health centers (1 RHC and 6 sub-centers) assessed by the supervision team. All the basic health infrastructure materials such as weighing machines, wall clock, IMNCI guidelines (2017) package, MCH booklet/mother’s card and patient register books were available in all health centers (100%). There was no area specifically identified as an ORT corner in all health centers and none had an ORT register book. However, essential materials for ORT treatment were available in all health centers (100%) and drinking water was available in 86% of health centers. In all health centers (100%), all types of vaccines were available, kept properly in a cold chain system and storage. Immunization records were found in all health centers but there were no functioning sterilizers. Patient treatment records were properly used in all health centers, but only in 71% of health centers were the forms completely filled up. In all health centers, there were no stock of Injection Diazepam, inhaled bronchodilators, spacer, Injection Artesunate, ART, RUTF, Iron syrup, Gentian violet, cannulas and nasal tube. Oral anti-malaria drugs were available in more than half of the health centers. Two types of disposable syringes were available only in 14% of health centers. However ORS sachets, Paracetamol tablets, Iron/Folate tablets and deworming agents were available in all health centers (100%). Post-training supervision visits

Tang Yan Township Post-training supervision visits were conducted in Tang Yan Township from 28th to 30th May. The field visits were led by three supervisors/trainers, one from the State Training team and 2 trainers from the township training team, jointly with Dr. Aung Than Oo, MCSP Program Officer. There were 10 BHS (1 LHV and 9 midwives) supervised in 1 MCH center, 2 RHCs and 3 sub-centers (Annex 5, 7 and 8).

Findings Skills assessment of BHS Almost all BHS (90%) assessed general danger signs and symptoms of four main diseases in childhood illnesses. All supervised BHS (100%) assessed the status of Nutrition, HIV, EPI and mouth and gum condition in children. However only 70% of BHS assessed the growth and development of children. All BHS (100%) knew the referral criteria for severe patients and knew how to provide pre- referral services according to the supervisory checklist. They all (100%) knew how to provide oral antibiotics and anti-malaria drugs to those in need. According to the checklist of the supervisors, all BHS (100%) knew to provide suggestions for home care management for the sick child and danger signs for immediate return to the health centers. Only 70% of BHS assessed the immunization status of the child and discussed appointments for next visits for the children in need. Only 60% of BHS assessed the feeding practice of children under 2 and 70% conducted counseling to the mother on child feeding practices. Less than half of BHS (40%) discussed about other health problems of the children. Assessment of caretakers or mothers There were 10 mothers interviewed and all of them (100%) were able to describe the home treatment and ORS solution preparation. All of them knew three home care methods in the treatment of diarrhoea. All interviewees said they were satisfied with the case management of the BHS and 60% of them received health education from the BHS. Health infrastructure and drug stock management There were 6 health centers supervised and all of them (100%) had basic infrastructure and materials such as weighing machine, wall clock, IMNCI guidelines, MCH booklet and patient register books. None of the supervised health centers had a specific identified place for the ORT corner, but all of them had an ORT register book. Many health centers had drinking water (83%) and essential materials for an ORT corner (67%). All supervised health centers (100%) had an effective cold chain system, proper vaccine storage, accessible immunization records and all types of vaccines available. None of them used sterilizers because all BHS used disposable syringes and needles. All health centers had patient treatment records and they were completely filled up. In the drug storage, all health centers did not have Injection Diazepam, Injection Artesunate, inhaled bronchodilators, spacer, RUTF, iron syrup, nasal tubes and ART drugs. ORS sachets were found available in all health centers (100%). Anti-malaria drugs such as ACT tablets were available in 50% of health centers, while Chloroquine and Primaquine tablets were available only in 33%. Cotrimoxazole tablets, Gentian violet and cannula were available in only 17% of health centers.

4.5 Southern Shan state

The State and Regional ToT training was conducted from 16th to 19th January 2018, attended by 24 participants, with 3 participants each from the township training teams in Mong Kai, Mong Hsu, Pindaya, Ywa Ngan, Mauk Mai, Lang Kho, Mong Pan, and Nan Sang townships. The participants were 4 medical doctors, 5 THNs, 1 LHV, 8 Senior Nurses and 6 Trained Nurses. The training was led by 5 trainers, namely 3 medical doctors and 2 senior nurses, from the State training team. The Follow-up training was done from 13th to 16th February, for the same 24 participants. The training was led by 5 trainers from the State Training team, composed of 3 Medical doctors, 1 District Public Health Nurse and 1 Nursing Officer. It was organized for four days, with the initial 3 days consisting of lectures and field visits to Nam Kok RHC and Long Hay sub- center for practice. On the 4th day, the participants learned about use of the CME modules under the guidance of the trainers. Dr. Kaung Myat Bo, MCSP Program Officer, participated in all activities from training to supervision visits in close collaboration with the MOHS team. The supervision visit plan was prepared by the township supervision teams, in discussion with the state training teams and MCSP staff.

Photo 7: Field visit group photo, IMNCI State Level Follow Up after Training, Long Hay Sub-center, Hopong Township, Southern Shan state , February 2018 The township-level multiplier training was organized in the training hall of Mong Kai township health department on 21st to 25th February 2018. It was attended by 22 BHS (4 LHVs and 18 midwives) from the Urban Health Center, MCH center, 3 RHC and 9 sub- centers. The training was led by 7 trainers (2 medical doctors and 5 nurses) from the State and township training team.

CME session MCSP introduced the two CME modules on Pneumonia and Diarrhoea at the monthly CME sessions in the township meeting hall on 30th March 2018. A total of 49 BHS from all RHC and sub-centers and two staff from the township hospital participated. Each participant was provided with the handout for the modules and handbills. Five trainers from the State and township training teams led the session and explained about the two common childhood diseases by Photo 8: CME Activity, Mong Kai Township, S Shan using power point state, March 2018 presentations. The participants refreshed their knowledge by using the handbills and shared their experience of case management in health centers for cases of pneumonia and diarrhea in children.

Post-training supervision visits (Mong Kai Township, S Shan state) During the supervision visits conducted from 28th March to 2nd April 2018, 3 out of 4 trained LHV (75%) and 13 out of 18 trained midwives (72 %) were assessed and supervised. The Urban Health Center, MCH and 3 RHCs were supervised, along with 3 sub-centers out of 9 sub-centers (33%). Dr. Kaung Myat Bo participated in the supervision visits along with three township supervisors, to support and facilitate the activity (Annex 5, 7 and 8). Findings Out of 22 BHS trained, 16 were jointly supervised by the township training team and MCSP Program Officer. All supervised BHS (100%) checked the general danger signs and 88% checked the symptoms of four main diseases. Almost all BHS (94%) checked the status of the patient on EPI, Nutrition and mouth and gum problems. Around 70% of BHS checked HIV status and growth and development of the child. All supervised BHS (100%) correctly knew about the criteria for referral of severely ill patients and conducted the pre-referral service according to the checklist. All BHS (100%) correctly performed while providing oral antibiotics and anti-malaria drugs according to the supervisory checklist. The majority of BHS (88%) provided suggestions on diarrhoea management at home and explained about two danger signs for immediate return (94%). All BHS (100%) did not miss to check the immunization status of the child and made an appointment for the next immunization of the children in need. More than 75% of supervised BHS assessed the feeding practice of the child and counseled the mother for proper feeding practices for children under 2 years. All the supervised BHS (100%) asked the mother about

other health problems of the child. Due to renovation work, there was not enough space for patient care in two sub-centers. Health centers were open from 9 am to 4 pm every day, however they were accessible anytime for emergency cases. Assessment of caretakers or mothers There were 16 mothers interviewed for their opinion on the BHS's performance. In assessing the mothers' knowledge on treatment provided, 100% of interviewed mothers were able to describe the home treatment for their child’s illness and ORS solution preparation according to the checklist. Additionally, 94% of them well knew about three home care methods. Most interviewed mothers (94%) said that they were satisfied with the performance of the BHS on case management, patient examination, treatment provision and health knowledge received from the BHS. Health infrastructure and drug stock management There were 8 Health centers (1 UHC, 1 MCH, 3 RHC and 3 sub-centers) included in the assessment visits. All the basic health infrastructure materials such as weighing machines, wall clock, IMNCI guidelines (2017) package, MCH booklet and patient register book were available in all heath centers (100%). There was an ORT corner with accessible drinking water in every health center (100%). Only one third of health centers (38%) had the essential materials for ORT corners and none of them had an ORT register book to record the cases treated. For the EPI activity, there was a proper cold chain system, vaccine storage and availability of all types of vaccines in the health centers (100%). They said there was no sterilizer used in all the health centers. The BHS used the disposable syringes during EPI activity and when providing injectable drugs to the patients. All health centers (100%) had patient treatment records in the OPD and they were completed with treatment information. There was no stock of inhaled bronchodilators, spacer, RUTF, Nystatin syrup, cannula and ART in supervised health centers. Drugs and consumables such as Injection Gentamycin, ORS sachets, Zinc Sulphate tablets, ACT and paracetamol tablets were available in all health centers (100%). Other essential drugs and consumables such as Inj. Ampicillin, Ciprofloxacin capsules, some oral anti-malaria drugs and Iron/Folate tablets were available only in some health centers (50-75%).

5. Summary of Training and Post-training supervision visits

5.1 Training

Both trainers and BHS were provided training on updated IMNCI guidelines. A total of 124 trainers from five States and Regions were trained during implementation. The highest number of participants attending the ToT was in Magway region (30 pax) and the lowest number was in Northern Shan state (19 participant trainers). Among the trained participants, 23% were Medical doctors, 29% were LHVs and 15% were Township Health Nurses (Figure 1, Annex 6).

NO. OF PARTICIPANTS WHO ATTENDED TOT (FIVE STATES & REGIONS)

Magway region 30

Ayeyarwaddy region 25

Rakhine state 22

N Shan state 19

S Shan state 28

Fig 1. Number of participants who attended ToT from five States and Regions

There were 280 existing BHS (34 LHVs and 246 midwives) in six townships, which was the target of MCSP for IMNCI training at township level. Out of them, a total of 252 BHS (21 LHVs and 231 midwives) participated in the training. Among those trained, 107 BHS (11 LHVs and 96 Midwives) were supervised. In total, 90% of existing BHS (LHVs and midwife) participated in the training and 42% of the trained BHS were supervised. The trainer: participant ratio was 1:5-8 in most trainings, in order to provide proper attention to the participants by qualified trainers (Figure 2, Annex 7).

PERCENTAGE OF BHS (LHV & MIDWIFE) TRAINED AND SUPERVISED

% of BHS trained % of BHS supervised 100% 94% 94% 90% 88% 87% 77% 73% 51% 43% 42% 35% 33% 33%

TAUNGDWINGYIINGAPU MINBYA TANG YAN MONGYAI MONG KAI TOTAL

Fig 2. Percentage of BHS, trained and supervised in six selected townships (BHS: LHVs & midwife) In six implementing townships, there were 206 existing health centers (UHC, MCH, RHC and sub-centers). The BHS from 196 health centers participated in the township multiplier trainings. Out of them, 82 heath centers were accessed during the post-training follow-up visits. In total, 95% of existing health centers participated in the training and 42% of them were included in the post-training supervision visits. The supervisors assessed clinical skills

management of BHS, health care facilities, health center infrastructure and drug stock management (Figure 3, Annex 8).

PERCENTAGE OF HEALTH CENTERS, TRAINED AND SUPERVISED

Health centers trained Health centers supervised 100% 100% 97% 95% 95% 90% 90% 57% 56% 47% 42% 35% 32% 32%

TAUNGDWINGYIINGAPU MINBYA TANG YAN MONGYAI MONG KAI TOTAL

Fig 3. Percentage of health centers, trained and supervised in six selected townships ( Health centers: UHC, MCH, RHC, sub-center) Each training participant was tested on their clinical skills assessment. There were three case scenarios developed by the Child Health Development Division, and each participant in the training selected one of them randomly. Three case scenarios were based on child patients with signs and symptoms of several common childhood illnesses, such as diarrhoea, pneumonia, asthma, growth and development problems. Within the time limitation, the participant filled up the patient record form while presenting how to conduct the clinical examination and treatment. To the trainer or examiner, the participant presented the steps of clinical assessment according to the IMNCI guideline. In all training batches, there was a remarkable increase in the assessment scores from Pre- test to Post-test. The minimum average score increased from 2.7 to 6.8 (total possible score was 10) between Pre- and Post-tests. The maximum average scores increased from 4.9 to 8.1 between Pre- and Post-tests. In all implementation sites, the post-test scores were increased between 1.4 times to 2.6 times over the pre-test scores (Fig.4). Some individual scores in the Post-test reached 10 out of 10 among participants in trainings in S Shan state. The percent increase overall was 45% in N Shan and 156% in S Shan (Annex 9 a, b). The BHS required time to find the correct treatment selection and dosages in the handbills. With practice they became more familiar with the handbill. Some BHS forgot to provide health education messages to the mother and sometimes forgot to make an appointment for the follow-up visit.

PRE- AND POST-TEST SCORES ASSESSMENT

Pre-test average scores Post-test average scores 8.1 7.9 7.1 6.9 6.8 4.9 4.8 4.7 3.7 2.7

MAGWAY AYEYARWADDY RAKHINE N SHAN S SHAN

Fig 4. Pre- and Post-test scores achievement Almost all BHS and supervisors were positive about the Updated IMNCI guidelines (2017), as they felt it has been developed with a user-friendly design, and there were good linkages between the provider guide, handbill, exercise book, photo book and video clips. The handbill (chart booklet) is the most vital material, with key points of the IMNCI guidelines organized concisely for the BHS, for easy access to essential information on patient care and treatment. As it is a bit large and heavy, there is some limitation or challenge for the BHS to carry the handbill to the mobile clinic service sites in the hard-to-reach areas. Most BHS were pleased to use the patient record form, because by following the screening method, there was very little chance of missing any common childhood illness. One office copy of the updated IMNCI guidelines (2017) should be kept in the RHC and sub-centers in case the trained BHS are transferred. Most BHS would prefer to take the IMNCI guidelines materials package with them when they are transferred to another location. There was some disagreement between the BHS and Health Assistants, as the latter would like the guidelines to be left in the health center. To solve this problem, more copies need to be provided. The WHO video clips include counseling for the patient/caretaker, plus examination and treatment, including for mother's care at home. These can be used as IEC materials to be shown to the mothers in the health centers, during health education sessions to motivate and increase public awareness about under-5 childcare and treatment. One State Health Director pointed out that it is important to have a treatment and patient care approach that is consistent in all States and Regions. The Updated IMNCI training should be provided to the BHS of all townships throughout the entire country as soon as possible. It has been suggested by the state and regional training teams that the updated IMNCI guidelines (2017) be included in the pre-service training curriculum of the BHS in the midwifery school and other related trainings.

Refresher training to the BHS and the supervisors is required to be included in the schedule for every alternate year. The font of text in the handbill is small and some older BHS could not read the words properly. The handbill was designed as a flow-chart with assessment, diagnosis, classification and treatment in one page. Due to the limited space available, the small font size was used. Training participants should be consistent (the same persons) for the whole training cascade, as much as possible. New participants who have not participated in the State and Regional training would find challenges to catch up with the activity in the Follow-up training. It was suggested by trained BHS to include IMNCI review in the monthly meetings at township level.

5.2 Post-training follow-up and supervision visits

5.2.1 Assessment on clinical skills

Almost all BHS (97%) assessed the general danger signs, four main signs and symptoms of childhood illnesses. Ninety-three percent assessed the EPI status of the child and checked the condition of the mouth and gums, while 92% checked the nutritional status of the patient. Eighty-two percent of BHS checked the HIV status of mothers/caretakers and children. However, only 70% of BHS assessed growth and development status of the children. All BHS (100%) correctly knew the referral criteria and pre-referral service recommended (providing intramuscular injection). According to the supervisory checklist, 100% of supervised BHS correctly performed in providing oral antibiotics for child patients with malaria, dysentery and ear infections while 98% performed correct pneumonia management. More than 90% of the supervised BHS were able to decide which patients were in need of diarrhoea treatment by ORS and conducted counseling on home-care management. Ninety-three percent of supervised BHS checked the immunization status of the child patient and made appointments for the next immunization as needed. Eighty-four percent of BHS assessed the feeding practice of the mother for the child under 2 years of age and 88% provided counseling to the mother for feeding and nutrition purposes. It was also found that 77% of BHS assessed other health problems of children. In assessing the mother's satisfaction, almost all of the interviewed mothers (98%) were able to describe the home treatment for sick children and ORS solution preparation. Out of them, 96% were able to mention three home care methods for a child patient with diarrhoea. It was found out that 99% of mothers were satisfied with the clinical case management of their child by the BHS. All mothers (100%) were satisfied with the treatment provided and 93% of interviewed mothers said that they gained health knowledge from the BHS.

5.2.2 Infrastructure

All supervised health centers (100%) had basic materials such as weighing machine, wall clocks, IMNCI guideline, MCH booklet and 99% had a patient register book. Fifty-one percent of health centers did not have a proper ORT corner. Most health centers had

accessible drinking water (95%) and essential materials for providing treatment (89%). Only 15% of health centers had separate ORT register books. In the rest of the health centers, the diarrhoea patient data were recorded in the general register. All health centers (100%) had a functioning cold chain system with all types of vaccines available. All health centers maintained a specific immunization register book. Disinfection equipment, such as sterilizers, was not functioning or accessible in all health centers and BHS used disposable syringes for the EPI program and other injections. All health centers (100 %) had patient treatment records, but only 82% had complete records. Some health centers were under renovation of their infrastructure, resulting in a lack of feasibility to adequately observe the drug storage and management. There was limited space for proper ORT corner set up, appropriate for child treatment. There was inadequate space for the OPD and drug storage due to the damaged infrastructure in some health centers. Some sub-centers had limited access to running water. Placing water containers in the building solved this issue. There was inadequate furniture for proper storage of drugs and consumables in some health centers.

5.2.3 Drug stock management

All health centers (100%) did not have inhaled bronchodilator, spacer and ART. HIV patients went to the township NAP team for the ART. Nearly 90% of health centers had ACT tablets for malaria, but only half of them (53%) had Chloroquine and Primaquine tablets and18% of health centers had injection Artesunate. There was a shortage of some essential drugs in health centers, resulting in limited availability of injection Diazepam (8%), injection Ampicillin (44%), injection Gentamycin (49%), Gentian violet (45%) and Nystatin syrup (23%). ORS sachets were seen in 85% of health centers. More than 95% of health centers had Amoxicillin capsules, Paracetamol tablets, Vitamin A capsules and deworming agents available. As consumable materials, cannula and scalp vein were available in more than half of supervised health centers; nasal tubes were available in only 12% of health centers.

The MOHS trainers and supervisors provided the following comments and recommendations based on their findings during the supervision visits. OPD: It was suggested by the supervisors that there should be separate ORT corners for diarrhoea patients. Due to the limited availability of real patients, some non-patient children, who had actually been ill and treated a few days earlier, were used for the practical sessions during the supervision visits. Although the supervisors could not see the real treatment situation, it was partially effective for them to observe how the trained BHS followed the guidelines and used the patient record forms. The Health Assistants were motivated and eagerly participated in the supervision visits. The BHS felt more confident in treating patients using the updated IMNCI guidelines (2017) due to their clear instructions and guidance for treatment. Regular supervision, at least quarterly, is needed to the trained BHS who are concerned with providing IMNCI services for children 2-59 months. The high transport cost and workload of

both township supervisors and BHS are the main barriers to regular supervision to the trained BHS for assessing their management of under-5 children. The patient record forms used by the BHS and the supervision checklists used by the supervisors, need to be provided in sufficient quantity. Some Health Assistants mentioned that they will provide the required forms by photocopying them in the township health departments. Interviews with mothers: In the interviews with mothers, no one refused to respond about the HIV testing results during pregnancy and delivery. During the assessment of the mother's experience and her opinion of the BHS and service of the health center, it sometimes happened that the trained BHS were nearby, due to the limited physical space in the health centers. Therefore, the feedback received from the mothers may not always have been accurate and reliable. Training guidelines and supervision tools: According to the updated IMNCI guidelines (2017), the BHS clearly understood the disease classifications and the danger signs. The severe patients were identified for early referral, for further health care management at a higher-level facility. The BHS need to use the handbills and patient record forms in the management of every case of childhood illness, in order to have more practice, and to improve their diagnosis and treatment and confidence in using the tools. Some indicators and definitions in the supervision check lists, such as sterilization materials, patient register book, MCH booklet, need to be clear and consistently understood by the supervisory teams in states and regions. Register books, forms and formats: BHS are to be encouraged to use the patient record forms, along with handbills, in the clinical management of every child patient. Most BHS have patient register books in the health centers, which are used for all patient consultations. There were no separate register books to record data for newborns and children 2-59 month. Supervisors suggested that the BHS maintain the under-5 patient register separately. By following the history-taking and screening process in the patient record forms, there was a build-up of trust between the mother and the BHS. However, some mothers did not have patience for the long duration of the assessment of the child, according to the guidelines and patient record form. However, some mothers were pleased and satisfied with the thorough assessment for accurate diagnosis and treatment. As challenges, there were not enough referral forms to provide for the patients referred to the higher health facilities. Due to difficult transportation, limited access to remote places and the large workload of the BHS, there were no regular follow-up visits to the patients by the BHS. There were limited transportation facilities in hard-to-reach areas, which affected the likelihood of completed referral of patients to township hospitals from health centers. Drugs and drug stock management: Most of the essential drugs needed for the treatment of 2-59 months children were available, with valid expiry dates, with the exception of: injectable diazepam, bronchodilator inhalers, spacers, ready-to-use-therapeutic food (RUTF) for malnourished children, anti-malaria drugs, antiretroviral therapy (ART) drugs and nasal tubes. ART drugs were only available at ART centers at the township level. These required drugs and materials will be on the procurement order of the MOHS for next year’s plan.

Rectal suppositories of Diazepam should be included in the drug procurement list and available in health centers instead of Injectable Diazepam. Inj. Diazepam ampules were not provided to the health centers due to their inclusion in the narcotic drugs group. The diagnosed HIV positive patients were referred to the township NAP team for the ART drugs. Some equipment and materials, such as MUAC tapes, record forms for z-scores and height measuring equipment were not adequate in some health centers. In most health centers, there was no proper sterilizing machine for disinfection purposes. The BHS used disposable syringes during EPI activities and when providing injection treatment to the patients. There needs to be an adequate and regular supply of drugs for management of sick children (2- 59 months) according to the IMNCI guideline’s recommended drug list. The BHS need to inform their supervisors (HA or LHV) if there is any shortage of drugs or nearly expired drugs. The BHS need to conduct a regular update of drugs and material consumption in the drug stock management and maintain bin cards to improve their system. In order to keep some drugs and paper documents safely and properly, the BHS should request additional cupboards, if necessary. The supervision reports submitted by the State/Regional, and Township training teams contain useful information for the CHD for assessing the effectiveness of the guideline utilization, and problems and challenges at the implementation level. These inputs can guide timing of the refresher training to the BHS and future revisions of guidelines. The supervision visits provided feedback, experience and lessons learned on the utilization of the updated IMNCI guidelines (2017). LPIC center: There was limited use of Learning and Performance Improvement centers by the trained BHS. The LPIC centers are situated in the State and Regional Health Department and the BHS trained on the Updated IMNCI guidelines (2017) are in the township at RHCs and sub-centers. The distance from the township to the LPIC and the routine workload of the BHS are barriers for the trained participants to use the LPICs, except when they get a chance during other meetings or trainings. Most IMNCI training aid materials are already familiar to the existing BHS and most of the medicines and equipment displayed in the L&PICs are used currently in the RHCs and sub-centers for patient examination and treatment. CME modules: Based on the format of the two modules and handouts, already developed for pneumonia and diarrhea CME, the township health teams can develop other modules for CME on seasonal diseases and the nutrition, HIV, and growth and development sessions, as well. Experience sharing and presenting problems and challenges of using the Updated IMNCI guidelines (2017) can be done by the BHS at the township CME sessions occasionally. It will be good practice for the participants, as similar CME sessions are prepared on seasonal diseases of childhood illness, based on the updated information in the IMNCI guideline.

6. Key Recommendations Training - Roll out the updated IMNCI training nationwide as rapidly as possible for consistency in management of childhood illness. - Conduct refresher courses every 3 years to cover as many trained staff as possible – considering time and budget limitations. - Develop a plan for efficient training of newly assigned BHS if trained staff are transferred. - Allow transferred staff to take their IMNCI training materials with them to their new post - Print and distribute additional copies of the IMNCI training materials to all BHS and office copies to be kept in all health centers.

Infrastructure - Strengthen the infrastructure of health centers to provide clean water access and basic equipment, e.g. for functioning ORT corners. - Consider the need to provide support for some essential materials such as availability of running water, sterilizers for smooth implementation and better patient management.

Drug management - Strengthen drug supply chain and provision of consumable materials to prevent stock out of essential drugs and equipment as defined in the updated IMNCI guidelines (2017). Currently missing items include: bronchodilators, spacers, salbutamol, diazepam suppositories, nasal tubes, etc. - Involve additional national programs (such as National AIDs Program, NMCP and TB) to inform the further addition of specific drugs to the supply for RHCs.

General support - Provide sufficient quantities of the Patient Record form to ensure that IMNCI- trained staff have the necessary tools for use with each new case. - Perform regular follow-up and supervisory visits (preferably quarterly). (Where human resources and time may be limited, supervision could be initially targeted to facilities where the staff showed some challenges in grasping the information provided in the training. Use pre and post test scores from training to help identify areas where more support may be needed). - Provide feedback on utilization of the updated IMNCI guidelines in the program evaluation meeting on yearly basis. - Procure needed drugs and materials in the near future - Encourage more family and community participation, to work in close collaboration with the BHS, to support reduction of IMR and U5MR in the townships, states/regions and nationwide.

Photo 9: MCSP, Child Health Team (JSI-Myanmar) at Follow up after Training TOT, Naypyitaw

7. References

1. WHO (2018) Integrated Management of Childhood Illness (IMCI). Available at http://www.who.int/maternal_child_adolescent/topics/child/imci/en/ (Accessed 12 June 2018) 2. WHO Introduction, IMCI Training Player, ICATT (2013). Available at http://online.icatt-training.org/se-266098999fe14093b27ad8d5df779ffd/82019dd0- 5fe1-4b1e-958d-e544d17ea473/ 3. MOHS, Nay Pyi Taw (2017) Myanmar Demographic Health Survey (2015-16). Available at https://dhsprogram.com/pubs/pdf/FR324/FR324.pdf 4. UNICEF fact sheet. https://www.unicef.org/eapro/MNH_Myanmar.pdf 5. Sustainable Development Goal 3. https://sustainabledevelopment.un.org/sdg3

8. Annexes Annex 1. Agenda of Central MToT on updated IMNCI guidelines (2017) Man Myanmar hotel, Nay Pyi Taw

Note: Similar training curriculum was used in State and Regional level IMNCI training in five states and regions.

� �� (��.��.�� )

� �� - ��

�� - �� ဧ�� - All Trainers �� - �� Dr. Theingi Aung �� - �� Dr. Thida Win ��

- �� - �� Dr. Zaw Myo Aung �� - ��

�� - �� Dr. Kyaw Thant Sin �� - �� Dr. Wai Min Oo �� - Role play exercise with OSCE All trainers �� (��.��.�� ) � �� - Recap and Tea Break All trainers �� - �� Dr. Dr. Thida Win

�� - �� Dr. Zaw Myo Aung �� \ - �� Dr. Kyaw Thant Sin �� - �� Dr. Wai Min Oo ��

� - �� - �� Dr. Kyaw Thant Sin �� - ��

�� - �� Dr. Wai Min Oo �� - Role play exercise with OSCE All trainers �� (��.��.�� ) � �� - Recap and Tea Break

�� - ��\ �� Dr. Theingi Aung �� - �� Dr. Thida Win �� - Dr. Zaw Myo Aung �� Exerci - se and Role play Dr. Wai Min Oo ��

- �� - �� Dr. Kyaw Thant Sin ��

� �� - ��

�� - �� Dr. Kyaw Thant Sin �� - Role play exercise with OSCE All trainers �� (��.��.�� )

� �� - Recap and Tea Break �� - Role play exercise with OSCE �� Role play exercise with OSCE �� - �� Role play exercise with OSCE �� - �� (knowledge) �� - �� Luncg break - �� - �� (skill using OSCE) �� - Coffee break �� - �� (skill using OSCE) �� - �� (skill using OSCE) ��

English Translation Agenda of Central MToT on updated IMNCI guidelines (2017) Man Myanmar hotel, Nay Pyi Taw

No Date and time Topic Responsible person

First Day (27.11.2017) 1) 8:00 – 9:00 Registration 2) 9:00 – 10:00 Opening Ceremony and Tea Break 3) 10:00 – 10:45 Pretest All Trainers Introduction, Assess and classify child, Ask 4) 10:45 – 11:15 the mother about the child problems, Check Dr. Theingi Aung for general danger signs, Exercise Assess cough and difficult breathing and 5) 11:15 – 12:00 Classification, Assess diarrhoea and Dr. Thida Win classification 6) 12:00 – 1:15 Lunch Break Assess fever, Assess ear problem, Check for 7) 1:15 – 2:15 acute malnutrition and anaemia, Classification Dr. Zaw Myo Aung and exercise 8) 2:15 – 2:30 Coffee Break

Check for HIV infection, Check 9) 2:30 – 3:30 immunization, Vitamin A and Deworming Dr. Kyaw Thant Sin status Assess other problems including mouth and 10) 3:30 – 4:30 gum conditions, Feeding children, Assess Dr. Wai Min Oo development 11) 4:30 – 5:00 Role Play Exercises with OSCE All trainers SECOND DAY (28.11.2017) 1) 8:00 – 9:00 Recap and Tea Break All trainers Identify treatment for child with cough and 2) 9:00 – 10:00 Dr. Dr. Thida Win difficult breathing, and diarrhoea, Exercise Identify treatment for child with fever, ear 3) 10:00- 10:45 Dr. Zaw Myo Aung problem, malnutrition and anaemia Identify treatment for child infected with HIV, 4) 10:45-11:15 during Immunization, Vit A, deworming and Dr. Kyaw Thant Sin Exercise Identify treatment for child with teeth and 5) 11:15-12:00 gums problems, feeding and developmental Dr. Wai Min Oo milestones, Exercise 12:00-1:15 LUNCH BREAK 6) Treatment of cough, difficult breathing, 7) 1:15-2:15 Dr. Kyaw Thant Sin diarrhoea and Exercise 8) 2:15-2:30 COFFEE BREAK Treatment of Fever, Ear Problems, Nutritional 9) 2:30-3:30 Dr. Wai Min Oo Status and Anaemia, and Exercise 10) 3:30-4:30 Role Play Exercises with OSCE All trainers THIRD DAY (29.11.2017) 1) 8:00-9:00 AM Recap and Tea Break Treatment of HIV infected child, 2) 9:00-10:00 Immunization, Vit A, Deworming and Dr. Theingi Aung Exercise Treatment of teeth and Gums problems, 3) 10:00-10:45 Feeding and Developmental Milestones and Dr. Thida Win Exercise 4) 10:45-11:15 Counselling of Mother Dr. Zaw Myo Aung Counselling of Mother, Exercise and Role 5) 11:15-12:00 Dr. Wai Min Oo Play 6) 12:00-1:15 LUNCH BREAK 7) 1:15-2:15 Follow-up the child Dr. Kyaw Thant Sin 8) 2:15-2:30 Coffee Break 9) 2:30-3:30 Follow-up visit and Exercise Dr. Kyaw Thant Sin 10) 3:30-4:30 Role Play Exercises with OSCE All trainers FOURTH DAY (30.11.2017) 1) 8:00-9:00 Recap and Tea Break All trainers 2) 9:00-10:00 Role Play Exercises with OSCE All trainers 3) 10:00-10:45 Role Play Exercises with OSCE All trainers 4) 10:45-11:15 Role Play Exercises with OSCE All trainers 5) 11:15-12:00 Evaluation after Training (Knowledge) All trainers 6) 12:00-1:15 LUNCH BREAK 7) 1:15-2:15 Evaluation after Training (Skill using OSCE) All trainers

8) 2:15-2:30 COFFEE BREAK 9) 2:30-3:30 Evaluation After Training (Skill using OSCE) All trainers 10) 3:30-4:30 Evaluation After Training (Skill using OSCE) All trainers

Annex 2. Agenda for Central MTOT on Follow-up training of updated IMNCI guidelines (2017) Man Myanmar Hotel, Nay Pyi Taw

� �� (��.�.��) �� - �� - �� - Coffee break �� - �� (�.� - �.�) �� - �� (�.�) �� - Lunch break �� - �� (�.� - �.� - �.�) �� - �� - �� Coffee break �� - �� (�) �� 4:30-5:00 �� (�) �� (��.�.�� )

�� - �� (�)�� - Lunch break �� - �� (�)�� (��.�.�� ) �� - �� - Coffee break �� - �� - Lunch break �� - ��

English Translation Agenda for Central MTOT on Follow-up training of updated IMNCI guidelines (2017), January 2018 Man Myanmar Hotel, Nay Pyi Taw

No Date and time Topic Responsible person Day 1 (10.1.2018) 1 8:00-9:00 Registration 2 9:00- 10:00 Goals and objectives of IMNCI follow up Dr.Theingi Aung after training 3 10:00-10:45 Coffee break 4 10:45-11:15 Follow up after training (1.1 - 1.2) Dr.Theingi Aung 5 11:15- 12:00 Follow up after training (1.3) Dr.Theingi Aung 6 12:00-1:00 Lunch break

7 1:15-2:15 Follow up after training(1.4-1.5-1.6) Dr.Soe Ye Yint Htun 8 2:15-2:30 Procedures and guidelines for follow up after Dr.Aung Naing Soe training, meeting and central meeting 9 2:30-3:30 Coffee break 10 3:30-4:30 Teaching on check list for follow up after Dr.Zaw Myo Aung training (1) 11 4:30-5:00 Teaching on check list for follow up after Dr.Zaw Myo Aung training (2) & linked with card exercises Day 2 (11.1.2018) 1 8:00-12:00 Supervision visit to RHC by dividing four All participants groups 2 12:00-1:15 Lunch break 3 1:15-4:30 Supervision visit to SRHC by dividing four All participants groups Day 3 (12.1.2018) 1 9:00-10:00 Group discussion on follow up after training All participants 2 10:00-10:45 Coffee break 3 10:45- 12:00 Group discussion on follow up after training All participants 4 12:00-1:15 Lunch break 5 1:15-4:15 Group discussion on follow up after training All participants 6 4:15-4:30 Closing ceremony

Annex 3. Agenda for State level Follow-up training of updated IMNCI guidelines (2017), Taunggyi, S Shan state

� �� (��.�.��) �� - �� - �� - Coffee break �� - �� (�.� - �.�) �� - �� (�.�) �� - Lunch break �� - �� (�.� - �.� - �.�) �� - �� - �� Coffee break �� - �� (�) �� 4:30-5:00 �� (�) �� (��.�.��) �� - �� (�)�� - Lunch break �� - �� (�)�� (��.�.��)

�� - �� - Coffee break �� - �� - Lunch break �� - �� (��.�.��) �� - �� - Coffee break �� - �� CME �� - Lunch break �� - �� CME �� - �� Coffee break �� - ��

CME �� - ��

English Translation Agenda for State level Follow-up training of updated IMNCI guidelines (2017), Taunggyi, S Shan state

No Date and time Topic Responsible person Day 1 (13.2.2018) 1 8:00-9:00 Registration 2 9:00- 10:00 Goals and objectives of IMNCI follow up Daw Aye Aye San after training 3 10:00-10:45 Coffee break 4 10:45-11:15 Follow up after training (1.1 - 1.2) Daw Aye Aye San 5 11:15- 12:00 Follow up after training (1.3) Daw Sein Lae Nway 6 12:00-1:00 Lunch break 7 1:15-2:15 Follow up after training(1.4-1.5-1.6) Daw Sein Lae Nway 8 2:15-2:30 Procedures and guidelines for follow up All facilitators after training, meeting and central meeting 9 2:30-3:30 Coffee break 10 3:30-4:30 Teaching on check list for follow up after Dr. Khaing Myae training 11 4:30-5:00 Teaching on check list for follow up after Dr. Khaing Myae training Day 2 (14.2.2018) 1 8:00-12:00 Supervision visit to RHC by dividing four All participants groups (Nam Kok RHC, Hopong Township) 2 12:00-1:15 Lunch break

3 1:15-4:30 Supervision visit to SRHC by dividing four All participants groups (Long Hay SRHC, Hopong Township) Day 3 (15.2.2018) 1 9:00-10:00 Group discussion on follow up after training All participants 2 10:00-10:45 Coffee break 3 10:45- 12:00 Group discussion on follow up after training All participants 4 12:00-1:15 Lunch break 5 1:15-4:30 Group discussion on follow up after training All participants Day 4 (16.2.18) 1 9:00 – 10:15 Review session about Pneumonia and All participants AM Diarrhoea 2 10:15 – 10:45 Coffee Break AM 3 10:45 – 12:00 Group presentation on All participants PM Pneumonia/Diarrhoea by each township training team 4 12:00 – 1:00 Lunch PM 5 1:00 – 3:00 PM Group presentation on All participants Pneumonia/Diarrhoea by each township training team 6 3:00 – 3:30 PM Coffee Break 7 3:30 – 4:30 PM Group presentation on All participants Pneumonia/Diarrhoea by each township training team 8 4:30 – 5:00 PM Closing Ceremony

Annex 4. Agenda for Township level Multiplier training, Mong Kai Township, S Shan state, February 2018

Note: Similar training agenda was used for other townships.

� �� (��.�.��) � �� - �� - �� ဧ�� - �� - �� - �� - �� - �� - �� - �� (��.�.��) � �� - Recap �� - �� - �� - �� - � �� - �� - �� - �� (��.�.��)

� �� - Recap �� - �� - �� - �� - �� - �� - �� - �� (��.�.��) � �� - Recap �� - �� \ �� - �� - �� - �� - �� - �� - Role play exercise with OSCE �� (��.�.��) � �� - Recap and Tea Break �� - Role play exercise with OSCE ��

� �� - �� - Role play exercise with OSCE �� - �� (knowledge) �� - �� - �� (skill �� using OSCE) �� - �� - �� (skill �� using OSCE) �� - �� (skill �� using OSCE) ��

English translation Agenda for Township level Multiplier training, Mong Kai township, S Shan state, February 2018 No Date and time Topic Responsible person First Day (21.2.2018) 1) 8:30 – 9:00 Registration and Opening Ceremony 2) 9:00 – 9:30 COFFEE BREAK 3) 9:30 – 10:00 Pretest All Trainers 4) 10:00 – 10:30 Introduction Daw Sein Lae Nway 5) 10:30 – 12:00 Assess and classify child, Ask the mother Daw Sein Lae Nway about the child problems, Check for general danger signs, Exercise 6) 12:00 – 1:00 LUNCH BREAK 7) 1:00 – 2:30 Assess cough and difficult breathing and Daw Aye Aye San Classification 8) 2:30 – 3:00 COFFEE BREAK 9) 3:30 – 4:30 Identify treatment for child with cough Daw Aye Aye San and difficult breathing and Exercises SECOND DAY (22.2.2018) 1) 9:00 – 9:15 Recap All trainers 2) 9:15 – 10:15 Assess diarrhoea and classification Daw Nang Kham Hlaing 3) 10:15 – 10:30 COFFEE BREAK Dr. Zaw Myo Aung 4) 10:30 – 12:00 Identify treatment for child with diarrhoea Daw Nang Kham and Exercises Hlaing 5) 12:00 – 1:00 LUNCH BREAK Dr. Wai Min Oo 6) 1:00 – 2:30 Assess ear problem and classification Daw Nang Mo Ngin 7) 2:30 – 3:00 COFFEE BREAK Dr. Kyaw Thant Sin 8) 3:00 – 4:30 Identify treatment for ear problem and Daw Nang Mo Ngin Exercises THIRD DAY (23.2.2018) 1) 9:00 – 9:15 Recap All Trainers 2) 9:15 – 10:15 Assess fever and classification Daw Nang Kham Lu 3) 10:15 – 10:30 COFFEE BREAK Dr. Thida Win 4) 10:30 – 12:00 Identify treatment for fever and Exercises Daw Nang Kham Lu 5) 12:00 – 1:00 LUNCH BREAK Dr. Wai Min Oo 6) 1:00 – 2:30 Check for acute malnutrition and anaemia, Daw Sein Lae Nway Classification and Exercises 7) 2:30 – 3:00 COFFEE BREAK Dr. Kyaw Thant Sin 8) 3:00 – 4:30 Assess feeding Children and Daw Sein Lae Nway developmental milestones and Exercise FOURTH DAY (24.2.2018) 1) 9:00 – 9:15 Recap All Trainers 2) 9:15 – 10:15 Check for HIV infection, Identify Daw Aye Aye San treatment for child infected with HIV and

Exercises 3) 10:15 – 10:30 COFFEE BREAK All trainers 4) 10:30 – 12:00 Check immunization, Vitamin A and Daw Nang Kham Deworming status, Identify treatment and Hlaing Exercises 5) 12:00 – 1:00 LUNCH BREAK All trainers 6) 1:00 – 2:30 Assess other problems including mouth and gum conditions, Identify treatment for Daw Nang Mo Ngin child with teeth and gums problems and Exercises 7) 2:30 – 3:00 COFFEE BREAK All trainers 8) 3:00 – 4:30 Role play exercise with OSCE All Trainers FIFTH DAY (25.2.2017) 1) 9:00 – 9:15 Recap and Tea Break All Trainers 2) 9:15 – 10:15 Role play exercise with OSCE All Trainers 3) 10:15 – 10:30 COFFEE BREAK All trainers 4) 10:30 – 11:15 Role play exercise with OSCE All Trainers 5) 10:30 – 12:00 Knowledge Examination (post-test) All Trainers 6) 12:00 – 1:15 LUNCH BREAK Daw Nang Mo Ngin 7) 1:15 – 2:15 Skill Examination using OSCE All Trainers 8) 2:15 – 2:30 COFFEE BREAK All Trainers 9) 2:30 – 3:30 Skill Examination using OSCE All Trainers 10) 3:30 – 4:30 Skill Examination using OSCE All Trainers

Annex 5. List of participants in training and supervision visits

Training Date Central/Region/State/ Number of Participants No Training Name Place Types of Types of From To Township Male Female Total participants activity IMNCI Training and follow-up activity Central MTOT in Nay Pyi Taw 1 27-11-17 30-11-17 Central MToT IMNCI Training Naypyitaw Central 8 13 21 Trainers Training 2 10-01-18 12-01-18 Central MToT, Follow-up training Naypyitaw Central 4 14 18 Trainers Training Magway Region 1 27-12-17 30-12-17 State/ Regional Level ToT Training Magway Regional 11 14 25 Trainers Training Township level BHS Multiplier 2 15-01-18 19-01-18 Taungdwingyi Township 0 30 30 Training BHS Training State/Regional Level Follow-up 3 01-02-18 03-02-18 Magway Regional 11 14 25 Traiining Trainers Training Township level BHS Multiplier 4 15-02-18 19-02-18 Taungdwingyi Township 0 30 30 Training BHS Training 5 08-03-18 19-03-18 Follow-up activity Taungdwingyi Township 0 26 26 BHS Supervision Ayeyarwaddy Region 1 26-12-17 29-12-17 State/ Regional Level ToT Training Pathein Regional 0 20 20 Trainers Training Township level BHS Multiplier 2 15-01-18 19-01-18 Ingapu Township 0 27 27 Training BHS Training Township level BHS Multiplier 3 03-02-18 07-02-18 Ingapu Township 0 27 27 Training BHS Training Township level BHS Multiplier 4 05-03-18 09-03-18 Ingapu Township 0 21 21 Training BHS Training State/Regional Level Follow-up 5 19-03-18 21-03-18 Pathein Regional 0 21 21 Traiining Trainers Training 6 27-02-18 27-02-18 Follow-up activity Ingapu Township 0 1 1 BHS Supervision 7 20-03-18 20-03-18 Follow-up activity Ingapu Township 0 4 4 BHS Supervision 8 26-03-18 30-03-18 Follow-up activity Ingapu Township 0 20 20 BHS Supervision

Training Date Central/Region/State/ Number of Participants No Training Name Place From To Township Male Female Total Types of Types of IMNCI Training and follow-up activity participants activity Central MTOT in Nay Pyi Taw Rakhine state 1 15-01-18 18-01-18 State/ Regional Level ToT Training Sittwe Township 3 17 20 Trainers Training Township level BHS Multiplier 2 23-02-18 27-02-18 Min Bya Township 0 23 23 Training BHS Training Township level BHS Multiplier 3 25-03-18 29-03-18 Min Bya Township 0 22 22 Training BHS Training 4 05-05-18 18-05-18 Follow-up activity Min Bya Township 0 23 23 BHS Supervision Northern Shan 1 27-12-17 30-12-17 State/ Regional Level ToT Training Lashio State 0 14 14 Trainers Training State/Regional Level Follow-up 2 05-03-18 07-03-18 Lashio State 0 13 13 Training Trainers Training Township level BHS Multiplier 3 27-03-18 30-03-18 Mongyai Township 0 20 20 Training BHS Training Township level BHS Multiplier 4 27-04-18 30-04-18 Tang Yan Township 0 30 30 Training BHS Training 5 14-05-18 16-05-18 Follow-up activity Mongyai Township 0 7 7 BHS Supervision 6 28-05-18 30-05-18 Follow-up activity Tang Yan Township 0 10 10 BHS Supervision Southern Shan 1 16-01-18 19-01-18 State/ Regional Level ToT Training Taunggyi State 3 21 24 Trainers Training State/Regional Level Follow-up 2 13-02-18 16-02-18 Taunggyi State 3 21 24 Training Trainers Training Township level BHS Multiplier 3 21-02-18 25-02-18 Mong Kai Township 0 22 22 Training BHS Training 4 30-03-18 30-03-18 CME activity Mong Kai Township 10 39 49 BHS CME session 5 28-03-18 02-04-18 Follow-up activity Mong Kai Township 0 16 16 BHS Supervision

Annex 6. Number and percentage of trained MOHS trainers in the state, regional and township training teams

Med- Trained trainers on updated IMNCI ical Doctor Nursing Officer THN SN TN THA HA LHV MW PHS 1 Tutor Total Magway region 12 2 2 2 10 2 30 Ayeyarwaddy region 5 1 5 13 1 25 Rakhine state 1 2 2 4 9 1 1 2 22 N Shan state 4 4 11 19 S Shan state 6 1 6 8 6 1 28 Total number 28 6 19 8 6 2 14 36 2 1 2 124 Total percentage 23% 5% 15% 6% 5% 2% 11% 29% 2% 1% 2%

Medical Doctors: Team leaders of Child Health team or Township Medical Officer or Station Medical Officer Nursing Officer: Senior nurse based at State and Regional Health Department THN: Township Health Nurse at Township Health Department SN: Staff Nurse at the Township Health Department TN: Trained Nurse at the Township Health Department THA: Township Health Assistant HA: Health Assistant LHV: Lady Health Visitor MW: Midwife PHS 1: Public Health Supervisor 1 Tutor: Nurse at the Nursing and Midwifery Training School

Annex 7. BHS (LHV and Midwife) existing, trained and supervised

LHV Midwife Total State/ Region Township Existing Trained Supervised Existing Trained Supervised Existing Trained Supervised Magway Taungdwingyi 9 4 (44%) 4 (100%) 59 56 (95%) 22 (39%) 68 60 (88%) 26(43%) Ayeyarwaddy Ingapu 6 4 (67%) 0 74 71 (96%) 25 (35%) 80 75 (94%) 25 (33%) Rakhine state Minbya 9 7 (78%) 3 (42%) 43 38 (88%) 20 (53%) 52 45 (87%) 23 (51%) N Shan Tang Yan 3 1 (33%) 1 (100%) 29 29 (100%) 9 (31%) 32 30 (94%) 10 (33%) N Shan Mongyai 3 1 (33%) 0 23 19 (83%) 7 (37%) 26 20 (77%) 7 (35%) S Shan Mong Kai 4 4 (100%) 3 (75%) 18 18 (100%) 13 (72%) 22 22 (100%) 16 (73%) Total 34 21 (60%) 11 (52%) 246 231 (94%) 96 (42%) 280 252 (90%) 107 (42%)

Annex 8. Health centers (UHC, MCH, RHC, sub-center) existing, trained and supervised

UHC MCH RHC Sub-center Total Region/ Township State Existi Traine Superv Existi Superv Exist Traine Supervis Existi Supervis Existi Traine Supervis Trained Trained ng d ised ng ised ing d ed ng ed ng d ed Taungdwin 1 8 7 36 14 45 21 Magway 1 1 0 8 40 50 gyi (100%) (100%) (88%) (90%) (39%) (90%) (47%)

Ayeyarwa 1 1 11 6 51 13 63 20 Ingapu 1 1 11 52 65 ddy (100%) (100%) (100%) (55%) (98%) (25%) (97%) (32%)

1 1 6 6 29 13 36 20 Rakhine Minbya 0 1 6 29 36 (100%) (100%) (100%) (100%) (100%) (45%) (100%) (56%)

1 1 4 2 14 3 19 6 N Shan Tang Yan 0 1 4 16 21 (100%) (100%) (100%) (50%) (88%) (21%) (90%) (32%)

1 2 1 16 6 19 7 Mongyai 0 1 0 3 16 20 (100%) (67%) (50%) (100%) (35%) (95%) (35%)

1 1 1 1 3 3 9 3 14 8 S Shan Mong Kai 1 1 3 9 14 (100%) (100%) (100%) (100%) (100%) (100%) (100%) (33%) (100%) (57%)

1 1 6 4 34 25 155 52 196 82 Total 3 6 35 162 206 (33%) (100%) (100%) (67%) (97%) (74%) (96%) (33%) (95%) (42%)

Annex 9 (a). Pre- and Post-test scores of participants in trainings

Pre-test (/10 scores) Post-test (/10 scores)

# participants Minimum scores Maximum scores Average scores Minimum scores Maximum scores Average scores Nay Pyi Taw Central MToT 20 2.5 10 5 2 10 6 Magway State and Regional ToT training 25 2 4 2.7 6.5 9.5 8.3 Township training, Batch 1 30 4 5 4.4 7 9 7.8 Township training, Batch 2 30 2 5 3.2 7 10 8.2 18 3 6 4.8 5 9 7 Ayeyarwaddy State and Regional ToT training Township training, Batch 1 27 3 8 4.4 6 9.5 8 Township training, Batch 2 27 3 8 4.9 6 9.5 8.2 Township training, Batch 3 21 3 7 5 6 9.5 8.2 Rakhine State and Regional ToT training 13 1 8 4.8 6 8.5 7.3 Township training, Batch 1 23 2 6 3.8 5 8 6.6 Township training, Batch 2 22 1 4.5 2.4 5 9 6.4 N Shan State and Regional ToT training 14 3 7.5 4 4 8.5 5.3 Township training, Tang Yan 24 3.3 7.7 5 6.7 10 8.8 Township training, Mongyai 20 3 8.5 5.7 6 9 7.3 S Shan State and Regional ToT training 24 1 5.5 3.3 5 10 7 Township training, Mong Kai 22 1 6 2.1 4.5 10 6.8

Annex 9 (b). Percent increase

Pre-test Post-test Percent Township average average Difference increase scores scores Central MToT 5 6 1 20 Magway 4.7 8.1 3.4 72 Ayeyarwaddy 4.8 7.9 3.1 65 Rakhine 3.7 6.8 3.1 84 N Shan 4.9 7.1 2.2 45 S Shan 2.7 6.9 4.2 156

Annex 10. Case Scenarios (OSCE) for Pre- and Post-tests in updated IMNCI training

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English Translation

1) Name – Maung Maung, Age – (3) Yrs, Body Weight – (10) kg, Height – (98) cm He has a complaint of fever with cough. It is his first time to clinic. He has body temperature 38˚C. There is no general danger signs on the child. He has been coughing for (5) days. On examination, respiratory rate of the child is 43/min. There is no chest indrawing and stridor. But he has wheezing. The child does not have diarrhoea. He lives in no Malaria area. He has no history of Measles. There is no mouth and gum ulcers and eye problem. He does not have any sign about Dengue Haemorrhagic Fever. There is no ear problem in this child. When health worker checked the nutrition status of the child, there is no pitting oedema and palmar pallor. He can eat half of RUTF within (30) minutes. The child was not infected with HIV. He has not been received any immunization according to the age. He also never takes Vitamin-A pill or Deworming pills. When health worker checked Maung Maung’s development for age, he can climb up and down the ladder. He is able to speak his name and age. But he cannot draw a circle. Treat the child according to IMNCI.

2) Name – Aye Aye, Age – (1) yr and (3) mths She is having a diarrhoea and this is her first time to clinic. Her body weight is (12) kg and she is (86) cm tall. Her body temperature is 37.4˚C at the time of measuring. There is no general danger signs on the baby. She does not have cough and difficult breathing. She has been having loose motion for three days and there was no mucus or blood. The stool is watery but not cloudy. The baby is not lethargic. She drink eagerly and her skin pinch goes back slowly. The mother said that the baby has sunken eyes. There is no other health problems. She does not have history of HIV Exposure. Her MUAC is (120) mm and there is no pitting oedema. When health worker assessed the feeding history of the baby, he found that the baby has two meals of rice per day. And her mother stopped breastfeeding her. The one who feeds the baby is her 10 years old sister. Since the baby had fever, the regular meals are ceased and she drinks only water. She never received immunization and Vitamin pills. She can walk. She can drink with cup. She can speak “May May”. Treat the child.

3) Name – Mu Mu, Age – (2) yr and (10) days The mother of the baby is PMCT-positive mother and the baby got ART Prophylaxis (6) weeks. The baby’s complaint for now is difficult breathing with “Shuu Shuu” breathing sound. Her body weight is (4) kg and she is (53) cm tall. This is her first time to clinic for difficult breathing. There is no general danger signs. The baby is difficult in breathing and her respiratory rate is (60) per minutes. There is no chest indrawing and stridor. The baby had wheezing and was treated with inhaled bronchodilator (Salbutamol). Her respiratory rate dropped to 40 per minute and she asked for food after being treated with inhaled bronchodilator. There is no loose motion, no fever. The baby has oral thrushes. She does not have ear problem and anaemia. There is no sign of malnutrition. DNC-PCR test result is negative. The baby is not breastfed. She was bottle fed according to HIV counseling. She was not stop drinking milk. The baby received all the immunization. She is able to hold head up. She knows her mother’s face. She usually wakes up through loud sounds. She can response with a smile to teasing. Treat the baby according to IMNCI guideline.

Annex 11. Follow-up after training_ Supervision tools (English translation) Follow-up after training, Form 1

State/Region______District______Township______Name of Position______Date______Address______Supervisor______

Please note down the name of health center, name of staff and date. Name of Health

Center Date Total Name of Staff Activity 1 2 3 4 5 If supervisor's opinion is the same as staff's opinion, Supervisor Supervisor Supervisor Supervisor Supervisor Total please mark ( ). If Staff Staff Staff Staff ì Staff scores Total scores not, please mark (o). by by staff If the activity is not Supervis ( )

required to do, ì or ( ) please mark cross ì line through two columns. 1. ASSESSMENT 1. General danger 1 signs 1. Four main 2 diseases ( Coughing, Diarrhoea, Fever, Ear Problems) 1. Nutrition : 3 weighing the child's body weight and record on Weight Chart, Check Z-score, knows how to measure the mid upper arm circumstances

1. HIV : HIV testing, 4 Asking mother for HIV infection status during pregnancy and delivery. If HV (+), ask about the HIV status of the child such as HIV testing and results. 1. EPI: assessment 5 on immunization status of the child 1. Mouth and Gum 6 : Assessment on mouth and gum and other health problems 1. Growth and 7 Development : Assessment according to child's age

2. TREATMENT 2. Patient referral 1 of severe disease Providing intramuscular injection 2. Oral antibiotics 2 (or) Oral anti- malarial drugs Antibiotics for pneumonia Antibiotics for ear infection Antibiotics for dysentry Oral anti- malarial drugs for malaria

2. Providing ORS 3 solution for diarrhoea Suggest to provide more fluids and to continue meals Explain to provide more fluids and to continue meals and explain two dangers signs for emergency return Immunization given during this visit or 3. appointment for next immunization 4. ASSESSMENT AND COUNSELLING ON FEEDING 4. Assessment on 1 feeding including breast feeding in under 2 4. Counselling on 2 child feeding and nutrition according to the age of under 2 ASSESSMENT OF 5. OTHER HEALTH PROBLEMS

Duration

Please note down the name of health center, name of staff and date.

Follow-up after training, Form 2

Use one column for one person.

1 2 3 4 5 Note down the If he/she can answer correctly, please numbers of person mark ( ). If not, please mark (o). Please interviewed and Health Knowledge of caretaker ì make cross mark along the column for numbers of person unnecessary line. who know correct answer.

DISCUSSIONS The mother is able to 1 describe the home treatment. The mother correctly 2 knows the ORS solution preparation. The mother is able to describe the home 3 treatment and ORS solution preparation. The mothers know the (3) home care methods 4 as giving fluid, food and indication for urgent return Mother/Caretaker's Satisfaction Mother's satisfaction on 5 BHS' case management

6 Detail Description Agree on examination 6.1 time of BHS Ways of BHS 6.2 examination on the child Treatment provided by 6.3 BHS Communication skills of 6.4 BHS Health knowledge 6.5 received from BHS 6.6 Others

Follow-up after training, Form 3

State/Region______District______Township______Department______Check the following items. If you found dufficulties, please mark (*). Please mark () on possible solutions. 1. Infractures and Materials Possible Solutions a) Patient Examination Place Reposition the clinic space 1. Enough Space Advice the mininum standard for patient 2. Table, Chairs examination place. 3. Weighing Machine Submit requests for requirements to TMO or 4. Wall Clock Supervisor. 5. IMNCI Guideline Books 6. MCH booklet 7. Patient Registration 8. Patient Record Book 9. Water, Mug and Spoon

2. ORT Corner Possible Solutions 1. ORT Corner Advice to position ORT corner and required Did babies receive ORT? materials for ORT corner. 2. Enough Space Advice to have drinking water. 3. Table and Chair (For mother/caretaker) Select responsible person for ORT corner. 4. Water pot Submit requests for requirements to TMO or 5. Glass, Measuring Jar and Spoon for ORS Supervisor. preparation 6. ORT Register Book

3. Immunization place and materials Possible Solutions Advice to have enough space for 1. Enough Space immunization. 2. Table and Cupboard Submit requests for requirements to TMO or 3. Vaccine Carrier, Cold Box Supervisor. 4. Freeze Test 5. Sterilizer 6. Immunization Records 7. Suitable Temperature (4˚C to 8˚C) 8. All vaccines (+/-) (BCG, OPV, DPT, Measles, HBV)

4. Outpatient Clinics and Referral Possible Solutions Prepare clinic opening time is accessable by 1. Clinic opening time as planned children. 2. Does clinic opening time match with patients' Advice to provide health education during free time? the waiting time.

Discussion about emergency treatment and 3. Is there child patients? referral. 4. Can you provide medicine on every clinic day? Check for places that can support referral. 5. Can you provide immunization on everyday? Submit requests for requirements to TMO or 6. Does ORT Corner open on every clinic day? Supervisor. 7. Is it possible to refer to nearest hospital in time? 8. Can be referred on both day and night?

5. Case Management (If missed, please mark (*). Possible Solutions 1. Regular Patient Registration For routine activities, 2. Weighing - delegate tasks 3. Assessment and Classification diseases - solve problems 4. Referral - sharing knowledges to other staff 5. Identifying breastfeeding and other feeding - prepare for readiness (less time problems consuming) 6. Counselling on feeding and nutrition - esure all the patients are checked during 7. Advices to take medicine at home clinic opening time. 8. Can provide ORS? 9. Teach mothers "How to prepare ORS solution at home" 10. Patient Record Completeness 11. Can you provide first treatment before referral? 12. Advices to take medicine at home 13. Can you provide drugs? 14. Can you provide immunization?

6. Record Keeping Possible Solutions a) Do you keep records for every patient? Advice to keep records systematically. b) If yes, what do you keep? Trained with a child patient to be able to - History taking, Physical Examination keep patient records. - Classification (or) Diagnosis - Treatment - Supervision Records

7. Drug Management Possible Solutions 1. Drug stock books Advice to keep records systematically. - Do you keep drugs in cupboards? Advice how to fill the stock ledgers and how - Does the storage place dry? to keep the records. - Do you keep ORS sachets in dry place? - Do you fill drug stock books correctly?

8. Drugs Possible Solutions

At the time of supervision visit, check the following Try to find out the related problems with drugs are enough for next three months or not. drugs and materials. Please mark absent drugs with (*). Injection Diazepem Injection Ampicillin Injection Gentamycin Amoxicillin Capsules Oral Sabultamol Inhaled bronchodilator Spacer ORS sachet Zinc Sulphate tablets Ciprofloxacin capsules Injection Artesunate ACT tablets Chloroquine tablets Primaquine tablets Paracetamol tablets RUTF Iron/Folate tablets Iron syrup Cotrimoxazole tablets Nevirapine(NVP) tablets Zidovudine (AZT) tablets Tetracycline eye oinment Gentian Violet Nystatin syrup Vit A capsule Albendazole Deworming tablets water for injection Disposable syringes 1 cc 3 cc 5 cc 10 cc Scalp vein set cannula (Yellow) Alcohol spirit Nasal tube Other drugs and drugs supplies

Annex 12 . IMNCI Materials placed at L&PICs (5 states/regions)

Description Unit Amount Remark 1.Paracetamol 500 mg tablet (10x10) Box 1 Essential drugs 2.Paracetamol 120mg/5ml, oral suspension Bot 1 Essential drugs 3.Paracetamol 250mg/5ml oral suspension Bot 3 Essential drugs 4.Amoxicillin 250 mg capsule (10x10) Box 1 Essential drugs 5.Amoxicillin 125mg/5ml oral suspension Bot 2 Essential drugs Box 1 6.Cotrimoxazole 80/400mg tablet (10x10) Essential drugs 7.Ciprofloxacin 250mg tablet (10x10) Box 1 Essential drugs 8.Metronidazole 200mg tablet (10x10) Box 1 Essential drugs 9.Metronidazole 200mg/5ml oral suspension Bot 2 Essential drugs 10.Inj Ampicillin (500 mg) vial for injection Amp 2 Essential drugs 11.Inj Gentamycin (80 mg) vial for injection Amp 2 Essential drugs 12.Diazepam suppository Cap 0 Essential drugs 13.ORS sachet Sachet 2 Essential drugs 14.Clean water bottle (1 liter) Bot 2 Essential drugs

15.Zinc supplementation solution (10 mg/5ml) Bot 2 Essential drugs 16. Gentian violet solution 15ml (0.25 %) Bot 2 Essential drugs 17.Anti-malaria drugs -ACT , card Box 1 Essential drugs 18.Primaquine 7.5 mg tablet (10x10) Box 0 Essential drugs 19.Inj IM Artesunate 60mg ampule Amp 0 Essential drugs 20.Ferrous sulfate 200mg +250 µg Folate (10x10) Box 1 Essential drugs 21.Ferrous fumarate syrup, 100mg per 5ml Bot 2 Essential drugs 22.Albendazole 400 mg tablet, single tablet Tab 5 Essential drugs 23.Nystatin oral suspension, 60ml Bot 1 Essential drugs 24.Tetracycline 1% eye ointment tube Tube 2 Essential drugs 25.Nebulizer with chamber Set 2 Essential drugs 26.Salbutamol Respirator Solution (Ventolin solution) 5mg/ml Amp 2 (10ml) Essential drugs 27.Intravenous infusion bottles (DW) 500ml Bot 2 Injections 28.Intravenous infusion bottles ( DS) 500 ml Bot 2 Injections 29.Intravenous infusion bottles ( MS) 500ml Bot 2 Injections 30.Intravenous infusion bottles (RL) ml Bot 2 Injections 31.Infusion sets, piece Set 4 Injections 32.Butterfly needle (scalp vein 23G) piece Pcs 2 Injections 33.Cannula (24 G, Yellow) piece Pcs 2 Injections 34.Oropharyngeal Airway (Guedel) Pcs 2 Materials 35.Bags and Masks (child size) Set 1 Materials 36.Respiratory timer (if not available any timer will do) Pcs 2 Materials 37.Pulse oxymeter Pcs 1 Materials 38.BP cuff (child) Pcs 1 Materials 39.Glucometer Pcs 1 Materials 40.Glucometer test kits 25’s box Box 1 Materials 41.Disposable syringe (1 ml) Pcs 0 Materials 42.Disposable syringe (3 ml) Pcs 2 Materials 43.Disposable syringe (5 ml) Pcs 2 Materials

44.Disposable syringe (10 ml) Pcs 2 Materials 45.Feeding tube (size 6) Pcs 7 Materials 46.Feeding tube (size 8) Pcs 0 Materials 47.Feeding tube (size 10) Pcs 0 Materials 48.Feeding tube (size 12) Pcs 4 Materials 49.Weighing machine Pcs 1 Nutrition 50.MUAC (MOHS approved version) Pcs 1 Nutrition 51.Weight chart (MOHS approved version) Pcs 0 Nutrition 52.Immunization chart (MOHS approved version) Pcs 0 Nutrition Infectious 53.HIV rapid test kit (Commonly used test kit) (MOHS approved) Pcs 2 disease Infectious 54.Malaria rapid test (RDT) (MOHS approved) Pcs 2 disease Infectious 55.Dengue Haemorrhagic fever (DHF) test kit (MOHS approved) Pcs 2 disease Infectious 56.Thermometer (Digital) Pcs 1 disease 57.Cup for the ORS preparation Pcs 2 Accessories 58.Spoon for the ORS preparation Pcs 2 Accessories 59. Hand gel 20ml bottle Bot 2 Accessories 60.Cotton wool Pcs 1 Accessories 61.Spelling bandage Pcs 2 Accessories 62.Spirit bottle, 60ml Pcs 2 Accessories 63.Micropore Pcs 3 Accessories 64.Stethoscope Pcs 2 Accessories 65.Handy plaster Pcs 5 Accessories 66.Disposable or plastic gloves box Box 1 Accessories 67.Salter Scale Pcs 1 Materials 68.Thermometer ( Mercury) Pcs 2 Materials 69. IMNCI guidelines set Set 2 Guidelines Modules 70. CME modules set Set 1 booklets with CD

Annex 13. Success stories