Guinea Ebola Response Plan II: End of Project Report June 02, 2015–May 31, 2016

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

Submitted by: Jhpiego Corporation

The Maternal and Child Survival Program (MCSP) is a global United States Agency for International Development (USAID) Cooperative Agreement to introduce and support high-impact health interventions with a focus on 25 high-priority countries with the ultimate goal of ending preventable child and maternal deaths within a generation. Visit www.mcsprogram.org to learn more.

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

Guinea Summary

Strategic Objectives Support health care workers and facilities to continue to offer high-quality health services in safe environment by strengthening infection prevention and control (IPC) practices through training, supportive supervision, and complementary monitoring and evaluation.

Program Dates June 02, 2015 to May 31, 2016 (originally 6 month project, received 6 month extension) PY1 Approved $2,400,000 Budget Geographic 5 prefectures of Boke, Dabola, Dinguiraye, Faranah, and Mandiana Focus Area No. of facilities and/or No. of regions (%) No. of prefectures (%) Geographic communities (%) Presence 3/8 (38%) 5/38 (13%) 59/461 (13%) Technical OTHER: Ebola Response—Infection Prevention and Control Interventions

Selected Programmatic Data Number/percentage of staff in health facility who 1,345 (99%) receive IPC training Number/percentage of health facilities that have access to disinfecting agents (and sufficient quantity for 76% (31/41) of SDP at least one month) 11% of facilities at second assessment; none of the facilities met this indicator at baseline Percentage of health facilities achieving / compliant with at least 75% of IPC performance standards 23% of hospital services at second assessment; 2% at the baseline.

Percentage of trained staff who receive post-training 56% follow-up supervision

Guinea Ebola Response Plan II: End of Project Report 3 Contents

List of Tables and Figures ...... 5

Acknowledgments ...... 7

Executive Summary ...... 8

Introduction ...... 9

Major Accomplishments ...... 10

1.1. Active participation of MCSP in national level coordination ...... 10 1.2. Conduct rapid assessment, staff identification at selected health facilities and preparation for IPC training and supervision ...... 10 1.3. Conduct IPC training for facility staff- healthcare providers and support staff ...... 11 1.4. Procure and supply necessary IPC and sanitation/waste management equipment to support IPC performance healthcare facilities ...... 13 1.5. Conduct routine quality assurance visits and provide additional follow-up support ...... 14 1.6. Partnership and collaboration ...... 15 1.7. Monitoring and evaluation: IPC performance assessments at focus facilities ...... 15 Challenges and Opportunities ...... 21 Annex A. List of Local Coach and Focal points ...... 22 Annex B: List of IPC materials provided to Boké prefecture ...... 23 Annex C: Facilities receiving autoclaves ...... 24 Annex D: Performance Monitoring Indicators ...... 25

Guinea Ebola Response Plan II: End of Project Report 4 List of Tables and Figures Table 1: Number of personnel trained by prefecture ...... 12 Table 2: Health providers trained on IPC by professional category ...... 12 Table 3: Facilities receiving IPC support by type ...... 12 Table 4: Facilities receiving incinerators ...... 14 Table 5: Supportive Supervision of providers trained in IPC ...... 14 Figure 1: Evolution of IPC performance at health centers from baseline to final evaluation in Boké, Faranah, Dabola, Dinguiraye and Mandiana ...... 16 Figure 2: Evolution of IPC performance in hospital services in Boké, Faranah, Dabola, Dinguiraye and Mandiana ...... 16 Table 6: Additional analysis of specific IPC performance standards ...... 17 Table 7: Summary of IPC scores by quartile for baseline and final assessments, health centers and hospital services ...... 18 Table 8: Comparison of IPC baseline, mid-term and final assessments in health centers in Boké Prefecture ...... 18 Table 9. Comparison of IPC baseline, mid-term and final assessments in the services of Boké Regional Hospital and Kamsar Hospital ...... 19 Table 10: Comparison of IPC baseline and final assessments in the services of regional and prefectural hospitals- Faranah, Dinguraye and Mandiana ...... 19 Table 11: Comparison of IPC baseline and final assessment in health centers in Faranah and Dabola prefectures (includes Dabola Prefectural Hospital) ...... 20 Table 12: Comparison of IPC baseline and final assessment in health centers in Dinguraye and Mandiana prefectures...... 20

Guinea Ebola Response Plan II: End of Project Report 5 Abbreviations and Acronyms

CMC Centres Médical Communal (Communal Medical Center) Coordination Nationale de Lutte contre la Maladie à Virus Ebola (National Coordination for CNLEB the Fight against the Ebola Virus) CS Centre de santé (health center) CSR Centre de santé rurale (rural health center) CSU Centre de santé urbain (urban health center) DART Disaster Assistance Response Team DPS Direction Préfectoral de la Santé (Prefecural Health Directorate) DRS Direction Regionale de la Santé (Regional Health Direcotrate) EVD Ebola Viral Disease HP hôpital préfectorale (prefectural hospital) HR hôpital regionale (regional hospital) IP Infection Prevention IPC Infection prevention and control MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MNH Maternal and Newborn Health MOH Ministry of Health MSF-B Medecins sans Frontiers- Belge NGO Nongovernmental Organization OFDA Office of U.S. Foreign Disaster Assistance PPE personal protective equipment SBM-R Standards-Based Management and Recognition WHO World Health Organization

Guinea Ebola Response Plan II: End of Project Report 6 Acknowledgments Key Partners

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

The MCSP Team

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

Guinea Ebola Response Plan II: End of Project Report 7 Executive Summary The Maternal and Child Survival Program (MCSP) is a global cooperative agreement funded by the United States Agency for International Development (USAID) to introduce and support high-impact health interventions in 25 priority countries, and has the ultimate goal of ending preventable maternal and child deaths within a generation. MCSP carries forward the momentum and lessons learned from the highly successful USAID-funded Maternal and Child Health Integrated Program (MCHIP), which has made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America, and the Caribbean. MCSP interventions build on the development of local training capacity among health care providers in Guinea with a focus on competency-based training methods that work to improve both knowledge and skills. These build from previous work, specifically on infection prevention practices in health care facilities, and a commitment to quality improvement and supportive mentoring and supervision to assist health care providers translate new skills into their ongoing practice. The goal of the MCSP Ebola Response Project in Guinea was to scale up efforts to prevent and control the spread of EVD to protect and maintain quality reproductive, maternal, newborn, and child health services. To achieve this goal, the key objective of the project was to improve infection prevention in health care facilities. Through funding from USAID’s Office of Foreign Disaster Assistance (OFDA), this project built upon MCSP’s comprehensive IPC training and supportive supervision activities in Conakry, Beyla, Kissidougou, and Forécariah prefectures, which previously trained 2,985 health workers in 55 targeted health structures from December 2014 - August 2015. The focus areas for this second project were the five prefectures of Boké, Dabola, Dinguiraye, Faranah, and Mandiana and operated from June 2015 through May 2016. Prior to initiating IPC training in a prefecture, MCSP conducted an assessment of IPC performance and the availability of key materials for IPC in each of the public hospitals and health centers of the prefecture. The assessment tool for IPC is based on a set of 32 performance standards that originate from the Standards-based Management and Recognition (SBM-R®) methodology for quality improvement. These same performance standards are used throughout the IPC training as well as for supportive supervision/coaching visits following training. The MCSP Ebola Response II Project provided intensive IPC training to 1,345 health care providers from 249 healthcare facilities across the five prefectures. 62 providers also benefited from a three-day training specifically on setting up and managing triage of patients seeking care at health facilities in Boké. Supervision and coaching visits to support continued IPC performance were conducted to all facilities and reached 78% of trained providers. In addition, 67 staff who were posted to the focus facilities after the training sessions received onsite orientations on IPC during supervision visits. 271 support staff also received IPC orientation and coaching in local languages. As part of the support to these prefectures, MCSP donated IPC materials and consumables to the MOH facilities in order to support correct and consistent practice of the skills learned and reinforced during the IPC training. 29 autoclaves and seven incinerators were also purchased and installed to support instrument processing and waste management respectively. 94% of health facilities (51/54) improved IPC scores from baseline to final assessment (improving by at least one quartile), and 6 (11%) reached the 75% threshold of desired minimum performance. Among five hospitals that were assessed by service area, 86% of services (36/48) improved IPC scores and 11 (23%) reached or exceeded the 75% threshold. Training alone is not sufficient to realize the behavior change needed to achieve high levels of IPC performance given previously poor habits and continual challenges with the availability of basic IPC materials such as gloves and bleach for cleaning surfaces and instruments. While the project was able to reach a lot of providers and facilities in a short period of time, the behavior change and consistent availability of supplies for improved IPC appears to require ongoing coaching, supervision and attention to supply systems to bring about consistent improvement. This experience of working to strengthen IPC in health facilities serves to highlight the need to identify measures to hold health personnel and managers accountable for basic health service functioning, with IPC as one of those basic elements.

Guinea Ebola Response Plan II: End of Project Report 8 Introduction The Maternal and Child Survival Program (MCSP) is a global cooperative agreement funded by the United States Agency for International Development (USAID) to introduce and support high-impact health interventions in 25 priority countries, and has the ultimate goal of ending preventable maternal and child deaths within a generation. MCSP carries forward the momentum and lessons learned from the highly successful USAID-funded Maternal and Child Health Integrated Program (MCHIP), which has made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America, and the Caribbean. MCSP interventions build on the development of local training capacity among health care providers in Guinea with a focus on competency-based training methods that work to improve both knowledge and skills. These build from previous work, specifically on infection prevention practices in health care facilities, and a commitment to quality improvement and supportive mentoring and supervision to assist health care providers translate new skills into their ongoing practice.

Jhpiego, an affiliate of Johns Hopkins University, is leveraging the achievements of previous and ongoing projects to improve and extend activities strengthening infection prevention and control (IPC) initiatives in response to the Ebola Virus Disease (EVD) epidemic in prefectures that currently lack donor support. Through funding from USAID’s Office of Foreign Disaster Assistance (OFDA), this project is building upon MCSP’s comprehensive IPC training and supportive supervision activities in Conakry, Beyla, Kissidougou, and Forécariah prefectures, which trained 2,985 health workers in 55 targeted health structures from December 2014 - August 2015.

The focus areas for this project were the five prefectures of Boké, Dabola, Dinguiraye, Faranah, and Mandiana. In the original proposal, Kouroussa prefecture was suggested by the National Ebola Coordination (CNLEB), but this was changed at the beginning of the project in order to address the arrival of EVD cases in Boke prefecture in May 2015.

This final report describes the activities conducted during the contractual period of the project from June 2015 through February 2016 (with an extension to complete incinerator installation through May 2016).

Goal and Objective

The goal of the MCSP Ebola Response Project (part 2) in Guinea is to scale up efforts to prevent and control the spread of the Ebola Virus Disease (EVD) to protect and maintain quality reproductive, maternal, newborn, and child health services.

The key objective of this activity was to work with the MOH and key partners to support healthcare workers and facilities to continue to offer high quality health services in a safe environment by strengthening infection prevention and control (IPC) practices through training, supportive supervision, and complementary monitoring and evaluation.

Guinea Ebola Response Plan II: End of Project Report 9 Major Accomplishments Building on the momentum of the training of nearly 3000 healthcare workers and support to strengthen IPC in facilities between November 2014 and March 2015, the MCSP Ebola Response 2 project set out to extend this attention to five prefectures that had not received support to strengthen IPC. While these prefectures had thankfully been affected by few or no cases of EVD, the risk persisted in Guinea, as seen with the request from CNLEB to change focus prefectures under this project when the first cases of EVD were identified in Boké prefecture in May 2015. The flexibility of OFDA and of MCSP were greatly appreciated by the Ministry of Health allowing to redirect emergency response resources to where they were most needed.

This work built on the previous Ebola Response project’s Objective 1 focused on supporting health care workers and facilities to continue to offer high quality health services in a safe environment by strengthening IPC practices through training, supportive supervision, and complementary monitoring and evaluation. A similar series of activities as the first project was laid out in the project workplan to support increased knowledge and skills, improve service delivery conditions for correct and consistent IPC and coaching and monitoring to help sustain improved practices.

1.1. Active participation of MCSP in national level coordination

The National Ebola Coordination (CNLEB) was formed to lead the national, multi-sectoral EVD response and consists of several technical working groups, including IPC and community engagement. MCSP has been an active leader in several initiatives and working groups coordinating the national response to the EVD epidemic in Guinea.

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

MCSP also worked closely with partners to develop triage protocols for routine health services in order to screen patients for EVD symptoms for prompt referral to Ebola Treatment Units (ETUs) and avoid admittance of EVD patients into the hospital.

1.2. Conduct rapid assessment, staff identification at selected health facilities and preparation for IPC training and supervision

Prior to initiating IPC training in a prefecture, MCSP conducted an assessment of IPC performance and the availability of key materials for IPC in each of the public hospitals and health centers of the prefecture. The assessment tool for IPC is based on a set of 32 performance standards that originate from the Standards-based Management and Recognition (SBM-R®) methodology for quality improvement. These same performance standards are used throughout the IPC training as well as for supportive supervision/coaching visits following training. SBM-R has been selected by the MOH of Guinea as the preferred QI tool, and had previously been introduced in 60 facilities across the country. When MCSP first began to support IPC strengthening as part of the Ebola response, the IPC performance standards were updated to include performance standards specific to EVD. The data from these baseline assessments are presented below in section 1.7 in comparison to the final performance assessment data.

Guinea Ebola Response Plan II: End of Project Report 10

1.3. Conduct IPC training for facility staff- healthcare providers and support staff

Between June and December 2015, the MCSP Ebola Response 2 project organized 48 training sessions on IPC for 1,345 health workers in the facilities of the prefectures of Boké, Faranah, Dabola, Dinguiraye and Mandiana. Numbers of providers by prefecture and professional category are provided in Table 1 and 2. These training sessions were conducted by trainers developed by MCSP. Each session lasted five days during which the theoretical course was provided along with classroom simulated practice sessions and field visits with real patient interactions in the different departments of the hospitals and the health center where the trainings were conducted. IPC orientation for support staff such as cleaners, drivers, guards, etc. were provided in local languages during the coaching visits conducted follow provider training. The training involved providers from 249 health facilities, of which 189 were public health facilities (Table 3). The project originally planned to focus on 59 public sector hospitals and health centers but was able to accommodate the request of prefectural health authorities (DPS) to include health post staff as well as private facilities in the focus districts.

It should be noted that the training sessions for Boké were conducted in June and July, following the request to target this region urgently following the arrival of the EVD cases in the prefecture. The training for the other four prefectures, however, did not occur until November-December as a result of political unrest and also competing activities in the prefectures that delayed the organization of training sessions.

Resource leveraging in Boke prefecture: Jhpiego received a grant in April 2015 to provide IPC support to healthcare providers at three health centers near mining operations supported by Alcoa Corporation. Just as the project team visited Boke health officials to introduce the project, the first cases of EVD were reported at Boke Hospital. The preparations for this grant helped to facilitate MCSP’s rapid response to take on IPC support for all of Boke prefecture. Further, although approximately 100 providers were said to be working at the three target facilities for the Alcoa grant, the closure of local private facilities appeared to bring a lot of providers back into the public facilities. Thus with MCSP resources, 85 additional staff at these three health centers were able to participate in the IPC training such that all healthcare workers in the prefecture were reached. Given the shared resources to support these facilities, the performance of these three health centers are presented in section 1.7 below. (The assessments as well as coaching visits and material donations were supported by the Alcoa grant).

62 providers also benefited from a three-day training specifically on setting up and managing triage of patients seeking care at health facilities in Boké. Triage is an important aspect of containing the EVD epidemic; steering suspect cases to the right testing and care and maintaining the safety of routine health care services in order to protect healthcare workers and restore community confidence in healthcare services. This was not originally planned as part of this project, as several partners were supporting triage in affected prefectures at the time, but the arrival of EVD in the Boké necessitated the inclusion of this component by MCSP.

Guinea Ebola Response Plan II: End of Project Report 11 Table 1: Number of personnel trained by prefecture Healthcare Total health Support DPS/ DRS Region DPS providers NGO staff personnel staff trained staff trained trained onsite Boké Boké 476 6 9 491 124 Faranah 321 3 0 324 45 Faranah Dabola 156 7 2 165 38 Dinguiraye 179 3 1 183 34 Kankan Mandiana 201 4 0 205 30 Total 1333 23 12 1368 271

Table 2: Health providers trained on IPC by professional category

Type of Health Facility

Auxiliary Nurse (ATS) Nurse Auxiliary Nurse Midwife Doctor Biologist Technician Laboratory Pharmacist Technician Health Public Other Total Grand Health Center 454 40 17 14 21 5 2 4 557 Hospital 210 111 33 79 36 19 8 2 16 514 Health Post 159 8 1 2 1 171 Private Facility 54 14 2 13 9 6 1 2 101 Prefrectural Health Office (DPS) 5 5 8 1 1 20 Regional Health Office (DRS) 1 3 4 NGO 1 1 Total 882 179 52 119 68 31 9 5 23 1368

Table 3: Facilities receiving IPC support by type

Private Total Health Health Region Prefecture Hospitals Health facilities Centers Posts Facilities covered

Boké Boké 2 13 19 27 61 Faranah 1 12 19 14 46 Faranah Dabola 1 8 11 4 24 Dinguiraye 1 8 18 1 28 Kankan Mandiana 1 12 73 4 90 Total 6 53 140 50 249

Guinea Ebola Response Plan II: End of Project Report 12 1.4. Procure and supply necessary IPC and sanitation/waste management equipment to support IPC performance healthcare facilities

The availability and utilization of IPC inputs is one of the key pillars of an effective IPC program. As part of the support to these prefectures, MCSP donated IPC materials and consumables to the MOH facilities in order to support correct and consistent practice of the skills learned and reinforced during the IPC training.

The official presentation of the IPC materials and consumables was made in the presence of prefectural health managers, partners and the administrative and municipal authorities of each prefecture as a means to encourage to attention to including IPC materials in procurement planning. The allocations were calculated on the basis of data obtained during the baseline assessment as well as data on monthly client loads for the facility and hospital services.

The donations included IPC products and personal protective equipment and consumables, such as examination and sterile gloves, soap, masks, goggles, thermoflash thermometers, hand washing stations, as well as waste management materials, such as buckets for separating waste and used instruments, sharps boxes, trash cans and trash bags, mops, brooms, chlorine powder. A sample list of materials donated in Boke prefecture can be found in Annex B.

Based on the experience of the first phase of this project, waste management and sterilization of instruments were identified as clear gaps in improving IPC. Sterilization of instruments was identified as a deficiency in many of the hospitals and high volume health centers. All too often, one can find an old autoclave that no longer works or is too large for the electrical capacity of the facility. MCSP intentionally purchased smaller capacity autoclaves of 24 and 39 liters that can be operated in these facilities. Non- electric autoclaves that can be operated by heating them on a propane or compressed natural gas burner were provided to facilities where consistent electrical power is not available. A total of 29 autoclaves were purchased and distributed to facilities supported by the previous Ebola Response Project as well as this second phase. A complete list of the facilities receiving autoclaves can be found in Annex C. Nine of the autoclaves were donated to facilities targeted in this project specifically, including all of the public regional or prefectural hospitals.

Specific to incineration of medical waste, WHO conducted an assessment of incineration options at the request of MOH and made recommendations for two models which were selected as the nationally preferred options. WHO and World Bank committed to providing incinerators to select facilities, and MCSP was requested to provide incinerators to up to eight focus facilities not already receiving them from other donors. Following the prior approval and vendor verification processes, MCSP purchased and installed seven Univers Redline incinerators in facilities selected by the MOH (see table 4). The company that installed the incinerators also constructed a shelter for each unit and provided training to staff at each facility on operation and maintenance. Handover events were held to engage hospital and MOH authorities in the assumption of operating costs. Fuel costs for the new incinerators is estimated to be much lower than for previous incinerators where they existed.

Newly installed incinerators at HN Kipe; incinerator in use at HR Boké; Shelter and smoke venting for incinerators

Guinea Ebola Response Plan II: End of Project Report 13

Table 4: Facilities receiving incinerators Region Facility Number of beds 1 Conakry Kipé National Hospital (Sino-Guineen) 200 2 CMC Ratoma 100 3 CMC Miniere 100 4 CMC Matam 100 5 Faranah Faranah Regional Hospital 200 6 Kankan Kankan Regional Hospital 200 7 Boké Boké Regional Hospital 200

1.5. Conduct routine quality assurance visits and provide additional follow-up support

MCSP conducted supervisory visits to providers trained in IPC with the following objectives:

1. To ensure that the IPC measures developed during the training sessions are applied at work sites using the performance checklists that also guided the training. 2. To further reinforce the skills of health staff in order to achieve positive behavior change with regard to IPC practices through demonstrations and the review of steps for different tasks, from putting on and removing gloves, to preparing chlorine solutions, and sorting soiled materials and instruments among others. 3. To equip managers and local supervisors to ensure internal supervision, availability of IPC materials, and strengthen health and safety committees in each health facility.

For each health district in the project area, six to eight coaches were selected based on their performance in IPC, and their availability to monitor the application of hygiene measures. The organization of the coaching activities was coordinated by IPC focal points in larger facilities, department heads, health facility administrators, and members of the health and safety committee of each facility; with monitoring of implementation ensured by trainers and local supervisors. Each prefecture received an average of 2-3 supervision visits during the nine month project period to follow-up on coaching activities, provide an external assessment of IPC performance and feedback on coaching and performance. The number of visits were lower in Dinguraye and Mandiana districts as a result of the delayed training in these districts, there was less time between the training and the end of the project to conduct supportive supervision. These districts were also considered lower priority compared to districts that had experienced EVD cases.

In addition, 67 staff who were posted to the focus facilities after the training sessions received onsite orientations on IPC during supervision visits. A total of 271 support staff also received IPC orientation and coaching in local languages as mentioned above in section 1.3.

Table 5: Supportive Supervision of providers trained in IPC # of providers reached # providers to DPS by at least two coaching % of providers coached coach visits Boké 491 483 98% Faranah 324 227 70% Dabola 165 136 82% Dinguiraye 183 89 48% Mandiana 205 79 39% Total 1368 1014 78%

Guinea Ebola Response Plan II: End of Project Report 14 1.6. Partnership and collaboration

MCSP worked closely with partners engaged in IPC, such as WHO, CDC, Expertise France and Alcoa Foundation in the realization of the activities described in this project. MCSP participated in the IPC cluster of the National Ebola Coordination until the coordination was dissolved in early 2016, after the epidemic was declared over. In particular, the decision about what model incinerators would be provided was based on an assessment by WHO and World Bank. MCSP also used the cluster meetings to advocate for availability of IPC materials at facilities beyond what was provided by the project following training, and also coordination of triage training to link up with the IPC training provided by MCSP, in areas still experiencing EVD cases. Many of the supervision visits mentioned above were conducted jointly with IPC partners.

Collaboration was also promoted through regular presentation of IPC coaching and supervision results during monthly meetings at the DPS level that involved prefectural health managers, heads of hospitals services and health centers and partners. The objective of these debriefs was to strengthen the engagement of decision makers and managers in the ongoing improvement of IPC measures.

1.7. Monitoring and evaluation: IPC performance assessments at focus facilities

Prior to the implementation of training, MCSP conducted baseline assessments in targeted health facilities using the MOH approved performance standards for IPC to identify the current level of IPC performance and to identify gaps to be addressed via training and on-site supportive supervision. The same performance standards were also used during supervision and coaching visits as well as for final assessment of all sites in January 2016. There was also a mid-term assessment in Boke prefecture since the training for this prefecture occurred earlier than the others. For hospitals, each service was assessed separately and a score generated per service, rather than for the facility as a whole, except for Dabola prefectural hospitals. Thus for five hospitals, data is provided for 47 separate services including medical services- surgery, pediatrics, maternity and ancillary services such as laundry, laboratory, etc.

The performance standards for IPC are part of the Standards-based Management Recognition (SBM-R®) process for quality assurance. This methodology had previously been introduced by USAID-funded projects since 2009, such as ACCESS and MCHIP, as well as with support from UNFPA in 60 facilities throughout the country. The MOH selected SBM-R as its preferred quality assurance process. The initial sets of performance standards introduced with the methodology are IPC, Family Planning and Maternal and Newborn Care (maternity care), therefore the IPC standards were already familiar to many health managers and trainers. Under the first Ebola Response project, the IPC performance standards were reviewed and updated with MOH and partners to integrate standards specific to EVD, such as availability of triage, high-level PPE, etc.

94% of health facilities (51/54) improved IPC scores from baseline to final assessment (improving by at least one quartile), and 6 (11%) reached the 75% threshold of desired minimum performance. Among five hospitals that were assessed by service area, 86% of services (36/48) improved IPC scores and 11 (23%) reached or exceeded the 75% threshold. Table 7 provides a summary of scores by quartile and the results for each health center and the individual services of the hospitals are presented in Tables 8-12. The results per facility were presented to DPS and DRS authorities and facility managers in order to encourage continued follow-up, particularly in facilities and services that had not made much progress or even regressed.

Guinea Ebola Response Plan II: End of Project Report 15 Figure 1: Evolution of IPC performance at health centers from baseline to final evaluation in Boké, Faranah, Dabola, Dinguiraye and Mandiana

100%

80% 80%

60% 52% 55% 40%

17% 20% 16%

0% 0% Evaluation Base (Juin, Sept, Oct 2015) Evaluation finale (jan, avril 2016) Minimum Median Maximum

Figure 2: Evolution of IPC performance in hospital services in Boké, Faranah, Dabola, Dinguiraye and Mandiana

100% 95%

80% 79% 65% 60%

40%

20% 20% 0% 0% 0% Evaluation Base (Juin, Sept, Oct 2015) Evaluation finale (jan, avril 2016) Minimum Median Maximum

A deeper analysis of individual performance standards helped to identify which elements were the source of performance improvements and which tended to be more challenging to improve upon. As seen in the table below, provider performance of many key skills improved, but the availability of supplies and infrastructure for IPC remain weak spots. A big risk with this is that provider habits will also decline if they do not have consistent access to the supplies required for hand hygiene, waste management, etc. Specific to triage, MCSPs observation has been that this has been one of the weakest aspects of response to the EVD epidemic in helping to maintain functioning health services in the public sector. The topic tended to come up after IPC training was initiated and partners who committed to support triage were delayed or reached far fewer facilities. Triage should be better integrated into how health services are set up in general.

Guinea Ebola Response Plan II: End of Project Report 16 Table 6: Additional analysis of specific IPC performance standards Hospital services Health Centers Most improved Provider activities Provider activities Correct hand washing/hand hygiene Correct hand washing/hand hygiene Cleaning of surfaces and instruments Management of contaminated waste Collection and treatment of contaminated linen Putting on and taking off PPE Management of contaminated waste Equipment and materials Instrument processing Availability of PPE Packaging of instruments Decontamination supplies High-level disinfection Hand washing supplies (soap or alcohol-based hand rub) Infrastructure Infrastructure Availability of water point or antiseptic in service Designated areas for triage and isolation delivery areas Least improved Equipment Provider activities Availability of personal protective materials Collection and treatment of soiled linen Infrastructure Certain steps in instrument sterilization Established triage area Equipment and supplies Established isolation area Supply of antiseptics, disinfectants Functioning incinerator for waste management Infrastructure Adequate space for laundry Availability of water points in service delivery areas Adequate space for morgue Facility cleanliness

The improvements in IPC performance, particularly those achieving the desired performance of 75% or higher, while moving in the right direction were not as positive nor consistent as expected. Several factors may contribute to this. The project was implemented in a very compressed period which did not allow for more than three coaching visits per facility, particularly in the four eastern prefectures. Training alone may not be sufficient to bring about the behavior change required for correct and consistent IPC performance given previously poor habits and continual challenges with the availability of basic IPC materials such as gloves and bleach for cleaning surfaces and instruments. This hypothesis likely applies to both classroom based training with simulation and practical sessions, as well as of on-site training; supervision and coaching needs to continue beyond the training period to effectively change practice. Referring back to IPC supplies, MCSP provided materials for approximately one month (consumables) to encourage the practices covered during training and encouraged facility and prefectural managers to include these in supply management and restocking, and providers to ask for them, yet there are many challenges with Guinea’s procurement and distribution system for drugs and medical supplies that surpass the purview of this project. Another possible influence is that several of the prefectures were barely touched by the EVD epidemic and healthcare workers in these regions may not have felt the same sense of danger and therefore need to protect themselves or patients. Further, the end of the EVD epidemic was declared in December 2015 which may have led some to relax their diligence in performing IPC practices. This may help to explain why some scores went down between the mid-line and final assessment in Boké.

Guinea Ebola Response Plan II: End of Project Report 17 Table 7: Summary of IPC scores by quartile for baseline and final assessments, health centers and hospital services

Health Centers Hospital Services Health Centers Baseline IPC Assessment Final IPC Assessment Baseline IPC Assessment Final IPC Assessment N=54 % N % N=48 % N % Score of 75% or higher 0 0% 6 11% 1 2% 11 23% Score of 50-74% 1 2% 28 52% 7 15% 13 27% Score of 25-49% 13 24% 19 35% 11 23% 17 35% Score of 0-24% 39 72% 1 2% 28 58% 3 6% Missing Data 1 2% 0 0% 1 2% 4 8% Missing data due to inaccessibility of a health center because of impassable roads, or no staff from a given service were available during the assessment team’s visit.

Table 8: Comparison of IPC baseline, mid-term and final assessments in health centers in Boké Prefecture Boke Health Centers

* * *

*

Performance (%) CS Sansalé NènèCS Port CS Kanfarandé CS Dibia CS Malapouyah CS Bintimodia CS Kayenguissa Tanènè CS CS Korera CS Dabis CS Koulifanya CS Kolaboui CS Kassapo CS Sangaredi Baseline Assessment 0% 4% 8% 12% 16% 21% 25% 28% 29% 29% 31% 16% 24% 32% June 2015 2nd Evaluation NA 46% NA 80% NA 64% 54% 58% 52% 69% 69% 58% 76% 27% Sept 2015 3rd Evaluation 56% 36% 50% 33% 77% 38% 50% 50% 85% 73% 73% 63% 77% 38% January 2016 * Facilities supported by Alcoa foundation grant, MCSP supported training of 85 additional staff

Guinea Ebola Response Plan II: End of Project Report 18 Table 9. Comparison of IPC baseline, mid-term and final assessments in the services of Boké Regional Hospital and Kamsar Hospital Boké Regional Hospital Kamsar Hospital, Boke

Performance

(%) Pediatric Emergency Surgery Laboratory General Medicine Ear,Nose, and Throat Pharmacy Odontostomat ology Maternity Ophthalmology Radiology Medicine Pediatric Laboratory Emergency Radiology Pharmacy Resuscitation Morgue Surgery Maternity Ear,Nose, and Throat Baseline Assessment - 0% 9% 1% 15% 15% 18% 20% 25% 35% 52% 52% 24% 33% 33% 37% 38% 47% 50% 50% 52% 58% 60% Jun 2015 2nd Evaluation – 55% 56% 59% 59% 41% NA 85% 75% 54% 67% 67% 89% 48% 68% 81% 88% 41% 68% 74% 73% 68% 82% Sep 2015

3rd Evaluation - 59% 80% 37% 23% 48% NA 56% 45% 58% 81% 38% 83% 63% 75% 81% 68% 93% 47% 41% 60% 79% NA Jan 2016

Table 10: Comparison of IPC baseline and final assessments in the services of regional and prefectural hospitals- Faranah, Dinguraye and Mandiana Faranah Regional Hospital- Services Dinguraye Prefectural Hospital Mandiana Prefectural Hospital

Performance

(%) Laundry Pediatric Medicine Emergency Surgery Maternity Pharmacy Sterilization Laboratory Surgery Emergency Pediatric Dental Maternity Laboratory Pharmacy Medicine Maintenance Radiology Pediatric Emergency Pharmacy Surgery Laboratory Maternity Baseline Assessment 0% 6% 6% 11% 11% 20% 22% 33% NA 3% 5% 5% 8% 14% 15% 31% 6% 7% 7% 18% 18% 20% 24% 28% 36% Sept 2015

2nd Evaluation 0% 45% 42% 29% 56% 54% 78% NA 36% 68% 59% 82% NA 52% 76% 82% 53% 13% 31% 41% 38% 47% 44% 52% 31% Jan 2016

Guinea Ebola Response Plan II: End of Project Report 19 Table 11: Comparison of IPC baseline and final assessment in health centers in Faranah and Dabola prefectures (includes Dabola Prefectural Hospital) Faranah Health Centers Dabola Health Centers and Prefectural Hospital

Health

Facilities/

Performance

(%) Dogomet CSU Abattoir CS Marché CS Passayah CS Tiro CS Hèrèmakono CS Kobikoro CS Niala CS Beindou Tindo CS CS Banian CS Sangoyah CS Sandenia Bissikirima CS CS Kankama CS Konso CS Arfamoussaya CS Konindou CS Banko CSU Dabola CS Hospital Dabola Baseline Assessment 4% 4% 12% 15% 19% 19% 19% 19% 23% 27% 38% NA 8% 16% 16% 16% 28% 28% 28% 36% 76% Sept 2015

2nd Evaluation 58% 31% 60% 50% 50% 35% 50% 46% 58% 58% 54% 38% 73% 42% 40% 59% 69% 58% 77% 73% 46% Jan 2016

Table 12: Comparison of IPC baseline and final assessment in health centers in Dinguraye and Mandiana prefectures Dinguraye Health Centers Mandiana Health Centers

Performance

(%) bomet Dinguraye

CS Lansanaya CS Sélouma CS Gagnakaly CS M’ CS Dialakoro CS Diatifèrè CSU CS Kalinko CS Morodou CS Kondianakoro CS Balandougouba CS Kinieran CS Saladou CS Koundian CS Kantoumania CS Sansado CS Niantanina CS Dialakoro CS Faralako CSU Mandiana Baseline Assessment – 4% 4% 4% 4% 8% 8% 12% 52% 0% 0% 4% 4% 5% 8% 8% 9% 9% 13% 17% 28% Oct 2015

2nd Evaluation – 56% 68% 76% 50% 60% 48% 68% 79% 35% 32% 40% 39% 54% 38% 38% 17% 56% 33% 44% 71% Jan 2016

Guinea Ebola Response Plan II: End of Project Report 20

Challenges and Opportunities

The training alone was not sufficient to realize the behavior change needed to achieve high levels of IPC performance. The short implementation period for this project did not allow for as much follow-up coaching and supervision as the first IPC project. Additionally, activities were delayed in four prefectures, particularly after quickly responding to the need to focus on Boke, due to competing health activities in the prefectures as well election related violence in October 2015. Prior approval and procurement of the incinerators was a long process leading to the request for an extension to complete this activity.

While the project was able to reach a lot of providers and facilities in a short period of time, the behavior change for improved IPC appears to require ongoing coaching and supervision to bring about consistent improvement. The project was unable to reach all trained providers with coaching visits due to the short implementation period and resources relative to the number of prefectures covered. If a provider was not present at the time of the visit, there may not have been another opportunity to follow-up with him/her. The extension period was requested to complete the installation of the incinerators but the project budget and activities for IPC strengthening were completed with only minimal delay as described above.

This experience of working to strengthen IPC in health facilities serves to highlight the need to identify measures to hold health personnel and managers accountable for basic health service functioning, with IPC as one of those basic elements. The project’s efforts to train prefectural and facility managers as IPC coaches and feedback of results to managers are steps in this direction, but a formalized system of accountability could serve to systematize these roles and responsibilities and promote readiness to respond to potential epidemic disease, not to mention improved quality of care.

Ebola recovery funding will help to continue coaching support to some of the facilities reached by both of phases of the Ebola Response funding. The MCSP Restoration of Health Services project will continue to provide coaching and periodic assessments, while the MCSP Health Systems Strengthening project will continue to advocate for issues surrounding IPC policy, strategies, commodities and monitoring as a means to integrate IPC as a foundational healthcare task.

The Restoration of Health Services project, also funded through MCSP, overlapped with this project by a few months and could have provided an opportunity to provide continued follow-up, but due to differences in focus regions, this is only relevant for one prefecture, Boké, which did receive continuous IPC coaching and support after this project ended. The USAID-funded Health Service Delivery (HSD) award, led by Jhpiego, was not issued until after the IPC work of this project was completed (the extension period of this project from December 2015 to May 2016 was only for the completion of the incinerator installation). Nevertheless, since HSD has started, continued attention to the use of IPC standards for supervision is being provided by that project, as well as support for the revision of national policies and guideline to include better definition of IPC requirements, advocacy for consistent availability of IPC supplies, as well as attention to use and maintenance of waste management.

Guinea Ebola Response Plan II: End of Project Report 21 Annex A. List of Local Coach and Focal points No Prefecture Name Site Location Contact 49 Boké Ibrahima Camara DPS 50 Abdoulaye Keita HR 51 Ismael Dieudonne Maomou HR 52 Toumani Diallo DRS 53 Sekou Naba Camara HR 54 Apollinaire Camara CCS Port Nene 55 Sekou Amara Camara CSR Kassapo 56 Ibrahima Camara DPS 57 Faranah Sekou Conde CSU Abattoir 622 01 46 95 58 Nakan Traoré CSU Abattoir 628 96 70 90 59 Ibrahima Sovogui HR Faranah 628 50 19 44 60 Oumar Bailo Diallo HR Faranah 622 01 95 15 61 Glima Bamba HR Faranah 622 09 95 55 62 Ibrahima Solo Conde HR Faranah 628 18 03 82 63 Dabola Hadja Boh Fanta Conde 622 64 88 13 64 Mohamed Habib Kaba 622 91 96 91 65 Moumini Diallo 622 04 98 34 66 Mamadouba Sylla 622 12 05 33 67 Kadiatou Camara 628 41 06 58 68 Fodé Mamadouno 69 Dinguiraye Mariame Touré DPS 624 82 73 83 70 Camara Ousmane HP 71 Kolié Emmanuel HP 72 Camara Almamy CSU 73 Sow Hadja Hawa Diallo HP 74 Siba Sakouvogui HP 75 Mandiana Ibrahima Diakite HP 76 Diabola Conde HP 77 Mathos Zaly Lamah CSU 78 Ibrahima Doumbouya HP 79 Moussa Keita HP 80 Halimatou Diallo CSR 81 Diamila Sidibe DPS

Guinea Ebola Response Plan II: End of Project Report 22 Annex B: List of IPC materials provided to Boké prefecture

No Désignation Quantité 1 Bottes 215 paires 2 Serpillères 1005 3 Thermoflachs 98 4 Lunettes de protection 215 5 Bactigel grd model 80 cartons de 12 par cartons 6 Aseptoman 3 cartons 7 Savon diamant 87 cartons 8 Gants de ménages 2 cartons plus 99 paires 9 Gants d’examen 91 cartons 10 Tyveck 25 cartons 11 Bavettes 66 cartons 12 Boites de sécurités 112 cartons 13 Pioches 54 14 Pelles 56 15 La daba 56 16 Raclettes 52 17 Râteaux 52 18 Brouettes 28 19 Sceau a Poubelle 140 20 petit sceau 140 21 Grand sceau 242 22 Tasse 189 23 cuve avec couvercles 14 24 Hypo chlorites 30 bidons de 50 kg et 1 bidon de 25 kg 25 Gants stériles 5 cartons 26 Brosse à dents 1000 27 Masque 3 paires 28 Poubelles 102 29 Bonnets 13 paquets de 1000 et 5 de 2000

Guinea Ebola Response Plan II: End of Project Report 23 Annex C: Facilities receiving autoclaves Facility Capacity Quantity Type Région de Conakry 1. HN Donka- Emergency 39 litres 2 Electric 2. HN Donka- Dermatology 39 litres 2 Electric 3. HN Ignace Deen- Trauma 39 litres 2 Electric 4. HN Ignace Deen- Surgery 39 litres 2 Electric 5. HN Ignace Deen- Maternity 39 litres 2 Electric 6. HN Ignace Deen- ENT and Dental 24 litres 1 Electric 7. CMC Matam 39 litres 1 Electric 8. CMC Ratoma 39 litres 1 Electric Région de Faranah 0 9. Hôpital regional* 39 litres 1 Electric 10. HP Dabola* 24 litres 1 Electric 11. HP Dinguiraye* 24 litres 1 Electric 12. HP Kissidougou 39 litres 2 Electric Région de Kankan 0 Electric 13. Hôpital régional de Kankan 39 litres 1 Electric 14. HP Kérouané 24 litres 1 Non-Electric 15. HP Kouroussa 24 litres 1 Electric 16. HP Mandiana* 24 litres 1 Non-Electric 17. HP Siguiri 24 litres 1 Electric 18. CSA Banankoro (Kérouané) 24 litres 1 Non-Electric Région de Nzérékoré 0 19. HP Macenta 24 litres 1 Electric 20. CMC de Sinko (Beyla) 24 litres 1 Non-Electric 21. HP Beyla 24 litres 1 Non-Electric Région de Kindia 0 22. HP Forécariah 24 litres 1 Electric Région de Boké 0 23. Hôpital régional Boké* 39 litres 1 Electric 29 Additional autoclaves purchased with WHO and Alcoa Foundation funding were distributed along with those listed above

Guinea Ebola Response Plan II: End of Project Report 24 Annex D: Performance Monitoring Indicators April-June 2015 July-sept 2015 October-Dec 2015 Jan-April 2016 Indicator1 Target Health Hospital Health Hospital Health Hospital Health Hospital Total Comments centers (services) centers (services) centers (services) centers (services) 1,368 Number/percentage of (100% of 271 support staff also staff in health facility 877 providers at 100% 280 211 NA NA staff in 60 oriented in local who receive IPC 147 suppport staff public languages training facilities) Number/percentage of trained staff who 100% 0 0 102 18 710 1069 receive post-training follow-up supervision 167 (112 115 Number of supportive 12 57 visits 22 (of in public services supervision visits 400 0 0 (of 14 (to 53 48 XX) facilities) (in six conducted on site HCs) HCs) hospitals) Percentage of 0/11 1/10 3/57 0/2 (0%) 1/2 (50%) 1/6 (17%) 3/56(5%) 0/6(0%) supported health (0%) (10%) (5%) facilities that have the 100% following components: 0/11 2/10 13/57 3/56 3 HCs in Boke for 0/2 (0%) 0/2 (0%) 1/6 (17%) 1/6 (17%) 1) area of patient (0%) (20%) (23%) (5%) supported by Alcoa each isolation; 2) changing grant excluded compo room for health care nent 3/11 5/15 3/9 10/15 17/57 17/24 17/56 11/26 workers; 3) area for cleaning/laundering (27%) (33%) (33% (67%) (30%) (71%) (30%) (42%) contaminated supplies; Number/percentage of health facilities that have appropriate (and 9% 5% 90% 32% 42% 20% 34/56 16/47 100% sufficient quantity of) (1/11) (1/21) (9/10) (7/22) (23/55) (8/41) (61%) (34%) PPE for at least one month

1Based on indicators found in: CDC and WHO.Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting.Atlanta, CDC, 1998: 1–198 http://www.cdc.gov/vhf/abroad/vhf-manual.html and WHO.Aide memoire: For infection prevention and control in a health care facility, 2004 http://www.who.int/injection_safety/AM_InfectionControl_Final.pdf ; and Jhpiego’s MCSP project.

Guinea Ebola Response Plan II: End of Project Report 25 April-June 2015 July-sept 2015 October-Dec 2015 Jan-April 2016 Indicator1 Target Health Hospital Health Hospital Health Hospital Health Hospital Total Comments centers (services) centers (services) centers (services) centers (services) Number/percentage of health facilities that 73% 46% 27/45 76% of 80% 33% 31/56 have access to clean 100% 0% (16/22) of (21/46) (60%) of (SDP) (8/10) (19/57) (55%) water in each service (0/11) SDP of SDP SDP delivery point Number/percentage of health facilities that have access to 95% 76% 81% 81% of 90% 65%(37/ 53/56 41/43 disinfecting agents 100% (21/22) of (31/41) (9/11) SDP (9/10) 57) (95%) (95%) SDP (and sufficient quantity SDP of SDP for at least one month) Percentage of health facility staff observed 100% 100% 46% 35% 53/56 33/47 performing hand 100% NA NA (10/10) (7/7) (26/57) (17/48) (95%) (70%) hygiene before attending to patients Percentage of staff observed wearing gloves and appropriate 100% NA NA NA NA NA NA PPE when exposure to blood or body fluids is anticipated Number/percentage of health facilities achieving/compliant 0% of 11% 5/22 2% 2% 13% 100% 0% 8% (4/48) with at least 80% of SDP (1/9) (23%) (1/57) (1/56) (6/47) performance standards of IPC Percentage of health facilities with presence 100% 62% of 3/10 100% 100% 55% 80% of health care waste in 0 5% (1/22) (11/11) SDP (30%) (57/57) (48/48) (31/56) (37/46) the surroundings of the facility

Guinea Ebola Response Plan II: End of Project Report 26 April-June 2015 July-sept 2015 October-Dec 2015 Jan-April 2016 Indicator1 Target Health Hospital Health Hospital Health Hospital Health Hospital Total Comments centers (services) centers (services) centers (services) centers (services) Number/percentage of health facilities that 5% TBC TBC TBC TBC TBC TBC TBC 100% (6/6) 9 have appropriate (3/54) autoclave provided Number/percentage of health facilities that have fully Installation finalized in TBC 0 0 0 0 0 0 NA 7 7 installed/renovated May 2016 and functioning incinerators

Guinea Ebola Response Plan II: End of Project Report 27