MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-388-LA-13-00004)
Quarterly Report January 01, 2018– March 31, 2018
Submitted
April 30, 2018 Cover Photo Story: Nijhum Dwip looks forward to a healthy future
“I would deliver at home as I did before”, Shaheena said when she was asked what she would do if the health center were not there. Shaheena had her second baby delivered at the Nijhum Dwip (a remote island in Hatiya upazila on the south of Bangladesh) Union Health and Family Welfare Centre (UH&FWC) on the day the facility started functioning. For Shaheena, delivering at a health facility was hardly an option before. Shaheena lives in a village in Nijhum Dwip. The nearest health facility from Nijhum Dwip was in Jahajmara union which was hard-to-reach and expensive, would take at least 2-3 hours journey by engine boat and rikshaw van. For about 30,000 people who call Nijhum Dwip their home, ‘delivery at home’ had therefore been the only option. On November 1, 2017, the remote island got its first health center equipped with sufficient essentials to provide a range of basic healthcare services including normal delivery services. Six weeks later, the Nijhum Dwip UH&FWC started providing 24/7 normal delivery services to the community. Now the people of Nijhum Dwip, one of the hardest-to-reach areas in Bangladesh, have the option to avail normal delivery services by skilled birth attendants around-the-clock and free of cost.
The establishment of the Nijhum Dwip UH&FWC represents a novel initiative undertaken by the district family planning department and local government with MaMoni HSS project playing the facilitation role. Instead of constructing a new building, they converted part of a shelter canter to house this health facility. With this new UH&FWC in place, Hatiya now has six 24/7 delivery centres, all of them upgraded through coordination with local government authorities, the district family planning department, and the MaMoni HSS Project.
Photo (top): Shaheena with her baby boy. She is the first mother to have delivered at the new health facility in rural and hard-to-reach Nijhum Dwip. Photo (bottom): Inauguration of Nijhum Dwip UH&FWC as 24/7 normal delivery canter
Photo credit: Murad Ahamed Khan
This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), Bangladesh (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report ii TABLE OF CONTENTS
Abbreviations ...... iv Executive summary ...... 1 Introduction ...... 3 Data Sources ...... 4 Program results of the year ...... 5 IR 1. Improve service readiness through critical gap management ...... 5 IR 2: Strengthen health systems at the district level and below ...... 18 IR 3. Promote an enabling environment to strengthen district level health systems ...... 31 IR 4. Identify and reduce barriers to accessing health services ...... 35 Challenges, Solutions and Action taken ...... 39 Appendix 1: Scope and Geographical coverage of MaMoni HSS program ...... 42 Appendix 2: Data Sources ...... 43 Appendix 3: Program Performance Indicators (Jan-Mar 2018) ...... 44 appendix 4. Additional National level indicators ...... 54 Appendix 5: MaMoni HSS Program Learning and Documentation Matrix ...... 56
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report iii ABBREVIATIONS
5S Sort, set, shine, standardize and sustain AAP American Academy of Pediatrics ACS Antenatal corticosteroid AHI Assistant health inspector AMTSL Active management of third stage of labor ANC Antenatal care BCC Behavior change communication BMJ British Medical Journal BNF Bangladesh Neonatal Forum BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community action group CC Community clinic CCSDP Clinical Contraceptive Service Delivery Program CCU Coronary care unit CDCS Country Development Cooperation Strategy CEmONC Comprehensive emergency obstetric and newborn care CHCP Community health care provider CHW Community health worker CHX Chlorhexidine CI Critical illness CIPRB Center for Injury Prevention and Research Bangladesh cMPM Community microplanning meeting CNCP Comprehensive newborn care package CS Civil Surgeon CSA Community sales agent CSBA Community-skilled birth attendant CSG Community support group CSI Clinical severe infection CV Community volunteer DC District commissioner DG Director General DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DH District hospital DHIS-2 District Health Information System-2 DMCH Dhaka Medical College Hospital DP Development partner DQA Data quality assessment eAMS Electronic asset management system eLMIS Electronic logistics management information system eMIS Electronic management information system EmONC Emergency obstetric and newborn care ENC Essential newborn care EPCMD Ending preventable child and maternal deaths eTMS Electronic training management system FGD focus group discussion FP Family planning FPI Family planning inspector FTC Field training centre FWA Family welfare assistant FWV Family welfare visitor FWVTI Family Welfare Visitor Training Institute GIS Geographic information system GMP Growth monitoring and promotion GOB Government of Bangladesh GPS Global positioning system HA Health assistant HBB Helping babies breathe
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report iv HI High intensity HID Health identity document HNN Healthy Newborn Network HPNSP Health, Population and Nutrition Sector Program HR Human resource HRIS Human resource information system HSCS Health systems capacity strengthening HSM Hospital services management icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh ICU Intensive cate unit ID Identity document IDD Iodine deficiency disorder IFA Iron and folic acid IFB fast breathing as a single sign of illness IHI Institute of Healthcare Improvement IMCI Integrated management of childhood illness IP Infection prevention IPC Infection prevention and control IPHN Institute of Public Health and Nutrition IR Intermediate result IUCD Intra uterine contraceptive device JSV Joint supervisory visit KII Key informant interview KMC Kangaroo mother care LARC Long-acting reversible contraceptive LARC&PM Long-acting reversible contraceptive and permanent method LBI Local bacterial infection MAM Moderate acute malnutrition MCH Maternal and child health MCHIP Maternal child health integrated program MCHTI Maternal and Child Health Training Institute MCRAH Maternal, child, reproductive and adolescent health MCWC Maternal and child welfare center MEC Medical eligibility criteria MFSTC Mohammadpur Fertility Services and Training Centre MgSO4 Magnesium sulfate MIS Management information system MNCH/FP/N Maternal, newborn and child health, family planning, and nutrition MO Medical officer MOHFW Ministry of Health and Family Welfare MO-MCH/FP Medical Officer-Maternal, Child Health and Family Planning MP Member of Parliament MPDSR Maternal and perinatal death surveillance and response MSH Management Sciences for Health NGO Nongovernmental organization NIPORT National Institute of Population Research and Training NIPSOM National Institute of Preventive and Social Medicine NNHP National Newborn Health Program NNS National Nutrition Services OBGYN Obstetrics and Gynecology OGSB Obstetrical and Gynecological Society of Bangladesh OP Operational plan OT Operation theatre pCSBA Private community-skilled birth attendant PDCA Plan-do-check-act PE/E Pre-eclampsia/eclampsia PHC Primary health care PHD Partners in Health and Development PI Principal investigator PM Program Manager MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report v PNC Postnatal care PPFP Postpartum family planning PPH Postpartum hemorrhage PPIUCD Postpartum intra-uterine contraceptive device PSBI Possible severe bacterial infection QI Quality improvement QIC Quality improvement committee QIS Quality Improvement Secretariat QoC Quality of care QPRM Quarterly performance review meeting RMNCAH Reproductive, maternal, newborn, child and adolescent health RMO Resident Medical Officer RRQIT Regional roaming quality improvement team RTC Regional training center SACMO Sub-assistant community medical officer SAM Severe acute malnutrition SBA Skilled birth attendant SBCC Social and behavioral change communication SCANU Special care newborn unit SCI Save the Children International SCMP Supply chain management portal SDP Service delivery point ShSMCH Shaheed Suhrawardy Medical College Hospital SIAPS Systems for Improved Access to Pharmaceuticals and Services SIP Sector Improvement Plan SMC Social Marketing Company SNL Saving Newborn Lives SOP Standard operating procedure SSMCH Sir Salimullah Medical College Hospital TAG Technical advisory group ToT Training of trainers UFPA Upazila family planning assistant UFPO Upazila family planning officer UH&FPO Upazila health and family planning officer UH&FWC Union health and family welfare center UHC Upazila health complex UK United Kingdom UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UP Union Parishad USAID United States Agency for International Development USC Union sub-center WHO World Health Organization WISN Workload indictors of staffing need WIT Work improvement team
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report vi EXECUTIVE SUMMARY
During the reporting quarter, the MaMoni Health Systems Strengthening (MaMoni HSS) project continued to support the Ministry of Health and Family Welfare (MOHFW) to strengthen health systems at the national and district levels. During Year 5, the program’s technical assistance at the national level and implementation at the district level are under consolidation. The project currently supports 40 upazilas in 6 districts, 23 of which are designated high intensity areas and 17 of which are health systems capacity strengthening (HSCS) areas. At the district level, MaMoni HSS continued to support the scale-up of priority ending preventable child and maternal deaths (EPCMD) interventions and to improve the quality of facility-based care.
Key accomplishments Notable accomplishments during the reporting period include: Local governments have deployed six paramedics at Union Health and Family Welfare Centers (UH&FWC) to provide maternal, newborn and child health, family planning, and nutrition (MNH/FP/N) services; There is an increasing trend in the use of long acting reversible contraceptive (LARC) method; The application of 7.1% chlorhexidine (CHX) onto newborn umbilical cords for deliveries with a skilled birth attendant (SBA) has increased: 98 percent of newborns who were delivered by SBAs received CHX; The analysis of data for the revisit of priority newborn interventions has been completed and a policy brief drafted; Community volunteers’ contribution to the use of long acting reversible contraceptive and permanent method (LARC & PM) has increased; District and union level plans to strengthen services and improve key health indicators have been developed for two districts; The electronic management information system (eMIS) has been rolled out in Lakshmipur and Noakhali districts; The Plan-Do-Check-Act (PDCA) training manual has been finalized and in press for printing; The safe surgery checklist has been introduced in 13 model hospitals and two medical college hospitals; The final version of the reproductive, maternal, newborn, child and adolescent health (RMNCAH) quality improvement (QI) Framework has been submitted for approval. The electronic asset management system (eAMS) for the National Institute of Population Research and Training (NIPORT) is ready for field-testing.
Challenges and mitigation strategies
. In this quarter low coverage has been observed for a few key services. The possible explanations may be retirement of a good number of family welfare visitors (FWVs), withdrawal of MaMoni supported paramedics and involvement of partner NGO staff in project close-out activities. However, this will be discussed in performance review meetings during this quarter to explore potential mitigation strategies. . Actual detection of pre-eclampsia/eclampsia (PE/E) cases is quite far from the estimated numbers. The project is working with local level health managers and service providers to improve and strengthen case detection.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 1 . Despite multipronged efforts from MaMoni HSS, misoprostol distribution coverage is still low in the project areas, only 39 percent of the pregnant women in high intensity areas received misoprostol tablets during the reporting quarter. The project has taken several initiatives to address the issue and is exploring more ways to increase coverage. . A decreasing trend in postpartum intra-uterine contraceptive device (PPIUCD) performance has been observed over the last year. National and local level dialogues have been initiated with Directorate General of Family Planning (DGFP) managers to better understand the issues and identify appropriate measures. . Lack of coordination between the Quality Improvement Secretariat (QIS) and the Hospital Services Management (HSM) unit of the Directorate General of Health Services (DGHS) and maternal, child, reproductive and adolescent health (MCRAH) unit of DGFP has remained as a challenge for the implementation of quality of care (QoC) in Bangladesh. MaMoni HSS has initiated work with HSM and MCRAH to ensure involvement of these units in QIS activities. . The project has withdrawn 34 project supported paramedics from the union level facilities as part of the transition process. Dialogues with local health and FP managers as well as local government going on for absorbing these paramedics and continue MNCH/FP/N services in the areas. So far 6 paramedics have been taken over by the Union Parishad (UP). The district teams are working hard to engage more UPs and motivate them to take over the responsibility of deploying service providers (paramedics) in the UH&FWCs of their respective union centers. . A shortage of faculty members in NIPORT is a challenge for conduction of trainings. MaMoni HSS facilitated the development of training resource pools that consist of trainers from government and non-government sectors. Another challenge is how to develop NIPORT’s collaboration with other government or non-government training institutes to conduct large scale trainings. NIPORT’s policy doesn’t support such provision. MaMoni HSS is exploring ways for developing such collaboration. . The eMIS has been implemented in all upazilas in four high intensity districts. Providers are maintaining both paper based and electronic records of services. Keeping the records updated in both the systems is a challenge.
Way Forward In the third quarter of year five the project will initiate close-out activities in all districts while focusing more on national activities. Technical assistance to National Newborn Health Program (NNHP) implementation and HSM OP implementation will be strengthened. The continuation of MaMoni HSS interventions through government systems will be facilitated at all levels. Also documentation of lessons learned and dissemination of results will be done in a systematic manner. Some of the major focus areas for the quarter are as follows: . Maternal Health: MaMoni HSS will be supporting DGFP to develop standard operating procedures (SOP) on maternal and immediate newborn care in UH&FWCs. This will be based on the national maternal health approved SOPs. Also refresher training for private community-skilled birth attendants (pCSBAs) will be organized.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 2 . Newborn Health: Newly developed special care newborn units (SCANUs) in 2 DGFP facilities in Dhaka and Khulna Shishu Hospital will be made functional in this quarter. 63 KMC corners will be functional across the country including two in Dhaka Medical College Hospital (DMCH) and Sir Salimullah Medical College Hospital (SSMCH). Comprehensive newborn care package (CNCP) trainings in these two hospitals will be launched in this quarter. . QoC: Reproductive, maternal, newborn, child and adolescent health (RMNCAH) quality improvement (QI) framework pilot implementation in Narshingdi district hospitals, two upazila health complex (UHC) and maternal and child welfare center (MCWC). The project has plans to document the process through a systematic approach. The development and printing of the PDCA manual, the infection prevention manual, the patient safety strategic plan and the patient centered communication strategy will be completed in this quarter. . Dissemination of MaMoni learning: during this quarter, the dissemination of findings is planned for the following areas: increasing quality and utilization of facilities for deliveries, the workload indicators of staffing need (WISN) study, and for the findings on the revisit of newborn health interventions. Policy briefs on antenatal corticosteroid (ACS), revisit findings, possible severe bacterial infection (PSBI) and kangaroo mother care (KMC) have been drafted. MaMoni HSS will use these briefs in different dissemination events. . In collaboration with World Health Organization (WHO) Bangladesh, the project will support the HSM unit of DGHS to develop a referral care guideline which is a key activity in the operational plan.
. Electronic asset management systems (eAMS) and electronic training management system (eTMS) for NIPORT will be completed in this quarter
. .
INTRODUCTION The MaMoni Health Systems Strengthening project is a five-year USAID-funded award1 aimed at improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services in Bangladesh. The project’s objective is to increase availability and quality of high-impact interventions through strengthening district-level local management and health systems. This objective is well-aligned with the Government of Bangladesh’s (GOB) Health, Population, and Nutrition Sector Program (HPNSP) 2017-2022 and its Sector Improvement Plan (SIP) 2016-2021. MaMoni HSS provides support and assistance to the Ministry of Health and Family Welfare (MOHFW) at national and district levels, and directly supports the “USAID/Bangladesh- Health Status Improved” Activity under the Investing in People Objective, Health Project Area of the U.S. Foreign Assistance Framework. The four Intermediate Results (IR) of the project are to:
1MaMoni HSS is implemented through an Associate Award under the Maternal and Child Health Integrated Program, which is led by Jhpiego, with a period of performance from September 24, 2013 to September 23, 2018. MaMoni HSS is led by Save the Children in Bangladesh, in partnership with Jhpiego, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 3 • Improve service readiness through critical gap management • Strengthen health systems at the district level and below • Promote an enabling environment to strengthen district-level health systems • Identify and address barriers to accessing health services
Over several years of implementation, the project has expanded the technical assistance role at the national level, while consolidating the implementation at the district level. The project supports 40 upazilas in 6 districts, 23 of which are designated high intensity (HI) areas, and the remaining 17 of which are designated health systems capacity strengthening (HSCS) areas. The scope and geographical coverage of the MaMoni HSS project has been summarized in Table 1. Detailed coverage has been included in Appendix 1.
Table 1: Summary of the geographic scope of MaMoni HSS
Number Population Number of health facilities Number of Area of (2017 UH&FWC/ upazilas DH MCWC UHC CC unions projection) USC High intensity 23 (Habiganj-8, 226 6,662,456 4 7 20 213 619 areas Noakhali-4, Lakshmipur-5, Jhalokathi-4, Pirojpur-2) Health systems 17 (Bhola-7, 151 4,870,933 2 5 14 126 488 capacity Noakhali-5, strengthening Pirojpur-5) (HSCS) areas Total 40 377 11,533,389 6 12 34 339 1,107
DATA SOURCES This report uses data from various sources, including: sentinel surveys in selected facilities in MaMoni HSS districts; Service Delivery Point (SDP) assessments in selected facilities2; re-visitation of specific newborn interventions in 14 districts; and routine Management Information System (MIS) from the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP). The complete list and scope of the surveys are attached as Appendix 2.
2 DH, MCWC, UHC, UH&FWC and USC in 21 high intensity areas in 4 districts (Habiganj, Noakhali, Lakshmipur and Jhalokathi)
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 4 Program results of the year IR 1. Improve service readiness through critical gap management
1.1 Increase availability of health service providers 1.1.1 Management of critical human resource gaps of GOB service providers In year five, MaMoni HSS continued to support the MOHFW in managing critical human resource gaps of service providers by providing eleven Community Health Workers (CHWs) in place of Family Welfare Assistants (FWA), twenty four paramedics in place of Family Welfare Visitors (FWVs), two nurses, and one obstetrics and gynecology consultant in program areas. The MaMoni HSS district teams are advocating with local government, parliamentarians, and local level stakeholders to take on the responsibility of filling vacancies and to develop long term solutions for when the project phases out. During the reporting period, Union Parishads deployed six paramedics in MaMoni HSS districts (4 in Habiganj, 1 in Lakshmipur, and 1 in Noakhali). The current gap management staff status is shown in Table 2.
Table 2. Critical human resource gaps filled-in by MaMoni HSS FWA FWV/Paramedics Nurses OBGYN Consultant
HSS HSS HSS HSS osts osts osts District osts
p p p p Vacant Vacancy filled by MOHFW Vacancy filled by MaMoni Vacant Vacancy filled by MOHFW Vacancy filled MaMoni Vacant Vacancy filled by MOHFW Vacancy filled by MaMoni Vacant Vacancy filled by MOHFW Vacancy filled by MaMoni
Habiganj 102 1 11 31 0 10 70 0 0 1 0 0 Jhalokathi 82 0 0 10 0 1 11 0 0 0 0 0 Noakhali 172 0 0 19 0 11 101 0 2 2 0 1 Lakshmipur 86 0 0 10 0 2 62 0 0 2 0 0 Total 442 1 11 70 0 24 244 0 2 5 0 1
1.2 Strengthen capacity of service providers to provide quality services 1.2.1 Introduction and scale-up of MNCH/FP/N interventions a. Maternal health The program’s major interventions in maternal health are pregnancy identification and registration through frontline health workers; the provision of at least four antenatal care (ANC) contacts with Quality of Care (QoC) from a trained provider; birth planning; promotion of, and increased availability and accessibility to quality skilled birth attendants, including active management of the third stage of labor (AMTSL); distribution of misoprostol for home-based deliveries; and ensuring four postnatal visits, including the promotion of post-partum family planning. There are also special interventions in select areas, such as the management of severe pre-eclampsia and eclampsia through the administration of magnesium sulfate (MgSO4).
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 5 i. Antenatal care coverage ANC is a gateway intervention wherein a woman makes what may be the first contact in her life with a health facility or health care provider as a result of her pregnancy. MaMoni HSS has taken a multipronged approach to address the shortage of service providers, to ensure satellite clinics, and to confirm the availability of equipment and provide logistic support for providers. The project is implementing an integrated approach to improve the quality of ANC by supporting service providers to follow the clinical standards, providing supportive supervision, monitoring the availability of ANC logistics and measuring the quality of ANC services in sentinel sites through direct observation. Routine MIS data for this quarter shows slight decrease in ANC coverage in MaMoni HSS areas compared to previous quarters (Figure 1 and Figure 2). It can be noted here that the project has withdrawn 34 project supported paramedics from the union level facilities as part of the transition process. The low performance of ANC is presumably a result of withdrawing project supported health workers from the facilities. To mitigate the negative impact of these changes the project continued advocacy with local governments to take on the responsibility of hiring health workers to cover human resource gaps. Figure 1: Percentage of pregnant women who received at least one antenatal care visit from a medically trained provider in MaMoni HSS districts
100 80 79 80 70 73 74 56 60 52 52 47 41 40 Percentage 20
0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
High intensity area Health systems capacity strengthening area
Source: MIS-4, CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
Figure 2: Percentage of women who received four or more antenatal care visits from a medically trained provider in MaMoni HSS districts
100
80 61 63 60 54 54 56
40
Percentage 29 25 23 20 23 20
0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
High intensity area Health systems capacity strengthening area
Source: MIS-4, CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 6 ii. Severe pre-eclampsia/eclampsia (PE/E) management at union level facilities Pre-eclampsia/eclampsia is the second leading cause of maternal death in Bangladesh, accounting for 24 percent of all maternal deaths (BMMS 2016 Preliminary Report).
Injectable magnesium sulphate (MgSO4) is considered to be an appropriate and potentially affordable drug to prevent and manage severe preeclampsia/eclampsia (PE/E). MaMoni HSS has been rolling out and supporting the management of PE/E in 197 Union Health and Family Welfare Centers (UH&FWC) of 23 upazilas in four MaMoni HSS districts: Habiganj, Noakhali, Lakshmipur, and Jhalokathi. Through the routine MIS of DGFP the project tracks the identification and management of PE/E cases. Figure 3 shows trends in PE/E case identification and management at UH&FWCs in MaMoni HSS districts. It is revealed from the figure that the PE/E case identification is quite far from the estimated number3 in the districts, only 7 percent of estimated cases have been identified and managed from UH&FWCs during the reporting quarter. The project has been working with the local level managers and service providers to build awareness among pregnant mothers and their families on the consequences of severe PE/E and importance of ANC during pregnancy. Service providers were also educated about the importance of severe PE/E case detection and management. During their supervisory visits, supervisors follow up with the service providers on whether counseling is provided to the pregnant mother about the danger signs of pregnancy or not.
Figure 3: Percentage of pregnant women with PE/E identified and managed at UH&FWCs in MaMoni HSS districts
12 10 10 8 8 7 6 6
Percentage 4
2
0 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: MIS-3, DGFP iii. Misoprostol to prevent postpartum hemorrhage (PPH) for home births MaMoni HSS facilitated the distribution of misoprostol tablets to pregnant women in their third trimester in order to prevent postpartum hemorrhage (PPH) following home deliveries. The coverage of misoprostol tablets distribution is low in MaMoni HSS areas, only 39 percent of the estimated pregnant women in high intensity areas received the tablets during the reporting period which is 13 percentage point lower than that of the previous quarter as shown in Figure 4.
3 2.8% of live births
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 7 Figure 4: Percentage of pregnant women who received misoprostol tablets in MaMoni HSS districts
100
80
60 52 47 46 48 39 40 33 34
Percentage 31 27 30
20
0 High intensity area Health systems capacity strengthening areas
Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: MIS-4, DGFP
iv. Deliveries assisted by skilled birth attendants (SBAs) Routine MIS data shows that SBA deliveries has also decreased in MaMoni HSS areas. Forty nine percent of the estimated deliveries in MaMoni areas were assisted by skilled birth attendants, which was 6 percentage point lower than that of previous quarter (Figure 5). Figure 5: Percentage of SBA deliveries in MaMoni HSS districts
100 90 80 70 58 55 60 51 47 48 47 48 49 50 43 39 40 Percentage 30 20 10 0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
High intensity area Health systems capacity strengthening area
Source: DGFP MIS 2 & 4; CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
The project continued its efforts to increase deliveries at union level facilities through ensuring round the clock delivery services from designated 24/7 UH&FWCs. At the end of this quarter, the total number of UH&FWCs providing 24/7 delivery services was 100; this number was 103 in previous quarter and decreased due to the withdrawal of project supported paramedics form 3 UH&FWCs. Twelve percent of the estimated deliveries were conducted at these 24/7 facilities during the reporting period, although the performance has slightly declined compared to last quarter as shown in Figure 6.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 8 Figure 6: Trends in deliveries in 24/7 UH&FWCs in MaMoni HSS high intensity areas
100 16 14 14 80 12 12 11 10 60 9 9 9 9 8 40 6 7
Number 6 4 Percentage 20 65 65 75 75 81 81 94 103 100 2 0 0 Q2-Y3 Q3-Y3 Q4-Y3 Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Number of 24/7 UH&FWC Percentage of delivery
Source: MIS-3, DGFP v. Private Community Skilled Birth Attendants (pCSBA) assisted deliveries MaMoni HSS continued supporting 70 private CSBAs in Habiganj, Noakhali and Lakshmipur districts through facilitating supplies, and regular monitoring and supervision. During the reporting quarter, 411 deliveries were assisted by the pCSBAs. On average, each pCSBA assisted 6 deliveries during the quarter which is six percent of the estimated deliveries in their catchment areas as shown in Figure 7. Figure 7: Trends in deliveries by MaMoni HSS supported pCSBAs
100 8
80 6 6 60 5 5 4 4 4 4 4 40 3 3 2
Number of pCSBA 2
20 delivery of Percentage 52 52 91 89 64 71 68 68 69 70 0 0 Q1-Y3 Q2-Y3 Q3-Y3 Q4-Y3 Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Number of pCSBA Delivery assisted by pCSBA
Source: Project MIS
b. Newborn health A. Newborn health national support i. Scale-up of priority newborn health interventions
MaMoni HSS continued supporting the MOHFW in the national scale-up of newborn interventions and in improving the quality of facility based care. The project continued support to the National Newborn and Child Health Cell, which provides management support to the national newborn and child health program activities and coordinates national scale-up, including monitoring the interventions through post-training follow-up led by DGHS. MaMoni HSS provides technical assistance to the MOHFW through this cell.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 9 ii. Re-visitation of priority newborn interventions The three-pronged activity included: a) identification of newborn focal persons from each upazila, divisional and district level advocacy meetings for use of helping babies breathe (HBB) and 7.1% CHX; b) refresher training of SBAs on essential newborn care (ENC), including HBB and use of 7.1% CHX on the umbilical stump; and c) a quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, medicine and supply stocks including 7.1% CHX. The revisit also included the replacement/ or provision of supplies for newborn resuscitation equipment (bag, mask and sucker) in the facilities. The National Newborn and Child Health Cell supported by MaMoni HSS provided management support for this activity. Data collectors from partner organizations, Partners in Health and Development (PHD) and Bangabandhu Sheikh Mujib Medical University (BSMMU), conducted the revisits and gathered data using a standard checklist. The revisits was completed in all the 64 districts by end of previous quarter. Revisit data analysis from quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, pharmaceutical stocks, and medical supply stocks was also completed during the reporting quarter. The findings from the revisit data are shown in Table 3. It is revealed that 91 percent of the facilities offered delivery services, 7.1% Chlorhexidine was available in 54 percent of the facilities, HBB kits were available in 88 percent of the facilities. Seventy three percent of the service providers were found to be trained on ENC including 7.1% CHX and 53 percent were found to be trained on HBB. Table 3 Findings of revisit in 64 districts Offer Amoxicillin Injectable delivery 7.1% Functional pediatric Gentamicin Facility Type service CHX HBB Kit MgSO4 drop (80mg/20mg) N (%) (%) (%) (%) (%) (%) DH 100 47 79 29 39 45 62
MCWC 100 68 89 15 85 2 87
UHC 91 48 86 14 29 35 460
UH&FWC-FP 93 54 89 7 78 1 3182
UH&FWC-H 85 53 88 3 79 1 242
Total 91 54 88 7 72 6 4033
iii. Workshop on Evidence based Practices for Improvements in Quality (EPIQ) MaMoni HSS project supported a workshop on ‘Evidence- based Practices for Improvements in Quality (EPIQ)’ from February 28 to March 1, 2018. The objective of the workshop was to sensitize the key managers from the National Newborn Health Program (NNHP), other technical and implementing partners of MOHFW, and representatives of professional bodies on the importance and process for integrating quality improvement initiatives in the implementation of newborn MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 10 care interventions. Two eminent pediatricians from American Academy of Pediatric (AAP) - Dr. Douglas Donald McMillan, Head, Division of Neonatal-Perinatal Medicine, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada, and Professor Dr. Nalini Singhal, Professor of Pediatrics, University of Calgary, Calgary, Canada – facilitated the workshop. The workshop contents were adapted from the Evidence-based Practices for Improvements in Quality (EPIQ) model that demonstrated effective results in the Canadian neonatal network for improve newborn outcomes. The workshop has enabled participants to complete a quality improvement (QI) exercise. A group of facilitators was developed who understand principles of QI, how QI is taught and how QI is introduced in the workplace. Prof. Abul Kalam Azad, Director General, DGHS inaugurated the workshop and expressed his confidence for its implications in quality improvement of various health interventions of Bangladesh. On the concluding session, Prof. Shahidullah, Director-PHC and PM-NNHP & IMCI and Chief of Party-MCHIP had committed to take the EPIQ tools forward and BSMMU would include a session on EPIQ tools in different training packages and master trainers will conduct trainings of a few pilot batches in the near future.
iv. Other national activities The project continues to provide technical support for publication of the National Newborn Health Bulletin. The 5th issue of the bulletin was published during the last quarter. The purpose of this quarterly bulletin is to provide regular updates on the progress made by various initiatives by MOHFW, development partners, professional associations and other stakeholders to improve the survival and wellbeing of newborn in the country. The bulletin primarily focuses on the evidence based interventions prioritized by the Government of Bangladesh for accelerating the reduction of newborn mortality in the country. This issue was a special tribute to Rohingya newborns and children. The bulletin was shared with all stakeholders and posted in Healthy Newborn Network (HNN) web page. Printed copies of the 4th National Newborn Health Bulletin were distributed among the participants of 5th International Conference of Bangladesh Neonatal Forum (BNF) during the conference.
B. Newborn health district interventions Project initiatives during the reporting period focused not only on increasing coverage, but also on improving the quality of service delivery through building the capacity of service providers on priority newborn interventions, including record keeping and reporting, availability of logistics, job aids, and on-the-job coaching, as well as community awareness.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 11 i. Helping Babies Breathe (HBB) MaMoni HSS has been supporting the HBB intervention in all 64 districts under national scale-up activities. The project supported the training of 2,962 new and untrained nurses and midwives on priority newborn interventions including HBB and CHX in 30 districts during the reporting period. BSMMU and PHD facilitated these trainings in their assigned districts. In Quarter 2, Year 5, a total of 5,985 newborns were resuscitated in facilities across the country using a bag and mask. Figure 8 shows that there was no significant changes in resuscitation using bag and musk. Figure 8 Percentage of newborns for whom resuscitation actions were initiated, using a bag and mask, in 7 divisions of Bangladesh
100 90 80 70 60 50 40 Percentage 30 19 20 14 101012 10 7 7 8 9 8 8 6 8 4 5 6 6 6 5 4 4 4 5 4 6 5 4 5 6 6 6 6 10 3 2 1 3 1 1 2 2 1 0 Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet
Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: MIS-3 and EmOC report of DHIS-2
ii. Application of 7.1% Chlorhexidine (CHX) for newborn cord care The application of 7.1% CHX to the umbilical cord stump is one of the major interventions to prevent newborn sepsis for all newborns, irrespective of their place of delivery. As a part of the essential newborn care (ENC) package, the project supports implementation of 7.1% CHX application in six project districts not only from public facilities but also from private facilities on a small scale. In addition to GOB supply chain, the project works with the manufacturing company to ensure availability of 7.1% CHX in local level pharmacies. MOHFW’s routine MIS tracks the application of 7.1% CHX for all SBA assisted deliveries, both at the facility and in the community. Figure 9 shows an increasing trend in the application of 7.1% CHX to the umbilical cord stump in MaMoni HSS districts. The figure shows that all the newborns whose births were assisted by SBAs in MaMoni HSS districts received 7.1% CHX on to their umbilical cords after delivery.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 12 Figure 9: Number of newborns that received 7.1% CHX on their umbilical cords immediately following birth in MaMoni HSS districts.
100 96 100 80 83 80 60 55 60 51 52 48 47 48 45 40 Percentage 20
0 Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Percentage of SBA delivery agaisnt projection Percentage of 7.1 % chlorhexidine use in SBA delivery
Source: DGFP MIS 2 & 4, CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
iii. Facility based care for sick children a. Management of sick children (<2 months of age) in union level facilities MaMoni HSS continued supporting the management of sick young infants (<2 months of age) from 148 UH&FWCs in 4 project districts following national guideline where a trained Sub-Assistant Community Medical Officer (SACMO) is available. At the beginning of the program, all the SCAMOs received a competency-based two day training in addition to CNCP training. As per national protocol, Family Planning Inspectors (FPI) of respective unions also received the refresher training on “Day 8 follow up” at household level. As shown in Figure 10, during the reporting period, a total of 1,547 cases were identified and managed by trained SACMOs. Among them 13 were classified as critical illness (CI), 85 clinical severe infection (CSI) and 534 fast breathing as a single sign of illness (IFB) and 343 local bacterial infection (LBI) and 572 as others. Figure 10: Number of sick children (<2 months of age) treated at 148 UH&FWCs in 4 MaMoni HSS districts
2000 1800 1706 1600 1547 1477 1400 1351 1338 1200 1000 686 Number 800 615 578 572 537 534 528 600 518 372 364 348 343 307 291 400 270 101 88 85 76 67
200 45 37 30 14 13 0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
CI CSI IFB LBI Others Total
Source: Project MIS
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 13 b. Management of sick children from Special Care Newborn Units (SCANUs) All the 5 SCANUs at district hospitals in project areas continued to provide services for critically sick newborns. SCANU data from the facilities is entered into DHIS 2. Figure 11 shows the number of admissions of sick newborns in five project supported SCANUs. In this quarter 1,070 newborns were admitted for special care and treatment. Twenty seven percent of these newborns were referred from same facilities. The average length of stay at the hospitals was 5.5 days. Fourteen percent of these sick newborns died from severe condition or complication. Figure 11: Trends in admissions of sick newborns at 5 project supported SCANUs
1400 1161 1200 1071
1000 875 900
800
Number 600
310 400 273
200
0 Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: DHIS-2
iv. Kangaroo Mother Care (KMC) at district and upazila level facilities Twenty nine facilities in 4 MaMoni HSS districts have been providing KMC services for low birth weight babies following national guidelines. All these facilities have at least one doctor and two nurses trained, necessary logistics to manage at least five cases, and necessary job aids with record keeping and reporting tools for documentation. During the reporting period a total number of 78 (Hg-18, Nk-29, Lk-26 and Jk-5) low birth weight newborns received KMC services in project areas.
c. Family Planning (FP) Major achievements in Q2 of Y5 are the following: i. Supported finalization of PPFP counselling module and brochure on myths and misconception of FP and PPFP ii. Supported printing and distribution of 5000 pieces of Medical Eligibility Criteria (MEC) wheel iii. Supported orientation on FP policy changes and MEC wheel for FP service providers in MaMoni HSS districts iv. Organized training on Protecting Life in Global Health Assistance (formerly referred to as the Mexico City Policy) for all categories of MaMoni HSS project and partner staff.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 14 Family planning performance in MaMoni HSS districts i. Postpartum family planning (PPFP) Performance of postpartum IUCD (PPIUCD) is very low in MaMoni HSS districts. Only 4 percent of women who delivered in public health facilities accepted PPIUCDs as a method of family planning as shown in Figure 12.
Figure 12: Percentage of women who delivered at public health facilities in MaMoni HSS districts received postpartum IUCD
10
8
6 6 5 4 4 4 4 Percentage
2
0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: MIS-4, DGFP ii. Long acting and reversible contraceptive (LARC) method Figure 13 shows increasing trends in the use of long acting and reversible contraceptive methods in MaMoni HSS districts. However, utilization of permanent methods shows slight decreasing trends as shown in Figure 14.
Figure 13: Trends in LARC performance in MaMoni HSS districts
8000 6601 5921 5726 5815 6000 4983 4822 4970 4476 3911 4000 3469
2000
0 High intensity area Health systems capacity strengthening area
Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: MIS-4, DGFP
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 15 Figure 14: Trends in performance of permanent method (PM) in MaMoni HSS districts
1400 1200 1177 1200 1000 927 941 784 803 800 728 733 600 659 600 Number 400 200 0 High intensity area Health systems capacity strengthening area
Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: MIS-4, DGFP
iii. Promotion of FP services through community volunteers In Quarter 2 Year-5, 26 percent of new LARC&PM users were referred by community volunteers (CV) of MaMoni HSS. Figure 15 shows the contribution of CVs to LARC&PM in project districts.
Figure 15: Contribution of community volunteers (CVs) to LARC&PM performance in MaMoni HSS districts
100%
80%
60% 76% 77% 73% 76% 77% 74%
40%
20% 24% 23% 27% 24% 23% 26% 0% Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5 % referred by CVs % referred by GoB staff
Source: MIS-4, DGFP and Project MIS
d. Nutrition To reduce the prevalence of underweight among children under 5 years old and to reduce child mortality from malnutrition by strengthening communities and government facilities’ capacity to identify, treat, and prevent malnutrition is one of the mandates of MaMoni HSS. The project aims to prove that a holistic, decentralized, community-based approach to malnutrition eradication will have better health outcomes, be more inclusive for children under 5 and will be more cost-effective in the long-run than centralized approaches, especially for rural, marginalized communities. This project empowers communities through health literacy and connects rural communities with the government health and nutrition services available. MaMoni HSS does not just act as a catalyst for mobilizing communities to the resources available, but also works on a more intimate level with government health and nutrition workers to help build their capacity towards social mobilization, referrals, and provision of effective nutrition counseling. In
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 16 year 5, the project supported the National Nutrition Services (NNS) operational plan to develop skilled community front line health workers on nutrition screening (basic nutrition) and counseling which will help the program to mainstream and expand the coverage by active-case-findings and ultimately mitigate the burden of the problem in a precise way. Data from DGFP MIS, DHIS-2 and project MIS showed the following results in MaMoni implementation areas in last quarter:
. 326,017 children and mothers (60,183 mothers and 265,834 children) were reached with nutrition interventions from different service delivery points from community to district (Community Clinics, UH&FWCs, UHCs and DHs from where IMCI and nutrition services are provided)
. 97,108 caretakers received BCC interventions that promote essential infant and young feeding practices (hand washing, IDD, Vit-A etc.) . 60,183 pregnant mothers were reached with iron and folic acid (IFA) supplementation during ANC visits
. 1,438 children were identified who has been suffering from MAM . 511 children were identified as SAM patient and were refered
. Among all children who were reached, 18,823 (5%) children had been suffering from different forms of under nutrition. Among these 18,823 children, 4,121 (30%) were identified as stunted, 3,189 (23%) as wasted and 6,513 (47%) were identified as underweight (Figure 16). Figure 16. Nutritional status of children under 5 in MaMoni HSS districts
[
10000 8860 8750 7705 8000 7033 6917 6318 6513 6000 5238 4690 4769 4121
Number 4000 3189
2000
0 Stunting (height-for-age) Wasting (weight-for-height) Underweight (weight-for-age)
Q3-Y4 Q4-Y4 Q1-Y5 Q2-Y5
Source: MIS-4, DGFP and DHIS-2
. SAM child management: During the reporting period, 54 children with severe acute malnutrition (SAM) were enrolled at 16 SAM units of district hospitals and upazila health complexes across the project areas. Among these children, 49 were discharged after treatment and the remaining five continued with the treatment at the facilities.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 17 1.3 Strengthen infrastructure preparedness to improve MNCH service utilization 1.3.1 Upgrading UH&FWCs to provide 24/7 delivery services
Currently a total of 120 UH&FWCs are providing 24/7 delivery services in six project districts. According to UH&FWC assessment data a total of 65 UH&FWC were in Category ‘A’ in MaMoni HSS districts, among those 56 UH&FWCs are now providing 24/7 delivery services.
IR 2: Strengthen health systems at the district level and below 2.1 Improve leadership and management at district level and below 2.1.1 Quarterly performance review meeting (QPRM) The project facilitated a quarterly performance review meeting (QPRM) jointly organized by DGHS and DGFP in Habiganj district. District and Upazila level managers, other officials, NGO representatives and MaMoni HSS staff in the district attended the QPRM. Upazila level MNCHN- FP performance indicators were reviewed and further actions were planned accordingly. The district action plan, joint supervisory visits (JSV) and data quality assessment (DQA) findings, local government engagement, challenges and up-coming priorities were also shared in the meeting. Based on the participatory review and discussions, some action points and decisions were taken to improve the coverage and quality of program activities. Besides this, upazila health and family planning departments and MaMoni HSS jointly conducted monthly coordination meetings at upazila level. The respective UH&FPO, UFPO and MOMCH organized the meetings with service providers, statisticians and first line supervisors of both DGHS and DGFP to analyze performance per union, review action plans, and discuss the findings of joint supervisory visits and DQA. 2.1.2. District and union level planning workshop To improve the maternal, newborn, child health, family planning and nutrition (MNCH/FP/N) situation in MaMoni HSS districts, the MaMoni HSS project supported the development of upazila and union level plans in Habiganj and Jhalokathi districts through identifying the bottle necks with specific actions where the performances of key indicators were low. The process included analysis of current status and identification of bottlenecks towards improving utilization of MCH/FP/N services using available data, developing corrective action plans along with resources required and setting achievable targets with monitoring plan. Identification of bottlenecks was under four domains- service availability, accessibility, utilization and quality index. A minimal set of interventions like ANC, SBA delivery, MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 18 essential newborn care (ENC), PNC and family planning were focused on which have the highest impact on reducing maternal and neonatal mortality and improving quality of life. Some other priority MNCH/FP/N interventions like EmONC, newborn care interventions (e.g., chlorhexidine, antenatal corticosteroids, Kangaroo Mother Care, sepsis management, HBB), IMCI, Management of maternal complications & newborn complications and advanced newborn care (e.g., SCANU, referral system) were also considered during the planning process. The planning workshops were facilitated by GOB health and FP managers. UH&FPO, UFPO and representatives from local level health and family planning staff and local government representatives attended the workshops. Through these workshops two district plans, two MCWC plans, twelve upazila plans and twenty four union plans were developed. These plans are being monitored during Joint Supervisory Visit (JSV) and reviewed during monthly meetings at facilities and in QPRMs. These local level planning helped the local level managers in decision-making and resource mobilization both from public and private sectors. It is an ongoing process for improvement and availability of services with quality.
2.2 Improve district level comprehensive planning (including human resources) to meet local needs 2.2.1. Health Workforce Management: Workload and staffing needs assessment study
MaMoni HSS and WHO agreed to collaborate along with Human Resource unit of MOHFW for a joint dissemination of the key findings and recommendations of the two studies on “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities” conducted by WHO and MaMoni HSS respectively. WHO supported study report has recently been finalized. A joint dissemination has been planned for May. A small group comprising of Principal Investigators (PIs) of the two studies and technical persons from MaMoni HSS and WHO Bangladesh has developed a draft policy brief based on these studies which will be finalized before the dissemination. 2.2.2 Implementation of central HRIS: Support DGHS and DGFP to implement central Human Resource Information System (HRIS) The MaMoni HSS project continued to provide support for capacity building of DGFP staff for rolling out of central Human Resource Information System (HRIS). During the reporting quarter three batches of trainings were organized in collaboration with MIS unit of DGFP. A total 74 staffs were trained on HRIS in three batches. At central level the Deputy Program Managers, Family Planning Officers, Computer Operators of different units /departments of DGFP who have been identified as HRIS focal points of their MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 19 respective departments were trained. At Habiganj and Noakhali districts the Assistant Director-Family Planning, Statistician, Upazila Family Planning Officer (UFPO), Medical Officer-MCH, Upazila Family Planning Assistant (UFPA) were trained. With this initial capacity building support from ManMoni HSS project, MIS unit planned to provide training to relevant staff at division, district and upazila level throughout the country utilizing their Operational Plan (OP) budget for national roll out of HRIS. The project has also facilitated formation of a ‘HRIS core committee’ led by Program Manager MIS Unit that consists of six members. This committee at central level will work for further development of HRIS and deal with technical issues during implementation of HRIS.
2.3 Strengthen local management information systems 2.3.1 Development and scale-up of electronic Management Information System (eMIS) Development and upgradation of eMIS system is a continuous process. During the reporting quarter major development and upgradation activities took place under different modules. Some of these were work plan tasks already scheduled and others were re-prioritized tasks required to deal with issues identified from the field. Major development activities are listed in Table 4. Table 4 eMIS development activities Activity Description Status Combined child DGHS and DGFP use two different formats for After multiple review the final care register the child care register. The existing child care draft/design is agreed upon and the first register for DGFP also do not have the provision digital version is scheduled for sharing of recording data required to report IMCI with relevant stakeholders. activities under MIS3. The team is working to develop a combined child care register that meet requirement of the both the agencies and meet the IMCI guideline for 0-2 months and 2– 59 months. The guideline is being developed in consensus with the national/international stakeholders from GOB officials, icddr,b and SNL. Automated The laborious activity of satellite session The first draft is ready and will be field Satellite Session planning has been automated. Now a service tested shortly. Planning Tool provider can produce the annual satellite session with only few clicks. Dashboard for A dashboard based notification system for The dashboard is active in the provider providers have been developed. This dashboard Madhabpur upazila primarily focusing notifies providers to follow up with clients for on the clients with long acting family upcoming and due services. It also provides planning methods. The work is quick access to individual service statistics and underway to introduce more services provide better insight to their performance. under dashboard notification.
Monitoring Tool Based on requests from the field, a number of o Inter or intra sub-district transfer of Enhancement enhancements have been added to the provider now can be handled. monitoring tool. These additions provide better o Ward/unit information assignment monitoring capacity required for smooth update is critical for proper MIS implementation. reporting and was of great concern. Now individual household record can be updated through monitoring tool. o Provider’s service location tracking through GPS is incorporated.
E- Supervision Digitalization of paper register allows o Field level managers now can modernization of existing business process. As review and approve MIS-3 form
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 20 Activity Description Status part of the upgradation paper based submission from the monitoring administrative process are migrated through tool. eMIS now.
Offline Data Based on the last two years of implementation o A parallel synchronization system is Synchronization experience it was observed that the device developed to reduce the enhancement offline database is often tampered and troubleshooting effort. If it seems manipulated at the field despite the existence the online MIS-3 report is not up to of a number of protective mechanism. This date from the providers end the impacts the provider’s ability to synchronize synchronization can manually be work recorded in the offline mode. As a result, initiated. when the providers are asked to submit their o An exact replica offline database can offline work manually in such situations, it be requested from server for rapid often takes weeks to resolve individual issues. deployment and troubleshooting. Therefore, the system is being developed so that the system can take of such issues on its own.
Database Since its implementation began in the field, the o Monitoring tool is updated so that it schema eMIS system has gone through multiple phases can extract information from both upgradation for of alteration. A lot of GoB officials’ and relevant legacy database and updated system stakeholder’s requests have been catered for. database seamlessly enhancement Though best practices are mostly followed, due o Each of the android application and to strict timelines, sometimes compromises corresponding web service for every were made in the analysis and design which are provider type is refactored to adopt now due for update. As part of the broader eMIS the new database schema. initiative, before scaling up eMIS activities in Migration plan for old data from new districts an extensive overhauling of the o legacy database is underway. entire eMIS system will be undertaken.
2.3.2 Scale-up of electronic Management Information System (eMIS) ToTs on HA, AHI, HI and FPI eRegisters have been completed for Lakshmipur and Noakhali districts. UH&FPO, UFPO, MO (MCH-FP), HIS Coordinators and project M,E&D staff were participants of the ToT. Basic training on community modules (FWA and HA eRegisters) are ongoing in these districts. All the Health ID cards have been printed for Madhabpur and almost 95% of the registered population have received HID cards. In Lakhai upazila, 72% PRS have been completed and 100% of registered population have received HID cards. The HAs and FWAs distributed the HID cards during their HH visits. 2.3.3 Data Quality Assessment (DQA) DQA is a routine activity in order to improve data quality in the project even though most of the data is from MOHFW’s routine MIS. MIS and program staff in each district conduct DQA on a monthly basis. During the reporting quarter, 23 DQAs were conducted in project districts using structured formats.
The DQA covers ANC, PNC, delivery, family planning and community mobilization data. The reported number of service data and community mobilization data are cross-checked with respective service providers’ reports and registers. The DQAs found a few mismatches in reported vs register data. The findings from DQA were shared with the concerned managers and corrected accordingly. MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 21 2.4 Establish a quality assurance system for MNCH/FP/N services at district level and below 2.4.1 Updates on MaMoni HSS project staff seconded to QIS In this quarter, two divisional QI coordinators (Rangpur and Rajshahi) left while five new staff have joined the project. They include: a) divisional QI coordinator for Barisal, Mymensingh and Rangpur (Rangpur DC joined on 1st April) divisions; b) district QI coordinator of Narsingdi; and c) district QI monitor of Barisal. At this moment, out of 19 staff seconded to QIS (including Narsingdi), 17 positions are filled. Divisional QI coordinator for Rajshahi, and one district QI monitor for Sylhet division are still vacant. To fill up the vacancies, all the positions were advertised several times. It was difficult to find suitable candidates because of short duration of contract and asking salary of suitable candidates were higher than the budget allocated. 2.4.2 Implementation of ‘5S’ in district hospitals During this reporting period, 5S was introduced at 3 district hospitals of Rangpur division with financial support from QIS. The district hospitals were- Lalmonirhat, Nilphamari and Dinajpur. 5S was also introduced in Khulna Medical College Hospital with support from MaMoni HSS project during this period.
To introduce 5S at the hospitals, a day-long orientation was provided to the WIT members on 5S. The number of hospital staff trained on 5S include – 35 in Lalmonirhat, 50 in Nilphamari, 35 in Dinajpur district hospital and 218 in Khulna MCH. The total number of district hospitals currently practicing 5S is 47 (30 in 4 divisions supported by MaMoni HSS Project). All these workshops were either chaired by the Civil Surgeons or the Hospital Superintendent. The overall objective of the workshop was to improve understanding of the participants on 5S and develop WIT wise action plans to implement 5S activities to improve the working environment, which is the gateway for quality improvement. All these workshops were facilitated by the divisional QI coordinator. 2.4.3 Maternal and perinatal death surveillance and response (MPDSR) During this quarter, facility-based MPDSR was introduced in Feni district hospital of Chittagong Division, and Pirojpur and Barisal General Hospital of Barisal division supported by MaMoni HSS Project. MPDSR sub-committees were formed at the hospitals before the orientation. The orientations (on facility-based MPDSR) were attended by the staff working at OBGYN and pediatrics departments (SSN, medical officers and consultant) along with the sub-committee members. The total number of staff that attended the orientation was 33 in Feni, 26 in Pirojpur and 29 in Barisal (total staff trained is 88). The total number of facilities where facility-based MPDSR has been introduced in 3 MaMoni supported divisions is now 20 (out of 21). The lone facility where MPDSR is not introduced is Chittagong General Hospital. MPDSR is not introduced because the hospital did not have any maternal or neonatal deaths in 2017 (the hospital refers all the serious cases to Chittagong medical college hospital).
2.4.4 RMNCAH QI pilot in Narsingdi district The RMNCAH framework is currently being piloted in the district hospital, MCWC and two UHCs (Shibpur and Palash) in Narsingdi district. It is a collaboration between MaMoni HSS project and QIS. One MaMoni staff (district QI monitor) has been deployed MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 22 at the district to coordinate and facilitate implementation of the activities. The other staff (district QI coordinator) is expected to join soon. To evaluate the pilot project, icddr,b has been assigned to conduct the baseline assessment. The tools for the baseline survey were finalized in the last quarter. icddr,b has recruited staff for data collection in this quarter and organized a three-day long training for them to collect the baseline data. In total, 17 data collectors and supervisors have been trained. The data collection is underway and is expected to be completed by the end of the quarter.
2.4.5 Quality improvement committee and district resource pool All the divisional and district QI committees have been formed and district resource pools developed. Continuous efforts are being given to activate (and hold regular meetings) the divisional and district QICs. Table 5 shows the number of districts where QIC and district resource pools have been formed. Table 5 Information about quality improvement committees (QIC)
District District District QIC District QIC Number of resource pool hospital QIC Division formed meetings held districts developed meeting held (cumulative) (Jan-Mar 18) (cumulative) (Jan-Mar 18) Chittagong 11 11 11 8 11 Sylhet 4 4 4 2 4 Barisal 6 6 6 5 6 Khulna 10 10 10 4 8 Dhaka 13 13 13 NI NI Rajshahi 8 8 8 3 6 Rangpur 8 8 8 NI NI Mymensingh 4 3 3 NI NI Total 64 63 63 22 35 NI: No information (because of lack of staff at the divisions)
2.4.6 Infection prevention and control (IPC) manual development The manual for Infection Prevention and Control (IPC) is being developed under the guidance of QIS and with the support from MaMoni HSS Project. In order to review the outlines (contents) of the IPC manual, a meeting was held in January at QIS. The meeting was attended by the QIS team and representatives from DGFP and DGHS. The QIS organized a workshop on 31 January for finalizing the IPC manual. The workshop was attended by 58 participants from DPs (WHO, USAID, MaMoni HSS Project, JHPIEGO, Apollo Hospital, Marie Stopes, EngenderHealth, etc.), DGHS, DGFP, professional bodies (OGSB, Nursing council), medical college hospitals, Shishu Hospital, private hospital, and others. In the workshop, the draft IPC manual was distributed and feedback was received from the participants. Simultaneously, the document was shared with a WHO expert on infection control for comments. Based on all the feedback from the participants and WHO, the manual is in the process of finalization.
[[
2.4.7 Development of ICU QI standards
QIS has taken the initiative to develop a QI framework for ICUs (Intensive Care Units). In order to develop the framework, QIS organized a workshop on 9 January. The workshop was attended by 50 participants from multiple disciplines including medicine, surgery, MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 23 OBGYN, anesthesiology, pediatrics, neurosurgery, urology etc. Mr. Md. Habibur Rahman Khan, Additional Secretary, MOHFW attended the workshop as the chief guest, while the workshop was chaired by Mr. Nuruzzaman, acting DG, HEU. In the workshop the draft ICU QI framework was shared and feedback was received. The document is currently being updated by QIS and the recommendations from participants are being incorporated.
2.4.8 Development of patient safety strategy This activity has been contracted out to a consultant from CIPRB. A short meeting on the patient safety strategy was held at the HEU on 14 January. In the meeting, the draft document was reviewed and some changes were suggested. The consultant, after incorporating the suggestions, distributed the draft document to the stakeholders for review and comments. Subsequently, a workshop was organized on 24 January to get feedback from the stakeholders. The workshop was chaired by the DG, HEU, while Mr. Md. Habibur Rahman Khan, Additional Secretary, Hospital Section, MOHFW attended as the Chief Guest. The workshop was attended by 42 participants from DGHS, DGFP, DG Nursing, representatives from public and private hospitals, TAG members and representatives from professional bodies, DPs (USAID, JHPIEGO, MaMoni HSS Project) NGOs, CIPRB, private universities and others. The draft document was also shared with a patient safety expert at IHI. The consultant has incorporated all the suggestions received in the workshop and from IHI, and submitted the draft document to QIS.
2.4.9 Development of communication strategy for quality improvement The MaMoni HSS project is providing technical support to QIS to develop a communication strategy for service providers in order to improve quality of care. A draft outline of the strategy has already been developed by the QIS and it was shared in a meeting with relevant stakeholders where representatives from QIS, CIPRB, SCI, USAID supported SBCC project, DGHS, and WHO were present. It was decided in the meeting to review existing documents to develop a situation analysis, and then to conduct a SWOT analysis before developing the communication strategy.
2.4.10 PDCA training manual development The PDCA training manual has been updated after incorporating comments from USAID. The manual is currently being formatted for printing. It is expected that the printed copy will be ready by the end of April.
2.4.11 Documentation of QI activities The document “Quality Improvement Secretariat Activities and Achievements” has been finalized after incorporating the comments of stakeholders. The document is being formatted for printing.
2.4.12 Development of SOP for radiology, pathology and operation theatre A meeting to develop the SOPs on radiology, pathology and OT was held on 22 February. The meeting was attended by 11 participants (radiologists, anesthesiologists and pathologists) from DMCH, SSMCH, and BSMMU. In the meeting, the draft SOPs developed by the QIS were reviewed. It was decided that further inputs from experts would be needed before the SOPs are finalized. MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 24 2.4.13 Safe surgery checklist The safe surgery checklist was printed for QIS with the support from MaMoni HSS project in the last quarter. The checklist has been introduced through the hospital quality improvement committees in 13 model hospitals and two medical college hospitals. The checklist is being used in the OT.
2.4.14 RMNCAH QI framework The draft RMNCAH QI framework developed by QIS was further reviewed and updated and submitted to the Focal Person, QIS for approval.
2.4.15 Workshops a. Workshop on MPDSR cause of death analysis A cause of death analysis workshop was conducted in Sylhet division (at Sylhet Medical College Hospital conference room) on 13 February to review the community-based maternal and perinatal deaths. The director of the MCH chaired the session. The workshop was attended by the divisional director along with other senior staff members (deputy director and assistant director) of the divisional health office, consultants (OG and pediatrics) from the medical college hospital, civil surgeons of all the four districts, and the members of the MPDSR committee (total no. of participants were 36). The objective of the workshop was to review all the community-level maternal and perinatal deaths to identify the medical and social causes of deaths. In the workshop, 197 maternal and 515 neonatal death investigation forms of 3 districts (Sunamganj, Moulavibazar and Sylhet) were reviewed to assign the causes of deaths. The main causes of maternal deaths identified were PPH, eclampsia, and obstructed labor, while the main causes of neonatal deaths were birth asphyxia and prematurity/ low birth weight. It was not possible to assign the causes of deaths for a number of maternal and neonatal deaths due to inadequate information. b. Workshop on MPDSR A workshop on MPDSR was organized at DGHS by QIS on 11 January to discuss the current maternal and perinatal death situation and challenges. It was chaired by the Line Director, MNCAH with participation from the Civil Surgeons and RMOs from 22 MPDSR districts (total no. participants was 62). The current situation of maternal and neonatal deaths at the targeted districts were presented (based on DHIS2 data) in the workshop including the challenges. The district managers and the focal persons have been requested to upload data in the DHIS-2 timely and expedite the MPDSR activities at their respective districts to avert avoidable maternal and neonatal deaths. It was also decided to organize another workshop with the focal persons to develop the district MPDSR action plan. c. Workshop on MPDSR action plan The MPDSR action plan development workshop was organized by the QIS on 29 January at the HEU. The workshop was attended by the MPDSR focal persons from 22 MPDSR districts. In the workshop, challenges of MPDSR implementation were discussed. The participants reviewed the draft action plan developed by QIS (including the checklist) and finalized it for their own district/hospitals.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 25 d. Workshop to review national MPDSR action plan The QIS organized a workshop to review the national MPDSR action plan on 14 February. Forty three participants from DGHS, DGFP, DG Nursing, development partners, professional bodies and selected district managers attended the workshop. In the workshop, data of 22 districts related to MPDSR was presented. Finally, the participants worked in groups and provided some recommendation to carry forward the MPDSR activities.
2.4.16 Meetings a. Quarterly coordination meeting The quarterly coordination meeting of MaMoni HSS staff seconded to QIS was held at HEU on 21 January. The meeting was chaired by the acting DG, HEU. In the meeting, all the divisional coordinators presented their activities and achievements of last quarter. The challenges were discussed and necessary directives were provided by the QIS Focal Person to carry forward the QI activities in the divisions. b. Technical Advisory Group (TAG) meeting A TAG meeting was held at the HEU on 4 February. The meeting was chaired by Dr. Aminul Hasan and was attended by Prof. MA Faiz, Dr. Iffat, Prof. Jamal, and Dr. Afroza. In the meeting it was suggested to finalize the patient safety guideline, IPC manual and ICU framework as soon as possible. As most of the members could not attend the meeting, there was not that much discussion. However, it was suggested to select some simple issues for implementation, such as hand washing at ICU, HDU, OT at DMCH and ShSMCH. c. Review meeting on QI approach for RMNCAH and EMEN pilot in Kurigram district A meeting to review the QI approach for RMNCAH and EMEN piloting at Kurigram district was held at the HEU on 13 February. The meeting was attended by 27 participants from UNICEF, UNFPA, EngenderHealth, DGHS, IPHN, Marie Stopes, MaMoni HSS Project, BRAC, and SCI etc. In the meeting achievements of Kurigram district was presented and discussed. The major challenges identified were chronic shortage of staff, patient overload, and inadequate motivation of staff. It was decided to provide continuous support to achieve the goals.
2.4.17 Improving delivery of MNCH/FP/N services in MaMoni HSS districts a. Increasing local ownership of QI by establishing and supporting Quality Improvement Committees (QIC) and through the engagement of local government The project continued supporting the establishment and facilitation of QIC at district, upazila, and health facility levels. Major support included organizing QIC meetings, summarizing action points, and following up on identified actions. Table 6 below shows an update on the status of the formation and activation of QI Committees at district and upazila levels by district.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 26 Table 6 Status of Quality Improvement Committee formation and activation
District Number of QI Committees Habiganj Noakhali Lakshmipur Jhalakati
Total to be formed 18 19 11 10
Actually formed 18 19 11 10 Active (had at least 1 meeting in the last 17 18 11 10 3 months)
b. Strengthening routine supervision system and promoting supportive supervision through Joint Supervisory Visits (JSV) The project supports joint supervisory visits (JSV) by second line government supervisors using structured checklists in areas of infection prevention, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI, normal vaginal delivery, and postnatal care. This facilitates gap identification, action plan for improvement, and following up on results. Sixty one JSVs were conducted during the reporting quarter in MaMoni HSS districts. Table 7 shows an example of JSV findings and follow up action in Jhalokathi district. Table 7 Examples of JSV finding and follow up action in Jhalokathi Observations during the visits Initiatives taken GMP session needs to be conducted with necessary Shared with upazila managers & started logistics in IMCI corner partially Height, weight measuring board, salter scale and On the job training was given, RMO/MO will nutrition card are not properly used in IMCI corner monitor. Instruments were not autoclaved properly On job training given and will be monitored by the MOMCH and/or UFPO Privacy was not maintained during ANC Shared with upazila managers. As per direction & initiatives of the manager now privacy is maintained IMCI register was not maintained properly. Shared with Upazila mangers. Another visit will be arranged for OJT/discussion
c. Improving the quality of clinical care in stages The project continued to support the district health managers to improve the quality of clinical care provided by health facilities in stages:
. Stage 1: to improve the cleanliness, infection prevention, and medical waste management; . Stage 2: to improve sterilization measures and compliance with antenatal care and newborn care services, and . Stage 3: to improve compliance with all range of MNCH/FP/N standards. A total of 266 facilities (DH, MCWC, UHC and UH&FWC) in MaMoni HSS districts are under continuous monitoring and stages are determined accordingly. Among these facilities 153 facilities are in Stage 1, 73 facilities are in Stage 2 and 40 facilities are in Stage 3.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 27 2.5 Develop comprehensive logistic management systems for essential MNCH/FP/N commodities at the district level 2.5.1 Monitoring and improving the availability of essential MNCH/FP/N drugs MaMoni HSS has been implementing eLMIS in Noakhali, Habiganj and Jhalokathi districts with support from SIAPS/MSH and monthly reporting in DHIS-2 since August, 2017 from Community Clinic, Union sub-center, Upazila Health Complex, District Hospital and District Store. The eLMIS reporting rate has been drastically reduced (Figure 17) during the quarter due to strike of CHCPs. The strike ended in March, 2018 and it is expected that eLMIS reporting would be increased as before.
Figure 17 Reporting rate of eLMIS in DHIS-2 in MaMoni HSS districts 100 97 100 100 100 92 89
80 88 86 85
60 68 68 56 40 Percentage 39
20 28 28 19 18 13 10 8 0 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Habiganj Jhalokathi Lakshmipur Noakhali
Source: DHIS-2
2.5.2 District level activity for improving availability of MNCH essential drugs and family planning commodities a. Trouble shooting meeting on eLMIS for priority Maternal, Newborn and Child Health medicines reporting in DHIS-2 Trouble shooting meetings were organized for improving the reporting rate as well as improving the data quality of monthly eLMIS reporting into DHIS-2. The daylong meeting was completed at Habiganj and Jhalokathi districts. A total of 149 providers from Habiganj district and 56 providers from Jhalokathi district attended the meeting. b. Meeting with statisticians and store keepers of MOHFW on record keeping, reporting and data utilization of LMIS including eLMIS A meeting was arranged with statisticians and store keepers of MOHFW on record keeping, reporting and data utilization of LMIS including eLMIS at Lakshmipur, Noakhali and Jhalokathi district. The objective was to discuss the importance of MNCH essential medicines related to maternal and neonatal service delivery and review the eLMIS reporting system in DHIS-2 and Supply Chain Management Portal (SCMP). Detailed data on availability misoprostol in the last year was shared to improve the availability of essential MNCH medicines to prevent future stock outs. MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 28 The findings from color coded reporting were shared to improve the distribution, utilization, stock out prevention and reduce misuse of MNCH essential medicines in upazila stores and facilities providing MNCH services. Detailed discusion was held on the present situation of unavailability of Tab. Misoprostol from GOB sources and ways to prevent stock outs such as us of local GOB fund, contributions from upazila chairman, etc. The present status of 7.1% chlorhexidine was also dicussed to prevent stockout in the next six months. Figure 18 shows the monthly stock status of Tab. Misoprostol at selected DGFP stores in Lakshmipur. Figure 18. Monthly availability of misoprostol tablets at selected DGFP upazila stores in Lakshmipur district
Sl Name of the Jul. 17 Aug.17 Sep.17 Oct.17 Nov.17 Dec.17 Jan.18 Feb. 18 No. store 1 Begumganj 2 Chatkhil 3 Companiganj 4 Hatiya 5 Kobirhat 6 Sadar 7 Senbag 8 Sonaimuri 9 Subarnochar
Item is available Item is not available (Stock Out) Item is available but has a stock that will expires within 6 month
MaMoni HSS facilitates ensuring the availability of priority MNCH medicines at facilities in the project districts and works closely with local level managers and local government bodies to this end. The following rearrangements were made to ensure availability of priority MNCH medicines in MaMoni HSS districts:
• From Begumgonj UHC, Noakhali supplied 100 units of 7.1% CHX to Durgapur UH&FWC 24/7 delivery center. • Ensured 100 units of 7.1% CHX in Naruttampur UH&FWC 24/7 delivery center from Durgapur UH&FWC under Begumgonj Upazila, Noakhali district. • From Senbag FP Store redistributed 100 units of 7.1% CHX in Senbag UHC, Noakhali district. • Ensured supply of 1000 Iron Folic from Hatiya FP Store to Hatiya UHC, Noakhali district. • Ensured 200 pcs Inj Gentamycin from Begumgonj UHC to Durgapur UH&FWC(100), to Kutubpur UH&FWC(50) and to Rajgonj UH&FWC (50) at Noakhali district. • Ensured 4 HBB kits from CS Store to (District Hospital -02 ,Hatiya UHC-01 and Chatkhil UHC -01) at Noakhali district. • Ensured 100 pcs Tab. Misoprostol from Companigong FP store to Senbagh FP Store,Noakhali district. • Ensured 250 pcs Tab. Misoprostol from Senbag FP Store to Senbag UHC,Noakhali district
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 29 • Ensured supply of total 308 vial of 7.1% CHX from 308 from Ramgonj UHC to Keroa UH&FWC-208 and Bamni UH&FWC-100 Under Raipur Upazila,Lakshmipur district. • Ensured redistribution of 100 Pcs of 7.1% CHX to Sonapur UH&FWC from Char Mohana UH&FWC Under Raipur Upazila,lakshmipur district. • Ensured 200 vials of 7.1% CHX from Kamalnagar UHC to Char Folcon UH&FWC and Hazirhat UH&FWC under Kamalnagar upazila of Lakshmipur district. • Redistribution of 300 vials of 7.1% CHX from MCWC to upazila and SDP level for reduce stock out and prevent wastage.
2.6 Improve local governance and oversight for MNCH/FP/N Advocacy and planning meetings were conducted with all union parishads (UPs) in MaMoni HSS districts to engage them in quality service delivery from the UH&FWCs. Union parishads have deployed three paramedics in Noakhali (Charbhata UH&FWC of Subarnachar upazila, Rajganj UH&FWC of Begumganj upazila and Joyag UH&FWC of Sunaimuri upazila) and two paramedics in Lakshmipur (Vatra/Dolta UH&FWC of Ramganj upazila and Uttar Joypur UH&FWC of Sadar upazila). In Habiganj, UP deployed four paramedics, three pCSBAs, six ayas, four night guards and one driver for water ambulance in different health facilities of Ajmiriganj, Baniachong, Nabiganj, Habiganj Sadar, Lakhai and Madhabpur upazila during the reporting period. The district teams worked to engage more UPs to motivate them for deploying service providers (paramedics) in the UH&FWCs of their unions. With active involvement of thecommunity, UP and local Member of Parliament (MP), three UH&FWCs have been upgraded to provide 24/7 delivery services at Sunaimuri, Kabirhat and Hatiya upazilas. MaMoni HSS also works with the union parishads to allocate funds for MNCH/FP/N services in the unions. Table 8 shows the fund allocation and utilization status by local government bodies for MNCH/FP/N activities for the reporting period. These funds were mainly used for construction, repair, and maintenance of facilities; purchasing emergency medicine (especially during stock-outs); purchasing small medical and non-medical equipment and logistics; financial support to temporary support staff; and construction of approaching roads. Table 8 Union parishad budget allocation and utilization Number of Percentage of Number Total budget Total budget Percentage unions unions District of allocated FY-17- utilized (BDT) of budget allocated allocated Unions 18) (BDT) up to Mar 18 utilization budget budget Habiganj 77 77 100 10594850 6060885 57 Jhalokathi 32 31 97 4054000 1039410 26 Lakshmipur 58 58 100 15556975 3814350 25 Noakhali 91 90 99 9610000 4783530 50 Total 258 256 99 39815825 15698175 39
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 30 IR 3. Promote an enabling environment to strengthen district level health systems 3.1 Policy reforms in place to promote local planning and need-based human resource deployment in the public sector 3.1.1 Maternal health SOPs and Strategy MaMoni HSS facilitated the development of Maternal Health SOPs and supported development of the Maternal Health (MH) strategy. The SOPs have already been approved by the MOHFW and are under the printing process. MOHFW suggested that the strategy be translated and MaMoni HSS is actively involved in the translation process.
3.1.2 Development of an Accreditation System for Health Services Accreditation is one of the most important approaches for improving the quality of healthcare structures. In most developed and developing countries, accreditation helps the hospitals enhance patient care through continuous quality improvement process. Hospital accreditation is an ongoing system and national ownership is crucial, both to lay the foundation and to maintain its function from the beginning. Establishing national accreditation systems will help ensure that hospitals, whether public or private, national or expatriate, play their expected roles in national health systems. Developing an accreditation system in Bangladesh is one of the priorities identified in the Health, Nutrition, and Population Sector Programme (HPNSDP) 2017-2022 and is therefore included in the Operational Plans for Hospital Service Management. MaMoni HSS is supporting the Hospital Services Management (HSM) Operational Plan for developing the accreditation system, regulatory framework and a hospital accreditation act. In this quarter, MaMoni HSS hired two national consultants (one legal consultant and the other to facilitate the process) and USAID Bangladesh hired two international consultants to provide technical assistance to the HSM. The consultant team reviewed the available documents and organized workshops and meetings with different stakeholders within government and private sectors. The consultants also proposed a “road map” that designated the different activities required to bring about the establishment of an accreditation system. A draft act has been developed and submitted to the MOHFW for review.
3.3 Conduct and disseminate operations research and program learning/ documentation activities 3.3.1 Operational research
Implementation of two operational research activities was completed in this quarter. The study team has wrapped up all data collection activities of “A competency assessment of FWVs to effectively screen for pre-eclampsia/eclampsia” and started processing data for final analysis and reporting.
The formative part of “An implementation research to reduce discontinuation of LARCs (IUCD and implants)” has been completed. A presentation has been prepared and shared with USAID for review. The team is now working with the eMIS team to review implementation of the automated information system to understand the follow-up process of LARC clients to improve continuation, which is the main intervention to be tracked through this research.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 31 A draft report has been prepared from operations research titled “Private Community Skilled Birth Attendant Program in Bangladesh: Evaluation of the utilization and sustainability of the program”.
Data analysis of “National case study on scaling up of 7.1% CHX nationwide” is on-going.
3.3.2 Program learning Five abstracts have been submitted in the Health System Research Conference, 2018 (HSR 2018). The project has also submitted another 3 abstracts to FIGO 2018. Acceptance notifications of the abstracts will be provided by conference authorities in April.
Manuscripts: Three manuscripts have been prepared and finalized for submission to journals in this quarter. One of them has been submitted in PLOS ONE titled “A cross-sectional study of partograph utilization as a decision making tool for referral of abnormal labour in primary health care facilities of Bangladesh”. “Provision of permanent family planning methods in three districts in Bangladesh: An observational study” formatted for Journal of Family Planning and Reproductive Health Care was submitted to USAID for review during the quarter. Another paper titled “Using spatial analysis and GIS to improve district level resource allocation and annual activity planning by health managers in a rural district of Bangladesh” has been submitted to BMJ Global Health.
Process documentation: A summary of MaMoni HSS process documentation activities has been provided in Appendix 5.
3.4 Strengthening NIPORT to deliver a capacity-building program for community level health workers to deliver community-based interventions of the essential services package a. ToT and Training on Team Training curriculum for HA, FWA and CHCP
Five batches of sToT on Team Training curriculum for HA, FWA and CHCP were conducted at NIPORT. The first batch of ToTs was considered as pilot batch. The curriculum was updated by incorporating feedback and practical learning from the first batch. A total of 126 trainers were trained on the updated Team Training Curriculum. Following the ToT, Team Training for HA, FWA and CHCP is ongoing in all twenty RTC’s with an aim to cover 140 batches by end of the project.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 32 b. ToT and training on Management and Leadership Training for Upazila level managers Facilitators’ and Participant’s Manual for ‘Management and Leadership Training for Upazila Health and Family Planning Managers to Strengthen Community Health Systems’ have been finalized based on the content approved by Technical Committee for curriculum development. A four-day Training of Trainers (ToT) was provided to 20 trainers from NIPORT, DGHS, DGFP and NGOs. A few experienced but now retired government trainers were also included in the ToT. Following the ToT, two batches of training were organized by NIPORT. A total of 36 Upazila Health and Family Planning Officer (UH&FPO), Upazila Family Planning Officer (UFPO), Medical Officer-MCH-FP (MO-MCHF P) and Resident Medical Officers (RMOs) have been trained. c. Rapid assessment of the institutional and managerial capacity of NIPORT and its RTC An assessment on capacity of NIPORT and its Regional Training Centers was conducted through a structured questionnaire. Throughout the assessment, NIPORT officials were engaged with the MaMoni HSS team in analyzing the data and suggesting recommendations for sustainable capacity development of NIPORT and its RTCs as per the assessment report. A directory with at-a- glance information about each RTC is attached with the assessment report. This assessment report is finalized by incorporating feedback of NIPORT and taking expert support from SCI USA. The report is now being printed and will be shared soon with relevant stakeholders.
d. Mapping of potential collaborating institutions for managing large- scale training of CHWs A structured questionnaire was developed in consultation with NIPORT and MaMoni HSS for collecting information of potential collaborating institutes in all sixty four districts for managing large – scale training of Community Health Workers (CHWs), supervisors and managers. Data collection involved all training quality monitoring officers of MaMoni HSS. The data collection, data analysis and draft report writing were completed.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 33 e. Electronic Training Management and Asset Management System for NIPORT The NIPORT and RTC assessment revealed that the training and asset management system of NIPORT and its RTCs need upgrading by establishing an electronic system of training management, asset management and effective linkages with the existing human resource and management information systems (MIS) of MOH&FW, especially DGHS and DGFP. MaMoni HSS has been supporting NIPORT in developing and installing a robust electronic training and asset management system. The development work on the electronic training management system (eTMS) is on-going. A series of development meetings for system requirements were held during the quarter and a system prototype has been designed. The eTMS will be ready for field-testing by end of April 2018. Figure 19 shows screen shots of the eTMS. Figure 19. Screen shot of login page of electronic training management system (eTMS)
The first version of the electronic asset management system (eAMS) was completed during the quarter. A day long workshop was held for taking feedback on eAMS from NIPORT officials, including DG, NIPORT and other Directors. A two-day long training session was also organized for select users of the system in order to field-test the system in 3 RTCs and NIPORT Head Office. The field-testing will commence from April 2018. Figure 20 shows a screen shot of the dashboard of eAMS.
Figure 20. Screen shot of the dashboard of electronic asset management system (eAMS)
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 34 IR 4. Identify and reduce barriers to accessing health services 4.1 Promote awareness of MNCH through innovative BCC approach
4.1.1 Reaching the community through Aponjon services Aponjon continued to provide critical maternal, newborn, child health, nutrition and family planning messages to pregnant and lactating mothers during pregnancy and postpartum period through the subscription based Shogorbha program. As of March 31, a cumulative total of 2,053,244 women have subscribed to the messaging service, an increase of 38,078 in this quarter. Aponjon acquires subscribers through partnership with different outreach channels. Currently fifteen local NGOs partner have been working with Aponjon to promote its services and acquire subscribers. Figure 21 shows Aponjon acquisition trends. Figure 21 Aponjon Shogorbha acquisition trends
4500 4000 3500 3000 2500 2000 1500 1000 500 0
18-Jan 18-Feb 18-Mar
Throughout the quarter the main focus was on preparing digital content for promotional purposes and revamping the website to maximize the user experience. During this period, 12,605 Aponjon Shogorva app subscribers were added. Figure 22 shows Aponjon reach through different digital channels.
Figure 22 Aponjon reach through different digital channels
Acquisition: A total of 38078 Mobile App: A number of subscriber reached through 12605 Shogorbha App text & voice channel Downloaded
Aponjon Reach
Blog Visit: an average of Social Media Reach: 520448 40000 per month
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 35 Aponjon Shogorbha app was downloaded for 12696 times and the Koishor app was downloaded for 401 times during this period. Monthly app download statistics for the quarter are given in Table 9. Table 9 Mobile app downloads of Aponjon Shogorbha and Koishor Shogorbha App Koishor App
OS Android Windows iOS Android Windows iOS January 7513 90 25 38 66 2 February 3924 71 26 18 67 2 March 889 55 12 15 55 1 Total 12326 216 63 71 188 5
Aponjon also targeted smartphone users and maintains an interactive Shogorbha app through Android, iOS and Windows mobile platforms. 12,696 women downloaded the app in this quarter. An average of 40,000 blog readers visit the Aponjon blog every month. The social media reach of Aponjon is 1.5 million.
Aponjon manages a call center as a live interface with the customer and provides support for general service related issues and queries as well as for medical related issues. The call center agents and medical professionals provide service on a 24/7 basis with varying capacity through voice call and chat services. Table 10 below shows the call summary for 2nd quarter. Table 10 Inbound and outbound call summary for call center and counselling line Inbound call Outbound call Counselling Counselling Date of birth Month Call Center Call Center QA-QC line line Update January 880 950 208 182 1433 22069 1298 1059 274 131 1867 48306 February
March 1640 1177 436 188 2482 89199 Total 3818 3186 918 501 5782 159574
Aponjon has been focusing on brand promotion to increase self-registration rate to decrease the dependency of assisted registration through other parties. For this, communication materials like posters, brochures, leaflets, signboards, key rings, car and door stickers were prepared and a 4-day campaign named ‘Aponjon Road Show’ was organized in most populated and busiest areas of Dhaka city like, Dhanmondi, Mohammadpur, Mirpur and Nikunjo. The communication materials were distributed to potential users during the campaign. 9,300 posters and 40,000 door and car stickers were placed in hospitals, cars and CNGs. A number of 35 signboards featuring Aponjon service was also established in pharmacies in this purpose. All these promotional activities resulted in increased number of incoming calls to the call center.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 36
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 37 4.1.2 BCC activities in MaMoni HSS districts MaMoni HSS carried out comprehensive behavior change communication activities in the selected areas of Habiganj, Lakshmipur and Noakhali including Hatiya. The activities were focused mainly in the low performing areas based on crucial health indicators such as ANC, SBA delivery, and facility delivery. Activities like video shows, milking (announcements using microphones), meeting with pregnant women, mother’s support groups (Ma Somabesh), advocacy meetings, and popular theater show were Theater show in Habiganj organized. An estimated number of 195,660 beneficiaries (female 51%, male 49%) were reached through these BCC activities.
4.2 Enhance community engagement in addressing health needs 4.2.1 Community mobilization in MaMoni HSS districts Community Action Group (CAG) meetings and Community Microplanning Meetings (cMPM) were facilitated by frontline MOHFW field workers –HAs and FWAs. Health Assistants took over the responsibility of cMPM facilitation and reporting. The cMPM report includes CAG meeting information of the area. At present there are 23,929 community volunteers (CVs)/community action groups (CAGs) active in four MaMoni HSS districts.
Community mobilization related performances for the period are shown in Table 11, Table 12, Table 13 and Table 14.
Table 11 Percentage of CAG meeting held against plan
Name of the district CAG planned CAG meeting held % of CAG against plan
Habiganj 25012 20943 84 Jhalokathi 6915 2323 34 Lakshmipur 18918 11600 61 Noakhali 16559 8929 54 Total 67404 43795 65
Table 12 Percentage of cMPM held against plan
Name of the district cMPM planned cMPM held % of cMPM against plan Habiganj 2739 2689 98 Jhalokathi 1110 759 68 Lakshmipur 2000 1981 99 Noakhali 1713 1388 91 Total 7562 6817 90
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 38 Table 13 Percentage of cMPM where both HA and FWA attended # cMPM where both HA % cMPM where both Name of the district # cMPM held and FWA attended HA and FWA attended Habiganj 2689 2124 79 Jhalokathi 759 375 49 Lakshmipur 1981 1472 74 Noakhali 1388 733 53 Total 6817 4704 69
Table 14 Number of pregnant women identified and LAPM client referred by CVs # of pregnant women # of LAPM client Name of the district identified referred by CVs Habiganj 5465 663 Jhalokathi 4563 258 Lakshmipur 3502 203 Noakhali 1078 56 Total 14608 1180
4.2.2 Piloting cMPM through Community Support Group (CSG) In project year 4, MaMoni HSS initiated community micro planning through the community mobilization structures of government, community support group (CSGs) in 3 unions of 3 districts - Noakhali, Habiganj and Jhalokathi. In Year 5, cMPMs through CSGs scaled up in another 4 unions of Habiganj, Lakshmipur and Jhalokathi. During the reporting period, 100% (118) CSG based cMPM held against planned in the 7 unions where it has been rolled out. Total 395 pregnant women and 374 births were notified in the cMPMs.
4.2.3 Transformation of MaMoni Community Volunteer (CV) to Community Sales Agent (CSA) This activity is designed in collaboration with Social Marketing Company (SMC). MaMoni HSS has replicated the experience of “Notun Din” project of SMC for developing women entrepreneurs as community sales agents (CSAs) in MaMoni HSS areas. Based on the experience of 3 unions during Year 4, this model was scaled up in 6 more unions of Noakhali, Lahshmipur and Habiganj in quarter 1 of Year 5. The 37 CSAs continued selling commodities in 9 unions in 3 districts. In addition to selling commodities, the CSAs also sold Hexicord (7.1% chlorhexidine). On an average, each CSA sold an amount of BDT 3384 making 25 – 30% profit on the sale.
Challenges, Solutions and Action taken Challenges and Mitigation Strategies
. In this quarter low coverage has been observed for a few key services. The possible explanations may be retirement of a good number of family welfare visitors (FWVs), withdrawal of MaMoni HSS supported paramedics and involvement of partner NGO staff in project close-out activities. However, this will be discussed in performance review meetings of this quarter for exploring the mitigation strategies.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 39 . Pre-eclampsia/eclampsia (PE/E) case detection is quite far from the estimated number. The project is working with the local level health managers and service providers to improve the situation.
. Despite of multipronged efforts of the project, misoprostol distribution coverage is still low in the project areas, only 39 percent of the pregnant women in high intensity areas received misoprostol tablets during the reporting quarter. The project has taken several initiatives to address the issue and exploring more ways to increase the coverage. . A decreasing trend in postpartum intra-uterine contraceptive device (PPIUCD) performance has been observed over last one year. National and local level dialogues have been initiated with Directorate General of Family Planning (DGFP) managers to better understand the issues and taking appropriate measures. . Lack of coordination between the Quality Improvement Secretariat (QIS) and Hospital Services Management (HSM) unit of Directorate General of Health Services (DGHS) and maternal, child, reproductive and adolescent health (MCRAH) unit of DGFP has remained as a constant challenge for implementation of quality of care (QoC) in Bangladesh. MaMoni HSS has initiated working with HSM and MCRAH to ensure involvement of these units in QIS activities. . The project has withdrawn 34 project supported paramedics from the union level facilities as part of the transition process. Dialogues with local health and FP managers as well as local government going on for absorbing these paramedics and continue MNCH/FP/N services in the areas. So far 6 paramedics have been taken over by the Union Parishad (UP). The district teams are working hard to engage more UPs and motivate them for taking over the responsibilities of deploying service providers (paramedics) in the UH&FWCs of their respective union centers. . Shortage of faculty members in NIPORT is a challenge for conduction of trainings. MaMoni HSS facilitated developing resource pools from government and non- government sectors. Another challenge is developing collaboration of NIPORT with other government or non-government training institutes for conduction of large scale trainings. NIPORT’s policy doesn’t support such provision. MaMoni HSS is exploring ways for developing such collaboration. . eMIS has been implemented in all upazilas in four high intensity districts. Providers are maintaining both paper based and electronic records of services. Keeping the records updated in both the systems is a challenge.
Way Forward In quarter 3 of Y-5, the project will initiate close-out activities in all districts while focusing more on national activities. Technical assistance to National Newborn Health Program (NNHP) implementation and HSM OP implementation will be strengthened. Continuation of MaMoni interventions through government systems will be facilitated at all levels. Also documentation of lessons learned and dissemination of results will be done in a systematic manner. Some of the major focus areas are as follows:
. Maternal Health: MaMoni HSS will be supporting DGFP to develop standard operating procedure (SOP) on maternal and immediate newborn care in UH&FWCs. MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 40 This will be based on the national maternal health approved SOPs. Also refresher trainings for private community-skilled birth attendants (pCSBAs) will be organized. . Newborn Health: Newly developed special care newborn units (SCANUs) in 2 DGFP facilities in Dhaka and Khulna Shishu Hospital will be functional in this quarter. 63 KMC corners will be functional across the country including 2 in Dhaka Medical College Hospital (DMCH) and Sir Salimullah Medical College Hospital (SSMCH). Comprehensive newborn care package (CNCP) trainings in these 2 hospitals will be launched in this quarter. . QoC: Reproductive, maternal, newborn, child and adolescent health (RMNCAH) quality improvement (QI) Framework pilot implementation in Narshingdi district hospitals, 2 upazila health complex (UHC) and maternal and child welfare center (MCWC). The project has plans to document the process through systematic approach. Development and printing of PDCA manual, infection prevention manual, patient safety strategic plan and patient centered communication strategy will be complete in this quarter.
. Dissemination of MaMoni learning: during this quarter, the dissemination of findings is planned for the following areas: increasing quality and utilization of facilities for deliveries, the workload indicators of staffing need (WISN) study, and for the findings on the revisit of newborn health interventions. Policy briefs on antenatal corticosteroid (ACS), revisit findings, possible severe bacterial infection (PSBI) and kangaroo mother care (KMC) have been drafted. MaMoni HSS will use these briefs in different dissemination events. . In collaboration with World Health Organization (WHO) Bangladesh, the project will support the HSM unit of DGHS to develop a referral care guideline which is a key activity in the operational plan. . Electronic asset management systems (eAMS) and electronic training management system (eTMS) for NIPORT will be completed in this quarter. Also training of first line supervisors on supervision and monitoring and training of health workers of ICSW areas have been planned.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 41 APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF MAMONI HSS PROGRAM The program’s objectives are well aligned with the GoB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016; and also directly support the USAID/ Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh. MaMoni HSS designed a two-pronged approach in which districts and upazilas were categorized into one of two groups – high-intensity intervention areas and High health system capacity Health System strengthening (HSCS) areas. The aim of the high-intensity areas is to demonstrate best practice models of MNCH/FP/N health care delivery through intensive support to the GOB, and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi districts, while in Noakhali and Pirojpur districts, four and two upazilas were supported, respectively. The HSCS areas cover 17 upazilas - all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirojpur districts (refer to Table 1). While the high-intensity areas focus on supporting for a complete package of MNCH/FP/N interventions, the HSCS areas receive less intensive technical assistance on a selected set of interventions. Minimal support is provided to public health systems to scale-up interventions such as 24/7 UH&FWCs, 7.1% CHX for newborn cord care, and HBB; instead, the focus is on strengthening of existing MNCH/FP/N services in HSCS areas.
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 42 APPENDIX 2: DATA SOURCES Assessment Assessment Type Frequency Geographical Coverage Name Population Independent cross 2 rounds in 23 high intensity upazilas of 5 MaMoni districts based tracer sectional assessment a year. Each (Habiganj, Jhalokathi, Noakhali, Lakshmipur, and survey by third party round is for Pirojpur). In addition, during the initial stages of (icddr,b) six months program – starting from October 2013 – this population based assessment was also conducted for Bhola district along with Noakhali and Lakshmipur. This included a baseline assessment and two rounds of the population- based survey. In October 2014, there was a major shift in the MaMoni HSS program strategy and the scale of program activities were reduced in Bhola. Accordingly, the project monitoring plan (PMP) was revised and the population based survey no longer covers Bhola, with the exception of conducting an end line survey in 2017. Sentinel survey Selected sentinel site Twice in a Selected DH, MCWC, UHC, UH&FWC and satellite assessments using year clinics in Habiganj, Jhalokathi, Noakhali and structured tool Lakshmipur district. Service Periodic facility Twice in a 21 high intensity upazilas of Habiganj, Jhalokathi, delivery point assessment by using year Noakhali and Lakshmipur district. assessment structured tool Newborn Nationwide Once in All over the country revisit assessment by project life upazila on HBB and 7.1% CHX using structured questionnaire Routine MIS, Routine MIS forms Monthly All over the country MOHFW of DGHS and DGFP Project MIS Routine MIS reports Monthly Only in high intensity project areas
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 43 APPENDIX 3: PROGRAM PERFORMANCE INDICATORS (JAN-MAR 2018) Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services
Percent of women received at least one antenatal care visit from a medically trained provider High intensity areas Lakshmipur 70 77 77 Noakhali* 67 86 85 Habiganj 70 79 85 Jhalokathi 73 80 83 Pirojpur* 70 73 72 HSCS areas Pirojpur 67 NA 67 Bhola 56 NA 56 Noakhali 63 NA 63
Percent of births receiving at least four antenatal care (ANC) visits during pregnancy
High intensity areas Lakshmipur 26 24 32 Noakhali* 26 40 45 Habiganj 26 40 45 Jhalokathi 50 36 46 Pirojpur* 36 31 36 HSCS areas Pirojpur 44 NA 44 Bhola 24 NA 24 Noakhali 21 NA 21 Percent of Births Attended by a Skilled
Doctor, Nurse or Midwife High intensity area Lakshmipur 45 45 45 Noakhali* 40 54 45 Habiganj 40 41 40 Jhalokathi 53 55 55 Pirojpur* 50 44 50 HSCS areas Pirojpur 50 NA 50
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 44 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Bhola 30 NA 30 Noakhali 38 NA 38 Percent of women with home births who consumed misoprostol to prevent post- partum hemorrhage High intensity areas Lakshmipur 30 20 20 Noakhali* 30 23 23 Habiganj 50 38 40 Jhalokathi 55 29 25 Pirojpur* 45 33 25 HSCS areas Pirojpur 32 NA 32 Bhola 25 NA 25 Noakhali 20 NA 20 Percent of newborns initiated breastfeeding within one hour after birth High intensity areas Lakshmipur 75 76 65 Noakhali* 72 64 60 Habiganj 85 84 80 Jhalokathi 70 70 55 Pirojpur* 63 63 55 HSCS areas Pirojpur 58 NA 58 Bhola 70 NA 70 Noakhali 76 NA 76 Percent of newborns received CHX application on their umbilical cord immediately following birth High intensity areas
Lakshmipur 60 38 25 Noakhali* 60 41 30 Habiganj 60 30 20 Jhalokathi 60 24 10 Pirojpur* 60 16 10 HSCS areas Pirojpur 35 NA 10 Bhola 35 NA 10 Noakhali 35 NA 10
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 45 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Percent of newborns receiving postnatal health check within two days of birth High intensity areas Lakshmipur: 20 21 36 Noakhali:* 20 35 47 Habiganj: 32 29 32 Jhalokathi: 33 40 48 Pirojpur:* 18 40 41 HSCS areas Pirojpur: 10 NA 10 Bhola: 10 NA 10 Noakhali: 20 NA 20 Modern contraceptive method prevalence rate High intensity areas Lakshmipur 55 50 55 Noakhali* 53 58 53 Habiganj 48 46 48 Jhalokathi 58 68 58 Pirojpur* 58 68 58 HSCS areas Pirojpur 55 NA 55 Bhola 58 NA 58 Noakhali 59 NA 59 Couple years of protection (CYP) in USG- supported programs Overall 1087492 110,311 901298 From DGFP Lakshmipur 163,817 28,486 138942 MIS Noakhali 235128 52,910 217475 From DGFP MIS From DGFP Habiganj 191,852 35,199 149475 MIS From DGFP Jhalokathi 77,389 12,211 51762 MIS From DGFP Pirojpur 139069 27,346 113933 MIS
From DGFP Bhola 263,795 48,034 229711 MIS
Intermediate Result 1: Improve service readiness through critical gap management
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 46 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Percent of targeted facilities that are ready to provide essential newborn care
High intensity areas Lakshmipur 90 81 90 Noakhali* 90 62 90 Habiganj 90 77 90 Jhalokathi 90 73 90 Pirojpur* 90 NA 90 HSCS areas Pirojpur 70 NA 70 Bhola 70 NA 70 Noakhali 70 NA 70
Percentage of public health facilities with functional bags and masks (two neonatal size mask) in the delivery room High intensity areas Lakshmipur 50 81 70 Noakhali* 50 81 70 Habiganj 50 86 70 Jhalokathi 50 85 70 Pirojpur* 50 NA 70
Percent of USG-assisted service delivery sites providing family planning (FP) counselling and/or services High intensity areas Lakshmipur 95 78 95 Noakhali* 95 88 95 Habiganj 99 90 99 Jhalokathi 95 76 95 Pirojpur* 95 NA 95 HSCS areas Pirojpur 17 NA 17 Bhola NA NA NA Noakhali 25 NA 25
Number of targeted facilities ready to provide delivery services 24 hours a day, seven days a week High intensity areas Lakshmipur 25 33 32 Noakhali* 19 30 30 Habiganj 39 48 42 Jhalokathi 21 16 21 MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 47 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Pirojpur* 4 NA 5 HSCS areas Pirojpur 9 NA 13 Bhola 32 NA 18 Noakhali 7 NA 7 Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by Only GOB temporary non-GoB health workers service provider positions are included High intensity areas Lakshmipur 10 2 10 FWV-2 FWV-11, Nurses-2, 15 14 15 OBGYN Noakhali* Consultant-1 Habiganj 10 10 10 FWV-10 Jhalokathi 10 1 10 FWV-1 Pirojpur* NA NA NA Sub-IR 1.2: Strengthen capacity of service providers to provide quality services
Number of people trained in 2,149 5986 16519 (2604 maternal/newborn health through USG- for MaMoni 4 supported programs districts and 13915 for national scale- up initiatives) Number of people trained in FP/RH with 225 -- 70 USG funds Number of people trained in child health 200 -- 0 and nutrition through USG-supported programs Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization Number of union level public health 75 121 101 facilities that are ready to provide normal delivery services High intensity areas Lakshmipur 29 25 Noakhali* 34 23 Habiganj 57 35 Jhalokathi 15 15 Pirojpur* NA 3
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 48 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Intermediate Result 2: Strengthen health systems at district level and below Number of district level quarterly 24 2 12 performance review meeting held for data-driven performance review and planning High intensity areas Lakshmipur -- 2 Noakhali* -- 2 Habiganj 1 2 Jhalokathi 1 2 Pirojpur* NA 1 Bhola NA 1 Intra partum still birth rate in project assisted facilities
High intensity areas <5/1000 NA NA Lakshmipur <5/1000 NA NA Noakhali* <5/1000 NA NA Habiganj <5/1000 NA NA Jhalokathi <5/1000 NA NA Pirojpur* <5/1000 NA NA Sub-IR 2.1: Improve leadership and management at district level and below Number of GoB managers supported for leadership and management capacity development
Lakshmipur NA NA NA Noakhali NA NA NA Habiganj NA NA NA Jhalokathi NA NA NA Pirojpur NA NA NA Bhola NA NA NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated 23 12 23 . comprehensive annual MNCH/FP/N plan High intensity areas Lakshmipur 5 0 5 Noakhali 4 0 9 Habiganj 8 8 8
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 49 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Jhalokathi 4 4 4 Pirojpur 2 NA NA Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting monthly meeting High intensity area Lakshmipur 95 99 90 Noakhali* 95 81 90 Habiganj 100 98 95 Jhalokathi 95 68 85 Pirojpur* 95 NA NA Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a supervision tool was used and findings shared with providers High intensity areas Lakshmipur 90 13 90 Noakhali* 90 125 90 Habiganj 90 142 90 Jhalokathi 90 125 90 Pirojpur* 90 NA 90 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas Lakshmipur <3 6 <2 Noakhali <3 2 <2 Habiganj <3 2 <2 Jhalokathi <3 0 <2 Pirojpur <3 0 <2 Sub-IR 2.6: Strengthen local government planning and engagement in health service provision Percentage of unions that had at least 50 percent of the estimated births registered within 45 days of birth
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 50 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) High intensity areas Lakshmipur 60 NA NA Noakhali* 60 NA NA Habiganj 60 NA NA Jhalokathi 60 NA NA Pirojpur* 60 NA NA Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of Union Parishads (UP) that spent funds to support MNCH/FP/N activities High intensity areas Lakshmipur 58 18 58 Noakhali* 44 15 44 Habiganj 77 34 77 Jhalokathi 32 10 32 Pirojpur* 15 NA NA Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GoB recruitment or redeployment in project areas
High intensity areas Lakshmipur 5 0 5 Noakhali 5 0 5 Habiganj 5 1 5 (FWA-1) Jhalokathi 5 0 5 Pirojpur* 5 NA 5 Sub-IR 3.1: Policy reforms in place to promote local planning and need- based human resource deployment in the public sector Number of policies/ strategies/guidelines on MNH developed/revised with MaMoni 4 1 4 HSS support Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program Number of program learning initiatives 10 -- 15 completed and disseminated Intermediate Result 4: Identify and reduce barriers to accessing health services
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 51 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Number of deliveries with a SBA in USG- assisted programs High intensity areas Lakshmipur 19,687 5511 19,687 Noakhali* 12,288 4016 12,288 Habiganj 25,896 6360 25,896 Jhalokathi 7,054 2049 7,054 Pirojpur* 2,658 596 2,658 HSCS areas Pirojpur 12,148 2826 12,148 Bhola 1,982 3982 1,982 Noakhali 37,848 2263 37,848 Number of antenatal care (ANC) visits by skilled providers from USG-assisted facilities High intensity areas Lakshmipur 53,730 34835 53,730 Noakhali* 43,414 26193 43,414 Habiganj 210,611 45572 210,611 Jhalokathi 16,553 10429 16,553 HSCS areas Pirojpur 44,612 5015 44,612 Bhola 68,546 22626 68,546 Noakhali 97,682 19556 97,682 Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Number of people reached through 666,143 195862 999215 project supported BCC activities High intensity areas Lakshmipur 200,000 -- 300000 Women -- Men -- Noakhali* 145,556 183198 218334 Women 88604 Men 94594 Habiganj 205,000 10596 307500 Women 8932 Men 1664 Jhalokathi 115,587 2068 173381 Women 1550
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 52 Achievement Indicator Target 2017 (January- Target 2018 Remarks March 2018) Men 518 Sub-IR 4.2: Enhance community engagement in addressing health needs Number of trained community volunteers 28,371 23,493 28,371 promoting MNCHFPN through project support
High intensity areas Lakshmipur 6,710 6130 6,710 Noakhali* 5,900 6701 5,900 Habiganj 8,379 8357 8,379 Jhalokathi 2,731 2305 2,731 Pirojpur* 1,205 0 1,205 Number of Community Action Groups 24,355 20,261 24,355 with an emergency transport system for maternal and newborn health care through USG-supported programs High intensity areas Lakshmipur 6,461 6018 6,461 Noakhali 3,876 4368 3,876 Habiganj 4,369 8076 4,369 Jhalokathi 3,746 1593 3,746 Pirojpur* 1,549 0 1,549 * High intensity upazilas
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 53 APPENDIX 4. ADDITIONAL NATIONAL LEVEL INDICATORS Achieve Target Target Indicator ment Remarks FY 17 2018 2017 Percentage of newborns receiving Source: DGFP MIS-3 and CHX application at birth in MOHFW EmONC report of DHIS-2 facilities National 50 82 60 Barisal 50 77 60 Chittagong 50 86 60 Dhaka 50 78 60 Khulna 50 91 60 Rajshahi 50 82 60 Rangpur 50 78 60 Sylhet 50 86 60 Number of upazilas where a review of Completed last quarter Newborn interventions held Total 326 NA 165 Barisal 42 NA Chittagong NA 100 Dhaka 124 NA Khulna 53 NA 7 Rajshahi 68 NA Rangpur NA 58 Sylhet 39 NA Number of Newborn for whom Source: DGFP MIS-3, resuscitation actions using bag and EmNOC mask were initiated Total 14,817 5912 16272 Barisal 640 302 7,03 Chittagong 3,137 1572 3,445 Dhaka 4,453 1451 4,890 Khulna 1,952 719 2,144 Rajshahi 1,995 696 2,191 Rangpur 1,716 657 1,885 Sylhet 924 516 1,015 Number of Union Health and Family Welfare Centers (UH&FWCs) in the Source: Project report project area using electronic MIS tools Total 130 176 71 Lakshmipur 51 42 Noakhali 69 44 Habiganj 61 70 Jhalokati 35 29 Pirojpur NA NA NA Bhola NA NA MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 54 Achieve Target Target Indicator ment Remarks FY 17 2018 2017 Number of districts having an active
Quality Improvement (QI) committee Total 32 22 64 Barisal 3 5 6 Chittagong 6 8 11 Dhaka 9 0 17 Khulna 5 4 10 Rajshahi 4 3 8 Rangpur 3 0 8 Sylhet 2 2 4
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 55 APPENDIX 5: MAMONI HSS PROGRAM LEARNING AND DOCUMENTATION MATRIX MaMoni HSS will contribute to the following learning priorities over the life of the project:
Lead Sl Area/Topic Product Current status Partner MANUSCRIPTS
COMPLETED 1 Partograph Manuscript MaMoni HSS Submitted to PLOS One 2 FP-PM Manuscript MaMoni HSS Submitted to Global Health: Science and Practice journal
3 GIS Manuscript Manuscript Submitted to BMJ Global Health ONGOING 4 Integrated MNH at UHFWCs, focus Manuscript MaMoni HSS Analysis ongoing on day of birth 5 PSBI JHU/IIP Early June MaMoni HSS 6 CHX Scale Up Manuscript MaMoni HSS Format drafted with JHU/IIP
7 MCSP Systematic Scale Up (CHX Manuscript TBD Bangladesh) 8 Private CSBA - income viability, 3 Manuscripts MaMoni HSS, Analysis ongoing service delivery in underserved areas JHU/IIP (reducing inequities)
9 QI - district
10 Tracer survey Manuscript Ongoing
11 Equity Manuscript Ongoing
12 Leadership Manuscript JHU Data analysis ongoing 13 Severe preeclampsia/Eclampsia Program Brief, Maybe MaMoni HSS Program brief Manuscript drafted, data analysis ongoing PROCESS DOCUMENTATION
DRAFTED / COMPLETED
14 KMC Poster presentation Completed
15 Partograph Research Brief Completed
16 FP-PM Research Brief Completed
17 ANC Research Brief Completed
18 PCSBA Income Viability Research Brief Completed
ONGOING
19 PSBI Report & Research brief Final draft under review
20 ACS Program Brief Completed
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 56 Lead Sl Area/Topic Product Current status Partner
21 SCANU Program brief Data analysis ongoing
22 Integrated MNH at UHFWC's; focus Program Brief Analysis ongoing on day of birth
23 KMC Program Brief Completed
24 CHX Scale-up Process Ongoing Documentation/Report
25 CHX Scale-up Program Brief Completed
26 QI Summary of MHSS Interventions Report Ongoing
27 Misoprostol + CHX CBD in Program Brief Program brief Lakshmipur drafted, data analysis ongoing
28 PP-FP Program Brief Program brief write-up ongoing
29 Nutrition Program Brief Program brief drafted
30 eMIS Program Brief Ongoing
31 HRH Program Brief Complete
32 E/PE Case Detection: FWV's & BP Research brief Data analysis ongoing
33 LARC discontinuation Research Brief Data analysis (formative findings, not completed and the intervention) shared
34 Planning and Management Research Brief (Case Ongoing study of three upazilas)
35 SPA - limit to union level, looking at Program Report Ongoing national and MaMoni
36 Community mobilization Program report & PPT End March
37 Local government & community Program brief Ongoing engagement
38 Logistics & SCM Program Brief Analysis ongoing
39 Reducing MMR by Strengthening Program Brief Ongoing Service Readiness at Targeted Facilities
40 MCSP/PSBI Synthesis of learning: Report Ongoing 10yr Ethiopia + Bangladesh
MaMoni Health Systems Strengthening Activity: FY18 Q2 Quarterly Report 57