Maternal and Child Survival Program Quarter 2 Report – January 1‐ March 31, 2017

Submission Date: April 30, 2017 Cooperative Agreement Number: AID-OAA-A-N-00028 [COR/AOR/Activity Manager] Name: AOR (Dr. Nahed Matta) Activity Manager Name: (Dr. Mary Kabanyana)

Submitted by: Dr. Stephen Mutwiwa, Chief of Party Jhpiego Corporation KN 8 Avenue, Kacyiru National Police Road , Rwanda Tel: +250-78-830-8191 Email: [email protected]

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PROGRAM OVERVIEW

Program Name: MCSP

Start Date And End Date: April 2015-September 30, 2018

Name of Prime Implementing Jhpiego Corporation Partner: [Contract/Agreement] AID-OAA-A-N-00028 Number: Jhpiego (lead) – maternal health, family planning/reproductive health, quality improvement and gender; JSI – child health; Save the Children – newborn health, Partner Organizations adolescent sexual and reproductive health, and community mobilization; ICF – community mobilization; R4D – health systems strengthening

Ministry of Health – Rwanda Biomedical Center (RBC) including the Maternal Child and Community Health (MCCH) Division, the Malaria and Other Parasitic Key Partners Diseases Division (Mal&OPDD), Rwanda Health Communication Center (RHCC); WHO/AFRO, UNICEF, and other USAID implementing partners

Reporting Period: January 1 to March 31, 2017 RMNCH districts- Nyaruguru, Nyamagabe, Huye, Musanze, Nyabihu, Kamonyi, , Gatsibo, Rwamagana and Ngoma.

Geographical coverage ICCM districts - Kayonza, Kirehe, Ngoma, Gasabo, Kicukiro, Nyarugenge and Ruhango

IST Districts- Huye and Kamonyi

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CONTENTS PROGRAM OVERVIEW ...... 2 CONTENTS...... 3 ACRONYMS AND ABBREVIATIONS ...... 4 PROGRAM DESCRIPTION ...... 6 Program Goal and Overall Objective ...... 6 MCSP RESULTS FRAMEWORK ...... 7 ACTIVITY IMPLEMENTATION PROGRESS...... ……………9 1. Overview of Progress ...... 9 2. Implementation Progress ...... 11 2.1. SO1: Improve the quality, equity, gender sensitivity and sustainability of RMNCH services along the continuum of care ...... 11 2.2. SO2: Support for scale‐up of high‐impact interventions to improve RMNCH and malaria outcomes in public and private sectors ...... 24 2.3. SO3: Increase community mobilization for, participation in, and utilization of high‐quality RMNCH and malaria services ...... 26 2.4. SO4: Build capacity to use data for decision and action at all levels of the health system ...... 30 2.5. SO5: Increase capacity to manage and control malaria in Rwanda ...... 32 3. Implementation Challenges ...... 34 4. Collaboration with other partners, including USG funded projects ...... 34 5. International Travel ...... 34 6. Short Term Technical Assistance (STTA) ...... 35 7. Management and Administrative Issues ...... 35 8. Lessons Learned ...... 35 9. Sub‐grant Management ...... 36

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ACRONYMS AND ABBREVIATIONS ACT Atemisinin-based Combination Therapy ANC Antenatal Care ASM Animatrice de santé maternelle ASRH Adolescent Sexual and Reproductive Health BCC Behavior Change Communication BEmONC Basic Emergency Obstetric and Newborn Care CAC Community Action Cycle CBMNH Community Based Maternal and Newborn Health CHW Community Health Worker CM Community Mobilization CSO Civil Society Organization CVI Community Vision Initiative DH District Hospital DHIS District Health Information System DHMT District Health Management Team DHS Demographic and Health Survey DQA Data Quality Assessment EmONC Emergency Obstetric and Newborn care ENC Essential Newborn Care EPCMD Ending Preventable Child and Maternal Deaths ETAT Emergency Triage Assessment and Treatment FANC Focused Antenatal Care FP Family Planning GBV Gender-Based Violence GIS Geographic Information Systems HBB Helping Babies Breathe HC Health Center HII High Impact Interventions HMIS Health Management Information System ICATT IMCI Computerized Adapted Training Tool iCCM Integrated Community Case Management IEC Information, Education, and Communication IFA Iron and Folic Acid IMCI Integrated Management of Childhood Illness IPV Intimate Partner Violence IRB Institutional Review Board IST Intermittent Screening and Treatment IUD Intrauterine Device JHU Johns Hopkins University KMC Kangaroo Mother Care LAM Lactational Amenorrhea Method LARC Long-Acting Reversible Contraception LDHF Low Dose High Frequency M&E Monitoring and Evaluation

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Mal&OPDD Malaria and Other Parasitic Disease Division MCCH Maternal Child and Community Health MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MIP Malaria in Pregnancy MNCH Maternal, Neonatal, and Child Health MNH Maternal and Newborn Health MOH Ministry of Health MPDSR Maternal and Perinatal Death Surveillance and Verbal Autopsies MSH Management Sciences for Health NMCP National Malaria Control Program NSV No Scalpel Vasectomy OJT On the Job Training PMI Presidents Malaria Imitative PNC Postnatal Care PPFP Postpartum Family Planning PPH Postpartum Hemorrhage PPIUD Postpartum Intrauterine Device QI Quality Improvement RAM Rwanda Association of Midwives RBC Rwanda Biomedical Center RDT Rapid Diagnostic Test RFHP Rwanda Family Health Project RHCC Rwanda Health Communication Center RHSSA Rwanda Health Systems Strengthening Activity RICH Rwanda Interfaith Council for Health RMC Respectful Maternity Care RMNCH Reproductive, Maternal, Newborn and Child Health RNEC Rwanda National Ethics Committee RPA Rwanda Pediatric Association RSOG Rwanda Society of Obstetrics and Gynecology SBCC Social and Behavior Change Communication SFH Society for Family Health SRH Sexual Reproductive Health STTA Short-Term Technical Assistance TOT Training of Trainers TWG Technical Working Group USAID U.S. Agency for International Development WHO World Health Organization

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PROGRAM DESCRIPTION

MCSP Rwanda is part of the wider Maternal and Child Survival Program (MSCP) which is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in over 25 priority countries with the ultimate goal of ending preventable maternal and child deaths (EPMCD) within a generation. MCSP engages governments, policymakers, private sector leaders, health care providers, civil society, faith-based organizations and communities in adopting and accelerating proven approaches to address the major causes of maternal, newborn and child mortality such as postpartum hemorrhage (PPH), birth asphyxia and diarrhea, respectively, and seeks to improve the quality of health services from the community to the hospital. In Rwanda, MCSP supports the Ministry of Health to tackle these issues through approaches that focus on health systems strengthening, community mobilization, gender integration and e-Health, among others. This is in support of the Government of Rwanda’s Vision 2020, Economic Development and Poverty Reduction Strategy (2013–2018) and USAID/Rwanda’s commitment to ending preventable child and maternal deaths.

Program Goal and Overall Objective The overall objective of MCSP in Rwanda is to strengthen the capacity of the Ministry of Health (MOH) to manage and scale up high-impact RMNCH interventions and strengthen Malaria prevention and control efforts. The program has five strategic objectives underneath this overall objective: 1. Improve the quality, equity, gender sensitivity and sustainability of RMNCH services along the continuum of care 2. Support the scale-up of high-impact interventions to improve RMNCH outcomes in the public and private sectors 3. Increase community mobilization for, participation in and utilization of high-quality RMNCH and malaria services 4. Build capacity to use data for decision-making and action at all levels of the health system 5. Increase capacity to manage and control malaria in Rwanda

In Rwanda, MCSP is building upon the previous successes of USAID’s investments like MCHIP and RFHP and aims to achieve the goal of accelerating the reduction of preventable child, neonatal and maternal mortality in selected 10 districts and supporting implementation of the National Malaria Strategic Plan in 7 districts.

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MCSP RESULTS FRAMEWORK Overall Objective : STRENGTHEN THE CAPACITY OF THE MOH AT CENTRAL AND DECENTRALIZED LEVEL TO MANAGE AND SCALE UP HIGH-IMPACT RMNCH INTERVENTIONS Quality Scale-up Community Engagement Data for Decision-Making Malaria SO1. Improve the quality, SO2. Support the scale-up of SO3. Increase community SO4. Build capacity to use data SO5. Increase capacity to manage and equity, gender sensitivity and high-impact interventions to mobilization for, participation for decision and action at all control malaria in Rwanda sustainability of RMNCH improve RMNCH outcomes in in, and utilization of high-quality levels of the health system services along the continuum public and private sectors RMNCH and malaria services of care 1.1 Ensure clinical competence 2.1 Support the scale up of 3.1 In partnership with national 4.1 Strengthen existing capacity 5.1 Support early detection and and readiness at all levels, evidence-based RMNCH MoH counterparts, build to collect, manage and utilize treatment of MIP including CHWs and interventions and strategies district and health center data for decision-making at all community systems capacity to plan for and levels of the health system coordinate integrated service delivery by CHWs (as complementary to SO1) 1.2 Strengthen CQI for Clinical 2.2 Generate and utilize 3.2. Support district social 4.2 Targeted support for 5.2 Enhance community surveillance, case RMNCH services and their program learning to prioritize clusters to strengthen capacity capacity building for the use of investigation, and epidemic response in management at facility and program activities for of sector level social clusters data driven systems epidemic-prone districts community levels institutionalization and and health center staff to informed scale-up catalyze community mobilization and engagement processes 1.3 Strengthen quality of 2.3 Scale up Youth friendly 3.3 Contribute to improved 4.3 Support MoH to analyze 5.3 Contribute to strengthening quality youth-friendly services centers and services in processes for quality and use MPDSR data standards for malaria diagnostics supported districts improvement of health services at the community level, including community accountability approaches 1.4 Strengthen quality of 3.4 Strengthen capacity for 4.4 Strengthen capacity to 5.4 Provide support to Mal&OPDD’s transformative, gender- increased community generate and use data related M&E, supervision, and management sensitive services awareness of and response to to GBV services efforts at national and district levels GBV

Overall Objective : STRENGTHEN THE CAPACITY OF THE MOH AT CENTRAL AND DECENTRALIZED LEVEL TO MANAGE AND SCALE UP HIGH-IMPACT RMNCH INTERVENTIONS Quality Scale-up Community Engagement Data for Decision-Making Malaria 1.6 Strengthen capacity for 3.6 Provide strategic support 4.5 Support peer CQI review 5.5 Strengthen iCCM services in 7 MCSP- detection and management of to the Rwanda Health meetings across supported supported districts gender-based violence in all Communication Center districts to facilitate sharing of MCSP-supported districts (RHCC) in development of best practice and learning integrated SBCC messaging and curricula 1.7 Support implementation of 3.7 Strengthen advocacy for 4.6 Support implementation of the MPDSR. high impact RMNCH accreditation standards in interventions and fistula care at supported districts for all levels of decision making improved RMNCH outcomes 1.8 Strengthen referral systems 4.7 Track referral systems across all supported across all supported interventions interventions

ACTIVITY IMPLEMENTATION PROGRESS Overview of Progress

This report highlights Reproductive, Maternal, Newborn, and Child Health (RMNCH) and malaria activities, implemented between January 1st and March 31st, 2017 (FY17 Q2). Following the standard collaborative approach, the project worked with MoH and RBC to develop a quarterly work plan prior to actual implementation of activities. An overview of implemented activities by technical area is presented below.

MCSP supported implementation of a variety of activities under maternal health including: introduction of Uterine Balloon Tamponade (UBT) for prevention of PPH, orienting health providers from Rwamagana, Shyira, Kaduha, Kigeme, Munini and Kabutare on triage and rapid response to maternal emergencies, conducting fistula screening for 44 clients and successful repair of 5 cases, assessment of a potential capacity building center at Kigeme Hospital, mentorship of health providers on focused antenatal care (FANC) and basic emergency obstetric and newborn care (BEmONC) in collaboration with Rwanda Association of Midwives (RAM) and district-based mentors as well as mentorship of medical doctors in comprehensive emergency obstetric and newborn care (CEmONC) in collaboration with the Rwanda Society of Obstetricians and Gynecologists (RSOG) in all RMNCH supported districts.

Since FY16, MCSP has been supporting the development of the National MNCH Strategy and the National FP/ASRH Strategy in collaboration with MOH, RBC, UNFPA and WHO. In this reporting period, a stakeholders meeting was held for the MNCH strategy and key stakeholder interviews began. The questionnaires for the FP and ASRH pieces were also drafted in this quarter. It is anticipated that both of the draft strategies will be ready for review in the next quarter.

MCSP also supported low dose-high frequency (LDHF) essential newborn care (ENC) training of 92 health care providers from Nyabihu, Nyamagabe and Nyaruguru, ENC mentorship for 168 health care providers from 10 districts, supervision of 28 ENC mentors by MCSP staff, mentorship on care of sick newborn in 12 hospitals in collaboration with Rwanda Pediatric Association (RPA). The project also organized a quarterly mentorship coordination meeting. Oversight visits during ENC mentorship were also conducted to support documentation of quality of care indicators and implementation of recommendations from national scale up workshops. Under child health, MCSP supported integrated management of childhood illness (IMCI) mentorship and on the job training (OJT) on IMCI priority skills in 10 districts and updating of the national ICATT.

Capacity building activities on family planning (FP) clinical skills were supported in Huye, Nyabihu, Nyagatare and Nyamagabe districts. These included OJT in all FP methods, FP mentorship, training on postpartum family planning (PPFP) training and FP permanent methods. At the community level, there was community based provision of family planning (CBP-FP) training and mentorship of community health workers (CHWs) on FP in Gatsibo, Musanze and Nyagatare districts.

In addition, MCSP supported FP coordination/mobilization activities including a coordination meeting of FP focal points countrywide, an orientation workshop of district local leaders on FP and an FP campaign in Huye. Family planning kits and materials were also distributed to supported health facilities (PPFP and IUD interval kits). Regarding adolescent sexual reproductive health (ASRH), MCSP trained 24 ASRH district based mentors, supported sensitization of youth and young people on adolescent risk behavior prevention (4,839 individuals reached) and developed ASRH monitoring and evaluation (M&E) tools, to capture use of health services and participation in IEC sessions by youth, that were validated by the ASRH technical working group (TWG).

In order to promote gender integration in RMNCH services, MCSP supported district based gender trainers to conduct supportive supervisions at 162 MCSP supported health centers, implementation of a baseline assessment using a gender-based violence (GBV) quality assurance tool at Kigeme, Munini, Nyagatare and Shyira Isange One Stop Centers (IOSCs) and integration of routine GBV screening into ANC/FP services at supported health facilities. MCSP also supported MIGEPROF to organize the International Women’s Day (IWD) and contributed to implementation of ASRH activities during the women’s month.

9 MCSP oriented mentor candidates on integrated community case management (iCCM) mentorship in 4 supported districts (Kirehe, Ruhango, Kayonza and Gasabo) followed by initiation of iCCM mentorship in the same districts. MCSP also continued to support community mentorship activities in Ngoma and Kicukiro districts, validated iCCM training materials and tools, resumed intermittent screening and treatment (IST) study recruitment and applied for institutional review board (IRB) review of the KAP survey.

In support of social and behavior change communication (SBCC)/community mobilization (CM) initiatives, MCSP held an orientation meeting with district authorities on the community action cycle (CAC) approach in 3 RMNCH supported districts (Gatsibo, Nyabihu and Musanze), organized workshops to develop and finalize district communication action plans in the 7 remaining RMNCH districts and oriented district trainers on community action cycle in 2 districts (Gatsibo and Nyabihu). In addition, the project organized a workshop to review CB-MNH/PPH translated documents and conducted CB-MNH community health mentorship orientation for candidate mentors from Kamonyi and , and supported a CB-MNH training of trainers in .

In quarter 2, MCSP continued to support RMNCH and malaria data management and use for programing and quality improvement across supported districts. The team worked with the MoH HMIS team and national level performance based financing (PBF) staff to revise the new health management information system (HMIS) reporting template as well as the PBF checklist to match changes reflected in the new postnatal care guidelines. Updated versions were then shared with all hospitals countrywide. MCSP also collected information on use of new postnatal care tools and availability of tracer drugs and lifesaving equipment in delivery rooms. The team also conducted integrated supervision in Huye, Musanze, Nyabihu, Nyamagabe, Nyaruguru, Nyagatare, Rwamagana, Gatsibo and Kamonyi, data quality assessment (DQA) on FP and RMNCH indicators in Musanze, Huye, Nyamagabe, Nyabihu, Gatsibo, Nyagatare and data quality review in the 7 iCCM supported districts.

In addition, the project supported district level technical coordination meetings in Nyamagabe, Nyaruguru, Nyabihu, Kamonyi, Huye, Rwamagana, Gatsibo, Nyagatare, Musanze and Ruhango and organized RapidSMS training of trainers in Nyagatare, Gatsibo, Huye, Gasabo, Kirehe and Ruhango and training of new CHWs on RapidSMS in Huye, Ruhango, Nyagatare, Gatsibo, Kicukiro, Gasabo and Kayonza.

At the request of the Honorable Minister of health, MCSP worked with the MoH HMIS team to analyze and present results of key MNCH indicators in MCSP supported Districts to the MoH during an inner senior management meeting.

In support for quality improvement of health services at supported health facilities, MCSP worked in collaboration with the ministry of health to conduct an experience sharing workshop with hospital accreditation officers and quality improvement (QI) focal points from the 12 RMNCH supported hospitals. Furthermore, the project supported QI supportive supervision conducted by hospital QI staff at health centers in their respective catchment areas at all 10 RMNCH supported districts.

During quarter 2, MCSP supported district health management team (DHMT) meetings in Ngoma, Nyagatare, Huye, Musanze, Nyaruguru, Nyamagabe, Nyabihu, Nyarugenge districts, CHWs quarterly coordination meetings in all 16 districts, annual DHMT supervision visits in Rwamagana and Nyagatare districts, Ngoma and open days conducted by the district Joint Action Development Forum (JADF).

Overall, the total number of individuals benefiting from MCSP capacity building activities this reporting period were 1,898 (597 males and 1,301 females). This includes 138 health providers trained in ENC; 109 health providers in FP/RH and 1,307 CHWs in CBP/FP; 44 lab technician in malaria diagnostic and 13 lab technician in semen analysis; 82 CM/SBCC trainers; 24 ASRH mentors; 122 in GBV prevention and management and 59 in maternal/newborn health. This is expected to contribute to improved management of childhood illness, provision of family planning services, quality of maternal and newborn health care services, data use and community health services respectively.

Over the next period, MCSP will continue to work in collaboration with MoH to support health facilities to increase access and quality of RMNCH services in order to improve RMNCH outcomes in Rwanda.

10 IMPLEMENTATION PROGRESS

SO1: Improve the quality, equity, gender sensitivity and sustainability of RMNCH services along the continuum of care

Maternal Health Orientation on Uterine Balloon Tamponade for PPH Management MCSP conducted a one-day orientation workshop on utilization of Uterine Balloon Tamponade (UBT) for management of PPH due to uterine atony. It was attended by 26 participants including medical doctors and midwives in charge of maternity services from the 12 MCSP supported hospitals, 2 representatives from RSOG and 1 representative from RAM. The theoretical session of the orientation focused on indications and contra-indications of UBT, how to assemble a UBT kit, description of the UBT technique and how to monitor a client with a UBT. After the theoretical session, participants practiced UBT on anatomic models to gain skills in the procedure. A key message of the workshop was the importance of implementing UBT as part of a comprehensive approach to manage PPH.

UBT for PPH due to uterine atony was also presented to the Safe Motherhood TWG and to the MCH TWG. The intervention was received with Figure 01: Lisa Noguchi (MCSP) demonstrates the use of Uterine Balloon much interest as PPH is still the leading cause of Tamponade to workshop participants maternal mortality in Rwanda.

The Safe Motherhood TWG recommended that the procedure be implemented in Rwanda and that all staff working in maternity should be trained on the procedure starting with hospitals and health centers in a few districts before scaling up countrywide. A concept note on UBT will be submitted to the MoH leadership for their approval before rollout.

Obstetric Fistula Screening and Repair MCSP conducted fistula screening and repair for clients in Nyamagabe, Rwamagana and Nyagatare districts. In total, 44 clients were screened (Kaduha: 4, Kigeme: 16, Rwamagana: 11, Nyagatare: 13) and 6 were operable cases (2 RVF and 4 VVF). Five of these were eligible for repair and were successfully repaired. One client who was not repaired was a 72-year-old with high blood pressure who was first admitted to internal medicine for follow up. Eight cases were found to be inoperable - most of whom had undergone surgery in previous years and developed complications such as severe vaginal fibrosis and urethral stenosis. The lack of specialized experts to repair complicated cases remains a challenge. The other clients were found to be cases of stress incontinence, vesical and rectal prolapse, advanced stage cervical cancer (2 cases) and others had no gynecological abnormality.

During the exercise, a USAID Communications team from Washington, DC visited the repair site and had the opportunity to interact with the Ruhengeri hospital management team, the team of doctors conducting the fistula repairs, clients waiting for repair, post-op clients and women whose fistula had been successfully repaired during previous campaigns who shared their testimonies about how their lives had been completely transformed after the surgery. Figure 02: USAID team listens to testimonies from 3 Orientation Workshop on Triage and Rapid Response to women who had undergone successful fistula Maternal Emergencies

11 Since maternal emergencies may occur any time and in any setting with maternity services, facilities need to be prepared to perform good triage and provide rapid response to the emergencies in order to reduce maternal mortality. For this reason, MCSP conducted a one-day orientation workshop with Rwamagana, Kaduha, Kigeme, Munini, Huye and Shyira hospital teams on triage and rapid response to maternal emergencies.

The objectives of the workshop was to describe potential maternal emergencies that exist in their hospitals, discuss key challenges they face in terms of rapid and effective response to maternal emergencies, suggest feasible solutions for improvement according to their context and develop action plans to guide implementation of actions for improvement. Each hospital team included the hospital director, hospital administrator or HR, medical doctor in charge of maternity, midwife in charge of maternity, chief anesthetist, a representative of the hospital quality improvement committee, head of laboratory, head of pharmacy, head of surgery, one staff from the maintenance department, transport officer in charge of ambulances, head of neonatology, monitoring and evaluation officer, night and weekend duty coordinator (where applicable), clinical director, head nurse and MCH supervisor. A total of 65 participants were oriented.

Based on each hospital’s identified gaps, action plans were developed to improve effective triage and rapid response to maternal emergencies and core teams were established to coordinate Figure 03: Kaduha hospital team working on action plans to improve rapid response to implementation of the action plans. maternal emergencies

Development of a Pool of RAM Mentors MCSP sub granted to the Rwanda Association of Midwives to help strengthen mentorship on BEmONC, FANC, ENC and postnatal care (PNC) and to conduct formative supervision of district based mentors in 10 RMNCH supported districts. The first activity involved creation of a pool of competent mentors by orienting them on clinical training skills as well as clinical mentorship principles and procedures. A total of 79 RAM mentors were oriented by MCSP.

Figure 04: RAM candidate mentors practice clinical coaching during clinical training skills course

FANC and BEmONC Mentorship MCSP supported continuous BEmONC and FANC mentorship conducted by district based mentors and RAM mentors in 10 RMNCH supported districts in order to improve the quality of maternal and newborn health care. In total, 171 health facilities were visited by BEmONC mentors and 243 health care providers were

12 mentored while 159 health centers were visited by FANC mentors and 189 health care providers were mentored.

Orientation Meeting on Mentorship with District Level Stakeholders MCSP organized a one-day meeting with district level stakeholders in Nyabihu, Nyagatare, Gatsibo, Huye, Nyamagabe and Nyaruguru to create common understanding on the continuous mentorship which is scheduled to follow LDHF on BEmONC and to have their support for its successful implementation.

The district stakeholders who attended the meeting in each district included the hospital director, district health unit director, heads of health centers, district based BEmONC and FANC mentors, MCH supervisor, hospital M&E officer and the head nurse.

Figure 05: The Director of Nyagatare Hospital explains the need for joint support from stakeholders for successful implementation of BEmONC mentorship

Mentorship Quarterly Coordination Meeting in Rwamagana MCSP organized a meeting in Rwamagana Hospital to harmonize the way mentorship activities are implemented across all technical areas including BEmONC, FANC, FP, ENC and IMCI. In total, 48 participants attended the meeting including the district health unit director, hospital director, M&E officer, MCH supervisor, heads of health centers and BEmONC, FANC, ENC, FP, IMCI district based mentors and RAM mentors. During the meeting, participants discussed challenges faced by mentors during their mentorship as well as solutions to resolve the challenges. The challenges included lack of inclusion of mentorship in routine health facility schedules, lack of ownership of the activity by some of heads of facility (which affected availability of mentees) and delayed decision making in some hospital maternity departments. To address these challenges, mentors established and shared mentorship plans for integration in health facility work schedules, sensitized heads of health facilities about the benefits of mentorship and supported hospitals to develop QI projects to prevent delayed decision making in maternity departments.

Integrated BEmONC/ENC Mentorship A team of MCSP staff composed of 2 maternal health coordinators, 2 newborn coordinators and 1 obstetrician- gynecologist conducted an integrated BEmONC and ENC mentorship exercise in Kabutare district hospital (DH) and 5 HCs. The main objective was to mentor health care providers working in maternity services at the hospital and the health centers to improve service delivery and health outcomes of maternal and newborn care services. The exercise lasted 5 days and allowed the team to identify gaps in the skills of health care providers and in the work environment and implement actions to address these gaps.

13 Table 1: Challenges and Solutions Identified during Integrated BEmONC/ENC Training

Challenges Encountered Implemented Solutions Inadequate use of partographs for labor Mentorship of all staff working in maternity on monitoring both at Kabutare hospital and the 5 effective use of partographs for labor monitoring health centers;

Poor APGAR evaluation. Presentations of AGRAR score evaluation and birth asphyxia were done during morning staff meetings Birth asphyxia audits not systematically done; Sensitization of head nurses, heads of maternity and neonatology and the clinical director to conduct birth asphyxia audits Medical doctors in need of capacity building on Mentorship of medical doctors working in maternity C/Section; on C-section by RSOG mentors Lack of isolation area for cases with post-operative It is expected that this infrastructure problem will be surgical site infections at Kabutare Hospital; resolved in a few months since the hospital is building another maternity and neonatology wards. High turnover of staff, especially medical doctors in This is a long standing issue in the country. MoH is Kabutare hospital; working on strategies to improve retention of health care providers in public facilities. PNC not properly done; registers for PNC and post Presentation on PNC were done during all staff abortion care (PAC) not well filled; meetings at facility level to show the importance of PNC in identifying newborn dangers signs and preventing newborn deaths. The PAC package was explained to maternity department staff and they were encouraged to improve documentation in PAC registers. No magnesium sulfate available in maternity of the 5 Requisition from the district pharmacy was done during visited health centers; the mentorship exercise 0.5% chlorine solution for decontamination unavailable Requisition from the district pharmacy was done during in Kabutare DH and 1 HC. the mentorship exercise

14 CEmONC Mentorship MCSP worked with RSOG to mentor medical doctors from the 12 RMNCH supported hospitals aimed at improving their skills in performing safe caesarian sections and in managing obstetrical complications. So far up to 60 medical doctors are being mentored (5 per hospital) and there is evident improvement in theatre preparedness (use of surgical check lists), a decrease in misuse of antibiotics and a decrease in post-operative infections in Rwamagana, Figure 06: A mentee performs C/Section under supervision of a mentor Ngoma, Kigeme and Munini hospital.

Assessment of Potential Capacity Building Centers As agreed with RBC’s MCCH division, Munini and Kigeme hospital were assessed as potential capacity building centers and Kigeme was selected to be the capacity building center. The hospital has a new building with two separate rooms that can be used for this purpose.

The MCCH division also requested MCSP to establish an additional capacity building center at Kibungo hospital. MCSP plans to equip the two capacity building centers over the next period.

Figure 07: Potential capacity building center at Kigeme DH Hospital

Newborn Health OJT and Mentorship on Neonatal Protocols During quarter 2, MCSP supported 24 pediatricians from RPA to continue mentorship on neonatal protocols at each of the 12 RMNCH hospitals. The main activities implemented include:

15 Development of QI projects for each neonatal service with objectives, methods of measurement, baselines, targets and action items (e.g. reduction of birth asphyxia cases by 50% in Ruhengeri hospital, reduction of newborns admitted to neonatology with hypothermia from 65% to 15% in Rwamagana hospital, etc.). The mentors also supported mentees to measure their progress, through review of routine data on morbidity and mortality due to birth asphyxia, prematurity and neonatal sepsis. As a result, positive changes have been created at facility level:  Mentees feel free to call their mentors at any time for advice in managing cases or when a referral is needed.  Mentors play a role in advocating for improved working environment  Improved mentor-mentee rapport Sessions on neonatal protocols focused on: Figure 10: A pediatrician demonstrates the use of CPAP to  Neonatal resuscitation (theory) health care providers  Neonatal resuscitation (practical sessions): all mentees either did hands-on or simulated neonatal resuscitation  Neonatal sepsis

Bedside teaching was done during ward rounds and complicated cases were discussed between mentors and mentees. Lectures were given immediately after the staff meetings and a total of 71 mentees benefited from the on job training.

As a result of mentorship, all neonatal staff are able to use CPAP to manage preterm babies with respiratory distress. Other equipment for newborn service, such as incubators, radiant warmers, syringe pumps and phototherapy machines are also being utilized. Fluid and feeding management of pre-term babies is improving and so is the use of protocols in general.

Supervision of District-based ENC Mentors The MCSP newborn health team conducted oversight supervision of 28 ENC mentors to ensure that the mentorship exercise was being conducted and that high impact interventions were well implemented. The main finding was that ENC mentorship is effective at all visited health facilities. Essential newborn care procedures are now routine practice, including early breastfeeding within 1 hour, immediate skin to skin for at least 1 hour for prevention of hypothermia, Vitamin K to all babies, delayed cord clamping and clean dry cord care. Newborn resuscitation is improving for all mentees but there is still need to reach all staff working in maternity at some facilities. Practical helping babies breathe (HBB) simulation exercises using anatomic models was not performed regularly. To address this, the team recommended heads of facilities to support and follow up this peer mentorship activity. Compliance with PNC guidelines and use of pre-discharge checklists was still unsatisfactory, especially in district hospitals.

16 Oversight Supervision of RPA Mentors MCSP provided oversight supervision for 8 pediatricians during RPA mentorship at Remera Rukoma, Kigeme, Kabutare and Nyagatare DH. It was aimed at verifying and ensuring the quality of mentorship provided by the pediatricians. It was evident that the mentorship conducted by RPA was well appreciated by mentees and by the hospital leadership. A good working relationship has been developed between mentors and mentees and their communication is easy and unhindered. Planned sessions were all given according to schedule, mentees are implementing action items on their QI projects and ward rounds are done together with mentees (doctors or nurses). However, PNC documentation is still a challenge in all visited hospitals. After each visit, meetings were held with hospital leaders and mentors to provide feedback and recommendations.

Birth Asphyxia Case Study In collaboration with the head of the MCCH division of RBC, MCSP supported the development of a summary birth asphyxia case study for Rwanda that was shared with WHO to be published in the Every Newborn Action Plan report for 2017. This will be presented in the World Health Assembly in May 2017.

Child Health IMCI Mentorship MCSP continued to support IMCI mentorship in all 163 health centers in the 10 RMNCH supported districts to improve the quality of care for sick children. The district based mentors trained through MCSP’s support performed monthly visits to the providers who had completed LDHF training on IMCI and any other providers working in IMCI units who may have received IMCI training under previous initiatives. During mentorship visits, mentors conducted a variety of activities with their mentees including: Case management observation, performance evaluation and provision of immediate feedback and on-site coaching to the mentees, review of IMCI registers, followed by feedback to the providers regarding adherence of recorded cases to the guidelines, Setup or reorganization of the overall flow of patients, including the oral rehydration therapy corner, On site follow-up of the cases managed with the mentees through phone consultation, Selection and registration of candidates for IMCI OJT (detailed in next section), Setting up ICATT software in facility computers for use by providers as self-training, Checking the availability of drugs that are frequently used in IMCI, Meeting the management of the health centers for advocacy purposes.

A total of 233 mentorship visits were conducted between January and March 2017, reaching 321 providers. In addition, the mentors spent over 35 hours in phone correspondence with their respective mentees on IMCI related cases between the mentorship visits, and ensured follow-up once back to the site.

As a result of the mentorship more than 60% of all providers in the facilities have developed the capacity to assess and appropriately manage a child with danger signs including administration of urgent pre-transfer treatment and oral rehydration therapy corners with adequate supplies were established in health facilities where they did not exist previously.

Improving Access to Health Care for Children in Ruhengeri Prison At the orientation meeting on Low Dose High Frequency approach held in Musanze in July 2016, the head of Ruhengeri Prison Health Center expressed the concern that his health facility was unable to provide IMCI services since none of the health care providers was trained on IMCI. The facility also lacked adequate tools and equipment to provide appropriate care to children in accordance with the protocol even though the prison was host to around 80 children under-five whose mothers were inmates.

Since then, MCSP has provided the facility with the necessary IMCI tools and equipment, then trained 2 providers using the LDHF approach. The facility has also received mentorship and today has a fully functional IMCI unit. The children receive care in accordance with the IMCI protocol. The head of the facility expressed gratitude toward MCSP, the mentors and the district for their assistance in the establishment the IMCI unit.

17 On the Job Training on IMCI In order to increase the number of providers capable of treating children under five in accordance with the recommended IMCI protocol, a large scale OJT on IMCI was initiated to reach additional providers through on site sessions complemented by self-learning using ICATT. The OJT activity enrolled 2 to 5 additional providers in each of the 163 supported health centers and is intended to bring the number of trained providers over the recommended minimum standard of 60%.

Figure 12: Providers and their mentor during an OJT session on The ongoing OJT on IMCI will be conducted IMCI/ICATT over a 7-month period from February to August 2017, which includes 2 sessions per month. Each session is conducted as follows: A series of seven mini-lectures of approximately two hours each, provided by district mentors during monthly mentorship visits, to introduce the main chapters in IMCI, Sessions facilitated by peer mentors to consolidate the material learned during the mini lectures, Complementary assignments in ICATT and follow up to encourage providers to complete the assignments.

As of March 31, 2017, 538 providers had been registered for the OJT on IMCI as learners and 185 as peer mentors. In addition, all 163 heads of health centers are involved as facility coordinators of the OJT activity. Despite a few difficulties in the launch, 27% of the facilities are on schedule, 53% are one session behind schedule while 20% are two sessions behind schedule. A strategy has been put in place to allow facilities that are behind schedule to catch up. It includes setting fixed days each month for OJT activities and encouraging active involvement of heads of health centers who are serving as coordinators of the OJT in their respective facilities.

Mentorship on ETAT+ The Emergency, Triage, Assessment and Treatment plus Admission Care (ETAT+) is a comprehensive and proven approach toward improving emergency pediatric care that was developed by the World Health Organization. It was adopted and adapted in Rwanda in 2010 and is the currently recommended guideline for management of sick children in district hospitals across the country.

In collaboration with the Rwanda Pediatric Association (RPA), MCSP continued to support ETAT+ mentorship in the 12 supported hospitals. Over the last three months, RPA’s pediatrician consultants made 3 mentorship visits in each of the 12 RMNCH supported hospitals (one per month) and mentored 24 pediatric care providers. They also spent over 400 minutes in consultative phone correspondences with their respective mentees at the supported hospitals.

Some key achievements resulting from ETAT + mentorship:  Musanze hospital established a dedicated pediatric emergency unit as per the recommendations of RPA mentors.  Kibungo hospital reinforced internal auditing of pediatric patient charts.  All 12 hospitals achieved 30 to 75% improvements in their respective QI projects.

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During their mentorship visits, the mentors engaged in a variety of capacity building activities including: Offering morning lectures on selected clinical topics (e.g. Management of an acute asthma attack, hypovolemic shock, pneumonia, anemia etc.), Accompanying ward rounds and providing bedside teaching, advanced consultation on difficult hospitalized Figure 13: A pediatrician consultant, conducts bedside teaching during a mentorship cases, Engaging with hospital leadership session at Kigeme Hospital. to advocate for some necessary changes, Initiating and monitoring Quality Improvement Projects for individual hospitals.

Family Planning OJT on all FP Methods In the past quarter, MCSP organized the introduction and implementation of OJT in Huye and Nyabihu districts. The process began with updating of providers who will serve as site trainers and this involved a refresher on all FP methods including short-acting reversible contraceptives and long-acting reversible contraceptives (LARCs) for 19 FP providers from Nyabihu district as well as training and validation of 33 providers from Huye and Nyabihu district on clinical training skills. By the end of the quarter, the OJT on all FP methods was ongoing in with 105 staff participating.

MCSP also distributed various anatomic models to be used in FP mentorship and provided orientation to mentors on effective use of the models for capacity building (4 mentors from Nyaruguru district and 14 OJT site trainers from Huye received orientation).

FP Clinical Mentorship Clinical mentorship on FP is being implemented as a continuous capacity building approach in 10 RMNCH supported districts. MCSP conducted an orientation workshop on FP clinical mentorship followed by field visits to provide existing mentors with technical support and to validate those who were recently oriented.

The clinical mentorship includes but is not limited to building capacity of providers on FP/PPFP knowledge and skills in order to achieve acceptable proficiency in FP service provision, documentation, data management/reporting and quality improvement. The mentees are showing good progress since all of them are now able to adequately perform at least 7 out of 10 procedures listed in the FP clinical mentorship guideline. There are now a total of 39 FP/PPFP clinical mentors and up to 158 mentees reached with special focus on skills on counselling, implant insertion and removal, intrauterine (IUD)/postpartum intrauterine device (PPIUD) insertion and follow up.

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Capacity Building on FP Permanent Methods This activity involved mentorship of doctors in hospitals, outreach activities, and a three-day workshop on semen analysis for lab-technicians to support post vasectomy cases at health facilities. Under mentorship, 3 national trainers mentored a total of 9 medical doctors on no scalpel vasectomy (NSV) and Tubal Ligation.

Figure 18: Mentorship on NSV Figure 19: Mentorship on TL

Under outreach, the following interventions were performed: 59 TLs and 2 NSVs in January, 59 TLs and 13 NSVs in February and 71 TLs and 13 NSVs in March. Looking at the trend from start of MCSP support in the 10 districts, FP permanent method clients have been steadily increasing. The trend shows that TL during caesarian section (TL C/S) was the leading method between January and March 2016. From July 2016, after introduction of the outreach approach, TL under local anesthesia conducted outside hospital setting increased and replaced TL C/S as the leading method also increasing the overall number of clients on FP permanent methods.

In collaboration with MoH, MCSP trained 13 lab technicians from all 12 RMNCH district hospitals on semen analysis. They will support in confirmation of the success of NSV interventions. During the practical exercise, all 6 clients who received vasectomy service had a total absence of sperms (azoospermia) for all three semen samples provided during post vasectomy follow up.

Community-Based Provision of Family Planning During the past quarter, MCSP provided training for new trainers of CHWs (nurses in charge of community health) as well as refresher training for existing trainers of CHWs on CBP-FP. This was aimed at increasing their knowledge and updating them on changes in the CBP training module and data collection tools. In total 28 new trainers received first time orientation while 148 existing trainers of CHWs received refresher training.

This was followed by two weeks of training for new CHWs including ASMs on CBP/FP conducted simultaneously at all HCs in Musanze, Gatsibo (Kiziguro) and Nyagatare districts so as to increase the Figure 21: New CHW simulating injection number of CHWs capable of providing FP services at village level. using an anatomic model Many sessions are organized depending on the number of new CHWs to be trained. By the end of quarter 2, a total of 1,654 new CHWs (763 in Musanze, 316 in Gatsibo and 575 in ) were trained. A follow up period of practical exercise with actual clients will be organized at health center level under supervision of CHW trainers (the health center in charge of community health and the in charge of FP) to gain skills that they will apply in the community.

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Community health mentorship MCSP organized orientation workshops on community health mentorship in which 98 CH candidate mentors from 3 districts were orientated: Ngoma (24), Nyamagabe (44) and Nyaruguru (30). Following these workshops, every community health candidate mentor from Ngoma and Nyamagabe had an opportunity to conduct a community health mentorship session with CHWs as part of field orientation with the support of national mentors, MCSP and MoH/RBC. Community health candidates mentored from Nyaruguru will receive orientation during quarter 3. Regular follow up of mentors conducting community mentorship was done in Kamonyi, Huye, Figure 22: Community health mentorship orientation Rwamagana and where a total of 633 CBP-FP workshop in mentorship field visits were performed during which 97.7% of the targeted mentees (4,303 out 4,405 CHWs) were reached.

National FP coordination meeting MCSP organized a quarterly national coordination meeting on FP in bringing together 43 FP focal points from all hospitals in the country to discuss FP issues. The main recommendations from the meeting were about the need to scale up PPFP in all districts countrywide, follow up to ensure implementation of MoH instruction on the FP services at FBOs (availability of nearby health posts that provides modern FP methods), continuous monitoring of compliance US abortion and FP legislative requirements. Figure 23: National FP coordination meeting

FP Sensitization and Mobilization An orientation workshop on FP for local leaders was conducted in Musanze and Huye where 123 and 132 participants attended respectively. This was followed by mass campaign on family planning that was conducted in Huye. The campaign reached 13,095 people with FP counselling and key information.

Adolescent and Sexual Reproductive Health In quarter 2, MCSP supported implementation of ASRH activities in 10 districts. 24 health care providers were trained as district mentors in ASRH (2 per hospital in the 12 MCSP supported hospitals) in order to support other providers to provide youth-friendly services for adolescents. MCSP organized sensitization meetings for 24 youth clubs who had previously received training on adolescent risky behavior prevention and during the meetings each member committed to sensitize at least 10 peers in their community on the subject. As a result, up to 4,839 youth were reached with the adolescent risky behavior prevention message (1,964 female and 2,875 male).

In addition, between January and March 2017, across the 171 youth corners in the 10 RMNCH supported Figure 24: Youth club members after a sensitization meeting districts, 41,800 adolescents have received ASRH messages during IEC sessions at youth corners and 9,050 received one on one counselling services. This may include some double counting since a few adolescents could have participated in more than one session.

MCSP also conducted follow up visits at 24 health centers that had received equipment for youth corners also to help set up the equipment in youth friendly manner. The equipment included a TV Screen, DVD player, TV 21 stand, office chairs, office desk, printers, computers and a bench (all the equipment were appropriately branded).

Gender Integration Support to MIGEPROF in Organizing National Events MCSP participated in preparatory meetings of the International Women’s Day (IWD) and contributed to implementation of planned activities during Women’s Empowerment Month (March 2017) including community mobilization aimed at raising awareness to prevent teenage pregnancies and procurement of communication materials like T-shirts for the events with messages for awareness raising during women empowerment month with the theme “Preserving the Dignity Restored”. During the national event, MCSP had a booth where MCSP and Shyira hospital staff presented project interventions that are contributing to a reduction in preventable maternal, newborn and child deaths to the First Lady and other high ranking officials.

Baseline Assessment using GBV Quality Assurance Tool During quarter 2, MCSP completed collection of information using a GBV quality assurance tool at the four remaining districts (Kigeme, Munini, Nyagatare and Shyira) IOSCs to establish a baseline as an effort to contribute to improving performance of IOSCs in providing comprehensive care and support to GBV victims. At end of the supervision and baseline assessment, the MCSP Gender Specialist worked with IOSC teams to develop action plans to address identified gaps. An analysis showed that most IOSCs scored high on victim- centered clinical care & communication, provision of post-exposure prophylaxis in a timely manner and provision of emergency contraceptives as appropriate. In most facilities the guidelines, protocol, multidisciplinary model and algorithm are respected. On other hand, gaps identified were on availability & appropriateness of services, referral system and follow up of GBV victims as well as use of data in decision making. For the follow up of GBV victims, there is no documented information about the prophylaxis outcome to know whether or not post-exposure prophylaxis HIV or emergency contraceptive was successful in prevention of HIV infection or pregnancies and thus no follow up actions are taken. MCSP will also monitor implementation of action plans developed to address gaps for continuous quality improvement.

Supportive Supervision by District Based Gender Trainers MCSP supported district based gender trainers to conduct supportive supervision at all MCSP supported HCs on gender integration and improved GBV services. The objectives of those supervisions were to assess whether or not GBV services are being provided according to the sets of standards, identify gaps and challenges in GBV service delivery and assess male involvement into RMNCH services. It was found out that GBV services are available and GBV focal points are appointed and trained on gender integration and GBV case management. Each HC has 3 staff trained on gender integration and GBV case management which guarantee the availability of services.

Post-exposure prophylaxis for HIV and emergency contraceptive are provided according to the national protocol and guidelines. Teenage pregnancies are identified as high risky pregnancies and GBV cases are systematically referred to the district hospital for appropriate care and support. Identified gaps include; lack of separate reception rooms for GBV victims, lack of individual GBV victim files kept at the health centers which makes it hard to monitor how services are delivered, some providers do not know how to complete registers and report data related to GBV or are using outdated registers, there is a lack of specific actions to increase male involvement in RMNCAH services, there are no mechanisms in place to track GBV clients referred to IOSC or to do follow up of the GBV victims, lack of emergency contraceptive methods in Faith Based Organization which leads to GBV victims cover long distances seeking services with the risk of delay. Some gaps were directly addressed during the visit through coaching and during monthly meeting with heads of health centers while others are still being addressed.

Enabling Environment for Gender Mainstreaming, Gender Equality, and Diversity The MSCP gender team facilitated an in-house dialogue and reflection session on power dynamics as many studies have confirmed that power imbalance is the root cause of GBV and barriers for women to access health services leading to maternal and child deaths. The objective of the presentation was to help staff to understand the four types of power, and make the link between the four types of power and MCSP interventions. It was also an opportunity to build capacity and improve comfort of MCSP staff in talking about power and make an

22 effort to balancing power with others in their relationships, in their own lives as well as in their daily work. Participants also had the opportunity to learn about “HeForShe Campaign’’ as a national commitment from the higher leadership and all were encouraged to pledge.

Integrating routine GBV screening in ANC/FP services The WHO recently recommended routine GBV screening for intimate partner violence during pregnancy in ANC services. This is due to its prevalence and adverse health consequences. In quarter 2, MCSP worked in collaboration with the MoH to integrate routine GBV screening in 10 selected health centers - 5 located near IOSCs and 5 furthest from the IOSCs in their respective districts. Preparatory activities were conducted including several consultative meetings with stakeholders to review tools, develop a training rollout plan and an implementation plan. The GBV screening tools were then adapted to the Rwanda context and translated to Kinyarwanda while relevant indicators and data collection mechanisms were put in place. In order to achieve buy in from district officials prior to implementation, MCSP organized a consultative meeting with 10 hospital directors and clinical directors on the GBV screening intervention.

BEmONC/FANC/FP/gender district-based mentors also received one day orientation on the intervention to ensure that it is included among the elements on which health care providers are mentored. This was followed by on the job training of up to 90 health care workers from the 10 selected health centers on GBV screening in ANC and FP. It was conducted by previously trained district based GBV trainers under the supervision of the MCSP gender specialist. After the training, the necessary tools were distributed and are now being used for routine GBV screening in ANC and FP services according to predetermined standards.

Engagement of Men in RMNCAH Services and GBV Prevention In quarter 2, MCSP supported RWAMREC to train 32 couple facilitators in Kabarore and Matimba (Gatsibo and Nyagatare district respectively) as part of the “men engage approach”. Due to a delay in introduction of the MCSP-RWMAREC initiative to sector officials in Nyamagabe district, the same training will be conducted there in April 2017.

Formative Assessment on Gender Sensitive Barriers to RMC Under the sub-grant from MCSP, the study team of Promundo shared data collection tools for the formative assessment on gender sensitive barriers to RMC with MCSP for input and a final draft of the study protocol will be shared with the mission for comments and approval before proceeding to submit for IRB approval.

Quality Improvement Workshop on Compliance with Quality Driven Standards In order to support health facilities to improve their compliance with quality driven standards for accreditation at both hospital and health center levels, MCSP worked with MoH to conduct a workshop that brought together a total of 24 hospital accreditation officers and QI focal points (2 participants from each of the 12 RMNCH supported hospitals). The objective of the workshop was to share experiences about compliance with QI driven standards and adapt/harmonize policies and procedures for each standard in the accreditation system. In addition, participants provided recommendations to improve compliance with these standards at hospital and health center level. The session was facilitated by three MoH staff from the quality assurance desk and two MCSP staff.

After the MoH presented hospital specific results that showed declining performance of most hospitals in the recent accreditation assessments, participants shared challenges and best practices from their respective hospitals. Afterwards, accreditation officers from better performing hospitals (Kibungo, Ruhengeri and Rwamagana) assisted participants from the remaining hospitals to adapt/revise policies and procedures for standards in each of the five risk areas assessed in order to improve their performance.

Furthermore, in preparation for hospital to health center quality improvement supportive supervision, the participants revised the QI supervisory checklist and developed tools for standardized QI practices at health center level. The tools included:  Terms of reference for quality management committees,

23  Job description for customer care focal point,  Incident report form and list of events to be reported,  Dress code,  Complaints register,  Patient satisfaction survey form,  Staff satisfaction survey form.

Supportive Supervision MCSP also supported hospital accreditation officers and QI focal points from the 10 RMNCH supported districts to conduct a second round of QI supportive supervision at all health centers located in their catchment areas. The main objective of the activity was to facilitate health centers to improve their compliance with quality standards thereby improving the quality of health services in general as well as health outcomes. The exercise was guided by a QI supervisory check list that reflects priorities of the national accreditation standards in Risk area 4: clinical services, and Risk area 5: quality and safety. During the site visits, the supervision teams provided background information on the primary health care standards and the purpose and methodology of the exercise. In addition to support for compliance with standards, health facility data managers were mentored on utilization of routine data through RMNCH dashboards to support continuous quality improvement.

It was evident that most health centers had not implemented recommendations from the previous site visits, which mostly related to development of the QI tools listed above. Fortunately, hospital accreditation officers and QI focal points had already developed them and provided the health centers with both soft and hard copies for implementation. Since this exercise will take place on a quarterly basis, it is expected that the next round of supportive supervision will show marked improvement because all the necessary QI tools are now available at the health facilities.

SO2: Support for scale-up of high-impact interventions to improve RMNCH and malaria outcomes in public and private sectors

Strengthening the capacity of the MoH at central and decentralized levels to manage and scale up high-impact RMNCH interventions is an overarching strategy for MCSP Rwanda. Under the coordination and guidance of Newborn and FP TWGs led by the MoH, MCSP implemented practice improvement for ENC/HBB and labor management and PPFP activities in four initial districts in PY2. Based on experiences and lessons learned during PY3, MCSP rolled out the two interventions to 6 additional districts with a focus on building the capacity of providers to improve and scale up ENC/HBB services using LDHF and mentorship approach and to provide PPFP. MCSP will continue to document and share experiences and best practices for better and improved maternal and newborn services, thereby contributing to reduction of maternal and newborn deaths.

Rollout of PPFP and Practice improvement for ENC/HBB and Labor monitoring During quarter 1, MCSP in collaboration with MoH organized and conducted 2 consecutive workshops for ENC/HBB and PPFP scale up aimed at sharing findings and experiences from phase I of implementation in 4 districts and developing a plan to scale up the intervention to 6 additional MCSP districts. During these workshops, district and national stakeholders shared recommendations for better implementation of the two interventions. After the scale up workshops, MCSP worked with MoH to rollout the interventions to the 6 remaining MCSP supported districts (Nyagatare, Gatsibo, Nyaruguru, Nyabihu, Huye and Nyamagabe) while implementing recommended actions from the workshop in order to achieve effective service expansion and institutionalization of the practice improvement package for ENC/HBB and labor management as well as PPFP.

ENC/HBB Mentorship During the past quarter, district-based ENC mentors continued mentorship activities in all 10 districts. This involves one visit per month to each health center. The 71 ENC mentors reached 178 health care providers in January, 169 in February and 156 in March. As a result of the mentorship, the following improvements were observed in essential newborn care: 24  Preparation of chlorine solution for decontamination before delivery is done at all visited health facilities,  Preparation of the delivery and newborn resuscitation area is routine at all visited health facilities and mentees report many newborn resuscitation success stories,  Improved documentation of monitoring labor at some facilities,  Implementation of PNC in maternity is well done at a few health facilities,  Pre-discharge check list is well used at a few health facilities,  Availability of resuscitation kit at all visited health facilities,  Monitoring of fetal heart rate on admission is done at all visited health facilities (hospitals and health centers),  Involvement of companions of choice in the delivery room is encouraged at some health facilities,  Cutting of cord within 1-3 minutes is well done,  Vitamin K1 is given to all newborns Figure 27: A woman with a companion of choice (her mother) in delivery according to guideline at all visited room in health facilities.

LDHF Training on ENC/HBB LDHF training on ENC/HBB was conducted in 3 districts: Nyabihu, Nyamagabe and Nyaruguru. The training was divided into 3 sessions organized as follows:  Session 1: Basics of essential newborn care (immediate care, PNC, clinical examination of newborn, infection control and breastfeeding  Session 2: Helping Babies Breathe (newborn resuscitation)  Session 3: Kangaroo mother Care for LBW babies and newborns at risk of neonatal infection focusing on neonatal resuscitation, routine care of the newborn, breastfeeding, post-natal care, clinical examination, care for low birth weight babies, KMC and newborns at risk of infection. A total of 92 health care providers were trained and 95% of them succeeded in the post test with the exception of 4 in Kaduha. Their main challenge was that they had night duty during the training period and had no time to review their lessons. They will be invited again during the 2nd cohort of training.

Postpartum Family Planning (PPFP) Activities Over the past quarter, MCSP focused on strengthening PPFP at health facilities that already initiated the intervention, extending the intervention to new health facilities and conducting post-training follow up to reinforce knowledge on PPFP/PPIUD. Three months after the training on PPFP counselling, a post-training follow up was conducted for providers in Huye district at their place of work. During the visits, that the teams discovered that PPFP had been initiated where trained providers were working and PPFP had been integrated in registers and other recording tools. This post training follow-up was an opportunity to conduct onsite orientation Figure 28: Data management orientation during PPFP post- on PPFP for providers working in health facilities. training follow up

25 In addition, 3 sessions on PPFP clinical training skills were organized for providers from Nyagatare, Nyamagabe and Nyabihu districts. During first two days, classroom sessions were held in which each participant had the opportunity to conduct practical simulation using anatomical models to ensure that they all gained the skill.

The following two days were spent in the facility with actual clients: 57 participants were trained (Nyagatare: 20, Kaduha: 18, Nyabihu: 19). During practical sessions, participants performed group and individual counselling followed by provision of contraceptives. In total, 32 clients received contraceptives with 25 receiving long acting reversible contraceptives and 7 clients receiving short acting contraceptives. Figure 29: PPIUD Demonstration on MAMA U

A total of 183 PPIUD kits were distributed in Huye, Nyabihu, Nyamagabe and Nyagatare districts to support this new intervention in the health facilities.

Participation in FP and Neonatal sub-Technical Working Groups MCSP participated in the FP and neonatal sub-technical working groups to share scale up workshop feedback. Members of the technical working group appreciated MCSP actions including to implement some of the recommendations from the workshop such as inclusion of PPFP and HBB scale up indicators in the HMIS. It is through these TWGs that PPFP indicators were added in the HMIS as well as some key indicators relating to ENC/HBB such as bag and mask.

Documentation of scale up related indicators and monitoring implementation of scale up workshop recommendations A total of 46 health facilities were reached by the MCSP scale up team during this reporting period in an effort to support documentation of scale up related indicators and to ensure implementation of recommendations from national scale up workshops that took place during Q1.

MCSP participated in the FP and Neonatal sub-technical working groups to share scale up workshop feedback where members of the technical working groups expressed interest in MCSP’s initiatives and commited to facilitate implementation of some the workshp recommendations such as inclusion of some PPFP and HBB scale up indicators in the HMIS.

Other recommendations implemented so far :

Intervention Recommendations implemented so far

 Improved peer mentorship  Regular peer-to peer mentorship with mannequins, at last 2 times a week  Introduction of “helper program” on maternity ward  Mentors working in collaboration with MCH supervisors  Strengthened newborn asphyxia audits in some hospitals ( Ruhengeri hospital)  Proposed indicators presented for inclusion in HMIS (awaiting feedback from HIMS team)  Invited district staff to national newborn TWG meetings to provide feedback

Practice improvement for ENC/HBB & Labor monitoring  Conceptualized experience sharing/lessons learned approach with RBC

26  Organized field visits to districts to review progress and share lessons  Reviewed tools for facility data collection and reporting and advocated to include PPFP indicators in HMIS  Improved use of existing column “counseling on FP” in maternity register, to document PPFP uptake  Discussed PPFP during FP TWG quarterly meeting  Conducting costing exercise to determine cost of establishing and maintaining PPFP

PPFP services in additional districts —at the level of collecting financial expenditures.

SO3: Increase community mobilization for, participation in, and utilization of high- quality RMNCH and malaria services

Community Health Mentorship Workshops and Field Orientation During this reporting period, MCSP, in collaboration with RBC and the respective districts, conducted orientation workshops for candidate mentors of Nyamagabe (68 participants), Kamonyi (22 participants), and Nyaruguru (44 participants) districts on CB-MNH. The aim of this orientation workshop was to equip health providers with knowledge of the community mentorship model principles and tools used in mentorship of CHWs. Principles of adult learning were also shared during the workshop as well as how to provide feedback to ASMs. In Nyamagabe, the workshop was combined with CBP-FP. Participants included the in-charge of community health workers, nurse trained on CB-MNH and nurse trained on CBP-FP at the health center level, and the supervisor of community health supervisor of MCH, M&E, and nurse trained on both CBMNH and CBP-FP at hospital level. Field orientation is scheduled in the next quarter (April 2017).

In addition to community health mentorship orientation workshops, MCSP in collaboration with RBC and Huye, Ngoma and Rwamagana districts, conducted mentorship of health center mentors for follow up of implementation of the mentorship program. During this visit, the team of facilitators were looking at checklists and reports from the field to evaluate how the mentorship was conducted and how documents were completed. After this review, facilitators engaged in discussion to dig deeper and understand how the mentorship was done and then provided feedback. During the feedback, facilitators took the opportunity to remind on the steps of mentorship emphasizing on points to improve, highlighting at the same time the strengths of the mentors that should be maintained. In 2 of the visited districts, all mentors were implementing the approach. In Huye district, 3 health centers had candidate mentors who were recently trained but not oriented. It was hence an opportunity to orient those mentors during these visits.

Capacity Building CB-MNH/PPH MCSP in collaboration with RBC and Nyabihu district conducted a 5-day training of trainers (TOT) on CB- MNH/PPH for health providers of Nyabihu district. The aim of this activity was to build the capacity of health providers on community based maternal and newborn health care integrated with prevention of PPH program. Participants in the TOT were providers from health facilities of Nyabihu district and most of them were new in community health programs. The district hospital provided 4 participants including an M&E officer, data manager, medical doctor working in maternity, and nurse working in maternity. Every health center provided three people which included in charge of community health workers, data manager, and nurse from maternity. In addition, seven people from two different districts (Huye and Rwamagana) joined the group for a catch-up training as they were new in the program. After the training, participants were capable of teaching CHWs/ASMs on the roles and responsibilities of the ASM, the importance of care for pregnant women, mothers and newborns, updated skills of counselling of pregnant women and mothers using MNH and PPH combined counseling cards during home visits, how to complete CB-MNH tools and the reporting process including the RapidSMS. The training was successful as the average on the pretest was 61% and post-test was 90%. In total, 59 health providers were trained as trainers of CHWs/ASMS on CB-MNH/PPH. Data analysis shows an increase in the number of women delivering in the community who received misoprostol from ASMs to prevent PPH from 40% in quarter 1 to 57% in quarter 2. This could be a result of MCSP support to 27 community mentorship on CB_MNH/PPH and following up on availability of misoprostol at district pharmacies in supported districts.

Review of Translated Documents List of Translated Documents : MCSP worked with MCCH/RBC to  CB-MNH participant`s guide conduct a 5-day national workshop to  CB-MNH Facilitator’s guide review CB-MNH documents  Caneva SISCOM translated into English from  Register for recording girls and Women in the childbearing age in Kinyarwanda. Participants included the village MCCH staff, national trainers for  Community health worker`s activity supervision form by cell CBMNH and MCSP staff. As a coordinator result, 9 documents were reviewed  Community health worker`s product requisition form and finalized during the workshop.  Register for community pregnancy follow-up  Community health worker`s monitoring form by the health center Workshop to Finalize and  Counselling cards Harmonize the District Communication Action Plans During quarter 2, MCSP in collaboration with RBC conducted a 2-day workshop in 3 RMNCH-supported districts (Nyagatare, Ngoma and Kamonyi) to finalize and harmonize the district communication action plans that were developed during Q1. One district communication action plan was reviewed by all team members to serve as a template for other action plans. Each district member used the agreed upon template and worked on their district communication action plans. Each district presented its communication plan and comments were provided in order to improve the action plans. All district communication plan drafts were reviewed and finalized and are being shared with the district mayors for signature.

Workshop to Develop District Communication Action Plans MCSP in collaboration with RBC organized a 2-day workshop to support DHMT in developing their district communication action plans. As a result, the 7 RMNCH districts who had not developed their plans in the previous quarter developed district communication plan drafts focusing on RMNCH and malaria indicators and other key health related issues. The next steps for this activity are to finalize and share the plan with key stakeholders for their input as well as the district mayor. This will be completed in the next quarter.

Orientation Meeting of District Authorities on Community Mobilization Using CAC Approach MCSP in collaboration with RBC and districts of Gatsibo, Musanze and Nyabihu organized a 1-day meeting to orient districts’ authorities on Experiences from Nyabihu after one month of community mobilization using the new approach CAC implementation : called “Community Action Cycle”, or CAC. The  Enrollment in community-based health insurance team provided an overview of MCSP, followed increased from 57% to 97% in Tububuru village by a presentation on community action cycle as and from 42% to 95% in Maraba village an approach of community mobilization, as well  34 out of 40 households without toilets in as structures, members and roles and Tububuru village received the support of their responsibilities of each structure. The experiences neighbours to construct good toilets of Nyaruguru district that first piloted the CAC  approach were shared. Following this orientation All 138 households in Sekera village have received meeting, each district developed its community bed nets distributed by VCMT. action cycle implementation plan. MCSP will work with the districts in the next quarter on implementation of their plans.

Training of District Trainers (District CMT) on CAC Cascaded CAC Trainings During the reporting period, MCSP, in collaboration with RBC and Gatsibo and Nyabihu districts, conducted a 5-day training of district trainers on CAC. In total, 73 district CMTs members attended the training and were equipped with knowledge and skills to form and train the sector CMTs members on CAC. The training was facilitated by national trainers. After the training, the district CMT developed a training plan for the sector

28 CMT. A cascaded CAC training has been conducted for all sector CMT members of Nyabihu district and they received a comprehensive package of knowledge and skills to conduct CAC orientation for the VCMT to be able to identify their health issues and find the solutions to overcome them. In total, 240 sector CMT members attended the training. The training was facilitated by district trainers and supervised by national trainers.

Workshop to Coordinate the Implementation of CAC on Village Level in Nyaruguru District MCSP worked with RBC and Nyaruguru district, to organize and conduct a 3 day workshop to monitor the implementation of CAC. MCSP worked with RBC and Nyaruguru district, to organize and conduct a 3-day workshop to monitor the implementation of CAC. 35 District and sector level CAC members attended. Some key achievements highlighted during the meeting included: Increase in health insurance from 79% - 85% in Munini sector, Community members have trusted CMT and household hygiene has improved; 52% of the population are using a toilet with the required norms and 62% of the houses have boards protected with local materials to improve the hygiene of the house, and an assessment has been conducted in each household of Nyaruguru district. The baseline looked at the following items: basic information on the population, maternal and child health, reproductive health, FP, hygiene and sanitation, malaria prevention, community insurance (mutuelle) and nutrition and growth monitoring of under five children. Challenges included low level of documentation by the village CMT; some misunderstanding among CMTs about their roles and responsibilities; and community ownership is still low in some sectors.

After this meeting, a coordination meeting was planned for the first week of May 2017 to follow up the implementation plan, decide together how CAC champions will be selected, and recognize the hard work that impacted community members’ lives in Nyaruguru, as a motivation to CMT.

29 SO4: Build capacity to use data for decision and action at all levels of the health system MCSP continued to support the MoH at national, district and facility levels with capacity building and ongoing mentorship to improve data quality and use for data for decision making. Through targeted technical assistance and regular coordination, MCSP supported the MoH to use data for improvement of quality of health services at all levels of the health system that can sustain beyond the MCSP program.

Quarterly Data Review Meetings with District, Hospital and Health Center M&E Staff MCSP provided support to conduct district level quarterly coordination meetings in 7 districts (Huye, Nyamagabe, Kamonyi, Nyaruguru, Nyabihu, Rwamagana and Ruhango) out of the 16 MCSP supported districts. In total, 221 participants attended the meetings (109 from HCs, 36 from hospital level, 19 from admin level). Participants to the meetings were data managers, in charge of CHWs and facility managers from HCs. During each meeting, hospital M&E staff or M&E of administration district and district level CHW supervisors made presentations on Q1FY17 HMIS data reported for RMNCH and malaria indicators. The Vice Mayors in charge of social affairs and the director of hospitals were present and facilitated the meeting to take decisions as necessary. Some health facilities were requested to improve data quality in the reporting system while others were asked to improve completeness of HMIS tools. Actions recommended to improve data quality include reinforcement routine DQA from hospitals to health center and from health centers to the community. In addition, participants decided to be more focused in community sensitization to improve 4 ANC standard visits, delivery at the facility level and adherence to community based health insurance.

Mentorship from Hospital to Health Center in Data Quality Assurance and Data Use MCSP in collaboration with hospital data managers organized data quality reviews and onsite coaching focusing on data quality for HC data managers from 7 MCSP supported ICCM districts. Reviews were performed for community data reported in Q1FY17 in order to correct errors and improve data use by facility managers. The following malaria indicators were reviewed:  Number of suspected malaria cases (seen for fever).  Number of suspected malaria cases tested for malaria.  Number of people suspected to have malaria who tested positive for malaria.  Number of suspected malaria cases who tested positive for malaria who receive ACTs.

The following main gaps were noted:  Some data managers and CHW supervisors at hospital level detect data quality issues in SISCOM but do not act as required.  Incompleteness of source documents.  Inconsistency in data between cases seen for malaria and cases tested as well as between cases tested RDT positive and cases treated.  SISCOM data not consistently analyzed.

The team noted that most CHW Supervisors at health centers need capacity building in data analysis and access to the HMIS system. MCSP discussed and made recommendations accordingly, and will continue to monitor implementation during the next reporting period.

Support for use of tools Following the distribution of PNC guidelines and partographs, MCSP supported facilities to use the new tools. However, during the exercise it was noted that PNC guidelines were not adequately used. It was also noted that there was a mismatch between some of the new PNC guideline and the PBF checklist. MCSP therefore worked in collaboration with HMIS and the RBC-MCCH team as well as the National PBF team to harmonize the PBF checklist with the new PNC guidelines. The revised checklist was shared with all hospitals in Rwanda.

At the request of MoH, MCSP worked with HMIS team to analyze and present results of key MNCH indicator outcomes to the MoH senior management. The joint team generated key MNCH indicator results focusing on

30 mortality trends in the country from 2012 to 2016. MCSP is expected to present the findings in a senior management meeting at the MoH. It is expected that key actions to reduce preventable deaths will be discussed. The team will continue this exercise on a quarterly basis.

Tracking Referrals and Counter Referrals MCSP collected referral and counter referral data to assess the status of the referral systems at both health center and community levels. Community level findings revealed that almost all patients referred to HC had corresponding counter referrals. It was noted that most counter referral forms were not filled out by providers. In addition, the referral notes are no longer in PBF checklists for hospitals while they are included in those of health centers. MCSP will continue to track the referrals every quarter to assess the trend and also make recommendations for improvement. Some of the scheduled action points include a workshop in quarter 3 to advocate with hospital management and clinical staff to improve completion and record keeping of the counter- referrals and to propose use of district based mentors for routine delivery of counter referrals from hospitals to health centers.

Support technical coordination meetings MCSP in collaboration with administrative districts and hospitals organized technical coordination meetings in Kamonyi, Nyamagabe, Rwamagana, Gatsibo, Nyaruguru, Musanze, Huye and Nyabihu districts. The aim of the meetings was to discuss key health indicators and take actions to resolve challenges as needed and provide orientation to DHMT to anlayze, present and use data for decision making.

Build Capacity on use of New Version of RapidSMS Figure 30: Technical coordination meeting in Nyabihu MCSP supported RBC to train health providers as trainers district on the new version of RapidSMS in Kirehe, Ruhango, Huye and Gasabo. It includes additional features including PNC, children under 5 and red alerts for children and infants (originally only mothers had red alerts). Up to 254 health providers were trained and these included data managers, CHW Supervisors, nurses in charge of maternity as well as health center managers. After the training of trainers, the health providers trained new CHWs on new version of RapidSMS and a total of 2,628 Community health workers were trained in Gatsibo, Nyagatare, Huye, Ruhango, Gasabo, Kayonza and Kicukiro.

Support for Quarterly DHMT Meetings During Q2 of FY17, MCSP supported DHMT meetings in 8 out of 16 MCSP districts. The aim of these quarterly meetings were to discuss health related issues using indicators. During these meetings RMNCH indictors including Malaria were presented and the team exchanged ideas and recommended key actions for improvement. For example in Ngoma, participants discussed possible causes of an observed increase in malaria cases, community health supervisors pointed out that during home visits many individuals expressed reluctance to use mosquito nets and it recommended that CHWs would reinforce efforts to sensitize the community about the importance of using mosquito nets. Other districts were unable to have their meetings during the quarter because of conflicting agenda and will plan these in the coming period.

31 SO5: Increase capacity to manage and control malaria in Rwanda

The Intermittent Screening and Treatment (IST) in Pregnancy Study in Rwanda The Government of Rwanda would like to determine whether or not the IST approach is effective, appropriate and feasible as a malaria in pregnancy (MIP) intervention for the national malaria strategy. In this regard, MCSP is supporting the Rwanda NMCP to implement IST in Rwanda. After developing the study protocol, obtaining approvals from Johns Hopkins University (JHU) and Rwanda National Ethics Committee (RNEC), and training of study teams on study protocol and procedures, data collection was initiated in September 2016 in the 14 study sites of Huye and Kamonyi districts.

Key achievements so far:  Obtained JHU and RNEC approvals to the protocol amendment.  Continued follow up of the 183 previously enrolled study participants. This involves data collection during their subsequent ANC visits.  Orient Kabutare and Remera Rukoma district hospitals on the IST study procedures (data collection and blood samples) at delivery, since some study participants are referred to hospitals for better care.  Held meetings with all 442 ASMs from the 14 study sites to let them know their role in the implementation of the IST study.

Since the protocol amendment is now approved, MCSP plans to resume recruitment of additional study participants during the next quarter.

Malaria Strategic Plan Development 2013-2020 After the midterm review of the 2013-2017 Malaria Strategic Plan in September 2016, the MOPDD in collaboration with the Malaria Steering Committee (composed of malaria key stakeholders and partners) worked on developing the 2013-2020 Malaria Strategic Plan and the Global Fund Concept note. This activity took place from the 9th January to the 3rd February 2017 in . Following this activity, an extended 2013- 2020 Malaria Strategic Plan was developed and approved and the Global Fund Concept note was successfully developed and submitted. The goal of the extended Malaria Strategic Plan is to reduce malaria mortality by 30% by 2020, some new approaches in the strategy include but are not limited to partnership and multi-sectoral approach to malaria control, home based management of fever for adults and strengthening of reporting severe malaria cases as well as malaria deaths in real time.

Evaluation of the LLINs mass distribution of household for the universal coverage In this reporting period, MCSP supported the Mal&OPDD to conduct supervision activities in Rubavu, Musanze, Butaro, Gicumbi, and Rulindo districts to evaluate the long lasting insecticide nets (LLINs) mass distribution of household conducted from November 2016 up to January 2017.

The objectives of the evaluation were to:  Verify data reported by health centers on the LLINs distribution;  Verify the availability of the registering forms of beneficiaries and management tools  Compare the LLINs distribution report and registering forms of beneficiaries in order to get real number of LLINs distributed to households;  Verify the remaining stock of LLINs and to plan their distribution to beneficiaries who have not received LLINs, through community health workers channels.

Main findings:  All district hospitals received the right quantity for household mass distribution for household coverage.  All health centers conducted the LLINs mass distribution in their catchment area. The distribution was done at distribution outreach sites planned in each health center.  LLINs management tools and guidelines for the LLINs distribution were shared to all health centers and has been used and followed as recommended by MOPDD.

32  The total coverage in these 5 districts is 94.5%.  Discrepancies between reported data and counted were observed in approximately 30% of HFs.  Some LLINs received by households were not hanged.

The Malaria Control Behavioral Survey MCSP is supporting the Mal&OPDD to conduct the Malaria Control Behavioral survey (KAP survey). The main objectives of this study are to assess community’s knowledge, attitudes and practices in relation to malaria prevention and control and use the information obtained to design more effective strategic/behavior change communication (BCC) interventions. After review, USAID/PMI suggested a revision of the study questionnaires according to other PMI supported countries. The study data collection is planned to start in May 2017. So far, the study team has finalized study protocol and tools, obtained approval from Rwanda National Health Research committee and submitted the protocol to RNEC and JHU for IRB.

Drug Efficacy Survey Monitoring the efficacy of antimalarial medicines is a key component of malaria control. WHO recommends that national malaria control programs adopt antimalarial medicines with a parasitological cure rate of more than 95% and medicines should then be monitored at least once every 24 months at established sentinel sites. Protecting the efficacy of ACTs as the current first-line treatment for P. falciparum malaria is now among the top global public health priorities. In Rwanda, the last drug efficacy study that was conducted in 2010, showed an efficacy of 96.5% for Artemether–Lumefantrine the first line treatment for simple Malaria. MCSP is working in collaboration with Mal&OPDD and CDC on developing a new protocol to assess the efficacy of Artemether Lumefantrine.in rural Rwanda. During this reporting period, the team finalized the study protocol and held a meeting with study sites to discuss on the implementation of the study in their respective facilities. Next steps include seeking IRB approvals and initiating recruitment of study participants.

Malaria Behavior Change Communication Strategy MCSP and USAID in collaboration with Mal&OPDD are developing a Malaria Behavior Change Communication (BCC) strategy for Rwanda for the next five years. This strategy will promote positive behavior change among the population of Rwanda with special attention to populations at risk. Key achievements for this activity so far include recruitment of a local consultant to develop the strategy, conduct of a situation analysis and interviews with key malaria stakeholders. The report is now under development and a workshop to share findings from the interviews is planned in the next quarter.

Training of Lab Technicians in Malaria Microscopy Diagnostics Accurate malaria diagnostic methods have a great effect in the reduction of the number of malaria-infected individuals and should help to obtain the real prevalence of each Plasmodium species. Based on this MCSP with the Mal&OPDD and the National Reference Laboratory /Rwanda Biomedical Center organized a training of lab technicians in March 2017. Lab technicians from all district and referral hospitals were trained on performing Malaria Microscopy diagnosis and on conducting Malaria Microscopy QA/QC for the health centers. As a result, 44 lab technicians from all district hospitals and referral hospitals were trained and their average score increased from 56.2% (pretest) to 88% for the post test. Post training follow-up visits are planned in the next quarter to ensure that trained lab Figure 31: Training of Lab technicians in malaria microscopy diagnostics technicians are implementing adequately what they learned during the training.

Integrated Community Case Management Mentorship In collaboration with MoH and other partners, MCSP supported the development of the Community Mentorship Guidelines and tools and plans to extend the approach in all supported districts. The Mentors candidates were oriented on the mentorship guideline, facilitation of field mentorship sessions, evaluation of mentees and on how to provide feedback at the end of the mentorship session. 33 As a result:  44 mentors from Ruhango district were oriented and 114 CHWs were mentored,  49 participants from were oriented and 138 CHWs were mentored,  53 mentors from were oriented and 116 were mentored.

Under this activity, the team plans to orient on iCCM mentorship and will conduct regular supervision of iCCM mentorship activities in the next quarter.

IMPLEMENTATION CHALLENGES  Heavy workload, rotation of staff, night duty, and shortage of staff at most health facilities often limits the amount of interaction time between mentors and mentees during mentorship or OJT visits.  There are still occasional stock-outs of iron and folic acid in ANC services at some MCSP supported health facilities. MCSP supported FANC mentorship which included advocacy to ensure constant availability of Iron and Folic Acid in ANC service outlets.  The delayed approval of RWAMREC and Promundo subawards might affect timely achievement of their objectives. As a mitigation measure, MCSP is closely supporting RWAMREC to implement a catch-up plan and Promundo is collaborating with MCSP HQ to ensure that the assessment study protocol is finalized as soon as possible.  Due to the irregularity of DHMT meetings and supervision visits, some recommendations from the previous quarter, e.g., provision of misoprostol at community level, were not yet implemented. These irregularities mainly result from shifting priorities and coinciding activities at district level.  The long duration of the ethical approval process for the IST amendment led to delayed recruitment of new participants for the study.

COLLABORATION WITH OTHER PARTNERS & USG FUNDED PROJECTS

MCSP is co-chair of the Child Health Technical Working Group (TWG) and has continued to play a prominent role in the process of improving child health services in Rwanda by participating and actively supporting the work of the child health TWG. The child health TWG continues to serve as a platform for the MoH and its partners to meet on a monthly basis and discuss strategies for continuous improvement in child health. Organizations actively involved in the child health TWG include MCSP, WHO, UNICEF, Save the Children, Partners in Health, Handicap International, Swiss Cooperation and TSAM (Western Ontario University). MCSP provided technical and financial support for the child health TWG monthly meetings convened in January, February and March.

MCSP is also the co-chair of the Safe Motherhood Technical Working Group and actively participates in the FP Technical Working Group, ASRH Technical Working Group and Newborn Technical Working Group and this facilitates collaboration with a number of partners working in Rwanda, including UNICEF, WHO, UNFPA, PIH and others.

MCSP also collaborates with PIH and UNICEF in the scale up of HBB/ENC to prevent duplication of efforts and attempt to standardize approaches across the different districts. In the same vein, for PPFP scale up, MCSP works closely with UNFPA and other agencies working in family planning. MCSP also ensures that any investments made by donor agencies, such as the purchase of newborn equipment by UNICEF in MCSP- supported districts is well utilized by health providers and that they are trained appropriately in their use. MCSP worked in collaboration with RSOG to mentor young medical doctors on labor surveillance, management of obstetrical complications and safe caesarian section techniques and with RPA to support the improvement of neonatal care provided in the 12 district.

INTERNATIONAL TRAVEL 34 Khatidja Naithani, Senior Program Manager, traveled to South Africa from 25-31 March, 2017, as a member of the Rwanda delegation to the Institutionalizing Community Health Conference. She supported the delegation to develop an action plan with recommendations to the MoH for improving the community health program in Rwanda.

SHORT TERM TECHNICAL ASSISTANCE (STTA) Bill Winfrey, Modeling and Costing Advisor, visited from 16-26 January, 2017. The purpose of the trip was to finalize the DHS secondary analysis for family planning, create a plan for implementing FP Goals and identify mechanisms for costing the FP/ASRH strategy. During his visit, he presented the draft secondary analysis to various audiences including FP technical staff at MCSP/Rwanda, the Core Group for the FP/ASRH strategy, USAID, FP technical working group, Minister of State for Community and Primary Health Care, MCCH division manager at RBC and Director General of RBC. Melanie Yahner, Senior Specialist for Sexual and Reproductive Health, visited from 13-17 February, 2017. The purpose of the trip was to discuss and plan for implementation and documentation of ASRH activities in Rwanda for PY3. Ms. Yahner reviewed drafts of data collection tools to capture service uptake by youth, youth corner attendance, IEC and counseling sessions and also developed an ASRH mentor checklist, adapted directly from the MoH ASRH supervision guidelines, to guide mentors’ facility visits. She will continue to liaise with MCSP/HQ staff to plan for contributions to the FP/ASRH strategy. Lisa Noguchi, Senior Maternal Health Advisor, visited from 4-11 February, 2017. The purpose of the trip was to provide technical support for implementation of various maternal health initiatives. During her visit, she oriented MCSP staff on the new MCSP/RMC operational guidance and the 2016 WHO recommendations for ANC, co-facilitated an orientation workshop on triage and rapid response to maternal emergencies and a clinical workshop on use of uterine balloon. She also presented UBT to the Safe Motherhood sub technical working group.

MANAGEMENT AND ADMINISTRATIVE ISSUES During quarter 2, MCSP had no major management and administrative issues. The semi-annual work plan implementation reports were submitted on time to the Government of Rwanda Immigration Office and to districts for approval. The project finalized the distribution of 5,370 CHW boxes to MCSP supported districts and procured materials for CHWs (3,000 torches and 21,844 bags) as well as family planning materials for all supported hospitals. The materials are ready for distribution which is scheduled to take place during quarter 3.

Regarding staffing updates, MCSP hired an additional 6 drivers, 1 SBCC coordinator to replace the coordinator who resigned in January 2017, and 1 child health coordinator to replace the one who resigned in February 2016.

Other routine management activities included monthly SMT meetings to address emerging issues, monthly review of the program financial reports, weekly team lead meetings to coordinate implementation of work-plan activities, monthly staff meeting to provide updates to all staff and district coordinator meeting.

LESSONS LEARNED  Having a multidisciplinary hospital team with representation from all departments present during orientation on triage and rapid response to maternal emergencies encouraged active involvement and complementarity from all departments in developing a comprehensive action- oriented improvement plan.  Coordination meetings with all mentors (ENC/HBB, BEmONC, FANC, FP, M&E, and RAM) are an ideal platform for efficient coordination of activities, dissemination of tools/initiatives, sharing of best practices, challenges and lessons learnt. This in turn facilitate improved implementation of mentorship activities.  Involvement of adolescents themselves through existing youth club members in sensitizing their peers provides an opportunity to reach much larger numbers with ASRH messages and increases awareness about youth corners.

35  Working closely with ASMs at IST sites assists in the follow up of pregnant mothers and improves their attendance of all required ANC visits.

SUB-GRANT MANAGEMENT

MCSP is currently managing sub-agreements with the following organizations: Rwanda Pediatric Association (RPA), Rwanda Society of Obstetrics and Gynecology (RSOG), Rwanda Men’s Resource Centre (RWAMREC) and Rwanda Association of Midwives (RAM).  Rwanda Pediatric Association (RPA) to strengthen capacity of health providers in District Hospitals to ensure the labor room, neonatal units and Kangaroo Care units are following newborn care practices in line with the national standards and guidelines.  Rwanda Society of Obstetrics and Gynecology (RSOG) to contribute to the prevention of cesarean- related complications including potential fistulae, postpartum hemorrhage, infections, and immediate newborn care in 10 MCSP supported districts.  Rwanda Men’s Resource Centre (RWAMREC) to involve men and boys in gender equality efforts through Men Engage approaches including but not limited to engaging men as care-giving partners for women in health, promoting positive fatherhood, empowering men as change agents and role models for peers, and working with men as supportive partners of women and child health. The second phase of the subawards approved in February and three new districts were targeted (Gatsibo, Nyagatare and Nyamagabe).  Rwanda Association of Midwives (RAM) to conduct mentorship of district-based mentors during their monthly mentorship on FANC and BEmONC/ENC in health facilities and conduct integrated supportive supervision on PNC and use of pre-discharge checklist in facilities to ensure that moms and babies remain in the facility at least 24 hours following birth. Approval was received by USAID in February 2017 and mentorship is ongoing.

The project organized refresher training on grant management for RPA and RSOG sub-grant management teams in January 2017 and also conducted onsite monitoring of their work as they conducted mentorship at Kabutare hospital in February 2017.

Following the approval of the RAM sub-grant in February 2017, MCSP organized an orientation session for RAM representatives outlining the USAID- fixed award amount assistance mechanism. It was attended by nine RAM members (the executive secretary, program management team and district master trainers). During the same month the project conducted an orientation workshop on the sub-agreement program description as well as roles and responsibilities that was attended by 79 RAM mentors.

In the past quarter, MCSP hosted experience sharing/coordination meetings for RSOG, RPA and RAM mentors to share best practices and lessons learnt, discuss challenges and propose solutions.

In February, 2017, phase 2 activities of RWAMREC were approved. Following the approval, MCSP trained the RWAMREC finance manager, accountant and two districts coordinators on sub grant management. They were also provided with an operations module to use as a daily management guide.

36

ANNEX A: MCSP Environmental Monitoring and Mitigation Report (EMMP) Cooperative Agreement: AID-OAA-A-14-00028 Mitigation measure from Status of mitigation measures Outstanding issues relating Remarks column 3 in the EMMR to required conditions, Mitigation Plan (EMMR Including deadlines and Part 2 of 3) responsible party 1.Continuing education on MCSP visited all health facilities in the period of January The documentation of MCSP will continue to ensure that waste disposal to March 2017 during integrated supportive supervision, educational sessions on waste waste management and infection mentorship, data quality audit, on job training or disposal at health facilities need control is integrated in all training community health worker technical coordination to be improved manuals. In addition, MCSP will meetings. During these visits MCSP discussed with monitor that all HF integrate waste environment, hygiene and sanitation officers and heads of disposal session in IEC/BCC and each health center on waste management, hygiene that it is well documented. conditions, safe sharps handling, proper use of protective clothing etc. They ensured that all medical and non- medical staff were reminded about medical waste management and the new staff were oriented. They regularly ensure that waste disposal is being done correctly and that waste bins are available, labeled and staff understand clearly what kind of waste based belongs in which container. They provide IEC to the clients who visit the HC on the way to keep health center clean and request them to use the available waste disposal in each health facility compound. In addition, MCSP conducted CBP/FP training of new CHWs, District trainers and mentors in ASRH; training on ENC Under LDHF; training on FP all methods, training on GBV Screening in ANC and FP services; training of lab technicians on Semen Analysis , training of lab technician on Malaria Laboratory Diagnosis, training on PPFP clinical skills, Tot on CBP/FP of new in Charge of CHWs, Training of Trainers on CB-MNH and all these have training manual that include an infection control and waste management course.

37 Mitigation measure from Status of mitigation measures Outstanding issues relating Remarks column 3 in the EMMR to required conditions, Mitigation Plan (EMMR Including deadlines and Part 2 of 3) responsible party 2. Completion of the Annual All health facilities were oriented on how to complete this This activity has started but During supervision; on-site Health Care Waste tool and most of health facilities started to complete not yet covered all facilities training; post training follow up, Management Minimum Health Care Waste Management Minimum Program mentorship as well as other visit at Program Checklist and Action Checklist and Action Plan. facilities MCSP will continue to Plan ensure that all health facilities have a waste management plan and staff comply with waste management guidelines 3. Proper Waste Segregation During mentorship, the mentors check for waste Some health facilities have Continue monitoring waste and Disposal through management with proper colored bins. This is done in bins that are not color coded; segregation and disposal provision of color coded bins most health facilities especially those that are under the only differentiation of & Liners accreditation process. In some health facilities visited, waste bins is the labeling that waste segregation is being done based on its type but there separates the infectious wastes are no liners (plastic bags) from noninfectious waste. They also do not have plastic bags. 4. Rearrangement of clinical Optimization of clinical settings and client flow to The rearrangement of clinical MCSP will continue to advise the settings and client flow improve delivery of health services were also discussed setting and patient flow is management of health facility the with all HFs visited. This is done in all hospitals especially ongoing in some Health readjustment of clinical setting and that are under accreditation process. facilities like Coko, Kirwa HC client flow where possible in aim in Nyaruguru and Ngoma of facilitating the efficient use of district respectively. services. All facilities requested to avail hand washing station with liquid soap in client waiting rooms to promote hand washing and prevention of some hygiene related infections and nosocomial infections.

38 Mitigation measure from Status of mitigation measures Outstanding issues relating Remarks column 3 in the EMMR to required conditions, Mitigation Plan (EMMR Including deadlines and Part 2 of 3) responsible party 5. Monitoring availability of In all HFs visited during the period PEP guidelines were The monitoring of availability Continue monitoring PEP and guidelines available. of guidelines should be done regularly by during supervision from hospitals to HCs to ensure all facilities have at least one 6. Use of water dispensers All MCSP staff are educated on the use of safe water The empty water bottles and Continue monitoring during trainings and meetings within work premises and the MCSP office has water sometimes plastic cups remain dispensers for use. Some training sites are using water in the training room may be dispensers but others are still using bottles, all training and disposed of in the meetings at health facilities level are still using bottles. environment of the training sites 7. Monitoring of updated bin During mentorship, integrated supervision and other Some heath facilities do not Continue monitoring cards with expiry dates visits, MCSP ensures that HFs update bin cards with have been cards or do not expiry dates. The environmental health officer of the replace expired bin cards. health facility is in charge of ensuring regular updating of bin cards 8. Summary of monthly All health facilities make monthly reports on drug The expired drug disposal MCSP will continue to ensure that expirations and quarterly expiration and submit the report to the district pharmacy. schedule is based on the expired drugs are removed from schedules for disposal of Expired drugs are reported, removed from the pharmacy quantity to be disposed pharmacy stores and disposed of expired medicines stores and taken to the district pharmacy or hospital for regularly final disposal where incinerators that meet required standards are available 9 .Monitoring quarterly During mentorship and integrated supervision from Some expired drugs remain in Regularly remove all expired drugs schedules for disposal of hospitals to health centers, supervisors/mentors verifies pharmacies with the risk of from pharmacy shelves to avoid expired medicines how health center pharmacies manage the medicines accidental distribution accidental distribution. Before including how expired drugs are disposed. distributing any medication, first verify its expiry date. 10. Safe disposal of All consumables are appropriately disposed of and health Sometimes the disposal bins Environmental health officers consumables by providing facilities have boxes for disposal of used syringes are full and are not emptied on (EHO) are responsible of disposal bins time. This creates risk of providing the required disposal bins. Continue monitoring

39 Mitigation measure from Status of mitigation measures Outstanding issues relating Remarks column 3 in the EMMR to required conditions, Mitigation Plan (EMMR Including deadlines and Part 2 of 3) responsible party contamination to the environment 11. Monitoring of use of log This activity was highlighted at capacity building centers This activity needs to be MCSP will continue monitoring its books for tracking application in Rwamagana and Ruhengeri. And some health facilities initiated at all health facilities. introduction at other health of EMMP at Health facilities started implementation facilities during the year. 12. Use of waste disposal During health facility visits, mentorship and integrated Some facilities in Kamonyi Hospital EHO at Remera Rukoma SOPs supervision, technical teams checked for availability of district do not have the SOPs DH will help to avail Waste waste disposal SOPs. and need support. disposal SOPs to all HFs. MCSP Waste disposal SOPs are available at HCs and hospital will Continue monitoring and advise for those who do not have waste disposal SOPs

40 ANNEX B: UPDATES ON FP COMPLIANCE (JAN-MAR 2017)

ACTIVITIES PURPOSE TARGETS Current status/ Achievements Next step/ Observations

Preventive Activities

1.Orient MCSP staff on U.S. Ensure all All MCSP/Rwanda All MCSP staff including new staff Continue to orient/train new family planning and abortion MCSP/Rwanda staff staff were oriented and passed the global e- staff on board as needed legal and policy requirements trained on compliance in learning course on FP compliance (New staff in MCSP perform e- person or through global 2017 version as they come on board. A learning as part of 90- e-learning course. certificate is presented upon dayintroductory orientation and completion of the course. conduct refresher training annually)

Orient MCSP- sub-grant staff Ensure FP compliance in MCSP Sub- grant Sub grant staff oriented and certificates Continue to orient new sub on US abortion and FP the activities staff available grant staff requirements implemented by MCSP Sub-grant staff

Organize quarterly meeting of Ensure FP Compliance at Committee including The quarterly meeting was conducted The next meeting is scheduled MCSP/FP compliance the service delivery level Technical and in March 2017 for June 2017 committee through monitoring administrative MCSP activities during field staff visits

Organize quarterly meetings on Ensure FP compliance MCSP supported The quarterly meeting was conducted The next quarterly meeting is FP compliance with all District and discussion on any health facilities on 17 February 2017 scheduled for May 2017 focal points (Focal points from related issue in MCSP districts meet to share supported districts experience, discuss on current

41 status and relevant risks to FP compliance if any.

Orient new staff in MCSP To ensure that staff of Service providers in This is a continuous activity that aims - Will continue to train all supported districts on U.S MCSP supported districts MCSP supported to orient new staff in MCSP supported staff in MCSP supported abortion and FP requirements and health facilities are districts/ health districts on US abortion and FP districts appropriate monitoring aware of US abortion and facilities legislative requirements. This activity - Abortion and FP activities FP compliance was integrated in all ASRH/FP compliance requirements requirements trainings such as FP all methods training will continue to be trainings, PPFP trainings, CBP/FP integrated in the agenda of trainings, FP mentorship workshops MCSP activities to speed up dissemination of the  112 Health care providers oriented information. trough FP all method training ,PPFP clinical training and FP mentorship orientation workshop  1,657 CHWs oriented during CBP-FP training  254 local leaders oriented during the orientation meeting on family planning Distribute printed posters, flip To ensure all MCSP supported FP job aids and required documents Distribution scheduled to start charts and leaflets on FP as well providers/clients have Health facilities for this FY are ready for distribution on 18th April 2017 as client file, individual cards tools with accurate information on FP MCSP will continue to print contraceptive methods and distribute FP job aids on a regular basis.

Monitoring Plan

Orient new MCSP staff on To document due All MCSP field staff  Monitoring checklists were shared - Will share monitoring monitoring checklists and diligence in monitoring with the field coordination team checklists with other MCSP questionnaires to be used by compliance with and all ASRH/FP team members staff who conduct field MCSP staff conducting field requirements.  Client and provider exit interviews visits visits (see the list on annexes). conducted in Musanze and - Will continue to monitor Nyamagabe district FP compliance in all HFs

42 Carry out facility monitoring Ensure that all MCSP MCSP supported Feedback from field visits is shared This will be integrated with and feedback on FP compliance partners are in Health facilities, among MCSP staff and districts as well monitoring of other activities, compliance with US MCSP sub-grants as MCSP sub grants and will be done quarterly abortion and FP organizations requirements This information is also shared during the quarterly meeting with district FP compliance focal points

Regular documentation and Ensure documentation All FP compliance All activities relating to US abortion This will be integrated with reporting on US abortion and and reporting of all activities documented and FP compliance are reported and monitoring of other activities, FP requirements available information and reported filed in a specific folder and will be done quarterly. relating to FP compliance by MCSP-Rwanda

43 ANNEX C: KEY ACTIVITIES PLANNED FOR NEXT QUARTER (April - June 2017)

SO1: Improve the quality, equity, gender sensitivity and sustainability of RMNCH and malaria services along the continuum of care. Maternal Health • Continue mentorship on FANC, B-EmONC, PNC in collaboration with district based mentors and RAM mentors • Obstetric Fistula screening and repair and equip Kibungo fistula repair site. • Continue support to mentorship in collaboration with RSOG • Formative supervision of hospital core teams to improve triage and rapid response to maternal emergencies • Support HFs to conduct self-assessment and improvement in terms of RMC • Equip health centers and hospitals with basic life-saving equipment based on needs assessment findings. • Equip 2 capacity building centers (Kigeme and Ngoma).

Neonatal Health • Organize LDHF ENC training for Kabutare district • Continue ENC monthly mentorship in 10 districts by district based mentors • Continue Supervision of ENC mentors • Continue OJT on neonatal protocols and mentorship in 12 DH by RPA mentors • Continue supervision of pediatricians in 8 DH • Organize quarterly meeting with all mentors in 10 districts at district level

Child Health • Continue IMCI Mentorship for trained providers in the 10 supported districts • Continue OJT on IMCI priority skills for additional providers in the 10 MCSP supported districts (on-going) • Support Quality Improvement Teams to reinforce the child health component and integrate facility and community QI processes in Ngoma

Family Planning 1. Conduct capacity building of providers on FP: • OJT approach: Nyabihu, Huye • FP Mentorship approach: all districts • PPFP/PPIUD clinical training and mentorship: all districts • Mentorship on permanent methods: TL and NSV • Train new CHWs (ASMs & Binomes) and provide refresher training (through mentorship approach) of CHWs on CBP-FP 2. Finalize distribution of tools, equipment and bags for CHWs and HFs

44 3. Distribute FP tools and material for HF and CHWs

Gender Integration • Coordinate RWAMREC to promote male engagement in RMNCH services and GBV prevention. • Work with Promundo to conduct a formative assessment study. • Conduct refresher -training for GBV IOSC coordinators on the delivery of comprehensive post-GBV care • Organize Quarterly supportive supervision in IOSCs and HCs. • Conduct supportive supervision of ANC/FP providers on GBV screening • Support MCCH to finalize, validate, print and distribute GBV training manuals and tools. • Support Gatsibo District to organize community mobilization on GBV prevention and service utilization.

ASRH Conduct community mobilization on FP and ASRH: • Local leaders orientation workshop: Ngoma, Nyamagabe • Campaign on FP service delivery in Musanze and Nyamagabe • ASRH activities in HFs and in community

Quality Improvement • Support creation of DHIS 2 dashboards containing RMNCH quality of care indicators at hospital and HC level for CQI. • Facilitate improved compliance with compliance with quality driven standards at hospital level.

SO2: Scale up high impact interventions Learning and Scale-Up • Support roll out of ENC/HBB and PPFP/PPIUD package in 10 MCSP supported districts through mentorship and supportive supervision. • Conduct national experience sharing workshop on implementation of PPFP and ENC/HBB scale up interventions

SO3: Increase community mobilization for, participation in, and utilization of high-quality RMNCH and malaria services CM/SBCC:

• Support quarterly meetings to monitor the community action plans’ implementation progress and behaviour change. • Organize one day in each district to provide recognition and a prize to the behaviour change champion. • Distribute Booklets on RMNCH and FP through different platforms such Umugoroba w’ababyeyi (Evening for Parents) • Support RHCC to elaborate SBCC training materials and tools

45 • Support regular coordination meeting of HP TWG once a month • Support and participate in different forums such as DHMT and JADF to raise awareness about community interventions and share experience • Conduct TOT for health providers on CB-MNH/PPH in 4 remaining districts. • Support training of ASMs on CB-MNH/PPH in 4 remaining districts. • Sensitization meeting for local authorities of 4 districts on CB-MNH and PPH prevention program

SO4: Build capacity to use data for decision making and action at all levels of the health system M&E: Capacity Building: • Conduct training of new CHWs on RapidSMS in Kirehe, Ngoma and Nyarugenge • Organize and conduct integrated supervision in MCSP supported districts • Organize technical coordination meetings in MCSP supported districts • Conduct data quality audit of FP and MNCH indicators in Rwamagana, Nyaruguru, Kamonyi and Nyabihu • Hold a workshop on advanced GIS • Conduct mentorship on GIS for district level staff • Support community DQA including use of RapidSMS

M&E: Program monitoring and reporting • Support mentorship from hospital to HC in DQA and data use • Support MoH to conduct a 5 day workshop to review of HMIS data collection tools • Support a workshop at DH for dissemination of new HMIS data collection tools • Support organization of quarterly meeting with hospital and district M&E staff to review district level data and identify action steps. • Work with national HMIS team to analyze and validate quarterly data • Support analysis of clinical death audit reports from12 MCSP supported hospitals • Track referral and counter referral systems across RMNCH interventions

Field Coordination: • Facilitate quarterly DHMT Meetings in 16 districts • Facilitate community health workers quarterly Coordination Meetings in 16 districts • Support annual DHMT supervision visits in Nyabihu, Huye, Musanze and Kayonza districts • Participate in all pertinent district level events including meetings organized by Districts and support and Huye JADF open day

46 SO5: Increase capacity to manage and control malaria in Rwanda Malaria: • Initiate iCCM Mentorship in Nyarugenge • Train new Binomes in iCMM in the 7 supported districts • Continue iCMM Mentorship activities in the 7 districts • Print and distribute iCCM validated tools to the 7 supported districts • Implement IST, KAP and Drug Efficacy studies

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