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SEXUAL AND REPRODUCTIVE HEALTH FOR ALL INITIATIVE (SARAI) AID-611-A-15-00001
JANUARY TO MARCH 2019 QUARTERLY REPORT
SOCIETY FOR FAMILY HEALTH
In partnership with Population Services International Development Aid from People to People Zambia ChildFund International
Activity Summary
Implementing Party Society for Family Health
Sub Awardees Development of Aid from People to People (DAPP) Population Services International (PSI) ChildFund International Activity Name Sexual and Reproductive Health for All Initiative(SARAI) AID-611-A- 15-00001
Project Period 20th April 2015 to 19th April 2020
Total estimated Amount $15,250,000
Objective To provide support for a program in Integrated Family Planning and Reproductive Health Project Sites Copperbelt Province: Chililabombwe, Chingola, Kalulushi, Kitwe, Mufulira, Ndola Muchinga Province: Mpika, Mafinga, Shiwa Ngandu, Nakonde, Lavushi Manda, Kanchibuyia Luapula Province: Mansa, Chienge, Lunga, Nchelenge, Kawambwa Report Submitted by Gina M. Smith, Deputy Country Representative/Chief of Party – Society for Family Health Society for Family Health Plot 549 Ituna Road, Ridgeway P O Box 50770, Lusaka Tel +260 211 257407 Email: [email protected]
April 2019 This report was produced for review to the United States Agency for International Development It was prepared by SFH for the Sexual and Reproductive Health for All Initiative Project. Table of Contents
ACRONYMS ...... 5
1. INTRODUCTION ...... 7
2. OPERATIONAL ACTIVITIES ...... 7
3. FAMILY PLANNING SERVICE DELIVERY IMPROVED ...... 9 3.1. Improved Method Mix through Enhanced Community Based and Facility Service Delivery Models for Family Planning ...... 10 3.2. Enhanced FP/HIV Integrated ...... 21
4. USE OF HEALTHY FANILY PLANNING AND REPRODUCTIVE HEALTH PRACTICES INCREASED ...... 23 4.1. Revise FP messaging with a focus on youth engagement...... 23
5. FAMILY PLANNING SERVICE DELIVERY SYSTEMS AND ACCOUNTABILITY STRENGTHENED...... 26 5.1. Strengthen Quality of FP Service Delivery ...... 26 5.2. Strengthened Use Of Data For Decision Making...... 30
6. PROJECT INDICATOR TRACKING ...... 32
7. CHALLENGES / MITIGATION ...... 32
8. CONCLUSION ...... 33
LIST OF TABLES Table 1: Off-Duty Provider Services ...... 12 Table 2: FP Contribution of SARAI Supported vs. Non-Supported Health Facilities ...... 13 Table 3: Number Of Clients Who Received FP Services By Age And Type Of Method ...... 17 Table 4: Number Of Clients Switching FP Method By Province ...... 17 Table 5:Number Of Referrals by FP Method ...... 19 Table 6: Number Of Women Referred For FP Services By Age Group By FP Method ...... 20 Table 7: FP integration indicators ...... 22 Table 8: Indicator tracking table* ...... 32
LIST OF FIGURES Figure 1: District DHIS2 Reporting Rates by Month ...... 10 Figure 2: Distribution of new FP acceptors by Month...... 10 Figure 3: Distribution of FP commodities by quarter ...... 11 Figure 4: Distribution of FP commodities by Province ...... 11 Figure 5: Total Active CBDs By Province ...... 14 Figure 6: FP Distribution By Method And By Province ...... 16 Figure 7: Total Condoms Distributed In Quarter One By Province ...... 18
3 Figure 8: Comparison Of CBDs Reporting Stock-Outs By Method And Province ...... 19 Figure 9: Referrals and Feedbacks by Province ...... 21 Figure 10: Clients reached with SRH messages by FP Champions ...... 25 Figure 11: Number of Facilities Adhering to Quality Standards ...... 26 Figure 12: Number of Facilities Reporting Stock out by Commodity ...... 27 Figure 13: Total Number of Days Facilities Reporting Stock Out by FP Commodity ...... 28 Figure 14: Number of Facilities Conforming To Waste Management Standards By Region ...... 29 Figure 15: Number of Facilities Adhering to Providing Quality Community FP Services By Region ...... 29
4 ACRONYMS AE Adverse Event CBD Community Based Distributor CSE Comprehensive Sexuality Education DAPP Development Aid from People to People DMPA SC Depo Provera Subcutaneous DHO District Health Office DQA Data Quality Assessment eMTCT Elimination of Mother to Child Transmission FP Family Planning FY Financial year HIA2 Health Information Aggregation 2 HCW Health Care Worker HCD Human Centered Design HMIS Health Management Information System HIV Human Immunodeficiency Virus HTS HIV Testing Services IGA Income Generating Activity IPC Interpersonal Communication IUCD Intra Uterine Contraceptive Device LARC Long Acting Reversible Contraceptives MCPR Modern Contraceptive Prevalence Rate M&E Monitoring and Evaluation MOGE Ministry of General Education MOH Ministry of Health OVC Orphans and Vulnerable Children PNO Principal Nursing Officer PPE Personal Protective Equipment PSI Population Services International QA Quality Assurance RH Reproductive Health SARAI Sexual and Reproductive Health for All Initiative SBC Social Behavior Change SIMS Site Improvement through Monitoring Systems
5 SFH Society for Family Health SRH Sexual and Reproductive Health USAID United States Agency for International Development VMMC Voluntary Medical Male Circumcision YFHS Youth Friendly Health Services
DISCLAIMER: The author’s views expressed in this report do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government.
6 1. INTRODUCTION The Sexual and Reproductive Health for All Initiative (SARAI) is a USAID-funded, five-year project whose goal is to increase the annual Contraceptive Prevalence Rate (CPR) by 2% in the supported sites. SARAI aims to achieve this goal by; i. Improving Family Planning (FP) service delivery; ii. Strengthening accountability of FP service delivery systems; and iii. Increasing healthy FP and Reproductive Health practices.
The project which begun in April 2015 is being implemented in Copperbelt, Luapula and Muchinga provinces in 17 districts by SFH and its sub awardee, DAPP, ChildFund and PSI. SARAI is currently supporting 143 facilities.
This report gives an account of the SARAI project activities conducted from 1st January to 31st March 2019 by SFH and its sub awardees. As per award agreement, this report focusses on the seven quarterly indicators as specified in the SARAI monitoring and evaluation plan related to facility based FP service provision, community based service provision and quality assurance.
2. OPERATIONAL ACTIVITIES
The project successfully held a semi-annual review meeting in Mansa in February 2019. The participants included staff from SFH HQ, DAPP and regional project staff. Amongst the areas the meeting reviewed were project progress performance to date, challenges, sharing of best practices, and the 2019 project workplan. Other aspects of this meeting included updates on PEPFAR indicators, reporting and programming, refining of the youth programming and site visits.
As part of the workplan activities, the project staff from the SFH HQ, three regional offices and DAPP participated in national, provincial and district level meetings in order to build strong working relationships, keep abreast with national policies, provide technical support and share project progress reports. The HQ team participated in the monthly national FP, Adolescent and Supply Chain Technical Working Group (TWG) meetings during the period under review. In Copperbelt, Muchinga and Luapula Provinces, SARAI took part in Provincial Integrated Meetings (PIM) with participants from Provincial Health Offices, District Health Offices, Third Level Hospitals, Second Level Hospitals, and Health Program Training Institutions. The deliberations of these meetings included need for accountability towards work, enhanced partner coordination, sexual and reproductive health and HIV activities, supply chain system with emphasis on a
7 robust and responsiveness of MSL, and the importance of data and therapeutic meetings. The participants were implored to submit quarterly reports to the PHO for these activities.
In March 2019 the SARAI CoP was among select members of the Zambia National FP Technical Working Group to participate in the DMPA-SC study tour to Uganda funded by PATH. Delegations from Zambia, Myannmar and Kenya were invited to witness evidence-based implementation of DMPA-SC with particular focus on self-injection. Lessons from across the different countries were also shared. It was observed that DMPA-SC roll-out in Uganda for facility based providers and CBDs has been successful and client. Self- administration can be done safely and effectively. In addition, opportunities were identified which could play a role in increasing access to DMPA-SC. There was evidence that DMPA-SC assisted in mitigating access related barriers for women, increased contraceptive continuation rates, and enhanced women’s autonomy. It was agreed that Zambia would propose a progressive roll-out of self-injection in the public sector, however further discussions would be required for private sector involvement.
During this reporting period, sub award monitoring of DAPP in Ndola was conducted in February 2019 for the period October to December 2018. This activity was completed by the office of Technical Services Manager, Internal Auditor Manager and the Grants and Contracts Accountant. The main focus included the review of expenditure, review of control areas such as payroll management, Cash and Bank, fleet management, fixed assets and compliance to USAID regulations. Majority of action items had been implemented however disallowed costs due to potential fraud were identified, which were subsequently communicated to USAID and the Office of Inspector General (OIG). The final report with recommendations is being finalised and will be shared with DAPP. Meetings with DAPP management will continue and follow up visits will be conducted to investigate further.
SARAI hosted a delegation from USAID Washington who visited Copperbelt Province. The main objectives of the visit were to assess LNG-IUS implementation, familiarize themselves with CBD activities and to observe the integration of HIV/FP with a particular focus on TLD roll-out. They assessed both FP providers and Clinicians on prescription of TLD for women of reproductive age in relation to providing informed choice through counselling and ART options, including DTG. All the three facilities that were visited had ART guidelines from the MoH on the use of TLD. The team assessed CBDs and FP providers and expressed satisfaction that both cadres had demonstrated a high level of skill and adhered to the set protocols and guidelines. The delegation appreciated the support that SARAI offers to MoH. The delegation also discussed the need for SARAI to pre-position for the launch of the Avibela product. The team further interacted with LNG-IUS clients who were very satisfied and enthusiastic about use of the product. 8 The HQ team held monthly meetings with the USAID and the sub-awardee in order to share project updates and hold discussions on various issues. The discussions mainly were centred on approval of 2019 work plan, financial and technical reporting, and completion of 2019 USAID compliance courses, review of the M&E plan, site visits and preparations for scaling up SARAI activities to 30 new public facilities.
The CoP, Technical Services Manager and Senior M&E officer also participated in SARAI was part of the DMPA Access Collaborative MLE workshop with the MOH and other DMPA-SC partners in Zambia held in March of 2019. The main objective of the workshop was to understand monitoring approach for DMPA- SC, agree on tracking indicators, identify data needs of various stakeholders, process for data submission and build partner commitments to share data. The workshop as led by PATH. Status of each indicator was reviewed and updated. It was agreed that reporting on DMPA-SC in DHIS2 would be rendered functional. Once the global tracker is finalized, stakeholders will have access.
SARAI is seen as a pioneer of the FP CBD programme. Thanks to the recognition of the project’s success, UNFPA, on behalf of the Ministry of Health, has engaged the Population Council to document family planning community based distributors (CBD) programme in Zambia. The purpose of the documentation is to share lessons of what has worked in task sharing, shifting from health care workers to CBDs in FP service provision and to highlight successes and areas for improvement to further strengthen the CBD programme in Zambia. Interviews were conducted in March with various stakeholders including those from SARAI. The project is expected to be featured prominently in the document.
The project is on track with expenditure with $11,934,272 spent through end of March 2019 representing 78% of the total budget and 92% of the obligated amount of $12,963,541. A request for increase in obligation was submitted to USAID as the project has reached over 75% of its current obligated amount, however only an increase of one million dollars was approved until the funds arrive in Zambia. Due to delays in funds transfer, SARAI has postponed some activities planned in March and April including the CBD trainings in new scale up sites, therefore it is expected that once funds become available, spending will increase dramatically in the upcoming months.
3. FAMILY PLANNING SERVICE DELIVERY IMPROVED SARAI directly provide support to 143 out of 303 facilities in 17 implementing districts across Copperbelt (6), Luapula (5) and Muchinga (6) Provinces. The project uses project and MoH DHIS2 district wide data to measure progress towards achievement of set targets in the M&E Plan. During the period under review, MoH DHIS2 facility reporting rate was on average at 98% in all SARAI implementing districts. The figure
9 below shows DHIS2 reporting rates for the period under review.
Figure 1: District DHIS2 Reporting Rates by Month
99% 98% 98%
January February March
Source: MOH DHIS2 district data
Comparing to previous quarter, the reporting rate increased by 1%. The project has continued recording high reporting rates of above 95%. This is attributed to strengthened working relationships with MoH through conduction of joint data audits and review meetings.
3.1. Improved Method Mix through Enhanced Community Based and Facility Service Delivery Models for Family Planning
3.1.1. Dedicated And Off-Duty Provider Model Implemented Progress towards the Number of Women of Reproductive Age Who Receive FP Methods: According to data obtained from DHIS2, 159,026 FP related visits were made by women of reproductive age during the period 1st January 2019 to 31st March 2019. Among the women seeking FP service, 40,607 were new acceptors while 118,419 were repeat visitors. Compared to previous quarter, this quarter recored a 25% increase for new FP acceptors . Figure 2 below shows the distribution of new FP acceptors by quarter. However it should be noted that this figure is likely an underrepresentation of the total new FP acceptors because the new FP register, which is the main data collection tool used is not available in most facilities, as a result, some facilities have resorted to using the old registers which do not contain this measure.
Figure 2: Distribution of new FP acceptors by Month
Q1 2019 40,607 Q4 2018 32,395
10 Source: MOH DHIS2 district data, mCPR calculator
During the period under review, various FP commodities were distributed both at facility and community level. The figure shows the distribution of FP commodities in comparison to last quarter.
Figure 3: Distribution of FP commodities by quarter
Jan - Mar 2019 Oct - Dec 2018
Sterilisation - male 7 0
Male condoms distributed 961,375 800,308
Sterilisation female 78 154
Oral pill cycle 37,318 28,592
Progesterone only pill 18,783 14,974
Norethisterone enanthate injection 13,698 15,504
Medroxyprogesterone injection 83,077 74,909
IUCD inserted 1,078 1,183
Implant 10,911 9,530
Female condoms distributed 27,900 19,780
0% 20% 40% 60% 80% 100%
Source: MoH DHIS2
Comparing to the previous quarter performance the following trends were observed: • Generally, 9% decrease in IUCDs attributed to stock-outs in 91 facilities with an average stock- out rate of 9 days per facility • Significant increase (41%) in female condom distributed due to increased distribution during road shows in Copperbelt Province and youth festivals held in Muchinga and Luapula Provinces.
The table below shows distribution of FP methods in SARAI supported regions. Figure 4: Distribution of FP commodities by Province
11 Copperbelt Luapula Muchinga
Sterilisation - male 7
Male condoms distributed 462,120 352,845 146,410
Sterilisation female 48 6 24
Oral pill cycle 25,233 4,501 7,584
Progesterone only pill 12,372 2,549 3,862
Norethisterone enanthate injection 6,725 2,714 4,259
Medroxyprogesterone injection 50,016 23,384 9,677
IUCD inserted 555 339 184
Implant 5,396 2,516 2,999
Female condoms distributed 9,516 14,947 3,437
0% 20% 40% 60% 80% 100%
Source: MoH DHIS2
Among all FP methods provided, male condoms were the most accessed across three regions while male sterilization was the least accessed. Despite Copperbelt having more CBDs and supported facilities Luapula distributed more female condoms. This was attributed to frequent stock out of female condoms in the Copperbelt Province.
Besides the use of community based distributors and routine facility-based FP service provision, SARAI also uses the off-duty provider model to provide, where possible, additional support to ensure uninterrupted provision of FP services as well as support the provision of LARCs. The off-duty model was used in 116 high volume facilities. The table below shows the performance of the off-duty model.
Table 1: Off-Duty Provider Services
Off-duty FP provision Copperbelt Luapula Muchinga Total Number of Facilities 37 45 34 116 Number of off-duty providers 154 61 19 234
12 Number of off-duty shifts 389 302 142 833 Number of clients seen 8,165 3,328 1,753 13,246 Source: Project data (Client intake forms)
During the period under review, 13,246 clients were seen by off-duty providers representing an increase of 2% from last quarter. Off-duty providers in Copperbelt Province contributed a significantly high number of clients compared to Muchinga and Luapula Regions. This was attributed to high population of WRA on Copperbelt province. In addition, Copperbelt province had the highest number of off-duty providers.
3.1.2. Contribution of SARAI Supported Facilities To District Wide FP Methods Distribution During the reporting period, the project directly supported 143 facilities out of 303 facilities across 17 implementing districts. SARAI supported facilities have a total catchment area population of 483,151 WRA representing 64% of WRA. The table below shows the proportional contribution of directly supported facilities to overall performance.
Table 2: FP Contribution of SARAI Supported vs. Non-Supported Health Facilities
SARAI SARAI & % FP Method Supported Non-SARAI Distributed Female condoms distributed 23,586 27,900 85% Implant 7,938 10,911 73% IUCD inserted 686 1,078 64% Medroxyprogesterone injection 52,340 83,077 63% Norethisterone enanthate injection 8,783 13,698 64% Progesterone only pill 12,149 18,783 65% Oral pill cycle 25,324 37,318 68% Sterilisation female 31 78 40% Male condoms distributed 581,120 961,375 60% Sterilisation - male 0 7 0% Source: MOH DHIS2 district data
Generally, SARAI supported facilities contributed significantly (above 64%) across LARCs, pills and female condoms representing an expected performance of 100% and above compared to the catchment area. This was attributed to improved FP messaging, CBDs service provision, engaging of off-duty
13 providers and other demand creation strategies. On the other hand, non-SARAI supported sites contributed significantly on Medroxyprogesterone injection and male condoms. This was attributed to national wide
roll out of DMPA SC.
3.1.3. Community Based FP Service Provision
Monitoring and Supervision of CBDs: The project actively worked with 821 of the 855 trained CBDs. These CBDs provided FP services with emphasis on the importance of FP accessibility and improved method mix. More mentorship and monitoring of CBDs was done to ensure that CBDs submitted reports on monthly basis and that the data was also recorded correctly in the health facility HIV integration registers. The proportion of trained CBDs actively reporting was at 96% showing a reduction of 1% likely due to CBDs taking part in farming season activities and less in health work.
Figure 5: Total Active CBDs By Province
Muchinga, 199, 24% Copperbelt, 373, 46% Luapula, 249, 30%
Copperbelt Luapula Muchinga
Monthly monitoring of CBDs continued during the reporting period in the 143 health facilities to assess the quality and competence of FP service delivery . This included assessments to ensure that the service delivery was in accordance with the MoH guidelines, standard operating procedures and requirements. The supervisors gave feedback to CBDs on their findings to ensure improved service delivery. Supervisors use a checklist which was specifically developed to monitor CBDs as a way of ensuring that quality services are maintained.
It was observed that CBDs were offering services in accordance with MoH guidelines and procedures using the new messaging tool, other FP counselling tools and FP counselling flow charts. In addition, CBDs were able to dispose off sharps and other medical wastes appropriately. There is need to continue mentoring the CBDs to ensure that data is updated in the Family Planning Integrated register at the health facility.
14 Monitoring of trained CBDs in injectables DMPA IM in newly scaled up health facilities in all the supported provinces was conducted. During this reporting period, 96 CBDs (Luapula 53 CBDs and Copperbelt 43 CBDs) who were still doing practicums in health facilities have since been certified and have started offering FP/SRH services in the communities.
The National Family Planning TWG through the Safety Committee conducted safety assessment for CBDs that offer DMPA IM and SC nationally including in SARAI supported districts of Kalulushi in Copperbelt, Mafinga in Muchinga and Kawambwa in Luapula Provinces in February 2019. The teams comprised of representatives from MOH headquarters and Provincial Health Offices, SARAI SFH, DAPP, GHSC-PSM, Population Council and JSI SAFE. Specific objectives of the CBD safety committee included to;
• Monitoring for adherence to recommended safety measures in the provision of FP injectable methods as per national guidelines
• Assessing CBD’s ability to safely and effectively provide DMPA injections to clients
• Determinng the extent to which CBDs are meeting basic minimum standards during the provision of injectable DMPA IM and SC
• Identifing any adverse events and incidences experienced by CBDs and
• Assessing the quality of data collected by the CBDs.
All the CBDs visited in the community had FP commodity storage boxes, sharp boxes to store used needles and syringes, bin liners and buckets used to dispose of waste generated at community level. The CBDs correctly explained that once the sharp boxes and bins are quarter full, they are taken to the health facility for effective disposal. CBDs were following the prescribed MoH safety standards. The committee also found out that CBDs were supervised, albeit not consistently due competing demands on the part of supervisors and lack of transport at the health facilities. However the assessment team learnt that health facilities have begun to integrate CBD supervision in other outreach programmes such as growth monitoring and CBD’s monthly visits to the health facility by engaging them in a discussion on the standards and how they are abiding to these standards. The team reviewed CBD data and found that data is accurately captured and submitted to facilities on a monthly basis. Overall, the team was satisfied that the CBD programme has been successfully implemented, the community has accepted the concept and it is contributing to decongesting health facilities and freeing health care workers to allow them time to concentrate on more specialized services. A final report will be drafted and presented to the FP TWG.
15 Community Based Distribution of FP products: During the period under review, the CBDs distributed and conducted demand creation activities for FP services through community mobilization and outreach activities. This resulted in CBDs distributing family planning commodities to a total of 72,359 clients. Comparing to quarter four of 2018, the project recorded an increase of 2%.
Figure 6: FP Distribution By Method And By Province
Injectable Injectable Pill Male Female Totals DMPA IM DMPA SC Condoms Condms Copperbelt 18,244 1,208 4,531 10,612 788 35,383 Luapula 7,663 724 1,525 12,506 832 23,250 Muchinga 3,888 1,459 2,449 5,699 231 13,726 Totals 29,795 3,391 8,505 28,817 1,851 72,359
Copperbelt reached a total of 35,383 compared to 34,919 clients in the previous quarter, representing a 1% increase. Luapula recorded 23,250 clients compared to 21,054 representing an increase of 9% from the previous quarter. The observed increase in the supported provinces was attributed to enhanced outreach activities, community mobilization, increased monitoring supervisions as well as increased supply of FP stocks. While Muchinga province recorded 13,726 clients compared to 15,332 representing a 10% reduction. The reduction was as a result of the continued stock outs experienced in the province especially for oral (combined?) pill and condoms compared to last quarter. Below is the number of clients who received FP services by age and type of method.
In order to improve family planning method mix, prevent STIs and HIV infection and unwanted pregnancies amongst the youths and women, the project continued distributing free condoms, creating more condom service delivery points and sharing of information on the correct and consistent use of condoms. During this reporting period, a total of 472,511 condoms (459,811 male condoms and 12,700 female condoms) were
16 distributed compared to 480,623 condoms (466,655 male condoms & 13,968 female condoms) distributed last quarter. This shows a reduction of 2% attributed to the condom stock outs experienced in the period under review in many sites where the project is operating. Below is the table showing the distribution of condoms by provinces. Table 3: Number Of Clients Who Received FP Services (from CBDs?) By Age And Type Of Method
Age Group Total Type of contraceptive 10-14yrs 15-19yrs 20-24yrs 25-49yrs 49 Client Switching Behavior: The project continued monitoring clients’ switching behavior by tracking the number of clients that switched from one contraceptive to another. During the reporting period, 1,155 clients switched compared to 504 reported last quarter. A total of 796 clients compared to 386 clients switched from Injectable DMPA IM to DMPA SC, 185 clients to 3 clients from Injectable DMPA SC to DMPA IM, 161 clients to 111 clients from pill to Injectable DMPA SC. The clients reported that they switched from one method to another because of the following reasons: 1) The commodity was readily available in the communities, 2) Injectable DMPA SC was readily pre packed and easy to use; 3) the needle for DMPA SC is small and less painful when being administered. Table 4: Number Of Clients Switching FP Method By Province Switching from Switching to Copperbelt Luapula Muchinga Total Injectable DMPA IM Injectable DMPA SC 4 198 594 796 17 Injectable DMPA SC Injectable DMPA IM 1 0 184 185 Pill Injectable DMPA SC 1 22 138 161 IUCD Injectable DMPA SC 0 0 20 20 Female Condom Injectable DMPA SC 0 0 13 13 Implant Injectable DMPA SC 0 0 0 0 In order to improve the family planning method mix, prevention of STIs and HIV infection as well as unwanted pregnancies amongst the youths, women, the project continued distributing free condoms, creating more condom service points and sharing of information on the correct condom use. During this reporting period, a total of 472,511 condoms (459,811 male condoms and 12,700 female condoms) compared to 480,623 condoms (466,655 male condoms & 13,968 female condoms) distributed last quarter. This shows a reduction of 2% attributed to the condom stock outs experienced in the period under review in many sites where the project is operating. Below is the figure showing the distribution of condoms by provinces. Figure 7: Total Condoms Distributed In Quarter One By Province 459,811 193,337 149,516 116,958 5117 5720 1863 12,700 Copperbelt Luapula Muchinga Total Male Condoms Female Condoms CBD family planning commodity supply restocked at supported health facilities: During this reporting period, the project-supported facilities continued to experience stock outs of different FP commodities, this was due to less stocks in the facilities. The project had 821 active CBDs in the period under review, of which, 389 CBDs (47%) reported stock outs in female condoms, 185 (23%) in male condoms, CBDs (93%) in pill, 46 (6%) in injectable Depo and 55 (7%) in Syringes. The highest stock outs reported were in pills by 334 CBDs in Copperbelt province, 239 CBDs in Luapula and 189 CBDs in Muchinga. However, the project has continued working at ensuring that the health facilities receive adequate FP commodities through the support from the District Health Director and District Nursing Officers. To reduce the stock outs, the project provided transport as they visited the operation districts and worked closely with the pharmacists in provinces and districts to re-district FP commodities. 18 Figure 8: Comparison Of CBDs Reporting Stock-Outs By Method And Province Jan Feb Mar Jan Feb Mar Jan Feb Mar Copperbelt Luapula Muchinga Female Condoms 174 159 152 114 95 89 127 136 120 Male Condoms 70 57 70 73 43 44 67 72 58 Pills 342 336 324 242 240 235 189 196 181 Injectable Depo 11 15 17 10 9 8 21 27 22 Syringes 0 0 13 4 4 4 24 55 34 Female Condoms Male Condoms Pills Injectable Depo Syringes Referral system established for CBDs to link clients for LARC and other services: The project recorded 4,927 referrals compared to 5,695 referrals reported last quarter showing a reduction of 13%. This reduction is attributed to the farming season where clients spent more time working in their field, nevertheless, most clients preferred receiving the service in the afternoon upon return from the fields. The table below shows referrals made by province and by FP type in comparison with quarter four of 2018. Table 5:Number Of Referrals by FP Method Referred for Province Injectable Implant IUCD Sterilization Sub-Totals Other Copperbelt 1,064 490 65 19 309 1,947 Quarter 4 Luapula 1,767 610 20 48 129 2,574 (2018) Muchinga 705 216 20 2 231 1,174 Totals 3,536 1,316 105 69 669 5,695 Referred for Province Injectable Implant IUCD Sterilization Sub-Totals Other Copperbelt 658 373 50 7 250 1,338 Quarter 1 Luapula 1,751 484 16 5 131 2,387 (2019) Muchinga 645 291 8 0 258 1,202 Totals 3,054 1,148 74 12 639 4,927 19 For implants, Muchinga province reached 291 clients compared to 216 clients in the previous quarter representing an increase of 26%. The project has continued conducting combined outreach activities with key players in reproductive health and family planning services resulting to increased awareness on FP information. Luapula performed better compared the other two regions. Luapula mobilized outreaches that provided a good platform for the providers to find potential clients for long-term methods. The mobilization was done by regional staff and project leaders in the districts working with CBDs. On the outreach day in some facilities, CBDs went round with megaphones to announce the arrival of the LARC providers at the facility. the regional technical staff also used this platiform to observe health staff who provide LARC for competence . This approach of mobilization which Luapula used will be replicated to Copperbelt and Muchinga provinces for better results going forward. Table 6: Number Of Women Referred For FP Services By Age Group By FP Method 10-14yrs 15-19yrs 20-24yrs 25-49yrs >49yrs Injectable Depo 3 498 1,185 1,327 41 Implant - 127 452 547 22 IUCDs - 7 22 42 3 Sterilization - - 1 9 2 Referred for others 12 85 204 316 22 Totals 15 717 1,864 2,241 90 From the table above, of those referred, clients aged 24 to 49 were the majority and those in the age range 10 to 14 years old were the least. 62% of the women were referred for injectable DMPA. Proportion of completed referrals: The referral system linked clients to facilities in order to be assessed for eligibility and administration of LARC. During this reporting period, the project recorded 4,927 referrals of which 3,659 provided feedback. This represented a total of 74% of referred clients who confirmed having accessed health services. In comparison to 4th quarter of 2018, this represented a reduction of 5% on the total feedback collected. This was attributed to the farming season where CBDs and people in the communities are involved in farming activities and not always at home. 20 Figure 9: Referrals and Feedbacks by Province 4,927 3,659 2,3872,037 1,338 1,202 789 833 59% 85% 69% 74% Copperbelt Luapula Muchinga Project Overall Referrals Feedback Percentange 3.2.Enhanced FP/HIV Integrated 3.2.1. Adolescents reached with age appropriate sexual education and linked to FP/RH Services Review meetings for guidance and counselling teachers in the SARAI project-supported schools: To ensure that sexual and reproductive health education reaches children that are in schools, the project continued implementing Comprehensive Sexuality Education (CSE) through guidance teachers and peer educators in 505 schools. As such, during this reporting period, the in-school clubs shared health information to 9,881 pupils after conducting 193 health education session. Below are pictures showing activities with in school youth clubs. School health clubs and out-of-school youth clubs supported to conduct FP/SRH awareness activities: During this reporting period, key messaging in 165 out of school youth clubs continued on sexual and reproductive health, early marriages, HIV/AIDs and other health related issues. The clubs reached 13,212 adolescents compared to 33,716 adolescents reported in fourth quarter of 2018. A total of 54,728 condoms compared to 75,958 condoms in the previous quarter, were also distributed to 3,679 clients. Condom and IEC materials distributed by trained shop owners: 472 Shop owners continued distributing condoms and ensuring that correct information on the effective use of condom was shared to the youths, men and women in their communities. During this reporting period, 472 shop owners distributed 36,600 condoms to 3,079 clients. These shop owners also conducted 239 education sessions reaching a total of 4,652 people. Train school peer educators/strengthening AIDS clubs: Strengthening of the Anti-AID clubs continued in the 505 supported-schools through health information sharing to the adolescents and youths. The guidance teachers/matrons continued providing mentorship and supervising of peer educators so that more education 21 sessions could be conducted to assist pupils in schools with information on sexual and reproductive health. During the reporting period, the project recorded a total of 9,881 pupils having received SRH information compared to 38,854 pupils recorded last quarter. 3.2.2. FP Integration Facilitated In line with the Ministry of Health FP integration scale up plan 2012 – 2020, SARAI continued to implement Family planning integration activities. The project prioritized integration of family planning into other clinical areas such as HIV testing services (HTS), elimination of mother to child transmission (eMTCT), voluntary medical male circumcision (VMMC), safe motherhood, cervical cancer screening, immunization and out- patient department (OPD). During the period under review, all 143 supported facilities offered integrated services. According to project data, the project facilitated testing of 17,403 women for HIV during static and outreach family planning services. Compared with the previous quarter, the period under review recorded a 36% decrease in number of women being tested for HIV. This is attributed to persist stock out of HIV testing kits. Out of the total number tested, 88 tested positive (0.5%) and were provided with appropriate post testing services. The table below shows family planning integration indicators the project is tracking and performance recorded during period under review. Table 7: FP integration indicators Indicator Muchinga Luapula Copperbelt Total Number of integrated sites 34 44 65 143 Number of women receiving FP from ART 0 0 476 476 Number of women counselled for FP at VCT 115 1,856 6,995 8,966 Number of women counselled for HIV at FP 13,591 6,354 13,129 33,074 Number of women tested for HIV at FP 4,518 3,679 9,206 17,403 Number of women tested positive for HIV at FP 14 5 69 88 USAID FP Integration Meeting: The SFH Executive Director and Senior QA Officer attended the USAID FP/HIV integration meeting facilitated by a delegation from USAID Washington. During the meeting the USAID priorities for HIV/FP integration were discussed which included strengthening supply chain management systems, review of HIV national guidelines to integrate FP; and capacity building of service 22 providers in provision of FP and HIV services and scale up long-acting family planning service provision through training of health care providers to ensure an expanded contraceptive method mix in the facilities. The successes of integration that were highlighted included but not limited to: WHO 2015 MEC wheel reviewed and adapted for Zambia, engaged with parliamentarians to discuss FP advocacy and programming, integration of FP services into other RMNCAH-N services e.g. child health clinics, cervical cancer screening and HIV counselling and testing, national quantification and forecasting meetings conducted regularly, involvement of the community health providers (CBDs, SMAGS, Lay counselors); orientation on FP and HIV messaging in their demand creation activities, review of the data collection tools to enhance tracking and assessment of integrated services. Presentations and resources on USG guiding principles for FP/HIV integration - voluntarism and informed choice were shared during the meeting. A presentation on the Hormonal Contraception and Risk of HIV Acquisition, and the ECHO Trial was made. A presentation on Zambia transitioning to Tenofavir, Lamivudine, Dolutegravir (TLD) regimen in ART and its presumed effect for women of child bearing age was made with the following key take home messages: for adult women and adolescent girls of childbearing potential (1) Offer contraception, (2) Provide informed choice through counselling and (3) ART options, including Dolutegravir (DTG). 4. USE OF HEALTHY FANILY PLANNING AND REPRODUCTIVE HEALTH PRACTICES INCREASED 4.1. Revise FP messaging with a focus on youth engagement Community and individual awareness of FP developed: Family planning key messaging assists promotion of the use of modern family planning methods in order to help individuals and families have informed decision on FP choices as well as creating more demand for FP/SRH. During this reporting period, the project conducted 10,040 sessions reaching 253,676 people compared to 253,434 people in the past quarter. Copperbelt reached 108, 429 client compared to 112,268 clients in the past quarter, while Luapula and Muchinga reached 77,533 from 76,319 (4,429 sessions) and 67,714 compared to 64,847 clients (1,844 sessions) respectively. This shows that there was an increase in number of clients reached with FP messaging in Luapula and Muchinga while Copperbelt had reduction of 3%. • Youth Day Celebration - During this reporting period, SARAI project in Copperbelt, Luapula, and Muchinga Provinces participated in Youth Day Celebration whose theme was “Let's Bring Change to the World”. The youth shared information on sexual and reproductive health and distributed condoms to an estimated number of 420 youths. 23 • International Women’s Day Celebration - The project participated in the international women’s day commemoration whose theme was “Think Equal builds smart innovate for change”. During this activity, the project provided FP/SRH information and services clients who visited the project tents. An estimated number of 260 people were reached through health information and Family Planning services. Male Involvement in FP: The project continued involving males in FP/SRH awareness in communities. During this reporting period, the project reached 1,142 people (680 males) compared to 807 people (566 males) reported in fourth quarter with FP/SRH information. This was as a result of involvement of Bwacha (13 males) group of Mansa, Global Industries (25 males) of Ndola, taxi drivers (25 males) of Kitwe and Mulonga Water Company (35) of Chililabombwe. The men at Global Industries appreciated the meetings as it gave them insights on family planning and reproductive health. Some of the issues raised during the meeting included lack of their involvement in family planning by their spouses, misconceptions that family planning destroys fertility in women and that women on family planning are considered to have extra marital affairs. They also shared that their spouses do not always tell them when they have gone for family planning, hence the need for couples to engage more with each other. Male involvement in family planning reduces the above doubts however the recommendation was that next meeting all men are encouraged to come with their spouses for reproductive health education and this will result both men and women engaging each other in family planning. Adolescents engaged in FP service delivery: The project continued collaborating with Breakthrough Action, reviewing the core designing of approaches which will assist males, adolescent, and youth to access HIV, family planning, nutrition and malaria services. The project plans to conduct youth wellness days in selected health facilities in order to test the developed designs. Tools have been finalized and a training of trainers (TOT) conducted. Adolescents reached with FP counselling using youth champions: The 1,455 champions (439 youths and 1,016 adults) managed to conduct 1,747 Sexual and Reproductive Health messaging sessions reaching 29,640 adolescents and youth. They also managed to distribute 79,266 (64 female condoms) pieces of condoms to 15,061 (4,445 males) adolescents and youths. 24 Figure 10: Clients reached with SRH messages by FP Champions 10 - 14 15-19 20-24 >24 Total Sessions Copperbelt 2,002 3,966 2,812 2,224 308 Luapula 2,109 2,644 2,773 3,268 1,189 Muchinga 1,325 1,713 2,309 2,495 250 Copperbelt Luapula Muchinga Awareness of FP/HIV developed among OVCs (OVC SERV PEPFAR Indicator): This indicator is captured in Copperbelt Province working with ZAMFAM. The project provides information on Sexual and Reproductive Health to the OVCs through in and out-of-School Youth Clubs, door-to-door campaigns, peer to peer interaction, community meetings, youth friendly spaces and road shows. In addition, SARAI trained CBDs enroll and screen OVCs in Non-ZAMFAM catchment areas. During the period under review, the project reached 6,189 OVCs representing 91% progress made against an annual target of 6,829. The Project will continue working with the established structures to ensure the target is met by end of FY19. OVC HIV status and services: The target population are Orphans and Vulnerable Children (OVCs) aged between 10 and 18 years. The indicator tracks self-reporting of HIV status of OVCs including report of no status. During this reporting period, SARAI CBDs reached a total of 2,187 adolescent girls. All (89) HIV positive OVCs reported being on care and treatment. However, 20 OVCs did not disclose their HIV status for various reasons. It is important to note that this indicator is the subset of the OVC_Serv and in ideal circumstances OVC_HIV_STAT would be 100% of OVC_Serv indicator. The OVC Serv indicator represents those OVCs registered by ZAMFAM who also report directly to USAID for OVC_HIV_STAT. To avoid duplication SARAI have only included OVC HIV status for those that were directly registered by SARAI CBDs. Priority Population Prevention (PP-Prev): The project conducted SRH awareness activities including community meetings, one-on-one sessions and drama performances targeting adolescent girls and young women (AGYW) aged 10-24 through use of CBDs, youth champions, peer educators and in out of school clubs. Among the topics covered during the activities included educating adolescent girls and young women on HIV and AIDS prevention, decision making, personal hygiene, alcohol abuse and sexual reproductive 25 health. Ministry of Health Standard Peer Educators Manual and Ministry of Community Development and Social Services National Peer Education manual were used to guide the activities. Condoms were also provided to some of the target audiences where needed. A total of 80,179 AGYW were reached against annual target of 5,637. 5. FAMILY PLANNING SERVICE DELIVERY SYSTEMS AND ACCOUNTABILITY STRENGTHENED 5.1. Strengthen Quality of FP Service Delivery Adherence to Quality Standards: The project performs quarterly routine assessments to ensure that quality standards are adhered to at all times. The purpose of these assessments is to ensure that the standards have been achieved and are maintained and the gaps that are identified are rectified. The project plays an important role in educating and mentoring the facility providers on the importance of providing quality FP services. The results are communicated at all levels of the ministry of health in order to ensure that there is positive influence in prioritizing quality in FP provision. These assessments ensure that couples’ FP needs are met in a safe and confidential environment and where their rights are respected. Continuity of care and client’s informed choice are also assessed to ensure that facilities are compliant. The project conducted an assessment in 138 out of the 143 supported facilities to determine whether the facilities had available choices for contraceptive methods, integration of FP in other clinical areas, trained staff, adolescent friendly health services and availability of FP data management tools. Out of 137 facilities, 138 scored above 80% which is a bench mark set for quality assessments, accounting for 99% of the assessed facilities. Five facilities were not assessed because four of the facilities in Luapula province were not accessible due to challenging weather patterns and one facility on the Copperbelt is still closed for renovations. Figure 11: Number of Facilities Adhering to Quality Standards The facilities generally performed Facilities Adhering to Quality Standards Total Number of Facilities well in all areas of the assessment with a 138 few notable gaps 137 which included inadequate IEC materials on FP, 64 64 40 39 34 inadequate 34 infection prevention 26 COPPERBELT LUAPULA MUCHINGA TOTAL (IP) materials in some facilities, and some facilities not having the full equipment for the provision of FP. The project will provide buckets for IP and some IEC materials and will continue working with the facilities and the District Health Offices on other identified gaps. Family planning commodity stock out rate: Availability of a wide range of FP commodities at facility level is vital in the delivery of quality FP services at both community and facility levels in order to promote method mix and informed patient choice. This enables families to choose a preferred method of FP. The project aims at ensuring that FP commodities are available at all health facilities through continuous periodic assessment, identification of gaps, lobbying and advocating to the MoH in order for remedial actions to be executed timely. During the quarter under review all the 138 facilities were assessed to monitor FP commodity availability. Four facilities were not accessible in Lunda District of Luapula Province and one in Copperbelt is under renovation. The project also worked closely with other partners such as PSM in order that commodities are tracked effectively. A total of 89 facilities (Copperbelt 38, Luapula 26 and Muchinga 25) experienced commodity stock of out of one or more commodities, giving an average of 64%. The percentage has reduced in comparison to last y quarter’s percentage which was at 40%. The number of facilities that experienced a stock out has increased as well as the average number of days in which the facilities experienced a stock. The project has been actively participate at the national, provincial, district and facility level to ensure that FP commodity stock outs are mitigated. Despite the reduced number of facilities that experience a stock out, the number of facilities that experienced a stock out by commodity has increased as well as the average number of days in which the commodities were stocked out. As indicated in the graphs below. Figure 12: Number of Facilities Reporting Stock out by Commodity 27 100 91 Sum of Implant 90 80 Sum of IUCD 70 Sum of Progesterone only pill 60 57 Sum of Medroxyprogesterone injection 50 44 Sum of Female Condom 40 35 29 30 Sum of Male Condom 19 20 Sum of Combined Oral 8 contraceptives 10 2 Sum of Norethisterone enanthate 0 injection Total Figure 13: Total Number of Days Facilities Reporting Stock Out by FP Commodity 1200 Sum of Implant 967 1000 Sum of IUCD 889 812 Sum of Progesterone only pill 800 Sum of Medroxyprogesterone injection 600 524 544 Sum of Female Condom 387 400 Sum of Male Condom 200 Sum of Combined Oral 102 contraceptives 51 Sum of Norethisterone 0 enanthate injection Total Environmental Monitoring and Management: Environmental monitoring and mitigation is a necessary step in ensuring that waste which is generated is disposed of in a manner that does not cause harm to the environment through the release of chemical or biological hazards, including drug-resistant microorganisms, into the environment. This measure protects the health of clients, health workers, and the general public. For this reason 28 the project focuses on Environmental Mitigation and Monitoring Plan (EMMP) to be adhered to both at facility and community levels. The assessment focus areas include policies and practices, waste segregation, waste handling, interim storage and the final disposal. Figure 14: Number of Facilities Conforming To Waste Management Standards By Region 150 138 123 100 64 50 40 50 39 34 34 0 Copperbelt Luapula Muchinga Total YFHS Facilities Total no. of facilities From the data above 89% (123 of 138 SARAI supported facilities) were adherent to the minimum acceptable standards for the waste management. The facilities continued to experience inadequate colour coded bin liners, inadequate utility gloves and no fencing on the waste pits. The project has continued to lobby with the DHOs and the facility In-charges to prioritise the waste segregation according to the colour codes. Community Family Planning Assessment (CBD): All the facilities supported by the project are assessed for their ability to provide community based family planning services by the CBDs. The assessments focus on the facilities’ having a functional CBD program, if YFHS counselling is offered with age appropriate messaging, adherence to quality practices, mentorship and supervision, supply chain, and data management. During the quarter under review 99% of the supported facilities (136 of the 138 facilities) adhered to offering quality community FP services as shown in the table below. Figure 15: Number of Facilities Adhering to Providing Quality Community FP Services By Region 29 160 136 138 140 120 100 80 59 64 60 44 40 40 33 34 20 0 Copperbelt Luapula Muchinga Total Facilities Adhering to minimum Community FP standard Total no. of facilities Supervision of the CBDs by the facility staff still remains a challenge as there is no allocated transportat for the facility staff to visit the communities. Also, the facility staff have limited time due to competing activities gaps at the facility. There were no minutes for meeting where CDBs data was analysed. The Project is working together with the facility staff to maximise the use of the established systems to rectify the identified gaps. Model District-Community Family Planning Service Delivery Systems Established: During the quarter under review the project assessed thirty facilities for scale up (20 Copperbelt, 5 Muchinga, and 5 Luapula). The selection of the facilities was done in consultation with the Provincial Health Office. Some of the facilities had trained LARC providers, active youth groups and CHWs that are not trained in FP service provision. The commonly noted gaps included the lack of IEC materials and FP protocols, inadequate FP instruments, no designated room of the provision of FP services, no LARC trained providers, no providers trained in provision of AYFHS, inadequate IP supplies, FP commodity stock outs, lack of fencing at disposal sites and low community mobilization for FP. No facilities were graduated in the quarter under review. The project will review the assessments for gradual graduation of the remaining 36 facilities as and when they meet the graduation criteria. 5.2. Strengthened Use Of Data For Decision Making During the quarter, several activities were conducted aimed at strengthening MoH M&E systems. Among the keys activities were; Data Quality Assessment (DQA): During the period under review, SARAI M&E team conducted DQA using a rotational mechanism thereby providing equal chance of visiting select project sites across the three supported regions. The selection criteria involved facilities that showed persistent trend of data errors in past reports. The exercise aimed at data validation, auditing capacity of M&E systems and providing technical 30 support on data management. The team focused on checking for completeness, correctness and consistency of reproductive health facility data that was reported by all sub-reporting levels for period 1st January 2019 to 31st March, 2019. Based on DQA findings, the region documented evidence on monitoring visits, technical support and data review meeting. Further, all project staff were well informed on both project and MoH reporting timelines and procedures. In addition, the region had a feedback mechanism in place which was mostly via phone. Also, data filed at the region matched 100% with data reported at HQ. At facility level, data captured on the aggregation form (HIA2) matched 100% with data reported onto DHIS2 database. On the contrary, a data mismatch between data captured on aggregation form and the registers was observed especially in the scale up facilities. This was due to delays by the CBDs to update facility registers with FP data captured from the community. All Facility staff interviewed mentioned that one day meeting with the CBDs was insufficient time to complete this exercise. As an action point, it was recommended that during outreach programs the facility staff meet the CBDs in their respective catchment area and update the registers. Lack of updating facility registers with community FP data resulted into discrepancies between HIA2 and registers, however the facility included data captured by CBDs to aggregate data when reporting to the districts. Data Review Meetings: To promote HMIS data use among healthcare providers, the project undertook quarterly data review meetings in all the three SARAI regions. Key MoH staff (i.e., District Health Director, District Health Information Officer, District MCH coordinator, District Pharmacist) at the district office and two healthcare providers from each SARAI supported facility attended the meeting. The meeting focused on discussing data management, stock forecasting and quantification, FP service provision at both facility and community level. Furthermore, the providers were oriented on MoH data flow requirements and feedback mechanism using the MoH HMIS procedures manual. 31 6. PROJECT INDICATOR TRACKING Table 8: Indicator tracking table* PERIOD PROJECT LIFE INDICATOR % Oct 18 –Sep Oct - Dec 18 Jan – Mar 19 Target Achieved 19 Target Achieved Achieved Achieved 1. # of additional SARAI trained CBDs providing FP information and/or services 180 0 0 1135 855 77% during the year 2. # of women requiring other services that 54,480 5,695 4,927 134,120 46,965 35% are referred by CBDs 3. Proportion of women referred for other FP methods who access the services (age, 95% 79% 74% 90% 74% 74% method) 4. % of CBDs providing FP services after 97% 97% 96% 97% 96% 96% one year post-training 5. Percentage of SARAI supported health facilities stocked out, by family planning 10% 40% 64% 10% 64% 64% product or method, on the day of the assessment during the reporting period. 6. % of FP access points adhering to quality 70% 96% 99% 70% 99% 96% standards for service provision 7. Completeness of reporting by facility 95% 97% 98% 95% 98% 98% 8. Data Quality Assessments conducted 12 3 2 48 38 79% 9. SARAI supported quarterly data review 12 3 3 48 38 79% meetings held *Table includes only quarterly tracked indicators. 7. CHALLENGES / MITIGATION CHALLENGES PROPOSED SOLUTION Inability for the facilities to graduate due failure Project to continue engaging MOH to rectify the of meeting the graduation criteria. identified gaps. Inability for the facilities to graduate due failure Project to continue engaging MOH to rectify of meeting the graduation criteria. Among the the identified gaps. gaps identified are inadequate IEC materials, inadequate IP materials, stock out, no rooms designated for provision of FP services. 32 Frequent stock-outs of FP commodities (i.e COC, SARAI staff to conduct joint TSS visits with Noristerate, IUDs, condoms and DMPA etc) and MOH PHO and DHO staff, liaising with disconnect with stock levels at MSL vs facility DHOs pharmacists. Gaps noted during national level. TWG meetings to identify potential solutions. Further collaboration with GHSCM-PSM project and USAID. Continued transfer of LARC trained providers to Continued engagement with DHO and PHO to non-SARAI supported sites ensure trained staff are maintained. Seek additional resources/partner trainings to train providers. Poor was t e management of waste in the SARAI staff to liaise with DHO on possibilities facilities across the program in areas such as of including on DHO budgets fencing of the fencing of pit latrines for waste disposal, mixing pits through use of grants and each time of waste, lack of bin liners. SARAI officers are making monthly plans; there should be always be an objective on EMMP. EQA results to be shared widely. Omission of CBD data in registers. Data entry clerks assigned to heavily affected districts to assist District Health Officers with entering backlog data; DQA findings to be shared and mentoring to be done. Inability for the facilities to graduate due failure Project to continue engaging MOH to rectify of meeting the graduation criteria. Among the the identified gaps. gaps identified are inadequate IEC materials, inadequate IP materials, stock out, no rooms designated for provision of FP services. 8. CONCLUSION It can be concluded from the details presented in this report that the SARAI is making great strides towards meeting the goal of increasing the modern contraceptive prevalence rate by 2% annually. Both facility based providers and CBDs continue to increasingly reach more woman and youth with FP services. Uptake of long-term methods continues to rise in the most challenging sites even though decreasing in some high volume facilities. The CBD model continues to flourish and there are more women using DMPA- SC, 33 bringing services closer to the community. In general high quality services are being offered, however commodity stockouts continue to be an ongoing challenge that must addressed at all levels of the supply chain with Muchinga being affected dramatically this reporting period. Scale up assessments is of major focus during the period to increase access and bring services closer to those in need. Despite the challenges, SARAI has been able to quickly adapt and adapt based on lessons learned to keep the project relevant and maximize health impact. In the next quarter, the project will start trainings for the new scale up sites, pilot new youth interventions, distribute materials. Project staff plan to attend the FP Annual Review Meeting. The project plans to coordinate more with other partners and projects on the ground such as Population Media, creating synergies and lessening duplication of resources. The project has high expectations in the last full year of the project, therefore a strong effort will be made to maximize the impact and sustainability even beyond SARAI sites. 34