Scoping of Integrated Community Case Management (Iccm) in Burma

Scoping of integrated Community Case Management (iCCM) in Burma

Report

September 20-October 11, 2015

Dr. Agnes Guyon Dr. Cynthie Tin Oo Ms. Maura Gaughan

Table of Contents List of Acronyms ...... 4 I. Introduction ...... 5 II. Background ...... 5 III. Methods ...... 7 IV. Findings ...... 7 V. Summary of Key Findings ...... 14 VI. Recommendations and Proposed Strategies ...... 14 VI. Other Technical Areas/Interventions to Reduce Under-Five Mortality ...... 15 VII. Appendixes ...... 16

List of Acronyms

ACT Artemisinin-based Combination Therapy AMW Auxiliary Midwife CCM Community Case Management CHLWG Child Health Lead Working Group D&P Diarrhea and Pneumonia EPI Expanded Program on Immunization HMIS Health Management Information System iCCM Integrated Community Case Management IMNCI Integrated Management of Childhood Illness INGO Implementing Non-Governmental Organization LHV Lady Health Visitor LLINs Long Lasting Insecticide Treated Nets MCH Maternal and Child Health MCSP Maternal and Child Survival Program MICS Multiple Indicator Cluster Survey MNCH Maternal, Newborn, and Child Health MOH Ministry of Health ORS Oral Rehydration Solution PHS Public Health Supervisor PMI President’s Malaria Initiative RDT Rapid Diagnostic Testing RHC Rural Health Center RMNCA Reproductive, Maternal, Newborn, Child, Adolescent Health SARA Service Availability and Readiness Assessment SBCC Social Behavior Change Communication TOT Training of Trainers TMO Township Medical Officer UNICEF United Nations Children's Fund

I. Introduction Burma/Myanmar has experienced a steady and consistent improvement of under-five mortality, moving from 106 per 1,000 live births in 1990 to 72 per 1,000 live births in 20151. Despite the progress in reducing under- five mortality rates, Burma/Myanmar was unable to meet its MDG 4 target of under-five deaths per 1,000 live births by 2015. Burma/Myanmar has one of the highest under-five child mortality rates in the Mekong Region: Thailand (12)2, Vietnam (23), Cambodia (38), Laos (72) per 1,000 live births; and among neighboring border countries: Bangladesh (41), China (11), India (56) per 1,000 live births3. Next to neonatal deaths which make up 51% of the under-five mortality, disease burdens for children under-five (caused by acute respiratory infection, diarrhea, and malaria with the underlying cause of malnutrition) contribute to 45% of these deaths3,4. Two-thirds of the population is in the rural areas, living more than 5 km away from the nearest sub-center or rural health center. Community case management (CCM) of diarrhea and pneumonia (D&P) and, to some degree, community-based health education, exists in rural and hard-to-reach communities throughout the country. The Ministry of Health (MOH) has adopted CCM D&P as a national strategy for reducing under-five mortality. However, it is unclear where CCM D&P is being implemented, why those sites were selected, why malaria was not included with pneumonia and diarrhea community-based treatment, and which of the various donor groups are assisting. Additionally, the degree to which supportive policies, practices, and infrastructure are in place to successfully implement a national program is unknown. From September 20 - October 11, 2015 the Maternal and Child Survival Program (MCSP) conducted a scoping assessment of integrated Community Case Management (iCCM) implementation as part of Objective 5 in the approved MCSP Workplan 2014-20165. The scoping assessment was conducted to achieve a better understanding of how CCM D&P is implemented, particularly looking at the potential for expanding the scope of existing malaria volunteers to include treatment for diarrhea and pneumonia. The goal was to identify gaps and strategically target technical areas where USAID/Burma could invest in strengthening the national roll-out of CCM D&P or iCCM in the country. Please refer to the debriefing presentation (Appendix A). II. Background Community Case Management of Diarrhea and Pneumonia

CCM D&P represents a relatively new strategy for reducing under-five mortality in Burma/Myanmar, despite the fact that community volunteerism has historically been a strong component of village life. In 2004, Save the Children worked with the MOH to implement maternal, newborn and child health (MNCH) programs, which included CCM D&P in 11 townships in 5 region/states. Volunteers were trained to diagnose and treat diarrhea and pneumonia, and refer severe cases. Save the Children has continued to work with the MOH to expand CCM D&P to new sites under 3MDG funding (Appendix B). In 2010, the MOH Child Health Division, with support from Unicef, piloted an implementation of CCM D&P/malaria in Dawei township (Tanintharyi Region). The pilot aimed to document the implementation process and operationalization to inform future CCM D&P/malaria programs. In 2011, an evaluation of the pilot revealed that while CCM was effective, challenges included: payment for transportation costs for supervisory visits; stock-out considerations, especially in areas severely compromised during the rainy season; attrition of volunteers, and incentives for keeping volunteers motivated6.

1 Dept. of Population, Ministry of Immigration and Population. The 2014 Myanmar Population and Housing Census: the Union Report, Vol 2. May 2015. 2 The Inter-agency Group for Child Mortality Estimation (UN IGME).Levels and Trends in Child Mortality Report 2015. http://www.childmortality.org/files_v20/download/IGME%20report%202015%20child%20mortality%20final.pdf 3 Countdown to 2015 Maternal, Newborn, and Child Survival. http://www.countdown2015mnch.org/country-profiles 4 UNICEF and the SITAN Technical Working Group. The Situation Analysis of Children in Myanmar 2012. http://www.unicef.org/eapro/Myanmar_Situation_Analysis.pdf 5 Objective 5: Collaborate with the MOH to provide national technical assistance for malaria in pregnancy and iCCM. Expected Results: Increased understanding of gaps in CCM coverage in Burma.

6 Ministry of Health, Dept. of Women and Child Health. Evaluation of Community Case Management of Pneumonia and Diarrhea in Dawei Township, Myanmar. 2011. 5

Two key outcomes from the pilot in Dawei were: 1) Unicef’s support for the expansion of CCM D&P (not including malaria) to four more townships (Lashio, Kengtung, Taunggyi, Hpa-an) in two states; and 2) the buy- in of the MOH with the development of the Implementation Guide: A Toolkit for Community Case Management of Childhood Illnesses and Technical Supplements in 2012. The expansion of CCM D&P was in line with the MOH’s 2010-2014 Newborn and Child Health Strategic Plan to increase community-based health services to rural areas and hard-to-reach places.7 The guide includes information on and endorses the treatment of diarrhea with oral rehydration solution (ORS) and Zinc, and of pneumonia with Amoxicillin. Malaria and nutrition were not included in this 2012 guide.

In 2014, 3MDG8 awarded 10 implementing non-government organizations (INGOs) to support the expansion of CCM D&P in select townships within five states/regions: Shan, Kayah, Magway, Chin, and Ayeyarwady (Appendix B). INGOs work together with township medical officers (TMO) to implement CCM D&P. While the training and supervision of community volunteers are done by government staff, INGOs are responsible for management, supply chain for drugs and commodities, data collection and reporting. Funding under 3MDG spans from 2015-2017. Currently, funding efforts from Unicef and 3MDG have increased the coverage of CCM D&P to 11.5% of all townships (330). The Department of Child Health and Development released a draft of The Newborn and Child Health Strategic Plan 2015-2018 in April 2015. The focus of this strategy is to strengthen interventions along the continuum of care, linking newborn and child health at both facility and community level. Finalization of the plan is pending until the associated budget has been completed and approved (currently being compiled by Unicef-supported consultants). The strategy and budget are targeted for completion by February 2016. According to the Multiple Indicator Cluster Survey (MICS) 2010 data, 33% of children under five are stunted and 8% are wasted, which is the highest rate in the region. Despite this statistic, nutrition counseling is almost non-existent and is not part of the CCM D&P curriculum. Upon visiting both the rural health and sub-center clinics, social behavior change communication (SBCC) materials displayed on the walls were not up-to-date with international/WHO guidelines.

Malaria

Malaria can be found in approximately 62% of Burma/Myanmar with varying degrees of risk to the population (see Figure 1: Map of malaria risk stratification by township). Three states in Burma/Myanmar (Mon, Tanintharyi, and Bago-East) have reported cases of artemisinin-resistant malaria (P. Falciparum). Overall, morbidity and mortality rates of malaria infection have dropped dramatically since 1990 from 24.4 and 12.6 per 100,000 people to 11.2 and 1.2 per 100,000 people, respectively9. The reduction in malaria is believed to be due to a variety of factors, namely: 1) the expanded community-based efforts for immediate rapid diagnostic testing (RDT) and treatment with artemisinin-based combination therapies (ACTs); 2) wide distribution and use of long lasting insecticide treated nets (LLINS); 3) and the rapid rate of deforestation due to commercial FIGURE 1: (SOURCE: PMI GREATER MEKONG agriculture, illegal logging, and infrastructure projects such as hydropower SUB REGION, MALARIA OPERATIONAL PLAN FY 10 dams and roads. 2015

7 Newborn and Child Health Strategic Plan 2012-2015. 8 3MDG is a funding mechanism that is comprised of 7 bilateral agencies from Australia, Denmark, the European Union, Sweden, Switzerland, the United Kingdom and the United States of America.. 3MDG promotes the efficient and effective use of development funds. With commitments totaling more than $330 million for the period 2012-16, 3MDG is currently the largest development fund in Myanmar. It is managed by the United Nations Office for Project Services (UNOPS). 9 PMI FY 2015-Greater Mekong Sub-region, Malaria Operational Plan. 10 Kevin Woods. Commercial Agriculture Expansion in Myanmar: Links to Deforestation, Conversion Timber, and Land Conflicts. March 2015. http://forest- trends.org/releases/uploads/Conversion_Timber_in_Myanmar.pdf. 6

According to the MOH’s Department of Diseases Control, approximately 10,000 malaria volunteers have been trained and are working at the community level using RDTs and ACTs. However, due to the dramatic drop in cases of malaria, the Department of Diseases Control and malaria program donors are concerned that there will not be enough cases to keep the volunteers motivated and active. In addition, as cases of malaria decrease, the country is moving towards malaria “elimination phase” which requires assertive techniques to detect and stop transmission from confirmed malaria cases (i.e. volunteers must test and treat the patients in a timely manner, and then test all household members). Volunteers must also notify disease control authorities so a full investigation, including an entomological analysis, can be conducted11. Malaria volunteers serve as an especially important agent where there is a significant population migration. Therefore, both the Department of Disease Control and the malaria donor community are interested in exploring the possibility of using existing malaria volunteers to diagnose and treat diarrhea and pneumonia for children under five in an effort to keep volunteers active during this elimination phase.

III. Methods Three methods were combined to carry out this scoping assessment. For further details, the schedule of the assessment team can be found in Appendix C. 1. A desk review of key documents relevant to CCM D&P and malaria (Appendix D). Documents were gathered from: online resources, an existing library of soft- and hard-copy materials at the local JSI office, interviewees, and meetings attended by the team in Burma/Myanmar.12 Details of all the materials were entered in a spreadsheet to establish the completeness of its contents (i.e. if elements were missing), and whether materials reflected current WHO-endorsed recommendations. Based on these findings, informants were asked about materials, specifically to comment on areas that were considered to be “missing” or not reflective of current WHO recommendations.

2. Semi-structured interviews were conducted with key informants (Appendix E) using a question guide and iCCM Benchmark Indicator Framework13 (Appendix F) developed by the global iCCM Task Force to distinguish implementation stages (Advocacy & Planning, Pilot & Early Implementation, and Expansion/Scale-Up) and eight required components of the health system (Coordination and Policy Setting, Costing and Financing, Human Resources, Supply Chain, Social Behavior Change Communication, Supervision, M&E/Health Management Information System [HMIS]). Analyzing responses from interviewees (Appendix E) using this guide helps to understand which benchmarks were achieved, in progress, or not started.

3. The Assessment Team conducted field visits of two Unicef-supported CCM D&P sites in Taunggyi township in Shan state accompanied by Dr. Moe, Tun/Township Public Health Officer. Field visits included: (1) Taung Ni rural health center (RHC), Kyaunk Ni sub-RHC and Tha-yet-pin-hla village where volunteers reside; (2) HumSee RHC, Katku sub-RHC and Ga-naing-tawt village where CCM volunteers reside.

IV. Findings Coverage In May 2015 the Department of Population under the Ministry of Immigration and Population released the 2014 Myanmar Population and Housing Census: The Union Report; the first census in Burma/Myanmar since 1983. According to the census, under-five mortality is 72 per 1,000 live births, higher than previously estimated at 52 per 1,000 live births (MICS 2010), with the highest rates being in Magway (108); Ayeyarwady (105); Chin (90); and Tanintharyi (84). When calculating the under-five mortality using population estimates

11 WHO, Roll Back Malaria. Disease surveillance for malaria elimination: An operational manual.2012 12 Community Case Management Training of Trainers (TOT), second batch funded by 3MDG Fund for 3MDG Fund townships and WHO’s Service Availability and Readiness Assessment (SARA) dissemination meeting conducted by Myanmar Dept of Medical Research, on September 29, 2015 in Naw Pyi Taw. 13 iCCM Benchmark Indicators, http://ccmcentral.com/benchmarks-and-indicators/benchmarks-framework/ accessed Oct 30, 2015. 7

and the census data, the regions/states that ranked among the highest are: Ayeyarwady (60,284); Yangon (60,284); Magway (53,236); Shan (41,770); Sagaing (32,500); and Mandalay (32,500) (See Appendix H). Table 1 shows the distribution of the current CCM D&P implementation compared to the highest under-five mortality burden regions/states: there is no CCM D&P in peri-urban Yangon or in Sagaing and Mandalay where Table 1: States and Regions: Under-five mortality, under-five mortality rates, CCM D&P Coverage Under 5 Under-5 Region/ State Existing CCM D&P Coverage Mortality deaths per 1,000 live births 60,284 60 Yangon 60,284 105 Ayeyarwady 6 funded by 3MDG (IOM, Save the Children, RI, MDM) 53,236 108 Magway 5 funded by 3MDG (MSI, Save the Children) 41,770 70 Shan 9 funded by 3MDG( RI, Save the Children, Cesvi, HPA) 3 funded by Unicef 33,372 70 Sagaing 32,500 86 Mandalay 30,590 72 Bago 18,656 48 Mon 13,432 76 Rakhine 12,416 84 Tanintharyi 1 funded by Unicef 12,346 70 Kayin 1 funded by Unicef 9,477 61 Kachin 7,653 73 Naypyidaw 5,935 90 Chin 9 funded by 3MDG (Save the Children, DRC, International Red Cross) 2,244 72 Kayah 7 funded by 3MDG (IRC)

the highest numbers of child deaths are found; while Kayah and Chin states have the most CCM programs with very low numbers of under-five deaths. Magway and Ayeyarwady regions continue to have two of the highest under-five mortality rates, 108 and 105 per 1,000 live births, respectively. This seemingly non-strategic targeting is explained by the fact that CCM sites were selected before the information from the census was available and was targeting underserved ethnic populations.

Benchmark #1. Coordination and Policy Setting Coordination at the National Level Over the last three years (2013-2015) the MOH and other ministries in Burma/Myanmar have undergone a reorganization that has resulted in two separate departments: the Department of Medical Care and the Department of Public Health. The Department of Medical Care oversees hospital administrative and clinical functions, while the Department of Public Health oversees administrative and clinical functions for facility care, below the township hospital level and community level. Key informants said the majority (approximately 66%) of the funds allocated for health in the national budget went to the Department of Medical Care, leaving the Department of Public Health insufficiently funded, in particular for rolling out CCM D&P on a national scale. No public information was available regarding the budgets for either department. As a result of the reorganization, the Department of Public Health is in the process of creating new administrative processes, protocols and systems (i.e. human resources, administration, budgeting/finance, drug and medical supply procurement and delivery) as well as developing a strategy called the “Reproductive, Maternal, Newborn, Child and Adolescent (RMNCA) Health Plus Plus,” that includes CCM D&P. The strategy

8 aims to better integrate interventions along the RMNCA continuum of care and across both communicable (i.e. plus) and non-communicable diseases (i.e. plus) at the facility and community level. Informants from both the Department of Disease Control and the Child Health Division agreed that adding D&P treatment onto the portfolio of malaria volunteers’ services is a good use of resources, since the volunteers are already trained to test and treat for malaria. However, MOH informants recognize that coordination between National Malaria Control Program and Child Health Division will be challenging.

Coordination for CCM for diarrhea and pneumonia Implementation of CCM is predominately being implemented in 41 out of 330 townships: supported by Unicef in 5 townships and 3MDG in 36 townships through implementing partners. Both Unicef and 3MDG work closely with the MOH’s Department of Disease Control and the Child Health Division at the national level, and at the township level with the TMO to coordinate the CCM D&P implementation. The Child Health Division is in charge of selecting townships to implement CCM D&P based on whether the township is a hard-to-reach area and has a high under-five mortality rate; future selection will be based on the under-five mortality data from the 2014 census report. The Department Child Health Division oversees the Child Health Lead Working Group (CHLWG), which is a subgroup of the larger RMNCA Health Technical Strategic Group led by the Deputy Minister of Health. The CHLWG is brought together to discuss multiple child health-related issues, including CCM D&P, and includes all NGO and donors working in child health in Burma/Myammar. An informant from the Department of Disease Control and Child Health Division did not think that there was a need for a separate CCM D&P Working Group, but agreed that a task team from the CHLWG would be helpful to further coordinate CCM D&P implementation, learn from the current implementation, and assist the MOH in strengthening this program. At township level, CCM D&P is part of the monthly review coordinated by the TMO; however, other programs often overshadow the CCM program.

Policy Setting The 2012 CCM Implementation Guide serves as a government-endorsed policy document supporting treatment of diarrhea using Zinc and ORS, and pneumonia with antibiotics for children under five years of age at the community level.14 The exclusion of malaria in the guide was due to a belief that it would be difficult for volunteers to distinguish pneumonia from malaria, so they would misdiagnose patients. While volunteers use RDTs in the community to test for malaria, there was still resistance to providing them with ACTs. Therefore, malaria was left out of the guide and remains the responsibility of malaria volunteers to test, diagnose, and treat malaria at the community level. While the policy is supportive of volunteers using antibiotics, budget implications disincentivize TMOs to allow volunteer usage of antibiotics at the township level. Supportive national guidelines and policies have been set for CCM for D&P. To some degree, the MOH has established leadership for CCM D&P, including developing roles and responsibilities with donors and implementing partners, but is unable to create a technical coordination group to fully monitor and involve partners. According to the iCCM Benchmark Indicator Framework, the Coordination and Policy Setting Component remains in the Advocacy and Planning Phase. To move toward an Early Implementation Phase, further coordination and planning will need to be established to integrate malaria and nutrition into the CCM D&P, and to target townships with the highest under-five morality.

14 The Myanmar Medical Association is an extension of the government comprised of members from the medical profession from both the government and civil society.

Benchmark #2: Costing and Financing Currently, the MOH does not financially support CCM D&P, with the exception of paying the salaries for government staff (i.e. TMO, health assistants, lady health visitors [LHVs], midwives,). Financing for CCM D&P predominantly comes from two main sources: Unicef since 2010 and 3MDG from 2015 to 2017. In Unicef- supported townships (five townships total), government staff at the rural-health and sub-center levels implement activities, and Unicef funds all costs of trainings and procurement of supplies. 3MDG funds 10 implementing NGOS in 36 townships to implement, manage, supply drugs and commodities, and collect data on CCM D&P. Townships conduct micro-plans to manage administrative and clinical healthcare costs. Once township microplanning is complete, World Bank funds are used to fund priority activities that are not covered in the budget at any of the health facility levels. Township microplanning training has just begun and will continue throughout 2016. Informants said they intend to use World Bank funds to cover the transportation costs for midwives’ monthly and LHVs’ quarterly visits in villages where volunteers are providing CCM D&P. World Bank provides townships with targets and a set of indicators to collect data on funded activities; townships are given increased funds if they meet proposed targets. A cost analysis for the National Newborn and Child Health Strategy was conducted under the support of Unicef in an effort to forecast national level costs. Informants from the CHLWG relayed concern about how much CCM D&P was included as part of child health cost estimate. Currently, the Department of Child Health and Development is awaiting the finalization of a different cost analysis, supported by Unicef using the One Health Tool, which includes the costs of CCM D&P in the 2015-2018 Strategic Plan. It’s unclear how much the MOH Department of Public Health will be able to financially support CCM D&P in the future. Informants expressed concern about the Government having sufficient funds and infrastructure in place to support a national CCM D&P program by 2017, when the current donor programming for CCM will end. Costing and financing efforts for CCM are in the Advocacy and Planning Phase. The Unicef-supported costing estimate will assist the MOH to move towards Early Implementation Phase. However, until the MOH can begin to include CCM D&P as part of their health budget, CCM D&P will remain in the Advocacy and Planning Phase.

Benchmark #3: Human Resources The structure of roles and responsibilities of healthcare providers at the facility and community level are well established (See Appendix I). Each township has RHC where health assistants, LHVs, Public Health Supervisor (PHS) 1s and midwives work. Under each RHC, there are 4-5 sub-rural health centers, each sub-center having one midwife who oversees 3-5 villages varying widely in population size. The Government has trained and deployed a modest number of PHS 2s; a cadre that provides environmental and communicable disease control education, assists the midwife in record keeping and administrative tasks, and jointly oversees volunteers. While currently there are not many trained PHS 2s, the MOH is awaiting an approval from Congress (slated for January 2016) for funding that will allow them to proactively recruit, train, and position more PHS 2s. However, it is still unclear what their role will be in regards to CCM D&P, as they will probably focus on environmental health and disease control. Village leaders and sub-center midwives jointly select volunteers: auxillary midwives (AMWs), community health workers and malaria volunteers. The following criterion is used to select AMWs: if they have some education, are well respected in the community, and are 18-50 years old. Currently, the MOH is scaling-up recruitment and training for additional AMWs, which represents an opportunity as AMWs seem to be the volunteer of choice for maternal and child health (MCH), but also a challenge as they are usually young, unexperienced women. Informants said that young AMWs often struggle with gaining the confidence of the community, especially if there is another prominent person in the village for whom villagers seek care and counsel (i.e. traditional birth attendants). Payment or institutionalized incentives do not currently exist for either volunteer cadres, but the government encourages communities to support and organize an “Outstanding Volunteer Award” to stimulate the spirit of volunteerism (every other year). MOH informants expressed frustration as implementing partners provide different types of incentives to different types of volunteers, including monetary incentives.

Training Materials and Guides 10

Government-approved training guides for various volunteers and community programs are used and readily available: for example, the AMW training manual is well written with clear and concise instructions, and it reflects current WHO recommendations. However, the Guide for Community Health Workers is very general and not specific enough to inform volunteers on how to complete tasks. For example, the guide instructs volunteers to look for danger signs for pneumonia, yet doesn’t specifically outline the danger signs for pneumonia in under-fives.

CCM Training The 2012 CCM training Guide includes guidance on management of D&P and reflects WHO recommendations; however, there is no information on malaria or nutrition. The training strategy includes TOT (see Appendix J – a TOT was recently held for a 3MDG-supported township), a supervisory training for midwives overseeing CCM D&P volunteers, and a five-day volunteer training (done by township, RHC and sub-center staff). As part of the CCM D&P training, volunteers receive a CCM volunteer guide, CCM volunteer handbill, treatment record form, patient register book, drug stock book, monthly report forms, respiratory timer, digital thermometer, and drugs. For the ongoing CCM sites (supported by Unicef), refresher trainings are being conducted and include the seven “Household Messages for Child Survival and Development15.” The Human Resources Component of iCCM programs is in the Advocacy and Planning Phase. Recruitment, roles and responsibilities have been defined for volunteers and training materials have been created and are in use.

Benchmark #4: Supply Chain Management Burma/Myammar last updated its Essential Drugs List in 2005; therefore, drugs and commodities by level of care don’t reflect the current treatment and guidelines (especially at community level). The 2015 WHO Service Availability and Readiness Assessment (SARA) survey estimates that only 20% of sampled public rural health centers and sub-centers have Amoxicillin. This grim estimate confirms the expressed concerns from informants about the lack of readiness to procure and distribute drugs and commodities at the primary health care level (facility and community levels). The current supply chain for CCM D&P (and also for malaria) is not fully integrated in the health system. Unicef procures CCM D&P drugs and commodities through its own system and delivers them to the government central warehouse where they enter into the government supply chain system. At the end of the chain, volunteers in Unicef-supported sites receive drugs and commodities during monthly supervision visits from the midwife, who herself receives drugs and commodities from the RHC (which in turn receives its supply from the township). In sites visited by the Assessment Team, it was noted that Amoxicillin and Paracetamol in adult dosage capsules (100mg and 250mg Amoxicillin) were the only commodities available for treatment of under- five pneumonia, while the original intended Unicef procurement package included child-appropriate dosage capsules. The 3MDG implementation partners currently procure drugs and commodities through the 3MDG’s own procurement system and support distribution from the township to RHC, sub-center and volunteers.

FIGURE 2: AMOXICILLIN 250MG CAPSULES FROM AMWS CCM D&P SUPPLIES, TAUNGGYI TOWNSHIP, SHAN REGION

15 Seven Household Messages for Child Survival and Development is a new communication tool that targets reducing child mortality using promotive and preventative messaging.

The supply chain management for CCM D&P is in Advocacy and Planning Phase. The distribution of drugs and commodities is not part of the current government supply chain system and it is unclear how the CCM supply chain will function after the phase-out of Unicef and 3MDG. Inventory control, resupply logistic system, and standard operating procedures for iCCM need to be developed.

Benchmark #5: Service Delivery and Referral: Emergency referral guidelines Burma/Myanmar has a robust culture of health-based volunteerism at the community level. The MOH cited several different types of volunteers that carry out various functions of MNCH and disease control services, and education at the community level that complements the work of government-paid staff (See Appendix F). Volunteers are trained and funded through separate sources and programs at the central and township levels. However, at the community level, one person may be the volunteer for several programs, and therefore in charge of providing several services. MOH informants recognize that there are drawbacks to having one person in the community acting as a volunteer for more than one program, but it is unclear whether a volunteer is doing too much; there is no available information on the partition of volunteer tasks. The selection of volunteers is largely left up to the village leaders and the midwife at the local sub-centers. For CCM D&P service provision, it is recommended to utilize the services of a pre-existing cadre of volunteers. While community involvement is largely accepted, low utilization of facilities was observed during field visits. Informants at rural health centers and sub-centers conveyed that people come to the facility before or after they tend to their farms. However, patients were almost non-existent during site visits of one urban health facility, two rural health centers, and two sub-centers. The plan for the national use of medicines and commodities has been defined for CCM D&P. Guidelines for diagnosis and clinical assessment, handbills and forms have been developed and are a part of the CCM D&P curriculum and training. However, guidelines and systems for referral and counter referral, and clarity around roles and responsibilities at the facility level are currently being defined and developed by 3MDG. Newly released results from the WHO SARA survey cites that 43% of RHC and sub-center staff are trained on integrated management of neonatal and childhood illness (IMNCI), and 60% had access to the IMNCI guidelines. This lack of readiness raises concern about competency to treat D&P when referral from community is done. Currently the Word Bank is providing funding to scale-up IMNCI training in the country. Burma/Myanmar is still in the Advocacy and Planning Phase for CCM service delivery, but will be considered in the Early Implementation Phase once the referral system is better defined, and implementation and capacity are strengthened at the health facility level.

Benchmark #6: Communication and Social Mobilization Capacity building for SBCC is limited, and counseling to support parents is weak, despite materials like existing posters in the rural health and sub-centers and the MCH Handbook. The MCH Handbook contains information on antenatal, delivery and postnatal care; newborn care and danger signs; and immunizations and home care of infants with diarrhea, with some promotive and preventative messaging. However, the MCH Handbook does not include information on signs and symptoms for fever and pneumonia. Each pregnant woman is 12 supposed to receive an MCH Handbook during her antenatal care visits, but in some townships shortages were reported. The Department of Health Promotion and Education Division has recently designed new health materials and counseling guidelines (i.e. flipchart, and bills for community volunteers) that promote seven household health behaviors for MNCH; they are now included into community volunteer training. Promotional household health behaviors are based on the Global Action Plan for Diarrhea and Pneumonia Framework and include: exclusive breastfeeding and complementary feeding, immunization, sleeping under LLINs, handwashing, treating water for safe drinking, reducing indoor air pollution, and referral. Among other achievements, several MOH informants hope that this will contribute to an increase in the current rate of exclusive breastfeeding (currently low at 26%16). While promotive and counseling materials are used during monthly community health talks, midwives at rural health centers and sub-centers are not well equipped in counseling or group facilitation skills. Communication and social mobilization is in the Advocacy and Planning Phase. While new CCM D&P communication tools and job aids have been developed for community volunteers, SBCC strategies for their utilization and the promotion of CCM D&P are not well defined for targeting groups (i.e.policy makers, local leaders, caregivers, or communities). It is also unclear how nutrition and other prevention interventions will be a part of health promotion and counseling under CCM. A communication and social mobilization strategy and plan for CCM are needed for the country to move into Early Implementation Phase.

Benchmark #7: Supervision and Performance Quality Assurance The supervision system from RHC to sub-centers and to the community level is clearly defined and mainly represents the collection of information: LHVs make quarterly visits to sub-centers and villages to meet midwives and sometimes volunteers. Midwives are responsible for monthly visits to volunteers (mainly AMWs) in order to mentor/supervise, routinely collect patient data, and provide supplies. Supervision consists of testing volunteers’ knowledge of diagnosis and treatment, their ability to know danger signs for referrals, and to record case information. Midwives also check the medicines used against case recordings and utilization of services at the community level. A supervisory checklist exists; however, it is unclear how the midwife uses this checklist to “case mentor,” ensuring that the volunteer knows how to properly assess, diagnose, treat, and refer cases in the absence of a sick patient at the time of the visit. Therefore, it is difficult to assess the quality of care provided for CCM D&P. The MOH CCM D&P annual review describes supervision as being a key challenge. Obstacles such as poor road conditions due to the rainy season (June-Oct) and increased security due to rebel groups have made it difficult to visit and supervise volunteers in their communities. In instances where midwives cannot get to the villages, data is given to a village member going into town to deliver the forms to the sub-centers. Supervision tools, checklists, and plans (including the number of visits) have been developed and supervisors have been trained. The country has moved from Advocacy & Planning Phase into Early Implementation Phase. To strengthen the Early Implementation Phase, checklists and other tools need to be used more to move toward improving the quality of case management.

Benchmark #8: Monitoring and Evaluation and Health Information Systems The Department of Child Health Division’s CHLWG is in the process of developing a CCM D&P monitoring system to monitor implementation at Unicef- and 3MDG-supported sites. Baseline data from the 3MDG funding will help to better track impact on the number of cases seen at the facility (i.e. whether there is a decrease in cases as a result of CCM), trends and treatment of cases. The final product is targeted for late 2015; new reporting forms may have to be developed to accommodate the data required from this framework. Sub-center level data captures diarrhea (dehydration, dysentery, and treatment), pneumonia, and malaria (testing and treatment). The sub-center level is the lowest level of health service delivery that is captured in the HMIS. Therefore, the CCM D&P data collection process runs parallel to the existing HMIS.

16 42014 Census

The CCM D&P data that midwives collect from the community volunteers isn’t routinely discussed at the monthly township meetings or at the quarterly CHLWG meetings. Currently, there are no plans to incorporate CCM D&P data into the national HMIS, as CCM D&P is not present in all townships. Burma/Myanmar is still in the Advocacy and Planning Phase for M&E of its CCM program. The country is in the process of standardizing information to be collected. The next steps would be to strengthen how data is incorporated into the HMIS and how it is used for decision-making to move M&E into Early Implementation Phase. V. Summary of Key Findings  CCM D&P in Burma/Myanmar is still in the Advocacy and Planning Phase according to the iCCM Benchmark Indicator Framework. However, the MOH Department of Child Health and Development actively supports its implementation.

 CCM D&P is solely funded through donor support (i.e. Unicef and 3MDG) but MOH staff are actively involved in training and supervision at all levels, and working closely with implementers.

 CCM D&P current implementation does not cover the regions with the highest number of under-five deaths: Magway, Yangon, Ayerwaddy, Sagaing and Mandalay.

 CCM D&P is not fully integrated in the health system. CCM D&P implementation, data collection and drug procurement (outside of the Unicef townships) are managed through vertical donor programs.

 The current approach to CCM for D&P is vertical and implemented as stand-alone intervention; it does not include malaria or nutrition and does not reflect the continuum of care (vertical and horizontal). The MOH recognizes this and wants to move towards a more integrated approach including prevention (water, sanitation and hygiene; environment, nutrition).

 Burma/Myanmar has a strong history of volunteerism. Existing AMWs at the village level are the preferred cadre to deliver CCM D&P because they are already responsible for MCH services.

 In malaria-endemic areas, the malaria volunteers can also be selected by communities for CCM D&P, as they are already active in the community. However, the central-level systems for malaria and CCM have historically run in parallel (MOH departments, objectives, drugs, supervision, reporting), so a complete merge might be a challenge.

VI. Recommendations and Proposed Strategies  Support the MOH in implementing CCM D&P through the health system in two additional townships where coverage is low and under-five mortality is high (i.e. Sagaing, Magway, Ayeyarwady and Shan). This model will aim to: 1) build the township’s capacity to integrate CCM D&P into the health system, and 2) provide a roadmap that the MOH and partners could use to roll-out CCM nationwide.

 Conduct an assessment to better understand factors that contribute to high under-five mortality in urban or peri-urban settings such as Yangon, with a special focus on whether CCM would be applicable to reduce under-five mortality.

 Conduct an assessment to better understand factors for continued high under-five mortality rates in areas (i.e. Magway and Ayeyarwady) with historically heavy donor programing for under-fives.

 Provide technical assistance to strengthen the CCM D&P coordination among Unicef and 3MDG implementers, with a particular attention to integrate pneumonia and diarrhea with malaria volunteers.

 Provide technical assistance to build MOH basic health staff and volunteer capacities (AMWs) in SBCC/counseling to be able to use the MCH Booklet/Family Health Handbook as a counseling tool.

 Assist MOH in updating the Essential Drugs List to include commodities for the community work (and other programs as needed).

 Use existing supply chain technical assistance to include CCM D&P drugs and commodities into the government supply chain.

 Assist MOH to include CCM D&P and other community-based programs into the HMIS.

VI. Other Technical Areas/Interventions to Reduce Under-Five Mortality

Immunization

 Support MOH in improving Expanded Program on Immunization (EPI) cold chain (refer to SARA survey). There is little data on EPI vaccine service-readiness for cold chain in health facilities. SARA national data found only 4% of facilities had refrigerators and 55% had a cold box with ice packs. Similarly, of the sampled facilities, 11% had refrigerators and 55% had a cold box with ice packs.

 Provide technical assistance to support MOH in introducing new vaccines (rotavirus and pneumococcal). Burma/ Myanmar hasn’t introduced either pneumococcal nor rotavirus; but the country is planning to do so in 2017.

Nutrition

 Provide technical assistance to update current recommendations on women’s nutrition and infant and young child feeding (focus on 1000 days); especially strengthening counseling using the life cycle approach.

VII. Appendixes

Appendix A: CCM Program Township List

Township Name Region/ State Donors/Implementers

The Gon Bago Save the Children-Phased Out Kani Sagaing Save the Children-Phased Out Mawlamyinegyun Ayeyarwady 3MDG IOM

Bogale 3MDG IOM Lubutta 3MDG Save the Children Ngapudaw 3MDG Save the Children Dedaye 3MDG RI Pyapon 3MDG MDM Hakha Chin 3MDG Save the Children Tiddim 3MDG Save the Children Falam 3MDG Save the Children Mindat 3MDG DRC

Madupi 3MDG DRC

Tonzang 3MDG Save the Children Htantalang 3MDG Save the Children Paletwa 3MDG International Red Cross Kanpetlet 3MDG International Red Cross Seik Phyu Magway 3MDG MSI Gangaw 3MDG Save the Children Myaing 3MDG MSI

Pauk 3MDG MSI Saw Save the Children-phased out Mindon Save the Children-phased out Sadoktaya Save the Children-phased out Nga Phe Save the Children Loikaw 3MDG IRC Demoso 3MDG IRC Hpruso 3MDG IRC

Hpasawng 3MDG IRC

Bawlakhe 3MDG IRC

Shadaw 3MDG IRC Mese 3MDG IRC

Taunggyi Shan ( South) UNICEF

Hsihseng 3MDG RI

Mawkmai 3MDG RI

Laikha 3MDG RI

Lashio Shan (North ) UNICEF Kutkai 3MDG Save the Children Namthu 3MDG Cesvi

Namhsan 3MDG Cesvi Manton 3MDG Cesvi Pangsang 3MDG HPA ( Wa and SR 4) Mongla 3MDG HPA ( Wa and SR 4) Kyaing Tong Shan (East) UNICEF

Hpa-An Kayin UNICEF Hpa An Save the Children-Phased out HIaing Bwe Save the Children-Phased out

Kawkareik Save the Children-Phased out Myawaddy Save the Children-Phased out Dawei Tanintharyi UNICEF

Yangon Save the Children-Phased out Kungyangone

Appendix B: CCM-iCCM Desk Review List of Documents for Desk Review CCM Scoping in Myanmar

Creator/Designed by Date Created No Title of document Type of Material For whom

Toolkit for Community Case Management of Implementation Guide Basic health staff and CCM volunteers 1 Childhood Illness ARI/Pneumonia and Diarrhea - MOH/UNICEF 2013 Implementation Guide (English) Toolkit for Community Case Management of Tools for Community Basic health staff and CCM volunteers Childhood Volunteers 2 MOH/UNICEF 2013 Illness ARI/Pneumonia and Diarrhea - Technical Supplements (English) Toolkit for Community Case Management of tools for Community Basic health staff and CCM volunteers Childhood Volunteers 3 MOH/UNICEF 2013 Illnesses - Technical Supplements - Photo Album, Videos, Handbill, Patient Registration Book (Burmese) 4 Community Case Management of Childhood Illness guidelines MOH/UNICEF 2013 Basic health staff and CCM volunteers ARI/Pneumonia and Diarrhea - Trainer's Guide

5 Community Case Management of Childhood Illness guidelines MOH/UNICEF 2013 Basic health staff and CCM volunteers ARI/Pneumonia and Diarrhea - Facilitator's Guide, National Newborn and Child Health Development 2nd April those working on 6 Strategic Plan (2015 -2018) policy docs Gov't-CHD 2015 newborn child health in Myanmar (Final Maternal and Newborn Health Country Profile - newborn child health in Myanmar Myanmar 7 policy docs MOH/UNICEF ? 2012

No Title of document Type of Material Creator/Designed by Date Created For whom Emergency referal guidelines for mothers and young August those working on 8 guidelines 3MDG children (Final draft) 2015 newborn child health 9 Child Death Surveillance and Response (CDSR) – guidelines Gov't-CHD 2015 health professionals Technical Guideline for Action to Prevent Child Death (draft) in Evaluation of Community Case Management of 10 Gov't-Dept of PH 2011 health professionals Pneumonia and Diarrhoea in Dawei Township 11 Just in time (comic book) Save the Children community CHW - community volunteers 12 Community base health care (CCM) manual manual Save the Children 2010

CHW chart - Care for the sick children age between 2 tools for Community CHW - community volunteers 13 Save the Children 2010 months and 5 year old Volunteers tools for Community CHW - community volunteers 14 Sick child record form (Burmese) Save the Children 2010 Volunteers 15 Treatment form for sick children tools for Community Save the Children 2010 CHW - community volunteers Volunteers

16 Supervsiroy check list for child care (Burmese) tools for Community Save the Children 2010 Basic health staff and CCM volunteers Volunteers

Monitoring framework for Community Case 17 guidelines MOH/UNICEF 2015 health professionals Management on Pneumonia and Diarrhea 18 Newborn and Child Health Manual for Basic Health manual MOH/UNICEF 2012 Bais health staff Staff 19 Newborn and Child Health Treatment Guidelines for guidelines MOH/UNICEF 2010 Basic health staff 20 Integrated Management of Childhood Illness - Training MOH/UNICEF 2005 Basic health staff and CCM volunteers Video CD 1,2,3,4 Guidelines for Malaria Control and Treament in Gov't-Nat'l Malaria 21 guidelines 2015 health professionals Myanmar Control Summary of Myanmar National Drug Policy for Malaria Gov't-Nat'l Malaria August 22 policy docs health professionals (Draft) Control 2014

No Title of Document Type of Material Creator/Designed by Date Created For whom 23 Census Main Report (Union) - Myanmar policy docs 2015 all audience ARI, Pneumonia and Diarrhoea : assessment and volunteer health workers 24 guidelines MOH/UNICEF 2010 treatment Trainees manual (for volunteer health ARI, Pneumonia and Diarrhoea : assessment and volunteer health workers 25 guidelines MOH/UNICEF 2010 treatment Trainers manual (for volunteer health ARI, Pneumonia and Diarrhoea : assessment and tools for Community volunteer health workers 26 treatment - photo album(for volunteer health Volunteers MOH/UNICEF 2010 workers)- ARI, Pneumonia and Diarrhoea : assessment and tools for Community volunteer health workers 27 MOH/UNICEF 2010 treatment - Handbill / flip chart (for volunteer health Volunteers ARI, Pneumonia and Diarrhoea : assessment and tools for Community volunteer health workers 28 MOH/UNICEF 2010 treatment - patient registration book (for volunteer Volunteers ARI, Pneumonia and Diarrhoea : assessment and tools for Community volunteer health workers 29 MOH/UNICEF 2010 treatment - record keeping (for volunteer health Volunteers 30 INGO Profile 2015 - English manual MOH/UNICEF 2015 all audience Primary Health Care - Community Health Worker's CHW - community volunteers 31 manual MOH 2009 Manual - Burmese Community Health Workers' Training Curriculum - CHW - community volunteers 32 guidelines MOH 2009 Burmese 33 Job Descriptions of Basic health Staff - Burmese guidelines MOH BHS 34 Assessment of Newborn Health in Myanmar guidelines MOH/UNICEF 2013 all audience 35 Maternal and Child Health Handbook Tools for Community MOH all audience Volunteers 36 Auxiliary Midwife training manual (latest version) manual MOH 2014 health professionals

Appendix C: iCCM Questionnaire Guide Basic public health data for: BURAM/MYANMAR Documents: Do you have these key docs? - Child Health statistics and epidemiology for:  National Health Strategic/Development Plan o Under five mortality_____72/1,000 live births; Magway is 108/1000 while X Child Health Strategic Plan Ayeyarwady is 105 per 1,000 live births (Union Census, 2014)  Child Health Operational Plan o Neonatal mortality (first 28 days)______ Child Health/IMCI Strategic Plan o Infant mortality: _62/1000 live births (rural 68/1,000). By State and Region,  Child Health/IMCI Operational Plan Magway and Ayeyarwady have the highest rates with 89 and 87 deaths per  Child Health/CCM Strategic Plan 1,000 live births, respectively (Union Census, 2014)  Child Health/CCM Operational Plan - U5 rates of morbidity and mortality for: X Malaria Operational Plan o Malaria Mortality:______ Child Survival Strategic Plan o Pneumonia Mortality: 28%, (Myanmar Dept. of Child Health and Development) X Situational analysis (regional/national) o Diarrhea Mortality: 6.7%(Myanmar Dept. of Child Health and Development)  APR Launched - Care-seeking data (%):  DHS o Diarrhea: private_____na__ public _na______X MICS 2010 o Pneumonia: 93.3 % can’t recognize signs/symptoms, 6.5% can recognize at least  HMIS/DHMIS 2 signs/symptoms  DIHS2 data o Malaria: private______public______X Other plans? 2014 Myanmar Union Report-Myanmar Dept. of Population - Other relevant indicators: and Housing o Stunting: __35%_Wasting: 8%, MICS, 2010 o Exclusive Breastfeeding: __24%, (Union Census, 2014) o Immunization rates: __91%, 88.6%; full immunization at 1 yr. (MICS, 2010) o Access to clean water: tube well/bore hole 31% for drinking water, 38% (Union Census, 2014) _ o Access to improved latrines: _2.1% flush, 72.2% water seal/pit latrine, (Union Census, 2014) - Deprivation index (UNDP-district level) : ___na______

Background The Myanmar MoH has adopted community case management of diarrhea and pneumonia (CCM D&P) as a national strategy for reducing under-five mortality by training two cadres, community health workers (CHWs) and auxiliary midwives (AMWs), to diagnose and treat diarrhea and pneumonia in the community. However, it is unclear which townships and villages are implementing CCM D&P, why those sites were selected for implementation, why community-based treatment of malaria was not included with pneumonia and diarrhea community-based treatment (i.e. iCCM), and which of the various donor groups are assisting with funds and management of CCM D&P and malaria programing. Additionally, the degree to which supportive policies, practices, and infrastructure are in place to successfully implement a national CCM D&P program is unknown. Understanding how CCM D&P and community-based malaria is implemented in Burma/Myanmar is critical for improving strategies to increase access to quality essential health services to reduce under-five mortality. Therefore, the iCCM Benchmark Indicators will be used to shape the development of a questionnaire guide aimed to better understand details the of CCM D&P and malaria implementation in Myanmar.

Research Methods: Semi-structured In addition to document review, findings will be synthesized from semi-structured interviews with key informants involved in aspects of decision-making for and implementation of CCM D&P and malaria in Myanmar. Semi-structured interviews are a qualitative research tool that allow for focused, conversational communication. Semi- structured interviews are used to gain an individual’s insights into particular issues, to probe for what is not known, and to gauge perceptions. Unlike formal questionnaires, where detailed questions are formulated in advance, in semi-structured interviews, not all questions are designed ahead of time; many are created during the interview, allowing flexibility to probe for details or discuss unexpected issues that arise. Semi-structured interviews are guided only in the sense that some form of interview guide is prepared beforehand, and provides a framework for the interview.

Introduction This semi-structured questionnaire guide was modeled after the iCCM Benchmark Indicators created by the iCCM Task Force. Each section of the guide is divided by eight components necessary for national implementation and scale up of CCM. Within each component, we ask questions that aim to understand the phase of progress of CCM. These phases are: Advocacy & Planning, Pilot & Early Implementation, and Expansion/Scale-Up. Knowing the phase of progress per the eight components will help to understand which benchmarks have been achieved, are in progress, or not started. Knowing where the country has progressed and stalled, will help to identify where the USAID mission can invest resources to assist the MoH. Each phase is coded with a number: 1 - Advocacy & Planning; 2- Pilot & Early Implementation; 3- Expansion/Scale-Up.

Interview Guide

Introduction: Thank you for taking the time to talk with us today we really appreciate it and want to assure you that your responses will remain anonymous. I am______and I work for USAID’s Maternal and Child Survival Program in Washington DC. We have been asked by the USAID/Myanmar mission to help them better understand how CCM has been implemented in Myanmar. As part of this process, we are talking with people who have been involved with some aspect of CCM in Myanmar. Information gathered will ultimately be used to identify the Ministry’s goals for the scale up CCM and areas where the USAID mission can support those goals. Our specific aims are to get a better understanding:  What CCM is (illnesses are/are not covered ) and how it is implemented in a country  The degree to which a supportive policy environment and infrastructure exists for CCM  The degree to which CCM has been implemented in the country (coverage, partner implementation)  How stakeholders see the implementation and future scale up of CCM in the country happening Do you have any questions before we get started? Great, let’s begin.

A. Coordination and Policy Setting Follow up Code Question

1 1. Can you tell me whether there is a child health technical advisory group and if so, how has the group planned for

implementation and scale up of CCM? Have stakeholders’ roles been defined? (Probe: who leads it; whether they discussed how national policies and guidelines support/ impact CCM; whether the group conducted a mapping of iCCM/CCM partners working in Myanmar).

1 2. Has there been a needs assessment and situation analysis for package of services conducted-either through the group or with other agencies?

2 3. How does the MOH work with partners to manage the implementation of iCCM/CCM programing (Alt question: Do you think there is sufficient leadership and coverage for CCM?)

2 4. Can you say a little bit about whether there are ongoing discussions among major groups (i.e. associations, gov’t

dept.) that might impact the policies that support the implementation of iCCM/CCM in Myanmar?

5. Is CCM institutionalized within the health system? If so, how? (PROBE: Are partners meeting regularly to 3 coordinate geographic –and equity-based coverage for CCM?

What are the major challenges and gaps in coordination and policy setting?:

Code Questions/Answers Follow up

B. Budgeting, Costing and Financing 1. Has there been a CCM/iCCM cost estimate conducted to better understand all the costs associated with CCM 1 services delivery requirements? If so, who conducted it and what were the results? (PROBE: How was this information used for planning purposes, or in a strategic plan?)

1 2. Do you think there are there sufficient finances for CCM cost related to: medicines, training, supervision, supplies, reporting? 3. Has a financing gap analysis been completed and carried forward to secure commodities from donors? 2 4. Is there a specific government budget for CCM cost related to: medicines, training, supervision, supplies, 2 reporting?

Code Questions/Answers Follow up 5. Has there been a long-term strategy for sustainability and financial viability put into place? And if so, who was 3 behind the development of this strategy? 6. How has the MoH moved towards sustained investment in CCM, and did you have/what was your role? 3

What are the major challenges and gaps in budgeting, costing and financing?:

A. Human Resources

Code Question/Answers Follow up

1 1. What services do CHWS deliver? (Probe: diarrhea, ARI/Pneumonia, Malaria, malnutrition, others-WASH)

1 2. Can you tell me a little about the criteria for CHWs and how they are recruited and their roles? (Probe: the CHWs role in treatment and referral services)

1-plan 3. Describe the plan for CHW training and refresher training and what the biggest challenges are for implementation? (Probe: are there modules, training of trainers, monitoring and evaluation?) 2-imple

1-plan 4. Has Myanmar developed and implemented a CHW retention strategy with incentives? (probe: are these strategies a part of the training curriculum) 2-imple

2 5. In your opinion, what are the biggest challenges for retaining CHWs?

3 6. Can you talk little about what the participation is of the community and health facility provider in recruitment, training, and retention? 7. Do CHWs undergo refresher training that updates them on new skills and reinforces their initial training? 3 8. Are there mechanisms for advancement for CHWs within the health system? 3

What are the major challenges and gaps for human resources?

B. Supply Chain Management

Code Questions /Answers Follow up

1 1. Can you tell me which medicines CHWs use for treatment in the community-are these medicines on the list of essential medicines? (Probe: whether the list is consistent with the national policy)

1-plan 2. Is there a procurement plan and processes for iCCM medicines and supplies in place? Is the plan processes consistent with the national plan and policies? 2-process

1 3. Is there a SOP for a logistics system for iCCM supplies (i.e. inventory control, resupply logistics system)? 4. How are the logistics systems supporting the maintenance of optimal quantity and quality products for 2 iCCM? 5. Can you describe how the medical stocks and supplies are tracked at all levels-are they tracked as a part 3 of a routine monitoring system? (Probe: is the information used to improve supply chain management?)

monitored 6. Is there an inventory control and resupply logistics system in place for iCCM (probe: Has this systems 3 been able to reduce stock-outs) What are the major challenges and gaps for supply chain management?

C. Service Delivery and Referral

Code Questions/Answers Follow up

1 Has the gov’t and partners developed a plan for the needed amount of medicines for CHWs to provide quality care? (Probe: costed?)

1-plan Can you describe the plan for how CHWs can conduct clinical assessments, diagnosis, manage and referral and counter referral? Are there CHW guidelines? 2-process

3 Would you say that CHWs are routinely providing timely, appropriate diagnosis, and treatment in their communities?

What are the major challenges and gaps for services delivery and referral?

D. Communication and Social Mobilization

Code Questions/Answers Follow up

1-plan 1. I’d like to know more about whether there are strategies developed to communicate with different groups (policy makers, community members) about CCM? If so, how have of these strategies been 2-imple implemented? (probe: how CHWs are promoting CCM utilization, are there materials for communicating-job aids, posters, training materials)

2 2. Has a communication and social mobilization plan been launched?

3 3. Has the CCM communication plan been refined based on M&E?

What are the major challenges and gaps for SBC?

E. Supervision and Performance Quality Assurance

Code Questions/Answers Follow up 1. Is there a supervision plan and types of supervision tools that have been developed –checklists/other 1 tools? If so, do they include for diagnosis, number of visits, roles of supervisors, elements of self- supervision? 2. Are supervision visits occurring every 1-3 mo, where supervisors have been trained and given materials 2 to couching to CHWs? 3. Are supervision visits part of the supervisor’s performance review? 3 4. Can you describe how CHWs are routinely supervised for quality assurance and performance, and how 3 that data is used for community feed-back and problem solving? 5. Are there yearly evaluations that include individual performance and evaluation of coverage or 3 monitoring data?

What are the major challenges for supervision and performance quality assurance?

F. M&E and Health Information System

Codes Questions Follow up 1. Can you describe for me how data are collected for the treatment of diarrhea, pneumonia, and malaria 1 case management of malnutrition in the community? (Probe: is there a research agenda for CCM documented and circulated?) 2. How have the CHWs and supervisors trained on the CCM framework, its components and how to use 2 the data 3. Has there been a monitoring framework tested using registers and reporting documents? (Probe: has it 2 been modified after being tested?) 3 4. Are CCM data being routinely collected and used to maintain quality and problem solve? 5. Can data from the community be disaggregated from the HMIS, so it can help solve community based 3 problems? (Probe: if not, are there plans for this in the future) 6. How are the data analyzed and used for decision-making? 3

What are the major challenges and gaps for M&E and HMIS?

Appendix D: Under Five Mortality in Burma/Myanmar, Union Census 2014

Appendix E: Implementation guide for CCM Chapters 1,2,3,4, and 5

Chapter 1

•Non-complicated pneumonia and diarrhea Chapter 4 •Under 5 children linkage with malaria •Early diagnosis and treatment •Selection process (township Health team and •Timely referral with danger signs community) •Quality essential generic medicine •Hard to reach villages •Key family practices related with child survival •Village selection (geographical accessibility, Existence of health care providers, size of under 5 population) Chapter 2 •Identification of potential villages (mapping of areas, health facilities, hard to reach more •Medicine (para,amoxicillan,cotrimoxizol,ORS, than5 km, numbers of inhabitants) Zinc) •Distance of each villages, other villages •Respiratory timer, digital thermometer, plastic covered by the identified village, distance box, bag, between identified village and the health •Patient register book, treatment record, center) medicine stock record, Monthly Report form, IEC) •Receipt and storage of medicines •Physical inventory of medicines •Dispensing of medicines Selection •BHS cover Chapter 3 •Communities mobilize and further activities •partner volunteers •Information to local authorities •Volunteers selection •Support of local authorities and leaders. •Promotion CCM volunteers at least 3years •Various trainers and supervisors of •Known residence intermediate and peripheral level. •Read and write (1) Advocacy meeting of different level. •Good relation (2) Social mobilization(Raise awareness, •Age (18-50) Community participation, improve utilization)

Volunteer selection

•Midwife/BHS lead volunteer •Supervise township health department

•At least 3years/support by community •Training •Motivation/access to medicines •Setting up a plan for urgent

Chapter 5 Training Level supervision

•Trainers (TOT3days) •Township level •Supervisors (3 days) •RHC •CCM volunteers (5days) •Supervision checklist •Supervisors (selection) •Supervisor task •CCM volunteer hand out •Review treatment record form •CCM volunteer guide •Completeness •Management of common childhood illnesses •Remarks •Photo album •Signs/symptoms and classification •Video •Classification and treatment •Treatment record form •Age and the dose of drug •Patient registerbook •Patient follow up visit •Drug stock book •Frequency of supervision •Supervision checklist •Instruction on the selection of villages and volunteers Recording and reporting •Record and status Volunteer training •Compilation of data and reporting •Monitoring and use of data •CCM volunteer guide •Motivation and retention of volunteers •CCM volunteer handbill •Photo Album •Video •Treatment record form •Patient register book •Drug stock book •Monthly report forms •Respiratory timer •Digital tharmometer •Life-saving medicines

Training evaluation follow up action

•Additional 2days training •Repeat examination •Different stimulation exercises Supervision Medicine Correct diagnosis Interview and access the knowledge of mothers Actively collect data and report Support

Appendix F: Human Resource Structure for Government Public Health Workers and Volunteers Cadre Training Funding Where they Responsibilities Source work Health Bachelor’s degree in -Manages RHC: staff and budget, Assistant community health (4 -Oversees overall activities and years) Government commodities (new training) Rural Health Lady Health 9 months after 3 years Center -Supervise all midwives Visitor of service as midwife. (RHC) Public Completion of high -Conduct environmental health Health school education and outreach Supervisor 6months training on -Compile data from RHC and sub- PHS1 environmental health. centers Public Completion of high Sub-rural -Compile data from sub-centers and Health school education and health village Supervisor 6months training on center -Conduct outreach on environmental PHS2 environmental health health, communicable (dengue, after 3-5 years of malaria, TB) and supervise volunteers experience at sub- (CHW and malaria) center as PHS1. - Conduct environmental checks on latrines, safe drinking, cook stoves 2 years -See all patients at the facility (revision in process) -Provide maternal (AN, delivery, PN) Midwife and child health care services Sub-rural -Conduct outreach for immunization health and supervise volunteers (AMW) center -Attends monthly meeting at RHC to discuss data/program and receive drugs/vaccines 6 months Training (3 -Conduct all community maternal and Auxiliary theory and 3 practical) + Not paid, child health, community tasks Midwife 5 days for CCM when may receive including treatment of diarrhea with Workers CCM is implemented stipend or ORS and Zinc, treatment of (AMW)* other Community pneumonia with antibiotics if CCM) or benefits referrals, community-based newborn from donor care and referrals for delivery Community 1 month CHW training and/or -Focus on communicable diseases and Health + 5 days for CCM when community environmental health Workers CCM is implemented Conducts health education talks

(CHW)* CCM D&P* 5 days training but often Diagnose and treat diarrhea and selected as existing pneumonia volunteer

Malaria 5 days for malaria -Test and treat malaria cases and Volunteers* household members Self-Help unknown -Provide education, and counseling for Group HIV and TB, including for drug (SHG) compliance *Can be the same person or not as selected by the community

Appendix G: List of People the Team met in Myanmar JSI-MCSP Yangon : September 24 to October 10th 2015

Name Organization Position ThuVan Dinh USAID Senior Health Technical Advisor Leah Thayer Jhpiego Country Director Dr. Hnin Wai Hlaing Jhpiego Deputy Country Director Dr. Kyaw Kyaw Cho Jhpiego Senior Programs Manager

Alyssa Davis Save the Children Thematic Advisor (Health) Dr. Kyi Kyi Ohn Save the Children Head of Program (Health)

Dr. Phone Zaw Phyo Save the Children MCSP Newborn Manager Susanna Save the Children Dr. San San Myint Save the Children Director (3MDGFund program) Senior Public Health Officer Dr. Yin Yin Htun Ngwe 3 MDG Fund (MNCH) Dr. Maharajan Muthu UNICEF Chief, Health Section Dr. Sarabibi Thuzarwin UNICEF Health Specialist (MNCH)

Dr. Aye Thwin UNICEF Consultant / Nutrition Specialist Ruth Dixon Malaria Consortium Country Representative Yasmin Padasmee Malaria Consoritium Former Country Director Myanmar Health Assistant Dr. Khin Tar Tar Association (MHAA) Advisor

U Soe Aung MHAA Secretary

Sa Nay Lin MHAA Project Officer Brain Mulligan JSI Country Representative

Chris Wareen JSI Francis Tain JSI

Dr. Zar Ni Soe JSI Dr. Tin Moe Aung JSI

JSI-MCSP

Nay Pyi Taw : September 27th to 30th 2015

Date Place Name Position Deputy Director General, Dept of 28-Sep Ministry of Health Dr. Yin Thandar Lwin Public Health Dr. Hla Myat Thway Eindra Director, Health Promotion

Dr. Thuza Chit Tin Director, Basic Health Services

Dr. Myint Myint Than Director, Child Health Development

29-Sep CCM Train the Trainers (TOT) Dr. Myint Myint Than Director, Child Health Development workshop, 1000 Bedded Hospital, Deputy Director, Child Health Nay Pyi Taw Dr. Thida Aung Development SARA Dissemination Meeting, Mingala Thiri Hotel Dr. Thandar Lwin Director, Disease Control

30-Sep Ministry of Health Dr. May Khin Than Director, National Nutrion Center

JSI-MCSP

Taunggyi Township Trip : October 5th to 7th 2015

Date Place Name Position 5- Oct Taunggyi State Health Department Dr Moe Swe State Health Director Taunggyi Township Health Department Dr Moe Tun Township Public Health Officer Taunggyi MCH clinic Dr Mway Mway Medical Officer Daw Moe Moe Thein LHV

Daw Myint Than LHV

Daw Hlaing Hlaing Tin LHV Daw Aye Aye Win MW Daw Khin Swe Myint MW Daw Lay Nyo MW Daw Aye Nyunt MW (Par Moe Nae SC)

6- Taung Ni RHC Oct U Si Thu Myint Thein HA Daw Hla Kyi LHV

Daw Than Aye MW (main center) Daw Moe Moe Wai PHS 1 Kyaut Ni SC Daw Saw Muyar MW Thayat Pin Hla Village Daw Saw Htwe CCM Volunteer+ AMW

7- Ham See RHC Oct Daw Htay Htay Myint LHV Daw Nang Yadanar Oo MW Katku SC Daw Nang Cherry Htwe MW

Ga Naing Htau Village Nang Soat CCM Volunteer + AMW

MCH = Maternal Child Health Clinic RHC = Rural Health Center SC = Sub rural health center

Appendix H: Work Schedule of JSI MCSP team to conduct iCCM scoping exercise in Burma/Myanmar (September 24 – October 10, 2015)

Team members 1) Dr. Agnes Guyon, 2) Maura Gaughan 3) Dr. Cynthie Tin Oo

Dates Activities Location

Sep 24, 2015  Team meeting at JSI office Yangon Thursday  Compile background documents; guidelines, training manuals, strategic plan, etc. for desk reviews

 JSI team members to meet with USAID/MCSP team at JHPIEGO office with JHPIEGO team and Save the Children team to discuss tentative plan

Sep 25, 2015  JSI team members preparation for the work ; developing tools for scoping exercise and discussion travel plan with JSI Country Representative Friday  Follow up meeting and travel approvals at IHD/MOH  Meeting with Yasmin Padasmee/ former country representative of Malaria Consortium

Sep 26, 2015 -  Meeting with Dr Yin Yin Htun Ngwe / Senior Public Health (MNCH) Specialist of 3MDG Fund Saturday

Sep 27, 2015 -  Travel to Nay Pyi Taw Sunday

Sep 28, 2015  Meetings with Dr Yin Thandar Lwin/ Deputy Director General of Department of Public Health, Dr. Hla Mya Thway Indra / Director Nay Pyi Taw of Health Promotion, Dr. Thuzar Chit Tin/ Director of Basic health Service Monday  Observe Comprehensive Township Micro Plan workshop at the MOH  Meeting with Dr. Myint Myint Than / Director of Child health Development

Sep 29, 2015  Observe Community Case Management Training of Trainers (TOT), second batch at 100 bedded Hospital funded by 3MDG Fund for 3MDG Fund townships Tuesday  Observe SARA data dissemination meeting conducted by Department of Medical Research at Mingalar Thiri Hotel  Meeting with Dr. Thandar Lwin/ Director, Disease Control

Sep 30, 2015  Team to review notes and collected data/ information Wednesday  Meeting with Dr May Khin Than/ Director of National Nutrition Center

Dates Activities Location

 Travel back to Yangon

Oct 1, 2015  Meeting with JSI SCMS-LMIS staff at JSI office Yangon Thursday  Meeting with Ruth / interim Country Representative of Malaria Consortium  Meeting with Burma/Myanmar Health Assistant Association to learn their program and malaria volunteers

Oct 2, 2015  Meeting at UNICEF with Sarabibi / MNCH Specialist and Muthu / Head of UNICEF Health section Friday  Meeting with USAID Burma/Myanmar to brief our scope of work and team visit to Burma/Myanmar

 Meeting at Save the Children office to learn Save’s CCM work since 2010 in Burma/Myanmar and their current CCM activities in Save townships

Oct 3, 2015  Individual team member to review notes and compiled information collected Saturday

Oct 4, 2015  Travel to Taunggyi Taunggyi Sunday

Oct 5, 2015  Curtesy meeting with Dr Moe Swe/ Shan State Health Director

Monday  Meeting and discussion of our scoping exercise with Dr. Moe Tun/ Township Health Officer, MCH Officer, LHV, Midwives at MCH centers and urban health center

 Develop field visit itinerary with Township Health officer

Oct 6, 2015  Field visit to Taung Ni RHC, Kyaunk Ni sub-RHC and Tha-yet-pin-hla village where AMW/CCM volunteer resides

Tuesday  Meeting with Health assistant, Lady health Visitor, Midwives, AMW and community members

Oct 7, 2015  Field visit to HumSee RHC, Katku sub-RHC and Ga-naing-tawt village where AMW/CCM volunteer resides

Wednesday  Meeting with Health assistant, Lady health Visitor, Midwives, AMW trainees and CCM volunteer

 Travel back to Yangon

Oct 8, 2015  Prepare for the debrief meeting Yangon

Thursday  USAID debrief meeting at JHPIEGO Office

Dates Activities Location

Oct 9, 2015  Prepare for the report Friday

Oct 10, 2015  End of the trip Saturday

Appendix I CCM- Benchmarks and Indicators Chart

Component Advocacy & Planning Pilot & Early Implementation Expansion/Scale-Up

Mapping of iCCM partners conducted Technical advisory group (TAG) established including community leaders, iCCM champion & CHW Coordination and MOH leadership established to manage unified MOH leadership institutionalized to ensure sustainability representation Policy Setting iCCM Needs assessment and situation analysis for package of services conducted Stakeholder meetings to define roles and discuss current Discussions completed regarding ongoing policy Routine stakeholders meetings held to ensure policies held change (where necessary) coordination of iCCM partners National policies and guidelines reviewed Costing and Financing iCCM costing estimates undertaken based on all Financing gap analysis completed Long-term strategy for sustainability and financial service delivery requirements viability developed Finances for iCCM medicines, supplies, and all MOH funding invested in iCCM program MOH investment in iCCM sustained program costs secured

Roles of CHWs, communities and referral service Role of and expectations for CHW made clear to Process in place for update and discussion of CHW providers defined by communities and MOH community and referral service providers role/expectations

Criteria for CHW recruitment defined by communities and MOH

Plan for comprehensive CHW training and refresher Human Resources training developed (modules, training of trainers, CHWs trained, with community and facility Ongoing training provided to update CHW on new skills, monitoring and evaluation) participation reinforce initial training CHW retention strategies, incentive/motivation CHW retention strategies reviewed and revised as plan implemented and made clear to CHW; necessary

community plays a role in providing rewards, CHW retention strategies, incentive/motivation plan MOH provides Advancement, promotion, retirement offered to CHWs developed who express desire support

Appropriate iCCM medicines and supplies consistent with national policies (RDTs where appropriate) included

in essential drug list Stocks of medicines and supplies at all levels of the system Quantifications for iCCM medicines and supplies monitored (through routine information system and/or Supply Chain iCCM medicines and supplies procured completed supervision) Management consistent with national policies and plan Procurement plan for medicines and supplies developed Inventory control, resupply logistic system, and standard Inventory control and resupply logistics system for iCCM operating procedures for iCCM developed implemented and adapted based on results of pilot with Logistics system implemented to maintain no substantial stock-out periods quantity and quality of products for iCCM

Plan for rational use of medicines (and RDTs where CHWs rationally use medicines and diagnostics Timely receipt of appropriate diagnosis and treatment by appropriate) by CHWs and patients developed to assess, diagnose and treat sick children CHWs made routine

Guidelines for clinical assessment, diagnosis, Guidelines reviewed and modified based on pilot Guidelines regularly reviewed and modified as needed management and referral developed Service Delivery and Referral

Referral and counter referral system CHWs referral and counter referral with patient implemented; community information on compliance is routine, along with information flow from Referral and counter referral system developed location of referral facility clarified; health referral facility back to CHW with returned referral slips personnel clear on their referral roles

Communication strategies developed, including messaging on prevention and management of

community illness for policy makers, local leaders, health providers, CHWs, communities and Communication and social mobilization plan implemented Communication and other target groups Social Mobilization Community and social mobilization content developed Materials and messages to aide CHWs are for CHWs on iCCM and other messages (training available Communication and social mobilization plan and materials, job aids, etc.) implementation reviewed and refined based on Materials and messages for iCCM defined, targeting the CHWs dialogue with parents and community monitoring and evaluation community & other groups members about iCCM and other messages Appropriate supervision checklists and other tools, Supervision visits every 1-3 months, includes CHWs routinely supervised for quality assurance and including those for use of diagnostics, developed report review, data monitoring performance Supervision and Performance Quality Assurance Supervision plan, including number of visits, supportive Supervisor visits community, makes home visits, Data from reports and community feed-back used for supervision roles, self-supervision, etc., provides skills coaching to CHWs problem-solving and coaching established Supervisor trained in supervision and has access to iCCM supervision included as part of the CHW Yearly evaluation includes individual performance and appropriate supervision tools supervisor's performance review evaluation of coverage or monitoring data

Monitoring framework for all components of iCCM Monitoring framework tested and modified M&E through HMIS data performed to sustain program developed and sources of information identified accordingly impact

M&E and Health Standardized registers and reporting documents Information Systems developed Registers and reporting documents reviewed Indicators and standards for HMIS and iCCM surveys Operations research and external evaluations of iCCM defined performed as necessary to inform scale-up and Research agenda for iCCM documented and circulated CHWs, supervisors and M&E staff trained sustainability on the new framework, its components, and use of data

Scoping Assessment on Integrated Community Case

Management in Burma

Dr. Cynthie Tin-Oo Ms. Maura Gaughan Dr. Agnes Guyon

Workplan (October 2014 – September 2016)

- Objective 5: Collaborate with the Ministry of Health (MoH) to provide national technical assistance for malaria in pregnancy and iCCM.

- Expected Results: Increased understanding of gaps in iCCM coverage in Burma/Myanmar.

Demographics – Population: 51,486,253* – Under-five mortality: 72/1000 live births* – Post-neonatal mortality (first 28 days to one year): 62/1000 live births* – Pneumonia mortality: 28% – Diarrhea mortality: 6.7% – Stunting: 35%; wasting: 8%** – Exclusive breastfeeding: 24%* – Immunization rates: 91% – Full immunization at one year. : 88.6%** – Access to drinking water: 38%*

*Census, 2014 ** MICS, 2010

Methodology

Using the existing iCCM Benchmark Indicators Framework as a guide (8 sub-components), with a special focus on malaria volunteers, for: -Desk review (studies, guidelines, training and other materials) - Interviews with government managers, key partners - Field visits in Taunggyi township to existing sites supported by Unicef

History CCM (diarrhea and pneumonia – D&P) and malaria have parallel paths; no nutrition included - 2004: CCM Save the Children (Yangon, Bago, Magway, Sagaing) - 2010: MoH Pilot in Dawei CCM D&P (Unicef) - 2011:Assessment site in Dawei & MoH approval to expand to four additional townships - 2015 - CCM (5 Unicef and 36 3MDG townships) - 11.5% township coverage - 10,000 malaria volunteers trained: the country is moving towards malaria elimination

I. Coordination & Policy Setting (1)

- Government engaged in CCM and malaria at all levels - Toolkits, guidelines and training materials developed for CCM and malaria (no nutrition) - No objections in principle to merge CCM and malaria (even nutrition) from MoH Public Health and Disease Control directors. - Antibiotics available for treatment of pneumonia at community level when CCM supported by either INGOs or Unicef

1. Coordination & Policy Setting (2)

- At national level: Lead Child Health Group meeting, CCM being included & annual CCM review - At township level: data-oriented monthly review covering all programs. - No township plan for expansion (if needed to cover additional hard-to-reach areas)

2. Costing & Financing

-There is no direct government support to CCM except staff (i. e. training and supervision) - 5 townships funded by Unicef directly for CCM - 36 townships funded by 3MDG funds through 10 implementing partners (IPS) for management, drugs/supplies, data collection - Newborn/child health costing done, however unclear if and how CCM has been included (supported by Unicef)

3. Human Resources (1) CCM: Department of Public Health (DoPH) - National guidelines approved with amoxicillin and ORS/zinc - Training of trainers done for 36 3MDG townships - Training for CCM supervisors: ongoing - Training of CCM volunteers: 5 days - Refresher training done for 5 Unicef townships (3 days) - Partial CCM for basic auxiliary midwife (AMW) training (treatment of diarrhea and referrals for pneumonia): 3 months theory + 3 months practicum Malaria (Department of Disease Control) - National guidelines revised (2015) - Training malaria volunteers: 5 days - Training CHWs includes some malaria training

3. Human Resources (2)

Choice of volunteers - Variable but purposeful selection with priority for existing ones, often AMW

- Many AMW being trained, but most are young women (creating opportunity and challenges)

4. Supply Chain

- Essential drugs list revised in 2005 does not include updated list of commodities per level of care - SARA survey: availability of antibiotics is less then 20% at rural health clinic (RHC) and sub-centers - INGO have a parallel system (not through township system) - Unicef procures drugs and supplies to be delivered through the DoPH, but correct dosages are not getting to AMWs (125mg and 250mg)

5. Service delivery - Under utilization of clinic facilities - Guidelines, protocols, handbill and forms exist - Very driven by quantitative data; there is limited qualitative data on quality of care, health education and counseling

Referrals - A separate document being drafted by 3MDG - Currently done by volunteers for D&P danger signs - IMNCI readiness in RHC & sub-centers, 43% trained staff, 60% availability of guideline (SARA survey)

6. Social Behavior Change Communication (SBCC) - Culture of volunteerism is strong, some volunteers are in villages for many years - Government recognizes volunteers - Advocacy on CCM program exists - Limited SBCC capacity building, therefore limited counseling support to parents (despite existing supports such as posters and Maternal & Child Health Handbook) - Nutrition counseling not up-to-date with international/ WHO guidelines

7. Supervision - Checklists and forms exist,AMW fill in monthly data forms - Monthly visits from sub-centers (MW) - Quarterly visits from RHC (lady health visitors or MW) - Lot of focus on numbers (reliability of information?) - Difficult to do “case mentoring” as very few cases to observe; monitoring quality of care not strong - Last annual review: important emphasis on supervision challenges, i.e. raining season and low security in some areas - PHS2 supervise CHWs/AMWs (focus on environmental health and communicable diseases). More PHS2s deployed in January 2016 (conditional to congress budget approval)

8. M&E and HIS

- Draft CCM framework on indicators being developed - CCM (as malaria control) has a parallel system to sub- center integrated +/- with government - HMIS stopped at sub-center and does not include community information, directly reported separately - Diarrhea (dehydration, dysentery, treatment), pneumonia, and malaria (testing and treatment) reported in HMIS

Conclusions

- CCM (D&P) well accepted by MoH, however still a new concept. Led and funded by donors (not fully integrated in the health system) - AMW might be the volunteer of choice for CCM: - as represents the MCH community agent - potential for a large government workforce - Malaria volunteers can be selected by community for CCM, however the two systems are parallel (MoH departments, objectives, drugs, supervision, reporting),therefore a total merge might not be the best option. - The current strategy for selection of CCM volunteer is through the community (this is working well)

Gaps

- CCM (D&P) current implementation does not cover highest under-five mortality states/regions

- CCM is stand alone and not integrated into the health system in the continuum of care - vertical with referrals - horizontal as life cycle approach and with prevention interventions (WASH, environment, nutrition)

Opportunities (1) - Support MoH in implementing CCM in additional townships, in particular where coverage is low and U5M is high (Sagaing, Magway, Ayeyarwady and Shan) • not as an INGO, but working through MoH system to establish state-of-the-art implementation to fully integrate CCM into the health system, in particular under5 care (Newborn and Child Health Strategic Plan) - Conduct assessment to understand urban or peri-urban settings to target Yangon’s high U5M - Conduct assessment of high U5M in Magway and Ayeyarwady, despite a history of donor investment

Opportunities (2) - Provide TA to strengthen the CCM coordination - Provide TA to build MoH (BHS) and volunteer capacities (AMW) in SBCC/counseling to be able to use the Maternal & Child Health Handbook as counseling tool - Assist MoH in updating Essential Drugs List to include commodities for the community work (and other programs as needed) - Use existing supply chain TA to include CCM into the government supply chain - Assist MoH to include CCM and other community programs in HMIS

Other opportunities related to under 5 IMCI/Midwife pre-service training - Provide TA to introduce the child health component in current midwifery-strengthening work Immunization - Support MoH in - improving EPI cold chain (refer to SARA survey) - introducing new vaccines (rotavirus and pneumococcal) Nutrition - Provide TA to update current recommendations on women’s nutrition and infant and young child feeding ( focus on1000 days) strengthening in counseling using the life cycle approach

Cè-zù tin-ba-deh! Thank you!