Integrated Health Project in Burundi (IHPB) Contract Number: AID-623-C-14-00001
Quarterly Report January – March 2017
Submitted by: FHI 360 and partners
Submission date: April 30, 2017
Table of Contents
Table of Contents ...... 2 Introduction ...... 7 CLIN 1: Increased Positive Behaviors at the Individual, Household and Community Levels ...... 10 Sub-CLIN 1.1: Improved key behavioral pre-determinants at the individual, household and community levels ..... 10 Sub-CLIN 1.2: Increased accessibility and availability of health products to individuals and households ...... 15 Sub-CLIN 1.3: Strengthened support for positive gender norms and behavior and increased access to GBV services ...... 19 CLIN 2: Increased Use of Quality Integrated Health and Support Services ...... 25 Sub-CLIN 2.1: Increased access to health and support services within communities...... 25 Sub-CLIN 2.2: Increased percent of facilities that provide quality integrated health and support services ...... 27 Sub-CLIN 2.3: Increased capacity of providers and managers to provide quality integrated health services ...... 37 CLIN 3: Strengthened Health Systems and Capacity ...... 41 Sub-CLIN 3.1: Strengthened decentralized health care and systems in targeted geographic areas ...... 41 Sub-CLIN 3.2: Strengthen M&E and data management systems at the facility and community levels ...... 45 Sub-CLIN 3.3: Increased civil society capacity to support positive behaviors and quality integrated services ...... 50 Priority Health Domain Strategies ...... 52 Malaria Strategy ...... 52 Child Health Strategy ...... 59 Maternal and Newborn Health Strategy ...... 63 Reproductive Health Strategy ...... 67 HIV/AIDS Strategy ...... 73 Innovation study: Pilot of Integration of Prevention of Mother-to-Child Transmission (PMTCT) and Early Infant Diagnosis (EID) of HIV into Routine Newborn and Child Health Care ...... 88 Implement learning, documentation and dissemination activities ...... 90 Program Monitoring & Evaluation ...... 91 Program Management ...... 92 Annex I: Change packages as defined for the extension of improvements in Kirundo & Kyanza health provinces .... 95 Annex II: Progress and discussion on October - March PEPFAR targets ...... 101 Annex III: Success stories ...... 102 Annex IV: Results from data analysis meetings ...... 103 Annex V: IHPB Indicators – Achievements for the period October 1, 2016 – March 31, 2017 ...... 105
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Acronyms and Abbreviations
AIDS Acquired Immune Deficiency Syndrome ABUBEF Association Burundaise pour le Bien Etre Familial ACTs Artemisinin-based Combination Therapy ADBC Agent Distributeur à Base Communautaire (Community Based Distributor of Contraceptives) AMTSL Active Management of the Third Stage of Labor ANC Antenatal Care ANSS Association Nationale de Soutien aux Séropositifs et aux Sidéens ART Anti-Retroviral Therapy BCC Behavior Change Communication BDS Bureau du District Sanitaire (District Health Bureau) BEmONC Basic Emergency Obstetric and Neonatal Care BMCHP Burundi Maternal and Child Health Project BPS Bureau Provincial de la Santé (Provincial Health Bureau) BRAVI Burundians Responding Against Violence and Inequality BTC Belgian Technical Cooperation CAM Carte d’Assistance Médicale (Health Assistance Card) CBO Community-Based Organization C-Change Communication for Change CCM Community case management CCT Community Conversation Toolkit CFR/OMB Code of Federal Regulations/Office of Management and Budget CHW Community Health Worker CLA Collaborating, Learning and Adapting COP Chief of Party COSA Comité de Santé CPSD Cadre de Concertation pour la Santé et le Développement CPVV Comité Provincial de Vérification et de Validation CS Capacity Strengthening CSO Civil Society Organization CTN Cellule Technique Nationale CT FBP Cellule technique du Financement Basé sur la Performance DATIM Data for Accountability, Transparency and Impact DBS Dried Blood Samples DCOP Deputy Chief of Party DHE District Health Educator DHIS District Health Information System DHS Demographic and Health Survey DHT District Health Team
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DPE Direction Provinciale de l’Enseignement DPSHA Département de Promotion de la Santé, Hygiène et Assainissement DQA Data Quality Assurance EC Emergency Contraception EID Early Infant Diagnostic EONC Essential Obstetric and Neonatal Care ENA Emergency Nutrition Assessment FAB Formative Analysis and Baseline Assessment FGD Focus Group Discussion FHI 360 Family Health International FFP Flexible Family Planning Project FP Family Planning FQA Facility Qualitative Assessment FTO Field Technical Officer FSW Female Sex Worker GASC Groupement d’Agents de Santé communautaire GBV Gender Based Violence GoB Government of Burundi HBC Home-Based Care HD Health District HealthNet TPO Dutch aid agency – merger between HealthNet International and Transcultural Psychosocial Organization HH Household HIV Human Immunodeficiency Virus HPT Health Promotion Technician HIS Health Information System HQ Headquarters HR Human Resources HRH Human Resources for Health HSS Health Systems Strengthening HTC HIV Testing and Counseling iCCM Integrated Community Case Management IDI In-Depth Interview IHPB Integrated Health Project in Burundi INGO International Non-Governmental Organizations IP Implementing Partner IIP Institutional Improvement Plan IPC Inter Personal Communication IKG In-Kind Grants IPTp Intermittent Preventive Treatment of malaria during Pregnancy IPC Interpersonal Communication IRB Institutional Review Board
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ISTEEBU Institut de Statistiques et d’Etudes Economiques du Burundi ITN Insecticide-Treated Net IYCF Infant Young Child Feeding JICA Japanese International Cooperation Agency Kfw Kreditanstalt für Wiederaufbau (Établissement de crédit pour la reconstruction) Allemand (German Development Bank) KII Key Informant Interview LLIN Long Lasting Insecticide-treated Nets LMIS Logistics Management Information System LOE Level of Effort LOP Life of Project LPT Local Partner Transition LS Learning Session MAP Men As Partners M&E Monitoring and Evaluation MARPs Most at Risk Populations MCH Maternal and Child Health MNCH Maternal, Neonatal and Child Health MoU Memorandum of Understanding MPHFA Ministry of Public Health and the Fight against AIDS MSH Management Sciences for Health MSM Men who have Sex with Men MUAC Mid-Upper Arm Circumference NHIS National Health Information System NPAC National Program for AIDS/STIs Control NMCP National Malaria Control Program NGO Non-Governmental Organization OASIs OASIs (“Outil d’amélioration des services intégrés” OIRE Office of International Research Ethics ORS Oral Rehydration Salts OVC Orphans and Vulnerable Children PBF Performance-Based Financing PCR Polymerase Chain Reaction PECADOM Prise en Charge à domicile (Community case Management) PEP Post-Exposure Prophylaxis PEPFAR US President’s Emergency Plan for AIDS Relief PIRS Performance Indicator Reference Sheet PLHIV People Living with HIV PMEP Performance Monitoring & Evaluation Plan PMTCT Prevention of Mother-to-Child Transmission PNILP Programme National Intégré de Lutte contre le Paludisme PNSR Programme National de Santé de la Reproduction
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PPP Public-Private Partnership PSA Public Service Announcement PTO Program Technical Officer QA/QI Quality Assurance/Quality Improvement QA Quality Assurance QI Quality Improvement RBP+ Réseau Burundais des Personnes vivant avec le VIH RDTs Rapid Diagnostic Tests RH Reproductive Health ROADS II Roads to a Healthy Future SARA Services Availability and Readiness Assessment SDPs Service Delivery Points SBC Strategic Behavior Change SBCC Social and Behavior Change Communication SCM Supply Chain Management SCMS Supply Chain Management System SDA Small Doable Action SIAPS System for Improved Access to Pharmaceuticals and Services SIMS Site Improvement through Monitoring System SLT Senior Leadership Team SMS Short Message Service SOP Standard Operating Procedures STA Senior Technical Advisor STI Sexually Transmitted Infection STTA Short-Term Technical Assistance SWAA Society for Women against AIDS in Africa TA Technical Assistance TAG Technical Advisory Group TB Tuberculosis TOR Terms of Reference ToT Training of Trainers TWG Technical Working Group UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government URC University Research Corporation VMMC Voluntary Medical Male Circumcision WHO World Health Organization WP Work Plan Y4 Project Year 4
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Introduction The Integrated Health Project in Burundi (IHPB) is a five-year project (December 23, 2013 to December 22, 2018) funded by the United States Agency for International Development (USAID). IHPB builds on USAID’s legacy of support to the health sector in Burundi and FHI 360 and Pathfinder’s successes in assisting the Government of Burundi (GoB) to expand and integrate essential services for HIV/AIDS; maternal, neonatal and child health (MNCH); malaria; family planning (FP); and reproductive health (RH).
The Ministry of Public Health and Fight against AIDS (MPHFA) is a major partner that is involved at every step throughout project planning and implementation. IHPB’s goal is to assist the GoB, communities, and civil society organizations (CSOs) to improve the health status of populations in 12 health districts (HDs) located in the provinces of Karusi, Kayanza, and Kirundo, and Muyinga. IHPB’s expected results are: 1) Increased positive behaviors at the individual and household levels; 2) Increased use of quality integrated health and support services; and 3) Strengthened health system and civil society capacity.
Highlights for this quarter This quarterly report details program activities and results during the period from January 1, 2017 to March 31, 2017. Following the official declaration of a malaria epidemic in February 2017 in 26 health districts (HDs) in Burundi (that includes the 12 IHPB HDs), while fully supporting and participating in the response to the malaria epidemic, IHPB continued implementing Y4 work planned activities. Highlights of activities and achievements during the quarter are presented below: Through the 62 Health Promotion Technicians trained (HPTs) as inter personal communication (IPC) master trainers, IHPB trained and equipped 3,278 CHWs with skills to counsel parents using communication materials during home visits and community gatherings. Produced, in collaboration with the Information, education and Communication (IEC) Unit of the MPHFA, 8 radio programs aired two times and 8 public service announcements (PSAs) aired three times on National Radio station - reached an estimated 109,230 household in the four provinces. Organized 10 sessions of mobile cinema as part of community mobilization interventions in Kirundo and Muyinga Provinces - reached an estimated 6,227 people on malaria prevention message during the malaria epidemic response. Finalized the supply chain management (SCM) Module of the newly named OASIs (“Outil d’amélioration des services intégrés”) and piloted it in Buhiga and Nyabikere HDs during integrated supervision visits. With the objective to reduce gender-based stigma towards men who have sex with men (MSM) and female sex workers (FSWs), in partnership with the LINKAGES project, organized and trained 6 (1 male and 5 female) health care providers as master trainers who will do a step-down training with 90 health care providers in the IHPB intervention provinces. Community awareness events on gender-based violence (GBV) conducted with 143 participants (105 male and 38 female) and quarterly coordination meetings organized with 81 participants (64 male and 17 female). . Pilot CHW peer supervision approach activities launched.
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IHPB partnered with Kayanza and Kirundo provincial health authorities to organize the third Quality Improvement (QI) learning session (LS), on integration of family planning into maternal and child health and HIV services in Kayanza and integration of early ante natal care (ANC), nutrition, HIV and SGBV into curative services in Kirundo. Change package and extension strategy designed and started implementation in 55 additional facilities. Continuously updated the IHPB training database and made important progress to pilot the electronic integrated assessment and improvement instrument called Outil d’amélioration des services intégrés de santé (OASIs). Through in-kind grants (IKGs), supported nine health districts to organize one-day quarterly data review meetings followed by one-day coordination meetings and conducted 158 joint supervisions across the 12 IHPB health districts. Finalized a supervision systems assessment tool and a coordination meeting assessment tool and started using them to identify opportunities for improvement of these district functions. In partnership with the MPHFA’s Health Information System Department, organized and trained 48 trainers (13 female and 35 male) who in turn trained 267 (197 male and 70 female) participants on the new DHIS2 data collection and reporting tools. Fully participated in the response to the malaria epidemic – provided technical and financial support to carry out mobile clinics/fixed sites (24,133 cases tested positive were treated) and supported micro plan development in the four IHPB provinces. Conducted community theaters and mobile cinemas on malaria themes during malaria epidemic – 6,227 e) in Muyinga and Kirundo have been reached with key messages on malaria prevention (use of LLNIs, taking all anti malaria drug as prescribed, early treatment seeking behavior with consequences of delaying treatment) 148 health care workers (77 female and 71 male) from eight districts of Karusi, Muyinga and Kayanza provinces were trained on integration of IPTp within ante natal care (ANC), hence achieving the target of two health workers per facility trained across the eight HDs. Supported a one-day orientation of 806 CHWs (350 female and 456 male) from Muyinga province to systematically register every newborn and ensure immunization schedules are adhered to. The last batch of 334 CHWs from Mukenke and Kirundo HDs were trained on management of acute malnutrition – across the 12 IHPB target HDs, at the community level, 127,360 children under five were screened for malnutrition: 14,451 (11.3%) had moderate malnutrition and 4,455 (3.5%) severe malnutrition) and 2,299 referred to a health center; 156,208 people were educated (by CHWs) on exclusive breastfeeding; 98,938 on importance of complementary feeding; and 115,409 on hygiene and hand washing. Continuous joint (IHPB and HD staff) supervisions (with a focus on maternal and neonatal health) contributed to achieving 97% of women receiving uterotonic in the third stage of labor for the prevention of postpartum hemorrhage. In partnership with the National Reproductive Health Program (PNSR) and its partners (WHO and UNFPA, IHPB supported an eight-week mentoring for health providers from hospitals in Muyinga and Kirundo on life-saving services using principles of basic and comprehensive emergency obstetric and neonatal care – 243 caesarian sections (Kirundo: 199 and Muyinga: 44), 3 hysterectomies, 1 myomectomy, and 3 laparotomies were conducted. Conducted quarterly community level data analysis meetings in Kayanza, Muyinga and Kirundo demonstrating learning and improvement in the services provided by the 2,046 CHWs trained on
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community-based distribution of contraceptives – 171,118 male condoms, 6,411 pills, 1,185 female condoms were distributed; 64,715 households visited; 299,642 people reached; and 3,942 referred for modern contraception. Conducted a five-day training session on vasectomy for five doctors and five operation room nurses (six male and four female) - 74 men performed vasectomy starting from the date of training to the end of March 2017. Supported 492 outreach HIV testing and counseling (HTC) sessions in hotspots to identify populations at high risk of HIV infection (female sex workers and men who have sex with men), as well as among other groups with higher risk of HIV transmission (single mothers, separated couples, men and women with sexual multiple partners, etc.). Of the 13,243 individuals (5,609 male and 7,634 female) that volunteered to be tested, 478 (196 male and 262 female) that were found positive were referred to an ART site for enrollment. This is a 3.6% rate of HIV+ result. Compared to the 1.4% prevalence in the general population, this means that the team carefully selected hot spot areas and high risk groups to do the testing. Performed mentoring visits to sensitize and enable healthcare providers -nurses prescribing and following up antiretroviral therapy in decentralized ART sites - a total of 72 ART sites visited and 516 (225 male and 291 female) new PLHIV enrolled on ART. Supported viral load assessment and early HIV infant diagnostic (EID) logistics (collecting, transportation of samples and getting back test results from health facilities to specialized laboratories). Results of 343 dried blood samples (DBS) and 2,104 viral loads examined were given to the beneficiaries. Convened the 2nd Technical Advisory Group (TAG) on the Pilot Integration of Prevention of Mother to Child Transmission (PMTCT) - Early Infant Diagnosis (EID) of HIV/AIDS to assess progress. Collaborating, Learning and Adapting (CLA) scope of work finalized and shared with MPHFA. A joint (MPHFA, IHPB and USAID) technical and logistical team will be established in April to begin preparations. A two-day CLA meeting is tentatively scheduled to take place on May 23rd and 24th.
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CLIN 1: Increased Positive Behaviors at the Individual, Household and Community Levels Sub-CLIN 1.1: Improved key behavioral pre-determinants at the individual, household and community levels Planned for January- March Achievement and Results Comments 2017 Train 63 HPTs as trainers on Achieved 41 trained during the period January IPC to March 2017 and 21, from October – December 2016 Train 1,000 CHWs on use of Achieved 3,251 CHWs trained (2,754 from communication materials January to March and 497 from October – December 2016) Develop, pretest and print 5 communication materials 3,500 flips charts, communication materials for (flipchart, invitation cards, 2 330, 000 invitation cards “Parents with children under posters and leaflet) developed 330 ,000 posters, age five” life stage and pretested 30, 000 leaflets will be printed and ready for distribution in April and May Conduct regular monitoring 7 joint supervision visits 236 CHWs were visited during the 7 visits to CHWs conducted in Buhiga and sessions to identify families that will Nyabikere HDs receive certificates for being role models in implementing the nine key doable actions Continue production, and Continuous IHPB has advertised for local monitoring of radio drama. company that will produce a serial Expand programming to radio drama of 24 episodes with include public service messages targeting parent of announcements children under five 8 radio programs aired twice and 20 radio programs are planned for Continue production of weekly 8 PSAs produced and aired 3 this fiscal year. The project has radio programs to reinforce times each on the National Radio already produced 12 radio programs. community mobilization efforts Station The 8 remaining will be finalized next quarter Develop and produce trigger Field research and filming carried Editing of videos underway, video on 3 life stages out for each of 3 trigger videos on completed videos will be available children under five, adolescent May 2017 and adult. Conduct mobile cinema on 10 sessions of mobile cinema on 10 sessions out of 24 planned for this the 4 life stages 1st life stage carried out. fiscal year have been conducted. 14 sessions will be conducted next quarter with an emphasis on parents with children under five, adolescents and young adult life stages.
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Planned for January- March Achievement and Results Comments 2017 Conduct mobilization Continuous IHPB has identified a service campaign using roadshow as provider. Roadshow will commence a communication tool next quarter
During the reporting period, the SBCC activities implemented in line with IHPB’s strategic framework are:
Train HPTs as trainers on IPC Last quarter, SBCC team developed a TOT module on interpersonal communication. The module is centered on small doable actions for pregnant women. During this quarter, SBCC conducted 3-day- training of trainers (ToT) to strengthen their capacity in interpersonal communication. The ToT targeted 13 health promotion technicians of Kirundo (12 males and 1 female) and 8 health technicians of Kayanza health District (6 male and 2 female) as well as the Provincial Coordinator of health promotion of Kirundo. SBCC team also trained also 12 District supervisors from IHPB intervention area on the same module. The trained health promotion technicians (HPT) cascaded the training in their catchment areas. HPTs successfully trained all the community health workers in the four IHPB provinces.
Train CHW’s on counseling techniques using health promotion materials After each TOT, the 62 HPTs from the 4 provinces, in turn, organized two-day-training sessions in their catchment areas. In Kayanza, 855 community health workers (452 male and 403 female) were trained on interpersonal communication and use of communication materials. The training was conducted from February 7th - 16th by 12 HPTs under the supervision of IHPB staff. In Muyinga, HPTs trained 409 community health workers (239 male and 170 female). In Karusi, the training targeted 481 Community health workers (276 male and 205 female). In Kirundo, 1,009 CHW (539 female and 470 male) were trained.
A total of 2,754 CHWs were trained during the quarter. Currently, 3,251 CHWs from the 12 Districts have been equipped with skills to counsel parents using communication materials during home visits and community gatherings. Immediately after the workshops, CHWs started promoting the 9 key actions to pregnant women and their partners.
Develop, pretest and print communication materials for parents of children under age five The development of the materials for “parents with children under five years” life stage was done with the help of graphic designer, Yitagasu Mergia. Mr. Yitagasu produced 15 illustrations that promote the 9 key actions identified by IHPB and its partners. The national technical working group was invited to provide feedback on the technical and artistic quality of the illustrations. The materials kit for the life stage is composed of: a flip chart, 2 posters, a booklet and leaflet promote the key messages. The action- based messages promote: sleeping under an LLIN,
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timely immunization, exclusive breastfeeding for 6 months, feeding children diverse foods, hand washing with soap at critical times (after defecation, after changing diapers and before food preparation and eating) ORS treatment at onset of symptoms of diarrhea.
Through a competitive process, IHPB identified a local company that has been contracted to print the materials for 3 life stages: children under five, adolescent and young adults. The printed materials will be ready for use in May. IHPB already contracted with three local print companies to deliver 3,500 flips charts (CHWs), 330,000 invitation cards (families and households), 330,000 posters (families and households), and 30,000 leaflets (CHWs and health facilities).
Conduct regular monitoring visits to community health workers During this quarter, with the assistance of trained supervisors and HPTs, IHPB conducted 7 joint supervision visits to support the CHW’s in their daily health promotion tasks. The supportive supervision visits reached a total of 236 CHW’s in Karusi Province.
From February 21st - 23rd IHPB conducted a joint supervision with HPTs in the Buhiga Health District on promotion of 9 the key actions for pregnant woman, integrated management of childhood illness (IMCI- C) and community-based distribution (CBD) of family planning services. The supervision reached 222 CHW (66 male and 156 female). The activity also helped identify families that have made significant progress in carrying out the 9 key actions. When these families have successfully completed the proposed actions, they will earn certificates of merit, which, in turn, will help boost additional positive behaviors among community members. In the period from March 7 - 10; IHPB also provided technical supportive supervision for CHWs in Nyabikere and Buhiga in their routine activities. During these joint supervision visits, the team noted that the 14 CHWs (8 male and 6 female) had already reached out to a total of 722 community members, including 233 men and 489 women, many of whom were pregnant. Among many other themes, the supervising team assessed how successful CHWs had been in sensitizing families to undertake the proposed behaviors and how effective they are in using the interpersonal communication skills they acquired.
CHW are now satisfied with the new peer to peer support. CHWs have received training on how to use interpersonal communication skills to create dialogue in group on how each and individual can help each other to accomplish the small doable actions. A group of individual on a given locality sit together and discuss challenges, barriers to adopt the key action. Those people who have achieved 2 or 3 small doable actions out of the 9 can share their success.
The dialogue created around is facilitated by the trained CHW. This system is effective as it creates peer to peer support system in given locality. 4 out of the 9 key actions we are promoting for pregnant
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women are directed to men engagement to help the family (accompanying his wife to early ANC or when pregnancy danger signs occur, reducing the heavy workload, providing supplement food diet with proteins, male involvement for delivery plan and post-natal care,…). CHW trained on IPC are now satisfied with new approach. They now need to ensure that the husband is present during home visits. This brings more result for the couple as they discuss together on way to accomplish the SDA.
Continue production of weekly radio programs to reinforce community mobilization efforts During this quarter, in collaboration with the IEC Unit of the MPHFA, IHPB aired a total of eight (8) radio programs and eight (8) public service announcements (PSAs). A detailed breakdown of themes and dates of broadcast are as follow: 1. The first two programs focused on delivery plan (on 17th January 2017 through “Intungamagara Radio Program”), reducing heavy work during pregnancy (on 15th January 2017 through “Irondoka rijanye n’amagara meza radio program”). 2. Radio programs 3 and 4 centered on the importance of post-natal consultation and the prevention of mother-to-child HIV transmission through “Intungamagara “and “Irondoka rijanye n’amagara meza”, on National Radio channel (RTNB). 3. A program (Irondoka rijanye n’amagara meza) on importance of PMTCT was aired on Sunday, 29th of January 2017 and the second (Intungamagara) on importance of -and barriers - to post- natal care on Tuesday, 31st January 2017. 4. A public service announcement on post-natal care was also produced and aired on January 28th, 2017 and be re-broadcast three times during the following week. 5. In February, a program was aired on the importance of the presence of the husband during ANC and post-natal care (aired on February 19th and re-aired on February 26th) through “Irondoka rijanye n’amagara meza” radio program. 6. A program was also produced and aired on importance of initiating breastfeeding within 30 minutes of delivery and exclusive breastfeeding during the first 6 months of the baby’s life. This radio program was aired on February 21st and rebroadcast on February 28th. Both radio programs were aired at the National Radio (RTNB). 7. From March 20th _ 24th, IHPB broadcast programs on the importance of using long-lasting mosquito net in malaria prevention and the importance of pre-natal consultation. Besides, the radio program (Irondoka rijanye n’amagara meza) on importance of using long-lasting mosquito net was aired on Sunday, 26th of March 2017 and the second (Intungamagara) on importance and barriers of pre-natal consultation will be broadcasted on Tuesday, April 4th 2017, on National Radio Station (RTNB).
Continue production and monitoring of radio drama and expand programming to include public service announcements Following the end of PCI Media impact contract that had produced 6 episodes of serial radio drama with messages targeting pregnant women, this mass media approach proved to be an efficient way to engage and spark the dialogue around avenues to overcome challenges that prohibit the audience for adopting
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healthy behaviors. During this quarter, IHPB advertised for a local company that will produce a serial radio drama of 24 episodes that will focus on messages for caretakers of children under five.
Conduct mobile cinema on the four life stages During the reporting period, IHPB strengthened community mobilization using mobile cinema in the Kirundo and Muyinga provinces. This activity is prepared and conducted with close participation of the MPHFA IEC Unit staff. While targeting pregnant women in the community to adopt healthy behaviors, a strong focus was placed on the response to the outbreak of malaria. The mobile cinema vehicle visited 10 sites in the 2 provinces during this quarter reaching approximately 6,227 community members.
Develop and produce trigger video on the three life stages. During this quarter, IHPB signed a contract with Papy Jamaica Production to produce 3 trigger videos on adolescents, young adults and parents of under five children. Papy Jamaica Production’s first activity was to conduct field research in Kayanza, Kirundo and Muyinga to understand more about promoting positive behaviors at individual and household levels. After the field research, the production house organized the filming schedule and gathered footage between March 16 - 25 in Muyinga, for the young adult video, in Kirundo for the parents of children of under-five video and finally Kayanza for the video targeting adolescents. Papy Jamaica production is currently editing the 3 videos which will be delivered to IHPB in May 2017 for use during mobile cinema sessions. .
Progress and discussion on SBCC indicators Indicator Target Achieved to date FY2017 October- January February March TOTAL December 1.0.1. Percent of the targeted audiences who report practicing positive behaviors at the individual and household levels [Mandatory Result] 1.1.1. Percent of the targeted audiences who report key behavioral pre-determinants at the individual, household, and community levels Outcome indictors will be measured via end of project survey [Mandatory Result] 1.1.2. Percent of targeted population who correctly report causes of specific illness (e.g. HIV/AIDS; malaria; diarrhea) [Mandatory Result] 1.1.3. Percent of the target population who recall hearing or seeing or reading a specific HC message 1.1.4 Number of health 8 0 0 5i 0 5
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Indicator Target Achieved to date FY2017 communication materials developed, field tested, and disseminated for use
1.1.4. Number of health communication materials developed, field tested and disseminated The target for Y4 is 8 communication materials. During the quarter January – March 2017, IHPB produced 5 communication materials (2 posters, 1 flipchart, 1 invitation card and 1 leaflet) for parents of children under five life stages. The five materials have been reviewed and approved by the Health Communication Technical Working Group.
Sub-CLIN 1.2: Increased accessibility and availability of health products to individuals and households Using results from SARA, FQA, BDS assessments, Year 2 and Year 3 experiences as a basis for planning Year 4, IHPB’s SCM work focused on promoting uninterrupted supply of HIV/IST related commodities, malaria supply, neonatal and childhood and family planning from central warehouses to communities, via health facilities.
Planned for January-March 2017 Achievements Comments and results Four-day training session on SCM for 24 pharmacy Achieved 24 HF pharmacy staff trained for staff from Vumbi health district Vumbi HD Develop and pilot SCM module for integrated Achieved SCM module developed, and instrument (newly named OASIs, for “Outil available for Program Technical d’amélioration des services intégrés”) for SCM Officer (PTO) pilot use; additional support at facility level feedback from test will be considered (planned in Q3) Support PTOs to deploy the SCM module of OASIs; In progress 7 health facilities from Buhiga (2) conduct monthly supervision visits to strengthen and Nyabikere have been SCM to priority districts, facilities and communities supervised within Q2, using the as identified through the integrated instrument SCMS module. Gather, analyze, compile, and share data from In progress Done in Buhiga and Nyabikere Oasis’s SCM module and supportive supervision health districts visits for use at quarterly district data use and coordination meetings Deliver and replenish pharmaceutical products Achieved 867 CHWs (Gahombo:242, (purchased by UNICEF), including amoxicillin, ORS Gashoho :160, Musema:208 and and zinc; provide and replenish non- Kirundo:257) have received iCCM pharmaceutical products for complete iCCM kits for kits CHWs in focus areas Avail and track project-supported vehicles for Continuous Trucks have been rented in timely delivery of commodities to health facilities response to gaps in vehicle per districts’ requests availability at district level; 22 times in Q2 Requisition and quantification of HIV commodities Continuous HIV commodities requisitioned 8 and reagents times in Q2 and participation in quarterly quantification session
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Planned for January-March 2017 Achievements Comments and results for HIV/AIDs
The activities achieved from January to March 2017:
4-day training on supply chain management for Vumbi health facilities’ pharmacy staff In collaboration with Vumbi health district office, IHPB organized and conducted a 4-day training session in Vumbi health district, attended by 37 pharmacy staff (10 female and 27 male). The training aimed at reducing stock-outs by improving the calculation of average monthly consumption of inputs based on their stock cards, improved filing and keeping management tools, filing tools, and shared best practices on distribution, especially for HIV/AIDS, malaria, and family planning and reproductive health commodities. At the beginning of the training, pre-tests to assess their level of knowledge were done with an average score of 57%. After training, post-test scores averaged 84%. Note that such a training session was previously organized during the second year of the project to cover the project zone pharmacy staff. However, it was found that many pharmacy staff have been newly assigned to the project zone due to staff movement and had not been trained. As such, IHPB and Vumbi health district organized new training sessions.
Develop and pilot SCM module for integrated instrument for SCM support at facility level The SCM Module of the newly named OASIs (“Outil d’amélioration des services intégrés”) was finalized and piloted in Buhiga and Nyabikere health districts within integrated supervision visits. Some modifications related to staff lists, health centers list, and others have been made and the SCM module has been updated in ODK Collect (for tablet-based data collection).
Avail project vehicles (upon need basis) for timely delivery of commodities to health facilities per districts’ requests In response to needs expressed by districts, within the 2nd quarter of Year 4, IHPB rented trucks 24 times for the transport of essential health products from the central level to districts, facilities, and communities – Vumbi (2), Mukenke (3), Gahombo (3), Kayanza (2), Nyabikere (4), Buhiga (4), Giteranyi (2), Muyinga (2) and Musema (2).
Support PTOs to deploy the SCM module of the OASIs integrated instrument; conduct monthly supervision visits to strengthen SCM to priority districts, facilities and communities as identified through the integrated instrument Using the SCM Module of the OASIs integrated instrument, IHPB project staff (SCM Specialist, HSS Officer and Buhiga’s PTO) in collaboration with health district offices (two districts pharmacy staff from Buhiga and Nyabikere), conducted 4 days of supervisions visits to Cirambo and Gitaramuka health centers in Buhiga HD and Nyabikere, Gatonde, Mugogo, Rusamaza and Nyarunazi health facilities in Nyabikere HD. The 7 health facilities visited have been identified based on data collected in DHIS2 on stock out for essentials medicines reported by the project (indicator 1.2.1, percent of supported facilities that experience a stock out at any time during the last three months). The causes of stock outs were: Substitution of a product by an quivalent product. This was observed for the substitution of ACT (1-5 years) which was about to expire by ACT (1-11 months) and also for Methergin, presently by Oxytocin. Stock out at district level: Paradoxically, HF with high inventory performance are those that often- experienced stock out for health commodities. This could be explained, apart from the stock outs
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at the district level, by limiting to 5 Million (Burundi Francs) the supply funds for replenishment, banning supplies elsewhere than at the district level, but also by a very large population served. A list of stock out at central warehouse identified in the field included Mebendazole, Metronidazole, Quinine (500 mg), and Rapid Diagnostic Test for malaria and HIV.
Deliver and replenish pharmaceutical products (purchased by UNICEF), including amoxicillin, ORS and zinc; provide and replenish non-pharmaceutical products for complete iCCM kits for CHWs in focus areas To further support the implementation of ICCM in Gahombo, Gasohol, Musema and Kirundo health districts, IHPB distributed some tools and materials as detailed in the table below:
Gahombo HD Musema HD Kirundo Gashoho CHW iCCM Kit items Individual tracking record for the sick 242 208 0 0 child Register of cases 242 0 0 0 Transfer book 242 0 0 0 Requisition cards 242 0 0 0 Stock cards 484 416 0 0 Taking algorithm managed at home 242 0 0 0 with diarrhea iCCM book 242 0 0 0 Waste bin 242 0 257 160 Garbage can 242 0 0 0
Requisition and quantification of HIV commodities and reagents IHPB facilitated the transport of HIV reagents and blood samples from Kayanza (6 times) and Kirundo (8 times) to the contracted private laboratory (Centre de Recherche de Virologie et de diagnostic Biologique) and communication of results.
In addition, as a member of the National Quantification Committee for HIV/STI, IHPB Supply Chain Specialist participated in a 5-day meeting (February 6 to 11, 2017) whose objectives were to: analyze distribution data (from CAMEBU, National Warehouse) for anti-retroviral drugs; identify gaps; formulate and validate data to be used for quantification; and develop a procurement plan for HIV reagents for the period January 2017 to December 2018.
Discussion and analysis of the SCM results indicators
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Indicator Target Achieved to date FY2017 % October- January February March1 TOTAL December 1.2.1. Percent of supported facilities 55 70.9 that experience a stock out at any time during the last three months(MR)2 1.2.2. Percent of USG-assisted service 10 3.5 0% 1.3% 9.6% 10.7% delivery points(SDPS) that experience a stock out of a contraceptive method that the SDP is expected to provide at any time during the reporting period 1.2.3. Percent of health centers that 88 meet minimum SCM standards3
% of supported facilities that experience a stock-out at any time during the last three months [MR]: The Y4 target was not achieved during the first quarter due to lack of products at central warehouse and purchasing in private sector limited to 5 million Burundi Francs per district per year. During the 2nd quarter, reduced stock-outs are expected with the availability of inputs at the district level but more explanation will be provided once data will be available.
% of USG-assisted service delivery points (SDPs) that experience a stock out of a contraceptive method that the SDP is expected to provide at any time during the reporting period: For the first quarter of Y4, the target was achieved. According to data collected from quarterly contraceptive management reports, in March, implants have been highly consumed in Musema and Gashoho HDs which led to stock out in 1 health facility in Gahomboo and 1 health facility during February and the trend for consumption continue to increase during March with 9 health facilities in Musema and 4 facilities in Gahombo HD experiencing stockouts. Contraceptives commodity stock out
Injection Implants Pill Male condoms Female condoms Average # days of stockouts January 0 0 0 0 0 30 February 0 2 0 0 0 28 March 0 15 1 0 0 31
% of health centers that meet minimum SCM standards. The data used to be calculated from the PBF reports.
1 Data for March were not available at the time of reporting 2 Data for January, February and March not available in DHIS 3 Data calculated from PBF reports. IHPB not supporting PBF following PEPFAR COP 2015 geographic pivot
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Sub-CLIN 1.3: Strengthened support for positive gender norms and behavior and increased access to GBV services 1.3. a.: Strengthened support for positive gender norms and behavior
Planned for January-March 2017 Achievements and Comments results Increase the capacity of the Bujumbura-based Achieved 19 technical staff trained technical staff in gender planning and gender including 5 new staff members budgeting Convene stakeholders’ meeting on gender Scheduled for 3rd Delayed due to the Ministry's through the TWG quarter focus on the malaria epidemic
Increase the capacity of field office and HD staff Scheduled for Postponed due to malaria rd in gender integration through training 3 quarter epidemic Reduce gender-based stigma towards MSM and Ongoing 6 health providers trained as FSW through training of HIV service providers trainers (including 3 from Karusi and 3 from Muyinga) Build capacity of HPTs in gender and gender Achieved 26 HPTs and 2 community programming via Male As Partners (MAP) ToT mobilizers trained
Implement MAP intervention Scheduled for 3rd Postponed due to the malaria quarter outbreak Implement ANC outreach strategy that includes Ongoing ANC outreach strategy that male engagement includes male engagement discussed during a family planning meeting in Kayanza Promote positive gender norms through SBCC Ongoing Gender program continued to mass media activities including the serial integrate gender in 8 radio drama, radio programs and PSAs programs, 8 PSAs and the 1
radio drama Conduct mobilization campaign to promote Ongoing Recruitment of the CSO that will positive gender norms conduct community mobilization underway
Increase the capacity development of the Bujumbura technical staff in gender planning and gender budgeting In March, a three-day training workshop on gender integration was convened for Bujumbura-based IHPB technical staff. Facilitated by the Gender Program Officer, it was attended by 19 staff members (including 4 women and 15 men). The workshop was designed to increase participants’ knowledge on gender as a development approach and how gender integration is important for achieving IHPB program indicators. The training concluded with the recommendation for all staff to integrate gender considerations into the
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4 key project interventions (i.e. Malaria, HIV, MCH and FP) in order to contribute to health and gender equity.
Reduce gender-based stigma towards MSM and FSW through training of HIV service providers IHPB partnered with the FHI 360-led LINKAGES project to convene five-day training-of-trainer’s workshop to reduce gender-based stigma among health providers. The training of trainers was conducted with 6 health providers including 3 in Karusi and 3 in Muyinga districts. The participants included 1 woman and 5 men. male 3 from each province participated to organized in partnership with Linkages project. These participants are now master trainers who will do a step-down training with 90 health care providers in May 2017 to strengthen their capacity to provide stigma-free services to these key populations.
Build capacity of HPTs in gender and gender programming via Male as Partners (MAP) ToT IHPB conducted a 5-day training of trainers on Men as Partners (MAP) for 26 Health Promotion Technicians (3 women and 23 men) from Nyabikere (7), Buhiga (7) Kayanza (7) and Musema (5) districts and 2 IHPB community mobilizers. The MAP training was conducted utilizing Engender Health modules and tools. The training focused on how to engage husbands to support reproductive health and identified opportunities to address gender themes across IHPB interventions and technical strategies (e.g. male norms, GBV, service equity, power imbalances within the household, etc.). In addition, a leaflet has been developed as a community sensitization tool for CHWs to support the MAP community module in Kirundi.
Implement MAP intervention The first step in implementing the MAP intervention is to traini the CHWs to deliver the program. Unfortunately, the training schedule for March was postponed until next quarter due to malaria outbreaks in the targeted provinces. In the meantime, a two-day GBV coordination meeting was convened for Buhiga and Nyabikere stakeholders and has provided an opportunity to begin sensitizing participants on how male’s norms and behaviors and power imbalances within the household are the root causes of GBV which negatively impacts health outcomes.
Implement ANC outreach strategy that includes male engagement A family planning working group meeting was convened with 65 administrative and other stakeholders in Kayanza (including 16 women and 49 men) where the rate of population growth is a major problem. At the meeting a new ANC outreach strategy to promote gender equity and positive gender norms by involving men was discussed as a key strategy for improving ANC and promoting family planning use.
Promote positive gender norms through SBCC mass media activities including the serial drama, radio programs and PSAs During the quarter October – December 2016, the gender integration program contributed to making SBCC interventions “Gender Transformative” by including gender considerations in SBCC tools. This quarter gender program continued to integrate gender into the monitoring activities for SBCC including 8 radio programs, 8 public service announcements (PSAs) and the one radio drama entitled “Kira Mama” which aired on Isanganiro and Umuco FM radio.
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Conduct mobilization campaign to promote positive gender norms Ten community mobilization sessions are expected to be organized by a CSO (Burundi Red Cross) selected as a partner to work in Karusi to deliver a comprehensive package of services to GBV survivors and promote positive gender norms.
Discussion and analysis on the Gender results indicators Indicator Target Achieved to date FY 2017 FY2017 Oct-Dec January February March Total 2016 2017 2017 2017 1.3.1. Number of project interventions 5 1 2 2 2 7 that address at least one gender theme (e.g. male norms, GBV, service equity, power imbalance within the household) 1.3.3. Percent of target population reporting agreement with the concept Indicator will be measured that males and females should have equal through end of project access to social, economic, and political survey opportunities
The target for Y4 is to achieve 5 project interventions that address at least one gender theme. The interventions can be classified into two main axes: training and mobilization. During the quarter, three training of trainer sessions (MAP, GBV and reduce gender-based stigma toward MSM and FSW), two training sessions (one on gender integration and another on GBV case management), and one mobilization meeting were organized. In addition, all the SBCC activities implemented had undergone a gender integration review.
1.3. b.: Expand access to high quality and comprehensive services for GBV survivors Planned for January – March Achievement and Comments 2017 results Conduct SGBV landscape Postponed due to Data collection tools available. mapping exercise malaria epidemic Conduct a ten-day ToT on GBV Achieved In addition to one Bujumbura-based IHPB staff, 20 for five health workers per participants (5 females and 15 males), five from province each of the four IHPB intervention provinces, were trained Train 86 providers on GBV case Partially achieved 45 providers trained and 41 providers will be management trained in April 2017 Disseminate job aids on clinical Not achieved We are waiting for the NRHP to adopt the management of SGBV, once necessary tools and adoption will be done during adopted by PNSR the April to June quarter Follow-up supervisions Not achieved Postponed because the need to respond to the
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Planned for January – March Achievement and Comments 2017 results malaria epidemic.
Support quarterly coordination Achieved Two separate one-day quarterly coordination meetings meetings were organized and facilitated. Develop CSO partnership for In progress Red Cross Burundi was chosen. Once Program comprehensive package of Description, is finalized, IHPB will seek USAID services to GBV victims approval for recruiting Burundi Red Cross Train CHWs from Buhiga and Not achieved Postponed because of response to the malaria Nyabikere districts on GBV epidemic
During the January – March 2017 quarter, IHPB conducted the following activities to effectively fight against gender-based violence and improve access to quality care for victims.
Conduct SGBV landscape mapping exercise: This activity was planned for March 2017 and the data collection tool is available. Note that implementation has been hindered by the necessity to respond to the malaria epidemic - exercise has been postponed for the quarter April – June 2017.
Conduct a 10-day ToT on GBV for five health workers per province In partnership with the National Reproductive Health Program (PNSR), IHPB organized and conducted a 10-day training of trainers session utilizing “Guide de Formation sur la Prise en Charge integree des Victimes de Violence Sexuelles et Basées sur le Genre” (Training Guide for Integrated Case Management of Victims of SGBV). In addition to one Bujumbura-based IHPB staff, 20 participants (5 female and 15 male), five from each of the IHPB intervention provinces, were trained. Trainees included nine medical doctors, one psychologist, four district supervisors, and six nurses.
Train 86 providers on GBV case management: In partnership with the PSNR, IHPB organized and conducted a 6-day training of health care providers from health districts of Kirundo and Vumbi in two consecutive sessions. These training sessions are facilitated by a multidisciplinary team of four facilitators sent by PNSR. The training module used is “Guide de Formation sur la Prise en Charge integree des Victimes de Violence Sexuelles et Basées sur le Genre” (Training Guide for Integrated Case Management of Victims of SGBV). A total of 45 health care providers (28 male and 17 female) participate in the training. Of the 45 participants, 23 health care providers came from Kirundo HD and 22 from Vumbi HD (44 were nurses and one was a medical doctor).
Disseminate job aids on clinical management of SGBV once adopted by PNSR: A GBV stakeholder meeting was chaired by the PNSR to review and amend the document including the tools, which will be multiplied and distributed. The stage of adoption will follow and this activity will be carried out in the third quarter.
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Follow-up supervisions Since all health care providers were mobilized for the response of the malaria epidemic, supervision was not possible. The activity was postponed for the quarter of April to June 2017.
Support quarterly coordination meetings: Two separate one-day quarterly coordination meetings were organized and attended by a total of 81 participants (81 male and 17 female) – 40 from Buhiga HD and 41 from Nyabikere HD. Recommendations made include: Sensitization of communities on gender-specific legislation, particularly by judicial and legal authorities to deter potential perpetrators Implement a coordination/collaboration/communication mechanism between stakeholders at the provincial level Set up joint committees (administrative, health, police, justice, CDFC) to combat SGBV and protect victims Establish a referral and/or support mechanism for SGBV victims from the top level (province) to the low level (colline) Implement a strategy for collecting and exchanging data between different stakeholders (CDFC, PJ, prosecutor, care structure) with a suitable tool to ensure that periodic and reliable data are available Those responsible for implementing these recommendations are the provincial authorities in collaboration with stakeholders working in the province of Karusi. Develop CSO partnership for comprehensive package of services to GBV victims: IHPB selection committee recommended Burundi Red Cross to support activities on the support of comprehensive care of victims of sexual and gender-based violence. Program description, indicators, timeline and determination of the targets to be achieved by the project are being finalized.
Train CHWs from Buhiga and Nyabikere districts on GBV The activity was not carried out because of the malaria epidemic. Progress and discussion on GBV indicators Indicator Target Achieved to date FY2017 October-Dec January February March TOTAL 1.3.2. Percent of supported districts that 4 0 0 0 0 have at least one comprehensive GBV program and at least one male involvement initiative with referrals to health services and products 1.3.4. Number of people receiving post- 170 44 9 7 8 68 GBV care (post-rape care, other post- (40%) GBV care, PEP) 1.3.5. Number of facilities that provide 34 30 30 30 31 31 PEP to GBV survivors (91%) Number of people trained on GBV case 634 0 20 45 0 65 management (trainers, health care (10%) providers and community health workers)
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Percent of supported districts that have at least one comprehensive GBV program and at least one male involvement initiative with referrals to health services and products In Y4, Buhiga, Nyabikere, Vumbi and Kirundo are the four target HDs where activities that involve both the GBV and male involvement initiative will be implemented starting April – June quarter including training 122 care providers on psychological support methods and referral to legal services.
Number of people receiving post-GBV care (post-rape care, other post-GBV care, PEP) During the reporting period, 24 survivors received post-GBV care in the two PEPFAR provinces.
Number of facilities that provide post-exposure prophylaxis (PEP) to GBV survivors: During this quarter, 31 facilities (representing 91%) in the two IHPB PEPFAR provinces reported on PEP provision to GBV survivors (20 from Kayanza and 11 from Kirundo).
Number of people trained on GBV case management: During this, quarter, 65 health workers (20 trained as trainers and 45 trained on the care of GBV victims), were trained. This represents 10% of the Y4 target of 634. Target will be achieved once training of CHWs starts during the quarter April – June 2017.
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CLIN 2: Increased Use of Quality Integrated Health and Support Services
Sub-CLIN 2.1: Increased access to health and support services within communities
Planned for January-March 2017 Achievement and Comments results Conduct a one-day training on standard 334 CHWs trained 97 CHWs trained during October- reporting tools for 443 CHWs from during the quarter December 2016 quarter Kirundo and Mukenke HDs in 15 sessions January to march 2017 Organize, at commune level, regular CHWs Achieved Meetings were held as planned in meeting to debate community health Muyinga and Kirundo provinces. system matters including data analysis in four provinces Pilot the CHWs peer supervision strategy Ongoing Conducted 2-day orientation session in Vumbi HD for HD staff, HPTs, and HC heads; peer support groups coordinators elected; 3-day orientation session for 86 CHWs peer support group coordinators. Organize a semi-annual coordination Not achieved Delayed due to malaria outbreak; it will meeting at province level be conducted next quarter Conduct one-day orientation for 164 Not achieved Delayed due to malaria outbreak; it will nurses in-chief and 164 COSA presidents be conducted next quarter from 12 HDs on community health system
The following community systems strengthening activities were carried out during the period January to March 2017.
Training CHWs from Mukenke and Kirundo health districts on the standard reporting tool4 During the previous years, IHPB trained CHWs on the standard reporting tool in 9 out of 12 IHPB-health districts. During year 4, IHPB is planning to cover two additional health districts, namely Mukenke, and Kirundo, in Kirundo province by training 443 CHWs. IHPB trained 89 CHWs (38 female and 51 male) from Mukenke HD and 245 CHWs (119 female and 126 male) from Kirundo HD. The training on the CHWs standard reporting tool was integrated with the training on the management of acute malnutrition, organized in collaboration with Mukenke and Kirundo health district offices. Because of IHPB assistance, 11 health districts are using the consolidated reporting tool. The 12th health district (Busoni in Kirundo province) is supported by another partner (CONCERN) in the same area of community system strengthening including activities such as nutrition, ICCM, WASH, etc. Organize, at commune level, regular CHWs meeting to debate community health system matters including data analysis
4 The standard reporting tool is a MPHFA reporting template for tracking the information on the number of educational sessions, home visits, malnutrition screening, referral, and some events such as home death, home- births, etc. Additional forms are used by CHW in these districts to report on FP and iCCM.
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In collaboration with the health district offices, CHWs quarterly meetings were held in Muyinga and Kirundo provinces, gathering CHWs, health center heads and health promotion technicians. In Muyinga, meetings were held in 7 communes (out of 7); 813 CHWs (out of 844), 20 health promotion technicians (HPTs), and 45 health centers heads attended the meetings while 5 staff from the province health office, and 5 staff from each of the 3 district offices participated in facilitating the meetings. In Kirundo, these meetings were held in 7 communes (out of 7) and were attended by 989 CHWs, 38 health centers heads, and 13 health promotion technicians while 2 staff from the province health office, and 5 staff from each of the 4 district offices participated in facilitating the meetings. The purpose of the meeting was to coach health centers and CHWs on correcting the monthly reports, analyzing community data, and making evidence-based decisions. The points discussed were: completion of CHWs monthly reports, analysis of the data: activities not done and why, alarming figures, issues, and recommendations. These meetings contributed to resolve problems such as the following: - It was noted that some CHWs newly trained on community based distribution of contraceptives did not provide the service; the district officials pressured the CHWs and the HC heads to collaborate and start the service provision immediately. - In Vumbi health district where the CHWs support group strategy is implemented, it was an opportunity for CHWs forming the peer support groups to meet and build quarterly work plan with the assistance from the HPTs and the HC heads.
Pilot the CHWs peer supervision strategy in Vumbi health district Realizing that in IHPB-target provinces, HPTs are too few to conduct field visit to supervise CHWs, it was judged worth exploring other types of support to CHWs. Thus, IHPB suggested a CHW peer-to-peer supervision approach where existing CHW groups (health center level) would be divided into smaller sub- groups at colline level, to form peer support groups (PSG) which would have about 4-8 members, with a support group coordinator selected among the CHWs. The support groups will facilitate and improve communication between the HPT/HC and CHWs through the support group coordinators, compilation by CHW of community data, collaboration with other community actors, such as the local government, motivation, and accountability of CHWs, and quality and coverage of CHW activities. The program is being tested in Vumbi health district because it has the lowest ratio HPT/CHW (1:129). The establishment of the peer-to-peer CHW program involved: - A 2-day orientation for health district office staff, health centers heads, and HPTs. The strategy was welcome by attendees. - Support group geographic delimitation: support groups are generally identified with the collines, but it was noted that some collines have so many CHWs that managing them as one group would be challenging; it was therefore agreed to form groups not exceeding 8 CHWs. So, some collines were divided into two support groups. - Election of peer support groups coordinators based on criteria such as dynamism, respect in the community, and ownership of a cellphone. - A 3-day orientation for 86 CHWs elected as coordinators of support groups. - Development of CHWs support groups quarterly work plan. Next steps will include supervising the support groups and collecting, compiling and analyzing CHW support group reports, and hold a quarterly workshop to evaluate the strategy implementation.
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Discussion and analysis of the results Indicator Target Achieved to date FY 2017 FY2017 October- January February March Total December 2016 2017 2017 2017 2.1.1 Percent of supported 36% N/A N/A N/A N/A health centers with CHWs that provide the core package of quality integrated health and support services5 2.1.2 Number of cases 94,000 53,296 23,277 17,618 24,141 118,332 treated or referred by CHWs 2.1.3 Percent of health 25% N/A N/A N/A N/A facilities that have functional CHW systems6 2.1.4 Percent of COSAs that 42% N/A N/A N/A N/A meet defined functionality standards7
2.1.1 Percent of supported health centers with CHWs that provide the core package of quality integrated health and support services: Since this indicator is informed by baseline, mid-term, and end -of-project surveys, IHPB did not establish a FY 2017 target. 36% is the mid-term result.
2.1.2 Number of cases treated or referred by CHWs: This information is extracted from CHWs monthly reports. While the 2017 annual target is 94,000, data from December 2016 to March 2017 make a total of 118,332 (125%) of the annual target), mainly due to the malaria outbreak. In addition, CHWs from Kirundo health district were trained on diarrhea and pneumonia management extending the range of diseases managed and the number of children treated by CHWs.
2.1.3 Percent of health facilities that have functional CHW systems: This indicator is collected annually using PBF mechanism, not supported by the IHPB. HCs that meet functionality standards are those that have always scored 50/50 at the PBF indicator on CHWs activities during the 4 successive quarterly quality evaluations. While the baseline for this indicator was 11%, the 2017 target set at 42%.
2.1.4 Percent of COSAs that meet defined functionality standards: Since this indicator is informed by baseline, mid-term, and end of-project surveys IHPB used the mid-term results of 72% as FY 2017 target
Sub-CLIN 2.2: Increased percent of facilities that provide quality integrated health and support services
2.2. C: Support integration with a QI model and prepare districts for scale-up of best practices During the second quarter of Y4, the focus of the QI activities was on completing learning sessions, developing the extension plan for Kirundo and Kayanza provinces, continuing the documentation of the QI work, coaching the extension teams and monitoring the extension of improvements in all facilities. The
5 No monthly data available for this indicator which will be informed by end-of-project survey. 6 Data not available monthly - indicator collected annually using PBF database. 7 Data not available monthly; indicator will be informed by end-of-project survey.
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following table provides a summary update on the level of implementation of the planned activities described in the FY17 work plan.
Planned activities January-March, 2017. Achievements Comments And results Complete the QI demonstration phase in the 46 initial sites Identify and coach the QI teams who have not Achieved Two sites out of 11 facilities in achieved their integration objectives Karusi, five out of 17 in Kirundo, and four out of 15 in Kayanza received intensified coaching support. Organize the second learning session (LS) in Achieved 2nd LS was conducted in Muyinga Muyinga on January 31 to February 2nd and attended by 32 participants. Extend best practices to the remaining facilities within each province Organize the third LS in Kirundo, Kayanza and Achieved for 3nd LS was conducted in Kirundo, Muyinga to identify the extension team and Kirundo and attended by 73 participants, develop the extension strategy Kayanza andin Kayanza , attended by 53 participants. Third LS in Muyinga is planned in May Support and accompany the extension teams & Achieved 55 new QIT have been set up in monitor the extension and adjust the strategy the extension sites, (33 in Kirundo accordingly and 22 in Kayanza). Document the QI Initiative Finalize the template Achieved Collect the information In progress The document is being updated according to progress Review drafts In progress Waiting for information on Muyinga to complete the first draft Supporting activities Train 15 PF providers in Kayanza province on Not Achieved This activity was postponed until contraceptive technology the beginning of May 2017 due to the malaria outbreak.
Results of second learning session at Muyinga health province on integration of prevention of malaria into ANC Jointly with Muyinga province and districts health bureau, IHPB, organized its second LS over 3 days (January 31 to February 2nd), to review progress and share best practices on the integration of malaria prevention into ANC services. The workshop gathered 32 participants (5 F and 27 M) including the head of each of QIT, 3 HIS in charge, 3 district supervisors, 1 coach per district, 3 health district managers and the director of Muyinga health province.
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Progress results a) Integration of IPTp into ANC care. Chart1: % of pregnant women receiving two doses of IPTP during ANC3 in six QI sites of Muyinga health province.
80 69 64 67 70 58 61 60 51 42 50 38 39 38 35 34 35
% 40 28 30 Before QI 20 8 10 0 0 0
Months
Results can be linked to the following changes implemented by the teams: 1) sensitization meetings of CHWs to sensitize households about the benefits of IPTP and Early ANC; 2) Reduce the number of days of stock-out of SP by correctly calculating the expected number of pregnant women and ordering Fansidar (SP) based on the Average Monthly Consumption.
b) Integration of LLITN into ANC care. From September 2015 to December 2016, 2,943 out of 3,599 (82%) women attending ANC1 received a LLITN. In addition, the rate of pregnant women receiving LITN in ANC1 increased from 30% (before QI) to 92% (December 2016). These improvements are linked to the following changes: . Put the Long-Lasting Insecticide Treated Nets in ANC services so that every pregnant woman can get it easily; . Establish the stock record sheet for LLITN. . Record daily LLITN consumption in the requisition register. The national stock out of during July-October does not seem to have affected the performance of the QI teams too much.
Results of Kirundo third learning session on the extension of improvements into 33 facilities In partnership with Kirundo province and districts health bureau, IHPB organized its third LS to develop the change package to extend to all facilities in the province for the integration of early ANC, nutrition, HIV, SGBV into curative services. The workshop gathered 28 participants for the first two days including a chairman of QIT per site, 4 HIS in charge, 3 district supervisors, 1 coaches per district, 4 health district managers and the director of Kirundo health province.
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During the 3rd and 4th day, 33 in charge of new facilities joined to learn about the extension strategy. A total of 61 within 29 females and 52 males attended the workshop. By the end of the workshop, an extension charter was developed and co-signed by partners and IHPB. The following charts present the results of Kirundo health province. a) Integration of early ANC into curative services. Chart 2: % of pregnant women seen in curative care who benefited from early ANC in 17 QI HC of Kirundo
120 97 97 100 98 91 100 87 89 86 88 90 76 76 80 67 68 71 68 64 64 59 60
40 14 20 Before QI/ 0 integration.
The early ANC rate (number of ANC clients with less than 12 weeks of amenorrhea out of the total of ANC1) increased from 13.8% in 2013 (before QI) to 81% (December, 2016).
Results at the end of the demonstration phase. At the end of the QI demonstration phase, we compared early ANC rate (between QI and non-QI sites. As shown in chart 3, QI Integration efforts yielded 2 times higher rates than non-QI sites in 2016.
Chart3: Comparison of early ANC clients in QI vs. non-QI sites from January to Dec. 2016 in Kirundo HP.
1000 881 900 822 850 848 753 800 736 679 688 707 637 654 700 595 600 500 429 439 431 423 388 379 366 362 357 350 341 400 304 300 200 100 0 J F M A M J J A S O N D
Sites QI/Integr. Sites non QI/Integr.
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Changes tested linked to the results: . Systematic search for cases of early pregnancy in any woman of childbearing age seen in curative care with delayed menstruation (between 8-12 weeks of amenorrhea) who are not under a contraceptive method; and . Offer to do the pregnancy test for free the same day. If the test is positive, the provider uses support staff who accompanies the client in ANC where she receives other services, including HIV testing the same day. . Enhanced quality of ANC services by assigning a qualified provider in that service.
Lessons learned: . Providers mentioned that clients expressed satisfaction for the delivery of integrated services the same day, saving time and repeated visits to a facility. . Fortuitous discovery of pregnancy allows provider to prescribe a suitable medicine that is appropriate and safe in pregnancy and does not harm the health of the fetus. . Early ANC allows early detection of risk factors associated with the pregnancy. It also contributes to increase the number of pregnant women achieving ANC3 in the third trimester of pregnancy.
b) Integration of SGBVs management into curative services
From June 2015 to December 2016 a total of 92 SGBV have been recorded in 17 QI sites of Kirundo health province and all victims received PEP. The change tested that led to this are: Active screening and correct management of SGBVs in curative services, Health providers identify with the CHW, the hills where SGBVs cases are reported, and organize an awareness-raising campaign on SGBVs; explain the risks of the conflicts resolutions done friendly between author and victim, obscuring the underlying health problems, The provider agrees with the populations, that the CHWs will accompany the victims of the SGBV to the health center for a medical care. Upon returning to the health center, the provider conducts a health education session to sensitize on the existing services and package of interventions to be offered to the victims. Any case of SGBV seen at the facility, instead of referring the victim, they re-order medicines for PEP by telephone for those who do not have them.
c) Integration of malnutrition screening into curative services
Chart 4: % of women before six months of breastfeeding screened for malnutrition and those diagnosed as malnourished in Kirundo HP .
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100 92 93 91 90 92 90 85 81 81 81 84 90 76 79 71 80 67 69 64 60 70 56 60 50 40 30 20 10 9 9 7 7 7 4 4 7 5 5 7 8 8 6 10 3 1 2 3 0
% of women before six months of breastfeeding screened for malnutrition
% of women before six months of breastfeeding screened malnourished
The rate of malnutrition is around 6%. This variation reflects the Kirundo periods of food insecurity which every year leads to migration of the population to other regions. Prior to integration, data from provincial HIS in 2013 showed a malnutrition rate of 7% which is close to the global malnutrition threshold of 10%. Thus, the malnutrition in Kirundo deserves special attention: Intervention to decrease the rate as part of QI effort is limited by a repeated stock-outs of nutritional inputs at health facilities level while the malnutrition cases are partly related to local practices observed in community, like food ignorance (sale of crops). However, there is a small decrease of the rate at 3% compared to 7% before QI/Integration. Changes tested are: The nurse receptionist checks the nutritional parameters before the consultation by the medical provider..
d) Integration of HCT screening into curative services From June 2015 to December 12, 936 out of 22,016 (38%) clients attending curative care were tested for HIV. Change ideas linked to those results are: . Provide indexed counseling and testing to patients with risk factors (Sexual Transmitted Infections, Tuberculosis, malnutrition, Sex workers, family members of PLHIV, opportunistic infections, multiple sexual partners) and whose status is unknown or the last screening is more than 3 months. . Record the result in the register of curative services and refer and accompany the client whose test is positive to ART management care.
Challenges and what worked less well a) Issues related to malnutrition. . Cases of moderate acute malnutrition who are referred to other facilities for nutrition services do not go due to long to distances.
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. Frequent shortage of nutritional inputs which led to poor/inadequate management of malnutrition. . Breastfeeding women under six months of age diagnosed with malnutrition benefit only nutritional advice and are referred to the FARN for a culinary demonstration. . Since they do not have enough breast milk, providers wait six months for children to be admitted to nutritional services.
b) Issues related to HIV testing at provider`s initiative Low-quality HIV screening reagents detected in facilities during the period from March to June, 2016 (because, generated many undetermined and false positive results) that had to be removed, slowed down the implementation of the changes.
Results of Kayanza health province third learning session for the extension of improvements to 22 facilities IHPB, in collaboration with MOPHFA, conducted its third LS in Kayanza health province to extend the integration of FP services into MCH and HIV services. The workshop gathered 31 participants for the first two days including a chairman of QIT per site, 2 district supervisors, 1 coache per district, 3 health district managers, the director of Kayanza health province who did the opening remarks. During the 3rd and 4th day, 22 in charge of facilities for extension phase were invited to learn about the extension strategies. A total of 53 within 10 females and 43 males attended the workshop. At the end of the workshop, an extension charter was developed and co-signed by partners and IHPB. The following run chart shows the results achieved during the demonstration phase:
Progress results: From October 2015 to December 2016, a total of 15,834 women attending in Post Natal care received FP counselling and 2,231 (14%) out of them accepted a FP method.
Chart 5: Cumulative percent of seropositives women who receive PF methods in HIV care services. The following chart shows that from June 2015 to December 2016, 10,099 PPLWHA were followed in 9 QI HIV care services. Among them, 2,367 (42%) were counselled and accepted a FP method.
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Cumulative percent of HIV+ women of childbearing age who received PF mehods in HIV care services. 42 45 39 40 40 34 36 35 30 30
25 20 20 % 20 13 14 14 15 15 11 12 10 5 0 0
Months
Changes tested linked to these results include: Make available contraceptive methods in HIV counselling room for demonstration Provide FP counselling to every seropositive woman in reproductive age among persons followed up in HIV care. Providers plan ART appointment supply and FP methods services on the same day as well as FP counselling for those who are not yet under method.
Lessons learned from these results are: There is still a self-stigmatization in new created ART sites where some patients take the ART in hiding. Providers organize PLWHA-led speech groups / testimonies of their positive lives with the seropositive status to address to that challenge.
Results at the end of the demonstration phase. At the end of extension phase, a comparison of clients put on Long acting FP was done among QI and non- QI sites. Results are shown below:
IUDs and implants in 15 QI/ Integration sites and 15 non-QI sites in 2016 at Kayanza HP
1400 1192 Graph shows that the 1200 QI/Integration efforts 1000 855 contributed to an increase 800 IUD and implants acceptors in QI sites 600 compared to none QI 400 sites. 200 141 93
0 Page | 34 IUD Implants QI Non QI
Comparison of women under long-term injectable FP method in 15 QI/ Integration sites and 15 non-QI sites in 2016 at Kayanza HP
Comparison 40,000 30,000 QI efforts yielded two times as many acceptors for 20,000 10,000 injectable contraceptives 0 QI Injections FP methods Non QI QI 31,503 Non QI 16,756 Changes linked to the results are: Organize immunization of BCG and post-natal care on same day; Identify in the vaccination service, the women attending postnatal care and vaccinate first their children; Accompany them in postnatal care service to offer a counselling on FP; the same provider who did the counselling provide the method; Assign permanently a qualified staff in immunization and postnatal care services;
Lessons learned FP methods are available every day in the various services and offered discretely in an integrated way in the services of post-natal care, and HIV / AIDS services: the clients received FP services in private room, which reduced missed opportunities.
Coaching of extension teams & monitoring the implementation of the extension strategy Extension of the integration of FP into MCH in Karusi health province In partnership with HD, IHPB organized the visit to QI pilot sites by 24 members of 12 extension sites (2 providers from new extension site to one pilot site). Extension agents selected from performing sites conducted a second visit of 7 extension sites to help them: set up their QI team, introduce the change package and present the QI operational tools. A total of 12 QIT have been set up in new sites. From 20 to 23 February 2017, coaching visits were organized to new integration sites. A total of 18 sites were visited during this period including former less performing sites (Buhiga Hospital, Buhiga, Nyaruhinda, Ntunda, Nyakabugu, Rugazi, Buhindye, Rukamba and Kanyange HCs for Buhiga HD and 9 Sites for the Nyabikere HD: Nyabikere, Nyabibuye, Gihogazi, Mugogo, Rabiro, Gasera, Ruganira, Nyarurambi and Nyarunazi HCs). The purpose was to help new QIT in data collection.
Organized jointly coaching visits in Muyinga health province In the period from 27 December to 05 January 2017, coaching visits were organized to the pilot sites as part of the collaborative effort to improve the quality of integrated services. During the visits, it was observed that the QI sites take ownership of the approach, but there remain observable difficulties to perform their ideas change due to outbreak of malaria epidemic. Organize field visits for the first and second waves of extension in Kirundo health province From January 24 to March 17, 2017 IHPB organized in partnership with HD, first visit of experience exchanges: from the site of extension to pilot sites of Mukenke HD; nine members from nine extension sites of Vumbi HD; 13 members of 13 extension sites of Kirundo HD; 6 members of 6 extension sites of Busoni.
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Extension agents selected from performing sites conducted a second visit at 33 extension sites to help them: set up their QI team, introduce the change package and present the QI operational tools. A total of 33 QIT have been set up in new sites. During the visits, the lack of some materials for ANC and nutrition was observed in some new sites.
Organize field visits for the first and second waves of extension in Kayanza health province From February 21 to March7, 2017, IHPB in partnership with HD supported the first visit to the pilot sites for the extension of improvements in 22 new sites.
From 14 to March 30, 2017, extension agents selected from performing sites conducted second visits to 22 extension sites for on-site-training, setting up quality improvement team at each extension site, introducing the package change of best practices, give=ing and explaining the different functionality tools of the QI team, and explaining the plan for monitoring indicators. A total of 8 QIT were set up in 8 sites of Musema HD namely, Musagara, Musema, Kabuye II, Gikomero, Gaheta, Burarana, Nyarumanga, Ninga; 9 QIT were set up in 9 sites of Kayanza HD namely, Murima, Remera, Rugazi, Kabarore, Ryamukona, Nyabihogo, Gahahe, SWWAA Kyanza, Ste ISIDORA and 5 set up QIT in 5 sites of Gahombo HD namely, Ceyerezi, Muhanga II, Kibaribari, Nzewe, Gahombo
Lessons learned from the extension phase Health providers appreciated the coaching visits done by their colleagues/extension agents from performing pilotes sites. Some of them expressed, “We are very pleased to be coached by our colleagues, because we ask freely many questions of clarification which improve our understanding.”
Challenge encountered is that pre-established timetable was not scrupulously respected because of the malaria epidemic response.
Contribution of QI activities to mandatory results linked to sub-CLIN 2.2
Indicator Target FY 2017 Achieved to date FY 2017 October- January February March Total December 2016 2017 2017 2017 Percent of supported 37% 42% NA NA 31% 73% health facilities that provide a core/expanded package of quality integrated health services
After the extension phase in Karusi, Kirundo and Kayanza 76 more facilities are experiencing integrating a package of services (PF, Early ANC VSBG, Malnutrition, HTC, TPIg,). Thus, during the two quarters oy Y17 we achieved 73% while the target was 37%.
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Sub-CLIN 2.3: Increased capacity of providers and managers to provide quality integrated health services
Planned for January-March 2017 Achievement Comments and results Develop and pilot II-ARC modules Achieved The tool has been rebranded “OASIS” (“Outil through project-led, human- d’amélioration des services intégrés de santé”) centered design, with support Several modules have been designed in their XML from Tech Lab. versions (2,3,6,7,9,10,12). Step-wise field deployment will begin at the end of April-early May. Continuously update the IHPB Continuous The tracking of trainees is now exclusively managed training database, including using the digital database. A total of 2,076 learner contribution to Standard sessions were completed, with 1,973 unique operating procedures for M&E learners; whereas 3,033 learner sessions were Officers and trainers and their role planned for the quarter. Of the unique learners, in collecting trainee data 1,641 were CHWs, 21 were managers, and 311 were health care providers. Plan and coordinate supervision Achieved 13 trainees were followed up ,6 in management of visits supported by IHPB and the biomedical waste and 7 in supply chain II-ARC management.
Participate in national- and Achieved HSS team (HSS officer, SCM specialist) participated in intermediate-level technical a meeting with DODS’ staff of MoFAH which aimed meetings and working groups on to present the IHPB's integrated supervision HRH and iHRIS proposed approach in development and to ask the MSPLS’ contributions for piloting and finalization of the integrated instrument held 19th January,2017. The DODS named a focal point for the OASIs activities, Dr. Véronique Barankenyereye. HSS Officer contributes Continuous Share Point site created and used. HSS officer was experiences, perspectives, and also active to mobilize Burundi staff in preparation best practices to the FHI 360 for World Health Worker Week. Health Workforce Strengthening Task Force
During this quarter (January-March), the following Sub-CLIN 2.3 activities were conducted:
Develop and pilot II-ARC modules through project-led, human-centered design, with support from TechLab. HSS team (HSS officer, SCM specialist) participated in a meeting with DODS’ staff of MPHFA which aimed to present the IHPB's integrated supervision tool in development and to ask the MSPLS’ contributions for piloting and finalization the integrated instrument held 19th January 2017. The mobile application is designed to streamline job aids and supportive supervision best practices in its workflow. A training in ODK Collect was organized from 6th to 10th February 2017. 19 trainees ,18 males and 1 female attended. Four M&E, three QI Officer and 3 PTO from Provinces were trained. HSS team (3), two Data analysts, a Data Manager and research & Innovation studies specialist were also trained.
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To deploy the Integrated Instrument (now named the Outil d’amélioration des services intégrés de santé, or OASIS), a user guide has been developed. Users will be trained in April 2017. Among these users are PTOs, District Supervisors, FOMs, and M&E officers.
Several modules have been designed in their XML versions (2,3,6,7,9,10,12). We already have 5 modules in their versions ODK collect on the shelves (1, 4,5,8, 11). Note that the integrated instrument will be composed by 12 modules, 9 reflecting the services that are in the CDS and three transverse modules for SCM, RHS and the lab.
Operationalization of II-ARC using tablets by PTOs and other project staff during project-supported and joint supervision visits A draft user guide of the instrument has been elaborated to train the users. The guide explains the use of both the tablets and the modules contained in it. Users are PTO's and district supervisors. With the aim of deploying the instrument in our area of intervention and promoting the durability of the tool, MSPLS has been associated and involved and the Head of DODS has been designated as the focal point.
Continuously update the IHPB training database During this quarter, ten different trainings were conducted. A total of 2,076 learner session were completed, with 1,973 unique learners; whereas 3,033 learner sessions were planned for the quarter. Of the unique learners, 1,641 were CHWs, 21 were managers, and 311 were health care providers. The large proportion of CHW learners is due to the implementation of planned SBCC activities, after key communication materials were developed and ready for use. In addition, home-based malaria care was scaled up within iCCM, and community-based family planning was scaled up from Muyinga to Kayanza. 100% of the pre- and post-test scores were captured for the learners in this quarter (and also year to date), which is a great improvement from previous years, where fewer than half of the scores were captured.
Plan and coordinate supervision visits supported by IHPB and the II-ARC A post training-follow-up joint supervision was conducted (IHPB & Muyinga HD) in Nyaruhengeri, Muramba, Rugongo and Kibimba HC in Muyinga HD in management of biomedical waste. Six trainees were followed up on. A post training-follow-up joint supervision on Supply Chain Management was conducted (IHPB, Nyabikere & Buhiga HD) at the follow Health District: Gitaramuka, Nyarunazi, Mugogo, Rusamaza, Cirambo, Gatonde and Nyabikere from 21st to 23rd February. For post-training follow-up, two tools were used: the post-training action plan drawn up by the provider and the post-training follow-up form. In each plan, restitution is recommended as well as two or three actions to improve the services. For the 5 action plans reviewed during the follow-up, we noted that the refunds were made. Two important points have been included in the action plans, notably the calculation of the CMMs and the implementation of management tools tracing the medication circuit from the main pharmacy to the services. Thus, we have seen the establishment of a register for the daily release of medicines and the establishment of drug stock cards in the departments. The biggest challenge remains the calculation of vaccine CMMs. An action was carried out by the SCM Specialist by demonstration and by application of the CMM calculation formulas of the Vaccines
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Participate in national- and intermediate-level technical meetings and working groups on HRH and iHRIS HSS team (HSS officer, SCM specialist) participated in a meeting with DODS staff of MPHFA which aimed to present the IHPB's integrated supervision proposed approach in development and solicit MPHFA contributions for piloting and finalization of the integrated instrument held January 19th 2017. The DODS was very supportive of the approach, and delegated a focal person to guide the activities.
HSS Officer contributes experiences, perspectives, and best practices to the FHI 360 Health Workforce Strengthening Task Force From January, a SharePoint site of the IHPB project was created with a section on strengthening health systems, the HRH part of which is maintained by the HSS Officer. Several documents have been shared, including the modules that will form the integrated tool as well as the draft of the user guide. The HSS Officer also actively mobilized IHPB staff for social media events for World Health Worker Week (April 2-8, 2017).
Indicators Achieved to date Target October- January February March Total FY2017 December 2.3.1. Percent of trained health 95% N/A N/A N/A N/A N/A providers, managers and CHWs who perform to a defined standard post- training [Mandatory Result] 2.3.2. Percent of supported health 90% 98.4% 90% 82.3% 96.8% 90.1% providers, managers and CHWs who (n=1,358) (n=77) (n=51) (n=288) (n=416) have demonstrated improvement post-training [Mandatory Result] 2.3.3. Percent of trained health care 69% 79,2%8 N/A N/A N/A staff who report positive attitudes (composite indicator) about work and the workplace [Mandatory Result] 2.3.4. Percent of health facilities with 100% N/A9 N/A N/A N/A at least 80% of clients reporting satisfaction with services received [MR] 2.3.5. Number of health care workers 1,525 158 88 311 295 694 who successfully completed an in‐ service training program 2.3.6. Number of community 6,558 1,716 1,495 1,187 0 2,682 health/para-social workers who successfully completed a pre-service training program
8 Mid- term evaluation 9 PBF source
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Discussion and analysis of Sub Clin 2.3 (HR) % of trained health providers, managers and CHWs who perform to a defined standard post-training With 13 trainees followed this quarter, 84.6% performed to a defined standard post-training. They were trained on biomedical waste management.
% of supported health providers, managers and CHWs who have demonstrated improvement post-training Pre- and post-test are regularly given and results are collected and the progress by trainee is estimated. FY 2017 target is 90%. Of 345 trainees assessed, 311 succeeded and made a progress between pre- and post-test to be 90.1%.
% of trained health care staff who report positive attitudes (composite indicator) about work and the workplace The target for positive health worker attitudes is set to 69%. This indicator was measured by mid-term evaluation through Facility Qualitative Assessment (FQA) conducted in 45 health facilities and 9 hospitals were assessed in October 2016.- Health Provider Interviews. 79.2% of Health providers report positive attitudes about work and the workplace.
% of health facilities with at least 80% of clients reporting satisfaction with services received This is a PBF indicator with a target of 100%.
Number of health care workers who successfully completed an in‐service training program As planned, 1,525 managers and health workers will be trained this year (FY17) and 332 were trained in this quarter (January-March). For the two first quarters of Y4, 375 health workers are already trained (24.6%)
Number of community health/para-social workers who successfully completed a pre-service training program A total of 6,558 Community Health Workers are targeted to be trained by the end of FY 17; this quarter 1,641 were trained. During the Q1 and this Q2, 3,600 CHW are already trained (80.8%)
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CLIN 3: Strengthened Health Systems and Capacity
Sub-CLIN 3.1: Strengthened decentralized health care and systems in targeted geographic areas
3.1. a.: Work with provincial and district health bureaus to progressively strengthen district-level capacity and performance in managing the decentralized health system Planned for January-March 2017 Achievement Comments and results Share data on reference documents with Continuous Data on reference documents is shared the districts quarterly with the districts Support inventory of documents and Continuous Inventory of documents is done quarterly and distribution through supervision visits distribution is done if necessary
Train/Orient IHPB staff on the IHPB’s Achieved 22 IHPB staff have been trained/oriented on district intervention approach the IHPB’s district intervention approach. Plan and participate to joint data Continuous IHPB supported and participated to 9 review/use & quarterly coordination quarterly data revue & coordination meetings workshops Assess the effectiveness of the In progress A coordination meeting assessment tool is coordination meetings finalized. This tool will be used during the third quarter (April-June 2017) Continuous mentoring of lab Continuous 2 supervision visits per health facility were technicians through IHPB technical conducted by IHPB Lab technicians in officers Kirundo and Kayanza health provinces Develop and pilot a tool to assess the In progress A supervision system assessment tool is supervision system finalized and will be used during the third quarter (April-June 2017) Plan and conduct joint supervision visits Continuous 158 Joint supervision visits conducted by IHPB provincial staff in the 12 twelve districts
During the quarter under review, IHPB continued to work collaboratively with provincial and district health bureaus to strengthen district health teams’ capacity to perform priority functions that most affect the delivery of services.
Share data on reference documents with the districts During the quarter under review, IHPB identified and distributed 23 “Directives nationales 2016 d’utilisation des antirétroviraux pour la prevention et le traitement du VIH” to 23 healthcare providers (doctors) from Gahombo, Kayanza and Musema, Kirundo and Mukenke district hospitals, ANSS, Izere health center and ABUBEF during a training session. A database of reference documents needed by FOSAs was developed by IHPB but has not yet been installed on district team computers. We noticed that district supervisors check the availability of these documents and explain to providers the usefulness of using these documents as references. During the coordination meetings, the FOSAs show the situation of these documents, which is a significant step forward in their appropriation.
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Train/Orient new PTOs on the IHPB’s district intervention approach IHPB conducted a five-day training session for 22 IHPB Staff (4 female and 18 male) from Karusi (4), Kayanza (6), Kirundo (3), Muyinga (4) and Bujumbura (5). Participants gained practical and comprehensive knowledge on district planning; monitoring and evaluation of activities including health information systems, integrated supervision; SBCC; quality improvement; the district approach and the importance of communication and documentation of achievement and the role of the supervision system. PTOs, in turn, will support the districts in implementing these key activities.
Plan, participate and improve the joint data review (use) and quarterly coordination meetings During the reporting period, IHPB provided technical and financial support to the organization and conduct of nine quarterly one-day health data analysis meetings followed by one-day coordination meetings in two HDs (Gashoho and Muyinga) of Muyinga province, two HDs (Mukenke and Kirundo) Kirundo province, three HDs (Musema, Gahombo, and Kayanza) of Kayanza province and two HDs (Buhiga and Nyablkere) of Karusi provonce.
Noting that these meetings were organized during the malaria epidemic, this influenced the agenda of the meetings: follow up on recommendations of the previous meeting; presentation on the evolution of malaria cases in the district; weekly trend of malaria cases; and the situation on other health indicators. Refer to Annex IV for illustrative examples that show progress made and evolution on certain indicators.
Continuous mentoring of lab technicians through IHPB technical officers During the reporting period, Kirundo-based and Kayanza-based IHPB lab technicians participated in formative supervision visits to 48 and 43 health facilities respectively – these visits enabled laboratories to: Initiate the quality control registry of the reagents and tests offered at the CDS level Perform quality control for each reagent batch Complete inventory sheets daily Laboratory-level quality control system set up in the laboratory Chronologically classify temperature records Perform preventive maintenance before and after handling (Daily clean) and then clean after one month or after measuring 500 samples Keep the slides for quality control Keep all HIV testing kit together (we found it difficult to find the diluent of the test determined while the kit was new) Monitor the quality of each new kit of HIV testing reagents to avoid false result Avoid voids in the registers
Assess the effectiveness of the coordination meetings and strengthen the supervision system During the reporting quarter, a supervision system assessment tool was finalized – actual assessments in the 12 HDs will begin during the quarter April – June 2017. This tool is designed to guide the development of the improved supportive supervision system by providing a better understanding of the challenges health supervisors encounter as a basis to suggest solutions. The proposed indicators that will be tracked are as follows:
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% of districts that plan supervision visits per MPHFA guidelines • % of district offices that had all the necessary documentation available to inform development of the supervision plan • % of district supervisors that correctly prepared for the supervision visit per the MPHFA guidelines • % of supervision visits that happen as planned • % of facilities that received the minimum required number of visits in the last quarter. • % of supervision visits that were conducted per MPHFA Guidelines • % of facility managers and supervisors that think the frequency of supervision is adequate to meet facility’s needs. • % of supervision recommendations from the past 3 visits that have been implemented • % of performance gap improved
Also, coordination meetings assessment tool was finalized during the quarter. The tool has 3 parts: (1) Feedback/evaluation questionnaire of participants; (2) Direct observation; and (3) Analysis of minutes. This tool will be used to measure the effectiveness of the coordination meetings by the IHPB field office and the HSS advisor. Strengths and weaknesses will be identified and the instrument will be shared with district teams for self-assessment. This activity will start during the quarter April – June 2017.
Plan and conduct joint supervision visits IHΡB provided logistical and financial support via sub-grants to districts, to conduct joint (IHPB PTO and District Supervisor) and integrated site visits. During the reporting period, a total of 158 visits were jointly planned and conducted.
Health District January February March Total Buhiga 0 11 6 17 Nyabikere 4 12 1 17 Gahombo 8 2 4 14 Kayanza 8 0 2 10 Musema 7 0 1 8 Busoni 6 7 6 19 Kirundo 7 0 13 20 Mukenke 3 5 0 8 Vumbi 7 6 7 20 Gashoho 1 4 0 5 Giteranyi 2 10 0 12 Muyinga 4 0 4 8 Total 57 57 44 158
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Progress and discussion on the HSS (Sub CLIN 3.1) results indicators Indicators Target for Achieved to date FY 2017 October- January February March Total December 3.1.1 Percent of supported facilities FP/RH: that have available all current 24.4% national health policies, protocols, ANC: 38% and guidelines [Mandatory Result]10 MH: 49% CH: 27% HIV: 50% Malaria: 98% GBV: 33% 3.1.2 Percent of supported facilities 51.1% 51.1% 51.1% 51.1% 51.1% that have 70% of the required equipment to provide core/expanded packages of quality integrated health services [Mandatory Result] 3.1.3 Number of supported testing 100% 80% 80% 80% 80%11 facilities with capacity to perform (5/5) clinical laboratory tests [PEPFAR LAB_CAP] 3.1.4 (previously 2.2.4 in PIRS) 100% 40.1% 33.6% 73.7% Percent of supported facilities that receive supportive supervision on a regular basis [Mandatory Result] 3.1.5 Percent of supported districts 100% 100% 100% 100% 100% and provinces that conduct planning and resource coordination meetings on a continual basis [Mandatory Result]
3.1.1 Percent of supported facilities that have available all current national health policies, protocols, and guidelines [Mandatory Result] Since IHPB did not establish FY 2017 targets for tracking progress on this indicator, progress that was made in Y3 for FP/RH (24.4%), ANC (38%), MH (49%), CH 927%), Malaria (98%) and GBV (33%) is presented as FY 2017 targets while for HIV, the target of 50% that was set for FY 2016 is used as FY 2017
10 During the quarter July – September 2017, IHPB will conduct active data collection to assess progress on this indicator. 11 To have capacity to perform clinical laboratory, Gahombo district hospital still needs a CD4 count machine with tests
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target. As was the case for Y3, before the end of the FY, IHPB will conduct active data collection to assess progress on this indicator.
3.1.2 Percent of supported facilities that have 70% of the required equipment to provide core/expanded packages of quality integrated health services [Mandatory Result] During the quarter January – March 2017, there has been no change in this indicator and IHPB is not planning to deliver more equipment because of budget restrictions. Improvement in this indicator might come from the MPHFA itself, the budgeting at district level and other donors. However, one must also notice that the LOP mandatory result (31.6%), established after the SARA baseline (26.6%), has already been exceeded.
3.1.3 Number of supported testing facilities with capacity to perform clinical laboratory tests [PEPFAR LAB_CAP] The situation is unchanged from previous quarter.
2.2.4 Percent of supported facilities that receive supportive supervision on a regular basis [Mandatory Result] This indicator measures only the supervision visits conducted by the district supervisors (not the IHPB staff) and is extracted from the GESIS/DHIS2 databases. From the table, above, 73.7% of the supervision visits were conducted as planned.
3.1.5 Percent of supported districts and provinces that conduct planning and resource coordination meetings on a continual basis [Mandatory Result] During the quarter, 9 health districts conducted resource coordination meetings.
Sub-CLIN 3.2: Strengthen M&E and data management systems at the facility and community levels
Planned for January-March 2017 Achievements and Comments results Train 154 HIS focal points in health Achieved: Newly updated tools necessitated the facilities 48 trainers and training of more staff than planned. 267 participants trained Upgrade the community Case Achieved: Presentation of the new database planned Management of Malaria (CCMM) Database for April 2017 database into iCCM database upgraded Conduct routine data quality 58 (97% of target) DQA conducted as planned assessments (DQAs) HFs visited for DQA Strengthen capacity of district teams 9 (out of 12 Data review meetings in Giteranyi, Busoni and facility managers on data use planned) meetings and Vumbi were postponed to April due to through quarterly workshops
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Planned for January-March 2017 Achievements and Comments results conducted malaria epidemic Develop and disseminate simple-to- Annual target of 138 will be achieved before use data visualization dashboards for 63 (out of 138 September 2017. use at the facility level targeted) HFs coached Support quarterly community data 15 (out of 30 Meetings could not be organized due to review meetings at the health facility planned) meetings malaria epidemic level already completed
Train 154 HIS focal points in health facilities With the aim to improve the quality of facility driven data, IHPB had planned to train HIS focal points in supported health facilities during the quarter under review. That period coincided with the full migration from GESIS to DHIS2 as the new National Health Information System (NHIS) platform with updated data collection and reporting tools parameterized accordingly.
Thus, at the request of the Department of National Health Information System (DNHIS), IHPB first supported a training of trainers at the provincial and district levels before conducting the one for health providers. Hence, a five-day training (February 13-17, 2017) was conducted during which 48 trainers (35 males and 13 females) from Karusi (10), Kayanza (12), Kirundo (15) and Muyinga (11) were trained on the new data collection and reporting tools set for DHIS 2. Attendees included BPS and BDS HIS in-charges and supervisors along with IHPB monitoring and evaluation technical officers.
The following weeks, IHPB partnered with the BPS and BDS health authorities to activate the freshly trained trainers to train health providers as planned. Therefore, 267 participants (197 male and 70 female) from Karusi (65), Kayanza (62), Kirundo (71) and Muyinga (69), completed the training on the use of data collection and reporting tools. Four training sessions were organized separately, each in the respective provinces.
Upgrade the community Case Management of Malaria (CCMM) database into iCCM database One of the community health services supported by IHPB is the Community Case Management of Malaria in six project-supported districts (Gahombo, Musema, Gashoho, Giteranyi, Muyinga and Kirundo). To get and use information derived from CHW-provided services, IHPB set up an access-database specific to CCMM which had been in use until now.
After a request of the Department of Offer and Demand of Care Services (DODS), IHPB upgraded the CCMM database in iCCM (Integrated Community Case Management) with the inclusion of data related to pneumonia and diarrhea components. By the end of the quarter under review, the iCCM database and its user guide were ready to be presented to the DODS and other iCCM partners, planned for April 5, 2017.
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Conduct routine data quality assessments (DQAs) During the reporting period, IHPB, in partnership with BPS and BDS HIS in-charges, conducted DQAs in 58 supported health facilities distributed in Karusi (10), Kayanza (16), Kirundo (14) and Muyinga (18).
DQAs targeted indicators related to HIV testing and counseling, PMTCT services, ARV services, ANC services, Intermittent Preventive Treatment of malaria in pregnancy, Immunization services (DPT3, Measles), assisted delivery and Active Management of the Third Stage of Labor (AMTSL), as well as Family Planning (FP) data where applicable.
Key specific objectives of the DQA exercises were to: (1) identify opportunities for capacity strengthening; (2) involve provincial and district core teams in the integration of data quality aspects in their supervisions; (3) improve the quality of data for program use.
Results of the DQAs showed that there are still several data quality issues. Out of the 11 districts assessed, five (45.4%) including two of the three districts in Kayanza, had an average variance higher than 5% with an overall variance of 6.0%; the table below presents the average variances by health district.
Table 1: Average scores of DQAs covering the period Oct-Dec 2016 conducted during the Q2, FY 2017
Health District # Health facilities Average Variance (%) Buhiga 5 2.0% (-1.5 – 6.8) Nyabikere 5 4.8% (0 - 8.9) Gahombo 4 7.1% (-5.1 - 27.4) Kayanza 7 2.8% (-0.1 – 7.3) Musema 5 16.1% (9.6 – 21) Busoni 3 14.6% (-8.7 – 20.5) Kirundo 6 3.0% (-1.9 – 14.3) Vumbi 5 0.5% (-4.6 – 6.4) Gashoho 5 12.2% (-8.2 -27.5) Giteranyi 8 2.4% (-9.1 -24) Muyinga 5 0.9% (-3.8 – 5.6) Total/Average 58 6.0%
Most of the time, data issues were observed in new health areas such as AMTSL, IPTp and ARV services in new sites. The main causes include: (1) the lack of standard data collection tools for those services; (2) few human resources; and (3) increasing number of reports to aggregate within tight deadlines.
It is expected that the training on newly updated tools will foster improvement as they include record fields for those health areas. IHPB already initiated a process to procure and supply updated tools to all supported health facilities. In addition, following the identification of the data issues, the DQA teams formulated an action plan for each facility, especially where the average variance rate was +/- 5%.
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Strengthen capacity of district teams and facility managers on data use through quarterly workshops In the framework of information sharing on data quality and use of services, quarterly data analysis workshops were organized in nine (75%) health districts: Buhiga, Nyabikere, Gahombo, Kayanza, Musema, Gashoho, Muyinga, Kirundo and Mukenke. Topics covered included ANC, assisted and home delivery rates, immunization and FP coverage, birth weight, malaria outbreaks and its consequences, integrated community case management (iCCM) and referral system. In Gahombo, Kayanza and Musema health districts, HIV data (through the PMTCT cascade) and MNCH data (Number/percent of women giving birth who received uterotonics during the third stage of labor and number/percent of children who received DPT3 by 12 months of age) were analyzed for the period running from June to November 2016. Data related to pregnant women who received Intermittent Preventive Treatment of malaria in pregnancy (IPTp) during ANC visit during October to December 2016 were also analyzed.
In Gashoho, Muyinga and Mukenke HDs. Among other, the following recommendations were made: (1) in-depth analysis of data before report submission; (2) networking with the community health workers to retrieve immunization drop-outs; and (3) enssuring the supply of individual PLHIV files.
In addition, a provincial data analysis workshop was organized in Karusi whereby MNCH (ANC, PNC, deliveries, nutrition, acute respiratory infection, diarrhea), malaria, Reproductive Health (number of new users for each contraceptive modern method) and Sexually Transmitted Infections data (STI incidence rate per total of curative consultations) for January through November 2016, were analyzed.
Key common findings from Karusi province data review workshop include (1) high incidence of malaria and malnutrition in almost all supported districts, (2) Persistency of a relatively high numbers of home delivery case (eg. 127 in Muyinga HD within the quarter); (3) low uptake of early ANC1, postnatal consultations and FP; (4) low performance in the provision of some services due to stock outs. Data discrepancies persist generally due to lack of third party review before data report submission or unavailability of some data collection tools such as ART individual files due to ART decentralization, inclusion of services not foreseen when existing data collection tools were developed (AMTSL, IPTp);
Appropriate actions to undertake in addressing shortcomings were set up: Notify regularly home delivery cases; Review and analyze data before transmission to the HD level; Avoiding stock shortages of uterotonics and specify in the delivery registers if uterotonics were administered; Sensitize and encourage for CHW and local administration authorities to jointly develop local strategies to increase early ANC1 and FP uptake; On a regular basis, complete the dashboards and display them in each service; Advocate to the NHIS department and partners for availability of ART individual files and updated MNCH data collection tools; Train health providers on the management of acute malnutrition.
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Develop and disseminate simple-to-use data visualization dashboards for use at the facility level Data visualization dashboards posted in health facilities and promote data use as anyone can see services uptake and morbidity progress across a period of time. They are usually recommended for certain services such as immunization, ANC, FP and notifiable diseases, as well as malaria.
To review and update data visualization dashboards, IHPB conducted coaching visits in 63 health centers distributed in Karusi (17), Kayanza (9), Kirundo (5) and Muyinga (32) provinces.
Most of the health facilities that were visited have data visualizations dashboards which are not regularly updated, either because the staff skilled to complete them left or due to lack of diligence. Staffs in health centers without dashboards were immediately refreshed on the why and how to develop and regularly update dashboards for key indicators. Additionally, we encouraged providers to add malaria indicators and do so on a weekly basis.
Support quarterly community data review meetings at the health facility level IHPB supports community services related to Integrated Community Case Management (iCCM) in six supported health districts, and community-based distribution of FP commodities (CBD), and awareness of the importance of exclusive breastfeeding during the first six months of birth, in all HDs.
To improve performance of community health workers in the provision of those services, IHPB held 15 community data review meetings with CHWs in the communes of Buhinyuza, Butihinda, Gashoho, Gasorwe, Muyinga and Mwakiro in Muyinga Province, and Butaganzwa, Matongo, Muruta, Rango, Gahombo, Kayanza, Gatara, Muhanga and Kabarore in Kayanza province. Topics discussed included experience sharing of CHWs from different facility catchment areas and communes, review of data reports on integrated community case management (iCCM), community based distribution of contraceptives and GASC (Groupement d’Agents de Santé Communautaires).
With the objective to improve the quality of data provided by CHWs, IHPB took advantage of Community- based distribution (CBD) of contraceptives training to train 89 CHWs (52 male, 37 female) of Mukenke health district on standard data collection and the reporting tool commonly called GASC.
Progress and discussion on M&E indicators Indicator Target FY4 Oct-Dec 2016 Jan-Mar 2017 EP Target 2017 3.2.1 Percent of facilities that maintain 97.8% 100% 65% +5% timely reporting [MR] 3.2.2 Percent of districts and facilities that Facility: 95% Facility: 94% Facility: 94% +10% demonstrably use facility- and District: 90% District: 89% District: 89% community-level data for timely decision making [MR]
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There are two IHPB contractual indicators related to monitoring and Evaluation (M&E):
1) Percent of facilities that maintain timely reporting: this indicator already had a good baseline. Thanks to the Performance-based financing mechanism, achievement is consistently at 100% and IHPB is working to maintain the good level that has been reached. There is a drop of timeliness achievement during the reporting period (65%) due to new reporting forms introduced before the training of providers. It is expected that they will catch up after the training conducted in March 2017.
2) Percent of provinces, districts and facilities that demonstrably use facility- and community-level data for timely decision making. To inform progress made on this indicator, in October IHPB actively collected data which showed improvements in both facility and district levels of data use for decision making, i.e. from 90 to 94% for facility and from 80 to 89% for districts.
Sub-CLIN 3.3: Increased civil society capacity to support positive behaviors and quality integrated services
Planned for January-March 2017 Achievement Comments and Results Conduct orientation session for three Achieved for For SWAA Burundi and RBP+, the orientation CSOs (RBP+, ANSS and SWAA Burundi) on ANSS session will be conducted when Grant new expanded HIV roles awarded Conduct training on integrating RH, HIV and PMTCT services for SWAA Kayanza Currently, the administrative process of Ensure one five-day training for RBP+ reestablishing partnership with SWAA community workers on community HIV Burundi and RBP+ is underway. awareness Conduct one-day training on USG requirements in FP for SWAA in Kayanza Conduct at least semiannual joint Ongoing IHPB carried out a supervision visit to assess supportive supervision (IHPB and BDS progress against the improvement plan supervisors) focused on technical developed after the Dec 2016 supervision activities carried out with the SIMS tool. Recruit CSOs for non-HIV indicators Procurement An organization (with experience in GBV) has followed by appropriate training process is been identified and the contracting process including follow up ongoing is underway.
During Year 4, IHPB planned to strengthen the capacity of CSOs in technical and organizational areas. The performance of CSOs in technical areas will contribute to improved indicators of HIV activities and SGBV activities. To meet these requirements, the following activities were carried out during this quarter:
Conduct at least semiannual joint supportive supervision focused on technical activities During the first quarter (December 2016), a USAID team conducted jointly with the IHPB staff a supervision of ANSS Kirundo to assess HIV infection control activities using the SIMS tool. In general, it
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was found that the ANSS clinic meets the elements contained in the form. Following this visit, IHPB staff conducted a visit for supporting the ANSS staff in developing a plan to implement the recommendations issued by the USAID team. During this quarter, the IHPB staff conducted a supervision to inquire about the implementation of the recommendations issued. The following conclusions were reached: Concerning the implementation of the quality improvement process: training and exchange visits have been carried out; the Quality Improvement Team was established; the change package is being implemented and concerns the integration of early ANC, HIV counseling and testing, malnutrition and SGBV in curative consultation. Other recommendations were to strengthen medication dispensing, adherence support, partner HIV testing, lubricant availability at point of service, capacity to provide post violence care services, and patient rights. During this most recent supervision, it was noted that ANSS has implemented these recommendations to a very high degree of satisfaction.
As illustrated in the table below, ANSS Kirundo has exceeded its targets except in HIV early infant diagnosis:
January February March Total Target Percentage HTC Number of persons tested 128 224 203 555 300 185% No 8 10 10 28 Number of HIV seropositive target- Number of condoms No 3,888 1,906 2,090 7,884 distributed target- Treated No 1,010 1,020 1,020 1,020 Total number of PLHIV target PLHIV on ART 998 1,010 1,015 1,015 985 103% PLHIV on cotrimoxazole 990 999 994 994 870 114% Number of viral load tests 135 101 136 372 75 496% No 125 62 123 310 Number of CD4 analyses target- PMTCT Number of pregnant 75% seropositive women on ARV 2 3 4 9 12 and PMTCT program Children HIV exposed put on 24% 3 4 4 11 45 cotrimoxazole
Reestablish partnership with SWAA Burundi and RBP+ To further the goals and objectives of the IHPB in Kayanza and Kirundo provinces, the IHPB project requested USAID to renew the partnership with SWAA Burundi and RBP+ due to their history of strong performance and presence in the target areas. SWAA Burundi would work in HIV service integration and add activities focusing on KPs (MSM and FSW) in high HIV risk areas of Kayanza province and RBP+ would work at community level to increase demand for HIV screening and treatment in Kayanza and Kirundo provinces. The program descriptions, indicators, targets, timeline of projects proposed have already been
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developed. Once concurrence has been obtained from USAID, the contracting process can proceed. The dialogue between IHPB and USAID concerning these partnerships is ongoing as of the end of the quarter.
Recruit CSO for non-HIV indicators followed by appropriate training and follow-up In monitoring the activities of the IHPB, it appears that the indicators related to the activities of SGBV suffer and hence the decision to recruit a CSO expert in this area has been made. As provided in the FHI 360 and USAID regulations, a solicitation for CSOs to implement SGBV activities has been released. Nineteen applications were received and a six-member procurement committee has identified one organization, Burundi Red-Cross. Currently the program description and the budget related to is being finalized by both parties. In the coming quarter, IHPB will submit the completed subaward to USAID for concurrence. Cross
Priority Health Domain Strategies
Malaria Strategy Planned for January-March 2017 Achievement Comments and results Conduct integrated training session on iCCM for Achieved 37 health care providers trained health providers Training CHWs on iCCM: case management of Achieved 176 CHWs (99 Gashoho, 77 Kirundo ) diarrhea trained on case management of diarrhea Supply equipment to CHWs for iCCM Achieved Activity done every three months Conduct HH visits to CHWs involved in CCM of Achieved 5 households of CHWs visited and 5 malaria community members met Conduct supportive supervision visits at the Achieved 27 health centers visited facility level Provided technical and financial support to carry Achieved 24,133 cases tested positive and out mobile clinics/mass drug treatment treated for malaria out of 34,712 cases activities during malaria epidemic period with fever including 8,824 children under five years, 375 pregnant women, and 14,934 were over 5 years during 2 weeks. Support information and micro-planning On track Planned for the beginning of April workshops on malaria response at district level 2017 Conduct community theater on malaria themes Achieved 3,064 participants (2,139 female and 925 male) attended in Buhiga HD Conduct mobile cinema on malaria Achieved 6,227 participants reached with key messages on malaria prevention. Conduct integrated training sessions on IPTp Achieved 148 health care providers trained (77 within ANC female and 71 male) Partner with PNILP and DPSHA to adapt existing On track Illustrations posters malaria messages, then produce and designed/collected disseminate flipcharts Support community malaria prevention efforts On track Areas to be supported have been targeted and depends on availability of malaria posters
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Integrated training session on iCCM for health providers In the process of implementing iCCM in Kirundo health district, two 5-day training sessions on iCCM have been conducted for 37 healthcare workers from 15 health centers including one district hospital (2 health care providers per health center): 8 female, 29 male including 4 health promotion technicians and 3 health district supervisors. Health district trainers led the sessions using the iCCM training guide and tools developed by IHPB in collaboration with DODS. Considering that iCCM is a new strategy in the national health policy, participants showed a good performance in the pre-and post-test results. At the pre-test, the lowest score was 2 and the highest was 10 (out of 20). At the end of the trainings, the lowest score was 15.5 and the highest score was 19 (out of 20). Post training supervision vists, one month after training, provided an opportunity to support those who scored less in post-test At the closure of the training, participants agreed on the schedule of training of community health workers. IHPB expected to train two healthcare workers on iCCM per health center in the four iCCM health districts (Musema, Gashoho, Kirundo, and Gahombo), training was completed in Gahombo and Kirundo HD. An additional health care worker in Gashoho and Musema HD will be trained later. The table below shows the training coverage of targeted audiences since Y3 (March 2015) to September 2017.
Health District Health care workers trained on iCCM Y3 Y4 Target Trained Target Trained (January-March 2017) Gahombo 0 0 33 33 Gashoho 0 0 42 24 Kirundo 0 0 43 37 Musema 30 30 20 0 Total 30 30 138 94
The remaining 44 health providers to be trained are in Musema (20) and Gashoho (24) HD are expected to be trained in April 2017. Conduct training sessions on iCCM for community health workers (CHWs): case management of diarrhea12 With respect for iCCM guidance, IHPB coordinated with DODS (Direction de l’Offre et de la demande des Soins) in Kirundo and Gashoho health districts to select13 CHWs who will implement iCCM in the cited districts. Using a writing assessment test, 176 CHWs were selected in Gashoho (99 [ 35 female and 64 male] out of 160 total CHWs) and Kirundo (77 ([40 female and 37 male) out of 257 total CHWs) have been selected to implement iCCM. In both districts where community case management of malaria has been implemented since 2014, healthcare providers trained on iCCM organized and conducted nine separate 3-day training sessions on case management of diarrhea at the commune level. In each health district, participants have been dispatched in groups of 15 to 19 participants and all 176 selected CHWs attended. This module training
12 ICCM consists of case management of 3 diseases (malaria, diarrhea, pneumonia) at the community level by CHWs. Implementation of iCCM is done step by step (one after one disease). According to availability of commodities, community case management of malaria was the entry way of iCCM. After three months of implementation, diarrhea was introduced. After other three months of implementation of malaria and diarrhea, pneumonia will be introduced 13 2 CHWs per colline are required to implement iCCM. Some collines have more than 2 subcollines and each sub colline has a CHW.
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was led by health care workers using the iCCM training guide with other didactical material and iCCM tools. Training sessions focused on the diagnostic procedure of a child with abnormal stools (using the algorithm), on treatment protocols, on recording cases in the register, and on the monthly report. The training was concluded by distributing an iCCM kit14 to each participant. The iCCM strategy is composed of four modules15. Each module lasts 2-3 days and after 3-4 months, another module is introduced. In the IHPB catchment area, one module, case management of pneumonia, remains.
Supply equipment to CHWs for iCCM To further support iCCM implementation in Kirundo and Gashoho health districts, IHPB distributed the materials and tools detailed in the table below.
CHW iCCM Kit items Kirundo16 Gashoho HD HD Individual tracking record for the sick child 80 100 Register of cases 80 100 Transfer book 80 100 Requisition cards 80 100 Stock cards 240 300 Taking algorithm managed at home with diarrhea 80 100 iCCM book 80 100
Conduct household visits to CHWs involved in CCM of malaria After rolling out iCCM in Gahombo by introducing case management of diarrhea and giving updated tools, IHPB, in coordination with nurses-in charge and health promotion technicians (HPT), conducted home visits to five CHWs. The goal was to verify the status of tools distributed and all aspects of recording children with fever and diarrhea that consult CHWs at the household level. This visit was also an opportunity to understand the points of view of community members about services offered by CHWs. Community members complained that there is stock out of ORS at the community level. Three out of the five CHWs that benefited from this visit did not know how to complete the monthly report template correctly. The supervision team explained to CHWs how to do this correctly, and advised them on the replacement of ORS. The team also demonstrated to community members how to prepare ORS locally, using water, salt, and sugar, to treat diarrhea.
Conduct supportive supervision visits at facility level
14 ICCM kit: registers, stocks cards, transferal books, algorithm of case management of diarrhea, monthly report template. 15 ICCM modules: malaria, diarrhea, pneumonia and screening of malnutrition. 16 IHPB started implementing diarrhea case management in Kirundo and Gashoho at the community level in February 2017, necessitating supply of kits
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Using the integrated supervision guide developed by the National Malaria Control Program, IHPB conducted supportive supervision visits in 27 health centers. Six in Gashoho HD (Mirwa, Gashoho, Gisanze, Kigoganya, Nyungu and Gashoho), five in Muyinga HD (Rugabano, Mwakiro, Kinazi, Kiyange and Muramba), 10 in Giteranyi HD (Masaka, Ngomo, Kidasha, Nonwe, Mugano, Rabiro, Tura, Butihinda, Gahararo, and Buhorana) and six in Gahombo HD (Mubogora, Muhanga II, Nzewe, Ngoro, Rukago and Kibaribari II) were visited. These supervision visits were focused on integration of IPTp, LLINs in ANC, reporting and availability of Sulphadoxine Pyrimethamine (SP), and implementation of guidelines on malaria treatment. These visits discovered discrepancies between the notified data (in the register) and the reported data (Mirwa, Kigoganya), due to bad reporting of doses of SP distributed (Mirwa), no offer of SP for pregnant women with signs of malaria without biological confirmation (Gashoho), stock out of SP (Gisanze), and low rate of early antenatal care. In a restitution session, health center teams agreed to compile data week by week in order to minimize errors at the end of the month. The supervision team advised health center teams to share roles in reporting of different data according to the competencies of health center staff. In Gahombo HD, this supportive supervision was a follow-up visit on iCCM at the health facility level to verify if data from the community are compiled and analyzed by health care workers and how community workers record data and fill out tools. The main finding was that data on iCCM are compiled on a wrong template and incomplete. The supervision team shared the updated template and showed how to compile it. That supportive supervision was followed by a reflection with all health facilities in Gahombo HD on strengths and weaknesses encountered in iCCM implementation. All health workers took time to compile data and submit them at district level.
Provided technical and financial support to carry out mobile clinics/mass drug treatment activities during malaria epidemic period As shown in the chart below, malaria cases have critically increased and gone above the epidemic level. Since week 39 in 2016, there has been a further rise in malaria cases and an increase in cases of continuous malaria. This abnormal increase in cases is more marked in the Northern, central and Eastern health districts. In 2016, four provinces were particularly affected with an incidence rate of at least 100%: Kirundo, Muyinga, Karusi and Cankuzo, as shown in the chart below. IHPB catchment areas are among the more affected zones. Health centers were overwhelmed by cases and thus it was necessary to organize advanced strategy for treatment.
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Evolution of malaria incidence in Burundi (2013-2016)
2013 2014 2015 2016
120 100 80 60 40 20 0
The mobile clinics strategy has ensured early diagnosis of malaria to avoid severe malaria during the malaria epidemic period. In Mukenke, Musema, Kirundo, Vumbi, Busoni, Giteranyi, Kayanza, Gahombo, and Musema HD (the more affected district), IHPB provided technical and financial support to carry out mobile clinics and outreach treatment activities during the malaria epidemic period. The observed malaria cases are detailed in the table below.
Cases with RDT+ and treated Children under Pregnant Over 5 years of Location fever with ACT 5 women age
Mukenke 9,792 7,062 3,762 209 3,091 Vumbi 5,327 4,204 2,205 77 1,922 Busoni 5,440 3,618 1,105 48 2,465 Giteranyi 4,604 2,763 696 11 2,056 Musema 4,360 2,868 260 12 2,596 Gahombo 3,559 2,550 449 7 2,094 Kayanza 1,630 1,068 347 11 710 Total 34,712 24,133 8,824 375 14,934
The malaria specialist participated in a ten-day exercise to develop the National Malaria Control Program Global Fund concept note and the malaria epidemic response plan as declared on 13th March, 2017.
Support information and micro-planning workshops on malaria response at district level IHPB has been proposed to be a member of the task force team in charge of developing the response plan for the malaria epidemic, thereby working closely with WHO technical staff and consultants as well
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as with other members of the task force. The validated response plan for the malaria epidemic is expected to conduct micro-planning that will be done at the district level at the beginning of April 2017.
Conduct Community Theater on malaria themes In coordination with the health district and provincial office, and with the involvement of communal administrators, IHPB conducted four separate sessions of interactive community theater to raise the community awareness on malaria prevention. In Buhiga HD, the team visited the health centers (Buhiga, Nyabikere, Rugazi and Rusamaza) to gather data on which villages had high rates of malaria. These villages were then targeted for the intervention. A total of 3,064 participants (2,139 female and 925 male) from four villages attended the community theatre sessions. Simple and severe malaria symptoms and promotion of use of ITN and environmental hygiene messages have been developed into the performances. This effort was developed and led by the drama group in Buhiga, after they received an orientation from IHPB staff and provincial coordinator for health promotion.
Conduct mobile cinema on malaria The SBCC team carried out this activity to support malaria outreach activities during the epidemic period. With the use of communications materials and IEC (information, education, and communication service of the MPHFA staff, IHPB supported using mobile cinema sessions on malaria in Muyinga and Kirundi reaching an estimated 6,227 people with key messages on malaria prevention. After the mobile cinema was conducted, participants were given a chance to ask questions and were informed on prices for commodities such as jerry cans and radios.
Conduct integrated training sessions on IPTp within ANC In coordination with health district trainers on IPTp, IHPB conducted eight 3-day training sessions on IPTp for 148 (84F, 64M) additional health care providers from nine health districts. These trainings sessions targeted 1 additional17 health care provider per health facility including three from the health district hospital.
Partner with PNILP and DPSHA to adapt existing malaria messages, then produce and disseminate flipcharts In collaboration with the health communication working group (Comité Consultatif) and the SBCC team, the malaria specialist developed key malaria messages. With the help of IHPB’s SBCC program officer, illustration posters that matched the messages have been collected and then made into a complete flipchart to be validated by the health communication working group in April 2017. This communication material will be multiplied and distributed to CHWs to be used during SBCC sessions at the community level and in the event of malaria epidemic period.
Support community malaria prevention efforts. Based on aggregated data from the Demographic Health Information System 2 (DHIS2) database in 2016, 2 health districts recorded 361,426 positive cases of malaria in Buhiga HD (111 deaths) and 336,117 case in Gashoho HD (110 deaths). In each of the two HDs (Buhiga and Gashoho), 2 HCs (Buhiga: Buhiga and Cirambo; Gashoho: Gisanze and Gisabazuba) were
17 One health care provider per health facility in 12 IHPB health districts has been trained in 2015 at the beginning of the strategy.
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identified with many more cases than normal. These health centers were targeted to work with community members to empower them to fight malaria by practicing small, achievable, high impact actions on malaria prevention (correct use of LLINs and environmental hygiene), .
Progress and discussion on malaria indicators
Target Achieved to date (October 2016-March 2017) Indicator FY2017 Oct-Dec.2016 January February March Total % of children under one 97 62% 86.40% 85.77% %18 86.14% year who had received (16165/25950) (7934/9183) (5538/6457) LLINs through USG funds % of pregnant women 96 59,6% 83.12% 79.35% %19 81.7% who had received LLINs (20409/34252) (10235/12314) (5807/7318) during ANC through USG funds % of children under five 75 75%(34981/466 79.4% 78.7% 79,8% with fever who received 15) 75, 5% (51,83 % (10315/1292 ACT within 24 hours of (14592/19332) 9/65,2 3) onset of fever 50) % of pregnant women 70 84,4%(18378/2 84.2 84% who received IPTp during 1769) % 83,8% 83,6% ANC visit (8094 (6265/7474) (6096/7294) /9615 ) Number of community 417 475 0 176 0 176 health workers trained on iCCM (case management of diarrhea at community level)
% of children under one year who had received LLINs through USG funds: IHPB accessed this aggregated data from the DHIS2 database. Given that the level of achievement of this indicator up to date is 86.14% and the annual target set at 97%, the FY2017 target is on its way to being achieved.
% of pregnant women who had received LLINs during ANC through USG funds: IHPB accessed this aggregated data from the DHIS2 database. The level of achievement of the indicator to date is 81.7% and the target at the end of the year is estimated at 96%. We can safely assume that at the end of FY17 the result to be achieved will be close to the target. IHPB is responsible of the awareness of use of ANC service as well as the use of LLINs.
18 Data will be available in coming days (May 2017) 19 Data will be available in coming days (May 2017)
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% of children under five with fever who received ACT within 24 hours of onset of fever: Considering the level of achievement to date (January-March2017), 78.7% of children that received ACT within 24 hours of onset of fever, the annual target of 75% had been achieved. From October to date, the indicator performance is maintained. During the epidemic period, in March 2017, community health workers tested (RDT) 65,250 children of which, 51,839 were positive. This number is five times higher than that was recorded in January and February 2017.
% of pregnant women who received IPTp during ANC visit: The indicator achieved during this quarter (83.7 %), is over the target of 70%. Sensitization sessions made by community health workers, health promotion technicians, and messages delivered during Community Theater and mobile cinemas contributed to effective adoption of IPTp.
Number of community health workers trained on iCCM (case management of diarrhea at community level) IHPB planned to train 417 community health workers on case management of diarrhea at the community level (160 from Gashoho and 257 from Kirundo). Due to a change in the national strategy for community health, only two CHWs per colline are required to implement iCCM. Thus, in Gashoho and Kirundo HD, a selection test has been given by the MOHFA/DODS and DPSHA (Department pour la Promotion de la Santé, Hygiène et Assainissement) to all CHWs to identify only 2 CHWs per colline Thus, 99 CHWs were selected in Gashoho and 77 in Kirundo to implement iCCM.
Child Health Strategy
Planned for January-March 2017 Achievements and results Comments
Conduct one-day training for 844 CHWs from 95% of target achieved 806 CHWs were trained Muyinga on the use of registers to conduct immunization surveillance. Conduct four-day training of 30 trainers from Achieved 20 trainers were trained this Kirundo and Mukenke HDs on community- quarter; 16 trainers had been based management of acute malnutrition trained during last quarter Conduct a three-day training of 443 CHWs Achieved 334 CHWs trained during this from Kirundo and Mukenke HDs on quarter; 97 CHWs had been community-based management of acute trained during last 2016 malnutrition quarter (a total of 431 CHWs trained) Work with the MPHFA to conduct supervision 66% of target achieved 24 HCs were supervised; 12 of 36 health centers on clinical IMCI in Karusi remaining HCs will be and Kirundo supervised next quarter. Train 46 health care providers in two Not achieved A malaria outbreak brought sessions, from Kirundo and Mukenke HDs, on about the postponement of the management of acute malnutrition and the activity; it will be IYCF conducted next quarter
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In the child health area, IHPB carried out activities in relation to nutrition, integrated management of childhood illnesses, and immunization. The following are the activities carried out during the reporting period. Conduct one-day training for CHWs from Muyinga province on the use of registers to conduct immunization surveillance. To facilitate the identification of children who have never been vaccinated, and help to identify those who are late to getting additional vaccines, IHPB proposed to utilize the potential capacity of CHWs in immunization surveillance. Children who never begin the immunization program remain unknown to the health center (statistics are based on population estimates), and children who drop from the immunization program are considered as “lost to follow-up” (LTFU), even though they may have gone elsewhere to receive the additional vaccinations. A regular follow-up of all children within the community could better inform these situations. Thus, a one-day session was held with 806 CHWs (350 female and 456 male) from Muyinga province to refresh them on the national immunization schedule, and orient them on immunization surveillance; 38 CHWs did not attend the training. A pad of paper, a pen, and a ruler were provided to each CHW to help them register all children of vaccination age and to check if they got all the indicated vaccines. CHWs will systematically register every newborn and will follow the immunization schedule for each child, reminding the mothers of the predicted date of vaccination, and retrieving children who have missed their vaccination appointments. Evaluation of the activity will be conducted during CHWs quarterly meetings.
Conduct training of trainers from Kirundo HD on community-based management of acute malnutrition In collaboration with the BPS and BDS, IHPB conducted a 3-day training of 20 participants (5 female and 15 male) from Kirundo health district including 14 health centers heads, 2 HPTs, 3 supervisors, and the district HIS chief. The training focused on three components: 1) malnutrition screening and the referral of severe acute malnutrition cases, 2) the seven key family behavioral practices of child health, including nutritional education, and 3) the monthly report of CHW groups. The documents used were the booklet on the seven key practices of child health and the manual for the management and prevention of malnutrition designed for CHWs. The methodology used was interactive presentation, brainstorming, and exercises in group work. The topics discussed included the concept of nutritional status, causes and consequences of malnutrition, detection of malnutrition, protocol for the management of malnutrition at the community level, the seven key practices of community IMCI, the referral form, the CHWs group monthly report form, and the exercise on filling out the monthly GASC report. The training began with a pre-test, which recorded an average result of 67% (range: 27% to 83%). The post-training test recorded an average of 97% (range: 88% to 100%). All the 20 participants successfully completed the training. The 20 participants in this training, along with the 16 from Mukenke who were trained last quarter, make a total of 36 trained, or 120% of the 30 trainers planned for year 4.
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Conduct three-day training of 334 CHWs from Mukenke and Kirundo HDs on community-based management of acute malnutrition The acute malnutrition management services at the community level are currently provided in 10 of 12 IHPB health districts, with the support from different partners. IHPB is supporting Nyabikere and Vumbi health district and is striving to cover the remaining health districts: Mukenke and Kirundo. During this quarter, IHPB, in collaboration with the health district offices, conducted a 3-day training of 89 CHWs (38 female and 51 male) from Mukenke HD and 245 CHWs (119 female and 126 male) from Kirundo HD. The participants were distributed in three classes, each run by three trainers. The 3-day training focused on screening for acute malnutrition, case referrals, education on the seven key practices of child health including the exclusive breastfeeding, as well as the CHWs groups monthly reporting template. The manual for malnutrition care and prevention for CHWs and the booklet on the seven key practices of child health were used. The screening of malnutrition session consisted of brainstorming and a demonstration. For education on the seven key practices of child health, three groups were formed per class. Each group worked on questions about each practice and presented while other participants commented. Then, the trainer gave feedback and read them what was proposed in the booklet on the seven practices. For the monthly report of CHWs group, all the participants went through the canvas together, each one reading in turn, and asking questions of clarification. The CHWs were then grouped to work on the exercise of filling the report template. The training began with a pre-test and ended with a post-test, which were completed with averages of 50% for the pre-test and 81% for the post-test. The 334 CHWs trained this quarter, together with the 97 CHWs from Mukenke HD who were trained last quarter, give a total of 431 CHWs trained. This constitutes 99.54% the 433 total CHWs who were planned for year 4. Thus, the 12 IHPB-target health districts are providing nutrition-related services at community level. The following are the quantities of services provided: 127,360 children under five (68,245 female and 59,115 male) were screened for malnutrition, 14,451 (7,792 female and 6,659 male) had moderate malnutrition, 4,455 (2,033 female and 2,422 male) had severe malnutrition, 2,299 (1,211 female and 1,088 male) were referred to health center; 156,208 people (87,257 female and 63,141 male) were educated on exclusive breastfeeding, 98,938 people (60,014 female and 38,893 male) on complementary feeding, 115,409 people (68,373 female and 47,002 male) on hygiene and hand washing. Work with the MPHFA to conduct supervision of 24 health centers on clinical IMCI in Karusi and Kirundo During year 4, IHPB planned to support a supervision of 60 HCs in Karusi and Kirundo provinces (Buhiga, Nyabikere in Karusi; and Kirundo, Busoni, Mukenke, and Vumbi in Kirundo) on the clinical IMCI. This is a two-session supervision, the first session is conducted by the central level of the MPHFA, and the second one is conducted by the district supervisors. During this quarter, the first session of supervision was conducted in Busoni and Mukenke health districts and reached 12 HCs; the second session of supervision was conducted in Buhiga and Nyabikere HDs (the first session had been conducted during last quarter) and reached 12 HCs.
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To date, 51 HCs have been supervised. The planned supervision sessions were completed in Karusi province (Buhiga and Nyabikere HDs) using the 30-page tool designed by the MPHFA. A last session of supervision is to be conducted in Kirundo province (Kirundo, Busoni, Mukenke, and Vumbi) next quarter and will target 16 HDs. The supervision of clinical IMCI will be then included in the integrated supervision tool initiated by IHPB. Some challenges were noted, such as:
IMCI guide is not systematically used Lack of places for oral rehydration treatment, children with dehydration are not for cared in HCs Thirst test is not conducted for children with diarrhea Anemia, malnutrition, and HIV infection are not systematically screened Most of health care providers forget to advise mothers on their children illness, the treatment, and the ill-child nutrition.
Demonstration was conducted by the supervisors, and a meeting was systematically held with each health facility staff at the end of supervision to talk about how to address the challenges, and the health facilities staff committed to fill the gap.
Discussion and analysis of the results Indicator Achieved to date FY 2017 Target October- January February March Total FY2017 December 2016 2017 2017 2017 2.0.4 Number/percent of 103,333 22,555 7,155 6,104 20 35,814 children who received DPT3 by 12 months of age 2.0.6 Number/percent of 118,000 63,038 35,160 28,610 30,744 157,552 women reached with education on exclusive breastfeeding
2.0.4 Number/percent of children who received DPT3 by 12 months of age This information is extracted from the health centers’ monthly report. While the annual target is 103,333, data up to February 2017 realized 35,814 (35%). In five months, we achieved only 34% of the annual target; the annual target is not likely to be reached, this is because IHPB target provinces were subject to a malaria outbreak and hunger, so immunization was no longer a priority for the populations. CHWs will help to track children lost to follow-up for immunization and evaluation will be conducted during regular CHWs meetings.
2.0.6 Number/percent of women reached with education on exclusive breastfeeding This information is gathered from CHWs’ monthly reports. While the 2017 annual target was set to 118,000, the available data up to March 2017 realized 157,552 (133%) of the annual target). In six
20 Data for March 2017 not yet available
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months, we have over achieved the annual target. This is because the target was set with data from two provinces (Kayanza and Muyinga) while the area where the information is collected from two additional provinces (Karusi and Kirundo), by training the CHWs on nutrition education and standard reporting. In addition, the CHWs’ reporting system follow-up was improved by regular monthly data analysis and report collection.
Maternal and Newborn Health Strategy
Planned for January – March 2017 Achievements and Comments results Organize maternal death audit sessions Continuous 12 sessions conducted
Train on the use of maternal death Achieved Mentoring exercise on CEmONC organized data collection tools or support an with support from 3 main partners (WHO, eight-week long mentoring exercise for UNFPA, IHPB) 16 (8 Muyinga and 8 Kirundo) health workers Conduct formative supervision Continuous 6 health facilities supervised for BEmONC services in Karusi Conduct training of trainers on Achieved 2 sessions conducted for a total of 27 BEmONC people Conduct training of trainers on EmONC Not achieved The MPHFA postponed all activities and for Kirundo and Kayanza focused effort on the malaria outbreak Organize workshop to sensitize CHWs Achieved All CHWs sensitized through SBCC on danger signs during pregnancy activities Equip Ngozi Nursing School for EmONC Started and Anatomic models purchased, room and BEmONC continuos identified
To further enhance Burundi’s health system capacity and contribute to the reduction of maternal and neonatal mortality, IHPB conducted the following activities during the reporting period (January – March 2017): Support maternal death audits in hospital: During this quarter, 17 maternal deaths were reported in hospitals in the IHPB intervention area (Karusi:2, Buhiga:3, Kayanza:3, Musema:1, Kirundo:5, Gashoho:2, and Muyinga hospital:1). 13 maternal death audits were conducted, eight that occurred last quarter and were not audited, and five that occurred in this quarter. We noticed that 12 maternal deaths were not audited and audits were postponed because of the malaria outbreak. All activities were related to malaria in the epidemic area, including our intervention provinces. The causes identified were: metastatic cervical cancer (1), post-partum hemorrhage (2), severe malaria (5), pulmonary edema (1), uterine rupture (1)., septicemia (2), and complications of tuberculosis (1). The situation observed showed that malaria is still the main cause of maternal death in the project’s 4 target provinces during this period.
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Train on the use of maternal death data collection tools or support an eight-week long mentoring exercise for 16 (8 in Muyinga and 8 in Kirundo) health workers: From a meeting held with PNSR on this activity, IHPB was asked to wait until PNSR collected available data on the those already trained with other partners to avoid duplication. Given the alarming level of maternal deaths being recorded in Kirundo and Muyinga hospitals as of recent, IHPB with other PNSR partners (WHO, UNFPA) supported the capacity building of providers from hospitals in Muyinga and Kirundo on life-saving services using principles of basic and comprehensive emergency obstetric and neonatal care through an eight-week mentoring program exercise. The mentoring program consisted in bringing gynecologists, midwives, and anesthesiologists to train and coach Muyinga and Kirundo hospital staff in offering the nine comprehensive emergency obstetric and neonatal care (CEmONC) services which are: parenteral treatment of infections (antibiotics), parenteral treatment of pre-eclampsia/eclampsia (anticonvulsants), parenteral treatment of postpartum hemorrhage (uterotonics), manual removal of the placenta, manual vacuum aspiration of retained products of conception, vacuum assisted delivery, newborn resuscitation, surgical capabilities (C-section), and blood . The methodology of the exercise consists in power point presentation, case review, practical exercise on mannequin. Participants observe the specialist performing some techniques, and then perform the same techniques themselves under the specialist’s supervision and coaching. During the eight-week period of the mentoring exercise, a total of 243 caesarian section were performed (Kirundo:199 and Muyinga:44). Some other surgical procedures were also performed, including 3 hysterectomies, 1 myomectomy, and 3 laparotomies.
Conducted formative supervision on BEmONC for 6 health facilities in Karusi: In collaboration with PNSR, IHPB organized a supervision where national trainers went to see how BEmONC services are provided. This was also an opportunity for newly trained supervisors from Karusi to conduct supervision under their trainers’ support. A total of 8 health providers from 6 health facilities were supervised (Bugenyuzi HC:2, Rudaraza HC:1, Buhindye HC:1, Rusi HC:2, Gisimbawaga HC:1, Buhiga hospital:1).
A supervision tool developed by PNSR was used with a focus on 4 main aspects: infrastructure, equipment, drugs, and BEmONC services availability for which a score was set per the situation as shown in the graph below:
Results from BEmONC supervision in 6 HF in Karusi 100
50
0 RUSI HC BUHIGA GISIMBAWAGA BUGENYUZI HC RUDARAZA HC BUHINDYE HC hospital HC
infrastructure equipment drugs avalability BEmONC services availability
The main findings in terms of challenges were: • While all facilities have adequate infrastructure, drug availability is a problem in every facility. One of the health centers supervised did not have “lifesaving drugs” on hand at all, and others
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were general deficient. IHPB will work closely with the facility to change the situation. The work will consist of coaching health providers to purchase those drugs available at the national level and the avoidance of stock-out through quantification and forecasting. The health system strengthening team will be involved through its supply chain management expert. • Lack of some materials (syringes for manual vacuum aspiration, ventouse). For this challenge, IHPB gave feedback to PNSR and the available materials are sent regularly to health facilities. IHPB will continue to check if health facilities are equipped and, if needed, we will support in transportation of those materials • Health providers are not providing regular BEmONC services because there are not many cases which need to be managed as emergency, and they easily forget how to provide services. IHPB will continue to organize formative supervisions in partnership with PNSR using anatomic models.
Beside this specific supervision, IHPB also conducted integrated supervisions. In Muyinga HD, 4 health center were supervised (Nyaruhengeri, Muramba, Rugongo, and Kibimba HC) on vaccination, maternity, and post-training follow-up. In Kayanza HD, 8 health centers (Ryamukona, Rwegura, Rubura, Rugazi, Kabarore, Jene, Mubuga, and Remera) were supervised on HIV, maternity, and supply chain related services. It was noticed that every woman received oxytocin for the AMTSL and the drug was available. The main finding in terms of gaps during these supervisions were: A partogram was not used in all facilities. So supervisors took time to review how partograms are used. Algorithms on AMTSL are not used in delivery rooms and supervisors fixed the algorithm that were already available in health centers. There were stock-outs of magnesium sulfate in some health centers. Health providers explained that they do not buy the drug because they are not cases of preeclampsia or eclampsia in health centers. Supervisors insist upon having the drug in health centers in case of emergency.
Conduct training of trainers on EONC for Kirundo and Kayanza: IHPB planned to conduct this activity during this quarter but the training, as other activities, was postponed due to fact that there was a malaria epidemic situation in the country.
Organized workshop to sensitize CHWs on danger signs during pregnancy: IHPB developed materials on the “pregnant women” life stage for community field activities, with specific messages related to danger signs during pregnancy. During this quarter, the SBCC team continued to organize two-day training sessions on interpersonal communication whereby CHWs were also sensitized on danger signs during pregnancy. All the CHWs in the intervention area are now trained and every trained CHW has BCC materials (flip chart, leaflet, and booklet) for life stage 1 related to pregnant woman for use during home visits.
Equip Ngozi Nursing School for EONC and BEmONC: during this quarter, IHPB and PNSR visited the nursing school of Ngozi to discuss the feasibility of equipping the school to become a training center on BEmONC and EONC. The school authorities were supportive of the initiative and the room to equip was identified. The process of equipping the space with anatomic models is underway. The models have been purchased and are due to arrive in the coming weeks. As the room identified needed minor renovation, IHPB is in
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the process of finding a local service provider for minor renovations such as painting, and the replacement of broken windows.
Progress and discussion on maternal and neonatal health indicators Indicator Target Achieved to date FY2017 Oct - Dec 2016 January February March 2017 Total 2017 2017 2.0.5 Number/percent of 80 % 91% 98.12% 98.95% 95.33% women giving birth who (17,894/19,627) 6,995/7,129 (6,713/6,784) (8,118/8,516) 94.45%21 received uterotonic in (39,720/33,056) the third stage of labor through USG-supported programs Number of people 69 59/69(86%) 0 0 0 59/69(86%) 22 trained in maternal /newborn through Burundi MCH supported programs Number of USG- NA 41.7%24 41.7% 41.7% 41.7% 41.7%25 supported facilities that provide appropriate life-saving maternity care (This will be defined as seven signal functions for BEmONC and nine signal functions for CEmONC 23
Number of women giving birth who received uterotonic in the third stage of labor through USG- supported programs The above table shows that during the second quarter of Y4, available data show that a total of 21,826 women (97.31% of women who delivered in health facilities) received uterotonic during the third phase of labor to prevent postpartum hemorrhage. This situation is a result of close follow-up through joint integrated supervision conducted by IHPB and health district supervisors in health facilities. 94.45% of
21 IHPB data base 22 Achieved in Q1 23 Reporting Frequency: Baseline, Mid-term, End-term 24 Report from data collection conducted in 36 health facilities. 25 Report from data collection conducted in 36 health facilities.
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women who delivered in health facilities received uterotonics during the period October 2016 to March 31, 2017.
Number of people trained in maternal /newborn through Burundi MCH supported programs No training was conducted this quarter because of the malaria epidemic declared by the Minister of Public Health and the Fight against AIDS. All other malaria non-related activities were postponed until the epidemic situation is under control.
Number of USG-supported facilities that provide appropriate life-saving maternity care (defined as seven signal functions for BEmONC and nine signal functions for CEmONC) The SARA identified 38 health facilities providing life-saving maternity care as defined by the seven signal functions for BEmONC and the nine functions for CEmONC. IHPB conducted training on BEmONC for a total of 86 health providers from 43 health facilities in Karusi, Kirundo, and Muyinga. From a small data collection conducted during Y3, it was noticed that 41.7% (15/36) of health facilities targeted are offering lifesaving maternity care as defined above. IHPB continues to conduct supervision for the 86 health providers trained in order make sure that quality services are available. The endline survey will better inform our achievement on this indicator.
Reproductive Health Strategy Planned for January - March 2017 Comments Achievement and results
Conduct integrated supervision visit for FP Ongoing activity 21 HFs (12%) supervised in integrated activities supervision sessions in Muyinga, Kayanza, Kirundo, Karusi Hold quarterly supervisory meetings of Ongoing activity Quarterly meetings to be conducted in community distributors (CHWs) documenting Muyinga, Kayanza, and Kirundo learning and improvement including activities related review26 Provide CBD kits to the CHWs trained Achieved activity 2,037CBD kits provided in February for all trained CHWs in 8 new districts
Conduct awareness sessions by theatre Ongoing activity 6 sessions conducted in Kayanza, groups in new districts Musema, Gahombo, Buhiga, and Nyabikere HDs Conduct video awareness sessions in health Achieved activity 520 DVD distributed to 65 HFs with facilities and communities electricity, and video awareness conducted in waiting areas of each HF Increase the contraceptive method mix Ongoing activity 18 sessions conducted by integrated counseled about/or provided by integrated mobile health teams in Kirundo, mobile health teams Kayanza, and Karusi health provinces Identify the demand and the potential Ongoing activity 10 providers trained in vasectomy in
26 Previously organized monthly, those meetings are held quarterly due to integration process
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Planned for January - March 2017 Comments Achievement and results strategies for quality counseling and service Kayanza and 74 vasectomies delivery of male sterilization performed during and after training session Addition of evidence-based activities in Postponed Conflict of agenda existing youth-friendly health facilities Strengthen existing relationships for youth- Postponed Conflict of agenda friendly sensitization in secondary schools
IHPB conducted many activities and realized many achievements during the January to March quarter period. Community activities realized greater improvement than clinical activities, and the CBD activities saw greater improved compared to previous quarters. This was due to the effort made by 2,037 CHWs trained on CBD in the October- November-December period. The achievements are detailed below.
Conduct quarterly follow-up on reproductive health activities at the health facility level During the January-March 2017 quarter, in partnership with health district teams, IHPB conducted supervision in 21 health facilities. The supervision sessions included family planning activities, malaria, health facility administration, maternal and child health activities, and the major activities focused on family planning and youth and adolescent-friendly services. During these activities, the supervision team saw improvement in adherence to contraceptive methods particularly after launching strategic activities in March (e.g. the beginning of focus groups to recruitnew clients in Kayanza) to address rumors related to family planning (such as the migration of implants towards the brain or heart). To strengthen activities, the project has organized a field trip for Kayanza health province authorities to visit Ngozi, a province that has some of the best family planning indicators in Burundi. The project held a workshop to address the socio-cultural and religious barriers to adherence to family planning methods, in partnership with administrative, religious, and health authorities. The workshop recommended to health centers’ providers to adopt the “focus group” strategy in sensitization sessions on long-acting contraceptive methods. CHWs will continue to develop new strategies to organize regular sensitization and household visits focusing on long-acting methods. In partnership with the PNSR team and the health district teams, IHPB conducted a post training supervision for eight health providers (four doctors and four operating room nurses (one male and 3 female) trained in vasectomy from Kayanza, Musema and Gahombo District hospital; 23 cases of vasectomy were undergone since the training session and all trainees are performed.
Hold quarterly supervisory meetings of community distributors (CHWs) documenting learning and improvement During this quarter, IHPB organized quarterly supervisory meetings of CHWs to train them on the implementation of community-based distribution of contraceptives (CBDCs) in Muyinga, Kayanza, and Kirundo. Attendees by commune are detailed in the table below:
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Province Commune Male CHWs Female CHWs Total CHWs Muyinga Buhinyuza 46 37 83 Butihinda 46 33 79 Gashoho 46 36 82 Gasorwe 65 31 96 Giteranyi 87 58 145 Muyinga 102 81 183 Mwakiro 84 61 145 TOTAL MUYINGA 476 337 813 Kayanza Butaganzwa 33 40 73 Matongo 40 63 103 Muruta 43 42 85 Rango 50 56 106 Gahombo 39 41 80 Muhanga 55 38 93 Gatara 41 60 101 Kayanza 81 63 144 Kabarore 58 54 112 TOTAL KAYANZA 440 457 897 Kirundo Bugabira 58 65 123 Kirundo 60 63 123 Bwambarangwe 49 47 96 Gitobe 51 38 89 Vumbi 77 70 147 Busoni 99 78 177 TOTAL KIRUNDO 394 361 755
All CHWS who attended the supervisory meeting discussed DBC, PECADOM, and ICCM items. It has been an opportunity for data collection and analysis related to community FP activities. The attendees received refresher training on the distribution of some FP methods at the community level. Results related to CBD activities in the four provinces are as follows:
Raising awareness activities Kayanza Muyinga Karusi Kirundo Total conducted Households visited 20,470 11,188 21,826 11,231 64,715 # People reached 137,417 48,830 52,399 60,996 299,642 FP commodities distributed Male Condoms 85,470 12,896 22,152 50,600 171,118 Female condoms 624 120 52 389 1,185 Pills 2,845 35 2,217 1,314 6,411 People referred to health facilities 1,260 844 674 1,164 3,942 for modern contraception
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Provide equipment to trained CHWs During this, IHPB distributed CBD kits for 2,037 CHWs from eight new health districts who were trained in the October to December period on CBD of contraceptives. Each kit includes a bag for transportation of CBD commodities, data collection notebooks, boots, and an umbrella.
Conduct awareness sessions by theater groups in new districts With the objective to address rumors affecting long-acting and short-term family planning (FP) methods and to increase adherence to contraceptive methods, IHPB, in partnership with Gahombo and Musema HDs, organized six separate FP awareness sessions by using a theatre group in nine collines that fall in the catchment areas of three public facilities (Gakenke, Ngoro and Gaheta) and one faith-based health facility (Gatara). These facilities were targeted because of low rates of adherence to FP methods. 1,291 people (612 males and 679 females) were reached with FP messages. In Kayanza HD, IHPB, in partnership with local administration and the district teams, organized six awareness sessions by theatre group in six sites making up the catchment area of two public health facilities (Kabarore and Nyabihogo); 1,495 (776 male and 719 female) attended and were reached with family planning messages. In Buhiga HD, IHPB organized a three-day FP awareness creation event using a local theatre group targeting Gitaramuka, Bugenyuzi, and Buhindye collines, the catchment areas of two faith-based health facilities (Gitaramuka and Bugenyuzi) and one public health facility (Buhindye HF) with low rates of adherence to FP methods and covered by faith-based health centers. 1,520 (453 males and 1,067 females) attended. The objective was to raise FP indicators in the respective health facilities by sensitizing community members on FP adherence through theatrical presentations, followed by an interactive discussion addressing rumors related to all FP methods.
Conduct video awareness sessions in health facilities and communities During this quarter, IHPB gave 520 DVDs to 65 health facilities to help them conduct videos sessions in waiting rooms. There are eight videos on reproductive health, youth-friendly services, and FP which were duplicated into 520 copies total and were distributed in February 2017 to heath facilities with electricity. In Muyinga, six health facilities (Mwakiro, Kinazi, Kinyami, Giteranyi, Nyagatovu, and Nyungu) received the DVDs and opted to play them every day in their waiting rooms. In Kirundo, two HFs (Gitobe and Buhoro) have opted for the same strategy. In Kayanza, 35 health facilities received the DVDs and each of them showed two movies per month in waiting rooms (70 movies in the province).
Expand the contraceptive method mix counseled about/or provided by integrated mobile health teams During this quarter, IHPB, in partnership with health facility teams, conducted integrated mobile team activities in eight collines (Rungazi, Kajage, Rutamba, Gaturanda, Nyakarama, Gaharo, Nkoronko, and and Cumba-). All are health facilities with low rates of FP adherence. 1,040 (347 male and 693 female) attended and were reached with FP messages. Of these, 53 females accepted and received FP methods: pills (12), condoms (2) and injectables (39). At Mutarishwa site of Bugorora health center (Mukenke HD), a catchment area with a low FP adherence rate, an integrated mobile strategy was introduced. Of the 229 people (101 male and 128 female) who attended, 66 (44 female and 22 male) accepted to be counseled on FP methods: four females accepted and received injectables.. IHPB organized integrated outreach mobile team activities in four collines (Matonyanga, Namba, Rwimbogo and Runyinya) in Mukerwa HF’s
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catchment area. 324 people (126 male and 198 female) attended and were reached with FP messages. 31 peoples (18 new acceptors of methods and 13 reminders) accepted and received FP methods (pills:6, injectable:20, and condoms:5).. In Kayanza, integrated mobile teams’ activities to be conducted in seven collines in Museuma HD (Rruhinga, Nyabibuye, Munyinya, Caro, Gatare, Kiramahira, and Gasenyi). 1,165 people (453 male and 712 female) attended the awareness sessions. 99 people (7 male and 92 female) received FP counseling 93 (6 male and 87 female) accepted and received contraceptive methods: 19 implants, 49 injectable, 19 females received pills, and 6 men received vasectomies at Musema hospital.
Identify the demand and the potential strategies for quality counseling and service delivery of male sterilization The National program of Reproductive Health plan is to have a minimum of two doctors per district hospital trained in voluntary contraception surgery. Per the routine data from the district and provincial levels, there are some district hospitals that do not meet this requirement, resulting in unmet need in the community. In Kayanza province, 100 men requested the sterilization, but there was only one doctor who is trained in male sterilization surgery. There are no doctors trained in tubal ligation. During this quarter, IHPB conducted a five-day training on no-scalpel vasectomy attended by 5 doctors and 5 operating room nurses that came from the following hospitals: Kayanza (2), Musema (4), and Gahombo (2), and Kirundo (2). During practical training, 50 men and one woman underwent voluntary sterilization. A post-training supervision for eight health providers trained in vasectomy from Kayanza, Musema, and Gahombo district hospitals has been conducted and 23 vasectomies were performed in all three hospitals since the training session. None of the doctors trained in vasectomy are trained in tubal ligation. An outreach strategy in vasectomy at the health center level is waiting to be implemented in some HCs that have more advanced infrastructure and personnel in Kayanza province. In accordance with the PNSR,the health district team will able to reach clients who live far away from the district hospital with tubal ligation services soon.
Addition of evidence – based activities in existing youth friendly health facilities This activity was scheduled in the January – March 2017 quarter but has been postponed because of the current malaria epidemic. A workshop meeting for youth-friendly activity networking committee members from the youth-friendly health facilities is waiting to be conducted in the four IHPB intervention provinces.
Strengthen existing relationships for youth friendly sensitization in secondary schools Sensitization in secondary schools is a joint activity involving the Ministry of Public Health and the Fight against AIDS, and the Ministry of Education. As IHPB does not work with the educational authorities, to organize such an activity requires collaborative contact with all stakeholders. Contacts have been made at the school, communal, and provincial levels of the educational sector and the project staff have managed to collaborate at the top level of the Ministry of Education before beginning sensitization sessions.
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Progress and discussion on FP indicators Target Contribution of each method to couple years protection – Indicator FY 2017 achieved to date FY 2017 October – January February March27 Total December 2016 2.0.1. Couple Years 153,795 Protection in USG supported programs (USAID 3.1.7.1-1) Pills 25,236 2,065 1,322 N/A 28,623 Injectable 53,633 10,454 7,884 N/A 71,971 Male Condom 50,005 26,370 23,158 N/A 99,533 Female condom 639 848 430 N/A 1,917 IUD 949 689 599 N/A 2,237 Implant (Jadelle) 5,778 4,039 3,529 N/A 13,346 Male sterilization 63 14 0 N/A 77 Female sterilization 66 35 4 N/A 105 2.2.2. Percent of USG- assisted service delivery 100% 82% 159/183 159/183 159/183 sites providing family (86.9%) (86.9%) (86.9%) planning (FP) counseling and/or services (USAID 3.1.7.1-3)
Couple Years Protection in USG supported programs This indicator is reported annually. Each method distributed is expected to contribute to increased couple years’ protection with a specific coefficient. Due to the data channel, we did not have data for March, and it will be available within the first week of the May. We noticed low cases of injectable and pills during this period, which is probably due to reporting system that has been changing some data items and some data is not available in the DHS2 at the reporting time. Some strategies are being implemented at the community level to strengthen the community-based distribution of contraceptives through which FP messages. Those are awareness sessions by theatre groups, the integrated mobile team activities which combine counseling and family planning commodities provision, and information given by community health workers during household visits and meetings.
Percent of USG-assisted service delivery sites providing family planning (FP) counseling and/or services As of February 2017, 86.9% of facilities (public, private, and faith-based) delivered counseling and/or contraceptive methods. There is improvement from the end of last quarter to February 2017 achievement (while in the previous quarter we achieved 82.1%), and new facilities have opened the
27 March data not available (NA) as of writing this quarterly report.
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family planning services during the reporting period. The indicator is calculated considering health facilities reporting methods distributed, while we include faith-based facilities on the denominator, which do not offer modern FP methods. With the objective to reach 37% (an additional 5%) at the end of project, we have already added 54.9% to the baseline of 32%. Based on this achievement, the ME component manager would review the target indicator.
HIV/AIDS Strategy Planned for January-March 2017 Achievement Comments and results Organize 60 outreach HTC sessions in hotspots Achieved 492 outreach HTC sessions organized Contract PLHIV networks to sensitize persons On track Draft scope of work available and with high risk of HIV to HTC in hotspots, request for approval submitted to participate in HTC sessions, provide support to USAID HIV infected persons and help their integration in care Contract civil society organizations (CSO) to On track One CSO contracted in Kirundo create multipoint HTC in popular and poor (ANSS). For Kayanza province, draft neighborhoods of Kayanza and Kirundo urban scope of work is available and request for approval submitted to USAID Test for HIV a household of HIV positive patient Achieved 50 ART sites implement index-testing (index-testing); 8 ART sites implement index- testing 8 HTC services sites prioritize HIV test for TB and Achieved 95 HTC services sites provide HTC or suspicious TB infection patient, malnourished services prioritizing of TB and or children, STI cases and all patients with HIV suspicious TB infection patient, related signs in curative consultations; malnourished children, STI cases and all patients with HIV related signs in curative consultations Perform 88 formative supervision visits to Achieved 95 formative supervision visits sensitize and enable healthcare providers performed Organize a five-day training session for 109 Partially A five-day training session organized health care providers and supervisors on the new achieved for 23 physicians. guidelines on ART Support health facilities and districts through Achieved Seven HDs and five hospitals IKGs for running costs to provide quality and benefited of In-Kind Grants to provide integrated HIV services quality and integrated HIV services Organize support groups to maintain adherence Achieved Support groups organized in 10 ART on ARV and promote positive prevention for sites PLHIV in 8 ART sites Maintain the contract with the private laboratory Achieved Contract maintained and DBS and for early diagnosis of HIV in infant and viral Viral load samples are examined by measure the Centre de Recherche virologique et de Diagnostic Biologique (CRDBi) Organize outreach HTC sessions in hotspots In collaboration with the Kayanza and Kirundo provincial and district health offices, IHPB supported outreach HTC sessions in hotspots to identify populations at high risk of HIV infection (female sex workers
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and men who have sex with men), as well as among other groups with higher risk of HIV transmission (single mothers, separated couples, men and women with sexual multiple partners, etc.). Of the 13,243 individuals (5,609 male and 7,634 female) that volunteered to be tested through this outreach, all 478 (196 male and 262 female) that were found positive were referred to an ART site for enrollment. This is a 3.6% rate of HIV+ result. Compared to the 1.4% prevalence in the general population, this means that the team carefully selected hot spot areas and high risk groups to do the testing.
Test for HIV a household of HIV positive patient (index-testing) In collaboration with health facilities, IHPB supported index testing (among families of PLWHA) in 50 ART sites– of the 4,193 that volunteered to be tested (1,927 male and 2,166 female), 209 tested positive (80 male and 129 female) and were referred to ART sites. Here the rate of HIV+ results is almost 5%; more than 3 times the sero-prevalence in the general population.
Prioritize HIV test for TB and or suspicious TB infection patient, malnourished children, STI cases and all patients with HIV related signs in curative consultations In collaboration with health districts, IHPB supported Provider-Initiated Testing and Counseling targeting TB and/or suspicious TB infection patients, malnourished children, STI cases, HIV-exposed infant and all patients with HIV related signs- of the 661 patients that volunteered to be tested (245 male and 416 female), the 26 that tested positive (7 male and 19 female) were referred to ART sites.
Perform formative supervision visits to sensitize and enable healthcare providers In partnership with Health Districts, IHPB conducted 95 supervision visits in 72 ART sites. These include mentoring visits to enable nurses prescribing and following up antiretroviral therapy in decentralized ART sites and 516 new PLHIV (225 male and 291 female) have been enrolled on ART.
Organize a five-day training session for 109 health care providers and supervisors on the new guidelines on ART In collaboration with the Kayanza and Kirundo provincial and district health offices, IHPB organized a five- day training session for 23 healthcare providers - doctors (21 male and 2 female) on new national guidelines for HIV care and prevention using anti-retrovirals.
Support health facilities and districts through IKGs for running costs to provide quality and integrated HIV services; In partnership with Health Districts and through IKGs, IHPB supported transportation of 343 DBS and 2,104 Viral load samples from health facilities to the Centre de Recherche de Virologie et de Diagnostic Biologique (CRDBi).
Organize support groups to maintain adherence on ARV and promote positive prevention for PLHIV In partnership with 10 ART sites, IHPB organized separate adherence counseling sessions for 264 PLHIV (114 males and 150 females) with the objective of improving ART adherence and follow up.
Maintain the contract with the private laboratory for early diagnosis of HIV in infant and viral measure Thanks to the private laboratory CRDBi, 2,104 Viral Load and 343 DBS sample have been examined.
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Discussion and Analysis on PEPFAR (Refer to table in Annex II)
Number of individuals who received HTC services and their test results Of the 39,387 individuals targeted in Kayanza and 38,118 in Kirundo, individuals that received HTC services are respectively 92,387 (235%) and 75,317 (198%).
Number of HIV positive individuals Of the 701 individuals targeted in Kayanza and 706 in Kirundo, individuals tested HIV positive are respectively 717 (102%) and 1,695 (140%).
Number of HIV-positive pregnant women who received antiretroviral to reduce risk of mother-to-child- transmission (MTCT) during pregnancy and delivery Of the 77 targeted in Kayanza and 257 in Kirundo, HIV-positive pregnant women who received antiretroviral to reduce risk of mother-to-child-transmission (MTCT) during pregnancy and delivery are respectively 104 (135%) and 336 (131%).
Number of infants who had a virologic HIV test within 12 months of birth during the reporting period Of the 77 targeted in Kayanza and 257 in Kirundo, HIV-exposed children whom a virologic HIV test have been done are respectively 102 (132%) and 418 (163%). Achievements are over expectations due to strengthened logistics for transportation of DBS samples and getting back of results between health facilities and specialized laboratories.
Number of people receiving post-GBV care The progress for this indicator exceeds October 2016 - March 2017 expected cases of sexual-based violence victims: 68/55 (124%). IHPB’s support for GBV survivors at health facilities will continue.
Number of HIV-positive adults and children newly enrolled in clinical care The FY 2017 mid-term’s target for newly adults and children enrolled in clinical care is 701 (Kayanza) and 706 (Kirundo). Achievements are 614 (88%) patients enrolled in care in Kayanza and 1,305 (185%) in Kirundo. Nonetheless, Kayanza and Kirundo combined make achievement of 136% (1,919/1407). Given that Kayanza has achieved the number of individuals tested HIV positive, the linkage between HTC services and HIV care is challenging. To increase HIV service demand, IHPB will collaborate with PLHIV network to track patients who missed-appointments.
Number of HIV-positive adults and children who received at least one of the following: clinical assessment (WHO staging) OR CD4 count OR viral load (DSD). Of the 5,329 targeted in Kayanza and 3,481 in Kirundo, 3,169 (59% -Kayanza) and 5,714 (164% -Kirundo) HIV-positive adults and children are enrolled in care that is 8,810 out of 8,883 (101%) both Kayanza and Kirundo combined. Kayanza has difficulties to find out HIV positive people and enroll them on treatment. Better identification of hotspots in Kayanza will improve yield of HIV positive individuals. Moreover, IHPB will work with community health workers and PLHIV network in communities to retrieve missed- appointment patients. At last, mentoring supported health facilities to provide ART will be continued.
Number of adults and children newly enrolled on ART Overall excellent performance 2,125 /1,363 (156%) but fluctuation between provinces is noted 681/906: 75% (Kayanza) and 1,444/457: 316% (Kirundo). This weak progress in Kayanza is due to the fact of not finding enough HIV positive cases, less utilization of HIV services and poor coverage of ART sites. Combined strategies such as index trailing approach to reach partners of those found HIV positive, outreach HTC services, collaboration with PLHIV network and community health workers to retrieve
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missed-appointment patients as well as task-shifting for ART sites at scale will produce greater results in Kayanza.
Number of adults and children receiving ART [current] (TA-only) Of the 4,518 targeted in Kayanza and 3,285 in Kirundo, 3,050 (68 %) (Kayanza) and 5,278 (161%) (Kirundo) of adults and children are receiving ART. Overall performance is 102% (8,328/7,803). This weak progress in Kayanza is because the number of adults and children newly enrolled in care and treatment is very small. As mentioned above, combined strategies such as index trailing approach to reach partners of those found HIV positive, outreach HTC services, collaboration with PLHIV network network and community health workers to retrieve missed-appointment patients aa well as task-shifting for ART sites at scale will improve results.
Number of PLHIV followed up screened for tuberculosis (TB_SCREEN) Of the 3,169 and 5,714 PLHIV in care respectively in Kayanza and Kirundo, those screened for tuberculosis represent 81% (2,567/3,169-Kayanza) and 51% (2,908/5,714-Kirundo). In partnership with health districts, IHPB will continue to sensitize health providers for TB screening at each medical visit of PLHIV.
Number of registered new and relapsed TB cases with documented HIV status, during the reporting period. of PLHIV treated for tuberculosis (TB_STAT) Of 139 targeted in Kayanza and 287 in Kirundo, registered TB cases with documented HIV status are respectively 117 (84%) and 246 (86%). Integrating HIV screening in TB clinics by increased awareness of health providers will improve results.
Number of HIV patients with tuberculosis enrolled on ART (TB_ART) Of the 20 targeted in Kayanza and 15 in Kirundo, PLHIV with tuberculosis enrolled on ART are respectively 12 (60%) and 14 (93%). Continued task-shifting for ART sites at scale and systematic HIV test to TB or suspicious TB patients in targeted provinces will lead to greater results especially in Kayanza province.
Progress and discussions on HIV/AIDS project indicator
Indicator 1.3.4: Number of persons receiving post-GBV care (PEP, Post-rape care, other post-GBV care) [GEND_GBV]
Although achievements are satisfying, yearly targets are not reached -except the FY 2015 because only 76% of health facilities offer post exposure prophylaxis to GBV survivors. In addition, community interventions are not effective to improve health care demand. Achievements by mid-term of the FY 2017 are 40% (68/170). Continued decentralization of ART, integration of GBV package of services in health centers and community GBV-related activities will increase results by FY 2017 and beyond.
Indicator 2.0.7 & 2.0.8: Percent of pregnant women with known status [PEPFAR PMTCT_STAT_DSD] and Percent of pregnant women who received antiretrovirals to reduce the risk of mother-to-child-transmission (MTCT) during pregnancy and delivery [PEPFAR PMTCT_ARV_DSD]
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PMTCT 96% 95% 95% 95% 95% 94% 94% 92% 93% 90% 91% 89% 89% 88% 87% 86% 85% 84% 83% 82% 80% 78% 76% FY 2014 FY 2015 FY 2016 FY 2017 (Oct-Mars 2017)
2.0.7 [PEPFAR PMTCT_STAT_DSD] 2.0.8 [PEPFAR PMTCT_ARV_DSD] Target
We note continuous progress over the fiscal years resulting to the overreach of FY 2015 target for the pregnant women who received antiretrovirals to reduce the risk of mother-to-child-transmission (MTCT) during pregnancy and delivery. However, the proportion of pregnant women knowing their HIV status is still under expectations (90% counting for the six-months of the FY 2016) due to persistent HIV test refusal among pregnant women. The lack of support by their partners and social discrimination are mainly reasons. Intensifying HIV awareness among partners is one of the strategies to enhance acceptance of HIV testing among pregnant women that IHPB is supporting
Indicator 2.0.9: Number of individuals who received Testing and Counseling (T&C) services for HIV and received their results [PEPFAR HTC_TST_DSD]
Individuals who received Testing and Counseling (T&C) services for HIV We have overall good 400,000 367,842 357,023 utilization of HIV testing and 332844 350,000 321944 counseling services thanks to 300475 provider-initiated HIV testing 300,000 and counseling. As of FY 2016, 250,000 PEPFAR is focusing on people 200,000 167704 at high risk of HIV infection 155008 /transmission and targets have 150,000 138048 been diminished. Due to great 100,000 acceptance of HTC services targets are always 50,000 overachieved. 0 FY 2014 FY 2015 FY 2016 FY 2017 (Oct- Mars 2017)
Target Achievement
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Indicator 2.0.10 and 2.0.13: Number of HIV-infected adults and children who received at least one of the following during the reporting period: clinical staging or CD4 count or viral load [PEPFAR CARE_CURR_DSD] and Number of adults and children receiving ART (TA only) [PEPFAR TX_CURR_TA]
Although PLHIV in care constantly is increasing, the targets remain hard to meet during FY 2014, 2015 and 2016 shown in chart below. In FY 2016, folllowing decision by USAID to focus activities only in Kayanza and Kirundo, resulted in decrease in total number of PLWHIV in care. Achievements in midst of the FY 2017, 87% (8,883/10,216) and 93% (8,328/8,580) respectively related to HIV-infected adults and children in care and adults and children receiving ART indicators provide hope to reach the FY 2017 targets. Strategies such as HTC services focused on individual at high risk of HIV in mobile and static HTC approaches as well as mentoring health centers and performing task shifting for antiretroviral therapy will be intensively implemented.
Care and Antiretroviral Therapy 16000
14000 13544 13077 12539
12000
10071 10216 10000 88839000 8435 8328 8033 8000 7000 7200 6500 6595 6025 6211 6000
4000
2000
0 FY 2014 FY 2015 FY 2016 FY 2017 (Oct-Mars 2017)
Target 2.0.10 [PEPFAR CARE_CURR_DSD] Target 2.0.13 [Tx current]
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In addition, improvements are noticed in terms of the effectiveness follow up of antiretroviral therapy. While none viral load assessment had been performed in FY2015, progress had been made in FY 2016 and 44% (2,724/6,211) of PLHIV on ART benefited from viral load assessment. As shown by the chart below, major achievements (6,516 / 8,328 (78%) are observed within FY 2017 thanks to reinforced logistics of Viral load samples transportation from health facilities to specialized laboratories. 93% (6032/6516) of viral load tests confirmed suppression.
Tend 90,90,90
10,000 8883 8328 7,689 8,033 8,000 6516 6211 6032 6,000 3861 4,000 2724 2519 2,000 0 0 0 FY 2015 FY 2016 FY 2017 (Oct-Mars 2017)
2.0.10 [PEPFAR CARE_CURR_DSD] 2.0.13 [Tx current] VL Test VL suppressed
Besides, application of new national guidelines on ART and test and treat strategy -initiation of ARV regardless the number of CD4 count cells is resulting in an increased number of PLHIV enrolled on ARV. Period from October-March 2017 marks low gap of diagnosed HIV positive persons who have not commenced yet antiretrovirals as illustrated in the chart below. 93.6% (1,113/1,189) of individuals tested HIV positive were enrolled on ART in from October 2016 to March FY 2017 while in FY 2016, 63.8% (2,165/3,392) were enrolled.
HIV treatment cascade 4000 3392 2680 1782 2165 2000 1068 1189 928 1113 330 0 FY 2015 FY 2016 FY 2017 (Oct-Mars 2017)
Number of HIV positive individuals Number of HIV-positive adults and children newly enrolled in clinical care Number of adults and children newly enrolled on ART
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Indicator 2.0.11: Percentage of PLHIV in HIV clinical care who were screened for TB symptoms at the last clinical visit [PEPFAR TB_SCREEN] PLHIV in HIV clinical care screened for TB symptoms IHPB support increased screening TB symptoms awareness of personnel in clinical care centers. 100% 80% 61.70% 62.00% And the number of PLHIV in HIV clinical care 42.10% 50% 50% 30% screened for TB symptoms at the last clinical 20% 14.50% visit is ascending: 14.50% (FY2014), 42.10% (FY 0% 2015), 61.70% (FY 2016) and 62% (FY 2017 Oct- FY 2014 FY 2015 FY 2016 FY 2017 (Oct- March 2017) Mars 2017)
Target Achievement
2.0.12 Percent of infants born to HIV-positive women that receive a virologic HIV test done within 12 months of birth [PEPFAR PMTCT_EID]
Percent of infants born to HIV-positive Poor achievements for FY2014 and FY 2015 are women that receive a virologic HIV test due to repetitive breakdowns of machine at done within 12 months of birth national laboratory. The contracting of private 75% 80% 70% 61% laboratory as of FY 2016 while national ones are 60% 50% 40% 45% not functioning allows better results. 40% 20% 11.60% 0% 0% FY 2014 FY 2015 FY 2016 FY 2017 (Oct- Mars 2017)
Target Achievement
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Innovation study: Pilot of Integration of Prevention of Mother-to-Child Transmission (PMTCT) and Early Infant Diagnosis (EID) of HIV into Routine Newborn and Child Health Care
Planned for January-March Achievement Comments 2017 and Results Conduct meeting with the TAG Achieved Meeting was conducted on February 21, 2017
Conduct meetings with BPS Achieved Meeting was conducted on January 17, 2017
Conduct data collection and Ongoing 50 mother-child pairs already enrolled in 14 study supervision intervention sites
The implementation and follow-up of the pilot study for the integration of PMTCT /EID into MNCH services went on during the January-March2017 quarter. Technical Advisory Group (TAG) and BPS meetings, sites’ supervisions and data collection were conducted.
Conduct meeting with the TAG
On February 21, 2017, the innovative study Technical Advisory Group held its second quarterly meeting. Concerning the monitor of the Integration of PMTC/EID in routine health care services study progress, some key points were discussed: Feedback from the January 2017 local stockholders meeting in which partners were informed on the number of mother/infant couples enrolled site by site, challenges encountered and strategies implemented to overcome challenges; A schedule of joint supervisions and training sessions on the new PMTCT protocol for all providers was planned; and A detailed analysis of each health facility to identify challenges and determine solutions going forward.
Keys problems pointed out were: (i) insufficient quantity of test kits provided to Kayanza District for pregnant women, PITC and community HIV testing; (ii) field visits not announced early enough to allow the TAG to request for field travel authorizations; (iii) by February the total number of cases enrolled was at 39 whereas it was expected to have been 100 by end of April 2017.
Following discussions on the identified challenges, the TAG convened on the following key actions to undertake: Extend the period of enrollment; Invite MPHFA members of the TAG early to be part of field monitoring visits; IHPB will continue to work with the National Program for AIDS/STIs Control and the Global Health Supply Chain – Procurement and Supply Management (GHSC-PSM) for permanent availability of test kits; Strengthen the capacity of providers on the study protocol and data collection forms; Conduct regular meetings with the provincial health bureau.
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Conduct meetings with the Provincial Health Bureau (BPS) Jointly with the Kayanza provincial health bureau, IHPB organized a one-day meeting to inform all the stakeholders on the pilot study progress. The meeting offered an opportunity to present in detail the progress on each intervention site as observed during supervision visits.
About constraints on implementation of the study interventions, participants raised issues related to insufficient HIV rapid tests kits. In addition, the lack of immunization services due to broken fridges was mentioned in two sites limiting the integration of PMTCT services in Child health services. To better involve all field-based implementing partners, joint supervision timelines and a schedule of training sessions on new PMTCT guidelines were convened during the meeting.
Conduct data collection and supervision Within the framework of the pilot study progress monitoring and jointly with Kayanza health authorities, and the TAG, IHPB conducted two formative supervision visits (Feb 28-March 3 and March 27-31) which covered all the 14 pilot study health centers (Kayanza, Mubuga, Remera, Rubura, Jene, Rwegura, Kavoga, Kaborore, Rugazi, Ryamukona, Murima, Nyabihogo, Gahahe and Kabuye I).
Both sessions were based on (1) observation of the patient flow; (2) review of data collection tools (registers, file patients, mother-child cards) to check for proof of PMTCT HIV counseling and testing; (3) data cross-check by comparing study data collection forms with information in other tools (registers, patient files), and content of site-based data collection forms with entries in study specific database; (4) distribution of the new PCR algorithm and handouts on prophylactic ARVs regimen and dosage according to the new guidelines; (5) debrief of all health providers on the strengths and weaknesses identified, and develop and approve the improvement plan accordingly.
In general, supervision visits discovered that HIV testing of women in MNCH services has resumed following the availability of rapid test kits. This made it possible to implement the recommendations of the field partners and TAG meetings. In total, the 14 intervention sites of the pilot study have already enrolled 55 mother-child couples distributed as follows:
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For the upcoming quarter (April-June 2017), activities planned are: (1) jointly monthly supervisions, (2) data collection and entry in the study database, (3) field-based stakeholders meeting, (4) third meeting of the Study Technical Advisory Group; (5) request for study period extension to the Burundi Ethics Committee for one additional month.
Implement learning, documentation and dissemination activities
Planned for January - Achievement and Comments March 2017 results Organize and convene a Ongoing until May CLA scope of work finalized and shared with MoH and CLA USAID. A technical and logistical joint committee will be established in April to begin CLA preparations. The CLA event will take place in May. Transfer FAB reports into Ongoing All FABs are translated. IHPB is formatting them into a template and translate harmonized template and expects to have the final into French/English versions available by end of July 2017. Produce PPT for each Ongoing PPTs are being refined by FAB technical leads and are FAB and translate into expected to be available by May 5, 2017. English, French and Kirundi Produce FAB technical Ongoing These briefs will be drafted immediately after final briefs and translate into formatted reports are issued. French, English and Kirundi Draft conference abstract Ongoing Abstract drafted for ICASA but unable to meet or manuscript outline for submission deadline. Further abstracts and/or >2 FABs manuscripts to be drafted following Program Documentation & Dissemination workshop. Complete >4 cumulative Ongoing An introductory training was provided the project staff abstracts and prior to the program documentation and dissemination manuscript drafts workshop that will be offered with STA in May and will focus on refining key knowledge products drafted by project staff. Adapt and translate Ongoing STTA providers from FHI360 home office are closely project documentation working with project counterparts to adapt and curriculum translate the project documentation curriculum for the Burundi context. Prepare for and convene Ongoing Preparations have started; curriculum to be available in project documentation late April and workshop convene in May. workshop FAB results presented to Not yet achieved Due to malaria outbreak, this activity is postponed until 3 provinces the epidemic is under control. Schedule and distribute Not achieved This activity is postponed due to the malaria outbreak, save the date for national and may be cancelled if epidemic is not controlled conference on FABs Page | 90
Planned for January - Achievement and Comments March 2017 results soon. Produce QI newsletter Achieved QI newsletter was finalized and is awaiting final sign-off for distribution. Draft uterotonics Continuous With STA from Pathfinder, the technical brief draft is abstract or brief still under review by the technical staff Produce >1 newsletter or Achieved 7 documents were produced and have been published success story per month or are pending final sign-off for distribution: - 2 success stories on vasectomy (under review) - 1 success story on community case management of diarrhea and acute malnutrition (under review) - 1 newsletter on QI (final review) - 1 newsletter on community theater (finalized review); - 1 technical brief on Vasectomy (under review) - 1 Malaria Brief for Muyinga (published)
IHPB has continued to document and disseminate information on project implementation and achievements. During the quarter IHPB produced three success stories (one on community case management of diarrhea and acute malnutrition, and two on vasectomy); two newsletters (on QI and community theater); a technical brief on vasectomy, and a brief on the project’s response to malaria in Muyinga. One of these items has been published, and six others are pending final sign-off before disseminating.
Program Monitoring & Evaluation Planned for January-March 2017 Achievements and Comments results Prepare end-of-project surveys to be conducted Ongoing HHS protocol and questionnaire in Year 5 drafts are under review Train IHPB staff on ODK Achieved 19 IHPB staff trained (18 males and 1 female)
Prepare end-of-project surveys to be conducted in year 5 End-of-project studies planned include Household Survey (HHS), Services Availability and Readiness Assessment (SARA), Facility Qualitative Study (FQA) and Districts Health Systems Diagnostic, according to needs. Some of the studies will require three approval steps before start-up: FHI 360 PHSC, Burundi Ethics Committee and ISTEEBU approvals.
During the quarter under review, IHPB started the update of HHS protocol and data collection form (questionnaire), the informed consent forms and other related tools. The endline household survey protocol maintains the same study design, sample size, inclusion and exclusion criteria as at the baseline, of course with specific objectives and an update of the data collection form. The tools are now under review and will be submitted soon to the Protection of Human Subjects Committee of FHI 360.
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Based on the findings generated by the 2014 SARA baseline and the October 2016 midterm evaluation, the development of SARA protocol includes review of study objectives, considers a sample of health facilities instead of inclusion of all supported ones, and keeps the same study design. The facility assessment tool used in 2014 baseline SARA was reviewed to update some questions.
Nevertheless, as the Ministry of Public Health and Fight against AIDS (MPHFA) is conducting its Demographic and Health Survey (DHS) along with a SARA nationwide, IHPB may consider to drop these two studies once the national studies present useful results and indicators to inform outcomes of the project in the supported provinces.
Train IHPB staff on use of ODK Collect/Aggregate Of the end-line surveys, the FQA and District Health Systems Diagnostic tools were paper-based; the household and SARA tools are electronic form questionnaires and need minor updates. Moreover, IHPB has been working on an integrated supervision tool which would be more useful once it is electronically installed on to tablets purchased by the project for data collection.
Based on lessons learned during the baseline surveys, data collection using electronic forms presents many advantages, especially in terms of time with quick data collection, no need for separate data entry at an office, and more security of the information as the data are transmitted to the server in real time.
Thus, to better prepare the technical staff to conduct these end-of-project studies and successfully take advantage of the project tablets during supervisions, IHPB successfully conducted a four-day training on the use of ODK collect/aggregate/build. The training included forms design using XLSForms, XML conversion, loading forms to ODK Aggregate, deploying forms to mobile devices, basic data visualization using Aggregate, data transfer mechanisms with emphasis to Briefcase, and localizing forms to different languages.
This valuable training will allow M&E staff to develop electronic forms for FQA and District Health Systems Diagnostic and make minor edits to the household questionnaire and SARA as needed. The training was facilitated by the FHI 360 TechLab Program Director, Berhane Gebru; 19 participants (18 male and one female) attended the training including M&E staff (7), QI Officers (3), PTOs (3), and HSS team members (3).
Program Management Planned for January-March 2017 Achievement Comments and results Submit monthly, quarterly, and annual reports Achieved All deliverables were submitted on time Bujumbura-based staff conduct support visits Achieved Muyinga, Karusi, Kayanza and Kirundo to sub-offices offices visited Hold quarterly staff planning and Achieved In addition to the regular weekly management meetings meetings, one quarterly meeting was held Participate in collaboration, coordination and Achieved See details below partnership-building meetings at the national and field office levels Perform modifications for grantees as needed No modifications for grantees were and monitor grants implementation performed Submit monthly, quarterly, and annual reports
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During the reporting period, as required by the IHPB contract, FHI 360 submitted monthly progress reports for the months of January, February, and March. The monthly reports present achievements during the report period.
Bujumbura-based staff conduct support visits to sub-offices Senior staff including the COP, DCOP, Senior Leadership Team members, and other technical specialists and advisors conducted support supervision visits while key project activities were underway.
Hold quarterly staff planning and management meetings Under the leadership of the Chief of Party, the six-member Senior Leadership Team (COP, Deputy COP, Associate Director of Finance & Administration, Senior Technical Advisor of Health Systems Strengthening, Senior Technical Advisor of Monitoring and Evaluation, and the Integrated Services Advisor held regular meetings to make strategic decisions and monitor program implementation including coordinating with USAID, GOB entities and other USG partners. Under the leadership of a Field Office Manager, technical teams also held regular meetings with their respective staff and in their respective offices.
Participate in collaboration, coordination, and partnership-building meetings at the national and field office levels During the reporting period, IHPB fostered collaboration and coordination with USG-funded projects and organizations and MPHFA. The table below presents key events and meetings attended by project staff.
Date Title of IHPB Staff Member Theme of Meeting/Event January 5, January 11, Maternal Health Specialist Coordination meetings organized by the PNSR and January 18, 2017 for mentoring exercise organization January 15, 2017 Reproductive Health Catholic Church contributions to family Specialist planning organized by the PNSR January 18, 2017 Malaria Specialist Malaria partnership coordination meeting organized by the National Malaria Control Program January 20, 2017 COP, DCOP, Capacity Meeting with the Minister of the MPHFA Building Advisor focused on the preparation of the CLA January 24 – 27, 2017 Malaria Specialist Workshop on the development of MPHFA malaria concept note for submission to the Global Fund February 6 – 10, 2017 Malaria Specialist Workshop on the development of MPHFA malaria concept note for submission to the Global Fund February 9, 2017 Capacity Building Advisor PEPFAR workshop for preparing COP 2017 and Community Mobilization Officer February 17, 18, and 23, Malaria Specialist Development of the Burundi malaria epidemic 2017 response plan organized by the World Health Organization
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Date Title of IHPB Staff Member Theme of Meeting/Event March 1 and 9, 2017 Maternal Health Specialist Preparations for the organization of 7th African Immunization Week March 5, 2017 Malaria Specialist State of iCCM implementation organized by the DODS March 11 and 18, 2017 Malaria Specialist Preparation for World Malaria Day called by the NMCP March 13, 2017 COP and Malaria Specialist Attend declaration of malaria epidemic in Burundi organized by the MPHFA March 15, 2017 Capacity Building Advisor Meeting with the Assistant to the Minister of the MPHFA in preparation for the CLA March 16, 2017 DCOP and Malaria Socialist Mobilization of funds for the malaria epidemic organized by the MPHFA March 20, 27, 31, 2017 Malaria Specialist Monitoring and evaluation of malaria epidemic activities
Problems Encountered/Solved or Outstanding Following the outbreak of malaria that affected 11 provinces including the four IHPB provinces, the MPHFA instructed that all activities other than the emergency malaria response be suspended and that all staff (at the central and peripheral levels) should support peripheral health care providers in diagnosing and treating malaria cases. This situation delayed implementation of certain planned activities for the quarter. All IHPB vehicles (in each province) and staff were made available for the malaria response.
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Annex I: Change packages as defined for the extension of improvements in Kirundo & Kyanza health provinces I. Change package of Kirundo health province Improvement objectives Changes to be implemented Detailed Activities / best practices At the health center level 1.Take the pregnancy test free of charge to any woman or 1.a) Make available the stock sheet of pregnancy test equipment in 1. Improve the supply of early girl of childbearing age who comes in curative consultation curative consultation (strips, urine flasks, gloves,) prenatal consultation services with delayed menstruation and is not on contraceptive b) Requisition the equipment (strips and urine flasks, pedal bins, gloves) to pregnant women seen in method. of the pregnancy test in the laboratory and place them in the healing curative consultation. room. c) Take sample of urine from the health center toilet. d) Perform a free pregnancy test in the curative care service and the deliver the results by the same provider. At the health center level 2. Improve the provision of 2. a) Conduct in depth a medical history to look for an 2. (a) Setting up a listening and counselling room for sexual and gender services for the prevention, eventual symptom of sexual and gender based violence, do based violence(SGBV). medical management of sexual the clinical examination, notify it with code (I/VSBG) to red b) Facilitate a Health Education Session(HES)/ week session sexual and and gender based for any case of sexual and gender based violence, (change in gender based violence(SGBV). violence(SGBV). mood /Behavior). (c) Provide post-exposure prophylaxis (ART) : Contraceptives ; b) To provide the victim with the complete care package antibiotics against sexually transmitted infections. 3. Improve the screening and 3.a) Take and interpret anthropometric measurements 3.a) Notify the integrated cases with the red pen by the “I/DM” code management of (weight, brachial perimeter and height) in all children under b) Taking weight, height, perimeter brachial systematically each child malnutrition in children 5 years, look for other signs in favor of malnutrition such as who came to the curative consultation. under 5 years of age, bilateral edema and take care if service available or refer if c) Register on mother health notebooks and in the register of child and pregnant and lactating women before 6 months of service not available. infant care curative consultation. breastfeeding seen in b) For any pregnant or lactating woman whose child is under d) Draw the growth curve of the infant on the mother health notebook. curative consultation. 6 months of age, seen in curative consultation, take the e) Take the perimeter brachial to all pregnant and lactating women perimeter brachial and notify it with code, if malnourished, whose child is under 6 months of age. give nutritional advice. f) Refer to ambulatory therapeutic Service cases of Severe acute c) Screening for malnutrition in women who bring their Malnutrition. children to curative consultation. g) Take an appetite test, if positive test, immediately supply Ready-to- Use therapeutic Food (for children) h) If negative appetite test, call ambulance for transfer to the Therapeutic Stabilization Service.
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Improvement objectives Changes to be implemented Detailed Activities / best practices i) If a woman is malnourished, note the “I/DM” code and the perimeter brachial below the child's name. j) Give the patient number to the reception for any malnourished woman who has brought her child in curative consultation
4. Improve HIV counseling and 4.a) Provide indexed counseling and testing (with risk 4.a) Notify the ‘’I/DIP’’ code with a red pen if anyone has accepted the testing at provider’s initiative in factors: test and accompany it to the laboratory for sample collection. curative service. -Sexual Transmitted Infections-Tuberculosis-malnutrition B) Offer the result on the same day. - Sex workers, family members of PLHIV C) Take charge of any positive cases detected. - opportunistic infections, multiple sexual partners) in curative service. At the hospital level 5. Improve the provision of early 5. Actively look for signs of pregnancy in all women of child- 5a) Pregnancy test free of charge to any woman or girl of childbearing ANC services to pregnant bearing age who come for outpatient care, Gynecological age with delayed menstruation which is not under contraceptive women seen in outpatient care, obstetrics and emergencies, PLHIV care services, and chronic methods. gynecologic obstetrics and diseases b) Accompany the woman whose pregnancy test proved positive to the emergency. health care center near to the hospital to complete the early prenatal consultation package. 6. 6. 6. Improve provider-initiated HIV Provide counseling and indexed or targeted screening (with a) Provide pre-test counseling counseling and testing for any risk factors- Sexual Transmitted Infection -Tuberculosis- b) Save the ‘’I/ DIP’’ code in the red pen under the patient number. outpatient cases, Gynecological malnutrition- Sex workers, family member of the PLHIV) for c) Take samples and forward them to the laboratory for testing obstetrics and emergency. anyone seen in outpatient care, Gynecological obstetrics and d) Retrieve the results and give the post test advice. emergency. e) Submit the results in an envelope for confidentiality 7. 7. 7. Improving the provision of Actively look for sexual violence based on gender signs in a) Examine and notify under the patient number the ‘’I/VSBG’’ code prevention services, medical any suspected case in a doctor's office, PLHIV care service, with a red pen in the register of the concerned service. care for sexual violence based emergency departments and Gynecological obstetrics b) Offer the complete package of care (Post-exposure prophylaxis, on gender. Sexual Transmitted Infection, prevention of unwanted pregnancy, etc…) 8.Improve the detection and 8. Systematically screen for malnutrition in any child under 5 8. (a) Systematically take and record anthropometric management of malnutrition in years, any lactating woman less than 6 months and pregnant measurements in all children under 5 years of age, pregnant children under 5 years, woman who comes to an outpatient consultation, and lactating women less than 6 months of breastfeeding who
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Improvement objectives Changes to be implemented Detailed Activities / best practices pregnant and lactating women emergency departments, Gynecological obstetrics, come to an outpatient consultation, emergency departments, before 6 months of pediatrics, PLHIV care service and chronic care. gynecological obstetrics, pediatrics, PLHIV care service and breastfeeding seen in curative chronic diseases consultation. b) Look for other signs of malnutrition such as bilateral edema that takes the bucket c) Write the I / DM code under the patient number in the register At the community level 9. Improve the quality of 9.Conduct an information / sensitization meeting at the local 9. a) To develop the themes on sexual violence based on gender referral of sexual violence based government office (local elected representatives), religious to be taught. on gender victims from the denominations, community health workers and other b) Launch a letter of invitation community to health care community actors to explain the importance of the c) Provide reference sheets for sexual violence based on centers immediate referral of sexual and gender based violence’s gender cases (SGBV) to the health care center. d) Explain the filling of the reference sheets e) Accompany the victim to health center for medical care. f) Classify at Health care center the community reference sheets. g) Holding a monthly analysis meeting on community health workers activities and reference sheet.
II. KAYANZA package Change. Objectives of Change Changes to be implemented Detailed Activities / best practices At the health center level Reduce the missed opportunities to 1. Provide community health education 1.(a) Make available a health education booklet offer family planning advice to pregnant to pregnant women and/or couples seen (b) Develop messages about rumors in family planning, side effects of family women and/or couples seen in pre- in pre-natal consultation planning methods, benefits of all methods including surgical methods targeting natal consultation. the partner who meets the criteria (partner age * Children: greater than or equal to 120). c) Guide the partners who want the surgical method. d) Notify in the prenatal consultation register just in front of the partner's name, 2. Offer individual advice on family the ‘’CPF’’code.
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Objectives of Change Changes to be implemented Detailed Activities / best practices planning in confidence to the couple especially the partners who accept. Reduce missed opportunities by 3. Conduct a collective education on family 3.a) Set up a health education booklet counseling on family planning any planning in the immunization room. b) Develop themes incorporating messages on side effects, rumors about family woman who brings her child to a planning method, advantages of methods. vaccination or who comes to post-natal c) Organize the immunization room to provide community health education on consultation and / or HIV care. family planning. d) Use modern methods available for demonstration. e) Use audiovisual media, if available. f) Choose a volunteer who uses a FP method among women who come to have their children immunized to testify to the benefits of family planning. g) Begin to vaccinate children who are going to have BCG vaccine. h) Guide mothers to post-natal consultation and provide a family planning advice.
4. Invite men to accompany their women 4.a) Write the letter of invitation (ubutumire in Kirundi) in post-natal consultation to benefit b) Send the letter of invitation to the partner through mother on leaving the together a family planning advice. maternity ward. c) Organize post-natal consultation and BCG vaccine on the same day.
5. Provide FP advice to any HIV-positive 5. a) Develop a timetable for health education facilitation sessions on family woman of childbearing age attended in planning the HIV care services. b) Develop key messages about side effects, rumors about methods, benefits of methods c) Make available a register for the preparation of health education sessions. Reduce missed opportunities to offer FP 6. Make available and provide family 6. a) Require FP inputs to the stock of the health care’s pharmacy. methods to women seen in post-natal planning methods in the same post-natal b) Record inputs on stock record consultation, HIV care and community consultation and HIV care services if c) Make family planning consultation Sheets available in post-natal consultation referrals. possible by the same provider. and HIV care services d) Offer the family planning method e)Forward family planning client records in FP service and classifying them in the schedule after registration in the standard register(FP register)
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Objectives of Change Changes to be implemented Detailed Activities / best practices f) Return unused methods to the pharmacy stock of the Health Center. g) Assign a unit in the post-natal consultation service that is qualified and trained in contraceptive technology. h) Plan the appointment date for ART supply at the same date of renewal or control of the method. i) Accompany a woman who wants a long-acting method to family planning service. j) To receive priority women referred by the CHW with reference sheet. k) Classifying the reference sheet. l) Hold a monthly comparative analysis of the reference sheets of community health workers activities and reports.
At the hospital level To reduce the missed opportunities to 7. Provide FP advice in the maternity ward 7a) Give an individual FP advice to any postpartum woman in the maternity offer a FP advice in maternity and in the by trained and qualified staff in family service. HIV care services. planning. b) Assign qualified personnel in the Maternity Service and trained in Contraceptive Technology. 8. Give an individual FP advice to clients of 8. a) Give an individual FP advice to any clients received in the HIV care. childbearing age who have come to the b) Locally train all providers of maternity, internal medicine, HIV care and HIV care. pediatrics in FP advice. Reduce missed opportunities to offer FP 9. Provide all FP methods in the HIV care 9. a) Require FP methods to the pharmacy stock of the hospital. methods to women seen in maternity except IUD and Implant. b) Record inputs on stock records and HIV care services. c) Provide the FP method in the same HIV care service by the same provider. d) Return unused FP methods to the hospital pharmacy stock. e) Assign a qualified and trained in contraceptive technology unit in the HIV care. f) Merge the appointment date for ART supply and the date of renewal or control of the FP method. g) Accompany a woman who wishes a long-term method in the FP service. h) Design a unit that will verify that all FP clients are registered in the FP register, HIV care register and maternity register. 10. a) Make available FP methods (DMPA, COP and implant) by requisitioning at 10. Provide FP methods in the maternity the hospital pharmacy
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Objectives of Change Changes to be implemented Detailed Activities / best practices service. b) Save to stock records. c) Offer the family planning method in the same maternity service by the same provider. d) Return unused methods to the hospital pharmacy stock. e) assign to the maternity unit a qualified and trained personnel in contraceptive technology unit. Objectives of Change Changes to be implemented Activities / best practices At the community level Increase demand for FP services at the 11. Conduct a monthly awareness-raising 11. a) Develop the themes on family planning methods to be taught. community level meeting of the Community Health b) Introduce a letter of invitation to the community health workers meeting. Worker’s Group on FP methods and c) Make available the reference sheets for FP methods referral to health care center. d) Explain to community health workers the completion of the reference sheets.
e) Accompany / refer the client to health care to receive the family planning method.
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Annex II: Progress and discussion on October - March PEPFAR targets Kayanza province Kirundo province Total (Kayanza and Kirundo combined Indicator Target Achievement Target Achievement Target Achievement Q1+Q2 Q1 Q2 Q1+Q2 Q1+Q2 Q1 Q2 Q1+Q2 Q1+Q2 Q1 Q2 Q1+Q2 Number of individuals who received HTC services and 46,37 92,387 75,317 167,704 39,387 46,011 38,118 40,071 35,246 77,505 86,447 81,257 their test results 6 (235%) (198%) (216%) 717 1,695 2,412 Number of people HIV positive tested 701 360 357 706 829 866 1,407 1,189 1,223 (102%) (140%) (171%) Number of HIV-positive pregnant women who received antiretroviral to reduce risk of mother-to- 104 336 440 77 41 63 257 159 177 334 200 240 child-transmission (MTCT) during pregnancy and (135%) (131%) (132%) delivery Number of infants who had a virologic HIV test within 102 418 520 77 34 68 257 128 290 334 162 358 12 months of birth during the reporting period (132%) (163%) (156%) 21 47 68 Number of people receiving post-GBV care 25 14 7 30 30 17 55 44 24 (84%) (157%) (124%) Number of HIV-positive adults and children newly enrolled in clinical care during reporting period who 614 1,305 1,919 received at least one of the following at enrollment: 701 293 321 706 635 670 1,407 928 991 (88%) (185%) (136%) clinical assessment (WHO staging), CD4 count, OR viral load Number of HIV-positive adults and children who received at least one of the following during the 3,169 5,714 8,883 5,329 3,088 3,169 3,481 5,492 5,714 8,810 8,580 8,883 reporting period: clinical assessment (WHO staging) (59%) (164%) (101%) OR CD4 count OR viral load (DSD) 681 1,444 2,125 Number of adults and children newly enrolled on ART 906 355 326 457 755 689 1,363 1,110 1,015 (75%) (316%) (156%) Number of adults and children receiving ART [current] 3,050 5,278 8,328 4,518 2,819 3,050 3,285 4,452 5,278 7,803 7,271 8,328 (TA-only) (68%) (161%) (102%) Number of PLHIV followed up screened for 2,567 2,908 5,475 3,169 3,024 2,567 5,714 5,479 2908 8,883 8,503 5,475 tuberculosis (TB_SCREEN) (81%) (51%) (62%) Number of registered new and relapsed TB cases with 117 246 documented HIV status, during the reporting period 139 47 70 287 158 88 426 205 158 363 (85 (84%) (86%) (TB_STAT) Number of patients with tuberculosis enrolled on ART 12 14 20 5 7 15 12 2 35 17 9 26 (74%) (TB_ART) (60%) (93%)
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Annex III: Success stories Increase in numbers of people adopting vasectomy in IHPB intervention zone
Since its start, IHPB has helped strengthen local capacity in vasectomy in Karusi, Kayanza, Kirundo and Muyinga health provinces Here ten doctors and nurses trained by the project work at Kirundo, Buhiga, Muyinga, Kayanza, Musema and Gahombo District Hospitals.
IHPB has also helped increase community awareness and demand for FP methods. Together this heightened demand and local capacity are helping increase uptake of vasectomy procedures, particularly in areas with large families and socio-economic difficulties. Between October and December 2016, trained providers performed 63 vasectomies in IHPB districts — a XX % increase over the quarterly average.
4 main reasons why it is solicited are following: a) it is a very simple and not painful operation. At worst, it will cause a slight discomfort for a few days; b) it is the safest contraceptive, if you are sure you do not want (or more) children, that can fight quickly against the monstrous observed population growth; c) it does not interfere with sexual intercourse, with the ability to have an erection, with libido or the possibility of reaching orgasm; d) you can resume your sex life one week after the operation.
Following are success stories and feed-back from vasectomy clients in Kayanza:
Bizimana Frederic, Cultivator, Gasuru Sub-Hill, Kinga Hill, Zone-Commune-Province Kayanza, February 2017 “I know the contraceptive methods such as injection, pills, IUDs, condoms as well as permanent male contraception. My wife and I have used some a lot since our first-born in 1997. We had the 2nd child in 1998, and this non-spacing in difficult financial circumstances led our child to develop kwashiorkor. My wife had started using pills but with side effects and terrible pain during intercourse. She changed and took injections until 2013, but we were not successful. We had our 7th child. We said that we had to stop making children by taking a permanent contraceptive method and my wife wanted me to accompany her. As I noticed the side effects and pain she had endured, also because her health has become increasingly fragile with already 7 pregnancies, I offered to take a permanent male contraception myself regardless frightening rumors and beliefs that it was downright castrating the man. The main reason for my vasectomy was the fact that I had more unplanned children (7 children when we wanted just 5); while my wife and I are still very young (she`s 35 years and I 40 years today) with the risks of making other children. Moreover, I realize that I have increasingly very little financial resources to raise them"
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Ndikumana Simeon, Cultivator, Kavoga Sub-Hill, Gwegura Zone, Muruta Commune, Kayanza Province, February 2017: "There is a demographic increase in my country. I have nine children today. I was 43 years old at my last child. With 47 years old today, I am afraid to continue making children. My wife is a Christian of the Pentecostal Protestant Church and does not want to take any contraceptive method. Since the 5th child, I begged her but she refused. She is still very young: I married her at 19. She was 38 years old when she got her 9th pregnancy. I was surprised and not happy. I decided to take myself a method for men. It was the CHW of Kavoga who told me that a permanent contraception for men existed. I visited him again so that he explained well and he referred me to Kavoga health center where the chief nurse explained everything to me. I felt reassured. Back home, my wife did not agree at all. I explained to her that I will do it for our good. Indeed, for some time, she was sick from successive pregnancies. She also had tuberculosis and I could no longer see her suffer more. Also, I was tired by the housework alone. Later, my wife agreed that I take it myself. I was then accompanied by the CHW at Kayanza Hospital. There, they welcomed me, and put under anesthesia. The operation took an average of thirty minutes. It was not at all painful. I went back home and, 4 days later, I could go into the fields again. It was after 30 days that I started to re-engage sex normally; I find more enjoyment than before, I even double the time of enjoyment. I no longer feel any pain in my spine after intercourse when before I suffered terribly. I did the vasectomy for free, but after the good effects on me, I would even be able to pay the fees if asked. ".
Annex IV: Results from data analysis meetings
Indicators Buhiga HD Nyabikere HD J-M A-J J-S O-D - J-M J-M A-J J-S O-D J-M 2016 2016 2016 2016 2017 2016 2016 2016 2016 2017 AMTSL Indicator Evolution 29% 58% 57% 81% 97% 31% 53% 86% 97% 100% IPTp Indicator Evolution 66% 73% 85% 84% 86% 75% 89% 91% 85% 92% Early ANC Evolution 20% 23% 36% 34% 37% 25% 31% 40% 40% 49%
Evolution of the rate of pregnant women who received at least 2 doses of SP in ANC 3:
% of pregnant women who received at least 2 doses of SP in PNC 3 100% 80% 60% 40% 20% 0% Q4-2015 Q1-2016 Q2-2016 Q3-2016 Q4-2016 Q1-2017 Q2-2017
Muyinga Gashoho Giteranyi Average
ANC from 2014 to 2016
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Evolution of early pregnancy rates 80%
60%
40%
20%
0% Early PNC 2014 Early PNC 2015 Early PNC 2016
Gashoho Giteranyi Muyinga
Evolution of the rate of women who received a dose of uterotonics within one minute of fetal expulsion
% of women who received a dose of uterotonics within one minute of fetal expulsion 120%
100%
80%
60%
40%
20%
0% Q4-2-15 Q1-2016 Q2-2016 Q3-2016 Q4-2016 Q1-2017
Muyinga Giteranyi Gashoho Average
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Annex V: IHPB Indicators – Achievements for the period October 1, 2016 – March 31, 2017 28 PMEP No Indicator Data Source Collection Reporting Baseline Year 3 Year 4 Target October- January – Method Frequency Achievement December 2016 March 2017
1.2.1 Percent of supported facilities that Facility Document experienced a stock-out at any point review / Monthly 70.9% 40.7% during the last three months [MR] HIS Quarterly 62% 57% (94/164) 55% Report (122/172) (75/184) database review 1.2.2 Percent of USG-assisted service SARA/Channel Data will delivery points (SDPs) that be experience a stock out at any time extracted during the reporting period of a From SARA/ 3.4% 10.7% Quarterly 37.6% 14% (20/147) 10% contraceptive method that the SDP Channel (5/147) (16/150) is expected to provide (District [FP/RH level 3.1.7.1-2] database) 1.3.4 Number of persons receiving post Facility Document [GEND_GBV] GBV care (Post-rape care, other Records review Quarterly 102 139 170 44 24 post-GBV care, PEP) 1.3.5 Number of facilities that provide PEP Facility Document Quarterly 7 26 34 30 31 to GBV survivors Records review 2.0.3 Number of individuals who were Facility GESIS referred to and received other Reports analysis Quarterly 7,137 20,464 18,200 5,871 5,624 health and non-health services [MR]
2.0.4 Number/percent of children who Facility Document 81.9% received DPT3 by 12 months of age Records review 105.9% 85.7% 90.8% 76,0% Quarterly GESIS in USG-Assisted programs (107,874/101,820) (15,405/16970) (13259/17425) 2013 [3.1.6-61]
28 December data not available for the following indicators – 1.2.1, 2.0.3, 2.0.4, 2.0.15 and 3.2.1.
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PMEP No Indicator Data Collection Reporting Baseline Year 3 Year 4 October- January – Source Method Frequency Achievemen Target December 2016 March 2017 t
2.0.5 Number/percent of women giving birth who Facility Document Quarterl 0 74% 80% 91.2% 95.9% received uterotonics in the third stage of labor Records review y (41540/54121 (17,894/19,627) (22,310/23,25 through USG-supported programs [3.1.6- 64] ) 6) 2.0.6 Number/percent of women reached with CHWs Document Quarterl NA 211,286 118,000 63,038 94,514 education on exclusive breastfeeding monthly review y report 2.0.7 Number and percent of pregnant women with Facility HIV data Quarterl 94% 89.3% 95% 87.2% 87.1% [PEPFAR known HIV status Records base y 127,306 (57,406/64,2 (14,603/16,751) (12,863/14,76 PMTCT_STA [MR] analysis /135626 80) 0) T] 2.0.8 Percent of pregnant women who received Facility Document Quarterly 93% 92.5% 95% 93.9% 94.5% [PEPFAR antiretrovirals to reduce the risk of mother- records review 957/1028 (851/920) (200/213) (240/254) PMTCT_ARV tochild transmission (MTCT) during pregnancy ] and delivery [MR] 2.0.9 Number of individuals who received Testing and Facility Routine Quarterly 360,446 321,944 138,048 85,830 81,314 [PEPFAR Counseling (T&C) services for HIV and records data HTC_TST] received their results 2.0.10 Number of HIV-infected adults and children who Facility/ Routine Quarterly 10,071 8,033 12,535 8,580 8,938 [PEPFAR received at least one of the following during the Client data CARE_CURR reporting period: clinical staging or CD4 count or record collection ] viral load 2.0.11 Percent of HIV-positive positive patients who Facility Routine Quarterly 12,8% 61.7% 80% 53.6% 53.7% [PEPFAR were screened for TB in HIV care or treatment records data (4,961/8,033) (4,603/8,580) (4798/8938) TB_SCREEN] setting collection
2.0.12 Percent of infants born to HIV positive women Facility Routine Quarterly 31% 45% 70% 76% (161/213) 117.7% [PEPFAR that receive a virological HIV test within 12 records data (314/1,028) (412/924 (299/254) PMTCT_EID] months of birth collection )
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PMEP Indicator Data Collection Reporting Baseline Year 3 Achievement Year 4 October- January – No Source Method Frequency Target December 2016 March 2017
2.0.13 Number of adults and children receiving ART (TA Facility Routine data Quarterly 4,996 6,211 9,000 7,284 8,340 [PEPFAR only) records collection TX_CURR] 2.0.14 IPTp2 under direct observation of a health worker Facility Document Quarterly NA7 67.6% 80% 84.4% 83.9% records review (76,426/113,078) (18,378/21,769) (20,455/24,383)
2.0.15 Proportion of pregnant women attending ANC who Facility Routine data Quarterly 80,3% 80.7% 95% 49.5% 82.2% received ITNs records collection 116160 (17,299/21,046) (70,718/113,078) (10,981/22,152) /144,739 2.0.16 Proportion of children under five with fever who CHW Routine data Quarterly 66.6% 73.8% 75% 75.6% 79.4% received ACT reports collection 20666 (102,715/139,111) (40,003/52,851) (51,839/65,250) within 24 hours of onset of fever /31060 2.0.16a Proportion of children under five RDT positive who CHW Routine data Quarterly 98.8% 99.4% 99.4% received ACTs reports collection (110,387/111,633 (43,919/43,944 (55,641/55,967) 2.1.2 Number of cases treated or referred by CHWs CHW Routine data Quarterly NA 93523 94,000 Treated: 43,919 Treated: 55,641 (Malaria, diarrhea, ARI, FP, malnutrition, iron for reports collection Referred: 9,377 Referred: 9,395 pregnant women) [MR] 2.2.2 Percentage of HIV service delivery points Facility Routine Data Quarterly 26% 74.7% (71/95) 80% 78.9% (75/95) 79.2% (76/96) supported by PEPFAR that are directly providing Records collection/HIV 45 integrated voluntary family planning services database /173 [PEPFAR FPINT_STE] 2.3.2 Percent of supported health providers, managers Training Document Quarterly N/A HP : 94.6% (n=3885) 98.8%95% (2,014/2,038) 90.1% (311/345) 29 and CHWs who have demonstrated improvement reports review CHW :93.9% (n=1353) CHW - NA post-training [MR] 2.3.5 Number of health care workers who successfully Training Document Quarterly NA 1,832 1,336 281 416 completed an inservice training program records review 2.3.6 Number of community health/parasocial workers Training Document Quarterly NA 1,444 7,151 2,975 2,642 who successfully completed a pre- logs review service training program 3.2.1 Percent of facilities that maintain timely reporting Facility HMS (GESIS) Quarterly 95% 100% 98.8% 100% (182/182) 64.1% (118/184) [MR] reports analysis 165/173
29 Pre and post test not adapted to the SBCC training conducted (Training on interpersonal communication -IPC) – this training was based on a practical guide
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i 5 Communication materials have been produced and will be disseminated next quarter
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