FORM #3 Grants Solicitation and Management

Quarterly Progress Report

Grantee Name: Maternal and Child Survival Program Grant Number: # AID-OAA-A-14- 00028

Primary contact person regarding this report: Mira Thompson ([email protected])

Reporting for the quarter Period: Year 2, Quarter 4 (July to September 2018)

1. Briefly describe any significant highlights/accomplishments that took place during this reporting period. Please limit your comments to a maximum of 4 to 6 sentences. • Following the gaps that were identified during the routine TA visits to the districts in the first and second quarters, MCSP engaged the districts in the supported provinces in revising their 2018 annual workplans and budgets based on the data (scorecards) and service quality assessment (SQA) findings. Using these tools, MCSP influenced the inclusion of appropriate high-impact interventions (HIIs) to respond to identified gaps in the revised workplans and recommended the allocation of resources in an equitable manner. Consequently, Districts revised the 2018 CoC plans to incorporate these recommendations and identified interventions that would be included in the 2019 plans in all provinces. Additional details are provided in the provincial report annexes. • MCSP provided technical assistance (TA) during the provincial integrated management meeting (PIM) across all of the four target provinces. These meetings provided an opportunity for MCSP to identify areas requiring TA in a context-specific and responsive manner to the needs of each district. MCSP contributed to discussions in those meetings by making on-the-spot recommendations for improving specific indicators. For example, using a very brief role play, MCSP graphically showed districts a simple way of estimating the number of new FP acceptors. By sharing in those meetings how certain districts had used SQA for planning on how to respond to poorly performing indicators, districts that had not incorporated this in their plans saw the need to and requested orientation by MCSP. Most evidently, MCSP saw an opportunity to provide capacity building of districts teams in using MOH Quality Assurance (QA) tools such as Quality Improvement (QI) projects in addition to the Mentorship and Service Quality Assessment Tools (SQA), processes that MCSP was already providing TA on. MCSP provided TA during the CoC pre-planning and planning cycle. During the TA,

1

MCSP used HMIS data and bottleneck analyses to decide on the inclusion of the following high impact interventions:

o Renovation/construction of outreach posts/shelters in 9 Districts in and 37 in Eastern Province o Procurement of tents in 6 districts in Muchinga o RED strategy training in 6 Districts in Muchinga, 5 Districts in o ETAT, IMCI, iCCM and RED strategy training and/or mentorship o Procurement of case management job aids such as IMCI booklet charts • Using the SQA findings, MCSP influenced two Districts in ( and Districts) to design quality improvement projects. Chipili’s project is looking at case management titled Improving IMCI Services at Chipili Rural Health Centre while that of Mwense aims at improving EPI services in that district. • MCSP worked closely with Mansa District Health Office (DHO) during the measles outbreak along the -Democratic Republic of Congo boarder. The TA provided by MCSP resulted in the Provincial team extending the Supplementary Immunization Activities (SIA) to other catchment areas where Zambians easily mingle with Congolese. • MCSP has been facilitating formation of mentorship teams in the provinces and has strengthened the district mentorship teams across 43 districts in the four provinces. During the period under review, MCSP supported 3 districts (, Lavushimanda ) in Muchinga and orientated them in development of mentorship dashboards, which should inform mentorship rounds. The technical assistance has resulted in formation of teams in 8 districts (out of the nine) in and are using MOH mentorship tools. A number of districts now have functional mentorship teams that are using the revised MOH mentorship tools. For example, in Eastern Province, all districts have made their mentorship teams functional and are being oriented on mentorship dashboards that have already begun being used in that province. • MCSP obtained ethical approval for the General Nursing Council of Zambia to conduct a study to find out the feasibility of decentralizing its continuous professional development (CPD) program. Additional details are provided on page 18 (objective 2). • MCSP completed instructional design workshops for the development of four e-learning modules in antenatal care (ANC), HIV, integrated management of acute malnutrition (IMAM) and in maternal, infant and young child nutrition (MIYCN) courses. Additional details are given on page 16 (objective 3). • MCSP completed the first round of qualitative data collection for its learning question study on the MCSP/Zambia technical assistance model. This study aims to understand the success of the TA model, especially the acceptability of TA without direct funding, the ability of the project to influence technical direction of activities implemented with G2G funds, the extent to which project objectives are achieved and the major factors that have affected the achievement of results positively or negatively. The study through these objectives will effectively document the best practices and lessons learned from implementing this TA approach.

2

2. Briefly describe any unforeseen obstacles or challenges that are having a negative impact on the implementation of the grant activity. For any mentioned, please describe your possible strategy for resolution. • Some DHOs did not adhere to the agreed action points during the pre-planning, such that for the final planning they brought in activities that were outside what had been identified during bottleneck analysis in their districts. TA in this has been ongoing to make the DHOs prioritize context-specific interventions that would appropriately respond to the needs of each district. • Delayed authorization of expenditure of the COC budgets by the national level resulted in delayed implementation of activities by districts and disrupted the opportunities for provision of TA by MCSP. These delays have been discussed at the national level COC coordination meetings and it is expected that they will reduce in future. • Generally, there is a lack of IEC materials and job aids in the facilities across the four provinces. TA in IMCI faced a lot of challenges due to lack of job aids such as IMCI chart booklets, IMCI wallcharts and ARI timers. MCSP continued to advocate to districts to budget for the job aids through the G2G grants and MOH resources. • Districts did not fully understand ETAT training (Emergency Triage & Treatment), making provinces fail to prioritize it. There are no TOTs in any of the four provinces thereby requiring trainers from the national level MOH for any training. With no one trained at Provincial level, the Province has no capacity to promote ETAT in a way the Districts can appreciate it. MCSP has been lobbying for Provincial TOTs to be established. This has not yet been done considering the competing priorities for the same money. MCSP continued to recommend the inclusion of training through the G2G grants. • Inadequate transport hampering follow up visits to districts. With the procurement of vehicles and motorcycles through the G2G grants, this is likely to improve in the near future.

3. Please describe activities to monitor field activities and ensure compliance with USAID family planning and commodity regulations as described in Appendix 2. Activities may include staff training, supervision visits, observation, monitoring of reports, etc. Please indicate whether there are any concerns or questions. • All MCSP staff at the national and provincial levels have been trained and certified in FP compliance as required by USAID. The certificates are on file with the MCSP Zambia Program Officer. MCSP continues to ensure that all staff are oriented to FP compliance and are trained and certified so that they are able to prevent and look out for any violations. • MCSP has continued to repeatedly emphasize to MOH at all levels on the need for compliance with FP rules and regulations. This TA has also included recommendation for MOH personnel to take the appropriate online courses on Global Health eLearning Center

3

4. Briefly comment on the status of the activity as compared with the agreed-to work plan. Mention whether you are behind, consistent with, or ahead of the work plan.

Objective 1: Provide demand-driven technical assistance for sustainable scale up of RMNCAH&N intervention across the four focus . MCSP is on track under Objective 1. In the reporting period, MCSP worked closely with all districts in the four supported provinces to make recommendations for the most appropriate high impact interventions that are responsive to the needs of each district based on their performance as gathered and displayed using MOH tools of service quality assessments and dashboards, mentorship dashboards and district scorecards. Multiple avenues were used to provide technical support, including provincial and district integrated meetings, maternal and perinatal death surveillance and response meetings, planning meetings and other opportunities as they arose. Please find below an abbreviated list of activities that occurred during the quarter. For additional detailed information regarding the program, please see the Annexes.

Provided TA for Maternal, Newborn and Reproductive Health: o In maternal, newborn and reproductive health, MCSP supported the districts in the four provinces to incorporate high impact interventions in FP and MNH in their 2019 plans to respond to each district’s performance as shown through the scorecards. MCSP supported 43 Districts (9 in Eastern, 9 in Muchinga, 12 in Luapula and 13 in Southern provinces) to strengthen their 2019 CoC plans. Examples of HIIs included community engagement to respond to low community acceptance and participation. Recommendations were made to districts to improve infrastructure that would allow integration of ANC, FP, and PNC services during outreach services that has been poor due to inadequate outreach infrastructure o MCSP oriented health care workers in specific health care facilities on the use of SQA tools with a live demonstration on antenatal care (ANC), family planning (FP), and infection prevention and control (IPC). This provided an opportunity to mentor the district health staff on how to effectively use SQA. In similarly scenarios elsewhere, MCSP influenced the DNOs to conduct onsite mentorship to staff on duty in labor wards after conducting SQAs. SQA in reproductive, maternal and newborn health has been accepted by a number of districts and is being used to identify gaps for targeted interventions. o MCSP has provided simulation models to all the four provinces, for simulated mentorship in instances when there are no clients, thereby improving skills among the HCWs and student nurses and midwives. o In Luapula Province, MCSP participated in the Mansa District Perinatal and Maternal Death Surveillance and Response (PNMDSR) meeting and influenced the DHO staff to provide integrated mentorship to facility staff with regard to considering competent trained mentors/conducting drills for mentors in maternal health so that HF staff handling maternal cases have the needed competencies to promote quality of care. MCSP influenced the DNOs for , Chipili and Samfya to conduct onsite mentorship to labor ward staff on gaps identified in the SQA and encouraged them to come up with quality improvement project. o MCSP also offered TA during the PNMDSR Meetings in three districts in Eastern province (Mambwe, Chipata and ). For , most of the maternal

4

deaths were as off referrals from other HFs who were dying at Chipata CH and emphasized on the need to implement the National Maternal and Neonatal Referral Guidelines NMNRG to prevent late referrals and improve outcomes. MCSP suggested to districts to provide regular mentorship to health care facilities where late referrals were coming from. Some districts planned to intensify their mentorship by having more experienced health care workers making more regular supportive supervision and mentorship visits to lower level health care facilities. MCSP recommended appropriate HIIs to reduce the number of maternal deaths, stillbirths and neonatal deaths from common causes including poor monitoring of labor, prematurity MCSP influenced the need for all the districts to use the prescribed perinatal and neonatal deaths audit forms, partographs to manage labor and the National Maternal and Neonatal Referral Guidelines and have forms printed in booklets to improve the referral system. o MCSP supported Chipata district, in Eastern Province, in developing a weekly reporting template for accountability of MNCH indicators, which were not doing well as identified during PIM and MDSR meetings. The tool will enhance tracking of performance by each HF on a weekly basis and will help the district team to offer TSS/Mentorship to the poorly performing HFs instantly. The template will be rolled out to other districts if it works out well in Chipata district. o In Southern Province, MCSP provided TA in the formation of mentorship teams in Sinazongwe, , Siavonga, Kazungula, Namwala, Monze, Zimba, and Livingstone Districts. These teams have been active and they have been conducting mentorship rounds, which has resulted in the improved quality of service delivery, and steadily improved some indicators like ANC booking before 14 weeks, postnatal within 6 days, and ANC 4+ visits. In Muchinga Province, MCSP held one discussion mentorship with the PNO MNCH and MNCH Coordinators on the importance of health care providers on duty at the time a facility records a stillbirth or Maternal Death to write a verbatim. This has already been done by district were 2 MDs were recorded in September. o In Eastern Province, MCSP provided TA to Chipata, Chadiza and Districts Mentorship teams in the use of the mentorship dashboards to track competencies of mentees. For Chipata district, dashboards for the mentorship conducted in May 2018 in ANC, EmONC and FP were developed while remote support and soft copy of the dashboards was provided to Chadiza and Nyimba Districts. The team of mentors was advised to provide follow up mentorship to the staff whose competencies were in red so that they can build on what was done earlier. In the subsequent quarter, MCSP will work with the districts to track progress against the mentorship dashboards. o MCSP provided TA to , in Eastern province, during their RMNCAHN indicators performance review meeting. It was discovered that there was poor linkage between the HF, Safe Motherhood Action Groups (SMAG) and St. Francis Hospital when a woman is referred for Hospital delivery before her pregnancy is to term. MCSP guided the HF team to strengthen the linkages between SMAGs and St. Francis and to ensure that every referred woman is linked to a specific SMAG member who will be responsible for monitoring and follow-up. This would help in reducing delays as well as follow up care such as Postnatal Care. It is anticipated that in the next reporting period, the results of MCSP’s TA will lead to an improvement in PNC and other indicators

5

o In Luapula Province, MCSP supported PHO to strengthen the provincial Safe motherhood technical working group (SMTWG) by providing technical assistance and leadership through reviewing and formulation of terms of reference (TOR). During this meeting, PHO had no terms of reference to existing SMTWG but MCSP in collaboration with SARAI developed some proposed TORs which were shared to the team, reviewed and refined to stand as provincial SMTWG TORs. These TORs have since been shared to other partners who are member of the SMTWG. o In Muchinga Province, MCSP provided TA on the management of labor using a partograph. During the TA visits MCSP observed that the partograph was not effectively used to monitor fetal wellbeing during labor. Discussed with the MCH coordinators to conduct onsite mentorship to facility staff on the use of partograph. All districts except for Mafinga had started conducting mentorship on the use of the partograph. Skills in the effective use of the partograph will help reduce on the number of stillbirths. The teams were advised to ensure adequate supply of WHO partograph in all facilities. MCSP will continue to work closely with the districts to track effective utilization of the partograph for decision making. o In Muchinga and Eastern, MCSP oriented four facility managers on infection prevention guidelines and management of neonatal resuscitation equipment to help prevent cross infection as a standard guideline in newborn health care. Flow charts on reprocessing of neonatal resuscitation equipment were provided to the facilities to help adherence to the recommended guidelines. In Eastern Province, MCSP has continued to advise the districts on the importance of separating the infant resuscitation equipment from the delivery and MVA equipment during the decontamination process. o MCSP in Eastern province commended Chimutende Rural Health Centre in Katete for implementing the 48hrs postnatal care postnatal care policy despite limited space. Other facilities in Eastern Province indicated that they were also practicing but there was no documentation. CSP provided TA on the importance of 48hrs PNC to reduce the post- partum complications and documentation of the practices/ indicator improvement. MCSP has observed that the numbers for the postnatal within 48hrs for the period under review had increased. o In Eastern and Southern Provinces, MCSP provided TA on the importance of continuous Kangaroo Mother Care (KMC) to the mothers at Nyanje Mission Hospital. MCSP discussed with the district health team to orient and mentor staff on KMC as a way to roll out the KMC to all the facilities in the district so that the staff acquire knowledge for effective counselling of the mothers with preterm babies, though most facilities have inadequate infrastructure for KMC. o During TA visits, MCSP ensured that the necessary protocols and guidelines were available for staff to reference. MCSP provided TA to the facility in charges at Mpika Urban Clinic Urban Clinic in Muchinga and Nyanje Mission Hospital in Eastern Province on the need for newborn health protocols, such as HBB, displayed on the walls for quick reference during service provision with the facility managers. This will consequently help health facilities adhere to standards during service provision and improve on newborn outcomes. Soft copies of HBB were provided and facilities requested to either print/ hand write the protocols and have them displayed in appropriate places in labor wards. Similarly, in other facilities that did not have the HBB corner, MCSP, together with the DHO staff, managed to set them up. For any

6

guidelines that were not present, MCSP shared the soft copies with the DHO MCH Coordinator and urged them to print and distribute to all the facilities in the district. o MCSP provided TA to four facilities (Mpika Urban Clinic in , Lubwa, Kalwala, and Muundu Health centres in District) to start conducting clinical meetings to improve knowledge and skills in management of the newborn. This will help improve the knowledge and skills of HCWs in different thematic areas including newborn health. o During the TA visits at Undi Rural Health Centre, Hospital, Hospital, MCSP observed that the partographs were not effectively used to monitor fetal wellbeing during labor because in the rural health centre like Undi deliveries are being conducted by non-midwives. In the hospitals, the midwives lack close supervision and the supervisors do not frequently review the used partographs to control the situation. MCSP discussed with the MCH coordinators to conduct onsite mentorship to facility staff on the use of partograph. Skills in the effective use of the partograph will help reduce on the number of stillbirths and improve the neonatal outcomes after delivery.

Provided TA on Child Health and Immunization: o Provided technical assistance to 16 DHO program officers from Eastern Province as they oriented their staff on the RED/REC microplanning process resulting in completed annual microplans. The training included 5 staff from Chikoma Zonal RHC in district, 5 staff from Sadzu Zonal HC, 3 staff from Zemba RHCs in Chadiza district and 3 staff from Undi RHC in Katete district. The microplans are intended to improve the antigen coverages and reduce dropout rates. In Luapula Province, MCSP supported RED/REC orientation in 6 districts resulting in 4 districts (Chienge, , and Chifunabuli) developing microplans. The dropout rate for Measles 1- Measles 2 was high at 39% in the province and engagement of the community was emphasized. Community Health Volunteers in Chipata from 8 neighborhood health committees and Mansa from 6 neighborhood Health committees were also oriented on RED/REC. Community registers were revamped and this too will reduce the dropout rates. In Southern Province, MCSP provided TA to during integrated outreach in four facilities namely Nalube, Chilalantambo, Masuku Mission and Nakempa where it was noted that outreach posts did not have community registers for the children in the zones. TA was provided to districts MCH coordinators to equip the CBVs and HCWs with knowledge and skills in reaching every child through onsite training. Review of the revised 2018 COC plans shows that Choma District conducted training of CBVs in RED and the holding of quarterly meeting with the CBVs as included in its plans o Supported the rollout of the electronic IMCI/EPI training tool in all provinces and installed computers in 8 District Health Offices. Twenty-one staff including 17 nurses, two Environmental Health Technologists (EHTs), one nutritionist and one Clinical Officer from 9 districts in Muchinga completed the course. More details by province can be found in the report annexes. o Facilitated distribution of child health guidelines to DHOs for case identification and management including worms, pneumonia, diarrhea and other danger signs. Oral rehydration treatment corners were distributed with the child health guidelines in

7

Eastern Province. o Provided TA to MOH in Muchinga Province during the annual planning process to integrate the existing training databases to identify the training gaps. Cumulative training figures were as follows: IMCI- 84; ICCM-331; and RED strategy-110. o Facilitated Chipili and Mwense districts in Luapula Province to improve the quality of child health and immunization projects. After analyzing the data, MCSP observed in Chipili only 30% of children at Chipili Rural Health Centre were screened according to IMCI guidelines. Thus, MCSP has started to improve quality by focusing on installing job aids and procurement of IMCI equipment, such as portable hand washing facilities in the screening rooms and ARI timers. MCSP will continue to provide mentorship to ascertain best practices in IMCI as well. Mwense District started a project to improve EPI services as the reports stated that only 20% of the documents reviewed at Mwense Stage II Rural Health Centre had met the minimum standard in EPI. The project in Mwense will focus on building capacity of the health workers in effective vaccine management. Both projects were influenced by MCSP monthly TA visits and the SQA dashboard and analysis from the previous two quarters were used to determine the interventions. o In Luapula Province, MCSP provided TA to the Mansa DHO during a measles outbreak along the Congolese border. MCSP provided technical assistance during supplementary immunization activities (SIA). MCSP helped to ensure SIAs targeted children four months to 15 years with measles immunization and covered all hotspot areas including borders. The identified surveillance sites were Mansa, Chembe, Nchelenge, Chienge, Chipili and Mwansabombwe districts.

Provided TA on ASRH: o MCSP in Southern Province facilitated and provided TA during the training of 60 health care workers in ADH (37 females and 23 males - 30 in Choma, 17 females and 13 male; and 30 in Monze 20 female and 10 males). MCSP provided TA to the district through provision of the materials for the training. MCSP sourced for training materials and other relevant materials needed for the trainings as requested by the district health offices respectively. Going forward, the districts are expected to have improved ADH work through the peer educators to be deployed in various facilities in the districts. o MCSP facilitated and provided TA to establish District Adolescent Health Technical Working Groups and Provincial Health Promotion Technical Working Group in order to promote effective engagement of stakeholders in working in Adolescent health and Behavioral Change Community in MCSP supported districts and improve community responsiveness to adolescent health and community engagement issues in districts. The ADH technical working group have since been formed in Chinsali, Mansa, Livingstone and Mazabuka while the existing ones MCSP re-oriented and provided soft copies of ADH strategy to Mpika, , Siavonga, Chikankata Gwembe, Sianazongwe and Siavonga districts. It is expected that the districts will see an improvement in coordination and provision of ADH services across all facilities for increased service uptake by adolescents. o MCSP facilitated the orientation of District Health Offices in Adolescent Health Strategy 2017-2021: following the orientations at the provincial level in the second quarter on ADH Strategy, MCSP has been following up on the implementation and

8

reorientation at the district health office level. An orientation was conducted to Kazungula (31 participants: Female 15, Male 16) Choma (39: Female 20, Male 19) and Livingstone (24 participants; Female 11, Male 13) on the same. The orientation enhanced understanding on the national priority of adolescent health issues. It is hoped that the persons oriented will support the ADH programs in their districts and facilities respectively. o MCSP provided TA to the districts to encourage the use of the reporting tools by peer educators in the facilities. This came in the work of peer educators not utilizing the reporting tools and submitting them to DHO. Data collected through the reporting tools is useful for planning and improving adolescent health programming. It is expected that going forward utilization and subsequent submission of reports to the district will improve in the districts o Provided TA to Chinsali and Mpika district ADH Focal Point staff in the administration of ASRH SQA. One facility in administered a SQA & the findings attached in form of a dashboard in appendices of this report. Mpika is yet to administer SQAs in ADH. Administration of SQAs is expected to be rolled out by all districts and facilities to improve quality service delivery of ADH service o Participation in the 2019 CoC Planning MCSP participated and provided technical support to all the districts in the 2019 CoC planning by assisting in the bottleneck analysis for adolescent health indicator i.e. ANC coverage for women under 20 years. MCSP also distributed a list of high impact interventions that districts used to choose from for them to include in their plans for the year 2019. Among interventions that they integrated into their plans include training of service providers in ADH, formation of Adolescent Health Technical Working Group, supportive supervisory visits to the health centers offering ADH, Integrated Community outreaches and Job aids procurement among others.

Provided TA on Nutrition: o At national level, MCSP has continued with coordinating the process of developing the two nutrition e-learning courses namely MAYCIN and IMAM. The process is in the last stages of development and five out of nine MAYICN modules have already been signed off in readiness for assembly by iSchool. o Consulted with the Ministry of Health national level with the STTA, Patti Welch during her visit to Zambia on the best approach to revitalizing BFHFI activities in Zambia. The consultations were done with the MoH, nutrition unit and the Newborn Advisors o MCSP provided TA in nutrition participated in during the pre-planning and planning process across the four provinces, with an increased focus on Muchinga and Southern provinces. The process involved lobbying for inclusion of nutrition activities in the CoC plans for 2019 arising from the HIIs. Patti Welch, MCSP Nutrition Technical advisor (PATH) completed an STTA trip to Zambia and visited Eastern province in July/ August to three districts - Chipata, and Katete to support TA provided during this planning process. MCSP TA was also provided during the STTA visit to Chipata General Hospital, and together with the Provincial nutritionist, MCSP Eastern province nutritionist and the hospital nutritionist visited the maternity ward and pediatric wards to establish key gaps around the provision of nutrition services in IYCF and IMAM in the Pediatric / malnutrition children’s wards as well the neonatal unit

9

(NICU). o MCSP procured and distributed 24 nutrition breast models for the four MCSP supported provinces. The models will make demonstrations sessions on breastfeeding during MAYICN training much easier to deliver. o MCSP provided technical assistance across the four provinces in the process of formulating, interpreting and formation of dashboards for nutrition SQA. These dashboards will act as baseline for improving service delivery and reference for effective nutrition interventions. This TA has resulted in the following outputs: districts having since included short term trainings in nutrition and procurement of basic anthropometric equipment in the revised 2018 and 2019 CoC plans; creation of space for a nutrition section with graphically displays monthly performance of the facility on nutrition indicators like stunting, wasting, underweight, deworming, vitamin A supplementation and breastfeeding within the first one hour after birth etc; and the displaying of key nutrition messages in key health facilities. o MCSP conducted follow up TA to the four provinces so as to refine and consolidate first drafts of nutrition activities for inclusion in the CoC plans for 2019 following the guidelines from the agreed HII on nutrition. Some of the selected activities in the plans while they await approval include; training of CBV in GMP, Mentorship in GMP, IMAM and NACS, Intensified active case finding of the malnourished children, Community MAIYCN training, Nutrition review meetings and TSS, Orientation in OTP, CBV training in OTP. Provide technical assistance during planning of 2019 CoC grants. o MCSP provided TA in conducting nutrition assessments, categorizing and classifying. In Muchinga province the on the use of guidelines for identifications, classification and management of malnutrition were used for demonstrations. o MCSP provided TA around trainings to HCWs and community health volunteers in Eastern and Muchinga provinces on nutrition. In Eastern, TA was provided on integrating nutrition counselling messages to pregnant women at the mothers’ waiting shelter to improve their nutrition status as well as facilitating trainings to empower HCWs working in the Special Care Baby Unit (SCBU), labour and delivery and paediatric wards to understand the importance of nutrition and influence breast-feeding is initiated within the first hour after delivery as well as improve documentation in the maternity register. In Muchinga province TA was provided via trainings to strengthen the follow-up mechanisms of malnourished children who are referred to higher levels of care from lower health facilities up to the time they are discharged into the community. o MCSP provided TA on strengthening linkages between the community and health facility levels. In Katete district, there was need was demonstrated between St. Francis hospital and Chibolya and Katete health facilities as they has recorded 38 and 18 cases of malnutrition respectively in 2017 and 2018.

Provided TA on Community Engagement: o MCSP provided TA support to districts in the four target provinces and facilitated the formation, revitalization and strengthening of provincial, district and community engagement structures for accountability of RMANCH&N services between the district and community stakeholders through capacity building of district (404) and health

10

facility level (558) staff in sound community engagement approaches. 962 (district and facility) has been oriented in CE approached from all 43 target districts. This intervention has improved the capacity of facilities to plan, execute and monitor community engagement activities as observed in the 2019 CoC plans which are stronger compared to the 2018 plans. The number of staff at DHO level is above the target because of other positions at the district level that were also oriented such as the DHIO and other districts have more than two EHTs at district level. o MCSP supported Mwansabombwe and Chembe districts in Luapula Province in implementation of community capacity strengthening approaches through facilitation of community based collaborative meetings with traditional leaders. In Mwansabombwe 26, leaders were engaged (19 Males, 9 females) and Chembe 12 traditional leaders (11 males, 1 female) districts were reached. The aim of the support was to improve community linkages and strengthen implementation of CE activities at community level in order to address social norms and adoption of recommended RMNCH&N practices. o MCSP facilitated the formation of District Health Promotion Teams (DHPT). Twenty three (23) against the target of 20 (Five per Province) DHPTs across the four provinces have been established (Eastern Province: 6; Luapula Province:4; Muchinga Province:7; and in Southern Province: 6). In the remaining districts, stakeholder mapping is ongoing and districts will soon be completing the formation of DHPTs. Furthermore, MCSP worked and supported the Provincial Health Office in forming the first ever- Provincial Health Promotion Technical Working Group in Muchinga Province. The team was formed on 17th July 2018 with composition of 14 members (10 males, 4 females). During the meeting, MCSP provided inputs and guidance on functions of the TWG, selection criteria and process of ratification. MCSP also provided resource materials including the MoH terms of reference for Health Promotion Coordinating Committees that will be used during the TWG orientation meetings. This will enhance routine stakeholder coordination of community health activities o MCSP introduced and oriented DHOs and facilities in Eastern, Muchinga and Southern provinces in use of Integrated Community Registers in Luapula Province, introduction of the registers had delayed due to non-availability of the registers. In the three province named above, MCSP utilized District integrated meetings, District and facility TA visitations and Health Center Committee (HCC) meetings to orient and launch the use of community registers. The Community registers will help to provide head count data for the ANC mothers, Postnatal Mothers, under five Children, to inform the planning of equity based Integrated Outreaches and follow up of target populations (Women of Child bearing and Under-five Children) in zonal catchment areas. MCSP additionally facilitated the distribution of registers to facilities in Eastern, Muchinga and Southern Provinces. Luapula Province did not receive supply of registers from the national level. The MOH is yet to distribute the registers to Luapula Province. In the meantime, MCSP will work with PHO to make follow up with the MOH for the supply of registers. Full implementation of this activity is at a slow pace in all provinces due to the following challenges: Registers have not been distributed to Luapula province; Muchinga, Eastern and Southern Provinces received very few copies and are not available in most facilities; Very few CBVs are oriented and have access to the registers and Lack of motivation for CBVs. However, with the aid of the ICCM trained

11

Community Based Volunteers (CBVs), the registers are being rolled out to all Neighbourhood Health Committee (NHCs) zones in some facilities. o In the three provinces however, in some facilities, implementation has begun. It is expected that once fully implemented, facilities will have an additional tool to aid them in effective planning and monitoring of community based RMNCHAN related activities such as integrated outreaches, monitoring non-immunized children populations, and monitor children’s nutrition status, follow up of pregnant women and monitor o At National Level MCSP has continued participating actively in MOH technical working group (TWG) meetings such as Adolescent Health TWG, Health Promotion TWG, Community Health TWG, Integrated Management of Childhood Illness (IMCI) & Expanded Program on Immunization (EPI) TWG to provide on spot technical support in standardization of policies and national guidelines to guide grassroots implementation. Noteworthy this Quarter, MCSP has provided TA to; o Directorate of Health Promotion and Social Determinants of Health (DHPSDH) in finalization and validation of the RMNCH-N Communication Strategy held in Kabwe; the strategy is now almost ready for printing. This strategy will harmonize the communication messages being communicated on RMNCAH-N across the country and scale up health promotion and demand generation o At National level MCSP provided Technical Support to the newly created unit “Community Health Unit “in the review and development of MOH community engagement technical updates during the MTEF planning period. This resulted into dissemination of key focus areas and high impact interventions to guide community health planning across the country. o Provided Technical Support to the Community Health Unit in development of the unit Operational Plan during the one-week meeting held at Mulugushi Conference Centre. The operational plan once completed will guide implementation of key interventions out lined in the NHSP for delivery of effective Community Health interventions across the country o MCSP has continued engaging its national level CoC partners through participating in the CoC partnership meeting to strengthen coordination of the G2G program. The last quarter’s focus was strengthening of 2019 C0C planning. These meetings facilitated the development of templates for use by the provinces, harmonization of high impact interventions (HII) and formation of teams to support the provincial level planning process. This resulted into successfully coordination of 2019 planning process at all levels o MCSP also presented to USAID the Community Engagement Approach for the programs, highlighting the TA focus, mode of delivery successes, challenges and next steps. This harmonized the understanding of the roles of MCSP Community Engagement for RMNCAH -N programs. USAID has since expressed interest to scale up CE approaches to facility and community level for greater program impact. MCSP has since scaled up implementation of CE to facility level and has started tracking some lower level process indicators as requested by USAID.

Provided TA on MEL: o At national level, MCSP supported the consolidation and sharing of the data quality

12

gaps in the DHIS2 from the provinces on gaps in how certain indicators are calculated. An analysis of the MCSP indicators was conducted and a number of gaps identified that have since been shared with the relevant department at the Ministry of Health for action. Feedback from the department indicate that the gaps have been addressed will be addressed through the continuous support to the districts and facilities. Among the key indw up support in the provinces, following up on adolescent health and community engagement activities in the districts. o MCSP continued to provide technical support to the feasibility of introduction of LNG- IUS into the public health sector. Key activities implemented to date include; o Phone interviews with 61 study participants in the four provinces have been conducted. Recruitment of women into the study has been slower than initially anticipated, the provincial teams continue to follow up with health care facilities for voluntary enrollment of eligible women who consent to participate o MCSP conducted 7 focus group discussions in all the 4 provinces with women using the LNG-IUS to get their experiences of the family planning as part of the study. FGDS were conducted with mentors and mentees and the interviews are being transcribed after which data analysis will be done. o At national level, MCSP supported the data extraction activity from 21 facilities in the 4 LNG-IUS provinces. The activity focused on reviewing the family planning registers and the quality of data. The findings have since been entered in a database and analysis will be conducted soon. The key observations from the trips report indicate that some facilities are using old family planning registers, have no trained staff in the data collection tools and data management and usage is a big challenge. Onsite support to the facilities to address the gaps identified has continued by the provincial team. TA has continued to be provided to the facilities through routine activities in addressing gaps such as challenges with capturing accurate data on family planning by facility staff. Engagement of districts to ensure facilities have the appropriate registers and capacity has also continued. We anticipate to see an improvement in data quality and less data quality issues from the facilities. We also anticipate to see more facility dashboards on family planning. o In Southern province, MCSP also worked with SM 360+ and conducted a joint data verification exercise at three LNG IUS study sites namely. The team reviewed the family planning registers and the uptake of the LNG-IUS method in the three study sites. Some of the challenges observed include retrieving of data on family planning from the Smart care system, inaccurate family planning data, absence of dashboards, use of old family planning registers, poor documentation and absence of trained staff in some facilities. The team made a follow up visit in the period under and worked with the facilities to develop the dashboards to monitor the use of family planning services and orientated facility staff in using the integrated family register to enhance the quality of data being collected. We anticipate an improvement in data use and quality of data in family planning data. o MCSP at national level in collaboration with the provincial team developed a protocol for data quality assessment titled enhanced data quality assessment (EDQA). The focus on the protocol is to promote standardization of the key processes in undertaking data

13

quality assessment and broaden the scope of the assessment by including reviewing the availability of new tools and capacity in using the tools. The protocol is almost finalized and will be piloted and shared with districts for possible use. o In the provincial offices, the provincial monitoring and evaluation officers focused on conducting interviews for the MCSP qualitative study, support CoC activities such as data quality assessments and support the 2019 MTEF planning in the period under review. o MCSP in Muchinga supported the review of population data in the DHIS2 after it was observed that the new population figures provided by CSO through the Ministry of Health HQ for Muchinga were significantly less than the previous population. The districts have since been engaged with support from SHIO to update the DHIS2 with the new CSO projections. The District Health Information Officers have since entered the new population data in the DHIS2 and districts are suing the population to quantify and analyze data. o In Muchinga, MCSP collaborated with PAMO in the period under review and oriented 30 health staff from Kanchibiya, Chama, Nakonde, Mafinga, Mpika and Lavushimanda in HMIS/DHIS2 and data use. The training focused on the registers, HIA tools and tally sheets. Emphasis was also placed on the need to engage the neighborhood health committee in reviewing the data. This training has empowered the staff with skills to capture accurate data and we anticipate a reduction in the number of data quality issues raised from data audits. o In Luapula MCSP supported the DHOs program officers in reviewing RMNCAH& N indictors in preparation for the 2019 MTEF planning. Key high impact interventions were identified with the districts based on the findings and recommended for inclusion in the 2019 MTEF plans. The recommendations included HMIS training, data reviews/audits, orientation meeting in the usage of community registers, training/Orientations in Quality Improvement and onsite orientation of HC staff in data capturing and compilation. o In Luapula MCSP supported two districts in strengthening the mentorship teams by orientating district staff in the mentorship and SQA approaches. MCSP managed to orient 10 staff in 2 districts and 6 facilities. The districts and facilities will use SQA and mentorship to review their performance and for planning that will improve on service delivery. o MCSP provided technical support to the provinces in the province during the pre- planning for the 2019 MTEF plans in the period under review. The process involved visiting the districts, reviewing their performance using data in DHIS2, other reports and identifying high impact interventions. A number of interventions that were proposed included quarterly data quality audits, promoting QI approaches such as mentorship and SQA. o MCSP provided TA to in the data quality audit in conducted in the period under review with the district health information officer. MCSP supported the DHIO in addressing the capacity gaps in four facilities in the use of the antennal, child and mother follow up in four facilities by conducting onsite orientation of staff in the registers was conducted. o MCSP in Eastern provided TA to Chadiza, Katete and Chipata in analyzing data from DHIS2, PA reports, DIM and quarterly reviews to inform the 2019 CoC planning.

14

RMNCAHN indicators were reviewed to identify areas were the districts are not performing well and identify high impact interventions. High impact interventions were identified and a list of key interventions to address the gaps were identified and included in the districts plans. The key activities that districts included in the 2019 plans include quarterly data quality audits, data reviews, bundles for data entry and HMIS orientation for new staff. o MCSP in Eastern province also supported the districts in reviewing the data in the DHIS2 in terms of completeness, accuracy and generally for data quality. The major challenge in the period under review was mostly the system itself, however, most challenges have been addressed and this has resulted in an improvement in the accuracy and completeness of the data in the system. The timeliness of data entry in the system has improved from 5.9% in Q1, 24.7% in Q2 to 51.6% in Q3. MCSP continues to engage the districts to ensure timelines is above 95% o MCSP in Eastern province also supported orientation of staff at Hospital ward and departmental managers in SQA and creation of dashboards. With skills in conducting Service Quality Assessments, the hospital has planned to conduct SQAs across the different thematic areas in the hospital by the end of Q4, 2018, so that decision making can also be based on such results.

Objective 2: Foster institutional collaboration to build local capacity in RMNCAH&N MCSP has been working with General Nursing Council of Zambia (GNC) and the Medical Women’s Association of Zambia (MWAZ) to foster institutional collaboration to help build capacity of these two local institutions so that they can effectively provide technical support to RMNCAHN activities. The two institutions were identified as being able to provide mentorship support in RMNCAHN beyond the life of MCSP. The GNC was nominated as it regulates the nursing and midwifery professions in the country and provides capacity-building support including mentorship through various platforms and systems including the continuing professional development (CPD) system to ensure the nurses and midwives are able to provide effective services. The GNC would like to decentralize its CPD system to bring the licensing and mentorship system closer to all the nurses and midwives across the country. MCSP has thus twinned the GNC with the Nursing Council of Kenya (NCK) that has recently successfully initiated the process of decentralization of its services to the subnational level in Kenya. MCSP has facilitated capacity-building efforts between the two institutions. In the last quarter, the GNC conducted a self-assessment to identify areas of need. These gaps were shared with NCK, which has been providing remote support in some of the identified areas. Additionally, the GNC drafted a proposal titled Assessing the Feasibility of Enhancing the Capacity of Nurses and Midwives through Decentralized Continuing Professional Development (CPD) Program in Zambia. The proposal passed ethical approval and following this, the council conducted an orientation for data collectors to allow the collection of views and insights from nurses and midwives on how they would like the CPD program to be decentralized.

During the quarter, MCSP continued to support MWAZ after it recently selected its executive to guide the process of developing its strategic plan. MCSP identified this as an opportunity to provide technical support in the process of developing the tools to collect input from its members and in the development of the plan. In the last quarter, MCSP drafted the data collection tool and

15

a strategic plan template. The tool will be used to collect the views of the members of MWAZ on the priorities that they would like to have included in the strategic plan.

Objective 3: Develop eLearning training courses to improve provider knowledge In the last quarter, progress was made in the development of the e-learning courses. 78 % of the IDWs have been completed and additional questions/clarifications addressed prior to assembling of the modules. Four modules are yet to be reviewed by SMEs. MCSP is still experiencing delays from the subject matter experts and their failure to upload the latest versions of IDWs and respond to queries. There have also been delays with approval of the completed ANC modules. These delays are not surprising given that the subject matter experts drawn from MOH have competing duties and responsibilities. MCSP has earnestly continued to impress upon the MOH SMEs and their supervisors of the need to expedite the process– MAIYCN and IMAM. Instructional Design Workshop sheets for health care workers to begin using these courses as soon as possible. At the same time, MCSP has been consulting closely with iSchool, the vendor contracted to convert the content into e-learning format, towards having the vendor ready to finalize the remaining elements of the courses as soon as the SMEs do their part. With the vendor having confirmed that the work will be complete by January 31, 2019, MCSP is confident that this objective will be finalized long before closeout on March 31, 2019.

The courses are expected to be completed as follows:

Course Expected Completion Date ANC November 30, 2018 MIYCN November 30, 2018 IMAM January 21, 2018 HIV January 21, 2019

Once complete, the eLearning courses will provide a platform for health care workers to update their knowledge by distant learning. The courses will also provide an added tool for advocacy to the national level MOH for procurement of appropriate evidence-based supplies, including pharmaceutical commodities.

5. USAID Branding and Marking status: • Did any of your activities during this quarter result in printed materials, training events, web page development or other instances where the application of USAID logo/brandmark may be required? If so, please list and include examples of each. No materials requiring branding were printed in the period under review

• Are you anticipating any activities during the next quarter that will produce or result in printed materials, training events, web development, or other instances where the application of USAID logo/brandmark may be required? If so, please list them. N/A

16

6. Please provide an updated status on the indicators developed for your activities. The table below shows the status of key indicators and results indicate that overall, we are on track on most of the indicators and we are off track in 5 indicators. Generally, the provincial MCSP teams review the indicators and identify districts that are not doing well and follow up to discuss and come up with interventions. The result from the quarter indicate that we are below target in the following indicators: 1. Number of new clients adopting new FP method: results indicated that Muchinga is below 50% of the target, Southern, Eastern and Luapula are above 50%. Low usage continues to be challenge in most facilities. Our TA to the districts have focused on strengthening community engagement structures and sharing some community engagement strategies 2. Number /Percentage of newborns initiated on breastfeeding within 1 hour of birth: Overall the data indicates that by quarter we are 60% of women initiating breastfeeding within 1hr. A review of data reviewed and discussion with the Ministry revealed challenges with reporting of this indicators following the updating of the tools. There was a lot of under reporting from the facilities in quarter 1, as data in the system shows that only 33% of the women initiated breastfeeding within an hour. 3. Number /Percentage of active District Mentorship teams: Overall results show that onl;y 50% of the districts have active mentorship teams with Eastern And Luapula having more active mentorship teams. Muchinga and Southern had challenges with resources to conduct mentorship sessions. Resources were disbursed late 4) Number of facility staff oriented in community engagement strategies/approaches: This was recently agreed that community engagement activities can focus on facility level staff as focusing on the district was not having any impact. The target was just agreed in quarter 3 and a number of activities to orient facility level staff have been planned for Q4.

17

Quarterly Trend Bulletin

18

Annexes

1. Project expenditures to-date 2. Theory of Change 3. Success Stories 4. Provincial Reports

MCSP Zambia Quarter Report: July-September 2018 19

Annex 1: Quarterly Financial Analysis

Actual Actual Estimated Total Total Actual Expenditures Actual Expenditures Total Remaining Estimated Funds Expenditures for Previous Actual Expenditures for Estimated Obligated Award Obligated thru Quarter April Expenditures for August September Accrued Expenditures Funds to Amount To Date 06/30/2018 - June 2018 for July 2018 2018 2018 Expenditures to Date Date $9,000,000 $5,578,775 $1,495,262 $656,792 $340,875 $479,475 $298,170 $7,354,087 $1,645,912.88

Annex 2: MCSP Zambia Theory of Change

MCSP Zambia Quarter Report: July-September 2018 20 Annex 3: Success Story SUCCESS STORY ZAMBIA Midwife’s Improved Competencies Result to Nil Maternal & Neonatal Deaths After completing her in-service trainings and a 6 months internship as a certified midwife, Onastasia Zanga was posted to Chimtende Rural Health Centre (RHC) in Katete District of Eastern Zambia. Her excitement of being posted was almost matched with the challenges that awaited her arrival. She is the only midwife at the facility, but works closely with a Clinical Officer, Registered Nurse and Environmental Health Technologist.

Among a host of challenges that Onastasia had to contend with were her inability to appreciate and implement the Ministry of Health (MOH) recommendation of keeping mothers and newly born babies for at least 48 hours in the facility after delivery. The community also lacked awareness and understanding of the policy as they were used to being discharged six hours after delivery. As a result, in 2017, Chimtende RHC recorded 0% postnatal care within 48 hours coverage.

The story changed for Onastasia and team when the USAID funded Maternal and Child Survival Program (MCSP) oriented them on the Photo: Onastazia Sanga, Certified Midwife Working at importance of the MOH recommendation of 48 hours post-natal care for Chimtende RHC (left), Chimtende RHC postnatal ward (right) both mother and baby. The health facility staff were also oriented on how to offer resuscitation within the golden minute to neonates born NAME with Asphyxia. Chimtende Rural Health Center (RHC) Onastasia now takes keen interest in monitoring the mothers for any danger signs such as vaginal bleeding, rise in BP or temperature. She also checks ROLE the babies for any bleeding from the umbilical cord, convulsions, high Certified Midwife temperature or failure to breastfeed.

She has gained full competence in educating the mothers during ante-natal LOCATION care (ANC) visits on the 48 hours postnatal care. She says “as a result, when Katete, Eastern Province they come for delivery, they come prepared to be kept for at least 48 hours after delivery.”

SUMMARY Onastasia has oriented the entire health facility team and some Safe Certified midwife Anastazia Sanga ensures Motherhood Action Group (SMAG) members on the importance of all women delivering at her facility receive postnatal care to women and babies with 48 hours. This has made the team 48 hours of post-natal care after delivery. at the RHC to practice this good and high impact intervention, moving from 0% in 2017 to 21.5% in 2018 Quarter 1.

“I feel good when I discharge a mother The result – 0% maternal and neonatal deaths in 2018. Those who may and her baby in a good condition after show any danger signs are kept longer or referred for advanced care, mostly observing them for 48 hours after to St. Francis Hospital.

delivery. It satisfies me.” Chimtende RHC has a catchment population of about 9,465 people, with - Anastazia Sanga, CM, Chimtende over 490 live births expected by end of 2018. The facility is one of the best performing in Katete District in terms of offering comprehensive postnatal care. By: Goodson Mukosa Mpumba, Moses Mwanza, Bubile Mzumara and Pauline Sikazwe

Annex 4: Province Reports

MCSP Zambia Quarter Report: July-September 2018 22

EASTERN PROVINCE QUARTER 4, 2018 REPORT

MCSP NBH TA, Pauline Sikazwe, Assisting a mother at Nyanje Hospital how to Practice KMC

Team Members 1. Goodson Mukosa Mpumba Provincial Coordinator 2. Moses Mwanza Provincial Technical Officer 3. Pauline Sikazwe Newborn Health Technical Advisor 4. Wilson Siachalinga Nutrition Technical Advisor 5. Robert Sakutaha Community Engagement Technical Advisor 6. Bubile Mzumara Provincial Monitoring, Evaluation and Research Officer 7. Misheck Kwenda Driver/General Duties Province: Eastern Province Reporting Period: Quarter 3 2018 (July to September)

Summary of Major Accomplishments MCSP managed to give TA to all the 9 Districts in the province in the period under review. The major activities were around planning for 2019 with a view of making the plans better. The major activities were to work with the district health office program officers in analyzing their performance; identified gaps and their attributes then developed High Impact Interventions for possible inclusion in the plans. This seem to have bettered the planning process as opposed to meeting the districts at once at the provincial planning review meeting. Focus was also on the Result Based financing (RBF) RMNCAHN Indicators in which districts like Katete, Vubwi and Chadiza did not perform very well in 2017. (No more than 3 bullets per thematic area) Directions: In this section, you’ll discuss key

MCSP Zambia Quarter Report: July-September 2018 23

accomplishments for the reporting period. Please include information on how each accomplishment has contributed to the achievement of program results. Rather than focusing on process, highlight why this matters – the “so what” question. What outputs or outcomes came out of the process? Example: XX [ PROCESS], contributing to XX. [ THE “SO WHAT”] Below are examples of achievements which have a ,’So what ‘ component.

1. Reproductive and Maternal Health a. MCSP supported Chadiza, Chipata, Katete, Lundazi, Mambwe, Nyimba, Petauke, and Vubwi Districts to strengthen their 2019 CoC plans in which we took time to analyze the district performance together with the District health office Program Officers. The indicators looked at included Percentage of clients accessing long acting reversible contraceptives, Antenatal 1st visit before 14 weeks (%),Antenatal: Pregnant Women Accessing at least 4 Visits to ANC (%),Percentage deliveries by skilled personnel, Percentage of pregnant women diagnosed with Anaemia, Maternal deaths in facility. Some of the attributes for the poor performance surrounding these indicators included low community acceptance and participation, lack of integration of ANC, FP, and PNC services during outreach services due to poor outreach infrastructures. High Impact Interventions were developed based on the gaps identified. Refer to the annex for the HIIs proposed and those adopted b. MCSP Offered Technical Assistance to Kapata HAHC team in use of SQA tools and conducted SQA in Focused Antenatal Care (FANC), Family Planning (FP) and Infection Prevention and Control (IPC) in which it was discovered that the HF did not have an Ultrasound Scan in the MCH department, the women starting ANC were not being offered gravindex test to rule out pregnancy, there were no APH protocols displayed in the department and there were no IPC guidelines. Guidance was give to the team to lobby for the ultrasound machine for the department, source for APH protocols and display them. The SQA dashboards were developed and the facility staff were employed to work on the gaps identified. Refer to the SQA dashboards in the Annex. c. MCSP has provided mentorship models to 4 districts (Katete, Sinda, Chadiza and Vubwi) and 3 Nursing and Midwifery Training Institutions (Chipata, Mwami and St. Francis) with mentorship models totaling to 5 RITA Reproductive Implant Training Arm S519, 8 Zoe Gynecological Simulator S504.100, 6 Vinyl Pelvic Model 54058, 4 Mama-U Postpartum Uterus Model Basic, 5 Mama Natalie Birthing Simulator (Dark) - LGH- 340-00233, and 5 Neo Natalie Basic (Dark) - 104-10001. These models are expected to be used for simulations in instances when there will no clients thereby promoting the improvement of skills among the HCWs and student nurses and midwives 2. Newborn Health a. MCSP provided TA during During the MoH MTEF/CoC planning process in the provinces. The technical assistance included facilitating discussions on key indicators in all the thematic areas of RMNCAH&N which included Newborn health key indicators, Reviewing of district performance indicators for 2017 using the HMIS score MCSP Zambia Quarter Report: July-September 2018 24

card and discussed the attributes for performance, Sharing of high impact interventions according to the identified gaps and Supported the provincial health office in reviewing of the final district plans with a focus on the 2019 CoC grants which resulted in the evidence based plans with development of high impact interventions in the 2019 plans b. MCSP Offered TA to Nyanje Hospital in managing children using KMC. The team was supported with including feeding documentation of every baby admitted to the Special Care Baby Unit (SCBU), check weight every day and ensure that the women practiced the KMC consistently and correctly to promote quick recovery. MCSP guided the team to procure the locally made KMC chairs and KMC wrappers to ensure that the women were comfortable when nursing their babies. 3. Child Health a. MCSP Influenced the nine districts and zonal facilities to ensure that they used their performance data, identified gaps from PA, DIM reports, scorecards and quarterly work plan reviews to inform their interventions which should be in line with the 2017-21 National Health Strategic Plan (NHSP) and thereafter MCSP shared their proposed child health high impact interventions based on the identified district performance gaps in the nine districts of Eastern province during the pre-planning process for inclusion in their 2019 MTEF/CoC action plans. b. MCSP ensured that the districts had Child health proposed high impact interventions included in the CoC plans. For instance, MCSP influenced the inclusion for the construction of outreach posts using the outreach post matrix in Mambwe, Lundazi, and Vubwi districts to improve outreach services. The district adopted for inclusion the following high impact interventions: Conduct the REC strategy, conduct supervision to facility ICCM supervisors, provide Standard Case Management in common diseases (Malaria, Malnutrition, diarrhea, etc.) and conduct mentorship/TSS in case management. These interventions will reduce child morbidities and mortalities. c. MCSP managed to orient staff at Chikoma Zonal RHC in , Nsadzu Zonal and Zemba RHCs in Chadiza district) RHCs and Undi RHC in Katete district in the REC/EPI microplanning process and draft micro plans were prepared in the four facilities. The purpose was to make sure that the facilities produce high quality micro plans, increase immunization coverage and reduce drop-outs for under five children, identify and target the unimmunized and regularly use data to monitor and follow up on progress.

4. Adolescent and Reproductive Health a. MCSP provided TA to Sinda, Katete, Vubwi and Chadiza Districts on the importance of formulation of district ADH TWGs. Chadiza has since formed one and are awaiting orientation of members in TORs. Katete has one, which is not active but will hold their meeting in October. Sinda has planned to form one in October 2018 and will orient the members in the TORs

MCSP Zambia Quarter Report: July-September 2018 25

b. MCSP has worked with Provincial ADH coordinator/FPP, the Principal Nursing Officer Standards, in developing a concept note on how to strengthen and form District ADH TWGs in Eastern province. The activity is supposed to be conducted in October 2018 c. 3 5. Nutrition a. Provided TA to Mwita, Dwankhonzi, Magwero health centres under Chipata district to ensure that RMNCAH&N activities are included in their plans. TA provided to Chipata DHO planner on nutrition activities to include under District. b. Oriented the EHT at Undi clinic and Nyanje Nutritionist on how to use BMI chart, documentation and interpreting of results to inform appropriate nutrition counseling based on classification. In addition to this Undi health centre staff were advised to strengthen nutrition interventions in the three NHCs where they recorded high number of under weights and assign specific volunteers to follow up the clients and provide onsite nutrition counseling to care takers. c. Provided guidance to the district nutritionist at Sinda DHO to find time to work at ART or MCH clinic when not busy and provide mentorship to volunteers and staff in carrying out quality nutrition assessments, classification and counseling. d. Following the orientation of nurses and nutritionists in maternal neonatal infant young and child nutrition by Chipata Central, MCSP guided that there is need to ensure that the Infant growth assessment tools are always available in NICU room to all premature babies to determine growth adequacy in uterine and for monitoring post-delivery growth. In addition, attached to the client's folder should be documentation of daily weight and head circumference status. Furthermore, the breast milk expressed by the mothers of premature babies, the amount of milk expressed should be recorded and amount taken in by each baby be recorded in a milk daily intake chart. This will assist in assessing weight gain of the babies. 6. Community Engagement a. Attended and presented at a joint health partners meeting (16-17/7/2018) of partners providing various support to the Ministry of Health. The purpose of this meeting was to share experiences of partners supporting the Ministry of Health and see how best the partners could further their support for human wellbeing; b. Conducted monthly TA visits to DHOs to provide technical assistance to the DHOs during their planning period for the 2019 MTEF/CoC budget preparations in order to ensure that the DHO prioritized what the donor considered as high impact interventions that would help achieve the RMNCAH&N indicators for better wellbeing of communities in the province. Another objective of these visits was for MCSP to take the DHO teams through the scorecards, analyze each indicator’s performance, and develop proposed activities to close the gap. Additionally, MCSP monitored the formation of DHPCC as well as usage of community registers for client listing. These were as follows:

MCSP Zambia Quarter Report: July-September 2018 26

i. Chipata DHO (Kapata Urban Health Centre and Eastern Command RHC) 19/7/2018, 10/8/2018, 27/8/2018; ii. Lundazi (23-25/7/2018) iii. Chadiza DHO (27/7/2018, 22/8/2018); iv. Katete DHO (1/8/2018) v. Mambwe DHO (3/8/20018); vi. Vubwi DHO (2/8/2018, 4/8/2018, 20-21/8/2018, vii. Attended one joint MTEF/CoC planning launch meeting (13-15/8/2018) at which MCSP supported the EPHO and DHOs to come up with final budgets and plans for 2019 that would be reflective of what will provide value for money for the wellbeing of eastern province communities in health service provision; c. Conducted two TA visits to Chipata DHO (31/8/2018) and Mambwe DHO (5/9/2018) to attend the district MDSR meetings at which MCSP supported the districts in reviewing their maternal deaths that occurred in the districts. This was with the view to help find mitigations for further reduction of maternal deaths so that no mothers should die while giving birth; d. Conducted TA visits to Vubwi (6/9/2018) and Chadiza (11/9/2018) as post budget planning reviews to consider the response to the donor, Sida, towards the released budget plans, in order to realign some funds that were considered not well allocated to budget lines not likely to bring high impact.

7. MER a. MCSP team supported the districts to conduct data analysis during the MTEF/CoC 2019 planning process. This was done through situational and SWOT analysis and scorecards. The teams were able to use data for decision making and inform 2019 activities to be planned for so as to improve on indicators that are performing poorly. b. MCSP managed to conduct the MCSP TA model qualitative study. The study collected data on the influence and results of the MCSP/Zambia technical assistance model and documented best practices and lessons learned in implementing the MCSP TA model. Interviews were conducted in Chipata, Lundazi, Chadiza and Nyimba districts including cooperating partners like SIDA, SBH and SM360+. c. The team participated and provided TA during quarter 1 and 2, 2018 provincial integrated meeting. The team worked closely with the SHIO in revising the presentation template and data analysis. The team also presented MCSP achievements during quarter 1 and 2, 2018. 8. Crosscutting a. MCSP managed to discuss with Sinda Nyanje Mission Hospital management on the need to create a Zonal mentorship hub at the facility, which will help to improve the staff competences in the district, it was agreed that the hub will be created in the 4th

MCSP Zambia Quarter Report: July-September 2018 27

quarter 2018.

MCSP Zambia Quarter Report: July-September 2018 28

Objective 1: Provide demand-driven technical assistance for sustainable scale up of RMNCAH&N interventions across the four focus provinces of Zambia Technical Activity Progress of the Activity Next Steps for this Activity Area Activity 1.1: Technical Assistance to CoC Program • MCSP supported Chipata and Chadiza districts during their • Perinatal, Neonatal and Maternal Deaths Surveillance and Response Meetings, which were held in August and September respectively. For Chipata District, most of the maternal deaths were as off referrals from other HFs who were dying at Chipata CH. The team was advised to enhance implementation of the national maternal and neonatal referral guidelines to prevent late referrals. Most of the neonatal deaths were due to prematurity; the teams were advised to implement strategies such as provided for in the WHO ANC 2016 guidelines to prevent the escalating premature pregnancy outcomes. Reproductive • TA was provided to Vubwi district during their DIM and it was and Provide technical established that most of the HFs were not performing well in terms Maternal assistance during of ANC first visit within 14 weeks Health implementation of • MCSP provided TA to Katete district during their RMNCAN 2018 CoC grants Indicators performance review meeting. It was discovered that there was poor linkage between the HF, SMAGs and St. Francis Hospital when a woman is referred for Hospital delivery antenatally, before her pregnancy was term. MCSP guided the HF • Katete DHO to procure the team to enhance linkages with the SMAGs and St. Francis. They National Maternal and should ensure that every woman who is referred for Hospital Neonatal referral books and Delivery is linked to a specific SMAG member so that they have them stationed in all monitor when the woman is supposed to report to the hospital and HFs to improve referral when they report as well as when they come back. This would help system in reducing delays as well as follow up care such as Postnatal Care. The HF staff should use the right referral tools/form on which the Hospital must provide feedback and in collaboration with the SMAGs ensure that the women took back the referral

MCSP Zambia Quarter Report: July-September 2018 29

feedbacks to the Health Centre. MCSP guided the Nursing Officer to work with the procurement team to procure the carbonated Maternal and Neonatal referral forms so that they are in use to improve the referrals being made. MCSP guided which documents • Nyanje MH Labour and to print out as the NO was not sure Delivery ward to source for • MCSP provided TA to Nyanje Mission Hospital which did not protocols; Management of have protocols and guidelines displayed in the labour making it PPH, Management of difficult for midwives whenever they had a specific case to Severe Pre & Eclampsia, manage. MCSP guided the team to ensure they had protocols, Manual removal of the even handwritten for now, as they were waiting for the original placenta, Management of printed ones. This would easy the work of the midwives as they APH, Referral Guidelines, will be able to easily refer to the displayed protocols whenever e.t.c to easy management of managing a case such as PPH. labour and delivery complications in mothers and babies Provide technical • MCSP provided remote support to the CoC provincial coordinator assistance during during the Sida/MOH team visit to the Eastern province to monitor • monitoring of 2018 the progress of the RMNCAHN implementation in Eastern CoC Grants province. Provide technical • MCSP supported all the nine districts in analyzing their assistance during performance and identified gaps as well as the attributes of the • planning of 2019 gaps. HIIs interventions such as CoC grants Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship • MCSP influenced the Sinda DHO teams to ensure that they included training of mentors in their CoC 2018 Q3 &4 plans to Establish increase the numbers of mentors so that they could form Zonal • mentorship teams mentorship teams which will in time enhance the frequency of mentorship in Reproductive and Maternal Health thereby increasing the Equip mentorship • MCSP has provided mentorship models to 4 districts (Katete, • To offer follow up support teams with models Sinda, Chadiza and Vubwi) and 3 Nursing and Midwifery Training to Katete, Sinda, Chadiza

MCSP Zambia Quarter Report: July-September 2018 30

Institutions (Chipata, Mwami and St. Francis) with mentorship and Vubwi Districts and models totaling to 5 RITA Reproductive Implant Training Arm Chipata, Mwami and St. S519, 8 Zoe Gynecological Simulator S504.100, 6 Vinyl Pelvic Francis Schools of Nursing Model 54058, 4 Mama-U Postpartum Uterus Model Basic, 5 and support them with Mama Natalie Birthing Simulator (Dark) - LGH-340-00233, and setting up their mentorship 5 Neo Natalie Basic (Dark) - 104-10001 hubs and monitor the usage of the models to improve the skills of the HCWs and student nurses and midwives. Technical • Follow up on finalizing the • MCSP supported Chadiza, and Nyimba districts remotely on how Assistance to development of the to develop mentorship dashboards to enhance accountability for programming for mentorship dashboards for each staff’s skill and provide grounds for follow up. The mentorship in 2019 Chadiza and Nyimba mentorship dashboard template was provided CoC Plans districts Activity 1.1: Technical Assistance to CoC Program 2018 National Maternal and Neonatal Referral Guidelines;

• MCSP orientated staff at Minga mission hospital and Chimtende RHC in Eastern on the new maternal neonatal referral guidelines to ensure prompt referrals. The soft copy of the guidelines was provided and the team encouraged having them printed for reference by facility staff. Provide technical Newborn assistance during Infection Prevention; • implementation of • 2018 CoC grants MCSP discussed with the facility managers on the need to follow guidelines on infection prevention in reprocessing and storage of neonatal resuscitation equipment to help prevent cross infection and consequently reduce on neonatal mortality and morbidity due to sepsis. MCSP has continued to advise the districts on the importance of separating the infant resuscitation equipment from the delivery and MVA equipment during the decontamination process

MCSP Zambia Quarter Report: July-September 2018 31

48hrs postnatal care;

• MCSP in Eastern province commended Chimtende RHC for implementing the 48hrs PNC policy despite limited space. Some facilities also are practicing but lack documentation. TA provided on the importance of 48hrs PNC to reduce the post-partum complications practices and documentation of the practice/indicator.

Newborn Heath Protocols;

• MCSP discussed with facility in charges at Nyanje mission hospital on the need for newborn health protocols such as HBB displayed on the walls for quick reference during service provision with the facility managers. This will consequently help health facilities adhere to standards during service provision and improve on newborn outcomes.

Perinatal death reviews:

• During the TA visits MCSP observed that facilities were not conducting perinatal death reviews at the facility level. MCSP have been discussing with districts the need to conduct the perinatal death reviews to draw lessons and avoid similar occurrences in future. The districts were given a soft copy of perinatal death audit form to guide the reviews. The discussions were with all the districts.

Kangaroo Mother Care (KMC);

• MCSP supported Nyanje Hospital in the importance of continuous KMC to the mothers that were not found in the KMC. MCSP discussed with the District to orient and mentor staff on KMC as a way to roll out this HII to all the facilities in the district so that the staff acquire knowledge for effective counselling of the mothers with preterm babies. •

MCSP Zambia Quarter Report: July-September 2018 32

Perinatal and Maternal Death Surveillance and Response meetings MCSP in Eastern and Muchinga provided TA during the quarterly PNMDSR meeting in Chipata to help contribute to the improvement of the maternal and neonatal indicators.

In Chipata, the following data was presented for 1st and 2nd quarter 2018 in the district: • FSBs –21, MSBs—23, Neonatal deaths—57 due to prematurity. • Chipata district has trained 32 facility staff in KMC out of the 66 district facilities. • District has mentored staff in ENBC and HBB. All the neonatal deaths due to prematurity occurred at Chipata Central Hospital as most preterm labors are referred to the hospital from health • MCSP to support the facilities. Some of the identified gaps were not addressing the districts to consider scaling Provide technical newborn health problems up of KMC to the health facilities to address the assistance during • MCSP advised the district to come up with gaps that can directly neonatal deaths due to monitoring of 2018 address the actual problems of the newborn health especially the preterm deliveries. prematurity, KMC being CoC Grants the high impact At Chimtende Health Centre (Katete district) intervention. • The resuscitation space is operational but the HF has not yet • sourced for the buckets for decontaminating Neonatal Resuscitation equipment. MCSP still advised the HF team to ensure that they separate the neonatal resuscitation equipment from the delivery equipment when cleaning them. At Chimtende RHC Good Practice This is a facility, which keep all women and children for 48 hours after delivery despite having challenges with space and beds. One way they have managed to keep up with this indicator is that they counsel women antenatally on the importance of being at the HF for 48 hours before discharge. This was confirmed from one woman who was in labour; she said that she would only be discharged after 2 days. MCSP will continue promoting such good practices by disseminating them to the authorities and other HFs. Child health Activity 1.1: Technical Assistance to CoC Program

MCSP Zambia Quarter Report: July-September 2018 33

• Provided TA to during the orientation of the eight NHCs in the under five cards and registers at Kapata urban clinic of Chipata district. The MCSP team discussed with the NHC members on the need for GMPs to have community registers for under five children and other related data. The team introduced the new • Monitoring the registers by MoH, entitled Integrated Maternal Health, New Born immunization coverages, and Under 5 Community Registers, specifically designed for use dropout rates and use of by community-based CBVs. The MCSP oriented the participants registers from the 8 NHCs of the facility on their role in the REC strategy to improve immunization coverages and the dropout rates. • Orientation of staff in four facilities (Chikoma Zonal, Nsadzu Zonal, Zemba and Undi RHCs) in the on development of the 2019 REC strategy micro plans and orient DHO staff in REC TSS tool. • TA provided during the Chipata DHO 1st & 2nd quarter 2018 Provide technical performance assessment reviews at Kasenga, Mkanda Zonal and assistance during Magwero RHCs. MCSP requested the facility staff in the three to implementation of be entering and recording all the antigens given to children in the 2018 CoC grants under-five register as it was their primary source of data and not the tally sheet. • At Katete DHO, MCSP Oriented 4 program officers in the EPI/IMCI Electronic training course and installed the software on • Development of the 2019 two computers REC micro plans

• During the RMNCAHN Indicators performance data review

meeting, MCSP oriented 5 staff in the EPI/IMCI electronic

training course; 1 from Mzunza RHP, 1 from Kafumbwe RHC, 1 • Data collation in the from Lukweta RHP, 1 from Chibolya UHC and 1 from Mindolo registers and HIA2 RHC (5 in total), and it was installed on their laptops

• At Undi RHC in Katete district, MCSP oriented the HCWs (1 Midwife, 1 Nurse and 1 EHT) on how to use the Electronic EPI/IMCI training package. The package was installed on the HF

MCSP Zambia Quarter Report: July-September 2018 34

computer and the staff were encouraged to complete the course at least within a month • At Chadiza DHO, MCSP

• ORT Corners were set up in both the IPD and OPD at Kapata urban clinic of Chipata district and had the required supplies (ORS Provide technical sachets, Zinc Sulphate tablets, Cups, Bucket, spoons, containers assistance during with already made ORS and ORT registers on display.

monitoring of 2018 • Staff at Kapata and Eastern Command clinics of Chipata district CoC Grants were able to update and interpret their immunization monitoring • Use of the immunization charts correctly monitoring charts in the other facilities

• Managed to have the nine district the Child health proposed high impact interventions included in their 2019 MTEF/CoC plans. For instance, MCSP influenced the inclusion for the construction of outreach posts using the outreach post matrix in Mambwe, Provide technical Lundazi, and Vubwi districts. The districts included the following assistance during high impact interventions: • planning of 2019  Conduct the REC strategy CoC grants  Conduct supervision to facility ICCM supervisors  Provide Standard Case Management in common diseases (malaria, malnutrition, diarrhea etc.)  Conduct mentorship/TSS in case management

Technical Assistance to • MCSP Influenced the nine districts to plan and include integrated programming for mentorship to address IMCI/EPI issues in their 2019 MTEF/CoC • mentorship in 2019 action plans. CoC Plans Community Activity 1.4 Increased demand for services through increased community engagement engagement Strengthening TA PROVIDED AT PARTNERS’ MEETING IN CHIPATA • Ministry of Health and

MCSP Zambia Quarter Report: July-September 2018 35

district & On 16/07/2018, MCSP CE attended a Partners’ Meeting of Partners must interact and community organizations involved in RMNCAH&N activities in the province, at involve each other in platforms for which 65 participants attended. 11 partners, including the Ministry of activities they implement in accountability of Health, presented what services they provide in the province. The the province for better RMANCH&N following Partners made their presentations: community health services between a) Ministry of Health: The Ministry of Health was only the district and coordinating the meeting, and did not make any presentations as the community meeting was solely for partners working with the Ministry of stakeholders Health. such as DHPTs, b) Broadreach: a computer connectivity NGO who presented on NHC, HCC, Implementation of Programs to Support Integration of Health SMAGs, IYCF, Information Systems and HIV/AIDS/TB Treatment Services in CBD, CHWs, Peer the Republic of Zambia under the President’s Emergency Plan Educators, CHP etc. for AIDS (PEPFAR)”; through stakeholder c) CRS: who presented on Epidemic Control 90-90-90 (EpiC 3- profiling and 90) supports the Ministry of Health (MOH) in targeted faith- strengthening / based sites to achieve UNAIDS Fast Track goals for epidemic establishment of control; structures d) APHL: which presented on Support to MOH on Strengthening /platforms Laboratory Capacity • Provide e) Health Workforce for the 21st Century (HW21): which Technical presented on: Assistance • Increased regulatory councils and MOH capacities in HRH during management through strengthened human resource information implementation systems for decision making; of 2018 CoC • Increase the number and capacity of nurses to prescribe grants: Joint ART/PrEP to manage and provide ongoing support for PLHIV Provincial • mproved health care workers’ HIV service delivery capacity Health Partners’ through continuing professional development (CPD) by building Meeting tele education/tele mentoring technology platforms using the ECHO model™. f) SM360+ who presented on:

MCSP Zambia Quarter Report: July-September 2018 36

• To reduce maternal mortality ratio and neonatal mortality rate by 35% across the 16 target districts g) University of Zambia, Department of Population Studies who presented on: • Health System Strengthening Capacity Building Services • Training, Research and Surveillance Activities; h) Program for the Advancement of Malaria Outcomes (PAMO) who presented on: • Increase access to and uptake of quality malaria control • Facility staff to ensure that interventions in four target provinces to contribute to reductions in all NHCs have the malaria mortality by two-thirds, malaria incidence by three-fourths, Integrated Community and malaria parasitemia in children under five maternal, Newborn and i) Maternal and Child Survival Program Child Health Registers so (MCSP) who presented on: that the members know • Provide demand-driven TA for sustainable scale up of their communities by RMNCAH&N interventions through routine mentorship, trouble- recording their shooting and implementation support focused on the technical demographic profiles in the aspects of the continuum of care; and minimum effort of 80% registers. district and 20% province and central levels. • DHOs to ensure that • Work in collaboration with local institutions to increase local facilities are visited capacity in RMNCAH&N regularly, and that NHCs

• Develop e-Learning training courses to improve provider are also visited regularly by knowledge health facility in-charges to

j) Systems for Better Health (SBH) CoC Program who presented support their work on:

• BH- is focused on Health Systems Strengthening; Where as

MCSP provide program TA on RMNCAH&N

• Areas of technical support by SBH TA team are:

Performance Management, Health Management Information

system and Public Financial Management

k) USAID GLOBAL HEALTH SUPPLY CHAIN-

PROCUREMENT AND SUPPLY MANAGEMENT (GHSC-

MCSP Zambia Quarter Report: July-September 2018 37

PSM) who presented on: • Procurement and supply management programs to ensure uninterrupted supplies of health commodities in support of U.S. government-funded public health initiatives around the world. • Project ECHO (Extension for Community Healthcare Outcomes) who presented on: • A movement to demonopolize knowledge and amplify local capacity to provide best practice care for underserved people all over the world.; • Project ECHO is committed to addressing the needs of the most vulnerable populations by equipping communities with the right knowledge, at the right place, at the right time; • Utilizes the low dose high frequency (LDHF) (Onsite, need- based, shorter & more frequent interactive learning) approach to learning. • Eastern Province Health Partners Meeting Previous Action Points are presented as Appendix 1 below;

• Find the 2018 Eastern Province Health Partners Meeting Action Points attached as Appendix 2 below the report.

Findings:

• Duplication of efforts/activities by partners and the Ministry of

Health. Action was that PHO, DHOs, Health Facilities and

Partners should share activity plans;

• Health institutions were working without targets because of the

perception that targets are for projects/partners and not public

institutions. Action was that DHOs and Partners should distribute

targets to all their facilities based on their action plans and/or

national targets where targets are not available.

• Activities funded directly to health facilities by partners were not

monitored by Districts because they are usually not shared.

Action was that all partners funding programs/activities directly

MCSP Zambia Quarter Report: July-September 2018 38

to health facilities must share with DHOs in areas of jurisdiction as well as PHO. • Different interpretations of indicators/guidelines given to health facilities and partners due to implementation of activities in silos. Action was that partners must ensure that they are accompanied by a DHO staff whenever they are in facilities of jurisdiction for any activity. • Effective resource mapping and allocation still remains a challenge at all levels. Action was that all concerned should ensure full disclosure of support to facilities and supervising institutions. • Access to Viral Load testing is still a challenge due to limited capacity in the province. Action was to ensure that the identified space at Chipata Central Hospital is rehabilitated to allow for installation of the allocated VL machine with bigger capacity. In addition, that St. Francis Hospital to identify space for placement of the machine currently installed at Chipata Central Hospital.

MCSP CE Conducted monthly TA visits to facilities: Chipata DHO (Kapata Urban Health Centre and Eastern Command RHC) 19/7/2018, 10/8/2018, 27/8/2018;  Kapata Urban Health Facility has a total population of 30,183 as at 1st January 2018, with a monthly patient target population of 1,527;  At both facilities, two ORT corners were in existence;  Monthly child immunization charts were updated;  CE reviewed the Health Promotion Quarter 2 SQAs and Dashboards, and it was agreed that the next SQAs will be developed at the start of quarter 4;  Four Health Promotion Staff seen at both facilities (Kapata 1 female, 1 male; Eastern Command 1 male, 1 female).

MCSP Zambia Quarter Report: July-September 2018 39

MCSP CE Conducted monthly TA visits to DHOs:  Chipata DHO (Kapata Urban Health Centre and Eastern Command RHC) 19/7/2018, 10/8/2018, 27/8/2018;  Lundazi (23-25/7/2018)  Chadiza DHO (27/7/2018, 22/8/2018);  Katete DHO (1/8/2018)  Mambwe DHO (3/8/20018);  Vubwi DHO (2/8/2018, 4/8/2018, 20-21/8/2018,

Inclusion of High Impact Interventions in budgets  MCSP CE provided technical assistance to six DHOs during their planning period for the 2019 MTEF/CoC budget preparations to ensure DHO prioritized what the donor considered as high impact interventions that would help achieve the RMNCAH&N indicators for better wellbeing of communities in the province.  MCSP guided the six DHO teams to ensure that the CoC plan was all RMNCAHN, CE inclusive.  MCSP advised the six DHOs to plan for quarterly mentorship for the CBVs to enhance their performance in demand creation. Familiarization with SQAs, Scorecards and Dashboards  MCSP took the six DHO teams through the scorecards, analyzed each indicator’s performance, and developed proposed activities to close the gap.  Team urged DHOs to utilize SQAs and Dashboards as a means of assessing levels of service provision.

Construction/renovation of Outreach Posts  Most facilities had several children dropping out on immunization as was shown on immunization charts.  The six DHO teams were advised to utilize the outreach matrix data to prioritize outreach posts for construction/renovation in 2019 in partnership with the MCSP Zambia Quarter Report: July-September 2018 40

• Provide community in order to improve immunization services and Technical integration of health services during outreach. Assistance during Formation of the DHPCCs implementation  The six DHOs had not yet formalized formation of DHPCC. of 2018 CoC  MCSP advised all the five districts to prioritize the formation grants: of the DHPCCs to ensure that all the community engagement Conducted related activities were coordinated through this group and monthly TA supervise the HCCs and NHCs. visits to six  The DHO teams were advised to consider planning for DHOs meetings for the DHPCC in the 2019 CoC allocation. • MCSP guided the districts to ensure that all the mentors in the districts were updated to the list of mentors with their specific competences noted. All the mentorship reports must be kept in one folder with all the used tools filed.

Capacity building TA provision to Eastern Provincial Health Joint MTEF/CoC •  Observations were that in CE package: Planning Meeting – 13-15/8/18 DHOs and the EPHO Provincial, District The Eastern Provincial Health Joint MTEF/CoC Planning Meeting waited too much to the very and community took place in Chipata district from 13 to 15 August 2018 at Luangwa end before starting the members and House Lodge, involving staff from all the nine DHOs in the province. planning process. This groups’ capacity to 85 participants attended it from the DHOs, the EPHO, including resulted in there being little plan and mobilize partners. time for all the process resources in order The role played by MCSP in this joint planning meeting was to elements like bottleneck, to implement and provide TA to the DHOs in ensuring that their plans and budgets base line survey and data monitor RMNCH-N reflected what would bring about high impact in people’s lives in the review preventive and provision of health services • Since budgeting is known promotional MCSP supported all the nine districts throughout their deliberations of that it will always be there, activities. coming up with plan that reflected the 9 MOH Legacy goals, starting MCSP should support • To with Peer Assessment by other DHOs, ending up with assessment by DHOs to start early in their participate Core Assessors. next planning process and provide MCSP supported all the nine districts to consider activities on the

MCSP Zambia Quarter Report: July-September 2018 41

TA on CoC high impact interventions lists provided and discussions held. Some of 2019 the high impact interventions included in the plans were such as: planning • Supervision of SMAGS by Chipata = K370,416.00 activities to • Procure FANC logistics by Chipata = 399, 370.00 be included • Support to SMAG by Chipata = K317,250.00 in the • Conduct Local leaders meeting to discuss RMNCH indicators by district plans Chipata = K20,910.00 during the • Induction of staff in RMNCAH by Chipata = K79,800.00 Provincial • Conduct outreach ANC/FP by Chipata = K63,360.00 planning hese are given as some examples of activities the districts included in launch eir MTEF/CoC SIDA funded budgets that show us that our TA was week. cepted.

• All the districts were urged to plan for formation of the District Health Promotion Coordinating Committees and subsequent meetings

• All the Districts were guided on considering strengthening

HCCs, NHCs/CBVs through routing and continued mentorship and

TSS to the volunteers on all matters they take part in.

TA on CoC 2019 budget reviews

 In the month of September 2018, MCSP provided TA to Vubwi,

Chadiza and Sinda as way of follow up to review the distribution of

funds in the 2019 MTEF/CoC budgets, and present concerns raised

by Sida on the same.

 Districts in Eastern Province were asked to review and realign

their CoC plans for Quarter 3 and 4 2018 in June. After this review,

Sida expressed some concerns with plans for Vubwi, Chadiza and

Sinda Districts. However, the concern for Vubwi district was

something that they could change remotely and they did so. The

concerns for Chadiza and Sinda districts needed some time and TA

MCSP Zambia Quarter Report: July-September 2018 42

support. Therefore, MCSP offered one-day desk technical assistance to Chadiza District, on 11th September 2018, and , on 12th September 2018.

COMMENTS FROM SIDA

Chadiza District  The district has dropped some activities in the budget and increased the amount for Motor Vehicle Insurance. The amount for • MCSP to monitor Sida motor vehicle insurance is too high as it includes insurance debts resource allocation in accrued for the GRZ fleet. Sida funds cannot be used to pay motor implementation of vehicle insurance for GRZ funded vehicles. RMNCAH&N interventions to realize Sinda District intended goals for the  Submission report to EPHO cannot be funded from the budget. better health for all Sinda is not doing any concrete activities on adolescent health - only procuring items to be used in 4 facilities! Are staff trained in • To provide ASRHR? Is there really a need to prioritze quarterly MDSR follow-up Meetings at 100 000 K when you have few maternal deaths and TA on CoC few resources? Also, they spend 200 000K for the planning of the 2019 MTEF! The budget is very heavy on management functions and budget very little on service delivery. When looking at their Q2 report, reviews they have in fact done the HIV/STI sensitization at a cost of 24 000 K but will drop the planned second sensitization. How can it be cut out from the work plan when funds have already been allocated and spent?

Vubwi District  The district is experiencing challenges in improving some of the RMNCAH&N indicators because of the number of Malawian nationals who access services in Vubwi Districts. The district is having challenges with follow up visits e.g postnatal care, some deliver. They can and should travel to but keeping the MCSP Zambia Quarter Report: July-September 2018 43

Zambian DSA levels.

TECHNICAL ASSISTANCE PROCESS  MCSP dedicated a day each to Chadiza and Sinda Districts.  The District program officers, with the DHDs present for both districts, were taken through the comments from Sida plans review.  Team emphasized the need for more investment on service delivery activities as opposed to investing more in administrative activities.  MCSP advised Chadiza that the funds could only cater for RMNCAHN vehicles and Motorbikes in terms of insurance and service. SBH was present during the Sinda meeting. The following was resolved for each district;

Chadiza District The following was done;  Reduced insurance for vehicles to only 3 RMNCAHN vehicles  Reduced the service for the motorbikes to only 10 motorbikes  Removed procurement of IDs for the CBVs  The following was proposed to be included in the plans with the savings made;  PPH packs to enhance management of PPH which is the leading cause of MDs  Training of ADH peer educators to enhance ADH issues in the district  Procurement of locally made KMC Chairs and Wrappers to strengthen KMC at Chadiza DH  Supervision of CBVs by HF staff in all thematic areas to strengthen community engagement

Sinda District Some activities were reduced in cost and these included the following; MCSP Zambia Quarter Report: July-September 2018 44

 MTEF planning, and consolidation,  DIM,  MDSR  The funds saved were used for the following services;  Procurement of KMC Chairs and Wrappers Locally made to enhance KMC services at Nyanje Mission Hospital  Training of 17 mentors in generic mentorship to add to the only 3 number of mentors in the district  Orientation of Staff in ASRHR to enhance supervision of Adolescents in ADH services  Supervision of CBVs by HF staff to enhance Community engagement in all thematic areas  Increase the amount for mentorship and shift from EmONC to RMNCAHN Mentorship as the most effective capacity building means with limited resources

Lessons Learned  With good collaboration by the Provincial CoC Coordinator, MCSP, SBH and MOH/PHO/DHO whenever there is need to have the CoC plans reviewed, there is a high possibility that the outcomes of the reviews would be of good quality.  There is need to strengthen the quarterly action plans reviews by all the districts and institutions implementing the CoC funded activities to ensure that the plans are addressing prevailing issues and to account for what has been implemented and the outcomes contributing to improving services. Conclusion  This review and realignment acted as an eye opener to the districts which were supported and it is a lesson learned to ensure that plans are reviewed together and are answering to particular gaps as opposed to focus on activities without looking at performance.  MCSP will continue supporting the districts to conduct their MCSP Zambia Quarter Report: July-September 2018 45

quarterly action plans/performance reviews by use of Scorecards to ensure that their activities are answering to their performance challenges and successes.

Activity 1.1: Technical Assistance to CoC Program • TA PROVIDED AT PARTNERS’ MEETING IN CHIPATA On 16/07/2018, MCSP CE attended a Partners’ Meeting of • Ministry of Health and organizations involved in RMNCAH&N activities in the province, at Partners must interact and Provide technical which 65 participants attended. 11 partners, including the Ministry of involve each other in assistance during Health, presented what services they provide in the province. The activities they implement in implementation of following Partners made their presentations: the province for better 2018 CoC grants • In this meeting, MCSP presented on the requirement by MoH to community health form or strengthen (where they already exist) the Adolescent

Health Technical Working Groups in all the nine districts in the province. MCSP CE Conducted monthly TA visits to DHOs: • Facility staff to ensure that hipata DHO (Kapata Urban Health Centre and Eastern Command RHC) all NHCs have the Adolescent /7/2018, 10/8/2018, 27/8/2018; Integrated Community Health Lundazi (23-25/7/2018) maternal, Newborn and Chadiza DHO (27/7/2018, 22/8/2018); Child Health Registers so Katete DHO (1/8/2018) that the members know Mambwe DHO (3/8/20018); Provide technical their communities by Vubwi DHO (2/8/2018, 4/8/2018, 20-21/8/2018, assistance during recording their

monitoring of 2018 demographic profiles in the Inclusion of High Impact Interventions in budgets CoC Grants registers. MCSP CE provided technical assistance to six DHOs during their • DHOs to ensure that planning period for the 2019 MTEF/CoC budget preparations to facilities are visited ensure DHO prioritized what the donor considered as Adolescent regularly, and that NHCs Health high impact interventions that would help achieve the are also visited regularly by RMNCAH&N indicators for better wellbeing of communities in the health facility in-charges to province. support their work MCSP guided the six DHO teams to ensure that the CoC plan was

MCSP Zambia Quarter Report: July-September 2018 46

all RMNCAHN, ADH inclusive. MCSP advised the six DHOs to plan for quarterly multidisciplinary mentorship for the ADH CBVs to enhance their performance in demand creation for adolescent health. • Observations were that • TA provision to Eastern Provincial Health Joint MTEF/CoC DHOs and the EPHO Planning Meeting – 13-15/8/18 waited too much to the very The Eastern Provincial Health Joint MTEF/CoC Planning Meeting end before starting the took place in Chipata district from 13 to 15 August 2018 at Luangwa planning process. This House Lodge, involving staff from all the nine DHOs in the province. resulted in there being little 85 participants attended it from the DHOs, the EPHO, including time for all the process Provide technical partners. elements like bottleneck, assistance during The role played by MCSP in this joint planning meeting was to base line survey and data planning of 2019 provide TA to the DHOs in ensuring that their plans and budgets review CoC grants reflected what would bring about high impact in people’s lives in the • Since budgeting is known provision of adolescent health services that it will always be there, MCSP supported all the nine districts throughout their deliberations of MCSP should support coming up with plans that reflected the 9 MOH Legacy goals, starting DHOs to start early in their with Peer Assessment by other DHOs, ending up with assessment by next planning process Core Assessors. • Activity 1.1: Technical Assistance to CoC Program Following the training of nurses and nutritionists at Chipata Central hospital in Maternal Neonatal Infant Young and Child nutrition. The Provide technical provincial health office to consider rolling out the training to other assistance during health workers in the province from hospitals /facilities in MNIYCN

Nutrition implementation of to provide quality health and nutrition care to neonates. 2018 CoC grants Ensure that all mothers after delivery within an hour breast-feeding is initiated and information reflected in the maternity register.

Activity 1.3: Improve collection, monitoring and use of data use for decision making and quality improvement M&E Provide TA to • Support was offered to Chipata Central hospital to have the HIA3 • Support the districts in

MCSP Zambia Quarter Report: July-September 2018 47

DHIO data data entry template attached to the hospital to update data. conducting any upcoming verification • Identified that Katete data had low numbers and it was discovered DQAs. activities, including that data was lost making it difficult to use data for analysis. Thus • quarterly integrated had to be re enter data. supportive • MCSP provided support to Chadiza and Sinda districts in supervision and identifying data that had outliers or low numbers for instance data quality underweight children and PNC. assessments DQA in provinces Support one data • Chadiza District presented a QI Project proposal during PIM on • MCSP to meet up with use and Improving Institutional deliveries in HFs in Chadiza Districts. The Chadiza QI team on the management presentation had gaps as most of the ‘but why’ was not conclusive. refining and quality MCSP will work with the them in refining their QI project as they commencement of the QI improvement are the only ones with a QI project. project project per province Build facility • MCSP supported the districts in analyzing data during the 2019 • Next steps will be to follow capacity in data MTEF/CoC planning including the launch. The team used the up on how data generate di collection, scorecards, SWOT and situational analysis to inform activities to being utilized for informing management, and be implemented. decisions. usage techniques • Support collection of service delivery • Participated in the Sinda and Vubwi DIMs. Main issues emerging data using facility • Support DHOs in ensuring from the meetings is the understanding of indicators such as skilled monitoring tools action points are deliveries and regular data reviews Support facilities to • MCSP ensured that every facility visited was oriented on the need develop and update to have an updated dashboard for data use. For instance, Zemba • Continued support to DHO dashboards and RHC in Chadiza last updated their dashboard in 2017 and MCSP and facilities in developing utilize for decision offered TA on updating the dashboard as well as producing good dashboards for data use. making graphs with a message. Support distribution • •

MCSP Zambia Quarter Report: July-September 2018 48

of new HMIS tools to all facilities Establish • District mentorship team established in Sinda but with few trained • DHO to conduct the mentorship teams mentors generic mentorship training • Advised the Sinda mentorship team to get the models from Njanje Equip mentorship Mission Hospital which had enough models for use during the • teams with models mentorship rounds. Crosscutting Technical Assistance to • MCSP Influenced the nine districts to plan and include integrated programming for • mentorship in their 2019 MTEF/CoC action plans mentorship in 2019 CoC Plans

• Challenges and recommendations

Recommendations to Address the Thematic Area Challenge Challenge Newborn • It has been observed that some districts and HFs are not using • At least each HF should have not these tools, the Perinatal and Neonatal Deaths Audit Form, less than five copies of each of MDSR audit form, MD Notification form, MDSR these Community Autopsy. These are very important documents, tools (depending on how busy which will help us, identify the problems for proper that HF is, you may need to interventions. Some of the reasons why these tools are not provide them with more being used is because DNOs/Nos only provided soft copies to • The DNOs/NOs/Maternity Ward the HFs, there are no printed copies ready for use, the staff on In charges MUST orient their duty at the time of the death or stillbirth felt lazy to complete teams in the use of the tools. the document, or they have never been oriented to the tools. MCSP to support and facilitate the use of the tools and plan for the printing of the tools in their quarterly plan reviews. • The availability of a completed tool should be

MCSP Zambia Quarter Report: July-September 2018 49

handed over during hand over or change of shifts, if a death or stillbirth occurred, MUST be one of the things that should be checked.

Neonatal deaths issues seemed not to have been prioritized by the • MCH coordinators to ensure that districts and facility staff as they were not conducting the neonatal the District facilities are death reviews as soon as they occur at facility level to establish conducting Neonatal Deaths causes such as birth asphyxia, prematurity e.t.c and develop reviews as they occur at facility necessary interventions for prevention such as KMC level • MCSP to support the district facilities during the process using the new perinatal audit forms

Most of the newborn health activities seemed not to have been • Mentorship on the use of standing alone but included to the maternal Health activities, which partograph to monitor fetal paused a danger of having newborn health neglected at the wellbeing and implementation period. progress of labour and prompt referral following the revised maternal and neonatal referral guidelines. • Districts to plan for the procurement of Doppler’s and fetal scopes for facilities who do not have enough.

• Districts to plan for mentorship of staff in essential Newborn care.

Child health • Most facilities in Chipata districts were still using graphs for • MCSP to help the district to orient immunization coverages without dropout rates calculated facility staff on the usage of the instead of monitoring charts. immunization monitoring charts

MCSP Zambia Quarter Report: July-September 2018 50

• The 9 districts have not rolled out the IMCI/EPI electronic • MCSP to help the districts roll out training to staff in the facilities the IMCI/EPI electronic training to all facilities

• Some facilities in Chipata district were still using the tally • MCSP to help the district to sheets to aggregate their HIA2 data provide TSS to the facilities

Community engagement • Inadequate transport hampering follows up visits to districts. • MCSP to encourage joint trips MCSP Staff are not able to reach target areas as and when with partner organizations to needed due to limited transport. Use of one vehicle to all leverage transport resources districts in the province is a challenge. It sometimes takes a • MCSP to encourage joint trips long time to provide TA visits. with partner organizations to • Cancellation of planned Technical Assistance Visits and leverage transport resources delayed expenditure Authorization by national level resulting into delayed activity implementation by districts

• Community Education and Social Mobilisation are not priority MCSP to advocate for allocation of in DHDs’ planning. It appears that most departments push their more financial support to enable the activities under Public Health to access funding to be used back sector carry out its activities in their individual departments and not for public effectively Adolescent health Limited understanding of ADH programming by DHO staff MCSP and appointed District ADH appears to hinder effective rollout of the program to facilities Focal point staff to disseminate to DHO staff to bring them to speed on ADH programming Cancellation of planned Technical Assistance Visits and delayed MCSP to continue lobbying for more expenditure Authorization by national level resulting into delayed financial support to enable staff activity implementation by districts conduct TA visits Inadequate transport hampering follows up visits to districts. MCSP to encourage joint trips with MCSP Staff are not able to reach target areas as and when needed partner organisations to leverage due to limited transport. Use of one vehicle to all districts in the transport resources province is a challenge. It sometimes takes a long time to provide TA visits.

MCSP Zambia Quarter Report: July-September 2018 51

Nutrition The synergy between the Hospital Nutrition Technologists and the • Nutrition officers at Chipata District Nutrition Technologists for Chipata and Katete districts is Central Hospital and St. Francis poor thereby affecting the follow up of the malnourished Hospital to strengthen the linkage discharged children. This impedes adequate follow up and with the Chipata and Katete mentorship of the HFs where the cases are coming from Districts Nutrition technologists, respectively, in terms of management of discharged children who were nursed for malnutrition. M&E • Some districts (Katete, etc) lost data despite having entered the • Ensure national level is informed it thus forced to reenter. to rectify the problem.

Crosscutting Last minute guidance from MoH HQ, affected some To ensure that all the guidance for recommendations which MCSP made earlier to the DHOs planning are communicated in time to all the interested parties such as MCSP

Previous Quarter Recommendation and Action taken Thematic area Previous recommendation Current statues Next step for quarter • MCSP has provided some Support Katete, Sinda, Ensure that districts plan to procure job aids such as mentorship models to Chadiza and Vubwi models and protocols through the COC grants Sinda, Katete, Chadiza districts in setting up their and Vubwi districts mentorship Hubs • MCSP worked with all • Continue engaging the Reproductive and Maternal the 9 Districts in the districts in ensuring province to develop the that their CoC activities Work with Districts to develop schedules/timelines timelines for the CoC had specific timelines for their CoC plans in time to enable adequate time activities however they to coordinate logistics were not comprehensive as responsible program officers were still waiting

MCSP Zambia Quarter Report: July-September 2018 52

for sittings with the entire district team. • MCSP has managed to get some schedules from • Offer TA to the district districts such as Lundazi, which have provided Mambwe and Chipata timelines for their districts activities • Chadiza and Nyimba Districts conducted a mentorship round in Support the districts which Ensure that the mentorship rounds are planned for September conducted mentorship in and executed as such in Vubwi, Chadiza, Katete and 2018…………………. completing their Sinda Districts • Katete, Sinda and Vubwi mentorship dashboards Districts are yet to conduct their mentorship rounds District to plan for mentorships trainings and round

during the 2019 CoC planning cycle. The district mentorship teams to provide onsite mentorship on the critical areas for managing maternal and neonatal complications following the

protocol guidelines for management of various pregnancy and labour and delivery conditions for both the mother and the baby. Newborn Facility in charges to intensify supervision of HCWs and support staff in terms of maintaining a clean delivery practices and environment for mothers and their babies using the 5S quality improvement approach as this is one of the MOH intervention in reducing maternal and neonatal morbidity and mortality. MCSP to provide TA to DHO to conduct onsite support using the 5S quality improvement approach. • The districts to include procurement of Procurement of IMCI flow IMCI flow charts and booklets in their 2019 charts included in the 2019 Child health CoC plans. MTEF/CoC plans • District to follow up on the usage of the On-going

MCSP Zambia Quarter Report: July-September 2018 53

immunization monitoring charts and facility staff to orient other staff on plotting the immunization charts and interpretation of the graphs during the subsequent monthly data compilation. • District to include REC/RED strategy REC strategy included in the

training in the 2019 CoC plans. 2019 MTEF/CoC plans Five districts (Lundazi,

• Follow up districts that have not submitted Mambwe, Sinda, Nyimba

the outreach posts matrix. and Vubwi) submitted their

outreach post matrix • MCSP to share the identified high impact interventions for child health with all the done districts for inclusion in their 2019 CoC plans. Provide technical assistance during implementation of 2018 CoC grants to districts by providing technical Assistance visits to DHO in orienting On-going NHCs in their roles

ovide technical assistance during monitoring of 2018 CoC Grants by participating in DIM and PIM events organized by District and province Done

Community engagement ovide technical assistance during planning of 2019 oC grants through support to districts during eparatory meetings for the planning process for CoC Done d METF 2019 plans and participating in MOH ovincial Planning meetings Support facilities to develop and update dashboards and utilize for decision making by offering technical assistance to districts on the formation On-going and interpretation of dashboards of key indicators for decision making for community engagement

Nutrition • MCSP to provide guidance during budgeting to • Chadiza and Mambwe •

MCSP Zambia Quarter Report: July-September 2018 54

include procurements of necessary districts have budgeted anthropometric tools and any other nutrition job for procurement of some aids. Anthropometric equipment

• MCSP provided TA to all the 9 districts prior to the provincial Planning review meeting, during the district consolidation meetings and during the • MCSP to provide guidance during 2019 CoC provincial planning planning. review meetings and HIIs were proposed with some having been adopted. • Only Vubwi of the 9 districts has not budgeted • Engage Vubwi district for any nutrition activities on how they can under the CoC. prioritize nutrition activities • MCSP to ensure that DHDs assist in • Katete and Lundazi encouraging programme officers share reports Districts shared some of • of implemented activities since in most cases we their reports for the are not there. activities they conducted. chnical Assistance to CoC Program by providing TA the formation of District Technical Working Groups ASRH On-going ASRH in all the nine districts

Follow up Districts on upcoming scheduled On-going as districts recently supportive supervision to provide TA in conducting received funds for next data verification activities. quarter Follow-up on the progress of identified MCSP will provide TA and M&E Chipata and Chadiza districts improvement projects and identify which ones will support to the districts on have been identified be supported. the QI projects MCSP to work with the Provide TA to selected facilities during data reviews Not done. DHIO to attend a facility to ensure quality data for data use. data review and provide

MCSP Zambia Quarter Report: July-September 2018 55

necessary TA. Done. All visited facilities are Continuous TA on the need Conduct checks to ensure the registers are being using the correct and updated to complete registers so utilised and data is documented accurately to help registers. However, some data is complete and improve collection and data use. registers are incomplete. accurate. Assist selected facilities in use of dashboards and Schedule is being Selected facilities around develop schedule for dashboard updating and developed and MCSP will Chipata were selected. review. provide TA to the facilities.

MCSP Zambia Quarter Report: July-September 2018 56

I. Lessons Learned – Cross cutting

1. Working together with Chipata DHO during their 2018 1st and 2nd quarter performance assessment to facilities offered an opportunity for MCSP and them to identify performance gaps together and come up with interventions for the facilities to address them. This allowed DHO and MCSP to plan for follow up TA/TSS and mentorship, data audit and review meetings together. 2. MCSP CE component worked with SM360+ to encourage five (5) Radio Listening Groups in Chipata (2 groups), Lundazi (2 groups), and Mambwe (1 group). 3. MCSP collaborated well with SBH during the 2019 plans strengthening TA meetings. SBH looked at the Scorecards, and system strengthening, while MCSP concentrated on delving into the analysis of the performance and asking why such a performance then together with the DHO teams proposed HIIs to close up the gaps. 4. The MTEF planning guideline guide that the planning process starts in April of every year, however none of the districts do so, including PHO. If PHO strengthened this area, the districts would develop very better plans. 5. During the pre-planning TA by MCSP, a parallel performance analysis tool was used and not the planning template for the districts. This therefore risked only a few of the proposed HIIs being taken up by the districts. It is therefore important, next time, to use the planning hand book process when engaging the districts prior to planning as this will easy their work when they come to do their final document as they will not have to referring to a different template when planning as all the guidance and assistance will be done within the working document. However engaging them early proved better than meeting them at the provincial planning consolidation. 6. Most of the accountants had completed their budgeting with specific activities even before the program officers had completed their bottleneck analysis. This has a potential of plans containing activities that do not answer to the prevailing challenges. If program officers could do their self-bottleneck analysis for their thematic areas way in time then there would be no panic for the budgeting team to just be picking activities without prioritizing 7. There seem to be no clear guidance on limits to budgeting for certain activities such as Vehicle servicing, Vehicle insurance. Most districts opted to budget for all their vehicles, RMNCAHN and GRZ vehicles, to be serviced and insured using the CoC funds. This therefore made most of the funds to go to administration as opposed to service delivery. If clear guidance could be developed, from both the funders and the TA partners and shared with MOH HQ, PHOs and DHOs then the situation would be different, much better

MCSP Zambia Quarter Report: July-September 2018 57

II. Major Activities Planned for Next Quarter Thematic Activity According to the Approved Work plan TA Planned (Activity According to Provincial Plans) area Reproductive Activity 1.1: Technical Assistance to CoC Program and Maternal Provide technical assistance during implementation • Support the nine districts in the implementation of the CoC activities such Health of 2018 CoC grants as PNMDSR, Integration of ANC in outreach services, mentorship and data review so that RMH issues are prioritized Provide technical assistance during monitoring of • Participate in the 9 Districts’ data audits and verifications to ensure that 2018 CoC Grants RMH gaps identified are intervened accordingly Provide technical assistance during planning of 2019 • CoC grants Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams • Support Sinda, Katete, Chadiza and Vubwi Districts in setting up of their mentorship Hubs Equip mentorship teams with models Expand Technical scope of mentorship to include • Work with the CCS in ensuring that all the districts had formed their child health, nutrition and community engagement multidisciplinary mentorship teams; all the districts to submit their topics mentorship team members, mentorship schedules, mentorship reports/dashboards Provide technical assistance to districts to link • Support Chadiza District in refining and kick starting their QI project on mentorship with existing quality assurance activities Improving Institutional Deliveries in Chadiza Technical Assistance to programming for • Work with Sinda District in conducting a mentorship training and mentorship in 2019 CoC Plans conduct mentorship to HCWs in the district Newborn Activity 1.1: Technical Assistance to CoC Program Provide technical assistance during implementation • TA visits to Districts of 2018 CoC grants • Identify and disseminate best practices and innovations Make recommendations to introduce innovations through CoC grants. Provide technical assistance during monitoring of • Participate in District and provincial integrated meetings 2018 CoC Grants • Review and provide feedback to CoC district reports • Review and provide feedback to national CoC Program report Prepare written recommendations to revise CoC district plans Provide technical assistance during planning of 2019 • Provide feedback to districts to revised CoC plans CoC grants • Identify innovations to be programmed through revisions to 2018 CoC grants or 2019 CoC plans • Make recommendations to introduce innovations through CoC grants Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship

MCSP Zambia Quarter Report: July-September 2018 58

Establish mentorship teams • Coordinate with districts to include mentors in planned clinical trainings in 2018 CoC grant • Provide TA for mentorship activities (mentor visits) Equip mentorship teams with models • Distribute anatomical models and printed material to skills lab Expand Technical scope of mentorship to include • Provide TA to decentralize to zonal areas child health, nutrition and community engagement • Provide TA to PHO and District Hospital CoC grants for hospital-based topics mentorship Provide technical assistance to districts to link mentorship with existing quality assurance activities Technical Assistance to programming for mentorship in 2019 CoC Plans Child health Activity 1.1: Technical Assistance to CoC Program Provide technical assistance during implementation • Participating in TSS/mentorship visits to facilities in Chipata district and of 2018 CoC grants orient them on the immunization monitoring charts Provide technical assistance during monitoring of • Following the districts to review the implementation status of the CoC 2018 CoC Grants 3rd quarter 2018 in the nine districts Provide technical assistance during planning of 2019 CoC grants Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Equip mentorship teams with models Expand Technical scope of mentorship to include child health, nutrition and community engagement topics Provide technical assistance to districts to link mentorship with existing quality assurance activities Technical Assistance to programming for mentorship in 2019 CoC Plans Community Activity 1.4 Increased demand for services through increased community engagement engagement Strengthening district & community platforms for • Conduct a DHO survey and assess the establishment and accountability of RMANCH&N services between functionality of the District Health Promotion Coordinating the district and community stakeholders Committees (DHPCCs) such as DHPTs, NHC, HCC, SMAGs, IYCF, CBD, • Assessing and determining the functionality (activeness) of CHWs, Peer Educators, CHP etc. through community-based community engagement structures (NHCs, stakeholder profiling and strengthening / HCCs) establishment of structures /platforms • Profiling of community-based community engagement structures

MCSP Zambia Quarter Report: July-September 2018 59

(NHCs, HCCs) • Stakeholder mapping and involvement • Implementation of Integrated Community Registers and use of integrated equity-based approach in reaching communities

Capacity building in CE package: Provincial, To support Public Health section in accessing financial support from the District and community members and groups’ Sida funded budgets at the DHOs as planned in the MTEF/CoC 2018 capacity to plan and mobilize resources in order to budget implement and monitor RMNCH-N preventive and promotional activities. Adolescent Activity 1.1: Technical Assistance to CoC Program Health Provide technical assistance during implementation Provide TA in the formation and strengthening of ADH District Technical of 2018 CoC grants Working Groups in ASRH in all the nine districts Provide technical assistance during monitoring of Provide TA during training of ADH Peer Educators in ADH in all the nine 2018 CoC Grants districts Provide technical assistance during planning of 2019 CoC grants Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Equip mentorship teams with models Participate in multi-disciplinary mentorship activities in all the nine districts Crosscutting Establish mentorship teams • TA to all the districts to ensure that their mentorship teams are multidisciplinary Expand Technical scope of mentorship to include • TA to all the districts to ensure that their mentorship teams are child health, nutrition and community engagement multidisciplinary topics Technical Assistance to programming for mentorship in 2019 CoC Plans

MCSP Zambia Quarter Report: July-September 2018 60

PROVINCE: LUAPULA REPORTING PERIOD: QUARTER 4 (JULY – SEPTEMBER, 2018)

Summary of Major Accomplishments MCSP Technical team visited all districts during the quarter for technical assistance in all thematic areas. During the visits the team worked together with district staff, identified gaps in service delivery and provided technical assistance needed. MCSP tagged in most of the visits with SBH which resulted into effective collaboration. MCSP provided TA before planning, during planning and after planning of 2019 CoC interventions. Through this support, districts were guided to plan well ahead of time and identify RMNCAHN key intervention areas for inclusion in the 2019 Mid Term Expenditure Framework (MTEF) and Continuum of Care (CoC) plans. This will result in the quality of MTEF and continuum of care plans for 2019. During this activity MCSP with support from STAs office provided technical assistance at all levels of planning process( Pre-planning, planning launch and during review of final G2G plans for 2019. MCSP is one of the active and visible partner at provincial level and was assigned to refine all G2G plans with RMNCAH&N-C coordinator and SBH team. MCSP worked with SBH and the CoC Program Coordinator to improve the planning process with a focus on starting the process early. MCSP team came up with HII for districts to select some interventions for planning. This was helpful because most of the interventions were addressing identified gaps from individual district scorecards, making the districts fail to perform well in addressing KPI. This made the planning review of CoC activities stress free for the province. MCSP provided TA to Chembe, Samfya, , Chipili, Lunga and Mwense on implementation of service quality assessment (SQA) and quality improvement (QI) in line with MoH goal as to have “a society in which Zambians create environments conducive to health, learn the art of being well and provide basic level health care for all.” This was achieved by strengthening QI teams capacitated them with a skill on how to develop a district and facility dashboards, construe it and come up with a QI project. This will benefit the districts and facilities improve service delivery MCSP strengthened implementation of CE activities at community level to address social norms for gradual adoption of recommended RMNCH&N practices through varies community platforms. During the quarter, MCSP participated and provided on spot TA during the community advocacy meetings with key community members and gate keepers in Mwansabombwe with 26 (19M, 7F) and Chembe 13 (1F, 12M) districts of Luapula province. The meeting was aimed at linking health centers with key community members, to created platforms for lobbying, soliciting and involving influential community gatekeepers in adopting recommended RMNCAHN practices. MATERNAL HEALTH a) MCSP strengthen MoH provincial Safe motherhood technical working group (SMTWG) by providing technical assistance and leadership through reviewing and formulation of terms of reference (TOR). This was during the meeting where the MoH had no terms of reference to existing SMTWG. This has resulted into provincial SMTWG come up with TOR and were shared among the members. b) MCSP influenced the DNOs to conduct onsite mentorship to staff on duty in labour wards by administering an SQA tool. MCSP visited Chembe, Samfya, Milenge and Lunga to administer TA tracker, identified gaps in maternal health service delivery and provided TA. This motivated facility staff in 6 facilities visited by acquiring a skill in SQA. Most facilities promised to improve in infection prevention, displaying labour protocols and guidelines to allow for effective service delivery by the staff working in labour ward. NEWBORN HEALTH a) MCSP visited Chembe district and identified possible causes of neonatal deaths (Asphyxia due to inadequate staff skills in ENC/HBB and prematurity) together with DHO staff, established interventions to address this problem by prioritizing ENC training in their G2G 2019 plans. Meanwhile the DHD as a mentor together with other team members were influenced by MCSP team to consider neonatal deaths as a QI project and start working on interventions and process of reducing its impact in the district b) MCSP shared the High Impact Interventions on New born health to the 10 districts visited and reviewed the score cards with the planning team. Districts were guided to include selected HII to be included in the 2019 CoC plans to address the problem of Birth Asphyxias and Fresh Still births c) MCSP visited Chembe district and administered a TA tracker tool to identify the gaps and or good practices in Newborn care and provide TA. The following were the findings: - Neonatal register was well documented and updated, the facility had necessary basic equipment for neonatal resuscitation in place such as penguin sucker, resuscitare machine and infant ambu bags with different size masks as advised in the previous TA. This facility status will prevent neonatal deaths with such basic commodities and supplies there by reducing the neonatal death rate in the district. The facility had most of the newborn protocols and guidelines such as breastfeeding within 24 hours, KMC guidelines, newborn resuscitation process, ENC guidelines and helping baby to breath process displayed on the walls

CHILD HEALTH a) Provided TA during CoC pre-planning to 12 districts of Luapula province in child health. Out of this TA during planning launch and process 9 districts have included Renovation/Construction of outreach posts/shelters, 3 district planned to procure tents and 6 districts to conduct RED strategy training. b) MCSP visited 6/12 districts for TA to strengthen Reaching Every District (RED) Strategy. MCSP influenced the districts to implement REC for achieving good coverages especially in fully immunized and measles 2 coverage which is a challenge at all levels. Conducted SQA orientation with review of district cold chain and vaccines management.at both facility and district. This was aimed at achieving quality management of vaccines at all levels and results in quality service delivery to the end users (Children) c) MCSP influenced Chipili and Mwense districts to come up with a quality improvement project in Child health. Chipili came up with IMCI where the actual performance states that only 30% of children at Chipili Rural Health Centre are being screened according to IMCI guidelines. This made the facility to come up with a project name “Improve IMCI Services at Chipili Rural Health Centre.” Mwense stage 2 RHC came up with a QI project in immunization with the actual performance stating, only 20% of documents reviewed at Mwense Stage II Rural Health Centre had met the minimum standard in EPI.” All these two projects were influenced by MCSP monthly TA visit with the aim to improve primary health care in all service delivery points. SQA dashboard and analysis of the facility scorecard performance for the previous two quarters were used to arrive at those projects. d) MCSP provided TA to Mansa DHO during measles outbreak. Mansa district surveillance team was strengthened through MCSP TA by addressing the need for the team to come up with extending the SIA to other catchment areas where Zambians easily mingle with Congolese. This was to increase the radius of preventing spread of a disease e) MCSP installed the EPI/IMCI course to 4 MCSP staff computers, 11 DNOs and a number of mentors in Mansa district. Together with DNOs in other districts as MCSP, we have embarked on scaling up this training to all mentors in the province. This EPI training will largely assist in ensuring that all mentorship activities includes child health adequately, thereby ensuring that integrated mentorship is upheld.

61 | Page

ADOLESCENT HEALTH a) MCSP provided TA to Mansa, Chipili and Chembe in strengthening the quality and availability of adolescent reproductive health services, including expanding integrated youth-friendly services and BFHI services in Zonal health centers (Chembe ZRHC). This has resulted in Chembe creating a youth space at Chipili zonal clinic to address adolescent health challenges especially access to service delivery. This will contribute to community awareness and reduce on adolescent pregnancies by accessing family planning and other awareness services b) MCSP provided TA during adolescent health technical working group meeting for Mansa district and guided the members on the importance of TOR. TOR will guide the committee and give direction on what to discuss during the meeting. This was the first ever meeting for Mansa district which attracted partners from Ministry of education, PLAN international, SARAI, SM360+ and community development and social services. MCSP motivated the partners by influencing development of a time table and way forward. This will help the district to sustain and adhere to a schedule of meetings. NUTRITION a) MCSP provided TA to Samfya, Lunga, Milenge and Chembe districts. The activity was aimed at capacity building to district staff in terms of skill in formulating, interpreting and formation of dashboards for nutrition SQA category. A total of eight (8) facilities were visited with two (2) in each district. Visited 8 facilities (Samfya (1), Chembe (1) Lunga (2), Mwense (1) and Milenge (3) and districts came up with a dashboard in nutrition. This will act as baseline for improving service delivery and reference for effective interventions by the districts to improve service delivery. b) MCSP administered SQAs in nutrition mentorship and came up with 2/4 districts visited having conducted mentorship with support from SM360+ and CHAI, reaching 12 facility staff and 8 community staff as mentees. The orientation was conducted in Lunga and Chembe districts with 4 staff from Lunga and 2 staff from Chembe district. c) MCSP visited Chipili and Mwense for TA. Shared with DHO and facility staff new QI guidelines including SQA and Mentorship tools and advised DHO to initiate QI projects in all the facilities with proper documentation. MCSP advised DHO and Facility staff to conduct SQA and mentorship with dashboards on quarterly basis. This will help the district easily identify gaps for effective review of a plan in nutrition service deliverables COMMUNITY ENGAGEMENT a) MCSP provided technical assistance to capacity building of 8 staff 6( 3M, 3F) in Chipili district and 2 ( 1M and 1 F) in Chembe in the administration of the service quality assessment tool and community engagement approaches, this was aimed at allowing the CBVs identify the gaps that hinge on service delivery in different thematic areas b) MCSP undertook collaborative meetings and provided TA during engagement of traditional leaders in Luapula 26 (M19 F 7) Mwansabombwe and 12 (M11 F1) Chembe), to lobby and solicit for their support aimed at influencing community adoption of recommended RMNCAHN practices. The purpose of these meetings was to enhance community partnerships through engagement of key community gatekeepers. MCSP provided technical assistance on the formulation of the action plan, which would be used to track the progress of the agreed action points c) MCSP provided technical support on community engagement to community based volunteers (42) 40 in Chembe and 2 in Chipili (M18 24F) on the importance of community linkage with a view of influencing the uptake of services by community members d) MCSP provided TA support to facilitate the formation, revitalization and strengthening of provincial, district and community engagement structures for accountability of RMANCH&N services between the district and community stakeholders through capacity building in 8 districts and 42 facilities in sound community engagement approaches. A total of 47 staff were oriented in CE approaches. This intervention has improved the capacity of facilities to plan, execute and monitor community engagement activities as observed in the 2019 CoC plans. e) MCSP oriented 8 districts on the TOR for the DHPT, consolidate and collect a complete CBVs matrix. This aims at strengthening the understanding of its importance especially in terms of implementing meetings. MONITORING AND EVALUATION a) MCSP advised 12 districts on ways to improve the use of data for decision making that will inform immediate adjustments to the plans and planning in the 2019-2021 MTEF plans. The districts were encouraged to prioritize quarterly review of plans by factoring in the 2019 cost sheet as one of the HII. b) MCSP supported the strengthening of the district mentorship teams by conducting orientations of district staff in the mentorship and SQA approaches. This was conducted in 2 districts and 6 facilities with 10 members of staff oriented. This will help the facilities review their data and KPI using dashboards. The facilities appreciated that it will help them come up with quality improvement projects. CROSS-CUTTING a) MCSP provided technical support during the pre-planning stages in all the 12 districts of Luapula province with the aim of helping districts to identify the priority areas in the 2019 plan that would help come up with high impact activities to mitigate the poor performing RMCHAN indicators. b) During the launch of the 2019 MTF planning. MCSP provided technical assistance to the districts on what should be in the plans. Furthermore, MCSP followed up the districts to their respective districts to assist in refining and consolidating the G2G plans by ensuring that the planned activities are in line with the needs of the district and will be in a position to influence the outcome of indicators before being submitted for donor approval. c) MCSP supported DHO staff from 12 districts across all thematic areas in planning for 2019-2021 MTEF and donor. This made all the districts come up with high impact interventions to address the challenges they have been facing by not reaching the target key national indictors. The districts have submitted CoC interventions for 2019 G2G funding. d) MCSP guided districts on the content of 2019 MTEF plans to ensure the interventions and supporting activities, address the gaps identified and prioritize through the bottleneck analysis in all thematic area’s high impact interventions to address key priority indicators. e) MCSP provided TA to districts by supporting establishing and strengthening mentorship systems in the districts, targeting non SM360+ districts where there are no mentorship teams. Currently MCSP has influenced 6/8 remaining districts to activate and form mentorship teams through trained mentors. All DHDs were trained as mentors and can be used as the lead, until one among the team members has

62 | Page

interest and skill to take up the task as lead. Chienge, Nchelenge, Mwense, Chipili and Kawambwa teams have been strengthened. MCSP is using lessons learned by SM360+ to provide technical support for decentralization of mentorship.

63 | Page

Objective 1: Provide demand-driven technical assistance for sustainable scale up of RMNCAH&N interventions across the four focus provinces of Zambia Thematic Area Activity Progress of the Activity Next Steps for this Activity Reproductive & Activity 1.1: Technical Assistance to CoC Program Maternal health Provide technical • MCSP emphasized to Facility staff on the need to provide quality service to the clients by • MCSP to follow up the data for Chipili for it is too assistance during providing them with a full package of FANC at every ANC visit. This was derived from the late good to attract audit. implementation of booking of antenatal mothers in 11 districts apart from Chipili which was at 95% in < 14 weeks 2018 CoC grants first ANC visit • During the MDSR meeting held for Mansa district, MCSP influenced the DHO staff to provide • MCSP to make a follow up on the composition of integrated mentorship to facility staff with regard to considering trained mentors with quality skills mentorship teams and the post mentorship report in maternal health. and outcome • MCSP influenced the DNOs for Chembe, Chipili and Samfya to conduct onsite mentorship to staff on duty in labour ward in administering SQA tool for easy identification of unit gaps( Labour • MCSP to tag with the teams going for mentorship ward) so as to come up with quality improvement project on the ward to review and provide a continuous TA even during mentorship

• MCSP to follow up on the identified ward QI projects Provide technical • MCSP provided TA to all the districts two weeks before MTEF/ national launch in order to • During planning to work and follow up on whether assistance during strengthen the planning process targeting the RMNCAH&N interventions with reference to 2017 the districts have included such interventions planning of 2019 CoC and 2018 districts data( dashboards/scorecards) in identifying the gaps • grants To follow up during planning if districts are using • MCSP came up with identified possible High impact interventions to share with all the districts data as source of identifying a gap for interventions during the pre-planning as in appendix. MCSP influenced all the districts to include in the final G2G plan the following;  MCSP to look through approved G2G plans for all the districts and a provincial one  Conducting mentorship of health workers in LARC- Chifunabuli, Chipili, Lunga included this intervention and cost  d it in their final G2G plan  Conducting Quarterly onsite clinical mentorship in BEmONC- Milenge, Chifunabuli, Chembe, Chipili, Mansa, Nchelenge, and St. Paul’s Hospital planned and costed in their G2G 2019 plan  Training of staff in EmONC- only Milenge and Chembe planned for this training. MCSP stressed the importance of this training as an intervention to strengthen health care provider skills (pre and in- service) for delivery of quality EmONC services with a focus on mentorship systems  Orientation of HCWs in new referral protocols- Mwansabombwe and planned for this intervention.  Mentors HCWs in Respectful maternity care by Mansa General and St. Paul’s mission hospital. This was aimed at addressing a strategy of strengthening respectful maternity care.

Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship

64 | Page

Expand Technical • MCSP tagged with SM360+ in Lunga providing mentorship to staff in maternal health. During the • Teams to sustain the holistic approach in scope of mentorship mentorship, the team had objectives in IMCI. MCSP provided technical advice in the integration mentorship by reaching all the thematic areas, to include child with immunizations since the IMCI is targeting a child. using the standardized MoH mentorship tools. health, nutrition and community engagement topics Newborn Activity 1.1: Technical Assistance to CoC Program

TA provided in • MCSP made a follow up TA to all districts in prioritizing QI projects in Lunga, Milenge, • MCSP to follow up on the districts without projects addressing still births Mwansabombwe and Kawambwa. This was apart from the already existing projects in Nchelenge and strengthen them to start at least with one. & neonatal deaths and Chienge.

• The newly QI projects identified by the districts was due to MCSP influence in upholding the

importance of QI in service delivery

• Most districts are able to explain the objective and importance of QI teams

• MCSP influenced DHO staff (DNOs) to address facility staff in prioritizing creation of space for KMC in all districts within the maternity annex or elsewhere within the facility • MCSP shared protocols for KMC with the DNOs for facility staff • MCSP to make follow ups on the spaces created as • DNOs advised to facilitate mentorship to labour ward staff in KMC whilst waiting for staff to this is one of the reasons why neonates die. undergo formal ENC training and this is in 8/12 districts. • MCSP to discuss with districts affected on the review of action plans in terms of infrastructure rehabilitation and building of new and standardized maternity annex in some districts Provide technical MCSP visited Chembe zonal clinic and identified possible causes to neonatal deaths (Asphyxia due to • MCSP to look through approved G2G plans for all assistance during inadequate staff skills in ENC/HBB and prematurity) together with DHO staff established interventions the districts and a provincial one planning of 2019 CoC to address this problem by prioritizing ENC training in their G2G 2019 plan grants During planning, under newborn health the following activities were influenced to be part of the plans and were included in final G2G plans  MCSP shared the importance of timely resuscitation of all asphyxiated babies within the golden minute to strengthen provision of quality newborn health care services by influencing districts plan for resuscitation machine, penguin suckers and neonatal ambubags in all districts and all of the districts have costed them.  Training of staff in ENC, this will strengthen capacity of staff to improve newborn health care and reduce on neonatal and still births( St. Paul’s mission Hospital,  Conduct perinatal death review ( Mansa, Lunga, Kawambwa, Mwense, Chifunabuli and Chienge)  Conduct mentorship in ENC services and infection prevention ( Mansa, Lunga, Kawambwa, Chifunabuli and Chienge) On the procurements MCSP influenced districts and hospitals were a lot of neonatal and still births were recorded (Chienge, Nchelenge and Samfya) to procure; Infant resuscitare ( Samfya, Mansa GH and Nchelenge)

65 | Page

Suction machine ( Chienge, Kawambwa, Mansa GH and Nchelenge) Fetal Doppler machines ( Chipili, Chifunabuli, Kawambwa, Lunga, Mansa, Mansa GH and Nchelenge) Child health Activity 1.1: Technical Assistance to CoC Program

Provide technical • MCSP visited Mansa district during a measles outbreak for TA in active surveillance. Influenced • MCSP to make a follow up on implementation of assistance during the district surveillance team to share the outbreak line list with key partners for analysis and re- surveillance sites as one of the sites to be added on implementation of strategizing. MCSP also influenced the initiation of SIA activities which was targeting children 4 outreach sites for immunization of under-five 2018 CoC grants months to 15 years of age. MCSP joined the Mansa district surveillance team constituted to combat children the measles out-break in the district at Paul RHC. • MCSP further influenced the surveillance team to extend the SIA to other catchment areas where • MCSP to make a follow up on all District G2G Zambians easily mingle with Congolese. Currently, the team which came from CDC for Ebola plans to prioritize for RED/C strategy training. outbreak in Congo, used MCSP idea and the districts we proposed as MCSP for surveillance sites were Mansa, Chembe, Nchelenge, Chienge, Chipili and Mwansabombwe • MCSP influences RED strategy in Chienge, Nchelenge, Kawambwa and Chifunabuli have since developed micro plans for immunization • MCSP followed up Mansa district on the IMCI charts and IEC materials if provided by the DNO • MCSP to encourage the CCO and the DNO from DHO. It was discovered during Mansa TA that the affected facility was supplied with the supervise and sustain the trend. This need to scale guidelines and charts and the graphs to monitor the trends of diseases in the same facilities were up to other facilities in Mansa district. The % is updated (Central clinic, Senama, ) so as to conform to standards in data just 5/56 facilities (8.9%)

Provide technical Under child health the following activities were influenced to be part of the plans and were costed; • MCSP with MoH to follow up final and approved assistance during  One of the MoH strategy was to Increase immunization coverage through routine, child health plans and focus on what was included for planning of 2019 CoC days and outreach services; care for the sick child; and emergency triage assessment and implementation grants treatment. 6/12 districts (Chifunabuli, Chipili, Samfya, Lunga, Nchelenge and Mansa) planned • TA provided to Train staff and NHCs in RED strategy. during  10/12 districts planned for integrated outreach services to enable them increase the coverage provincial on measles 2 and reduce the dropout rates. planning  The other strategy was to strengthen data quality management with particular emphasis at lower process level. Districts like Chembe and Mwansabombwe planned for quarterly data audit meetings with ICCM staff.  In order for districts to expand, strengthen, and enforce the use of all components of IMCI strategy Chifunabuli, Chipili, Milenge and Nchelenge had planned to conduct training of HCWs in IMCI.  ICCM training was planned by Chipili district only.  11/12 districts planned to conduct mentorship in child health and immunization services to facility and community based volunteers.

LESSONS LEARNT

100% of districts had knowledge on the child health interventions using the MoH HII and the partner contribution

Most districts did not use a copy and paste planning theory because of our close guidance and support throughout the planning process and this need to be sustained

CHALLENGES

66 | Page

 Most districts needed IMCI training but the cost to train was very high(4/12 districts planned but with few number of staff to be trained)  Districts did not understand the ETAT training(Emergency Triage & Treatment) and this had made the whole province not prioritizing the training

RECOMMENDATIONS

MCSP TA approach to be sustained in order for the districts to understand and comprehend the interventions included in the action plan and results into quality planning with evidence

District senior managers to be oriented in ETAT immediately so as to address the MoH goal “to reduce the under-five mortality rate from 75 (ZDHS, 2013-14) to 56 deaths per 1,000 live births by 2021,” with a strategy to expand, strengthen, and enforce the use of all components of IMCI strategy

Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Conducted an SQA  MCSP provided TA to districts by supporting, establishing and strengthening mentorship  DHOs to display mentorship teams on the and district tracker in systems in the districts, targeting non SM360+ districts where there are no mentorship teams. notice boards, budgets and implementation mentorship to 6/12 Currently MCSP has influenced 6/8 remaining districts to activate and form mentorship teams schedule districts in Luapula through trained mentors. All DHDs were trained as mentors and can be used as the lead, until namely Chembe, one among the team members has interest and skill to take up the task as lead. Chienge, Samfya, Lunga, Nchelenge, Mwense, Chipili and Kawambwa teams have been strengthened. MCSP is using lessons learned by SM360+ to provide technical support for decentralization of mentorship. Milenge, Chipili and Mansa Community engagement Activity 1.4 Increased demand for services through increased community engagement Strengthen The Community Engagement team participated and provided on spot TA during the community  Complete packaging of key messages and implementation of advocacy meetings with key community members and gate keepers in Mwansabombwe 26 (19M, 7F) distribute to facilities for CBV and HCWs use CE activities at and Chembe 13 (1F, 12M) districts of Luapula province. The meeting was aimed at linking health for awareness creation community level to centers with key community members, to created platforms for lobbying, soliciting and involving  Continue engaging gatekeepers for improved address social norms RMNCAH-N services for gradual adoption of influential community gatekeepers in adopting recommended RMNCAHN practices. The findings in recommended the meetings were RMNCH&N practices • Low ANC attendance at 14 weeks. through varies • Low male involvement community platforms • Lack of knowledge and ignorance of benefits such as community • dialogues, drama and Inactive SMAGs social mass media • Lack of birth plan preparation communication. • Myths and misconceptions • Rules of man escorting women for the facility to those who do not have partners they stay away

• Not having the required commodities for FANC MCSP provided technical support to DHO and gatekeepers to  Develop joint community sensitization meeting (SMAGs/Traditional Leaders) plan  Address all the discussed barriers during community meetings  Myths such as pointing at the pregnancy should be done early to those who believe to ensure that the woman can start attending ANC on time. However, this should be clear that that is a myth.

67 | Page

 The facility team also made it clear that dressing should not be a barrier; all what is needed is decent appropriate dressing and not expensive clothing Provide technical  MCSP in Luapula province conducted collaborative visits with systems for better health to all  Conduct mentorship to DHO staff on assistance during pre- (12) the districts with the use of the scorecards to identify the contributing factors as to why involvement of stakeholders during the planning of 2019 plans some indicators were poorly performing and develop high impact interventions. Through this planning process

support, DHOs were guided to plan well ahead of time and identify RMNCAHN key  Conduct mentorship to DHO staff on intervention areas for inclusion in the 2019 Mid Term Expenditure Framework (MTEF) and Community engagement strategies and roles Continuum of Care (CoC) plans. This will result in the quality of MTEF and continuum of care and responsibilities of NHCs plans for 2019. During the pre-planning meeting, the following were the issues that came out:  Lack /inactive NHCs  Poor governance at community level

MCSP made the following recommendations to the districts  Strengthen stakeholder involvement during the planning process  Ensure that the communities are engaged early during the planning period  Plan for training of staff in community engagement in the continuum of care plans  Plan for training of NHCs in the NHCs guidelines and community health planning in the continuum of care plans  Plan for HCC review meetings CHALLENGES • Ownership of the G to G seems to be a challenge as most DHO staff feel it’s a provincial driven agenda • Delayed planning was seen in all the districts as they were waiting for the national launch for them to start the planning • Most facilities did not review their data and could not provide satisfactory responses regarding indicator performances Among the HII MCSP provided and contributed to the districts were; • Districts to form the DHPT to ensure that all the community engagement related activities are coordinated through this group and supervise the HCCs and NHCs. The DHO team was advised to consider planning for meetings for the DHPT in the 2019 CoC allocation. • District to plan for quarterly mentorship to the CBVs to enhance their performance in demand creation. RECOMMENDATIONS MCSP influenced the DHO team to ensure that the CoC plan was all RMNCAHN, CE inclusive. Provide technical Following the launch that was conducted at provincial level MCSP undertook the initiative to visit the assistance during districts to refine and consolidate activities in the G2G Plan to ensure that the plans addresses the planning of 2019 CoC concerns of the district in relation to indicators grants Under community engagement the following activities were influenced to be part of the plans and were

MSCP provided costed technical assistance to  Orientation of DHO staff in NHC guidelines. This activity is in the following districts 12 District Health (Nchelenge, Chienge, chifunabuli, Kawambwa, Mwansabombwe.)  PHO to prioritize pre planning HII as advised Offices (DHOs) in  Orientation of NHC in NHC guidelines. (Nchelenge, Chembe, Chienge, chifunabuli, Luapula during the by MCSP Kawambwa, lunga, Mansa, Milenge, Mwansabombwe.) CoC and MTF  USAID and SIDA to consider local trainings planning launch. were resource personnel are available.

68 | Page

Provided technical  Quarterly HCC review meeting. (Nchelenge, Chienge, chifunabuli, Kawambwa, lunga,  SIDA/ USAID to consider apportioning assistance in the Mwansabombwe.) percentage to different thematic areas for the refining and  Quarterly stakeholder review meeting. (Nchelenge, Chembe, Milenge, Chienge, insurance of equal distribution of planned consolidation of the Mwansabombwe.) activities. G2G plans at district  level by ensuring that Quarterly meeting with community gatekeepers (traditional leaders). (Nchelenge, Chienge,  MCSP to make follows to all district approved the planned activities chifunabuli, Milenge, Samfya, lunga, Mwansabombwe.) G2G and MTEF plans are in line with the  Training of SMAGs. (Nchelenge, Chipili, Samfya.)

needs of the district  Quarterly meeting with SMAGs.(Nchelenge)

and will be in a  Train staff in ASRH (Chienge, Chipili, and Mwansabombwe.) position to influence  Quarterly DHPT meeting ( chifunabuli) the outcome of the  Conduct radio sensitization programs ( Samfya) indicators  Staff orientation in BCC. ( Samfya)  MCSP to make follow ups during final review and consolidation process with PHO/SBH CHALLENGES  Most districts did not prioritize the component of community engagement during routine visits  Most activities were inclined to one thematic area maternal health Improve collection,  MCSP in Luapula province supported Chembe and Chipili district and the facility staff • DHO staff to scale up use of SQA tools across all monitoring and use of administer the SQA tool under health promotion. Facility health promotion focal point person the districts in the next quarter. data use for decision at Mwenda RHC and Chembe RHC were oriented. making and quality  The SQA tools aim at supporting the DHO and the facilities to be able to identify existing gaps improvement at the intervention level that will hamper sound delivery of RMNCH-N services. Capacity building in • MCSP visited Chembe and Chipili where DHO and facility staff in Chembe (2 staff a male and a • MCSP to follow up and support facilities and CE package: female) and Chipili 6 staff (3males and 3females) in Community Engagement Approaches were DHOs in planning for community engagement Provincial, District and oriented onsite. In a special way, the district health promotions focal point person being a capacity building community members supervisor was oriented in the development and implementation of RMNNACH-N Community and groups’ capacity Action Plans buying into the needs of the NHCs from HCC meetings to plan and mobilize resources in order to implement and monitor RMNCH-N preventive and promotional activities.  Additionally, staff were supported in rescheduling and Ghantting of quarter 2, 2018 CoC Provide technical approved activities. Districts have since submitted rescheduled quarter 2, 2018 CoC plans to assistance during provincial health office ( PHO )and MCSP making it easier for PHO and MSCP to effectively implementation of monitor and coordinate activity implementation 2018 CoC grants

Adolescent Health Activity 1.1: Technical Assistance to CoC Program

Provide technical • MCSP conducted a follow up visit to selected facilities in Mansa district; Senama clinic, Chembe • MCSP to encourage DHO staff provide TSS assistance during district; Chembe RHC, ; Kashikishi RHC to discuss ASRH programming and

implementation of data collected at Senama clinic to understand how adolescents access services was conducted as 2018 CoC grants seen in the appendix. We aimed at contributing to reduction of adolescent getting pregnant, which results into complications like septic abortions and death thus increasing maternal and neonatal death

69 | Page

• MCSP influenced Mansa DHO to support adolescents with IEC materials (T-shirts and drums) at Luamfumu RHC and Central clinic with G2G funds it received. The DHO staff had challenges in • DHO advised to scale up support to other facilities slow procurements of planned items. They also provided some facilities with ASRH protocols and in stages guidelines. The focal point person at district level was identified and MCSP has assigned the ASRHFPP to scale up to facilities and do the same selection of the ASRHFPP for the good coordination

Provide technical  MCSP team influenced DHO staff for Lunga and Samfya to be part of a meeting during the • MCSP to remind the DHD over the activity as we assistance during formation of Adolescent Technical working group. This is in order for MCSP to strengthen visit the districts during monthly TA monitoring of 2018 DHO staff on the understanding of ASRHTWG by sharing with them the TOR CoC Grants

Provide technical MCSP influenced districts on HII on adolescent sexual and reproductive health and the following were • MCSP to make follows to all district approved assistance during included in the final G2G plans; G2G and MTEF plans planning of 2019 CoC  ASRH training of youths. This activity is in the following districts (Nchelenge, Chienge, grants Chifunabuli, Chipili, Kawambwa, Mansa, and Mwansabombwe.)  Refurbishing youth friendly spaces. (Nchelenge, Kawambwa)  Monthly meetings with peer educators. (Nchelenge, Chembe, lunga, Mansa, Milenge.)

 Conduct radio sensitization programs with youths ( Samfya)

 Staff orientation in BCC. ( Samfya)  Train staff in ASRH (Chienge, Chipili, and Mwansabombwe.) This was to address the identified gaps in ASRH and address the MoH goal as to improve the health status of adolescents by 2021

LESSONS LEARNT

 Adolescent health appeared to be a new intervention for planning and this made all the districts planning teams experience difficulties to identify interventions to address the gap rather than trainings  Most districts planned for capacity building of community and staff in ASRH than interventions

to reduce teenage pregnancies and other gaps identified

 Most districts did not use the data for interventions because of difficulties in interpreting KPI for adolescents • MCSP advised all districts with such a challenge to CHALLENGES create space by rehabilitating or procure tents

 Most districts had no ASRH spaces in the facilities • The PNO-MCH was influenced to explain briefly on why ASRH than YFS and its relationship

 Districts had no much knowledge on ASRH in terms of the difference between youth friendly and ASRH services  No plans were available for adolescent health in the previous years

Activity 1.1: Technical Assistance to CoC Program

70 | Page

Nutrition Provide technical MCSP visited Lunga and for TA in nutrition to district key staff and selected facilities. assistance during Milenge district nutritionist was oriented in SQA and formation of a dashboard and provided with softy implementation of copies for sustainability. 2018 CoC grants • MCSP visited Milenge east 7 rural health Centre in Milenge with the aim to follow up on nutritional services. The facility was found with the following; adequate room for Nutrition screen, counselling and reception, a good number of staff and volunteers trained in nutrition short courses, availability of basic equipment and supplies, documentation and follow up SAM and IMAM children well implemented, guidelines were not in place. This was due to MCSP previous TA • MCSP to follow up Milenge District which targeted nutrition in Milenge • MCSP visited Kasoma Lunga RHC of and the following were the finding; functional Nutritionist in sourcing for clinical nutrition basic equipment in place, most of the guidelines and protocols are in place, two staff trained in guidelines, Zambia food composition tables, nutrition short courses and 13 volunteers oriented in GMP. This was out of MCSP influence during IMAM protocols and guidelines, latest 2015 planning in 2017. operational standards for NACs (procedure manual), latest 2015 NACs flow charts.

• MCSP to make a follow up Lunga district Nutritionist to source for more equipment and RUFT and provide TSS to facility In- charge in sourcing for a standard register for unweight

Provide technical • MCSP conducted follow up TA to all districts so as to refine and consolidate 1st draft G2G planned • MCSP to follow up an approved plan and budget assistance during activity plan for 2019 in nutrition following the guidelines from the agreed HII on nutrition. for 2019-2021 MTEF planning of 2019 CoC Districts selected and included in their action plans the following and awaiting approval; grants  Training of CBV in GMP (Nchelenge, Chembe, Chifunabuli, Chipili, Samfya, Mansa)  Cooking Demonstrations (Nchelenge)  Mentorship in GMP,IMAM and NACS (Chienge, Chifunabuli ,Kawambwa, Lunga)  Intensified case finding of the malnourished children (Chienge)  Community MIYCN training (Chienge, Chifunabuli, Chipili, Mansa ,Milenge)  Nutrition review meetings and TSS (Kawambwa)  Orientation in OTP (Kawambwa)  CBV training in OTP (Mansa)  Orientation of CBV in IMAM (Milenge)  IMAM training for HCW (Milenge, St Paul’s Hospital)  Training of HCW in GMP and MYICN (Mwansabombwe)  OTP site monitoring (Samfya) The districts were also influenced by MCSP to include anthropometric equipment, nutritional supplements and kitchen utensils according to their need. Some of the equipment included; scales, MUAC tapes, length boards, height boards and kitchen scales.  Chembe (Bowls, cups, kitchen food scale, knifes, measuring and storage jugs  Chienge (Heater, MUAC tapes, Scales, height and length boards)  Mwansabombwe CMV,F75,resoMal,RUTF)  Chipili (HEPS blend)  Kawambwa (CMV,HEPS blend, RUTF, kitchen scale)  Lunga (Length and height boards)  Milenge (Stove)  St Paul’s Mission Hospital (F100,F75)

LESSONS LEARNT Most districts had to avoid trainings in nutrition because of the next trench coming had nutrition

71 | Page

trainings and most districts conducted a lot of trainings in both community and facility trainings All districts have a nutritionist trained and based at the district and hospital and this made the planning easier for all the districts

CHALLENGES Most districts had no challenges in nutrition, because the Principle nutritionist was active and always to make sure interventions proposed are adhered to by the districts

M&E Activity 1.3: Improve collection, monitoring and use of data use for decision making and quality improvement

MCSP attended the meeting to strengthening district CoC 2019 plans during the provincial planning • MCSP to follow on an approved MTEF plan for launch. verification of interventions This activity draw the participation of all the districts in Luapula province who were brought at the central level during the CoC/MTF planning launch ( 12 districts Chembe, Mansa, Samfya, Chifunabuli, lunga, Milenge, Mwense, Chipili, Mwansabombwe, Nchelenge, Kawambwa and Chienge.). The objective was to ensure that the CoC plans were in alinement with the action points agreed upon during the routine TA visits. We managed to develop agreed upon check list of M&E interventions. During launching most districts failed to understand the planning template for G2G interventions which may lead to poor planning. Districts also were not consistent in referring the identified gaps from scorecards, dashboards, PA reports, TA/TSS reports and this was taken up by MCSP to conduct TA by following them in districts with the aim to consolidate the final first G2G draft plan for 2019.

MCSP conducted follow up TA to all districts so as to refine and consolidate 1st draft G2G activity plan for 2019 During a follow up TA in various districts, MCSP oriented district planning team in the use, process and interpretation of a template MCSP influenced all districts visited during follow up TA to adhere to source of problems as data. Data will lead to quality planning for it will address the gaps. Most districts appreciated the follow up Provide technical activity conducted assistance during Under M&E the following activities were influenced to be part of the plans and were costed; planning of 2019 CoC • Administer SQA in Family planning, FANC, Labour and delivery services, IPC practices and grants Conduct SQA, mentorship and create dash boards by all the districts • Orient staff in the New ANC guideline and monthly TSS • Conduct supportive supervision using TA trackers/SQA tools /mentorship tools- This is to maintain good infection prevention practices in all neonatal units, labour and delivery rooms • Orient facility staff in administration of an SQA and formation of dashboards. All districts adopted this intervention and the rationale shared was makes it easier to provide quality service with data available and well interpreted in a simple color coded presentation. • Conducting onsite orientation mentorship/TSS activities facility staff in development and updating of facility dashboards • Conduct orientation of facility staff in new HMIS tools- ( Chifunabuli, Lunga and Chienge) • Conduct quarterly district data review meetings, all district planned for this activity with the aim to beat up a gap of inconsistent Data Review Meetings/DIMS by districts • DQA was also planned by all districts after a TA in terms of understanding its concept and difference from data audit meetings • On procurements, MCSP influenced districts with a challenge of printing scorecards and dashboards to prioritize laptops for data storage, photocopiers and color printers for effective and sustainable printing of dashboards and scorecards. The following districts planned for laptops Lunga, Chifunabuli, Chembe, Chienge, Mwense, Kawambwa, Milenge and Nchelenge. • Photocopier (Chipili, Mwense, Kawambwa, Lunga, Milenge and Nchelenge

72 | Page

MCSP visited Chembe and Chipili district for TA in order to increase capacity of program officers and facility staff in administration/interpretation of SQA and data management i.e. capturing of data in

registers, verification and promote quality

In Chembe MCSP visited two facilities (Chipete RHC and Chembe zonal health Centre are provided TA to 3 Nurses, 2 clinical Officers and 1 midwife. Facilities were using new HMIS registers and tools for capturing of data and have designated rooms for data capturing with neatly packed patient books which made our work easier to access the data for effective TA. In most of their registers were updated and smart. MCSP had to discover during TA that staff had inadequate knowledge on how to administer SQA and its interpretation. This resulted in finding no dashboards displayed on the walls. MCSP exposed facility staff on how to administer the SQAs and interpret the dashboard so as to come up with informed pattern to make decisions based on the indicator in question. MCSP also advised staff to formulate dash boards for the indicators on quarterly basis with emphasis from PMERO on the importance and interpretation of dashboards/graphs (talking walls) in the facility which foster data ownership and direction in decision making. At Chipete RHC in Chembe, MCSP did not find the new HMIS data collection tools such as revised child health activity sheets, guidelines/ protocols (Indicator and HMIS manuals) for reference in sustaining quality data capturing. Instead, MCSP printed revised tick sheets i.e. ANC/PNC, Under 5 and Family Planning and left them with the Nursing Officer (MNCH Coordinator) and information Provide technical officer who ensured they were delivered to the facility. Later the DHO staff were mandated to hold assistance during monthly data review meeting with all DHO program officers and partners (MCSP/SBH) before • MCSP to follow up on meeting minutes for DHO from DHIO/DNO during TA monitoring of 2018 submitting the DHIS report to PHO

CoC Grants MCSP conducted a followed up TA visit to Chipili district health office and at Chipili zonal health

Centre and addressed all areas where they are having challenges with a goal to target dashboards and data capturing system for verification of data related to 95.5% in institutional deliveries for quarter 2 of 2018. The team administered a tracker and an SQA tool; TA offered in areas where they are having • challenges with dashboards and data capturing MCSP to follow up on meeting minutes for DHO from DHIO/DNO during TA and the centre in The two facilities had no dashboards and graphs displayed on the wall apart from disease trends in charge. pneumonia and HIV/AIDS. MCSP queried data quality after discovering that the district had no new • MCSP to follow up on TSS provided to Facility by HMIS activity sheets for child health at the time of visit and this compromises on quality of data DHIO and DNO in terms of displaying facility collection tools and its interpretation. Gaps in delivery register were identified and partograph not well dashboards and DHO scorecards filled by staff in labour ward to help in case of case review during unforeseen circumstances such as • A Follow on DHIO printing and photocopying maternal or neonatal death. enough activity sheets foe child health and stock some in his filling cabinets for other facilities In order to address this, MCSP advised DHO staff in reminding the In-charge that whenever the HIA2 report is submitted to the district, it must be accompanied by meeting minutes as evidence that the produced data was discussed by all members of staff; this is in order to enhance data ownership. In- charge advised on the importance of dashboards/graphs (talking walls) in the facility which foster data ownership and direction in decision making; he was therefore oriented on how to come up with simple bar graphs that can be displayed as dashboards. Facility in-charge encouraged to ensure staff complete the delivery register and partograph entries. MCSP encouraged staff to develop a habit of sustainable internal mentorship by not waiting for zonal mentorship team visit.

73 | Page

• MCSP visited Samfya, Chembe, Lunga and Milenge districts and their selected facilities to • To make follow ups to all the districts and review provided TA in conducting SQA for district staff and creating district dash boards successfully the implementation status targeting all RMNCAH&N programme officers namely DNO, DHPO, Nutritionist, DHIO, ASRHO, EPI technician and the Planner. Out of this intervention district program officers were influenced to initiate a QI project from areas not performing well as flagged by their dashboards. Milenge, Lunga. The reason for conducting this TA was derived from the sense that The DHO staff did not have any record of SQA conducted and no dash boards displayed, either at DHO or facility Build facility capacity in all the districts visited due to knowledge gap in formulating a dashboard and coming up with a in data collection, QI management, and

usage techniques • MCSP provided TA on formation of facility dashboards to two (2) facilities in Samfya, two(2) facilities in Chipili, four(4) facilities in Mansa and two(2) facilities in Mwansabombwe districts in SQA and formation of basic facility dashboards. We also conducted an orientation of SQA

formation and dashboard data/colour interpretation to Mansa General Hospital Gynaecology and Obstetric team (2 obstetricians, 1 Surgeon, 3 Resident Medical officers and 2 Nurses and . midwives) which will help in planning for priority areas to combat maternal and neonatal deaths in the facilities. MCSP conducted a data audit in family planning registers and LNG-IUS stock levels with the aim of quality service delivery in family planning. The team tagged with SM360+ and visited  MCSP & SM360+ Technical Officers to liaise Chembe, Samfya and Mansa where LNG-IUS facilities are located. with hospital management on how best this can The audit on family planning registers were conducted in five(5) facilities namely Mansa General be resolved to prevent women walking from hospital, Senama Clinic and Central Clinic( Mansa district), Chembe Rural Health Centre in Chembe postnatal to Gynae ward just to access Family district and Samfya stage II Clinic in Samfya district. Planning services after delivery  PMERO, DHIO and Hospital Information FINDINGS/TA PROVIDED officer to look into this  PMERO to work with DHIO and support the  Staff not following the register instructions as they enter data. Onsite mentorship by the team hospital to come up with a Family Planning was provided to the facility staff on where to find the register instructions dashboard  Registers were incomplete in terms of filling in all necessary columns with expected  PMERO to discuss this with DHIO on way information. Staff advised to fill the necessary information for quality outcome of data forward Improve collection,  On data review from the registers, Mansa GH had a low uptake of LNG-IUS, service not  PMERO to engage Mansa DHIO to discuss a monitoring of data integrated/provided in labour ward thus compromising the standard of FP integration. The use for decision way forward on data capturing of the outside service is provided 200 metres away from the labour ward( Gynaecology ward).This catchment area and use of an activity sheets by making and quality contributes to clients after labour and delivery NOT access the service easily the facility to extract a report instead of the improvement  Mansa general Hospital is still using an old version of a FP register and this contributes to data register compromise in terms of quality.  Evidence of data ownership and utilization absent as there are no dashboards or graphs in all the facilities visited.  MCSP and SM360+ technical officers to make a follow in quarter 4, 2018.  At Senama Clinic, now first referral hospital, big discrepancy between data in HIA2 and registers on FP revisits and the facility MCH Coordinator attributed this to the fact that FP clients coming for revisits from outside the facility catchment area are just tallied but not entered in the FP register

74 | Page

 With Samfya district, despite LNG Stock being kept at Samfya District Hospital all FP clients are attended to at Samfya Stage 2 clinic. The few that access services at the hospital are also recorded in the FP register at Samfya Stage 2. Facility is using new FP register since May 2018, No blanks on type column of FP attendance in the register as it was with the rest of the four (4) facilities. MCSP advised the MCH Coordinator to ensure staff start using codes correctly, i.e. “C” for clients continuing FP, “R” for clients restarting and “N” for New acceptors The team also urged the MCH Coordinator to ensure data for LNG-IUS/ LARCs removals are also entered in the register and summaries written at the end of each month

MCSP with SM360+ conducted LNG Stock audited in the five facilities where the data audit on family planning registers was conducted

FINDINGS; Mansa General Hospital  The hospital had 6 packs of LNG all expiring in December 2018 Senama Clinic  The facility had 10 packs of LNG stock all expiring in December 2018 Chembe RHC  The facility sent 2 packs (expiring in December) to Kunda Mfumu RHC where there is a trained LARC provider but none has been inserted yet  3 packs remaining at the facility and also expiring in December 2018 Samfya District Hospital/Stage 2 Clinic  3 packs that expired in January 2018 retrieved  The facility is remaining with 6 packs expiring in December 2018 Clinic  The facility had 12 packs of LNG stock all expiring in December 2018

 All facilities visited (5/5) had adequate stocks of LNG-IUS which is expiring in December, 2018. There was no overstock or understock observed, though one facility had a stock out due to loaning to another facility with high demand and volume of clients in need of a service. The facility decision was based on drug expiring within 6 months with low demand at their facility may result into wastage of the product TA PROVIDED  MCSP and SM360+ commended the facility but advised to have kept at least 2 LNG-IUS devices in case of a client. The staff was advised to go and get/retrieve at least two (2) devices in case of clients because the facility without a family planning method is considered dead more especially long acting reverse contraceptives (LARCs). Crosscutting MCSP worked with SBH to improve the structure and agenda of DIM meetings. MCSP attended  MCSP to join all planned DIM and PIM Mansa district integrated meeting only, where we influenced the district on the format of facility meetings and prepare written feedback and Participate in DIM performance presentation. The district has 56 facilities in the catchment area recommendations for changes to the CoC grant events organized by plans based on analysis from the DIM meetings District and province MCSP had a brief presentation done during the meeting to try and introduce MCSP to other facilities and review of reports and provided TA and staff that have not yet interacted with the team. MCSP objectives and how MCSP is supporting the especially on data CoC grant explained. The concept of change was also shared and was related to the grant in terms of management and the inputs that the district has so far received to help in the gaps contributing to poor performance and poor patient health outcomes. mentorship activities A presentation on SQA was done during DIM and stressed the importance of the districts to start using SQA to inform areas that are not doing well and plan for structured support. Few examples from the districts focusing on some specific thematic areas were presented. The DHIO presented score cards on

75 | Page

RMNCAH&N indicators and explained how the facility can utilize the score cards for decision making. Most indicators showed that the facilities were not doing well and need to concoct strategies to improve the picture. The district was encouraged to assist facilities to understand and start utilizing data from the score cards for decision making

76 | Page

• Challenges and recommendations ( not more than 3 per thematic areas)

Thematic Area Challenge Recommendations to Address the Challenge

Maternal  Non availability of job aids such as models, guidelines and protocols for • Ensure that districts plan to procure through the COC grants reference in execution of quality service • Districts to plan for color printers in order to print out the documents from soft copies shared by MCSP

 Inadequate transport logistics therefore most District MNDSR meetings are not • Work with Districts to develop schedules in time to enable adequate time to coordinate supported technically logistics

 Inadequate skills of staff attending to most mothers, especially that most • PHO to prioritize training of staff in rural areas in EmONC and Midwifery deliveries are in the rural health Centers • Mentorship to most affected areas to be well planned by the districts

Newborn  Facilities have no space for KMC. This will continue contributing to increased • PHO and DHO staff were advised to plan in 2019 CoC activities. number of neonatal deaths reported.

 Unavailability of resuscitation machines in 85% of district facilities making it • Districts to plan for procurement of resuscitation machines for most of the facilities in difficult for the clinics to resuscitate the problem newborn babies Luapula province are connected to national grid electricity.

 Inadequate skills in trained staff to care for the newly born baby with problems • Capacity building in HBB, ENC and midwifery.

Child health  Poor cold chain management • Districts to provide mentorship, orientations and trainings in management of vaccines( EPI training)

 IMCI not provided as per protocols and guidelines • Districts to provide onsite and continuous mentorship and train non skilled providers in IMCI

 Facilities do not display graphs for malaria, pneumonia and non-bloody diarrhea • Districts to make follow ups and make all facilities display all the KPI in under five care. in under five

Community engagement  Inadequate transport / budget for follow up visits to Districts and facilities (MCSP • Jhpiego to consider bus fares with this limited transport in order to work on the speed the Staff are not able to reach target areas as and when needed due to limited activity demands. transport)

 It has been a challenge to provide TA at facility level on CE because of limited • Need for additional logistics support to support CE TA logistics hampered by group packs Adolescent health  Province has no Focal Point Persons in all the 8/12 districts • All districts to appoint one focal point person for effective communication and coordination of ASRH services

 Planned activities were focused on capacity building for 2019, which made the • Districts to improve and review the 2018 CoC planning by involving the MCSP ASRH ASRH services stood still in the areas of service delivery specialist in selected districts attend the planning cycles

 No infrastructure for adolescent health in districts. This makes ASRH services • Districts to defend a 2019 CoC planning on the rehabilitations and construction of new inaccessible to adolescents. structures in the facilities as they receive the approved budget

77 | Page

Nutrition  Inadequate equipment such as Seca scales, length and height boards, MUAC • Districts to prioritise during planning 2019 CoC plans tapes for adults

 No protocols and guidelines for IMAM, IYCF, GMP, 10 steps to breast feeding • Districts to plan for procurement of stationery( Flip charts, ream of papers, markers and and MAYCIN in districts computers as well as printers)

• Districts to procure colour printers for the printing of protocols and guidelines to be displayed on the facility walls for this is MoH service delivery standard M&E  Inadequate quantities and varieties of revised HMIS tools sent to Luapula  PMERO to work closely with SHIO and see how best the shortage of new HMIS tools can be resolved quickly  Gaps continue in the understanding of the data elements, registers and reporting  MCSP to work with the SHIO, DHIOs and facility-level staff to ensure efficient and tools at the district and facility level. Major barriers include the interpretation of reliable data systems are in place and to promote data use at all levels. data elements, accurate documentation and recording of service data in real time, and capturing data using the right tools. The increased emphasis for facilities, districts, and provinces to use data for decision-making has increased the need for reliable data at the district and facility level.  MCSP to work closely with DHIOs and where dashboards already exist, the rollout team will provide technical support for continuous utilization of the existing tools.  70% of districts have no dashboards displayed in their work places (DHOs). This Low performing facilities will be visited at least once per month, and low performing is a possible indicator that districts are not honoring the data and are not using it facilities may also receive additional support as needed. for decision making

Crosscutting  Inadequate transport to cover the province as planned • MCSP to sustain the fuel requested to use GRZ vehicles  Downward adjustment of activity time frame in districts( Time spent to work drastically reduced in terms of number of districts, facilities and time) • Jhpiego program unit to get the down up approach in terms of adjustments and follow the quarterly work plans

 Limitations to material support which are recommended in our follow up TA such as • MCSP to prioritize the printing of IEC materials, RMNCAH&N protocols and guidelines Job aids, RMNCAH&N protocols and IEC materials such as HBB, VVM,MDVP, PPH, APH, FP, ENC and many others for distribution to affected districts

78 | Page

LESSONS LEARNED – CROSS CUTTING WHAT WORKED WELL? 1. Good collaboration with other partner organizations like SM360+ in line with mentorship and LARCs, Systems for Better Health (SBH) with planning which resulted into team work with good results in service delivery. 2. The involvement of DHO staff in monthly TAs made MCSP work easier and well understood by the facilities and communities. 3. Continued presentations of TA at various fora has led to consistency in building up the partners to understand MCSP mandate in the province, unlike the situation that existed before where there was open hostility towards the team. MCSP has championed the orientation of SQAs and Dash Boards for determining performance of facilities. 4. In house coordination through joint planning with TA partners had led to leveraging of resources like use of one vehicle when going to the same district to provide TA 5. MoH has been so helpful in terms of transport provision in a situation where we only have one vehicle against 12 districts which need to be covered and reached on a monthly basis. The partner used to assist us with transport and provide a driver, but it was our mandate to pay the allowances for the GRZ driver and put in fuel. 6. MCSP has been so helpful in the quarter for reaching all the hard to reach districts of Luapula province at 100%, namely Chienge, Milenge and Lunga for TA and the MoH integrated their TSS to facilities and communities at large. For the PHO to visit Lunga district it usually needs a lot of resources in terms of fuel and allowances as well as risking being on the water transport. With these challenges MCSP advised PHO to prioritize such districts and plan with an intent to reach them with or without resources. The TA provided to PHO was for them to partner with other GRZ departments like fisheries, Ministry of local government, and other stakeholders like NAPSA who frequently visit the district on a monthly basis and agree on contributions/ cost sharing. WHAT DIDN’T GO WELL? 1. Inadequate transport hampering follow up visits to districts. MCSP Staff are not able to reach target areas as and when needed due to limited transport. Use of one vehicle to all districts in the province is a challenge. It sometimes takes a long time to provide TA visits as follow to districts. 2. Some DHO not adhering to the agreed action points during the pre-planning, when it came to planning they planned things that were not in line with the action points. 3. Abrupt adjustments to planned Technical Assistance Visits and delayed expenditure Authorization by national level resulting intdelayed activity implementation by district.

79 | Page

III. Major Activities Planned for Next Quarter Thematic area Activity According to the Approved Work plan TA Planned (Activity According to Provincial Plans) Maternal Activity 1.1: Technical Assistance to CoC Program

Provide technical assistance during implementation of 2018 CoC grants • Follow on Maternal deaths in Chienge and provide TA with Senior Obstetrician to Chienge District and Selected HFs in Maternal and newborn health. This district has contributed a higher number of maternal deaths in Luapula province. * Introduction and strengthening of Quality Improvement approaches Provide technical assistance during monitoring of 2018 CoC Grants • Monthly Technical Assistance to Mansa District in Reproductive, Maternal, Nutrition and Child Health. There will be capturing of lessons learnt in form of success stories • Participated in the review and realigning the second 50% trench in order to balance and support the districts adhere to following the G2G approved 2018 plans

Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship

Expand Technical scope of mentorship to include child health, nutrition and community • Follow up on TA given in the previous quarter and consolidate QI, DHPT and zonal mentorship engagement topics teams *Dashboards to be developed in the respective thematic areas to act as baseline of identifying the impact of the trainings for subsequent visits

Newborn Activity 1.1: Technical Assistance to CoC Program

Provide technical assistance during monitoring of 2018 CoC Grants • Monthly TA in Maternal Health (Institutional deliveries against home deliveries, Perinatal deaths), Strengthening the good performance in Postnatal within 6 days Nutrition.

Child health Activity 1.1: Technical Assistance to CoC Program

Provide technical assistance during implementation of 2018 CoC grants • Monthly Technical Assistance to Kawambwa and Nchelenge District in Strengthening Zonal Mentorship and RED/C Strategy Implementation Provide technical assistance during monitoring of 2018 CoC Grants • Attend participate in the review and realigning the second 50% trench in order to balance and support the districts adhere to following the G2G approved 2018 plans

Community Activity 1.4 Increased demand for services through increased community engagement engagement • Monthly TA in ASRH, Maternal health, child health immunization and community engagement • Support the districts in completion of stakeholder mapping matrix and prioritize the Strengthening district & community platforms for accountability of RMANCH&N services establishment of DHPT in target districts between the district and community stakeholders • Provide TA to formation of DHPTs in the five target districts such as DHPTs, NHC, HCC, SMAGs, IYCF, CBD, CHWs, Peer Educators, CHP etc. through stakeholder profiling and strengthening / establishment of structures /platforms • Follow up on TA given in the previous month and consolidate QI, DHPT and zonal mentorship teams *Dashboards to be developed in the respective thematic areas to act as baseline of identifying the impact of the trainings for subsequent visits

80 | Page

• To provide TA to DHOs in orienting NHCs in their roles provide TA to DHOs in the content of Capacity building in CE package: Provincial, District and community members and groups’ the training for health care workers in Community Engagement Approaches. capacity to plan and mobilize resources in order to implement and monitor RMNCH-N preventive and promotional activities.

Adolescent Health Activity 1.1: Technical Assistance to CoC Program

Provide technical assistance during monitoring of 2018 CoC Grants • Follow up TA to Mansa selected facilities and Chipili district Follow up TA to Districts on success stories in ASRH, the formation of mentorship teams in selected districts, Community engagement( NHCs, DHPs and HPs formation)

Activity 1.1: Technical Assistance to CoC Program Provide technical assistance during implementation of 2018 CoC grants Provincial TA in Nutrition, child health, newborn health, maternal health and data management Nutrition • To conduct a review orientation in SQA to all program officers in RMNCAH& N programs( Nutritionist, Principal Nursing officer, Health promotions, EPI technician, SHIO) to come up with provincial dashboards in all thematic areas and display the results in all respective program officers notice board and one in the PHD/PHS notice board. * Discuss the importance of strengthening district QI teams and be updated with projects for follow up by the PHS/ provincial QI team. To discuss with PHD/PHS on the EOP recommendations and provincial status. Provide technical assistance during planning of 2019 CoC grants • Following up TA in EmONC, ENC, ARSH and MIYCN and discuss updated dashboards in mentorship, Nutrition, ASRH and Child Health with QI project at Mansa GH Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship

Equip mentorship teams with models • Distribute anatomical models needed to support mentorship teams. • MCSP Mansa office will target non SM360+ districts. The is to equip mentorship teams with models so as to perfect and strengthen zonal mentorship teams with a goal to reach quality service delivery by skilled staff in facilities* To discuss/orient mentorship teams in SQA M&E Activity 1.3: Improve collection, monitoring and use of data use for decision making and quality improvement

• Monthly Technical Assistance to Chifunabuli for being newly formed from Samfya in Data Provide TA to DHIO data verification activities, including quarterly integrated supportive Audit and Verification, Strengthen performance in Maternal, Newborn and Child Health and supervision and data quality assessments DQA in provinces Immunization. * To review and come up with an SQA. *To review QI teams and come up with a project. Follow up TA to in M&E Support one data use and management quality improvement project per province • Following up on quarter 3 recommendations on IMCI, ASRH and nutrition success stories * Formulation of SQAs in mentorship and nutrition for EOP * QI way forward on projects identified by the district and one selected facility Support collection of service delivery data using facility monitoring tools and regular data • Attending and participating in DIMS and PIMS to offer TA and identify the gaps for planning reviews and advise on the way forward recommendations

Support collection and reporting of community activity data by supporting rollout of new • Follow up TA to Chembe district on good practices the district has been implementing in MOH tool at the district level maintaining a zero rate of maternal deaths and conduct a verification and quantification of data

81 | Page

Crosscutting • Participate in monthly TA avenues in existing DIMs, Data Review Audits, Performance review, MDSR and HCC meetings to provide sound CE TA and identify the gaps for planning and Participate and provide TA in integrated RMNCAH&N meetings advice on the way forward recommendations. To prepare a presentation in each and every PHO/DHO RMNCAH&N related meetings, write up activity report and submit to STAs. Monthly report writing and partner meeting with SBH, G2G and SM360+ team leads • This is to maintain timely submission of monthly report. * Discuss MCSP EOP district status and recommendations MCSP staff review meeting on the EOP provincial status, recommendations • To consolidate districts recommendations for submission to MCSP team lead/STAs • This to consolidate and submit a report to PHD and the team on the provincial status and way MCSP team meeting with PHO staff on the EOP feedback forward on sustaining TA/TSS in the absence of MCSP EOP handover and repatriations • Repatriation processes

82 | Page

MUCHINGA PROVINCE QUARTER 4, 2018 REPORT

Team Members 8. Beatrice M. Zulu - Provincial TA/Coordinator 9. Constance Choka - TA RH/Maternal &Newborn 10. David Matafwali - Provincial Technical Officer 11. Vincent Simangolwa- TA ASRH 12. Elvis Chipili - TA Community Engagement 13. Stanley Patela – TA Child Health 14. Methodius Chishimba - PMERO 15. Mike Tembo - Driver/General Duties

83 | Page

1. Reproductive and Maternal Health a. MCSP provided the link for the USAID FP and Abortion Policy guidelines and online course. Two facilities in Nakonde and four members of staff at Nakonde DHO have already taken the course and were grateful for the guidelines provided in the course and knowledge received. b. In the previous quarter, MCSP in the presence of the DHO staff, provided guidance to the health care providers in the labour ward on the use of recommended protocols in the management of obstetric emergencies and the importance of having a well set emergency tray within the delivery room. The team further guided facility in-charges on the need to assign each staff topics for presentation during clinical meetings and come up with schedules for the said meetings. More facilities that received the guidance started holding clinical meetings and testified that it was very helpful for the staff as the meetings provided opportunities for revisions and skills acquisition. c. MCSP held one discussion mentorship to the PHO PNO MCH and DHO MCH Coordinators on the need to ask health care providers on duty at the time a facility records a still birth or Maternal Death to write their statements. This would save as a more detailed written account during review meetings. As a result on 21st September, Mafinga reported two MDs and the PNO asked the MCH Coordinator to make sure the HC provider who took care of the two mothers had to write their statements and these would be used during review both at facility district and provincial review meetings.

2. Newborn Health a. MCSP participated in the PNMDSR meetings in which they helped the districts identify gaps and recommendations to improve newborn outcomes b. MCSP provided onsite mentorship in infection prevention at Mpika urban, residential clinic and Chinsali general hospital in Muchinga. MCSP discussed with the facility In-Charges on the need to follow guidelines on infection prevention in reprocessing and storage of neonatal resuscitation equipment to help prevent cross infection and consequently reduce on neonatal mortality and morbidity due to sepsis. The facilities provided with flow charts on reprocessing of neonatal resuscitation equipment. By September, 7 districts had procured IP buckets for neonatal resuscitation equipment and these were distributed to facilities. 3. Child Health a. Roll out of eIMCI/EPI training to all districts increasing number of HCWs trained from 4 in the second quarter of 2018 to 21 in the third quarter. The eIMCI/EPI MCSP training package was been installed on computers in 8 districts out of 9 districts in Muchinga and 21 staff took the course i.e. Nurses -17, EHTs- 2, Nutritionist-1 and Clinical Officer 1.DHO facility staff welcome and appreciated the innovation i.e. Mafinga and DHOs indicated that the course was good and helpful in reminding staff in facilities to improving Child Health and Immunization indicators and they promise to ensure that at least one HCW at all facilities completed the course.

b. Distributed child health guidelines for case identification and management to DHOs (Danger Signs, Worms, Pneumonia and Diarrhoea signs). MCSP Muchinga received the materials from MoH via MCSP Head Office in Lusaka. The materials were produced by MoH with support from UKaid, SIDA and UNICEF.

4. ASRH a. Provision of ASRH TA during 2019 CoC planning: MCSP provided technical support to all the districts in the 2019 CoC planning by assisting in the bottleneck analysis for adolescent health indicator i.e. ANC coverage for women under 20 years. MCSP also distributed a list of high impact interventions that the district used to choose from for them to include in

84 | Page

their plans for the year 2019. All the districts in the province supported with high impact interventions. Among that they integrated into their plans include training of service providers in ADH, formation of Adolescent Health Technical Working Group, supportive supervisory visits to the health centres offering ADH, Integrated Community outreaches and Job aids procurement among other funds b. MCSP provided TA to establish Chinsali district adolescent technical working group. The setting up of the technical worming group for adolescent meant to improve the facilities responsiveness to adolescent health issues in the district. c. MCSP provided TA and now the province has 20 Youth Friendly spaces in various facilities. d. Provided TA to Chinsali and Mpika district ADH Focal Point staff in the administration of ASRH SQA. One facility in Chinsali district administered a SQA & the findings attached in form of a dashboard in appendices of this report. Mpika is yet to administer SQAs in ADH. Administration of SQAs is expected to be rolled out by all districts and facilities to improve quality service delivery of ADH services

5. Nutrition a. Through the TA provided by MCSP the Nutritionist at Kalwala has created space for a nutrition section and has now started displaying graphically displays in nutrition monthly indicators on stunting, wasting, underweight, deworming, vitamin A supplementation and breastfeeding within the first one hour after birth etc. The facility displayed key nutrition message. The MCSP nutritionist also helped the health facility to acquire protocols on RUTF administration displayed. b. MCSP made follow-up to Chinsali General Hospital to do on-spot checks on the display of key messages on breastfeeding within the first hour and message on breast feeding within one hour was displayed. Through the MCSP TA, the hospital nutritionists has since displayed graphs on the numbers of malnourished children admitted and discharged. TA provided to ensure that the quarterly and monthly variations in the admissions over time and trends explained. c. MCSP provided technical support and guidelines on the formation of District Nutrition Coordinating Committee (DNCC) in Chama. Health Office working with other partners like Reformed Open Community Schools (ROCS) has since spearheaded formation of the DNCC the and this committee will linked to the provincial coordinator SUNFUND district nutrition team of the for further support d. TA provided on the importance of following up malnourished children who are referred to higher levels of care once they are discharged to the community. The trained CHVs in IYCF are actively involved in the identification of children with malnutrition within the communities, refer the cases to the facility which carries out a comprehensive assessment (in the facilities and communities under Chinsali district).

6. Community Engagement a. Supported the Provincial Health Office in establishing the first ever-Provincial Health Promotion Technical Working Group for Muchinga Province. The team further provided TA to the districts to establish District Health Promotion Teams (DHPTs). By the end of the quarter, 7 districts had established the DHPT while 2 were still being helped to come up with the said teams. b. The focus of the TA provided to the districts was four fold: conduct on the spot-check and assess the functionality and establishment of the district community engagement platforms (DHPTs), Assessing and determining the functionality (activeness) of community based community engagement structures (NHCs, HCCs) and the implementation of Integrated Community Registers for Equity based Integrated Approach. Guidance provided to the districts

85 | Page

that had challenges with establishment of the DHPT and some districts had shared the TORs and started holding meetings.

7. MER a. Collaborated with PAMO to train thirty (30) health staff (10 Kanchibiya health centre staff , 7 staff from Lavushimanda , 2 staff from Nakonde, 2staff from Mafinga, 3 from Chama, 2 from Mpika specifically Chilonga General Hospital, 1 from Isoka and one (1) from Shiwangandu. We also had two DHIOs; one from Chama the other one from Kanchibiya.) in HMIS/DHIS2 and data use. Therefore, the MCSP staff provided technical assistance on setting of the pretest and reading out the results of the data audit exercise conducted in May and June. On average participants recorded 58% of data skills, knowledge, use and analysis. Participants were taken through the information cycle, data collecting tools (Registers, HIA tools and tally sheets). Provided clarification on the OPD registers, Under 5 registers, Mother and child follow up (0-23 & 23-59 months) registers, aggregation forms (HIA1, 2, 3 and 4), antenatal register, family planning registers, postnatal registers and Integrated maternal health newborn and Under 5 community register. Oriented the participants on the Integrated Maternal Health newborn and under 5 register. Emphasized on the need to check what Neighborhood Health Committees (NHCs) are doing with the registers since that gives them an insight of the community and offer health services at primary level. Despite the health Centre staff not trained in iCCM, it is important to check them registers so to supervise the work, which the NHCs are offering at community level through that register. Need to be calling the NHCs to review the data with the facility at certain time intervals. b. MSCP successfully provided technical assistance to all the districts during the 2019 Provincial Planning Review and consolidation meeting in HMIS related activities. This TA resulted into guiding all the 9 DHIOs in the following M&E activities to prioritize for their 2019 inclusion/implementation; Purchase of 5 laptops and dongles per district for the facilities. We wanted to prioritize 5 HF for the start to do facility level DHIS2 data entry, Plan to train at least 2 HCWs in the 5 facilities per district in DHIS2 data entry. Therefore, needed to plan for DHIOs to be part of the training as well as one additional staff from DHO to provide technical supervision when the training is done, Plan to conduct technical supervision in DHIS2 to the facilities, Plan to purchase monthly talktime for data entry for health facilities, Plan to train DHO program officers in Data analysis and use through DHIS2, Plan to train/orient/mentor Health centre in charges in data presentation and analysis. This will enhance data presentation and analysis during data review meeting, Plan to train health facilities and program officers in QI/QA and SQA, Plan to conduct any research topic/success story in RMNCAHN, Plan to provide DHIS2/HMIS technical support/mentorship to facilities, Plan to district any latest HMIS registers to the facilities. This will also enable us to be on the look out of stock outs of registers in the facilities and distribute as quickly as possible, Plan to train/orient health centre staff in the new/updated HMIS registers. This was in line with National Health policy, legacy goals and M&E framework for 2019. c. MCSP successfully conducted interviews on key lessons documented from Ministry of Health staff and partners at provincial, district and facility level on the TA MCSP provides. The interviews went as per schedule, we managed to interview two (2) district nursing officers (DNO-MCH) in Mpika and Chinsali, two (2) district health directors (DHDs) in Kanchibiya and Nakonde, one (1) district health information officer (DHIO) in Chama, two MCSP staff, one SBH staff, the provincial health director (PHD) and one provincial CoC coordinator. The province just received the CoC coordinator who is less than 1 month old, hence the coordination of the RMNCAH&N activities were under the provincial public health specialist (PHS). Therefore, we interviewed the PHS in the capacity of the Provincial CoC coordinator. In total, we reached out to fifteen (15) staff.

86 | Page

8. Crosscutting a. Conducted TA visit in conjunction with the Provincial Health Office to assess and determine the level of implementation of the 2018 CoC activities in all the nine districts of Muchinga Province. The district levels of completeness with regard to implementation of 2018 CoC planned activities established to be at 50% in one district while the other eight districts were above 50%. During this process, districts narrated a number of success recorded with the coming of G2G and TA from MCSP. Districts were encouraged to work with MCSP to document all their success stories b. MCSP conducted TA visits to the last four districts in the province (Chama, Isoka, Nakonde and Mafinga) and supported the DHO in the prioritization and identification of appropriate, evidence based, high impact interventions to be used during planning for the 2019 MTEF and CoC Plans. The TA support was provided to all the 9 districts in the province before the planning launch and this was a better preparation for the districts as the planning process was made easier. c. MCSP strengthened the capacity of the mentorship teams in the use Service Quality Assessment tools (SQA) to identify gaps that need attention and development of mentorship dash boards to inform mentorship rounds. This resulted in 7 districts out of 9 forming District mentorship teams d. MCSP participated well in the Provincial Planning Launch, review of action plans (at district and provincial level) as well as during the Provincial Integrated Meeting (PIM)).

87 | Page

Objective 1: Provision of Demand Driven TA (what, when, where, why, how- so what)

Next Technical Activity from the work Progress of the Activity Steps/Recommendation/TA Area plan opportunities Activity 1.1: Technical Assistance to CoC Program

Provided guidance on the institutionalizing and use of the WHO 2016 ANC Guidelines DHO and MCH Coordinators to

continue monitoring the use of • TA and discussions continued on the need for facilities to keep mothers for 48 hours post-delivery as this was the most critical standard WHO guidelines by facility period for both mother and the baby. This practice will promote staff the health of both the mothers and newborns and thus improve Provide technical the indicator for PN attendance within 48 hours. assistance during • Management of labour using a partograph; During the TA visits implementation of 2018 MCSP observed that the partograph was not effectively used to MCSP to follow up on the CoC grants monitor fetal wellbeing during labour. Discussed with the MCH implementation and documentation coordinators to conduct onsite mentorship to facility staff on the of the post-natal care within 48hrs use of partograph. All districts except for Mafinga had stared according to postnatal care guidelines with facilities informed by Maternal conducting mentorship on the use of the partograph. Skills in the effective use of the partograph will help reduce on the number of the 48 hours’ post-natal indicators stillbirths. The teams were advised to ensure adequate supply of WHO partograph in all facilities

MCSP highlighted the lack of basic skills in the management of obstetric emergencies among skilled birth attendants (e.g. management of DHOs to continue strengthening eclampsia), lack of stocked emergency trays in the delivery rooms, gaps in onsite mentorship in the the utilization and interpretation of the partograph during management of management of obstetric Provide technical women in labour. emergencies. assistance during monitoring of 2018 In the presence of MCH Coordinators, CoC Grants • MCH provided guidance to the health care providers in the labour ward on the use of recommended protocols in the management of DHOs to provide facilities with all obstetric emergencies and the importance having a well set necessary medicines and equipment emergency tray within the delivery room. The team further guided used in emergencies and set up

88 | Page

facility in-charges on the need to assign each staff topics for emergency trays presentation during clinical meetings and come up with schedules for the said meetings. More facilities that were talked to have since started holding clinical meetings and testified that it was very helpful for the staff as the meetings provided opportunities for DHOs to develop mentorship score revisions and skills acquisition cards and provide onsite training • Continued provision of TA to MCH Coordinators to guide the using the low dose-high frequency nurses and midwives (especially those trained in EmONC) during approach in the facilities onsite mentorship on utilization and interpretation of the partograph in monitoring progress of labour and maternal wellbeing and early detection of signs of complications. MCH Coordinators to follow up • MCSP in conjunction with the PNO at PHO and the Nursing with facilities to make sure there is Officer at Chinsali General Hospital made three tours of the new separation of delivery and MVA labour ward at CGH to identify and made follow-ups on the IPP. beds The first recommendations given to the NO and follow up visits showed a marked improvement in that IP buckets were brought into the delivery room.

MCSP provided technical assistance during the pre-planning meetings for Mpika, Kanchibiya, Lavushimanda, Chama and Chinsali districts to DHOs to prioritize strengthening Provide technical strengthen the reproductive and maternal component in the 2019 plans outreach sites thus provision of assistance during which was missed out during the 2018 CoC plans by ensuring that the outreach services to also offer ANC planning of 2019 CoC reproductive and maternal high impact interventions are included in the services. This will further improve grants 2019 CoC plans. With the inclusion of the high impact interventions in the first ANC coverage. the 2019 plans, the plans will be more focused and targeting what will further improve the outcome of the RMNCAHN services Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship TA Offered to Chinsali, Mpika, Kanchibiya, Shiwangandu, Isoka and MCSP to follow up the formation of Establish mentorship on how to form mentorship teams which should include integrated mentorship teams in the teams Maternal and Reproductive Health said districts TA offered to Districts to include in the 2019 CoC plans the for Equip mentorship MCSP to attend the district planning procurement of mentorship models such as Baby/Mama natalie/birthie teams with models meetings for use during simulations during mentorship MCSP facilitated the distribution of WHO recommended pregnancy MCSP and MoH to continue Other activities wheels and FP protocols to all the districts in the province. With the providing districts with approved coordination available tools, staff in facilities will be providing FP and ANC services in standard guidelines for use in the a more focused manner and thereby improve the health of mothers and facilities.

89 | Page

contribute to the improvement of RMNCAHN indicators DHO to continue monitoring the facilities for their adherence to provided guidelines in service provision Activity 1.1: Technical Assistance to CoC Program

Monthly TA visits: MCSP conducted monthly TA visits to the 3 health facilities in the province. Technical assistance was provided on the following topics:

Infection Prevention; • MCSP provided onsite mentorship in infection prevention at Mpika urban, residential clinic and Chinsali general hospital in Muchinga. • DHOs to facilitate MCSP discussed with the facility managers on the need to follow procurement of IP buckets for guidelines on infection prevention in reprocessing and storage of neonatal equipment neonatal resuscitation equipment to help prevent cross infection and consequently reduce on neonatal mortality and morbidity due to

1.1.1. Provide sepsis. The facilities provided with flow charts on reprocessing of technical neonatal resuscitation equipment. assistance Newborn 48hrs postnatal care; during • MCSP emphasized to the districts, the need for RHC to implementation implementing the 48hrs PNC policy despite limited space. Some of 2018 CoC facilities reported to be practicing but lacked documentation. grants Designated spaces for resuscitation; • MCSP in discussed the need of having designated resuscitation spaces at TAZARA clinic for efficient and effective resuscitation of the • MCSP will continue promoting asphyxiated newborn. such good practices by Kangaroo Mother Care (KMC); disseminating them to the authorities and other HFs that • MCSP discussed the importance of establishing or identifying a room have not started implementing for KMC at Chinsali General Hospital. The hospital will also need to the 48hrs postnatal policy. orient and mentor staff on KMC as a way to roll out the KMC to all the facilities in the district so that the staff acquire knowledge for • Facility in charge at TAZARA effective counselling of the mothers with preterm babies, although to follow up with the carpenter most facilities have inadequate infrastructure for KMC. who has been given the order to make a resuscitation table

90 | Page

Newborn Health Protocols; • MCSP discussed with facility in charges at Mpika urban clinic in Muchinga on the need for newborn health protocols such as HBB • MCSP to follow up the displayed on the walls for quick reference during service provision implementation of the with the facility managers. This will consequently help health facilities recommendations on the adhere to standards during service provision and improve on provision of identification of a newborn outcomes. Soft copies of HBB provided and districts room to be used for KMC at requested to either print/ hand write the protocols and have them CGH. displayed in appropriate places in the labour wards.

Follow up TA visit to the districts : • Infection Prevention: MCSP had provided TA on the importance of adhering to IPC standards in the labour wards to reduce on morbidity and mortality for the newborn due to sepsis. Chama, Isoka, and Mafinga including Chinsali general hospital had acquired IP buckets • MCSP to follow up use of the with lids for reprocessing and storage of neonatal equipment. perinatal death audit form to Kanchibiya was still waiting for the vendor to deliver the buckets this review perinatal deaths month (Septemebr 2018). Lavushimanda will do the procurement occurring at the facilities using RBF funds this month (September) This positive development • MCSP and the district health will go a long way in reducing neonatal morbidity and mortality due office to follow up on the to sepsis and hence contribute to the improvement of the newborn indicators. In Eastern Province MCSP has continued to advise the effective use of the infant districts on the importance of separating the infant resuscitation resuscitation protocols being equipment from the delivery and MVA equipments during the informed by the facility perinatal decontamination process. data and provide technical • Newborn Resuscitation equipment: During TA visits in Muchinga assistance accordingly. MCSP observed that most facilities did not have recommended basic neonatal resuscitation equipment and discussed with the districts on the importance of such equipment. All districts except for Kachibiya had procured recommended basic neonatal equipment for the facilities that did not have. This will improve resuscitation outcomes for the asphyxiated babies and reduce on the number of babies dying due to asphyxia. Kanchibiya had not budgeted for the same in the 2018 CoC budgets and hence advised to treat this as urgent and

procure the equipment using other budget lines such as RBF. TA

provide on the storage of the equipment to avoid dust and cross infection.

91 | Page

• Perinatal death reviews: During the TA visits MCSP observed that facilities were not conducting perinatal death reviews at the facility. MCSP in discussed with districts the need to conduct the perinatal death reviews to draw lessons and avoid similar occurrences in future. The districts were given a soft copy of perinatal death audit form to

guide the reviews. MCSP discussed with the in charges and the staff MCSP to follow up on the on duty at Mpika urban and TAZARA clinic on the need to conduct implementation and documentation perinatal death reviews, as they occur to learn from the experience of the post-natal care within 48hrs and avoid similar occurrences in future. Mpika urban clinic were according to postnatal care already using the forms despite not conducting the reviews. guidelines with facilities informed by All districts in Muchinga had started conducting perinatal death the 48 hours’ post-natal indicators reviews at facility level as they occur although some facilities were still not doing so especially in Nakonde where only three facilities were conducting the reviews. In only the hospital and Kasoka urban centres were conducting the reviews. Discussed with district teams on the need to conduct such reviews at facility level. The teams advised to follow up on any facility that reported a perinatal death and ensure that the death reviewed and notes shared with DHO for possible support. Use of the perinatal audit form emphasized especially to Lavushimanda and Mafinga who were not using the new revised form

to guide the reviews. The soft copy of the audit form given to the MCH coordinators to print and distribute to the facilities.

• Protocols: During the TA visits, MCSP discussed the need to have • Facility In-Charge to newborn health protocols displayed on the walls for quick reference periodically review the during service provision in order to save lives of the newborn. partographs to check on the Facilities in Kachibiya had newborn health protocols despite not competence of the midwives in displayed on wall. The DHO team advised to ensure the charts terms of management of labour displayed for quick reference in an emergency. Lavushimanda and and monitoring of fetal Shiwang’andu distributed protocols to some facilities but not enough wellbeing. to cover all the facilities and hence were encouraging the facilities to • MCSP to provide technical display hand written ones. Mafinga will be distributing protocols in assistance during mentorship the last week f September, while Nakonde had challenges with neonatal resuscitation protocols. MCSP shared the soft copy for the round on essential new born districts to print and distribute to the facilities. care and HBB.

92 | Page

• Clinical meetings; During the TA visits MCSP encouraged facilities to start conducting clinical meetings to improve knowledge and skills • MCSP to provide technical in management of the newborn. Isoka, Kachibiya, lavushimanda, and assistance during the planning Mafinga had started conducting clinical meetings although not all process for 2019 on the High facilities were sharing minutes. The DHO teams were encouraged to Impact Interventions for ensure all facilities share the schedules for clinical meetings and make implementing Kangaroo follow-ups for the minutes to provide the necessary support. This Mother Care. help improve the knowledge and skills of HCWs in different thematic • District mentorship teams to areas including newborn health. continue providing mentorship informed by data on fresh still • Special Care Baby Unit; had established an SCBU, which births and early neonatal deaths has led to an improvement in management of the sick newborn. Isoka and MCSP to provide technical district has also seen a reduction in perinatal deaths, which the district assistance during district visits has partly attributed to the training of staff in ENC. • MCSP to follow up on the perinatal reviews at facility level • MCSP to support the Districts to conduct Monthly mentorship to staff on the proper use of partographs to monitor progress of labour and to interpret the partographs for quick action in cases of obstructed labour. • MCSP to support the districts in strengthening the reviews of stillbirth and birth asphyxias at facility level within 24hrs of occurrence.

• DHOs to carry out orientation/Mentorship of staff on newborn resuscitation using

93 | Page

the small dose high frequency approach.

• Printing protocols/guidelines/job aids for health care works and community volunteers. • MCSP to provide the guidelines and work with the clinical team in ensuring that the Multidisciplinary mentorship teams are in place so as to improve the quality of work among all staff across the RMNCAH/N CoC. • Make follow up visits to districts to ensure adherence to good infection prevention practices and District health offices to support facilities in acquisition of storage containers for processed equipment • MCSP to follow up with Facility In-Charges to temporally print the soft copies of helping babies breath charts shared or hand write as they wait for the district health office to provide. MCSP and DHO to follow up the facilities for the utilization of the same.

94 | Page

Perinatal and Maternal Death Surveillance and Response meetings

MCSP provided TA during the quarterly PNMDSR meeting in Chinsali. to help contribute to the improvement of the maternal and neonatal indicators. MCSP to participate and provide technical support in the meetings for 1.1.2. Provide the other districts. technical In Muchinga contributing factors that led to the maternal and perinatal

assistance deaths were isolated with MoH staff and TA provided in the following MCSP to support the districts to during areas monitoring of • Early referral of clients especially at facilities with limited staff consider scaling up of KMC to the 2018 CoC competences and medical facilities health facilities to address the Grants • need to provide mentorship in clinical decision making to facility neonatal deaths due to prematurity, staff KMC being the high impact • Need for full history taking, full examination and detailed intervention. documentation of the findings on a client. • Need to start a documentation quality improvement project at Chinsali and Isoka hospitals to improve documentation.

MCSP provided technical assistance during the pre-planning meetings for MCSP to ensure that the districts Nakonde in Muchinga, province to strengthen the newborn component have considered some activities Provide technical in the 2019 plans which was missed out during the 2018 CoC plans by which they could not implement in assistance during ensuring that the newborn high impact interventions are included in the 2018 for various reasons to be planning of 2019 CoC 2019 CoC plans budgeted for in 2019 for as long as grants • they were to bring impact on the Discussions on the key indicators in all the thematic areas of RMNCAH&N which included Newborn key indicators gaps.

Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship MCSP discussed the need for district to plan for mentorship follow up Establish mentorship To follow up the formation of visits as according to the Essential New Born Care mentorship teams integrated mentorship teams dashboards. MCSP to continue supporting Equip mentorship MCSP provided TA on the inclusion of models to be procured (under districts as they revise their 2019 teams with models G2G) in the 2019 CoC district plans. CoC plans Provide technical MCSP teams oriented the hospital and facility staff on the service quality MCSP to follow up the rest of the assistance to districts to assessment tolls and how to create SQA and mentorship dash boards in districts yet to complete the creation link mentorship with Mpika, Kanchibiya, Nakonde and Mafinga districts for easy identification of mentorship dashboards in

95 | Page

existing quality of quality service provision province assurance activities MCSP district health office to MCSP facilitated the coordination of essential newborn care trainings follow up on the trained providers Other activities (MoH and PHO). Skills gained will contribute to improved newborn to ensure skills gained are being coordination outcomes. utilized to improve newborn

indicators Activity 1.1: Technical Assistance to CoC Program

Provide technical assistance during TA provided to DHO staff in Mpika, Kanchibiya and Lavushimanda District and Provincial during the District Planning launch meeting. Discussed the use of findings • PHO and MCSP to supervise 2019 CoC planning from DIM, PA and TSS to inform decisions. Shared the list of high the identified High Impact meetings impact interventions in child health and immunizations such as RED Interventions for Child Health

strategy, IMCI training, Outreach services, mentorship and procurement are incorporated in the 2019

of IMCI job aids.. plans

It was expected that TA provided would result into improvements in •

quality of 2019 Action Plans and budgets

• All DHOs to continue the roll out of eIMCI/EPI training to Oriented DHO staff at Mafinga, Isoka and Nakonde on the electronic Child health ensure at least one HCW IMCI/EPI training. Installed the application on 2 computer in Mafinga, 2 (Nurses, midwives, EHTs, Provided Technical computers in Isoka and 1 computer in Nakonde. The officers who took Nutritionists and COs) at Assistance to Nakonde, the course by end of quarter 3 included Nurses 17, EHTs- 2, Nutritionist-1 facility level is trained by end Isoka and Mafinga and Clinical Officer-1 of the year. Districts • DHDs to ensure program It was expected that TA provided would result into improvements in officers, supervisor and number of staff in the districts starting and completing the course mentors at the district take up the course

Working with the PNO- MCH and G2G Provincial coordinator, MCSP • All district to continue spearheaded the development of districts and provincial capacity building Provided TA to the updating the Capacity building database. Data base consist of names, designation, District, facility, year districts and PHO database for health workers trained and funder/sponsor. So far the Cumulative figures from the same and use the information for database are; decision making

96 | Page

IMCI- 84 • District to include eIMCI/EPI RED strategy-110 in the capacity building ICCM-331 database MCSP used the senior nurses WhatsApp group to share challenges and way forward with the database information. Activity 1.1: Technical Assistance to CoC Program

Conducted TA visit to assess and determine the level of activity implementation of the 2018 CoC activities in all the nine districts of • DHOs to plan for DHPT Muchinga Province. The TA visit jointly undertaken with the Provincial planning and review meetings Health Office (PHO) from 9th to 15th September 2018. The focus of the

trip for Community Engagement was four fold:

• Conduct on the spot check and assess the functionality and establishment of the district community engagement platforms • Support DHOs and facilities in (DHPTs) completing NHC data base • Assessing and determining the functionality (activeness) of and training matrix community based community engagement structures (NHCs, HCCs) • Facilities to actively support • Stakeholder mapping and involvement 1.1.1 Provide technical and Supervise NHCs Community assistance during • Implementation of Integrated Community Registers and use of engagement integrated equity based approach in reaching communities implementation of 2018

CoC grants • Provide TA to support DHOs Findings: and facilities in implementation

of community registers DHPT establishment and Functionality • Mentors facility staff in use of • Seven out of nine districts completed the formation of DHPTs. The community registers for two districts that did not complete the process were Chama and Mafinga. The two districts however, completed their partner mapping evidence based decision and will soon be holding start up meetings before the end of making September 2018. • Facilities to support utilization • Two districts (Isoka and Chinsali) conducted two days training for of Integrated registers by DHPT members in roles and responsibilities with financial support CBVs from Breakthrough Action.

TA Provided:

97 | Page

• Chama and Mafinga supported with guidelines for the formation of • Support PHO in strengthening District Health Promotion Teams Provincial Health Promotion • DHOs urged to schedule regular DHPT meetings (Planning and Technical Working Groups review) and keep the teams active • Support DHOs in strengthening Provincial Revitalization and Profiling of NHCs Health Promotion Technical • NHC structures are functional in all districts Working Groups • All districts have completed NHC profiling • Support DHOs in • Currently NHCs comprise of Community Based Volunteer groups strengthening community • Over 80% of NHCs are active and submitting reports. Most active based collaborative meetings groups are SMAGs, CBDs, ICCM with key stakeholders including FBO, Traditional and Implementation of Integrated Community Registers civic leaders

• In all districts, registers have been distributed to NHC zones, but DHOs and facilities have not started monitoring their utilization • DHIOs were oriented in the registers • Registers at zone level are being used by CBVs trained in ICCM • Facilities have not started using the registers for implementation of equity based integrated outreaches.

Establishment of the Provincial Health Promotion Technical Working Group

• MCSP worked and supported the Provincial Health Office in forming the first ever-Provincial Health Promotion Technical Working Group. The team was formed on 17th July 2018 with composition of 14 members (10 males, 4 females). Through collaboration with Breakthrough Action, the PHO received financial support and conducted a two day training to orient the team in their roles and responsibilities

Achievements: • MCSP consistent and sustained TA both at provincial and district levels resulted into establishment of the Provincial and District

98 | Page

Community Support Structures (platforms) and at facility level, the revitalization of community support structures (NHCs). • The Provincial Health Promotion Technical Working Group (PHPTWG) was formed in July, whilst the DHPTs have been established in seven of the nine (78%) target districts. This realization is a greater achievement towards the fulfilment of the MCSP mandate of supporting provinces, districts and facilities in the development of functional community engagement systems. Going forward, the established district health promotion teams under the supervision and coordination of respective DHO should take an active role in coordination of NHCs to increase demand for RMNCAH&N services. • MCSP TA support to the districts facilitated the introduction and implementation of Integrated Community Registers at Community level in all districts. The registers, which have been widely distributed in all facilities, when fully utilized, will become an evidence based key source document to facilities, and communities in the implementation of equity based integrated outreaches, monitoring and follow of antenatal and Post-natal mothers, follow up of defaulting / non- immunized under five children and will provide record of pregnancy outcomes.

Activity 1.1: Technical Assistance to CoC Program • MCSP influenced Districts to display the Guidelines/posters for ten steps to successful breastfeeding, management of malnutrition and these have been distributed to and displayed in some of the HFs Provided TA on the use • Through the TA provided by MCSP the Nutritionist at Kalwala has of guidelines for created space for a nutrition section graphically displays monthly Nutrition identifications, performance of the facility on nutrition indicators like stunting, classification and wasting, underweight, deworming, vitamin A supplementation and management of breastfeeding within the first one hour after birth etc. malnutrition • The facility has displayed key nutrition message, the facility had wrong protocols on RUTF administration, through the help and support from MCSP appropriate charts accessed and displayed by the health facility.

99 | Page

• With the constant guidance from MCSP, Chinsali General Hospital now able to identify malnourished children from among the children Provided TA on the admitted for other ailments. The facility has since strengthened importance of activity case finding of children with malnutrition during routine reclassifying all children growth monitoring at the facility and during outreach. They have admitted in the children further started providing RUTF to the children with moderate acute MCSP to continue offering TA to medical ward for malnutrition. other DHOs to give further Malnutrition and those • Trained CHVs in IYCF are actively involved in the identification of guidance to facilities found to be children with malnutrition within the communities and are referring malnourished to the cases to the facility which carries out a comprehensive undergo rehabilitation assessment.

MCSP and DHO to make a Provide technical schedule for monitoring the MCSP worked with the provincial Nutritionist and managed to have 12 assistance during impact of the knowledge gained Community health volunteers trained from Lubwa RHC trained in monitoring of 2018 IYCF/MIYCN under the G2G program. from the trainings among the CoC Grants CHV.

• MCSP conducted three (4) meetings with District staff in Lavushimanda, Kanchibiya, Mpika and Shiwangandu districts to orient staff on the 2019 CoC planning and share high impact Provide technical interventions. assistance during MCSP to participate and continue planning of 2019 CoC • Provided TA to the Provincial Nutritionist on the importance of offering technical assistance to grants including in the 2019 plans, procurement and provision of formula districts feeds to the districts to ensure effectiveness in the management of SAM clients.

Activity 1.1: Technical Assistance to CoC Program The following were the activities undertaken during the period under 1.1 Technical review in providing TA to the districts: ASRH Assistance to CoC • The • The Districts to Use Program Dissemination of the ASRH High Impact Intervention: the High impact high impact interventions were to help the districts during 2019 planning, an initiative districts appreciated. The high impact interventions in their

100 | Page

interventions were the addition to the earlier ASRH activity menu programming developed and compressed all the necessary interventions for addressing ADH. It is hoped that the 2019 plans will produce • MCSP to continue positive results because of this dissemination of high impact offering TA in the interventions. implementation of High impact • Participation in the 2019 CoC Planning MCSP participated in interventions the MCSP provided technical support to all the districts in the 2019 CoC planning by assisting in the bottleneck analysis for • MCSP to support the adolescent health indicator i.e. ANC coverage for women under districts in the review of the 20 years. MCSP also distributed a list of high impact plans in order to ensure that interventions that the district used to choose from for them to the high impact include in their plans for the year 2019. Among interventions intervention are not missed that they integrated into their plans include training of service out providers in ADH, formation of Adolescent Health Technical Working Group, supportive supervisory visits to the health centers offering ADH, Integrated Community outreaches and Job aids procurement among others.

• Provided TA in the Formation of ADH Technical Working Groups: MCSP provided TA Chinsali to form ADH TWGs. Other districts with the ADH TWGs include Mpika, Nakonde. It is expected that the districts will see an improvement in ADH across the facilities. • TA in the training of Peer Educators in Chinsali District: MCSP provided TA in to the district through provision of the materials for the training. MCSP sourced for training materials and other relevant materials needed for the trainings as requested by the district health offices respectively. Going forward, the districts are expected to have improved ADH work through the peer educators to be deployed in various facilities in the districts. • Provided TA to Chinsali and Mpika district ADH Focal Point staff in the administration of ASRH SQA. One facility in Chinsali district administered a SQA & the findings attached in form of a dashboard in appendices of this report. Mpika is yet to administer SQAs in ADH. Administration of SQAs is expected to be rolled out by all districts and facilities to improve quality service delivery

101 | Page

of ADH services

• TA provided to Chinsali DHO on the steps to take on . convening a district ADH TWG: The district had partners • DHO to monitor and working in adolescent health but without an established technical provide support to all working group to coordinate adolescent health activities. MCSP trained peer educators in provided TA to the district ADH FP and MCH coordinator on the execution of their roles the TWG TORs, importance of convening a TWG with a multisector representation based on the national standards and at facility level. This is an guidelines for adolescent friendly health services. Advice given to ongoing process the district to set a date for the first meeting and invite all partners identified in stakeholder partner matrix. It was expected that the district would hold their first meeting to establish a • MCSP to provide TA to district ADH TWG before the end of August, 2018. the district ADH FP to roll out the SQA administration • Orientation of ADH TWG members on the Adolescent to other facilities in the Strategy and roles of TWG : MCSP Provided TA to Chinsali district following an DHO in orienting Adolescent Technical Working Group orientation on how to Members on the Adolescent Health Strategy and guidelines. The administer the ASRH SQA members of the Technical working group were also oriented on This will be done between their roles and responsibilities. It is expected that going forward Q3 and Q4 across all the all members of the technical working group will have a clear facilities. understanding of adolescent health programming and contribute to the implementation of activities to improve the adolescent health status in the district. • MCSP to provide TA for • Provided TA to Chinsali and Mpika on use of peer DHO to continue educators reporting tools: MCSP provided TA to the districts populating the partner to encourage the use of the reporting tools by peer educators in matrix to aid in identifying the facilities. This came in the wake of peer educators not more partners in ADH. utilizing the reporting tools and submitting the DHO. Data This is an ongoing process collected through the reporting tools is useful for planning and improving adolescent health programming. It is expected that • MCSP to continue going forward utilization and subsequent submission of reports providing TA to strengthen to the district will improve in the districts the functionality of the technical working group

102 | Page

• MCSP to follow up on the use of reporting templates by peer educators. This is an ongoing process until all districts and facilities begin to use the reporting templates • MCSP to provide TA to the districts to begin using the data collated in the reporting templates to make decisions. This is an ongoing process During the period under review, MCSP made efforts in ensuring that the data referred to. The scorecard provided a mirror for the districts and the facilities on how they were fairing in addressing the indicators. For adolescent health only Antenatal Coverage for women below 20 years • MCSP to continue 1.3 Improve collection, captured the rest not segregated by age. The ANC coverage for the supporting the districts in monitoring and data women aged 20 years and below revealed that there were many teenage ensuring that data is always use for decision making pregnancies and so during the bottleneck analysis and the planning for referred to and quality 2019, the districts did introspection and interrogation of the said indicator • MCSP to encourage data improvement and how the situation could be improved. It was recommended that review meetings in the strengthening ADH programmes in the districts would help reduce district teenage pregnancies.

• Conducted TA visits to the last four districts in Muchinga Province • Support DHOs to conduct (Chama, Isoka, Nakonde and Mafinga and supported them in the data and performance prioritization of appropriate and identification of evidence- based review meetings using 1.1.3 Provide technical interventions during planning for the 2019 MTEF and CoC Plans. proven data review tools assistance during The staff who received technical assistance improved their skills in Crosscutting planning of 2019 CoC the development of evidence based activity plans with targeted and • Support in prioritization grants appropriate interventions. and rescheduling of CoC activities • Throughout the process of interaction, the MCSP team took the leadership role in mentoring and couching DHO and facility teams in

103 | Page

the identification of performance gaps through use of HMIS data collection tools / reports, scorecard indicators, mentorship and Service Quality Assessment reports and dashboards. The DHO and facility teams provided with the MoH proposed high impact interventions across the RMNCAHN thematic areas as reference document to aid the planning process.

Achievements: • As part of the ongoing process of equipping health care workers with adequate knowledge in development of annual health care plans that are linked to performance, Health care workers in the all the nine DHOs improved their capacity in assessing evidences and identification of high impact interventions. It is therefore expected that 2019 MTEF and CoC Districts plans will not only improve in quality but will contain evidence based, targeted and appropriate interventions

• Challenges and recommendations (not more than 3 per thematic areas)

Thematic Challenge Recommendations to Address the Challenge Maternal Not all staff working in labour wards are midwives and this Ensure MCH Coordinators to mentor facility staff and resulted in lack of skills and confidence in performing encourage them to be holding clinical meetings so as procedures like those required to manage obstetric emergencies. to strengthen knowledge and skills in management of obstetric emergencies Non adherence to standard IPP due to low supply of Chlorine Districts and facilities to plan to procure more to the delivery rooms because of non -availability of the quantities of chlorine in the 2019 grants commodity to last a month. Inadequate transport logistics resulting in most District MNDSR Plan with the PHO to come up with a schedule in time meetings not being supported technically to enable MCSP coordinates logistics in good time Newborn Neonatal deaths issues seemed not to have been prioritized by the MCH coordinators to ensure that the District facilities districts and facility staff as they were not conducting the neonatal are conducting Neonatal Deaths reviews as they occur death reviews as soon as they occur at facility level to establish at facility level causes such as birth asphyxia, prematurity etc. and develop MCSP to support the district facilities necessary interventions for prevention such as KMC during the process

104 | Page

Most of the newborn health activities seemed not to have been The district mentorship teams to continue providing standing alone but included to the maternal Health activities, onsite mentorship which paused a danger of having newborn health neglected at DHO and MCH Coordinators advised to come up the implementation period. with newborn health activities that will address the increasing numbers of stillbirths, neonatal deaths and birth asphyxias so that they can be implemented during the implementation period.

Some districts and HFs are not using the Perinatal and • At least each HF should have not less than Neonatal Deaths Audit Form, MDSR audit form, MD five copies of each of these tools (depending Notification form, MDSR Community Autopsy. There are on how busy that HF is, you may need to no printed copies ready for use, the staff on duty at the time of provide them with more the death or stillbirth felt lazy to complete the document, or they have never been oriented to the tools. • The availability of a completed tool (up to the point as prescribed) during hand over or change of shifts, if a death or stillbirth occurred, MUST be one of the things that should be checked.

Child health Poor Case Management of Childhood illnesses. This is due to 1. Mentorship in Case Management inadequate numbers of staff trained in IMCI, lack of job aids, lack of 2. Capacity building HCWs skills i.e. training mentorship and supportive supervision from DHOs and no Quality IMCI and ETAT Improvement activities 3. Service Quality Assessment (SQA) to identify areas of improvement

Poor Quality of Immunization Services. This is due to poorly 1. Mentorship in RED/C integrated outreach activities, inadequate number of staff 2. Capacity building in RED/C strategy trained in RED strategy, lack of mentorship activities in 3. Service Quality Assessment (SQA) to identify Immunizations as evidenced by low fully immunized coverage areas of improvement and high drop out rates in the province 4. Community Engagement Community Weak Coordination and supervision of community engagement • DHOs and facilities to prioritize activities to engagement platforms at DHO and facility levels strengthen DHPTs and NHCs

DHO and Facility staff not Prioritising Community Engagement • DHOs and facilities to prioritize community

105 | Page

activities engagement activities • Integrate community engagement activities in other ongoing funded activities Weak program integration at both DHOs and Facilities. • DHOs and facilities to be holding monthly and RMNCAHN activity implementation considered to be an MCH quarterly performance review meetings with all activity for MCH Coordinators team members • Activity implementation to involve wider participation of DHO and facility team members Nutrition Lack of knowledge in the DHOs to develop the nutrition MCSP to give TA to DHOs with the development of mentorship dashboards dashboards

Majority of the districts are making their own feeds using milk, The provincial nutritionist to facilitate the inclusion of cooking oil and sugar because the districts have been finding procuring therapeutic feeds in the 2019 CoC plans for challenges to procure F-75 and F-100 formula feeds. the district. Lack of IEC materials on nutrition in some facilities DHOs advised to include printing of IEC materials in the 2019 CoC plans

Adolescent Sexual Inadequate transport to facilitate field visit to all the districts To strengthen integration of ASRH technical Reproductive Health assistance in other technical areas

To reinforce integration of ASRH in the field visit possibly TA trackers should be used to track ASRH activities Delayed response to approve the revised 2018 CoC Plans by SIDA, this delayed the implementation of activities in the • The District health office to enhance districts communication with the SIDA focal point person for feedback Limited understanding of ADH programming by DHO staff. • District ADH Focal point staff to make use of the district meetings to share information with DHO staff as a way to bring them to speed on ADH programming

Crosscutting Some districts are yet to form District Multidisciplinary Support Districts in forming and developing schedules Mentorship Teams for their District Multidisciplinary Mentorship teams

106 | Page

107 | Page

IV. Lessons Learned – Cross cutting (what worked well and what did not work well) things you did to get to the end of the road

Newborn Lesson Learnt • District do not use indicator performance scorecard to analyze the performance of RMNCAH/N indicators. • Eastern Province has an Eastern Province Zambia Maternal Neonatal and Child Health Alliance CSO stakeholder Coalition Building and Advocacy Steering Committee that has a goal of improving maternal, neonatal and child health in the province through advocacy.

Adolescent Health – Lessons learnt

During the period under review, the following were some of the Lessons Learned: i. The extracted high impact intervention given to the districts helped the DHOs align their programming to the National Health Strategic Plan and the ADH Strategy ii. The allocations to the districts for 2019 plans was insufficient to cutter for all the proposed interventions, however some high impact activities were prioritized and integrated iii. The use of the scorecard was helpful for the districts to prioritize key interventions to be include in the 2019 CoC plans iv. There was need for more orientations and trainings of health care workers in ADH as most of them were not exposed to working with adolescent health

Community Engagement - Lessons learnt What went well? Good collaboration with other partners organization supporting PHO (PAMO, JSI, Breakthrough Action) has resulted into partner meeting every two weeks chaired by MCSP Good collaboration with Break Through Action resulting into formation of Provincial Health Promotion Technical Working Group Good collaboration with GRZ counterparts (PHO, DHO and facilities). PHO has been providing transport to facilitate MCSP movements

What didn’t go well? Inadequate transport and budgets hampering MCSP follow up visits to districts DHO staff not being proactive in implementing Technical Assistance visit recommendations. Most recommendations are either partially undertaken or not done at all. DHO teams are willing to undertake activities associated with immediate monetary gain creating an imbalance in activity implementation Facilities and DHOs not having data review meetings DHOs not engaging themselves in explaining to facilities the MCSP and G2G support. Most facilities were unaware of the G2G and MCSP mandate. Poor program coordination between MCSP and SBH. Weak program integration at district level. Weak program ownership which might challenge continuity once MCSP comes to an end.

Lessons Learnt: Joint programme undertaking between MCSP, SBH and PHO should be planned and encouraged. When teams move together, they complement each other and provide immediate assistance. The recent MCSP and PHO trip from 9th to 15th September is one good example.

108 | Page

DHO teams do not hold regular monthly and quarterly meeting and do not share information. This has resulted into TA visits appearing to be ineffective. Programme officers keep information to themselves and in most instances if they did not implement the recommendations end up refusing having been oriented / mentored. Continued presentations of TA at various fora is leading to acceptance of MCSP TA in the province and particularly at DHO level. The community engagement agenda is still not a priority when developing activity plans. TA in this area should be strengthened Weak programme integration at DHO. Need for DHO programme officers to do joint programme planning MCSP team should spend much time at facility level because DHOs do not usually reach out, rarely share program information, and DHOs have highly centralized RMNCAHN activity implementation. Most facilities do not have clear understanding of RMNCAHN programme.

109 | Page

V. Major Activities Planned for Next Quarter Recommendations for TA / TA Planned (- What Small TA Thematic area Activity- refer to the approved WP activities are u going to do) Maternal 1.1.1 TA visits to Districts assist the MCH Coordinators plan for follow up Provide technical assistance during visits to staff who have been trained in short courses like EmONC in implementation of 2018 CoC grants specific facilities 1.1.2 Participate in the District Integrated Meetings and provide TA during Provide technical assistance during monitoring the review of data from facilities of 2018 CoC Grants 1.1.3 Provide technical assistance during planning of Provide feedback to districts to the developed 2019 CoC plans 2019 CoC grants Technical Assistance to programming for Provide TA during the planning for mentorship activities at PHO and mentorship in the province district levels with the use of the developed mentorship dashboards. Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Visit the districts to follow up on the establishment of multi- disciplinary district mentorship teams to effectively conduct mentorship rounds in the facilities under the specific districts. Equip mentorship teams with models To attend district planning meetings and follow up the inclusion of models and job aids in the 2019 CoC plans. Distribute the models according to the distribution list developed by PHO and MCSP Newborn 1.1.1 • TA visits to districts Provide technical assistance during • Identify and disseminate best practices and innovations implementation of 2018 CoC grants • Make recommendations to introduce innovations through CoC grants 1.1.2 Provide technical assistance during monitoring Participate in District and provincial integrated meetings of 2018 CoC Grants Review and provide feedback to CoC district reports Review and provide feedback to national CoC program report Prepare written recommendations to revise CoC district plans 1.1.3 Participate in MOH district and Provincial Planning meetings Provide technical assistance during planning of 2019 CoC grants Provide feedback to districts to revised CoC plans Identify innovations to be programmed through revisions to 2018 CoC grants or 2019 plans

110 | Page

Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Coordinate with districts to include mentors in planned clinical trainings in 2018 CoC grant

Equip mentorship teams with models Distribute anatomical models and printed material to skills lab Technical Assistance to programming for mentorship in 2019 CoC Plans Provide TA to PHO and District Hospital CoC grants for hospital- based mentorship Child health 1.1.1 • TA Visits to districts build capacity in the DHO staff to provide Provide technical assistance during mentorship to facility staff implementation of 2018 CoC grants • Follow up the roll out of eIMCI/EPI training package • Follow up the implementation of QI projects in facilities . 1.1.2 • Provide TA to districts during DIMs, Data Review meetings to Provide technical assistance during monitoring help the districts use data for decision making of 2018 CoC Grants • Follow up the use of mentorship and SQA tools and dashboards Strengthen the capacity of DHO to analyze community data from CBVs trained in ICCM 1.1.3 Provide TA to districts on finalization and refining of 2019 CoC plans Provide technical assistance during planning of 2019 CoC grants Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Follow up the formation of integrated mentorship teams Provide technical assistance to districts to link Follow up the implementation of SQA and formation of mentorship mentorship with existing quality assurance dash boards in the districts activities Community 1.1.1 Provide technical assistance during implementation of 2018 CoC engagement Provide technical assistance during grants to all nine target districts implementation of 2018 CoC grants 1.1.2 Provide technical assistance during monitoring of 2018 CoC Grants in Provide technical assistance during monitoring all nine target districts of 2018 CoC Grants

1.3.8 Support facilities to develop and update • Offer Technical assistance to districts on the formation and dashboards and utilize for decision making interpretation of dashboards of key indicators for decision making for community engagement to result in increased access

111 | Page

of certain services • Facilitate development of RMNCAHN Risk maps and mentorship dash boards • Provide TA in SQA and Community Engagement. 1.4.1 Strengthening district & community Follow up TA to all districts to strengthening district & community platforms for accountability of RMANCH&N platforms for accountability of RMANCH&N services services between the district and community stakeholders through stakeholder profiling and strengthening / establishment of structures 1.4.2 Improve capacity of district, facility and Improve capacity of district, facility and community members to plan community members to plan and mobilize and mobilize resources in order to implement and monitor RMNCH- resources in order to implement and monitor N preventive and promotional activities in 9 districts RMNCH-N preventive and promotional activities 1.4.3 Strengthen implementation of CE Follow up TA to districts to strengthen implementation of CE activities at community level to address social activities at community level to address social norms for gradual norms for gradual adoption of recommended adoption of recommended RMNCH&N practices through varies RMNCH&N practices through varies community platforms such as community dialogues, drama and social community platforms such as community mass media communication. dialogues, drama and social mass media communication. Nutrition 1.1.1 Nutrition TA visits to districts to be re-enforced Provide technical assistance during implementation of 2018 CoC grants 1.1.2 Provide TA to districts to be able to create the nutrition dashboards Provide technical assistance during monitoring for easy monitoring of 2018 CoC Grants 1.1.3 Provide TA for districts to identify the nutrition high impact Provide technical assistance during planning of interventions included in the 2019 CoC plans 2019 CoC grants ASRH 1.1.1 • Provide TA in the formation of District Technical Working Provide technical assistance during CoC Groups in ASRH in Kanchibiya. Strengthen functionality of planning already set up ADH TWGs in Chinsali, Mpika, and Nakonde

• Provide TA to Chinsali DHO in the establishment of the district youth friendly space

112 | Page

• Develop list of ADH focal point staff in the 4 provinces to improve channel of providing TA in ASRH

113 | Page

MUCHINGA PROVINCE QUARTER 4, 2018 REPORT

Team Members 16. Beatrice M. Zulu - Provincial TA/Coordinator 17. Constance Choka - TA RH/Maternal &Newborn 18. David Matafwali - Provincial Technical Officer 19. Vincent Simangolwa- TA ASRH 20. Elvis Chipili - TA Community Engagement 21. Stanley Patela – TA Child Health 22. Methodius Chishimba - PMERO 23. Mike Tembo - Driver/General Duties

114 | Page

9. Reproductive and Maternal Health d. MCSP provided the link for the USAID FP and Abortion Policy guidelines and online course. Two facilities in Nakonde and four members of staff at Nakonde DHO have already taken the course and were grateful for the guidelines provided in the course and knowledge received. e. In the previous quarter, MCSP in the presence of the DHO staff, provided guidance to the health care providers in the labour ward on the use of recommended protocols in the management of obstetric emergencies and the importance of having a well set emergency tray within the delivery room. The team further guided facility in-charges on the need to assign each staff topics for presentation during clinical meetings and come up with schedules for the said meetings. More facilities that received the guidance started holding clinical meetings and testified that it was very helpful for the staff as the meetings provided opportunities for revisions and skills acquisition. f. MCSP held one discussion mentorship to the PHO PNO MCH and DHO MCH Coordinators on the need to ask health care providers on duty at the time a facility records a still birth or Maternal Death to write their statements. This would save as a more detailed written account during review meetings. As a result on 21st September, Mafinga reported two MDs and the PNO asked the MCH Coordinator to make sure the HC provider who took care of the two mothers had to write their statements and these would be used during review both at facility district and provincial review meetings.

10. Newborn Health c. MCSP participated in the PNMDSR meetings in which they helped the districts identify gaps and recommendations to improve newborn outcomes d. MCSP provided onsite mentorship in infection prevention at Mpika urban, residential clinic and Chinsali general hospital in Muchinga. MCSP discussed with the facility In-Charges on the need to follow guidelines on infection prevention in reprocessing and storage of neonatal resuscitation equipment to help prevent cross infection and consequently reduce on neonatal mortality and morbidity due to sepsis. The facilities provided with flow charts on reprocessing of neonatal resuscitation equipment. By September, 7 districts had procured IP buckets for neonatal resuscitation equipment and these were distributed to facilities. 11. Child Health a. Roll out of eIMCI/EPI training to all districts increasing number of HCWs trained from 4 in the second quarter of 2018 to 21 in the third quarter. The eIMCI/EPI MCSP training package was been installed on computers in 8 districts out of 9 districts in Muchinga and 21 staff took the course i.e. Nurses -17, EHTs- 2, Nutritionist-1 and Clinical Officer 1.DHO facility staff welcome and appreciated the innovation i.e. Mafinga and Isoka DHOs indicated that the course was good and helpful in reminding staff in facilities to improving Child Health and Immunization indicators and they promise to ensure that at least one HCW at all facilities completed the course.

b. Distributed child health guidelines for case identification and management to DHOs (Danger Signs, Worms, Pneumonia and Diarrhoea signs). MCSP Muchinga received the materials from MoH via MCSP Head Office in Lusaka. The materials were produced by MoH with support from UKaid, SIDA and UNICEF.

12. ASRH a. Provision of ASRH TA during 2019 CoC planning: MCSP provided technical support to all the districts in the 2019 CoC planning by assisting in the bottleneck analysis for adolescent health indicator i.e. ANC coverage for women under 20 years. MCSP also distributed a list of high impact interventions that the district used to choose from for them to include in

115 | Page

their plans for the year 2019. All the districts in the province supported with high impact interventions. Among that they integrated into their plans include training of service providers in ADH, formation of Adolescent Health Technical Working Group, supportive supervisory visits to the health centres offering ADH, Integrated Community outreaches and Job aids procurement among other funds b. MCSP provided TA to establish Chinsali district adolescent technical working group. The setting up of the technical worming group for adolescent meant to improve the facilities responsiveness to adolescent health issues in the district. c. MCSP provided TA and now the province has 20 Youth Friendly spaces in various facilities. d. Provided TA to Chinsali and Mpika district ADH Focal Point staff in the administration of ASRH SQA. One facility in Chinsali district administered a SQA & the findings attached in form of a dashboard in appendices of this report. Mpika is yet to administer SQAs in ADH. Administration of SQAs is expected to be rolled out by all districts and facilities to improve quality service delivery of ADH services

13. Nutrition e. Through the TA provided by MCSP the Nutritionist at Kalwala has created space for a nutrition section and has now started displaying graphically displays in nutrition monthly indicators on stunting, wasting, underweight, deworming, vitamin A supplementation and breastfeeding within the first one hour after birth etc. The facility displayed key nutrition message. The MCSP nutritionist also helped the health facility to acquire protocols on RUTF administration displayed. f. MCSP made follow-up to Chinsali General Hospital to do on-spot checks on the display of key messages on breastfeeding within the first hour and message on breast feeding within one hour was displayed. Through the MCSP TA, the hospital nutritionists has since displayed graphs on the numbers of malnourished children admitted and discharged. TA provided to ensure that the quarterly and monthly variations in the admissions over time and trends explained. g. MCSP provided technical support and guidelines on the formation of District Nutrition Coordinating Committee (DNCC) in Chama. Chama District Health Office working with other partners like Reformed Open Community Schools (ROCS) has since spearheaded formation of the DNCC the and this committee will linked to the provincial coordinator SUNFUND district nutrition team of the for further support h. TA provided on the importance of following up malnourished children who are referred to higher levels of care once they are discharged to the community. The trained CHVs in IYCF are actively involved in the identification of children with malnutrition within the communities, refer the cases to the facility which carries out a comprehensive assessment (in the facilities and communities under Chinsali district).

14. Community Engagement c. Supported the Provincial Health Office in establishing the first ever-Provincial Health Promotion Technical Working Group for Muchinga Province. The team further provided TA to the districts to establish District Health Promotion Teams (DHPTs). By the end of the quarter, 7 districts had established the DHPT while 2 were still being helped to come up with the said teams. d. The focus of the TA provided to the districts was four fold: conduct on the spot-check and assess the functionality and establishment of the district community engagement platforms (DHPTs), Assessing and determining the functionality (activeness) of community based community engagement structures (NHCs, HCCs) and the implementation of Integrated Community Registers for Equity based Integrated Approach. Guidance provided to the districts

116 | Page

that had challenges with establishment of the DHPT and some districts had shared the TORs and started holding meetings.

15. MER d. Collaborated with PAMO to train thirty (30) health staff (10 Kanchibiya health centre staff , 7 staff from Lavushimanda , 2 staff from Nakonde, 2staff from Mafinga, 3 from Chama, 2 from Mpika specifically Chilonga General Hospital, 1 from Isoka and one (1) from Shiwangandu. We also had two DHIOs; one from Chama the other one from Kanchibiya.) in HMIS/DHIS2 and data use. Therefore, the MCSP staff provided technical assistance on setting of the pretest and reading out the results of the data audit exercise conducted in May and June. On average participants recorded 58% of data skills, knowledge, use and analysis. Participants were taken through the information cycle, data collecting tools (Registers, HIA tools and tally sheets). Provided clarification on the OPD registers, Under 5 registers, Mother and child follow up (0-23 & 23-59 months) registers, aggregation forms (HIA1, 2, 3 and 4), antenatal register, family planning registers, postnatal registers and Integrated maternal health newborn and Under 5 community register. Oriented the participants on the Integrated Maternal Health newborn and under 5 register. Emphasized on the need to check what Neighborhood Health Committees (NHCs) are doing with the registers since that gives them an insight of the community and offer health services at primary level. Despite the health Centre staff not trained in iCCM, it is important to check them registers so to supervise the work, which the NHCs are offering at community level through that register. Need to be calling the NHCs to review the data with the facility at certain time intervals. e. MSCP successfully provided technical assistance to all the districts during the 2019 Provincial Planning Review and consolidation meeting in HMIS related activities. This TA resulted into guiding all the 9 DHIOs in the following M&E activities to prioritize for their 2019 inclusion/implementation; Purchase of 5 laptops and dongles per district for the facilities. We wanted to prioritize 5 HF for the start to do facility level DHIS2 data entry, Plan to train at least 2 HCWs in the 5 facilities per district in DHIS2 data entry. Therefore, needed to plan for DHIOs to be part of the training as well as one additional staff from DHO to provide technical supervision when the training is done, Plan to conduct technical supervision in DHIS2 to the facilities, Plan to purchase monthly talktime for data entry for health facilities, Plan to train DHO program officers in Data analysis and use through DHIS2, Plan to train/orient/mentor Health centre in charges in data presentation and analysis. This will enhance data presentation and analysis during data review meeting, Plan to train health facilities and program officers in QI/QA and SQA, Plan to conduct any research topic/success story in RMNCAHN, Plan to provide DHIS2/HMIS technical support/mentorship to facilities, Plan to district any latest HMIS registers to the facilities. This will also enable us to be on the look out of stock outs of registers in the facilities and distribute as quickly as possible, Plan to train/orient health centre staff in the new/updated HMIS registers. This was in line with National Health policy, legacy goals and M&E framework for 2019. f. MCSP successfully conducted interviews on key lessons documented from Ministry of Health staff and partners at provincial, district and facility level on the TA MCSP provides. The interviews went as per schedule, we managed to interview two (2) district nursing officers (DNO-MCH) in Mpika and Chinsali, two (2) district health directors (DHDs) in Kanchibiya and Nakonde, one (1) district health information officer (DHIO) in Chama, two MCSP staff, one SBH staff, the provincial health director (PHD) and one provincial CoC coordinator. The province just received the CoC coordinator who is less than 1 month old, hence the coordination of the RMNCAH&N activities were under the provincial public health specialist (PHS). Therefore, we interviewed the PHS in the capacity of the Provincial CoC coordinator. In total, we reached out to fifteen (15) staff.

117 | Page

16. Crosscutting e. Conducted TA visit in conjunction with the Provincial Health Office to assess and determine the level of implementation of the 2018 CoC activities in all the nine districts of Muchinga Province. The district levels of completeness with regard to implementation of 2018 CoC planned activities established to be at 50% in one district while the other eight districts were above 50%. During this process, districts narrated a number of success recorded with the coming of G2G and TA from MCSP. Districts were encouraged to work with MCSP to document all their success stories f. MCSP conducted TA visits to the last four districts in the province (Chama, Isoka, Nakonde and Mafinga) and supported the DHO in the prioritization and identification of appropriate, evidence based, high impact interventions to be used during planning for the 2019 MTEF and CoC Plans. The TA support was provided to all the 9 districts in the province before the planning launch and this was a better preparation for the districts as the planning process was made easier. g. MCSP strengthened the capacity of the mentorship teams in the use Service Quality Assessment tools (SQA) to identify gaps that need attention and development of mentorship dash boards to inform mentorship rounds. This resulted in 7 districts out of 9 forming District mentorship teams h. MCSP participated well in the Provincial Planning Launch, review of action plans (at district and provincial level) as well as during the Provincial Integrated Meeting (PIM)).

118 | Page

Objective 1: Provision of Demand Driven TA (what, when, where, why, how- so what)

Progress of the Activity Next Technical Activity from the work Steps/Recommendation/TA Area plan opportunities Maternal Activity 1.1: Technical Assistance to CoC Program

Provide technical Provided guidance on the institutionalizing and use of the WHO 2016 DHO and MCH Coordinators to assistance during ANC Guidelines continue monitoring the use of implementation of 2018 standard WHO guidelines by facility CoC grants • TA and discussions continued on the need for facilities to keep staff mothers for 48 hours post-delivery as this was the most critical period for both mother and the baby. This practice will promote the health of both the mothers and newborns and thus improve the indicator for PN attendance within 48 hours. MCSP to follow up on the • Management of labour using a partograph; During the TA visits implementation and documentation MCSP observed that the partograph was not effectively used to of the post-natal care within 48hrs monitor fetal wellbeing during labour. Discussed with the MCH according to postnatal care guidelines coordinators to conduct onsite mentorship to facility staff on the with facilities informed by the 48 use of partograph. All districts except for Mafinga had stared hours’ post-natal indicators conducting mentorship on the use of the partograph. Skills in the effective use of the partograph will help reduce on the number of stillbirths. The teams were advised to ensure adequate supply of WHO partograph in all facilities

Provide technical MCSP highlighted the lack of basic skills in the management of obstetric assistance during emergencies among skilled birth attendants (e.g. management of eclampsia), DHOs to continue strengthening monitoring of 2018 lack of stocked emergency trays in the delivery rooms, gaps in the utilization onsite mentorship in the CoC Grants and interpretation of the partograph during management of women in management of obstetric labour. emergencies.

In the presence of MCH Coordinators,

• MCH provided guidance to the health care providers in the labour ward on the use of recommended protocols in the management of DHOs to provide facilities with all obstetric emergencies and the importance having a well set necessary medicines and equipment emergency tray within the delivery room. The team further guided used in emergencies and set up

119 | Page

facility in-charges on the need to assign each staff topics for emergency trays presentation during clinical meetings and come up with schedules for the said meetings. More facilities that were talked to have since started holding clinical meetings and testified that it was very helpful for the staff as the meetings provided opportunities for DHOs to develop mentorship score revisions and skills acquisition cards and provide onsite training • Continued provision of TA to MCH Coordinators to guide the using the low dose-high frequency nurses and midwives (especially those trained in EmONC) during approach in the facilities onsite mentorship on utilization and interpretation of the partograph in monitoring progress of labour and maternal wellbeing and early detection of signs of complications. MCH Coordinators to follow up • MCSP in conjunction with the PNO at PHO and the Nursing with facilities to make sure there is Officer at Chinsali General Hospital made three tours of the new separation of delivery and MVA labour ward at CGH to identify and made follow-ups on the IPP. beds The first recommendations given to the NO and follow up visits showed a marked improvement in that IP buckets were brought into the delivery room.

Provide technical MCSP provided technical assistance during the pre-planning meetings for DHOs to prioritize strengthening assistance during Mpika, Kanchibiya, Lavushimanda, Chama and Chinsali districts to outreach sites thus provision of planning of 2019 CoC strengthen the reproductive and maternal component in the 2019 plans outreach services to also offer ANC grants which was missed out during the 2018 CoC plans by ensuring that the services. This will further improve reproductive and maternal high impact interventions are included in the the first ANC coverage. 2019 CoC plans. With the inclusion of the high impact interventions in the 2019 plans, the plans will be more focused and targeting what will further improve the outcome of the RMNCAHN services Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship TA Offered to Chinsali, Mpika, Kanchibiya, Shiwangandu, Isoka and MCSP to follow up the formation of teams Nakonde district on how to form mentorship teams which should include integrated mentorship teams in the Maternal and Reproductive Health said districts Equip mentorship TA offered to Districts to include in the 2019 CoC plans the for MCSP to attend the district planning teams with models procurement of mentorship models such as Baby/Mama natalie/birthie for meetings use during simulations during mentorship Other activities MCSP facilitated the distribution of WHO recommended pregnancy MCSP and MoH to continue coordination wheels and FP protocols to all the districts in the province. With the providing districts with approved available tools, staff in facilities will be providing FP and ANC services in standard guidelines for use in the a more focused manner and thereby improve the health of mothers and facilities.

120 | Page

contribute to the improvement of RMNCAHN indicators DHO to continue monitoring the facilities for their adherence to provided guidelines in service provision Newborn Activity 1.1: Technical Assistance to CoC Program

1.1.3. Provide Monthly TA visits: technical MCSP conducted monthly TA visits to the 3 health facilities in the assistance province. Technical assistance was provided on the following topics: during implementation Infection Prevention; of 2018 CoC • MCSP provided onsite mentorship in infection prevention at Mpika grants urban, residential clinic and Chinsali general hospital in Muchinga. • DHOs to facilitate procurement

MCSP discussed with the facility managers on the need to follow of IP buckets for neonatal guidelines on infection prevention in reprocessing and storage of equipment neonatal resuscitation equipment to help prevent cross infection and consequently reduce on neonatal mortality and morbidity due to

sepsis. The facilities provided with flow charts on reprocessing of neonatal resuscitation equipment. 48hrs postnatal care; • MCSP emphasized to the districts, the need for RHC to implementing the 48hrs PNC policy despite limited space. Some facilities reported to be practicing but lacked documentation. Designated spaces for resuscitation; • MCSP in discussed the need of having designated resuscitation spaces at TAZARA clinic for efficient and effective resuscitation of the • MCSP will continue promoting asphyxiated newborn. such good practices by Kangaroo Mother Care (KMC); disseminating them to the authorities and other HFs that • MCSP discussed the importance of establishing or identifying a room have not started implementing for KMC at Chinsali General Hospital. The hospital will also need to the 48hrs postnatal policy. orient and mentor staff on KMC as a way to roll out the KMC to all the facilities in the district so that the staff acquire knowledge for • Facility in charge at TAZARA to effective counselling of the mothers with preterm babies, although follow up with the carpenter most facilities have inadequate infrastructure for KMC. who has been given the order to make a resuscitation table

121 | Page

Newborn Health Protocols; • MCSP discussed with facility in charges at Mpika urban clinic in Muchinga on the need for newborn health protocols such as HBB • MCSP to follow up the displayed on the walls for quick reference during service provision implementation of the with the facility managers. This will consequently help health facilities recommendations on the adhere to standards during service provision and improve on provision of identification of a newborn outcomes. Soft copies of HBB provided and districts room to be used for KMC at requested to either print/ hand write the protocols and have them CGH. displayed in appropriate places in the labour wards.

Follow up TA visit to the districts : • Infection Prevention: MCSP had provided TA on the importance of adhering to IPC standards in the labour wards to reduce on morbidity and mortality for the newborn due to sepsis. Chama, Isoka, and Mafinga including Chinsali general hospital had acquired IP buckets • MCSP to follow up use of the with lids for reprocessing and storage of neonatal equipment. perinatal death audit form to Kanchibiya was still waiting for the vendor to deliver the buckets this review perinatal deaths month (Septemebr 2018). Lavushimanda will do the procurement occurring at the facilities using RBF funds this month (September) This positive development • MCSP and the district health will go a long way in reducing neonatal morbidity and mortality due to sepsis and hence contribute to the improvement of the newborn office to follow up on the indicators. In Eastern Province MCSP has continued to advise the effective use of the infant districts on the importance of separating the infant resuscitation resuscitation protocols being equipment from the delivery and MVA equipments during the informed by the facility perinatal decontamination process. data and provide technical • Newborn Resuscitation equipment: During TA visits in Muchinga assistance accordingly. MCSP observed that most facilities did not have recommended basic neonatal resuscitation equipment and discussed with the districts on the importance of such equipment. All districts except for Kachibiya had procured recommended basic neonatal equipment for the facilities that did not have. This will improve resuscitation outcomes for the asphyxiated babies and reduce on the number of babies dying due to asphyxia. Kanchibiya had not budgeted for the same in the 2018 CoC budgets and hence advised to treat this as urgent and procure the

equipment using other budget lines such as RBF. TA provide on the

storage of the equipment to avoid dust and cross infection.

122 | Page

• Perinatal death reviews: During the TA visits MCSP observed that facilities were not conducting perinatal death reviews at the facility. MCSP in discussed with districts the need to conduct the perinatal death reviews to draw lessons and avoid similar occurrences in future. The districts were given a soft copy of perinatal death audit form to

guide the reviews. MCSP discussed with the in charges and the staff MCSP to follow up on the on duty at Mpika urban and TAZARA clinic on the need to conduct implementation and documentation perinatal death reviews, as they occur to learn from the experience of the post-natal care within 48hrs and avoid similar occurrences in future. Mpika urban clinic were according to postnatal care guidelines already using the forms despite not conducting the reviews. with facilities informed by the 48 All districts in Muchinga had started conducting perinatal death reviews hours’ post-natal indicators at facility level as they occur although some facilities were still not doing so especially in Nakonde where only three facilities were conducting the reviews. In only the hospital and Kasoka urban centres were conducting the reviews. Discussed with district teams on the need to conduct such reviews at facility level. The teams advised to follow up on any facility that reported a perinatal death and ensure that the death reviewed and notes shared with DHO for possible support. Use of the perinatal audit form emphasized especially to Lavushimanda and Mafinga who were not using the new revised form to guide the reviews. The soft copy of

the audit form given to the MCH coordinators to print and distribute to the facilities.

• Protocols: During the TA visits, MCSP discussed the need to have • Facility In-Charge to newborn health protocols displayed on the walls for quick reference periodically review the during service provision in order to save lives of the newborn. partographs to check on the Facilities in Kachibiya had newborn health protocols despite not competence of the midwives in displayed on wall. The DHO team advised to ensure the charts terms of management of labour displayed for quick reference in an emergency. Lavushimanda and and monitoring of fetal Shiwang’andu distributed protocols to some facilities but not enough wellbeing. to cover all the facilities and hence were encouraging the facilities to • MCSP to provide technical display hand written ones. Mafinga will be distributing protocols in assistance during mentorship the last week f September, while Nakonde had challenges with neonatal resuscitation protocols. MCSP shared the soft copy for the round on essential new born districts to print and distribute to the facilities. care and HBB.

123 | Page

• Clinical meetings; During the TA visits MCSP encouraged facilities to start conducting clinical meetings to improve knowledge and skills • MCSP to provide technical in management of the newborn. Isoka, Kachibiya, lavushimanda, and assistance during the planning Mafinga had started conducting clinical meetings although not all process for 2019 on the High facilities were sharing minutes. The DHO teams were encouraged to Impact Interventions for ensure all facilities share the schedules for clinical meetings and make implementing Kangaroo follow-ups for the minutes to provide the necessary support. This Mother Care. help improve the knowledge and skills of HCWs in different thematic • District mentorship teams to areas including newborn health. continue providing mentorship informed by data on fresh still • Special Care Baby Unit; Isoka district had established an SCBU, which births and early neonatal deaths has led to an improvement in management of the sick newborn. Isoka and MCSP to provide technical district has also seen a reduction in perinatal deaths, which the district assistance during district visits has partly attributed to the training of staff in ENC. • MCSP to follow up on the perinatal reviews at facility level • MCSP to support the Districts to conduct Monthly mentorship to staff on the proper use of partographs to monitor progress of labour and to interpret the partographs for quick action in cases of obstructed labour. • MCSP to support the districts in strengthening the reviews of stillbirth and birth asphyxias at facility level within 24hrs of occurrence.

• DHOs to carry out orientation/Mentorship of staff on newborn resuscitation using

124 | Page

the small dose high frequency approach.

• Printing protocols/guidelines/job aids for health care works and community volunteers. • MCSP to provide the guidelines and work with the clinical team in ensuring that the Multidisciplinary mentorship teams are in place so as to improve the quality of work among all staff across the RMNCAH/N CoC. • Make follow up visits to districts to ensure adherence to good infection prevention practices and District health offices to support facilities in acquisition of storage containers for processed equipment • MCSP to follow up with Facility In-Charges to temporally print the soft copies of helping babies breath charts shared or hand write as they wait for the district health office to provide. MCSP and DHO to follow up the facilities for the utilization of the same.

125 | Page

1.1.4. Provide Perinatal and Maternal Death Surveillance and Response meetings technical assistance MCSP provided TA during the quarterly PNMDSR meeting in Chinsali. during to help contribute to the improvement of the maternal and neonatal monitoring of indicators. MCSP to participate and provide 2018 CoC technical support in the meetings for Grants In Muchinga contributing factors that led to the maternal and perinatal the other districts. deaths were isolated with MoH staff and TA provided in the following areas MCSP to support the districts to • Early referral of clients especially at facilities with limited staff consider scaling up of KMC to the competences and medical facilities health facilities to address the • need to provide mentorship in clinical decision making to facility neonatal deaths due to prematurity, staff KMC being the high impact • Need for full history taking, full examination and detailed intervention. documentation of the findings on a client. • Need to start a documentation quality improvement project at Chinsali and Isoka hospitals to improve documentation.

Provide technical MCSP provided technical assistance during the pre-planning meetings for MCSP to ensure that the districts assistance during Nakonde in Muchinga, province to strengthen the newborn component have considered some activities planning of 2019 CoC in the 2019 plans which was missed out during the 2018 CoC plans by which they could not implement in grants ensuring that the newborn high impact interventions are included in the 2018 for various reasons to be 2019 CoC plans budgeted for in 2019 for as long as • Discussions on the key indicators in all the thematic areas of they were to bring impact on the RMNCAH&N which included Newborn key indicators gaps.

Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship MCSP discussed the need for district to plan for mentorship follow up To follow up the formation of teams visits as according to the Essential New Born Care mentorship integrated mentorship teams dashboards. Equip mentorship MCSP provided TA on the inclusion of models to be procured (under MCSP to continue supporting teams with models G2G) in the 2019 CoC district plans. districts as they revise their 2019 CoC plans Provide technical MCSP teams oriented the hospital and facility staff on the service quality MCSP to follow up the rest of the assistance to districts to assessment tolls and how to create SQA and mentorship dash boards in districts yet to complete the creation link mentorship with Mpika, Kanchibiya, Nakonde and Mafinga districts for easy identification of of mentorship dashboards in

126 | Page

existing quality quality service provision province assurance activities Other activities MCSP facilitated the coordination of essential newborn care trainings MCSP district health office to coordination (MoH and PHO). Skills gained will contribute to improved newborn follow up on the trained providers outcomes. to ensure skills gained are being utilized to improve newborn indicators Child health Activity 1.1: Technical Assistance to CoC Program

Provide technical TA provided to DHO staff in Mpika, Kanchibiya and Lavushimanda • PHO and MCSP to supervise assistance during during the District Planning launch meeting. Discussed the use of findings the identified High Impact District and Provincial from DIM, PA and TSS to inform decisions. Shared the list of high Interventions for Child Health 2019 CoC planning impact interventions in child health and immunizations such as RED are incorporated in the 2019 meetings strategy, IMCI training, Outreach services, mentorship and procurement plans of IMCI job aids.. • It was expected that TA provided would result into improvements in quality of 2019 Action Plans and budgets

Provided Technical Oriented DHO staff at Mafinga, Isoka and Nakonde on the electronic • All DHOs to continue the roll Assistance to Nakonde, IMCI/EPI training. Installed the application on 2 computer in Mafinga, 2 out of eIMCI/EPI training to Isoka and Mafinga computers in Isoka and 1 computer in Nakonde. The officers who took ensure at least one HCW Districts the course by end of quarter 3 included Nurses 17, EHTs- 2, Nutritionist-1 (Nurses, midwives, EHTs, and Clinical Officer-1 Nutritionists and COs) at facility level is trained by end of the year. It was expected that TA provided would result into improvements in • DHDs to ensure program number of staff in the districts starting and completing the course officers, supervisor and mentors at the district take up the course

Provided TA to the Working with the PNO- MCH and G2G Provincial coordinator, MCSP • All district to continue districts and PHO spearheaded the development of districts and provincial capacity building updating the Capacity building database. Data base consist of names, designation, District, facility, year database for health workers trained and funder/sponsor. So far the Cumulative figures from the same and use the information for database are; decision making

127 | Page

IMCI- 84 • District to include eIMCI/EPI RED strategy-110 in the capacity building ICCM-331 database MCSP used the senior nurses WhatsApp group to share challenges and way forward with the database information. Community Activity 1.1: Technical Assistance to CoC Program engagement 1.1.1 Provide technical Conducted TA visit to assess and determine the level of activity assistance during implementation of the 2018 CoC activities in all the nine districts of implementation of 2018 Muchinga Province. The TA visit jointly undertaken with the Provincial • DHOs to plan for DHPT CoC grants Health Office (PHO) from 9th to 15th September 2018. The focus of the planning and review meetings trip for Community Engagement was four fold:

• Conduct on the spot check and assess the functionality and establishment of the district community engagement platforms (DHPTs) • Support DHOs and facilities in • Assessing and determining the functionality (activeness) of completing NHC data base community based community engagement structures (NHCs, HCCs) and training matrix • Stakeholder mapping and involvement • Facilities to actively support • Implementation of Integrated Community Registers and use of and Supervise NHCs integrated equity based approach in reaching communities

Findings: • Provide TA to support DHOs and facilities in implementation DHPT establishment and Functionality of community registers • Seven out of nine districts completed the formation of DHPTs. The • Mentors facility staff in use of two districts that did not complete the process were Chama and community registers for Mafinga. The two districts however, completed their partner mapping evidence based decision and will soon be holding start up meetings before the end of making September 2018. • Facilities to support utilization • Two districts (Isoka and Chinsali) conducted two days training for of Integrated registers by DHPT members in roles and responsibilities with financial support CBVs from Breakthrough Action.

TA Provided:

128 | Page

• Chama and Mafinga supported with guidelines for the formation of • Support PHO in strengthening District Health Promotion Teams Provincial Health Promotion • DHOs urged to schedule regular DHPT meetings (Planning and Technical Working Groups review) and keep the teams active • Support DHOs in strengthening Provincial Revitalization and Profiling of NHCs Health Promotion Technical • NHC structures are functional in all districts Working Groups • All districts have completed NHC profiling • Support DHOs in • Currently NHCs comprise of Community Based Volunteer groups strengthening community • Over 80% of NHCs are active and submitting reports. Most active based collaborative meetings groups are SMAGs, CBDs, ICCM with key stakeholders including FBO, Traditional and Implementation of Integrated Community Registers civic leaders

• In all districts, registers have been distributed to NHC zones, but DHOs and facilities have not started monitoring their utilization • DHIOs were oriented in the registers • Registers at zone level are being used by CBVs trained in ICCM • Facilities have not started using the registers for implementation of equity based integrated outreaches.

Establishment of the Provincial Health Promotion Technical Working Group

• MCSP worked and supported the Provincial Health Office in forming the first ever-Provincial Health Promotion Technical Working Group. The team was formed on 17th July 2018 with composition of 14 members (10 males, 4 females). Through collaboration with Breakthrough Action, the PHO received financial support and conducted a two day training to orient the team in their roles and responsibilities

Achievements: • MCSP consistent and sustained TA both at provincial and district levels resulted into establishment of the Provincial and District

129 | Page

Community Support Structures (platforms) and at facility level, the revitalization of community support structures (NHCs). • The Provincial Health Promotion Technical Working Group (PHPTWG) was formed in July, whilst the DHPTs have been established in seven of the nine (78%) target districts. This realization is a greater achievement towards the fulfilment of the MCSP mandate of supporting provinces, districts and facilities in the development of functional community engagement systems. Going forward, the established district health promotion teams under the supervision and coordination of respective DHO should take an active role in coordination of NHCs to increase demand for RMNCAH&N services. • MCSP TA support to the districts facilitated the introduction and implementation of Integrated Community Registers at Community level in all districts. The registers, which have been widely distributed in all facilities, when fully utilized, will become an evidence based key source document to facilities, and communities in the implementation of equity based integrated outreaches, monitoring and follow of antenatal and Post-natal mothers, follow up of defaulting / non- immunized under five children and will provide record of pregnancy outcomes.

Nutrition Activity 1.1: Technical Assistance to CoC Program Provided TA on the use • MCSP influenced Districts to display the Guidelines/posters for ten of guidelines for steps to successful breastfeeding, management of malnutrition and identifications, these have been distributed to and displayed in some of the HFs classification and • Through the TA provided by MCSP the Nutritionist at Kalwala has management of created space for a nutrition section graphically displays monthly malnutrition performance of the facility on nutrition indicators like stunting, wasting, underweight, deworming, vitamin A supplementation and breastfeeding within the first one hour after birth etc. • The facility has displayed key nutrition message, the facility had wrong protocols on RUTF administration, through the help and support from MCSP appropriate charts accessed and displayed by the health facility.

130 | Page

Provided TA on the • With the constant guidance from MCSP, Chinsali General Hospital MCSP to continue offering TA to importance of now able to identify malnourished children from among the children other DHOs to give further reclassifying all children admitted for other ailments. The facility has since strengthened activity guidance to facilities admitted in the children case finding of children with malnutrition during routine growth medical ward for monitoring at the facility and during outreach. They have further Malnutrition and those started providing RUTF to the children with moderate acute found to be malnutrition. malnourished to • Trained CHVs in IYCF are actively involved in the identification of undergo rehabilitation children with malnutrition within the communities and are referring the cases to the facility which carries out a comprehensive assessment.

Provide technical MCSP worked with the provincial Nutritionist and managed to have 12 MCSP and DHO to make a assistance during Community health volunteers trained from Lubwa RHC trained in schedule for monitoring the monitoring of 2018 IYCF/MIYCN under the G2G program. impact of the knowledge gained CoC Grants from the trainings among the CHV.

Provide technical • MCSP conducted three (4) meetings with District staff in MCSP to participate and continue assistance during Lavushimanda, Kanchibiya, Mpika and Shiwangandu districts to offering technical assistance to planning of 2019 CoC orient staff on the 2019 CoC planning and share high impact districts grants interventions.

• Provided TA to the Provincial Nutritionist on the importance of including in the 2019 plans, procurement and provision of formula feeds to the districts to ensure effectiveness in the management of SAM clients.

ASRH Activity 1.1: Technical Assistance to CoC Program 1.2 Technical The following were the activities undertaken during the period under Assistance to CoC review in providing TA to the districts: Program • Dissemination of the ASRH High Impact Intervention: The • The Districts to Use the high impact interventions were to help the districts during 2019 High impact planning, an initiative districts appreciated. The high impact interventions in their interventions were the addition to the earlier ASRH activity menu programming

131 | Page

developed and compressed all the necessary interventions for addressing ADH. It is hoped that the 2019 plans will produce • MCSP to continue positive results because of this dissemination of high impact offering TA in the interventions. implementation of High impact interventions • Participation in the 2019 CoC Planning MCSP participated in the MCSP provided technical support to all the districts in the 2019 • MCSP to support the CoC planning by assisting in the bottleneck analysis for adolescent districts in the review of the health indicator i.e. ANC coverage for women under 20 years. plans in order to ensure that MCSP also distributed a list of high impact interventions that the the high impact intervention district used to choose from for them to include in their plans for are not missed out the year 2019. Among interventions that they integrated into their plans include training of service providers in ADH, formation of Adolescent Health Technical Working Group, supportive supervisory visits to the health centers offering ADH, Integrated Community outreaches and Job aids procurement among others.

• Provided TA in the Formation of ADH Technical Working Groups: MCSP provided TA Chinsali to form ADH TWGs. Other districts with the ADH TWGs include Mpika, Nakonde. It is expected that the districts will see an improvement in ADH across the facilities. • TA in the training of Peer Educators in Chinsali District: MCSP provided TA in to the district through provision of the materials for the training. MCSP sourced for training materials and other relevant materials needed for the trainings as requested by the district health offices respectively. Going forward, the districts are expected to have improved ADH work through the peer educators to be deployed in various facilities in the districts. • Provided TA to Chinsali and Mpika district ADH Focal Point staff in the administration of ASRH SQA. One facility in Chinsali district administered a SQA & the findings attached in form of a dashboard in appendices of this report. Mpika is yet to administer SQAs in ADH. Administration of SQAs is expected to be rolled out by all districts and facilities to improve quality service delivery of ADH services .

132 | Page

• TA provided to Chinsali DHO on the steps to take on • DHO to monitor and convening a district ADH TWG: The district had partners provide support to all working in adolescent health but without an established technical trained peer educators in the working group to coordinate adolescent health activities. MCSP execution of their roles at provided TA to the district ADH FP and MCH coordinator on the TWG TORs, importance of convening a TWG with a multisector facility level. This is an representation based on the national standards and guidelines for ongoing process adolescent friendly health services. Advice given to the district to set a date for the first meeting and invite all partners identified in stakeholder partner matrix. It was expected that the district would • MCSP to provide TA to hold their first meeting to establish a district ADH TWG before the district ADH FP to roll the end of August, 2018. out the SQA administration to other facilities in the • Orientation of ADH TWG members on the Adolescent district following an Strategy and roles of TWG : MCSP Provided TA to Chinsali orientation on how to DHO in orienting Adolescent Technical Working Group administer the ASRH SQA Members on the Adolescent Health Strategy and guidelines. The This will be done between members of the Technical working group were also oriented on Q3 and Q4 across all the their roles and responsibilities. It is expected that going forward facilities. all members of the technical working group will have a clear understanding of adolescent health programming and contribute to the implementation of activities to improve the adolescent health status in the district. • MCSP to provide TA for DHO to continue • Provided TA to Chinsali and Mpika on use of peer educators populating the partner reporting tools: MCSP provided TA to the districts to encourage matrix to aid in identifying the use of the reporting tools by peer educators in the facilities. more partners in ADH. This came in the wake of peer educators not utilizing the reporting This is an ongoing process tools and submitting the DHO. Data collected through the reporting tools is useful for planning and improving adolescent • MCSP to continue health programming. It is expected that going forward utilization providing TA to strengthen and subsequent submission of reports to the district will improve the functionality of the in the districts technical working group

• MCSP to follow up on the use of reporting templates

133 | Page

by peer educators. This is an ongoing process until all districts and facilities begin to use the reporting templates • MCSP to provide TA to the districts to begin using the data collated in the reporting templates to make decisions. This is an ongoing process 1.3 Improve collection, During the period under review, MCSP made efforts in ensuring that the • MCSP to continue monitoring and data data referred to. The scorecard provided a mirror for the districts and the supporting the districts in use for decision making facilities on how they were fairing in addressing the indicators. For ensuring that data is always and quality adolescent health only Antenatal Coverage for women below 20 years referred to improvement captured the rest not segregated by age. The ANC coverage for the women • MCSP to encourage data aged 20 years and below revealed that there were many teenage pregnancies review meetings in the and so during the bottleneck analysis and the planning for 2019, the district districts did introspection and interrogation of the said indicator and how the situation could be improved. It was recommended that strengthening ADH programmes in the districts would help reduce teenage pregnancies.

Crosscutting 1.1.3 Provide technical • Conducted TA visits to the last four districts in Muchinga Province • Support DHOs to conduct assistance during (Chama, Isoka, Nakonde and Mafinga and supported them in the data and performance planning of 2019 CoC prioritization of appropriate and identification of evidence- based review meetings using grants interventions during planning for the 2019 MTEF and CoC Plans. proven data review tools The staff who received technical assistance improved their skills in the development of evidence based activity plans with targeted and • Support in prioritization appropriate interventions. and rescheduling of CoC activities • Throughout the process of interaction, the MCSP team took the leadership role in mentoring and couching DHO and facility teams in the identification of performance gaps through use of HMIS data collection tools / reports, scorecard indicators, mentorship and Service Quality Assessment reports and dashboards. The DHO and facility teams provided with the MoH proposed high impact

134 | Page

interventions across the RMNCAHN thematic areas as reference document to aid the planning process.

Achievements: • As part of the ongoing process of equipping health care workers with adequate knowledge in development of annual health care plans that are linked to performance, Health care workers in the all the nine DHOs improved their capacity in assessing evidences and identification of high impact interventions. It is therefore expected that 2019 MTEF and CoC Districts plans will not only improve in quality but will contain evidence based, targeted and appropriate interventions

• Challenges and recommendations (not more than 3 per thematic areas)

Thematic Challenge Recommendations to Address the Challenge Maternal Not all staff working in labour wards are midwives and this Ensure MCH Coordinators to mentor facility staff and resulted in lack of skills and confidence in performing encourage them to be holding clinical meetings so as procedures like those required to manage obstetric emergencies. to strengthen knowledge and skills in management of obstetric emergencies Non adherence to standard IPP due to low supply of Chlorine Districts and facilities to plan to procure more to the delivery rooms because of non -availability of the quantities of chlorine in the 2019 grants commodity to last a month. Inadequate transport logistics resulting in most District MNDSR Plan with the PHO to come up with a schedule in time meetings not being supported technically to enable MCSP coordinates logistics in good time Newborn Neonatal deaths issues seemed not to have been prioritized by the MCH coordinators to ensure that the District facilities districts and facility staff as they were not conducting the neonatal are conducting Neonatal Deaths reviews as they occur death reviews as soon as they occur at facility level to establish at facility level causes such as birth asphyxia, prematurity etc. and develop MCSP to support the district facilities necessary interventions for prevention such as KMC during the process

Most of the newborn health activities seemed not to have been The district mentorship teams to continue providing standing alone but included to the maternal Health activities, onsite mentorship which paused a danger of having newborn health neglected at DHO and MCH Coordinators advised to come up

135 | Page

the implementation period. with newborn health activities that will address the increasing numbers of stillbirths, neonatal deaths and birth asphyxias so that they can be implemented during the implementation period.

Some districts and HFs are not using the Perinatal and • At least each HF should have not less than Neonatal Deaths Audit Form, MDSR audit form, MD five copies of each of these tools (depending Notification form, MDSR Community Autopsy. There are on how busy that HF is, you may need to no printed copies ready for use, the staff on duty at the time of provide them with more the death or stillbirth felt lazy to complete the document, or they have never been oriented to the tools. • The availability of a completed tool (up to the point as prescribed) during hand over or change of shifts, if a death or stillbirth occurred, MUST be one of the things that should be checked.

Child health Poor Case Management of Childhood illnesses. This is due to 4. Mentorship in Case Management inadequate numbers of staff trained in IMCI, lack of job aids, lack of 5. Capacity building HCWs skills i.e. training mentorship and supportive supervision from DHOs and no Quality IMCI and ETAT Improvement activities 6. Service Quality Assessment (SQA) to identify areas of improvement

Poor Quality of Immunization Services. This is due to poorly 5. Mentorship in RED/C integrated outreach activities, inadequate number of staff 6. Capacity building in RED/C strategy trained in RED strategy, lack of mentorship activities in 7. Service Quality Assessment (SQA) to identify Immunizations as evidenced by low fully immunized coverage areas of improvement and high drop out rates in the province 8. Community Engagement Community Weak Coordination and supervision of community engagement • DHOs and facilities to prioritize activities to engagement platforms at DHO and facility levels strengthen DHPTs and NHCs

DHO and Facility staff not Prioritising Community Engagement • DHOs and facilities to prioritize community activities engagement activities • Integrate community engagement activities in other ongoing funded activities Weak program integration at both DHOs and Facilities. • DHOs and facilities to be holding monthly and

136 | Page

RMNCAHN activity implementation considered to be an MCH quarterly performance review meetings with all activity for MCH Coordinators team members • Activity implementation to involve wider participation of DHO and facility team members Nutrition Lack of knowledge in the DHOs to develop the nutrition MCSP to give TA to DHOs with the development of mentorship dashboards dashboards

Majority of the districts are making their own feeds using milk, The provincial nutritionist to facilitate the inclusion of cooking oil and sugar because the districts have been finding procuring therapeutic feeds in the 2019 CoC plans for challenges to procure F-75 and F-100 formula feeds. the district. Lack of IEC materials on nutrition in some facilities DHOs advised to include printing of IEC materials in the 2019 CoC plans

Adolescent Sexual Inadequate transport to facilitate field visit to all the districts To strengthen integration of ASRH technical Reproductive Health assistance in other technical areas

To reinforce integration of ASRH in the field visit possibly TA trackers should be used to track ASRH activities Delayed response to approve the revised 2018 CoC Plans by SIDA, this delayed the implementation of activities in the • The District health office to enhance districts communication with the SIDA focal point person for feedback Limited understanding of ADH programming by DHO staff. • District ADH Focal point staff to make use of the district meetings to share information with DHO staff as a way to bring them to speed on ADH programming

Crosscutting Some districts are yet to form District Multidisciplinary Support Districts in forming and developing schedules Mentorship Teams for their District Multidisciplinary Mentorship teams

137 | Page

VI. Lessons Learned – Cross cutting (what worked well and what did not work well) things you did to get to the end of the road

Newborn Lesson Learnt • District do not use indicator performance scorecard to analyze the performance of RMNCAH/N indicators. • Eastern Province has an Eastern Province Zambia Maternal Neonatal and Child Health Alliance CSO stakeholder Coalition Building and Advocacy Steering Committee that has a goal of improving maternal, neonatal and child health in the province through advocacy.

Adolescent Health – Lessons learnt

During the period under review, the following were some of the Lessons Learned: v. The extracted high impact intervention given to the districts helped the DHOs align their programming to the National Health Strategic Plan and the ADH Strategy vi. The allocations to the districts for 2019 plans was insufficient to cutter for all the proposed interventions, however some high impact activities were prioritized and integrated vii. The use of the scorecard was helpful for the districts to prioritize key interventions to be include in the 2019 CoC plans viii. There was need for more orientations and trainings of health care workers in ADH as most of them were not exposed to working with adolescent health

Community Engagement - Lessons learnt What went well? Good collaboration with other partners organization supporting PHO (PAMO, JSI, Breakthrough Action) has resulted into partner meeting every two weeks chaired by MCSP Good collaboration with Break Through Action resulting into formation of Provincial Health Promotion Technical Working Group Good collaboration with GRZ counterparts (PHO, DHO and facilities). PHO has been providing transport to facilitate MCSP movements

What didn’t go well? Inadequate transport and budgets hampering MCSP follow up visits to districts DHO staff not being proactive in implementing Technical Assistance visit recommendations. Most recommendations are either partially undertaken or not done at all. DHO teams are willing to undertake activities associated with immediate monetary gain creating an imbalance in activity implementation Facilities and DHOs not having data review meetings DHOs not engaging themselves in explaining to facilities the MCSP and G2G support. Most facilities were unaware of the G2G and MCSP mandate. Poor program coordination between MCSP and SBH. Weak program integration at district level. Weak program ownership which might challenge continuity once MCSP comes to an end.

Lessons Learnt: Joint programme undertaking between MCSP, SBH and PHO should be planned and encouraged. When teams move together, they complement each other and provide immediate assistance. The recent MCSP and PHO trip from 9th to 15th September is one good example.

138 | Page

DHO teams do not hold regular monthly and quarterly meeting and do not share information. This has resulted into TA visits appearing to be ineffective. Programme officers keep information to themselves and in most instances if they did not implement the recommendations end up refusing having been oriented / mentored. Continued presentations of TA at various fora is leading to acceptance of MCSP TA in the province and particularly at DHO level. The community engagement agenda is still not a priority when developing activity plans. TA in this area should be strengthened Weak programme integration at DHO. Need for DHO programme officers to do joint programme planning MCSP team should spend much time at facility level because DHOs do not usually reach out, rarely share program information, and DHOs have highly centralized RMNCAHN activity implementation. Most facilities do not have clear understanding of RMNCAHN programme.

139 | Page

VII. Major Activities Planned for Next Quarter Recommendations for TA / TA Planned (- What Small TA Thematic area Activity- refer to the approved WP activities are u going to do) Maternal 1.1.1 TA visits to Districts assist the MCH Coordinators plan for follow up Provide technical assistance during visits to staff who have been trained in short courses like EmONC in implementation of 2018 CoC grants specific facilities 1.1.2 Participate in the District Integrated Meetings and provide TA during Provide technical assistance during monitoring the review of data from facilities of 2018 CoC Grants 1.1.3 Provide technical assistance during planning of Provide feedback to districts to the developed 2019 CoC plans 2019 CoC grants Technical Assistance to programming for Provide TA during the planning for mentorship activities at PHO and mentorship in the province district levels with the use of the developed mentorship dashboards. Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Visit the districts to follow up on the establishment of multi- disciplinary district mentorship teams to effectively conduct mentorship rounds in the facilities under the specific districts. Equip mentorship teams with models To attend district planning meetings and follow up the inclusion of models and job aids in the 2019 CoC plans. Distribute the models according to the distribution list developed by PHO and MCSP Newborn 1.1.1 • TA visits to districts Provide technical assistance during • Identify and disseminate best practices and innovations implementation of 2018 CoC grants • Make recommendations to introduce innovations through CoC grants 1.1.2 Provide technical assistance during monitoring Participate in District and provincial integrated meetings of 2018 CoC Grants Review and provide feedback to CoC district reports Review and provide feedback to national CoC program report Prepare written recommendations to revise CoC district plans 1.1.3 Participate in MOH district and Provincial Planning meetings Provide technical assistance during planning of 2019 CoC grants Provide feedback to districts to revised CoC plans Identify innovations to be programmed through revisions to 2018 CoC grants or 2019 plans

140 | Page

Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Coordinate with districts to include mentors in planned clinical trainings in 2018 CoC grant

Equip mentorship teams with models Distribute anatomical models and printed material to skills lab Technical Assistance to programming for mentorship in 2019 CoC Plans Provide TA to PHO and District Hospital CoC grants for hospital- based mentorship Child health 1.1.1 • TA Visits to districts build capacity in the DHO staff to provide Provide technical assistance during mentorship to facility staff implementation of 2018 CoC grants • Follow up the roll out of eIMCI/EPI training package • Follow up the implementation of QI projects in facilities . 1.1.2 • Provide TA to districts during DIMs, Data Review meetings to Provide technical assistance during monitoring help the districts use data for decision making of 2018 CoC Grants • Follow up the use of mentorship and SQA tools and dashboards Strengthen the capacity of DHO to analyze community data from CBVs trained in ICCM 1.1.3 Provide TA to districts on finalization and refining of 2019 CoC plans Provide technical assistance during planning of 2019 CoC grants Activity 1.2: Improve quality of RMNCAH&N services through introduction/expansion of on-site mentorship Establish mentorship teams Follow up the formation of integrated mentorship teams Provide technical assistance to districts to link Follow up the implementation of SQA and formation of mentorship mentorship with existing quality assurance dash boards in the districts activities Community 1.1.1 Provide technical assistance during implementation of 2018 CoC engagement Provide technical assistance during grants to all nine target districts implementation of 2018 CoC grants 1.1.2 Provide technical assistance during monitoring of 2018 CoC Grants in Provide technical assistance during monitoring all nine target districts of 2018 CoC Grants

1.3.8 Support facilities to develop and update • Offer Technical assistance to districts on the formation and dashboards and utilize for decision making interpretation of dashboards of key indicators for decision making for community engagement to result in increased access

141 | Page

of certain services • Facilitate development of RMNCAHN Risk maps and mentorship dash boards • Provide TA in SQA and Community Engagement. 1.4.1 Strengthening district & community Follow up TA to all districts to strengthening district & community platforms for accountability of RMANCH&N platforms for accountability of RMANCH&N services services between the district and community stakeholders through stakeholder profiling and strengthening / establishment of structures 1.4.2 Improve capacity of district, facility and Improve capacity of district, facility and community members to plan community members to plan and mobilize and mobilize resources in order to implement and monitor RMNCH- resources in order to implement and monitor N preventive and promotional activities in 9 districts RMNCH-N preventive and promotional activities 1.4.3 Strengthen implementation of CE Follow up TA to districts to strengthen implementation of CE activities at community level to address social activities at community level to address social norms for gradual norms for gradual adoption of recommended adoption of recommended RMNCH&N practices through varies RMNCH&N practices through varies community platforms such as community dialogues, drama and social community platforms such as community mass media communication. dialogues, drama and social mass media communication. Nutrition 1.1.1 Nutrition TA visits to districts to be re-enforced Provide technical assistance during implementation of 2018 CoC grants 1.1.2 Provide TA to districts to be able to create the nutrition dashboards Provide technical assistance during monitoring for easy monitoring of 2018 CoC Grants 1.1.3 Provide TA for districts to identify the nutrition high impact Provide technical assistance during planning of interventions included in the 2019 CoC plans 2019 CoC grants ASRH 1.1.1 • Provide TA in the formation of District Technical Working Provide technical assistance during CoC Groups in ASRH in Kanchibiya. Strengthen functionality of planning already set up ADH TWGs in Chinsali, Mpika, and Nakonde

• Provide TA to Chinsali DHO in the establishment of the district youth friendly space

142 | Page

• Develop list of ADH focal point staff in the 4 provinces to improve channel of providing TA in ASRH

143 | Page