PPP ECD Programming

PPP ECD programming

CA AID-656-A-16-00002 (GDA ECD Programming)

Fiscal Year 2018 Year 3: April 2018–March 2019

Quarterly Report: Q4 January– March 2019

Submitted on: April 30, 2019 Submitted to: United States Agency for International Development Cooperative Agreement No. AID-656-A-16-00002

Submitted by: PATH Street address: 2201 Westlake Avenue, Suite 200 Seattle, WA 98121, USA Mailing address: PO Box 900922, Seattle, WA 98109, USA Tel: 206.285.3500; Fax: 206.285.6619 www.path.org

This work is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the sole responsibility of PATH and do not necessarily reflect the views of USAID or the United States Government

Contents

Abbreviations...... 2 1. Overview of the reporting period ...... 3 2. Project objectives ...... 5 3. Results framework/Logical framework ...... 5 4. Indicators ...... 7 Indicator 1 ...... 7 Progress and issues ...... 7 Indicator 2 ...... 8 Progress and issues ...... 9 Indicator 3 ...... 10 Progress and issues ...... 10 Indicator 4 ...... 11 Progress and issues ...... 11 Indicator 5 ...... 12 Progress and issues ...... 12 Indicator 6 ...... 17 Indicator 7 ...... 18 Indicator 8 ...... 18 Progress and issues ...... 19 Indicator 9 ...... 20 Progress and issues ...... 21 Indicator 10 ...... 21 Progress and issues ...... 21 Indicator 11 ...... 22 Progress and issues ...... 24 Indicator 13 ...... 25 Progress and issues ...... 25 Indicator 14 ...... 26 Progress and issues ...... 26 5. Monitoring and evaluation ...... 28 6. Upcoming plans ...... 32 7. Administrative update ...... 32 8. Financial information ...... 33 9. Appendices ...... 33 Appendix A. Success story ...... 33 How two health providers helped Juvêncio survive and thrive ...... 33

Abbreviations

ANC antenatal care APE agente polivalente elementar (community health worker) ART antiretroviral therapy CCD Consulta da Criança Doente (sick-child consultation) CCR Consulta da Criança em Risco (child-at-risk consultation) CCS Consulta de Criança Sadia (child well-being consultation) CHC child health committee CHW community health worker CPC child protection committee CPP Consulta Pós-Parto (post-partum consultation) DPGCAS Direcção Provincial do Género, Criança e Acção Social (Provincial Directorate of Gender, Children and Social Welfare) DLI disbursement linked indicators DPS Direcção Provincial de Saúde (Provincial Health Directorate) ECD early childhood development eECD Expanding Early Childhood Development (Project) EGPAF Elizabeth Glaser Pediatric AIDS Foundation GDA Global Development Alliance GFF Global Financing Facility HF health facility HIV human immunodeficiency virus IEC information, education, and communication IMCI Integrated Management of Childhood Illness IR intermediate result IYCF infant and young child feeding LOP life of project MCH maternal and child health MGCAS Ministério do Género, Criança e Acção Social (Ministry of Gender, Children and Social Action) MOH Ministry of Health NGO nongovernmental organization OVC orphans and vulnerable children PEPFAR US President's Emergency Plan for AIDS Relief PES Plano Económico e Social (Social and Economic Plan) PIN Pacote Integrado Nutrição (integrated nutrition package) PNC postnatal care PPP public-private partnership S-ECD Scaling Up Early Childhood Development (Project) SDSMAS District Directorate of Health, Women and Social Welfare TWG technical working group UNICEF United Nations Children's Fund USAID United States Agency for International Development WHO World Health Organization

1. Overview of the reporting period

The Integrating Early Childhood Development (ECD) Global Development Alliance (GDA) Programming is a public-private partnership (PPP) between the United States Agency for International Development (USAID), the Conrad N. Hilton Foundation, and PATH, which works to integrate ECD programming in Mozambique. This PPP focuses on improving child development outcomes for vulnerable children 0–3 years in targeted areas of Mozambique, through an integrated health, nutrition, sensitive care, and stimulation intervention for health and social services provided by government and partners. This PPP is a three-year cooperative agreement that started on April 6, 2016. This progress report summarizes the accomplishments of the project during the fourth quarter (January to March 2019) of the third year of project implementation. PATH has continued to support the Ministry of Health (MOH) and Ministry of Gender, Child and Social Action (MGCAS) in developing activities to reinforce the integration of ECD in health facilities (HFs) and communities with the objective to improve the life of children ages 0–3 years. To achieve these results, PATH combines innovation and provision of technical assistance for strengthening ECD service delivery through HFs and community-based organization.

During this quarter, the PPP team continued working with the Maternal Health, Child Health, Nutrition, and Mental Health departments and technical working groups (TWGs) of the MOH to review and follow up on a range of relevant documents for integrating ECD and for improvement screening and counselling on maternal depression.

PATH provided financial support for the launch of the National Infant and Young Child Feeding (IYCF) Strategy, which was reviewed by the PPP team in previous quarters to integrate specific ECD-related content and was approved in January 2019. The launch event took place in March 2019 and was presided by the First Lady of the Republic of Mozambique.

Although PATH is not directly involved in the clinical treatment of malnutrition, nutritional counseling to caregivers of children 0–5 years was carried out in all HFs supported by the project as part of the ECD integration strategy. A total of 14,128 children under five years were reached by community health workers (agentes polivalentes elementares [APEs]) with nutrition interventions in all seven districts with APEs.

At the HF level, data collected across all 55 target HFs of the eight target districts covered by the project indicated that 95,096 beneficiaries (caregivers of children under five) received ECD and nutrition counseling.

During this reporting period, a total of 40 health providers received mentoring visits, of whom 21 achieved the desired score of at least 80 percent threshold for the first time.

During the reporting period, 181 playbox sessions were conducted in the 12 target HFs, reaching a total of 17,857 caregivers of children under five.; and a total of 57 Projecting Health video sessions were conducted in HFs and child protection committees (CPC) across all intervention districts, except for Boane, and were attended by a total of 2,368 caregivers (658 male and 1,710 female). The playbox and the video sessions are part of the information, education, communication (IEC) activities facilitated by trained HF service auxiliary staff and HIV counselors and supported by maternal and child health (MCH) nurses. Playbox and video sessions are held in the early morning hours in HF waiting areas, while caregivers and their children wait to receive different MCH services—e.g., antenatal care (ANC), postnatal care

(PNC), consultation of children at risk (Consulta de Criança Sadia [CCR]), child well-being consultation (Consulta de Criança Sadia [CCS]), and pediatric antiretroviral therapy (ART).

The PPP team partnered with the Moamba District Directorate of Health, Women and Social Welfare (Serviço Distrital de Saúde, Mulher e Acção Social [SDSMAS]) to rehabilitate and refurbish the pediatric ward of the Moamba-Sede Health Center, with the objective of making the ward safer and more child-friendly. The new ward opened in March 2019.

The PPP team in collaboration with the SDSMAS continued to provide direct support, mentoring, and supervision to APEs in the districts. A total of 12 APEs in Manhiça and Moamba received mentoring and supervision visits, of whom seven reached the threshold score of 60 percent in previous quarters and two reached the threshold of 60 percent for the first time during this quarter. Additionally, a total of 155 APEs received refresher trainings in this quarter.

The PPP team supported the SDSMAS of Matutuíne and community partner CESAL in strengthening the implementation of the Parenting Education package through agricultural associations.

A total of 734 children monitored across CCS, CCR, CCD, pediatric ART, post-partum consultation (Consulta Pós-Parto [CPP]), and maternity services on first and following visits were suspected to have developmental delays.

IEC materials, as training materials produced under the PPP, continue to elicit high interest and demand at the district, provincial, national and regional levels. In the reporting quarter, IEC materials on developmental monitoring and stimulation developed under the PPP were distributed to all HFs in Monapo District, Nampula Province, and implementation sites in Matola District, Maputo Province, and were integrated into the new Child Health Booklet in Zambia.

The PPP team continued to disseminate its work and the concept of nurturing care for ECD for the youngest children through different national events, including commemorative days (e.g., Father’s Day) and field visits (e.g., USAID/Mozambique Mission Director’s visit to Moamba District and Her Royal Highness the Queen of Belgium’s visit to Marracuene District).

During the semester October 2018 to March 2019, APEs served a total of 4,301 orphan and vulnerable children (OVC) ages 0–4 years (2,064 male and 2,237 female), which represents a 44 percent increase in comparison to the previous quarter (2,994 OVC served from March to September 2018) and 100 percent achievement of the target for the reporting period.

As part of the close-out process, the PPP team conducted transition meetings in each of the initial six project districts and a provincial meeting, in which all eight districts of Maputo Province were represented. These meetings were used as a measure to promote ownership of the ECD- related activities included in the Social and Economic Plan (Plano Económico e Social [PES]) by the district and provincial health and social action authorities, with a much lighter support provided by PATH through the eECD project.

In January, PATH staff member Melanie Picolo assumed her new role as the PPP Project Director. USAID/Mozambique approved the project closeout plan and collaborated closely with

PATH to complete the preparations for the closeout event. Due to the occurrence of Cyclone Idai, a natural disaster of unprecedent impact in the African continent that hit central Mozambique, the closeout event was postponed. USAID granted PATH a three-month no-cost extension to finalize outstanding activities, including sharing the lessons of the PPP in a closeout event and finalizing the report and disseminating the results of the operational research.

2. Project objectives

The goal of the Global Development Alliance PPP for integrating ECD programming is to improve development outcomes for children 0–3 years in targeted areas of Mozambique through an integrated health, nutrition, sensitive care, and stimulation project. The project has three objectives/result areas:  Result 1: Create an enabling environment at the national level for the integration of ECD interventions, which target the youngest vulnerable children, into social action and health systems and services.  Result 2: Improve care and stimulation behaviors of caregivers of vulnerable children aged 0–3 years through social action and health-sector partnerships with government and civil society that expand integrated ECD programs in the country.  Result 3: Expand the knowledge and evidence base on integrated ECD.

3. Results framework/Logical framework

The results framework included in Figure 1 represents the PPP project’s vision for achieving its objectives.

Figure 1. Results framework for the Integrating Early Childhood Development Global Development Alliance Programming

4. Indicators

In line with our performance monitoring plan, below we discuss project progress and achievements toward results and intermediate results (IRs) indicators. For a better understanding of the indicators and their figures, the following concepts are defined:

LOP: Life of Project. The PPP lifetime is from April 2016 to June 2019, inclusive of a three- month no cost extension to allow for the PPP closing ceremony to be rescheduled. For indicator reporting purposes, project implementation ended April 6th, 2019. Of note is that the LOP also includes the lifetime of the Scaling Up Early Childhood Development (S-ECD) project funded by the Conrad N. Hilton Foundation.

S-ECD project only: Refers to results obtained under S-ECD project between July 2015 and March 2016—i.e., immediately before the start of the PPP. These results are mentioned as “baseline” in the terminology utilized in the PPP performance monitoring plan and are included in the LOP target column.

PPP Year 1, 2, 3 achievements refer to results obtained in project Years running from April- March, beginning April 2016.

Result 1: Create an enabling environment at the national level for the integration of ECD interventions, which target the youngest vulnerable children, into social action and health systems and services

IR 1.1: Improved adoption of orphans and vulnerable children (OVC), MCH, and community health worker (CHW) materials with integrated ECD content

Indicator 1

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Achievements Percent target only Achieve Achieve Y3 achieved of Indicator -ments -ments Annual Y3 annual target Q1 Q2 Q3 Q4 target

Number of PATH IEC materials approved 7 2 4 3 1 0 0 0 0 0% by provincial or national government

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year; IEC: information, education, and communication.

Progress and issues In this quarter, PATH continued to participate actively in relevant MOH TWG meetings throughout the quarter, including meetings of the IYCF TWG, the Nutrition Rehabilitation Program TWG, the Nutrition Social and Behavior Change Communication TWG, and the Prevention of Mother to Child Transmission TWG, to identify opportunities to integrate ECD- related content in national policies, strategies, guidelines and job aids and advocate for approval of PATH IEC materials that can be of use to others. Due to reasons outside PATH’s control, no new PATH IEC materials were approved by provincial health directorates or the national MOH

in the reporting period. PATH followed up with the MOH Nutrition Department to obtain their feedback on the recipe booklet submitted for approval in the previous quarter, however due to administrative issues within the MOH the feedback had not reached PATH by the end of quarter. During the reporting period PATH also submitted a complementary feeding counselling poster for the approval of the MOH Nutrition Department and advocated for its review and validation to be part of the agenda of the second IYCF TWG meeting of 2019. However, due to the focus on the emergency response to Cyclone Idai, the meeting did not take place by the end of the fourth quarter. PATH will continue to actively pursue the approval of these materials as part of the eECD project funded by the Conrad N. Hilton Foundation and promote its rollout in the eight provinces where the Global Financing Facility (GFF) disbursement-linked indicator (DLI) 4—Package of Nutrition Interventions will be implemented.

In this quarter, the MOH Mental Health and Maternal Health departments reviewed and validated the maternal depression screening and counselling protocol and the maternal depression counseling cards. The PPP team is currently planning the training and rollout of the materials in a six-month pilot in five HFs in Matola District and three HFs in Moamba District, in coordination with the MOH and the Maputo Provincial Directorate of Health (Direcção Provincial de Saúde [DPS]). By the end of the reporting period, the PPP team had conducted a baseline assessment in the eight pilot HFs and had begun developing the training materials.

In terms of ECD integration into relevant policies and strategies, the national IYCF Strategy that integrates specific ECD-related content, particularly on stimulation in the context of the treatment of acute malnutrition and in nutrition services offered to OVC, was approved in January 2019 and was launched in March 2019 at an event presided by the First Lady of the Republic of Mozambique, and supported by PATH.

Outside of the health sector, building from the results of the last quarter, the MGCAS requested technical and financial support from PATH to conduct a parenting education workshop with all its implementing partners—including Save the Children, Plan International, Care, ADPP, and the Ministry of Education—to inform their decision regarding the content of the national parenting education package. During the meeting, which will take place in the next quarter, each partner, including PATH, will present their parenting education package for MGCAS assessment. PATH will continue to support MGCAS in this effort through the eECD project funded by the Conrad N. Hilton Foundation.

IR 1.2: Increased ECD content in district and provincial social action and health plans

Indicator 2

LOP S- PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target ECD Achieve- Achieve- Annual achieved Indicator only ments ments target of Y3 Q1 Q2 Q3 Q4 annual target

Number of targeted health and social action plans that include ECD 20 3 5 7 8* N/A 8 N/A N/A 100% content and goals for ECD integration.

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. *Including Matola and Boane

Progress and issues During this quarter, PATH worked intensively with the Maputo DPS and SDSMAS of the eight districts of the province to implement the 2019 provincial- and district-level PES, where PATH supported the integration of nurturing care activities for ECD in the areas of maternal and child health (MCH), nutrition, community health workers (CHWs) and integrated management of childhood illnesses (IMCI).

As part of the close-out process, the PPP team conducted transition meetings in each of the six districts in which the project was implemented from the first year (Magude, Manhiça, Marracuene, Matutuíne, Moamba, Namaacha) as a measure to promote ownership of the ECD- related activities included in the PES by the district health and social action authorities, with a much lighter support provided by PATH through the eECD project. Furthermore, PATH co- hosted a meeting with the Maputo DPS on March 7th to take stock of the progress and achievements in the integration of nurturing care in health systems throughout the three years of implementation of the PPP, and how the support will continue as part of the eECD project. All eight districts were represented in the meeting. PATH presented key performance indicators per district, including how results changed over time and where each district is in terms of the proportion of health providers at the facility and community levels meeting performance standards. This allowed each district to prioritize areas to continue to work on as the PPP ends. Most participants made remarks about the positive influence the project has had in improving interactions among health providers and between health providers and clients as a result of improved interpersonal communication skills, as well as how the planning process improved as a result of supervision visits, since priorities could be identified from the action plans designed at the end of regular supervision visits. Remarks were also made as to how the PPP supported health providers in learning how to integrate nurturing care interventions in their day-to-day work, as they had learned about developmental monitoring and stimulation as part of pre- service training but had not come to understand how to effectively integrate the interventions in practice. Moreover, participants commented that when clients return to the HFs, they are eager to share their children’s developmental milestone achievements with health providers and that caregivers who have children with developmental delays are seeking care earlier.

PATH has agreed with the Maputo DPS and the SDSMAS of the six districts that support will continue to be provided for provincial annual planning cycles and district-level bi-annual supervision visits at the HF level and quarterly supervision visits at the community level, through the eECD project.

IR 1.3: Improved ECD content in existing health and social action curricula, guidelines, and data tools

Indicator 3

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Percent Y3 Achievements target only Achieve- Achieve Annual achieved of Indicator ments -ments target Y3 annual Q1 Q2 Q3 Q4 target

Number of government curricula, guidelines, and data tools revised by 4 1 1 2 1 5 1 0 0 600% PATH to include ECD content and adopted by government

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues A. Review of MCH nurse pre-service training curricula During this quarter, PATH received the IMCI and well-child clinic modules from the consultants working on the development of the MCH pre-service training curricula and revised them to integrate content on developmental monitoring and stimulation. The revised modules were submitted to the Training Department of the MOH for their consideration and finalization by the consultants. By the end of the reporting period, PATH was still waiting to receive the maternal health module to integrate content on screening and counselling for maternal depression.

B. Other technical assistance provided through participation in international forums and MOH/MGCAS TWGs HIV Through its participation in the Prevention of Mother to Child Transmission TWG, PATH was invited to contribute to the Mothers to Mothers (M2M) training manual and supervision tools, to improve their overall technical quality and to integrate relevant nurturing care content. PATH continues to advocate with all members of the TWG to ensure the integration of nurturing care content to improve ECD in HIV-related guidelines, manuals, and tools.

Nutrition Building from the work conducted in the previous quarter, PATH provided technical assistance to the Nutrition Department of the MOH to improve the pedagogical approach and technical quality of the integrated nutrition package (Pacote Integrado Nutrição [PIN]) materials to be used under the GFF DLI 4, through an agreement with UNICEF. PATH used content and illustrations from materials developed under the PPP to complete this work and promoted the use of the recipe book and complementary feeding counselling poster submitted to the MOH Nutrition Department for approval in the last and the current quarters, as previously reported, for the implementation of PIN. These activities allow work designed and validated in Maputo Province under the PPP to be scaled up across eight provinces of the country where the GFF DLI 4 will be implemented.

APEs During this quarter, PATH continued to work closely with UNICEF and the APEs TWG to advocate for the approval of the APE supervision manual, revised last quarter, and the revision of the APE supervision tools. By the end of the reporting period, the APE TWG had not been able to meet to conclude this work due to the focus of the MOH on the humanitarian emergency response.

Result 2: Improve care and stimulation behaviors of caregivers of vulnerable children aged 0 to 3 years through social action and health-sector partnerships with government and civil society that expand integrated ECD programs in the country.

IR 2.1: Improved ECD knowledge and skills of service providers at health facilities.

Indicator 4

LOP S-ECD PPP Y1 PPP Y2 PPP Percent Y3 Achievements target only Achieve Achieve Y3 achieved of Y3 Indicator -ments -ments Annual annual target target Q1 Q2 Q3 Q4

Number of health providers 370 135 85 115* 23** 93 28*** 0 125% trained on ECD 35 by PPP project

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. * 63 Health providers from Matola, 29 from Boane, and 23 new health providers from Marracuene ** In Q1 127 providers received ECD training in different components such as IMCI, nutrition in-patient treatment, etc. but only 23 of these providers were trained for first time. *** These providers were already trained in ECD in the past but received complementary training in specific areas integrating ECD, such as IMCI, in-patient treatment of malnutrition, etc.

Progress and issues

A. Trainings During this quarter no trainings were conducted, as the focus of the PPP team was on consolidating activities and transitioning them to SDSMAS in the six initial PPP districts. PATH continued to discuss the pilot of maternal depression protocols and counselling job aids in the two expansion districts (Boane and Matola) with the MOH and the DPS.

Planning for the initial training on maternal depression PATH partnered with the Mental Health and Maternal Health Departments of the MOH to conduct a meeting with the Maputo Province Medical Chief Officer, Provincial MCH focal point, Provincial Mental Health focal point, and their district counterparts from Boane and Matola to coordinate the pilot of the maternal depression protocols and counselling job aids developed by PATH and validated by the MOH in those two districts. The provincial and district teams selected eight HFs in which to conduct the pilot—namely Boane, Campoane and Beluluane in

Boane District and Matola II, Machava II, Ndlavela, Matola Gare and Khongolote in Matola District. PATH began developing the training materials to conduct the initial training on maternal depression for the health providers in those health centers. The districts’ maternal health and mental health focal points will collaborate with PATH to conduct a baseline assessment, and PATH and the MOH will co-facilitate the initial training in the next quarter, under the eECD project.

Indicator 5

Y3 Achievements Total Percent project PPP Y1 PPP Y2 PPP Y3 Q1 Q2 Q3 Q4 LOP S-ECD achieved accumula Indicator Achieve- Achieve Annual target only of annual -tive ments -ments target target Y3 achievement Percentage of health facility clinical providers reaching the 75% 24 91 32 75% NA NA 33 21 73% 76% threshold score of 80% for ECD services (*) Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*)This is 75% of the number of health providers who are eligible for receiving mentoring sessions according to the new strategy: 99 providers of Matola (46), Boane (31) and Marracuene (22), in addition to the 191 accumulated until Y2.

Progress and issues Implement an overall project quality improvement approach and support district supervision and facility-specific action plans around MCH, nutrition, and ECD.

A. Follow up of action plans During the reporting period, the PPP team conducted follow-up of activities in the action plans produced in the previous round of supervision in 16 HFs in three districts, so as to complete the supervision cycle. The HFs included Wamongo, Goba, Changalane, Mahelane, Mafuiane, Kulula, and Namaacha in Namaacha District; Ngolhosa, Tenga, Corrumane, Sábie, and Ressano Garcia in Moamba District; and Xinavane, Maragra, Maluana, and Nwamatibjana in Manhiça District. The PPP team and district focal points of MCH, IMCI, nutrition, and monitoring and evaluation from the three districts provided technical support on best practices in their respective technical areas and on integration of care and stimulation into routine services. In addition, the support focused on some of the gaps noted during previous supervision activities, such as:  Completion of children’s health cards and conducting CCS according to MOH norms.  Data collection and preparation of monthly summaries for ECD, MCH, and nutrition.  Correct implementation of developmental monitoring and stimulation and IMCI services.  Production and use of toys made with recycled materials during child visits, to promote child development.  Provision of nutrition counselling to caregivers during CCS visits.

 Carrying out developmental monitoring, according to MOH norms.  Correct use of the new CCS and CCD registers and using them to reinforce child development monitoring and counseling.

In general, the PPP team noted improvements in comparison to the previous supervision round:  Health providers demonstrated skills and knowledge in providing good quality services to clients.  Children’s health cards were appropriately completed.  CCS was implemented according to MOH norms.  Nutrition counselling was provided to caregivers.  Nurturing care interventions for ECD were integrated during the provision of health services to various clients.

B. Mentoring of new health providers in Matola, Boane, and Marracuene Following the training of 93 providers from Matola, Boane, and Marracuene districts in the previous quarter, the PPP team conducted joint mentoring with SDSMAS in the HFs of Marracuene Village, Michafutene, Mali, Eduardo Mondlane, Habel Jafar, Ricatla, Mumemo, and Macaneta in Marracuene District; Ndlavela, Matola II, and Machava II in Matola District; and Boane Village, Campoane and Beluluane in Boane District. In the current mentoring model, each health provider is mentored three times after being trained, and then integrated into regular supervision processes. During this reporting period, a total of 40 health providers received mentoring visits (15 in Marracuene District, 18 in Matola District, and 7 in Boane District), of whom 21 achieved the desired score of at least 80 percent threshold for the first time. Table 1 disaggregates the figures by sex and district. During mentoring visits, health service provision was observed to:  Monitor compliance with the recommendations provided in the previous mentoring visit.  Verify the integration of child development monitoring and stimulation in ANC, maternity, CPP, CCS, sick child consultation (Consulta da Criança Doente [CCD]) and pediatric ART.  Provide technical support in the implementation of new CCS and CCD register books.  Provide technical support to fill identified gaps.  Praise caregivers for practicing promoted behaviors and practices.

The team observed improvements in the performance of health providers as a result of the training and mentoring visits, including integration of nurturing care interventions in all HF sectors assessed; presence of registers and data reports; solid knowledge of nutrition interventions; promotion of male partner involvement in MCH services; and compliance with MOH protocols and norms. However, the team also identified persistent structural challenges, including lack of health providers in sufficient numbers in Boane District due to vacations, off- site trainings, and staff rotation; low quality CCS services and incomplete registers in Campoane HF due to services being led by interning students; and lack of use of the new CCS and CCD registers in Michafutene HF because the trained health provider was on vacation. The PPP and SDSMAS mentoring teams employed strategies to mitigate this, including sensitizing the leadership of the HFs to ensure adequate supervision of interning students and that knowledge transfer activities are appropriately scheduled, particularly when only one provider in a HF has been trained in a given subject.

Table 1. Number of health providers mentored, disaggregated by sex per district (Matola, Boane, and Marracuene). # HP mentored in # HP mentored in # HP trained that # HP mentored in Total # HP the quarter that the quarter that received the quarter that trained (eligible meet the 80% meet the 80% mentoring visit in did not meet the for mentoring) threshold (not 1st threshold (1st the quarter 80% threshold District time) time)

Male Male Male Male Male

Total Total Total Total Total

Female Female Female Female Female

Marracuene 23 17 6 15 10 5 5 4 1 10 6 4 0 0 0 Boane 29 27 2 7 7 0 0 0 0 4 4 0 3 3 0 Matola 41 37 4 18 18 0 10 10 0 7 7 0 1 1 0 Total 93 81 12 40 35 5 15 14 1 21 17 4 4 4 0

C. Supervision of the use of the new CCS and CCD registers During this reporting quarter, the PPP team provided financial and technical support to the DPS to conduct the first round of supervision to all eight districts of Maputo Province since the rollout of the new CCS and CCD registers began in December 2018. The objectives of the supervision visits were to:  Assess the level of implementation of the new child health register books and identify challenges faced.  Assess the quality, effectiveness, and efficiency of the child health care provided by the HPs.  Assess the accuracy in the identification of childhood illnesses and the provision of appropriate integrated management of all major illnesses, including treatment, counselling, and timely referrals of critically ill children.  Assess the availability of personnel in adequate number to provide care to children under five years of age.  Evaluate how nurturing care interventions are implemented and registered by health providers into the new registers.

During the supervision visits, the DPS and PPP teams identified that health providers are making an effort to complete the register books correctly but are facing several challenges, some of which are structural in nature—e.g., the lack of sufficient human resources to provide services with appropriate quality and register them, such as in HFs where a single health provider is responsible for providing services in all sectors—while others can be resolved through mentorship on how to enter data in the register books and daily and monthly reporting sheets, which was also provided during the visits. The following recommendations to reduce data entry errors and mitigate challenges were provided by the supervision teams:  The district-level monitoring and evaluation focal points should provide technical support and conduct regular supervision visits to all HFs in their respective districts.  The health providers trained in the new CCS and CCD registers should replicate the training in their HFs so that all health providers are able to appropriately enter data in the registers and reports.  Child health focal points should make timely requests for re-stocking of CCS and CCD registers to avoid stock outs at the HF level.

 All health providers in the CCS must perform nutritional assessments of all children attending the services and refer any children identified with malnutrition to the appropriate level of care.  All health providers in the CCD must screen eligible children attending the services for HIV, tuberculosis, and psychomotor development delays.  All health providers in the CCS—not just nutritionists, as many health providers seemed to believe—must enter data in the register books, daily reporting sheets, and monthly reporting sheets.  All referrals must be registered in the appropriate column in the CCS and CCD registers, in order for the referral to be recorded at the point of entry.

PATH will continue to support the implementation of these recommendations through the eECD project.

D. Support to ensure the integration of nurturing care activities in district mobile brigades During the reporting period, the PPP team supported one mobile brigade at the request of the SDSMAS of Boane, where immunization and nurturing care for ECD interventions were integrated. As noted in previous reports, mobile brigades comprise several technicians and are an MOH strategy to provide different services such as vaccination, MCH, nutrition, and medical consultations to remote communities with limited access to HFs.

E. Implementation of playbox sessions in target health facilities During this reporting period, the PPP team joined efforts with the SDSMAS of all seven districts to provide technical support to health providers who are responsible for supervising playbox facilitators daily and ensure that they are adequately recording and reporting data on the playbox sessions implemented in targeted HFs. The PPP team observed that playbox sessions are performed by capable facilitators, who are well versed on nutrition and developmental stimulation, know how to use job aids during the sessions, use clear and simple language, and engage caregivers—including male caregivers—in dialogue by asking relevant questions. The team could also observe that activities are adequately recorded and playboxes are well stocked with toys.

In total, 181 playbox sessions were conducted in the 12 target HFs, reaching a total of 17,857 caregivers of children under five. Playbox sessions are held in the early morning hours in the HF waiting areas, while caregivers and their children wait to receive health services (e.g., ANC, PNC, CCR, CCS, CCD, and pediatric ART).

Table 2 below summarizes the activities for the quarter.

Table 2. Number of playbox sessions and participants.

District # of Sessions # of Participants Namaacha 6 147 Marracuene 33 5,123 Matutuíne 3 47 Moamba 61 3,686 Magude 18 612 Manhiça 39 6,619 Boane 21 1,623 Total 181 17,857

F. Support to the rehabilitation and refurbishing of the pediatric ward of the Moamba-Sede Health Center

During this quarter, the PPP team partnered with the Moamba SDSMAS to rehabilitate and refurbish the pediatric ward of the Moamba-Sede Health Center, with the objective of making the ward safer and more child-friendly. The rehabilitation work included replacing light fixtures, repainting the internal and external walls and the floor, and substituting window panels. The refurbishment also entailed replacing bed sheets and improving the materials for the play corner.

Moamba-Sede Health Center Pediatric Ward before the Moamba-Sede Health Center Pediatric Ward after the rehabilitation. Photo credit: PATH/Tania Coutinho. rehabilitation. Photo credit: PATH/Hideke Sambo.

IR 2.2: Improved ECD knowledge and skills of community-based health and social action providers

Indicator 6

LOP S- PPP PPP PPP Year 3 Achievements Percent target ECD Year 1 Year 2 Year 3 achieved Indicator only Achieve- Achieve- Annual of Y3 ments ments target Q1 Q2 Q3 Q4 annual target

Number of beneficiaries (caregivers or children under 5) receiving 202,186 N/A 62,211 90,130 124,273 34,125 55,945 57,700 95,096 195% ECD and nutrition counseling in HFs

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; HF: health facility; PPP: public-private partnership; Q: quarter; Y: year. Target per quarter = 35,462

During the reporting period, a total of 95,096 beneficiaries received ECD and nutrition counseling in all 55 HFs of the eight PPP project implementation districts. This translates to an achievement of 268 percent of the quarterly target. The large increase from the previous quarter results from the introduction of the new child health registers in December 2018, which allowed for recording all children seen in the CCS and CCD consultations, who by the MOH norms and guidelines should all receive nutrition and stimulation counselling. This data was previously hard to capture, especially at the CCD consultations. While the registers allow for recording the number of children identified with developmental delays, unfortunately, they do not allow for the provision of counselling to be recorded, so the total number of children seen in the CCS and CCD is used as a proxy for this indicator. The PPP team acknowledges that that there may be issues with double reporting between the CCS and the CCD, as it has been noted during supervision and mentoring visits that providers register children who come to the HFs because they’re sick in the CCS registers first—as that is the first entry point for all children and where anthropometric measurements are taken—and then record them as referrals to the CCD, which means they are then registered in the CCD registers too. This guidance was provided by the DPS team and, hence, the PPP team could not counteract it, but PATH has alerted the child health section of the MOH to address this misconception. The trend has been generally upward during the project’s lifespan and can be attributed not just to overall improvement in ECD service delivery, but also better reporting using the registers in HFs.

Table 3 below provides more detailed information on achievements, with beneficiaries reached disaggregated by district and service delivery touch-points.

Table 3. Number of beneficiaries (caregivers of children under five) receiving ECD and nutrition counseling in health facilities (targets and achievements by district during the quarter).

ART District

CPP

CCS ANC

CCR CCD

Target

TOTAL

PED

MATERNITY

Percent achieved Percent

Age 0-59 M 0-18M 0-59 M 0-59 M Newborn Namaacha 701 121 3743 8 313 352 490 5,728 2,507 228 Marracuene 1,565 257 11,312 50 1,042 1,051 1,509 16,786 6,526 393 Matutuíne 648 49 4,454 7 152 167 217 5,694 1,346 423 Moamba 682 129 9,695 20 431 552 610 12,119 2,303 526 Magude 825 136 7,017 9 398 393 568 9,346 1,079 866 Manhica 1,831 331 7,210 88 1,503 1,432 922 13,317 4,124 321 Boane 1,466 194 4,157 5 586 618 678 7,704 3,262 237 Matola 4,384 409 13,990 40 1,399 1,894 2,286 24,402 14,315 170 TOTAL 12,102 1,626 61,578 227 5,824 6,459 7,280 95,096 35,462 268

Indicator 7

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved of Indicator ments -ments target Y3 annual Q1 Q2 Q3 Q4 target

Number of

CHWs trained 166 58 108 NA 30 NA 30 NA NA 100% on ECD by

PPP project

Abbreviations: CHW: community health worker: LOP, Life of Project: ECD, early childhood development; PPP: public-private partnership; Q: quarter; Y: year.

No new trainings were conducted this quarter, as all CHWs have been trained in previous quarters. The PPP team focused efforts on mentoring and supervising the previously trained CHWs and consolidating their activities, as reported in more detail below.

Indicator 8

S- PPP Y1 PPP Y2 PPP Y3 LOP Y3 Achievements Total project Indicator ECD Achieve- Achieve- Annual target accumulative only ments ments target Q1 Q2 Q3 Q4 achievement Percentage of CHWs reaching 75% the threshold 75% 7 55 69 13 2 2 2 111% (135)* score of 60% for ECD services (*)

Abbreviations: CHW: community health worker; LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*) This is 75% of all APEs of all districts including Boane and newly trained APEs (166+14=180)

Progress and issues As community interventions still require robust project support, the PPP team continued to work with the APE coordinators and supervisors at all levels to provide joint refresher trainings, mentoring, and supervision to APEs in the supported districts. The following sections provide more detailed information regarding ways in which the PPP team supported APEs.

A. Supervision and mentoring of APEs During the reporting period, the PPP team provided technical and financial support to APE supervisors in Manhiça and Moamba districts to support their APEs. These districts were prioritized because they had not benefited from this support last quarter, and Moamba had newly trained CHWs who required initial mentoring and support. A total of 12 APEs received mentoring and supervision visits and were supported to accurately screen for malnutrition using the mid-upper arm circumference tape, integrate counseling on stimulation into their household visits, correctly use the counseling cards, and collect and record data.

Of the 12 APEs who benefited from project-supported mentoring and supervision visits, seven reached the threshold score of 60 percent in previous quarters and two reached the threshold of 60 percent for the first time during this quarter.

Table 4 shows the mentoring distribution across target districts, disaggregated by sex.

Table 4. Number of APEs mentored, disaggregated by sex per district. # CHW mentored # CHW mentored # CHW # CHW Trained in the quarter in the quarter that mentored in the Total # CHW that received that meet the meet the quarter that do trained to date mentoring visit in 60% threshold 60% threshold not meet the the quarter District (not 1st time) (1st time) 60% threshold

Male Male Male Male Male

Total Total Total Total Total

Female Female Female Female Female

Namaacha 24 19 5 0 0 0 0 0 0 0 0 0 0 0 0 Marracuene 36 30 6 0 0 0 0 0 0 0 0 0 0 0 0 Matutuíne 19 13 6 0 0 0 0 0 0 0 0 0 0 0 0 Moamba 32 19 13 7 6 1 5 4 1 0 0 0 2 2 0 Magude 29 19 10 0 0 0 0 0 0 0 0 0 0 0 0 Manhica 40 25 15 5 2 3 2 1 1 2 0 2 1 1 0 Boane 17 13 4 0 0 0 0 0 0 0 0 0 0 0 0 Total 197 138 59 12 8 4 7 5 2 2 0 2 3 3 0

B. Refresher training for APEs During this reporting period, the PPP team provided technical and financial support to DPS- and SDSMAS-led refresher trainings for APEs from all districts, except Matola which does not have any APEs.

A total of 155 APEs received refresher trainings, which provided a venue for APEs and supervisors to discuss successes, challenges, and lessons learned from the implementation of the whole package of preventive and curative interventions delivered by APEs including nurturing care interventions for ECD. Key recommendations for improvement, particularly around data collection and reporting, were also provided by APE supervisors. Table 5 provides disaggregated data for APEs trained across target districts, disaggregated by sex.

During this quarter, incentive vouchers were provided to 11 APEs as a reward for their high performance. Performance was rated on correctly filled registers, timely submission of monthly reports, attendance of monthly meetings at the HF, having a bag of toys for stimulation demonstrations, and high identification and registration of OVC.

Table 5. Number of APEs who received refresher trainings, disaggregated by sex per district.

APEs Total number of Trained APEs receiving District Total number of trained APEs refresher training during Female Male trained APEs (Active) the quarter Namaacha 24 24 23 16 7 Marracuene 45 36 29 19 10 Matutuíne 21 19 11 8 3 Moamba 34 32 21 12 9 Magude 29 29 26 15 11 Manhiça 41 40 31 17 14 Boane 18 17 14 11 3 Total 212 197 155 98 57

Indicator 9

Indicator LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved of Y3 ments -ments target annual target Q1 Q2 Q3 Q4

Number of nongovernmental partners receiving 7 2 2 3 0 NA NA NA 1* NA technical assistance from PATH

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. *Provided Technical support to CESAL to reinforce parental education package during the quarter

Progress and issues A. Other community partners—home visits, parenting education, and awareness building/sensitization activities In this quarter, the PPP team supported the SDSMAS of Matutuíne and community partner, CESAL, in strengthening the implementation of the Parenting Education package in agricultural associations of Matutuíne District (through joint supervision with CESAL and SDSMAS). Specifically, the team built the technical capacity of facilitators to improve the quality of the parenting education sessions provided by the associations and the community. The team has found that facilitators’ performance improves with practice, and beneficiaries are generally eager to learn more about how to care for and improve the lives of the youngest children, along with the skills for improved food production obtained through the associations.

IR 2.3: Increased developmental monitoring and referrals of developmental delays Indicator 10

LOP S- PPP Y1 PPP Y2 PPP Percent Y3 Achievements target ECD Achieve- Achieve- Y3 achieved Indicator only ments ments Annual of Y3 target Q1 Q2 Q3 Q4 annual target

Number of children monitored for 29,095 N/A 9,726 13,652 15,816 4,160 6,406 6,619 12,102 185% developmental delays

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. Target revised as result of Boane Inclusion. Quarterly targets = 3,954

Progress and issues A. ECD counseling and child development monitoring at health facility-level With the introduction of the new CCS register, for the first time the PPP team is able to more confidently report on the number of children whose development is monitored in the CCS, as the new registers require providers to report on children identified with developmental delays, which in turn motivates them to monitor child development for all children seen in the CCS. This has led to an 83 percent increase in the number of children whose development was monitored in this quarter in the CCS alone (12,102) in comparison to the previous quarter (6,619).

During this reporting quarter, data collected across all 55 project target HFs in the eight project districts indicate that 12,102 children aged 0–59 months were monitored for developmental delays for the first time in the CCS consultation, which corresponds to an achievement of 306 percent of the target for this quarter. The cumulative number thus far corresponds to 185 percent of the Year 3 target.

A total of 734 children monitored across CCS, CCR, CCD, pediatric ART, CPP, and maternity services on first and following visits were suspected to have developmental delays, of which 610 were suspected on the first consultation and 124 on a following consultation. This number represents a substantial increase from the previous quarter (466), which is also attributable to the introduction of the new CCS and CCD registers and the integration of the indicator for developmental monitoring into the health information system, which motivates health providers to accurately track and report the indicator.

Table 6 below summarizes this information, disaggregated by district and by service delivery touch-point.

Table 6. Number of children suspected with developmental delays per service (first consultation and following consultation).

Total

PPC

CCS District CCR CCD

PED ARV

MATERNITY

Follow- Follow- Follow- Follow- Follow- First First First First NB First First ing ing ing ing ing Namaacha 2 9 8 1 2 0 0 5 0 1 17 11 Marracuene 2 2 0 0 72 0 0 16 0 0 90 2 Matutuíne 3 5 3 0 4 0 0 7 0 0 17 5 Moamba 1 6 7 6 21 0 5 3 0 0 32 17 Magude 2 2 0 2 13 0 0 8 0 0 23 4 Manhica 1 0 14 6 7 0 0 106 19 2 147 8 Boane 8 6 8 4 12 0 0 116 67 23 211 33 Matola 2 36 9 8 32 0 0 27 3 0 73 44 TOTAL 21 66 49 27 163 0 5 288 89 26 610 124

B. ECD counseling and child development monitoring at community-level

Indicator 11

Indicator LOP S- PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target ECD Achieve- Achieve- Annual achieved only ments ments target of Y3 Q1 Q2 Q3 Q4 annual target

Number of children referred by 25,716 NA NA 5,376 11,111 1,847 1,836 1,618 1,307 60% CHWs to health facility

During the reporting period, APEs made 1,307 referrals to HFs. This translates to an achievement of 47 percent of the planned target for the reporting period, and the cumulative figure over three quarters translates to 60 percent of the annual target. Of these referrals, 19 were due to malnutrition and no data was available for referrals due to suspected developmental delays (see table 7).

In this quarter the total number of referrals reduced in comparison to the previous quarter because it was clarified during supervision visits and refresher trainings that APEs should disaggregate referrals of children and adults and not report them as an aggregate number, which some did in previous quarters. APEs have corrected this error and the results reported here reflect referrals of children only.

Table 7. ECD counseling and early detection of signs of development delays at the community level.

–

5 years years 5

–

28 days old) days28 old)

5 years old 5 years

– District –

HF HF

DAG) APEs

by APEs by

old monitored for for monitored old

n pregnant and in in and n pregnant

and nutrition and

management)

community case case community

(home visits and and visits (home

postpartum period period postpartum was ECD in which

Children 1 month Children

old attended by APEs APEs by attended old

referred to HFs due to due to HFs referred

development by APEs by development

Children 0 Children

years to HF referred Children

Wome stimulation in counseled

Total children referred to referred children Total problems developmental

Newborn (0 Newborn

with malnutrition (DAM or or (DAM with malnutrition

Children 1 month Children

integrated, provided by the the by provided integrated,

monitored for development development for monitored

Health education sessions, sessions, education Health Namaacha 2,695 78 2,695 97 2 0 50 280 Marracuene 3,507 269 3,507 439 3 0 36 405 Matutuíne 706 17 706 14 0 0 1 202 Moamba 2,081 122 2,081 124 4 0 13 759 Magude 1,526 126 1,526 87 0 0 3 257 Manhiça 2,573 511 2,573 407 5 0 73 791 Boane 1,364 70 1,364 139 5 0 45 232 TOTAL 14,452 1,193 14,452 1,307 19 0 221 2,926

C. Follow-up of referrals of children identified with developmental delays by health providers During this quarter, the PPP team continued to collected data on follow-up of children suspected with developmental delays who were referred from the various entry points to other specialized services within the HF (intra-referrals) or to the referral HF (inter-referrals), in order to obtain a greater understanding of referral pathways. The most common cause for referral noted in the five HFs that have physiotherapy services and that the team tracked (Magude-Sede Health Center, Manhiça District Hospital, Moamba-Sede Health Center, Marracuene-Sede Health Center, and Provincial Hospital of Matola) is asphyxia, followed by illness and psychomotor developmental delays, and the main HF sectors from which children are referred are the pediatric ward, the neonatology unit, the CCS, and the CCR.

The team continued to face challenges to track the referral pathways as inter-referrals are not recorded (children are accompanied by the health provider who identified the suspected developmental delays to specialized services as way of referral), which makes monitoring the flow of referrals difficult. Because of the persistent challenges, PATH is planning to conduct a meeting with the DPS and SDSMAS to present the results of this tracking exercise and

determine strategies to improve the referral and counter-referral process, and how referrals and counter-referrals are recorded under the eECD project.

C. Physiotherapy supervision visits

In response to a request from the Maputo DPS, the PPP team provided financial support for supervision visits conducted by the Physical Medicine and Rehabilitation sector to support physiotherapy services who receive referrals, and CCS and CCD services who refer children to physiotherapy services. The supervision visits covered all districts of Maputo Province.

D. Other activities performed to ensure data capture and quality

The PPP monitoring and evaluation team and SDSMAS (district statistics staff and ECD focal points) conducted joint data collection and technical assistance visits to all eight project target districts to guarantee the quality of the data received from each district. This activity had a special focus on ECD but included other aspects of MCH as well and consisted of reviewing HF data, register books, monthly and daily summaries, and patient observation checklists and referral booklets across all MCH services (ANC, PNC, CCR, CCS, CCD, maternity, and medical consultations). Data entry in CCS and CCD registers and reporting sheets merited special attention in this quarter.

Result 3: Expand knowledge and evidence base on integrated ECD

IR 3.1: Increased demand for ECD materials and services among implementers and policymakers.

Indicator 12

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved Indicator ments -ments target of Y3 annual Q1 Q2 Q3 Q4 target

Number of partners using 7 2 4 6 1 0 2 1 2* 500% PATH materials for programming

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. *ESSOR is a new partner using PATH materials, and the Zambia MOH used PATH materials to integrate in the new child health booklet.

Progress and issues At the provincial level, PATH continued the distribution of IEC materials to newly trained HFs in Matola District. Additionally, PATH provided ten more Parenting Education kits to the agricultural associations supported by partner NGO CESAL, in response to the associations’ request. As reported earlier, the associations conduct parenting education sessions as part of their routine meetings.

At the national level, to respond to the Nurturing Care for ECD plan formulated in Nairobi, UNICEF has pledged to provide funding to print additional quantities of PATH-developed ECD posters for CCS consultations (only 600 kits were distributed at the request of the MOH, while more than 1,500 HFs exist in the country). The printing is scheduled for May 2019.

PATH shared the Community Preschool Manual with the Ministry of Gender, Children and Social Action and ESSOR—a French NGO working in preschool education in Sofala Province— to support to the humanitarian emergency response to Cyclone Idai in Beira.

IEC materials developed under the PPP have also been distributed to all HFs of Monapo District, Nampula Province through PATH’s Nurturing Care Project funded by UNICEF and the Conrad N. Hilton Foundation.

Regionally, PATH IEC materials on developmental monitoring and stimulation developed under the PPP have just been integrated into new Child Health Booklet in Zambia.

IR 3.2. Increased evidence base on high-quality ECD service provision and the impact of ECD services on care and stimulation behaviors in target communities.

Indicator 13

LOP S-ECD PPP Y1 PPP Y2 Y3 Y3 Achievements Percent target only Achieve- Achieve- Annual achieved of Indicator ments ments target annual target Q1 Q2 Q3 Q4 for Y3

Number of dissemination 24 6 11 8 6 5 4 6 4* 317% instances

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. *USAID/Mozambique Mission Director field visit; Her Royal Highness the Queen of Belgium field visit; Father’s Day; distribution of nurturing care calendars.

Progress and issues The PPP team continued to disseminate its work and the concept of nurturing care for ECD for the youngest children through different national events, including TWG meetings, commemorative days, field visits, and dissemination of materials that promote nurturing care. The different dissemination instances are detailed below.  On March 6, 2019, the USAID/Mozambique Mission Director, Dr. Jennifer Adams, participated in a field visit organized by the PPP team in coordination with the Maputo DPS and the Moamba SDSMAS, to see first-hand the health system strengthening activities conducted by the team to improve the provision of nurturing care for ECD at the facility and community levels in Moamba District. Dr. Adams observed a playbox session being facilitated by trained health providers, with the use of job aids produced under the PPP and toys made out of recycled materials promoted by the PPP in the Moamba-Sede Health Center. She also participated in a home visit that integrated counselling on child development stimulation. Dr. Adams ended the visit with a tour to the pediatric ward of the Moamba-Sede Health Center, which had just been re-opened after PATH supported the district in its rehabilitation and refurbishment.

 The PPP team collaborated with the Maputo DPS and the Marracuene SDSMAS to prepare for and participate in the visit of Her Royal Highness the Queen of Belgium to Habel Jafar Health Center, in support of her agenda as Sustainable Development Goals Ambassador. The visit was co-organized by UNICEF and WHO, and the team’s involvement was in response to a request from UNICEF, who acknowledged that the PPP team is one of the key partners of Maputo DPS. ECD was highlighted by the HF and district health teams during the visit, and plenty of job aids developed under the PPP were on display in the HF.  For Mozambique Father’s Day on March 19, PATH facilitated a session in the Pedagogic University of Maputo to promote fathers’ participation in the care and stimulation of their children. The session targeted students and lecturers alike and was attended by over 200 students and 15 lecturers.  PATH distributed over 200 2019 desk calendars that depict the Nurturing Care for ECD Framework to national, provincial, and district health and children’s services as well as to partners and donors.

Indicator 14

Y3 Achievements Percent S- PPP Y1 PPP Y2 Y3 achieved LOP Indicator ECD Achieve- Achieve- Annual of annual target ments only ments target Q1 Q2 Q3 Q4 target for Y3

Number of publications 40 10 10 9 10 2 2 2 2 80% (newsflashes)

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues During the reporting quarter, the PPP team continued to produce electronic newsflashes, where key project events and achievements were highlighted. In this quarter, two newsflashes were produced, one sharing highlights of the visit of USAID/Mozambique Mission Director to a PPP implementation site and another one on the rehabilitation and refurbishment of the Moamba- Sede Health Center pediatric ward to make it more child-friendly. The newsflashes were distributed to over 100 institutions and 250 recipients, including USAID/PEPFAR, UNICEF, WHO, World Bank, MOH, MGCAS, Ministry of Education and Human Development, Eduardo Mondlane University, Maputo DPS, multiple SDSMAS, EGPAF, ICAP, FHI 360, World Vision, and Save the Children, among others.

IR 3.3: Improved caregiver knowledge, attitudes, and practices on ECD.

Indicator 15

LOP S- PPP Y1 PPP Y2 Y3 Y3 Achievements Percent target ECD Achieve- Achieve- Annual achieved Indicator only ments ments target of annual Q1 Q2 Q3 Q4 target for Y3

Number of caregivers receiving IEC messages 901,072 NA 281,585 207,517 348,414 59,088 58,725 58,783 60,017 68% through CHW-led community talks

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; IEC: information, education, communication; CHW: community health worker; PPP: public-private partnership; Q: quarter; Y: year; N/A, not applicable. Revised as result of inclusion of Boane Quarterly targets = 87,104

During the reporting period, APEs reached a total of 60,017 caregivers in their community educational talk activities—which covered a range of different topics such as ECD, nutrition, family planning, hygiene, water and sanitation, and disease prevention. This figure corresponds to 69 percent of the planned target for this quarter and the cumulative figure for the four quarters corresponds to 68 percent of the annual target. Although the figures remain below target, in this quarter APEs reached the most caregivers of all quarters of Y3, which may reflect the increased number of APEs available in Maputo Province and therefore increased coverage of the target population.

Table 8. Number of caregivers receiving CHW IEC messages through community talks (targets and achievements by district during the quarter).

Indicator 3.3.1: Number of caregivers receiving IEC messages through APE-led community talks.

District Total of caregivers covered Target Achievement (%)

Namaacha 5,782 7,513 77 Marracuene 11,762 19,881 59 Matutuíne 3,971 3,545 112 Moamba 12,463 18,374 68 Magude 4,493 7,711 58 Manhiça 15,580 23,932 65 Boane 5,966 6,148 97 Total 60,017 87,104 69

Indicator 16

LOP S- PPP Y1 PPP Y2 Y3 Y2 Achievements Percent target ECD Achieve- Achieve- Annual achieved Indicator only ments ments target of annual Q1 Q2 Q3 Q4 target for Y3

Number of beneficiaries attending 23,976 NA NA 25,423 11,704 6,658 6,642 4,810 2,368 175% Projecting Heath

sessions at health facilities

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year; N/A, not applicable Quarterly targets = 3,194

Progress and issues A. Projecting Health: Facilitation of educational video sessions at health facility and community levels Projecting Health video sessions are held during early morning hours in the waiting areas of 17 HFs of six districts, including the Matola Provincial Hospital, and in CPCs at the community level. A total of 12 different videos addressing nutrition, children stimulation, and promotion of utilization of health services topics are currently in use in HFs.

During the reporting period, a total of 57 video sessions were conducted in HFs and CPCs across all intervention districts, except for Boane, and were attended by a total of 2,368 caregivers (658 male and 1,710 female). This figure translates to an achievement of 74 percent of the quarterly target, while the cumulative figures over four quarters corresponds to 175 percent of the annual target. It is important to note that the contribution of the community to these results is a total of four sessions covering 118 beneficiaries, of which three sessions covering 60 participants were conducted in the CPC of Macubulane and CPC of Nhongane in Magude District, and one session covering 58 participants from the CPC of Pessene in Moamba District. Table 9 below provides more detailed information about projecting health sessions conducted and participants.

Table 9. Number of Projecting Health sessions and participants, by sex per district.

Number of beneficiaries attending to Projecting Heath sessions at health facilities

District Male Female Total Target % Coverage # of sessions

Namaacha 7 149 156 338 46 6 Marracuene 121 632 753 484 156 14 Matutuíne 83 255 338 66 512 15 Moamba 101 240 341 631 54 8 Magude 105 381 486 172 283 12 Manhiça 241 53 294 429 69 2 Boane 0 0 0 1,074 0 0 Total 658 1,710 2,368 3,194 74 57

5. Monitoring and evaluation

A. Operations research and other assessments

During the reporting period the PPP team reviewed the draft report submitted by the sub- contractor and obtained a second draft from the sub-contractor. Due to several inconsistencies and incomplete reporting against the study objectives identified in the second draft of the report, the PPP team reviewed the deliverables and the cost of the sub-contract in agreement with the sub-contractor and made the decision to finalize the report in-house. By the end of the quarter, the PPP team had a near-final version of the report that was in the final stages of review. The report will be shared with USAID/Mozambique in May 2019, and the dissemination event will be planned for June 2019 under the NCE of the PPP.

B. PEPFAR OVC indicators OVC SERV indicator

During the semester October 2018 to March 2019, APEs served a total of 4,301 OVC ages 0–4 years (2,064 male and 2,237 female), which represents a 44 percent increase in comparison to the previous quarter (2,994 OVC served from March to September 2018) and 100 percent achievement of the target for the reporting period. The team partially attributes the increase from one reporting period to the other to the efforts employed during supervision visits and refresher trainings to sensitize and provide technical support to APEs to improve recording of OVC served in their registers. As for the percentage of the target achieved, it is important to note that there were no district targets set to Boane, but there were new APEs trained during the reporting period and allocated to Boane, and their contribution to the total results brought the achievement to 100 percent.

Table 10 below provides more detailed information about number of OVC served by APEs during the semester.

Table 10. Total number of orphan and vulnerable children served by community health workers during the last semester (October 2018–March 2019).

Code Indicator Name C.CCC.02.05-S Number of orphan and vulnerable children served (6 months) Male TOTAL Female TOTAL Total Target Achievement (%) District <1 Y 1-4 Y <1 Y 1-4 Y Magude 26 97 123 28 105 133 256 369 69 Manhica 159 600 759 173 649 822 1,581 1,819 87 Marracuene 75 282 357 81 306 387 744 908 82 Matutuine 19 73 92 21 79 100 192 394 49 Moamba 51 193 244 56 210 266 510 548 93 Namaacha 39 145 184 42 157 199 383 277 138 Boane 64 241 305 69 261 330 635 * * TOTAL 433 1,631 2,064 470 1,767 2,237 4,301 4,315 100 *Target for Boane was not defined

Table 11 shows detailed information of the total number of OVC served by the parenting caregiver program.

Table 11. Total number of active beneficiaries served by PEPFAR OVC Programs for children and families affected by HIV (October 2018–March 2019).

Code Indicator name Number of active beneficiaries served by PEPFAR OVC Programs for C.CCC.02.05.03 children and families affected by HIV Type of Service Parenting caregiver program Parenting caregiver program Male Total Female Total District <1 year 1-4 years Male <1 year 1-4 years Female TOTAL Magude 26 97 123 28 105 133 256 Manhica 159 600 759 173 649 822 1,581 Marracuene 75 282 357 81 306 387 744 Matutuine 19 73 92 21 79 100 192 Moamba 51 193 244 56 210 266 510 Namaacha 39 145 184 42 157 199 383 Boane 64 241 305 69 261 330 635 TOTAL 433 1,631 2,064 470 1,767 2,237 4,301

Table 12 below provides detailed information about new OVC served by community health workers. A total of 335 new OVC (174 female and 161 male) were identified and served by APEs during the reporting period (numbers included in tables 10 and 11).

Table 12. Total number of new orphan and vulnerable children served by community health workers during the last semester (October 2018–March 2019).

Code Indicator name C.CCC.02.05.08 Number of new orphan & vulnerable children served (6 months) Male Female Total District <1 year 1-4 years TOTAL <1 year 1-4 years TOTAL Magude 6 0 6 7 0 7 13 Manhica 76 0 76 82 0 82 158 Marracuene 33 0 33 35 0 35 68 Matutuine 4 0 4 4 0 4 8 Moamba 12 0 12 12 0 12 24 Namaacha 10 0 10 11 0 11 21 Boane 21 0 21 22 0 22 43 TOTAL 161 0 161 174 0 174 335

OVC HIV status

An unplanned and unwanted consequence of transition meetings conducted with SDSMAS as the PPP ends was that CHWs began to phase out the use of parallel reporting tools that allowed the team to report on the HIV status of OVC served. Regretably, for this reporting period the PPP team is not able to report on the HIV status of OVC served due to the unavailability of data.

Table 13. Percentage of orphans and vulnerable children (<18 years old) with HIV status reported to implementing partner (October 2018–March 2019).

OVC served HIV Status HIV Status

District Female Male Total Known Unknown TOTAL % Known % Unknown Magude 133 123 256 NA NA NA NA NA Manhica 822 759 1581 NA NA NA NA NA Marracuene 387 357 744 NA NA NA NA NA Matutuine 100 92 192 NA NA NA NA NA Moamba 266 244 510 NA NA NA NA NA Namaacha 199 184 383 NA NA NA NA NA Boane 330 305 635 NA NA NA NA NA TOTAL 2237 2064 4301 NA NA NA NA NA

C. HL. 9-1 INDICATOR While the PPP project is not supporting clinical nutrition interventions or treatment of nutrition conditions, it has a strong component of nutritional counseling to caregivers to improve nutritional knowledge and practices for their children as part of the approach of integrating ECD into clinical and community services.

Table 14 reflects the number of children benefiting from nutrition counseling provided by APEs during the period January to March 2019. A total of 14,128 children under five years (6,937 male and 7,515 female) were reached by APEs with nutrition interventions in all seven districts with APEs. Of these, 3,005 children were under one year of age (1,457 males and 1,548 female), and 11,446 children were aged 1–4 years (5,480 males and 5,966 female). This quarter’s figures represent an increase from the previous quarter, with a general positive trend across the four quarters as more districts and communities have been covered by the PPP project’s activities this year.

Table 14. HL. 9-1: Number of children under five (0–59 months) reached with nutrition-specific interventions through United States Government-supported programs (January–March 2019).

Code Indicator name HL. 9-1: Number of children under 5 (0-59 months) reached with nutrition-specific interventions through United States Government- HL. 9-1 supported programs Male TOTAL Female TOTAL Total Target Achievement (%) District <1 y 1-4 y Male <1 y 1-4 y Female General Namaacha 272 1,022 1,294 289 1,113 1,401 2,695 1,114 242 Marracuene 354 1,330 1,683 376 1,448 1,824 3,507 2,845 123 Matutuíne 71 268 339 76 291 367 706 474 149 Moamba 210 789 999 223 859 1,082 2,081 2,094 99

Magude 154 579 732 163 630 794 1,526 1,030 148 Manhiça 259 976 1,235 276 1,062 1,338 2,573 4,636 56 Boane 137 517 655 146 563 709 1,364 1,937 70 TOTAL 1,457 5,480 6,937 1,548 5,966 7,515 14,452 14,128 102

F. Progress in implementation of environmental mitigation and monitoring plan As proposed in the approved environmental mitigation and monitoring plan, the PPP team has continued promoting the use of recycled materials for toy production in every training.

G. Progress of gender analysis issues As previously reported, the PPP team was invited by the Pedagogic University of Maputo to facilitate a session on the role of fathers in promoting care and stimulation of their children, in commemoration of Mozambique Father’s Day on March 19th.

PATH’s provincial coordinator, Domingos Mahangue, shared with over 200 students and 15 lecturers the importance of fathers’ participation in stimulating their children’s development by providing responsive care and early learning opportunities, two critical components of Nurturing Care. The session was also used to promote the engagement of youth leaders, who will themselves become parents one day, in the promotion of nurturing care for ECD and male engagement in this area in a manner that is sensitive to Mozambican cultural values and socio- economic environment.

6. Upcoming plans

The following are some major activities planned for the upcoming quarter: 1. Disseminate the results of the operational research to key partners and stakeholders. 2. Conduct a closeout ceremony with different partners from government, NGOs, and donors.

7. Administrative update

Melanie Picolo, previously Senior Nutrition Advisor on the USAID-funded Maternal and Child Survival Program, transitioned to her new role as PPP Project Director in January 2019. The project closeout plan submitted by PATH in the last quarter was approved by USAID/Mozambique. USAID/Mozambique and PATH collaborated closely to prepare for the closeout event, including populating the agenda and participant list in coordination with the Maputo DPS; visiting the venue; drafting the press release and USAID/Mozambique Mission Director speech, and sending out invitations. However, due to the occurrence of Cyclone Idai in central Mozambique, the effects of which led the government to declare a state of national emergency, USAID/Mozambique and PATH jointly decided to postpone the closeout event and obtained concurrence from the Maputo DPS. USAID/Mozambique granted PATH a three-month no-cost extension until June 30, 2019, to conduct the closeout event and dissemination event of the operational research results.

8. Financial information

A total of $121,909.47 was expended during the quarter January – March 2019. The table below shows the expenses for the quarter by categories and projected expenses for April – June 2019.

Total Expenditures for Cumulative Total budget Projected approved current period Expenditures for remaining expenses budget (1/1/19–3/31/19) project to date (4/1/19–6/30/19) (4/6/16–3/31/19) Direct labor 566,852 49,455.65 564,122.50 2,729.00 2,729.00 Fringe benefits 176,909 18,042.13 174,151.72 2,756.78 2,756.78 Travel 86,042 2,976.14 83,211.37 2,830.54 2,830.54 Supplies 4,364.09 - 4,364.09 0 0 Sub-awards 54,140 11,079.13 49,909.45 4,230.55 4,230.55 Other direct costs 282,949 13,479.81 271,493.15 11,455.85 11,455.85 Indirect costs 328,192 26,876.36 322,462.81 5,729.19 5,729.19 Total project costs 1,499,447 121,909.47 1,469,715.09 29,731.91 29,731.91

9. Appendices

Appendix A. Success story

How two health providers helped Juvêncio survive and thrive Juvêncio Olizenio Gobo is running across the corridor of Ndlavela Health Center to give a hug to his pediatrician, Leofelda Sambo. Although Juvêncio is two years and five months old, he started walking and running just recently.

First child of Julieta Matável and Olizenio Gobo, a family that lives in São Dâmaso neighborhood of Matola District, Juvêncio came into this world with the odds stacked against him. Born two months early and diagnosed with HIV, Juvêncio had to stay in the hospital for the first month of his life as he was not able to breastfeed. Back at home, even though Juvêncio’s mother Julieta was registered for antiretroviral therapy, both mother and the child were using traditional remedies to treat HIV, following the advice of Julieta’s mother-in-law. Feeding difficulties and poor health led to Juvêncio moving between home and the hospital for much of the first year of his life.

When pediatrician Leofelda first met Juvêncio, the boy was one year and six months old. Leofelda diagnosed Juvêncio and started treating him for acute malnutrition but was immediately alarmed by the developmental delays Juvêncio showed. “I massaged his body, but he hardly responded to me and was not able to stand or to talk. While Juvêncio started treatment for malnutrition, I also referred him to physiotherapy and have been checking with the mother regularly to see how he is doing.”

Leofelda recalls that the training she received last year in developmental monitoring and stimulation from the district health services in partnership with PATH, through the Public-Private Partnership for Early Childhood Development (PPP-ECD), was what helped her detect and address developmental delays in Juvêncio, in addition to treating malnutrition.

The pediatrician was not the only one on Juvêncio’s case. When Leofelda found that Juvêncio was HIV positive, she called the mother-in-law for a talk and advised her to stop giving traditional remedies to Juvêncio, explaining how this was one likely reason behind his poor health. Juvêncio started pediatric antiretroviral treatment with Dr. Dulce Paulo. “When [Juvêncio] came here, he was very weak... But we have already started implementing (interventions for) ECD, which [together with treatment] helped a lot in Juvêncio’s recovery and his development,” recalled Dr. Dulce.

The training that both providers received from district services and PATH, through the PPP- ECD, focused a great deal on the quality of counseling, based on evidence that improved counseling is more likely to lead to a return for services and adoption of desired behaviors. The way the two providers have been supporting Juvêncio and his mother affected how the family now interacts with health services. Today Juvêncio is regularly coming in for his consultations and check-ups and has no fear of the hospital. “This child enjoys our company, he talks to everyone and makes everyone happy,” comments Dr. Dulce. Julieta does not hesitate to call either of the two doctors whenever she has a concern, including on the weekends. According to her, “Today my child is well and brings us much happiness. He does not get sick as frequently and is gaining weight. This is thanks to the nurses who always advise me and are always available to help me.”

Pediatrician Leofelda Sambo with Juvêncio and his The Gobo family enjoys seeing Juvêncio growing and mother, Julieta Matável. developing well.