MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-388-LA-13-00004)

Annual Report October 01, 2016– September 30, 2017

At the end of Year 4, we wanted to follow-up on some of the early cases of birth asphyxia that were managed in the field. In March 2012, in Faridpur district, Sakhina, a Community Skilled Birth Attendant, helped revive Rikta Begum’s baby, Tayeeba. Five years later, our Field Officer, Sarwar Hossain Topu, visited Tayyeba and captured her story. Photo A (on the left) taken in 2012, shows Tayeeba laying in her mother’s lap, as Sakhina sits beside them, while photo B (on the right), taken in 2017, shows a five-year old Tayeeba standing next to her parents.

Submitted

November 07, 2017

Cover Photo Story

A Most Beautiful Cry: How Tayeeba Survived Her Day of Birth

Tayeeba, the second child of Rikta Begum and Md. Tara Mia, is now five years old. They live in a remote village of Ganibyaparir dangi of Sadarpur Upazila, Faridpur district. Tayeeba is not going to school yet but she has grown like a normal child of her age. There was a chance that this asphyxiated baby’s cognitive development could have been compromised; nevertheless, she has memorized the Bangla alphabets, numbers, and rhymes, and plays with her friends. It is now incredible to imagine what this child went through in the first few hours of her life.

It was March 9, 2012. Tayeeba was not crying and had difficulty breathing after birth. She could not move. Fortunately, Sakhina Begum, a Community Skilled Birth Attendant (CSBA) who had just completed her Helping Babies Breathe (HBB) training, was around. Following the training, Sakhina also received HBB kits to provide delivery-related assistance at home.

When Rikta experienced labor pains, her husband, Tara Mia, quickly called Sakhina Begum to their home. Sakhina Begum first tried to clean the meconium from the mouth and nose of the newborn using a Penguin Sucker. She then attempted to stimulate the baby by rubbing the baby’s back, near its spinal cord. However, the baby did not cry, so she started artificial ventilation using a bag and mask. She managed to get through 40 rounds of artificial breathing per minute, when all of a sudden, the baby moved and cried.

“If I hadn’t received HBB training, I couldn’t imagine how I would have helped the baby survive such a serious condition at home,” Sakhina said with pride and joy.

Tayeeba’s mother, Rikta Begum is grateful to Sakhina. “Had Khala (Sakhina Begum) not been around, my child would not have survived”, Rikta said. For her third pregnancy, Rikta has already ensured that Sakhina will be beside her when she delivers.

Sakhina Begum has worked as a Health Assistant (HA) in her area since 2007. She received CSBA training for six months. In February 2012, she received HBB training that was organized by the Integrated Management of Childhood Illnesses unit supported by the MaMoni HSS Project and funded by USAID. She was promoted to the role of an Assistant Health Inspector (AHI) in the same year for her good performance

Cover photo credits: Photo A – Unknown; Photo B – Mr. Sarwar Hossain, BSMMU

This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), Bangladesh (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388- LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government. TABLE OF CONTENTS

MaMoni Health Systems Strengthening Activity ...... 1 Key accomplishments this year ...... 7 Way forward ...... 11 IR 1. Improve service readiness through critical gap management ...... 13 IR 2: Strengthen health systems at the district level and below ...... 44 IR 3. Promote an enabling environment to strengthen district level health systems .. 68

Appendix 1: Scope and Geographical coverage of the Mamoni HSS program ...... 80 Appendix 2: Data Sources ...... 81 Appendix 3: Program Performance Indicators ...... 82 Appendix 4: Additional Indicators (Added in 2016) ...... 92 APPENDIX 5: List of Union Facilities Upgraded ...... 94 Appendix 6: News clips published by MaMoni HSS ...... 98 Appendix 7: Forums where MaMoni HSS lessons were disseminated ...... 102 Appendix 8: list of process documentation activities ...... 104

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 3 ABBREVIATIONS

AAP American Academy of Pediatrics ACS Antenatal Corticosteroid ADCC Assistant Director Clinical Contraceptive AHI Assistant Health Inspector AMTSL Active Management of Third Stage of Labor ANC Antenatal Care APK Android package kit BCC Behavior Change Communication BEmONC Basic Emergency Obstetric and Newborn Care Bh Bhola BR Birth Registration BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CBT Competency Based Training CC Community Clinic CCSDP Clinical Contraceptive Service Delivery Program CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHW Community Health Worker CHX Chlorhexidine CIPRB Center for Injury Prevention and Research Bangladesh cMPM Community Micro Planning Meeting CNCP Comprehensive Newborn Care Package CS Civil Surgeon CSBA Community Skilled Birth Attendant CV Community Volunteer DDFP Deputy Director Family Planning DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DH District Hospital DHIS2 District Health Information System-2 DN Death Notification DO Development Objective DQA Data Quality Assessment ENC Essential Newborn Care EOC Emergency Obstetric Care EPCMD Ending Preventable Child and Maternal Deaths EPI Expanded Program on Immunization EoP End of Project ESD Essential Service Delivery eLMIS Electronic Logistics Management Information System eMIS Electronic Management Information System ETAT Emergency Triage Assessment and Treatment FDR Facility Death Review FP Family Planning FP-FSD Family Planning Field Service Delivery FPCS-QIT Family Planning Critical Supervision – Quality Improvement Team FPI Family Planning Inspector FSO Field Service Officer FWA Family Welfare Assistant FWV Female Welfare Visitor GIS Geographic Information System GoB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HEF Health Economics and Financing HEU Health Economics Unit Hg Habiganj HI High Intensity HIS Health Information System HPNSP Health, Population and Nutrition Sector Program

4 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report HPNSDP Health, Population, and Nutrition Sector Development Program HR Human Resource HNN Healthy Newborn Network HRD Human Resources and Development HRIS Human Resource Information System HRM Human Resource Management HRMU Human Resource Management Unit HS Health Systems HSCS Health Systems Capacity Strengthening HSS Health Systems Strengthening icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh ICT Information and Communication Technology IDD Iodine Deficiency Disorder IEC Information, Education and Communication IFA Iron Folic Acid IMCI Integrated Management of Childhood Illness Inj. Injection IP Infection Prevention IPHN Institute of Public Health Nutrition IPC Inter Personal Communication IR Intermediate Result IUCD Intra Uterine Contraceptive Device IUD Intra Uterine Death Jk Jhalokathi Jhpiego Johns Hopkins Program for International Education in Gynecology and Obstetrics JSV Joint Supervisory Visit KMC Kangaroo Mother Care KOICA Korea International Cooperation Agency LAPM Long-acting and Permanent Method LARC Long-acting Reversible Contraceptive LG Local Government LMIS Logistics Management Information System LOC Letter of Collaboration Lp Lakshmipur LRP Labor Room Protocol MCRAH Maternal Child Reproductive and Adolescent Health MCHIP Maternal and Child Health Integrated Program MCWC Maternal and Child Welfare Center MEC Medical Eligibility Criteria MFSTC Mohammadpur Fertility Services and Training Centre MgSO4 Magnesium Sulfate MIS Management Information System MIS-FP Management Information System Family Planning MNCH/FP/N Maternal, Newborn and Child Health, Family Planning, and Nutrition MNC&AH Maternal, Neonatal, Child and Adolescent Health MNH Maternal and Newborn Health MO Medical Officer MOCH Medical Officer Child Health MOCS Medical Officer Civil Surgeon MOHFW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MO-MCH-FP Medical Officer-Maternal and Child Health & Family Planning MPDSR Maternal and Perinatal Death Surveillance and Response NGO Non-government Organization NIPORT National Institute of Population Research and Training Nk Noakhali NNHP National Newborn Health Program NNS National Nutrition Services NTC National Technical Committee NVD Normal Vaginal Delivery OBGYN Obstetrics and Gynecology OGSB Obstetrical and Gynecological Society of Bangladesh OP Operational Plan OPHNE Office of Population, Health, Nutrition, and Education

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 5 OT Operation Theatre PAC Post Abortion Care pCSBA Private CSBA PDCA Plan-Do-Check-Act PE/E Pre-eclampsia/Eclampsia PHC Primary Health Care PHD Partners in Health and Development PIP Program Implementation Plan Pp Pirojpur PM Program Manager PMMU Planning, Monitoring and Management Unit PMP Project Monitoring Plan PNC Post Natal Care PPFP Post-partum Family Planning PPH Postpartum Hemorrhage PPIUCD Post-partum Intra-uterine Contraceptive Device PSBI Possible Serious Bacterial Infection PRS Population Registration System QI Quality Improvement QIC Quality Improvement Committees QIS Quality Improvement Secretariat QoC Quality of Care QPRM Quarterly Performance Review Meetings RHIS Routine Health Information Systems RMO Residential Medical Officer RMNCH Reproductive, Maternal, Newborn, Child and Adolescent health RRQIT Regional Roaming QI Teams RTC Regional Training Center SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SARRC South Asian Association for Regional Cooperation SBA Skilled Birth Attendant SBCC Social & Behavioral Change Communication SBM-R Standards-Based Management and Recognition SC Save the Children SCANU Special Care Newborn Unit SCMP Supply Chain Management Portal SDP Service Delivery Point SIAPS Systems for Improved Access to Pharmaceuticals and Services SIP Sector Improvement Plan SOP Standard of Protocols SPE/E Severe Pre-eclampsia and Eclampsia SSN Senior Staff Nurse SWPMM Sector-wide Program Management and Monitoring Tab Tablet Computer TAG Technical Advisory Group TIS Tracer Indicator Survey ToT Training of Trainers TO Technical Officer UEH&FPSC Union Education Health and FP Standing Committee UFPO Upazila Family Planning Officer UHC Upazila Health Complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Center UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UP Union Parishads USAID United States Agency for International Development USC Union Sub-center WISN Workload Indictors of Staffing Need WIT Work Improvement Teams WHO World Health Organization

6 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report

EXECUTIVE SUMMARY The MaMoni Health Systems Strengthening (MaMoni HSS) project continued to support the Ministry of Health and Family Welfare (MOHFW) to strengthen health systems at the national and district levels. During Year 4, the program’s technical assistance at the national level and implementation at the district level were under consolidation. The project currently supports 40 upazilas in 6 districts, 23 of which are designated high intensity (HI) areas and 17 of which are health systems capacity strengthening (HSCS) areas. At the district level, MaMoni HSS continued to support the scale-up of priority Ending Preventable Child and Maternal Deaths (EPCMD) interventions and to improve the quality of facility-based care.

Key accomplishments this year A. National level accomplishments . MaMoni HSS has been actively engaged in supporting the MOHFW in the development of the fourth Health Population and Nutrition Sector Program (HPNSP 2017-22) and its related Operational Plans (OPs). The priority areas advocated by MaMoni HSS have been incorporated in OPs, along with allocation of government budget for implementation. MaMoni HSS continued its formal support to the Planning Wing of MOHFW to provide operational and management support for the coordination and sector-wide management of the OPs. . During Y4, the project facilitated post-roll-out follow-up of essential newborn care (ENC) including 7.1% chlorhexidine (CHX) for newborn cord care and Helping Babies Breathe (HBB) through a revisit of priority newborn interventions. The revisit included rapid assessment of skill retention, availability of supply and stocks of 7.1% CHX and HBB equipment and skill refresher sessions. The revisits in 46 districts (2,811 facilities) of phase 1, phase 2 and phase 3 are completed. From the revisits it has been observed that 49 percent of facilities have 7.1% CHX available, and 81 percent of facilities have HBB kits available. It was also found that 75 percent of facilities have trained staff on use of 7.1% CHX and 53 percent of facilities have staff trained in HBB. These findings were shared through divisional meetings with the managers in all eight divisions so appropriate measures, based on the findings, could be taken, to increase utilization of newborn health care services. . In order to strengthen an effective monitoring system and follow-up actions for the managers, the project provided technical support through the National Newborn and Child Health (NNHP) Cell to establish a newborn health dashboard in District Health Information System-2 (DHIS-2). As per the requirement from national level managers, four major newborn indicators on 7.1% CHX use at facility, number of asphyxiated babies successfully resuscitated using bag and mask, PNC services within 2 days of birth and initiation of breast feeding within an hour after birth incorporated in newborn health dashboard into DHIS-2 and also included in monthly local health bulletin. Accordingly the managers from upazila to national level can monitor the progress, identify the gaps and take appropriate measures. . The project is implementing a comprehensive quality improvement strategy to support the MOHFW at the national and district levels to improve the quality of clinical care for Maternal, Newborn, Child Health, Family Planning and Nutrition (MNCH/FP/N) services.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 7 The project supported the national Quality Improvement Secretariat (QIS) to roll out the National Quality Improvement (QI) Strategic Plan. During the year, MaMoni HSS collaborated with other partners and stakeholders to support the development of a draft Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCH) Framework, in alignment with the World Health Organization’s (WHO) Quality of Care (QoC) Framework for maternal and newborn care. Through QI specialists deployed at the national QIS and divisional levels, MaMoni HSS supported the strengthening and capacity-building of QI implementation structures at the divisional, district and sub-district levels. By the end of Year four, 41 districts, out of the total 64, have functional QI committees. These committees meet at least once every three months to review clinical service performances using district data, and to identify and address critical quality gaps in service provision. Model QI facilities are being supported by the project in Lakshmipur and Bhola districts. MaMoni HSS provided substantial technical support to the MOHFW to finalize and approve maternal health standard operating procedures (SOPs) and the maternal health strategy. These documents have now been approved by the national technical committee. . MaMoni HSS supported the Human Resources Management Unit (HRMU) to conduct an assessment using the “Workload Indicators of Staffing Needs (WISN)”. The study findings were shared with the Technical Advisory Group (TAG) of the MOHFW. The study will inform decisions related to human resource (HR) planning, deployment and workload re- distribution. The project supported the MOHFW to implement the Human Resources Information System (HRIS) in two MaMoni HSS districts, which will now be extended to the other districts. . In Q4 of Year 4, MaMoni HSS signed a letter of collaboration with the National Institute of Population Research and Training (NIPORT) to develop and implement a capacity development program for the community health workers to implement the new essential services package. As part of this initiative, an assessment of the institutional capacity of the Regional Training Centers (RTCs) has been completed. The training modules for health workers, supervisors and sub-district level managers are being developed.

B. District level accomplishments . In order to track the service coverage, MaMoni HSS has conducted six-monthly population- based surveys known as Tracer Indicator Surveys. So far six rounds of surveys have been completed in 23 high intensity upazilas. Overall, the survey data indicates a significant increase in the proportion of women who received antenatal care (ANC), skilled birth assistance (SBA) during delivery, postnatal care (PNC) for mother and newborn, and essential newborn care. Facility delivery increased from round-I to Round-VI in Habiganj from 26% to 35%, Lakshmipur from 30% to 41%, Noakhali from 26% to 45% and Jhalokati from 39% to 49% respectively. The coverage of modern contraceptive prevalence is almost stagnant in most districts, with marginal improvements in all areas. . During Year 4, a total of 33 Union Health and Family Welfare Centers (UH&FWCs) were strengthened in the six project districts to provide maternal and newborn health (MNH) services on 24/7 basis. Thus, the total number of 24/7 UH&FWCs in the project area has increased from 80 in Y3 to 108 in Y4. This has contributed to a significant increase in the number of deliveries conducted by SBAs from 92,123 last year, to 122,330 this year, which is 51 percent ofestimated deliveries in y4 and 39 percent in y3 . In Year 4, MaMoni HSS continued to support 12 Family Welfare Assistants (FWAs), 40 Paramedics/Family Welfare Visitors (FWVs), and 22 nurses to fill-in the critical human resource gaps of GOB service providers. These efforts resulted in a large number of underserved population into MNCH/FP/N service coverage. The project has continued to advocate with local leaders (Union Parishad Chairman and Members of Parliament) for

8 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report long-term solutions by filling the vacancies through government recruitment. Meanwhile in Noakhali the Union Parishad (UP) of Charbata union has recruited paramedics in the UH&FWC using their own funds, and in Rajganj union, the Union Parishad is in the process of recruiting another paramedic. . In collaboration with the Obstetrics and Gynecological Society of Bangladesh (OGSB), the project has introduced severe pre-eclampsia and eclampsia management at the union level where a loading dose of injectable Magnesium Sulphate (MgSO4) is administered at the union level by FWVs. This intervention has been rolled out at 140 union level facilities in 16 upazilas of 4 districts. In Year 4, a total of 291 pre-eclampsia/eclampsia (PE/E) cases were identified and administered a pre-referral loading dose of MgSO4. . As a part of essential newborn care, 7.1% CHX application has been implemented in six project districts. The use of 7.1% CHX in Year 3 was 32,224, which increased to 77,477 in during the reporting year. During Year 4 project initiatives focused not only on increasing coverage but also on improving the quality of service delivery through capacity building, availability of logistics and job aids and on the job coaching along with community awareness. . MaMoni HSS has been implementing sick young infant (<2 months of age) management following national guideline from 148 UH&FWCs in 4 project districts. The intervention was only in union level facilities where there is a SACMO in Habiganj, Noakhali, Lakshmipur and Jhalokati districts. In Year 4, a total of 5,972 sick young infants were managed under this initiative. . In Year 4, the project has strengthened family planning interventions in collaboration with the Directorate General of Family Planning (DGFP), Directorate General of Health Services (DGHS) and Mayer Hashi II project. This year the project supported to finalize post-partum family planning (PPFP) counselling module of DGFP. A total of 49 senior staff nurses from DGHS were trained in basic intra-uterine contraceptive device (IUCD) and post-partum intra-uterine contraceptive device (PPIUCD), and 66 FWVs received a two- day refresher on PPFP and PPIUCD. This resulted in an increasing trend in the performance of PPIUCD in Year 3 from 1,179 to 1,785 in Year 4. MaMoni HSS also supported the training of 19 newly recruited Medical Officers on long acting reversible contraceptives (LARC) and permanent method (PM) services, which contributed to the increase of LARC and PM performance from 47,414 in Year 3 to 48,308 in Year 4 in the project districts.

Challenges and mitigation strategies . Staff turnover in key management positions in DGHS and DGFP remained a major challenge in the timely implementation of program activities. For example, the Director General of the DGFP changed twice, while the Director-MIS in the same directorate changed three times within a year. These key positions were also vacant for some time.

. The MOHFW has been recently divided into two divisions: the Health Services Division, and the Medical Education and Family Welfare division. Each of the divisions will have one secretary. This division has created uncertainties because of a lack of clear guidance on operational mechanisms. MaMoni is closely observing the changes and will adapt strategies accordingly. . A chronic shortage of human resources at service delivery points also hinders all project activities, particularly in improving the quality of health care. MaMoni HSS is facilitating the better use of available human resources, the project also fills-in the critical human resource gaps of GoB service providers on a temporary basis, while continuing to advocate

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 9 with local leaders for long-term solutions by filling the vacancies through GoB recruitment. Simultaneously, the project advocates with the government for newly recruited staff to be posted in underserved areas with major human resource shortages. As the project is approaching its end, it is important to engage with the MOHFW to ensure that the paramedics will be absorbed within the MOHFW cadres, or replaced, to ensure continuation of services in the health facilities where paramedics are currently working.

. Frequent stock outs of essential MNCH drugs is another challenge. The project is building the capacity of local managers to monitor the availability of essential drugs, and is taking local measures to avoid stock outs through routine tracking of the supply chain management portal (SCMP).

. The coverage of the use of misoprostol for home deliveries remains low and below the target. This is primarily due to interruptions in the national procurement and distribution of misoprostol and due to the increasing number of vacancies of FWAs who are responsible for home-based distribution of misoprostol.

. The establishment of QI committees has been a positive step in increasing the staff capacity in identifying gaps and implementing actions to address them. There are encouraging examples of QI committees that have been able to solve local problems and engage local government in resource mobilization. However, they still require significant facilitation by project staff and need to develop ownership of the program.

. There has been significant progress in updating clinical standards, guidelines, and training in the past year but the implementation of interventions leading to improvement of the quality of clinical care at health facility levels needs to be strengthened. MaMoni HSS is exploring innovative approaches to encourage local ownership and leadership for quality improvement.

. A good number of trainings are being conducted by different programs but there is no formal system of follow-up after training or supportive supervision. MaMoni HSS has supported post-training follow-up after ENC training (7.1% CHX and HBB). MaMoni HSS has initiated dialogues with the DGHS and DGFP for institutionalizing follow-up training and supportive supervision after each technical training, as these are important for skills retention and quality of care.

. Poor case admission and post-discharge follow-up of KMC as well as poor day-8 follow-up of PSBI cases remain as key challenges for newborn health. MaMoni HSS has arranged sensitization meetings and mentoring visits in implementation districts by national level managers and professionals. The project also plans to orient and engage union level supervisors of public sector for the follow-up of KMC and PSBI cases at community level. Orientation of Assistant Health Inspectors (AHI) of DGHS and Family Planning Inspectors (FPI) of DGFP have been planned for ensuring day-8 follow-up of PSBI and post-discharge follow-up of KMC.

. There is a need to improve the preparation, organization, and utilization of mobile camps for LARC and PM. MaMoni HSS is playing an active role in coordinating mobile camps with national level and district level partners and health managers. The purpose is to ensure availability of skilled service providers and supplies, strengthening health facility readiness, and strengthening community utilization of services provided by the mobile camps.

10 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Way forward In Year 5, MaMoni HSS will continue to provide support to the MOH&FW in strengthening health systems at the national level and to serve as a strategic partner for the government to implement the priorities identified in the new sector plan. In the upcoming year, the project will expand the technical assistance role at the national level, while consolidating the implementation at the district level. At the national level, MaMoni HSS will continue to work closely with the MOH&FW through the DGHS and DGFP, the Ministry of Local Government, Rural Development & Cooperatives (MOLGRD&C), as well as key development partners. MaMoni HSS held extensive consultations with the Planning Wing and the Program Monitoring and Management Unit (PMMU) of the MOH&FW and the relevant Operational Plans of DGHS and DGFP to identify the priority areas for technical and management support at the national level. Some of the major focus areas for implementation are:

• The workload and staffing need assessment study findings will be disseminated and policy briefs will be developed. The project will provide support to the Health Service Delivery (HSD) for capacity strengthening on central Human Resource Information System (HRIS). National level stakeholder workshops on HRIS will be organized, monitoring guidelines developed and data quality assurance/control (DQA) mechanisms will be developed in collaboration with DGHS and DGFP. Capacity of DGFP staff will be developed to facilitate regular updates to HR data in the HRIS at upazila and district level (DGHS and DGFP). • In Year 5, the project will facilitate the establishment and operationalization of the decentralized QI management structures at sub-national levels and provide technical assistance to the development and updating of national guidelines, protocols, and tools to support the implementation of the national QI strategy. The national guidelines for infection prevention, hygiene practices, and patient safety will be updated. The WHO- MNH QOC framework will be piloted in Narshingdi district. Line Directors and Program Managers of Hospital Services Management unit of DGHS participated in different workshops. The documentation of the QI initiative led by MOHFW and supported by various partners will be completed • Continue the remaining design of facility-level modules of the automated electronic management information system (eMIS) as well as support the national scale-up. Both community and facility modules will be implemented in Habiganj, Noakhali and Lakshmipur and only the facility module will be implemented in Jhalokathi. • Support the establishment of three special care newborn units (SCANUs), one in Khulna Shishu Hospital and two in national level facilities of the DGFP. • The project will also develop the information and communication technology (ICT) capacity of NIPORT and help in digitalize the training database. Both the national level and regional level facilities will be upgraded with modern ICT equipment enabling innovative ways to deliver trainings. The project is also supporting the review and revision of the existing Team Training Curriculum of NIPORT and adapting it for community based workers (HA, FWA and CHCP) training. A Leadership and Management training curriculum for upazila health and family planning managers (UHFPO, UFPO and MOMCH) is being developed by NIPORT under this project.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 11

INTRODUCTION

The MaMoni Health Systems Strengthening project, is a five-year USAID-funded award1 aimed at improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services in Bangladesh. The project’s objective is to increase availability and quality of high-impact interventions through strengthening district-level local management and health systems. This objective is well-aligned with the Government of Bangladesh’s (GoB) Health, Population, and Nutrition Sector Program (HPNSP) 2017-2022 and its Sector Improvement Plan (SIP) 2016-2021. MaMoni HSS provides support and assistance to the Ministry of Health and Family Welfare (MOHFW) at national and district levels, and directly supports the “USAID/Bangladesh-Health Status Improved” Activity under the Investing in People Objective, Health Project Area of the U.S. Foreign Assistance Framework.

The four Intermediate Results (IR) of the project are to: • Improve service readiness through critical gap management • Strengthen health systems at the district level and below • Promote an enabling environment to strengthen district-level health systems • Identify and address barriers to accessing health services

The project has expanded the technical assistance role at the national level, while consolidating the implementation at the district level. The project supports 40 upazilas in 6 districts, 23 of which are designated high intensity (HI) areas, and the remaining 17 of which are designated health systems capacity strengthening (HSCS) areas.

The scope and geographical coverage of the MaMoni HSS project has been summarized in Table 1. Detailed coverage has been included in Appendix 1.

Table 1. Summary of the geographic scope of MaMoni HSS

Number Population Number of Health Facilities Number of Area of (2017 Upazilas Projection) UH&FWC/ Unions DH MCWC UHC CC USC

High Intensity 23 (Habiganj-8, 226 6,662,456 4 7 20 213 619 Areas Noakhali-4, Lakshmipur-5, Jhalokathi-4,

1MaMoni HSS is implemented through an Associate Award under the Maternal and Child Health Integrated Program, which is led by Jhpiego, with a period of performance from September 24, 2013 to September 23, 2018. MaMoni HSS is led by Save the Children in Bangladesh, in partnership with Jhpiego, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU).

12 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Pirojpur-2)

Health Systems 17 (Bhola-7, 151 4,870,933 2 5 14 126 488 Capacity Noakhali-5, Strengthening Pirojpur-5) (HSCS) Areas

Total 40 377 10,718,274 6 12 34 339 1,107

In response to the recommendations of the mid-term evaluation, a few strategic shifts in human resources and program structure were implemented this year, such as a fifty percent reduction in the number of Field Service Officers (FSOs) in high intensity areas and their complete withdrawal from other areas. The Technical Officer (TO) position has been terminated across all project areas. Additionally, new positions were created, including: Facilitator-Service Delivery (26) in all high intensity districts; Upazila Facilitator-HIS (13) in Habiganj and Noakhali; and Upazila Facilitator-Community Based Service (CBS-13) in Noakhali and Jhalokathi. These staff are now on board and have received intensive job- based training.

DATA SOURCES

This report uses data from various sources, including: the population-based Tracer Indicator Survey (TIS) in high intensity areas; sentinel surveys in selected facilities in MaMoni HSS districts; Service Delivery Point (SDP) assessments in selected facilities2; re- visitation of specific newborn interventions in 14 districts; and routine MIS from the DGHS and DGFP. The complete list and scope of the surveys are attached as Appendix 2.

PROGRAM RESULTS OF THE YEAR

IR 1. Improve service readiness through critical gap management

1.1 Increase availability of health service providers

1.1.1 Management of critical human resource gaps of GOB service providers

2 DH, MCWC, UHC, UH&FWC and USC in 21 high intensity areas in 4 districts (Habiganj, Noakhali, Lakshmipur and Jhalokathi)

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 13 In Year 4, MaMoni HSS continued to provide support by appointing 12 FWAs, 40 paramedics/FWVs, 22 nurses and one obstetrics and gynecology (OBGYN) consultant to fill- in the critical human resource gaps of GoB service providers (Table 2), while continuing to advocate for long-term solutions with local leaders (Union Parishad Chairman and Members of Parliament), by filling vacancies through recruitment efforts involving the GoB. In addition, the project continued to advocate with the government for newly recruited staff to be posted in underserved areas with major human resource shortages. The decisions to fill such vacancies are made through discussions with district/upazila managers. Community health workers (CHWs) in Habiganj were appointed to vacant FWA positions to initiate population registration and roll out of the community based electronic Management Information System (eMIS). Paramedics were deployed to substitute for FWVs in strategically placed Union Health and Family Welfare Centers (UH&FWCs) to ensure 24/7 delivery. Additional paramedics were posted to help manage the case load in a few UH&FWCs, where the patient load was too high to be managed around the clock by a single provider. Nurses were placed in Habiganj and Lakshmipur District Hospitals as patient loads were high and additional staff were required for around the clock delivery service, as well as for newborn care, especially at the Special Care Newborn Unit (SCANU). An OBGYN consultant was posted in Hatiya, which is an isolated island without any facility to handle obstetrical emergencies. MaMoni HSS also continued its support to provide technical assistance (TA) and financial support for a yearlong Emergency Obstetrics Care (EOC) training for 12 medical officers from the Maternal and Child Health and Family Planning (MO-MCHFP) unit of the DGFP.

1

Table 2: Critical human resource gaps filled-in by MaMoni HSS

District FWA FWV/Paramedics Nurses OBGYN Consultant

filled up

Vacant Posts Vacancy GOB Vacancy filled up by (CHW) MaMoni Vacant Posts Vacancy filled up GOB Vacancy filled up by (Paramedic) MaMoni Vacant Posts Vacancy filled up GOB Vacancy filled up by (Nurse) MaMoni Vacant Posts Vacancy filled up GOB Vacancy filled up by MaMoni Habiganj 88 3 12 27 1 11 71 48 14 2 0 0 Jhalokathi 81 0 0 11 0 2 7 46 0 0 1 0 Noakhali 161 0 0 18 2 9 89 76 0 5 2 1 Lakshmipur 70 0 0 11 0 4 69 17 0 2 0 0 Total 400 3 12 67 3 26 236 187 14 9 3 1 In Year 4, the government appointed new staff to fill vacancies, while gradually reducing the numbers of project support staff. This year, three paramedics were replaced by GoB FWVs. The project strategy is to only provide technical staff in hard to reach areas and gradually decrease the number of supported positions. As there has been no FWA recruitment since 2014, there are many vacant positions. The project is advocating with

14 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report DGFP for placement of recently recruited paid volunteers in MaMoni districts. Only in Madhabpur, 12 CHWs have been hired to support eMIS implementation.

For Paramedics, the project is advocating and following up with DGFP to post newly recruited FWVs in MaMoni areas as well as advocating with the local government to recruit Paramedics.

1.2 Strengthen capacity of service providers to provide quality services 1.2.1 Introduction and scale-up of MNCH/FP/N interventions 1.2.1.a. Maternal health The program’s major interventions in maternal health are pregnancy identification and registration through frontline health workers; the provision of at least four antenatal care (ANC) contacts with Quality of Care (QoC); birth planning; promotion of, and increased availability and accessibility to quality skilled birth attendants, including active management of the third stage of labor (AMTSL); distribution of misoprostol for home- based deliveries; and ensuring four postnatal visits, including the promotion of post-partum family planning. There are also special interventions in selected areas, such as the management of severe pre-eclampsia and eclampsia through the administration of

Magnesium Sulfate (MgSO4).

i. ANC coverage ANC is the gateway intervention wherein a woman makes what might be the first contact in her life with a health facility or health care provider, as a result of her pregnancy. MaMoni HSS has taken a multipronged approach to address the shortage of service providers, to ensure satellite clinics, and to confirm the availability of equipment and provide logistical support for providers. The population based tracer survey reveals a steady increase in ANC-1 uptake for all the project supported districts, with all districts achieving the set End of Project (EoP) targets and most achieving up to 10 percentage points over their targets (Figure 1). A remarkable achievement has also been observed in ANC 4+ coverage in the districts particularly for Habiganj, Lakshmipur and Noakhali (Figure 2).

Figure 1: Percentage of women who received at least one ANC check-up from a medically trained provider

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 15 100 87 90 85 83 82 83 81 81 80 76 77 77 80 74 75 74 75 74 73 72 72 70 70 71 71 73 68 69 66 66 70 64 70 70 65 70 67 60 61 60 53 51 50 40 37 Percentage 30 20 10 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur 2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016(Round-IV) 2017(Round-V) 2017 (Round-VI) EoP target

Source: Tracer Indicator Survey (TIS)

Figure 2: Percentage of women who received four or more ANC check-ups

60 49 50 45 4450 46 44 42 43 43 40 41 39 40 39 3837 40 34 35 36 36 32 3031 30 36 30 26 26 25 23 22 26 2126 26 19 20 15 14 12 9 10

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) 2017 (Round-VI) EoP Target

Source: Tracer Indicator Survey (TIS)

ii. Severe pre-eclampsia/eclampsia (SPE/E) management at union level facilities In collaboration with the Obstetrics and Gynecological Society of Bangladesh (OGSB), the project has introduced severe pre-eclampsia and eclampsia (SPE/E) management at union level facilities (UH&FWC), where a loading dose of injectable MgSO4 is administered by trained FWVs and the patients and their family members are counselled for referral care at higher level facilities. In some cases, the staff also facilitates and supports the process of arranging for referral transport. This intervention has rolled out at 140 union level facilities in 16 upazilas (5 upazilas in year 3, and the remainder in year 4) in 4 districts – Habiganj, Noakhali, Lakshmipur, and Jhalokathi.

16 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report

Practical session of refresher training on PE/E at UHC (L) Prof. Firoza Begum, Secretary General-OGSB facilitates a session (R) Prof. Latifa Shamsuddin visits Auskandi UH&FWCs

Practical sessions on PE/Eclampsia

The expansion of intervention from 5 upazilas to 16 upazilas; refresher training of the service providers; periodic monitoring visits by OGSB professional bodies and on the job orientation; and discussions related to SPE/E case identification and management issues during monthly meetings at upazila Health&FP resulted in increased SPE/E case identification and referral, with pre-referral loading dose of injectable MgSO4 (Figure 3).

Figure 3: Number of patients with severe PE/E that received pre-referral loading dose of Injectable MgSO4 at UH&FWCs Source: MIS-3, DGFP 100 94 90 80 72 65 70

60 49 50

Number 40 30 20 10 3 0 MaMoni Health SystemsY3-Q4 StrengtheningY4-Q1 Activity: FY’ 17 AnnualY4-Q2 Report Y4-Q3 Y4-Q4 17 Quarter Estimates of PE/E cases are not available nationally or globally. An operation research is on- going under which population based surveillance are being conducted. Estimated figures will be available by end of project. Though WHO estimates the incidence (or number of new cases) of pre-eclampsia to be seven times higher in developing countries (2.8% of live births) than in developed countries (0.4%) (Dolea et al. 2003). If assumptions are made as per this estimate, the incidence in quarter four in the 16 upazilas would be 809; however the reported number is 94. The reported number of detected cases lags behind the estimated number of cases, suggesting challenges in case detection. The project is carrying out a number of initiatives to improve the situation. With support from MaMoni HSS, an electronic Management Information System (eMIS) was introduced that will assist the supervisors in monitoring eligible cases that are supposed to be referred by the provider. The supervisor will be able to follow up on referral cases after complete roll out of eMIS in MaMoni HSS districts. MaMoni HSS also tracked the outcomes of these referred patients. After receiving the loading dose, 60 percent of cases had normal deliveries, 25 percent needed caesarian sections, and 15 percent waited for final results post-discharge after consultation with a consultant/doctor. Maternal and fetal outcomes showed 100 percent survival of mothers, 96 percent live births and 4 percent still births. MaMoni HSS plans to expand this intervention in 7 additional upazilas of Noakhali district in Year 5.

Use of referral transport after receiving the loading dose

iii. Misoprostol to prevent postpartum hemorrhage (PPH) for home births MaMoni HSS facilitated the distribution of misoprostol tablets to pregnant women in their third trimester through FWAs and FWVs in order to prevent PPH following home deliveries. Routine MIS data shows that the distribution of misoprostol tablets to pregnant women was very low in MaMoni HSS districts (Figure 4).

Figure 4: Number of pregnant women who received misoprostol tablets in year four

18 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report 120000 106004

100000 81060 80000 62788 60000

Number 37722 40000 23714 38710 35956 20000 34873 28550 6363 5207 7148 19234 17175 10524 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

Number of pregnant women received ANC3 Number of pregnant women received misoprostol Estimated number of pregnant women

Source: MIS-4, DGFP Assumption: Estimated number of pregnant women is 3.5% of the population

The project also tracks misoprostol consumption through TIS. Although there was an increasing trend in misoprostol consumption, it was still very low compared to the EoP target (Figure 5). Misoprostol is distributed by FWAs through home visits and during the third ANC by FWVs. Some of the primary contributors to the low distribution coverage of misoprostol were: low coverage of ANC during the 3rd trimester (Table 4), stock out of tablets, vacancies of FWAs (29% vacancy in 4 HI districts) and FWVs (22% vacancy in 4 HI districts), inadequate home visits by FWAs, and the lack of a need based distribution system for misoprostol. The project continues advocacy at the national level for recruitment of vacant positions, but there is a court stay order for new recruitment by DGFP. The project is also following up on supply issues of misoprostol at the national level as well as at the district level. At the district level, the issues are discussed with local MOHFW managers in quarterly performance review meetings. Another contributor to low coverage is that a large number of private sector providers give ANC services but they do not have a misoprostol supply and are not distributing it. Moreover, private sector providers also have a lack of knowledge/training on use of and distribution of misoprostol. MaMoni will explore alternate options for misoprostol distribution i.e. through BRAC workers or other community based workers as well as to sensitize private sector providers for misoprostol use.

Figure 5: Percentage of women who consumed misoprostol tablets immediately after birth following home delivery

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 19 100 90 80 70 60 55 50 4243 50 38 45 40 3534 3332 Percentage 28 27 30 23 2625 30 30 25 25 23 19 21 22 17 14 14 1615 20 11 14 8 8 8 10 10 3 3 5 5 2 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) 2017 (Round-VI) EoP Target

Source: Tracer Indicator Survey (TIS)

Misoprostol consumption coverage is lower in Lakshmipur and Pirojpur. However, the results for Pirojpur include only two upazilas out of seven, and do not reflect the full district scenario. However, like other HSS districts, the project has limited input in Pirojpur in terms of interventions and resource allocation from the program. Although the coverage levels in Lakshmipur are still low, the rate of improvement for misoprostol consumption is actually highest among all the program districts. A new strategy of combined distribution of misoprostol and 7.1% CHX was introduced in Lakshmipur starting from August 2016, and was aimed at increasing the use of misoprostol. The recall period of round-VI was from September, 2016 to February, 2017, and it shows an increased trend of misoprostol distribution and consumption in Lakshmipur, which is highest ever among all the districts.

Figure 6: Number of misoprostol acceptors by districts among a comparable sample size, per round of tracer survey data collection

100% 93 90% 212 1016 338 86 80% 211 87 501 70% 152 68 8 60% 110 603 58 117 50% 69 183 77 620 40% 24 89 90 30% 870 600 145 20% 94 385 10% 938 68 172 0% Lakshmipur Noakhali Jhalokati Habiganj Pirojpur

Round-I Round-II Round-III Round-IV Round-V Round-VI

Source: Tracer survey

20 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report The figure above also shows that among all rounds of tracer survey the highest rate of increase in misoprostol acceptors from the previous round was between round V and round VI in Lakshmipur (124% increase) and in Noakhali (84% increase).

The MIS data shows a significant change in misoprostol distribution in Lakshmipur after the introduction of combined distribution of misoprostol and 7.1% chx at community level starting from August 2016.

Figure 7: Community distribution of misoprostol in Lakshmipur

2500 2148

2000 1644 1441 1402 1409 1500 1283 1342 1335 1333 1201 1247 1041 1081 1049 1000 635 671 519 558 500 308 143 146 6 0 64 0

No. of misoprostol acceptor at community

Source: MIS-2, DGFP

Therefore, considering the recall period and the trend of increase in misoprostol acceptors we expect the rate of misoprostol acceptors and consumption in home delivery may show an upward trend next tracer survey.

However, TIS’s reveal that the majority of women who received misoprostol during pregnancy, consumed the drug (Figure 8) following home delivery. Therefore, compliance was not a major issue; the majority of women who delivered at home were likely to consume the tablets if they had the supply in hand.

Figure 8: Percentage of women who consumed misoprostol tablets following home delivery, among pregnant women who received misoprostol tablets during pregnancy

100 98 96 91 91 85 80

60

Percent 40

20

0 MaMoni Health SystemsHabiganj StrengtheningNoakhali Activity: FY’ 17Lakshmipu Annual Report Jhalokati Pirojpur 21 Source: Tracer Indicator Survey (TIS), Round VI

The project has begun working with the MOHFW to develop a need-based system of misoprostol distribution, which involves closely monitoring the stock and distribution status, as well as focusing on increasing the ANC3 coverage. We hope to see improved distribution and consumption of misoprostol tablets in Year 5. iv. Deliveries assisted by skilled birth attendants (SBAs) MaMoni HSS supported the clinical placements of 20 FWVs and paramedics in District Hospitals (DH) and Maternal and Child Welfare Centers (MCWCs). The objective of the clinical attachment was to increase the numbers of facility deliveries and to improve the quality of normal vaginal delivery (NVD) services at UH&FWCs in MaMoni HSS areas. FWVs and paramedics from selected UH&FWCs were placed at the gynaecology outdoor ward; gynaecology ward; labor room; and postnatal and antenatal wards, including the post-partum family planning (PPFP) services of the DH and MCWC, in batches for 21 days. Senior staff nurses acted as full time mentors, while district level supervisors, such as the Hospital Superintendent, Civil Surgeon (CS), Deputy Director of Family Planning (DDFP) and Medical Officer of the Clinic (MO-Clinic), supervised and monitored the FWVs and paramedics.

(L) Conducting delivery (R) Practicing ENC on a dummy

SBA assisted deliveries are gradually increasing in MaMoni HSS districts. A total of 122,330 deliveries were conducted by SBAs in six MaMoni HSS districts in Year 4, an increase from 92,123 in Year 3 (Figure 9). A number of initiatives have been taken to improve SBA deliveries in the project areas to create demand. Demand creation is mainly done with community mobilization by local government, through community volunteers and local level SBCC activities. SBCC activities that include street drama, video shows, and TVCs are the main activities that reach the population in the project area. Moreover, with the leadership of local government, local level advocacy meetings and dissemination events are conducted whenever a 24/7 union level facility has been established in the respective community. A number of quality improvement interventions in the facilities have resulted in improved quality of services, which has also increased demand in the

22 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report community to access delivery care services from the facilities. Last but not least, a system of pregnancy registration in the project areas also helps providers to track and follow up pregnant women. This registration system starts with community volunteers who collect the names of newly pregnant women and their locations, and provide this information to the FWA, HA, FWV and CHCP during community microplanning meetings. Subsequently the FWA, FWV, HA and CHCP includes these lists of pregnant women into their registers for tracking, providing services, and further follow up.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 23 Figure 9: Number of SBA deliveries in MaMoni HSS districts

70000 67237

60000 51415 50000 39826 40500 40000

Number 30000 36958 23927

20000 27184 15041

25131 20900

20734 18722 18453 10000

13842 11042 5376 7793 8318 0 Habiganj Jhalokathi Lakhsmipur Noakhali Pirojepur Bhola

Y3 Y4 Estimated number of deliveries

Source: CSBA report of MIS-2 and MIS-4 of DGFP, EmOC and CSBA report of DHIS-2, pCSBA report of Project Assumption: Estimated number of deliveries is 2.22% of the population (Based on national CBR, BDHS 2011)

An increasing trend in deliveries in 24/7 UH&FWCs was also noticed in HI areas. As of September 2017, a total of 94 UH&FWCs in 21 HI upazilas and 14 in HSCS upazilas (total 108) were providing 24/7 delivery services. Figure 10 shows the delivery trends in these 24/7 UH&FWCs of HI upazilas as the delivery data is not available in HSCS areas through the existing DGFP MIS portal.

Figure 10: Trend of deliveries in 24/7 UH&FWCs in HI areas

100 18000 90 16000 15,466 80 14000 70 11,738 12000 60 10000 50 8,117 8000 Number 40 6000 30 4678 20 4000 2000 10 41 54 75 94 0 0 Year-1 Year-2 Year-3 Year-4

No. of 24/7 UH&FWC Number of delivery in 24/7 UH&FWCs

Source: DGFP MIS-3

24 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Contributors to the increase in the number of deliveries during the last quarter are an increase in the number of facilities in last quarter, also some facilities that were new in previous quarters have become fully functional and provided a higher number of normal deliveries. Additionally, 24/7 facilities were promoted through a number of BCC activities and local level advocacy in the community through engagement with local government functions (e.g.union parishad and upazila parishad).

The population-based TIS also reveals increasing trends in SBA deliveries, and the project is on track in achieving the EoP targets (Figure 11).

Figure 11: Percent of births attended by a skilled attendant

70 60 53 50 50 58 45 40 52 52 40 5151 5150 51 49 40 48 47 45 43 43 39 39 39 40 30 3636 36 3737 35 32 34 3235 3029 20 28 2826 19 10 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) 2017 (Round-VI) EoP target

Source: Tracer Indicator Survey (TIS)

Figure 11 shows a significant increase in coverage of SBA deliveries from the baseline survey, particularly in Habiganj, where deliveries moved from 19% during the baseline survey to 39% in the Round VI survey. Most of the program districts were hard to reach areas and ranked as the bottom in delivery index of Bangladesh. As a result, even though there are significant improvements in SBA coverage that are close to reaching end of project targets, SBA coverage in these areas still lags behind national coverage averages. v. Private CSBAs (pCSBA) assisted deliveries MaMoni HSS continued supporting 89 pCSBAs in Year 3 in three districts (Habiganj, Noakhali and Lakshmipur) through capacity building, facilitating supplies, and regular monitoring and supervision. pCSBAs are non-salaried community-based private skilled birth attendants, whose sole earnings come from charging for different services like ANC, deliveries, PNC and selling essential commodities. In Year 4, 21 pCSBAs dropped out, owing to the fact that many of them married and discontinued their services. The 68 pCSBAs who continued their services conducted 1,187 deliveries in their catchment areas during the reporting year. Figure 12 shows an increasing trend in deliveries by pCSBAs since their deployment.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 25 Figure 12: Trend of deliveries by pCSBAs

350 314 300 309 288 276 250 246

200

150 147 158 Number 100 112 91 89 50 64 71 68 68 52 52 0 Y3-Q1 Y3-Q2 Y3-Q3 Y3-Q4 Y4-Q1 Y4-Q2 Y4-Q3 Y4-Q4

Number of pCSBA Number of deliveries

Source: Project MIS In spite of a reduction in the number of pCSBA’s, the data shows an upward trend of delivery by pCSBAs. The initial numbers of pCSBA’s were higher, but due to attrition from marriage and migration to other areas, the number has reduced.

1.2.1.b Newborn health A. Newborn health national support i. Scale-up of priority newborn health interventions

MaMoni HSS continued to support the MOHFW in the introduction and national scale-up of new newborn interventions and in improving the quality of facility based care. The project continued supporting the National Newborn and Child Health Cell, which provides management support for the national newborn and child health program activities, as well as coordinates the national scale-up, including monitoring of the interventions through post-training follow-up led by DGHS. MaMoni HSS provides technical assistance to the MOHFW through this cell. As part of its routine activity, the newborn and child health cell continued to support the IMCI Program Manager (PM) in implementing IMCI, as well as re-visitation activities for specific newborn interventions through the country. The national cell also supported the scale-up of kangaroo mother care (KMC), emergency triage and treatment (ETAT), sick newborn care and newborn sepsis management.

ii. Re-visitation of priority newborn interventions

MaMoni HSS played an instrumental role in assisting the MOHFW in planning and

26 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report implementing the national scale-up of 7.1% CHX application for newborn cord care as a part of ENC. Previously, the project supported the MOHFW for the national scale-up of the HBB program. During Year 4, the project facilitated the follow-up of both scale-up interventions through the re-visitation of priority newborn interventions, which was conducted in phases. Forty-six district revisits (2,811 facilities) of phase 1, phase 2 and phase 3 were complete; 7 districts revisits in phase 4 are currently on-going. By December 2017, all 64 districts of the country will be covered by this intervention.

The three-pronged activity included: a) identification of newborn focal persons from each upazila, divisional and district level advocacy meetings for use of HBB and 7.1% CHX; b) refresher training of SBAs on ENC, including HBB and use of 7.1% CHX on the umbilical stump; and c) a quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, medicine and supply stocks (including 7.1% CHX). The revisit also included the replacement/ or provision of supplies for newborn resuscitation equipment (bag, mask and sucker) in the facilities. The National Newborn and Child Health Cell supported by MaMoni HSS provided management support for this activity. Data collectors from partner organizations, Partners in Health and Development (PHD) and Bangabandhu Sheikh Mujib Medical University (BSMMU), conducted the revisits and gathered data using a standard checklist. The findings of the revisit are shown in Table 3.

Table 3: Findings of revisit in 46 districts (phase 1, phase 2 and phase 3)

Offer 7.1% Facility Types delivery CHX HBB kit MgSO4 Amoxicillin Gentamicin N DH 100 70 70 30 33 65 46 MCWC 100 64 89 15 93 11 61 UHC 91 72 78 10 33 53 304 UH&FWC-FP 89 46 83 7 84 7 2018 UH&FWC-H 86 51 83 10 83 16 172 USC 49 26 34 0 45 11 53 RD 66 32 83 1 61 2 104 Others 42 26 55 4 45 13 53 Total 87 49 81 7 76 14 2811

Training Types n n %

7.1% CHX trained 15252 11484 75

HBB trained 12871 6830 53

iii. Divisional dissemination on post-training follow-up of the application of 7.1% CHX in the newborn umbilical cord As part of the technical assistance to the Newborn and Child Health Cell, MaMoni HSS organized 8 divisional dissemination meetings on post-training follow-up of 7.1% CHX for cord care in Dhaka, Mymensingh, Rajshahi, Khulna, Barisal, Sylhet, Chittagong and Rangpur divisions. The results of the post-training follow-up, conducted by 32 independent monitors in 64 districts in Year 3, were presented at these divisional dissemination meetings. The presentations included the status of human resources, skills and knowledge retention from trainings, availability and usage of 7.1% CHX across all level of facilities and

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 27 private pharmacies, and the availability and usage of HBB equipment and their cleanliness. The post-training follow-up revealed that 86 percent of the respondents (N=3400) who participated in the post-training follow-up received orientation on ENC, including the application of 7.1% CHX in the umbilical cord. At the time of the visit, 7.1% CHX was available in 49% percent of facilities. Eighty-four percent of providers could demonstrate correct use of 7.1% CHX and 47 percent of these providers had applied 7.1% CHX on the newborn umbilical cord during the past week. Eighty-six percent of the providers counseled pregnant mothers to use of 7.1% CHX and 54 percent of private pharmacies were found to stock 7.1% CHX. Resuscitation bag-masks and suckers were available in 84 percent of operation theatre (OT)/delivery rooms. Eighty-six percent of facilities supplied clean bag- masks and suckers. The divisional disseminations highlighted discussions on the DGFP’s revision of the operational plan (OP) and procurement of 7.1% CHX; distribution and use of CHX at the facility level; delays in the distribution of CHX from the district to the sub-district level; approaching the district manager for local procurement of CHX for interim periods during stock outs; the role of the proposed designated medical officer as a focal person of maternal and newborn activities; reporting on the use of 7.1% CHX from private sector to Civil Surgeons (CS); and an emphasis on cleanliness and service readiness to ensure quality service.

Professor Shahidullah speaks during the Dhaka divisional dissemination meeting

The divisional meetings also discussed issues related to the re-visitation of priority newborn interventions. Divisional and district level managers from the health and family planning division attended these meetings.

iv. Other national activities In Year 4, the project supported the Line Director of the Maternal, Neonatal, Child and Adolescent Health (MNC&AH) unit in preparing the operational plan (2017-2022). Through the National Newborn and Child Health Cell, MaMoni HSS facilitated the incorporation of newborn indicators in the sector plan, and adaptation of the newborn-related service delivery information in the facility registers and reports.

28 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Under the leadership of the National Newborn Health Program and Integrated Management of Childhood Illness (NNHP & IMCI) unit of the DGHS, the project facilitated the development of a national newborn dashboard in DHIS 2 through the National Newborn and Child Health Cell. HBB, SCANU, 7.1% CHX, KMC and ENC related indicators have been incorporated in the dashboard. Screenshot of the newborn dashboard in DHIS 2 The project continues to provide technical support for the publication of the National Newborn Health Bulletin. The third issue of the bulletin was published during the last quarter.

Issue 1 Issue 2 Issue 3

The bulletins were shared with stakeholders and uploaded to the Healthy Newborn Network (HNN) web page. The Director of PHC and PM-NNHP and IMCI plans to include this bulletin in the MIS bulletin section of DHIS 2.

ii. Newborn health district interventions

Project initiatives during Year 4 focused not only on increasing coverage, but also on improving the quality of service delivery through building capacity of service providers on priority newborn interventions, including recording and reporting; availability of logistics, job aids, and on-the-job coaching; as well as community awareness.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 29 a. Helping Babies Breathe (HBB)

The HBB intervention has been implemented in all 64 districts under national scale-up activities. In Year 4, a total of 21,450 newborns were resuscitated in facilities across the country using a bag and mask. Figure 13 shows the number of newborns resuscitated using bag and mask by divisions.

Figure 13: Number of newborns for whom resuscitation actions were initiated, using a bag and mask, in 7 divisions of Bangladesh

7000 6185 6000 4950 5000

4000

2886 2937

3000 2525 Number

1958

1996 1798 1694 2000 1541

1348

1316 1232

1081

989

737

704 676 646 644 547 502 502 479 449 1000 436 377 369 352 281 215 208 127 113 100 0 Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet

Q1 Q2 Q3 Q4 Total

Source: MIS-3, DGFP and DHIS-2 b. Application of 7.1% CHX for newborn cord care The application of 7.1% CHX to the umbilical cord stump is one of the major interventions to prevent newborn sepsis for all newborns, irrespective of their place of delivery. As a part of the ENC package, 7.1% CHX application has been implemented in six project districts under national scale-up activities. Routine MIS tracks the application of 7.1% CHX to the umbilical cord for all SBA assisted deliveries, both at the facility and in the community. Figure 14 shows an increasing trend in the application of CHX. The application of 7.1% CHX increased from 32,224 newborns in Year 3 to 77,477 newborns in Year 4.

30 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Figure 14: Number of newborns that received 7.1% CHX on their umbilical cords immediately following birth in Year 4, as reported by SBAs in MaMoni HSS districts

70000 59486 59486 59486 59486 60000 50000

40000 32882 31301 28689 29458 30000 22786 22411 Number 20000 15709 16571 10000 0 Y4-Q1 Y4-Q2 Y4-Q3 Y4-Q4

Number of estimated live birth Number of SBA delivery Application of 7.1% chlorhexidine

Source: MIS-2 & 4, DGFP, EmOC and CSBA report of DHIS-2 and pCSBA report of project MIS Though the data indicates that progress is being made to close the gaps between the total number of live births, total number of SBA-attended deliveries, and application of 7.1% chlorhexidine, there is still a gap in coverage. A major contributor to this gap is a lack of supply of 7.1% CHX, which DGHS procured once but has not made any procurements since. Initially, due to the lack of supply in DGFP at the district level and below, DGHS provided some CHX to those facilities as a temporary arrangement. DGFP also received approximately 110,000 bottles of 7.1% CHX from the CHX working group but the supply did not meet the demand. In the 4th sector plan, the supply challenges should be addressed as both DGHS and DGFP have included budgets for new procurement of 7.1% CHX. Population-based TIS reveals that the project is on track in achieving the EoP3 target for 7.1% CHX application on the newborn umbilical cord immediately following birth, except in Pirojpur district (Figure 15).

Figure 15: Percentage of newborns that received 7.1% CHX application on their umbilical cord immediately after birth in MaMoni HSS districts

3 EoP target revised in 2017.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 31 100 90 80 70 60 50 40

Percentage 30 29 30 25 24 16 20 20 10 13 10 10 8 10 10 4 4 4 5 10 3 0 1 1 2 1 1 2 1 2 0 2 1 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) 2017 (Round-VI) EoP Target

Source: Tracer Indicator Survey (TIS)During data collection for the tracer surveys, it was noted that there appears to be some recall bias related to use of 7.1% CHX. Specifically, it was sometimes difficult for mothers that delivered in facilities to remember and/or know whether the provider applied 7.1% CHX to the cord of the newborn or not. In most cases the mother was not able to remember. c. Postnatal checkup for newborns within 48 hours of birth

TIS data shows an increasing trend in postnatal checkups for newborns in all MaMoni HSS districts. This indicator achieved its EoP target for Jhalokathi, Lakshmipur, Noakhali and Pirojpur districts; Habiganj district lags slightly behind, but is on track in achieving its target (Figure 16).

Figure 16: Percentage of newborns, in MaMoni HSS districts, that received a postnatal check-up within 48 hours of birth from a medically trained provider

100

80

60 48 48 48 39 42 41 41 34 36 34 38 40 31 29 34 32 Percent 27 28 2232 24 33 20 25 19 15 19 19 20 12 20 11 11 20 4 7 7 6 3 18 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) 2017 (Round-VI) EoP Target

Source: Tracer Indicator Survey (TIS)

d. Facility based care for sick children i. Management of sick children (<2 months of age) in union level facilities MaMoni HSS has been supporting the identification and management of sick young infants (<2 months of age) in accordance with PSBI national guidelines in 148 UH&FWCs of 4

32 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report project districts, where a Sub-Assistant Community Medical Officer (SACMO) is available. Given that they have had three years of training, the SACMO is the designated provider for managing sick young infants with PSBI with the first dose of injectable gentamycin. FWVs are only authorized to provide the second dose of injectable gentamycin when a SACMO is unavailable and referral is not possible. This service is presently underutilized, perhaps due to the unavailability of service providers after clinic hours, poor case identification and management by service providers, and a lack of confidence among service providers in administering injections to small children. Figure 16 portrays the trend in sick children management at UH&FWCs in 4 MaMoni HSS districts.

Figure 17: Number of sick children (<2 months of age) treated at 148 UH&FWCs in 4 MaMoni HSS districts

800 700 719 640 600 544 500 497 494 486 472 447 431 424 442 400 376 299 Number

300 244 227 216 215 210 204 196 194 190 186 179 175 174 172 168 164 157 148 145 133

200 131 125 124 112 112 110 104 102 100 97 93 91 90 80 76 39

100 34

29 28 27 27

25

23 23 22 21 20 19 19 16 12 10 10 8 4 4 3 3 3 0 Oct'16 Nov'16 Dec'16 Jan'17 Feb'17 Mar'17 Apr'17 May'17 Jun'17 Jul'17 Aug'17 Sep'17

CI CSI IFB LBI Other Total

Source: Project MIS

Figure 18 shows the composition of PSBI in children (<2 months of age) during the reporting year in MaMoni districts. Fast breathing as a single sign of illness (IFB) was highest among all PSBI (81%), followed by clinical severe infection (CSI) and critical illness (CI), which were 14% and 5% respectively.

Figure 18: Composition of PSBI in children (<2 months of age) in MaMoni HSS districts

CI, 115, 5%

CSI, 314, 14%

IFB, 1764, 81%

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 33 Source: Project MIS ii. Management of sick children from Special Care Newborn Units (SCANUs) Of ten Special Care Newborn Units (SCANUs) established by the MOHFW using SAARC development funds, four SCANUs are located at districts hospitals within the project area, in Habiganj, Noakhali, Bhola and Pirojpur. The MaMoni HSS project exclusively supported the establishment of a SCANU in Lakshmipur. These SCANUs continue to provide services for critically sick newborns; however, this service delivery faces challenges due to a shortage of dedicated manpower and a lack of ownership. The project continues to support the capacity building of GoB staff, installation and maintenance of equipment, and the placement of trained staff nurses at selected SCANUs (Habiganj, Noakhali and Lakshmipur). SCANU data from the facilities is entered into DHIS 2. However, the completeness and quality of date reported in DHIS 2 is a major issue. The project continues to work to improve the timeliness and completeness of SCANU reports. Figure 19 shows the number of admissions of sick newborns at five project supported SCANUs.

Figure 19: Quarterly admission of sick newborns at 5 project supported SCANU centers

1000 875 900 900 800 700

600 500

Number 400 310 273 300 200 100 0 Y4-Q1 Y4-Q2 Y4-Q3 Y4-Q4

Source: DHIS-2

Figure 19.1: The case fatality rate at SCANUs, against total numbers of reported newborn admissions in Bangladesh, from October 2016 – September 2017

34 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report 9000 100 8000 90 7000 80 70

6000 60 5000 50 4000

Number 40 3000 30 Percentage 2000 20 14.2 14.0 14.1 14.0 1000 13.3 13.4 13.2 12.8 13.9 12.6 13.3 12.510 0 0

No. of newborn admission No. of death Case fatality rate

Source: DHIS-2

e. Kangaroo Mother Care (KMC) at district and upazila level facilities

The MaMoni HSS project supported the MOHFW in establishing KMC services at 15 district and upazila level facilities in 4 districts (Habiganj, Noakhali, Lakshmipur and Jhalokathi), according to the national guidelines for stable preterm and low birth weight babies. The facilities include 4 DHs, 2 MCWCs and 9 Upazila Health Complexes (UHCs). The project advocated with the GoB for national and local level ownership as well as for compliance in preparing facilities to provide services and post-discharge follow-up. During Year 4, a total of 122 cases received KMC services from these 15 facilities. However, KMC service utilization is low at these facilities. Most of the cases who availed of KMC services had a short hospital stay, opting for early discharge and discontinuation of services, against medical advice. The project is trying to explore gaps to identify possible solutions. Provider training alone may be insufficient to develop KMC related counselling skills. MaMoni HSS is presently working with the MOHFW and has already sensitized the district, upazila and union level service providers to refer low birth weight babies to KMC units. Furthermore, the project has oriented and engaged union level supervisors (Assistant Health Inspectors) to follow-up with cases within the community, following prior visits to DHs and UHCs. The project has also reproduced and supplied job aids to service providers for the purposes of providing KMC counseling to mothers and other key decision makers within families. The project plans to implement KMC services at all UHCs in 4 project districts by December 17, 2017.

f. Scale-up of Antenatal Corticosteroid (ACS) use to prevent complications related to prematurity The MOHFW has decided to scale-up the use of ACS nationwide to reduce neonatal mortality and morbidity in high-risk preterm deliveries.” It has developed a national guideline for the implementation of ACS. MaMoni HSS is supporting MOHFW to operationalize and gather learning on the implementation of this intervention in 3 district hospitals in Habiganj, Noakhali and Laksmipur. During this reporting year, a total of 314 pregnant women (Q1-93, Q2-60, Q3-114 and Q4-47) received ACS from Habiganj, Noakhali and Lakshmipur district hospitals.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 35

g. Mentoring visits for newborn interventions at district facilities As a partner of MaMoni HSS, the BSMMU continues to provide technical assistance to the MOHFW for the introduction and roll out of novel newborn interventions. As part of this activity, and as part of the strategy for successful project close-out, professionals from the Neonatology Department of the BSMMU conducted technical supervisory visits to the SCANUs and KMC units, including ACS application and newborn and child health service units, at Noakhali, Habiganj, Lakshmipur and Jhalakathi district hospitals.

Prof. Mannan visits the Noakhali SCANU and discusses his findings with relevant authorities and providers

The observations and recommendations following these visits were shared in a meeting with hospital superintendents, consultants, doctors and nurses on the same day. The SCANUs face challenges related to the involvement of GoB nurses in the SCANU unit, cleanliness and aseptic measures, and the functionality of equipment. The SCANU at Habiganj currently does not operate around the clock. Technical persons have recommended smooth and regular mechanisms for repair and maintenance of SCANU equipment, as well as adequate sitting arrangements for mothers with babies admitted in the SCANU, to ensure skin to skin care contact for at least 2 hours twice a day. They also advised keeping a detailed examination record in the history sheet of each case; displaying handwashing posters and KMC counselling materials; training more nurses and doctors; establishing a mechanism for post-discharge follow-up; eye screenings for retinopathy; increasing the number of dedicated nurses in the SCANU; arranging room temperatures using a recording thermometer; establishing monthly perinatal meetings and technical discussions between district and national level resource persons through Skype calls; and preparing a checklist for external technical supervisory visits to the SCANU and KMC units. Based on the technical recommendations a number of actions have been taken, including:

• A checklist for supervisory visits has been developed and is in place for use. • A hand washing poster was obtained and placed appropriately. • Post-discharge follow up of cases has been started in Noakhali district hospital • The establishment of eye screening for retinopathy is in process with the collaboration of BSMMU.

1.2.1.c Family Planning (FP)

36 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report This year, MaMoni HSS focused on increasing coordination between the DGHS and DGFP in promoting FP interventions, especially long acting and reversible contraceptives (LARCs), permanent methods (PMs), and post-partum family planning (PPFP), at all facility levels. Health managers are not oriented with FP or PPFP, and providers working under the DGHS do not have adequate skills to provide FP counseling to clients, despite a 44% unmet need for PPFP. MaMoni HSS supported the scale-up of FP services in general and PPFP in particular. The project placed special emphasis on strengthening the capacity of providers at health facilities managed by the DGHS to ensure service readiness and provision of care.

In addition to strengthening DGFP activities, the project supported a number of activities and interventions in Year 4, which were exclusive to DGHS. These are as follows:

i. Strengthening coordination between the DGFP and the DGHS

In September 2017, MaMoni HSS supported the DGFP of Noakhali and Lakhsimpur with the organization of post-training follow-up meetings. Dr. Nurun Nahar Begum, Deputy Director (QI), CCSDP, DGFP, was the chief guest and keynote speaker. Participants included consultant OB/GYNs, UH&FPO, UFPO, MO clinic, MO (MCH-FP), Medical Officer Civil Surgeon (MOCS) and nurses. Discussions centered around the strengthening of FP activities, chiefly PPFP, and the response of the Departments of Health and FP to increase PPFP coverage and providing the resources necessary for better performance.

The CS and DDFP of the DGHS and DGFP address PPFP-related performance improvement issues in Noakhali and Lakhsimpur

The meeting resulted in the following major recommendations: • The MO (MCH-FP) needs more exposure to tubectomy/NSV and supportive supervision for another 3 months; • Increased coordination among the Departments of Health and FP is required to ensure an adequate supply of IUDs and registers for recording and proper mobilization of Imprest funds in DHs and UHCs; • Where the UFPO helps or monitors, there is also a need for increased coordination between FWVs and nurses; • Consultant OB/GYNs and EOC doctors need training on PPFP to monitor the performance of nurses; • Since the DGHS has no PPFP service performance record register, a column will be created in the EOC register;

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 37 All upazila performances of FP and PPFP will be reviewed in monthly meetings and the highest performing facility will be recognized. The promotion of PPFP at the upazila level is one of the project strategies and the project is following up on the recommendations as noted: • In the regular upazila monthly meeting for FP only the performance of FP is reviewed. MaMoni HSS staff is trying to introduce a separate agenda item for PPFP and to share information on the previous month’s PPFP performance in the upazila. • MaMoni HSS follows up the performance in all upazila monthly meetings as well as Quarterly Performance Review Meetings (QPRM) in Districts.

ii. Orientation of DGHS providers from DHs and UHCs on FP service delivery, including PPFP Orientation sessions on FP and PPFP service delivery were held with DGHS managers and providers from the DHs and UHCs in all four districts. These orientation sessions sought to strengthen FP services at the upazila and district level DGHS facilities. The sessions were jointly arranged by the Departments of Health and Family Planning, with technical support from MaMoni HSS and the DGFP. A total of 124 participants, including UH&FPOs, MOCS, consultant OB/GYNS, RMO/UHC and SSNs attended these sessions.

(L) The CS speaks on the DGH role in provision of FP and PPFP (R) DGHS providers are oriented on FP and PPFP

Feedback from one health manager following the training stated, “This orientation will change the perception, knowledge, and attitude of DGHS managers, as well as provider’s roles and responsibilities on FP and PPFP”. During monthly meetings, managers will subsequently inform and build the capacity of other health service providers, to ensure that these providers are effectively counseled and build skills in offering clients easy access to a wide range of affordable, reliable, and high quality FP and PPFP contraceptive services, with a special focus in promoting methods like PPIUCD. A follow-up meeting will be organized in each quarter for intense liaison and communication between DGHS and DGFP providers.

iii. Sharing findings on facility readiness for LARC and PM services

38 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Due to the underutilization of LARC and PM services in intervention areas and a need to understand the facility readiness status, a facility readiness assessment, using a structured checklist, was conducted to identify gaps at 4 DHs, 6 MCWCs and 22 UHCs. The findings were shared with the CCSDP of the DGFP to advocate for support in terms of infrastructure; human resources; logistics and supply; capacity development of service providers; infection prevention (IP); and quality of care (QoC) to increase utilization and ensure patient satisfaction. The CCSDP found these findings highly beneficial and committed to support the facilities in readiness preparation efforts, as they have a budget for facility development in the current operational plan. An action plan has been developed to provide support and monitor the progresses of facilities to provide LARC and PM services in MaMoni HSS areas.

Family planning performance in MaMoni HSS districts

i. Postpartum family planning (PPFP) PPIUCD performance trends increased from 2,204 in Year 3 to 2,366 in Year 4 (Figure 20). The increase in performance can be attributed to capacity building, reviewing monthly performances, providing regular feedback to providers through local and central level monitoring, and joint supervisory visits by DGHS and DGFP officials.

Figure 20: Trend in PPIUCD performance in MaMoni HSS districts

2500

581 2000

1500 205

1000 1785

1179 500

0 Year-3 Year-4

HI HSCS

Source: MIS-4, DGFPAmong all placed IUCDs in Y3 and Y4, the removal rate before the full term of the IUCD was 21% (Y3) and 12% (Y4) respectively for Habiganj, 5% (Y3) and 9% (Y4) respectively for Lakshmipur, 11%(Y3) and 19%(Y4) respectively for Jhalokati. A study is being conducted in Habiganj district on discontinuation of IUCD and implant that will give more accurate indication of IUCD and implant removal rate.

ii. Long acting reversible contraceptive and permanent method (LARC&PM) LAPM performances in Year 3 and Year 4 showed overall increasing trends in Habiganj, Noakhali and Bhola (Figure 21), and a decreasing trend in Jhalokathi. Changes to the trends in Lakshimpur and Pirojpur were negligible. In Jhalokathi, project-supported FSOs responsible for motivating CVs to refer LARC&PM clients were withdrawn at the beginning

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 39 of Year 4. Additionally, the positions of GoB front line workers, particularly FWA positions, were vacant in Year 3 (37%) and in Year 4 (47%). The larger number of vacancies in Year 4, than in Year 3, had a negative impact on LAPM performances in Jhalokathi district.

Figure 21: LARC&PM performance in MaMoni HSS districts in Year 3 and Year 4

14000 12614 11528 12000 1095111431

10000 9200 8805 8000 6414 6365 5567 6015 6000 3754 4000 3078

2000

0 Habiganj Lakshmipur Noakhali Jhalokati Pirojpur Bhola

Year-3 Year-4

Source: MIS-4, DGFP Figure 22: LARC performance in Y3 and Y4 of 6 MaMoni HSS districts 12000 10709 9886 10000 9353 9474 8064 7817 8000

5600 5710 6000 4369 3888 4000 3230 2607

2000

0 Habiganj Lakshmipur Noakhali Jhalokati Pirojpur Bhola

Year 3 Year 4

Source: MIS-4, DGFP

Figure 23: Performance of permanent method in 6 MaMoni HSS districts in Y3 and Y4

40 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report 2500 2175

2000 1905 1679 1646 1477 1545 1500 1136 988 1000 814 655 524 471 500

0 Habiganj Lakshmipur Noakhali Jhalokati Pirojpur Bhola

Year 3 Year 4

Source: MIS-4, DGFP The above tables on disaggregated FP (22 and 23) show that in most of the districts LARC performance had a slight upward trend but performance of permanent methods remains the same or even reduced (in Lakshmipur, Noakhali, Jhalokati, and Pirojpur). A large number of vacancies for FWAs has had an effect on family planning services. The government has taken a few initiatives in the hard-to-reach areas to improve the situation. Specifically, the government has deployed 45 volunteers in Kabirhat, Senbag and Hatya upazila of Noakhali districts against the vacant FWA posts and has deployed 235 paid volunteers in Hatya and Begumganj upazila of Noakhali to assist the FWAs. The government has a plan to deploy more volunteers in Lakshmipur as well. iii. Use of modern methods of family planning Use of modern method of contraceptives has increased gradually across all MaMoni HSS districts. Figure 24 shows that the use of modern methods has increased between 2012 and 2017 in all districts. Jhalokathi district has already achieved the EoP target. All other districts are on track in achieving the target.

Figure 24: Prevalence of current use of modern method of contraception

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 41 100

80

61

57 57 60 5656 56 54 55 54 5556 53 58 5152 5052 5053 5353 52 5358 47 48 4955 47 49 45 44 53 4141 42 40 4248 Percent 40

20

0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur

2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) 2017 (Round-V) 2017 (Round-VI) EoP Target

Source: Tracer Indicator Survey

iv. Promotion of FP services through community volunteers In Year 4, 24% of new LAPM users were referred by community volunteers of the MaMoni HSS. Figure 25 shows the current progress in LAPM uptake in project districts. A comparison of referrals ascribable to the contribution of community volunteers shows a 6 percentage point increase from 18% in Year 3 to 24% in Year 4.

Figure 25: Contribution of community volunteers (CVs) to LAPM performance in MaMoni HSS districts in Year 3 and Year 4

Year-4 24% 76%

Year-3 18% 82%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% referred by CVS % referred by GoB staff

Source: MIS-4, DGFP and Project MIS

1.2.1.d Nutrition

42 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Malnutrition is one of the most serious health problems, among others, affecting infants, children and women of reproductive age in Bangladesh. Despite progress, millions of children and women still suffer from different forms of undernutrition, including low birth weight, stunting, underweight, wasting, vitamin A deficiency, iodine deficiency disorders, and anemia. The nutritional status of children is a proxy indicator of the state of health of a community or population. With this status in consideration, MaMoni HSS has been working in four districts (Noakhali, Lakshmipur, Jhalokathi and Habiganj) under the directive of the Institute of Public Health Nutrition (IPHN) and with the district and upazila level health and family planning authorities. MaMoni HSS supported the MOHFW in implementing nutrition interventions through an integrated MNCH service in all upazilas of 4 project districts, with a special focus in 9 upazilas in 4 districts (Companiganj and Hatiya upazilas in Noakhali; all upazilas in Lakshmipur; Madhabpur upazila in Habiganj; and Rajapur upazila in Jhalakati district). In Year 4, the project facilitated the development of skilled human resources by providing competency-based training on nutrition and severe acute malnutrition (SAM) management training under the leadership of the IPHN. The project also facilitated the distribution of basic equipment and supplies (50 spring scales, 50 height/length boards, 500 MUAC tapes), received from the IPHN, for nutritional status screenings at different Service Delivery Points (SDPs). Data from the DGFP MIS, DHIS 2 and Project MIS show the following results in MaMoni supported districts during this quarter: 594,496 children were reached (Habiganj: 272,278; Jhalakati: 56,561; Lakshmipur: 81,656; and Noakhali: 184,001) with nutrition interventions through various service delivery points where IMCI services are being provided (community clinics, UH&FWCs, UHCs and DHs). Of these children, 92,252 had some form of undernutrition (underweight, wasting, stunting, MAM and SAM). Among the undernourished children, 78,622 children were identified as underweight, stunted or wasted; 11,137 children were identified as MAM, and 2,493 children were identified as SAM.

At this point IPHN has no tracking mechanism to follow up on outpatient cases. The proposed CMAM intervention to address outpatient cases is still under discussion. However, the project is trying to strengthen counseling and BCC activities based on the existing platform.

A lot of BCC materials have been made available at SDPs through IPHN and the project also supplied a lot of BCC materials, including a nutrition flip chart, food plate with demonstration guide. Key messages have also been incorporated into the BCC activities of MaMoni HSS, such as the Community Action Group (CAG) meetings. Moreover, the District Nutrition Surveillance Office (DNSO) of UNICEF also working on it and we are working with them with regular coordination.Among children identified as SAM, only 217 children (45.16% male and 54.84% female) were admitted in SAM units at UHCs and DHs and received management at these facilities. Moreover, of these 217 children, only 194 children were discharged. Of these 217 children, 194 were discharged by the end of the month, the remaining 23 patients were carried forward as ‘patient total end of the month’ which is considered as ‘patient total beginning of the month’ in the subsequent month. The outcomes of the management for these cases will be categorized in the subsequent months. Furthermore,

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 43 among these 194 discharged children, 105 were cured4 (54.12%), none died5, 38 children were defaulters6 (19.58%) and 51 (26.28%) were discharged as “Discharged Stabilized7”.

. 243,846 caretakers received social and behavioral change communication (SBCC) interventions on essential infant and young feeding practices, hand washing, iodine deficiency disorders (IDD), and vitamin A. . 293,2966 pregnant mothers were reached with Iron Folic Acid (IFA) supplementation during ANC visits.

1.3 Strengthen infrastructure preparedness to improve MNCH service utilization

1.3.1 Upgrading UH&FWCs to provide 24/7 delivery services

In year 4, a total of 33 UH&FWCs (19 in HI upazilas in 4 districts, and 14 in HSCS upazilas in Bhola, Noakhali and Pirojpur districts) were upgraded in the six project districts to provide 24/7 delivery services. Thus, the total number of 24/7 UH&FWCs in the project area has increased to 108. Please see Appendix 5 for the list of UH&FWCs upgraded in MaMoni HSS districts. National level activities related to the upgrade of UH&FWCs has been described under IR 3.

IR 2: Strengthen health systems at the district level and below 2.1 Improve leadership and management at district level and below Quarterly performance review meetings (QPRM), district review meetings held jointly by the DGFP and DGHS staff with facilitation from MaMoni HSS, were held regularly for data driven problem solving, management decision-making and actions plans for program improvement. QPRM is the forum where upazila action plans are monitored, reviewed progress and followed-up.

2.2 Improve district level comprehensive planning (including human resources) to meet local needs MaMoni HSS supported the development of decentralized MNCH/FP/N action plans at district and upazila levels, using local level data and analysis. The data from Tracer Indicator Surveys (TIS) on priority MNH/FP indicators, along with routine MIS of DGHS (DHIS 2) and DGFP and project MIS informed the prioritization of interventions as well as geographic areas. Twenty-six action plans were developed for 26 upazilas.

4 Cure : Patient that has reached the discharge criteria as per national guidelines 5 Death : Patient that has died while enrolled in the program. For Outpatient Program the death has to be confirmed by a home visit 6 Defaulter : Patient that is absent for 2 consecutive weighing (2 days in in-patient and 2 weeks in outpatient) 7 Discharged Stabilized : Patient are discharged after completing the stabilization phase of when the patient is stabilized

44 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report

Health Workforce Management The project supported the study titled, “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities”. The objective of the study was to understand the existing workloads of different cadres of health workers at health facilities and at the community level. The study adapted WHO’s “Workload Indicators of Staffing Need” (WISN) methodology to the Bangladeshi context. A Technical Advisory Group (TAG) formed by the MOHFW with representatives from key departments of the ministry, professionals and key stakeholders provided guidance and advice on technical issues, methodology, and tools to expedite the study. The study was conducted at one medical college hospital (Rajshahi Medical College Hospital), two district hospitals (Kushtia and Brahmanbaria), two MCWCs (Kushtia Sadar and Brahmanbaria Sadar), four selected UHCs (Daulatpur, Kumarkhali Nabinagar, Sarail), eight union level facilities, four community clinics, and with corresponding community level workers at selected unions in Kushtia and Brahmanbaria districts. Key findings and recommendations was shared with TAG and a draft report has been submitted to Human Resource Branch of MOHFW for review.

Interview with nurses Sharing key findings with TAG Key findings of the study • The workloads of health service providers such as physicians, nurses, FWVs, and FWAs were found to be very high at most facilities and community levels in the study area. • A significant proportion of the available working time of major health care providers, namely physicians and nurses, are spent on supporting activities rather than activities related to health care delivery. • There are inequalities in the workloads of similar categories of staff working at different facility levels (e.g. medical college hospital, DHs, UHCs), and at similar facility levels. • Different types of support services staff, such as cleaning, laundry, attending, kitchen, and security staff, are also important for the optimum performance of facilities. The existing numbers of various support staff at different facility levels are inadequate to manage the workload. There are significant shortages in almost all categories of support staff.

• The existing record keeping system does not capture all health service related activities, particularly prevention and promotion activities. Additionally, the lack of

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 45 discipline-specific data, even at the secondary and tertiary levels, makes it very difficult to accurately assess the workload.

Implementation of Central HRIS MaMoni HSS is presently supporting the MOHFW with the national roll out of the central HRIS, as well as its implementation in Habiganj and Noakhali districts. The central HRIS is a web-based software developed by the MOHFW for capturing the HR information for all directorates/agencies under the ministry at various levels across the country. The project also supported capacity building through the Training of Trainers (ToT) and provision of training to relevant staff (e.g. Statisticians, Assistant Chiefs, Programmers, and Assistant Programmers) from division, district and upazila levels. HRIS has been included as a regular agendum of the QMRM in Habiganj and Noakhali districts. Progress and major data gaps in HRIS were presented, and actions required for improvement were discussed at the ToT on HRIS last QPRMs. Following a request from the Divisional Director of Health, Barisal, the MaMoni HSS project also conducted the analysis of the HRIS data from the Barisal division. The findings of this analysis were presented at the divisional monthly coordination meeting with all the civil surgeons of the division. The DGHS has identified 10 data fields in the ‘Provider Registry’ and 7 data fields in the ‘Facility Registry’ in the HRIS to monitor the improvement in data quality and to ensure completeness. Improvements in data completeness in these selected fields in both registries (Provider registry: 40.7% to 51.3%, Facility registry: 1.7% to 9.1%) of the HRIS were observed between May and September 2017. If a complete HRIS system in place then it will help the managers to have a picture of his/her staffing and gaps. It helps a manager to manage the work force to:

• Identify gaps or staff vacancies so the manager can initiate further recruitment with the proper authorities. • On a priority basis, the managers can reduce the strain of temporary gaps through re-allocation of staff from more strongly staffed locations to locations where there are significant vacancies. • It also allows a manager to foresee how many staff will be retiring and when, so that the manager can plan how the pending gaps will be managed into the future.

46 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Figure 26: Data completeness in provider and facility registries of the HRIS in

100

80

60 55.3 51.8 49.7 51.3 47.0 45.6 40

% data of completeness 20 13.5 9.1 0.7 2.7 2.3 1.7 0 Habiganj Noakhali Overall Habiganj Noakhali Overall Provider Registry Facility Registry May 17 Sep 17

Habigonj and Noakhali

2.3 Strengthen local management information systems Development and scale-up of Electronic Management Information System (eMIS) Under the joint initiative of MEASURE Evaluation, International Centre for Diarrhoeal Research, Bangladesh (icddr,b), MaMoni HSS and MSH/SIAPS, the electronic management information system (eMIS) initiative has developed automated MIS tools for frontline health workers (HAs, FWAs, primary level facility workers, FWVs, SACMOs and their supervisors). A monitoring tool for district and upazila level managers at the DD-FP, UH&FPO, UFPO and MO-MCH has also been developed. MNH/FP/N indicators have been added into different modules. The Geographical Information System (GIS) plotting of categorized facilities included in the monitoring tool enables the district and sub-district level managers to skim through a lot of real time information in a very efficient manner. This GIS is capable of showing real-time service data. It also allows the incorporation of different geographic information as well as facility information from the UH&FWC assessment work. The tool was demonstrated at the GIS workshop organized by USAID/Bangladesh.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 47

MaMoni HSS eMIS team continuously monitored eMIS reports from UH&FWCs and provided feedback as needed using the monitoring tool.

Fig 27: Upazila ANC Services reported through e-MIS in Habiganj (October 1, 2016 - September 30, 2017)

7000 6513 6000 4887 5000 4283 3913 4000 3629 3106 3140 2844 2912 3023 2571 3000 2397 2278 1804 1902 2000 1526 1639 1574 1189 1368 1156 1274 962 803 861 937 495 630 570 1000 186 257 404 0 AJMIRIGANJ BAHUBAL BANIACHONG CHUNARUGHAT HABIGANJ LAKHAI MADHABPUR NABIGANJ SADAR

ANC1 ANC2 ANC3 ANC4

Under the eMIS initiative, the project has also developed an automated FP method screening tool for family planning clients, following Medical Eligibility Criteria (MEC), through rigorous consultation with DGFP experts. The tool comprises of a number of questions and physical examinations. Based on the answers from the ELCO and findings from physical examinations, the tool displays suitable method(s) for the client. Appropriate counseling for all suitable methods is also ensured. Using this tool, the provider can only proceed when all required criteria are met. This screening tool had been incorporated into the existing FP module. Implant eRegister has also been incorporated into the existing facility module. Provision of recording Post Abortion Care (PAC) services had also been added in the application.

48 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Various indicator based monitoring tools have also been developed, including the “high blood pressure monitoring” tool. During pregnancy, high blood pressure along with presence of albumin in the urine indicates “pre-eclampsia”. Since all data from ANC visits is now digitally available, the system can detect if the mother requires immediate referral and presents this information to upazila level managers. The system also alerts the managers if the service provider doesn’t refer clients when there is a need for referral.

eMIS digital registers helping providers in identifying risk pregnancy and referral

The primary objective of eMIS is to automate the business process of the government providers. The digitalization process allows for the development of rule based algorithms (Decision Support System) and alert systems, including automated Medical Eligibility Criteria for FP clients, detection of pre-eclampsia/eclampsia mothers and detection of Low Birth Weight [LBW] newborns, etc. This directly improves the quality of services of health providers. Moreover, integration with the community health workers (HA, FWA) and a customized client dashboard ensures better follow up and effective communication with the patients/clients. Finally the awareness that all of this activities are accessible though the monitoring system also raises the accountability at service provider end.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 49 Figure 28: Referral of pregnant women detected with high blood pressure and PE/E in Habiganj

90% 78% 80%

63% 70%

60%

50% 41% 40%

22% 30% 20% 10% Diastolic >= 90 PE

Nov'16 - Jan'17 Jun'17-Aug'17

The above graph indicates that after the introduction of the eMIS in Habiganj (in November, 2016), there has been an impact on both the quality and coverage of service delivery for PE/E case detection and referral in Habiganj. From November 2016 to January 2017, the eMIS has shown that the detection of high blood pressure and referral for PE/E was 22% and 63% respectively. When the monitoring tool was introduced in the eMIS, the detection referral rates have increased from Jun to August 2017, from 41% to 78% respectively.

50 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Case Study 1: Identifying risk pregnancy and PPFP

When Sazeda Khatun became pregnant for the fourth time in her forties, she came to the Dharmaghar UH&FWC for her antenatal visits. Following the automatic alert from the MNC e- register, the FWV, Seema Rani Dey, informed Sazeda about risk of having more than 3 children. The detailed medical records of Sazeda’s ANC visits were entered into the e-register. Following her delivery, Sazeda decided to take IUD as a PPFP method. When she returned to select an appropriate family planning method, all the details stored in the register at the time of her ANC visits, were automatically retrieved, resulting in a seamless process. The details of her follow-up visits were also recorded electronically. Now, all MNCH and FP records are available at one’s fingertips should they be require in the future.

Case Study 2: Identification and referral of pre-eclampsia through eMIS

Pollobi Rani Deb was a first time mother who came to Jagadishpur UH&FWC for her antenatal visit. During her third visit, she was diagnosed with high blood pressure (140/100). The embedded decision support system (DSS) in the eMIS e-register highlighted the high blood pressure and alerted the FWV, Jahanara Begum, of a potential pre- eclampsia case, since Pollobi also had blurred vision. According to the national guideline, Pollobi required referral to a higher level facility. Realizing the risk, Jahanara Begum, counselled Pollobi and referred her accordingly. Later, Pollobi gave birth to healthy boy through caesarian section at the hospital. Pollobi expressed her thanks to the FWV for her timely suggestion when she came back to UH&FWC for her postnatal checkup.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 51

One of the key features of the UH&FWC eRegister is its built-in medical intelligence. The electronic registers of the eMIS have the tremendous potential of improving the quality of care at the provider level. For example, an embedded requirement of adherence to the minimum standards required for ANC in the e-register ensures that the mother receives proper care and critical advice to avoid complications, such as pre-eclampsia/eclampsia, in later stages of pregnancy. The system can detect cases of high risk pregnancy as well as pregnant woman with severe PE/E. In Year 4, facility and community modules were piloted in Habiganj and Tangail districts. The facility modules are now being scaled up in Lakshmipur and Noakhali districts. Community modules will be scaled up at Lakshmipur and Noakhali in Year 5, and only facility modules will be rolled out in Jhalokathi.

Dr. Kazi Mustafa Sarwar, Director General, graces the inauguration of e-MIS activities in Lakshmipur, as a chief guest

2 2.4 Establish a quality assurance system for MNCH/FP/N services at the district level and below 2.4.1 Comprehensive strategy for improving the quality of clinical care The MaMoni HSS project is implementing a comprehensive quality improvement strategy to support the MOHFW at the national and district levels to improve the quality of clinical care for MNCH/FP/N services. The QI strategy has evolved based on lessons learned, experience in applying different approaches, and results documenting actual improvement of QI indicators. The project’s QI strategy comprises of three main components: A. Building national capacity and updating national standards and guidelines; B. Improving delivery of MNCH/FP/N services in MaMoni HSS districts; and, C. Measuring QI indicators and recognition of achievement. The project adopted the new WHO Framework for the quality of maternal and newborn health care as guiding principles for designing and implementing its QI interventions. The new Framework describes eight essential standards for ensuring quality of health care and puts equal weight to standards reflecting Provision of Care and standards reflecting Experience of Care from the client’s perspective.

52 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report

2.4.2 Building national capacity and updating national standards and guidelines: MaMoni HSS provided support to the national QIS in updating various national standards and guidelines including:

• Supporting national and divisional human resources capacity: Based on the Letter of Collaboration with the Health Economic Unit which is hosting the QIS, MaMoni HSS has recruited national level staff seconded to the QIS including senior advisor, national coordinator, information technology support, and administrative support staff. The project has also recruited QI divisional coordinators and seconded them as part of the technical capacity of all eight divisions of the country to support QI activities at the district level. In addition, in divisions where MaMoni HSS is working, four QI monitors have been recruited to provide more intensive support to QI activities at the district and sub-district levels.

• Supporting the development of QI committees and pool of resource persons: In order to increase local level ownership and participation of the QI process, the project provided support to the QIS in forming and facilitating QI committees at DHs and UHCs. In addition, the project supported the formation of district resource pools composed of MOHFW senior staff, supplemented by experts from medical colleges and professional associations, to provide monitoring and support to QI efforts at health facilities. Table 4 shows the number of district level QI committees and resource pools formed.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 53 Table 4: Number of district level QI committees and resource pools formed

Number of districts Number of districts Division Number of districts where resource pool where QIC formed developed

Chittagong 11 11 11

Sylhet 4 4 4

Barisal 6 6 6

Khulna 10 10 10

Dhaka 13 13 12

Rajshahi 8 8 8

Rangpur 8 8 8 3 2 Mymensingh 4 Total 64 63 61

• Developing national RMNCH QI standards and indicators: The project contributed to the national effort led by the QIS, and with participation of the DGFP, DGHS, and several national and international partners, to develop RMNCH QI standards and indicators based on the standards included in the WHO maternal and newborn health care QI Framework. The developed standards and indicators will contribute to establishing and measuring quality of RMNCH across the country. Standards and indicators have been finalized, tools are being developed to measure the indicators.

MaMoni HSS supported the MOHFW in developing the Maternal Health Strategy and Standard of Protocols (SOP). These two important, but long pending documents, were finalized and approved by the MOHFW this year. The project supported the DGFP in finalizing the PPFP counselling module.

• Developing Surgical Safety Checklist: Modified from the WHO, the Safe Surgery Checklist for Bangladesh has been developed by QIS with support from MaMoni HSS. The checklist aims to minimize mistakes at three points in any surgery: before induction of anesthesia, before incision, and before the patient leaves the operating room.

Developing national patient safety guidelines: The project is providing technical assistance to develop national patient safety guidelines. The guidelines include several domains such as: infection prevention, medication safety, patient identification and procedure matching, clinical handover, blood and blood product handling, and preventing pressure injuries.The first draft will be shared with a small group of subject matter specialists, professionals and then disseminated to a larger forum for finalization. • Developing national curriculum and providing training on the Plan-Do- Check-Act (PDCA) QI approach: The project led the effort to develop a structured

54 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report training course, including training sessions and accompanying materials. The purpose of the training is to empower health service providers to identify quality care gaps in their health facilities, understand the causes of the gaps, implement interventions to close the gaps, and measure results. During Year 4 of the project, PDCA training was conducted at nine district hospitals (Habiganj, Noakali, Lakshmipur, Jhalokathi, Bhola, Chandpur, Khagrachari, Cox’s bazar, and Moulovibazar).

• Developing QIS communication strategy: The project continues to provide technical support to develop a communication strategy to advocate for raising the profile of quality improvement efforts at the national level, increasing ownership and interest in quality care by service providers, and engaging community and other governmental and private entities in QI efforts.

• Updating national infection prevention guidelines: MaMoni HSS is providing technical support to updating the national infection prevention guidelines. The effort is led by the QIS with involvement of several national and developing partner experts. The guidelines include components of infection control program and practices, environmental management practices, care of health workers, and infection control precautions for selected situations.

• Supporting the implementation of 5S at district hospitals: The project is providing support to the QIS to scale-up the implementation of 5S, as a basic QI approach for ensuring health facility cleanliness and organization. To date, 11 district hospitals received 5S training (Perojpur, Comilla, Chittagong, Meherpur, Narail, Barguna, Netrokona, Jhalokathi, Braman Baria, Jessore, and Kulna).

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 55

• Providing support to developing Model Hospitals: The project is collaborating with the QIS to provide intensive support to 14 district hospitals around the country to become Model Hospitals to demonstrate improved quality of care and to inspire other district hospitals. The intensive support includes establishing and activating QI committees, forming Work Improvement Teams (WIT), 5S training, PDCA training, and intensive monitoring and supervision. Table 5 below includes a list of the selected Model Hospitals.

Table 5: List of the selected Model Hospitals

Division List of Model DHs

Chittagong 1. Cox.s Bazar 2. Laxmipur 3. Khagrachari 4. Chandpur

Sylhet 5. Moulavibazar

Barisal 6. Bhola

Khulna 7. Narail 8. Chuadanga

Rajshahi 9. Joypurhat 10. Siranganj 11. Natore

Dhaka 12. Tangail

Rangpur 13. Kurigram

Mymensingh 14. Netrocona

2.4.3 Improving delivery of MNCH/FP/N services in MaMoni HSS districts 2.4.3.a Increasing local ownership of QI by establishing and supporting Quality Improvement Committees (QIC) and through the engagement of the local government Based on the national guidelines set by the QIS, MaMoni HSS project continued to support the establishment and facilitation of QIC at district, upazila, and health facility levels. The project provides facilitation and support to the QICs at different levels so that they can take ownership in the QI process including identifying gaps in infection prevention, application of evidence-based standards of MNCH/FP/N services, including counseling and client satisfaction. Project facilitation includes providing supervisory checklists, supporting QIC meetings, summarizing important meeting points including identified gaps, action for improvement, roles and responsibilities, and following up on action implementation. Table 6 below includes an update on the status of the formation and activation of QI Committees by district.

56 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Table 6: Status of the formation and activation of Quality Improvement Committees by district, as of August 2017

Number of QI Committees

Active District Target Actual (had at least I meeting in last 3 months) Habiganj 86 86 86 Noakhali 43 42 41 Lakshmipur 54 54 49 Jhalokathi 40 35 31 Total 223 217 207

One key intervention that led to substantial improvements in the basic standards of infection prevention, including medical waste management, was the engagement of the local government. The local government contributed significant resources for health facility renovations, repairs, and construction of medical waste management dumping pits. Char Folcon Union, Lakshmipur district, provides an illustrative example of the successful engagement of the local government for quality improvement of UH&FWC.

.

Left: QIC meeting at Char Folcon UH&FWC

Right: A postpartum woman with service providers

2.4.3.b Strengthening routine supervision system and promoting supportive supervision The project supported the districts in developing monthly visit plans and in the coordination of Joint Supervisory Visits (JSV) by district and upazila supervisors. The objectives of the supervisory visit are to identifies gaps, develop action plans for improvement, and follow-up on results. The project introduced structured supervisory checklists and the supervisors conducted the JSVs using the checklists in areas including:

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 57 infection prevention measures, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI and normal vaginal delivery. Based on the findings, the supervisors provided supportive supervision including mentoring, on-the-job training, and problem solving. The status of JSVs is shown in Table 7.

Table 7: Planned and conducted JSVs in MaMoni HSS supported districts

Districts Planned Conducted Percent

Habiganj 48 38 79.2% Noakhali 96 96 100 % Lakshmipur 60 33 55 % Jhalakathi 16 11 68.8 % Total 220 178 80.9%

2.4.3.c Improving the quality of clinical care in stages The project continued to support district health managers in improving the quality of clinical care provided by health facilities in stages, as follows: • Stage 1: Improve the cleanliness, infection prevention, and medical waste management; • Stage 2: Improve sterilization measures and compliance with antenatal care and newborn care services; and, • Stage 3: Improve compliance with all range of MNCH/FP/N standards.

Figure 29 summarizes the progress at facilities that successfully passed Stage 1 of QI .

Figure 29: Number of health facilities in 4 districts meeting basic infection prevention standards (Stage 1)

120 97 100 80 60 36 34 39 40 31 16 16 14 20 9 8 8 10 5 5 0 0 6 0 0 4 0 Total Habiganj Noakhali Lakshmipur Jhalokati

Jul'15 Jan'16 Jul'16 Jul'17

Total Habiganj Noakhali Lakshmipur Jhalokathi Total number of facilities 230 79 57 59 35 % with acceptable IP 42% 43% 25% 66% 29% Source: Project Record

To measure acceptable IP some criteria have fixed. Those facilities who met that affixed criteria are considered as the facilities with acceptable IP. The criteria are as follows –

58 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report

• Hand hygiene (hand washing with soap or other hand cleaning solution e.g. Hexisol, air drying and appropriate use of clean gloves in outpatient area). • Used Instruments decontamination with chlorine solution. • Used instruments are cleaned (after decontamination) with detergent and brush. • Used instruments are disinfected by boiling, if autoclave is not available (after decontamination and cleaning).

Every month the district team have F/u whether the facility is maintaining those selected criteria or not.

*Basic Infection Prevention Standards include cleanliness; hand washing; use of gloves; decontamination by 0.5% chlorine solution and basic medical waste management.

2.4.3.d Monitoring quality of care at sentinel facilities MaMoni HSS monitors the quality of care at selected facilities through sentinel surveys. Figures 30 and 26 display the findings of surveys on the QoC of ANC and FP services, conducted in 2017 in Jhalokathi and Lakshmipur districts. The surveys were conducted by directly observing women attending ANC and FP services, separately.

Figure 30: Quality of ANC services in Jhalokathi and Lakshmipur districts

120 100 100 100 100 100 100 99 95 95 96 100 88 92 91 84 82 76 80 73 75 64 60 50 54

40

20

0 Blood pressure Weight of the Hemoglobin test Urine protein Nutrition diet Counseling givenCounseling given measured pregnant conducted test conducted discussed during on comlication on importnace women pregnancy during of four ANC measured pregnancy

Jhalokati Lakshmipur Total

Source: Sentinel survey, 2017 Total # of ANC Observation: 603 Jhalokathi: 301, Lakshmipur: 302

Figure 31: Quality of family planning counseling in Jhalokathi and Lakshmipur districts

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 59 120 100100 100 100100 100 98 97 97 96 100100 100 100 93 76 74 80 68 68 60 53 52 53 39 39 40 20 14 0 Visual privacy Audio privacy Asked about Discussed Discussed Asked client for Used job aid Informed about maintained maintained client's consent about negative about what to feedback during follow up visit impact of the do if there is counseling procedure negative impact

Jhalokati Lakshmipur Total

Source: Sentinel survey

60 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report 2.4.3.e Supporting the implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR) MaMoni HSS provided technical support to the QIS in scaling up MPDSR at the district and upazila level health facilities in Habiganj, Noakhali, Lakshmipur and Jhalokathi districts. Steps for MPDSR included improving Death Notification (DN) for maternal, neonatal, and stillbirths, and Facility Death Review (FDR). The project supported ToT on DN and FDR, with technical assistance from the Center for Injury Prevention and Research in Bangladesh (CIPRB). The ToT was followed by training for service providers of DHs, UHCs and MCWCs. In addition, the project provided technical support to MOHFW counterparts on the utilization of data collected through MPDSR. Data on the number and specific location of reported maternal, neonatal, and stillbirths have been depicted on a map and a summary of the death review results has been discussed with district and upazila level decision makers to identify health facility and community level actions required to avoid future mortality. The following is an example of the mapping and death review results from Begumganj upazila, Noakhali district.

The following is an example of the use of data from Kutubpur union in Noakhali district:

Verbal autopsies of maternal deaths result in identifying actions to prevent future maternal deaths. These actions include:

• Improving communication between the community and the health facility; • Improving referral to the health facility and establishing informal transportation for emergency care; and, • Increasing community awareness on the importance of delivery at a health facility.

2.4.3.f. Supporting CEmONC through Regional Roaming QI Teams (RRQIT) The project continues to support the RRQIT as an additional supervisory and mentoring team focused on monitoring and improving the quality of CEmONC provided at the district level in Habiganj, Noakhali, Lakshmipur and Jhalokathi districts. RRQITs include OBGYNs and neonatologists from medical colleges near project districts, as well as district level supervisors. RRQIT visits are conducted using structured checklists, which assess general CEmONC infection prevention measures, child birth services, CEmONC provision readiness, and neonatal care, including SCANUs. During the reporting year, RRQIT visits were conducted at district hospitals and MCWCs in Jhalokathi (2), Habiganj (3), Noakhali

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 61 (2), and Lakshmipur (2). Based on the findings, an action plan has been developed, in coordination with district hospital service providers and the QIC.

(L) The RRQIT visits a delivery room at a DH in Jhalokathi (R) The RRQIT debriefs with MCWC staff in Jhalokathi

The RRQIT visit included following up on the status of the implementation of action points identified during previous visits. Table 8 below summarizes these results:

Table 8: Progress on RRQIT Action Plan Implementation

Major findings from previous visits Improvement Jhalokathi Dirty environment and hospital floor in DH Basic cleanliness of district hospital improved Only one labor table was available in DH Two more labor tables supplied to DH OT lights with fused valves Arrangement of OT light Autoclave for labor room at DH was not functional Arrangement of autoclave for labor room at DH Inactive QI Committee at DH and MCWC Functional QI Committee at DH and MCWC

Poor medical waste management at MCWC Dumping pit at MCWC is under process Only one MO-MCHFP in the district Posting of 4 new MO-MCHFPs in the district and trained on LARC and PM. Two are attending EmOC training. Post for nurses was vacant in DH Posting of 35 nurses at DH, so a new maternal complex has been designed No use of partograph and practice of AMTSL for Use of partograph and practice of AMTSL for NVD at DH and MCWC NVD at DH and MCWC has begun Nonfunctioning digital x-ray and USG machine at Functional digital x-ray and USG machine at DH DH Only Sunday had the facility for C/S in MCWC Regular C/S in MCWC because of new MOMCH with support from DH has anesthesia training in sadar upazilla Habiganj Overcrowded hospital environment and dirty Crowds have been limited, general cleanliness hospital floor in DH improved, color coded beans used, cleaners wear protective clothing/gloves/boots. Senior OBGYN consultant was not present; there Senior OBGYN consultant and 6 nurses have was no 24/7 CEmOC services in DH joined the DH – the gynecology department has improved its performance Labor tables were old and broken in DH Labor tables were repaired and new one managed in DH OT lights with fused valves (low illumination) All were repaired (high illumination)

62 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Major findings from previous visits Improvement All GA machines were out of order All were repaired and are now functional Inactive QI Committee at DH and MCWC Active QIC at DH and MCWC and working for improving facilities Poor medical waste management at DH Municipality is working for medical waste management at DH Few MO-MCHFP in the district New 6 has been joined and trained on LARC and PM and two are in EmOC training Post for nurses was vacant in DH Vacant post has been filled Non Functioning radiant warmer at pediatric ward Well-functioning radiant warmer at pediatric ward SCANUs were non functional SCANU is functional Service register are non-available and record Service registers are available and record keeping was not done properly in the pediatric and keeping is done in the pediatric and gynecology gynecology wards and in the SCANU wards and in the SCANU. Regular online reporting is improving on EmOC. Performance in the OBGYN ward: previously As of March 2017, total admitted patient was admitted patient was less, 50-60 NVD was month, 517, of that 351 had NVD, 51 had C/S, 11 got 20-30 had C/S, no ACS or KMC service, most of ACS, 29 received SPE&E treatment, 6 were the time SPE&E cases were referred and total given KMC for baby, only 11 were referred and cases were high. maternal death was 1. Lakshmipur OBGYN medical officer was absent and there is no A senior OBGYN consultant is available. pediatric consultant but 2 sectioned post A junior pediatric consultant is available.

No training of medical officers on ETAT and KMC Already 2 nurses trained on ETAT, KMC but there has still been no training for medical officers. No post-operative reporting form Post-operative reporting form available Essential drugs for SCANU are not available Several essential drugs for SCANU are available with GoB channel. No sweeper at MCWC Part-time staff supported by the Municipality have been hired. Inadequate supply for cleaning materials Cleaning materials available Hospital waste management is not collected and Need based waste management disposal has disposed of properly by the Municipality. been arranged through the Municipality.

Recommendations from the RRQIT are summarized below: 1. Regular QIC meetings and monitoring of hospitals by members is needed. Discussions in the QIC and zilla parishad need to continue to arrange for dumping pits, waste disposal, local resource mobilization, hospital security and emergency support. 2. An increased number of MOs in the department of Obstetrics and Gynecology, as well as nurses in the SCANU, and CEmOC pair (both OBGYN Specialist and Anesthesiologist) for quality service of CEmOC and newborn care is required. 3. Regular monitoring and support for the maintenance and intermittent supply of instruments, supplies and drugs in the DH and MCWC is needed, for example, a general anesthesia machine in the operating theater in Jhalokathi. The local

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 63 government must ensure a greater supply of cleaning materials and cleaning personnel. 4. Patient diagnosis and management records must be improved for quality reporting, particularly on CEmOC, PPFP and newborn care. 5. National level liaison and advocacy is required to arrange for a pediatrician, phototherapy machine, radiant warmer and incubator in the neonatal ward and SCANU service at the DH in Jhalokathi. Sometimes, repairs are insufficient and building reconstruction is required for proper functioning, for example, at the MCWC in Habiganj. The post of an anesthetist remains vacant at a MCWC in Jhalokathi.

2.5 Develop comprehensive logistic management systems for essential MNCH/FP/N commodities at the district level 2.5.1 Monitoring and improving the availability of essential MNCH/FP/N drugs

2.5.1.a Scaling up the implementation of electronic logistics management information system (eLMIS), in coordination with Systems for Improved Access to Pharmaceuticals and Services (SIAPS)

In coordination with SIAPS, the project supports the MOHFW in introducing eLMIS in three additional districts (Habiganj, Noakhali, Jhalokathi) to improve recording, monitoring, and availably of essential drugs, particularly MNCH items. During the reporting quarter, the project oriented district level stakeholders in Habiganj, Noakhali, and Jhalokathi districts on eLMIS. Because the eLMIS will be linked to the national DHIS 2 data system, the project hired a consultant to input health facility specific data for the three districts into DHIS 2 as an initial step for implementing eLMIS. During the reporting quarter, the project conducted district level orientation on eLMIS for health managers in Noakhali, and Jhalokathi districts. The purpose of this orientation was to refresh the district level GoB managers’ knowledge on basic logistics management system, their roles and responsibilities in improving LMIS status, SCMP of MOHFW and the LMIS activity conducted to date at each district. MOCS facilitated sessions and MaMoni staff shared the overall idea of scaling up eLMIS. The new eLMIS is expected to improve monitoring the stock of essential drugs, the procurement process, and reduce stock outs.

eLMIS training for priority MNCH medicines, with technical support from SIAPS ToT: As part of the eLMIS activity, eLMIS ToT was conducted jointly with SIAPS who provided facilitators and the training guide. Thirty participants, including MOCS, district statisticians, and managers, from Habiganj, Noakhali, and Jhalokathi districts (Lakshmipur was covered earlier) received the training. The training included the eLMIS data entry system through DHIS 2 and practical sessions on stock data entry by the health facility. Participants developed a plan for training statisticians and health managers in their respective districts. Training of district statisticians and managers: Following the ToT, cascade training for scaling up eLIMS in Habiganj, Noakhali, and Jhalokathi districts was conducted with support from MaMoni HSS and SIAPS. The training covered a total of 684 facilities under DGHS (322 Noakhali, 266 Habiganj, 96 Jhalokathi). Facilities included DHs,

64 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report district reserve stores, UHCs, community clinics, USCs and UH and FWC under DGHS. In all districts, the training venue was primarily the civil surgeon’s office. 750 copies of the eLMIS training guide were provided by SIAPS.

eLMIS ToT, conducted with SIAPS, for Habiganj, Noakhali, and Jhalokathi districts – July 27, 2017 – MaMoni HSS projects office

2.5.1.b Improving distribution and storage conditions at national and regional levels • Supported national distribution of 7.1% CHX from the DGFP central warehouse: MaMoni HSS provided technical assistance to the DGFP to ensure efficient distribution of 7.1% CHX solution. In November 2016, a stock of 184,800 bottles was stored at the central DGFP warehouse. The project assisted the DGFP by preparing a distribution list for all districts of Bangladesh, based on forecasting numbers of health facility deliveries by district, and facilitating the distribution of the stock accordingly.

• Provided technical assistance to Sylhet Regional Warehouse: The project provided technical assistance to the Sylhet Regional Warehouse, DGFP to review storage conditions, the documentation process, and the condemnation process of expired drugs. The QIS Sylhet team participated in the visit.

Reviewing temperature maintenance and storage conditions, Regional Warehouse, DGFP, Sylhet

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 65

66 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report 2.5.1.c Improving data utilization to monitor the availability of essential drugs The project continued to provide support to Habiganj, Noakhali, Lakshmipur, and Jhalokathi districts to monitor the availability of essential MNCH drugs and to engage district managers in using stock information to take action to avoid stock out. This stock data monitoring is conducted by a color-coded chart to simplify data interpretation and use. The following is an example of the color-coded chart for tracking misoprostol stock:

Sl Name of the No. store Jan.16 Feb.16 Mar.16 Apr. 16 May. 16 16Jun. 16 Jul. Aug.16 Sep.16 Oct.16 Nov.16 Dec.16 Jan.17 Feb.17 Mar.17 Apr. 17 May. 17 17Jun. 17 Jul. Aug.17

1 Sadar 2 Lakhai

3 Bahubal

4 Madhabpur 5 Chunarughat

6 Nabiganj

7 Baniachang 8 Ajmeriganj Stock status of Tab Misoprostol 200 McG in DGFP stores of Habigonj district from January 2016 to August 2017. Green = stock available Red = stock out

Stock out can be addressed through supply chain management portal (SCMP) both at store and service delivery point (SDP) level. Regarding misoprostol MaMoni HSS communicated with MCH unit, DGFP and Central Ware House(CWH), DGFP after collecting information from Supply Chain Management Portal(SCMP) about availability of Tablet Misoprostol at CWH,DGFP. So Tab. Misoprostol was supplied from CWH, DGFP to the related Regional Ware House(RWH) of MaMoni HSS districts. Also at the district level, MaMoni HSS facilitated the process of distribution of tab Misoprostol from RWH to upazilla stores to address the stock out situation

Data utilization; examples of action taken to improve availability of essential MNCH drugs:

• MaMoni HSS facilitated moving Inj. Oxytocin from CS Store to Rajapur and Kathalia UHCs where NVD services are available but there was no supply. • Facilitated the process of redistributing 750 bottles of 7.1% CHX from Jhalokathi health store to Barisal Medical College. The expiration date was 30 May, 2017. However, as a result of the redistribution, the supplied amount of 7.1% CHX was used up. • F-75 and F-100 food supplements were inadequate at SAM corners at the Jhalokathi DH and Rajapur UHC early in the month of April 2017. After raising the issue with the CS-Jhalokathi, it was revealed that Pirojpur district had sufficient stock. By coordinating with the Pirojpur CS office, Zia Nagar UHC, the District Nutrition Surveillance Officer of the United Nations Children’s Fund (UNICEF), 1 carton (90 sachets) of F-100 and 1 carton (120 sachets) of F-75 were distributed to the SAM

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 67 corners of Jhalokathi DH and Rajapur UHC.

2.6 Strengthen local government planning and engagement in health service provision MaMoni HSS continued to engage the local government to strengthen the expanded program on immunization (EPI) linked birth registration (BR) and to allocate a greater proportion of their annual budget for health-related activities. In this regard, project staff facilitated the arrangement of bi-monthly Union Education Health and FP Standing Committee (UEH&FPSC) meetings. 2.7 Improve local governance and oversight for MNCH/FP/N To allocate adequate budget for MNCH/FP/N services for respective union parishads (UPs), the MaMoni HSS project staff participated and facilitated ward meetings and budget meetings in all unions. Advocacy and planning meetings were arranged with all UPs in all districts to engage them in the health service delivery of their unions. Some UPs are committed to deploying service providers (paramedics) in the UH&FWCs of their unions with the support of their budget. The district teams worked to engage more UPs to motivate them to deploy service providers (paramedics) in the UH&FWCs of their unions. In Noakhali, the UP of Charbata union recruited paramedics in the UH&FWC using their own funds, while the UP in Rajganj union is in the process of recruiting another paramedic. A remarkable achievement was made by involving the UPs to take the lead and also to mobilize funds to upgrade and/or maintain the services at 24/7 UH&FWCs. Table 9 shows the funds allocation and utilization status by local government bodies for MNCH/FP/N activities for the period of July 2016 to June 2017 (GoB fiscal year). These funds were mainly used for the construction, repair, and maintenance of facilities; purchasing emergency medicine (especially during stock-outs); purchasing small medical and non-medical equipment and logistics; financial support to temporary support staff; and work on approaching roads. Fund utilization was less due to local government (UP) elections during the past year.

Table 9: UP budget allocation and utilization, July 2016 to June 2017

Number Percentage Total Total Percentage Number of unions of unions budget budget District of budget of Unions allocated allocated allocated utilized utilization budget budget (BDT) (BDT)

Habiganj 77 57 74 7,298,945 4,449,311 61 Jhalokathi 32 21 65.6 3,080,069 1,009,640 33 Lakshmipur 58 42 72.4 6,035,208 5,887,871 98 Noakhali 44 38 86.4 4,518,000 6,260,098 139 Total 211 158 74.9 20,932,222 17,606,920 84.1

From the above table it is visualized that in Noakhali the budget utilization is highest 139% where as in Jhalokati it is very low 33%. In Noakhali the local governments founds enough motivated, enthuastic and willing to allocate resource for MNCHFPN services. A number of union parishad mobilize budget beyond their

68 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report allocated money from upazila parishad and zila parishad that exceeds their own allocated budget. Though Jhalokati has started to work with local government later than other districts still they are improving in resource mobilization. In Jhalokati the local government has less resources than Noakhali. Another important factor is local family planning and health managers yet to strengthen relation with local government at the peak level like Noakhali.

IR 3. Promote an enabling environment to strengthen district level health systems 3.1 Policy reforms in place to promote local planning and need-based human resource deployment in the public sector MaMoni HSS provided direct technical and administrative support to the planning wing of the MOHFW under a Letter of Collaboration (LOC). This support included the provision of salaries for 19 staff in different positions, relevant office supplies, support to the organization for policy dialogue, and facilitation of workshops/meetings for the development and finalization of OPs. The PMMU of the MOHFW plays a significant role in providing technical support in management, monitoring, and evaluation functions of the HPN Sector Program and MaMoni HSS had been an important partner in these activities. With the support of MaMoni HSS, the PMMU published the 10th issue of their quarterly newsletter. The project worked closely with the Line Directors to ensure that the project activities are incorporated into the OPs. This also helped to ensure that the OP’s priorities aligned with the priorities advocated by the project. Project inputs have been incorporated/ or are being discussed with nine OPs – Maternal Newborn Child and Adolescent Health (MNCAH); Maternal Child Reproductive and Adolescent Health (MCRAH); Clinical Contraceptive Delivery Program (CCSDP); Health Economics and Financing (HEF); Sector-wide Program Management and Monitoring (SWPMM); National Nutrition Services (NNS); Management Information System-FP (MIS-FP); Human Resources and Development (HRD); and Family Planning Field Service Delivery (FP-FSD). National technical assistance for upgrading UH&FWCs as 24/7 delivery facilities Following the national assessment in 2015-2016, 4,461 UH&FWCs were categorized as A, B or C based on coverage, delivery facility, HR, training, infrastructure, furniture, delivery services, human resource, and residence. During the assessment, 14% of facilities were listed in the “A category”, 69% in the “B category” and 17% in the “C category”. MaMoni HSS developed models of upgraded UH&FWCs through local level resource mobilization and local government involvement. The project is now supporting the DGFP in developing a costed workplan to upgrade these facilities nationally in phases. Because of extensive advocacy by the MaMoni HSS, the DGFP has already identified this as a priority activity in HPNSP and allocated a budget for upgrading these facilities. Journalist engagement This year, thirty-one news stories about the MaMoni HSS project and its advocacy issues were published by different media outlets as a result of broader media advocacy. The news stories included issue-specific situational updates, case studies, technical information with a call to action for required health systems improvement. The media engagement and capacity building program has resulted in a significant increase in media coverage on MNCH/FP/N issues and increased engagement of involved stakeholders. Representatives from the multiple government ministries/directorates, and non-governmental partners have been deeply involved in the program. This contributes immensely to facilitating closer

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 69 collaborations across organizations and resulted in both increased dialogue and news coverage. The MaMoni HSS project also facilitated participation of staff and stakeholders (professional bodies, local government representatives, government counterparts) on television programs to bring attention to critical policy gaps and feasible models. Please refer to Appendix 6 for links to published stories.

3.2 Strengthen advocacy and coordination for adoption of evidence-based learning in national policy and program

3.2.1 Participate in national and district level campaign activities on various national days MaMoni HSS supported the MOHFW at the national as well as at the district level to observe the following national and international days related to MNCH/FP/N issues: • Family Planning Service Week – November 12-17, 2016 • World Prematurity Day – November 19, 2016 • Safe Motherhood Day – May 28, 2017 • World Population Day – July 11, 2017 • World Breastfeeding Week – August 1-7, 2017 • Family Planning Service Week – November 12-17, 2016

At the national level, MaMoni HSS supported the design of posters for national use, printing of Information, Education and Communication (IEC) materials to commemorate the events, and participation in roundtable discussions and press conferences.

Poster for Safe Motherhood Day Poster for World Population Day

70 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report At the district level, the project supported the Civil Surgeon and Deputy Director of Family Planning by organizing collaborative meetings to present district situation and performance; participating in rallies; organizing volunteers to refer community members to the health facilities; and holding special SBCC events in hard to reach areas. For Safe Motherhood Day (May 28), MaMoni HSS also conducted a maternal death count in every district through the volunteers and presented the findings at the respective district seminars. By linking the community to each of the national activities, the project has created awareness on the health systems issues on a scale that would not be possible through traditional observation of special days.

3.3 Conduct and disseminate operations research and program learning / documentation activities

MaMoni HSS collaborated with various partners to document MaMoni HSS lessons on various issues. In Year 4, PE/E management at community level, quality of ANC at satellite clinics, viability of private CSBAs, use of partograph to inform referral decision-making, adherence to LAPM quality standards, and roll-out of CHX were documented, and shared on a limited scale. Eleven of the MaMoni HSS program lesson issues were shared in international forums in six countries through oral and poster presentations. In addition, twelve other abstracts have already been accepted in upcoming forums. At the time of submission of this report, two manuscripts have been prepared for peer reviewed journals, and are undergoing review. Appendix 7 summarizes the topics that have been presented in different global forums. MaMoni initiated three program learning initiatives during the reporting period. The program learning topics initiated are: • A national case study on scaling up of 7.1% CHX nationwide • A competency assessment of FWVs to effectively screen for pre-eclampsia/eclampsia • An implementation research to reduce discontinuation of LARCs (IUCD and implants)

Data collection on these program learnings are ongoing.

In Year 4, two studies were completed that were initiated in the previous year: • Sustainability of the Private Community Skilled Birth Attendant Model in Bangladesh • Implementation research to support the Bangladesh MOHFW to implement its national guidelines of management of infections in young infants in two rural districts of Bangladesh

MaMoni HSS also supported MEASURE DHS to conduct the Bangladesh Health Facility Survey 2017, a validation study on select chronic maternal morbidities, and the HRCI project of Johns Hopkins University to conduct an implementation research on PSBI management in union level facilities where referral is not possible. Data collection and analysis are underway, and the results will be presented in Year 5.

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 71 The project is also conducting routine process documentation on 25 other topics. A summary of these process documentation activities has been provided in Appendix 8.

3.4 Strengthening NIPORT to deliver a capacity-building program for community level health workers to deliver community-based interventions of the essential services package

A LOC has been signed between MaMoni HSS and NIPORT for strengthening the technical and managerial capacity of NIPORT to develop and implement a capacity development program for CHWs, their supervisors and first level managers. The LOC was signed by the Director General, NIPORT, and Country Director, SCI, in the presence of the Director, OPHNE, USAID, and other USAID representatives as well as other stakeholders from the MOHFW, DGHS, DGFP, NIPORT and SCI on 29 August 2017 at the NIPORT conference room. Recruitment of temporary staff has been completed and procurement initiated. Tools have been developed for assessing the institutional capacity of the RTCs and the assessment was completed in September 2017. A workshop was organized for review and updating the existing Team Training curriculum for CHWs. Curriculum for management and leadership skills for UHS strengthening has been initiated.

IR 4. Identify and reduce barriers to accessing health services

4.1 Promote awareness of MNCH through innovative BCC approach

4.1.1 Intensive SBCC implementation plan development A communication agency specializing in SBCC was hired to develop and implement a comprehensive area-specific community behavior enhancement strategy (i.e. Habiganj, Lakshmipur, Noakhali/Hatiya) along with an SBCC activity implementation plan to accelerate a change with care-seeking for appropriate MNCH/FP/N services as well as improving home-based care practices. The SBCC activities are also aimed at creating an enabling environment in families and communities that facilitate and support appropriate care-seeking behaviors. By the end of February, the plan was drafted based on the outcome of formative research and stakeholder consultations. In order to fine-tune the plan and ensure that it is comprehensive and culturally sensitive, two SBCC barrier analysis workshops (one in Hatiya and the other in Lakshmipur) were conducted. The participants of the workshops included community level health service providers, community representatives (local government representative and community volunteers), and MaMoni HSS field level officials who are mostly engaged in community level work. Through a rigorous participatory process, the workshop identified upazila specific SBCC barriers along with strategies/activities to address them in a more effective manner.

4.1.2 SBCC activities

72 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report MaMoni HSS carried out comprehensive behavior change communication activities throughout Lakshmipur, Noakahli and Hatiya. Major activities were focused in the low performing areas based on crucial health indicators such as ANC, SBA delivery, and facility delivery. Activities like video shows, mic’ing (announcements using micorphones, sometimes in one location and sometimes through mobile rickshaw van), mother’s support groups (Ma Somabesh), advocacy meetings, school health sessions and popular theater and community sensitization meetings by external communication agencies were conducted. A significant number of mothers, their caregivers and adolescents received the health key messages on MNCH/FP/N issues. Masses have gathered knowledge about the importance of facility deliveries offered through 24/7 centers, and the potentials risks associated with home deliveries.

The project reached 1,530,020 people in communities (43% female and 57% male) through courtyard meetings, video shows, local stakeholder meetings, popular theatre and other BCC activities.

4.1.3 Reaching the community through Aponjon services Aponjon continues to provide critical maternal, newborn, child health, nutrition and family planning messages to pregnant and lactating mothers during the pregnancy and postpartum period through the subscription based Shogorbha program. As of September 30, a cumulative total of 2,015,113 women have subscribed to the messaging service. A prepaid model was launched and was designed to ensure timely revenue for Aponjon and to ensure subsribers will not miss content due to an insufficient balance. Aponjon is exploring avenues for distributing the prepaid cards and has partnered with three commercial dealers to make the card available to subscribers. Promoting Aponjon services and increasing the brand visibility has been the major focus this year. Digital channels like Facebook and a blog have been used for marketing and have reached roughly 1.4 million and 56,000 users respectively. Aponjon is continuing to build its partnership with the GoB and various development agencies, participating in a consultative workshop to streamline Aponjon BCC activities with regular MNCH services. Aponjon also targeted smartphone users and introduced an interactive Shogorbha app through Android, iOS and Windows mobile platforms. 29,423 women downloaded the app, which is more than double the 12,597 downloads the previous year. The app won mBillionth Award 2017 in the “health and well-being” category.

Figure 32: Cumulative mobile app downloads of Aponjon Shogorbha

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 73

Aponjon has also introduced a regular blog with ten new articles both in Bangla and English over the year, which was accessed 493,521 times between December 2016 and August 2017. Through the website, Aponjon has also introduced a live chat where users can anonymously contact the call center through text. The chat service will be integrated into the mobile app.

4.2 Enhance community engagement in addressing health needs Community mobilization In Year 4, MaMoni HSS strategically grouped 6 districts as per the intervention component and scale of intervention:

4.2.1 Community mobilization in high intensity districts and Hatiya Community Action Group (CAG) meetings and Community Microplanning Meetings (cMPM) were facilitated by HAs and FWAs (front line MOHFW field workers). Field Support Officers (FSOs) supervised CAG meetings, cMPM and union follow-up meetings in two unions. The upazila level facilitators for service delivery monitored all activities in the upazilas. At present there are 23,929 community volunteers/CAGs active in high intensity upazilas in MaMoni HSS districts. Among them 18,452 CAGs have provision of emergency transportation arrangement as referral vehicles.

Table 10: Number of CAGs with an emergency transport system for MNCH care Target of CAG Achievement with Number of Number of District emergency CVs Target CVs transport Number Percentage system Habiganj 8379 8320 4369 8089 185 Jhalokathi 2731 2305 3746 1492 40 Lakshmipur 6710 6458 6461 6310 98 Noakhali 5900 6846 3876 4355 112 Total 23720 23929 18452 18,616 110

4.2.2 Community mobilization in other districts

74 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report CAG meetings and cMPMs were facilitated by frontline MOHFW field workers – HAs and FWAs. HAs took over the responsibility of cMPM facilitation and reporting. The cMPM report includes CAG meeting information of the area. HAs sent the cMPM report to the UHC and the upazila level facilitators for community based services (Uz F CBS) gathered all the cMPM reports from the UHC. The Uz F CBS was responsible for monitoring all CAG meetings, cMPM and upazila follow-up meetings with the support of HAs and FWAs. Eighty-five percent of cMPMs are regularly conducted by HA and FWAs in MaMoni HSS areas.

4.2.3 Piloting cMPM throug Community Support Group (CSG) One community clinic covering a population of approximately 6,000 has one community group (CG) and three CSG’s. One CSG covers a population of approximately 2000, which is almost similar to the area of a cMPM. MaMoni HSS initiated cMPMs through CSGs in 3 unions of 3 districts - Noakhali, Habiganj and Jhalokathi. In Year 5, cMPMs through CSGs will be scaled up in another 3 unions. Based on the experience of these unions, it will be scaled in selected upazilas through CBHC.

4.2.4 Transformation of MaMoni Community Volunteer (CV) to Community Sales Agent (CSA) MaMoni HSS initiated the transformation of selected MaMoni CVs to CSAs in 3 unions of 3 districts. This activity is designed in collaboration with Social Marketing Company (SMC). Experience of developing women entrepreneurs as CSAs like “Notun Din” project of SMC will be replicated in MaMoni HSS. Based on the experience of these 3 unions, this model will be scaled up in all upazilas in Year 5. In this quarter, total 37 CSAs started selling commodities in 9 unions of 3 districts; Habiganj, Noakhali and Lakshmipur. In addition to selling commodities, CSAs sold total 34 Hexicort (7.1% CHX) and ensured application in newborns’ umbilical cord. Sales of the CSAs are gradually improving as they are expanding their product range. Initially CSAs took only SMC products and Chlorhexidine. Recently they are taking Paracetamol, Ranitidine and Calcium Tablets as per their community demand. CSAs market demand usually determines their product range. Sometime lack of supply or short supply of the Blue Star Pharmacies (BSPs) affects CSAs sales.

Sales report of 14 older CSAs during Oct – Dec 2017: Sales amount Name of Remarks Union Octo’17 Nov’17 Dec’17

Nurpur In union of December, CSAs got Habiganj (4 4,894 4,729 1,189 CSA) their supply in last week

Uttar Hamsadi Union of 9,729 12,545 12,027 Lakshmipur (5 CSA)

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 75

Charkakra Union of Noakhali (5 8,730 7,580 8,970 CSA)

14 CSAs’ total sale 23,353 24,854 22,186

Monthly Net average Profit: sale/CSA 1,668 1,775 1,584 15%-20%

CHALLENGES, SOLUTIONS AND ACTIONS TAKEN Challenges and Mitigation Strategies Staff turnover: There were changes in leadership several times both at the DGHS and DGFP at the national level as well as at the district level. These included the Director General of the Directorate General Family Planning (DGFP), the Director - MNC&AH (DGFP), Director - MIS (DGFP), Director - MIS (DGHS), Director - PHC and Line Director ESD (DGHS) at the national level. Moreover, the Deputy Director - Family Planning (DDFP) of Habiganj retired, and a new DDFP has taken over the responsibilities. It took a considerable amount of time to orient and sensitize the new personnel which delayed planned activities. MaMoni HSS kept continuous communication with the departments to ensure progression of activities. Furthermore, the MOHFW has been recently divided into 2 divisions: the Health Services Division and the Medical Education and Family Welfare division. Each of the divisions will have one secretary. This division has created uncertainties because of a lack of clear guidance on operational mechanisms. MaMoni is closely observing the changes and will adapt strategies accordingly.

Shortage of staff: A chronic shortage of human resources poses challenges to all project activities especially in improving the quality of health care. The inadequate clinical and support staff in addition to the inadequate supervisory cadres, such as medical officers, continued to impede efforts to improve the quality of care. MaMoni HSS is facilitating the process of better utilization of available human resources through district and upazila planning. The project also supports with a small number of service providers to fill-in the critical human resource gaps of GOB service providers on temporary basis, while continuing to advocate with local leaders (Union Parishad Chairman and Members of Parliament) for long-term solutions by filling the vacancies through GOB recruitment. Simultaneously, the project continually advocates with the government for newly recruited staff to be posted in underserved areas with major human resource shortages.

76 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Frequent stock out of essential MNCH drugs: Frequent stock-out of essential MNCH drugs hindered efforts to improve health outcomes. As a response, the project is building the capacity of local managers to monitor the availability of essential drugs, and is taking local measures to avoid stock outs through routine tracking of the supply chain management portal.

Ownership and capacity development of QI committees: Transferring the ownership of the QI process to the project’s counterparts at district, sub-district, and health facility levels is a continuous challenge. The establishment of QI committees has been a positive step in increasing the staff capacity in identifying gaps and implementing actions to address them. There are encouraging examples of QI committees that have been able to solve local problems and engage local government in resource mobilization. However, while the QI committees have made a difference, they still require significant facilitation by project staff. Improving the quality of clinical care at a large scale: MaMoni HSS has been supporting the national QIS in developing and implementing a strategy for improving the quality of clinical care across the country. While there has been significant progress in updating standards, guidelines, and training, the implementation of interventions leading to improvement of the quality of clinical care at health facility level needs to be strengthened. Innovative approaches need to be tested to encourage local ownership and leadership for quality improvement as well as expanding the involvement of the local government in problem solving and quality improvement.

Community mobilization activities: Reduction of project staff (FSO) in the districts has reduced community mobilization activities. MaMoni HSS has engaged Has and FWAs to take over the responsibility of cMPM facilitation and reporting.

Ensuring continuity of services provided by paramedics: MaMoni HSS has been filling the HR gaps in selected health facilities by providing paramedics to provide MNCH/FP/N services. As the project is approaching its end, it is important to engage with the MOHFW to ensure that the paramedics will be absorbed within the MOHFW cadres, or replaced, to ensure continuation of services in the health facilities where paramedics are currently working. MaMoni has initiated dialogue with local health managers and local government bodies for ensuring this.

Performance of pCSBAs: pCSBAs’ performance are not as per expectation. Strategic re- distribution, motivation of pCSBAs, linking them with the formal health system, and central and district level monitoring should be increased.

Follow-up of service delivery after training: A good number of trainings are being conducted by different programs but there is no formal system of follow-up after training and supportive supervision. MaMoni HSS has supported post training follow-up after ENC training (7.1% CHX and HBB). However, training follow-up and on-the-job support to ensure provision of quality services after training are required after each technical training. For example, nurses working in district hospitals and UHC who received training on IUD and PPIUCD need support in providing services. MaMoni HSS has initiated dialogue with DGHS and DGFP for institutionalization of training follow-up and supportive supervision after each technical training.

Poor case admission and post discharge follow-up of KMC and poor day-8 follow- up of PSBI cases: Poor case admission and post discharge follow-up of KMC as well as poor day-8 follow-up of PSBI cases remain as key challenges for newborn health. To improve these interventions, MaMoni HSS has arranged sensitization meetings and

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 77 mentoring visits in implementation districts by national level managers and representatives from professional organization for new newborn interventions including KMC & PSBI. In consultation with national and district health managers, the project has plans to orient and engage union level supervisors of public sector providers for the follow- up of KMC and PSBI cases at community level. Orientation of Assistant Health Inspector (AHI) of DGHS and Family Planning Inspector (FPI) of DGFP have been planned for ensuring day-8 follow-up of PSBI and post discharge follow-up of KMC.

Improve organization and quality of LARC and PM services provided by Mobile Camps: In order to reap the benefit of Mobile Camps in boosting LARC and PM uptake, there is a need to improve the preparation, organization, and utilization of Mobile Camps. MaMoni HSS is playing an active role in coordinating Mobile Camps with national level and district level partners and health managers. This includes supporting the preparation of schedule for Mobile Camps within districts, coordinating with Mayer Hashi II project, DGFP to ensure availability of skilled service providers and supplies, strengthening health facility readiness, and strengthening community utilization of services provided by the Mobile Camps.

Way Forward In Year 5, MaMoni HSS will continue to provide support to the MOH&FW in strengthening health systems at the national level and to serve as a strategic partner for the government to implement the priorities identified in the new sector plan as well as EPCMD in Bangladesh. In the upcoming year, the project will expand the technical assistance role at the national level, while consolidating the implementation at the district level. Program activities for the year will also focus on deepening engagement and support to national-level HSS initiatives in health workforce development and management, quality improvement, strengthening the eMIS and improving capacity and quality of MNCH/FP/N service delivery. At the national level, MaMoni HSS will continue to work closely with the MOH&FW through the DGHS and DGFP, the Ministry of Local Government, Rural Development & Cooperatives (MOLGRD&C), as well as key development partners. MaMoni HSS held extensive consultations with the Planning Wing and the Program Monitoring and Management Unit (PMMU) of the MOH&FW and the relevant Operational Plans of DGHS and DGFP to identify the priority areas for technical and management support at the national level. Some of the major focus areas in next quarter are: • Dissemination of the workload and staffing need study findings and development of policy briefs; • Provide support to the Human Resource branch of Health Service Delivery (HSD) for capacity strengthening on central Human Resource Information System (HRIS) • Organize national level stakeholder workshops on HRIS to share learning and take it forward • Develop HRIS activity monitoring guidelines and data quality assurance/control (DQA) mechanisms in collaboration with DGHS and DGFP • Capacity building of DGFP staff on HRIS and facilitate regular updates to HR data in the HRIS at upazila and district level (DGHS and DGFP) • Facilitate the establishment and operationalization of the decentralized QI management structures at divisional, district and sub-district levels

78 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report • Provide technical assistance to the development and updating of national guidelines, protocols, and tools to support the implementation of the national QI strategy • Contribute to the development of standards, national guidelines, protocols, tools, measurement and monitoring framework for RMNCH interventions • Update national guidelines for infection prevention and hygiene practices • Supervision and clinical quality monitoring tools and protocols • Develop guidelines for appropriate motivation and recognition mechanisms for quality improvement • Complete the documentation of QI initiative led by MOHFW and supported by various partners across the country • Pilot implementation of RMNCH framework in Narsingdi district • Support the development of a system for developing and monitoring QI indicators for various clinical services • Continue the remaining design of facility-level modules of the automated eMIS as well as support their national scale-up. Both community and facility modules will be implemented in Habiganj, Noakhali and Lakshmipur and only the facility module will be implemented in Jhalokathi. Moreover, the project team will continue supporting icddr,b and MEASURE Evaluation in implementing the facility and community modules in Tangail. • In Year 5 the project will support the establishment of 3 special care newborn units, 1 in Khulna Shishu Hospital and 2 in national level facilities of the DGFP • The project will support development of the information and communication technology (ICT) capacity of NIPORT and help in digitalization of the training database. Both the national level and regional level facilities will be upgraded with modern ICT equipment enabling innovative ways to deliver trainings. • Review and revise the existing Team Training Curriculum of NIPORT and adapt it for community based workers (HA, FWA and CHCP) training. Also support NIPORT in developing Leadership and Management training curriculum for upazila health and family planning managers (UHFPO, UFPO and MOMCH)

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 79 APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF THE MAMONI HSS PROGRAM

The program’s objectives are well aligned with the GoB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011– 2016; and also directly support the USAID/ Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh. MaMoni HSS designed a two- pronged approach in which districts and upazilas were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high- intensity areas is to demonstrate best-practice High models of MNCH/FP/N health care delivery through intensive Health System support to the GoB, and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi districts, while in the Noakhali and Pirojpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirojpur (refer to Figure 1 and Table 1). While the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale- up interventions such as 24/7 UH&FWCs, CHX for cord care, and HBB; instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.

80 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report APPENDIX 2: DATA SOURCES Assessment Assessment Frequency Geographical Coverage Name Type Population Independent 2 rounds in 23 high intensity upazilas of 5 MaMoni districts based tracer cross sectional a year. (Habiganj, Jhalokathi, Noakhali, Lakshmipur, survey assessment by Each round and Pirojpur). In addition, during the initial third party is for six stages of program – starting from October 2013 – (icddr,b) months this population based assessment was also conducted for Bhola District along with Noakhali and Lakshmipur. This included a baseline assessment and two rounds of the population- based survey. In October 2014, there was a major shift in the MaMoni HSS program strategy and the scale of program activities were reduced in Bhola. Accordingly, the project monitoring plan (PMP) was revised and the population based survey no longer covers Bhola, with the exception of conducting an end line survey in 2017. Sentinel Selected Twice in a Selected DH, MCWC, UHC, UH&FWC and survey sentinel site year satellite clinics in Habiganj, Jhalokathi, assessments Noakhali and Lakshmipur district. using structured tool Service Periodic facility Twice in a 21 high intensity upazilas of Habiganj, delivery assessment by year Jhalokathi, Noakhali and Lakshmipur district. point using assessment structured tool Newborn Nationwide Once in All over the country revisit assessment by project life upazila on HBB and 7.1% CHX using structured questionnaire Routine MIS, Routine MIS Monthly All over the country MOHFW forms of DGHS and DGFP Project MIS Routine MIS Monthly Only in high intensity project areas reports

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 81 APPENDIX 3: PROGRAM PERFORMANCE INDICATORS

MaMoni Health Systems Strengthening Program Performance Indicators

Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Percent of women received at least one antenatal care visit from a medically trained provider High intensity areas Lakhsmipur 70 77 77 Noakhali* 67 87 85 Habiganj 70 85 85 Jhalokathi 73 83 83 Pirozepur* 70 71 72 Tracer Indicatorssurveys are

not conducted in HSCS areas HSCS areas Pirozepur 67 NA 67 Bhola 56 NA 56 Noakhali 63 NA 63 Percent of births receiving at least four antenatal care (ANC) visits during pregnancy High intensity areas Lakhsmipur 26 32 32 Noakhali* 26 49 45 Habiganj 26 45 45 Jhalokathi 50 46 46 Pirozepur* 36 40 36 Tracer Indicator surveys are not

conducted in HSCS HSCS areas areas Pirozepur 44 NA 44 Bhola 24 NA 24 Noakhali 21 NA 21

82 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks Percent of Births Attended by a Skilled

Doctor, Nurse or Midwife High intensity area Lakhsmipur 45 43 45 Noakhali* 40 48 45 Habiganj 40 39 40 Jhalokathi 53 52 55 Pirozepur* 50 49 50 Tracer Indicator surveys are not

conducted in HSCS HSCS areas areas Pirozepur 50 NA 50 Bhola 30 NA 30 Noakhali 38 NA 38 Percent of women with home births who consumed misoprostol to prevent post- partum hemorrhage High intensity areas Lakhsmipur 30 14 20 Noakhali* 30 25 23 Habiganj 50 38 40 Jhalokathi 55 25 25 Pirozepur* 45 23 25 Tracer Indicators surveys are not

conducted in HSCS HSCS areas areas Pirozepur 32 NA 32 Bhola 25 NA 25 Noakhali 20 NA 20 Percent of newborns initiated breastfeeding within one hour after birth High intensity areas Lakhsmipur 75 65 65 Noakhali* 72 60 60 Habiganj 85 80 80 Jhalokathi 70 52 55 Pirozepur* 63 54 55 HSCS areas Tracer Indicator

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 83 Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks surveys are not conducted in HSCS areas Pirozepur 58 NA 58 Bhola 70 NA 70 Noakhali 76 NA 76 Percent of newborns received chlorhexidine application on their umbilical cord immediately following birth High intensity areas Lakhsmipur 60 24 25 Noakhali* 60 29 30 Habiganj 60 16 20 Jhalokathi 60 8 10 Pirozepur* 60 5 10 Tracer Indicator surveys are not

conducted in HSCS HSCS areas areas Pirozepur 35 NA 10 Bhola 35 NA 10 Noakhali 35 NA 10

Percent of newborns receiving postnatal health check within two days of birth High intensity areas Lakhsmipur: 20 36 36 Noakhali:* 20 48 47 Habiganj: 32 31 32 Jhalokathi: 33 48 48 Pirozepur:* 18 41 41 Tracer Indicator surveys are not

conducted in HSCS HSCS areas areas Pirozepur: 10 NA 10 Bhola: 10 NA 10 Noakhali: 20 NA 20 Modern contraceptive method prevalence

84 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks rate High intensity areas Lakhsmipur 55 52 55 Noakhali* 53 53 53 Habiganj 48 44 48 Jhalokathi 58 61 58 Pirozepur* 58 56 58 Tracer Indicator surveys are not

conducted in HSCS HSCS areas areas Pirozepur 55 NA 55 Bhola 58 NA 58 Noakhali 59 NA 59 Couple years of protection (CYP) in USG- supported programs Overall 1,087,492 875,046 901,298 Lakhsmipur 163,817 132,281 138,942

Noakhali* 235,128 217,475 209,600 (All upazilas)

Habiganj 191,852 144,229 149,475 Jhalokathi 77,389 50,194 51,762

Pirozepur* 139,069 110,200 113,933 (all upazilas)

Bhola 263,795 221,407 229,711

Intermediate Result 1: Improve service readiness through critical gap management Percent of targeted facilities that are ready to provide essential newborn care High intensity areas Lakhsmipur 90 84.5 90 Noakhali* 90 66.7 90 Habiganj 90 77.8 90 Jhalokathi 90 82.9 90

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 85 Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks SDP assessments are 90 NA 90 not conducted in Pirozepur* Pirozepur SDP assessments are not conducted in HSCS areas HSCS areas Pirozepur 70 NA 70 Bhola 70 NA 70 Noakhali 70 NA 70 Percentage of public health facilities with functional bags and masks (two neonatal size mask) in the delivery room High intensity areas Lakhsmipur 50 82.8 70 Noakhali* 50 78.4 70 Habiganj 50 87.7 70 Jhalokathi 50 80.5 70 SDP assessments are 50 NA 70 not conducted in Pirozepur* Pirozepur Percent of USG-assisted service delivery SDP assessments are sites providing family planning (FP) not conducted in counselling and/or services HSCS areas High intensity areas Lakhsmipur 95 98.6 95 Noakhali* 95 97.8 95 Habiganj 99 97.2 99 Jhalokathi 95 92.1 95 SDP assessments are 95 NA 95 not conducted in Pirozepur* Pirozepur SDP assessments are not conducted in HSCS areas HSCS areas Pirozepur 17 NA 17 Bhola NA NA NA Noakhali 25 NA 25 Number of targeted facilities ready to provide delivery services 24 hours a day, seven days a week High intensity areas

86 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks Lakhsmipur 25 36 36 Noakhali* 19 26 30 Habiganj 39 44 44 Jhalokathi 21 17 21 Pirozepur* 4 5 5 Source project MIS HSCS areas Source: Project MIS Pirozepur 9 11 11 Bhola 32 18 18 Noakhali 7 6 7 Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by temporary non-GoB health workers High intensity areas Lakhsmipur 10 4 4 FWV-4 (FWV-9, Nurse-1, 15 11 11 Noakhali* Doctor -1) Habiganj 10 37 25 (FWV-11, Nurse-14) Jhalokathi 10 2 2 FWV-2 Pirozepur* NA Nil Nil Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Target 2018 includes 2,604 for MaMoni 4 Number of people trained in 2,149 8,701 16,519 districts and 13,915 maternal/newborn health through USG- for national scale up supported programs initiatives) Number of people trained in FP/RH with 225 147 70 USG funds Number of people trained in child health and nutrition through USG-supported 200 425 0 programs Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization Number of union level public health facilities that are ready to provide normal 75 119 119 delivery services High intensity areas Lakhsmipur 29 29 Noakhali* 25 25

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 87 Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks Habiganj 46 46 Jhalokathi 16 16 The sources: Project 03 03 Pirozepur* MIS Intermediate Result 2: Strengthen health systems at district level and below Number of district level quarterly performance review meeting held for data- 24 20 12 FY 18 targets are for driven performance review and planning 2 quarters only Lakhsmipur 4 4 2 Noakhali* 4 4 2 Habiganj 4 4 2 Jhalokathi 4 4 2 Pirozepur* 2 2 2 Bhola 2 2 2 No reliable data Intra partum still birth rate in project available from facility assisted facilities MIS High intensity areas <5/1000 NA NA Lakhsmipur <5/1000 NA NA Noakhali* <5/1000 NA NA Habiganj <5/1000 NA NA Jhalokathi <5/1000 NA NA Pirozepur* <5/1000 NA NA Sub-IR 2.1: Improve leadership and management at district level and below Number of GoB managers supported for leadership and management capacity The activity development completed in 2015 Lakhsmipur NA NA NA Noakhali NA NA NA Habiganj NA NA NA Jhalokathi NA NA NA Pirozepur NA NA NA Bhola NA NA NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated This activity started in 23 26 23 comprehensive annual MNCH/FP/N plan 2015

88 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks High intensity areas Lakhsmipur 5 5 5 Noakhali* 4 9 9 Habiganj 8 8 8 Jhalokathi 4 4 4 Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting monthly meeting High intensity area Lakhsmipur 95 99 90 Noakhali* 95 73 90 Habiganj 100 99 95 Jhalokathi 95 65 85 Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a supervision tool was used and findings shared with providers High intensity areas Lakhsmipur 90 42 90 Noakhali* 90 160 90 Habiganj 90 174 90 Jhalokathi 90 110 90 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas Lakhsmipur <3 2 <2 Noakhali* <3 1 <2 Habiganj <3 1 <2 Jhalokathi <3 0 <2 Sub-IR 2.6: Strengthen local government planning and engagement in health service provision

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 89 Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks

Percentage of unions that had at least 50 percent of the estimated births registered within 45 days of birth High intensity areas Lakhsmipur 60 NA NA Noakhali* 60 NA NA Habiganj 60 NA NA Jhalokathi 60 NA NA Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of Union Parishads (UP) that spent funds to support MNCH/FP/N activities High intensity areas Lakhsmipur 58 41 58 Noakhali* 44 38 44 Habiganj 77 57 77 Jhalokathi 32 23 32 Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GoB recruitment or redeployment in project areas High intensity areas Lakhsmipur 5 17 5 (Nurse-17) (FWV-2, Conslt. 5 80 5 Gyn/Obs-2, Nurse- Noakhali* 76) (FWA-3, FWV-1, 5 18 5 Habiganj Nurse-14) Jhalokathi 5 46 5 (Nurse-46) Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector Number of policies/ strategies/guidelines on MNH developed/revised with MaMoni 4 4 4 HSS support Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-

90 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks based learning in national policy and program Number of program learning initiatives 10 11 15 completed and disseminated Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA in USG- assisted programs High intensity areas Lakhsmipur 19,687 20,900 20,900 Noakhali* 12,288 17,360 17,360 Habiganj 25,896 27,184 27,184 Jhalokathi 7,054 7,793 7,793 Pirozepur* 2,658 2,421 2,421 HSCS areas Pirozepur 12,148 8,621 12,148 Bhola 1,982 18,453 18,453 Noakhali 37,848 19,598 37,848 Number of antenatal care (ANC) visits by skilled providers from USG-assisted facilities High intensity areas Lakhsmipur 53,730 98,109 98,109 Noakhali* 43,414 89,656 89,656 Habiganj 210,611 178,943 178,943 Jhalokathi 16,553 28,770 28,770 HSCS areas Pirozepur 44,612 43,826 43,826 Bhola 68,546 73,961 73,961 Noakhali 97,682 85,601 85,601 Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Number of people reached through project 666,143 1,530,020 499,607 supported BCC activities High intensity areas Lakhsmipur 200,000 179,291 150,000 Women 95,784 Men 83,507 Noakhali* 145,556 1,290,879 109,167

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 91 Target Achieveme (October nt (October Target 2016- 2016- 2018 September September 2017) 2017) Indicator Remarks Women 513,452 Men 777,427 Habiganj 205,000 48,391 153,750 Women 40,835 Men 7,556 Jhalokathi 115,587 11,459 86,690 Women 9,373 Men 2,086 Sub-IR 4.2: Enhance community engagement in addressing health needs Number of trained community volunteers promoting MNCHFPN through project 28,371 23,929 23,929 support High intensity areas Lakhsmipur 6,710 6,458 6,458 Noakhali* 5,900 6,846 6,846 Habiganj 8,379 8,320 8,320 Jhalokathi 2,731 2,305 2,305 Pirozepur* 1,205 0 0 Number of Community Action Groups with an emergency transport system for 24,355 maternal and newborn health care through 20,229 20,229 USG-supported programs High intensity areas Lakhsmipur 6,461 6,310 6,310 Noakhali 3,876 4,355 4,355 Habiganj 4,369 8,079 8,079 Jhalokathi 3,746 1,485 1,485 Pirozepur* 1,549 0 0

APPENDIX 4: ADDITIONAL INDICATORS (ADDED IN 2016)

92 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Target Achievement Target Indicator Remarks FY 17 2017 2018 Percentage of newborns receiving CHX Source: DGFP MIS-3 and application at birth in MoH&FW facilities EmOC report of DHIS-2 (By Division) National 50 47 60 Barisal 50 52 60 Chittagong 50 61 60 Dhaka 50 44 60 Khulna 50 54 60 Rajshahi 50 36 60 Rangpur 50 32 60 Sylhet 50 47 60 Number of upazilas where a review of Newborn interventions held Source: Project report (by Division) Total 326 326 165 Barisal 42 42 The plan was added Chittagong 38 100 after mid-year review Dhaka 124 90 Khulna 53 60 7 Rajshahi 68 58 Rangpur 0 58 Sylhet 39 38 Number of Newborn for whom Source: DGFP MIS- resuscitation actions using bag and mask 3,EOC were initiated (by Division) (31% of annual target, Total 14,817 21,450 21,450 within range) Barisal 640 1,316 1,316 Chittagong 3,137 4,950 4,950 Dhaka 4,453 6,185 6,185 Khulna 1,952 2,525 2,525 Rajshahi 1,995 1,541 1,541 Rangpur 1,716 1,996 1,996 Sylhet 924 2,937 2,937 Number of Union Health and Family Welfare Centers (UH&FWCs) in the project Source: Project report area using electronic MIS tools Noakhali implementation to Total 130 157 begin in April, delayed because of Measure procurement Lakshmipur 51 Noakhali 69

Habiganj 61 71

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 93 Target Achievement Target Indicator Remarks FY 17 2017 2018 Jhalokati 35 Pirojpur NA NA Bhola NA Number of districts having an active

Quality Improvement (QI) committee Total 32 41 64 Barisal 3 4 6

Chittagong 6 9 11

Dhaka 9 8 17 Khulna 5 6 10 Rajshahi 4 8 8 Rangpur 3 3 8 Sylhet 2 3 4

APPENDIX 5: LIST OF UNION FACILITIES UPGRADED

94 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report District Upazila Union Facility Name

Badalpur Badalpur Union Health and Family Welfare Centre Jalsuka Jalsuka Union Health and Family Welfare Centre Ajmiriganj Kakailseo Kakailseo Union Health and Family Welfare Centre Shibpasha Shibpasha Union Health and Family Welfare Centre Snanghat Snanghat Union Health and Family Welfare Centre Bahubal Mirpur Mirpur Union Health and Family Welfare Centre Khagaura Khagaura Union Health and Family Welfare Centre Pukhra Pukhra Union Health and Family Welfare Centre Baniachong Daulatpur Daulatpur Union Health and Family Welfare Centre Sujatpur Sujatpur Union Health and Family Welfare Centre Uttar Purba Uttar Purba Baniachang Union Health and Family Baniachang Welfare Centre Shatiajuri Shatiajuri Union Health and Family Welfare Centre Chunarughat Sankhola Sankhola Union Health and Family Welfare Centre Lukhra Lukhra Union Health and Family Welfare Centre Poil Poil Union Health and Family Welfare Centre Habiganj Tegharia Tegharia Union Health and Family Welfare Centre Sadar Nizampur Nizampur Union Health and Family Welfare Centre Habiganj Richi Richi Union Health and Family Welfare Centre Raziura Raziura Union Health and Family Welfare Centre Karab Karab Union Health and Family Welfare Centre Lakhai Murakari Murakari Union Health and Family Welfare Centre Muriauk Muriauk Union Health and Family Welfare Centre Bahara Bahara Union Health and Family Welfare Centre Madhabpur Jagadishpur Jagadishpur Union Health and Family Welfare Centre Noapara Noapara Union Health and Family Welfare Centre Debpara Debpara Union Health and Family Welfare Centre Dighalbak Dighalbak Union Health and Family Welfare Centre Paschim Bara Paschim Bara Bhakhair Union Health and Family Bhakhair Welfare Centre Purba Bara Bakhair Union Health and Family Welfare Purba Bara Bakhair Centre Nabiganj Auskandi Auskandi Union Health and Family Welfare Centre Bausha Bausha Union Health and Family Welfare Centre Gaznapur Gaznapur Union Health and Family Welfare Centre Kalair Banga Kalair Banga Union Health and Family Welfare Centre Kurshi Kurshi Union Health and Family Welfare Centre Paniunda Paniunda Union Health and Family Welfare Centre Binoykati Binoykati Union Health and Family Welfare Centre Kirtipasha Kirtipasha Union Health and Family Welfare Centre Jhalokathi Nathullabad Nathullabad Union Health and Family Welfare Centre Sadar Jhalokathi Keora Keora Union Health and Family Welfare Centre Ponabalia Ponabalia Union Health and Family Welfare Centre Chenchri Rampur Union Health and Family Welfare Kanthalia Chenchri Rampur Centre

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 95 District Upazila Union Facility Name

Patikhalghata Patikhalghata Union Health and Family Welfare Centre Bhairabpasha Bhairabpasha Union Health and Family Welfare Centre Kusanghal Kusanghal Union Health and Family Welfare Centre Nalchity Magar Magar Union Health and Family Welfare Centre Kulkati Kulkati Union Health and Family Welfare Centre Rajapur Saturia Saturia Union Health and Family Welfare Centre Chandraganj Chandraganj Union Health and Family Welfare Centre Dalal Bazar Dalal Bazar Union Health and Family Welfare Centre Datta Para Datta Para Union Health and Family Welfare Centre Dighali Dighali Union Health and Family Welfare Centre Lakshmipur Mandari Mandari Union Health and Family Welfare Centre Sadar Uttar Joypur Uttar Joypur Union Health and Family Welfare Centre Kushakhali Kushakhali Union Health and Family Welfare Centre Basikpur Basikpur Union Health and Family Welfare Centre Parbatinagar Parbatinagar Union Health and Family Welfare Centre Char Falcon Char Falcon Union Health and Family Welfare Centre Kamalnagar Hajirhat Hajirhat Union Health and Family Welfare Centre Char Kadira Char Kadira Union Health and Family Welfare Centre Darbeshpur Darbeshpur Union Health and Family Welfare Centre Chandipur Chandipur Union Health and Family Welfare Centre Ramganj Lamchar Lamchar Union Health and Family Welfare Centre Lakshmipur Kanchanpur Kanchanpur Union Health and Family Welfare Centre Bhatra Bhatra Union Health and Family Welfare Centre Bara Kheri Bara Kheri Union Health and Family Welfare Centre Char Algi Char Algi Union Health and Family Welfare Centre Ramgati Char Ramiz Char Ramiz Union Health and Family Welfare Centre Char Alexandar Union Health and Family Welfare Char Alexandar Centre Char Gazi Char Gazi Union Health and Family Welfare Centre Bamni Bamni Union Health and Family Welfare Centre Char Mohana Char Mohana Union Health and Family Welfare Centre Keroa Keroa Union Health and Family Welfare Centre Sonapur Sonapur Union Health and Family Welfare Centre Roypur Char Pata Char Pata Union Health and Family Welfare Centre North Char Ababil Union Health and Family Welfare North Char Ababil Centre South Char Ababil Union Health and Family Welfare South Char Ababil Centre Gopalpur Gopalpur Union Health and Family Welfare Centre Durgapur Durgapur Union Health and Family Welfare Centre Alyerapur Alyerapur Union Health and Family Welfare Centre Noakhali Begumganj Narottampur Narottampur Union Health and Family Welfare Centre Rasulpur Rasulpur Union Health and Family Welfare Centre Hajipur Hajipur Union Health and Family Welfare Centre Begumganj Begumganj Union Health and Family Welfare Centre

96 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report District Upazila Union Facility Name

Char Kakra Char Kakra Union Health and Family Welfare Centre Rampur Rampur Union Health and Family Welfare Centre Companiganj Sirajpur Sirajpur Union Health and Family Welfare Centre Musapur Musapur Union Health and Family Welfare Centre Kabilpur Kabilpur Union Health and Family Welfare Centre Senbagh Mohamadpur Mohamadpur Union Health and Family Welfare Centre Bejoybagh Bejoybagh Union Health and Family Welfare Centre Harni Harni Union Health and Family Welfare Centre Jahajmara Jahajmara Union Health and Family Welfare Centre Hatiya Sonadia Sonadia Union Health and Family Welfare Centre Chandnandi Chandnandi Union Health and Family Welfare Centre

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 97 APPENDIX 6: NEWS CLIPS PUBLISHED BY MaMoni HSS

Media Date Article Title and Link Daily Kaler October 2, �������������: ���� ������ ��� ��� Kantho 2016 http://www.kalerkantho.com/print-edition/last- page/2016/10/02/411703 Daily Kaler October ����� শত শত ���������������� Kantho 12, 2016 http://www.kalerkantho.com/print-edition/first- page/2016/10/12/415675 Daily Kaler November ������; এ পথ ��� �� ���... Kantho 18, 2016 http://www.kalerkantho.com/print-edition/last- page/2016/11/18/430446 Daily Observer November Baniachong health center raises hope for 25,000 people 21, 2016 http://www.observerbd.com/details.php?id=44540 Daily Star November Nearly 4.4 lakh premature babies born every year: study 17, 2016 http://www.thedailystar.net/country/nearly-44-lakh- premature-babies-born-every-year-study-1316227 Daily Star November Preterm birth main barrier to cutting under-5 child mortality 18, 2016 http://www.thedailystar.net/city/preterm-birth-main-barrier- cutting-under-5-child-mortality-1316542 Daily Star November Ending premature child deaths 20, 2016 http://www.thedailystar.net/health/ending-premature-child- deaths-1317316 Daily Prothom November ��������� �������� ���� �������� ���: Alo 13, 2016 ����������� ���� ��� (Editorial) http://www.prothom- alo.com/opinion/article/1019549/%E0%A6%B6%E0%A6%BF% E0%A6%B6%E0%A7%81%E0%A6%AE%E0%A7%83%E0%A6 %A4%E0%A7%8D%E0%A6%AF%E0%A7%81%E0%A6%B0- %E0%A6%89%E0%A6%9A%E0%A7%8D%E0%A6%9A- %E0%A6%B9%E0%A6%BE%E0%A6%B0 Daily Star December Prevent Deaths from Preterm Births: Experts comments on 8, 2016 world prematurity Day http://epaper.thedailystar.net/index.php?opt=view&page=11& date=2016-12-08 Daily Prothom November ৪ ��� ৩৮ ����� ���� ����� ���� ������ Alo 18, 2016 http://www.prothom- alo.com/bangladesh/article/1023277/%E0%A7%AA- %E0%A6%B2%E0%A6%BE%E0%A6%96- %E0%A7%A9%E0%A7%AE- %E0%A6%B9%E0%A6%BE%E0%A6%9C%E0%A6%BE%E0%A6 %B0-%E0%A6%B6%E0%A6%BF%E0%A6%B6%E0%A7%81- %E0%A6%85%E0%A6%95%E0%A6%BE%E0%A6%B2%E0%A7% 87-%E0%A6%9C%E0%A6%A8%E0%A7%8D%E0%A6%AE- %E0%A6%A8%E0%A6%BF%E0%A6%9A%E0%A7%8D%E0%A6% 9B%E0%A7%87

98 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Media Date Article Title and Link Daily Prothom March 2, নবজাতেকরনািভরযত্ন Alo 2017 http://www.prothom-alo.com/life- style/article/1094761/%E0%A6%A8%E0%A6%AC%E0%A6%9C%E 0%A6%BE%E0%A6%A4%E0%A6%95%E0%A7%87%E0%A6%B0- %E0%A6%A8%E0%A6%BE%E0%A6%AD%E0%A6%BF%E0%A6 %B0-%E0%A6%AF%E0%A6%A4%E0%A7%8D%E0%A6%A8 Daily Prothom February �া�뷍েসবা েথেক বহ‍দূের চর ও �ীেপর মানুষ Alo 12, 2017 http://www.prothom- alo.com/bangladesh/article/1079687/%E0%A6% Daily Prothom February ২৩ শতাংশ িশশ‍ জ�াে� কম ওজন িনেয় Alo 26, 2017 http://m.prothom- alo.com/bangladesh/article/1090540/%E0%A7%A8%E0%A7%A9- %E0%A6%B6%E0%A6%A4%E0%A6%BE%E0%A6%82%E0%A6% B6-%E0%A6%B6%E0%A6%BF%E0%A6%B6%E0%A7%81- %E0%A6%9C%E0%A6%A8%E0%A7%8D%E0%A6%AE%E0%A6% BE%E0%A6%9A%E0%A7%8D%E0%A6%9B%E0%A7%87- %E0%A6%95%E0%A6%AE- %E0%A6%93%E0%A6%9C%E0%A6%A8- %E0%A6%A8%E0%A6%BF%E0%A7%9F%E0%A7%87 Daily Ittefaq February �েয়াজন অপুি�িবেরাধী সমি�ত অিভযান 28, 2017 http://www.ittefaq.com.bd/print- edition/editorial/2017/02/28/179065.html Daily Kaler March 4, ব� েহাক অ�েয়াজনীয় িসজািরয়ান অপােরশন Kantho 2017 http://www.kalerkantho.com/online/prescription/2017/03/04/47063 8

Daily Prothom March 6, সব쇍জনীন �া�뷍সুর�ায় সমি�ত উেদ뷍াগ দরকার Alo 2017 http://www.prothom- alo.com/bangladesh/article/1098991/%E0%A6%B8%E0%A6%B0% E0%A7%8D%E0%A6%AC%E0%A6%9C%E0%A6%A8%E0%A7%8 0%E0%A6%A8- %E0%A6%B8%E0%A7%8D%E0%A6%AC%E0%A6%BE%E0%A6 %B8%E0%A7%8D%E0%A6%A5%E0%A7%8D%E0%A6%AF- %E0%A6%B8%E0%A7%81%E0%A6%B0%E0%A6%95%E0%A7%8 D%E0%A6%B7%E0%A6%BE%E0%A7%9F- %E0%A6%B8%E0%A6%AE%E0%A6%A8%E0%A7%8D%E0%A6% AC%E0%A6%BF%E0%A6%A4- %E0%A6%89%E0%A6%A6%E0%A7%8D%E0%A6%AF%E0%A7% 8B%E0%A6%97- %E0%A6%A6%E0%A6%B0%E0%A6%95%E0%A6%BE%E0%A6% B0 Sylhettoday24.co May 16, �������� �� ও ����� ��������� ����� পথ ���� m 2017 ��������� Link: http://www.sylhettoday24.com/news/details/Sylhet/41474 BDnew24.com May 29, ‘MaMoni HSS’ brings local level solutions to ensure safe 2017 motherhood in Bangladesh

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 99 Media Date Article Title and Link http://bdnews24.com/health/2017/05/29/MaMoni HSS-brings-local- level-solutions-to-ensure-safe-motherhood-in-bangladesh Currentnews.com May 28, ����������� ������ ������� ���� ����� .bd 2017 http://www.currentnews.com.bd/bn/news/245107 Newsgallerybd24. May 28, �������� ����� ������ ������� ������ র com 2017 ����� ও ������ ��� Link: http://newsgallerybd24.com/%E0%A6%B9%E0%A6%AC%E0%A6 %BF%E0%A6%97%E0%A6%9E%E0%A7%8D%E0%A6%9C%E0% A7%87- %E0%A6%AC%E0%A6%BF%E0%A6%B6%E0%A7%8D%E0%A6 %AC- %E0%A6%A8%E0%A6%BF%E0%A6%B0%E0%A6%BE%E0%A6 %AA%E0%A6%A6-%E0%A6%AE%E0%A6%BE/ Sylhettoday24.co May 28, ������ ������� ���� : ��������� ������� m 2017 ��������� ��������� ����� ������ ����� http://www.sylhettoday24.com/news/details/Sylhet/41884 Daily Observer May 29, World Safe Motherhood Day observed in districts 2017 http://www.observerbd.com/details.php?id=76107 Daily Deshjamin May 29, ������������� ���������� ���� ����� 2017 ������ ����� Offline only Daily Protidiner May 29, �������� এক ���� ��������� ������ �� ও Bani 2017 �������� ������: ����� ������ ���� ও ����������� ��� Offline only Newsgallerybd24. May 30, �������� ������ ������� ���� ������ com 2017 Link: http://newsgallerybd24.com/%e0%a6%ae%e0%a6%be%e0%a6%a7 %e0%a6%ac%e0%a6%aa%e0%a7%81%e0%a6%b0%e0%a7%87- %e0%a6%a8%e0%a6%bf%e0%a6%b0%e0%a6%be%e0%a6%aa%e0 %a6%a6- %e0%a6%ae%e0%a6%be%e0%a6%a4%e0%a7%83%e0%a6%a4%e 0%a7%8d%e0%a6%ac/ Daily Observer June 02, 29 women die in Laxmipur in 12 months while giving birth 2017 Link: http://www.observerbd.com/details.php?id=76794 Daily Khowai July 09, ��������� ��������� ����������� ������ 2017 ��� ���� ��� ॥ ���� ������� http://www.dailykhowai.com/news/2017/07/10/61476 Korangi News 24 July 09, �������� �� ও ���� ��������� ������ ����� 2017 �������� http://koranginews24.com/?p=4158 Habiganj Express July 09, �� ও ���� ��������� ������� ������� ������� 2017 ������ ������ ��������� ���� ������� ॥ ��������� ��������� ����������� ������

100 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Media Date Article Title and Link ��� ���� ��� http://www.habiganjexpress.com/?p=69926 News Gallery Bd July 09, ��������� ��������� ����������� ������ 24 2017 ��� ���� ��� ॥ ���� ������� http://newsgallerybd24.com/%E0%A6%B8%E0%A7%8D%E0%A6 %AC%E0%A6%BE%E0%A6%B8%E0%A7%8D%E0%A6%A5%E0 %A7%8D%E0%A6%AF- %E0%A6%AC%E0%A7%8D%E0%A6%AF%E0%A6%AC%E0%A6 %B8%E0%A7%8D%E0%A6%A5%E0%A6%BE%E0%A7%9F- %E0%A6%B8%E0%A6%AE%E0%A6%A8%E0%A7%8D/#.WWJZz G_z2mI.facebook

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 101

APPENDIX 7: FORUMS WHERE MAMONI HSS LESSONS WERE DISSEMINATED

Title Forum Month Type of Dissemination

Leveraging results from a Global Vancouver, Nationwide Symposium on Canada Health Systems Service Readiness Facility Research assessment Oral Nov 2016 Presentation To Prioritize Investments to establish 24/7 delivery services at peripheral level health Facilities in Bangladesh

Integrated mother‐ newborn Global Vancouver, registers and interface with Symposium on Canada community structures at Health Systems Poster peripheral level facilities enables Research Nov 2016 Presentation real time population level estimates on key maternal health indicators

Strengthening peripheral health Global Vancouver, facilities to increase skilled Symposium on Canada Poster Nov 2016 attendance at birth in rural Health Systems Presentation Bangladesh Research

Establishing an automated Vancouver, Global routine health information Canada Symposium on ePoster system to improve tracking of Nov 2016 Health Systems Presentation clients across the continuum of Research care

National scale-up of a clinical Vancouver, skills based training innovation: Global Canada Bangladesh’s experience with Symposium on Poster Nov 2016 improving neonatal resuscitation Health Systems Presentation using the Helping Babies Breathe Research curriculum

RH Scientific Nairobi, Oral Quality of LAPM Services Days, Save the Nov 2016 Kenya Presentation Children

Overcoming health system bottlenecks in implementing 11th Congress of Trieste, Poster Kangaroo Mother Care at district the International Nov 2016 Italy Presentation and sub-district level health Network on KMC facilities in Bangladesh

102 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Title Forum Month Type of Dissemination

Management of infection of the 0- Meeting of 59 days infants at union level Principal Investigators for Lagos, Poster facilities Nov 2016 PSBI Nigeria Presentation Ramgonj upazila, Lakshmipur Implementation district, Bangladesh Research

Technology readiness of peripheral and community level service delivery systems in rural Global Digital Washington Oral Dec 2016 Bangladesh to introduce Health Forum DC, USA Presentation electronic health information systems

Community Micro Planning (cMPM) - an innovative approach of MaMoni Health Systems Strengthening (HSS) project to Kampala, Oral CHW Symposium Feb 2017 strengthen public sector Uganda Presentation Community Health Workers (CHW) service delivery in Bangladesh

Recruiting, training and retaining of Community Kampala, Oral CHW Symposium Feb 2017 Volunteers: Experience from Uganda Presentation rural Bangladesh

Making a difference: community volunteers Kampala, Oral contributing to increasing use of CHW Symposium Feb 2017 Uganda Presentation effective family planning in Bangladesh

Development of community Kampala, Oral skilled birth attendants in hard- CHW Symposium Feb 2017 Uganda Presentation to-reach areas of Bangladesh

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 103

APPENDIX 8: LIST OF PROCESS DOCUMENTATION ACTIVITIES

MaMoni HSS will contribute to the following learning priorities over the life of the project: Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status 1. CHX Scale-Up Implementation Prospective / Ambispective MaMoni FY 2018 Qualitative Case Study: Documentation HSS, and Documentation of process, results Multiple sources: routine with quantitative and lessons of national scale-up by implementation data, JHU/IIP data (training all partners and stakeholders stakeholder meetings and and including MOHFW, NGOs, and the reviews, Newborn and monitoring) private sector. Child Health Cell records, collection tracer surveys ongoing, stakeholder workshop in January 2. Changes in Skilled Birth Prospective / Ambispective MaMoni FY 2018 Data Attendance rates as a result of Documentation HSS collection improvements at the UHFWC’s: ongoing - To what extent and how did the Source of Data approach of advocacy and Tracer surveys assessment lead to improvements HFS/SPA at UHFWC through sector plans District Planning outputs and local government budget Routine program data on allocations? UP budget utilization - Did improved service provision at UHFWC lead to increased utilization of UHFWC for delivery and increased coverage of SBA (MaMoni Areas)? 3. Case Study of the PCSBA Program Retrospective MaMoni A Study and their income viability Documentation of Habiganj HSS, in documenta protocol and Prospective collabora tion on approved by Documentation in Noakhali tion with pCSBA JHU IRB IRB required JHU/IIP completed data in FY collection 2016, but completed, scope data analysis expanded ongoing to include the new PCSBAs, expected to be completed by early FY18 4. Case Study of MaMoni Program Retrospective MaMoni FY 2018 Six rounds of

104 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status Impact on Service Equity: Documentation; tracer HSS tracer survey - ANC, SBA, and PNC in Habiganj indicator surveys conducted, – geographic and social equity final endline - Coverage of MNH, FP and survey to be nutrition across program districts completed in February 2018 5. Quality of service delivery for Cross-sectional Mixed MaMoni Data Data analysis Permanent Sterilization Methods of Method Study HSS analysis completed Family Planning with completed Two icddr,b Manuscrip manuscript ts FY 2018 ongoing

6. Quality Improvement: Routine Documentation Mamoni FY 2018 First draft . Document the QI framework through project MIS, Data HSS prepared (process), outputs (improvement from QI sentinel sites Documentatio in performance standards) and n ongoing overlay that data with quality performance indicators (health outcomes) 7. Newborn Sepsis (PSBI) Routine Documentation JHU/IIP FY 2018 Data Management in MaMoni Supported MaMoni collection Areas: Data source HSS ongoing . Has/how has the community Routine implementation Writing platform improved care-seeking? data workshop . How are upazilas maintaining Tracer surveys planned in records for newborn sepsis cases? KII with SACMOs, October 2017 Can outcomes be traced? pharmacists, village doctors FGD with community members 8. Misoprostol Implementation in Routine Documentation MaMoni FY 2018 Two rounds of MaMoni HSS Supported Areas HSS tracer survey Update: MaMoni HSS is piloting Data source completed a new model packaging Tracer Surveys with misoprostol and CHX together in Routine implementation additional Lakshmipur district data (DGFP reports) questions . Whether an integrated KII with service providers Endline distribution increases coverage survey to be . What are the barriers in service completed in delivery and demand side? Feb 2018 9. Nutrition: Routine Documentation MaMoni FY 2018 Data Update: Scope limited to Jhalokathi HSS collection district where MaMoni HSS Source of Data complete strengthened 82 community clinics Routine Implementation Data analysis to identify malnutrition (including training) data ongoing, . How is growth monitoring and Key Informant interview expected in promotion implemented? (KII) Dec 2017 . Did the intervention result in improved screening, referral and case management for MAM and SAM? 10. Postpartum Family Planning: Routine Documentation MaMoni FY 2017 Data

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 105 Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status . What has been the contribution HSS collection of MaMoni at community level to Source of data ongoing increasing demand for LAPM? Training data . Did PPFP uptake increase in Routine utilization data project areas? from DGFP KII of service providers FGD with communities 11. Local Government: Routine Documentation MaMoni FY 2017 Data for FY . Documentation of process and HSS 15 and FY 16 outputs with standing committee already meetings, open budget meetings, collected spending data Analysis . Stories of how MaMoni achieved framework success in increased government being engagement and MNCH developed spending 12. Leadership Management: Routine Documentation icddr,b FY 2017 Conceptual . Did decentralized district MaMoni framework planning help managers be more Routine implementation HSS, developed proactive and efficient for data icddr,b Data planning, other managerial Record review of planning collection practices? process and review initiated . How has the program meetings management practices – data- Key Informant Interview driven planning, supervision, FGD of providers in three program reviews, functional upazilas integration and collaboration – changed? 13. PE/E Management at union level Prospective documentation icddr,b FY 2018 Protocol facilities using loading dose MaMoni finalized magnesium sulfate Source of data HSS Data Record review at referral collection Update: Scope limited to 30 unions facilities ongoing in 4 districts Prospective documentation of whether FWVs can properly screen and identify women with SPE 14. Quality of ANC at Satellite Clinics Source of Data MaMoni FY 2018 GOB approval Assessing the physical preparedness Structured assessment of HSS (data received. of satellite clinics facilities collection Study Direct observation of ANC complete) completed. at SC Program brief Key informant interviews drafted 15. Use of partograph to inform referral Record review MaMoni FY 2018 Program brief decision-making KII HSS completed Were partograph effective in Manuscript identifying complications? drafted

16. Introducing Special Care Units in 3 KII MaMoni FY 2018 Data analysis district hospitals Record review HSS, completed icddr,b Program brief being drafted 17. Introduction of KMC in 14 facilities Record Review KII FGD of MaMoni FY 2018 Data

106 MaMoni Health Systems Strengthening Activity: FY’17 Annual Report Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status mothers HSS collection icddr,b ongoing 18. Intervention to reduce Record review MaMoni FY 2018 DGFP discontinuation of Implant and IUD Follow-up with clients HSS, permission KII of providers icddr,b received Data collection ongoing 19. Use of Antenatal Corticosteroid in Routine documentation MaMoni FY 2018 Data analysis two district hospitals Record review HSS, ongoing - Are providers able to KII icddr,b administer a complete dose of FGD with community dexamethasone (12 hour) - Estimation of gestational age 20. Effect of strengthening IP/Waste KII MaMoni FY 2018 Routine management at union level facilities HSS, documentatio icddr,b n

21. Evolution of community Record review JHU Fy 2018 Routine mobilization model in ACCESS, KII MaMoni documentatio MaMoni ISMNC, and MaMoni HSS HSS n project 22. Use of WISN tools to estimate WISN tools MaMoni FY2018 Study workload of government health Record review HSS completed by workers Stakeholder consultation BUHS, and draft report circulated

MaMoni Health Systems Strengthening Activity: FY’ 17 Annual Report 107