USAID Integrated Health Program

USAID INT EGRATED HEALTH PROGRAM Fiscal Year 2019 Quarterly Report 2 (January 1 through March 31, 2019)

Submitted May 15, 2019 Approved July 29, 2019

DISCLAIMER: This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The authors’ views expressed in this publication do not necessarily reflect the views of USAID or the United States Government.

Recommended Citation: USAID Integrated Health Program. “USAID Integrated Health Program: Fiscal Year 2019 Quarterly Report 2.” Prepared by Abt Associates, Rockville, Maryland, May 15, 2019.

Submitted to: Richard Matendo, Contracting Officer’s Representative, Maternal and Child Health Program Specialist, Health Office, USAID/Democratic Republic of the Congo (DRC), (+243 81 555 4514), Kinshasa, DRC.

Cover Photo: Credit: Jason Coetzee, Matchboxology for USAID Integrated Health Program (IHP)

During a community discussion to elicit inputs for USAID IHP’s human- centered design approach, a young mother from Kasaï-Oriental shares the daily challenges of keeping her children healthy in the context of many other daily household stresses.

Abt Associates Inc. 1 6130 Executive Boulevard 1 Rockville, Maryland 20814 1

T. 301.347.5000 1 www.abtassociates.com

With:

International Rescue Committee (IRC) Pathfinder International BlueSquare Training Resources Group (TRG) Mobile Accord/Geopoll i+Solutions Viamo Matchboxology

USAID INTEGRATED HEALTH PROGRAM Fiscal Year 2019 Quarterly Report 2 (January 1 through March 31, 2019)

Contract No.: 72066018C00001

DISCLAIMER: This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The authors’ views expressed in this publication do not necessarily reflect the views of USAID or the United States Government.

TABLE OF CONTENTS Table of Contents ...... i Acronyms and Abbreviations ...... iii Executive Summary ...... vii 1. Introduction ...... 1 1.1. Programmatic Scope ...... 1 1.2. Geographic Scope ...... 1 1.3. Partnerships ...... 2 2. Program Management ...... 3 2.1. Program Implementation ...... 3 2.2. Program Staffing ...... 3 2.3. Program Operations ...... 4 2.4. Security ...... 6 3. Objective 1 ...... 9 4. Objective 2 ...... 22 5. Objective 3: ...... 36 6. Cross-Cutting Areas ...... 45 6.1. Institutionalization and Sustainability of Gender Equality ...... 45 6.2. Conflict Sensitivity ...... 47 6.3. Capacity Building ...... 47 6.4. Environmental Mitigation and Monitoring ...... 47 7. Activity Research, Monitoring and Evaluation ...... 48 8. Lessons Learned...... 50 Annex A: Performance Indicators, Targets, and Achievements ...... 52 Annex B: Success Stories ...... 67 Annex C: Deliverables Submitted in FY 2019 Quarter 2 ...... 70 Annex D: Staff Hired During FY2019 Quarter 2 ...... 71 Annex E: Environmental Mitigation and Monitoring Report Annex E: Environmental Mitigation and Monitoring Report ...... 76

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | i LIST OF TABLES

Table 1: USAID IHP Regions, Provinces, and Zones de Santé ...... 2 Table 2: USAID IHP Regional and Provincial Offices as of March 31, 2019 ...... 5 Table 3: Number and Percentage of USG-Assisted Service Delivery Points that Experienced a Stockout of Tracer Commodities for at Least One Month during FY2019 Quarter 2 ...... 17 Table 4: Percentage of USAID IHP target ZS with an LMIS Reporting Completeness* Rate Greater Than 95 Percent ...... 19 Table 5: Results of Tuberculosis Search and Testing Campaigns, March 2019 ...... 29 Table 6: Functioning iCCM Sites in USAID IHP-Supported Provinces Having Reported, January to March 2019 ...... 31 Table 7: Causes of Maternal Deaths in Tanganyika ...... 34 Table 8: New Users of Family Planning as a Result of Campaign, by Method ...... 43 Table 9: Women’s Representation in Human Resources for Health in Haut-Lomami Province ...... 46 Table 10: Institutional Capacity Building Workshop Participants ...... 47

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | ii ACRONYMS AND ABBREVIATIONS

ACT Artemisinin-based combination therapy ADRA Adventist Development and Relief Agency AMEP Activity Management and Evaluation Plan ANC Antenatal care BCZS Bureau Central de la Zone de Santé (Office of the Health Zone Team) BEmONC Basic emergency obstetric and newborn care CA Conseil d’Administration (Administrative Council) CAC Cellule d’Animation Communautaire (Community Outreach Unit) CC Cycle collar (contraceptive) CCTM Cellule de Coordination de la Tuberculose Multirésistante (Multidrug-Resistant Tuberculosis Coordination Unit) CDCS Country Development Cooperation Strategy CDF Congolese Franc CEmONC Comprehensive emergency obstetric and newborn care CHW Community health worker CNP-SS Comité National de Pilotage du Secteur de la Santé (National Health Sector Steering Committee) COC Combination oral contraceptives CODESA Comité de Développement de l’Aire de Santé (Health Area Development Committee) COOPI Cooperazione Internazionale (Cooperation International) COP Chief of Party CPAEHA Comité Provincial d’Action de l’Eau, l’Hygiène et l’Assainissement (Provincial Water, Hygiene, and Sanitation Action Committee) CPLT Coordination Provinciale de Lutte contre la Tuberculose (Provincial Committee for Tuberculosis Control) CPP-SS Comité Provincial de Pilotage du Système de la Santé (Provincial Health System Steering Committee) CPR Cardiopulmonary resuscitation CRS Catholic Relief Services CSO Community service organization CTMP Comité Technique Multisectoriel Permanent (Permanent Multisectoral Technical Committee) CYP Couple years of protection DBC Distributeurs de base communautaire (community health workers trained in family planning) DEP Direction d’Etude et Planification (Directorate of Planning and Study) DFSA Development Food Security Activities

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | iii DGOGSS Direction Générale de l’Organisation et de Gestion des Services et des Soins de Santé (Directorate-General for the Organization and Management of Health Care Services) DHIS2 District Health Information System 2 DMPA Medroxyprogesterone acetate DMPA SC Subcutaneous DMPA DPS Division Provinciale de la Santé (Provincial Health Division) DRC Democratic Republic of the Congo E2A Evidence to Action ECZS Equipe Cadre de la Zone de Santé (Health Zone Management Team) EDS Enquête Démographique et de Santé (Demograhic and Health Survey) EEI Equipe d’Encadrement Intégré (Integrated Support Team) eLMIS Logistics Management Information System EMMP Environmental Mitigation and Monitoring Plan EMMR Environmental Mitigation and Monitoring Report EPP Encadreurs Provinciaux Polyvalents (Multidisciplinary Provincial Supervisors) FARCD Forces Armées de la République Démocratique du Congo (Armed Forces of the DRC) FFP Food for Peace FP Family planning FY Fiscal year GDRC Government of the Democratic Republic of the Congo GHSC-TA Global Health Supply Chain-Technical Assistance Project GIZ Deutche Gesellschaft fur Intenationale Zusammenarbeit (German Corporation for International Cooperation) GRID Geo-Referenced Infrastructure and Demographic Data for Development HCD Human-centered design HMIS Health Management Information System HSS Health systems strengthening ICB Institutional capacity building iCCM Integrated community case management IEE Initial Environmental Examination IGA Integrated Governance Activity IHPplus Integrated Health Project Plus iHRIS Integrated Human Resource Information System INH Isonicotinylhydrazide IPM Informed Push Distribution Model IPS Inspection Provinciale de la Santé (Provincial Health Inspectorate) IPT Intermittent preventive treatment IR Intermediate result

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | iv IRC International Rescue Committee ITN Insecticide-treated net IU International units IVR Interactive voice response JMT Journée Mondiale de Lutte contre la Tuberculose (World Tuberculosis Day) JSP Journées Scientifiques de Paludisme (Malaria Scientific Days) KN Kamuina Nsapu LMIS Logistics Management Information System M&E Monitoring and evaluation MCSP Maternal Child Survival Program MDR-TB Multi-drug resistant TB MNCH Maternal, neonatal, and child health MMR Maternal mortality rate MOH Ministry of Health (Ministère de la Santé) MR Mortality rate MUAC Mid-upper arm circumference NGO Nongovernmental organization ORS Oral rehydration salts OSAC Overseas Security Advisory Council PAO Plan d’Action Opérationnel (Annual Operations Plan) PCIMNE Prise en Charge Intégrée de la Maladie du Nouveau-né et de l'Enfant (Integrated Management of Newborn and Infant Illness) PDSS Projet de Développement de Système de la Santé (Health Care System Development Project) PEV Programme Elargi de Vaccination (Expanded Program on Immunization) PICAL Participatory Institutional Capacity Assessment and Learning PIRS Performance Indicator Reference Sheet PITT Performance Indicator Tracking Table PMI President’s Malaria Initiative PNAM Programme National d’Approvisionnement en Medicaments (National Drug Supply Program PNDS Plan National de Développement Sanitaire (National Health Development Plan) PNLP Programme National de Lutte contre le Paludisme (National Program to Combat Malaria) PNLT Programme National de la Lutte Contre la Tuberculose (National Program to Combat Tuberculosis) PNSR Programme National de la Santé de la Reproduction (National Program for Reproductive Health) POP Progestin-only oral contraceptive pill

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | v PRODS Programme de Renforcement de l’Offre et Développement de l'Accès aux Soins de Santé (Program for Strengthening of Supply and Development of Access to Health Care) PRONANUT Programme National de Nutrition (National Nutrition Program) RBF Reslts-based financing RDC Regional distribution center RDT Rapid diagnostic test RECO Relais communautaire (community health worker) RH Reproductive health RME Research, monitoring, and evaluation SBA Skilled birth attendant SBC Social and behavior change SDM Standard days method SDMR Surveillance de Décès Maternels et Riposte (Surveillance and Response to Maternal Deaths) SGBV Sexual and gender-based violence SMS Short messaging service SNIS Système National d'Information Sanitaire (National Health Information System) SONU B Soins obstétrico-néonatal d’urgence de base (basic emergency obstetric and neonatal care) S/P Sulfadoxine/pyrimethamine SVC Strengthening Value Chains (Activity) TB Tuberculosis TFP Technical and financial partner TPH Swiss Tropical and Public Health Institute TRG Training Resources Group U5MR Under 5 mortality rate UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development USAID IHP USAID Integrated Health Program USG United States Government WASH Water, sanitation, and hygiene WHO World Health Organization ZS Zone de santé (health zone)

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | vi EXECUTIVE SUMMARY

USAID’s Integrated Health Program (USAID IHP) in the Democratic Republic of the Congo (DRC) is designed to strengthen the capacity of Congolese institutions and communities to deliver quality integrated health services that sustainably improve the health status of the Congolese population. To achieve this purpose, USAID IHP has three objectives: 1. Strengthen health systems, governance, and leadership at provincial, health zone, and facility levels in target health zones 2. Increase access to quality integrated health services in target health zones 3. Increase adoption of healthy behaviors, including use of health services, in target health zones The Program works across nine provinces clustered in three regions: Eastern Congo (Sud-Kivu and Tanganyika); Kasaï (Kasaï-Central, Kasaï-Oriental, Lomami, and Sankuru); and Katanga (Haut-Katanga, Haut-Lomami, and Lualaba). We are building on previous USAID health investments in the DRC, USAID’s Country Development Cooperation Strategy (CDCS), and related Government of the DRC (GDRC) strategies and policies. In particular, we have aligned our activities with priorities contained in the Plan National de Développement Sanitaire (PNDS, National Health Development Plan) 2019–2022. During the second quarter of fiscal year (FY) 2019, the Program launched technical activities following an extensive planning process that culminated in an approved work plan in December 2018. With about 650 individual activities across nine provinces and six technical areas, our plans are ambitious. Despite a series of external and internal hurdles that have led to delays in getting many activities off the ground, we have nonetheless been able to actively engage with partners and counterparts and commence a number of key initiatives. Programmatic activities. USAID IHP’s first large-scale activity this quarter was providing technical and financial support for the annual planning process in provinces and zones de santé (ZS, health zones). Our efforts immersed the Program in health system planning and enabled us to understand how we can best help provincial and ZS institutions going forward. They also led to results that exceeded USAID IHP targets for FY2019. All nine target provinces developed Plans d’Action Opérationel (PAO, Annual Operations Plans) that are aligned with the PNDS 2019–2022 and all 178 target ZS established PAO that are aligned with provincial plans. Once the provincial PAO were in place, the Program assisted the Divisions Provinciales de la Santé (DPS, Provincial Health Divisions) in all nine provinces in establishing their contrat unique (single contract) to rationalize stakeholder resources. During this quarter, USAID IHP also launched other activities to strengthen health systems, governance, and leadership. We held workshops in each target region to orient DPS and Program staff on our institutional capacity building approach and prepare them to use the Participatory Institutional Capacity Assessment and Learning (PICAL) tool to conduct institutional assessments. Following these workshops, a team of USAID IHP specialists applied the PICAL to facilitate an assessment of the Sud-Kivu DPS. In March 2019, we organized orientation sessions for DPS in four provinces on the need to consider gender when developing human resources plans, with the goal of increasing women’s representation in health governance and management bodies. To provide provinces and ZS with the financial resources to fund their supervisory activities and planning, coordination, or monitoring events, Program staff worked with the USAID Health Team and Contracts Office to design instruments that would complement direct payment and in-kind support. We will continue to seek appropriate solutions during the coming quarter. USAID IHP also began efforts this quarter to address problems with the supply chain for essential and generic drugs. We hired Provincial Supply Chain Officers to help ZS and health facility staff use appropriate supply chain management tools and provided technical assistance to ensure that the

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | vii Logistics Management Information System (LMIS) takes into account the needs of the supply chain at the last mile. To improve access to quality, integrated health services during this reporting period, USAID IHP ensured that family planning (FP) commodities were supplied in four provinces, equipped 16 health facilities in Tanganyika with supplies to facilitate observation of adherence to intermittent preventive treatment (for malaria) in pregnancy, and helped fund the costs of the cold chain in Mbuji Mayi to protect the viability of vaccines. We also supported a variety of training efforts, including training on neonatal resuscitation and obstetric and neonatal care and a pilot retraining program for nurses and distributeurs de base communautaire (specialized community health workers) to improve their ability to provide FP services. During this quarter, USAID IHP provided extensive technical and financial support for the Journée Mondiale de Lutte contre la Tuberculose (JMT, World Tuberculosis Day) in Kinshasa and four provinces. We participated in scientific meetings and supported JMT celebration events, tuberculosis (TB) social and behavior change (SBC) campaigns, and TB awareness and testing campaigns that reached more than 54,000 people in five provinces. As a key step toward promoting the adoption of priority healthy behaviors, we kicked off the development of the Program’s SBC communication approach by using human-centered design principles to engage community members in Kasaï-Oriental. In addition, as part of the MOH’s Healthy Family Campaign, we supported an SBC campaign on family planning in Lomami and a school competition in Kasaï-Central that encouraged disease prevention and promoted essential family health practices. Cooperation and collaboration. Throughout the quarter, USAID IHP continued to collaborate with other implementing partners and donor programs. We looked for areas of synergy and identified opportunities, overlaps, and gaps so we can harmonize intervention strategies and avoid duplication. We also discussed gender approaches and sought ways to harmonize the Program’s gender efforts with those of other organizations. Our staff took an active part in meetings of many MOH bodies and health system organizations. These included not only province-level DPS meetings and ZS-level meetings of the Conseils d’Administration (Administrative Councils), but also key meetings of the Comités Provincials de Pilotage du Système de la Santé (Provincial Health System Steering Committees) and the Comité National de Pilotage du Système de la Santé (National Health System Steering Committee). Program personnel participated in national and provincial meetings on a wide range of technical issues, including ZS operating standards; water, sanitation, and hygiene (WASH); family planning; vaccinations; nutrition; neonatal and childhood illnesses; malaria; and tuberculosis. Looking forward. As USAID IHP moves into the second half of FY2019, we are drawing on lessons learned during the last few months. We continue to seek solutions and use adaptive management principles to address internal staffing, administrative, and financial challenges and to shape the Program in ways that will address external constraints that impact our technical efforts and our ability to deliver financing for government institutions. We have seen great receptivity to the Program’s core mission and especially to our focus on sustainability and the strengthening of Congolese institutions. USAID IHP’s work with provinces and ZS on their annual planning processes has shown us the importance of engaging a host of elements outside the health system, including other GDRC agencies, local governments, and private sector bodies. Accordingly, USAID IHP staff will continue to collaborate with counterparts throughout the health system and beyond as we accelerate the pace of activities. Our team remains dedicated to and focused on achieving our core objectives to strengthen institutions, improve access to quality services, and increase the adoption of healthy behaviors.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | viii 1. INTRODUCTION

This report describes implementation of USAID’s Integrated Health Program (USAID IHP) during the second quarter of USAID fiscal year (FY) 2019 (January–March 2019). The goal of the Program is to work with the Government of the Democratic Republic of Congo’s (GDRC’s) Ministry of Health (MOH) and other stakeholders to strengthen the capacity of Congolese institutions and communities to deliver sustainable, quality, integrated health services that improve the health status of Congolese men and women. To meet this goal, USAID IHP has three objectives:

1) Strengthen health systems, governance, and leadership at provincial, health zone, and facility levels in target health zones 2) Increase access to quality integrated health services in target health zones 3) Increase adoption of healthy behaviors, including use of health services, in target health zones

USAID IHP seeks to leverage the potential of decentralization and accelerate reductions in maternal, newborn, and child deaths. The program supports the MOH to tackle challenges identified in the Plan National de Développement Sanitaire (PNDS, National Health Development Plan) 2016–2020 and the reframed PNDS 2019–2022: poor quality of service delivery and insufficient infrastructure, equipment, human resources, commodity supplies, health financing, health information use, and governance.

Over seven years, USAID IHP will support provinces to increase the delivery of high-quality, integrated primary health care to 30 million people. We are designing our interventions within the country’s existing health systems framework to ensure that we contribute to their meaningful operationalization, especially by including communities and their respective health committees, known as Comités de Développement de l’Aire de Santé (CODESA, Health Area Development Committees), as prime stakeholders of a stronger health system.

1.1. PROGRAMMATIC SCOPE While USAID IHP builds on the integrated service delivery achievements of the former Integrated Health Project Plus (IHPplus), our programmatic scope now contains technical program elements that were implemented under separate mechanisms. USAID IHP includes programming in six different health technical areas: malaria; maternal, neonatal, and child health (MNCH); nutrition; reproductive health and family planning; tuberculosis (TB); and water, sanitation, and hygiene (WASH). All of these technical areas have been part of USAID’s health portfolio in previous years and they have had specific geographic and operational service delivery objectives that sometimes overlapped. By bundling them together into one contracting mechanism, USAID has increased opportunities for consistency in health system strengthening and for synergy in the dissemination and use of strategic health information.

1.2. GEOGRAPHIC SCOPE USAID IHP works across three regional provincial clusters: Eastern Congo, Kasaï, and Katanga, with multiple provinces and zones de santé (ZS, health zones) in each, as shown in Table 1. The Program’s organizational structure reflects such clustering. Our geographic scope includes nine provinces with 178 ZS and thousands of health center catchment areas and integrated community case management (iCCM) sites. In addition, certain activities will take into account the importance of economic corridors.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 1 Table 1: USAID IHP Regions, Provinces, and Zones It is important to understand that these de Santé entities—Divisions Provinciales de Santé (DPS, Region Province Zones de Santé Provincial Health Divisions), ZS, communities, Sud-Kivu 34 health centers, iCCM sites, etc.—are not Eastern Congo equal targets or beneficiaries of the different Tanganyika 11 technical programs that constitute USAID Kasaï-Central 26 IHP. The Program’s assistance is tailored to Kasaï-Oriental 19 Kasaï meet the needs of each ZS and also takes into Lomami 16 consideration their capacities, which can Sankuru 16 include physical facilities and infrastructure, Haut-Katanga 26 staffing and human resources, and special Katanga Haut-Lomami 16 needs such as concentrations of a particular Lualaba 14 infectious disease. It also takes into TOTAL 178 consideration what other projects or donors may be doing in the same ZS.

1.3. PARTNERSHIPS Abt Associates, as the prime contractor, leads a team of two core contract partners: the International Rescue Committee (IRC) and Pathfinder International. We also have six niche contract partners, each of which offers international expertise in specific health program domains combined with experience in innovative solutions for fragile health systems. Our niche partners are Bluesquare, iPlusSolutions, Matchboxology, Mobile Accord/Geopoll, Training Resources Group (TRG), and Viamo.

USAID IHP has multiple partners within the government and public service institutions. The national- level MOH is our key partner, providing overall guidance for the Program. USAID and the MOH have identified the Direction Générale de l’Organisation et de Gestion des Services et des Soins de Santé (DGOGSS, Directorate-General for the Organization and Management of Health Care Services) as the anchor that connects the Program to the MOH. At the provincial level, our key partners are the DPS and the Inspections Provinciale de la Santé (IPS, Provincial Health Inspectorate), while at the ZS level they are the Bureaux Central de la Zone de Santé (BCZS, Office of the Health Zone Team), health centers, and referral health centers. At the community level our institutional partners include CODESA and Cellules d’Animation Communautaire (CAC, Community Outreach Units).

USAID IHP’s efforts require collaboration with various stakeholders, including Breakthrough Action, Challenge TB, and the Integrated HIV/AIDS Project, as well as with other agencies and donors supporting health systems strengthening. To ensure complementarity and leverage resources toward common goals, the Program is coordinating closely with numerous programs funded by USAID and other donors. These include the Global Health Supply Chain-Technical Assistance (GHSC-TA) Project, the MEASURE Evaluation Phase IV project; the Integrated Governance Activity (IGA); the Food for Peace (FFP)-funded Budikadidi project and Development Food Security Activities (DFSA); the Projet de Développement de Système de la Santé (PDSS, Health Care System Development Project); the Programme de Renforcement de l’Offre et Développement de l'Accès aux Soins de Santé (PRODS, Program for Strengthening of Supply and Development of Access to Health Care); and the Strengthening Value Chains (SVC) Activity.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 2 2. PROGRAM MANAGEMENT

2.1. PROGRAM IMPLEMENTATION After the approval of the USAID IHP work plan in December 2018, our expectations for intensifying the pace of Program work were high, although we knew it would be demanding. Our work plan includes 173 distinct activities across our three objectives. Since many of them are scheduled to take place in multiple provinces, there are a total of about 650 individual activities. The majority of these activities are in the Program’s provincial work plans; activity budgets are allocated accordingly.

As the quarter began in January, we faced several external and internal hurdles that slowed our momentum. Following the DRC presidential elections in December, strikes erupted in several cities to pressure the government, creating an uncertain and insecure environment at the beginning of the quarter. The shutdown of the United States Government (USG) impacted the availability of program funds. Additionally, the Program has been working closely with USAID to set up a funding mechanism for providing financial support to provinces and ZS. During August 2018 planning with the nine DPS, and in-depth study of provincial and ZS needs led us to include activities in our work plan to support their routine work (identified in the work plan as technical and financial support for various statutory meetings, coordination activities, monitoring and supervision, coaching, and data collection). However, as of the end of FY2019 Quarter 2, USAID and the Program have not been able to find an appropriate and feasible contractual mechanism for funding these support activities, other than direct funding or in- kind support.

USAID IHP also faced staffing and administrative challenges that hampered implementation efforts. While recruitment of field staff intensified, it was the end of the quarter before we had most of our technical and support staff in the provinces and ready to support technical interventions. In addition, internal administrative hurdles, combined with challenges with banks, slowed transactions and imposed cumbersome procedures for getting implementation funds to our provincial teams. This created unavoidable delays in implementation that would only be resolved in the next quarter.

Nevertheless, USAID IHP staff and provincial offices engaged intensively with partners and counterparts. Our experts shared their experience and provided technical contributions for the continuous development, management, and support of the health system. In line with the MOH planning calendar, and as reported under Objective 1, we prioritized our first large-scale activity—support for the annual operations planning process at the provincial and ZS levels. Under Objective 2, USAID IHP supported a variety of training efforts, while under Objective 3 we launched the Program’s social and behavior change (SBC) approach by developing a human-centered design methodology, engaging community members to generate community-driven communications solutions.

This is still the first year of the Program and the implementation obstacles described above did not prevent us from ensuring that all staff fully understand USAID IHP’s mission and objectives and that they interact with the health system with the sole purpose of strengthening the institutions and communities providing services. We will ramp up activities in the coming quarter to overcome some of the delays.

2.2. PROGRAM STAFFING

Continued to hire and onboard Program staff

The work plan in place through May 2019 calls for USAID IHP to have 240-245 personnel in place when fully staffed. This includes 29 Equipes d’Encadrement Intégré (EEI, Integrated Support Teams), each of

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 3 which will have three staff, for a total of 87 EEI members. The pace of hiring sped up considerably during this reporting period. At the beginning of the quarter on January 1, 2019, USAID IHP had 74 staff hired and working in our Kinshasa, regional, and provincial offices. The elections in January slowed down recruitment, but the rate picked up in February and March. As of the end of the quarter on March 31, 2019, we have 180 personnel on board and working (21 percent female).1 The table in Annex D shows the locations, positions, and sex of the 109 staff hired during the quarter.2 During the coming quarter, the Program will focus on hiring EEI Specialists for all regional and provincial offices.

Provided orientation and training to staff

To ensure that all USAID IHP staff members, at every level and throughout each partner organization, are fully prepared to achieve results, the Program is investing in orientation for new staff and in continuous training for existing staff. Our national and regional experts are responsible for ensuring that every staff member meets and maintains high levels of competence through the life of the Program.

During this quarter, all new hires were oriented on standard operating procedures, safety and security, compliance with regulations, USAID programming guidelines, human resources management, and recruitment and interviews. In addition, within one week of their hire, all Abt staff members completed the company’s mandatory online e-learning programs on general security awareness, freedom from harassment, and Abt’s code of conduct.

From February 19 to 22, 2019, our national Compliance Officer led standard operating procedures training in Kinshasa for all Provincial Operations Managers who had been hired and were working at that time. Administrative and financial staff from the Kinshasa office also attended. The training covered compliance with Abt and USAID rules and regulations, Abt’s accounting system, procurement, administration, human resources management, security, and communications. In March 2019, our national Compliance Officer traveled to Lubumbashi, Kolwezi, and Kamina to assist with start-up in those office. While there, he provided some hands-on training on accounting and compliance.

During this quarter, we worked to ensure that all USAID IHP technical staff complete the online course “Protecting Life in Global Health Assistance and Statutory Abortum Restrictions” and obtain training certificates. The percent of technical staff having done so varies by office, depending on the hiring date of the team. We will continue to ensure staff take the 2019 online training until all personnel required to take this training have completed the course; we expect that all staff will have done so by the end of the coming quarter.

2.3. PROGRAM OPERATIONS Procured office space and worked to resolve related issues The USAID IHP office in Kinshasa is now fully operational. We are co-locating with Breakthrough Action and Impact Malaria, which reduces costs to USAID and facilitates synergy among our three programs. During the second quarter of FY2019, we focused on finalizing our leases and getting offices up and running in all regions and provinces. After signing contracts and opening our offices in Sankuru and

1 Due to attrition, this total (180) is slightly lower than the total number of people hired by the end of FY2019 Quarter 1 (74) plus the total number hired during Quarter 2 (109).

2 As of May 10, 2019, we have hired another 19 staff, for a total of 199.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 4 Kolwezi this quarter, eight of our 10 provincial offices are now open, as shown in Table 2. We identified office space in Uvira and received approval for the office. However, the process was complicated by the fact that the owner of the building lives in the U.S. and had to open a bank account in the DRC so we can pay taxes when we pay rent. We expect the contract to be finalized during the coming quarter. In addition, the USAID IHP office in Kamina has proven to be unsuitable for operations; we are searching for a new location.

Table 2: USAID IHP Regional and Provincial Offices as of March 31, 2019 Office City Status Eastern Region Eastern regional office and Sud-Kivu provincial office Bukavu Office open (co-located) Uvira branch office, reporting to Sud-Kivu provincial Uvira Office location approved; awaiting office final contract with owner Tanganyika provincial office Kalemie Office open Kasaï Region Kasaï regional office and Kasaï-Central provincial office Kananga City Office open (co-located) Kasaï-Oriental provincial office Mbuji Mayi Office open Lomami provincial office Kabinda Office open Sankuru provincial office Lodja Office open Katanga Region Katanga regional office and Haut-Katanga provincial Lubumbashi Office open office (co-located) Haut-Lomami provincial office Kamina Office open but search for new location underway Lualaba provincial office Kolwezi Office open

Procured supplies and equipment

During this quarter, USAID IHP finished equipping and furnishing our Kinshasa office and 10 regional and provincial offices. A few procurements remain outstanding:

Generators for various Program offices. The vendor has been selected and the generators will be delivered during the coming quarter.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 5 Internet service provider. During this quarter, the Program selected a vendor and prepared procurement documentation for submission to USAID.3 In the meantime, our offices are operating through Wi-Fi connections.

Vehicles. During start-up, we received vehicles from previous USAID implementing partners. However, some of them are not in acceptable operating condition and the Program will need to purchase 10 to 15 additional vehicles. One is being donated by the recently closed USAID-funded Maternal Child Survival program (MCSP) project; we are awaiting its delivery. We will issue a procurement for the new vehicles during the coming quarter.

In a further matter, in 2018 six vehicles were transferred to USAID IHP during the handover from the previous USAID IHPplus implementing partner. In November and December 2018, local authorities in Kananga seized two of those cars, claiming that the IHPplus implementing partner owned money to a local vendor. In January 2019, two more vehicles were seized from the Program office in Kananga based on claims from a second vendor. Then, in February 2019, the local tribunal sold two of the vehicles. In mid-March 2019, the U.S. Department of Justice’s Office of Foreign Litigation became involved in the matter. Subsequently, in late March 2019, the U.S. Government filed two lawsuits in Kananga’s High Court. The first suit targeted the four vehicles that were seized, and the second regarded the two cars that had been sold.4

2.4. SECURITY USAID IHP’s approach to security promotes an appropriate and measured response that is based on actual, rather than perceived, threat levels. We use predictive modelling of the security dynamic and plan for activities in coordination with these models so that security measures are escalated or de- escalated as appropriate. The nexus of our approach is to use data collection and evaluation to quantify and qualify physical security risks.

The USAID IHP Security Director co-chairs the DRC Overseas Security Advisory Council (OSAC). This provides excellent security networking opportunities for the USAID IHP security team and for U.S. stakeholders in the DRC. During FY2019 Quarter 2, USAID IHP hired new security officers in Mbuji Mayi and Bukavu, with additional hires underway in the coming quarter. Their presence strengthens our reporting and reaction systems and enables us to provide tailored solutions to specific security challenges. This approach continues to mitigate most security risks so that USAID IHP can continue to deliver support in a safe and secure manner.

Our security team updated the country-wide Security Risk Assessment, identifying 14 extreme risks and four high risks (before mitigation). We continue to update emergency plans in ways that are consistent with organizational growth and information systems and that are adapted to provide a proactive, alert- based system.

General security trends during FY2019 Quarter 2. This reporting period has been marked by relative calm following the election of the new President in January 2019. The numbers of politically

3 We sent procurement documentation to USAID on April 30, 2019. As of the time this report is submitted, we are awaiting approval.

4 On April 1, 2019, the High Court ruled in the U.S. Government’s favor on the first case, and lifted the attachment to the four cars that were seized. As of the time this report was prepared, the USAID IHP team is able to use the cars that were not sold. We are waiting on resolution of the second case regarding the two cars that were sold.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 6 motivated demonstrations and protests diminished significantly after the electoral period.5 Throughout the electoral campaign period the USAID IHP Security Director maintained a close watch on the security situation, collaborating at all points with the Chief of Party (COP) and the senior management team to advise on appropriate and measured responses based on the actual level of threat.

The Program designated January 10, 2019, as a work from home day. Given the result of the Presidential elections and the lack of incidents impacting USAID IHP, we returned to a business as usual stance on January 11, 2019. We continued to maintain a close eye on developments and prepared to shelter in place or evacuate, depending on the security situation.

Challenges continue in certain areas of the country, however. Problems related to freedom of movement continue in conflict areas in the eastern region, while poor infrastructure in the Kasai region, exacerbated further by seasonal rains, also creates difficulties.

Regional trends

 Kinshasa. Following the announcement of presidential election results, Kinshasa remained relatively calm in terms of security incidents during this reporting period. There were several strikes by police and civil servants requesting payment in arrears, and March 5–14, 2019, a strike of weekly paid workers for foreign-owned businesses in the area of Avenue du Commerce. These tended to be isolated and caused only minor disruptions to movements of the USAID IHP team, which were quickly mitigated. The USAID IHP security office continues to monitor for indicators of gathering momentum that could impact the Program in the future.  Kasaï Region. Since last year, the Kamuina Nsapu militia has split between the hawks and the doves. A large element of Kamuina Nsapu has surrendered its weapons. Activists in the area of Kananga have requested integration into the Forces Armées de la République Démocratique du Congo (FARDC, Armed Forces of the DRC). Now the challenge is for the FARDC to dispose of the weapons and reintegrate militia personnel into society, directing them away from armed conflict. In March 2019 there was a significant uptick in unauthorized check points, with report that the FARDC was requesting up to 10,000 Congolese Francs (CDF) to be granted passage. At time this report was written, these demands have been lifted, although they impacted freedom of movement and consideration for transport around Kananga. Illegal check points and human rights abuses tend to encourage the hawkish elements of Kamuina Nsapu. This leads to a cycle of resentment and hostility, which could provoke a resurgence in general violence by the Kamuina Nsapu towards the FARDC. While the checkpoints were in place, it was impossible to drive through the town without being stopped. Program vehicles are generally allowed to pass, but not without a degree of harassment and requests for money, which can cost significant time and fuel until the interaction is finished. The additional mileage on vehicles and fuel consumption while waiting in line for (or avoiding) checkpoints can have an impact on operational expenses of the Program.

 Eastern Region. In Bukavu and Uvira, the National Council for Renewal and Democracy, the Rwandan political opposition in exile, has split into two factions. One of them is moving south

5 Preliminary result of the elections were announced on January 20, 2019, and the new president was inaugurated on January 24, 2019.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 7 into Kalehe territory to exploit new and uncontested territory. Previous “non-attack” behavior is changing to sporadic clashes, resulting in significant population displacement in the area. FARDC operations to dislodge foreign and local armed groups from Uvira and Fizi’s highlands have continued throughout FY2019 Quarter 2. This has had a high impact on travel to the field and between USAID IHP provincial offices in Bukavu and Uvira. In order to mitigate this, we have identified hotspots of militia activity and zoned these areas to include escalating security measures according to the level of risk of encountering road blocks. In addition, we maintain strong information systems and networks so that we can avoid road blocks. Indicators suggest that militia elements are being reinforced by collaborating militias from Nord-Kivu, which ensures continued logistical and personnel support for groups such as Mai Mai Yakatumba. In Tanganyika, Mai Mai factions continued to destabilize the area, with frequent ambushes and attacks on civilians and local residents. The roads to the north of Kalemie that lead to Bendera and those to the west towards Nyunzu see most of the Mai Mai activity in the area of Kalemie. The area north of Kalemie is one of the identified hotspots for militia activity; USAID IHP is prioritizing activities in other areas to the west and south of Kalemie until military operations in the area subside.  Katanga Region. Following the announcement of election results in January 2019, there were some sporadic clashes between demonstrators and police in Lubumbashi. We used USAID IHP’s current alert system to easily avoid affected locations. The area is reasonably calm except for high crime rates in certain quarters such as Kenya and Matsupisha, which may impact staff on a personal level. No incidents were recorded during this reporting period.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 8 3. OBJECTIVE 1

STRENGTHEN HEALTH SYSTEMS, GOVERNANCE, AND LEADERSHIP AT PROVINCIAL, HEALTH ZONE, AND FACILITY LEVELS IN TARGET HEALTH ZONES

Commenced use of Participatory Institutional Capacity Assessment and Learning tool for institutional capacity building of provincial and ZS health divisions

The Program is using the Participatory Institutional Capacity Assessment and Learning (PICAL) tool as the backbone of our institutional strengthening methodology. We will apply the PICAL tool to help DPS and ZS conduct self-assessments, which will enable us to identify institution-level gaps and develop capacity building plans. During FY2019 Q2, USAID IHP developed a schedule and scope of work to carry out institutional assessments of seven DPS and one ZS, as called for in our Year 1 work plan. Haut-Katanga and Lualaba were not targeted for institutional assessments in Year 1 because USAID’s Health Finance and Governance project completed assessments of the DPS in these provinces in 2016 and 2017.

To lay the groundwork for these assessments, the Program held three regional institutional capacity building (ICB) workshops during the quarter—one in each target regions (see section 6.3 for details).

Jean Manasse Jean

Photo: Dr. Nathalie Mulongo (foreground) talks with Dr. Nick-Therese Kayila, Médecin Inspecteur Provincial (Provincial Health Inspector) (right) and facilitator M. Michel Toko (standing) at the ICB and PICAL training for the Haut-Katanga DPS.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 9 Following the workshops, a team of consultants used the PICAL tool to facilitate the first institutional assessment in Sud-Kivu, from March 10 to 23, 2019. The consultants worked closely with a four-person assessment team composed of three staff from the DPS and a fourth assessor from outside the DPS, as called for in the PICAL methodology. The team prepared a detailed analysis of strengths, weaknesses, opportunities, and threats, while also assigning scores to each PICAL dimension. These scores represent a group consensus, which was derived from a thorough discussion of individual scores that had been first assigned by the assessor team. The report includes an intervention plan to address institutional capacity needs.

The ICB assessment in Sud-Kivu represents the first step towards achieving the Program’s expected results in this area. We are on track to meet our targets for PICAL assessments, and will continue our work on this front during the coming quarters.

This activity produced data to measure Indicator 1.1: Annual score derived from PICAL for USG-supported provincial health divisions, which helps track progress toward Result 1.

Provided technical and financial support to DPS for the development of 2019 provincial PAO

USAID IHP is supporting the annual planning process in the Program’s nine target provinces. By the end of the quarter, all nine provinces (100 percent) had developed annual PAO that are aligned with the PNDS 2019–2022 and its budgetary framework. The Comités Provincial de Pilotage du Système de la Santé (CPP-SS, Provincial Health System Steering Committees) in all nine provinces had validated the PAO. These results are significantly above the USAID IHP Year 1 target of 40 percent for the number of provinces to have PAO aligned with the national plan.

The processes were participatory and inclusive. The Program provided technical and financial support for a workshop in each of the nine target provinces where the PAO for the ZS and specialized programs in that province were reviewed, adjusted, and consolidated. We also supported the Sud-Kivu: How the PAO process worked in one province deployment of Encadreurs Nationaux Polyvalents (Multidisciplinary National From January 9 to 12, 2019, the Sud-Kivu DPS, with support Supervisors) to the provinces to deliver from USAID IHP, organized a PAO consolidation workshop. technical assistance for validation of Participants were grouped according to different programs— provincial PAO during CPP-SS meetings. vaccinations; reproductive, maternal, newborn, child, and adolescent health; health information; TB; malaria; HIV; community WASH; and nutrition. Program staff participated in This process needs to be improved for different groups to ensure that USAID IHP support was the next cycles to make it much more appropriately integrated into PAO. During a January 15, 2019, participatory and inclusive. Health system meeting, the DPS presented the provincial PAO in the planning is a multidisciplinary decision- presence of the Provincial Minister of Health. making process and needs a dialogue Next, USAID IHP worked together with other partners to among stakeholders. This means that provide technical and financial support for a regular meeting of planning needs to take into account the the CPP-SS on February 14, 2019. We also supported an social determinants of health and involve extraordinary meeting of the CPP-SS on March 14, 2019, to the population in general, especially the continue the process of integrating and adopting elements that Entités Territoriales Décentralisées had not yet been included in the earlier draft of the DPS’s (Decentralized Territorial Entities), who PAO. are called on to finance the health sector at the local level.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 10

This activity produced data to measure Indicator 1.2: Percent of annual provincial action plans and budgets aligned with national action plans and budgets, which helps track progress toward Result 1.

Provided technical and financial support to ZS for the development of their 2019 PAO

During this quarter, USAID IHP provided technical and/or financial support for the MOH’s 2019 annual planning process in ZS across the nine provinces. By the end of the quarter, all of the Program’s 178 target ZS (100 percent) had annual PAO that aligned with provincial PAO and budgets.

The Program’s technical and/or financial assistance for the ZS planning process included supporting consolidation meetings of the Conseils d’Administration (CA, Administrative Councils) and deployment of Encadreurs Provinciaux Polyvalents (EPP, Multidisciplinary Provincial Supervisors) to provide needed technical assistance to help ZS reframe and validate their PAO during the CA meetings. Various stakeholders in the ZS participated in this process.

In the Kasaï Region, USAID IHP assisted CA in 66 out of 77 target ZS (85.7 percent) with their PAO. Other partners supported the other 11 ZS (14.3 percent). This complementary assistance ensured that all ZS now have 2019 PAO aligned with provincial PAO. In Kasaï-Central, we supported the PAO process in 15 out of 26 ZS; the DPS worked with the other 11 ZS. Gavi supported most of the planning process in Lomami. In Kasaï-Oriental, the Program provided technical and financial support to EPP as they assisted ZS in developing their PAO. We also delivered

technical and financial support to ZS in Sankuru up through the process of holding CA meetings.

In the Katanga Region, several

partners, including USAID IHP, supported Pathfinder Mbondo, Constantin the planning process in the ZS. Our work plan activities were harmonized and Photo: IHP USAID for International incorporated into the PAO in most ZS. In Mme Brigitte Bakambamba, Médecin Chef de Zone (Chief Medical Haut-Katanga, the United Nations Officer) of the Mikalayi ZS explains the PAO process. She is in charge of Children’s Fund (UNICEF) delivered drawing up the PAO for the zone. financing for development of the PAO, while we provided technical and financial support for adoption of the PAO by the CPP-SS. In Haut- Lomami, Gavi provided financial backing and USAID IHP delivered both technical and financial support to ZS for development and consolidation of PAO. We assisted with the planning process in Lualaba as well, where we were the only sponsor of the workshop where the various ZS PAO were presented, validated, and consolidated.

In the Eastern Congo Region, USAID IHP assisted with the operational planning process in all 45 ZS, all of which now have 2019 PAO. Fifteen out of the 45 ZS (33 percent) have already held CA meetings. In Sud-Kivu, by the end of March 2019, all 34 ZS (100 percent) had PAO that integrate USAID IHP activities. However, despite the mobilization of Program funds to organize CA meetings in Sud-Kivu, only 15 of the 34 ZS held meetings to validate their PAO because the DPS could not mobilize sufficient

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 11 funds to deploy administrators in all ZS. Each of these 15 ZS received technical and financial support from a USAID IHP staff member, two DPS experts, and representatives from other partners, such as Deutche Gesellschaft fur Intenationale Zusammenarbeit (GIZ, German Corporation for International Cooperation), the local nongovernmental organization (NGO) ASILI, the Bureau Diocesain des Oeuvres Médicales (Diocesan Office for Medical Charity), and the Agence d’Achat des Performances (Agency for Performance-Based Financing). The Sud-Kivu DPS is continuing to mobilize funds to cover CA meetings in the 19 ZS that have not yet held them.

In Tanganyika, the operational planning process benefited from USAID IHP and Gavi financial and technical support for the development of DPS and ZS PAO. All 11 ZS (100 percent) received support; each produced a valid PAO.

During the PAO meetings, our staff took the opportunity to present the Program, where needed, made brief presentations to the Chef de DPS (Head of the DPS), all the Médecins Chef de Zones (Chief Medical Officers of the ZS), and the coordinators of various programs attached to the DPS. This enabled us to ensure that USAID IHP’s work plan activities are incorporated into the 2019 PAO.

This activity produced data to measure Indicator 1.3: Percentage of health zones with annual action plans and budgets that are aligned with provincial action plans and budgets, which helps track progress toward Result 1.

IR 1.1 ENHANCED CAPACITY TO PLAN, IMPLEMENT, AND MONITOR SERVICES AT PROVINCIAL, HEALTH ZONE, AND FACILITY LEVELS

Conducted needs analysis and planning to develop dashboards to assist DPS and ZS in monitoring performance of provincial health services

Despite the implementation of a computerized Système National d'Information Sanitaire (SNIS, National Health Information System) use of data by the DRC health system remains limited. USAID IHP will strengthen the use of data through the design of performance dashboards for DPS and ZS. These dashboards will provide a data visualization system that will generate quality information for monitoring health system performance and generating quarterly performance reports. The performance dashboards are anchored in the vision of the Sécretariat Général de la Santé (Secretary General of Health) vision for a “cockpit” that will bring together 18 Internet-based strategic dashboards for health system performance monitoring and decision-making.

The Program’s activities in this area during FY2019 Quarter 2 focused on the design and configuration of the performance dashboard. The next step will be to test the dashboard with the MOH team and with USAID IHP to ensure optimal use. From February 18 to 23, 2019, we conducted a needs analysis, including interviewing different stakeholders, as a first step toward the design and implementation of these performance dashboards. The Program also provided technical support to the Sécretariat Général de la Santé to form a technical team to define content and implement the performance monitoring dashboards. During the coming quarter, USAID IHP will train DPS and ZS to use the performance dashboards. The training will improve their capacities to plan, execute, and control services at the provincial, ZS, and health facility levels.

This is a foundational activity that is critical to eventually producing data for Indicator 1.1.1: Percentage of DPS and health zones that have used data to produce their annual plans data analysis, which helps track progress toward IR 1.1.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 12 Supported DPS and ZS to use data analysis in their annual planning processes

USAID IHP is working with DPS in target provinces and with authorities in target ZS to strengthen their planning by ensuring that they follow MOH guidance to incorporate data analysis. During this quarter, all nine target DPS and all 178 target ZS produced PAO based on an analysis of provincial or ZS health data contained in the ZS 2018 annual reports. This enabled them to conduct situational analyses to identify bottlenecks and problems and prioritize interventions. The ZS started the planning process by analyzing data from the District Health Information System 2 (DHIS2) and looking at the data presented during CA meetings. Challenges stemmed from concerns about the quality and completeness of the data, and from disruptions caused by poor or lacking Internet connectivity. Other problems arose because of weak capacity on the part of some officials responsible for analyzing the DHIS2 data. The performance dashboard USAID IHP is working on with the MOH will help alleviate many of these problems.

This activity produced data to measure Indicator 1.1.1: Percentage of DPS and health zones that have used data to produce their annual plans using data analysis, which helps track progress toward IR 1.1.

IR 1.2 IMPROVED TRANSPARENCY AND OVERSIGHT IN HEALTH SERVICE FINANCING AND ADMINISTRATION AT PROVINCIAL, HEALTH ZONE, FACILITY, AND COMMUNITY LEVELS

Initiated efforts to integrate local mobile network operators into the fraud and complaints hotline

USAID IHP will support MOH efforts to conduct inspections to address fraud and corruption. During this quarter, the Program began work on integrating local mobile network operators into a fraud and complaints hotline that will give the MOH a system for receiving alerts and complaints. The hotline will enable the MOH to increase the number of alerts so it can target its inspection resources where there is the greatest need and engage the population in surveillance and monitoring. Although the hotline is not scheduled for launch until the end of USAID IHP Year 2, the complex business environment in DRC means that planning for the hotline and integration of the technical infrastructure requires a long set-up period. During this quarter, the Program began back-end negotiations with mobile network operators and providing technical support to develop a platform that will ensure the hotline will be ready to launch as scheduled.

This is a foundational activity that is critical to eventually producing data for Indicator 1.2.4: Number of tickets on the fraud and complaints hotline issue tracker, which helps track progress toward IR 1.2.

IR 1.3 STRENGTHENED CAPACITY OF COMMUNITY SERVICE ORGANIZATIONS AND COMMUNITY STRUCTURES TO PROVIDE HEALTH SYSTEM OVERSIGHT

Started work to support community service organizations and CODESA through our community engagement interventions

USAID IHP is committed to supporting the MOH's strategy for community engagement, which is designed to involve the population, particularly women, in identifying their own needs and making decisions about health care services. One of our objectives is to help community service organizations (CSOs) and CODESA use accountability tools such as scorecards and audit reports to monitor and demand improvements in financial management and service delivery.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 13 During this reporting period, the Program commenced work in this area during a March 21, 2019, meeting with MOH representatives. The USAID IHP Behavior Change Advisor described the steps we will follow to develop a strategy for community engagement. He also shared information about potential resources, tools, and approaches—particularly the community dashboard—that can help the MOH make decisions about its own community engagement strategy and tools. Following the presentation, USAID IHP and the MOH agreed on next steps, including two workshops to be facilitated by the Program in May 2019. These activities will support the implementation of the MOH’s Community Strategic Plan.

In the Kasaï Region, community engagement teams are preparing tools and documentation to start the process in the next quarter. Lomami organized a mini-campaign on family planning as part of the Healthy Family Campaign (see IR 3.1); this indirectly stimulated CSOs even though there has not yet been any institutional or financial capacity building.

In the Katanga Region, the Program supported DPS activities targeting CODESA. The purpose of these activities was to make initial contacts and prepare terms of reference to evaluate CODESA functionality and to train CODESA and CAC personnel. Our team designed a data collection template for evaluating CODESA functionality, incorporating contributions from each province. We are awaiting validation of the template by the central-level MOH. In the Eastern Congo region, we are supporting the DPS to develop and finalize a scale for evaluating CODESA functionality.

This is a foundational activity that is critical to eventually producing data for Indicator 1.3.2: Number and percentage of supported CSOs/CODESA using accountability tools (such as scorecards and audit reports) to monitor and/or demand improvement of financial management and/or service delivery, which helps track progress toward Intermediate Result 1.3.

IR 1.4 IMPROVED EFFECTIVENESS OF STAKEHOLDER COORDINATION AT THE PROVINCIAL AND HEALTH ZONE LEVELS

Aligned with and supported the implementation of the contrat unique process at the DPS level

Once a DPS has developed and harmonized its PAO and has a clear set of activities for the year, the next step is to develop a contrat unique (single contract) to rationalize resources among all technical and financial partners (TFPs). In each province, the contrat unique process is led by one organization or project designated as the lead TFP. This leader helps organize meetings and represents all partners. USAID IHP is the leader in seven of target nine provinces. In Haut-Katanga and Sud-Kivu, other partners are the lead. During this quarter, we worked with the CPP-SS in all target provinces to engage stakeholders in the contrat unique process. In the Kasaï Region, by the end of FY2019 Quarter 2, the contrat unique process was underway in Kasaï-Central and Lomami, with cost analysis and stakeholder mapping ongoing. In Kasaï-Central, although the process has begun, challenges with timing and with USAID IHP’s own operations prevented it from being finalized.

In the Katanga Region, the Lualaba DPS and all TFPs signed the contrat unique on February 16, 2019, with technical and financial support from USAID IHP as the lead TFP. The process is in its final stages in

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 14 Haut-Katanga and Haut-Lomami, where the contract awaits signature by the main stakeholders at a CPP-SS plenary session.

In the Eastern Congo Region, Sud-Kivu adopted its PAO and all partners approved the contrat unique at the end of a special CPP-SS meeting on March 14, 2019. USAID IHP is planning to support the Tanganyika CPP-SS technical secretariat meeting and a CPP-SS workshop once they take place.

This is a foundational activity that is critical to eventually producing data for Indicator 1.4.1: Percent of stakeholders who agree that their views are reflected in planning/policy processes, which helps track progress toward IR 1.4.

Coordinated USAID IHP activities with those of other programs at the national, regional, and provincial levels

Within the framework of collaboration, USAID IHP organized several meetings with other implementing partners.

 PDSS. During a meeting in Kinshasa, USAID IHP and PDSS shared information about the scope of our respective support for ZS and DPS. Our staff then participated in a joint USAID IHP and PDSS mission to Haut-Katanga and Lualaba from March 11 through 15, 2019. The key goal of this mission was to better understand ways we can collaborate with PDSS to harmonize interventions and avoid duplication of support on the ground.  PRODS. In the Kasaï Region, USAID IHP participated in the launch of PRODS activities in Kasaï-Central, Kasaï-Oriental, and Lomami. This synergy with PRODS will contribute to efficiency and to improvements in health care for the region’s population.  IGA. Our Kinshasa team met with the national IGA team and our provincial teams liaised with IGA province teams, resulting in synergy between our two programs. We have shared various program documents and prepared a formal collaboration document. Our Kasaï Regional Director and Kasaï-Central Provincial Director also participated in various coordination meetings and working groups in Kananga, while technical staff joined meetings of cooperative frameworks for health and WASH in the province. Our staff in Kasaï-Central also participated in humanitarian coordination meetings under the leadership of the United Nations Office for the Coordination of Humanitarian Affairs.

This is a foundational activity that is critical to eventually producing data for Indicator 1.4.2: Percent of coalitions or networks strengthened to fulfill their mandate as a result of USG assistance, which helps track progress toward IR 1.4.

IR 1.5 IMPROVED DISEASE SURVEILLANCE AND STRATEGIC INFORMATION GATHERING AND USE

Developed dashboards and organized training on use of data and dashboards

USAID IHP carried out the following activities during the quarter, all aimed at significantly improving access to and use of health data across the Program’s 178 target ZS.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 15  Improved and deployed the Carte Sanitaire (digital health map), in conjunction with the World Bank-financed PDSS. We deployed the dashboard management application in DHIS2 of the SNIS to enable the Carte Sanitaire to import data from the SNIS.  Developed the template for an application that will be used to enter data for the service delivery mapping survey (see IR 2.1). The data gathered through the service delivery mapping survey will be incorporated into the Carte Sanitaire. This will allow viewers to see a map of health facilities, drill down onto any facility, and see its characteristics.  Developed a DPS-level data completeness dashboard, which will enable any actor in USAID IHP’s target regions to understand whether data is actually reported (including which data and where) in the SNIS as expected. The first version will be presented to the MOH in early May 2019.  Provided technical support for a February 25, 2019, meeting convened by the Secretary General for Health during which he invited different MOH directorates and stakeholders to actively support his vision of a "cockpit" of 18 strategic Internet-based dashboards.  Developed a training plan for DPS to strengthen their capacity to use DHIS2 and to use real- time data dashboards in routine management tasks.

This is a foundational activity that is critical to eventually producing data for Indicator 1.5.2: Percentage of targeted DPS, ECZS, and FOSA teams that use real-time data dashboards in routine management tasks, which helps track progress toward IR 1.5.

IR 1.6 IMPROVED MANAGEMENT AND MOTIVATION OF HUMAN RESOURCES FOR HEALTH No activities were carried out under this intermediate result during this quarter.

IR 1.7 INCREASED AVAILABILITY OF ESSENTIAL COMMODITIES AT PROVINCIAL, HEALTH ZONE, FACILITY, AND COMMUNITY LEVELS Under IR 1.7, USAID IHP’s role is to address challenges over the last third of the USG-supported supply chain for drugs and essential products (the “last mile”). Currently, there are problems with product availability at multiple levels: upstream, due to arrival delays or lack of availability of products to be sent from the national level down to regional distribution centers (RDCs) and ZS; and downstream, from the ZS to the health facilities (the last mile). During this quarter, the Program addressed supply chain challenges through three key activities.

Initiated efforts to make supply chain management tools available at the ZS and health facility levels

USAID IHP has committed to assisting health facilities in target ZS to monitor six tracer products. These products have been chosen as samples, or proxies, to represent the availability of a larger package of essential medicines that USAID is providing in the DRC. As shown in Table 3, approximately one-half of service delivery points in target ZS experienced a stockout during FY2019 Quarter 2.

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Table 3: Number and Percentage of USG-Assisted Service Delivery Points that Experienced a Stockout of Tracer Commodities for at Least One Month during FY2019 Quarter 2 Region Total Number of Health Facilities Experiencing a Stockout during the Health Facilities Quarter Number Percent Output 5,971 2,568 52.4% Kasaï 2,596 1,494 57.6% Katanga 2,075 934 45.0% Eastern Congo 1,300 703 54.1% Source: DHIS2 Tracer commodities: Medroxyprogesterone acetate (Depo-Provera, 150 mg injectable); ORS; Oxytocin (10 international units [IU] injectable); Iron folate; Artemisinin-based combination therapy (ACT, 1-5 years) (250mg); and Rifampicin- Izoniazid 150mg+75mg Tablet

To address the problem of stock-outs, USAID IHP worked at both the upstream and downstream levels.

Upstream. We participated in a supply chain meeting with USAID and GHSC-TA on February 14, 2019, to discuss the status of the RDCs’ receipt of essential medicines and medical consumables ordered by USAID. As of the date of this meeting, RDCs had received only 28 percent of the outstanding orders—far below the 92 percent they should have received. During the first quarter of 2019, ZS received supplies from the RDCs as follows:  Kasaï Region. Eighteen out of 77 ZS (23 percent) only received anti-malarials. Sankuru is the only province in the Kasaï Region which, in addition to anti-malarials, received first-line anti- tuberculosis drugs (in 12 out of 16 ZS, or 75 percent). Two out of 16 ZS in Sankuru received essential medicines (12.5 percent) and one out of the 16 ZS (6 percent) received family planning products.  Katanga Region. Twenty-one out of 77 ZS (27 percent) received anti-malarials. In Haut- Lomami, two ZS received additional essential and generic drugs as well.  Eastern Congo Region. In Sud-Kivu, all 32 ZS (100 percent) received anti-malarials; 25 out of 32 (78 percent) also received family planning products. In Tanganyika, 7 out of 11 ZS (64 percent) received anti-malarials only.

Downstream. Health facilities’ reporting of logistics information to the ZS does not function well— facilities’ inaccurate and delayed reporting of logistic information hinders informed and timely decisions at different levels of the supply chain. With such a lack of information, good coordination is needed to make correct allocation decisions that will lead to a more rational and equitable distribution of medicines and family planning supplies to ZS and their health facilities. In addition to participating in a variety of exchanges that will contribute to more effective stakeholder coordination, USAID IHP is tackling downstream problems in other ways:

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 17  Putting in place Provincial Supply Chain Officers (recruited at the end of this quarter6) to organize training and supportive supervision for ZS staff. The ZS staff will in turn train their own health facility staff to use appropriate supply chain management tools.  Helping improve the InfoMed DRC portal operated by the Programme National d’Approvisionnement en Medicaments (PNAM, National Drug Supply Program), as described below.  Introducing a community Informed Push Distribution Model (IPM), as described below.

This is a foundational activity that is critical to eventually producing data for Indicator 1.7.1: Number and percentage of USG-assisted service delivery points that experience a stock-out of selected tracer commodities at any time during the reporting period, which helps track progress toward IR 1.7.

Introduced cost recovery mechanism for essential medicines funded by USAID

USAID has reduced the list of essential and generic drugs and medical consumables to be supplied and distributed through GHSC-TA and USAID IHP from around 100 products to around 20. USAID also agreed with MOH to allow these supplies to be included in the cost recovery mechanism that the MOH applies for similar products.

Although a large number of health facilities (45 percent, according to the Evaluation des Prestations des Services de Soins de Santé [Evaluation of Health Care Service Delivery] 2017-2018) apply a flat fee per disease episode, several variants of this scheme exist. Unfortunately, most are poorly documented. USAID IHP will help the MOH propose a simple, flat fee-based cost recovery model, based on evidence available in the literature as well as on past and current experiences in the DRC.

During this quarter, USAID IHP’s Health Financing Consultant met with different actors and MOH experts, took stock of available resources, and identified the different challenges the MOH may face. He proposed to establish a consensus around an approach that is easily replicable and adaptable to different implementation contexts in the three USAID IHP regions. Building on standard practice in the MOH, we proposed a clear normative framework for applying flat-rate pricing and a simple tool to calculate the flat rate to be applied in each context, which would be based on a health facility’s monthly revenue and expenses.

During the next quarter, we will use available data to finalize the tool and create a user guide. The next steps will be to review and validate both the tool and the process at the MOH level, followed by making the tool available to provinces and ZS.

This activity helps realize progress toward IR 1.7.

6 All nine Provincial Supply Chain Officers started work during the first week of April 2019. As of the time this report was submitted, they had all been oriented and trained and were working with the ZS and health facilities.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 18 Participated in implementing the Logistics Information System roadmap

The quality of logistical information reported from health facilities to ZS is a challenge. The MOH has set a target for at least 80 percent of drug inventory management reports to be reported in the Logistics Management Information System (LMIS) each quarter. Table 4 shows how close the three regions are in reaching that target. Province-level rates range from 71 percent in Haut-Katanga to 80.8 percent in Kasaï-Oriental. Current reporting reflects paper reports, since the electronic form of the LMIS (eLMIS) is not yet operational. USAID IHP will work to help provinces reach the target of 80 percent by the end of September 2019. During this quarter, USAID IHP carried Table 4: Percentage of USAID IHP out an in-depth analysis of the architecture of the new LMIS target ZS with an LMIS Reporting to support a new function that will better evaluate data Completeness* Rate Greater Than completeness. 95 Percent Percent Region In addition, we are working with the MOH to help it choose Completed technical solutions for ensuring that the LMIS (and eventually, Katanga 72 the eLMIS) takes into account the needs of the supply chain at the last mile. PNAM developed and initiated a plan for Kasaï 76 LMIS operationalization in February 2019. USAID IHP is Eastern Congo 73 committed to providing technical and financial support for Source: DHIS2, March 31, 2019 implementation of this plan, as are other partners such as GHSC-TA, UNFPA and the Global Fund. *Completeness: The number of reports submitted out of the total number that should be summited. One of USAID IHP’s roles is to support PNAM’s launch of the InfoMed DRC LMIS portal. This solution, built on DHIS2, is expected to help resolve logistics information problems. The official InfoMED launch took place May 13. The next steps are training of trainers at the national level, rolling out InfoMED in the provinces, and training Equipe Cadre Provinciale (Provincial Management Team) and Equipe Cadre de la Zone de Santé (ECZS, Health Zone Management Team) staff. In the meantime, the Program is not yet able to use InfoMED. This poses problems because we are relying on the use of this tool for a large part of our strategy for logistics information management, which is the heart of efforts to prevent stock-outs.

Until InfoMED is fully operational at the BCZS level, the Program’s Supply Chain and M&E staff are using Excel to compile and analyze logistics data from various sources, including DHIS2. Once ECZS use InfoMED correctly and all necessary data can be made available, we will stop conducting analyses with Excel.

During this quarter, USAID IHP’s contribution to this effort was technical in nature. In the coming quarters, we will support the MOH by training ZS staff on the correct use of the InfoMed DRC tool; printing inventory management tools that are compliant with the LMIS manual recently updated by PNAM; and distributing these tools to health facilities in target ZS.

This is a foundational activity that is critical to eventually producing data for Indicator 1.7.2: Percent of USG-supported health zones with LMIS reporting rates > 95 percent, which helps track progress toward IR 1.7.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 19 Conducted rapid assessments of the supply chain at the ZS and health facility levels and prepared to provide financial support to ZS to transport medicines and manage the supply chain

USAID IHP will contribute to the costs of transporting products from ZS pharmacies to health facilities. Currently, providers at health facilities initiate drug requisitions, deciding on the quantities of products to order, the dates for pick up at the ZS, and the mode of transport to the health facility. Only occasionally—at the request of technical partners or the DPS—do the ZS makes distribution plans for specific products. This is typically done in anticipation of mass campaigns or to rationalize stocks at the ZS level.

USAID IHP intends to reduce transport costs while improving logistics information reporting and ensuring product availability at service delivery points. To do this, we will use a community IPM approach that is structured around a close collaboration between the community, the Models for product distribution ZS staff, and health providers. This approach is based on consolidated There are two classic models for product distribution distribution plans developed by the ZS,  Pull model: Beneficiaries (in this case BCZS and health reliable information on stock status, and facilities) decide which items to order and in which rational distribution accomplished by quantities. They also ensure transport. The beneficiaries pooling deliveries through predetermined play the active role. distribution axes.  Push model: Suppliers (in this case RDCs and ZS) decide which items to order and in which quantities. They send Three to six ZS per province will start the products to beneficiaries based on quality logistical this approach during the next quarter. We information (as with an IPM) or based on adjusted will organize logistics design workshops in requisitions from beneficiaries. The suppliers play the active selected ZS, work with DPS to identify role. the best ways to implement the The community IPM approach that USAID IHP will test community IPM approach, and ensure redistributes the roles. The ECZS will play a more active effective monitoring and evaluation (M&E) role in making decisions about resupplying health centers, and documentation. based on accurate logistics information that is compiled and analyzed in a timely manner to enable rational and judicious USAID IHP will implement the community logistics decisions. The community will also play a IPM approach in 40 out of 178 target ZS supplementary role in managing medications and ensuring (22 percent) in the regions and ZS listed transport, together with the BCZS and service providers. This approach will allow service providers to concentrate below. Budgeted distribution plans will be on managing products within health facilities and on treating available from July 2019 onwards. illness.  Kasaï Region. Kasaï-Oriental (4 ZS), Kasaï-Central (6 ZS), Sankuru (3 ZS ) Lomami (3 ZS)  Katanga Region. Haut-Katanga (6 ZS), Lualaba (5 ZS), Haut-Lomami (4 ZS)  Eastern Congo Region. Sud-Kivu (6 ZS), Tanganyika (3 ZS)

This is a foundational activity that is critical to eventually producing data for Indicator 1.7.3: Percent of supported provinces and ZS with a documented and budgeted distribution plan, which helps track progress toward IR 1.7.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 20 IR 1.8 STRENGTHENED COLLABORATION BETWEEN CENTRAL AND DECENTRALIZED LEVELS THROUGH SHARING OF BEST PRACTICES AND CONTRIBUTIONS TO POLICY DIALOGUE

Participated in Comité National de Pilotage du Système de la Santé technical committee meetings

USAID IHP is committed to supporting collaboration among different levels of the health system in the DRC. As part of this process, we participate actively in various meetings and events of the Comité National de Pilotage du Système de la Santé (CNP-SS, National Health System Steering Committee). During this quarter, three of these consensus-building forums were held with Program assistance, compared to a Year 1 target of zero.

Firstly, together with other technical partners, we contributed to strengthening the management and coordination structure of the health system by supporting a February 28, 2019, retreat in Kinshasa aimed at revitalizing the CNP-SS. The purposes of the retreat were to discuss CNP-SS organization and functions, confirm the list of members of the CNP-SS technical committees, and validate the CNP-SS committees’ work plans and priority activities for 2019. USAID IHP staff were appointed as members of the CNP-SS Health Financing Committee (our Health System Strengthening [HSS] Advisor is permanent member), Governance Committee (our Director of Service Delivery is permanent member and our HSS Advisor is a partial member), and Health Services Delivery Committee (our Director of Service Delivery is permanent member).

On March 29, 2019, USAID IHP provided financial support for two technical committee meetings held on the premises of the MOH Direction d’Etude et Planification (DEP, Directorate of Planning and Study) We attended and provided technical support for the first 2019 meeting of the CNP-SS Health Financing Committee, where attendees reviewed the year’s activities and identified the subgroups responsible for each activity. The Program’s budgetary and programmatic contributions were among the topics of discussion. We also provided financial support for a Governance Committee meeting that was held at the same time as the Health Financing Committee meeting.

This activity produced data to measure Indicator 1.8.1: Number of consensus-building forums (multi-party, civil/security sector, and/or civil/political) held with USG assistance, which helps track progress toward IR 1.8.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 21 4. OBJECTIVE 2

INCREASE ACCESS TO QUALITY, INTEGRATED HEALTH SERVICES IN TARGET HEALTH ZONES

Ensured the provision of family planning commodities in four provinces

During FY2019 Quarter 2, USAID IHP ensured the availability of family planning commodities for health facilities in four target provinces:  Kasaï-Central (seven ZS: Bilomba, Luiza, Dibaya, Lubondaie, Yangala, Ndekesha, Luambo)  Kasaï-Oriental: (two ZS: Mpokolo and Dibindi)  Lomami: (six ZS: Mwene Ditu, Kalenda, Kanda Kanda, Luputa, Kamiji, and Wikong)  Sud-Kivu: (two ZS: Kadutu and Uvira)

USAID IHP worked with PNAM, USAID, and GHSC-TA to select ZS for this intervention. All partners approved the distribution plan for generic essential drugs and FP commodities in 78 ZS that had been previously been supported under IHPplus. The 17 ZS that received supplies during this reporting period were selected based on the availability of FP commodities in the RDCs and on the needs expressed by the ZS.

The commodities included cycle beads, female condoms, five-year implants (Jadelle), combined oral contraceptives (Microgynon), progestogen-only contraceptives (Microlut), medroxyprogesterone acetate (DMPA), and subcutaneous DMPA (DMPA-SC).

This activity takes place in conjunction with training for clinical providers and community providers, as described further under IR 2.2.

This activity produced data to measure Indicator 2.2: Couple years of protection in USG- supported programs, which helps track progress toward Result 2.

Equipped health facilities with water filters and cups to allow direct observation of adherence to intermittent preventive treatment in pregnant women

The Programme National de Lutte contre le Paludisme (PNLP, National Program to Combat Malaria) recommends supervised use of sulfadoxine/pyrimethamine (S/P) by pregnant women during antenatal care (ANC) consultations. However, due to the absence of appropriate materials and equipment, women following this recommendation often cannot be supervised in health facilities. To help remedy this problem in Tanganyika, during FY2019 Quarter 2 USAID IHP provided 16 health facilities in the Kalemie ZS with supplies—16 water filters and 114 cups—that will facilitate direct observation of adherence to intermittent preventive treatment (IPT) of pregnant women. We purchased the supplies in collaboration with provincial coordinators for the PNLP and the Programme National de Santé de Reproduction (PNSR, National Program for Reproductive Health), who handled distribution. The cups are reusable. The health facilities have basins to facilitate cleaning; they will clean the cups with soap before each use for antenatal care visits. We will organize supervisory visits to verify proper cleaning and provide assistance if there are gaps in cleaning the cups.

In the coming quarters, we will continue this activity in Haut-Katanga, Sankuru, and Sud-Kivu. We selected these provinces based on their low coverage of IPTp.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 22 This activity produced data to measure Indicator 2.4: Percent of pregnant women who received doses of S/P for IPT during ANC visits, which helps track progress toward Result 2.

IR 2.1 INCREASED AVAILABILITY OF QUALITY, INTEGRATED FACILITY-BASED HEALTH SERVICES

Developed and pre-tested a questionnaire for a service delivery mapping survey

In late January 2019, USAID IHP produced the first version of a document describing existing data systems in the DRC. This document is contributing to the Program’s data systems strategy, which is currently under development.

On February 11, 2019, USAID IHP digitized the first version of a questionnaire for the service delivery mapping survey, a detailed mapping exercise of partners, interventions, and intervention types covering USAID IHP program elements. On February 20 and 21, 2019, our team’s Health Data Systems Expert trained 11 Program staff on the use of the digitized questionnaire. We then conducted a pre-test of the questionnaire in the Kasa-Vubu ZS in Kinshasa on February 27, 2019, to identify the parts of the questionnaire that need to be improved. In coming quarter, USAID IHP will:  Revise the questionnaire based on feedback from USAID  Obtain MOH approval of the questionnaire  Digitize the final version of the MOH-validated service delivery mapping survey questionnaire  Conduct a second pre-test in Kinshasa and train the national trainers  Set up and configure the digitized questionnaire on android tablets  Deploy a team in the nine target DPS and 178 target ZS to conduct the service delivery mapping survey

This activity helps realize progress toward IR 2.1.

Carried out preliminary analysis aimed at increasing the percentage of pregnant women attending at least one ANC visit with a skilled provider

Although USAID IHP has not yet started activities aimed at increasing the number of women attending ANC visits, in an effort to avoid duplication of effort, we have assessed efforts underway by other implementing partners. For example, in Tanganyika, UNFPA built and equipped a maternity hospital in the Mushaba aire de santé, while Cooperazione Internazionale (COOPI, Cooperation International, an independent Italian NGO) trained ANC providers, provided subsidies for maternal and child health, and supplied equipment such as registers and scales.

With a better idea of other partners’ contributions, USAID IHP will initiate activities in a well-informed manner during the coming quarter. The project will deliver training on basic emergency obstetric and neonatal care (known in the DRC as soins obstétrico-néonatal d’urgence de base, or SONU B), post- abortion care, and maternal death surveillance and response. Our goal is to train 40 DPS staff—10 each from Haut-Lomami, Kasaï-Oriental, Lualaba, and Tanganyika.

In addition, the Program will distribute and raise awareness about norms and guidelines for maternal, neonatal, child, and adolescent health. The MOH, with support from its partners, has reproduced standards and guidelines for integrated interventions. These documents are stored in a depot at the PNSR office in Kinshasa, however, and are not available in the ZS where they are to be used. USAID IHP will ensure the transport and distribution of these documents within the ZS.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 23 This is a foundational activity that is critical to eventually producing data for Indicator 2.1.2: Percentage of pregnant women attending at least one antenatal care visit with a skilled provider from USG-supported health facilities, which helps track progress toward IR 2.1.

Provided technical support for training on basic obstetric care and SONU B

USAID IHP and the Programme National de Santé de Reproduction (PNSR, National Program for Reproductive Health) provided technical support to the Lomami DPS for a UNICEF-financed training for service providers on basic obstetric care and the seven aspects of SONU B. The training, which was held February 20–25, 2019, was delivered to Lomami DPS officials from the Kabinda, Makota, and Kamiji ZS. Through careful coordination with partners such as UNICEF, the Program will ensure that efforts are leveraged but not duplicated. This includes making sure that the Lomami DPS officials who received UNICEF-financed SONU B training do not also participate in our later training on the same topic.

This is a foundational activity that is critical to eventually producing data for Indicator 2.1.3: Percentage of deliveries with a skilled birth attendant in USG-supported facilities, which helps track progress toward IR 2.1.

Provided financial support for training on neonatal resuscitation

From March 11–14, 2019, USAID IHP provided financial support for a training-of- trainers program on neonatal resuscitation. This program, organized by the MOH training directorate in collaboration with Kinshasa University’s Hospital and the Church of the Latter-day Saints, was delivered to 50 national and provincial officials (29 women and 21 men), including 12 from seven USAID IHP- supported provinces (Haut-Katanga, Haut- Lomami, Kasaï-Oriental, Lualaba, Sankuru, Sud-Kivu, and Tanganyika). Three USAID

International Pathfinder Bapura, Jacqueline Photo: IHP for USAID IHP staff were also among the trainees. A mentor observes trainee Jacqueline Bapura, of USAID IHP, who Led by pediatrician-trainers from the resuscitates a newborn using an ambu bag—a concrete use of the Church of the Latter-day Saints, the low-dose, high-frequency approach: “Little theoretical lessons, lot of practice.” Marie-Noelle Dikuta Mawete, Chief Medical Officer at the training was based on the second edition Medical Technical Institute, takes notes. of “Helping the Baby Breathe,” which includes several important updates and improvements consistent with the International Liaison Committee on Resuscitation Consensus on Scientific and Treatment Recommendations 2015 and the World Health Organization (WHO) Guidelines on Basic Resuscitation in Newborns 2012. To support this training, the Church of the Latter Day Saints donated equipment to 700 health facilities. Donated equipment included Baby Nathalie mannequins, ambu bags, suctions, stethoscopes, and posters on helping infants breathe.

This is a foundational activity that is critical to eventually producing data for Indicator 2.1.5: Number of newborns not breathing at birth who were resuscitated in USG- supported programs, which helps track progress toward IR 2.1.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 24 Contributed to the costs of operating the cold chain to protect vaccine viability

The Programme Elargi de Vaccination (PEV, Expanded Program on Immunization) is responsible for ensuring that children 0-11 months and pregnant women have access to immunization services. However, it is challenging for the PEV to ensure that quality vaccines are available in health facilities and at its own branches. USAID IHP is committed to helping overcome this challenge by contributing to the costs of operating the cold chain that protects vaccine viability. During the January to March 2019 period, USAID IHP provided the PEV branch in Mbuji Mayi with 684 liters of fuel to operate its . This branch office serves health facilities in the Kasaï-Oriental and Lomami provinces.

This is a foundational activity that is critical to eventually producing data for Indicator 9: Number of children less than 12 months of age who received three doses of pentavalent vaccine and Indicator 2.1.9: Drop-out rate in DTP-HepB-Hib3 among children less than 12 months of age, which help track progress toward IR 2.1.

Established a framework for collaboration with Food for Peace-funded programs on nutrition and WASH

During this quarter, USAID IHP conducted field missions to Kasaï-Oriental and Sud-Kivu to meet with Food for Peace-funded programs and establish a framework for collaboration and cooperation.

Kasaï-Oriental. USAID IHP technical staff met with the Catholic Relief Services (CRS)-managed Budikadidi Project in Kinshasa on January 18, 2019, to discuss areas of convergence and synergy. This meeting was followed by a mission to Mbuji-Mayi and to the Kasansa ZS from January 23 through 30, 2019. During this mission, USAID IHP and Budikadidi met with representatives of the DPS Bureau d’Appui Technique (Technical Support Bureau) and WASH Bureau, as well as with the Provincial Committee for the Programme National de Nutrition (PRONANUT). Together with the DPS and Budikadidi, our national and provincial staff visited the Kasansa ZS to exchange information with the BCZS, two aires de santé, health centers, the Lukalaba maternity health center, and mamas lumière and care groups in the community.7

Sud-Kivu. During a March 17–26, 2019, visit to Sud-Kivu, USAID IHP met with DFSA (implemented by Mercy Corps and Food for the Hungry) to discuss nutrition and WASH activities. Together with these other implementing partners, our national, regional, and provincial staff met with the Chef de DPS and his team to plan visits to the Katana ZS, where Mercy Corps manages DFSA, and the Walungu ZS, where Food for the Hungry manages DFSA. We discussed DFSA activities and identified points of convergence and areas for consultation. Our team then travelled with DPS and PRONANUT officials to the Katana ZS to visit the Mercy Corps branch office, health facilities, the ECZS, care groups, water committees and water sources, and the CAC in the Kabushwa aire de santé. USAID IHP and the DPS team also visited the Walungu ZS, where we met with the BCZS, nurses at the Bideka health center, and care group members in the Bideka aire de santé.

7 Mamas lumière are women trained and supervised to conduct outreach. Each one reaches out to 14 households in her community (plus her own). Her role includes conducting monthly household visits to discuss topics such as preparation of Pablum (mush), cleanliness and hygiene, prenatal consultations, and handwashing. Care groups include 10 to 15 mamas lumière and a promoter who come together to share experiences and submit their activity reports.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 25 In both Kasaï-Oriental and Sud-Kivu, our missions enabled us to inventory the areas covered by the Food for Peace programs so we could identify opportunities for collaboration and synergy, identify possible areas of overlap, and look for gaps in the management of nutrition and WASH interventions. In Community Action for WASH both provinces, our role will be more clinical and USAID IHP will start by encouraging target operational, while Budikadidi and DFSA will focus on villages to take community ownership of community interventions. USAID IHP’s role will include water points and latrines. We will apply the the following: widely used Action Research approach, which helps communities engage in reflection and  WASH. We will finance water drilling in the identify and follow concrete actions to ensure Kasansa ZS in Kasaï-Oriental to complement sustainable and responsive solutions to their Budikadidi activities. We will also finance own concerns. Our first step will be an rehabilitation, extension, and implementation of organizational assessment of each village or water conveyances or mini-networks in the community structure. This will lead to the creation of a capacity building plan. Katana ZS in Sud-Kivu to complement Mercy Corps-managed DFSA work. In both locations, our goal will be to bring water points closer to communities to increase usage while also reducing the risks of violence against women when they have to travel far to fetch water. We will provide technical expertise to help communities build hygienic, quality, sustainable family latrines (see text box).  Nutrition. USAID IHP will train service providers on preschool consultations; infant (0–24 months) and young child feeding; provision of Vitamin A in health facilities; and proper use of family planning commodities and management tools such as preschool consultation forms, integrated management of childhood illness forms, and mid-upper arm circumference (MUAC) ribbons. This is a foundational activity that is critical to eventually producing data for Indicator 2.1.10: Number of individuals receiving nutrition-related professional training through USG-supported nutrition programs, Indicator 2.1.12: Number of children under two (0-23 months) reached with community-level nutrition interventions through USG- supported programs, and Indicator 2.1.13: Number of pregnant women reached with nutrition interventions through USG-supported programs, which help track progress toward IR 2.1.

Briefed PNLP on USAID IHP’s malaria work plan activities

USAID IHP organized a briefing January 20–29, 2019, in Lodja in Sankuru province to contribute to implementation of our overall work plan. As part of this workshop, we held two sessions on the Program’s malaria activities, which included a discussion of the Presidential Malaria Initiative’s (PMI’s) Malaria Operational Plan 2018 activities. Participants included nine PNLP members and four of our own provincial staff. In USAID IHP’s first six-month work plan, there are two major activities planned in Sankuru: (1) provide malaria case management re-training for health workers (covering, for example, malaria detection with rapid diagnostic tests and standards-based treatment of uncomplicated and severe cases); and (2) equip health facilities with water filters and cups to allow direct observation of adherence to IPT in pregnancy.

This is a foundational activity that is critical to eventually producing data for Indicator 2.1.14: Number of health workers trained in IPT in pregnancy with USG funds and Indicator 2.1.15: Number of health workers trained in case management with Artemisinin-

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 26 based combination therapy (ACT) with USG funds, which help track progress toward IR 2.1.

Strengthened implementation of malaria programming through participation in PNLP meetings

The PNLP routinely organizes workshops and meetings with all its technical and financial partners. A February 18–23, 2019, workshop at the Kinshasa Lassalien Center focused on the PNLP’s central-level PAO activities, which are based on recommendations from the MOH’s DEP. During this workshop, we presented USAID IHP work plan activities to the PNLP. In addition to our team, participants included representatives of PMI, Impact Malaria, the Global Fund, the WHO, UNICEF, the Sécretariat Général de la Santé, the University of Kinshasa School of Public Health, the University of North Carolina, the Swiss Tropical and Public Health Institute (TPH), and MEASURE Evaluation.

After assisting last quarter with planning for the third Journées Scientifiques de Paludisme (JSP, Malaria Scientific Days), during the January to March 2019 period we provided extensive logistical, technical, and financial support for eight JSP preparation meetings organized by the PNLP.

In addition, on March 15, 2019, a Malaria Thematic Group Management meeting was held at our Kinshasa office. We presented the Program’s malaria objectives and activities, our scope of work, and our regional- and provincial-level organization.

On March 26, 2019, Program staff attended a meeting in Kinshasa organized by PMI and its partners. The purpose of the meeting was to ensure that all PMI partners are familiar with each other’s programs, the activities carried out between September 2018 and March 2019, and those to be conducted during the first six months of 2019. In addition to PMI and USAID IHP, participants included Impact Malaria, Breakthrough Action, GHSC-TA, VectorLink, VectorWorks (represented by the University of Kinshasa School of Public Health), and UNICEF.

This is a foundational activity that is critical to eventually producing data for the malaria indicators: Indicator 2.1.14: Number of health workers trained in IPTp with USG funds, Indicator 2.1.15: Number of health workers trained in case management with Artemisinin-based combination therapy (ACT) with USG funds, and Indicator 2.1.16: Number of health workers trained in malaria laboratory diagnostics with USG funds, which help track progress toward IR 2.1.

Participated in a meeting of the Cellule de Coordination de la Tuberculose Multirésistante

The Cellule de Coordination de la Tuberculose Multirésistante (CCTM, Multi-drug Resistant Tuberculosis Coordination Unit) aims to improve the clinical and programmatic management of multi-drug resistant TB (MDR-TB). In addition to its scheduled monthly meetings, CCTM schedules expanded mentor meetings for the scientific team on a monthly or quarterly basis, based on the needs of affected patients. As part of follow-up activities, USAID IHP supported a CCTM-organized meeting at the Programme National de la Lutte Contre la Tuberculose (PNLT, National Program to Combat Tuberculosis) on March 29, 2019. This meeting brought together the scientific team and various partners involved in the fight against MDR-TB, including the Global Fund, Challenge TB, Action Damien, and Cordaid. The purpose of this meeting was to shed light on the management of MDR-TB with a short treatment regimen (including Bedaquiline) in hot-spot provinces (Haut-Katanga, Ituri, Kasaï-Oriental, Kongo-Central, and Kinshasa).

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 27 This is a foundational activity that is critical to eventually producing data for tuberculosis activities: Indicators 2.1.17 through 2.1.26, which help realize progress toward IR 2.1.

Organized a briefing in Lualaba for carriers of sputum samples from suspected TB patients

USAID IHP provided technical and financial support to the Lualaba Coordination Provinciale de Lutte contre la Tuberculose (CPLT, Provincial Committee for Tuberculosis Control) to prepare to collect and transport sputum samples from people suspected to have TB. On March 25, 2019, prior to the campaign to identify suspected patients and transport sputum samples, the CPLT selected and briefed 30 relais communautaire (RECO, community health workers) and members of the Club des Amis Damien (Club for the Friends of Damien) in the Kitizo aire de santé. The CPLT also provided the RECO with spittoons, collection cards, and orientation notes on the suspected TB patients.

This is a foundational activity that is critical to eventually producing data for Indicator 2.1.17: TB notification rate through USG-supported programs and Indicator 2.1.18: Number of patients diagnosed TB that have initiated first-line treatment, which help track progress toward IR 2.1.

Conducted active search for TB patients and subsidized the cost of transporting sputum samples from suspected TB patients to the Centre de Sante ́ de Diagnostic et Traitement

During FY2019 Quarter 2, USAID IHP provided technical and financial support for a range of events carried out in conjunction with the Journée Mondiale de Lutte contre la Tuberculose (JMT, World Tuberculosis Day), as described under IR 3.1. This included support for active searches for TB patients and for the collection, transport, and evaluation of sputum sample from people suspected to have the disease.

During the last week of March 2019, USAID IHP supported CPLT awareness and testing campaigns in five provinces: Kasaï-Oriental, Lualaba, Sankuru, Sud- Kivu, and Lomami. Activities in Kasaï- Oriental included outreach at Mbuji Mayi Prison to screen prisoners for TB.

In conjunction with TB mini-campaigns to raise awareness (as described under

Alain Binibangili, Abt Associates for for Associates Abt Binibangili, Alain IR 3.1), we provided technical and financial support to help RECO fan out Photo: IHP USAID across communities to collect sputum A woman enters a testing site at a TB Village outreach center during the samples and transport them to the search and testing campaign surrounding JMT. Centres de Sante ́ de Diagnostic et Traitment (CSDT, Diagnostic and Treatment Health Centers) for testing. Patients who tested positive were immediately put under treatment. Table 5 provides details about the results of the TB search and testing campaigns across all five provinces.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 28 Table 5: Results of Tuberculosis Search and Testing Campaigns, March 2019 RESULTS Zones de No. Aires No. No. Tested Pre- Tested Province Date Santé de Santé People Households Positive sumptive positive for Involved Involved Reached Visited for MDR- TB cases pulmonary TB TB March 30– 1. Bonsola Kasaï- April 1, 2. Diulu 9 13,652 1,765 554 15 2 Oriental 2019 3. Kansela 1. Dilala March 25– Lualaba 2. Manika 3 3,479 497 725 25 26, 2019 3. Lualaba March 31, Sankuru 1. Lodja 4 2,076 519 226 8 2019 March 26, Sud-Kivu 1. Kamituga 3 34,236 4,279 123 13 2019 March 25, Lomami 1. Kabinda 1 903 129 43 5 2019 5 9 20 54,346 7,189 1,671 66 2

This activity produced data to measure Indicator 2.1.17: TB notification rate through USG-supported programs and Indicator 2.1.18: Number of patients diagnosed TB that have initiated first-line treatment, which helps track progress toward IR 2.1.

IR 2.2 INCREASED AVAILABILITY OF QUALITY, INTEGRATED COMMUNITY-BASED HEALTH SERVICES

Designed audio job aids to support retraining of RECO at integrated Community Case Management sites that provide integrated care

USAID IHP will help retrain RECO to ensure they are What are iCCM sites? fully prepared to provide integrated services at integrated iCCM sites are established for villages or Community Case Management (iCCM) sites (see text communities where access to health care is box). To support this process, the Program is creating a limited. Trained and supervised RECO series of interactive voice response (IVR) audio job aids deliver curative interventions for malaria, that will reinforce the capacity of rural health extension pneumonia, and diarrhea. They also screen workers to understand iCCM requirements. Providing this for malnutrition among children under five information on mobile phones will eliminate printing and and refer complicated cases to health delivery costs while also decreasing the time required to facilities. distribute information. The information can be sent directly to target groups via their mobile phones; the job aids can also be accessed by individuals calling into a dedicated phone number. Because audio job aids can provide ongoing educational support, they are a vital tool in improving professional development. During this quarter, the Program began planning for the creation of a packet of audio job aids for the national information hotline 42502, which is hosted by Vodacom. The aids will be recorded in all five national languages (French, Lingala, Tshiluba, Kikongo, and Swahili).

USAID IHP is planning a content workshop in May 2019 with the MOH to validate 30 technical messages related to the DRC’s protocol for iCCM sites. The validated messages will serve as the content for the audio job aids.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 29 This activity helps realize progress toward IR 2.2.

Piloted retraining for existing community health workers and nurses

USAID IHP will support retraining of distributeurs de base communautaire (DBC), who are RECO trained in family planning (see text box for description of various community-based family planning actors). The goal of this training will be to improve their capacity to provide family planning information, counseling, and referrals. During the reporting period, we provided technical and financial support for a pilot retraining program targeting clinical providers who had been previously trained under the USAID- funded Evidence to Action (E2A) project. Participants comprised the Infirmières Titulaires (Registered Nurses) and Infirmières Titulaires Adjoint (Assistant Registered Nurses) from three aires de santé, as well as the ZS supervising nurse of Kalenda ZS in Lomami province. A key objective of the training was to find out how much the nurses had retained from previous trainings, to help us fine-tune the training we will provide at a larger scale later this year. E2A will deliver training in Kasaï-Central, Kasaï-Oriental, and Lomami. USAID IHP will provide the training in Sud-Kivu, Tanganyika, Haut-Lomami, Haut-Katanga, Lualaba, and Sankuru. We will select three ZS and five aires de santé in each of these provinces.

This is a foundational activity that is critical to eventually producing data for Indicator 2.2.1: Number of USG-assisted community health workers providing family planning information, referrals, and/or services during the year, which help track progress toward IR 2.2.

Community-based family planning actors in the DRC There are several key community actors who are vital to the DRC’s efforts to increase the number of people who use modern family planning methods. They include: DBC. Distributeurs de base communautaire are RECO who specialize in family planning. Their roles are to raise awareness, provide counseling, offer family planning methods, and direct clients to clinic-based providers (who provide injectable family planning methods and implants and manage side effects). Community leaders. Selected for their influence in the community, the role of these adult and youth leaders is to persuade their family members, neighbors, and peers to use family planning methods. The youth—called Peer Educators—talk to their contemporaries about family planning and encourage them to use modern methods. CODESA. Trained to raise awareness and monitor the health situation in their communities, the roles of these committees include detecting health problems and directing people to resources, including family planning resources. Community champion members. This is the name given to RECO who have been identified as having excelled in service delivery. Their role is to work with DBC to raise awareness, attracting large numbers of people and directing them to DBC to receive counseling and obtain family planning methods.

Assessed iCCM sites and studied the functionality of community-based services

To improve access to care in remote areas, USAID IHP will help revitalize iCCM sites across the target provinces. The first step will be to determine which iCCM sites are functioning well and which require support to strengthen their capacity to offer quality care. We will support the weak performers.

During this quarter, the Program inventoried sites across all nine target provinces to study their level of functionality. As shown in Table 6, health facilities indicated that 1,884 iCCM sites are in place

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 30 (functioning). Of these, 1,393 reported to DHIS2—an overall completion rate of 74 percent. During the next quarter, the DPS of Lualaba and Tanganyika will benefit from iCCM supervision visits by nurses. USAID IHP is planning to provide financing for these visits, which will reinforce the skills of the iCCM RECO, improving their ability to offer quality care and increasing the completion rate.

Table 6: Functioning iCCM Sites in USAID IHP-Supported Provinces Having Reported, January to March 2019 Number of Functioning iCCM Sites in Place in Percent of Functioning Province iCCM Sites Reporting January 2019 iCCM Sites Reporting during the quarter Lomami 227 176 77.5 Sankuru 134 116 86.6 Kasaï-Oriental 261 231 88.5 Kasaï-Central 366 257 70.2 Lualaba 116 95 81.9 Haut-Katanga 80 49 61.3 Haut-Lomami 211 183 86.7 Sud-Kivu 169 142 84.0 Tanganyika 320 144 45.0 Total 1,884 1,393 73.9 Source: DHIS2, January 2019

This is a foundational activity that is critical to eventually producing data for Indicator 2.2.4 Number of iCCM sites in USG-supported communities, which helps track progress toward IR 2.2.

IR 2.3 IMPROVED REFERRAL SYSTEM FROM COMMUNITY-BASED PLATFORMS TO HEALTH CENTERS AND REFERRAL HOSPITALS

Began work on the design of an mHealth-based system for managing follow up of referrals

USAID IHP began work during this reporting period on the design of the mReferral Tracker, an mHealth system for managing follow-up after referrals. We held planning meetings for USAID IHP staff and MOH counterparts to prepare for a short-term technical assistance visit in April 2019 from the Lead Designer for this activity. During this visit, the designer will apply a human-centered design (HCD) approach to conduct initial research on mReferral Tracker features. The HCD process will include interviews with end-users and stakeholders, prototyping, and continuously testing and gathering user feedback to improve the final solution.

This is a foundational activity that is critical to eventually producing data for Indicator 2.3.1: Number of individuals referred by community health workers/CBOs that were received by supported health facilities (completed referrals), which helps track progress toward IR 2.3.

IR 2.4 IMPROVED HEALTH PROVIDER ATTITUDES AND INTERPERSONAL SKILLS AT FACILITY AND COMMUNITY LEVELS Activities originally planned for FY2019 Quarter 2 have been postponed until Quarter 3.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 31 IR 2.5 INCREASED AVAILABILITY OF INNOVATIVE FINANCING APPROACHES No activities were planned under this intermediate result during the quarter.

IR 2.6 IMPROVED BASIC FACILITY INFRASTRUCTURE AND EQUIPMENT TO ENSURE QUALITY SERVICES

Participated in WASH meetings at the national and provincial levels

The USAID IHP WASH Advisor had a working session with the MOH Director of Hygiene and Sanitation on March 13, 2019. Discussions focused on the Program’s work plan and on an MOH document on WASH standards and guidelines that is under development. We agreed that USAID IHP will provide financial support for an April 2019 workshop to finalize and validate this document.

During this quarter, the USAID IHP WASH Advisor also met the Executive Secretary of the Sud-Kivu Comité Provincial d’Action de l’Eau, l’Hygiène et l’Assainissement (CPAEHA, Provincial Water Action, Hygiene and Sanitation Committee). Because the CPAEHA coordinates all province-level WASH activities, including those carried out by TFPs, we will keep it informed of our WASH activities in Sud- Kivu. This meeting was the first step in that coordination process. We discussed USAID IHP’s planned activities and the CPAEHA Executive Secretary shared findings and recommendations from a 2015 World Bank-supported study on autonomous water supply systems. He also talked about coaching the Entités Territoriales Décentralisées on taking care of water supply systems; the establishment of Comités Territorial d’Action de l’Eau, Hygiène et Assainissement (Territorial Water Action, Hygiene and Sanitation Committees) in Kabare and Kalehe; and monthly coordination meetings organized by the CPAEHA.

This is a foundational activity that is critical to eventually producing data for Indicator 2.6.1: Percentage of targeted health care facilities receiving infrastructure and/or equipment support, which helps track progress toward IR 2.6.

IR 2.7 STRENGTHENED COLLABORATION BETWEEN CENTRAL AND DECENTRALIZED LEVELS THROUGH SHARING OF BEST PRACTICES AND CONTRIBUTIONS TO POLICY DIALOGUE

Participated in MOH-organized workshop on ZS operating standards

The MOH Division des Soins de Santé Primaire (Division of Primary Health Care) organized a workshop in Kinshasa from February 12 through 16, 2019, to review 2012 operating standards for ZS, based on DRC Law N° 18/035 (published in December 2018), which establishes basic principles for the organization of public health. These standards incorporate revisions to regulatory documents, including standards for the creation, organization, and operation of health structures in ZS. USAID IHP actively participated in the workshop, leading a group charged with revising standards for health centers. The revised standards will be submitted to the Commission Prestations, Suivi, et Evaluation (Service Delivery, Monitoring and Evaluation Commission) for adoption.

This activity produced data for Indicator 2.7.1: Number of knowledge-sharing workshops supported, which helps track progress toward IR 2.7.

Provided technical and financial support for Comités Techniques Multisectoriels Permanents meetings

During this quarter, USAID IHP provided technical and financial support to reconstitute meetings of the Comités Techniques Multisectoriels Permanents (CTMP, Permanent Technical Multisectoral Committees) in

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 32 six provinces: Haut-Katanga, Kasaï-Central, Kasaï-Oriental, Lomami, Lualaba, and Sankuru). The Sud- Kivu CTMP will restart its meetings in April 2019. CTMP are provincial-level bodies whose chief role is to bring together all stakeholders to coordinate family planning interventions and avoid overlap. Their roles also include advocating for the mobilization of resources to purchase contraceptives and building the capacity of family planning service providers, both at the clinic and community levels. CTMP received past support from other implementing partners such as E2A, IHPplus, CARE International, and the Adventist Development and Relief Agency (ADRA), but when these programs ended, many CTMP did not have the resources to continue their work. Support from USAID IHP will enable them to continue to fulfill their vital functions.

This activity helps realize progress toward IR 2.7.

Participated in weekly PEV coordination meetings

Because vaccinations are one of USAID IHP’s priority areas of intervention, our Child Health/Nutrition Advisor participated this quarter in a series of PEV coordination meetings. A January 15, 2019, meeting focused on the replication of PEV management tools; preparations for formulation of the PEV Comprehensive Multi-Year Plan; the Mashako plan (the emergency plan for the revitalization of routine immunizations in the DRC); the measles response campaign; the BCG vaccines and stock of syringes; and training for engineers to maintain the cold chain. A week later, on January 22, 2019, the group met to follow up on recommendations made during the January 15, 2019 meeting. At a February 5, 2019, meeting, topics included the results of an immunization coverage survey in the Kinshasa ZS that was carried out by the University of Kinshasa School of Public Health, as well as the availability—through the Global Vaccine Action Plan—of inactivated polio vaccine packs in five-dose vials.

This activity produced data for Indicator 2.7.1: Number of knowledge-sharing workshops supported, which helps track progress toward IR 2.7.

Participated in the annual review of PRONANUT

USAID IHP participated in the annual PRONANUT review from February 11 through 16, 2019. The workshop brought together approximately 50 participants from the MOH (from the Secrétariat Général [General Secretariat], Inspection Générale [General Inspectorate], Direction de la Santé de la Famille et de Groupes Spécifiques [Directorate for the Health of Families and Special Groups], DEP, DGOGSS, and PRONANUT), the Ministry of Agriculture, the Ministry of Education, and various partners (the Food and Agriculture Organization, World Food Programme, UNICEF, PDSS, VitaminAngels, Interchurch Medical Assistance, GIZ, Caritas Congo, World Vision, ADRA, Action Contre la Faim [Action Against Hunger], Save the Children, and Doctors of Africa). USAID IHP actively participated in groups and plenary sessions that focused on topics such as the evaluation of coordination activities carried out under the 2018 PAO; the development of the 2019 PAO and presentation of planned 2019 activities, and the alignment of various partners’ activities. Based on our current work plan, USAID IHP will support integrated supervision in the ZS.

This is a foundational activity that is critical to eventually producing data for Indicator 2.7.1: Number of knowledge-sharing workshops supported, which helps track progress toward IR 2.7.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 33 Hosted the Prise en Charge Intégrée de la Maladie du Nouveau-né et de l'Enfant Coordination meeting at USAID IHP office

USAID IHP provided technical and financial support for the Prise en Charge Intégrée de la Maladie du Nouveau-né et de l'Enfant (PCIMNE, Integrated Management of Neonatal and Infant Illness) Coordination meeting, which was held on March 7, 2019, at our Kinshasa office. In addition to USAID IHP, participants included MOH officials from the Coordination PCIMNE/Programme National de Maladies Infectieuses et Respiratoires Aigües (National Program for Infectious Diseases and Respiratory Ailments), Programme National d’Elimination du Choléra et des autres Maladies Diarrhéelle (National Program for the Elimination of Cholera and other Diarrheal Diseases), PNSR, Programme National de Communication pour la Promotion de la Santé (National Communication Program for Health Promotion), and Programme National de Lutte contre la Drépanocytose (National Program to Combat Sickle-Cell Anemia). The University of Kinshasa School of Medicine and a number of TFPs also took part. After plenary sessions, the group shared information on child health, presented the PCIMNE National Strategic Plan and developed strategies for its extension and financing, shared information on mapping iCCM sites, discussed the status of the PCIMNE website and the digitized PCIMNE tool, and developed the work plan for the second quarter of 2019.

This activity produced data for Indicator 2.7.1: Number of knowledge-sharing workshops supported, which helps track progress toward IR 2.7.

Supported maternal mortality review meetings at DPS level

USAID IHP is working with the MOH in three provinces to help analyze and review cases of maternal mortality as a critical first step in reducing the number of maternal deaths. Provincial health authorities are making an effort to collect the data they need to identify causes and seek solutions.  In Sud-Kivu, USAID IHP provided technical and financial support during this quarter for meetings of the MOH’s Provincial Committee of the PNSR, which decided to create a multi- sectoral committee for Surveillance de Décès Table 7: Causes of Maternal Deaths in Maternels et Riposte (SDMR, Surveillance and Tanganyika Response to Maternal Deaths). USAID IHP Percent Cause partnered with UNFPA to support this of Total* initiative. The SDMR committee will Hemorrhage 48 support the PNSR in collaborating with Abortion (among teenagers) 17 local political and health authorities and Anemia 16 with the provincial general referral hospital Infection 12 to systematically notify and review maternal Eclampsia 8 mortality cases. Community members and Uterine rupture ** community organizations will be involved. Uterine atrophy ** A March 2019 meetings of the Santé de la Late transfer of severe cases (e.g., ** Réproduction, de la Mère, du Nouveau-né, de eclampsia and uterine rupture) l’Enfant, et de l’Adolescent (Reproductive, Insufficient plateau (supplies, ** Maternal, Newborn, Child and Adolescent materials for labor and delivery) Health) Task Force included a review of Providers insufficiently trained in ** maternal deaths at the community and SNMNEA skill areas facility levels. The results showed that 75 Source: 2007 Demographic and Health Survey percent of maternal deaths occurred during *Totals add up to more than 100% due to rounding. the postpartum period, while 25 percent **Percentage too small to contribute meaningfully to total occurred peripartum. The direct causes of

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 34 the peripartum deaths included uterine rupture, eclampsia, and uterine atonia, with some unknown. The review found that 75 percent of women did not have access to prenatal consultations; 75 percent of women were not followed using a partogram (a key surveillance tool that records maternal and fetal data); and 50 percent of women experienced delays with care decisions made at health facilities. Out of 34 ZS, six (Ibanda, Kadutu, Bagira, Idjwi, Kitutu, and Nyangezi) participated in a review of maternal deaths. Each of these ZS reported one maternal death, all among women ages 20–35. A review found causes for only four of the six reported maternal deaths.  In Tanganyika, the PNSR organized a maternal death review meeting, with technical and financial support from USAID IHP. The meeting found a variety of causes of maternal deaths, as shown inError! Reference source not found. on the preceding page.  In Haut-Lomami, USAID IHP provided the PNSR with technical and financial support for maternal death analysis. The review found 17 deaths in two ZS, including 10 cases in the Kamina ZS and 7 cases in the Kitenge ZS. The causes of these deaths included postpartum hemorrhage (13 cases), septicemia and peritonitis (3 cases), and uterine rupture (1 case).

This is a foundational activity that is critical to eventually producing data for Indicator 1: USAID IHP impact on MMR, U5MR, neonatal MR, infant MR, TB case notification rate, malaria mortality rate, CPR, and acute and chronic malnutrition rates. It also produced data to measure Indicator 2.7.1: Number of knowledge-sharing workshops supported, which helps track progress toward IR 2.7.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 35 5. OBJECTIVE 3:

INCREASE ADOPTION OF HEALTHY BEHAVIORS, INCLUDING USE OF HEALTH SERVICES, IN TARGET HEALTH ZONES

IR 3.1 INCREASED PRACTICE OF PRIORITY HEALTHY BEHAVIORS AT THE INDIVIDUAL, HOUSEHOLD, AND COMMUNITY LEVELS

Provided technical and financial support for Journée Mondiale de Lutte contre la Tuberculose events across the DRC

As part of USAID IHP’s commitment to supporting world days and national days, and as mentioned under IR 2.1, we provided technical and financial support this quarter for activities related to JMT in Kinshasa and four provinces (Kasaï-Oriental, Lomami, Lualaba, and Sankuru). The theme of the JMT, held this year on March 24, 2019, was "It's time ..." The DRC's sub-theme was "It's time to actively seek out all people with TB in our communities and prisons.”

 Kinshasa. USAID IHP participated in a scientific morning on March 22, 2019, organized by the PNLT. We presented an abstract of a study on performance of GeneXpert tests, which are routinely used as a secondary method for diagnosing pulmonary TB. The study led the PNLT to revise its strategy and insist on utilization of GeneXpert as the first-line test in hotspot provinces. The Program also joined other donors in providing financial support for a JMT celebration at the TB Village at Place Sainte Thérèse in Ndjili commune March 20–29, 2019. In addition, we helped organize active TB screenings, as described under IR 2.1.  Kasaï-Oriental. The JMT celebration in Mbuji-Mayi on March 30, 2019, was attended by political and administrative authorities, including the city’s Mayor and the Provincial Governor, who pledged to support the DPS in its fight against TB. In conjunction with this celebration, USAID IHP helped organize three TB and HIV awareness days, as described below in the description of mini-campaigns.  Lomami. USAID IHP and Challenge TB supported the JMT in Lomami, which was held on March 25, 2019, in the Kabinda ZS. High-level provincial authorities attended the event, including the Interim Governor and Deputy Governor, the Provincial Assembly President, the Provincial Minister of Health, members of the provincial government, and provincial deputies. These officials pledged to become involved in the fight against TB in Lomami. Following the speeches, the CPLT collected sputum samples and carried out an active TB search, as described under IR 2.1. SMS awareness messages sent for JMT  Lualaba and Sankuru. In French Tshiluba conjunction with JMT, in (1) Il est temps de réduire à (1) Diba dia kumbanyi bua kujikija these two provinces zéro la stigmatisation et la diengulangana ne disungulaja didi USAID IHP helped discrimination dues à la dimueka padiku disama dia tshiadi mobilize the population Tuberculose. anyi Tuberculose. and conduct active (2) Il est temps d'agir en (2) Diba dia kumbanyi dia kuenda searches for TB cases, as responsable pour orienter tout bu mulombodi wa bantu bua kuleja described under IR 2.1. malade qui tousse. njila kudi mubedi yonsu wa tshiadi. On March 28, 2019, we launched a short messaging service (SMS) awareness campaign for JMT, sending out two messages—each one in both French and Tshiluba (see text box). We sent a total of 2,080 SMS messages to beneficiaries in Kasaï-Oriental and 1,640 SMS messages to beneficiaries in Kasaï-Central, using a USAID IHP database of beneficiary phone numbers.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 36 This is a foundational activity that is critical to eventually producing data for Indicator 3.1.1: Percentage of health areas reached by Healthy Family Campaign SBC campaigns, which helps track progress toward IR 3.1. It will also contribute to expected results for the tuberculosis indicators: Indicators 2.1.17 through 2.1.26.

Supported Healthy Family Campaign social and behavior change campaigns for tuberculosis, family planning, and healthy family practices for youth

During this quarter, USAID IHP provided technical and financial support to DPS teams for the organization of five mini-campaigns (four focusing on TB, one on FP) to raise awareness about priority health behaviors. Additionally, we supported a competition and game in Kasaï-Central aimed at preventing diseases and promoting healthy family practices among youth.

The purpose of the campaigns was to promote adoption of priority health behaviors at the individual, family, and community levels. Targeted priority behaviors included undergoing voluntary TB screening and promptly seeking appropriate health services. The family planning campaign sought to create demand for modern contraceptive methods. Partners who played a key role in conducting the campaigns included DPS, ECZS, nurses, DBC, community champion members, CODESA, community leaders (including youth Peer Educators), students, and educators.

Prior to the start of the campaigns, USAID IHP Advisors and the ECZS worked with community members to identify key problems. For the family planning and TB campaigns, data was reviewed to determine which ZS had low levels of contraceptive use or high rates of TB. USAID IHP then collaborated with the ECZS and community to identify specific problems and select targeted activities. Activities carried out during FY2019 Quarter 2 are described below.

Tuberculosis

In conjunction with the JMT and the TB search and testing activities, USAID IHP supported four TB mini-campaigns this quarter:

 In Sankuru, the mini-campaign was organized in four aires de santé (Kalemie, Edingo, Djenenga, and Shilo) in the Lodja ZS. Local churches were involved in the campaigns, reading the messages to their congregations, while RECO conducted home visits to spread the messages.  In Sud-Kivu, the mini-campaign was organized in three aires de santé (Kabukungu, Soluluye, and Kele Sibemela) in the Kamituga ZS. RECO raised awareness through home visits and two community radio stations broadcast messages.  In Lualaba, authorities combined the TB mini-campaign with an active search for malaria and for malnutrition and pneumonia in children. Activities were carried out in three ZS: Manika, Dilala, and Lualaba. In Kolwezi, the Lualaba CPLT—with the help of provincial supervisors, health facility providers, RECO, and Club des Amis Damien volunteers—raised awareness and mobilized the community in a search for active TB cases in the Kitizo, Kisanfu, and Nord- Katanga aires de santé. On March 25 and 26, 2019, the team fanned out and used the TB Village approach to conduct the search (see IR 2.1 for results). In addition, the teams found five cases of malaria (out of 28 suspected cases) and 59 cases of pneumonia in children (out of 62 suspected cases).

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 37  In Kasai-Oriental, the DPS collaborated with the CPLT to carry out the following awareness-raising activities during the last week of March in nine aires de santé in the Diulu, Bonzola, and Kansele ZS:  Three radio channels broadcast the “message of the day” (developed by the MOH) two times a day for five days.  Five talk shows organized by two television channels discussed the awareness campaign during broadcasts that aired for five days.  Three radio stations and two television channels broadcast five series of messages in the local language (Tshiluba) on the fight against TB. They were broadcast three times a day for five days.  Twenty RECO were recruited to participate in this activity. After receiving orientation, they led educational discussions and engaged in interpersonal communication sessions aimed at counseling and informing community members about the availability of services.  RECO visited 300 households over a three-day period, referring 649 people with a cough to the nearest health center and TB Village.  RECO delivered educational talks at Mbuji Mayi Central Prison that reached 154 prisoners.  RECO used the HIV Village approach to counsel and test a total of 267 clients, all of whom received the results of their tests. From the households that received counseling and testing, six people tested positive and were moved to HIV treatment.

Family planning

Many of the key barriers to family planning in the DRC arise from men’s resistance to its utilization. For this reason, the USAID IHP-supported family planning mini-campaigns targeted both men and women. During this quarter, the Program provided technical and financial support to the Lomami DPS to organize a mini-campaign to raise awareness and promote the use of family planning, with the goal of increasing the number of modern contraceptive method users.

The campaign was carried out in the Kabiji, Kalenda Station, and Tshilomba aires de santé in the Kalenda ZS. Prior to the start of the campaign, the ECZS briefed 24 DBC, 15 community champion members, and community leaders on various family planning methods. From March 1 through 3, 2019, the DBC and community leaders led awareness-raising efforts in homes, churches, and markets. During this three-day period, they conducted nine outreach events, made 297 home visits, and held 87 group meetings and discussions in the community. The results included the following:  A total of 6,924 people received family planning information from DBC; community leaders (including youth Peer Educators); and community champion members. Of these, 2,275 people received family planning methods through consultations with DBC and clinical providers.  Interpersonal communications by clinical providers, DBC, community leaders, and community champion members reached 3,596 people with family planning messages.  Youth Peer Educators raised awareness of family planning and reproductive health among 2,165 adolescents and young people, reaching them through schools, churches, football fields, and homes.  Community champion members, community leaders, and CODESA referred 369 people to DBC for counseling; of these, 298 opted for and received family planning methods.  DBC counseled 608 new couples.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 38  A total of 1,568 people (851 women and 717 men) participated in gender discussion sessions and that addressed the roles of men and women in family planning, reproductive health, and MNCH.

School campaign targeting youth

USAID IHP organized a mini-campaign through a school competition and quiz for high school students in the Kananga ZS in Kasaï-Central. The campaign focused on prevention of diseases (especially malaria) and promotion of essential family health practices such as hand-washing, vaccination, and use of mosquito nets. The 100 students selected to actively participate in written and oral activities included 50 students from Buena Muntu High School and 50 students from the Normal School. Another1,000 students were in the audience to cheer on their classmates. The competition improved the students' knowledge of essential family planning practices for sexual and reproductive health, as well as sexual and gender-based violence, WASH, and malaria prevention.

The school event also provided an opportunity for young people to revitalize their ecole assainie (healthy school) committees, which will help students maintain quality IHP USAID Photo: healthy family practices. The Youth participants in a health-focused school competition and quiz show in

the Kananga ZS in Kasaï-Central. schools will ensure that girls are represented on the committees in accordance with school gender representation rules. As an additional benefit, the activity promoted collaboration between schools and the surrounding populations.

Following this activity, USAID IHP will support the following next steps:  Support school officials to organize student exchange meetings and develop micro- entrepreneurship projects that will strengthen resilience, especially among young girls, to help youth avoid high-risk sexual and other health-related behaviors.  Document the community interest activities carried out by young people (particularly girls) active in school committees. The young people who participated in this activity expressed appreciation for the opportunity to express themselves on issues that concern them, including those related to sexual and reproductive health. They felt that the competition and quiz framework was a useful way to continue exchanges on these topics.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 39 Drawing on the lessons learned during this first round of activities, USAID IHP will support at least two mini-campaigns each quarter in every province, targeting ZS with particularly low performance in specific health areas. Although results during this first round of campaigns were positive and were obtained quite efficiently, USAID IHP will work in the future toward greater adherence to best practices by integrating the population into the development of key communication messages for the next mini- campaigns. This will provide them with opportunities to identify problems and propose solutions to improve healthy family practices.

Healthy Family Campaigns: Using games to engage the population

USAID IHP is collaborating with Breakthrough Action to coordinate the creation and launch of the Healthy Family Campaign content on the 42502 national information service. USAID IHP will create 30 key messages related to this content, using the Wanji Game format, which is an interactive and educational audio adventure that empowers each participant to choose his or her own path and determine the story’s outcome. Mobile phones place this game directly in the hands of each player. Once it is operational, players will call the 42502 service free of charge to play a game on their preferred health topic. Through IVR, players will listen as they are placed within an interactive narrative and will use their phone’s keypad to make decisions that influence the outcome of the story. USAID IHP chose this format because it has been tested in other countries that use a national information service analogous to the DRC’s 42502 system and it has been found to be it highly effective. USAID IHP plans to launch the Health Family Campaign Wanji Game on 42502 in July 2019.

These activities produced data for Indicator 3.1.1: Percentage of health areas reached by Healthy Family Campaign SBC campaigns, which helps track progress toward IR 3.1.

Supported the Lomami DPS in assessing the capabilities of community agents

USAID IHP is helping train community agents (CODESA, CAC, and RECO) so that they can better perform their roles. During this quarter, we provided technical support to the Lomami DPS to conduct a situational analysis assessing the capabilities of community agents in the Kalambayi Kabanga ZS in five aires de santé (Kabala, Katombe, Bena Kazadi, Bajila Membele, and Bena Thibangu). The goal of the exercise was to determine:  The extent of political and administrative authorities’ involvement in CODESA and CAC activities.  The extent to which communities are following MOH recommendations for the formation and functioning of CODESA, CAC, and RECO.  The capacity building needs of CODESA, RECO, and CAC members, as well as their ability to operationalize.  How CODESA and CAC action plans are implemented.

Key findings of that assessment exercise were as follows:  Political and administrative authorities have been actively involved at all levels of the process of CODESA, RECO, and CAC formation. However, the formation of these community groups and their functioning did not meet the recommended standards.  Chairpersons of the community structures (CODESA, RECO, and CAC) demonstrated poor leadership skills. This is believed to contribute to a low rate of completion of planned activities. In addition, the assessment found that many actors and partners do not understand the roles of these community structures.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 40  Some ECZS members do not regularly supervise and monitor the implementation of the community structures’ action plans. This has likely resulted in their observed low level of functionality.  In addition to the lack of supervision, the assessment found that a lack of motivation among CODESA, RECO, and CAC members may play a significantly role in their low level of functionality.

The assessment exercise faced several challenges, including difficulties in physically reaching distant aires de santé and weak participation and support from the ECZS. Similar assessment processes were initiated in USAID IHP’s eight other target provinces during the quarter and is expected to be completed during the coming quarter. Next steps will include providing technical and financial support for:

 Completion of similar assessment exercises in USAID IHP’s eight other target provinces.  ECZS to effectively supervise community-based activities.  ECZS to train CODESA, RECO, and CAC members in the functionality of community participation structures, communication techniques, and essential family practices.  The DPS and ZS to actively involve key partners, including NGOs, faith-based organizations, and other civil society structures in working closely with the CODESA, RECO, and CAC.

This is a foundational activity that is critical to eventually producing data for Indicator 3.1.2: Percentage of community mobilisers trained and active at community level, which helps track progress toward IR 3.1.

Coordinated and collaborated with Breakthrough Action

During FY2019 Quarter 2, USAID met with Breakthrough Action to determine and clarify the roles and responsibilities of each program. We agreed to jointly develop a common work plan that will detail activities to be conducted by each organization, as well as those to be carried out together. We will develop the terms of reference for this work during the upcoming quarter.

This activity helps realize progress toward IR 3.1.

Initiated qualitative data analysis and HCD workshops

During FY2019 Quarter 2, USAID IHP launched the first steps in our HCD approach. National-level social and behavior change (SBC) innovation workshop. The Program invited stakeholders to participate in a two-day, national-level HCD workshop in Kinshasa on March 13–14, 2019. The objectives of this workshop were to:  Learn from stakeholders’ institutional knowledge and personal experiences with health and health system challenges in the DRC  Assess national-level perspectives on requirements for SBC campaigns  Introduce HCD thinking and methodologies to support USAID IHP’s SBC activities  Uncover SBC insights

The answers and communication strategies generated during this workshop will inform our larger methodology for developing community-generated SBC communications solutions as the Program progresses. This event was instrumental in helping all USAID IHP stakeholders understand how HCD

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 41 works and how it can help unearth real community-driven and individually driven solutions. There were 29 participants (20 male and 9 female) on the first day and 19 participants (12 male and 7 female) on the second day. Immersion exercises and workshop in Kasaï-Oriental. Following the national HCD workshop, we launched provincial immersion workshops in Mbuji Mayi from March 21 through 30, 2019. The first two days were devoted to immersion exercises. On Day 1, our team interviewed health practitioners in several health centers to shed light on the health environment, understand past and existing communications campaigns, and identify challenges and opportunities. On Day 2, we visited the residences of several community members—including community chiefs and traditional community healers—to better

USAID IHP IHP USAID understand the current state of health communications in these communities and to identify attitudes and beliefs about traditional medicine and other

, Matchboxology for , Matchboxology health interventions. We also held in-depth interviews with 16 health practitioners and community members (6 male and 10 female). Jason Coetzee Jason Day 3 was devoted to analysis of the immersion activities and Photo: Participants in the HCD workshop in Mbuji-Mayi work on a co-creation solution for preparation for the next two days. engaging pharmacies and other local private sector businesses for the upcoming

Healthy Families Campaign. On Days 4 and 5, USAID IHP hosted a tailored workshop for Mbuji Mayi community members and Program stakeholders. During this workshop, we dug deeper into the issues that surfaced during the immersion sessions to identify health communication solutions and interventions. Participants were challenged to evaluate “truths” about the health system in Mbuji Mayi and define what health communication success means to them and their community. We placed participants in groups where they developed ideas for SBC communications and designed elaborate health communications campaign plans. There were 40 participants (25 male and 15 female) during the first day of this workshop and five additional participants the second day, for a total of 45 (30 male and 15 female). USAID IHP will continue this process during May and June 2019 by repeating the Mbuji Mayi immersion exercise and tailored workshop in Haut-Lomami and Lualaba. In these provinces we will include revised elements based on what we learned in Kasaï-Oriental.

This is a foundational activity that is critical to eventually producing data for Indicator 3.1.1: Percentage of health areas reached by Healthy Family Campaign SBC campaigns, Indicator 3.1.2: Percentage of trained community mobilizers active at community level, Indicator 3.1.3: Number of facilities providers trained in interpersonal communication skills, Indicator 3.2.2: Number of awareness campaigns designed, implemented, and evaluated with community participation, and Indicator 3.3.1: Percentage of health areas reached by Healthy Family Campaign SBC events with messages disseminated targeting youth and other vulnerable groups per year, all of which help track progress toward Result 3.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 42 Conducted qualitative evaluations of Healthy Family campaigns

Lomami has a very low prevalence of Table 8: New Users of Family Planning as a Result of contraceptive use (4.5 percent, according to Campaign, by Method DPS data). As described under IR 3.1, Contraceptive Method New Users USAID IHP carried out a mini-campaign Combination oral contraceptives (COC) 182 during this quarter to increase use of family Progestin-oral contraceptive pill (POP) 57 planning services. Following the campaign, Cycle collar (CC) 156 the project analyzed the results. Male condoms 408 Community-based family planning actors Female condoms 101 (including DBC, community leaders, Medroxyprogesterone Acetate (DMPA) 48 CODESA, and community champion members) raised awareness of family DMPA subcutaneous (DMPA SC) 87 planning among 6,924 people and helped Five-year implant (Jadelle) 78 successfully recruit 1,187 new users (see Three-year implant (Implanon NXT) 70 Table 8 for details about the methods used Total 1,187 by new acceptors). The campaign successfully referred 667 people to clinical providers to receive modern contraceptive methods.

Through the 1,187 new accepters, the campaign was able to generate 926,339 couple years of protection (CYP), including through the home visits and advance strategies in the community.8

This activity produced data to measure Indicator 3.1.1 Percentage of health areas reached by Healthy Family Campaign SBC campaigns, which helps track progress toward IR 3.1. It is a foundational activity that is critical to eventually producing data for Indicator 2: Percentage of married women using any modern method of contraception, Indicator 3: Number of acceptors new to modern contraception in USG-supported family planning service delivery points, Indicator 2.1: CYP in USG-supported programs, Indicator 2.2: CYP after exclusion of LAM and Standard days methods for family planning in USG-supported programs, and Indicator 2.3: Number of counseling visits for family planning/reproductive health as result of USG support, which help track progress towards Result 2.

IR 3.2 INCREASED USE OF FACILITY- AND COMMUNITY-BASED HEALTH SERVICES No activities were carried out under this intermediate result during this quarter.

8 Advance strategies refer to targeted campaigns to seek out clients in places where large numbers of people gather (markets, schools, churches, stadiums, traffic circles). Forty-eight hours in advance, all of the community family planning actors spread out and raise awareness. The day of the event, the DBC, IT, and ITA provide information, counseling, and inputs for large numbers of people (including clinical family planning methods, thanks to the presence of the nurses).

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 43 IR 3.3 REDUCED SOCIO-CULTURAL BARRIERS TO THE USE OF HEALTH SERVICES AND THE PRACTICE OF KEY HEALTHY BEHAVIORS

Provided support for question-and-answer competition in secondary schools on family planning, gender, and WASH

USAID IHP carried out one Healthy Family Campaign SBC initiative targeting youth in Kasaï-Central. Details are contained under IR 3.1 and included under indicator 3.3.1 in the summary performance indicator table in Annex A.

This activity produced data to measure Indicator 3.1.1: Percentage of health areas reached by Healthy Family Campaign SBC campaigns and Indicator 3.3.1: Percentage of health areas reached by Healthy Family Campaign SBC events with messages disseminated targeting youth and other vulnerable groups per year, which helps track progress toward IR 3.3. This activity is also a foundational activity that is critical to eventually producing data for the family planning indicators: Indicator 2: Percentage of married women using any modern method of contraception, Indicator 3: Number of acceptors new to modern contraception in USG-supported family planning service delivery points, Indicator 2.1: CYP in USG-supported programs, Indicator 2.2. CYP after exclusion of LAM and Standard days methods (SDM) for family planning in USG-supported programs, and Indicator 2.3: Number of counseling visits for family planning/reproductive health as a result of USG support, which help track progress towards Result 2.

IR 3.4 STRENGTHENED COLLABORATION BETWEEN CENTRAL AND DECENTRALIZED LEVELS THROUGH SHARING OF BEST PRACTICES AND CONTRIBUTIONS TO POLICY DIALOGUE

Collaborated with SNIS and PDSS to support better use of digital tools

During FY2019 Quarter 2, USAID IHP worked with PDSS to match the list of health facilities in the SNIS with those in the PDSS database. The goal is to promote PDSS-SNIS interoperability and integrate PDSS data into the USAID IHP M&E platform to avoid fragmented information. By the end of March 2019, 547 out of the 3,100 health structures in the PDSS database still need to be matched with those in the SNIS. USAID IHP is continuing to work on this process and expects to finish during the coming quarter.

Additionally, in March 2019 we engaged in our first technical exchange with the Bill and Melinda Gates Foundation-funded Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) project team, which is providing USAID IHP with new geospatial data that will supplement existing data from routine health information systems (such as DHIS2) and improve data analyses and use.

This activity helps realize progress toward IR 3.4.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 44 6. CROSS-CUTTING AREAS

6.1. INSTITUTIONALIZATION AND SUSTAINABILITY OF GENDER EQUALITY During the second quarter of FY2019, USAID IHP carried out the gender integration activities described below. Provided gender support to the Kasaï-Oriental DPS during development of its 2019 PAO As part of our process of supporting the DPS in Kasaï-Oriental in developing its 2019 PAO (see Objective 1), USAID IHP shared the results of our gender analysis and presented our gender work plan activities during a meeting on January 21, 2019. In addition to senior DPS staff, participants included representatives from the provincial Coordination de Programmes Spécialisés du Ministère de la Santé (Organization for Coordination of MOH Specialized Programs). The goal was to help ensure that the DPS established a fully gender-integrated PAO.

Held exchange meetings on gender with other technical partners The USAID IHP Gender Adviser held working meetings with representatives of the Réseau National des ONG pour le Développement de la Femme (RENADEF, the Network of Nongovernmental Organizations for Women’s Development) and CRS to discuss our respective fields of intervention, geographic intervention locations, and possibilities for collaboration.

 RENADEF. We met with the RENADEF Provincial Coordinator on January 23, 2019. As an outcome of this meeting, USAID IHP will study possibilities for partnering with RENADEF in the fight against gender-based violence, specifically by providing holistic case management for survivors of sexual violence in the ZS where both programs intervene (RENADEF operates in 15 out of 19 ZS in Kasaï-Oriental). USAID IHP’s next steps will include:  Holding a working session with the RENADEF technical team to obtain a list of its 15 target ZS  Identifying ZS where the Global Fund supports medical care for survivors of sexual violence  Defining mechanisms for monitoring and referencing sexual assault cases for holistic care

 CRS. USAID met with the CRS Health Coordinator and Gender Specialist on January 24, 2019.9 The CRS team completed a gender analysis prior to implementation of the Budikadidi project (see IR 2.1 for more about our collaboration with this project). CRS plans to use a “positive masculinity” approach for gender mainstreaming; it has already developed a gender training module based on positive masculinity, as well as educational materials that take into account the gender dimension. Our next steps will include:  Exchanging gender analysis documents with CRS to identify points of convergence and gaps  Obtaining the educational tools and materials CRS already developed to build on the gains made by using transformative gender approaches that are based on analysis  Holding continuous exchanges with CRS on gender mainstreaming interventions and results

9 CRS intervenes in the Tshilundu, Miabi, and Kasansa ZS in Kasaï-Oriental.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 45  Reflecting on adjustments to be made, if necessary, in gender implementation based on each program’s experiences Organized orientation sessions for senior DPS teams on the consideration of gender in recruitment for human resources for health

The USAID IHP Gender Advisor facilitated orientation sessions on human resources for health (HRH) in Haut-Lomami (on March 4, 2019) for 20 DPS executives and representatives of the Ministry of Gender, Family and Children; in Lualaba (on March 6, 2019) for 10 DPS executives and representatives of MOH specialized programs; in Haut-Katanga (on March 7, 2019) for 30 DPS executives and representatives of MOH specialized programs; and in Kasaï-Central (on March 27, 2019) for 10 DPS executives and representatives of MOH specialized programs. During these sessions, the Program presented the following:  Key gender concepts that would enable participants to fully understand gendered power dynamics, gender-based inequalities, and other relevant concepts  A summary of the results of the USAID IHP gender analysis, particularly as it relates to HRH  Planned USAID IHP gender integration actions

At the end of our presentations, we asked participants to analyze the HRH situation in their provinces and produce a plan for mainstreaming gender in HRH recruitment. The group in Haut-Lomami followed the orientation session with a workshop, engaging in practical exercises and conducting a gender analysis. Table 9 below summarizes the group’s analysis, which shows that women are under- represented in health governance and management bodies in the province.

Table 9: Women’s Representation in Human Resources for Health in Haut-Lomami Province Staff Institutions/Health Facilities Total Men Women Women (Number) (Number) (Number) (Percentage) IPS 22 15 7 31.8% DPS 100 84 16 16.0% BCZS 311 233 78 25.7% General referral hospitals 728 483 245 33.7% Health centers 2,226 1,501 725 32.6% Total 3,387 2,316 1,071 31.6% Source : Haut-Lomami working group participants’ own resources, 2019

According to participants in the Haut-Lomami working group, recurrent problems that hinder parity in HRH include women’s comparatively low levels of education, especially in rural areas; the weight of traditional social customs; women’s low self-esteem and self-confidence; a lack of access to information by women in rural areas; discrimination; and sexual harassment.

The Haut-Lomami working group selected a series of actions to tackle these inequalities. These include:  Conducting advocacy among decision-makers for free primary education and facilities, to encourage schooling for girls and boys  Prioritizing recruitment of women in health centers  Sensitizing community leaders about the need to promote gender equality and parity

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 46  Raising awareness about Law No. 15/013 of August 1, 2015, on the implementation of women's rights and gender equality  Sensitizing women to build job search skills and develop self-confidence

6.2. CONFLICT SENSITIVITY During this quarter, USAID IHP’s main activity under this cross-cutting area was to prepare for the Do No Harm training scheduled for April 2019. This training will take place in Lubumbashi (for all three Katanga Region provinces), Bukavu (for both Eastern Congo provinces), and Mwene Ditu (for all four Kasaï Region provinces). Two members of each provincial DPS will participate, as will USAID IHP staff, including all provincial directors and regional managers and some EEI. The purposes of the training are to ensure that participants understand the concept of Do No Harm and how to apply it so that the Program does not inadvertently create harm in the communities where we operate (e.g., by exacerbating already existing intercommunity or ethnic conflicts).

6.3. CAPACITY BUILDING In addition to commencing work on institutional assessments of seven DPS and one ZS, as called for in our FY2019 work plan and described in Objective 2, USAID IHP’s capacity building work this quarter centered around three ICB training workshops, one in each target region.

The purpose of these events was to orient participants on our ICB approach, develop a common understanding of ICB in the context of USAID IHP, and prepare for institutional assessments at the provincial and ZS levels. The design of the three regional ICB workshops was modeled after one conducted by TRG in Kinshasa in October 2018. As shown in Table 10, participants included 75 DPS and USAID IHP staff from all nine provinces, 12 of whom were women.

Table 10: Institutional Capacity Building Workshop Participants Eastern Congo Kasaï Katanga Number of participants 19 32 24 Gender (16 male, 3 female) (27 male, 5 female) (20 male, 4 female) Kasaï-Oriental (5) Haut-Katanga (5) Sud-Kivu (7) Kasaï-Central (5) Provinces (number of DPS staff)* Lualaba (5) Tanganyika (5) Lomani (5) Haut-Lomami (4) Sankura (5) Kasaï-Oriental (4) Haut-Katanga (6) Sud-Kivu (5) USAID IHP participants Lomami (5) Haut-Katanga Regional (3) Tanganyika (2) Sankuru (3) Kinshasa (1) Provincial staff: in addition to DPS staff, this include one provincial MOH staff from Tanganyika and three from the provincial inspectorates in Haut-Kantanga. Haut-Lomani, and Lualaba.

The workshops increased participants’ familiarity with the Participatory Institutional Capacity Assessment and Learning (PICAL) tool, ICB M&E, and the range of possible USAID IHP capacity strengthening interventions. They also provided the basis for collaboration between DPS staff and newly hired USAID IHP Provincial ICB Advisors, who developed plans to work together on DPS- and ZS-level institutional assessments describe in Objective 2.

6.4. ENVIRONMENTAL MITIGATION AND MONITORING The Program will commence environmental mitigation and monitoring activities during Quarter 3.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 47 7. ACTIVITY RESEARCH, MONITORING AND EVALUATION

Oriented Program staff on the USAID IHP M&E system and procedures

The Program held M&E orientation sessions for our staff this quarter, since technical staff as well as the research, monitoring, and evaluation (RME) team must have an in-depth understanding of the USAID IHP M&E system. The first session took place in Kasaï-Oriental; comparable training followed in five additional provinces: Haut-Lomami, Lomami, Sankuru, Sud-Kivu, and Tanganyika. Training participants included USAID IHP provincial teams and SNIS office representatives from each DPS. The SNIS representatives provided brief DHIS2 training. A total of 68 Program staff (13 women and 55 men) participated, along with 24 DPS SNIS office representatives (5 women and 19 men). During the coming quarter, we will provide the same training in Haut-Katanga, Kasaï-Central, and Lualaba.

The orientation sessions covered the following topics:  USAID IHP objectives and performance work statement  The Activity Monitoring and Evaluation Plan (AMEP)  The Performance Indicator Tracking Table (PITT)  Content and relevance of the Performance Indicator Reference Sheets (PIRS)  Program data flow and discussions on associated challenges  Challenges related to the SNIS M&E system  Evidence-based decision-making  The Collaborating, Learning, and Adapting strategy  Data quality assurance and reporting schedule  Challenges related to TB indicators  Data quality challenges

These sessions gave staff a clear understanding of the USAID IHP M&E system and indicators. They also helped staff identify data quality challenges, especially those related to DHIS2 data.

Prepared for a baseline household survey in USAID IHP target provinces

Approximately 20 percent of USAID IHP indicators rely on data from surveys that will be undertaken by the Program. During FY2019 Quarter 2, we took steps to finalize our baseline data-gathering, most notably by preparing for a household survey. This included selecting a research firm to carry out the survey. We received 12 offers from research firms, short-listed four, and selected EXPERTS SARL. We submitted our selection rationale and procurement documentation to USAID for approval. We expect to agree on terms and finalize the contract during the third quarter of FY2019.

During this quarter, we continued to develop data collection tools for the household survey, including questionnaires and a survey protocol, working in partnership with Breakthrough Action, Breakthrough Research, and MEASURE Evaluation. As soon as the survey firm is approved, we will submit near-final versions of the tools and protocol to other stakeholders for review.

Prepared for additional DHIS2 module and an M&E retreat

Program indicator data come from various sources, including surveys, DHIS2, PICAL reports, and the internal USAID IHP M&E system. More than half of our indicator data will come from Program monitoring reports: the household survey will provide data for 20 indicators and the service delivery

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 48 mapping survey will provide data for seven indicators. For the others, we must take existing data collection tools and include them in existing data flow systems. This includes data that are included in registers and data in sources such as the Global TB Database. However, since such data are not entered into a routine data collection and reporting tool, they are not entered into DHIS2. For a few data we must design novel data collection tools so that they can be collected through the routine Health Management Information System (HMIS) and then be entered into DHIS2. The latter requires the design of an additional DHIS2 module. During the coming quarter we will work with the SNIS team to develop the tools and the additional DHIS2 module.

Finally, we have been developing tools for data that will be collected by our own staff for Program activities and indicators. We will finalize these tools with the full USAID IHP RME team during an M&E retreat scheduled for FY2019 Quarter 3. This retreat will provide comprehensive and in-depth training for our RME staff and give us the opportunity to develop the data quality assurance framework for Program data flows. Training will cover the USAID IHP M&E platform, initial data entry, refined indicator definitions, and data collection plans and tools. We developed the curriculum for the retreat during FY2019 Quarter 2.

Supported the allocation of data collection and transmission tools (sheets and registers)

USAID IHP has been asked to provide target DPS and ZS with the necessary tools to collect health facility data; this includes program, service, and facility registers and standardized monthly reports. Throughout the second quarter of FY2019, USAID IHP gathered copies of the tools that need to be reproduced and distributed to virtually every health facility in the nine USAID IHP target provinces. We will continue to gather copies of the tools, digitize them if they are not already digitized, and reproduce copies.

Assessed DPS and ZS Internet connectivity to support efforts to gather and transmit data to DHIS2

DPS and ZS need Internet connectivity so they can enter health facility-level data in DHIS2. To assist on this front, during this quarter USAID IHP began an assessment to identify the status of VSATs (small satellite ground stations) in target DPS and ZS. In addition to collecting information on the status of the VSATs, we are also investigating access to 3G+ or 4G+ telephone network coverage so we can consider filling gaps with modems and other ways to access the Internet. We will complete this assessment during the coming quarter.

Re

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 49 8. LESSONS LEARNED

When FY2019 Quarter 2 opened on January 1, 2019, we had established the USAID IHP work plan and finalized our AMEP. We anticipated demonstrating our commitment to the Program’s overall mission through an intense work agenda with a full roster of key activities and deliverables. Now, as we take stock at the end of Quarter 2, we acknowledge that it has taken us more time than envisioned to deploy all the resources needed to implement work plan activities. We learned some valuable lessons during this process:

There is great receptivity to the overall mission of the Program. As we interact with USAID IHP partners and onboard every new staff member, we repeat core messages about our mandate. The Program’s approach emphasizes sustainability and the intention to leave behind stronger institutions once our work is completed. In this, we are treading in the footsteps of our predecessor, IHPplus, which also had a strong focus on sustainability. Our message resonates deeply with our government partners, who aspire to be in full control as they continuously develop their capacity and deliver quality, integrated health services.

Government programs are extremely dependent on external funding. Implementation delays during the gap between IHPplus and USAID IHP operations have shown government programs’ deep reliance on outside funding sources. Indicators remained stable for a while after IHPplus ended but then began to trend downwards. This important lesson needs to be absorbed from USAID IHP’s beginning. The Program must tackle this key element of sustainable health systems—appropriately-scaled domestic funding for the health system’s core functions—at every single level.

Interactions with elements outside the health system are vital. From a health systems perspective, interactions with institutions outside the health system (e.g., local governments, provincial governments, the Ministry of Finance, the private sector) are extremely important. Such collaboration may have been insufficiently addressed in our work plan, even though some activities—such as institutional assessments and support for the PAO and contrat unique processes—have fostered this type of engagement with government counterparts and partners. USAID IHP’s increased understanding of the importance of this variable has inspired us to deepen our collaboration with IGA and draw even more lessons from that Activity’s experiences.

USAID IHP needs to work twice as hard to address gender institutionalization and sustainability. The Program is not yet gender-neutral. Although we increased our work force each month, we had a great deal of difficulty identifying and recruiting female candidates. As a result, men are over-represented among Program staff. This outcome reflects gender challenges both within our organization and in Congolese society at large. We need to work harder to demonstrate that we can address the impact of gender imbalances not only within our own team but also in communities, in workplaces, and in the accessibility and utilization of health services in the DRC.

Our next work plan needs to include both technical activities and financial transfers. The Program’s slower than expected onboarding of staff required technical staff already in place to shift their attention to operational and administrative tasks. In this context, many of our reported activities are essentially about funding interventions and less about actual technical work. This is appropriate for some activities where provinces and ZS have primarily financial, rather than technical, needs. Nevertheless, some important—and time-consuming—design work took place, including preparations and planning for various baseline surveys, performance dashboards, the cost recovery mechanism for medical supplies, mobile phone-based job aids, and the HCD approach for our SBC strategy.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 50 The Program must find pragmatic approaches for funding certain health system functions. We must identify a mechanism that is compatible with contractual restrictions on providing funding for government institutions and that responds to needs for external financing. As of the end of Quarter 2, this challenge remained unsolved, creating tensions with some of our government counterparts. Our proposals to use direct funding and in-kind funding as temporary alternative mechanisms caused frustration on their side. An important lesson learned is that even when relationships and dialogue are generally positive, they can quickly change. The USAID IHP management team, including our Regional and Provincial Directors and Technical Advisors, need to be able to guide discussions toward pragmatic solutions for problems over which there is no real control at the local level.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 51 ANNEX A: PERFORMANCE INDICATORS, TARGETS, AND ACHIEVEMENTS

% Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Sustainably improved ability of the DRC health system to deliver quality services by building the leadership, management, and technical Goal capacity of Congolese institutions and communities Impact† IHP DRC Impact: MMR, U5MR, Neonatal MR, Infant Kasai 1 MR, TB case notification rate, malaria mortality rate, Katanga CPR, and acute and chronic malnutrition rates* Eastern Congo Outcome 5.2% 5.9% EDS 2014 FP: Percentage of married women using any modern Kasai 4.8% 5.5% EDS 2014 2 method of contraception Katanga 4.4% 5.0% EDS 2014 Eastern Congo 6.7% 7.7% EDS 2014 FP: Number of acceptors new to modern Outcome 848,549 865,520 216,380 206,983 95.7% DHIS 2 3 Fee contraception in Kasai 368,326 375,693 93,923 80,171 85.4% DHIS 2 Proxy USG-supported family planning service delivery Katanga 272,927 278,386 69,596 71,893 103.3% DHIS 2 points (PROXY) Eastern Congo 207,296 211,442 52,860 54,919 103.9% DHIS 2 Outcome 50.3% 52.3% EDS 2014 MNCH: Percentage of children 0-59 months of age Kasai 53.7% 55.7% EDS 2014 4 Fee for whom treatment/advice was sought for acute Katanga 53.0% 55.0% EDS 2014 respiratory infection Eastern Congo 42.3% 44.3% EDS 2014 Outcome 1,143,154 1,166,017 291,504 298,717 102.5% DHIS 2 MNCH: Number of children under five years of age 5 Fee Kasai 569,695 581,089 145,272 147,805 101.7% DHIS 2 that received treatment for an acute respiratory Proxy Katanga 229,925 234,524 58,631 56,088 95.7% DHIS 2 infection from an appropriate provider Eastern Congo 343,534 350,405 87,601 94,824 108.2% DHIS 2 Outcome 38.0% 40.0% EDS 2014 MNCH: Percentage of children 0-59 months for Kasai 34.8% 36.8% EDS 2014 6 Fee whom treatment/advice was sought for diarrhea Katanga 33.3% 35.3% EDS 2014 Eastern Congo 46.5% 48.5% EDS 2014 Outcome 1,041,286 1,062,112 265,528 190,091 71.6% DHIS 2 MNCH: Number of cases of child diarrhea treated in Kasai 476,895 486,433 121,608 71,448 58.8% DHIS 2 Fee Proxy USG- supported programs (PROXY) Katanga 239,799 244,595 61,149 51,738 84.6% DHIS 2 Eastern Congo 324,592 331,084 82,771 66,905 80.8% DHIS 2 Outcome 44.8% 46.8% EDS 2014 8 MNCH: Percentage of children age 12-23 months Kasai 40.0% 42.0% EDS 2014 Contract who received all basic vaccinations Katanga 45.4% 47.4% EDS 2014 Eastern Congo 52.2% 54.2% EDS 2014

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 52 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Outcome 1,157,027 1,180,168 295,042 258,212 87.5% DHIS 2 MNCH: Number of children less than 12 months of 9 Fee Kasai 479,997 489,597 122,399 105,528 86.2% DHIS 2 age who received three doses of pentavalent vaccine Proxy Katanga 344,494 351,384 87,846 79,451 90.4% DHIS 2 (PROXY) Eastern Congo 332,536 339,187 84,797 73,233 86.4% DHIS 2 Outcome 1,115,918 1,138,236 284,559 261,593 91.9% DHIS 2 MNCH: Percent of children less than 12 months of age Kasai 478,162 487,725 121,931 110,868 90.9% DHIS 2 10 who received measles vaccine from USG-supported Katanga 330,445 337,054 84,263 81,577 96.8% DHIS 2 programs Eastern Congo 307,311 313,457 78,364 69,148 88.2% DHIS 2 Outcome 64.30% 66.3% EDS 2014 MNCH: Percentage of children less than 12-23 months Kasai 61.60% 63.6% EDS 2014 11 of age who received measles vaccine from USG- Katanga 58.00% 60.0% EDS 2014 supported programs Eastern Congo 75.60% 77.6% EDS 2014 Outcome MNCH: Percent of pregnant women attending at least Kasai 12 Fee four antenatal visits with a skilled provider from USG- Katanga supported health facilities Eastern Congo Outcome 778,425 793,994 198,498 192,345 96.9% DHIS 2 13 Fee MNCH: Number of pregnant women attending at least Kasai 418,461 426,830 106,708 101,636 95.2% DHIS 2 Proxy 4 antenatal care visits with a skilled provider (PROXY) Katanga 174,119 177,601 44,400 42,854 96.5% DHIS 2 Eastern Congo 185,845 189,562 47,390 47,855 101.0% DHIS 2 Outcome 37.70% 39.7% EDS 2014 MALARIA :Percent of children under 5 years of age Kasai 37.10% 39.1% EDS 2014 14 Fee for whom treatment/advice was sought for fever Katanga 41.40% 43.4% EDS 2014 Eastern Congo 36.00% 38.0% EDS 2014 MALARIA: Number of children under 5 years of age Outcome 2,868,866 2,926,243 731,561 637,251 87.1% DHIS 2 15 Fee with confirmed malaria who received treatment for Kasai 1,397,311 1,425,257 356,314 262,506 73.7% DHIS 2 Proxy malaria from an appropriate provider in USG- Katanga 681,602 695,234 173,809 188,791 108.6% DHIS 2 supported areas (PROXY) Eastern Congo 789,953 805,752 201,438 185,954 92.3% DHIS 2 Outcome 53.50% 55.5% EDS 2014 MALARIA :Proportion of children 0-59 months who Kasai 45.70% 47.7% EDS 2014 16 Fee slept under an Insecticide treated net (ITN) the Katanga 61.90% 63.9% EDS 2014 previous night Eastern Congo 57.30% 59.3% EDS 2014 Process 1,163,227 9,157,843 2,289,461 343,123 15.0% DHIS 2 MALARIA :Number of insecticide-treated nets (ITN) 17 Fee Kasai 552,961 3,838,231 959,558 143,615 15.0% DHIS 2 distributed during antenatal and/or child immunization Proxy Katanga 217,673 2,896,993 724,248 93,042 12.8% DHIS 2 visits (PROXY) Eastern Congo 392,593 2,422,618 605,655 106,466 17.6% DHIS 2

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 53 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Outcome Improved satisfaction by clients/citizens with the Kasai 18 Fee services they receive: % of individuals reporting Katanga satisfaction with health center services Eastern Congo Number of Basic Emergency Obstetric and Neonatal Outcome Center (BEmONC) or Comprehensive Emergency Kasai 19 Fee Obstetric Center (CEmONC) sites available in each Katanga province Eastern Congo Process Documentation and publication of operational Kasai 20 Fee research in peer reviewed journal Katanga Eastern Congo Process Conflict Sensitivity Analysis and Implementation Kasai 21 Fee Strategy Katanga Eastern Congo Outcome Percent of targeted facilities with quality improvement Kasai 22 Fee action plans documented and being implemented Katanga Eastern Congo Outcome Kasai 23 Fee Capacity Development Approach Katanga Eastern Congo Process Kasai 24 Fee Gender Analysis and Gender Implementation Strategy Katanga Eastern Congo RESULT 1: Strengthened health systems, governance, and leadership at provincial, health zone, and facility levels in target health zones Output Annual score derived from PICAL for USG-supported Kasai 1.1 Fee provincial health divisions Katanga Eastern Congo Outcome Percent of annual Provincial action plans and budgets Kasai 1.2 aligned with National action plans and budgets Katanga (expected contract result) Eastern Congo

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 54 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Outcome Percentage of health zones with annual action plans Kasai 1.3 and budgets that are aligned with provincial action Katanga plans and budgets (expected contract result) Eastern Congo IR 1.1: Enhanced capacity to plan, implement, and monitor services at provincial, health zone, and facility levels Outcome Percentage of DPS and health zones that have used Kasai 1.1.1 data to produce their annual plans data analysis Katanga (expected contract result) Eastern Congo Outcome Percentage of targeted sub-national health level Kasai 1.1.2 divisions that successfully implement 80% of resourced

action plan activities (expected contract result) Katanga Eastern Congo Outcome Number of Results Based Financing (RBF) grants Kasai 1.1.3 signed (expected contract result) Katanga Eastern Congo IR 1.2: Improved transparency and oversight in health service financing and administration at provincial, health zone, facility, and community levels Outcome Score for financial management sub-domains of the Kasai 1.2.1 PICAL assessment for provincial health divisions

(contract deliverable) Katanga Eastern Congo Output PICAL assessment accountability sub-domain score for Kasai 1.2.2 provinces and health zones receiving USG assistance

(contract deliverable) Katanga Eastern Congo Project Output TBD 100% 2.80% 2.80% 1 36 monitoring report Percentage of DPS and Health Zones supported by the Project program that are audited with USAID IHP DRC 1.2.3 Kasai TBD 100% 6.25% 6.25% 1 16 monitoring technical and/or financial support (contract report deliverable) Project Katanga TBD 100% 0% 0% 0 12 monitoring report

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 55 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Project Eastern Congo TBD 100% 0% 0% 0 8 monitoring report Output Number of tickets on the fraud and complaints hotline Kasai 1.2.4 issue tracker (expected contract result) Katanga Eastern Congo IR 1.3: Strengthened capacity of Community Service Organizations (CSOs) and community structures to provide health system oversight Output Percentage of active CCSOs/CODESAs in health Kasai 1.3.1 zones fully supported by the program, which receive Katanga financial support (contract deliverable) Eastern Congo Number and Percentage of supported Outcome CSOs/CODESAs using accountability tools (such as Kasai 1.3.2 scorecards and audit reports) to monitor and / or Katanga demand improvement of financial management and/or service delivery (contract deliverable) Eastern Congo Number of community service organizations Outcome 1.3.3 fee (CSOs)/Health Area Development Committees Kasai (Standard: (CODESAs) supported by the program that are Katanga CDCS-#) woman-led (contract deliverable) Eastern Congo IR 1.4: Improved effectiveness of stakeholder coordination at the provincial and health zone levels Output Percent of stakeholders who agree that their views are Kasai 1.4.1 reflected in planning/policy processes Katanga Eastern Congo Output 1.4.2 Percent of coalitions or networks strengthened to Kasai (Standard: fulfill their mandate as a result of USG assistance

CDCS-#) (contract deliverable) Katanga Eastern Congo Annual score of provincial level health divisions in Output PICAL sub-dimension 2.6 to assess for use of inclusive Kasai 1.4.3 stakeholder feedback to inform decision-making and Katanga implementation (contract deliverable) Eastern Congo

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 56 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. IR 1.5: Improved disease surveillance and strategic information gathering and use Annual PICAL score of sub-national level health Output divisions assessed for information management Kasai 1.5.1 capacity to monitor and inform their strategies Katanga (contract deliverable) Eastern Congo Output 16.2% 18.2% 18.2% 0.0% 0.0% 0 179 DHIS 2 Percentage of USG supported provinces and health Kasai 18.2% 20.2% 20.2% 0.0% 0.0% 0 77 DHIS 2 1.5.2 zones with MAPEPI DHIS2 reporting rates > 95% Katanga 15.8% 17.8% 17.8% 0.0% 0.0% 0 57 DHIS 2 (expected contract result) Eastern Congo 13.3% 15.3% 15.3% 0.0% 0.0% 0 45 DHIS 2 Output Percentage of targeted DPS, ECZS and FOSA teams Kasai 1.5.3 that use real-time data dashboards in routine Katanga management tasks (contract deliverable) Eastern Congo IR 1.6: Improved management and motivation of human resources for health Output Average score of provinces and health zones assessed Kasai 1.6.1 for HR management monitoring systems (contract Katanga deliverable) Eastern Congo Output Number of DPS/ECZS health workers trained in Kasai 1.6.2 Human Resources Management using iHRIS (expected Katanga contract result) Eastern Congo Output Number of ECDPs who have been coached according Kasai 1.6.3 to Ministry of Health guidelines for Human Resources Katanga Management (expected contract result) Eastern Congo Output Number of providers who have benefited from using Kasai 1.6.4 the Pathways to Change tool to improve their Katanga attitudes and behaviors (expected contract result) Eastern Congo IR 1.7: Increased availability of essential commodities at provincial, health zone, facility, and community levels Number and percentage of USG-assisted service Output 71.7% 69.7% 69.7% 52.4% 75.2% 2,568 5,971 DHIS 2 1.7.1 delivery points that experience a stock out of selected Kasai 77.9% 75.9% 75.9% 57.6% 75.9% 1,494 2,596 DHIS 2 (Standard: tracer commodities at any time during the reporting Katanga 61.4% 59.4% 59.4% 45.0% 75.8% 934 2,075 DHIS 2 CDCS) period (contract deliverable) Eastern Congo 76.0% 74.0% 74.0% 54.1% 73.1% 703 1,300 DHIS 2 Output 32.4% 34.4% 34.4% 16.8% 48.7% 30 179 DHIS 2 Percent of USG supported health zones with LMIS Kasai 42.9% 44.9% 44.9% 23.4% 52.1% 18 77 DHIS 2 1.7.2 reporting rates > 95% (expected contract result) Katanga 31.6% 33.6% 33.6% 14.0% 41.8% 8 57 DHIS 2 Eastern Congo 15.6% 17.6% 17.6% 8.9% 50.5% 4 45 DHIS 2

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 57 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Output Percent of supported sub-national level health Kasai 1.7.3 divisions with a documented and budgeted distribution Katanga plan (expected contract result) Eastern Congo Output Percentage of Health Zones with improved conditions Kasai 1.7.4 of medicines storage according the planned renovation Katanga (expected contract result) Eastern Congo IR 1.8: Strengthened collaboration between central and decentralized levels through sharing of best practices and contributions to policy dialogue Output 3 PMR 1.8.1 Number of consensus-building forums (multi-party, Kasai (Standard civil/security sector, and/or civil/political) held with Katanga DR 3.1-3) USG assistance (contract deliverable) Eastern Congo RESULT 2: Increased access to quality, integrated health services in target health zones Outcome 1,000,409 1,020,417 255,104 247,348 97.0% DHIS 2 2.1 CDCS FP: Couple years of protection (CYP) in USG- Kasai 383,777 391,452 97,863 95,939 98.0% DHIS 2 (Standard/ supported programs Katanga 329,122 335,704 83,926 77,731 92.6% DHIS 2 PPR) Eastern Congo 287,511 293,261 73,315 73,678 100.5% DHIS 2 Outcome 937,735 956,490 239,122 227,291 95.1% DHIS 2 FP: Couple years of protection (CYP) after exclusion Kasai 360,468 367,678 91,919 90,318 98.3% DHIS 2 2.2 of LAM and Standard days methods (SDM) for FP in Katanga 303,164 309,227 77,307 68,809 89.0% DHIS 2 USG-supported programs Eastern Congo 274,103 279,585 69,896 68,166 97.5% DHIS 2 Outcome 192,080 1,081,900 270,475 704 0.3% DHIS 2 FP: Number of counseling visits for FP/ RH as result of Kasai 150,200 469,616 117,404 704 0.6% DHIS 2 2.3 USG support Katanga 26,796 347,982 86,995 0 0.0% DHIS 2 Eastern Congo 15,084 264,302 66,076 0 0.0% DHIS 2 MALARIA:Percent of pregnant women who received Outcome 64.30% 80% 61.4% 76.8% 244,777 398,437 DHIS 2 2.4 doses of sulfadoxine/pyrimethamine (S/P) for Kasai 67.50% 80% 64.3% 80.4% 106,732 166,018 DHIS 2 (Standard: Intermittent Preventive Treatment (IPT) during ANC Katanga 58.50% 80% 56.6% 70.8% 71,828 126,793 DHIS 2 CDCS) visits Eastern Congo 66.30% 80% 62.7% 78.4% 66,217 105,626 DHIS 2 Outcome 2.5 Kasai (Standard: Percentage of population who use selected facilities Katanga CDCS) Eastern Congo

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 58 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Outcome Percentage of Health centers supported by the USG Kasai 2.6 implementing interventions to support the minimum Katanga package of activities (contract deliverable) Eastern Congo Percentage of hospitals supported by the USG Outcome implementing interventions to support the Kasai 2.7 complementary package of activities. (expected Katanga contract result) Eastern Congo Outcome Percentage of supported health facilities using MOH Kasai 2.8 QoC tool (contract deliverable) Katanga Eastern Congo Outcome 2.9 Percentage of population reporting improved Kasai (Standard: availability of selected services CDCS) Katanga Eastern Congo IR 2.1: Increased availability of quality, integrated facility-based health services Output 2.1.1 FP: Percent of USG-assisted service delivery sites Kasai (Standard) providing FP counseling and/or services Katanga Eastern Congo Output 95.7% 100% 100% 91% 91.2% 363,280 398,437 DHIS 2 MNCH: Percentage of pregnant women attending at Kasai 96.3% 100% 100% 92% 91.6% 152,001 166,018 DHIS 2 2.1.2 least one antenatal care (ANC) visit with a skilled Katanga 91.3% 100% 100% 86% 86.1% 109,201 126,793 DHIS 2 provider from USG-supported health facilities Eastern Congo 100.1% 100% 100% 97% 96.6% 102,078 105,626 DHIS 2 Outcome 75.4% 90% 90% 75% 83.1% 298,040 398,437 DHIS 2 MNCH: Percentage of deliveries with a skilled birth Kasai 82.6% 90% 90% 82% 90.9% 135,873 166,018 DHIS 2 2.1.3 attendant (SBA) in USG-supported facilities Katanga 69.6% 90% 90% 71% 79.0% 90,141 126,793 DHIS 2 Eastern Congo 70.7 90% 90% 68% 75.8% 72,026 105,626 DHIS 2 MNCH: Number of women giving birth who received Output 2.1.4 uterotonics in the third stage of labor (OR Kasai (PPR) immediately after birth) through USG-supported Katanga programs Eastern Congo Output 33,509 34,179 8,545 6,873 80.4% DHIS 2 2.1.5 MNCH: Number of newborns not breathing at birth Kasai 9,818 10,014 2,504 1,725 68.9% DHIS 2 (Standard/ who were resuscitated in USG-supported programs Katanga 14,450 14,739 3,685 3,110 84.4% DHIS 2 PPR) Eastern Congo 9,241 9,426 2,356 2,038 86.5% DHIS 2

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 59 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Output 1,121,703 1,144,137 286,034 281,585 98.4% DHIS 2 MNCH: Number of postpartum/newborn visits within Kasai 525,049 535,550 133,887 126,670 94.6% DHIS 2 2.1.6 three days of birth in USG-supported programs Katanga 336,949 343,688 85,922 88,111 102.5% DHIS 2 Eastern Congo 259,705 264,899 66,225 66,804 100.9% DHIS 2 Output 91.5% 100% 100% 93.2% 93.2% 268,584 288,214 DHIS 2 MNCH: Number and percentage of newborns 2.1.7 Kasai 91.8% 100% 100% 93.3% 93.3% 119,371 127,967 DHIS 2 receiving essential newborn care through USG- (CDCS) Katanga 89.7% 100% 100% 92.1% 92.1% 83,859 91,058 DHIS 2 supported programs Eastern Congo 93.2% 100% 100% 94.5% 94.5% 65,354 69,189 DHIS 2 Output 212,375 216,623 54,156 38,814 71.7% DHIS 2 MNCH: Number of newborns receiving antibiotic 2.1.8 Kasai 98,016 99,976 24,994 16,412 65.7% DHIS 2 treatment for infection from trained health workers (PPR) Katanga 89,734 91,529 22,882 17,698 77.3% DHIS 2 through USG- supported programs Eastern Congo 24,625 25,118 6,279 4,704 74.9% DHIS 2 Output 5.46% 5% 5% 6.8% 135.6% 18,783 276,995 DHIS 2 MNCH: Drop-out rate in DTP-HepB-Hib3 among Kasai 4.60% 4% 4% 6.0% 151.2% 6,791 112,319 DHIS 2 2.1.9 children less than 12 months of age Katanga 7.11% 6% 6% 8.5% 141.6% 7,378 86,829 DHIS 2 Eastern Congo 4.95% 4% 4% 5.9% 148.2% 4,614 77,847 DHIS 2 Output 2.1.10 NUTRITION: Number of individuals receiving Kasai (Standard/ nutrition- related professional training through USG Katanga PPR) supported nutrition programs Eastern Congo Output 2.1.11 NUTRITION: Number of children under-five (0-59 Kasai (Standard/ months) reached by USG-supported nutrition Katanga PPR) programs Eastern Congo Outcome NUTRITION: Number of children under two (0-23 2.1.12 Kasai months) reached with community-level nutrition (Standard) Katanga interventions through USG-supported programs Eastern Congo Output 1,043,172 1,064,035 266,009 DHIS 2 2.1.13 NUTRITION: Number of pregnant women reached Kasai 415,491 423,801 105,950 DHIS 2 (Standard/ with nutrition interventions through USG-supported Katanga 318,553 324,924 81,231 DHIS 2 PPR) programs Eastern Congo 309,128 315,311 78,828 DHIS 2 Output MALARIA: Number of health workers trained in IPTp Kasai 2.1.14 with USG funds Katanga Eastern Congo

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 60 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Output MALARIA: Number of health workers trained in case Kasai 2.1.15 management with ACTs with USG funds Katanga Eastern Congo Output MALARIA: Number of health workers trained in Kasai 2.1.16 malaria laboratory diagnostics (Rapid Diagnosis Tests Katanga (RDT) or microscopy) with USG funds Eastern Congo Output 126 150 0% TB: TB notification rate through USG- supported Kasai 126 150 0% 2.1.17 programs Katanga 156 150 0% Eastern Congo 94 150 0% Output 61,974 2.1.18 TB: Number of patients diagnosed with TB that have Kasai 28,508 (PPR) initiated first-line treatment. (PPR) Katanga 21,823 Eastern Congo 11,643 Output 64.7 95 TB: Therapeutic success rate through USG- supported Kasai 55.5 95 2.1.19 programs Katanga 76.7 95 Eastern Congo 63.7 95 Output 405 2.1.20 TB: HL.2.4-1 Number of multi-drug resistant (MDR) Kasai 190 (Standard) TB cases detected Katanga 158 Eastern Congo 57 Outcome 237 TB: Number of multi-drug resistant TB cases that have Kasai 130 2.1.21 initiated second line treatment Katanga 77 Eastern Congo 30 Output 75 89% TB: Therapeutic success rate for RR-/MDR-TB Kasai 75 96% 2.1.22 through USG- supported programs Katanga 75 81% Eastern Congo 75 90% Output 5,717 TB: Percentage of under five children who received Kasai 2,713 2.1.23 (or are receiving) INH prophylaxis through USG- supported programs Katanga 1,784 Eastern Congo 1,220

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 61 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Output 54% 100% TB: Percentage of new-enrolled HIV-positive patients Kasai 48% 100% 2.1.24 without TB who received (or are receiving) INH Katanga 59% 100% prophylaxis through USG- supported programs Eastern Congo 44% 100% Outcome 64.7% TB: Percentage of new-enrolled HIV-positive patients Kasai 55.5% 2.1.25 screened for TB through USG- supported programs Katanga 76.7% Eastern Congo 63.7% Output TB: Number of individuals trained in any component Kasai 2.1.26 of the World Health Organization Stop TB strategy Katanga with USG funding. Eastern Congo Outcome 8,318 8,318 2,080 1,743 83.8% 2.1.27 GBV: Number of women treated for gender-based Kasai 2,056 2,056 514 580 112.8% (PPR) violence. PPR. Katanga 599 599 150 119 79.5% Eastern Congo 5,663 5,663 1,416 1,044 73.7% Output 177 100 25 4 16.0% GBV: Number of surgical fistula repairs provided with Kasai 22 20 5 3 60.0% 2.1.28 USG-assistance Katanga 31 20 5 1 20.0% Eastern Congo 124 60 15 0 0.0% Output GBV: Number of surgical fistula repairs provided with Kasai 2.1.29 USG-assistance that remained closed after discharge Katanga Eastern Congo IR 2.2: Increased availability of quality, integrated community-based health services Output 2.2.1 FP: Number of USG-assisted community health Kasai (Standard workers (CHWs) providing FP information, referrals, Katanga PPR) and/or services during the year Eastern Congo Output Percent of target population who report that they are Kasai 2.2.2 able to access the basic health services available to Katanga their community (contract deliverable) Eastern Congo Impact Percent of citizens reporting improvement and equity Kasai 2.2.3 in service delivery of local level institutions with USG Katanga assistance (contract deliverable) Eastern Congo

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 62 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. Output Number of Integrated Community Case Management Kasai 2.2.4 (iCCM) sites in USG-supported communities Katanga (expected contract result) Eastern Congo Output Proportion of supervisory visits performed during the Kasai 2.2.5 quarter to relais Katanga Eastern Congo IR 2.3: Improved referral system from community-based platforms to health centers and reference hospitals Output Number of individuals referred to supported health Kasai 2.3.1 facilities by relais and CBDs (contract deliverable) Katanga Eastern Congo Output Number of individuals referred by relais/CBDs that Kasai 2.3.2 were received by supported health facilities Katanga (completed referrals) (expected contract result) Eastern Congo Output Number of women transported for facility delivery Kasai 2.3.3 (contract deliverable) Katanga Eastern Congo IR 2.4: Improved health provider attitudes and interpersonal skills at facility and community levels Output Average attitudes and interpersonal skills score as Kasai 2.4.1 measured by the Provider / User checklist at Katanga supported health facilities (expected contract result) Eastern Congo Output Number of supported facilities offering a package of Kasai 2.4.2 youth-friendly family planning services (contract Katanga deliverable) Eastern Congo Output Number of supported facilities offering a package of Kasai 2.4.3 comprehensive SGBV services (contract deliverable) Katanga Eastern Congo IR 2.5: Increased availability of innovative financing approaches Output Number of innovative financing tools piloted (contract Kasai 2.5.1 deliverable) Katanga Eastern Congo

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 63 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. IR 2.6: Improved basic facility infrastructure and equipment to ensure quality services Outcome 2.6.1 (Fee, Percentage of targeted health care facilities receiving Kasai CDCS) infrastructure and/or equipment support Katanga Eastern Congo Outcome 2.6.2 HL.8.1-1 Number of people gaining access to basic Kasai (Standard/ drinking water services as a result of USG assistance Katanga PPR) Eastern Congo Outcome 2.6.3 WASH: HL.8.2-2 Number of people gaining access to Kasai (Standard/ a basic sanitation service as a result of USG assistance Katanga PPR) Eastern Congo Outcome 2.6.4 WASH: HL.8.2-4 Number of basic sanitation facilities Kasai (Standard/ provided in institutional settings as a result of USG Katanga PPR) assistance Eastern Congo IR 2.7: Strengthened collaboration between central and decentralized levels through sharing of best practices and contributions to policy dialogue Output Number of knowledge sharing workshops supported Kasai 2.7.1 (contract deliverable) Katanga Eastern Congo Output Number of strategies / policies that have been updated Kasai 2.7.2 from good practices and lessons learned Katanga Eastern Congo Output N/A 36 9 2 22% Kasai N/A 16 4 2 50% 2.7.3 Number of success stories developed Katanga N/A 12 3 0 0% Eastern Congo N/A 8 2 0 0% RESULT 3: Increased adoption of healthy behaviors, including use of health services, in target health zones Outcome Percentage of USG-supported health zones that Kasai 3.1 demonstrate improvement in key accelerator behavior Katanga indicators Eastern Congo Outcome Percentage of children under age 2 living with the Kasai 3.2 mother who are exclusively breastfed, age 0-5 months Katanga Eastern Congo

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 64 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. IR 3.1: Increased practice of priority healthy behaviors at the individual, household, and community levels Project Output N/A N/A 100% 30.10% 22 73 Monitoring Report Project Kasai N/A N/A 100% 35.60% 16 45 Monitoring Percentage of health areas reached by Healthy Family Report 3.1.1 Fee Campaign SBC campaigns Project Katanga N/A N/A 100% 27.30% 3 11 Monitoring Report Project Eastern Congo N/A N/A 100% 17.60% 3 17 Monitoring Report IR 3.2: Increased use of facility- and community-based health services Output Percentage of trained community mobilizers active at Kasai 3.1.2 community level (contract deliverable) Katanga Eastern Congo Output Number of facilities providers trained in interpersonal Kasai 3.1.3 communication skills Katanga Eastern Congo Output Number of targeted communities that have access to Kasai 3.2.1 real-time information about availability of health Katanga services in their catchment areas (contract deliverable) Eastern Congo Project Output TBD 5 5 100% Monitoring Report Project Kasai TBD 3 1 100% Monitoring Number of awareness campaigns designed, Report 3.2.2 implemented, and evaluated with community Project participation. (contract deliverable) Katanga TBD 1 1 100% Monitoring Report Project Eastern Congo TBD 1 1 100% Monitoring Report

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 65 % Quarterly Achieved Percentage: Technical Areas, Illustrative Indicators Region 2017 2019 Achieved Sources Target Q2 Q2 Num. Denom. IR 3.3: Reduced socio-cultural barriers to the use of health services and the practice of key healthy behaviors Output Percentage of health areas reached by Healthy Family Kasai 3.3.1 Fee Campaign SBC events with messages disseminated Katanga targeting youth and other vulnerable groups per year Eastern Congo IR 3.4: Strengthened collaboration between central and decentralized levels through sharing of best practices and contributions to policy dialogue Percentage of CSO organizations participating in Output experience-sharing / lessons learned event held at the Kasai 3.4.1 ZS community participation day or provincial task Katanga force communication meetings Eastern Congo Note: There are minor discrepancies between some of the data in this table and the data shown in the MECC, due to rounding differences.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 66 ANNEX B: SUCCESS STORIES

1. Campaign brings family planning aid to community hubs

2. Hundreds receive testing and treatment at TB Villages

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 67 SUCCESS STORY Campaign brings family planning aid to community hubs

Three days of extensive In the Kalenda health zone—home to nearly a quarter-million people in Lomami province in the southern half of the Democratic campaigning brought family Republic of the Congo—the rate of contraceptive use is 4.2 planning services and percent, significantly below the national average of 19 percent. counselling to thousands in Habits, customs, and religious beliefs perpetuate a widespread fear the central community hubs that family planning methods will make women sterile. In January of Kalenda. 2019, only 642 people in the health zone signed up for contraceptive services. In late February and early March 2019, USAID supported the Provincial Health Division’s Health Family Campaign, which reached nearly 7,000 people in Kalenda. USAID’s Integrated Health Program (IHP) delivered technical and financial assistance for the campaign and its “advance strategy,” which took community health workers and nurses to the streets and community hubs for a series of health zone-wide outreach

Clément Tshibanda, Abt Associates Tshibanda,Clément Associates Abt activities.

Photo: IHPfor USAID On February 28, outreach began with a day-long training on key A community health worker speaks to family planning topics for influential members of the community, women and men at a local school to raise including 24 community health workers; 70 CODESA (health awareness about modern family planning committee) members; 30 village, school, and religious leaders; and methods. 24 young peer educators. This training of trainers taught community actors about different contraceptive methods, which “They always told me that they in turn shared with thousands of people during the health the methods were bad. zone campaign. For three days, this group of community health But I had the experience actors completed nine advance strategy sessions, 297 home visits, of giving birth every year. and 87 group discussion sessions in the community. I had been on [birth The advance strategy campaign targeted markets, schools, control] before and we churches, stadiums, traffic circles, and homes to spread awareness were able to space. When about family planning methods and provide on-site counselling to thousands of citizens. With this one-stop approach, a total of I stopped I had difficulties 6,924 attendees received a full range of convenient services at and today I am using the some of the busiest locations in Kalenda. Sayana Press again. It’s During the three-day campaign, 1,187 people adopted new family really beneficial.” planning practices, nearly doubling numbers from January. These new contraceptive users received services and products that included male and female condoms, oral contraceptives, health  Mrs. Mado Bitota counselling, and referrals for IUDs. The campaign referred 667 people to health clinics for modern contraceptive services—a Telling Our Story clear indicator of the campaign’s success in addressing U.S. Agency for International Development misinformation that prevents widespread uptake of family planning. Washington, DC 20523-1000 http://www.usaid.gov/results- data/success-stories

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 68 SUCCESS STORY Hundreds receive testing and treatment at TB Villages

Temporary “TB Village” Benoit Kabeya is a 49-year-old police officer living in the Dibindi posts in Kasaï-Oriental health zone in Kasaï-Oriental. Kabeya is responsible for ten children, but for more than two months, he suffered from a provided integrated and high- disruptive cough. Chest pains made nights painful, he had a fever quality health services to 554 every day, and he was rarely hungry. Despite taking modern and people and trained health traditional medicines immediately—including holy oil in church— practitioners to treat and he was not improving. diagnose TB. “One morning when I was beginning to despair, a community health worker came to my house and asked for an interview with my family. He told me that for a cough, even for a single day, I would have to go to the health center to get tested. I told him, but I have no money. He told me, it's free and you will have the results within an hour. He told me that the Ministry of Health, with the support of its partners, including the USAID Integrated Health Program, had organized a screening campaign in a place called a ‘TB Village.’"

From March 30 to April 1, 2019, the Ministry of Health established a TB Village in the Dibindi health zone, within the city of Mbuji- Photo: Marcel Makenga, Pathfinder International for International Pathfinder Makenga, Marcel Photo: IHP USAID Mayi. A TB Village is a temporary community-based health post Benoit Kabeya discusses testing procedures that offers free, quality treatment for tuberculosis—the most with a community health worker at the TB deadly infectious disease in the world—and treatment and Village site. screenings for ailments such as HIV/AIDS, malaria, diabetes, high blood pressure, and kidney failure. Community-implemented “This experience has awareness campaigns reached people at their homes and through allowed us to understand local media to encourage best health practices. that multi-drug-resistant USAID IHP helped the Kasaï-Oriental Provincial Committee for TB and sensitive TB are Tuberculosis Control recruit and train 20 community health prevalent in Mbuji-Mayi. workers on how to refer suspected TB cases. The training also We are interested in reached six supervisors and six laboratory technicians, who learned to collect samples from those suspected of having TB and continuing to ensure…the examine them using the sophisticated GeneXpert detection investigation of cases…to device. USAID IHP also helped transport samples from remote detect and take care of sites where there was no testing device. patients in time.” “Several other coughers were there. I gave my spit and the nurse told me that I had tuberculosis germs… The nurse told me that I Ms. Esperance Ngomba must be on treatment for six months. I told him, where would I Health Area Nurse find some money for this with a low salary? He told me, it's free!” Health workers in Kasaï-Oriental collected 554 samples from Telling Our Story throughout the health zone and found 15 TB-susceptible cases and U.S. Agency for International Development 2 cases of multi-drug-resistant TB, including Benoit Kabeya. Washington, DC 20523-1000 http://www.usaid.gov/results-data/success-stories

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 69 ANNEX C: DELIVERABLES SUBMITTED IN FY 2019 QUARTER 2

USAID IHP-DRC submitted the following deliverables during the second quarter of FY 2019.

Title of Deliverable Due Date Date Submitted Date Approved

Quarterly Performance Report February 14, 2019 February 14, 2019 March 22, 2019

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 70 ANNEX D: STAFF HIRED DURING FY2019 QUARTER 2

Position/Title Employee Name Gender Start Date Contractor Kinshasa Office Operations Manager Bertrand Solotshi M 23-Jan-19 Abt Associates Office Assistant Nadine Kinzola F 4-Mar-19 Abt Associates Child Health & Nutrition Wivine Mbwebwe F 2-Jan-19 IRC Advisor Kasaï Regional Office Kasaï-Central Province Office located in Kananga Sr. Regional M&E Manager Alex Bisinkam M 10-Jan-19 Abt Associates WASH & Renovation Engineer Michel Dibwe M 10-Jan-19 Abt Associates Bookkeeper Faustin Mafolo M 25-Mar-19 Abt Associates Admin. Assistant / Receptionist Marline Shampa F 18-Mar-19 Abt Associates Service Delivery Manager Christine Tshibwabwa Kapinga F 29-Jan-19 Pathfinder

Community Engagement Aimé Tshibanda Muteba M 14-Jan-19 Pathfinder Manager Community Engagement Anny Kaja Kazadi F 14-Jan-19 Pathfinder Specialist Community Engagement Germaine Sombamanya F 28-Jan-19 Pathfinder Specialist Mulunda Community Engagement Joseph Mputu Mbuama M 28-Jan-19 Pathfinder Specialist Service Delivery Specialist Alain Mulamba Mbuta M 28-Jan-19 Pathfinder Service Delivery Specialist Antoine Miaka Nedi M 28-Jan-19 Pathfinder Service Delivery Specialist Emmanuel Mulama Ntumba M 28-Jan-19 Pathfinder Kasaï-Oriental Province Office located in Mbuji Mayi DPS Capacity Building Advisor Ridier Mulolo M 14-Fev-19 Abt Associates Provincial M&E Manager Donat Mbale M 23-Jan-19 Abt Associates Accountant Nestor Kapenga M 25-Fev-19 Abt Associates Bookkeeper Constantin Mutombo M 4-Mar-19 Abt Associates Admin. Assistant / Receptionist Marie-Claire Awoy F 18-Fev-19 Abt Associates Security Officer Ruphin Kanda M 25-Fev-19 Abt Associates Francois Ilunga Driver M 4-Fev-19 Abt Associates Community Engagement Donat Ngoie Wa Lusamba M 14-Jan-19 Pathfinder Specialist Community Engagement Rose Kiabu Katompa F 28-Jan-19 Pathfinder Specialist

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 71 Position/Title Employee Name Gender Start Date Contractor Service Delivery Specialist Marcel Makenga Ntumba M 14-Jan-19 Pathfinder Service Delivery Specialist Fidelie Leonie Mbuyi Mukendi F 28-Jan-19 Pathfinder Lomami Province Office located in Kabinda M&E Manager Jean Mutombo M 10-Jan-19 Abt Associates EEI/HSS Specialist Pepin Kayamba M 3-Jan-19 Abt Associates EEI/HSS Specialist Clement Kalombo M 11-Fev-19 Abt Associates Accountant Therese Matunga F 20-Mar-19 Abt Associates Community Engagement Clément Tshibanda Kayembe M 14-Jan-19 Pathfinder Specialist Community Engagement Olive Mudimbiyi Lubo Lubo F 28-Jan-19 Pathfinder Specialist Service Delivery Specialist Teddy Mutebwa Ngandu M 14-Jan-19 Pathfinder Service Delivery Specialist Yvonne Ngudia Mitongu F 28-Jan-19 Pathfinder Sankuru Province Office located in Lodja M&E Manager Maurice Pong-i-yol' bin Kengel M 21-Jan-19 Abt Associates Bookkeeper Carine Ndjoka F 21-Mar-19 Abt Associates Admin. Assistant / Receptionist Henriette Olenga F 27-Mar-19 Abt Associates Driver Leon Ankese M 18-Fev-19 Abt Associates Community Engagement Jules Lomasa Okoka M 14-Jan-19 Pathfinder Specialist Community Engagement Jean-Benoît Kalambi Dibue M 28-Jan-19 Pathfinder Specialist Service Delivery Specialist Benjamin Kinombe Oyombo M 28-Jan-19 Pathfinder Service Delivery Specialist Jean-Benoît Mutshe Kayungu M 28-Jan-19 Pathfinder Eastern Congo Regional Office South Kivu Province Office located in Bukavu Driver Dodo Ilowa M 1-Mar-19 Abt Associates WASH & Renovation Engineer Paul Vumpa M 1-Mar-19 Abt Associates EEI/HSS Specialist Jean-Claude Lolale M 24-Jan-19 Abt Associates EEI/HSS Specialist Jimmy Kamathe M 24-Jan-19 Abt Associates Sr. Regional Accountant Elizabeth Maroti F 20-Mar-19 Abt Associates Bookkeeper Virginie Kinja F 18-Mar-19 Abt Associates Driver Evariste Kabala M 30-Jan-19 Abt Associates Service Delivery Manager Rose Bokashanga F 2-Jan-19 IRC Community Engagement James Songa Abwe M 18-Feb-19 IRC Manager

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 72 Position/Title Employee Name Gender Start Date Contractor Service Delivery Specialist Seraphin Birindwa Mushagalusa M 18-Feb-19 IRC Service Delivery Specialist Albert Rushingwa Bahati M 18-Feb-19 IRC Service Delivery Specialist Gisèle Munganga Furaha F 1-Mar-19 IRC Community Engagement Chirhalwirwa Naweza F 18-Feb-19 IRC Specialist Parfaitine Community Engagement Xavier Ntugulo Lukananda M 22-Feb-19 IRC Specialist Community Engagement Dieudonné Cigajir'omwirhwe M 26-Feb-19 IRC Specialist Rugendabanga Contract Coordinator Benjamin Mafundiko Metre M 1-Mar-19 IRC Finance Officer Osee Lusmabya Lubakila M 14-Mar-19 IRC Security Officer Philippe Ntumba M 18-Mar-19 IRC Uvira Branch Office EEI/HSS Specialist Deddy Ntumbak M 18-Jan-19 Abt Associates Community Engagement Josué Mabaya Mugaruka M 18-Feb-19 IRC Specialist Community Engagement John Majaribu Ruchumuka M 18-Feb-19 IRC Specialist Service Delivery Specialist Iyungamo Samamba Isa M 18-Feb-19 IRC Service Delivery Specialist Théophile Bangana Kinyunyi M 18-Feb-19 IRC Cashier Julienne Matabaro F 4-Mar-19 IRC Tanganyika Province Office located in Kalemie M&E Manager Claude Kasongo M 15-Jan-19 Abt Associates DPS Capacity Building Advisor Raphael Ilunga M 11-Fev-19 Abt Associates Accountant Jean-Paul Itshu M 27-Fev-19 Abt Associates Bookkeeper Joyful Akilimali M 1-Mar-19 Abt Associates Admin. Assistant /Receptionist Antoinette Safinia F 4-Mar-19 Abt Associates Community Engagement Liliane Kivira Kalumendo F 18-Feb-19 IRC Specialist Community Engagement Albert Ntumba Mangala M 18-Feb-19 IRC Specialist Service Delivery Specialist Kazadi Mbuyi Sophie F 21-Feb-19 IRC Katanga Regional Office Haut-Katanga Province Office located in Lubumbashi Driver Jean-Petit Kwesele M 1-Mar-19 Abt Associates DPS Capacity Building Advisor Bruno Kapinga-Mulume M 16-Jan-19 Abt Associates Sr. Regional M&E Manager Erick Tshikamba M 14-Mar-19 Abt Associates

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 73 Position/Title Employee Name Gender Start Date Contractor Senior Accountant Leandre Sangu M 14-Mar-19 Abt Associates Driver François Lukusa M 18-Mar-19 Abt Associates Service Delivery Manager Jean Paul Kasongo M 2-Jan-19 IRC Community Engagement Luc Mweze Masirika M 27-Feb-19 IRC Manager Service Delivery Specialist Munihuzi Byenda Jean-Pierre M 18-Feb-19 IRC Service Delivery Specialist Daniel Omambo Dimandia M 20-Feb-19 IRC Service Delivery Specialist Valance Ilunga Mwilambwe F 5-Mar-19 IRC Community Engagement Augustin Kabongo Nkumbi M 25-Feb-19 IRC Specialist Community Engagement Cryspin Mboyi Mulumba M 18-Feb-19 IRC Specialist Community Engagement Gaston Mutengi Muvudi M 28-Feb-19 IRC Specialist Senior HR Officer Esther Birhega F 1-Mar-19 IRC IHP Finance Lead Marius Mie Toko Mubo M 25-Mar-19 IRC Haut Lomami Province Office located in Kamina M&E Manager Paul-Hubert Muyunga M 6-Fev-19 Abt Associates Accountant Rodrigue Kabila M 27-Fev-19 Abt Associates Admin. Assistant / Receptionist Ruth Kyeusi F 27-Mar-19 Abt Associates Bookkeeper Mita Mitalalo M 18-Fev-19 Abt Associates Finance Officer Christian Kakudji Ngoy M 18-Feb-19 IRC HR Officer Mathys Numbi Wa Kasongo M 8-Mar-19 IRC Community Engagement Nsosa Ndaba Fils M 25-Feb-19 IRC Specialist Service Delivery Specialist Olongo Kinyamba Paul M 18-Feb-19 IRC Lualaba Province Office located in Kolwezi Lualaba Provincial Director Jean Ngoyi M 21-Fev-19 Abt Associates Lualaba Provincial Operations Joly Nshimba F 18-Fev-19 Abt Associates Manager DPS Capacity Building Advisor Cedric Kikuni M 26-Fev-19 Abt Associates M&E Manager Stanley Musumba M 20-Mar-19 Abt Associates Accountant Shabani Pauni M 25-Mar-19 Abt Associates Admin. Assistant / Receptionist Pamela Mpawoto F 4-Mar-19 Abt Associates Driver Didier Mutshaila M 4-Mar-19 Abt Associates Finance Officer Mamy Manyonga F 7-Jan-19 IRC

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 74 Position/Title Employee Name Gender Start Date Contractor HR Officer Mireille Muntumpe F 1-Mar-19 IRC Community Engagement Kangilo Sala Laetitia F 19-Feb-19 IRC Specialist Community Engagement Patrick Nduwa Kameya M 1-Mar-19 IRC Specialist Service Delivery Specialist Jonas Kabamba Tshibangu M 18-Feb-19 IRC TOTAL 109

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 75 ANNEX E: ENVIRONMENTAL MITIGATION AND MONITORING REPORT ANNEX E: ENVIRONMENTAL MITIGATION AND MONITORING REPORT

PROJECT/ACTIVITY DATA

Project/Activity Name: USAID’s Integrated Health Program (USAID IHP) Geographic Location(s) (Country/Region): Democratic Republic of the Congo Implementation Start/End Date: May 26, 2018–May 29, 202510 Contract/Award Number: 72066018C02001 Implementing Partner(s): Rio Malemba, Abt Associates Tracking ID: Tracking ID/link of Related EMMP: Tracking ID/link of Related IEE: DRC_Health_Portofolio_IEE: https://ecd.usaid.gov/repository/pdf/45611.pdf Tracking ID/link of Other, Related Analyses:

ORGANIZATIONAL/ADMINISTRATIVE DATA Implementing Operating Unit(s): USAID/Democratic Republic of the Congo (e.g., Mission or Bureau or Office) (USAID/DRC) Lead BEO Bureau: Prepared by: Date Prepared: Submitted by: USAID’s Integrated Health Program Date Submitted: May 15, 2019

ENVIRONMENTAL COMPLIANCE REVIEW DATA

Analysis Type: EMMR Additional Analyses/Reporting Required Water Quality Assessment Plan

PURPOSE

Environmental Mitigation and Monitoring Reports (EMMRs) are required for USAID-funded projects when the 22CFR216 documentation governing the project imposes conditions on at least one

10 Due to a stop work order, the Program did not start until May 26, 2018.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 76 project/activity component. EMMRs ensure that the ADS 204 requirements for reporting on environmental compliance are met. EMMRs are used to report on the status of mitigation and monitoring efforts in accordance with Initial Environmental Examination (IEE) requirements over the preceding project implementation period. They are typically provided annually, but the frequency will be stipulated in the IEE. Responsibility for developing the EMMRs lies with USAID, but EMMRs are usually prepared by the Implementing Partner and submitted to USAID.

SCOPE

The following EMMR documents the mitigation measures implemented as detailed in the project Environmental Mitigation and Monitoring Plan (EMMP), challenges encountered, and corrective actions taken. It describes the status of each required mitigation measure as stipulated in the EMMP and provides a succinct update on progress regarding the implementation and monitoring of the EMMP. These are the intervention activities that we anticipate. Each of these activities received categorical exclusion and negative determination based on what this activity involves.

CATEGORICAL NEGATIVE POSITIVE INTERVENTION CATEGORY EXCLUSION(S) DETERMINATION(S) DETERMINATION(S)

1. Studies, surveys/public health surveillance, and other data-gathering assessments, models, and capacity-building in support of all areas above; X X dissemination of resulting information/ lessons learned/ best practices

2. Healthcare provider training; health care X X workforce strengthening and development

3. Direct and capacity building support for health service delivery and access to health services, X X excluding commodity procurement/supply chain strengthening

4. Procurement, storage, management, distribution, and disposal of medical and X X pharmaceutical commodities

5. Social and behavior change communication X

6. Small-scale water supply and sanitation X X

7. Construction other than water/sanitation X X infrastructure

8. Technical support to indoor residual spraying X X

9. Policy and strategy development X X

Those activities that have negative determination with conditions activate the need for the EMMP. The EMMP elucidates impacts that may be expected from USAID IHP and mitigation efforts to eliminate or minimize those potential impacts; it also describes the system for monitoring implementation of the mitigation measures. During the life of the project, if activities are developed that include potential environmental impacts not anticipated here, the EMMP will be amended to address and mitigate them. A major environmental concern about health projects such as USAID IHP is the proper disposition of wastes generated from health facilities. These wastes include:

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 77  General health care waste, which is similar or identical to domestic waste, including materials such as packaging or unwanted paper. This waste is generally harmless and needs no special handling; 75–90% of waste generated by health care facilities falls into this category.  Hazardous health care waste, which includes infectious waste (except sharps and waste from patients with highly infectious diseases), small quantities of chemicals and pharmaceuticals, and non-recyclable pressurized containers.  Highly hazardous health care waste, which includes sharps, highly infectious non-sharp waste, stools from cholera patients, bodily fluids of patients with highly infectious diseases, large quantities of expired or unwanted pharmaceuticals and hazardous chemicals and radioactive wastes, genotoxic wastes (affecting genetic composition and multiple generations), or teratogenic wastes (affecting development of the exposed individual). (http://www.usaidgems.org/Sectors/healthcareWaste.htm) Particularly in developing countries, it can be difficult to identify facilities for proper disposal, and sensitivity of the need for proper disposal is often lacking. Storing pharmaceutical and medical commodities poses challenges as well, particularly special storage temperature requirements and expiration dates. Over-ordering or an unexpected reduction in demand can each result in expired pharmaceuticals that must be properly disposed of. Care must be taken to ensure security during storage of pharmaceuticals and commodities, to guard against losses and improper usage. Pharmaceuticals must be protected from contamination from incompatible materials stored in close proximity to them. Sub-grant activities can cover a wide range of interventions and the environmental compliance requirements will vary accordingly. Environmental Review Forms must be completed to gauge the potential environmental impacts of the contemplated activities under the grant and to develop mitigation strategies and plans. Due diligence must be performed on the grantee to confirm that they have the institutional knowledge, capacity, and will to perform within environmental compliance standards. Training must be provided and ongoing monitoring and inspection will likely be necessary. Much like the sub-grant activities discussed above, funding the acquisition of medical equipment for use by others can carry a broad set of concerns, including misuse and improper disposal. Care must be taken to perform due diligence to confirm the acquiring institution has the ability to use the equipment correctly and safely, receives the required training, and has the orientation and commitment to dispose of it properly. Another major concern that could arise from USAID IHP involves the small-scale construction and/or rehabilitation of existing facilities. Risks include construction methods that lead to contaminated runoff entering water resources; demolition of facilities containing hazardous substances, such as asbestos or lead piping; increased traffic from upgraded facilities leading to environmental degradation; and increased demand for water, sanitation, and hygiene (WASH) infrastructure, leading to environmental contamination if such facilities are not well-planned. There are distinct guidelines and requirements for rehabilitation of facilities delivering health care services, serving as diagnostic laboratories, or providing practical or lab-based health training, and for other types of buildings. Both types are represented and dealt with in the EMMP. The construction of water and sanitation systems is also contemplated under this project; such work has an extensive set of requirements to ensure the supply of sufficient water quantity and quality without compromising existing uses of source water. Proper location of facilities, use of appropriate materials, methods of purification, and maintenance of equipment must also be taken into consideration. Trainings on system operation and maintenance must also be provided.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 78 Insecticide-treated nets generate waste streams upon initial distribution and disposal. This waste must be managed according to World Health Organization best practices to avoid negative impacts on the environment—and possibly on human health. Office management and supply can also have negative impacts on the physical and social environment. Low-energy lighting and equipment must be preferentially purchased, and waste minimization and disposal must be planned and executed. Transportation of personnel and supplies must be carefully coordinated to minimize fuel usage and emissions.

USAID REVIEW OF EMMR

[The routing process and associated signature blocks may be customized by Bureau or Mission. Please follow Bureau- or Mission-specific guidance. Include signature blocks in accordance with Bureau and/or Mission policy. At a minimum include the noted required signatures. Add other signatures as necessary.] Approval: [NAME], Activity Manager/A/COR [required] Date

Clearance: [NAME], Mission Environmental Officer [as appropriate] Date

Clearance: [NAME], Regional Environmental Advisor [as appropriate] Date

Concurrence: [NAME], ______Bureau Environmental Officer [required] Date

DISTRIBUTION: [Distribution lists may be customized by Bureau or Mission. Please follow Bureau- or Mission-specific guidance.]

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 79 PROJECT/ACTIVITY SUMMARY

The goal of USAID’s Integrated Health Program (USAID IHP) is to strengthen the capacity of Congolese institutions and communities to deliver high-quality, integrated health services that sustainably improve the health status of the Congolese population. The Program builds on previous health investments in the Democratic Republic of the Congo (DRC), USAID’s Country Development Cooperation Strategy (CDCS), and related Government of the DRC (GDRC) strategies and policies. The Program provides support to empower zones de santé (ZS) and sustainably improve the ability of the DRC’s health system to deliver quality services in reproductive health and family planning; maternal, neonatal, and child health; nutrition; tuberculosis; malaria; WASH; and supply-chain services. Cross- sector areas of program focus include gender equity, conflict sensitivity, capacity building, and climate risk mitigation and environmental mitigation and monitoring. The Program aims to strengthen both facility-level and community-level primary health care platforms, including provincial administrative authorities and local organizations. USAID IHP operates in nine provinces, operationally grouped in three regions: Eastern Congo (Sud-Kivu and Tanganyika); Kasaï (Kasaï-Central, Kasaï-Oriental, Lomami, and Sankuru); and Katanga (Haut-Katanga, Haut-Lomami, and Lualaba). The implementation of USAID IHP is subject to the requirements of the USAID/DRC Health Office Portfolio IEE (https://ecd.usaid.gov/repository/pdf/45611.pdf), which examined the proposed activities of the portfolio and assigned to each activity a threshold determination. These include Categorical Exclusion, indicating no expected environmental impact; Negative Determination with Conditions, signifying that possible environmental impacts can be mitigated by use of particular methods or actions; and Positive Determination (likely to have an impact on the environment). Please see table below for results.

INSTRUCTIONS

No Bureau-specific EMMR requirements have been communicated.

MANAGEMENT STRUCTURE FOR ENVIRONMENTAL COMPLIANCE

As announced in Quarter 1 Report, the organization of the mitigation measures is now the full responsibility of the technical teams. USAID IHP WASH Advisor has taken the lead in organizing the integration of the mitigation measures into the overall activities of the program. Several activities are still in their early implementation stages and few activities require specific attention to mitigation measures proposed in the EMMP. The Program’s WASH Advisor will coordinate and supervise environmental compliance. WASH and Renovation Engineers (one in each region: Eastern Congo, Kasaï, and Katanga) will have specific responsibilities in conjunction with their responsibilities regarding renovations and WASH installations. The technical staff has been sensitized to the need to be familiar with environmental compliance requirements, but more work needs to be done to fully integrate the ownership of the design and implementation of the mitigation measures. The Director for Health Services and the Health Systems Strengthening (HSS) Advisor have started their collaboration with the WASH Advisor on environmental compliance, but this still needs to be translated into activities that become part of a work plan. They will report to their line manager (the Deputy Chief of Party), while overall reporting responsibility lies with the Chief of Party.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 80 MONITORING AND REPORTING FOR ENVIRONMENTAL COMPLIANCE

As per Africa and Global Health Bureau-approved Environmental Mitigation and Monitoring Plan.

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 81 EMMR TABLE FOR USAID IHP

OUTSTANDING ISSUES PROJECT/ACTIVITY/SUB- STATUS OF MITIGATION RELATING TO REMARK ACTIVITY MEASURES REQUIRED CONDITIONS Education, technical Training /supervision tools in No outstanding Introduce activities in the assistance, training to different program areas address issues identified work plan improve access to and appropriate management yet delivery of health care. practices (e.g. immunization, tuberculosis testing; malaria RDT)

No systematic review done of all existing curricula and training curricula and training programs.

No systematic review yet of the different checklists or job aids. Procurement, storage, and IHP USAID’s role will be Mitigation measures management of public health focused on supply chain encompass procurement, commodities, including strengthening from district to supply, distribution, pharmaceuticals and supply facilities storage, management chain strengthening activity. comprehensively. MOH training and supervision guidelines exist This should be translated in pragmatic, doable set of Such routine systems have low measures. performance, since no resources are allocated to them.

USAID IHP supply chain activities were very limited in Q2 Funding private sector No mitigation measures acquisition of diagnostic and required since no such treatment equipment. acquisition in the pipeline yet Very small-scale No mitigation measures construction or required since no such activity rehabilitation (less is underway than1000m2 total disturbed area) with no complicating factors. Small-scale construction. No mitigation measures required since no such small scale construction is underway

USAID IHP: FY2019 QUARTERLY REPORT 2 USAID.GOV | 82 Provision of long-lasting Some distribution has started; insecticidal nets for vector Health care providers inform control. mothers who receive LLINs on their use. No supervision of this training of mothers was conducted or supported Sub-grant activities. No mitigation measures required since no such sub- grant activities are underway Construction and WASH activities focused on From Q3 onwards WASH improvement of water and design of assessment tools, interventions are now a sanitation systems. negotiation with partners sites priority, given that the of interventions results to date are insignificant Office management and Some suppliers collect supply. electronic waste, such as used printer cartridges. -the offices installed water fountains to reduce the use of water bottles and thus reduce plastic waste. -Electric hand dryers will be used in the Kinshasa office’s bathrooms to reduce paper waste. -Staff is printing double-sided documents to reduce paper use and thus paper waste.

Transportation of personnel -The staff is being encouraged and supplies. to walk for short destinations.

-Some vehicles are fuel inefficient. Their use is kept to a minimum

[Add / remove rows as needed]

ADDITIONAL COMMENTS

USAID IHP-DRC: FY2019 QUARTERLY REPORT 2 USAID. GOV | 83 Add comments as needed

USAID IHP-DRC: FY2019 QUARTERLY REPORT 2 USAID. GOV | 84