IFPP - Integrated Family Planning Program

Agreement No. #AID-656-A-16-00005

Yearly Report:

Oct 2017 to September 2018 - 2nd Year of the Project

Table of Contents Acronym list ...... 3 Project Summary ...... 6 Summary of the reporting period (October 2017 to September 2018) ...... 7 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services 11 Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based FP/RH services ...... 11 Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based FP/RH services ...... 23 Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services ...... 28 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services ...... 29 Sub IR2.1: Improved ability of individuals to adopt healthy FP behaviors...... 29 Sub-IR 2.2: Improved community environment to support healthy FP behaviors ...... 31 Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions ...... 34 IR 3: Strengthened FP/RH health systems ...... 34 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution ...... 34 Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment ...... 38 Sub-IR 3.4: Improved government capacity to increase supply, distribution, and retention of skilled workers ...... 39 Sub-IR 3.5: Improved generation, dissemination, and use of FP data for more effective decision- making ...... 39 Project Performance Indicators ...... 45 Goal: Increase use of modern contraceptive methods ...... 45 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services 45 Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based ...... 48 Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based ..... 49 Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services ...... 49 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services ...... 49 Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors ...... 49 Sub-IR 2.3: Improved systems to implement and evaluate SBCC interventions ...... 50

IR 3: Strengthened FP/RH health systems ...... 51 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution ...... 53 Sub-IR 3.2: Improved management of commodities to ensure availability at local levels ...... 54 Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment ...... 54 Sub-IR 3.4: Improved government capacity to increase supply, distribution, and retention of skilled workers ...... 55 Sub-IR 3.5: Improved generation, dissemination, and use of FP data for more effective decision- making ...... 55 Collaboration with other donor projects ...... 56 Upcoming Plans ...... 56 IR 1: ...... 56 IR 2: ...... 57 IR 3: ...... 57 Annexes ...... 58 Annex A - Success story...... 58 Community Score Cards (CSC) process implemented successfully in Cheringoma district - Sofala province...... 58 Annex IA – Management Systems Compliance Assessments: Nampula Province ...... 61

Acronym list Acronym Description APE Agente Polivalente Elementar – Ministry of Health Approved Community Health Worker ART Antiretroviral Treatment CBOs Community Based Organizations CDCS Country Development Coordination Strategy CDFMP Cenário de Despesas Fiscal de Médio Prazo (Midterm Fiscal Review) CF Community Facilitator CHW Community Health Worker (including APEs, PTs, other health activists) CIHO Communication for Improved Health Outcomes CL Community Leader CLC Community Leader Council (at village level) – “Conselho de Lideres Comunitarios” CLL Locality’s local council (covering an area of approximately 20 villages) – “Conselho Local da Localidade” CMAM Central de Medicamentos e Artigos Médicos (National Drugs, Commodities and Supplies Warehouse) CPR Contraceptive Prevalence Rate CR Community Radio CSC Community Score Card CYP Couple Year Protected DDM Depósito Distrital de Medicamentos (District Medications Depot) DEPO/DMPA- Depo-Provera IM DMPA-SC Sayana Press DP District profile DPM Depósito Provincial de Medicamentos (Provincial Medications Depot) DPS Provincial Health Directorate EMMP Environmental mitigation and monitoring plan EPC Escola Primaria Completa – Primary School - 6th and 7th grade FP Family Planning FP/RH Family planning/reproductive health FS Field Supervisors FTP First Time Parents GIS Geographic Information System GRM Government of the Republic of Mozambique HCW Health Care Worker HF Health Facility HMIS Management Information System HP Health Provider HR Human Resources HRIS Human Resources Information System HSS Health Systems Strengthening

HTSP Health Timing and Spacing of Pregnancy IEE Initial Environmental Examination IFPP Integrated Family Planning Program IMASIDA National Malaria and HIV Indicator Survey IPC Interpersonal Communication Agents IT Information Technology IUD Intrauterine Device LARC Long Acting Reversible Contraceptive LOE Level of Effort LOP Life of Project LTM Long Term Method M&E Monitoring and Evaluation MB Mobile Brigade MCH Maternal and Child Health mCPR Modern Contraceptive Prevalence Rate MCSP Mother and Child Survival Program MISAU Mozambican Ministry of Health MOU Memorandum of Understanding MSC Management Standards Compliance NED District Statistical Nucleus NGOs Non-governmental Organizations NHS National Health System OC Oral Contraceptives OVC Orphans and Vulnerable Children PDSA Plan, Do, Study, Act PES Social and Economic Plan PESOD District Operational Social and Economic Plan PHD Provincial Health Directorate PMP Performance Monitoring Plan PSI Population Services International PPIUD Post-Partum IUD TA Technical Assistance TBA / “PT” Traditional Birth Attendant / “Parteira Tradicional” QI Quality Improvement RDQA Routine Data Quality Audit SAAJ Serviços Amigos dos Adolescentes e Jovens (Youth Friendly Services - YFS) SAPERS-CPF Sistema de Alerta Precoce para Evitar Roturas de Stock dos Consumíveis de Planeamento Familiar, or Early Warning System to Avoid Stock Outs of Family Planning Commodities SBCC Social and Behavioral Change Communication SDP Service Delivery Point

SDSMAS District Health Welfare and Women Directorate SGBV Sexual and Gender-Based Violence SIFo Training Information System SISLOG Sistemas e Tecnologias - Gestão de Clientes (Local Digital Technology Company) SIS-MA Sistema de Informação em Saúde – Monitoria e Avaliação (HMIS) SMATG-CPF Sistema Móvel de Assistência Técnica para Gestão dos Consumíveis de Planeamento Familiar, or System for Mobile Management of Family Planning Commodities SOPs Standard Operating Procedures SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health Rights STM Short Term Method TBAs Traditional Birth Attendants TEM+ “TEM mais” – Private clinic network ToR Terms of Reference TOT Training of Trainers TSO Technical Support Officers USAID United States Agency for International Development USAID AOR Agreement Officer’s Representative (USAID) USG United States Government WRA Women of Reproductive Age YFHS Youth-Friendly Health Services

Project Summary

Project Title: IFPP - Integrated Family Planning Program Duration: 5 years Start Date: June 2016 Life of project funding: $ 34,560,000 Geographic Focus: Nampula and Sofala provinces The Integrated Family Planning Program (IFPP) is a five-year USAID/Mozambique funded initiative to increase use of modern contraceptive methods by target populations in all 36 districts in Nampula and Sofala provinces in Mozambique. The IFPP responds to the United States Government (USG) strategy for development and foreign assistance in Mozambique through the Country Development Coordination Strategy (CDCS). The USAID/Mozambique CDCS outlines an overarching development objective health goal to “Improve the Health Status of Target Populations” through three results: 1) Increased coverage of high impact health and nutrition services, 2) Increased adoption of positive health and nutrition behaviors, and 3) Strengthened systems to deliver health, nutrition, and social services (CDCS, 2013).

In alignment with this goal and these results, IFPP aims to support the Government of the Republic of Mozambique (GRM) and Ministry of Health (MISAU) priorities and increase the use of modern contraceptive methods by target populations through three intermediate results: 1) Increased access to a wide range of modern contraceptive methods and quality family planning/reproductive health (FP/RH) services, 2) Increased demand for modern contraceptive methods and quality FP/RH services, and 3) Strengthened FP/RH health systems. Under IFPP, the three intermediate results (IRs) are integrated and mutually reinforcing. Activities under IR1 increase the quality of service delivery at facility and community level, activities under IR2 generate demand for those services and link the community with the facility. The health system strengthening activities proposed under IR3 are cross-cutting and support the sustainability and institutionalization of the service delivery improvement efforts (IR1) and demand generation interventions (IR2), and interact with IR2 activities to increase the community involvement in health system accountability.

IFPP aims to reach women with a particularly high unmet need for family planning (FP), namely: postpartum women; women living with HIV; adolescents, including orphans and vulnerable children (OVC); medium- and high-parity women; and post-abortion women. Additionally, IFPP recognizes that increasing the uptake of contraception in Mozambique requires shifting inequitable gender norms. Therefore, men and boys, alongside other key influencers, are meaningfully and systematically engaged throughout all intervention areas and intervention packages.

The project is led by Pathfinder International with a team of global and local partners—N’weti, Population Services International (PSI), and Abt Associates.

Summary of the reporting period (October 2017 to September 2018)

During FY2, the project continue to operationalize a phased roll-out strategy coupled with a quick win approach by prioritizing geographies1 that quickly generated new contraceptive users while simultaneously laying the groundwork for sustainable norm change and family planning/reproductive health (FP/RH) systems strengthening. Continuing to apply this strategy in FY2 was essential to the success of IFPP, as it allowed the project to sustain the quick wins of FY1, demonstrate results that engendered commitment from MISAU, DPS, Serviços Distritais de Saúde Mulher e Acção Social (SDSMAS), and community stakeholders, while at the same time additional activities were introduced contributing to high quality FP/RH services and strengthening of both, demand for FP and FP systems. The rural accessibility to FP services is progressively increasing as hard to reach HFs are integrated in the IFPP intervention, as APEs are covering more women with FP services and more mobile brigades are being carried out on a regular schedule. More FP mobile brigades are targeting secondary schools, as well as the 6th and 7th schooling years. The mCenas digital platform was launched in five secondary schools of Nampula province this June.

In Q1FY2, the roll-out of the cascade family planning (FP) training focus to cover harder to reach health facilities (HFs), increasing the percentage of HFs directly supported by IFPP from 68% at end of FY1 to 92% of all HFs from both provinces at end FY2; the number of health providers trained in IFPP integrated family planning modules reached 3,327 at end FY2, involving 1,018 additional HP in FP activities. Sixty- two facility-based-eight-days integrated FP trainings were carried out during FY2, each involving, in average 16 trainees per training ensuring an high level of trainee’s participation in theoretical and practical sessions. The first IFPP challenge to rapidly involve all HF is on the edge to be won by IFPP.

The second IFPP challenge is to maintain the highest number possible of trained health providers (HP) (3,327 since inception) offering pro-active FP services through their daily activities; in order to contribute to this challenge, IFPP has mentored 2,509 HPs and observed 16,596 task’s checklists against 7,359 during FY1. To strengthen the post-partum family planning (PPFP) buy-in by HF’s teams and as high disparities in post-partum IUD (PPIUD) / PPFP offering were noted between the HFs - some HFs attending very high numbers of deliveries and having low capacities in PPIUD / PPFP offering - IFPP has carried out in close collaboration with the Provincial Health Directorate (PHD), four Implementation Science Learning “Optimization” workshops involving the heads of the HF maternity ward and HFs’ directors of 41 selected HFs to boost the low ones offering more consistently PPFP, isolating key inhibiting and facilitating factors driving program post-partum IUD and implant service provision within maternity wards. The IFPP technical team had the active support of the SDSMAS and DPS of both provinces as 220 HF were supervised jointly in FY2. Integrated supervision visits are important as they

1 Starting with high volume facilities (≥ 80 deliveries per month) as one of high unmet need and untapped client pool are the Post-Partum women.

7 boost adoption of new comportment and increase ownership of the MoH FP strategy and consequently the sustainability of the FP program.

The third IFPP challenge was to expand the contraception method mix, within this context, IFPP had a leading role in the national training of trainers (TOT) held in Beira to introduce Implanon NXT as well as in the roll-out of the Implanon NXT cascade trainings at district level in both provinces. Furthermore, IFPP supported three mini-laparotomy trainings to perform tubal ligation under local anesthesia in Nampula province involving Health Providers (HP) coming from eight different districts - in total 225 mini-laparotomy were offered between March and September of this year in Nampula province – an encouraging result.

IFPP supported Contraception Week and the MCH National Health Week in all 36 districts through the demand creation component, and contributed the stipend for human resources as well as supported needed transportation (cars and motorbikes). Contraception Week was planned and organized with a special focus on adolescents; the 10 to 14 and the 15 to 19 age groups represented 7% and 30% respectively, of the first reproductive health consultations during Contraception Week in Nampula province. IFPP focused on creating the proper conditions to offer the full MOH method mix to all age groups. Consequently, the FP indicators peaked-up in Q1FY2 but the data may have been over-reported and should be taken with caution, nevertheless the CYP trends per quarter from inception to today are very encouraging as quarterly CYP has progressively increased from 147,351 in Q2FY1 to 340,624 in Q4FY2.

IFPP provincial and district coordinators and HSS imbedded technical assistance (TA) at DPS level have sustained a high level of commitment in pursuing the integration of the three IFPP tiers - the health system strengthening (HSS), the demand creation, and the service delivery components - participating in more management standard compliance reviews and ‘district profile’2 meetings, as well as participating in more community health promotion activities such as community dialogues, village health committees, and HF co-management committees.

During FY2, the IFPP demand generation component pursued the Community Score Card (CSC) activity in the 14 selected HFs’ catchment areas identified as the ones experiencing difficult community-HF relationship, involving SDSMAS, DPS, CBOs, HF providers, and community facilitators. Meetings with additional Locality’s local councils (CLLs) were carried out targeting the ones more reluctant in FP awareness activities: CLs are more and more involved in FP sensitization and demystification of myths and taboos. Three thousand two hundred twenty six community dialogue cycles, comprising 6 sessions, have been carried out since the inception of IFPP intervention in rural communities, focusing on CLCs and FTP – first time Parents – groups. The demand creation, both in rural and urban areas have generated in FY2 108,204 confirmed referrals at the HF’s level, estimated in 5,1% of all WRA of both provinces. To strengthen the registration, reference and monitoring mechanisms of the demand generation activities in

2 The district profile uses strategic information to guide data analysis meetings focused on key FP service delivery and program management performance indicators.

8 urban areas, the Connect with Sarah Platform was introduced in June 2018. This platform, in addition to recording the activities carried out by the IPC agents, addresses the gaps observed in the implementation of the activities with registration, reporting, and analysis of data based on Movercado.

During FY2, for the HSS tier, very encouraging results were achieved in management standard compliance (MSC) reviews as the seven districts reported at end of FY1 with a score ≥80% (Angoche, Nampula, Moma, Monapo, Mecuburi, Ribaue, Beira). They were reassessed during FY2 and have maintained their score. And furthermore, seven additional districts in Nampula (Erati, Meconta, Mossuril, Nacala Porto, Nacala Velha, Murrupula and Malema) and seven districts (Dondo, Nhamatanda, Buzi, Chibabava, Machanga, Caia, Gorongosa) in Sofala have reached for the first time a score ≥80%. Therefore, during FY2, IFPP has 21 unique districts assessed with a score ≥80% of a total of 24 districts assessed, compared to the target of 14 fixed for FY2 this is representing an achievement of 150% of the IFPP target and represents already 58% (21/36) of the LOP target.

IFPP team conducted a joint compliance review with the NEDs to complete the District Profile (PD) for the period of April to June 2018 and compared it to the previous quarters for use in decision making in 18 districts. IFPP also provided Technical Assistance in the methodologies for presentation and analysis of the tool in the monthly statistics meetings or in review meetings.

Overall during year 2 there was a significant reduction of stock outs in the HFs assisted by the project: only 6% of the HF assessed had stock-out compared to 14% reported in FY1. A combination of factors contributed to these results most notably the availability of FP commodities at the national level, as well as a number of IFPP supported interventions. These interventions include project-supported weekly follow up of any imminent or total stock outs identified by IFPP district coordinators in their routine TA. Throughout the FY2 IFPP’s TA teams provided routine TA to ensure each health facility’s pharmacy manager and service delivery point (SDP) focal point correctly and systematically used the MOH stock cards and requisition forms to properly manage contraceptive inventories in site depots and internally within SDPs. The project also supported four provincial and fourteen district FP task force meetings involving DPM, DDM and MCH health professionals. A significant gain achieved during Q4 was establishing task force in all districts in Sofala and holding task force meetings in 10 of the 13 districts of Sofala province, this was a result of the leadership of the DPS in this matter, while in Nampula it’s still a challenge to hold the district task force meetings. The meetings served to analyze maximum monthly consumption data and contraceptive commodity requisitions from each health facility to ensure enough stock is ordered to respond to the growing demand for FP commodities.

During the last quarter of FY2, the project started the pilot of SMS messages to strengthen FP commodity inventory management and facilitate identification and reporting of imminent stock outs in the districts not yet covered by SIGLUS. The project developed these platforms for SMATG-CPF (Sistema Móvel de Assistência Técnica para Gestão dos Consumíveis de Planeamento Familiar, or System for Mobile Management of Family Planning Commodities) and SAPERS-CPF (Sistema de Alerta Precoce para Evitar Roturas de Stock dos Consumíveis de Planeamento Familiar, or Early Warning System to Avoid Stock Outs of Family Planning Commodities).

Finally, In August 2018, a comprehensive data review and planning workshop was conducted at each provincial level. In this workshop, districts teams and project staff reviewed FP trends by analyzing HMIS data within the last 4 quarters for each health facility. In addition, workshop participants reviewed project activities that have already been implemented in Y1 and Y2, and conducted an assessment of the current FP enabling environment and reach for key target populations (e.g. adolescent girls and young women). By reviewing the project’s technical, community, and health system strengthening strategy for each facility, the district teams were able to identify and prioritize key effective activities to be supported during Y3 implementation.

Major Implementation Issues No major implementation issues was faced by IFPP during FY2 outside the existence of an heavy rainy season in Q2FY2. Nevertheless, HMIS quality data reporting is still below the expected one and will continue to be, in FY3, a key priority; additional involvement of SDSMAS and DPS staff and more joint RDQA will be carried out.

Goal: Increase use of modern contraceptive methods IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based FP/RH services

Cascade in-service training Table 1 –Project supported trainings at end of June 2018

# of Facility based trainings per quarter and province During the fourth Q1 FY1 Q2 FY1 Q3 FY1 Q4 FY1 TOTAL Q1FY2 Q2FY2 Q3FY2 Q4FY2 To date quarter of the second Nampula 27 27 17 20 91 11 5 12 4 123 Sofala 30 24 8 62 6 12 8 4 92 year of the project TOTAL 27 57 41 28 153 17 17 20 8 215

(Q4FY2), a total of 8 # of unique Health Providers reached thru FP training per quarter and province additional “eight-day FP Q1 FY1 Q2 FY1 Q3 FY1 Q4 FY1 TOTAL Q1FY2 Q2FY2 Q3FY2 Q4FY2 To date 565 408 205 240 1418 132 57 183 121 1911 facility-based trainings” Nampula 26 Alua TC were carried out (4 in 463 347 81 891 108 213 139 65 1416 Sofala 64 Nham. 26 Nham. 3 Nham. TC Nampula and 4 in TC TC Sofala). TOTAL 565 871 552 321 2309 240 270 322 186 3327

# of unique Health facilities reached thru FP training along quarters by province The trainings included Q1 FY1 Q2 FY1 Q3 FY1 Q4 FY1 TOTAL Q1FY2 Q2FY2 Q3FY2 Q4FY2 To date Nampula 36 34 34 23 16 14 staff from 56 health 147 / 226 4 additional 204/ 228 (cumulati 43 HF involved additional additional additional additional additional additional (65%) HF (89%) facilities (HF) (26 in ve %) HF HF HF HF HF HF Sofala 43 14 24 13 55 HF 112 /157 1 additional 150/157 (cumulati additional additional additional additional Sofala and 30 in involved (71%) HF (95%) ve %) HF HF HF HF Nampula), 8 of which TOTAL 43 134 211 259 68% 47 17 17 14 92% were hard to reach facilities involved for the first time since the project’s inception. The trainings reached a total of 186 public health providers (121 in Nampula and 65 in Sofala). As summarized in Table 1, since the launching of the project, a total of 3,327 health providers have been trained: 1,911 in Nampula and 1,416 in Sofala. During FY2, 1,018 health providers were trained in addition to the 2,309 of FY1, involving 95 additional HF. Cumulatively, 354 HFs have benefited from having at least one health provider trained: 204 in Nampula and 150 in Sofala, representing an increase in coverage from 68% to 92% of total project facilities from end FY1 to end FY2.

Prior to the training of health providers, HFs’ need assessments are usually conducted. During the reporting period, 10 additional HF assessments were carried out, 3 in Nampula and 7 in Sofala. These baseline HF assessments focused on commodity management, infection prevention, client flow, adolescent and youth friendliness, and FP data collection and aggregation, with the objective of identifying weaknesses to be addressed during the “eight-day facility-based trainings.” Based on these assessments, the project mitigated the lack of supplies and equipment needed to upgrade working conditions and apply the skills acquired during training for improving competency and sustaining behavior change. Cumulatively, 294 HFs, 141 in Nampula and 153 in Sofala, were assessed, representing 69%

(Nampula – 141/204) and 102% (Sofala – 153/150) of the HFs with at least one health provider already trained in FP.

Table 2 summarizes the number of Table 2: Number of project-supported Health Facilities enrolled in FP project-supported HFs enrolled in FP trainings, by district to date trainings with at least one health # of HF with at % of HF already # of HF with all % of HF with all # of HF per DISTRICT least 1 HP trained involved thru HP trained in FP HP trained in FP provider trained by district and district in FP to date training to date to date province. Ninety-six percent (96%) of Beira 17 16 94% 2 12% the HFs in Sofala province already have Dondo 15 15 100% 7 47% “at least one health provider trained in Nhamatanda 17 17 100% 16 94% FP” and 89% of the HF in Nampula Buzi 15 14 93% 9 60% Chibabava 15 15 100% 4 27% province. In Sofala out of the 7 missing Machanga 10 10 100% 6 60% HFs, 4, were recently built and are not Caia 12 11 92% 11 92% Marromeu 9 8 89% 6 67% yet operational; in Nampula, out of the Chemba 9 9 100% 7 78% 24 missing HFs, a large part of them Gorongosa 14 13 93% 9 64% Cheringoma 7 7 100% 6 86% (11) are located in Nampula district, 6 Maringue 9 8 89% 6 67% in Muecate and 4 in Angoche district Muanza 8 7 88% 6 75% SOFALA 157 150 96% 95 61% islands. Comparatively, Table 2 PROVINCE Angoche 19 15 79% 6 32% illustrates the number of HFs “with all Mogincual 6 6 100% 4 67% HPs trained in FP”: 61% (95/157) of the Liupo 3 3 100% 2 67% HFs, in Sofala, have already all their Npla Cid 25 14 56% 0 0% Erati 10 10 100% 6 60% eligible providers trained in FP and, in Memba 12 12 100% 8 67% Nampula, 35% (79/204) of the HFs Meconta 8 8 100% 3 38% Nacaroa 7 7 100% 2 29% have already all their eligible provider Muecate 11 5 45% 0 0% trained in FP. During Q4FY2, the NHS Mogovolas 7 7 100% 5 71% Moma 11 11 100% 7 64% has contracted a bunch of recently Lardes 6 6 100% 4 67% trained health providers while sending Monapo 17 17 100% 1 6% Mossuril 10 9 90% 1 10% the existing MCH basic level nurses to Ilha Moç. 5 5 100% 2 40% nursery school again to promote them N.Porto 14 12 86% 2 14% N.Velha 6 6 100% 4 67% to medium level. Murrupula 6 6 100% 4 67% Rapale 7 7 100% 1 14% Whenever possible, all clinical and Mecuburi 13 13 100% 6 46% Ribaue 9 9 100% 3 33% technical staff in each HF were trained Malema 10 10 100% 4 40% to more fully integrate FP activities into Lalaua 6 6 100% 4 67% Nampula 228 204 89% 79 35% the work of all wards, and to promote PROVINCE active FP integration as a key objective for each HF. Support staff (including cleaners) from each HF participated in select theoretical sessions for non-clinical providers of the training to sensitize them regarding their role in removing possible barriers to access quality FP services (for example, ensuring proper sterilization and storage of IUD or implant insertion and removal kits), as well as helping to create an enabling environment especially for youth and other vulnerable populations.

Class sizes during the clinical trainings continued to be limited to 15 to offer more personalized attention to trainees and to link them with future mentorship visits. Experience has shown that hosting training sessions often strengthens overall institutional buy-in. Since the beginning of the intervention, cumulatively, 107 HFs served as training centers (79 in Nampula and 28 in Sofala), balancing the need for high volume practicums while maximizing the overall project coverage resulting in high quality training with rapid and sustained integration of FP services in all out-patient’s consultations and at maternity ward.

During this Q4FY2, the percentage of health providers, in both provinces, who have completed the training on modern methods of contraception with passing scores on the written post-test was 94% In both provinces, participating trainees demonstrated a high degree of commitment.

Training of HPs in Rapale and Malema districts In-service training at the Nampula central hospital

Additional trainings supporting the expanding of the method mix pool, the strengthening of the family planning integration and, the post-partum family planning delivery

Additional trainings were carried out during FY2 as summarized in Table 3: After the national Table 3: Number of trainees thru other trainings carried out during FY2 training of trainers (TOT) of Implanon NXT supported partly thru IFPP in December 2017, # of unique Health Providers reached thru other trainings the project carried out four trainings in Q2FY2 Q2FY2 Q3FY2 Q3FY2 Q4FY2 Total Nampula gathering 58 HP from Nampula, one (Implanon) (BTL) (BTL) (ISL) (ISL) TOT in Sofala province gathering 30 participants from different DPSs and SDSMASs; Nampula 73 7 15 21 62 178 additionally, to allow the project staff Sofala 145 0 0 0 0 145 supporting the cascade trainings and the Total 218 7 15 21 62 323 mentorships visits, all IFPP technical staff and some MCSP, CHASS, PSI, DKT partner staff attended a specific training session, gathering 17 participants in Sofala and 15 in Nampula. Following the TOT in Sofala province, cascade trainings were carried out at district level, gathering a total of 98 trainees. Additionally, IFPP supported three mini-laparotomy trainings to perform tubal ligation under local anesthesia in Nampula province involving 21 Health Providers (HP) coming from eight different districts, as well as 4 ISL trainings involving Maternity responsible (41) and HF directors (40) from 41 different HFs.

Focus on the Mini-Laparotomy Bilateral Tubal Ligation Trainings in Nampula province

Since Q2FY2, the project has supported the Table 4: Number of trainees in mini-laparotomy by introduction of mini-laparotomy bilateral tubal provider’s categories and Health Facilities to date ligation (BTL) with local anesthesia as a permanent

Gynecology and method (PM) with the intent to expand the method- Bachelor Surgical Gynecology and Health Facilities MD Obstetrics MCH Nurse Officer Obstetrics PG mix pool responding to the unmet needs for limiting specialist births. One TOT was carried out in March 2018 HD Moma 1 1 HR Angoche 1 1 during which 8 MoH trainees performed 22 in- HD Monapo 1 training mini-laparotomies in Nacala Porto district HR Ribaue 1 HC Nampula 12 2 hospital, two additional trainings were carried out in HD Namapa 1 H. Militar 1 June at the Nampula Central Hospital resulting in 59 Nampula additional mini-lap and 15 additional trainees as HG Marrere 1 summarized in table 4. In Nampula province, the mCPR for female sterilization is about 0.2% (IMASIDA 2015), BTL were usually only offered to clients during a caesarian, strongly limiting the access for women who wish to choose this method. Medical equipment (BTL surgical boxes, gloves, sheets, and suture threads) was previously purchased by the project; IFPP community activists were informed two months prior about the launching of mini-laparotomy BTL services. The community activists then sensitized communities to the expanded method mix. Community

Figure 1. follow up of the number of mini-laparotomy carried over between March and September 2018, by site

59 60

20 # of TBL minilap per mths & sitesmths& minilapper of TBL # 10 11 10 9 9 8 9 9 10 7 7 7 6 7 7 5 4 5 3 3 2 3 3 0 HD Moma HR Angoche HD Monapo HR Ribaue HC Nampula HD Nacala Porto

March Apr May Jun Jul Aug Sept

members were offered comprehensive counseling, including all other available methods. Of note, neither community activists nor acceptors were given any incentives. Each training lasted five days and included practices in the mornings and theory and practical sessions with anatomic models in the afternoons. It’s important to highlight that several sites is now offering very regularly this method as shown in Figure 1:

14 in Monapo District hospital an additional HP should be trained as the trainee is no more available; the HD of Nacala Porto just received a gynecologist who will start to implement mini-laparotomy activities next quarter; in total 225 mini-laparotomy were offered between March and September of this year; the May pick (59) in Nampula central hospital and the March peak in Nacala Porto are related to the practical training sessions; Namapa District Hospital, Marrere General Hospital and the military hospital have not yet started to offer the mini-laparotomy services. This activity will be launched next FY in Sofala Province.

Joint MOH-IFPP supervision:

The IFPP technical team and SDSMAS/DPS staff Table 5: # of joint MOH-IFPP supervision at district level carried out technical support visits providing by province and by quarter during FY2 supervision to HFs as described in table 5. This joint supervision serves to strengthen # districts involved in integrated understanding and coordination to boost the Province supervision use of the MOH approved FP integration Q2 Q3 Q4 guidelines and SRH services, including FP Nampula 9 17 17 integration data aggregation tool, assessing the quality of the counseling, the techniques of # HFs involved 38 32 87 method insertion, cleanliness and organization Sofala 9 13 12 of the HF services, FP commodities, and # HFs involved 24 16 23 equipment management. Integrated supervision visits are important as they boost adoption of new comportment and increase ownership of the MoH FP strategy and consequently the sustainability of the FP program.

Table 6: Mentoring visits received by HFs Quality Improvement and Mentoring HFs categorized according to the # of mentoring visits already received at end Sept. 2018 Quality improvement (QI) is key to project success in % of HFs with # # of HF with # of HF trained HP District existing terms of achieving and maintaining a high quality of trained that received HF 1 to 5 6 to 15 >15 service provision, as well as garnering institutional visits visits visits at least 1 visit Beira 17 16 6 3 4 81% support and buy-in to address systemic challenges, and Dondo 15 15 9 4 1 93% to support the sustainability of FP integration efforts. Nhamatanda 17 17 13 3 1 100% Buzi 15 14 4 7 3 100% Chibabava 15 15 10 4 1 100% Mentorship drives the QI cycle through regular visits by Machanga 10 10 8 1 90% Caia 12 11 4 6 1 100% project MCH nurses and district coordinators. The Marromeu 9 8 3 2 1 75% objective of mentoring is primarily to guarantee that Chemba 9 9 4 4 1 100% Gorongosa 14 13 3 8 1 92% health providers trained by the project are engaged on a Cheringoma 7 7 2 4 1 100% Maringue 9 8 2 6 100% regular basis and supported to achieve and maintain Muanza 8 7 5 1 86% clinical proficiency and service quality. Mentoring Total 157 150 73 52 16 94% Angoche 19 15 8 4 2 93% includes direct observation of service quality provision, Mogincual 6 6 1 3 2 100% coupled with supplementary on-the-job training. A Liupo 3 3 2 1 100% Npla Cid 25 14 1 7 57% secondary objective of the mentoring visits is to cultivate Erati 10 10 1 6 3 100% Memba 12 12 3 6 3 100% institutional engagement and ownership among HF Meconta 8 8 3 3 2 100% management and staff to remove barriers to successful Nacaroa 7 7 2 4 1 100% Muecate 11 5 3 2 100% integration and greater uptake of FP services. The first Mogovolas 7 7 5 1 1 100% mentoring visit is scheduled approximately 10 days after Moma 11 11 4 1 1 55% Lardes 6 6 3 2 1 100% the end of the initial training. Subsequent mentoring Monapo 17 17 5 6 1 71% visits are scheduled depending on the findings of the first Mossuril 10 9 6 3 100% Ilha Moç. 5 5 2 1 1 80% visit, but the goal is to reach each health facility with N.Porto 14 12 5 5 2 100% trained HPs at least once per quarter. N.Velha 6 6 2 3 1 100% Murrupula 6 6 2 3 1 100% Rapale 7 7 3 3 1 100% Table 6 summarizes the number of mentoring visits Mecuburi 13 13 5 4 2 85% Ribaue 9 9 1 5 3 100% received by HFs by province since October 2016. The Malema 10 10 4 4 1 90% number of total visits to date is related to the date of Lalaua 6 6 2 3 1 100% Nampula 228 204 70 75 38 90% original training. Thus far, the number of visits received PROVINCE corresponds with the cascade training schedule.

To date, in Nampula and Sofala provinces, 90% or 183 out of 204, and 94% or 141 out of 150, of the HFs that received training also received at least one mentorship visit and all are scheduled to continue receiving visits during the next quarters. Twenty three out of 36 districts have 100% of their HFs with at least 1 HP trained, already involved in the mentorship cycle, while 9 additional districts have 80% or more

16 of their HFs enrolled and the Figure 2. # of unique Health Provider trained, registered in the App, remaining 4 districts are oscillating who received mentoring visit(s) per topic and province between 55% (Moma), 57% 1600 1448 (Nampula Cidade), 71% (Monapo) 1400 1200 and 75% (Marromeu). 1007 1061 1000 882 806 799 800 Mentorship App 624 661 600 536 450 438 400 338

To ensure the consistency of year by and topic by mentored mentorship and facilitate follow-up Providers Health Unique of # Cumulative 200 0 on action plans developed during Nampula Sofala mentoring visits, IFPP uses a FP counselling FY1 FP counselling FY2 Depo FY1 mentorship digital app, allowing Depo FY2 Implants FY1 Implants FY2 health provider-specific electronic notetaking and follow-up action 250 237 227 plans, which are discussed and 210 shared before leaving the HF. The 200 app provides prompts for mentors to 150 guide them through each step of the 113 103 mentorship process and sends 100 90 74 70 reminders to mentors for the next mentored by topic and by year by and topic by mentored 50

mentoring visit to ensure providers Cumulative # of Unique Health ProvidersHealth Unique of # Cumulative who require additional support are 0 mentored at appropriate intervals. Nampula Sofala As seen in Figure 2, at end FY2, IFPP IUD FY1 IUD FY2 PPIUD FY1 PPIUD FY2 staff have mentored 2,509 unique health providers (1,448 in Nampula Figure 3: # of competency standards checklist observed in FY2 and 1,061 in Sofala) against 1,506 compared to FY1 (882 in Nampula and 624 in Sofala) at end FY1: all of the 2,509 were mentored on comprehensive FP 6000 counselling on existing method-mix; 4897 5000 1,467 (806 in Nampula and 661 in 4169 Sofala) were mentored for depo 4000 2828 2875 injection (against 788 at end FY1); 3000 2081 1810 1,806 (1,007 in Nampula and 799 in 2000 1283 Sofala) at end of FY2 against 974 at 1151 1000 end FY1, were mentored for implant mentors by tasksof observed # insertion. Specific attention was 0 Nampula Sofala given to increase the number of HP Counseling FY1 Counseling FY2 mentored for IUD insertion and Others (Depo, Implants, DIU, DIUPP) FY1 Others (Depo, Implants, DIU, DIUPP) FY2 PPIUD insertion: comparing FY1 and FY2, 271 additional HP were

17 mentored for IUD (147 in Nampula and 124 in Sofala) and 180 for PPIUD (137 in Nampula and 43 in Sofala). As seen in Figure 3, during FY2, the total number of tasks observed by mentors increased from 6,325 (1151, 1283, 2081 and 1810) in FY1 to 14,769 in FY2 (2828, 2875, 4897 and 4169) highlighting the mentoring efforts: a little more than 50% of the tasks were dedicated to qualitative comprehensive counseling on method mix, centered on women and families reproductive needs (spacing / limiting birth); the other half of the tasks observed contributed to increase the quality of the different insertion techniques mainly for implants, IUD and PPIUD.

As seen in Figure 4, the ‘not Figure 4: ‘not meeting competency standards’ rate per FY and per meeting competency standards’ province for Implants, IUD and PPIUD rate for implant insertion, 45% 40% interval IUD and PPIUD, have 40% decreased from FY1 to FY2 in 35% 31% both provinces: in general, Sofala 30% 25% providers are meeting the 25% 20% 19% competency standards more 20% 17% 15% 15% easily than the Nampula 15% 11% 12% providers, who need a higher 10% 6% 6%

number of task observation to 5% Failure rate at task's observation rate Failure reach them. For example, for 0% implant insertion, Nampula FY1 FY2 FY1 FY2 FY1 FY2 providers have decreased from Implants IUD PPIUD 20% during FY1 to 15% in FY2 Nampula Sofala while Sofala providers have decreased from 11% (FY1) to 6% (FY2). In Nampula province, the most difficult technique to be learned is the PPIUD insertion (31% in FY2), followed by the interval IUD Figure 5: Unique HP mentored for PPIUD to date, by province. insertion (17% in FY2) and implant 220 insertion (15% in FY2) while in Sofala province, interval IUD 170 insertion (12% in FY2) is the most difficult technique to be learned 33 120 0 11 210 compared to implants and PPIUD 1

(6% in FY2 for both). Figure 2 70 113 116

(above) illustrates the of unique 94 5 # of Unique Health Provider Health of Unique #

Health Provider trained, 20 49 1 0 6 7 registered in the App, who Mentored Passed Still need Failed Mentored Passed Still need Failed received mentoring visit(s) per -30 improvement improvement Sofala Nampula topic and province. Figures 5, 6 Always "passed" Passed but previously "needed improvement" and 7 distribute, per province, Passed but previously had failed Always "needed improvement" how much of them have “always "Need improvement" but previously had failed Failed passed”, “passed but previously

18 needed improvement”, “passed but previously had failed”, “always needed improvement”, “need improvement but previously had failed” and “failed”.

Nampula HPs face more technical Figure 6: Unique HP mentored for IUD to date, by province. challenges, particularly for Mentorship results for IUD (Unique Health Providers) at end Sept. 2018 by PPIUDs, than those in Sofala province 250 province. Therefore, In March, in Nampula province, IFPP had 200 provided additional support to 30 16 the mentors to increase their 1 4 150 abilities to mentor high-need mentees through a one-week 227 237 100

mentor’s mentorship; the same 168 167 # of # UniqueProvidersHealth was carried out in Sofala during 50 Q4FY2. Overall, the mentorship 2 2 0 26 11 37 abilities and techniques rated 0 Mentored Passed Still need Failed Mentored Passed Still need Failed during the practical mentor’s improvement improvement mentoring sessions were high; Sofala Nampula Always "passed" Passed but previously "needed improvement" particular attention was given on Passed but previously had failed Always "needed improvement" the weaker PPIUD technique and Still "need improvement" but previously had failed Failed the “Balanced Counseling # of unique HP Mentored Strategy Plus”; these practical mentor’s mentoring sessions impacted the number of unique providers mentored for PPIUD as the number of unique HPs jumped from 86 (Q1FY2) to 111 (Q2FY2) to 169 Figure 7: Unique HP mentored for Implants. to date, by province. 1200 (Q3FY2) and then to 210 (Q4FY2). Nevertheless, the number of 1000 mentees requesting further 800 114 5 assistance remains relatively high in 110 8 Nampula: 49 for PPIUD, 37 for 600 interval IUD and 119 for implant 1007 400 799 749

compared respectively to 6, 26 and 632 # of # UniqueProviderHealth 39 in Sofala province. Consequent 200 efforts will continue to be carried 10 18 119 0 39 out next quarters to mentoring Mentored Passed Still need Failed Mentored Passed Still need Failed improvement improvement more frequently Implant, IUD, and Sofala Nampula Always "passed" Passed but previously "needed improvement" PPIUD techniques. The project will Passed but previously had failed Always "needed improvement" continue to multiply opportunities Still "need improvement" but previously had failed Failed # of unique HP Mentored and take advantage of the shift changeover meeting that takes place between maternity ward nurses. The maternity daily meeting offers an important glimpse into the HFs’ client load and service flow and provides an opportunity to give parturient women counselling and

19 immediate PPFP, including PPIUD insertions, and this allows us to catch night shift workers who are otherwise missed. Meanwhile in Nampula, despite the fact that some of the HPs still need to improve their PPIUD skills, it’s remarkable that out of 189 HFs attending institutional deliveries, 180 HFs (95%) are reporting offering at least 1 PPIUD during FY2; the 180 HFs have provided 4,109 PPIUD insertions this quarter, reaching a coverage rate in PPIUD of 7% of the Institutional deliveries attended, compared to 5.2% past quarter (Q3FY2). In Sofala province, out of 138 HFs attending institutional deliveries, 109 HF or 79% (compared to 89 HFs (64%) on a total of 136 HF attending institutional deliveries in FY1) are reporting offering at least 1 PPIUD; the 109 HFs have provided 1,199 PPIUD insertions this quarter, reaching a coverage rate of 5% of the Institutional deliveries attended, compared to 4.3% past quarter.

Implementation Science and Learning (ISL)

During Q2FY2, when analyzing the data in Nampula province, high disparities in PPIUD offering were noted between the HFs: Some HFs are attending very high numbers of deliveries and have low capacities in PPIUD offering. During Q3&4FY2, in close collaboration with the PHD, IFPP has carried out the four ISL (Implementation Science Learning) “Optimization” workshops involving the heads of the HF maternity ward and HFs’ directors of 41 selected HFs; in each ISL workshop, some of the HFs had low PPIUD coverage – less than 2.5% when others had medium PPIUD coverage (>2,5% to 10%) and few of them had a high PPIUD coverage (>10%). The provincial MCH responsible co-facilitated the workshops together with technical IFPP staff; sharing of experience and further understanding of the activities and attitudes that are promoting post-partum FP offering and FP integration in the other outpatient services were two of the objectives of the workshop as well as assisting them in designing a simple action plan to improve their outputs. Participants jointly reviewed health facility-level service statistics, clarified best-practices and lessons learned to date, and worked to isolate key inhibiting and facilitating factors driving program post- partum IUD and implant service provision within maternity wards as well as FP integration. In advance of the ISL “optimization” workshops, a simple self-assessment survey was administered to all available maternity ward nurses and the outpatient HPs of the HFs involved to quantify and compare health providers’ perceptions of various factors inhibiting or facilitating PPFP and FP service integration, including: contextual variables (adequate space, supplies, time constraints, etc.), client demand, measures of self-efficacy/technical confidence, motivation, and institutional support (feedback and perceived prioritization of LARC-PP by maternity ward and HF management)3 and results were presented to participants during the “optimization” workshops to inform strategy development. Workshop participants noted that maternity-ward nurses or outpatient HPs, in low-performing sites, were less likely to consider the offer of FP counseling during their daily tasks as either “urgent” or “obligatory”. Conversely, in health facilities with greater buy-in and support from the maternity ward in-charges, this task had become part of most outpatient HPs and maternity nurses’ daily routine. Furthermore, facility level observations revealed that due to cultural reasons, many women attending the maternity wards (even those counseled on FP during ANC visits) did not initiate requests for FP services during their visits to the maternity ward, and instead awaited nurse initiation, resulting in significant lost opportunities for post-partum FP uptake.

3 A health provider behavior-change framework was developed based on the Opportunities, Abilities and Motivations (OAM) framework developed by Ölander and Thøgersen (1995), and modified to better account for intrinsic and extrinsic motivations within an organizational/work-place context (Vallerand, 1997, Siesmen, 2008).

During the 2-day “optimization” workshop, participants identified several opportunities for performance improvement:

• Key attitudes that the HF director should address include: listening weekly to the staff’s complaints and constructive criticism; commending the maternity ward’s nurses or the outpatient HPs who improve their performance; giving feedback about statistical data to all of the HF’s staff; facilitating the sharing of the constraints, barriers, and solution that providers are confronted with in offering PPFP or FP services in outpatient services; clarifying FP related myths and taboos to the CLs and sensitize them more to the importance of FP and PPFP, in particular, to ensure better spacing of births; encouraging men to accompany their wives during ANC to discuss FP opportunities available during the post-partum period; recognizing twice-a-year the best MCH nurse with diplomas of merit. • Key attitudes that the maternity responsible should address include: giving technical support as frequently as needed; ensuring the availability of the needed sterilized equipment, as well as the FP commodities; praising the nurses improving their performance; accepting criticism from colleagues; daily monitoring of the PPFP activities; involving TBAs for PPFP sensitization at community level; improving support for in-depth PPFP counselling at ANC level, particularly when husbands are coming for HIV screening; ensuring that the FP method chosen is registered on the ANC card and taken in consideration at maternity level; sharing the action plan with the maternity team; and learning local idiom.

The action plans focused on sharing lessons learned in the offering of Photo 5, 6, 7: Discussion of the action plan to improve facility-level contraception at the maternity management buy-in for FP service integration; IUDPP insertion film projection. ward, defining activities to improve the LARC offer, sharing the posters with responsibilities for FP Integration Model Health Units, explaining the role of each key personnel, taking and exposing photo of the maternity responsible advertising about PPFP services offered at maternity level to increase user-provider demand.

Strategies established for FY3 in order to still increase the uptake of PPFP include: • Continue ISL optimization workshops with maternities having low outcome. • Organize additional specific in-service training for the providers who have already been FP trained through IFPP but identified as poorly performing in post training period through mentorship. • Conduct a five-day TOT for the 34 MCH district responsible to increase their skills in PPFP in-service training and mentoring, including FP pre-natal counseling, and on how to create demand for among the couples with no FP demand in immediate post-partum; improvement of their own IUDPP insertion

technique and how to include pro-actively the recently available mini-laparotomy method in the method-mix; challenging the trainees (MCH district responsible) to identify 3 HF with maternities to benefit of their active support during FY3.

Summary of the main observations of the mentoring and technical support visits: • Technical skills: difficulties persist in immediate postpartum counseling skills, especially for long-term methods. The PPIUD insertion technique is the most difficult for HPs and they need more mentorship to improve their self-confidence. • Family Planning integration: in most of the trained HFs, FP methods are offered, but non-MCH providers need more mentorship and follow-up with respect to long-term method provision, particularly implant insertion that non-MCH HPs are more often asked for by their clients. • M&E logbooks: more SRH/FP logbook‘s daily summaries are correctly fulfilled when comparing with previous quarters even if challenges remain. Problems arise when the regular MCH nurse in charge of the FP/SRH consultation is absent and there is a substitute nurse or student who is not familiar with the process. However, with the introduction of the HF data aggregation sheet, there was a significant improvement in the reporting of all FP data from other departments in the monthly HF summary form.

Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based FP/RH services Agente Polivalente Elementar Table 7: Distribution of APEs trained in FP thru IFPP, per province and district trainings (APEs). IFPP support to Agente Polivalente # of HF with # of % of # of HF with at least 1 active # of APEs trained in FP APEs at least 1 Elementar (APE), or Ministry of DISTRICT # of HF APE APEs trained APE trained (source: (source: Total to thru Health Approved Community thru IFPP FY1 FY2 DPS) DPS) date IFPP Health Workers, is a key activity that Beira 17 1 NA 5 NA NA NA NA will increase FP access for the hard Dondo 15 8 5 29 13 7 20 69% to reach rural population. APEs, Nhamatanda 17 15 15 43 3 35 38 88% during their initial training, are Buzi 15 9 2 28 5 0 5 18% trained on FP since 2016, even Chibabava 15 11 6 31 7 25 32 103% before IFPP started. However, the Machanga 10 7 9 23 3 20 23 100% Caia 12 9 6 30 12 15 27 90% MOH felt that APEs were not Marromeu 9 7 6 20 0 18 18 90% providing significant FP services by Chemba 9 6 6 19 7 12 19 100% the end of 2016. As such, the MOH Gorongosa 14 9 9 41 8 32 40 98% requested that IFPP strengthen Cheringoma 7 7 6 22 10 11 21 95% Maringue 9 6 7 21 2 7 9 43% APEs skills and increase support and Muanza 8 6 0 38 0 26 26 68% supervision to effectively integrate SOFALA 157 101 77 350 70 208 278 79% FP into their daily tasks. Angoche 19 15 1 84 9 0 9 11% Liupo 3 3 1 29 5 0 5 17% Therefore, IFPP included APEs Mogincual 6 5 1 20 6 0 6 30% working in IFPP HFs in the first two Nampula D. 25 6 5 14 15 0 15 100% days of HF provider trainings to Erati 10 10 5 70 25 0 25 36% refresh their knowledge and to Memba 12 12 3 55 18 0 18 33% Meconta 8 8 2 43 9 31 40 93% boost HF and APE coordination Nacaroa 7 7 3 37 13 22 35 95% mechanisms, including FP Muecate 11 11 10 33 20 11 31 94% commodities, supplies, referrals, Mogovolas 7 6 2 106 18 0 18 17% and supportive supervision Moma 11 10 5 79 21 0 21 27% Lardes 6 6 2 14 5 2 7 50% schedules. During Q4FY2, a total of Monapo 17 13 4 105 23 0 23 22% 67 additional APEs were trained Mossuril 10 5 1 39 3 0 3 8% trough IFPP. Cumulatively, by end of Ilha Moç. 5 NA NA 6 0 0 0 NA FY2, IFFP has now trained 50% (704) N.Porto 14 NA NA 15 0 0 0 NA N.Velha 6 6 2 34 13 0 13 38% of 1,421 active APEs compared to Murrupula 8 6 6 42 33 0 33 79% 417 of at the end of Y1. Rapale 13 7 4 32 9 0 9 28% Mecuburi 6 11 6 34 36 0 36 100% Specific attention was given to Ribaue 9 9 2 101 18 0 18 18% intensively support the APE Malema 10 8 6 49 29 0 29 59% Lalaua 6 6 5 30 19 13 32 107% program: the number of women NAMPULA 229 170 76 1071 347 79 426 40% served through APEs has increased, Both 386 271 153 1421 417 287 704 50% in Sofala province, from 5,558 (Q1FY2) to 14,885 (Q4FY2) and, in Nampula province, from 17,892 (Q1FY2) to 27,097 (Q4FY2).

IFPP is carrying out the following activities in both provinces to boost the involvement of APEs for FP delivery. 1) Increasing supervision visits of the IFPP technical team as well as supporting the APE supervisors at SDSMAS and DPS level for integrated supervision, focusing on counselling and the delivery of short term FP methods, FP registration in the APE logbook, referrals to HFs for long acting FP methods, and management of traditional birth attendants (TBAs) FP referrals that are directed to APEs. 2) Improve the supply of short term contraceptive methods (STM) available to APEs in both provinces supporting the dissemination of the MOH recommendations for the distribution of MCH APE training in Meconta District commodities for APEs, as well as the one clarifying that DMPA-IM injection can be provided by APEs as a substitution when DMPA-SC (Sayana Press) stocks are insufficient. 3) Provide technical support at the monthly “APEs – HF” coordination meeting for data analysis, experience sharing, and restocking FP methods and commodities. 4) Printing of register books and references slips when necessary.

Traditional Birth Attendant (TBA) Trainings IFPP’s rural supply-side strategy involves identifying, training, and supporting TBAs to conduct home visits and community-based FP counseling and referrals. It is expected that TBAs will generate demand by improving knowledge of FP, countering prevailing misconceptions and biases, Table 8 – TBAs trained in FP methods and community conveying the importance of healthy timing and sensitization spacing of pregnancy (HTSP), increasing self- TBAs trained in FP methods and efficacy, and promoting linkages with community sensitization Grand contraceptive service delivery points (IR1). TBAs FY1 FY2 TO date Total are trained and supervised by the HF trainers, in Nampula 762 79 841 1,112 partnership with the IFPP district coordinators. Sofala 92 179 271 TBAs are expected to reach all women and adolescents of reproductive age, specifically targeting first-time parents (FTPs) who are pregnant or postpartum and medium- and high-parity women (defined by IFPP as woman with three or more children). TBAs also engage household influencers and Delivery of IEC Material for TBAs and TBAs monthly meeting in Nametil – Mogovolas gatekeepers (for example, male partners and mothers-in-law).

During Q3&4 of FY2, IFPP Nampula has focused on the monthly review meetings led by the HF MCH nurse and supported by the IFPP technical teams. These follow-up meetings focused on TBAs sharing FP community sensitization experiences, reviewing FP referrals, and discussing completed FP referrals including successes with the different sub-groups (parturient referrals and PPFP pre-sensitization including FTPs; adolescents; medium and high parity women). Additionally, the MCH nurses prepared one refresher training topic. In Nampula province, these efforts were crowned with success as the referrals reported by TBAs has jumped from 425 (Q2FY2) to 5,847 (Q3FY2) to 9786 (Q4FY2); the 841 trained TBAs are concentrated in 76 rural HFs catchment areas and the HF’s MCH nurses were trained as TBAs trainers for the area of FP; in Sofala, IFPP had encountered more resistance to carry out the same strategy resulting in a more widespread strategy: the 272 trained TBAs are spread over 86 rural HFs catchment areas and not all HFs have a TBA trained MCH nurse; the review monthly meeting between the HF MCH nurse and the TBAs is more difficult to be organized; Sofala province has reported 4,170 confirmed referrals for FY2 compared to 16,595 in Nampula province. For both provinces, the cumulative number of confirmed referrals by HP jump from 2,138 (FY1) to 20,765 (FY2).

Interpersonal Communication Agent (IPC) Training The project’s urban demand creation strategy builds on the successful “TEM mais” or private clinic network (TEM+) model already used by PSI, which seeks to create informed demand for family planning directly at the household and community level through home visits and community meetings. During this FY2, 143 new Interpersonal Communication (IPC) agents were trained to extend urban demand generation activities (48 in Sofala and 95 in Nampula) and have carried out sensitization activities; at the end of FY2, still 128 were active (42 in Sofala and 86 in Nampula); the IPC’s resignation rate was quite high this FY2 due to their recruitment to the National Commission of Election to carry out community education and mobilization for the local elections of October 2018 and the 2019 planned presidential election. Other possible reasons are the low subsidy that they can make through this PBF activity as well as the pre-identification process of the potential candidates; to better understand the reasons of resignation and in order to reach additional efficiency, the IFPP and the Office of Evaluation Sciences (OES) with the support of USAID has initiated a short term operational research/study to conduct rapid, rigorous, low-cost evaluations of IPC’s mobilization and referral activities as well as their motivation, and to further propose cost-effective, behaviorally-informed solutions to improve IFPP results; to increase better follow up of the IPC agents, better planning of their activities and easy verification of community data, Movercado was abandoned and a new digital platform “Connect with Sarah” was introduced in June 2018.

Introducing the “Connect with Sarah” App (CwS)

To strengthen the registration, reference and monitoring mechanisms of the demand generation activities, the Connect with Sarah Platform was introduced in June. This platform, in addition to recording the activities carried out by the IPC agents, addresses the gaps observed in the implementation of the activities with registration, reporting, and analysis of data based on Movercado.

The IPC agents will be able to register the client and document the different interactions carried out during the year which will strengthen the follow-up of the clients, improve registration of the client’s FP needs, collect their feedback on the services provided, and track the referrals. As this App works on smartphones equipped with an android system, geo-localization of the households will be possible, as well as ease in internal audits and return visits. The App will be used by the IPC agents and the HPs. 111 IPC agents and 65 MCH nurses have been trained in the use of the App in June 2018.

Furthermore, jointly with the district coordinators and the FP project officer, technical updates were carried out on a monthly base to strengthen the knowledge and abilities of the IPC agents focusing on the different FP methods, benefits of FP, and informed choice.

Mapping of IPCs agents Table 9: Mapping of IPC agents by district and HFs # of IPC District Health Facility Neighborhood Furthermore, the community agents Natulo A, Nassapo, Namihuro, Nassapo- mobilization and counselling strategy FTM- Anchilo 5 zona verde, Nassapo-area da ES- Anchilo. has been redesigned. The IPCs agent C.S Napipine 5 Napipine, Murrapaniua C.S Namuthequeliua 6 Namuthequeliua, Mutava –Rex, were redistributed in pre-selected C.S 1 de Maio 3 Zona Central e alguma Zona de Namicopo Nampula C.S Namicopo 4 Namiepe, Namicopo, Carrupeia neighborhoods with the mission to C.S Muhala Expansao 6 Muahivire Expansao e Muhala Expansao. HM. Nampula 4 Cossore, Zona Militar , Paios, Mtadouro e reach progressively 100% of the WRA C.S 25 de Setembro 2 Mutauanha e Murrapaniua. HG Marrere 4 Substacao, Natikire, Muatala for FP counseling and further follow C.S Anexo ao Psiquiatrico 3 Pilototo, Murrapaniua, Mutauanha. FTM- Matapue 5 Matapue, Ontupaia, up. Therefore, working meetings have FTM- Urbano 6 Triangulo, Mocone, Bloco 1, C.S Akumi 3 Bloco 1, Triangulo been and will continue to be carried Nacala- CS Murrupelane 1 B Murrupelane e Muanona Porto PS ADPP 1 Muzuane out with the CLs to define the mapping PS. CFM 1 Triangulo e Mucuaipa C.S Ontupaia 2 Ontupaia and sensitize them on FP myths, Angoche HR Angoche 4 B Central, Puli taboos, and challenge. Seventeen city CS Inguri 4 Inguri CS Ilha Mocambique 2 Cidade da Ilha Ilha Moç. meetings gathering 80 community CS Lumbo 2 Lumbo CS Chamba 2 Inhamizua leaders have been held during FY2. The CS Chingussura 3 Chingussura e Vila Massane CS Chota 1 Chota areas of IPC agent distribution are CS Macurungo 3 Macurungo CS Marrocanhe 2 Muave summarized in Table 9. The technical CS Manga Loforte 2 Ndunda , Mungassa Beira CS Mascarenha 3 Manga Mascarenha support to the IPC agents, the CS Matadouro 1 Matadouro CS Munhava 4 Mananga, Maraza, Munhava Central e Vaz monitoring and follow-up of their CS Nhaconjo 3 Nhaconjo CS Pontagea 3 Ponta Gea, Macuti, Palmeiras e Chaimite activities and outputs will be easier to CS Ceramica 2 Cerâmica PS Militar Matacuane 5 Esturo e Matacuane. program and the collaboration and CS Lusalite 2 Lusalite CS Macharote 2 Macharote involvement of the CLs will be CS Nhamainga 2 Nhamainga CS Samora Machel 2 Samora Machel strengthened. Dondo CS Canhandula 2 Canhandula Consito, Mafarinha, Bairro Central, CS Dondo 5 Nhamaibwe, Mandruze Community Facilitators (CF) training Eduardo Mondlane, 4 de Outubro, CS Mafambisse 5 Mussassa, Munhonha During the FY2, 35 additional CFs were trained to substitute the CFs who left the project. The resignation rate for CFs remain low as only 35 on 238 had to be replaced (15%); during the Q1FY2, IFPP had trained the 203 CFs on topics related to the fourth, fifth, and sixth community dialogue sessions while 35 additional CFs (11 in Sofala and 24 in Nampula) were trained for the first time

26 on the contents of the sessions 1 to 6. In Q2FY2, 30 CFs were involved in the community score cards process (CSC) and were trained on this topic for 4 days.

The 119 CFs pairs (male and female) were covering 160 rural HF catchments areas (94 in Nampula and 66 in Sofala). Therefore, 52% (160/307) of HF catchment areas located in a rural area had CFs during FY2. As IFPP, in some of the 160 rural HF catchments areas have already completed 1 FTP group and 1 CLs group per village - each group receiving six community dialogue sessions - IFPP will, in FY3, expand community mobilization to 60 additional HF catchment area. For the time being, very few additional CFs are foreseen to be trained as IFPP intends to continue supporting this initial cadre of trained CFs to carry out activities in neighboring HF’s catchment areas.

Targeted Mobile Brigades (MBs) for priority populations

During the FY2, IFPP supported Photo 12: FP Sensitization and school mobile brigade in Sofala 2,182 in Nampula and 1,201 in Sofala. During Q4FY2, 433 more mobile brigades (MB) were carried out in Nampula and 153 in Sofala. It’s important to highlight that in

Sofala an additional 277 MBs were carried out through other partners such as PSI, DKT, and PNG - National Park of Gorongosa.

As MBs are key in increasing access to FP particularly for rural areas; district community health responsible for the districts of Moma, Angoche, Monapo, Meconta, Nacala Porto, Ribaue, and Erati participated in Q2FY2 to a one-day workshop for detailed MBs planning in order to better cover the MCH national health week spots. All of these districts increased their number of MBs carried out in Q3&4 of FY2. It will be important to replicate this activity next FY, involving the districts with weaker accomplishment (Rapale; Muecate; Mecuburi; Liupo; Larde). Still, some MBs are under-reported by the responsible HCs. Furthermore, the district of Nampula and Murrupula received additional support to implement MBs from PSI through Dutch funding. These MBs aren’t included in IFPP MB’s total.

IFPP continues to give a special attention to MBs at the school level as Adolescents and young people are an important target group of IFPP intervention. Most adolescents are badly informed about contraception. MoH strategy is well defined for reaching this group at secondary school while for primary school’s (EPC -Escola Primaria Completa) previous coordination is needed with CLL and EPCs; most secondary schools have a focal point teacher for SRH. During Q4FY2 IFPP increased the number of MB at school level and coordination activities were carried out to revitalize the school counseling corners to provide regular assistance to in-school adolescents. How to ensure continuity of the offer during the December-January school holiday will be one of the challenges. While in Q3FY2, 23 secondary schools were reached and nine primary schools - 6th and 7th grade (EPC) in Nampula province , in Q4FY2 36

27 secondary schools, 12 EPC, three technical training schools. Additionally, during the “jornadas cientificas”, a SRH/FP lecture was given at the University of Lúrio - Business School, with offering of FP services, attended by students, teachers and invited guests.

Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services Figure 6 shows trends in the number of confirmed referrals by CHW type, quarter, and province. The total number of confirmed referrals by health providers is 28,662 for Q4 FY2.

Figure 6: Number of confirmed referrals as 'attended at HF' by province, from October 2016 to Sept. 2018

14,000 13,960

11,910 12,000 11,655

9,786 10,589 9,805 10,000 9,527 8,962

8,000 5,847

6,657 6,782 6,132 6,000 5,207 4,892 4,224 3,346 3,764 4,000 1,726 2,745 3,659 1,192 3,149 2,692 3,057 2,880 2,622

336 2,000 735 1,732 1,643 917 88 791 620 537 425 380 425 150 - Q1 FY1 Q2 FY1 Q3 FY1 Q4 FY1 Q1 FY2 Q2 FY2 Q3 FY2 Q4 FY2 Q2 FY1 Q3 FY1 Q4 FY1 Q1 FY2 Q2 FY2 Q3 FY2 Q4 FY2 Nampula Sofala IPC TBA CF

The green bars in the graph represent the confirmed referrals sent to HFs by TBAs. The Q3FY2 results in Nampula province are illustrating an increase in the use of a more adequate system for TBA referrals for data reporting compared to Movercado. Since Q1FY2, IFPP piloted a paper-based tool that could more easily record TBA activities at a monthly accompaniment meeting at each HF led by the HF MCH nurse. TBA referrals’ data collected during Q3FY2 were coming from 75% or 606 of the 819 TBAs already trained by end of Q2FY2 in FP through IFPP intervention; it’s an acceptable report ratio taking into account the

28 usual TBA illiteracy. It’s now worthwhile to re-initiate the FP cascade training for TBAs as we can monitor their outputs and analyze data produced per HF catchment area. This data confirms the great opportunity that TBAs are representing for the demand generation at the rural level. The same data collection form was progressively used in Sofala province during Q3&4FY2 but still with a lot of under-reporting. Movercado platform was not being used anymore in Q4FY2. In Q4FY2 IPC agents and HP reported referral’s data only through the “Connect with Sarah” digital platform while CFs referral’s data are reported through the MOH referral paper form.

When comparing FY1 with FY2, the total number of confirmed referrals increased from 57,342 to 108,204 of which 35,972 occurs in urban areas and 72,232 in rural areas; taking in account that the expected number of WRA for both provinces in 2018 is about 2,129,000, IFPP urban and rural FP demand generation components have referred about 5% of the WRA, which is quite a success. Meanwhile, when calculating this WRA referral percentage by urban and community components, through the urban component, 8.2% of the WRA were referred and confirmed while in the rural component, 3.4% of WRA were actively referred and confirmed as attended. Although it’s expected that it’s more difficult to refer in rural areas, in FY3 IFPP has planned to intensify its efforts to train and involve additional TBAs to increase this percentage.

IR 2: Increased demand for modern contraceptive methods and quality FP/RH services IFPP prioritizes high impact demand generation activities at the individual (Sub IR 2.1) and social level (Sub IR 2.2) to be implemented in line with the phased roll-out of the project’s IR1.

Sub IR2.1: Improved ability of Health Provider one-page report to be fulfilled at the monthly TBA individuals to adopt healthy FP behaviors meeting A total of 322,583 women contacts Nome das PTs que participaram na reunião e relação de referências ( n ) ( c ) ( n ) ( c ) Nome da PT ( n ) e comunidade de actuação ( c ) have been reported this FY2, which is a 85% increase of results achieved in FY1 (174,531). Número de Grávidas e parceiros (casais) referidos Realizadas para a CPN para testagem HIV e aconselhamento Confirmadas Traditional Birth Attendants (TBA) em PF pós parto Por re-aconselhar As mentioned above in Sub IR1.2, Núnero de Grávidas referidas a parto na Realizadas by the end of FY2 1,112 TBAs have maternidade (e já pré aconselhado para o PF pós Confirmadas parto) been trained and have started Por re-aconselhar their sensitization activities at the Adolescentes Realizadas community level. ainda sem Confirmadas filhos Por re-aconselhar To date, sensitization contacts Realizadas Núnero de Mulheres referidas para Mulheres com Confirmadas reported by TBAs have increased a CPP/PF 1 a 4 filhos Por re-aconselhar by from 1,129 (FY1) to 23,651 Mulheres com Realizadas (FY2). HPs of the peripheral HFs, mais de 4 Confirmadas filhos which benefited from TBAs FP Por re-aconselhar training, are carrying out monthly

29 and/or quarterly meetings and fulfilling a one-page report to facilitate the report of contacts and confirmed referrals.

Interpersonal Communication Agent (IPC)

Additionally, by the end of the reporting period, IFPP leveraged at “TEM+” and public health facilities FP intervention in urban settings with the support of 86 active IPC agents, as an average number, who reported having contacted 76,120 women during FY2 compared to 63,845 in FY1.

Rural community facilitators (CFs) of the Community Dialogues (CD)

During FY2, 222,812 contacts with women were carried out through community dialogues compared to 109,833 in FY1. The community team remobilized the groups who already completed sessions one to three of the community dialogue trainings so that they could participate in sessions four to six and additionally have completed recently constituted groups with the complete 6 sessions package to be given in 6 successive weeks. Photo 13, 14, 15: Launching of mCenas at the Secondary School of Napipine (9 and 10) and in Secondary School of Nacala Porto (11) mCenas! In Q3FY2, mCenas was launched in five secondary schools in Nampula province reaching five different districts (Nacala Porto, Nampula city – Napipine school, Ilha de Moçambique, Angoche, and Ribaue – EBA school). The launch activities carried out included a SRH and PF contest, role plays, a health fair, FP consultations. It’s important to highlight the IFPP-DKT partnership as their mobile clinic joined the event providing FP/SRH services. At the end of Q4FY2, 857 adolescents and young people had already registered in mCenas and are receiving SMS. This activity was led by SDJET – Education Table 10: some SRH features of the mCenas users district directorate, in close collaboration with at end September 2018 SDSMAS and benefited from the IFPP support. currently currently Previous 61% of the mCenas users are boys and 39% girls. pregnant or have Gender Sexual partner already Exp. At enrollment users were asked some questions. pregnant a child The answers, collected thru the mCenas App data F 39% 326 69% 22% 27% base, are illustrated in Table 10. First, the vast M 61% 531 77% 23% 20% majority of the students are sexually active: 69%

30 of the female group and 77% of the males. Secondly, out of the 326 female students, 72 are currently pregnant (22%) and 88 have already a child (27%) attesting about the importance of school MB.

The distribution of the mCenas platform users is Figure 7: Distribution of mCenas users by age at end June 2018 represented in Figure 7 by sex and by age. It appears that all age groups are interested in 120 110 using the platform. 100 87 83 80 68 55 During the launch event, the MBs’ calendars was 60 51 defined jointly with SDSMAS, DKT, and IFPP to be 40 43 40 34 25 42 35 broadly disseminated within the target group. 21 18 14 14 14 20 11 29 9 5 Also, IFPP and the concerned HFs reclarified who 1 2 4 11 15 0 3 3 4 4 3 will attend to the students in each referral HF (all 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 providers, AYRH services – SAAJ, some clearly Feminino Masculino identified HPs).

Sub-IR 2.2: Improved community environment to support healthy FP behaviors To contribute to the IR2, IFPP/N’weti is implementing a systematic community dialogue process which involves groups of key CLs and influencers. The rationale behind the community dialogues is to address the social and gender norms and drivers behind the lack of use of modern FP. The rationale also is to create a more enabling environment at the community level for adherence to modern FP methods. CLs are important gate keepers and educators.

Fostering an enabling environment for demand creation Table 11: Distribution of the CLL meetings by To boost the local leadership involvement in the areas in province and district which CFs were facing a deficit in community leadership # of Meeting with CLL involvement, IFPP (in coordination with the head of the DISTRICT Q2FY2 Q3FY2 Q4FY2 Beira NA NA NA Locality “Chefe da Localidade”) has supported a one-day Dondo 0 0 1 meeting focused on gathering the members of the Nhamatanda 3 1 0 Conselhos Locais da Localidade (CLL). This Local Council is Buzi 1 0 1 a body of consultation for the local administration Chibabava 2 0 0 authorities in search of solutions to fundamental Machanga 1 1 0 Caia 1 0 0 questions that affect the lives of local communities as Marromeu 2 1 0 well as their well-being and sustainable development in Chemba 2 2 0 which participate the community authorities. Gorongosa 0 0 1 Cheringoma 0 1 0 Maringue 2 0 2 This FY2, 25 meetings were held in 11 districts in Sofala Muanza 0 0 0 SOFALA province and 39 meetings in 16 districts in Nampula 14 6 5 province. The main objective is to create a more enabling PROVINCE Angoche 3 0 2 environment for FP behaviour change within their Mogincual 1 0 1 communities, promoting social norms favorable to Liupo 2 0 1 reproductive health and HTSP and to strengthen their Npla Cid NA NA NA Erati 0 1 1 leadership to increase the community participation in Memba 0 0 1 community dialogues. These meetings included Meconta 1 1 1 participation from the HF Director, the MCH responsible, Nacaroa 0 0 0 as well as the provider in charge of the community Muecate 0 0 0 involvement. The main questions discussed included: In Mogovolas 3 1 0 Moma 1 0 0 your opinion, what are the reasons for the low use of Lardes 0 0 0 methods of contraception at community level? What Monapo 4 0 0 could each of us do to improve the use of FP in your family Mossuril 3 0 0 Ilha Moç. 3 0 0 circle and in your community? N.Porto NA NA NA N.Velha 2 0 0 The final exercise was mapping of the community, Murrupula 0 0 0 including highlighting the main roads, the schools, the Rapale 0 1 0 Mecuburi 0 1 0 health center, the APEs, the best-known PTs, and the Ribaue 2 0 1 MBs concentration points. Malema 0 0 0 Lalaua 1 0 0 Nampula Follow-up meetings are recommended to be carried out 26 5 8 PROVINCE every six months.

The CLs expressed their satisfaction with regards to the meeting and the contents. Their understanding about the role of the CFs has dramatically increased and subsequently their support. Leaders committed themselves to more engagement in the program, to interact with the churches to spread the FP messages, and to disseminate FP messages in communities.

Leveraging community partnerships through CBOs Technical support visits continue to be carried out, targeting the 88 community-based organizations (CBOs) to more qualitatively implement the agreement signed with IFPP by increasing their follow-up activities and including monitoring CF activities at the community and HF level. CBO representatives were involved in the CSCs process.

Use of community radio to Table 12: Radio sessions by radio amplify the community dialogues focused on HTSP, FP, and benefits for healthy families and Broadcasting communities Q3 Q4 Q1 Q2 Q3 Q4 FY1 FY1 FY2 FY2 FY2 FY2 IFPP is building on the community Province & district Radio name Mossuril CR Mossuril 4 9 4 5 20 dialogues and working with eight Monapo CR Monapo 22 26 22 11 10 community radios (CRs) in Meconta CRT Namialo 22 14 0 6 0 Nampula and four in Sofala to Memba CR Memba 12 16 0 0 0

Erati CR Namapa 10 16 0 0 26 Nampula broadcast dramas, interviews, and extended Ribaue CRT Ribaue 22 13 0 0 11 radio programs to help to Angoche CR Parapato 18 16 2 0 12 demystify and minimize barriers Nampula CRT Gemeas 12 15 0 te to process MOUin 0 linked to FP at the community Sub-total 122 125 28 0 22 79 Nhamatanda CR Acordos de Paz 0 16 11 4 10 21 level. CR staff were prepared to Gorongoza CR Gorongoza 4 14 18 12 20 14 Caia CR Caia 8 8 9 4 12 17 broadcast 16 sexual and Sofala reproductive health rights (SRHR) Marromeu CR Marromeu 8 18 8 4 10 18 Sub-total 20 56 46 24 52 70 and FP programs. Within IFPP’s communication and sensitization approach, the CRs complement the messages transmitted during CD sessions with CFs promoting SRHR, FP rights, and the duty of citizens to raise public awareness around SRHR and the benefits of FP services.

As illustrated in Table 12, During Q4FY2, 149 radio programs were broadcasted focusing on the contents of the sessions 4, 5 and 6 of the Community Dialogue – 79 in Nampula and 70 in Sofala. For five months and according to the Memorandum signed with each CR it was expected that they would have broadcasted one radio edition per week (one live and one deferred). CRs, such as Radio Gêmeas, had a serious breakdown and consequently interrupted completely its broadcasting. For the others CRs, due to equipment malfunctions and power outages, delays occur more frequently than expected. Nhamatanda CRs has been restructured and its personnel already trained by the IFPP was substituted. All the radio programs had the active participation of the Field Supervisors and the SDSMAS appointed HP; IFPP district coordinators tends to join as frequently as possible. Broadcasting of the remaining editions will be carried out during Q1FY3.

Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions During this FY2, IFPP has coordinated with IREX and H2N – a Mozambican organization focused on community-based communication, aimed at information sharing, community mobilization and demand generation for the public and private service with the primary focus on Health and Nutrition - who has developed two information mechanisms (XIPALAPALA and RCSN) with the aim of increasing access to information.

IR 3: Strengthened FP/RH health systems During the Jul – Sep 2018 quarter IFPP HSS activities were focused on the completion of the 2nd round of the family planning (FP) Management Standards Compliance (MSC) assessments in 3 of the 5 new expansion districts in Nampula (Malema,Mogovolas, and Murrupula), the 4th round of evaluations of district FP systems in three districts (Angoche, Erati and Mecuburi), three districts in Sofala (Beira, Dondo and Nhamatanda), and other three districts (Machanga,Gorongosa and Buzi) were assessed for third round.

IFPP team conducted a joint compliance review with the NEDs to complete the District Profile (PD) for the period of April to June 2018 and compare it to the previous quarters for use in decision making. This was done with the SDSMAS of Cidade de Nampula, Mogovolas, Nacala Porto, Naca-a-velha, Meconta, Murrupula, Mogovolas, Memba, Ribaue, Monapo, Mossuril, Angoche, Moma, Mecuburi e Malema and Dondo, Nhamatanda, Gorongosa, and DPS Sofala. IFPP also provided technical assistance in the methodologies for presentation and analysis of the tool in the monthly statistics meetings or in review meetings.

A key priority and major achievement during the quarter was the continued low number of visited HFs suffering from a contraceptive stock out. This was achieved through a combination of proactive communication between the key actors involved in the FP consumables supply chain management; TA to ensure HFs, and district and provincial medications depot managers properly forecast family planning commodities needs and plan for their efficient distribution; and monitoring of logistics activities in the control of eminence and stock out of contraceptives in the HFs through CommCare App and SIGLUS in 13 districts with the system already in use (eight districts in Nampula and five in Sofala).

The project also provided technical support in conducting PES review meetings to monitor the progress and implementation of the SDSMAS QI plans in 15 districts in Nampula and six in Sofala, including the respective DPSs. HSS advisors also participated and provided TA in the process of preparing PES 2019 and ensured the inclusion of FP activities in Sofala and Nampula.

Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution Activities within this sub-IR include capacity building and TA to the districts and DPS to appropriately apply the standard operating procedures (SOPs), using the Management Standards Compliance tool, and budget for evidence-based FP strategies in the annual provincial plans (Social and Economic Plan [PES]) and district plans (the District Operational Social and Economic Plan [PESOD]). The PES/PESOD cycle throughout the year includes monitoring of the annual PES/PESOD and understanding the next cycle by May-July.

During Q4 FY2, the HSS team provided TA to Table 16: MSC trends by district 128 Sofala and Nampula DPS and SDSMAS < or = 60% MSC District Scores Over Time >60% < or = 70% program managers including 44 new individuals (Target: achieve satisfactory scores ?80%) >70% < or = 80% receiving TA (16 in Nampula; 28 in Sofala) and >80% < or = 90% FY1 (Oct. 16 - FY2 (Oct. 17 - Sept. 18) 80 (65 in Nampula; 19 in Sofala) had received in >90% < or =100% Sept. 17) DISTRICT Q2 Q3 Q4 Q1 Q2 Q3 Q4 previous periods). This involved supporting the Angoche 40% 92% 94% 85% preparation of monthly and quarterly work Mogincual Liupo plans to guide implementation and facilitate Nampula D. 39% 83% 90% Erati 37% 75% 84% 84% routine monitoring of PES performance. Memba 55% 79% Meconta 68% 70% 84% Throughout FY2 135 new individuals were Nacaroa reached in TA session, this represents 89% of Muecate Mogovolas 57% 56% the annual target to train 152 unique Moma 42% 85% 85% Lardes individuals (four from each district and the Monapo 50% 92% 91% DPS), which is close to the expected Mossuril 53% 86% Ilha Moç. performance for the year. N.Porto 41% 66% 90% NAMPULA PROVINCE NAMPULA N.Velha 56% 88% Murrupula 49% 83% Table 16 illustrates the trends in MSC Rapale Mecuburi 41% 81% 88% 86% assessments carried out since the beginning of Ribaue 41% 92% 96% the IFPP intervention at SDSMAS and DPS level. Malema 38% 84% Lalaua The FY2 targets are to maintain satisfactory Beira 63% 86% 89% 90% Dondo 60% 71% 82% 87% scores (≥80%) in FY1 districts who graduated (7 Nhamatanda 65% 83% 82% 85% districts) and support those who did not Buzi 74% 82% Chibabava 60% 73% 79% 82% graduate in FY1 to achieve better results (Erati, Machanga 67% 85% Caia 54% 66% 83% Meconta, Nacala Porto, Dondo, Nhamatanda, Marromeu 70% Chemba Chibabava, Caia, and Gorongosa). Nine Gorongosa 66% 82% additional districts were enrolled for FY2 to SOFALAPROVINCE Cheringoma Maringue receive regular MSC assessments (Memba, Muanza Mogovolas, Mossuril, Nacala Velha, Murrupula, Malema, Buzi, Machanga, and Marromeu).

During this quarter, MSC assessments were conducted in 12 districts during the Q4FY2. Of the 12 MSC assessments, seven districts reached for the first time the score of 80% or greater.

During FY2, the seven districts reported at end of FY1 with a score ≥80% (Angoche, Nampula, Moma, Monapo, Mecuburi, Ribaue, Beira) were reassessed during FY2 and have maintained their score. Furthermore, 7 additional districts in Nampula (Erati, Meconta, Mossuril, Nacala Porto, Nacala Velha, Murrupula and Malema) and 7 districts (Dondo, Nhamatanda, Buzi, Chibabava, Machanga, Caia, Gorongosa) in Sofala have reached for the first time a score ≥80%. Therefore, during FY2, IFPP has 21 unique districts assessed with a score ≥80% on a total of 24 districts assessed (13/15 in Nampula and 8/9 in Sofala) compared to the target of 14 fixed for FY2 which represents an achievement of 150% of IFPP target. This results is encouraging as it represents already 58% (21/36) of the LOP target

Regarding the performance of the districts evaluated in the 4th Round in Sofala, all of them maintained a satisfactory score of (≥ 80%) with an increasing trend. According to the table districts, Chibabava, Machanga and Gorongosa have made significant progress reaching a satisfactory score of (≥ 80%) with 82% , 85% and 82% respectively. In Nampula province, Mossuril and Murrupula have made significant progress, reaching a satisfactory score of (≥ 80%) with 86% and 83% respectively. The district of Mogovolas has regressed due to the changes of managers of the areas of HR and Logistics (DDM). Regarding the performance of the districts evaluated in the 4th Round, all of them maintained a satisfactory score of (≥ 80%) although they lost a few percentage points: 9 and 2 Angoche and Mecuburi respectively; while the district of Erati remained with the same score (84%).

IFPP’s HSS team supported district managers to develop and update quality improvement (QI) action plans to improve performance and to guide follow-up TA in the implementation of corrective actions.

The Integration of the DPS technicians in the Technical Support activities (IFPP, DPS and SDSMAS) in the implementation of the QI Plans and carrying out the district evaluations of management standards (MSC), was a Positive implementation point.

Sub-IR 3.2: Improved management of commodities to ensure availability at local levels

Overall during year 2 there was a significant reduction of stock outs in the HFs assisted by the project. A combination of factors contributed to these results most notably the availability of FP commodities at the national level, as well as a number of IFPP supported interventions. These interventions include project- supported weekly follow up of any imminent or total stock outs identified by IFPP district coordinators in their routine TA.

During the Q4FY2, and throughout the FY2 IFPP’s TA teams provided routine TA to ensure each health facility’s pharmacy manager and SDP focal point correctly and systematically used the MOH stock cards and requisition forms to properly manage contraceptive inventories in site depots and internally within SDPs. The project also supported four provincial (three in Nampula and one in Sofala respectively) and 14 district (four in Nampula and ten in Sofala) FP task force meetings involving DPM, DDM and MCH health professionals. A significant gain achieved during Q4 was establishing task force in all districts in Sofala and holding task force meetings in 10 of the 13 districts of Sofala province, this was a result of the leadership of the DPS in this matter, while in Nampula it’s still a challenge to hold the district task force meetings. The meetings served to analyze maximum monthly consumption data and contraceptive commodity requisitions from each health facility to ensure enough stock is ordered to respond to the growing demand for FP commodities.

During the quarter the project started the pilot of SMS messages to strengthen FP commodity inventory management and facilitate identification and reporting of imminent stock outs in the districts not yet covered by SIGLUS. The project developed these platforms for SMATG-CPF (Sistema Móvel de Assistência Técnica para Gestão dos Consumíveis de Planeamento Familiar, or System for Mobile Management of Family Planning Commodities) and SAPERS-CPF (Sistema de Alerta Precoce para Evitar Roturas de Stock

36 dos Consumíveis de Planeamento Familiar, or Early Warning System to Avoid Stock Outs of Family Planning Commodities) throughout the FY 2. The results of this pilot will be shared over the next quarters.

For FY3, the project will continue with the actions for strengthening the logistics of the FP commodities and special attention will be devoted to TA in the implementation of SIGLUS, specifically to fix some difficulties in the use of the tablets by health providers that occur in these first months of implementation as well as disseminate between health providers and APEs the SMS systems for reporting and preventing contraceptive stock outs.

Photo 17: Joint teams of CMAM, PSM and IFPP in SIGLUS post-training supervision in Namitoria- Angoche district

With the introduction of SIGLUS in 8 districts in Nampula (Nampula City, Rapale, Monapo, Nacala Porto, Nacala-a-Velha, Memba, Moma, and Angoche) and 5 districts in Sofala (Beira, Dondo, Nhamatanda, Buzi and Marromeu), this quarter we used this source as well to report since it allows the analysis of the availability of stocks in all HFs of the districts covered.

ComCare, Nampula:

12 HF's were mentored and none of these registered any stock out meaning 0% of HF's with stock out.

SIGLUS, Nampula:

The implementation of this system began in June 2018, and 104 HF's of the 8 districts, (Nampula City, Rapale, Monapo, Nacala Porto, Nacala-a-Velha, Memba, Moma, Angoche) implementing the system were monitored and eight registered stock out of at least one method during the quarter, representing 8 %. In the SIGLUS appears a number superior to 8 HFs that registered stock outs but in fact what happened is that the HFs depots sent all the FP products to the MCH sector and for that reason they remained with stock zero in the stock card. This is a practice contrary to the rules of stock management and through on the job trainings and TA visits the project staff will encourage the depots managers to follow the stock management standards.

ComCare, Sofala:

28 HF's were mentored and none of these registered any stock out meaning 0% of HF's with stock out.

SIGLUS, Sofala:

The implementation of this system began in May 2018, and 65 HF's of the 5 districts (Beira, Dondo, Nhamatanda, Buzi e Marromeu) implementing the system were monitored and none HF registered stock out of FP methods .

Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment During past quarter, the Community Score Card (CSC) process was carried out at 14 selected HF in the districts of Chibabava, Buzi, Nhamatanda, Cheringoma, and Chemba in Sofala province (6 HFs) and Photo 18, Restitution event in Cheringoma district and signature of the report by the Secretary of the Bairro Angoche, Moma, Memba, Rapale, Mongovolas, Nacala a Velha, Meconta, and Table 13: Training participants and HF selected for the CSC Erati in Nampula province (8 HFs). The 14 Training participants Provin HFs were pre-selected based on the quality Districts HF targeted SDSMAS Field ces OCBs CFs of their existing relationship with & DPS Sup. Angoche Namaponda communities in their catchment area, Moma Moma favoring the HFs with clear weaker Memba Chipene relationships based on the community Rapale Namaita Mogovolas Iuluti 8 8 16 8

dialogue’s sessions conducted. In Nampula Nampula Nacala Velha Barragem province, eight interface meetings were Meconta Corrane Erati Alua performed, during which representatives of Nhamatanda Vinho the community groups and members of the Cheringoma Cheringoma HP’s group debated the results of the ratings Marromeu Marromeu Chemba Catulene 10 6 14 6 obtained at community and HF level and Sofala Chibabava Goonda drafted the action plan. Six restitution Buzi Bandua meetings, which restitute the results and Total 18 14 30 14 plan of action of the CSC process during a public meeting, were led by the district authorities. In Sofala province, the six interface meetings and five restitution meetings were carried out; the restitution meeting for Bandua HF in Buzi district still has to be carried out: it’s planned for next quarter as the SDSMAS director was newly appointed. Where these meetings took place, it was possible to have a massive presence of communities, Administrators and members of the District Government, DDSs, Chief Medical Practitioners, SMI / SESP Program Managers, Health Technicians involved in the CSC, and local leaderships. Local groups of music, theater and dance were involved to support the dissemination of PF messages in a less conventional way so that everyone could follow the messages. To further publicize the event, community radio stations were also involved

38 to cover the event. In Sofala, these meetings were attended by the RCs of Marromeu and Nhamatanda who did interviews on the spot and disseminated the event. All the action plans were drafted to improve and regularly monitor the quality of the “community – HF” relationship. As expected, revitalization of the co-management committee and improvement of the HF service quality were key points discussed. Six co- management committees (HFs of Barragem, Alua, Iuluti, Chipene, Corrane in Nampula and Divinho in Sofala) were revitalized (5) and 1 established from scratch; all are now operational.

Finalizing the CSC process is taking longer than expected, mainly due to superposition of agenda for some District counterparts as well as some reluctance for others district counterparts (Marromeu, Chemba, Cheringoma and Buzi).

Sub-IR 3.4: Improved government capacity to increase supply, distribution, and retention of skilled workers Based on the system assessment, capacity building, and systems strengthening action plans, IFPP supported DPS and district managers to more effectively manage the supply, distribution, and retention of skilled FP workers. In year one, the project supported DPS and district managers to track, report, and prioritize all FP/RH in-service and on-the-job trainings using the MISAU human resource information system (SIFO), and develop geographic information system (GIS) maps to identify districts and HFs with FP/RH training needs.

IFPP also provided TA in the institutionalization of district in service training centers, strengthening staff competencies in operating the MOH’s HRIS or SIFO platform. The project also developed and distributed clear SOPs for the reporting and registration of in-service trainings using SIFO forms in the respective platform. Overall, this support has decreased the volume of forms to be recorded at the provincial level. In Sofala province, all 13 districts and 8 in Nampula are now recording the SIFO forms locally, thereby streamlining the training registration process and ensuring more complete data in SIFO. During the Q4FY2, 141 technical staff and health care providers were recorded in the MOH’s SIFO HR training information system (HRIS) as trained in the integrated provision of family planning services. With a total of 849 recorded by the end of Q4, this represents a 94% achievement against the annual target

The next step will be to more pro-actively manage personnel changes related to HRH transfers (relocation related annual leave, in-service specialty training, post relocations, etc.). For instance, out of 228 HFs in Nampula, an in-depth analysis shows that FP services indicators had particularly low performance in 66 HFs with high HRH turnover during the Q2FY2. However, those with higher levels of staff retention maintained or even increased their performance. In Q3FY2, this data was presented to DPS and SDSMAS managers to draft possible alternatives to plan forehand and more smoothly HRH transfers.

Sub-IR 3.5: Improved generation, dissemination, and use of FP data for more effective decision-making The use of district profiles to guide quarterly data analysis meetings has strengthened the FP program’s capacity to acquire strategic information and use it for evidenced-based decision making to improve program performance.

In Q4FY2, 16 districts held data review meetings using district profiles (DPs), which were developed and analyzed with IFPP support. Specific sites included eight SDSMAS in Sofala (Beira, Dondo, Nhamatanda, Gorongosa, Machanga, Chibabava, Caia e Chemba) and eight districts in Nampula (Nacala porto, Ncala-a- velha, Moma, Mogovolas, Angoche, Ribaue, Malema e Memba). One positive aspect of the use of the DP in the review meetings during FY2 was the sharing of experiences and improvement actions between HF's with good and poor performance of the FP indicators, whenever possible between the Directors and MCH's of the peripheral HF's and district program managers.

For FY3 we will continue to encourage the use of the DP for the discussion of FP data, and joint development of QI plans between peripheral HFs and SDSMAS.

Monitoring, evaluation, and implementation research During the Q4 and during the FY2, the monitoring and evaluation (M&E) team continued activities focusing on assuring data quality. The main activities implemented were:

• Supervision and technical support • Support HFs to analyse and present monthly statistics; • Routine Data Quality Assurance (RDQA); • Support the M&E community component

The table below shows the activities supported by the M&E during the FY.

Q1 Q2 Q3 Q4 TOTAL FY2 FY2 FY2 FY2 Supervision 16 24 4 19 63 RDQAs 2 26 2 25 55 Integrated supervision 0 7 16 23 Nampula Support in the HF statistic 8 8 16 1 33 Support monthly discussion of data at HF 0 2 1 1 4 Support monthly discussion of Data at 0 4 3 0 7 district Supervision 19 9 14 10 52 RDQAs 6 20 17 40 83 Integrated supervision 0 0 0 0 0 Sofala Support in the HF statistic 3 1 3 5 12 Support monthly discussion of data at HF 0 1 0 0 1 Support monthly discussion of Data at 0 1 0 1 district

Supervision and technical support

In Nampula, during Q4FY2, 4 districts received technical supervision visits (Mecuburi, Lalaua, Mogovolas, Distrito de Nampula ) reaching 19 HF. During these supervision visits, RDQAs were also performed. In Sofala, supervision and technical support was given to 39 HF in 11 districts (Beira, Dondo, Nhamatanda, Chibabava, Machanga, Buzi, Gorongoza, Muanza, Marrumeu, Caia, and Cheringoma). Despite some progresses observed throughout the quarters, the main findings continue to focus on the daily Photo, 19. Technical support CS and monthly summary forms which are not consistently fulfilled. Also, Nacala Porto there is still a weakness persisting with regards to the registration and monthly aggregation of the mobile brigade activities.

Support APEs In order to ensure that the APEs contribution to the Family Planning program is effective and that the data reported by them are of a desirable quality, a semi-annual review meeting of APEs was held in Nampula province, in the districts of Ribáue, Nacaroa, Muecate and Meconta where aspects related to APEs logbook, data aggregation forms, information flow and presentation of the last 6 months data were observed and discussed. Support Nampula Provincial Health Directorate In coordination with the MCSP and DPS partners, a semi- Photo, XXX. Semi Annual discussion annual data discussion meeting of MCH data and nutrition was held at Nampula provincial health directorate. The districts received a single presentation template that they needed to insert data and present. It is important to mention that during the review meeting there was a technical update session on how to interpret FP indicators (new users, initiators, FP and method followers), as well as aspects related to the management of PFI (Planeamento Familiar Integrado), APE's and mobile brigades data.

Support to district monthly meetings and elaboration of HF monthly statistics During FY2, in Nampula, 44 HF were supported with monthly data review meetings to ensure that monthly reports were filled out correctly; in Sofala, 13 HF were supported. The teams also promoted the use of the daily FP reporting forms to improve data aggregation for the HFs’ monthly summary with a focus on FP integration data, that is one of the problems found during the RDQAs visits.

Routine Data Quality Assurance (RDQA) During the quarter, RDQA tools were applied to 65 HFs (25 in Nampula and 40 HF in Sofala). The main findings are: 1) some HF still don’t fill out the daily tally sheet; 2) FP integration monthly summary form

41 erroneously aggregated. To address both problems, they have been included as part of continued mentorship visits and support to HFs.

As part of the data quality assurance process, the Sofala province has presented data triangulation between SISMA data, the monthly forms data and data registered in the consultation logbook for women initiating pills and injectable, during the month of August in 5 districts of Sofala: only Marromeu district had a 37% discrepancy; the others had less than 4% of discrepancy. Photo, 19. RDQA at CS Napipine

Comparison of the data register in the SIS of women initiating pills or injectables during the month of August, 2018 37% 4500 40% 3856 4000 3720 3738 35% 3500 30% 3000 25% 2500 20% 1751 1802 1725 2000 1538 15% 1500 986 962 968 1104 967 1000 4% 10% 2% 513 4871% 508 1% 500 5% 0 0% Aug-18 Aug-18 Aug-18 Aug-18 Aug-18 CIDADE_DA_BEIRA GORONGOSA MACHANGA MARROMEU NHAMATANDA

MCD_SISMA MCD_Consolidado MCD_Ficha de Consolidacao % MCD_Descrepancia

When analysing the indicator of new users, the discrepancy of the data remains below 5% for Beira city, Gorongosa, Machanga and Nhamatanda, exept for Marromeu that has 41% discrepancy between SISMA and the summary form.

Comparison of the data register in the SIS of New Users with the data register in the summary forms, month of August 2018

6000 60%

4896 5000 4719 4743 50%

4000 41% 40%

3000 30% 2428 2376 2355

2000 1792 20%

1184 1124 1129 1054 1054 1000 10% 482 462 462 5% 4% 4% 3% 0 0% Aug-18 Aug-18 Aug-18 Aug-18 Aug-18 CIDADE_DA_BEIRA GORONGOSA MACHANGA MARROMEU NHAMATANDA

PF - Novas Utentes SISMA Novas Utentes_ Consolidado Novas Utentes_ Ficha de consolidacao % Descrepancia

Support to the community component The M&E team in both provinces supported the community component along FY2. Main activities carried out focused on:

• Monitoring of data registered into DHIS2 and its synchronization; • Support the field supervisors on management of Tablets (Scan, Email, and general use); • Support the CFs in the correct filling of the forms • Validation of referrals and confirmed referrals at HF level

FP and Environmental Compliance During FY2 157 HF (63 US in Nampula and 94 US in Sofala) were assessed for FP compliance: 26 were compliant, 112 were not in compliance and 19 had still to complete the visits. Most of the 112 HF are not in compliance because they have few providers that did not yet participated in the IFPP 8 days training. Also, Environmental compliance was assessed throughout FY2: out of 159 HF (64 in Nampula and Photo 21: Tihaert sensitization of the 95 in Sofala), 7 were complying, 12 with visits to be Namialo community radio personnel completed and 140 were assessed as not being in compliance. Corrective action plans have been drafted.

During the Q3FY2, the COP, DCOP, Finance Director and the Clinical Director of IFPP participated in a compliance training held at the USAID Mozambique office. Following this training, a supervision visit was held at the Nampula province targeting districts of Monapo, Ilha de Moçambique, Meconta, and Nampula city with the aim of observing all IFPP project components – the urban component, rural component, and clinical component. A FP compliance training for radio staff of Mossuril, Monapo and Namialo was carried out. The project staff have gone through their annual training during FY2.

Project Performance Indicators Goal: Increase use of modern contraceptive methods IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services Achieved FY2 Annual % Indicator LOP Target FY1 Annual Q1 Q2 Q3 Q4 Achieved Target 595,202 278,144 72,997 1396% 340,303 157,112 230,920 290,534 Since April 2016, the MOH “FP new user” indicator defined new users as “first time users 1.A. # new in life.” For the FY2, IFPP proposed the target of 72,997 defined taking in account the users of modern contraceptive prevalence rate (CPR) and the unmet need for FP (IFPP baseline). contraceptive Categorizing a client as a first-time user in her life is dependent on information provided methods by the user. The reliability of this information depends on the HF provider ability and time. The Q1FY2 data was very high as the MCH National Health Week and the 2017 National Contraception Week reported 172,880 new users.

3,045,547 544,230 775,596 149% 380,414 186,832 262,867 329,010 # of women The IFPP suggested the inclusion of this new indicator, "Number of women initiating a initiating a contraceptive method", disaggregated by type of method as more reliable to monitor the contraceptive trend of FP access. Q1 and Q4 are probably overreported due to implementation of the method MCH National health week and the SRH and CECAP “caravan” organized during the 2018 Russia football world championship. 658,958 399,381 432,828 148% 181,704 125,960 152,736 178,744 1.B. # continuers In coordination with the MOH definition, a “continuer” user is a woman who used a FP users of method already in her life and should be registered only once in the FP logbook. The data modern from Q1 includes 95,845 continuers users that were reached by MCH National Health contraceptive Week and the 2017 contraception week. During Q4 the intervention supported MOH to methods reached 178,744, an increase of 17% comparing with Q4FY2. At the end of FY2, 148% of IFPP annual target is reached. 2,963,877 591,722 615,391 200% 387,480 219,075 286,335 340,624

1.C. Couple Data disaggregated by method are presented in the PMP in annex; the FY2 annual target Years of proposed is 615,391. At the end of FY2 the project reached 200% of the annual target. This Protection achievement was influenced by the National Health Week and the 2017 contraception week that occurred during Q1 as well as the SRH and CECAP “caravan” organized during the 2018 Russia football world championship Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Achieved Target Target 18,465 3,136 6,522 153% 1,748 2,128 3,210 2,914 IFPP at the end of FY2 surpassed the annual target in 53%. 1.D. # women receiving contraceptive services in HIV services

Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Achieved Target Target 1.E. # 330,059 36,427 73,021 98% 17,810 16,561 18,542 18,460 postpartum During Q4FY2, 5,267 PPIUDs were inserted and 13,193 women accepted another modern clients accepting a contraceptive method. IFPP has reached 98% of the annual target. Important to note is modern that national logbooks report data on PPIUD and, all remaining FP methods are collected contraceptive under the “other methods” column. Comparing with the number of institutional deliveries method prior registered in Q4, 23% of the women who gave birth at a HF have accepted one of the to or at eligible post-partum FP methods and during the FY2 of all women who gave birth at a HF, discharge 22% accepted a PF method. During FY1 this percentage was of 13%. 1.F. # users 338,751 47,072 82,798 152% 23,450 27,639 32,870 41,982 receiving modern Q4FY2 data shows that IFPP surpassed its annual target and comparing Q4 with Q3 it was contraceptive an increase of 27%. methods from APEs at community level

Comments: In general, indicators Figure 8. Trends in women initiating a contraceptive method by type of method in attest a sustained Nampula and Sofala provinces - October 2016 to September 2018 (w/o PPFP at expansion of IFPP. Maternity and minilap) The Q1FY2 data were 300000 strongly influenced 250000 by the MCH National Health Week and the 200000 contraception week. 150000 It was expected that some of the STM 100000 new users and 50000 continuers reached during these two 0 events will have Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 difficulty refilling FY1 FY1 FY1 FY1 FY2 FY2 FY2 FY2 FY1 FY1 FY1 FY1 FY2 FY2 FY2 FY2 their methods in Nampula Sofala future quarters, Pills Injectable Implant IUD which will increase the STM discontinuation rate. Meanwhile, the initiators of LTM are important contributors for the mCPR and these events are also booming the IUD and implant additional user’s number. Figure 8 shows the trend in women initiating a contraceptive method. Q1FY2 received a huge pull with the National Health Week (NHW); when comparing Q4FY2 to Q4FY1, Nampula add an increase of 86 and Sofala of 51% of women initiating a contraceptive method.

CYP data of Q1FY1 are Figure 9 Trends in CYP in Nampula and Sofala provinces - October 2016 to September not comparable to 2018 the others as IFPP reported data only 250000 from 17 districts in 200000 Nampula compared 150000

to the 23 of following 100000 Axis Axis Title quarters. As Q2FY1, 50000 data reported on a 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 quarterly base are FY FY FY FY FY FY FY FY FY FY FY FY FY FY FY FY comparable. Interval 1 1 1 1 2 2 2 2 1 1 1 1 2 2 2 2 IUD insertion is Nampula Sofala stronger in Sofala T. Ligation 108 512 576 712 432 360 824 880 496 0 province while PPIUD Pos Partum IUD 245 659 113 163 172 143 148 189 249 513 548 507 455 462 532 IUD 609 136 162 209 367 194 269 403 0 133 176 177 281 206 229 226 is stronger in Implant 165 336 415 554 117 427 674 948 0 324 392 460 906 556 701 671 Nampula province. Injectable 177 255 277 335 544 372 486 597 0 112 112 134 199 142 165 157 All LTM have Pills 467 457 452 640 113 595 827 106 0 337 335 399 643 393 449 427 increased consequently. During Q4 the CYP in Nampula increased 35% when comparing with Q4Y2 with the LTM being 68% of the CYP and in Sofala the CYP decreased 3% but the LTM is still 85% of the weight of the CYP.

IFPP is increasing Figure 10, PP IUD and institutional deliveries by province from October 2016 to access to immediate September 2018 post-partum FP 4500 8.0% methods (IUD, 4000 6.4% 6.9% 7.0% 7.0% Implants and 3500 5.6% 5.2% 5.4% 6.0% 3000 5.2% 5.0% progestin pills). The 4.3% 4.7% 5.0% 2500 4.3% 4.7% 4.0% percentage of PPIUD 2000 3.0% on the total number 1500 2.6% 2.7… 2.0% of institutional 1000 1.3% 1.0% deliveries (figure 10) 500 0 0.0% is stabilizing along the Q1 Q2 (Jan Q3 Q4 (Jul FY2 Q1 FY2 Q2 FY2Q3 FY2Q4 Q2 (Jan Q3 Q4 (Jul FY2 Q1 FY2 Q2 FY2Q3 FY2Q4 (Oct to to Mar)(Apr to to (Oct to (Jan to (Apr to (Jul to to Mar)(Apr to to (Oct to (Jan to (Apr to (Jul to FY2 quarters and Dec) Jun) Sept) Dec) Mar) Jun) Set) Jun) Sept) Dec) Mar) Jun) Set) reaching 7% in Nampula Sofala Nampula province PP IUD in IFPP district PP IUD in non IFPP district % of PPIUD and 5% in Sofala province. A specific strategy was designed together with DPS in order to give a second breath for PPFP in FY3.

When analyzing post-partum women Figure 11, % of women accepting Post-partum FP method at Maternity by quarter and province from October 2016 to September 2018 accepting a modern 16000 30% contraceptive 14000 26% method at maternity 25% 23% 23% 23% level (Figure 11 - 12000 23% 18.6% 20% 10000 18% 17.7%17.7% PPIUD and other PP 16% 16% 15% methods), Nampula 8000 15% 6000 province is 10% 9% stabilizing around 4000 7% 5% 23% and Sofala 2000 2% province around 0 0% 18%, attesting a FY1Q1 FY1Q2 FY1Q3 FY1Q4 FY2Q1 FY2Q2 FY2Q3 FY2Q4FY1Q2 FY1Q3 FY1Q4 FY2Q1 FY2Q2 FY2Q3 FY2Q4 Nampula Sofala successful intervention. PP IUD Other methods % of women accepting a PPFP method

Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based

Achieved FY2 Annual % Indicator LOP Target FY1 Annual Q1 Q2 Q3 Q4 Achieved Target 3,749 2,309 720 143% 239 285 322 186 An accelerated start-up supported the MoH to reach its 2020 FP targets. The 1.1.1. # health target for FY2 was calculated having in account the number of trainings providers trained on planned for FY2 and the number of eligible HP. The life of project (LOP) modern methods of target changed from 1,665 to 3,749 as IFPP benchmark first targeting only contraception MCH nurses was extended to all eligible clinical health providers. During Q4FY2, IFPP trained 186 health providers surpassing its annual target in 43%. During the FY2 IFPP trained 1,032 1.1.2. % of health 80% 90% 80% 93% 93% 90% 96% 94% providers who have completed the A total of 94% of the providers trained during Q4FY2 completed the training training on modern successfully and during the FY2 93% of health providers completed the methods of training successfully. contraceptive with positive score in the post test 1.1.3. % of supported 100% 68% 100% 92% 79% 84% 88% 92% service delivery sites providing family At end of FY2, 360 out of 385 HF (92%) had already at least 1 HP trained in planning counseling FP thru IFPP. 150HF in Sofala out of the 157 and 204HF out of the 229 in and/or services Nampula

Comments The level of participation in trainings and knowledge retention after trainings is high, above 80%, the IFPP benchmark.

Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based Achieved LOP FY2 Annual Annual % Indicator FY1 Q1 Q2 Q3 Q4 Target Target Achieved

1.2.1. # of additional USG- assisted community health 3,735 1,763 800 90% 193 289 124 117 workers (CHWs) providing During FY2, 723 CHW were trained 287 APES, 258 TBAs, 143 IPC agents and family planning information and/or 35 community facilitators, reaching 90% of the annual target. services 12,594 1,639 2,528 134% 1821 370 591 586 1.2.2. # mobile brigades conducted including During Q4FY2, IFPP supported 585 mobile brigades and during the FY2 contraceptive services supported 3,283 (2,182 in Nampula and 1201 in Sofala) and surpassed the annual target in 44%

Comments The target for mobile brigades in FY2 was calculated by considering the number of HFs receiving support from IFPP. IFPP will support one mobile brigade per month per supported HF. The LOP was changed to reflect this calculation from 47,306 to 12,594. The first LOP target was calculated under the assumption that the project could support at least three MBs per month per HF; considering that in peripheral HF’s only two providers are available and they oversee a lot of other public health programs and services, the target has been revised. Data from Q1 was influenced by the MCH week and the 2017 contraception week while data for Q4 was influenced by the SRH and the 2018 contraception month which occurred in September 2018

Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services

Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Target Achieved Target 40% 57% 30% 68% 74% 70% 63% 66% 1.3.1. % confirmed With CwS plataform, all IPC agent’s referrals are now electronic and can be referrals from contabilized; for clients receiving a paper slip from a triplicated referral copy-book communities to from CFs and for client referred by TBAs whose referrals are confirmed thru the facilities for FP monthly HF-TBAs meetings. Out of 43,195 referrals made, health providers based at services HFs have confirmed 31,467 referrals, resulting in a confirmed referrals percentage of 66%, and referrals confirmed by electronic represents 25%.

IR 2: Increased demand for modern contraceptive methods and quality FP/RH services Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors

Achieved FY2 Annual % Indicator LOP Target FY1 Annual Q1 Q2 Q3 Q4 Achieved Target

2.1.1. 1,147,520 174,531 182,208 177% 50,896 46,940 94,276 130,471 # contacts conducted by IFPP have surpass the FY2 annual target by contacting 322,583 women through the trained community activities. TBAs/activists to women

Comments The number of women contacted in Nampula was about 99,855 (59,993 by CFs; 28,280 by IPC agent; 11,582 by TBAs) and 30,616 (22,187 by CF, 7,905 by IPC agents, and 524 by TBAs) in Sofala.

Sub-IR 2.2: Improved community environment to support healthy FP behaviors Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Target Achieved Target 2.2.1. # 13,056 0 2,856 113% 608 628 993 997 community dialogues IFPP reached 113% of the FY2 annual target. conducted on FP (6 sessions completed) 2.2.2. # 1,475 323 384 84% 74 24 74 149 community radio sessions During this quarter,149 CR sessions were broadcasted and during the FY2 321 broadcasted sessions were broadcasted. IFPP reached 84% of the annual target. on FP/HTSP

Sub-IR 2.3: Improved systems to implement and evaluate SBCC interventions Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Target Achieved Target 2.3.1. # meetings NA 2 2 100% 0 1 0 1 held with SBCC project to The IREX program is strengthening H2N – Health HIV and Nutrition local NGO with plan/coordinate which IFPP is partnering and coordinating since its inception. 1 coordination SBCC approaches meeting was held in July in Nampula. 2.3.2. # capacity 10 2 2 100% 0 0 0 2 building sessions for community 2 capacity building trainings for Community Radios were carried out this quarter, radios and one in Nampula and one in Sofala gathering respectively 21 participants in community groups Nampula covering 7 different CR) and 14 in Sofala. in SBCC for FP

IR 3: Strengthened FP/RH health systems Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Target Achieved Target 2 2 2 100% 2 2 2 2 During Q1, TA and recommendations were provided to assess 2017 performance, and then to improve and realign the FP program annual plan within the 2018 3.A. # DPS Nampula and Sofala PES in line with IFPP objectives. Q2, embedded technical including FP advisers supported the alignment of FP activities within monthly and semi-annual interventions in plans in IFPP priority districts. In addition, TA was provided to support provincial annual PES and performance review meetings analyzing Q1 performance against PES targets, and budget to define strategies to improve outcomes in Q2. During Q3 the embedded technical advisers monitored the implementation of PES/PESOD2018 activities in the MCH-FP component and aligned the monthly and quarterly MCH/FP activities with PESOD and in Q4 HSS advisors participated and provided TA in the process of preparing PES 2019 and ensured the inclusion of IFPP FP activities in Sofala and Nampula 36 7 14 150% 1 9 7 11 The district Management Standards Compliance (MSC) assessments were conducted in 12 districts during the Q4FY2. Of the 12 MSC assessments, seven districts reached for the first time the score of 80% or greater. 7 districts (reported at end of FY1) with a score ≥80% were reassessed during FY2 and have maintained 3.B. # SDSMAS/DPS their score ≥80%; achieving During FY2, 7 additional districts in Nampula (Erati, Meconta, Mossuril, Nacala satisfactory Porto, Nacala Velha, Murrupula, and Malema) and 7 districts (Dondo, Nhamatanda, scores in MSC Buzi, Chibabava, Machanga, Caia, Gorongosa) in Sofala have reached for the first assessment time a score ≥80%. Therefore, during FY2, IFPP has 21 unique districts assessed with a score ≥80% on a total of 24 districts assessed (13/15 in Nampula and 8/9 in Sofala) compared to the target of 14 fixed for FY2 which represents an achievement of 150% of IFPP target. This results is encouraging as it represents already 58% (21/36) of the LOP target

5% 14% 12% 6% 4% 3% 6% 6% 3.C. % USG- With the introduction of SIGLUS in 8 districts in Nampula (Nampula City, Rapale, assisted service Monapo, Nacala Porto, Nacala-a-Velha, Memba, Moma, and Angoche) and 5 delivery points districts in Sofala (Beira, Dondo, Nhamatanda, Buzi and Marromeu), this quarter we (SDPs) that used this source as well to report since it allows the analysis of the availability of experience a stock out at any stocks in all HFs of the districts covered. time during the ComCare, Nampula: reporting 12 HF's were mentored and none of these registered any stock out meaning 0% of period of a HF's with stock out. Out of those 12, 10 belong to district without SIGLUS contraceptive method that SIGLUS, Nampula: the SDP is The implementation of this system began in June 2018, and 104 HF's of the 8 expected to districts, (Nampula City, Rapale, Monapo, Nacala Porto, Nacala-a-Velha, Memba, provide Moma, Angoche) implementing the system were monitored and eight registered stock out of at least one method during the quarter, representing 8 %. In the SIGLUS

appears 29 HF that registered stock outs which is superior to 8 HFs but in fact what happened is that for 21 HF (29 minus 8) the HFs depots sent all the FP products to the MCH sector and for that reason they remained with stock zero in the stock card. This is a practice contrary to the rules of stock management and through on the job trainings and TA visits the project staff will encourage the depots managers to follow the stock management standards. ComCare, Sofala: 28 HF's were mentored and none of these registered any stock out meaning 0% of HF's with stock out. Out of those 28, 20 belong to district without SIGLUS SIGLUS, Sofala: The implementation of this system began in May 2018, and 65 HF's of the 5 districts (Beira, Dondo, Nhamatanda, Buzi e Marromeu) implementing the system were monitored and none HF registered stock out of FP methods . 3.D. % of 100% 32% 75% 45% 25% 33% 46% 45% supported SDPs with all eligible At the end of the fourth quarter of Year 45 % of all health facilities in both provinces health (60% or 95 of 157 HFs in Sofala, and 35% in Nampula or 79 of 228 HFs in Nampula) providers had all eligible health providers trained in a range of modern contraceptive methods trained in a Although it’s important to note that 96% of the HFs in Sofala province already have range of “at least one HP trained in FP” and 89% of the HFs in Nampula province. modern contraceptive methods

Comments See Annexes I and II to review performance of all assessed district MSC scores comparing R1 vs R2 vs R3 Vs R4 in Sofala and Nampula provinces since project inception.

ComCare, Nampula:

12 HF's were mentored and none of these registered any stock out meaning 0% of HF's with stock out.

SIGLUS, Nampula:

52 the job trainings and TA visits the project staff will encourage the depots managers to follow the stock management standards.

ComCare, Sofala:

28 HF's were mentored and none of these registered any stock out meaning 0% of HF's with stock out.

SIGLUS, Sofala:

Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution

Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Target Achieved Target 88 128 29 (14 in 49 (14 in (12 Sof, (47 Sof, 152 52 152 89% sofala and 15 sofala and 35 66 81 in Nampula) in Nampula) Nam) Nam) IFPP provided TA on the implementation of FP activities within the 2018 PES work 3.1.1. # DPS and plan to 128 individuals, including 44 new individuals receiving TA (16 in Nampula; 28 SDSMAS staff receiving in Sofala) and 80 (65 in Nampula; 19 in Sofala) who had received it before. These TA/capacity- individuals receiving TA were from Sofala and Nampula DPS, SDSMAS MCH and building in FP other FP related program managers (HR, NED, Pharmacy) (6 districts and DPS in planning, Sofala, and 15 districts and DPS in Nampula). This involved supporting the budgeting and preparation of the internal and the national PESOD in order to ensure that the FP implementation impact activities are included; preparation of monthly and quarterly work plans to guide implementation and facilitate routine monitoring of PES performance. Throughout Fy2 135 new individuals were reached in TA session, this represents 89% of the annual target to train 152 unique individuals (four from each district and the DPS), which is below the expected performance for the year.

Sub-IR 3.2: Improved management of commodities to ensure availability at local levels

Achieved LOP FY2 Annual Annual % Indicator FY1 Q1 Q2 Q3 Q4 Target Target Achieved 38 28 36 100% 28 28 28 36 3.2.1. # of supported In Sofala, 13 logistics maps were already developed by Abt staff as a part of the districts with a USAID funded CHASS-SMTN project. In Nampula, 15 logistics maps were documented FP developed and implemented in the districts targeted in Years 1 and 2. During Q4 logistics map to optimize commodity eight district maps were developed in order to reach all 23 districts in Nampula distribution, and two DPS maps. IFPP TA teams will continue to build capacity of DDM requisition and managers in both provinces during FY3 by supporting the correct usage and reporting maintenance of logistics maps to optimize supply chain management of FP commodities.

Comments Logistics maps serve as the primary reference material upon which each district develops its monthly distribution plan for commodities and weekly pick up and drop off plan for laboratory samples and results. It has also been particularly useful for rapidly developing contingency plans related to responding to inclement weather (like heavy rains) and other emergencies that cut off access routes, enabling districts to more effectively ensure uninterrupted access to essential medicines, consumables, and laboratory services

IFPP TA teams built capacity of DDM managers in both provinces during the quarter by supporting the correct usage and maintenance of logistics maps to optimize supply chain management of FP commodities. For instance, the project worked with district health authorities to ensure that fuel requisitions consistently align with known vehicle consumption rates and latest fuel costs for respective planned routes outlined in the logistics maps.

In the end of the FY2 IFPP was able to develop logistics maps to all distrits supported by IFPP and two DPS maps.

Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Target Achieved Target 3.3.1. # of HF that undergo CSC 42 0 14 71% 0 8 2 5 feedback processes through During this quarter CSC activity took place in 5 HFs in Sofala. community discussions at least once per year

Comments CSC activities were launched in 14 HF’s catchment areas this Q2 FY2 but the process has been finalized in 8 districts in Nampula province during Q2 an in 5 districts in Sofala during Q4.

Sub-IR 3.4: Improved government capacity to increase supply, distribution, and retention of skilled workers Achieved FY2 LOP Annual % Indicator FY1 Annual Q1 Q2 Q3 Q4 Target Achieved Target 3,533 1,911 902 95% 230 232 245 152 During the Jul-Sep quarter, IFPP trained 141 technical staff and health care providers at HF level in the integrated provision of family planning services with all participants 3.4.1. # DPS, recorded in the MOH’s SIFO HR training information system (HRIS). With a total of 849 SDSMAS & HF trained by the end of Q4, this represents a 94% achievement against the annual target staff trained to train 902 health care professionals. In terms of the LOP target to train 3,533 HRH, in family performance to date represents 78% (2,760 trained) achievement. planning that are registered in e-SIFo Throughout FY2 the project TA teams also provided TA on the institutionalization of (database) district in service training centers, strengthening staff competencies in operating the MOH’s HRIS or SIFO platform. Overall, this support has decreased the volume of forms to be recorded at the provincial level. In Sofala province all 13 districts and eight in Nampula are now recording the SIFO forms locally, thereby streamlining the training registration process and ensuring more complete data in SIFO. Comments IFPP provided TA in the institutionalization of district in-service training nucleus, strengthening staff competencies in operating the MOH’s HRIS or SIFO platform. The project also developed and distributed clear SOPs for the reporting and registration of in-service trainings using SIFO forms in the respective platform. In Sofala province all 13 districts and 8 in Nampula are now recording the SIFO forms locally, thereby streamlining the training registration process and ensuring more complete data in SIFO.

Sub-IR 3.5: Improved generation, dissemination, and use of FP data for more effective decision-making Indicator LOP Achieved FY1 FY2 Annual Annual % Q1 Q2 Q3 Q4 Target Target Achieved 36 16 24 67% 9 18 11 16 In Q4, 16 districts held data review meetings guided by District Profiles (DPs) developed and analyzed with IFPP support. Specific sites included eight SDSMAS in Sofala (Beira, Dondo, Nhamatanda, Gorongosa, Machanga, Chibabava, Caia e Chemba) and eight districts in Nampula (Nacala porto, Ncala-a-velha, Moma, Mogovolas, Angoche, Ribaue, Malema e Memba). This represents 67% achievement against 3.5.1. # of districts that hold quarterly the quarterly target to conduct 24 quarterly district data review meetings using data review DPs per quarter. Compared to Q3 there was a 22% increase, this was due to meetings using improvement in the preparation of DPs, as a result of transmission of skills during district profiles TA visits. One positive aspect of the use of the DP in the review meetings during FY2 was the sharing of experiences and improvement actions between HF's with good and poor performance of the FP indicators, whenever possible between the Directors and MCH's of the peripheral HF's and district program managers. For FY3 we will continue to encourage the use of the DP for the discussion of FP data, and joint development of QI plans between peripheral HFs and SDSMAS.

Collaboration with other donor projects During this reporting quarter, coordination meetings took place with government partners (Ministry of Health, Provincial Health Directorates, and District Directorates of Health) and other partners such as FHI360 and DKT.

The main agenda items at the discussion with the MOH through three National Technical Working groups were 1) mapping of all current and future FP implementing partners, 2) preparation of contraception week 2018, 3) coordination for SRH commodities forecasting meeting, 4) joint supervision visits to provinces, 5) roll-out of investment case DLI’s and 6) review of national distribution plan. At the provincial and district level, regular meetings were held to coordinate and plan activities each month such as trainings, mentorship visits, supervision visits, mobile brigades, commodities redistribution, and data review and district profile meetings.

Coordination with FHI360 was key after provincial portfolio review to leverage the CoVida community based intervention to maximize the referrals for FP services uptake. Also, the partnership and coordination with DKT was crucial in leveraging their existing intervention at schools and mobile clinics to roll-out mCenas and linking with service delivery.

In May, Lois Quam, CEO of Pathfinder International visited Mozambique office, and as part of her trip included visits to USAID mission Director, Jennifer Adams during which perspectives were shared to advance SRH agenda including Cervical Cancer Prevention, Adolescent and Youth and Maternal Health.

Lois, met with Minister of Health, Dr. Nazira Abdula advocated on advancing Adolescent and Youth SRH issues and Community engagement in hard to reach areas and potential ways to tackle inequalities, additionally she was also able to visit field work in Nampula and the advancement in family planning will be taken for cross-country learning with other projects funded by USAID in Ethiopia and Nigeria.

Upcoming Plans IR 1: • Conduct remaining health facility assessments and develop action plans for expansion to more HFs in both provinces • Based on the results of assessments and training plans, support the provision of necessary medical equipment and supplies • Continue to support MISAU roll-out of FP integration guidelines and data collection tools • Continue FP trainings at HF level and subsequent mentoring visit • Continue FP trainings for APEs and TBAs. • Support district MCH nurse to provide quarterly supportive supervision on FP/RH services to facilities • Strengthen the availability of contraceptive methods at the HF level and for APEs by reinforcing the SRH commodities taskforce at the central provincial and district level • Support routine mobile brigades in urban and rural areas, including schools

• Continue coordination meetings with MCSP to leverage support to health facilities and directorates, for the mobile brigades planning to increase access to FP commodities to remote communities • Continue to conduct FP and environmental compliance follow-up visit monitoring action plans to previously visited HFs and start the process for new HFs • Continue to implement ISL IUDPP workshops in Nampula province for HF • Implement the mentor’s mentoring workshop in Sofala province

IR 2: • Continue to mobilize the FY1 groups to complete the sessions four through six of the Community Dialogues and roll-out the six sessions community dialogues in additional community groups; • Continue the preparation, organization, and realization of CLL (Conselho Local da Localidade) meetings in alignment with the CFs areas of intervention ; • Finalize the CSC process in the 6 HFs’ catchment area of Sofala province; • Draft and implement the Community Radios contract addendum to broadcast radio programs related to sessions four through six of the community dialogues; • TA team to continue monitoring and evaluating of the community component; • Train and start using the urban CsW CommCare App in urban areas which will allow a more in- depth follow up and analysis. • Continue to support the follow-up of the TBAs monthly meetings at peripheral HF level and ensure a more in-depth analysis based on the standardized TBA meeting forms. IR 3: • Expand HSS activities for the remaining districts not yet covered in Nampula Province, namely Larde, Mogincual, Liúpo, Rapale, Lalaua, Ilha de Moçambique, Nacaroa and Muecate and Muanza, Maringue, Cheringoma and Chemba in Sofala

• Provide TA for the implementation and strengthening of SIGLUS in selected districts (Angoche, Monapo, Nacala Port, Nacala-a-Velha, Rapale and Nampula City; Beira, Dondo, Nhamatanda, Buzi and Marromeu in Sofala)

• Continue to provide TA to consolidate the holding of the district Task Force meetings in the SDSMAS already created and establish the district Task Force in the SDSMAS not yet created;

Evaluation/Assessment Update

Evaluations, Assessments, Studies, and Audits Include any and all types of evaluations, financial or programmatic, internal or external. Planned: List evaluations, assessments, studies, and/or audits planned for next quarter • Conduct operational research with the theme: Why is there a preference for short-term versus long-term contraceptives in Chibabava and Nhamatanda districts in Sofala Province? • Conduct FP focused operational research protocols in Ribaué, Moma, Mecuburi, Nacala Porto, Monapo and Meconta and submit to IRB for approval and eventual study start-up, with the following themes : o Nampula DPS : SRH OF ADOLESCENTS AND YOUNG PEOPLE: Determining factors for the establishment of SRH/PF services and use of modern methods of contraception,

adolescents and young people in fertile age in Nampula Province, from January to December 2017. o Ribaué: Low FP coverage in the oral contraceptives and IUD methods in women of Fertile age, Ribaué : District, 1st quarter of 2017 o Moma: Factors contributing to poor adherence to long-term methods (IUD and Implant) in the maternity ward of Chalaua health center o Mecuburi: Factors influencing poor adherence to long-term methods (IUD and implant) in women of fertile age, Mecuburi district, 1st semester 2017 o Nacala Porto: Evaluate the impact of the use and supply of FP services, as a result of the implementation of the Integrated Family Planning (PFI) strategy, case study of the Urban Health Center, 2017 o Monapo: SRH: Low adherence to long-term methods (IUD and Implant), in the SDSMAS of Monapo, I quarter of 2017 ▪ Meconta: Low FP coverage in the Age Group of 15 to 19 years, in Namialo health center, in 2017

Annexes • Annex A - Success story • Annex B - PMP • Annex IA – Management Systems Compliance Assessments: Nampula Province • Annex IB – Management Systems Compliance Assessments: Sofala Province • Annex II - Workplan • Annex III - Financial information

Annex A - Success story

Community Score Cards (CSC) process implemented successfully in Cheringoma district - Sofala province. The Inhaminga Health Facility (HF) located in the town of Cheringoma district, offers health services to 13 neighborhoods and some surrounding communities, including FP services integrated in 8 different service delivery points, namely EPI, stomatology, ART treatment, in-patient ward, emergency room, pediatric, medicine and adult consultations. Cheringoma HF, together with 5 other HF in Sofala province, were selected to undergo the CSC process to bettering the community – HF existing relationship as community complaints were quite important.

The CSC process started at community level with meetings clarifying and mobilizing on the CSC importance, purpose and methodology and on how this exercise will help to improve citizen participation in the improvement quality of the HF services and better community satisfaction. After several community meetings aimed to identify the complaints and the positive points and to score the degree of user’s satisfaction, a joint meeting was held between community representatives, local community authorities and HF health providers, during which several aspects related to the quality of FP

58 health services and the priorities of each community were discussed, culminating in the elaboration of an joint action plan.

In the course of the CSC process, the team faced several coordination and collaboration challenges with the Cheringoma health directorate team, who had the perception that they were not involved enough in the process, although they had already been integrated into the CSC objectives through the involvement of the district community health responsible in a previous training. Therefore, the public restitution meeting had been postponed several times by the district health directorate as they were at variance about the contents presented in the report of the joint Community – HF meeting, more specifically the points negatively scored. Furthermore, they raised concerns about the public restitution meeting, which should be held in presence of members of the local district administration. IFPP team was asked several times to clarify and justify some of the negatively scored points. Additionally, the methodology that was to be used during the restitution meeting was not accepted by the district health director, which suggested that only a simple meeting should be held with its technical team to resolve the appointed problems.

After several meetings of clarification and sensitization with the health district director, he finally gave his approval for the public restitution meeting, The meeting took place and was a great opportunity to bettering the relationship: the Chief Medical Officer gave a speech of satisfaction for the results of the CSC, since they reflect the community's concern regarding the quality of services provided at HF level, but also aroused the attention of the HF management team regarding the drug shortages complaints. He further acknowledged that the concerns raised by the community were justifiable and that some concerns were already being addressed.

In turn, the community was very satisfied with the implementation of CSC, which helped to solve the problems identified, and shared some testimonies regarding the improvement of services in the Inhangoma HF.

In addition to the aspects raised by the community, the health district director also took initiative to improve other aspects such as the necessity to get support to build a waiting porch in the courtyard for the SRH/FP consultation users.

Chief Medical doctor addressing his speech during the public restitution meeting and a mother providing testimony about positive changes having been happening since the joint community – HF meeting

During the follow-up and monitoring process of the five agreed priorities, it was possible to verify the improvement of most of them, which were witnessed by the community during a co-management HF meeting: • Regarding the problem of delay to be attended at the SRH/FP consultation, a permanent MCH nurse was appointed, • Regarding the need of a waiting porch, community supported the HF to build it with local materials. • Regarding the problem of lack of punctuality to initiate the consultations, the HF director solved the problem with his team • Regarding the problem of the frequent absence of the providers at their workplaces during the working hours, the community indicates that the providers already attend the users regularly. • Regarding the limited topics followed-up at the co-management committee, focusing mainly on malaria prevention program, it was proposed that the co-management committee should addressed all problems raised by users.

Annex IA – Management Systems Compliance Assessments: Nampula Province

Angoche Cidade de Nampula Planning Planning 100% 85%

90% MCH 100% MCH Programs Logistics Programs 60% 86% Logistics Mngmt Mngmt 100% 15% 86% 78% 32% 46% 17% 8% 46%

20% 35% 40% 80% 90% 80% 80% 85% 56% 80% Evaluation HRH Evaluation HRH 90% 86% 70% R1: 40% vs. R2: 92% vs. R3: 94% R1: 39% vs. R2: 83% vs. R3: 90% 80% R1 R2 R3 R1 R2 R3 100% 97% Monitoring Jan-17 Aug-17 Feb-18 Monitoring Jan-17 Sept-17 Mar -18

* District HRH manager was not available to present evidence of % MOH compliance with management standards in R2;

Erati Malema

Planning Planning 85% % 58% MCH MCH Programs 89% 70% Logistics Programs Logistics Mngmt 74% 78% Mngmt 60% 70% 41% 28% 36%

20% 40% 47% 60% 40% 80% 80% 65% Evaluation HRH Evaluation 90% HRH 80% 47% R1: 37% vs. R2: 75% vs. R3: 84% R1: 51%

90% R1 R2 R3 R1 Monitoring Feb-17 Sept-17 Mar -18 Monitoring Nov-17

Nov-17 Meconta Mecuburi Planning Planning 90% % 85% 90% MCH MCH 96% Programs Logistics Programs 81% 72% Logistics Mngmt 74% Mngmt 88% 74% 60% 70% 60% 27% 26%

30% 50% 55% 70% 55% 90% 80% Evaluation 70% HRH Evaluation 85% HRH 70%

70% R1: 68% vs. R2: 70% 80% R1: 41% vs. R2: 81% vs. R3: 88% R1 R2 90% R1 R2 R3 Monitoring Mar-17 Sept-17 Monitoring Apr-17 Sept-17 Mar -18

% % 61

Memba Mogovolas Planning Planning

60% 52% MCH MCH Programs Logistics Programs Logistics Mngmt 59% Mngmt 50% 47% 40%

40% 70% 70% Evaluation HRH Evaluation90% HRH 60% R1: 55% R1: 57% R1 R1 80% Monitoring Nov-17 Monitoring Jan-18

Moma Monapo Planning Planning 90% 100%

MCH 82% MCH 82% Programs Logistics Programs Logistics 76% 100% 86% Mngmt 89% Mngmt 82% 36% 38% 19% 46%

10% 30% 55% 80% 75% 80% 80% Evaluation90% HRH Evaluation HRH 70% 100% 70% R1: 42% vs. R2: 85% 80% R1: 50% vs. R2: 92% vs. R: 91% 100% R1 R2 R1 R2 R3 90% Monitoring Apr-17 Sept-17 Monitoring Feb-17 Aug-17 Mar -18 R1: 41% vs. R2: 92% Murrupula Mossuril Planning % Planning

63% 57% MCH MCH Programs Logistics Programs Logistics Mngmt Mngmt 54% 57% 33% 34%

40% 60% 65% Evaluation 80% HRH Evaluation HRH

60% R1: 49% 60% R1: 53% R1 R1 Monitoring Feb-18 Monitoring Feb-18

Nacala-A-Velha Nacala Porto Planning Planning 90% 92%

62% MCH MCH Programs Logistics Programs Logistics 78% Mngmt 63% 60% Mngmt 100% 70% 40% 70% 37% 40%

20% 35% 50% 40% 70% 39% 50% 100% 80% Evaluation HRH Evaluation HRH 43% 77% R1: 56% R1: 41% vs. R2: 66% vs. R3: 90% 80% R1 R1 R2 R3 Monitoring Nov-17 Monitoring Mar-17 Sept-17 Mar -18

* New HRH manager in Nacala Porto for R2

Ribaue Planning

100%

MCH Programs Logistics 42% 76% Mngmt 100% 46% 26%

15% 80% 47% 85% Evaluation HRH 100% 90% R1: 41% vs. R2: 92% R1 R2 Monitoring Feb-17 Sept-17

NampulaPlanning Province 86%

MCH Programs Logistics 88% 56% 76% Mngmt 40% 37%

63% 38% 83% 69% Evaluation 59% HRH

85% R1 Monitoring

Annex IB– Management Systems Compliance Assessments: Sofala Province Beira Buzi Planning Planning 85%

80% MCH 100% MCH Programs 89% 60% Logistics Programs 65% Logistics Mngmt 80% Mngmt 81% 74% 81% 78%

41%

60% 65% 80% 72% 88% Evaluation 85% HRH Evaluation HRH 90% 73% R1: 63% vs. R2: 86% vs. R3: 89% R1: 74% R1 R2 R3 R1 Monitoring90% Jan-17 Jul-17 Jan- 18 Monitoring Nov-17

Caia Chibabava Planning Planning 80% 85%

70% MCH MCH 70% Programs Logistics Programs Logistics 81% 74% Mngmt 60% Mngmt 70% 50% 60% 70% 72% 59% 39%

50% 50% 60% 70% 85% 70% 60% Evaluation HRH Evaluation 80% 60% HRH

70% R1: 54% vs. R2: 66% 70% R1: 60% vs. R2: 73% vs. R3: 79% R1 R2 R1 R2 R3 70% Monitoring Jan-17 Sept-17 Monitoring Feb-17 Sept-17 Feb -18

R Dondo Gorongosa Planning Planning 85%

80% MCH MCH Programs 81% 88% Logistics Programs Logistics 57% Mngmt 80% 50% 80% Mngmt 78% 63% 64% 59%

50% 60% 70% 65% 80% 60% 60% Evaluation 80% HRH Evaluation HRH 70% 80% R1: 60% vs. R2: 71% vs. R3: 82% R1: 66% 87% R1 R2 R3 R1 Jan-17 Jul-17 Jan-18 Monitoring Monitoring Apr-17

Machanga Nhamatanda Planning Planning Apr-17 85%

MCH MCH Programs 65% Logistics Programs 88% Logistics Mngmt 81% Mngmt 45% 70% 64% 71% 74%

60% 55% 60% 40% 80% Evaluation HRH Evaluation 67% 80% HRH 80% R1: 67% R1: 65% vs. R2: 83% R1 80% R1 R2 Jun-17 Nov-17 Monitoring Mar-18 Monitoring Marromeu Planning Apr-17 65% MCH Programs 88%Logistics Mngmt 59% 0% 0% 0% 0% 0% 0%

Evaluation70% 70%HRH

70% R1 Monitoring 64

Sofala Province

Planning

85% MCH 78% Programs 81% 60% 79%88%Logistics Mngmt 74% 71% 60%

R1: 63% vs. R2: 76% vs. R3: 83%

63% Q2-17 59% Q4-17 Q2-18 74% 80% 73% Evaluation84% 71% HRH 78% 83% R1 R2 Monitoring